P1087 - Incorporation of Fetal Cardiac Outflow Tract Imaging in Routine Prenatal Anatomic Survey Ultrasounds and Fetal Telecardiology: a Performance and Quality Improvement Initiative

Background:
Prenatal detection of transposition of the great arteries (TGA) varies by region, center type, and local practice pattern. One major practice pattern variation impacting detection rate is whether or not fetal cardiac outflow tracts are included in second trimester anatomic survey ultrasounds. Outflow tract assessment has been shown to improve detection of TGA and conotruncal anomalies compared to a four-chamber image alone. Despite the inclusion of the outflow tract views being currently recommended from the American Institute of Ultrasound Medicine (AIUM) and the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) not all centers perform these views as part of routine second trimester anatomic screening. Due to variations in provider training and practice patterns, prior to 2017 screening ultrasounds at Womack Army Medical Center (Fort Bragg, North Carolina) did not incorporate fetal cardiac outflow tract imaging into the protocol for second trimester screening ultrasounds.

Methods:
The Pediatric Cardiology service in conjunction with Maternal Fetal Medicine and Radiology staff at Womack embarked on a process improvement project to include outflow tract imaging in every second trimester anatomic survey. Maternal Fetal Medicine and Fetal Cardiology developed a training program to educate all prenatal sonographers and staff Radiologists reviewing these ultrasounds. We then reviewed the detection rate of TGA during the 4 years preceding the interventions. After identifying the baseline rate we prospectively monitored the detection rate of TGA throughout the performance improvement period. During the improve/control portions of our cycle the Pediatric Cardiology staff implemented a fetal telecardiology program for sustainment of the support and education provided to the Radiology and Maternal Fetal Medicine teams at Womack Army Medical Center.

Results:
For the period from 2013-2017 (prior to inclusion of the outflow tracts) prenatal detection of transposition of the great arteries and transposition physiology-type conotruncal anomalies was 0/7 (0%). Following the incorporation of inclusion of the cardiac outflow tracts in imaging prenatal detection of this lesion increased to 5/6 (83%) for the 36 months months following intervention.

Conclusion:
In our population inclusion of the fetal cardiac outflow tract views in all routine second trimester anatomic survey ultrasounds significantly improved the detection rate of Transposition of the Great Arteries (p=0.0047, Fisher’s exact test). This finding supports incorporating the recommendations of the AIUM and ISUOG into standard practice. Improved prenatal detection rates reduce the need for emergent transport of critically ill neonates that comes at significant risk to the infant and cost to the broader healthcare system. Centers with limited sub-specialty resources facing the challenge of meeting and sustaining this standard may benefit from utilization of remote tele-cardiology support to achieve and maintain quality improvement in this area of care which was successfully implemented at Womack AMC.