Overview

Antenatal screening for Congenital Heart Disease via "hands-on", on-site Fetal Heart Scan Training

Background
Despite improvements in diagnosing congenital malformations, over the last decade, diagnosis of congenital heart disease (CHD) still lags behind with only about 1/3 rd of cardiac defects detected.  (Source: CCAD, 2008)

CHD is far more common than reported and the early detection of isolated heart disease is extremely important to outcome.
Hands-on training, using the 5 View protocol is one of the best ways to improve the detection of CoHD at the 20-week scan.

The incidence of fetal heart disease has been reported as 7-13 per 1,000 scans, depending on the degree of perinatal cardiology support (ref. Pubmed doc 15284832 2004).

We aim for a detection rate for severe CoHD (that requiring surgery/intervention in the first year of life) of 3.5/1,000.

Theoretical vs Practical training
University training in obstetric ultrasound screening tends to be theoretical, yet the skills required for successful scanning are also practical, including: hand-eye co-ordination, pattern-matching, 3D visualisation.

A good comparison might be learning to ride a bike or drive a car. Some people take longer than others, but it helps to (a) know the rules and how the equipment works, (b) practice the basics, (c) have lessons with a competent, encouraging teacher, (d) gain practical experience "on the road" and (e) take and pass a practical and theoretical test. The bottom line is that a practical skill requires practice and lots of it!

Practice makes perfect
Everyone is different and different practice aids may be needed to improve practical skills, improve visualisation.
Hands-on training, fetal cardiac phantoms, training lectures/CDs, diagrams, 3D heart models ...

How do you know when a heart is not normal?
It is important to see plenty of normal fetal hearts to recognise the whole range of normality and then it is important to recognise when a heart is not normal. Some people sense / know / feel that something is not right, without necessarily being able to say why. Our advice is "trust your instincts" and get an expert second opinion.

It is important for screeners to have the confidence to look for and find fetal cardiac anomalies.

You are important!
The biggest single factor in increasing detection is you! It takes the best equipment, the best training and time to become experienced at scanning and detect more "heart babies".

Questions & Answers about our hands-on training

1. Who can receive training?
2. The goals of fetal heart scan training
3. Benefits of training / Successful screening
4. How can a unit apply for "hands-on" training?
5. What is the cost of training?
6. The importance of audit
7. How many training sessions will a sonographer need?
8. Do you train certain key personnel who then train others?
9. Attending a cardiac course before hands on training
10. How can we help the charity to train more sonographers?
11. How many training sessions will a sonographer need?

1. Who can receive our hands-on training?
We only provide "hands-on" training to an ultrasound screening department of an NHS maternity hospitals in the UK.
We do not train individuals.

All training is "on-site", using a department's own ultrasound equipment. This is the best way to improve day-to-day scanning and highlight issues that are particular to a department.

In addition, it is important to verify that equipment is correctly set-up, sonographers are given time to practice and develop their skills and all referrals are audited (with feedback from referrals used to verify that audit and highlight any training issues) - see 6., below.

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2. The goals of fetal heart scan training
Fetal cardiac scanning has been practiced in the United Kingdom for nearly twenty years, yet the vast majority of cardiac defects still remain undetected. The goal of our fetal heart scan training is to increase the antenatal detection of congenital heart disease from a national average of about 30-35% in the UK to above 75%.

The 4-chamber view alone can only detect half of major cardiac malformations. The addition of the outflow tracts of the heart at the anomaly scan (NICE Antenatal Update 2008) can improve antenatal detection of cardiac defects even further, but does not detect important aortic arch lesions, so we recommend including the 3 Vessel and Trachea view (View 5), within a systematic protocol such as the 5 Transverse Views.

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3. Benefits of training / Successful screening
The early detection of a fetus with heart disease offers more choices during pregnancy and can avoid unnecessary illness or delay before further treatment. Training itself has a major impact on the confidence of sonographers.

Tips for successful screening: From our experience since Oct. 2002 and based on a thesis on including Outflow Tracts, we can say that successful screening for heart defects at 20 weeks relies upon several factors:

• Practical Training: on-site "hands-on" training in a standard protocol by an experienced trainer;
• Correct equipment: modern, reliable ultrasound equipment with correct fetal echo settings;
• Support: from the department and hospital to give sonographers some extra time to learn and practice;
• Experts: Access to expert second opinion about suspected heart disease;
• Feedback: Constructive, no blame feedback about cases found or missed, which encourages review and learning.

Given these conditions, sonographers can acquire the confidence to look for and find fetal cardiac anomalies.

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4. How can a unit apply for "hands-on" training?
At present we are fully committed to training selected UK NHS Trust maternity hospitals in our programme.
We do not train individuals.

Department Superintendents (or equivalent) can apply to be considered for training for their obstetric ultrasound department. Please email your details & some information about your unit (location, size, relative experience of part & full-time staff, machines, current protocol & any relevant issues).

We also ask for good retrospective audit figures (births, scans, anomalies & outcomes over the last 2-3 years) plus a good ongoing audit, so we know where we are starting from & can measure improvement. The audit also helps you to maintain skills in the long run. Please email or contact us to discuss this.

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5. What is the cost of training?
We provide low-cost training, to cover our costs. Please contact us for latest rates. Compared to sending sonographers on a course, it is far more cost-effective to bring a trainer to a hospital. Hands-on training on your own equipment can be far more effective than on an unfamiliar machine.

Please email or contact us to discuss this.

All training is subject to our resources & discretion and we ask that you co-operate with our trainer and give priority to training sessions. We also ask that you maintain good audit, to measure improvements and maintain skill levels.

We reserve the right to withdraw training if these conditions are not met, as they impact on our limited resources and prevent us from reaching more hospitals.

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6. The importance of audit
Audit is vital if we are to make improvements in the detection of CoHD. It is no coincidence that the departments with the highest detection rates also have a good audit and use the feedback from this audit to gain further improvement.

Audit allows all cases of suspected CoHD that are referred for a full fetal echo to be tracked and verified. Missed cases are often picked up by other departments, such as Obstetrics, Paediatrics & Cardiology and this information can be useful feedback for further training. Feedback may be difficult where referrals are made to other cardiac units, so cooperation between departments is vital. If you have views on this, please email or contact us.

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7. How many training sessions will a sonographer need?
This depends on how much cardiac scanning an individual has done and how well they learn to perform a fetal cardiac scan. It is usual to have one full training session, so that training can be put into practice, until our trainer returns for a follow up visit.

Training should continue until sonographers become confident that all views can be consistently imaged so that suspicions or anomalies can be more easily detected, within time and resource constraints.

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8. Do you train certain key personnel who then train others?
The idea is to try and train each sonographer individually. In departments with a large proportion of part-time staff it may be necessary to train key personnel who then may train other staff. Staff who already have good fetal echo skills may also support the training. Our trainer will assess this and make recommendations.

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9. Should we attend a cardiac course before hands on training?
It is a good idea to have attended a basic fetal cardiac course just before “hands on” training begins. Some courses offer “hands on” scans as part of the course; others are just theoretical. See the Health Professionals page for more information on courses.

Sonographers have commented that they feel the departmental training makes more sense if they have already had some basic fetal cardiac scanning information.

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10. How can we help the charity to train more sonographers?
There is an increasing demand for fetal cardiac scanning and for more sonographers and more trainers.

We are actively raising funds, but any support you can give us would be most welcome. If you wish to fund-raise locally please email or contact us to discuss this and see how we can help.

Another way to fund training is for a group of hospitals in a region to each contribute a share of the training costs. We can coordinate this and create an independent training resource that will be fairly shared across these hospitals.

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11. Sponsored 2-day fetal cardiac training package
Our 2-day package provides a Senior Sonographer Trainer for 2 days "hands-on" fetal cardiac scan training for the whole department, in a suitable obstetric ultrasound unit in the UK. Costs £1,200 for 2 days including travel expenses within 1 hour, excluding flights or lengthy travel (please contact us for exact details).

The aim of this package is to demonstrate how to improve detection of fetal heart disease, using the 5 View protocol, at around 20 weeks' gestation.

This is subject to agreement with the Chief Sonographer of the department, the hospital and availability of suitable resources at the unit. Training is provided at our discretion, subject to availability of Tiny Tickers resources and terms apply. The charity may continue to provide training and support entirely at our discretion.

Our criteria for receiving "hands-on" training:
To help us provide the most relevant training to as many staff as possible, we ask for the full co-operation of the department in prioritising this training over other activities. We need some basic information about a unit (e.g. location, size, relative experience of part & full-time staff, machines, current protocols & any relevant issues).

We would also like to receive a retrospective audit (e.g. births, scans, anomalies & outcomes over the last 2-3 years), as this helps to understand current detection rates and where to target our training. We recommend that a unit has an ongoing audit of all referrals, as this helps to maintain skills in the long run.

Who can sponsor this package:
Any suitable sponsor who wishes to help a unit to improve detection of fetal heart disease can apply (e.g. Ultrasound manufacturers providing new equipment, Agencies providing sonographers, Companies, Charities and Hospitals).