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Poor return on investment: investigating the barriers that cause low credentialing yields in a resource-limited clinical ultrasound training programme

Poor return on investment: investigating the barriers that cause low credentialing yields in a... Background: Clinical ultrasound is commonly used in medical practices worldwide due to the multiple benefits the modality offers clinicians. Rigorous credentialing standards are necessary to safeguard patients against operator errors. The purpose of the study was to establish and analyse the barriers that specifically lead to poor credentialing success within a resource-limited clinical ultrasound training programme. Methods: An electronic cross-sectional survey was e-mailed to all trainees who attended the introductory clinical ultrasound courses held in Cape Town since its inception in 2009 to 2013. All trainees were followed until they completed their training programme in 2015. Results: Only one fifth of trainees (n = 43, 19.7%), who entered the Cape Town training programme, credentialed successfully. Ninety (n = 90, 41.3%) trainees responded to the survey. Eighty-six (n = 86) surveys were included for analysis. Time constraints were the highest ranked barrier amongst all trainees. Access barriers (to trainers and ultrasound machines) were the second highest ranked amongst the non-credentialed group. A combination between access and logistical barriers (e.g. difficulty in finding patients with pathology to scan) were the second highest ranked in the credentialed group. Conclusions: Access barriers conspire to burden the Cape Town clinical ultrasound training programme. Novel solutions are necessary to overcome these access barriers to improve future credentialing success. Keywords: Ultrasound, Training, Education assessment Background treatment and possible patient harm. Rigorous training The benefits of clinicians using ultrasound (clinical is needed to assure competency amongst CUS providers, ultrasound, CUS) at the point of patient care have been to reduce operator errors that may lead to patient ad- well proven over the past 20 years [1–3]. It allows clini- verse events. Internationally, many clinical ultrasound cians to produce additional diagnostic information at the training programmes exist, with slight variations in cur- patient’s bedside that is not assessable by physical exam- ricula content and delivery methods [5, 6]. In 2014, the ination alone. The benefits are enhanced in low- and International Federation for Emergency Medicine (IFEM) middle-income countries (LMIC) where limited re- Ultrasound Special Interest Group published guidelines sources significantly restrict special investigation access on how such a curriculum should be structured [7]. [4]. However, if used poorly, it has the potential to con- Nearly all training programmes follow the IFEM recom- tribute to misdiagnosis, needless downstream testing or mendations of starting with an introductory course, followed by completing a hands-on proctored scan list on real patients and finally a competency assessment to * Correspondence: hl@sun.ac.za complete the credentialing process [7]. Certification Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa should be provided to all successful candidates. Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Lamprecht et al. International Journal of Emergency Medicine (2018) 11:11 Page 2 of 6 South Africa, a middle-income country, has a similar completion, trainees should pass the CUS exit examin- CUS training programme accredited by the Emergency ation within a 2-year period to successfully credential. Medicine Society of South Africa (EMSSA) and College Those who fail to complete their training within the re- of Emergency Medicine of South Africa (CEMSA) [8]. quired period are obliged to re-enter the programme by Doctors from any specialty and level are allowed to enter repeating the introductory course [8]. the training programme by attending an introductory Cape Town is one of three national training centres re- course. Thereafter they are expected to gain experience sponsible for providing the prescribed training curricu- by logging 65 scans on real patients, including patients lum and kept a database of all CUS trainees since with positive pathological findings (example: abdominal inception of the programme on 1 June 2009. aorta aneurysm). Finally, trainees must pass a practical exit examination that consists of scanning live models Study population and patients with real pathological findings. Trainees All trainees who attended the Cape Town training cen- who eventually complete their credentialing are sup- tre’s introductory course between 1 June 2009 and 30 plied with provider certificates and registered on the June 2013 were eligible to partake in the study. None of EMSSA webpagetoassuretransparencyof their the other two training centres kept databases of their competency status. course attendees that could have enhanced the study’s Training the curriculum on the traditional apprentice- sample size. ship model (where certified trainers supervise and pro- The survey was conducted in October 2013 and the vide real-time feedback to trainees when scanning trainees were followed until 2015 to determine whether patients during the gaining experience phase) is an ex- they successfully credentialed as CUS providers (creden- pensive use of already scarce resources. Not surprisingly, tialed group) or not (non-credentialed group) within the recent studies identified many barriers that negatively required 2-year period limit. impact on trainees’ credentialing success in both LMIC and high-income country (HIC) settings [7, 9–13]. The Data collection and management process is severely time-consuming for both trainees and Trainees were invited by e-mail to complete an online trainers. Trainee doctors must add the scanning require- questionnaire (Additional file 1). Their participation im- ments to their busy clinical schedules; the same chal- plied consent. Non-responders were reminded at 1-week lenge applies to the trainers who are responsible for intervals until they responded or the submission dead- providing feedback on the scans. However, none of the line expired after 1 month. No personal or identifying studies analysed the type of barriers that prevent creden- information was collected to protect participant confi- tialing in relationship to the training setting’s resources dentiality. The online survey platform de-identified all and most importantly their impact on the eventual cre- responses before converting the data into an Excel® dentialing success. electronic spreadsheet. The electronic spreadsheet was There is a need for data that focuses on the barriers in password protected to ensure the integrity of the data. context to the training setting and credentialing out- The Health Research Ethics Committees at Stellenbosch comes. We undertook a study to establish and analyse University (ref: N13/04/056) approved the study. the barriers that specifically lead to poor credentialing outcome in a resource-limited CUS training programme. Analysis The study results will provide valuable data to conceptu- Descriptive statistics were used to describe all variables. alise future problem-solving research questions. Participants were analysed according to the credentialing status (credentialed versus non-credentialed group). Methods Their perceived barriers to credentialing were also Study design ranked. The most important barrier for each participant We undertook a cross-sectional study to conduct an received a value of 1, the second most important barrier electronic survey of trainees who entered the Cape a value of 2 and so forth until the least important barrier Town CUS training programme. The study was per- received a value of 7. A mean ranking score was cal- formed from October 2013 to November 2015. culated for every barrier (denominator used was the number of participants that ranked that specific bar- Study setting rier); the top ranked barrier would therefore have the The trainee’s attendance at the introductory course lowest mean score. marks their entry into the training programme. The re- quired 65 scans were completed under certified trainers’ Results supervision in central academic, regional and district Two hundred and eighteen trainees were invited by e- hospitals located in Cape Town, South Africa. Upon mail to participate in the study. Ninety trainees Lamprecht et al. International Journal of Emergency Medicine (2018) 11:11 Page 3 of 6 completed the survey (response rate 41.3%); four surveys Table 1 Demographics and credentialing success rate of clinical ultrasound providers participating in the study were excluded for being incomplete (Fig. 1). One fifth of trainees (n = 43, 19.7%) who entered the training All Credentialed programme prior to July 2013 credentialed successfully: n (%) n (%) 23 of them completed the survey. The medical special- Medical speciality ties and base hospitals of respondents at the time of the Emergency medicine 59 (68.6) 23 (39) survey are described in Table 1. Internal medicine 10 (11.6) 0 (0) All 23 successfully credentialed trainees were working Family medicine 5 (5.8) 0 (0) in the speciality of emergency medicine, yet the creden- Other (surgery, anaesthetics, critical care, 12 (14) 0 (0) tialing success amongst the emergency medicine cohort general practitioners) was only 39% (registrars n = 20, 87%; junior consultant Place of work with less than 5 years’ experience n = 2, 8.7%; senior Central academic hospital 28 (32.6) 6 (21.4) house officer in emergency medicine n = 1, 4.3%). The greatest barrier to credentialing amongst all Regional hospital 25 (29.1) 8 (32) trainees was severe time constraints, followed by access- District hospital 15 (17.4) 4 (26.7) related barriers (e.g. limited trainer access) (Table 2). Other (primary health care, private practice, 18 (20.9) 5 (27.8) Access barriers (to trainers and ultrasound machines) non-clinical management) were more dominant in the non-credentialed group whereas training logistics barriers (limited access to pa- tients to log scans and difficulty obtaining scans with credentialing success was most likely an overestimate positive pathology) featured highly in the credentialed of the national study population since the Cape Town group (Fig. 2). sample represented 50% of the study population but Alarmingly, 52.4% (n = 33) of the non-credentialed also accounted for 90% of the national credentialing group performed on average more than three scans per success. week on patients where the scan result influenced their The higher credentialing rate in the emergency medi- clinical management. However, 70% (n = 44) of the same cine cohort could be explained by the 2009 CEMSA rule group stated they were planning to complete the creden- that only emergency medicine specialist training doctors tialing process in the near future. (registrars) who successfully credentialed as clinical ultrasound providers are allowed to challenge the spe- Discussion cialist training exit examinations. The ruling may also The low credentialing success (19.7%) of the Cape Town explain why only emergency medicine doctors com- clinical ultrasound training programme is concerning pleted the credentialing process (87% were registrars). considering the time and resource investments made. However, the results also reflect poor uptake of ultra- The rate is significantly lower than six peer inter- sound training (0%) amongst more experienced (greater national training programmes, whose credentialing than 5 years) emergency medicine consultants. success ranged between 30.2 and 100%; however, all The most significant barrier to credentialing was se- six studies were conducted in high resource settings vere time constraints. Trainees have limited spare cap- [10–12, 14–16]. Of more concern, Cape Town’s acity in their current work schedules and found the additional training time burden extremely challenging. This finding concurs with two studies that surveyed comparable target populations: Australian emergency medicine registrars and consultants reported ‘limited time availability’ (44.5%) as their highest ranked barrier, and American registrars and consultants also flagged ‘too many other demands on time’ as their greatest bar- rier amongst 71.3% of the trainees who failed to creden- tial [10, 12]. The impact of limited access to resources on the time constraints barrier was not well described in any of the studies. To measure the positive effect on improving future time constraints when access barriers are alleviated will therefore need to be subjectively measured. The highly ranked access barriers as perceived by the Fig. 1 Flow diagram of study population non-credentialing group concur with findings of a Lamprecht et al. International Journal of Emergency Medicine (2018) 11:11 Page 4 of 6 Table 2 Top three ranked barriers according to ranked mean scores All Credentialed Non-credentialed Rank Barrier Rank Barrier Rank Barrier 1 Time constraints 1 Time constraints 1 Time constraints 2 Limited access to credentialed trainer 2 Difficulty to gather positive scans 2 Limited access to credentialed trainer 3 Difficulty to save images 3 Limited access to credentialed trainer 3 Limited access to ultrasound machine survey of health workers in 44 LMICs [9]. However, The finding that more than half of the study’s trainees three studies conducted in much higher resourced set- continued to perform ultrasound scans on their patients tings that also trained over long distances and at mul- despite not being credentialed as CUS providers is not tiple hospitals reported access to trainers and machines unique. Two studies reported similar results from doc- as their most important barriers after time constraints tors in Australia and New Zealand [10, 17]. Doctors per- [7, 10, 14, 15]. All these training programmes had low forming ultrasound on patients without completing their credentialing success rates (30.2 to 44.9%) but still credentialing open themselves to significant liability risks higher than Cape Town’s. Training programmes that di- irrespective of the frustration the perceived barriers may vided their training capacity between only a few hospi- cause them [18]. In fact, such actions are deemed as tals with a proper trainer and ultrasound machine access fraudulent and could result in doctors being barred from had the highest credentialing outcomes (67.7 to 100%) further clinical practice [18]. [12, 16]. Their trainees reported logistical barriers, re- The impacts of the study’s limitations were reduced in lated to their training programme curriculum, as their accordance with the selected study design. Regular re- highest perceived barriers to credentialing. minders were sent to bolster the survey’s participant Cape Town’s credentialed group experienced a com- numbers to reduce the non-responder bias impact on bination of access (trainers and machines) and logistic the results. The survey’s eventual 41.3% response rate barriers (difficulty to find patients with pathology to scan) was higher than peer surveys (9.6–15%), and close to the as most important. All the credentialed study participants 48% achieved by Shah et al., in studies that targeted were emergency medicine doctors. The majority of them similar ultrasound trainee study populations [9–11]. were based at relatively well-resourced hospitals for Trainees with a special interest in CUS were probably LMIC. They had better access to trainers and ultrasound more likely to respond, which introduced responder machines than their peer trainees in other specialties. bias, but stratifying the respondent surveys according to Stratifying the doctor’s hospital base to their credentialing their credentialing success reduced its impact. Barriers success suggested that higher resourced hospitals with reported by the non-credentialed group should be more better access to ultrasound machines and trainers had bet- reflective of the study population due to the high per- ter credentialing outcomes (refer to regional and district centage (80.3%) that failed to credential. The low cre- hospitals) (Table 1). Emergency medicine, a relatively new dentialing rate amongst the non-emergency medicine medical specialty in South Africa, is not yet well estab- doctors could be explained by the dominance of emer- lished at Cape Town’s central academic hospitals resulting gency medicine representation within the training fac- in limited trainers and ultrasound machine availability for ulty and the fact that the CUS curriculum includes both the trainees who were stationed there. trauma- and medicine-related module applications. Fig. 2 Perceived barriers to ultrasound credentialing (closest to centre is least important) Lamprecht et al. International Journal of Emergency Medicine (2018) 11:11 Page 5 of 6 Training doctors to become competent in CUS is an Acknowledgements We thank the study participants for generously providing us their time expensive investment for any health system. The cost of and insight. purchasing and maintaining ultrasound machines for training has direct budget implications. Providing CUS Funding No funding was awarded towards the study. trainers from an already scarce clinician pool has service delivery impacts. Credentialing success is a measurement Availability of data and materials of the investment return. It is essential to identify and All article datasets were presented in the main paper and included in the analyse the barriers that reduce Cape Town’s credential- additional supporting file. ing success (19.7%) to less than that of its peer groups, Authors’ contributions so that targeted solutions can be found. Cape Town’s HL, GL and NvH contributed substantially to the conception, design and training programme is burdened with low resources, acquisition of the study and contributed to the analysis and interpretation of multiple training centres and relatively long distances the data. HL, GL and NvH drafted the work and together with TK and LW revised the manuscript for important intellectual content. All authors read between training hospitals (rural hospitals outside Cape and approved the final manuscript. Town), all conspiring to exacerbate poor access. Novel solutions must focus on improving future trainees’ ac- Ethics approval and consent to participate cess to ultrasound machines and trainer feedback with- The Health Research Ethics Committees at Stellenbosch University (reference number: N13/04/056) approved the study. out adding to the high monetary and service delivery Participants were invited by e-mail to complete an online questionnaire sacrifices already made. (Additional file 1). Their participation implied consent. Others have recommended the use of distance learning Consent for publication web-based education platforms to overcome the unique Not applicable burdens of training ultrasound within LMIC settings [9]. Web-based education platforms can be integrated suc- Competing interests cessfully into a traditional well-structured apprenticeship The authors declare that they have no competing interests. model curriculums based on hands-on and simulation training [19]. The combination may result in improved Publisher’sNote skills proficiency when performing certain ultrasound- Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. guided clinical procedures if the web-based component is introduced early enough in the training of junior residents Author details (registrars or specialist training doctors) [19]. Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa. Future research must focus on adapting such web- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health based education platforms to improve overall access Sciences, Stellenbosch University, Cape Town, South Africa. where trainers can provide feedback on scans submitted Received: 8 June 2016 Accepted: 7 February 2018 by off-site trainees. The development of such a novel web-based learning platform, focussing on improving credentialing success, will need to be measured against References its efficacy in reducing the impact of these access bar- 1. Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success riers throughout its development. rates and reduces complications: a randomized, prospective study. Ann Emerg Med. 2006;48(5):540–7. 2. Ollerton JE, Sugrue M, Balogh Z, D'Amours SK, Giles A, Wyllie P. Prospective Conclusions study to evaluate the influence of FAST on trauma patient management. Access barriers to ultrasound machines and certified J Trauma. 2006;60(4):785–91. trainers are more prevalent in our low-resource setting. 3. Kanji HD, McCallum J, Sirounis D, MacRedmond R, Moss R, Boyd JH. Limited echocardiography-guided therapy in subacute shock is associated with Training over large distances and at multiple training lo- change in management and improved outcomes. J Crit Care. 2014;29(5): cations compounded the access barriers experienced. 700–5. Novel solutions are necessary to overcome these access 4. Steinmetz JP, Berger JP. Ultrasonography as an aid to diagnosis and treatment in a rural African hospital: a prospective study of 1,119 cases. Am barriers to eventually improve credentialing success. J Trop Med Hyg. 1999;60(1):119–23. 5. American College of Emergency P. Emergency ultrasound guidelines. Ann Additional file Emerg Med. 2009;53(4):550–70. 6. Jones PG, Peak S, McClelland A, Holden A, Higginson I, Gamble G. Emergency ultrasound credentialling for focused assessment sonography in Additional file 1: Survey questionnaire. (DOCX 91 kb) trauma and abdominal aortic aneurysm: a practical approach for Australasia. Emerg Med (Fremantle). 2003;15(1):54–62. Abbreviations 7. Atkinson P, Bowra J, Lambert M, Lamprecht H, Noble V, Jarman B. CEMSA: College of Emergency Medicine of South Africa; CUS: Clinical International Federation for Emergency Medicine point of care ultrasound ultrasound; EMSSA: Emergency Medicine Society of South Africa; HIC: High- curriculum. CJEM. 2015;17(2):161–70. income country; IFEM: International Federation for Emergency Medicine; 8. Wells MBS. College of Emergency Medicine of South Africa Policy Document: LMIC: Low- and middle-income countries emergency ultrasound in South Africa. Johannesburg: CEMSA; 2009. Lamprecht et al. International Journal of Emergency Medicine (2018) 11:11 Page 6 of 6 9. Shah S, Bellows BA, Adedipe AA, Totten JE, Backlund BH, Sajed D. Perceived barriers in the use of ultrasound in developing countries. Crit Ultrasound J. 2015;7(1):28. 10. Craig S, Egerton-Warburton D, Mellett T. Ultrasound use in Australasian emergency departments: a survey of Australasian College for Emergency Medicine fellows and trainees. Emerg Med Australas. 2014;26(3):268–73. 11. Lam K, Canty D, Royse C, Royse A. Hospital survey of point-of-care lung ultrasound use in the assessment of peri-operative and critically ill patients. Crit Care. 2012;16(3):437. 12. Lewiss RE, Saul T, Del Rios M. Acquiring credentials in bedside ultrasound: a cross-sectional survey. BMJ Open. 2013;3(8):e003502. 13. LaGrone LN, Sadasivam V, Kushner AL, Groen RS. A review of training opportunities for ultrasonography in low and middle income countries. Tropical Med Int Health. 2012;17(7):808–19. 14. Fox KF, Popescu BA, Janiszewski S, Nihoyannopoulos P, Fraser AG, Pinto FJ, et al. Report on the European Association of Echocardiography accreditations in echocardiography: December 2003–September 2006. Eur J Echocardiogr. 2007;8(1):74–9. 15. Wrightson JM. Development and efficacy of a 1-d thoracic ultrasound training course. Chest. 2012;142(5):1359–61. 16. Budhram MD. Implementation of a successful incentive-based ultrasound credentialing program for emergency physicians. West J Emerg Med. 2013; 14(6):603–8. 17. Kiuru S. Ultrasound in New Zealand emergency departments. ASUM Ultrasound Bull. 2006;9:21–4. 18. Oxorn D, Pearlman A. CON: physician-performed ultrasound: the time has come for routine use in acute care medicine. Anesth Analg. 2012;115(5): 1004–6. 19. Beaulieu Y, Laprise R, Drolet P, Thivierge RL, Serri K, Albert M, et al. Bedside ultrasound training using web-based e-learning and simulation early in the curriculum of residents. Crit Ultrasound J. 2015;7:1. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Emergency Medicine Springer Journals

Poor return on investment: investigating the barriers that cause low credentialing yields in a resource-limited clinical ultrasound training programme

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Publisher
Springer Journals
Copyright
Copyright © 2018 by The Author(s).
Subject
Medicine & Public Health; Emergency Medicine; Pediatrics; Internal Medicine; Angiology; Cardiology
ISSN
1865-1372
eISSN
1865-1380
DOI
10.1186/s12245-018-0168-9
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See Article on Publisher Site

Abstract

Background: Clinical ultrasound is commonly used in medical practices worldwide due to the multiple benefits the modality offers clinicians. Rigorous credentialing standards are necessary to safeguard patients against operator errors. The purpose of the study was to establish and analyse the barriers that specifically lead to poor credentialing success within a resource-limited clinical ultrasound training programme. Methods: An electronic cross-sectional survey was e-mailed to all trainees who attended the introductory clinical ultrasound courses held in Cape Town since its inception in 2009 to 2013. All trainees were followed until they completed their training programme in 2015. Results: Only one fifth of trainees (n = 43, 19.7%), who entered the Cape Town training programme, credentialed successfully. Ninety (n = 90, 41.3%) trainees responded to the survey. Eighty-six (n = 86) surveys were included for analysis. Time constraints were the highest ranked barrier amongst all trainees. Access barriers (to trainers and ultrasound machines) were the second highest ranked amongst the non-credentialed group. A combination between access and logistical barriers (e.g. difficulty in finding patients with pathology to scan) were the second highest ranked in the credentialed group. Conclusions: Access barriers conspire to burden the Cape Town clinical ultrasound training programme. Novel solutions are necessary to overcome these access barriers to improve future credentialing success. Keywords: Ultrasound, Training, Education assessment Background treatment and possible patient harm. Rigorous training The benefits of clinicians using ultrasound (clinical is needed to assure competency amongst CUS providers, ultrasound, CUS) at the point of patient care have been to reduce operator errors that may lead to patient ad- well proven over the past 20 years [1–3]. It allows clini- verse events. Internationally, many clinical ultrasound cians to produce additional diagnostic information at the training programmes exist, with slight variations in cur- patient’s bedside that is not assessable by physical exam- ricula content and delivery methods [5, 6]. In 2014, the ination alone. The benefits are enhanced in low- and International Federation for Emergency Medicine (IFEM) middle-income countries (LMIC) where limited re- Ultrasound Special Interest Group published guidelines sources significantly restrict special investigation access on how such a curriculum should be structured [7]. [4]. However, if used poorly, it has the potential to con- Nearly all training programmes follow the IFEM recom- tribute to misdiagnosis, needless downstream testing or mendations of starting with an introductory course, followed by completing a hands-on proctored scan list on real patients and finally a competency assessment to * Correspondence: hl@sun.ac.za complete the credentialing process [7]. Certification Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa should be provided to all successful candidates. Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Lamprecht et al. International Journal of Emergency Medicine (2018) 11:11 Page 2 of 6 South Africa, a middle-income country, has a similar completion, trainees should pass the CUS exit examin- CUS training programme accredited by the Emergency ation within a 2-year period to successfully credential. Medicine Society of South Africa (EMSSA) and College Those who fail to complete their training within the re- of Emergency Medicine of South Africa (CEMSA) [8]. quired period are obliged to re-enter the programme by Doctors from any specialty and level are allowed to enter repeating the introductory course [8]. the training programme by attending an introductory Cape Town is one of three national training centres re- course. Thereafter they are expected to gain experience sponsible for providing the prescribed training curricu- by logging 65 scans on real patients, including patients lum and kept a database of all CUS trainees since with positive pathological findings (example: abdominal inception of the programme on 1 June 2009. aorta aneurysm). Finally, trainees must pass a practical exit examination that consists of scanning live models Study population and patients with real pathological findings. Trainees All trainees who attended the Cape Town training cen- who eventually complete their credentialing are sup- tre’s introductory course between 1 June 2009 and 30 plied with provider certificates and registered on the June 2013 were eligible to partake in the study. None of EMSSA webpagetoassuretransparencyof their the other two training centres kept databases of their competency status. course attendees that could have enhanced the study’s Training the curriculum on the traditional apprentice- sample size. ship model (where certified trainers supervise and pro- The survey was conducted in October 2013 and the vide real-time feedback to trainees when scanning trainees were followed until 2015 to determine whether patients during the gaining experience phase) is an ex- they successfully credentialed as CUS providers (creden- pensive use of already scarce resources. Not surprisingly, tialed group) or not (non-credentialed group) within the recent studies identified many barriers that negatively required 2-year period limit. impact on trainees’ credentialing success in both LMIC and high-income country (HIC) settings [7, 9–13]. The Data collection and management process is severely time-consuming for both trainees and Trainees were invited by e-mail to complete an online trainers. Trainee doctors must add the scanning require- questionnaire (Additional file 1). Their participation im- ments to their busy clinical schedules; the same chal- plied consent. Non-responders were reminded at 1-week lenge applies to the trainers who are responsible for intervals until they responded or the submission dead- providing feedback on the scans. However, none of the line expired after 1 month. No personal or identifying studies analysed the type of barriers that prevent creden- information was collected to protect participant confi- tialing in relationship to the training setting’s resources dentiality. The online survey platform de-identified all and most importantly their impact on the eventual cre- responses before converting the data into an Excel® dentialing success. electronic spreadsheet. The electronic spreadsheet was There is a need for data that focuses on the barriers in password protected to ensure the integrity of the data. context to the training setting and credentialing out- The Health Research Ethics Committees at Stellenbosch comes. We undertook a study to establish and analyse University (ref: N13/04/056) approved the study. the barriers that specifically lead to poor credentialing outcome in a resource-limited CUS training programme. Analysis The study results will provide valuable data to conceptu- Descriptive statistics were used to describe all variables. alise future problem-solving research questions. Participants were analysed according to the credentialing status (credentialed versus non-credentialed group). Methods Their perceived barriers to credentialing were also Study design ranked. The most important barrier for each participant We undertook a cross-sectional study to conduct an received a value of 1, the second most important barrier electronic survey of trainees who entered the Cape a value of 2 and so forth until the least important barrier Town CUS training programme. The study was per- received a value of 7. A mean ranking score was cal- formed from October 2013 to November 2015. culated for every barrier (denominator used was the number of participants that ranked that specific bar- Study setting rier); the top ranked barrier would therefore have the The trainee’s attendance at the introductory course lowest mean score. marks their entry into the training programme. The re- quired 65 scans were completed under certified trainers’ Results supervision in central academic, regional and district Two hundred and eighteen trainees were invited by e- hospitals located in Cape Town, South Africa. Upon mail to participate in the study. Ninety trainees Lamprecht et al. International Journal of Emergency Medicine (2018) 11:11 Page 3 of 6 completed the survey (response rate 41.3%); four surveys Table 1 Demographics and credentialing success rate of clinical ultrasound providers participating in the study were excluded for being incomplete (Fig. 1). One fifth of trainees (n = 43, 19.7%) who entered the training All Credentialed programme prior to July 2013 credentialed successfully: n (%) n (%) 23 of them completed the survey. The medical special- Medical speciality ties and base hospitals of respondents at the time of the Emergency medicine 59 (68.6) 23 (39) survey are described in Table 1. Internal medicine 10 (11.6) 0 (0) All 23 successfully credentialed trainees were working Family medicine 5 (5.8) 0 (0) in the speciality of emergency medicine, yet the creden- Other (surgery, anaesthetics, critical care, 12 (14) 0 (0) tialing success amongst the emergency medicine cohort general practitioners) was only 39% (registrars n = 20, 87%; junior consultant Place of work with less than 5 years’ experience n = 2, 8.7%; senior Central academic hospital 28 (32.6) 6 (21.4) house officer in emergency medicine n = 1, 4.3%). The greatest barrier to credentialing amongst all Regional hospital 25 (29.1) 8 (32) trainees was severe time constraints, followed by access- District hospital 15 (17.4) 4 (26.7) related barriers (e.g. limited trainer access) (Table 2). Other (primary health care, private practice, 18 (20.9) 5 (27.8) Access barriers (to trainers and ultrasound machines) non-clinical management) were more dominant in the non-credentialed group whereas training logistics barriers (limited access to pa- tients to log scans and difficulty obtaining scans with credentialing success was most likely an overestimate positive pathology) featured highly in the credentialed of the national study population since the Cape Town group (Fig. 2). sample represented 50% of the study population but Alarmingly, 52.4% (n = 33) of the non-credentialed also accounted for 90% of the national credentialing group performed on average more than three scans per success. week on patients where the scan result influenced their The higher credentialing rate in the emergency medi- clinical management. However, 70% (n = 44) of the same cine cohort could be explained by the 2009 CEMSA rule group stated they were planning to complete the creden- that only emergency medicine specialist training doctors tialing process in the near future. (registrars) who successfully credentialed as clinical ultrasound providers are allowed to challenge the spe- Discussion cialist training exit examinations. The ruling may also The low credentialing success (19.7%) of the Cape Town explain why only emergency medicine doctors com- clinical ultrasound training programme is concerning pleted the credentialing process (87% were registrars). considering the time and resource investments made. However, the results also reflect poor uptake of ultra- The rate is significantly lower than six peer inter- sound training (0%) amongst more experienced (greater national training programmes, whose credentialing than 5 years) emergency medicine consultants. success ranged between 30.2 and 100%; however, all The most significant barrier to credentialing was se- six studies were conducted in high resource settings vere time constraints. Trainees have limited spare cap- [10–12, 14–16]. Of more concern, Cape Town’s acity in their current work schedules and found the additional training time burden extremely challenging. This finding concurs with two studies that surveyed comparable target populations: Australian emergency medicine registrars and consultants reported ‘limited time availability’ (44.5%) as their highest ranked barrier, and American registrars and consultants also flagged ‘too many other demands on time’ as their greatest bar- rier amongst 71.3% of the trainees who failed to creden- tial [10, 12]. The impact of limited access to resources on the time constraints barrier was not well described in any of the studies. To measure the positive effect on improving future time constraints when access barriers are alleviated will therefore need to be subjectively measured. The highly ranked access barriers as perceived by the Fig. 1 Flow diagram of study population non-credentialing group concur with findings of a Lamprecht et al. International Journal of Emergency Medicine (2018) 11:11 Page 4 of 6 Table 2 Top three ranked barriers according to ranked mean scores All Credentialed Non-credentialed Rank Barrier Rank Barrier Rank Barrier 1 Time constraints 1 Time constraints 1 Time constraints 2 Limited access to credentialed trainer 2 Difficulty to gather positive scans 2 Limited access to credentialed trainer 3 Difficulty to save images 3 Limited access to credentialed trainer 3 Limited access to ultrasound machine survey of health workers in 44 LMICs [9]. However, The finding that more than half of the study’s trainees three studies conducted in much higher resourced set- continued to perform ultrasound scans on their patients tings that also trained over long distances and at mul- despite not being credentialed as CUS providers is not tiple hospitals reported access to trainers and machines unique. Two studies reported similar results from doc- as their most important barriers after time constraints tors in Australia and New Zealand [10, 17]. Doctors per- [7, 10, 14, 15]. All these training programmes had low forming ultrasound on patients without completing their credentialing success rates (30.2 to 44.9%) but still credentialing open themselves to significant liability risks higher than Cape Town’s. Training programmes that di- irrespective of the frustration the perceived barriers may vided their training capacity between only a few hospi- cause them [18]. In fact, such actions are deemed as tals with a proper trainer and ultrasound machine access fraudulent and could result in doctors being barred from had the highest credentialing outcomes (67.7 to 100%) further clinical practice [18]. [12, 16]. Their trainees reported logistical barriers, re- The impacts of the study’s limitations were reduced in lated to their training programme curriculum, as their accordance with the selected study design. Regular re- highest perceived barriers to credentialing. minders were sent to bolster the survey’s participant Cape Town’s credentialed group experienced a com- numbers to reduce the non-responder bias impact on bination of access (trainers and machines) and logistic the results. The survey’s eventual 41.3% response rate barriers (difficulty to find patients with pathology to scan) was higher than peer surveys (9.6–15%), and close to the as most important. All the credentialed study participants 48% achieved by Shah et al., in studies that targeted were emergency medicine doctors. The majority of them similar ultrasound trainee study populations [9–11]. were based at relatively well-resourced hospitals for Trainees with a special interest in CUS were probably LMIC. They had better access to trainers and ultrasound more likely to respond, which introduced responder machines than their peer trainees in other specialties. bias, but stratifying the respondent surveys according to Stratifying the doctor’s hospital base to their credentialing their credentialing success reduced its impact. Barriers success suggested that higher resourced hospitals with reported by the non-credentialed group should be more better access to ultrasound machines and trainers had bet- reflective of the study population due to the high per- ter credentialing outcomes (refer to regional and district centage (80.3%) that failed to credential. The low cre- hospitals) (Table 1). Emergency medicine, a relatively new dentialing rate amongst the non-emergency medicine medical specialty in South Africa, is not yet well estab- doctors could be explained by the dominance of emer- lished at Cape Town’s central academic hospitals resulting gency medicine representation within the training fac- in limited trainers and ultrasound machine availability for ulty and the fact that the CUS curriculum includes both the trainees who were stationed there. trauma- and medicine-related module applications. Fig. 2 Perceived barriers to ultrasound credentialing (closest to centre is least important) Lamprecht et al. International Journal of Emergency Medicine (2018) 11:11 Page 5 of 6 Training doctors to become competent in CUS is an Acknowledgements We thank the study participants for generously providing us their time expensive investment for any health system. The cost of and insight. purchasing and maintaining ultrasound machines for training has direct budget implications. Providing CUS Funding No funding was awarded towards the study. trainers from an already scarce clinician pool has service delivery impacts. Credentialing success is a measurement Availability of data and materials of the investment return. It is essential to identify and All article datasets were presented in the main paper and included in the analyse the barriers that reduce Cape Town’s credential- additional supporting file. ing success (19.7%) to less than that of its peer groups, Authors’ contributions so that targeted solutions can be found. Cape Town’s HL, GL and NvH contributed substantially to the conception, design and training programme is burdened with low resources, acquisition of the study and contributed to the analysis and interpretation of multiple training centres and relatively long distances the data. HL, GL and NvH drafted the work and together with TK and LW revised the manuscript for important intellectual content. All authors read between training hospitals (rural hospitals outside Cape and approved the final manuscript. Town), all conspiring to exacerbate poor access. Novel solutions must focus on improving future trainees’ ac- Ethics approval and consent to participate cess to ultrasound machines and trainer feedback with- The Health Research Ethics Committees at Stellenbosch University (reference number: N13/04/056) approved the study. out adding to the high monetary and service delivery Participants were invited by e-mail to complete an online questionnaire sacrifices already made. (Additional file 1). Their participation implied consent. Others have recommended the use of distance learning Consent for publication web-based education platforms to overcome the unique Not applicable burdens of training ultrasound within LMIC settings [9]. Web-based education platforms can be integrated suc- Competing interests cessfully into a traditional well-structured apprenticeship The authors declare that they have no competing interests. model curriculums based on hands-on and simulation training [19]. The combination may result in improved Publisher’sNote skills proficiency when performing certain ultrasound- Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. guided clinical procedures if the web-based component is introduced early enough in the training of junior residents Author details (registrars or specialist training doctors) [19]. Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town 8000, South Africa. Future research must focus on adapting such web- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health based education platforms to improve overall access Sciences, Stellenbosch University, Cape Town, South Africa. where trainers can provide feedback on scans submitted Received: 8 June 2016 Accepted: 7 February 2018 by off-site trainees. The development of such a novel web-based learning platform, focussing on improving credentialing success, will need to be measured against References its efficacy in reducing the impact of these access bar- 1. Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success riers throughout its development. rates and reduces complications: a randomized, prospective study. Ann Emerg Med. 2006;48(5):540–7. 2. Ollerton JE, Sugrue M, Balogh Z, D'Amours SK, Giles A, Wyllie P. 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International Journal of Emergency MedicineSpringer Journals

Published: Feb 21, 2018

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