FASP Fetal Cardiac Ultrasound Education in UK BMUS Summer School 24th June, 2017 University College Dublin Dr Rita Phillips Consultant Sonographer Advisor FASP UK Senior lecturer UWE. Bristol Advanced Practitioner Ultrasound RUH NHS Trust Bath

UK National Screening Committee (UKNSC) Population screening programmes NHS abdominal aortic aneurysm (AAA) programme NHS bowel cancer screening (BCSP) programme NHS breast screening (BSP) programme NHS cervical screening (CSP) programme NHS diabetic eye screening (DES) programme NHS fetal anomaly screening programme (FASP) NHS infectious diseases in pregnancy screening (IDPS) programme NHS newborn and infant physical examination (NIPE) screening programme NHS newborn blood spot (NBS) screening programme NHS newborn hearing screening programme (NHSP) NHS sickle cell and thalassaemia (SCT) screening programme Screening and quality assurance (all programmes) FASP UK Fetal cardiac training project 2015-2017

Fetal Anomaly Screening Programme Combined Screening Test/NIPT CRL between 45mms and 84mms Quadruple test between 14+2 weeks to 20 weeks Fetal anomaly screening 18+0 to 20+6 (completed by 23 weeks) FASP UK Fetal cardiac training project 2015-2017

FASP Policy Standards Education Information for Professional Women Quality assurance Service specification Operational guidelines FASP UK Fetal cardiac training project 2015-2017

The National FASP Team Andrew Rostron – ANNB Programmes Lead Annette McHugh – Programme Manager Shirley Vickers – Project Lead Liane Powell –Project Lead Tessa Morgan– Data Manager Steve Kawandami – IT Specialist Lorraine Martin – Project Support Officer Advisors Mr Pranav Pandya – Clinical Advisor and chair of the steering group Dr Rita Phillips – Sonography Advisor Professor David Wright – DQASS Ian Smith & Carolyn Williams– Laboratory Advisors FASP Advisory Board with representation from stake holders from across the pathways FASP UK Fetal cardiac training project 2015-2017

Sets out the ‘must-do’s’ for delivery of the screening programme Set out how NHS Screening Programmes should be commissioned and delivered throughout England Sets out the ‘must-do’s’ for delivery of the screening programme FASP UK Fetal cardiac training project 2015-2017

FASP standards for 18+0 –20+6 weeks anomaly scan The conditions screened for as a minimum in England Conditions Detection rate %) Anencephaly 98 Open spina bifida 90 Cleft lip 75 Diaphragmatic hernia 60 Gastroschisis Exomphalos 80 Serious cardiac anomalies includes the following: Transposition of the Great Arteries (TGA) Atrioventricular Septal Defect (AVSD) Tetralogy of Fallot (TOF) Hypoplastic Left Heart Syndrome (HLHS) 50 Bilateral renal agenesis 84 Lethal skeletal dysplasia Edwards’ syndrome (Trisomy 18) 95** Patau’s syndrome (Trisomy 13) **Detections rates will be reviewed following implementation of screening as part of the combined screening strategy FASP UK Fetal cardiac training project 2015-2017

FASP Ultrasound Images to archive Local protocols may have additional requirements for example placental site, amniotic volume etc FASP UK Fetal cardiac training project 2015-2017

NCARDRS The National Congenital Anomaly and Rare Disease Registration Service (NCARDRS) records those people with congenital abnormalities and rare diseases Historically 49% of births were monitored by 7 regional registers. Unable to provide comprehensive outcome data for screening programmes in England Capture data from all of England Via 9 regional centres timely data collection local and national data feeds improved quality assurance Benefits to individual patients, their families FASP UK Fetal cardiac training project 2015-2017

Performance thresholds Acceptable: Detection rate ≥50% for each serious cardiac anomaly shown above. Fetal Anomaly Screening Programme Standards p 12; 2015-16 This is the area that detection rate needs improving FASP UK Fetal cardiac training project 2015-2017

FASP-Fetal Cardiac Protocol Rationale, Training and Implementation for the 3VT view

FASP Fetal Cardiac Protocol Smart Survey 2012 Recommendations by the FASP fetal cardiac expert working group Evidence supports that routine examination of the fetal heart using additional 3VV and 3VT views will improve detection rates for cardiac anomalies Particularly duct dependent abnormalities Benefits Ensure babies get appropriate and timely care after birth Increase the national detection rate of major cardiac abnormalities give parents earlier choice regarding the pregnancy options FASP UK Fetal cardiac training project 2015-2017

FASP Fetal Cardiac Protocol FASP UK Fetal cardiac training project 2015-2017

Training Needs Analysis Questionnaire survey carried out in May 2014 Web based survey 143 trusts across England were invited via screening support sonographers and screening support midwives 123 trusts responded (86%) All regions responded with a regional spread in non responders or no data. FASP UK Fetal cardiac training project 2015-2017

Which region is your screening unit based? FASP UK Fetal cardiac training project 2015-2017

Information gathered How many individual sonographers offer 20-20+6 weeks scan? What current practice for fetal cardiac examinations in their trusts? What theoretical training provision they currently accessed? What practical training for the fetal cardiac views did they access especially the 3VV AND 3VT view What requirements they needed for further training FASP UK Fetal cardiac training project 2015-2017

Summary of results Majority of trusts (75%) were already incorporating 3 vessel views in their fetal cardiac survey. Small percentage (7%) currently using 3 Vessel and Trachea view (3VT). 62% indicated they required full training and 33% require refresher training. 85% use FASP/FMF basic on-line resource for their theory training. Just under half of trusts (49.66%) are using in house training. Most effective way of training is a combination of on-line training and practical in house training via nominated cardiac “Champions” FASP UK Fetal cardiac training project 2015-2017

The project and training team FASP UK Fetal cardiac training project 2015-2017

Cardiac champions Local nominated sonographer Training support to develop and enhance skills in fetal cardiac scanning Will work with local sonographers to identify learning needs Cascade training to sonographers in their Trust Provide feedback to sonographers to review techniques and improve standards Liaise with other champions Named contact for tertiary referrals Improve communication FASP UK Fetal cardiac training project 2015-2017

Planned Fetal cardiac training FASP UK Fetal cardiac training project 2015-2017

Regional workshops Each trust nominate a cardiac sonographer to act as “Champion” Champions invited to attend regional workshop/s Lectures/forum to support New standards and evidence of detection rates Challenges & Solutions Identify practical session needs and support Opportunity to establish regional and national fetal cardiac networks Sharing experiences Resource package will be developed FASP UK Fetal cardiac training project 2015-2017

Fetal cardiac and 3VT e-learning Champions were required to complete on line training before commencing practical training FASP UK Fetal cardiac training project 2015-2017

Regional workshops Champions were invited to attend regional workshop/s Lectures/forum to support New standards and evidence of detection rates Challenges & Solutions Identify practical session needs and support Opportunity to establish regional and national fetal cardiac networks Sharing experiences Resource package was developed FASP UK Fetal cardiac training project 2015-2017

Theory day FASP UK Fetal cardiac training project 2015-2017

Practical “hands on” training day Pregnant women recruited Delegates worked in pairs Each delegate had opportunity to scan at least 4 women Each delegate had opportunity to work with at least 2 trainers Signed off by trainers and given certificate of attendance FASP UK Fetal cardiac training project 2015-2017

Additional resources FASP UK Fetal cardiac training project 2015-2017

Theoretical and Practical “hands on” training

Sonography training for the 3VT FASP UK Fetal cardiac training project 2015-2017

Sonography training for the 3VT FASP UK Fetal cardiac training project 2015-2017

Evaluation of 3VT training

Project evaluation The overall objective of the project was to support the training of sonographers to enable them to incorporate fetal cardiac outflow tract views as a routine element of the 18 to 20+6 week anomaly scan. Evaluation of theory and practical days Monitor the implementation of the cardiac protocol Longer term objectives were also identified i.e. To evaluate the detection rate of cardiac anomalies at the anomaly scan after the incorporation of the additional 3VT view. To evaluate the referral rates and the false positive results on local and tertiary service provision. To obtain data for the FASP four main conditions Atrioventricular Septal Valve Defect(AVSD), Hypoplastic Left Heart Syndrome (HLHS), Tetralogy of Fallot (TOF) and Transposition of the Great Arteries(TGA). FASP UK Fetal cardiac training project 2015-2017

Feedback on theory and practical days FASP UK Fetal cardiac training project 2015-2017

Training evaluation FASP UK Fetal cardiac training project 2015-2017

Implementation of FASP cardiac protocol

Implementation process FASP UK Fetal cardiac training project 2015-2017

1st January 2017 139 (96%) had implemented, 5 Trusts still to implement FASP UK Fetal cardiac training project 2015-2017

1st April 2017 142 (98.5 %) have implemented 2 trusts still to implement FASP UK Fetal cardiac training project 2015-2017

Examples of how Trusts implemented the 3VT View

Examples of sharing knowledge Self assessments for learning needs One to one training Peer training Group reviews Regular feedbacks Image audits 3VT images stuck on notice board for dissemination. Visits to tertiary centres FASP UK Fetal cardiac training project 2015-2017

Image audits FASP UK Fetal cardiac training project 2015-2017

Thank you any questions ?