Table 2 Training schedule
Day 0 | ||
Activities | Objective | |
• Learners received from their different counties and registered. • Issued with a Butterfly iQ + ™ probe, an iPad, and relevant accessories. • The iPads were preloaded with learning materials, pre and posttests, as well as surveys. | • Surveys were to be filled out by the learners at different time points: at month 1, 6 and 12 post training to assess the proficiency and impact of the knowledge and skills learned. • A patient survey to assess their experience and difference they felt Point of Care Ultrasound made to their management and outcome. | |
Day 1 | ||
Activity 1 and objectives | Activity 2 and objectives | Activity 3 and objectives |
• Introduction lecture and pre-recorded videos on navigating the butterfly application, introduction to ultrasound terminology, probe movements and handling, device cleaning, charging and maintenance. • Live demonstration session objectives: • How to unlock the device, and open the butterfly application • How to save images and video clips, as well as create folders for each patient • General features of the app such as presets, modes, freeze, saving images, and how to take measurements • Essence of adequate depth and gain in achieving optimum image quality | • Overview and fetal number. Session taught how to perform a quick overview scan and determine the fetal number. If the fetal number was uncertain despite the overview scan, learners were urged to repeat the scan from multiple angles. • The live demonstration session objectives included: • Demonstrate and practice on how to hold the probe and probe marker orientation • Stabilization of the probe by anchoring the scan hand to the learner’s skin • Practice longitudinal and transverse probe placement • Practice probe movements to scan the whole uterus • Recognize fetal head to determine number of fetuses present • Clinical Integration: Identification of multiple gestation as a high-risk condition | • Fetal presentation and lie. The key message from this session included how to evaluate the relationship of the fetal head to maternal pelvis. Learners were instructed to start the scan from the maternal symphysis pubis, how to identify the maternal urinary bladder, and how to identify the fetal head. Referral of the patient was recommended for any non-cephalic presentation as delivery would likely be complicated • Live demonstration session objectives included: • Identifying the fetal presenting part and differentiating cephalic from breech presentations • Identifying the fetal spine to determine the lie (longitudinal, transverse or oblique) • Ensuring proper probe placement and orientation |
Day 2 | ||
Activity 1 and objectives | Activity 2 and objectives | Activity 3 and objectives |
• Placenta location session focused on locating the placenta as a large hypoechoic structure adherent to the uterine wall, noting the placental tips, relating the lower tip to the cervix and fetal presenting part, and referring the patient if a low-lying placenta or previa was suspected. • The live demonstration session objectives included: • Placing probe on maternal pubic symphysis and identification of the cervix • Identifying the placenta and its location in relation to the presenting part • Determining the most distal part of the placenta and ruling out low lying placenta • Clinical Integration: Identification of low-lying and placenta previa as high-risk conditions | • Fetal heart rate assessment session demonstrated how to locate the fetal heart and use M-mode to measure fetal heart rate. • The live demonstration session objectives included: • Identifying the fetal heart • Optimize the image by adjusting probe position and depth • How to use M-mode to measure fetal heart rate • Clinical Integration: Identification of fetal distress | • Amniotic fluid assessment session instructed learners how to locate the deepest vertical pocket of amniotic fluid and evaluate volume of amniotic fluid using the single deepest pocket (SDP) method. Learners were also taught how to rule out obstructing cord using color doppler. • The live demonstration session objectives included: • How to divide the maternal abdomen into four quadrants • Identify amniotic fluid pockets free of fetal parts and umbilical cord • Use of color doppler to identify and confirm umbilical cord • Probe placement and measuring of the deepest pocket • Clinical Integration: Identification of oligo- and poly-hydramnios |
Day 3 and Day 4 | ||
Activities and objectives | ||
• Five public health facilities near Kenyatta University with high numbers of antenatal clients were identified, and learners were transported to these facilities for the opportunity to scan actual patients • One instructor would be assigned to supervise 4-5 learners in this setting | • Patients were explained the objectives of the scan and gave informed consent prior to any scanning • Scanning was restricted to the 5 thematic areas taught during the lectures and live demonstration. Every learner was expected to have a minimum of 20 scans throughout the week in each of the 5 thematic areas | • Of note, if any abnormal findings were discovered during the course of scanning patients, the patients’ primary medical team were notified and a formal ultrasound scan was recommended |
Day 5 | ||
Activity 1 | Activity 2 | |
Assessment • Learners that had at least 20 scans in each thematic area were allowed to sit for the exam • The exam was structured as an Observed Structured Clinical Exam (OSCE) with each learner assigned to one instructor for a period of 15 min (see Additional file 3) • Areas that were examined included probe basics, image optimization, image acquisition and interpretation of the 5 thematic areas that had been taught through the week | • Learners were deemed to have failed the assessment if they: had a score of zero in any of the 5 sections on the assessment tool, or had a total score of less than 13 out of a possible 26. If a learner failed, a remedial assessment was offered with a different instructor on either a specific section or the whole assessment • After completion of the OSCE, two post-tests, including both the Butterfly survey on the iPad and also a survey on the GUSI website, were completed by the learners. Both post tests were identical in content to the pre-tests | • Session on final thoughts was held where emphasis was made on probe care • Learners were also shown how to share saved images with colleagues or for consultation, as well as what to do in case their devices got lost • Learners who completed the 5-day sessions successfully received a certificate at the end of the course |