Development of a Bedside Echocardiogram Training Program at
Development of a Bedside Echocardiogram Training Program at a Zonal Referral Hospital in Rural Tanzania Mark Shaffer and Jeffery Hall Lyochi Iseme, Peter Kishimbo, Humphrey Kiwelu, Issakwisa Mwakyula, Dilan Ellegala, Joyce Nicholas
Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Mark Shaffer, Lyochi Iseme, Peter Kishimbo, Humphrey Kiwelu, Issakwisa Mwakyula, Jeffrey Hall, Dilan Ellegala, and Joyce Nicholas have indicated they have no relevant financial relationships to disclose. 2
Our Funding • Funded by the US Department of the Army through the Henry Jackson Foundation / Military HIV Research Program • Implemented through Madaktari Africa • The information presented does not necessarily reflect the views of the US government. The US Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick, MD 21702 -5014 is the awarding and administering acquisition office Army Cooperative Agreement Number: W 81 XWH-07 -2 -0067
Funding Explanation WRP/HJFMRI Direct HIV Care Support Mbeya Referral Hospital HJF/MHRP Madaktari Africa USC Family Medicine Complementary Support 4
Overview • • • Background Objective Methods Results Future Directions
Background • Tanzania suffers from high rates of both communicable and non-communicable heart diseases. (DMII, HTN, HIV, TB, etc) • Assess to Diagnostics Cardiac Imaging is Extremely Limited • Physician performed point-of-care ultrasound can improve access to diagnostic imaging
Point of Care Ultrasound • Steinmnetz and Berger AJTMH 1999 Bedside general ultrasound by physician influenced management in >60% of cases in Cameroon • Kobal et al. AJC 2004 Cardiologists visiting rural Mexico find bedside echo with highly portable ultrasound adequate in 90% of cases • Kwan et al. JACC 2013 Nurses in Rwanda use basic echocardiogram assessment in heart failure management protocol
ECHO Training in USA USC Global Health Fellow with One Month Intense Echocardiogram Training Performed 85 Interpreted additional 70 with a Cardiologist COMPARISON: Cardiology Fellow: 75 performed, 150 interpreted minimum over 3 months 150 performed, 300 interpreted to perform independently Echo Tech: 800 Performed Scans, 1600+ hours of training
The Objective To Develop a Self- Sustaining Echocardiography Training Program for Physicians in Mbeya, Tanzania.
Methods • • • Baseline Assessment Identify Local Partners Protocol and Reporting Tool Development Training Program Development Transition to Local Leadership Program Assessment
Mbeya Referral Hospital • Tertiary Healthcare Facility for the Southern Highland Zone in Tanzania • Catchment area of approximately 6. 3 million • Inpatient capacity of 477 beds, with an average 450 -500 outpatients per day 11
Baseline Assessment • “Sonographic Heart Survey” performed by 3 members of the X-Ray department • Performed w/o protocol with an abdominal probe, subxyphoid approach • Reported with Standard X -ray Form *Mock up for Presentation
Local Partners • Support from Hospital Director, and the Departments of Medicine and Radiology • Collaboration with MMRC (Mbeya Medical Research Center) and LMU (Ludwig-Maximilians University) to provide EKG and ECHO to HIV patients on 2 nd line therapy
Protocol and Report Form
Training Program Development 4 Trainees Identified from Medicine and Radiology • 10 Part Lecture Series • 75 Supervised Cases* • Final Examination * American College of Cardiology Level 1 Training Guidelines ACCF COCATS 3 Training Statement: Task Force 4
Examination • Image Interpretation of 5 Studies • Clinical Application Questions • Electronic Manipulation and E-Consultation Score 75% to Pass Score 90% for Honors
Certification
Transition to Local Leadership • 3 Additional Trainees Identified in Medicine and Pediatrics • New Tanzanian Experts Have Given Portion of Lectures and Supervise Practicum • Dr. Kiwelu, Head of Radiology, Taking Role of Proctoring Examination
The Next Generation
Program Assessment • Log Book Review: Data extracted for analysis. • Image Quality Review: Images captured by Tanzanian Trainees w/o supervision reviewed for quality and interpretation. • Chart Review: Extensive chart review underway of all patients with known cardiac and renal disease: Results Pending
Results: Physicians Trained & ECHOs Performed Participant Session # PK 1 96 PASSED W/HONORS HI 1 117 PASSED LI 1 166 Deferred HK 1 Deferred DN 2 101 57 PM 2 37 Pending JM 2 33 Pending Total Echos Performed* Exam Status** PASSED W/HONORS 610*** * Data Per Log Books as of Last Extraction May 31, 2013 ** As of June 27, 2013 *** 113 Without US Physician Supervision
Results: Indications 1013 58 30 Second Line Screen Other Screen Symptom Repeat Not Recorded 600 Total 711 Logged Scans by US and Tanzanian Providers
Results: Findings Other Pleural effusion/Ascites Pericardial Disease CHD Valve Disease PHTN CHF/DCM LVH Normal 0 50 100 150 200 250 300 350 Just Under 50% of Studies Normal or Essentially Normal
Change in Medical Management LVH Normal DCM w/Clot PHTN
Immediate Intervention Pericardial Effusion Pleural Effusion
Appropriate Referral Atrial Myxoma TOF Severe MS
Results: Clinical Impact 120% 100% 80% Non-Reported 60% Non-Significant 40% Scans Performed by Providers Outside of Radiology 23% More Likely to be Felt to Change Management 20% 0% Total Radiology Non-Rad
Image Quality Assessment 4 Images from 59 Studies Reviewed for Adherence to 19 image protocol, 83% completely adherent with adequate pictures. 93% missed only 1 view. 6 49 Complete >1 Missing 1 Image Missing Most commonly inadequate view was the apical 4 chamber
Image Quality Interpretation Images Sets Reviewed and Compared to Log Book Results (not full report) 5 54 Appropriate Inappropriate Only 5 Inappropriate Interpretations Noted: • Miss-measuring IVS • Wrong CHD identified • DCM when really just dilated chambers • Ascites noted • Non-Stenotic rheumatic valve missed All 22 exams by HONORS graduates had appropriate interpretations
Discussion • Project Limited by no 3 rd Party Assessment of Exam Quality or Clinical Impact • Despite This, a Significant Impact on Clinical Practice can be Demonstrated • Self-Sustainability not Yet Demonstrated
Looking Forward
Future Directions • Dr. Kiwelu, along with the Hospital Director, has decided to seek national accreditation. • An official curriculum has been submitted to the MOH. • If approved, it will be the first accredited Ultrasound training program in Tanzania.
First Graduates
Namshukuru Sana… • • Mbeya Referral Hospital Madaktari Africa HJF/MHRP MMRC LMU USC SOM Palmetto Health
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