0064: engaging clinicians in actively managing the risk of antenatal missed and mis-diagnosis

2
0061 Training in O & G Ultrasound Alan Cameron, Queen Mother’s Maternity Hospital, United Kingdom Ultrasound is a vital component of clinical obstetrics and gynaecology. In the past ultrasound training was opportunistic and only a small percentage of O&G trainees were formally taught ultrasound skills. Since August 2008 training clinicians to become competent in the ultrasound techniques required for modern clinical practice has become an essential part of the new RCOG curriculum. Ultrasound training has now become embedded in the training of all O& G trainees. Trainees entering the speciality now have a mandatory requirement to complete 2 basic ultrasound modules. Both are competency based and on completion the trainee will have been taught how to perform an early pregnancy ultrasound assessment at 8-12 weeks and how to use ultrasound to assess fetal size, liquor and the placenta. This is achieved with the aid of Objective Structured Assessments of Technologies (OSATs) which are competency based. Trainees wishing to pursue a career that involves a significant ultra- sound component can opt to have intermediate training in further modules: 1. Ultrasound of normal fetal anatomy 2. Ultrasound in Gynaecology 3. Ultrasound of early pregnancy complications The above modules are optional and are also competency based. They are prerequisites for those trainees who wish to undertake Advanced Training or Subspeciality training in the recognised RCOG subspeci- alities. Delivery of ultrasound training is coordinated at Deanery level by the Deanery Ultrasound Coordinator who liases with local Ultrasound Educational Supervisors. 0062 Effectiveness of the “Teaching the Teachers” Ultrasound Physician Training Program: A Summary of Three Programs Barry B Goldberg, Thomas Jefferson University Hospital, United States Oksana Baltarowich, Thomas Jefferson University Hospital, United States Anina Wilkes, Thomas Jefferson University Hospital, United States Adom Anane-Firempong, Thomas Jefferson University Hospital, United States Traci Fox, Thomas Jefferson University Hospital, United States Daniel A Merton, United States Objective: The objective of this study was to compare the effective- ness of 3 “Teaching the Teachers” ultrasound (US) training programs. Methods: Ultrasound education was provided to physicians from Cen- tral and Eastern Europe (Group 1; n112), Subsaharan Africa (Group 2; n12) and the Caribbean, Central and Latin America (Group 3; n12). Students received three months of training at an academic US facility in the USA. They were required to take uncued examinations including questions with and without US images. Exams were given to all students at the beginning of the training program (pre-test), at the end of the program (post-test) and follow-up tests approximately 6-months after returning to their home countries. From these Groups physicians were selected to establish affiliated training programs in their countries. Results: Mean test scores adjusted relative to multiple-choice exami- nations for Groups 1, 2 and 3 respectively were: Pre-test; 40%, 73%, 54%; Post-test; 84%, 92%, 79%; and Follow-up; 89%, 94%, 80%. The improvement in pre- to post-test scores was statistically significant (p 0.001). Forty affiliated US training programs were established; 24 from Group 1, 9 from Group 2, and 7 from Group 3. Conclusions: Statistical analysis of the test scores confirms the effec- tiveness of these Teaching the Teachers US training programs. Im- provement on follow-up test scores suggests retention of knowledge. Acknowledgement: These programs were the result of a grant from the Open Society Institute (Group 1) and RSNA Research and Education Foundation Grants (Groups 2 and 3). 0063 Network Theory and Ultrasound Labs Kathleen M Hannon, Massachusetts General Hospital, Boston, Massachusetts, United States New scientific perspectives indicate that networks will dominate the 21st century to a much greater degree than most people are ready to acknowledge. One example of network interconnectedness is the med- ical community. Within this community is a multi layered network with connections and webs between patients, therapists, physicians and facilities. Random network theory, introduced in 1959, states that things in the universe connect through intangible links and that all things in nature can be viewed as interconnected and not isolated. The field of ultrasound has shown enormous growth over the years and as a result, the nature of reviewing and obtaining diagnostic information has undergone a dramatic shift from being the physician’s expertise to that of the technologist. Intangibles such as economics, the level of trust or confidence between the technologist and physician, the tech- nology utilized, and the balance of power between the patient, the technologist and the physician all can have a profound effect on the success of an ultrasound lab. By uncovering the intangibles, one can realize that there is a layer of complexity in the ultrasound lab’s day to day operations that are not necessarily on the surface, using network theory as a frame work to identify unseen components of our ultra- sound lab’s systems, it can be an important means by which to improve upon patient care for health care providers. 0064 Engaging Clinicians in Actively Managing the Risk of Antenatal Missed and Mis-Diagnosis Elizabeth M Mullins, Avant Mutual Group, Australia Richard Clark, Avant Mutual Group, Australia Kate Bray, Avant Mutual Group, Australia The world is cluttered with guidelines established in good faith and providing useful advice, yet few have become part of mainstream practice. Evidence suggests key elements for successful implementa- tion of guidelines include involvement of the target group in their development, and to include (eg.) educational interventions or self- audit processes in the guidelines. Objective: Avant Mutual Group Limited (Avant), Australia’s largest medical defence organisation, completed an analysis of claims brought against members alleging negligent missed and mis-diagnosis of ante- natal fetal abnormalities. Building on this, Avant engaged with experts in fetal ultrasound to develop a practical risk modification program, designed to improve outcomes in fetal anomaly screening by minimis- ing the likelihood of diagnostic error. Method: A series of multidisciplinary workshops were convened by Avant. Participants identified factors contributing to missed or mis- diagnosis in fetal ultrasound and strategies to minimise their impact. Results: The outcome of these workshops was the Avant Fetal Ultra- sound Risk Modification Program, comprising risk modification guide- lines, risk indicators and practice implementation toolkits to support practices, establish practice patterns and implement risk modification strategies. Avant launched the Fetal Ultrasound Risk Modification Pilot Program in May 2008. Participants collected data over a defined period against specific risk indicators pertaining to practice patterns and out- S12 Ultrasound in Medicine and Biology Volume 35, Number 8S, 2009

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Page 1: 0064: Engaging Clinicians in Actively Managing the Risk of Antenatal Missed and Mis-Diagnosis

S12 Ultrasound in Medicine and Biology Volume 35, Number 8S, 2009

0061

Training in O & G UltrasoundAlan Cameron, Queen Mother’s Maternity Hospital, United Kingdom

Ultrasound is a vital component of clinical obstetrics and gynaecology.In the past ultrasound training was opportunistic and only a smallpercentage of O&G trainees were formally taught ultrasound skills.Since August 2008 training clinicians to become competent in theultrasound techniques required for modern clinical practice has becomean essential part of the new RCOG curriculum. Ultrasound training hasnow become embedded in the training of all O& G trainees.Trainees entering the speciality now have a mandatory requirement tocomplete 2 basic ultrasound modules. Both are competency based andon completion the trainee will have been taught how to perform anearly pregnancy ultrasound assessment at 8-12 weeks and how to useultrasound to assess fetal size, liquor and the placenta. This is achievedwith the aid of Objective Structured Assessments of Technologies(OSATs) which are competency based.Trainees wishing to pursue a career that involves a significant ultra-sound component can opt to have intermediate training in furthermodules:1. Ultrasound of normal fetal anatomy2. Ultrasound in Gynaecology3. Ultrasound of early pregnancy complicationsThe above modules are optional and are also competency based. Theyare prerequisites for those trainees who wish to undertake AdvancedTraining or Subspeciality training in the recognised RCOG subspeci-alities.Delivery of ultrasound training is coordinated at Deanery level by theDeanery Ultrasound Coordinator who liases with local UltrasoundEducational Supervisors.

0062

Effectiveness of the “Teaching the Teachers” UltrasoundPhysician Training Program: A Summary of Three ProgramsBarry B Goldberg, Thomas Jefferson University Hospital, UnitedStatesOksana Baltarowich, Thomas Jefferson University Hospital, UnitedStatesAnina Wilkes, Thomas Jefferson University Hospital, United StatesAdom Anane-Firempong, Thomas Jefferson University Hospital,United StatesTraci Fox, Thomas Jefferson University Hospital, United StatesDaniel A Merton, United States

Objective: The objective of this study was to compare the effective-ness of 3 “Teaching the Teachers” ultrasound (US) training programs.Methods: Ultrasound education was provided to physicians from Cen-tral and Eastern Europe (Group 1; n�112), Subsaharan Africa (Group2; n�12) and the Caribbean, Central and Latin America (Group 3;n�12). Students received three months of training at an academic USfacility in the USA. They were required to take uncued examinationsincluding questions with and without US images. Exams were given toall students at the beginning of the training program (pre-test), at theend of the program (post-test) and follow-up tests approximately6-months after returning to their home countries. From these Groupsphysicians were selected to establish affiliated training programs intheir countries.Results: Mean test scores adjusted relative to multiple-choice exami-nations for Groups 1, 2 and 3 respectively were: Pre-test; 40%, 73%,54%; Post-test; 84%, 92%, 79%; and Follow-up; 89%, 94%, 80%. Theimprovement in pre- to post-test scores was statistically significant (p�

0.001). Forty affiliated US training programs were established; 24 from

Group 1, 9 from Group 2, and 7 from Group 3.

Conclusions: Statistical analysis of the test scores confirms the effec-tiveness of these Teaching the Teachers US training programs. Im-provement on follow-up test scores suggests retention of knowledge.Acknowledgement: These programs were the result of a grant from theOpen Society Institute (Group 1) and RSNA Research and EducationFoundation Grants (Groups 2 and 3).

0063

Network Theory and Ultrasound LabsKathleen M Hannon, Massachusetts General Hospital, Boston,Massachusetts, United States

New scientific perspectives indicate that networks will dominate the21st century to a much greater degree than most people are ready toacknowledge. One example of network interconnectedness is the med-ical community. Within this community is a multi layered network withconnections and webs between patients, therapists, physicians andfacilities. Random network theory, introduced in 1959, states thatthings in the universe connect through intangible links and that allthings in nature can be viewed as interconnected and not isolated. Thefield of ultrasound has shown enormous growth over the years and asa result, the nature of reviewing and obtaining diagnostic informationhas undergone a dramatic shift from being the physician’s expertise tothat of the technologist. Intangibles such as economics, the level oftrust or confidence between the technologist and physician, the tech-nology utilized, and the balance of power between the patient, thetechnologist and the physician all can have a profound effect on thesuccess of an ultrasound lab. By uncovering the intangibles, one canrealize that there is a layer of complexity in the ultrasound lab’s day today operations that are not necessarily on the surface, using networktheory as a frame work to identify unseen components of our ultra-sound lab’s systems, it can be an important means by which to improveupon patient care for health care providers.

0064

Engaging Clinicians in Actively Managing the Risk of AntenatalMissed and Mis-DiagnosisElizabeth M Mullins, Avant Mutual Group, AustraliaRichard Clark, Avant Mutual Group, AustraliaKate Bray, Avant Mutual Group, Australia

The world is cluttered with guidelines established in good faith andproviding useful advice, yet few have become part of mainstreampractice. Evidence suggests key elements for successful implementa-tion of guidelines include involvement of the target group in theirdevelopment, and to include (eg.) educational interventions or self-audit processes in the guidelines.Objective: Avant Mutual Group Limited (Avant), Australia’s largestmedical defence organisation, completed an analysis of claims broughtagainst members alleging negligent missed and mis-diagnosis of ante-natal fetal abnormalities. Building on this, Avant engaged with expertsin fetal ultrasound to develop a practical risk modification program,designed to improve outcomes in fetal anomaly screening by minimis-ing the likelihood of diagnostic error.Method: A series of multidisciplinary workshops were convened byAvant. Participants identified factors contributing to missed or mis-diagnosis in fetal ultrasound and strategies to minimise their impact.Results: The outcome of these workshops was the Avant Fetal Ultra-sound Risk Modification Program, comprising risk modification guide-lines, risk indicators and practice implementation toolkits to supportpractices, establish practice patterns and implement risk modificationstrategies. Avant launched the Fetal Ultrasound Risk Modification PilotProgram in May 2008. Participants collected data over a defined period

against specific risk indicators pertaining to practice patterns and out-
Page 2: 0064: Engaging Clinicians in Actively Managing the Risk of Antenatal Missed and Mis-Diagnosis

Abstracts S13

comes. This pilot involved over 60 practitioners, 1000 scans and 40practices.Conclusion: This risk modification model provides a unique opportu-nity for clinician engagement, harnessing of clinician knowledge andexperience. This paper shares the experience of the pilot program andthe benefits of this process for clinician engagement.

0065

Establishment of Breast Ultrasound Training Course in JapanEriko Tohno, University of Tsukuba, JapanYasuhisa Fujimoto, Tachibana Hospital, Japan

Breast screening by ultrasound is accepted in many situations inJapan in addition to mammography especially for young women andwomen with dense breasts. To assure the quality of breast screeningby ultrasound, the educational committee of the Japanese Associa-tion of Breast and Thyroid Sonology has established the breastultrasound training course for the sonographers and physicians. TheCourse Detail : The training course lasts two days. The capacity foreach course is limited to less than 50 persons for effective training.The course for physicians consists of seven lectures and seven smallgroup activities and tests. The lectures include pathology, terminol-ogy and diagnostic criteria. We made unique category criteria todetermine whether the lesion needs further examination in screen-ing. The small group activities include practices of scanning andpractice to decide categories and diagnoses for the lesions. The testis held in the end of the course using personal computers andconsists of two parts, one for assessing ability of detecting abnor-malities in the moving ultrasound images and another for assessingability of diagnosing diseases from static ultrasound images. Thecourse for sonographers is almost similar, but the small groupactivity to teach ultrasound-guided intervention is omitted and a testasking basic knowledge of breast diseases and ultrasound is added.Results: In 2008, nineteen courses were held and about 500 physi-cians and 400 sonographers attended. The results of the tests wereimproving reflecting popularity of our diagnostic categories.

0066

Custom Open-System Software for SonographersTony de Souza-Daw, La Trobe University, AustraliaRichard Manasseh, Fluid Dynamics Group, CSIRO MaterialsScience and Engineering Division, AustraliaRobert Stewart, Fluid Dynamics Group, CSIRO Materials Scienceand Engineering Division, AustraliaPaul Junor, La Trobe University, AustraliaPhilip M Lewis, Department of Neurosurgery, Alfred Hospital,AustraliaJerome Maller, Brain Stimulation and Neuroimaging, AlfredPsychiatry Research Centre, Australia

Here we report on custom developed software for scientific researchusing the Ultrasonix Sonix RP platform and associated software de-velopment kits. Our objective was to create custom software that allowsthe user to control the transmitter and receiver transducers, therebyallowing greater flexibility. The open system design allows user anddeveloper transparency, and extensibility for additional features to beadded.In this design, low-level Radio Frequency (RF) data is captured at a

high data rate (40 MHz/s). This low level information, typically not

available on a standard machine, can enable the calculation of impor-tant acoustic characteristics such as backscatter, attenuation, speed ofsound, intensity, and acoustic impedance. These properties, inherent inthe RF data, can be processed and analysed on a personal computer tothe sonographer’s discretion. The software can be used to constructtraditional B-mode, M-Mode images and videos. An application of thishas been in the development of custom graphical user interfaces toselect key regions of interest and extract ultrasonic properties postexamination. This information was typically only possible during in-terrogation.By exposing users to the low-level processing as well as the high-leveloutput, a greater appreciation and understanding is gained of theprocesses and physics of ultrasound technology.The software presented here can be customized and tailored to meet theneeds of researchers and sonographers and provides much more flex-ibility in analysing the data.

0067

Fetal CNS: Ultrasound Evaluation of Development ThroughGestationAnts Toi, Mount Sinai Hospital, Canada

This presentation will discuss:� Cerebral development� First trimester anatomy� Second trimester anatomy� Cortical development� Some malformations of cortical development.Fetal cerebral development can be assessed by ultrasound in the firsttrimester. In the first trimester, normal appearances should not bemistaken for disorders. Some disorders such as hydrocephaly, anen-cephaly and holoprosencephaly can be detected.In the second trimester, sulci and gyri form and their regular develop-ment can be assessed starting as early as 18 weeks. Familiarity withdevelopment of the brain and cortex can allow suspicion and detectionof some cases of abnormal development as early as 20 - 23 weeks.These include lissencephaly such as type I (Miller-Dieker) and type II(congenital muscular dystrophy Walker-Warburg).

0068

Fetal NeurosonographyHernan Munoz, University of Chile, Chile

Fetal neural system malformations have an incidence of 20 every 1000newborn, with 40% lethality. And only 7% of mothers have someprevious high risk history.According ISUOG Guideline, Sonographic examination of the fetalcentral nervous system includes basic examination and the fetal neu-rosonogram.Normal basic examination includes head measurement, brain and spineexamination. In this examination we include size, shape, integrity anddensity ob the brain, scull and spine.Three axial planes are included. Trans ventricular and cerebellum planeallow visualization of the cerebral structures relevant to assess theanatomic integrity of the brain. Transthalamic plane is added, for thepurpose of biometry. Spine should be examined from head to sacrum inthe longitudinal and transverse sections.Measurement includes lateral ventricles, cerebellum (transverse cere-bellar diameter, and Cisterna magna.

Fetal neurosonogram or diagnostic examination is performed using