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Training: improving antenatal detection and outcomes of congenital heart disease
  1. Orhan Uzun1,2,
  2. Julia Kennedy3,
  3. Colin Davies4,
  4. Anthony Goodwin5,
  5. Nerys Thomas6,
  6. Delyth Rich7,
  7. Andrea Thomas8,
  8. David Tucker9,
  9. Bryan Beattie1,
  10. Michael J Lewis2
  1. 1 Department of Paediatric Cardiology, University Hospital of Wales, Cardiff, UK
  2. 2 School of Sport and Exercise Sciences and College of Engineering, Swansea University, Medical Physics and Biomedical Engineering, Swansea, UK
  3. 3 School of Health Sciences, Cardiff University, Cardiff, UK
  4. 4 Department of Radiology, Royal Glamorgan Hospital, Llantrisant, UK
  5. 5 Department of Paediatrics, Princess of Wales Hospital, Bridgend, UK
  6. 6 Department of Radiology, University Hospital of Wales, Cardiff, UK
  7. 7 Department of Obstetric of Gynaecology, Nevill Hall Hospital, Abergavenny, UK
  8. 8 Public Health Wales, Antenatal Screening Wales, Cardiff, UK
  9. 9 Public Health Wales, Congenital Anomaly Register Information Service, Swansea, UK
  1. Correspondence to Dr Orhan Uzun; orhanuzun{at}


Objectives This study describes the design, delivery and efficacy of a regional fetal cardiac ultrasound training programme. This programme aimed to improve the antenatal detection of congenital heart disease (CHD) and its effect on fetal and postnatal outcomes.

Design setting and participants This was a prospective study that compared antenatal CHD detection rates by professionals from 13 hospitals in Wales before and after engaging in our ‘skills development programme’. Existing fetal cardiac practice and perinatal outcomes were continuously audited and progressive targets were set. The work was undertaken by the Welsh Fetal Cardiovascular Network, Antenatal Screening Wales (ASW), a superintendent sonographer and a fetal cardiologist.

Interventions A core professional network was established, engaging all stakeholders (including patients, health boards, specialist commissioners, ASW, ultrasonographers, radiologists, obstetricians, midwives and paediatricians). A cardiac educational lead (midwife, superintendent sonographer, radiologist, obstetrician, or a fetal medicine specialist) was established in each hospital. A new cardiac anomaly screening protocol (‘outflow tract view’) was created and training on the new protocol was systematically delivered at each centre. Data were prospectively collected and outcomes were continuously audited: locally by the lead fetal cardiologist; regionally by the Congenital Anomaly Register and Information Service in Wales; and nationally by the National Institute for Cardiac Outcomes and Research (NICOR) in the UK.

Main outcome measures Patient satisfaction; improvements in individual sonographer skills, confidence and competency; true positive referral rate; local hospital detection rate; national detection rate of CHD; clinical outcomes of selected cardiac abnormalities; reduction of geographical health inequality; cost efficacy.

Results High levels of patient satisfaction were demonstrated and the professional skill mix in each centre was improved. The confidence and competency of sonographers was enhanced. Each centre demonstrated a reduction in the false-positive referral rate and a significant increase in cardiac anomaly detection rate. According to the latest NICOR data, since implementing the new training programme Wales has sustained its status as UK lead for CHD detection. Health outcomes of children with CHD have improved, especially in cases of transposition of the great arteries (for which no perinatal mortality has been reported since 2008). Standardised care led to reduction of geographical health inequalities with substantial cost saving to the National Health Service due to reduced false-positive referral rates. Our successful model has been adopted by other fetal anomaly screening programmes in the UK.

Conclusions Antenatal cardiac ultrasound mass training programmes can be delivered effectively with minimal impact on finite healthcare resources. Sustainably high CHD detection rates can only be achieved by empowering the regional screening workforce through continuous investment in lifelong learning activities. These should be underpinned by high quality service standards, effective care pathways, and robust clinical governance and audit practices.

  • fetal
  • cardiac
  • anomaly
  • training
  • ultrasound
  • improvement
  • outcome

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  • Contributors OU conceived, designed and conducted the study; delivered teaching and training alongside ASW and Tiny Tickers; OU, NT and JK organised courses, workshops and educational conferences in collaboration with ASW and the Welsh Fetal Cardiovascular Network; OU, JK, CD, DT, DR, MJL, AT, NT, BB, AG analysed and interpreted the data, and drafted, finalised and submitted the manuscript. JK, CD, DT, DR, MJL, AT, NT, BB, AG, OU interpreted the data and revised the manuscript for important intellectual content. AT, DR, AG, BB, OU, JK, NT, CD, DT and MJL had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. All authors approved the final version to be published.

  • Funding This paper had no external funding. Training programme continued until 2006 solely as individual effort of (OU, NT and screening midwives in South Wales) then Antenatal Screening Wales provided parallel training for sonographers through central funding from Public Health Wales. Additional event sponsorships were received from the exhibitors who attended annual conferences or workshops. Subsequent funding was awarded from Public Health Wales for a more structured training programme which was devised and delivered via Antenatal Screening Wales and Tiny Tickers Charity. Toshiba (Canon), General Electric, Philips, Siemens, and Samsung ultrasound divisions lent their application and equipment support for hands on courses. The funders had no role in the design and conduct of this paper; the collection, management, analysis and interpretation of the data and the preparation, review or approval of the manuscript.

  • Competing interests OU, NT, JK, AT and CD were all affiliated with Antenatal Screening Wales during defined periods to act as advisor on ultrasound experts advisory panel. OU and MJL are Professors at Swansea University. AT is an officer at ASW. OU and NT are appointed by ASW as responsible educators for delivering ongoing training to Cardiac Leads in each District General Hospital in Wales. DT is the CARIS manager. This study is part of the “Reducing perinatal mortality and improving postnatal outcomes from congenital heart disease by increasing antenatal anomaly detection programme” which won the BMJ Group Best Cardiology Team Award in the UK, in 2016.

  • Patient consent Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

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