Module 4: Point of care ultrasound in first trimester abortion (POCUS)

10. Practical competency

Once the course is completed, the health professional should ensure that their ability to perform, interpret and clinically integrate ultrasound findings meets an acceptable standard.

There are currently no nationally accepted standards of accreditation for point of care ultrasound, though Individual employers may have their own credentialing requirements it is essential that the individual practitioner can demonstrate that they are providing point of care ultrasound at an acceptable standard.

The remainder of this document provides the framework that the clinician can use to audit their skills as demonstration that they meet an acceptable standard of scanning before offering un-supervised point of care ultrasound. This framework is supported by The Abortion Providers Group of New Zealand (APGANZ) and the New Zealand College of Sexual and Reproductive Health (NZCSRH).

Benchmarking

Ideally, the trainee will have a suitably qualified mentor available to them to give in-person assistance during the training phase. The mentor can give practical advice on scanning techniques as well as providing review of the scan findings.

It is acknowledged that in some instances an abortion provider may be working in an environment where there is no suitably qualified individual available. In these circumstances the trainee can compare their scan interpretation with an external radiology performed scan (the result of which they are blinded to until they have completed their own scan to avoid bias) or develop a relationship with a distant suitably qualified individual who can review their scan images (taking care over patient confidentiality when transmitting images).

Note: suitably qualified individuals include a provider who has completed this accreditation programme, or other recognised and relevant point of care ultrasound training or a qualified ultrasonographer.

Skills to be demonstrated

1. Measure gestational age from Mean Sac Diameter
2. Measure gestational age from Crown Rump Length measurement
3. Diagnose an empty uterus
4. Diagnose retained products of conception
5. Diagnose intra-uterine cystic structure suggestive of gestation sac, but not diagnostic (early sac and ability to assess if ectopic pregnancy has or has not been ruled out)
6. Diagnose twin pregnancy

Standards to be met for each skill

• 1. Diagnose gestational age from mean sac diameter – Total 5 scans Standard obtained if
  • a. Review of image by suitably qualified individual. Scan quality and measurement deemed acceptable.
  • or
  • b. Comparison with external diagnostic scan
    If compared to external scan measurement must be accurate to within 3 days of gestational age with the external scan result.

• 2. Diagnose gestational age from crown rump length pregnancies 6 – 13 weeks – 10 scans
• Standard obtained if
  • a. Review of image by suitably qualified individual. Scan quality and measurement deemed acceptable.
  • or
  • b. Comparison with external diagnostic scan
    If compared to external scan measurement must be accurate to within 4 days of gestational age with the external scan result.

• 3. Diagnose empty uterus in – Total 10 scans
• Endometrial thickness < 10 mm
• Standard obtained if
  • a. Review of image by suitably qualified individual. Scan quality and measurement deemed acceptable.
  • or
  • b. Comparison with external diagnostic scan which confirms empty uterus

• 4. Diagnose potential retained products of conception – Total 5 scans
• (Note: ultrasound is not diagnostic for retained products of conception, but can be suggestive to support a clinical diagnosis)
• Endometrial thickness with heterogenous texture > 15 mm +/- vascularity
• Standard obtained if
  • a. Review of image by suitably qualified individual. Scan quality and measurement deemed acceptable.
  • or
  • b. Comparison with external diagnostic scan which confirms possible retained products uterus

• 5. Diagnose intra-uterine sac suggestive but NOT confirming intra-uterine pregnancy – Total 10 scans
• Standard obtained if
  • a. Review of image by suitably qualified individual. Scan quality and measurement deemed acceptable.
  • or
  • b. Comparison with external diagnostic scan which confirms intrauterine cystic structure without yolk sac.

• 6. Diagnose twin pregnancy – Total 1 scan
• (Note: twin pregnancy should be demonstrated in 2 planes to confirm that the finding is not artefact)
• Standard obtained if
  • a. Review of image by suitably qualified individual. Scan quality and measurement deemed acceptable.
  • or
  • b. Comparison with external diagnostic scan which confirms twin pregnancy

Summary

Documentation

Each scan in the log book must have a written report of the findings as well as the ability to refer back to the saved image.