348 Training and Competency of Emergency Department Advanced Practice Providers in First Trimester Pregnancy Ultrasound

Abstract

Assess advanced practice provider (APP) competency in ultrasound (US) for symptomatic first trimester pregnancy after a targeted training protocol. Describe confidence of APPs in US image acquisition and interpretation. As part of a quality assurance (QA) initiative, APPs were trained in point-of-care (POC) first trimester pregnancy transabdominal ultrasound (TAU) via a didactic and supervised examinations. Prior to training, APPs did not utilize POCUS. This is a retrospective chart review of the 6-month period encompassing the training period and subsequent US. All TAU was performed on stable patients in an academic urban tertiary care center emergency department. APPs utilized a brief, systematic acquisition protocol. If there was an intrauterine pregnancy (IUP), large free fluid, or large adnexal mass, a credentialed emergency physician over-read the US for safety. If no IUP was visualized, a radiology ultrasound (RUS) was ordered. A 10-question QA form including interpretations and confidence was completed for all US. Confidence was based on a 5-point Likert scale with the anchors of “not at all confident” (1) to “completely confident” (5). Of the 12 APPs who completed the didactic, 8 (67%) performed TAU. A total of 52 exams were performed identifying 36 (70%) IUPs. Fetal cardiac activity was noted in 94% (34), of which M-mode was obtained in 78% (28) versus visual inspection in 22% (5). Crown rump length (CRL) measurements were obtained in 67% (24) of IUPs. Of those with a calculated CRL, the average gestation was 8 weeks 6 days (SD 15 days). There were no missed ectopic pregnancies. For patients with a TAU confirmed IUP, confidence in identifying IUP, determining CRL, and scanning the adnexa was rated fairly to completely confident (4 or 5) in 86.1%, 79.2%, and 66.7% of exams respectively. There were 4 RUS for patients with an APP-identified IUP. The reasons for RUS were indeterminate if free fluid in the abdomen; no fetal cardiac activity; abnormal appearing cervix; and abnormal tissue in the gestational sac. RUS noted multiple uterine fibroids and small subchorionic hemorrhage; early embryonic demise; Nabothian cysts and cervical calcifications; and choriodecidual hematoma or chorionic bump, respectively. Of the 16 (30%) TAU that did not identify an IUP, 13 of the RUS found an IUP with average gestation of 6 weeks 4 days (SD 15 days). All RUS utilized transvaginal US. In 7 of the 13 RUS confirmed IUP, only a yolk sac and no fetal pole was identified. For TAU with no identified IUP, confidence in scanning the adnexa was 50%. Providing APPs with training and a protocol increased their POCUS utilization. In patients with an IUP, APPs were most confident in the assessment of the location of the pregnancy and least confident in scanning the adnexa. The average gestational age for radiology determined IUP was 2 weeks younger than APP determined IUP. In this small sample, APPs competently identified IUP or appropriately referred to a credentialed emergency physician or RUS. There were no missed ectopic pregnancies. The study of APP-performed first trimester pregnancy US is ongoing.