PROJECT SUMMARY. Heart failure (HF) is a lethal, yet treatable, cardiovascular disease that is common in
rural areas of Haiti and other low-income countries (LICs). In rural Haiti, where I have worked since 2012,
~46% of medical ward admissions are due to HF and inpatient fatality is 11%. Part of the problem is that
evidence-based medicines for HF are used only 21% of the time. However, suboptimal treatment cannot be
addressed unless we first confront the problem of diagnosis. The lack of access to (1) echocardiography, and
(2) clinicians with skills to interpret them are major barriers to HF treatment. Haiti has only 17 cardiologists for a
population of 11 million. The advent of low-cost, portable handheld ultrasound devices has the potential to
address both of these barriers. Our attention is focused on affordable and sustainable ways to train clinicians to
both acquire images and interpret the findings. Since 2008, we have developed, implemented, and evaluated
the training of mid-level clinicians using a simplified focused cardiac ultrasound (sFoCUS) protocol. We
successfully implemented this training in Rwanda, Liberia, and Malawi. However, the training model is
resource-intense requiring a 1-on-1 apprentice approach with cardiologist expert trainers. Limited availability
and cost of cardiologists are principal barriers to dissemination. To address this barrier, we propose employing
simulators to train mid-level clinicians in rural Haiti in our sFoCUS protocol. Our Seattle team has developed
novel training tools including visual guidance and image matching in a self-administered training simulator. This
novel simulator has been successfully tested among students and general physicians in the US. However,
incorporating simulation into sFoCUS training is unstudied in LICs. Because our simulator displays real patient
images, the curriculum can be adjusted to be consistent with the HF epidemiology in Haiti. We hypothesize that
a self-administered, simulation-based training intervention is feasible, acceptable, high-fidelity, and promotes
effective learning of echocardiography skills and interpretation in low-resourced settings. We will test this
hypothesis through the following specific aims.
AIM 1
: Adapt a simulator-based self-administered training
curriculum for the Haitian context. Using the ADAPT-ITT framework, we will first examine the current use of
echocardiography by informally trained Haitian staff, then assess the simulator’s usability and appropriateness.
We will obtain new cases from patients with pathology consistent with Haitian HF epidemiology.
AIM 2
:
Determine the effectiveness and study the implementation & cost of the adapted simulator-based
FoCUS training. We will train 50 clinicians using the simulator. Guided by the RE-AIM framework, we will
investigate reach, effectiveness, adoption, implementation, and maintenance. Our primary effectiveness
outcome will be improvement in diagnostic accuracy: proper HF category assignment of standardized
simulation cases. If successful, our study will lead to a feasible and scalable sFoCUS training platform to
improve access to HF diagnostics ready for dissemination throughout Haiti and to other LICs.