Pharmacists in advanced clinical practice roles in emergency departments (PARED).

Background Following evidence published in the Pharmacists in Emergency Departments (PIED 2016) study Health Education England funded novel advanced clinical practitioner training for pharmacists (ACP-p), to support service delivery.Objective To explore experiences and clinical activity of trainee ACP-p, and opinions and recommendations of both trainees and clinical supervisors.Setting Five Urgent/Emergency Care Departments in London UK.Method Longitudinal mixed-methods study in three phases of registered UK pharmacists appointed as trainee ACP-p. Phase 1 (May-July 2019) - early semi-structured interviews and focus group using an experiences, opinions and recommendations (EOR) framework, Phase 2 (January-December 2019) - prospective recording of trainee clinical activity, standardised using bespoke spreadsheet, Phase 3 (November-December 2019) - as Phase 1 but at conclusion of training.Main outcome measure Experiences, clinical activity, opinions and recommendations of study participants.Results Twelve (92 %) eligible trainee ACP-p and five supervisors were recruited. Identified themes were: trainee personality, educational components, length of programme, support/supervision, career transition, university and placement training alignment, recommendations. Success was dependent on effective support and supervision. Clinical supervisors should be allocated adequate supervision time. Trainees, their supervisors and emergency department staff should be given a clear brief. Study participants agreed that the programme could be successful. Trainee ACP-p reported that they could manage 82 % of 713 pre-selected clinical presentations. Additional training needs include: ECGs, X-rays and CT scans.Conclusions Pharmacists can successfully train as ACP-p in this setting over a two-year period. This career transition needs careful management and clear structures. Training ACP-p is a useful way of enhancing skills and supporting clinical services to large numbers of patients.

Treatment of cancer-associated venous thromboembolism: 12-month outcomes of the placebo versus rivaroxaban randomization of the SELECT-D Trial (SELECT-D: 12m).

BACKGROUND: The Anticoagulation Therapy in Selected Cancer Patients at Risk of Recurrence of Venous Thromboembolism (SELECT-D) trial demonstrated reduction in recurrent venous thromboembolism (VTE) but increased bleeding with rivaroxaban compared with dalteparin for treatment of acute VTE in cancer patients, at 6 months. Uncertainty remains around optimal duration of anticoagulation. OBJECTIVES: To assess VTE recurrence and bleeding, with anticoagulation or not, beyond 6 months. PATIENTS/METHODS: In SELECT-D, after 6 months of trial treatment for VTE, patients with active cancer and residual deep vein thrombosis (RDVT) or index pulmonary embolism (PE) were eligible for randomization to a further 6 months of rivaroxaban or placebo. Patients with no RDVT stopped anticoagulation. Primary outcome was VTE recurrence at 12 months. The second randomization closed prematurely because of low recruitment when 92 of the planned 300 patients were recruited. RESULTS: Ninety-two of 136 eligible patients were randomized to rivaroxaban or placebo. The cumulative VTE recurrence after 6 months from the second randomization was 14% with placebo and 4% with rivaroxaban (hazard ratio, 0.32; 95% confidence interval [CI], 0.06-1.58). The major and clinically relevant non-major bleeding rates were 0% and 0% with placebo; and 5% (95% CI, 1-18) and 4% (95% CI, 1-17) with rivaroxaban. In an exploratory analysis, 7 (15%) of 46 placebo patients with RDVT or an index PE experienced recurrent VTE compared to none in the 35 patients in the RDVT-negative cohort (P = .03). CONCLUSION: The SELECT-D trial was underpowered to detect a statistically significant reduction in recurrent VTE with extended anticoagulation. The absence of RDVT and/or index PE, defined a population at low risk of recurrence.

Extended training to prepare GPs for future workforce needs: a qualitative investigation of a 1-year fellowship in urgent care.

BACKGROUND: It has been argued that UK general practice specialist training should be extended to better prepare GPs for the challenges facing 21st-century health care. Evidence is needed to inform how this should occur. AIM: To investigate the experience of recently trained GPs undertaking a 1-year full-time fellowship programme designed to provide advanced skills training in urgent care, integrated care, leadership, and academic practice; and its impact on subsequent career development. DESIGN AND SETTING: Semi-structured interviews conducted longitudinally over 2 years augmented by observational data in the West Midlands, England. METHOD: Participants were interviewed on at least three occasions: twice while undertaking the fellowship, and at least once post-completion. Participants' clinical and academic activities were observed. Data were analysed using a framework approach. RESULTS: Seven GPs participated in the pilot scheme. The fellowship was highly rated and felt to be balanced in terms of the opportunities for skill development, academic advancement, and confidence building. GPs experienced enhanced employability on completing the scheme, and at follow-up were working in a variety of primary care/urgent care interface clinical and leadership roles. Participants believed it was making general practice a more attractive career option for newly qualified doctors. CONCLUSION: The 1-year fellowship provides a defined framework for training GPs to work in an enhanced manner across organisational interfaces with the skills to support service improvement and integration. It appears to be well suited to preparing GPs for portfolio roles, but its wider applicability and impact on NHS service delivery needs further investigation.

Translation of the Medical Leadership Competency Framework into a multisource feedback form for doctors in training using a verbal protocol technique.

This study describes the use of think-aloud techniques to capture the reactions of doctors in training, educational supervisors and clinical directors to a draft multisource feedback (MSF) tool. The tool is based on the competencies described in the Medical Leadership Competency Framework (MLCF), which is now a part of most postgraduate medical curricula. In order to reflect properly the extent to which doctors in training have developed the appropriate competencies, the MSF needs to modify the terminology used in the MLCF. This study of 24 doctors, of whom nine were doctors in training, showed that the draft MSF tested needed to be modified in order to differentiate clearly between situations where the assessed doctor had not had adequate opportunity to demonstrate competence, and those where competence was deemed inadequate. More senior doctors tended to favour longer, more detailed MSF questionnaires, possibly reflecting their experience of how MSF can prove valuable in personal development. However, some educational supervisors found an estimated completion time of 25 minutes to be a deterrent. Five doctors from general practice, two of whom were trainees, were included in this small qualitative study, which identified a greater facility for observing and assessing leadership competency development in primary care than in hospital specialities. This finding needs to be tested in a large-scale study of a modified MSF tool.

Effectiveness of an e-learning course in evidence-based medicine for foundation (internship) training.

AIM: To evaluate the educational effectiveness of a clinically integrated e-learning course for teaching basic evidence-based medicine (EBM) among postgraduate medical trainees compared to a traditional lecture-based course of equivalent content. METHODS: We conducted a cluster randomized controlled trial to compare a clinically integrated e-learning EBM course (intervention) to a lecture-based course (control) among postgraduate trainees at foundation or internship level in seven teaching hospitals in the UK West Midlands region. Knowledge gain among participants was measured with a validated instrument using multiple choice questions. Change in knowledge was compared between groups taking into account the cluster design and adjusted for covariates at baseline using generalized estimating equations (GEE) model. RESULTS: There were seven clusters involving teaching of 237 trainees (122 in the intervention and 115 in the control group). The total number of postgraduate trainees who completed the course was 88 in the intervention group and 72 in the control group. After adjusting for baseline knowledge, there was no difference in the amount of improvement in knowledge of EBM between the two groups. The adjusted post course difference between the intervention group and the control group was only 0.1 scoring points (95% CI -1.2-1.4). CONCLUSION: An e-learning course in EBM was as effective in improving knowledge as a standard lecture-based course. The benefits of an e-learning approach need to be considered when planning EBM curricula as it allows standardization of teaching materials and is a potential cost-effective alternative to standard lecture-based teaching.