Benefits and limitations of the transfer online of Irish College of General Practitioners (ICGP) continuing medical education (CME) small group learning (SGL) during COVID-19: a national Delphi study.

INTRODUCTION: In Ireland, continuing medical education (CME) small group learning (SGL) has been shown to be an effective way of delivering CME, particularly for rural general practitioners (GPs). This study sought to determine the benefits and limitations of the relocation of this education from face to face to online learning during COVID-19. METHODS: A Delphi survey method was used to obtain a consensus opinion from a group of GPs recruited via email through their respective CME tutors, and who had consented to participate. The first round gathered demographic details and asked doctors to report the benefits and/or limitations of learning online in their established Irish College of General Practitioners (ICGP) small groups. RESULTS: A total of 88 GPs from 10 different geographical areas participated. Response rates in rounds one, two and three were 72%, 62.5% and 64%, respectively. The study group was 40% male; 70% were in practice ≥15 years, 20% practiced rurally, and 20% were single-handed. Attending established CME-SGL groups allowed GPs to discuss the practical application of rapidly changing guidelines both in COVID-19 and non-COVID-19 care. They could discuss new local services and compare their practice with others during a time of change; this helped them feel less isolated. They reported that online meetings were less social; moreover, the informal learning that occurs before and after meetings did not take place. CONCLUSION: GPs in established CME-SGL groups benefited from online learning as they could discuss how to adapt to rapidly changing guidelines while feeling supported and less isolated. They report that face to face meetings offer more opportunities for informal learning.

Disrupted mana and systemic abdication: Maori qualitative experiences accessing healthcare in the 12 years post-injury.

BACKGROUND: Maori have been found to experience marked health inequities compared to non-Maori, including for injury. Accessing healthcare services post-injury can improve outcomes; however, longer-term experiences of healthcare access for injured Maori are unknown. This paper reports on data from the longitudinal Prospective Outcomes of Injury Study - 10 year follow up (POIS-10) Maori study in Aotearoa/New Zealand (NZ), to qualitatively understand Maori experiences of accessing injury-related healthcare services long-term. METHODS: Follow-up telephone interviews were conducted with 305 POIS-10 Maori participants, who were injured and recruited 12-years earlier, experiencing a range of injury types and severities. Free text responses about trouble accessing injury-related health services were thematically analysed. RESULTS: Sixty-one participants (20%) reported trouble accessing injury-related health services and provided free text responses. Three related themes describing participants' experiences were connected by the overarching concept that participants were engaging with a system that was not operating in a way it was intended to work: 1) Competing responsibilities and commitments encapsulates practical barriers to accessing services, such as a lack of time and having to prioritise other responsibilities such as work or whanau (family); 2) Disrupted mana refers to the feelings of personal disempowerment through, for example, receiving limited support, care or information tailored to participants' circumstances and is a consequence of patients contending with the practical barriers to accessing services; and 3) Systemic abdication highlights systemic barriers including conflicting information regarding diagnoses and treatment plans, and healthcare provider distrust of participants. CONCLUSIONS: Twelve years post-injury, a considerable proportion of Maori reported experiencing barriers to accessing healthcare services. To restore a sense of manaakitanga and improve Maori access to healthcare, Maori-specific supports are required and systemic barriers must be addressed and removed.

Prone positioning improves oxygenation and lung recruitment in patients with SARS-CoV-2 acute respiratory distress syndrome; a single centre cohort study of 20 consecutive patients.

OBJECTIVE: We aimed to characterize the effects of prone positioning on respiratory mechanics and oxygenation in invasively ventilated patients with SARS-CoV-2 ARDS. RESULTS: This was a prospective cohort study in the Intensive Care Unit (ICU) of a tertiary referral centre. We included 20 consecutive, invasively ventilated patients with laboratory confirmed SARS-CoV-2 related ARDS who underwent prone positioning in ICU as part of their management. The main outcome was the effect of prone positioning on gas exchange and respiratory mechanics. There was a median improvement in the PaO2/FiO2 ratio of 132 in the prone position compared to the supine position (IQR 67-228). We observed lower PaO2/FiO2 ratios in those with low (< median) baseline respiratory system static compliance, compared to those with higher (> median) static compliance (P < 0.05). There was no significant difference in respiratory system static compliance with prone positioning. Prone positioning was effective in improving oxygenation in SARS-CoV-2 ARDS. Furthermore, poor respiratory system static compliance was common and was associated with disease severity. Improvements in oxygenation were partly due to lung recruitment. Prone positioning should be considered in patients with SARS-CoV-2 ARDS.

A fast refocus;an irish dermatology department in the era of COVID-19

The arrival of Covid-19 in early 2020 posed a unique challenge for Dermatology, a largely outpatient based and highly visual specialty. We, a large Dermatology Department based in the south of Ireland, recognised that a dramatic reduction in face-to-face interaction must be delivered on a tight timeline to ensure patient and staff safety.The response to a crisis like this required us to refocus on our core objectives;maintaining care and safety for returning patients, whilst also providing continued access for acute and serious new referrals.With the arrival of Covid-19 to Irish shores in late February we immediately moved to telephone clinics for returning patients. Video consultations for new patients were introduced within two weeks. Later we increased the number of ‘see-and-treat’ surgical lists to manage suspected skin cancers, thereby minimising exposure risk. Our pre-existing photo-advice email service for GP’s was re-advertised, which helped us to triage referrals. Meanwhile our multidisciplinary meetings for Melanoma, Dermatology/Pathology and Dermatology/Plastic Surgery were moved to teleconferencing.We employed a ‘fail fast, learn fast’ approach. By example we soon learned that patients referred with skin lesions are not suitable for video consultation due to video fidelity issues. This led to a successful increase in ‘see-and-treat’ surgical lists to compensate.As a result of these changes we have managed to maintain our service, an achievement which is demonstrated by our clinic numbers for new and returning patients, our clinical meetings proceed uninterrupted and even unintended benefits, such as a reduction in our ‘did not attend’ rate (a decreased from 22% pre-COVID to a ‘did not answer’ rate of 7% during lockdown).Change may be forced, but in the words of Voltaire ‘Perfect is the enemy of good’. Through focus, courage and flexibility we weather the storm.