Antenatal screening for Congenital Heart Disease
An Overview of our "hands-on", on-site Fetal Heart Scan Training

Despite improvements in recording congenital malformations, over the last decade, the reporting of congenital heart disease (CHD) still lags behind with only about 1/3 rd of cardiac defects reported.  (Source: NW Thames CMR report on 2002 & 2003, pub. April 2005)

CHD is far more common than reported and the early detection of isolated CHD is extremely important to outcome.  Hands-on training, using the 5 View protocol is one of the best ways to improve the detection of congenital heart disease at the 20-week scan.

The incidence of fetal heart disease has been reported recently as 7-13 per 1,000 scans (2004), depending on the degree of perinatal cardiology support (ref. Pubmed doc 15284832 ).

We aim for a detection rate for severe CHD (that requiring surgery/intervention in the first year of life) of 3.5/1,000.

Questions & Answers

1. Who can receive training?
2. The goals of fetal heart scan training
3. Benefits of training
4. How can a unit apply for "hands-on" training?
5. What is the cost of training?
6. The importance of audit
7. How many training sessions will a sonographer need?
8. Do you train certain key personnel who then train others?
9. Should we attend a cardiac course before hands on training?
10. How can we help the charity to train more sonographers?
11. How many training sessions will a sonographer need?

1. Who can receive training?
We only provide "hands-on" training to an ultrasound screening department of UK NHS Trust maternity hospitals.
We do not train individuals.

All training is "on-site", in a unit's own ultrasound department with your own equipment.  This is the best way to improve day-to-day scanning and highlight issues that are particular to a department.

In addition, it is important to verify that equipment is correctly set-up, sonographers are given time to practice and develop their skills and all referrals are audited (with feedback from referrals used to verify that audit and highlight any training issues) - see 6., below.

2. The goals of fetal heart scan training
The goal of our fetal heart scan training is to increase the antenatal detection of congenital heart disease from a national average of about 30% in the UK to nearer 75%.  

Fetal cardiac scanning has been practiced in the United Kingdom for nearly twenty years, yet the vast majority of cardiac defects still remain undetected (upto 75% undetected according to RCOG in 2000).  

The 4-chamber view alone can only detect half of major cardiac malformations.  The addition of the outflow tracts of the heart at the anomaly scan (as per RCOG guidelines, 2002) can improve antenatal detection of cardiac defects even further, but does not detect important aortic arch lesions.

We recommend a systematic protocol that is understood and practiced by all sonographers, the 5 Transverse Views.

3. Benefits of training
The early detection of a fetus with heart disease offers more choices during pregnancy and can avoid unnecessary illness or delay before further treatment.  Training itself has a major impact on the confidence of sonographers.

From our experience since Oct. 2002 & based on a recent thesis on Outflow Tracts, we can say that successful screening for heart defects at 20 weeks relies upon:

• on-site "hands-on" training in the proper protocol by a practised trainer; 
• modern, reliable ultrasound equipment with fetal echo settings; 
• support from the department to give sonographers a little extra time to learn & apply the protocol; 
• ready access to second opinion about suspected heart disease; 
• constructive feedback about cases found & missed, which encourages review & learning.

Given these conditions, sonographers can acquire the confidence to look for and find fetal cardiac anomalies. 

4. How can a unit apply for "hands-on" training?
At present we are fully committed to training selected UK NHS Trust maternity hospitals in our programme.  
We do not train individuals.

Chief Sonographers (or equivalent) can apply to be considered for training for their obstetric ultrasound department.  Please email your details & some information about your unit (location, size, relative experience of part & full-time staff, machines, current protocol & any relevant issues).

We also ask for good retrospective audit figures (births, scans, anomalies & outcomes over the last 2-3 years) plus a good ongoing audit, so we know where we are starting from & can measure improvement.  The audit also helps you to maintain skills in the long run.  Please email or contact us to discuss this.

5. What is the cost of training? 
For the last 5 years, we have provided free training.  However, this is becoming increasingly difficult to fund and we are now moving towards providing low-cost training.  Please email or contact us to discuss this.

All training is subject to our resources & discretion and we ask that you co-operate with our trainer and give priority to training sessions.  Donations are very welcome to help to maintain our service.

We also ask that you maintain a good audit throughout, to measure improvements and maintain skill levels. 
We reserve the right to withdraw training if these conditions are not met, as they impact on our limited resources and prevent us from reaching more hospitals. 

6. The importance of audit
Audit is vital if we are to make improvements in the detection of CHD.  It is no coincidence that the departments with the highest detection rates also have a good audit and use the feedback from this audit to strive for further improvement.

Audit allows all cases of suspected CHD that are referred for a full fetal echo to be tracked and verifed.  Missed cases are often picked up by other departments, such as Obstetrics, Paediatrics & Cardiology and this information can be useful feedback for further training.  Feedback may be difficult where referrals are made to other cardiac units, so cooperation between departments is vital.  If you have views on this, please email or contact us.

7. How many training sessions will a sonographer need?
This depends on how much cardiac scanning an individual has done and how well they learn to perform a fetal cardiac scan.   It is usual to have one full training session, so that training can be put into practice, until our trainer returns for a follow up visit.

Training should continue until sonographers become confident that all views can be consistently imaged so that suspicions or anomalies can be more easily detected, within time and resource constraints.

8. Do you train certain key personnel who then train others?
The idea is to try and train each sonographer individually.  In departments with a large proportion of part-time staff it may be necessary to train key personnel who then may train other staff.  Staff who already have good fetal echo skills may also support the training.  Our trainer will assess this and make recommendations.

9. Should we attend a cardiac course before hands on training?
It is a good idea to have attended a basic fetal cardiac course just before “hands on” training begins.  Some courses offer “hands on” scans as part of the course;  others are just theoretical.  See the Health Professionals page for more information on courses.

Sonographers have commented that they feel the departmental training makes more sense if they have already had some basic fetal cardiac scanning information.

10. How can we help the charity to train more sonographers?
There is an increasing demand for fetal cardiac scanning and for more sonographers and more trainers. 

We are actively raising funds, but any support you can give us would be most welcome.  If you wish to fund-raise locally please email or contact us to discuss this and see how we can help.

Another way to fund training is for a group of hospitals in a region to each contribute a share of the training costs.  We can coordinate this and create an independent training resource that will be fairly shared across these hospitals.

11. Sponsored 2-day fetal cardiac training package
Our 2-day package provides a Sonographer Trainer for 2 days "hands-on" fetal cardiac scan training for the whole department, in a suitable obstetric ultrasound unit.  Costs start at £400 (please contact us for details). 

The aim of this package is to demonstrate how to improve detection of fetal heart disease, using the 5 View protocol, at around 20 weeks' gestation.  

This is subject to agreement with the Chief Sonographer of the department, the hospital and availability of suitable resources at the unit.  Training is provided at our discretion, subject to availability of Tiny Tickers resources and terms apply.  The charity may continue to provide training and support entirely at our discretion.

Our criteria for receiving "hands-on" training: 
To help us provide the most relevant training to as many staff as possible, we ask for the full co-operation of the department in prioritising this training over other activities.  We need some basic information about a unit (e.g. location, size, relative experience of part & full-time staff, machines, current protocols & any relevant issues).

We would also like to receive a retrospective audit (e.g. births, scans, anomalies & outcomes over the last 2-3 years), as this helps to understand current detection rates and where to target our training.  We recommend that a unit has an ongoing audit of all referrals, as this helps to maintain skills in the long run.

Who can sponsor this package:
Any suitable sponsor who wishes to help a unit to improve detection of fetal heart disease can apply (e.g. Ultrasound manufacturers providing new equipment, Agencies providing sonographers, Companies, Charities and Hospitals).

Finally ... Over to you!
The biggest single factor in increasing detection is you!  The best sonographers fight for the best equipment and the best training and take time to become experienced at scanning and so detect the most "heart babies".

Volunteer Trainers:  If you are interested in becoming a Volunteer Trainer ...

Hands-on Fetal Heart Scan Training:  Sponsors (2002 - 2005)

This important work was initiated by the British Heart Foundation and other donations.