The impact of outpatient versus inpatient management on health-related quality of life outcomes for patients with malignant pleural effusion: the OPTIMUM randomised clinical trial.

BACKGROUND: The principal aim of malignant pleural effusion (MPE) management is to improve health-related quality of life (HRQoL) and symptoms. METHODS: In this open-label randomised controlled trial, patients with symptomatic MPE were randomly assigned to either indwelling pleural catheter (IPC) insertion with the option of talc pleurodesis or chest drain and talc pleurodesis. The primary end-point was global health status, measured with the 30-item European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) at 30 days post-intervention. 142 participants were enrolled from July 2015 to December 2019. RESULTS: Of participants randomly assigned to the IPC (n=70) and chest drain (n=72) groups, primary outcome data were available in 58 and 56 patients, respectively. Global health status improved in both groups at day 30 compared with baseline: IPC (mean difference 13.11; p=0.001) and chest drain (mean difference 10.11; p=0.001). However, there was no significant between-group difference at day 30 (mean intergroup difference in baseline-adjusted global health status 2.06, 95% CI -5.86-9.99; p=0.61), day 60 or day 90. No significant differences were identified between groups in breathlessness and chest pain scores. All chest drain arm patients were admitted (median length of stay 4 days); seven patients in the IPC arm required intervention-related hospitalisation. CONCLUSIONS: While HRQoL significantly improved in both groups, there were no differences in patient-reported global health status at 30 days. The outpatient pathway using an IPC was not superior to inpatient treatment with a chest drain.

Using creative co-design to develop a decision support tool for people with malignant pleural effusion.

BACKGROUND: Malignant pleural effusion (MPE) is a common, serious problem predominantly seen in metastatic lung and breast cancer and malignant pleural mesothelioma. Recurrence of malignant pleural effusion is common, and symptoms significantly impair people's daily lives. Numerous treatment options exist, yet choosing the most suitable depends on many factors and making decisions can be challenging in pressured, time-sensitive clinical environments. Clinicians identified a need to develop a decision support tool. This paper reports the process of co-producing an initial prototype tool. METHODS: Creative co-design methods were used. Three pleural teams from three disparate clinical sites in the UK were involved. To overcome the geographical distance between sites and the ill-health of service users, novel distributed methods of creative co-design were used. Local workshops were designed and structured, including video clips of activities. These were run on each site with clinicians, patients and carers. A joint national workshop was then conducted with representatives from all stakeholder groups to consider the findings and outputs from local meetings. The design team worked with participants to develop outputs, including patient timelines and personas. These were used as the basis to develop and test prototype ideas. RESULTS: Key messages from the workshops informed prototype development. These messages were as follows. Understanding and managing the pleural effusion was the priority for patients, not their overall cancer journey. Preferred methods for receiving information were varied but visual and graphic approaches were favoured. The main influences on people's decisions about their MPE treatment were personal aspects of their lives, for example, how active they are, what support they have at home. The findings informed the development of a first prototype/service visualisation (a video representing a web-based support tool) to help people identify personal priorities and to guide shared treatment decisions. CONCLUSION: The creative design methods and distributed model used in this project overcame many of the barriers to traditional co-production methods such as power, language and time. They allowed specialist pleural teams and service users to work together to create a patient-facing decision support tool owned by those who will use it and ready for implementation and evaluation.

'You've got mail!': Clinical and practical skills teaching re-imagined during COVID-19.

With the outbreak of COVID-19, there was widespread cessation of face-to-face teaching in medical schools from March 2020. 130 students in their first clinical year at a large London medical school were at risk of missing part of their clinical and practical procedure teaching. We mailed a teaching pack containing clinical consumables and gave instructions to prepare fruit, vegetables and kitchen sponges as a replacement for manikins. Students used cucumbers for bladder catheterisation, oranges for injections, bananas for suturing and cannulated sponges for practising intravenous drug administration. A student evaluation after the course was favourable. Hands-on practice had a positive effect on the students' feelings of belongingness and identity and helped them feel like they were not missing out or being left behind. Technology was challenging for both students and tutors. The intervention is being repeated for all incoming students from September 2020.

DR WHO: a workshop for house officer preparation.

BACKGROUND: Newly qualified doctors should be competent in advanced life support (ALS) and critical care. The Resuscitation Council has published a course about ALS for undergraduate medical students (the intermediate life support (ILS) course). However, there is no undergraduate-level course on assessing and treating critically ill patients, despite the fact that postgraduate courses on this topic are extremely popular. We have developed a new course called Direct Response Workshop for House Officer Preparation (DR WHO), which teaches both ALS and critical care at an undergraduate level. METHODS: We taught the Resuscitation Council ILS course to our 2003-4 cohort of final year medical students (n = 350), and the new course (DR WHO) to our 2004-5 cohort (n = 338). Students filled in feedback forms immediately after the courses, and a subset repeated the feedback forms 4 months after they had started work as house officers. Course evaluation: Student and house officer feedback was positive. The DR WHO cohort was more confident in caring for critically ill patients (18/26 (69%) were confident after ILS, and 40/45 (89%) were confident after DR WHO (chi2 = 4.3; df = 1; p = 0.06)). Both cohorts were competent in ALS, each with a mean score of 18.6/20 in a finals level practical examination on this topic. CONCLUSIONS: The DR WHO course is popular with the students and practical to run. The course needs to be re-evaluated to determine the long-term competency of graduates.

Becoming 'ward smart' medical students.

BACKGROUND: A small number of medical students elect to work as health care assistants (HCAs) during or prior to their undergraduate training. There is a significant body of evidence in the literature regarding the impact of HCA experience on student nurses; however, little research has examined the effects of such experience on medical students. METHODS: All fourth-year medical students with self-declared experience as HCAs from a single UK medical school were invited to participate in focus groups to explore their experiences and perceptions. Ten students from the year group took part. RESULTS: Participants felt that their experience as HCAs enhanced their learning in the workplace through becoming 'ward smart', helping them to become socialised into the world of health care, providing early meaningful and humanised patient interaction, and increasing their understanding of multidisciplinary team (MDT) members' roles. Little research has examined the effects of [HCA] experience on medical students DISCUSSION: Becoming 'ward smart' and developing a sense of belonging are central to maximising learning in, from and through work on the ward. Experience as a HCA provides a range of learning and social opportunities for medical students, and legitimises their participation within clinical communities. HCA experience also seems to benefit in the 'hard to reach' dimensions of medical training: empathy; humanisation of patient care; professional socialisation; and providing a sense of belonging within health care environments.

The educational value of ward rounds for junior trainees.

The ward round (WR) is a complex task and medical teachers are often faced with the challenge of finding a balance between service provision and clinical development of learners. The educational value of WRs is an under-researched area. This short communication aims to evaluate the educational role of WRs for junior trainees and provides insight into current practices. It also identifies obstacles to effective teaching/training in this setting and provides suggestions for improving the quality of WR teaching.