Education/concepts
Getting It Right the First Time: Defining Regionally Relevant Training Curricula and Provider Core Competencies for Point-of-Care Ultrasound Education on the African Continent

https://doi.org/10.1016/j.annemergmed.2016.07.030Get rights and content

Significant evidence identifies point-of-care ultrasound (PoCUS) as an important diagnostic and therapeutic tool in resource-limited settings. Despite this evidence, local health care providers on the African continent continue to have limited access to and use of ultrasound, even in potentially high-impact fields such as obstetrics and trauma. Dedicated postgraduate emergency medicine residency training programs now exist in 8 countries, yet no current consensus exists in regard to core PoCUS competencies. The current practice of transferring resource-rich PoCUS curricula and delivery methods to resource-limited health systems fails to acknowledge the unique challenges, needs, and disease burdens of recipient systems. As emergency medicine leaders from 8 African countries, we introduce a practical algorithmic approach, based on the local epidemiology and resource constraints, to curriculum development and implementation. We describe an organizational structure composed of nexus learning centers for PoCUS learners and champions on the continent to keep credentialing rigorous and standardized. Finally, we put forth 5 key strategic considerations: to link training programs to hospital systems, to prioritize longitudinal learning models, to share resources to promote health equity, to maximize access, and to develop a regional consensus on training standards and credentialing.

Section snippets

Background

Many countries on the African continent have well-known high burdens of trauma and unacceptably high all-cause mortality among emergency department (ED) patients (2.2% to 12.3%).1, 2, 3, 4 This occurs, in part, because of limited access to basic and advanced laboratory facilities, along with limited diagnostic imaging equipment availability, including radiographs and computerized tomography (CT). As a result, point-of-care ultrasound (PoCUS) has gained increasing recognition as an important

Defining Relevant PoCUS Core Competencies

This conversation is timely and imperative because interest and engagement in emergency medicine on the African continent has significantly increased during the past decade. Dedicated postgraduate emergency medicine residency training programs now exist in 8 countries (Figure 1). Individuals involved in each of these programs report educational initiatives in PoCUS, but training appears to vary greatly, and there have been minimal efforts to coordinate educational resources within and between

Algorithmic Approach

To start, we recommend that programs adopt core competencies based on local disease and illness within infrastructure and training limitations. We suggest PoCUS be used early in a patient’s presentation, with algorithm-, organ-, and procedural-based scans triggered by presenting signs and symptoms.11 Throughout settings as varied as the slum areas of Kibera, conflict zones of the Democratic Republic of Congo, or relatively affluent areas of Dar Es Salaam, a majority of the population lacks

Alternative Core Competencies

Procedures critical to individual patient management are also identified that are not traditionally considered core PoCUS competencies in more resourced areas, such as ultrasound guided regional anesthesia,15 because many countries lack narcotic-purchasing power16 and have limited access to patient monitoring for conscious sedation outside major capital cities.17 Further suggestions for future curricula include obstetric scanning for second- and third-trimester patients. Many providers in

Limitations of Adapting High-Income Curricula

The current practice of adapting and transferring resource-rich PoCUS curricula and delivery methods to resource-limited health systems is not recommended.9, 19, 20 This is based on the observation that transferred curricula do not match local disease epidemiology, nor do they consider a lack of other imaging modalities. These observations are supported in the study by van Hoving et al19 that reported South African disease burden did not match the epidemiology of PoCUS curriculum content

Proposed Phases of Training

All PoCUS providers must reach and maintain competency to add value to their medical systems, even more so in resource-limited medical systems. Lack of access to formal radiologic investigations and other laboratory investigations inherently increases the responsibility of the PoCUS provider to ensure competency. Concurrent responsibilities for the expert teacher to ensure competency is greatly increased. We recommend a continent-wide means of training and support of ongoing skill maintenance.

Organizational Structure

In 2014, at the African Conference on Emergency Medicine, the African Ultrasound Committee became operational. Committee members include national directors of emergency medicine residency programs that formally incorporate PoCUS training in their curriculum and regional ultrasound experts. The aim of the committee is to provide support, including shared materials, curricula, training methods, and advisory services, to potential champions who pioneer PoCUS training on the African continent.

Building On Experience: Learning From African Regional Partnerships

Improving the culture of collaboration in the African region in PoCUS training and enabling regional experts will further drive other relevant regional agendas. South-South collaborations are likely to be more balanced than North-South partnerships, require reduced implementation costs, allow greater program ownership, and decrease cross-cultural barriers.21, 22, 23 Regional cooperation in PoCUS education and practice would also encourage and build a local marketplace, potentiating collective

Strategic Program Development Considerations

We identified 5 strategic program development considerations that will enhance the intended collaborative best practices, core competencies, and oversight in the African region for PoCUS training and use in emergency care in the African region:

  • 1.

    Prioritizing PoCUS training in emergency medicine training programs linked to hospital-based systems

We recommend an initial focus on creating nidi of concentrated champions, embedded in emergency medicine training programs in hospital-based systems, to

Conclusions

This article is a clarion call for coordinated action to foster collaboration around resource and knowledge sharing, to effectively disseminate and sustain PoCUS training initiatives in emergency medicine programs, and improve patient outcomes across the African continent. As the number of African emergency medicine training programs steadily grows, it will become increasingly important to have a thoughtful, regional approach to scaling up and introducing PoCUS technology and training into

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    Supervising editor: William R. Mower, MD, PhD

    Author contributions: MS, HL, LM, JP, SB, MMM, conceived of the commentary and recruited remaining authors for contributions. MS and HL coordinated the conversation. MD, JP, CH, BW, JK, and AK developed lists of core scans. MS, ML, CH, and HL drafted the manuscript, and all authors contributed substantially to the multiple iterations and revisions of the manuscript required for publication. MS takes responsibility for the commentary as a whole.

    Authors of this commentary are directors of emergency medicine residencies, ultrasound educational programs, or leaders of developing emergency medicine in the countries identified on the author institution list with the exception of Salmon, C. who is a specialist in building health systems in low resource settings. The conversation was initiated at the African Federation of Emergency Medicine Conference in Ghana (2012), continued at the S. African conference (2014) which then resulted in an email based group devoted to this subject. The initial discussion was among program leaders based in the Sub-Saharan region, after which authors from Egypt were recruited for comment to ensure a more-resourced (and Northern) perspective and Mozambique to ensure those with Portugese language. The corresponding author (Salmon, M.) directs programs in Democratic Republic of Congo where she is based 3-5 months per year and senior author (Lampretch, H.) is the chair of the African Federation of Emergency Medicine Ultrasound Section and directs an Ultrasound Fellowship in South Africa. French authors were included from Democratic Republic of Congo (Malemo, L. and Paluku, J.). Given the manuscript was submitted to an English language based journal, second and third authors (Landes, M., and Hunchak, C.) by default contributed most to the actual writing of the manuscript with English as their first language. Author order was based on who contributed most to the actual writing of the manuscript per World Health Organization recommendations but all authors listed had an active role in the writing and review of the manuscript and meet the 4 criteria for authorship described by the International Committee of Medical Journal Editors (ICJME).

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

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