PM1018: Increasing Prenatal Diagnosis of Congenital Heart Disease in a Community Setting- results from an Educational Interventional Initiative in Northern Washington

Purpose/Objectives: Despite fetal cardiac scanning guidelines for obstetric anatomy scans, rates of prenatal diagnosis of congenital heart disease (PND) are variable and inadequate. There is resulting preventable burden of congenital heart disease (CHD) that is not prenatally diagnosed and does not have adequate birth planning, parental and team preparation, counseling. Multiple barriers including level of expertise at location of primary care have been described. The hypothesis and global aim for this quality improvement project is that dissemination of scanning techniques and interpretation by a specialist (fetal cardiologist) to community providers (obstetrics, radiology) will improve rates of prenatal diagnosis of CHD.

Design/Methods: This educational outreach initiative involved didactic and hands-on demonstration of fetal cardiac scanning to 4 obstetric and radiology groups in Northern Washington (Phase 1, November 2015), extending to 2 groups in Eastern Washington (Phase 2, 2017) and 2 state ultrasound schools (Phase 3, 2018) followed by in-person observation in a tertiary care setting by team members from 4 centers (Phase 4, 2018). Pre-participation questionnaire was completed just before teaching sessions. Efficacy of intervention was assessed from state based congenital heart disease screening program data.

Results: A total of 32 core-sonographer team members (21 sonographers, 9 obstetric MDs, 2 radiology MDs) with a mean of 13 years of scanning experience (SE) (range 0-44y) and two full classes of ultrasound school participated. Only five were ‘very comfortable’ with fetal cardiac screening (mean 15 SE) and 40% self- reported 'knowledge gaps'. When faced with equivocal findings, 9 would discuss with a peer first (SE 8), 10 would extend their scan first (SE 13.6), 7 would consult with interpreting physician (SE 17), and 4 would directly refer to fetal cardiology (SE 22). When findings were suspicious for PND, most would discuss with their radiologist or radiology supervisor. Many of these same supervisors also shared that they did not receive adequate fetal cardiac screening training.
Based on published historical rates from national databases, PND rate was 36% for this region (2006-2012). This increased to 68% based on Washington state critical CHD screening data (2015-2017) and additionally to 71% most recently (2015-2018) during the multiple phases of the intervention from 2015-2018.

Conclusion/Discussion: Community based primary and secondary obstetric sonographers continue to self report knowledge gaps with PND. Transferring scanning skills from tertiary to community level providers is essential to increase PND in the most resource effective manner, addressing regional and access-to-care disparities, keep parents and families within their community. Strengthening partnerships between community obstetric providers and specialty level providers is a key consideration in achieving universal prenatal diagnosis. This project demonstrates the feasibility and success of such spread and should prompt advocacy partnerships by professional organizations at a national level.