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Adequacy of the emergency point-of-care ultrasound core curriculum for the local burden of disease in South Africa
  1. Daniël J van Hoving1,
  2. Heinrich H Lamprecht1,
  3. Melanie Stander1,
  4. Kamil Vallabh2,
  5. David Fredericks2,
  6. Pauline Louw1,
  7. Monique Müller1,
  8. Jacques J Malan2
  1. 1Division of Emergency Medicine, Stellenbosch University, Cape Town, Western Cape, South Africa
  2. 2Division of Emergency Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
  1. Correspondence to Dr Daniël Jacobus van Hoving, Division of Emergency Medicine, P.O Box 19063, Tygerberg, 7505, South Africa; nvhoving{at}sun.ac.za

Abstract

Objective This prospective cross-sectional study assesses the adequacy of the current South African emergency point-of-care ultrasound (EPCUS) core curriculum against the local burden of disease.

Method Patients presenting to five Emergency Centres during July 2011 were eligible for inclusion. Patients under the age of 12, after-hour presentations, missing folders and folders with incomplete notes were excluded. Emergency physicians with EPCUS exposure were responsible for data collection. They were all blinded to the study's aim. Summary statistics describe the proportion of clinical cases and procedures for which EPCUS was used. One investigator assessed the adequacy of the curriculum by matching the clinical indications of each module with the presenting complaint and final diagnosis of each patient. The ultrasound modules were ranked according to the frequency of their clinical indications. κ-Statistics are reported on 10% randomly selected cases to quantify interobserver agreement.

Results The study included 2971 patients. Ultrasound assisted with diagnosis in 384 (12.92%) patients and in 34 (1.14%) procedures. A total of 1933 EPCUS procedures were indicated in 1844 (66.07%) patients. The five most frequently indicated modules were pulmonary, musculoskeletal, cardiac, focused assessment with sonography of HIV/tuberculosis co-infection and renal. The interobserver agreement (κ) was 0.602 (95% CI 0.559 to 0.645).

Conclusions This study was an attempt to ensure an evidence-based approach to assess the adequacy of the EPCUS core curriculum in South Africa. The results illustrate that our local burden of disease may require a change of the current core curriculum.

  • Ultrasound
  • curriculum
  • emergency
  • burden of disease
  • South Africa
  • toxicology
  • education
  • teaching
  • ECG
  • acute medicine-other
  • cardiac arrest
  • clinical care
  • clinical management
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Introduction

The introduction of emergency point-of-care ultrasound (EPCUS) to the clinical practice of emergency medicine has completely revolutionised the approach to patient care.1 In the early 1990s, ultrasound began to be utilised by non-radiologists for numerous emergency indications including trauma, the shocked patient, vascular access and other procedures.1 ,2 These emergency scans are highly focused, limited and goal-directed to answer specific clinical questions.3 Various studies have proven that emergency physicians can perform accurate ultrasound scans with a minimum amount of training.4 ,5

Formal training programmes were developed internationally to incorporate this new skill into their emergency medicine curriculum. Australasia, the USA and the UK have developed national guidelines relating to EPCUS training.6–8 It is also a requirement that Emergency Medicine trainees in South Africa be proficient with EPCUS before attempting the final exam.9

The development of EPCUS is still in its infancy in South Africa. The specialty of emergency medicine was only officially recognised in 2003.10 The first EPCUS course to be held in the country was in 2007. The College of Emergency Medicine of South Africa published a policy document in 2009 which addresses the process of training and credentialing of EPCUS in South Africa.9 The core curriculum covers a basic introduction to ultrasound physics and five clinical components (extended focused assessment with sonography in trauma, assessment for abdominal aorta aneurysm, assessment for deep vein thrombosis, focused emergency echocardiography in resuscitation and ultrasound guided vascular access).9 This curriculum was mainly derived from EPCUS programmes in the USA, Australasia and the UK.9

However, international consensus regarding the requirements of the ‘ideal’ EPCUS curriculum is lacking.4 Even within the USA, different Emergency Medicine training programmes have different curricula; some not having a structured curriculum at all.11 It seems that most EPCUS curricula have been put together using a consensus opinion of local leaders in the field. It is inappropriate to blindly adopt another country's curriculum as huge differences exist between developed and developing countries regarding disease patterns, medical systems and resource availability. Needs assessments have also been used to both drive curriculum design and to evaluate whether the curriculum was fit for purpose.12 ,13 It is also a more objective way of determining a core curriculum than by consensus opinion.

The selection of specific EPCUS modules or components to be included in a postgraduate emergency medicine training programme in order to safely practice emergency medicine needs to be better defined. These modules should either have lifesaving capabilities or be able to provide rapid and accurate diagnostic information.14 The ultrasound examination itself should be fairly straightforward where lack of precision (eg, a 1 cm difference in an assessment for abdominal aorta aneurysm measurement) will not compromise the patient.15 Furthermore, the disease in question should also be highly prevalent. It is thus apparent that a more evidence-based approach is needed to determine the components of the core EPCUS curriculum.

Short courses are the basic requirement to start EPCUS training. All courses in South Africa must be accredited by the College of Emergency Medicine of South Africa Emergency Ultrasound Subcommittee and cover the current core curriculum.9 The courses contain theoretical knowledge and hands-on practical training with a formal assessment to determine if candidates have acquired an understanding of the principles and practice of emergency ultrasound. After attending a course, clinicians have to complete a logbook to ensure efficiency before completing a formative practical assessment in order to be accredited as a core EPCUS provider. Only then can physicians start implementing decisions made with the help of EPCUS. The Emergency Ultrasound Subcommittee of the International Federation of Emergency Medicine has endorsed future modular training and an international credentialing process (box 1).16 This will allow candidates to only attend the modules that they are interested in.

Box 1

Emergency point-of-care ultrasound modules

  1. Image acquisition, equipment and instrumentation.

  2. Aorta.

  3. Extended focused assessment with sonography in trauma.

  4. Vascular access and deep venous thrombosis.

  5. Cardiac.

  6. Renal (including ureter and bladder).

  7. Testicular.

  8. Liver (including gallbladder and cystic ducts).

  9. Gastrointestinal.

  10. First trimester pregnancy/pelvic.

  11. Musculoskeletal.

  12. Peripheral nerve blocks.

  13. Pulmonary.

  14. Focused assessment with sonography of HIV/tuberculosis.

  15. Shock protocols.

  16. Head & neck.

  17. Setting up an emergency point-of-care ultrasound training programme.

The South African EPCUS core curriculum has never been tested against the burden of disease seen in local Emergency Centres (ECs). The aim of this study was to assess the adequacy of the current South African core EPCUS curriculum for the burden of disease seen in ECs within the Western Cape Province of South Africa.

Methods

Study design

A prospective cross-sectional study design was used. Approval was obtained from the Stellenbosch University Health Research Ethics Committee (Ref: N11/02/053) and from the Western Cape Health Research Committee (Ref: 2011 RP 33).

Study setting and population

Five (of eight) secondary level hospitals situated within the Western Cape Province of South Africa were sampled. The hospitals were New Somerset Hospital (Green Point, Cape Town), Victoria Hospital (Wynberg, Cape Town), G.F. Jooste Hospital (Mannenberg, Cape Town), Paarl Hospital (Paarl) and Worcester Hospital (Worcester). These hospitals have trained emergency physicians with EPCUS experience; furthermore, the patient load of these hospitals is a mixture of adults and children presenting with both trauma and medical conditions.17 George Hospital (George) was not included due to the distance from Cape Town, whereas Karl Bremer Hospital (Bellville, Cape Town) and Helderberg Hospital (Somerset West) did not have EPCUS trained emergency physicians working in their ECs.

All patients presenting to the ECs of the included hospitals during July 2011 were eligible for inclusion. Patients under the age of 12, after hour presentations (17:00–07:00 and weekends), missing folders and folders with incomplete notes were excluded.

Measurements

Data collection was coordinated by site investigators located at each of the sampled hospitals. The site investigators were all qualified emergency physicians and were (at the least) trained Level 1 ultrasound providers. Site investigators received training on the completion of the data collection form (online appendix 1) and had overall responsibility for data collection at each hospital. A data collection form had to be completed for every patient seen in the EC during the study period. This was accomplished by the regular EC working force while the site investigators cross-checked every data collection form before submission to the central research office. At the time of the study, all Western Cape ECs were ultrasound naive and the collected data are intended to represent all ultrasound examinations that could have been done on the patients. The site investigators and the EC data collectors were blinded towards the specific aim and objectives of the study. Data were only collected during weekdays from 07:00 till 17:00 due to financial and time constraints. Data were collected anonymously and inserted into a password protected electronic spreadsheet (Microsoft Excel®, Microsoft Corporation, Redmond, Washington, USA). Incomplete data collection forms were excluded. All data collection forms were destroyed after data extraction by means of a paper shredder.

Data analysis

Summary statistics were used to describe the proportion of clinical cases and clinical procedures for which ultrasound was used to make the final diagnosis. The principal investigator (DJvH) assessed the adequacy of the EPCUS curriculum by matching the clinical indications of the EPCUS modules with the presenting complaint and final diagnosis of each case. The most frequent clinically indicated EPCUS modules were thus determined. A second investigator (HHL) completed 300 (10.1%) randomly selected cases to assess the reliability of the results. κ-Statistics are reported to indicate the inter-observer agreement.

Results

A total of 2971 patients were included in the study (table 1). The mean age of the study sample was 43.35 years with 1440 (48.47%) being male subjects. Ultrasound assisted with diagnosis in 384 (12.92%) patients and in 34 (1.14%) cases requiring procedures (table 2).

Table 1

Study population

Table 2

Ultrasound used during the study period

A total of 1933 emergency ultrasounds were deemed to be indicated in 1844 (66.07%) patients. Table 3 represents a ranked list of all the EPCUS modules for the included patients according to the frequency of their clinical indications (vascular access was omitted as it is indicated in most patients). The overall inter-observer agreement on 300 randomly selected cases was ‘good’ (κ=0.602; 95% CI 0.559 to 0.645).18

Table 3

EPCUS modules ranked according to frequency of clinical indications

Discussion

Ultrasound is a very important diagnostic adjunct in modern medicine. This is clearly demonstrated with 13% of EC patients receiving some form of ultrasound. This is far more than previously determined in a similar Western Cape EC population (4.5%).13 However, the use of ultrasound (15.91%) in patients with acute medical admissions to Cape Town public hospitals is very similar.19

The low usage of EPCUS for procedural assistance (1.14%) might be a reflection of the uncertainty in the use of EPCUS as it has been fairly recently introduced and we suspect that the use will increase as more physicians acquire the skill and experience related to EPCUS.

Any curriculum needs to reflect the local burden of disease in order to empower clinicians to deal with common entities. The top five defined causes of mortality for South Africa during 2007 were respiratory tuberculosis (13.8%), lower respiratory tract infections (9.7%), cardiac diseases including heart failure, hypertensive heart disease and ischaemic heart disease (7.0%), intestinal infectious diseases (6.8%) and HIV/AIDS (6.4%).20 Similarly, the commonest causes of premature mortality for persons in Cape Town during 2006 were trauma including homicide and road traffic accidents (19.7%), HIV/AIDS (16.1%), tuberculosis (8.4%), lower respiratory infections (4.1%) and ischaemic heart disease (3.7%).21 Two EC-based studies in the Western Cape give us further insight into the local burden of disease seen in our ECs.13 ,22 Hodkinson and Wallis found head injury, abdominal pain, pulmonary tuberculosis, dyspnoea and stab chest to be the commonest diagnosis or presentation.22 On the other hand, blunt trauma, abdominal pain, shortness of breath, lower respiratory tract infection and soft tissue injury topped the list of Cohen and Wallis.13 The most frequent EPCUS modules in our study mirror the burden of disease found in previous studies, but are also very different from the current core EPCUS curriculum. Clinical indications for pulmonary EPCUS were most frequently indicated. This is easily explainable with the high rate of tuberculosis and other lower respiratory tract infections. The study was also done during winter; increasing attendees presented with problems related to acute bronchospasm and pneumonia. Musculoskeletal indications were ranked second. It comprises a very large field and includes the evaluation of soft tissue infection, foreign body localisation and removal, rapid fracture detection, and imaging of tendons, joints and muscles. However, the majority of these views require a fair amount of expertise and it is unlikely to be included in a core curriculum. Cardiac disease is a leading cause of death in both the developed and developing world and therefore earns its third place. The focused assessment with sonography of HIV/TB co-infection module clearly needs to be introduced in the South African setting where HIV/AIDS and tuberculosis have a high prevalence. This is perfectly illustrated in a recent study on acute medical admissions in the Cape Town Metro where 31.9% of patients had symptomatic HIV, 2.3% suspected of having HIV and 17.2% diagnosed with active tuberculosis.19 Last, the renal module (including the bladder and ureters) was just ahead of the gastrointestinal and aorta modules. This module is helpful in renal failure, urinary retention, renal colic and suspected pyelonephritis.

The low ranks of extended focused assessment with sonography in trauma and shock protocols came as a surprise. It may be attributed to the fact that data collection only occurred on weekdays between 07:00 and 17:00; therefore, excluding the traditional presenting time of trauma patients. Furthermore, shock is neither a complaint nor a final diagnosis; therefore, it was impossible to determine whether patients would have required such an examination. Vascular access was omitted as it was impossible to identify the patients in need of it. However, it still remains a valuable tool and might just be included in a core curriculum.

The way forward

Content validity of any country's EPCUS curriculum is vitally important. Although this study only focuses on disease prevalence, the impact of the disease and the experience required obtaining adequate images are as important. Incorporating all of these aspects to determine the components of an EPCUS curriculum is challenging and it might be worthwhile exploring the medical education field for ideas.23 A possible solution might be to first assign weight to the three components (disease prevalence, disease impact and EPCUS difficulty) for each of the EPCUS modules (table 4). Second, we must calculate the relative weight of each module before ranking them (table 5). The ranked order of the modules might look different compared with using only the disease prevalence. This method allows a more objective approach in deciding which EPCUS modules to include in a curriculum. Furthermore, it would also reflect the local needs, whether it is in a developed or a developing world setting. However, the use of multifactorial weighting still needs to be validated and is a subject for future studies.

Table 4

Weighting for disease prevalence, disease impact and EPCUS difficulty of EPCUS modules

Table 5

Example of blueprint to determine the South African EPCUS core curriculum

Limitations

This study has several limitations that might have influenced the outcome. The convenience sample used excluded a large number of patients and future research should attempt to include afterhours as well. Including these patients might have altered the results as eluded to above. Similarly, seasonal variation could have resulted in an incorrect estimation of certain disease patterns. All the site investigators were trained Level 1 ultrasound providers, but it is possible that they differ from one another regarding competency of ultrasounds beyond Level 1. Their interpretation of indications for these ‘more advanced’ scans could have been different. Last, the matching of the EPCUS modules' clinical indications with the presenting complaint and final diagnosis of each case are very subjective. Physicians manage patients differently and complete agreement will never occur. Therefore, κ-statistics were used in an attempt to quantify the agreement beyond chance and subsequently increased the reliability of the results.

Conclusion

This study was an attempt to ensure an evidence-based approach to assess the adequacy of the core EPCUS curriculum in South Africa. The results illustrated that our local burden of disease might not match the current core curriculum and further studies are needed to ensure the adequacy of the South African EPCUS curriculum.

References

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Supplementary materials

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Footnotes

  • Funding This study received a grant from the Harry Crossley Foundation at Stellenbosch University.

  • Competing interests None.

  • Ethics approval Approval provided by the Stellenbosch University Health Research Ethics Committee (Ref: N11/02/053) and the Western Cape Health Research Committee (Ref: 2011 RP 33).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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