Palliative care teaching in the new internal medicine curriculum: Project ECHO-an innovative approach to postgraduate education.

BACKGROUND: The Internal Medicine Training (IMT) Programme is an evolution of Core Medical Training introduced in 2019. The IMT curriculum places an increased emphasis on palliative care; however, access to palliative care training is variable. Project ECHO (Extension of Community Healthcare Outcomes) develops communities of practice and is a valuable tool for medical education. We report on an evaluation of Project ECHO to deliver palliative medicine training across a geographically large deanery in the North of England. METHODS: The Project ECHO training programme involved multipoint video technology, telementoring, expert talks and case-based discussions over six sessions, and was fully mapped to the palliative care component of the IMT curriculum. We collected data particularly around attendance and self-reported confidence and knowledge. RESULTS: By creating a community of practice, we provided virtual placements and over 9 hours of virtual direct contact with palliative medicine consultants; and in total, 921 individual attendances occurred, with 62% attending all six sessions. The course was associated with an increase in self-reported confidence and high satisfaction. DISCUSSION: Project ECHO is an effective method of delivering teaching to trainees across a large geographical area. Course evaluation shows outstanding results in trainee satisfaction, confidence, knowledge, patient care, clinical skills and reduction in fear when managing death and dying.

Creating virtual communities of practice for ambulance paramedics: a qualitative evaluation of the use of Project ECHO in end-of-life care.

Introduction: Ambulance services play a key role in the recognition and care of patients nearing their end of life, yet are expected to recognise and manage these complex presentations often with limited education. Paramedics operate across large geographical areas, meaning education delivery is challenging. Yorkshire Ambulance Service implemented Project Extension for Community Healthcare Outcomes (ECHO), which is the creation of virtual communities of practice to address this problem and increase access to specialist supervision, education and sharing of practice. We undertook a service evaluation of the programme and interviewed paramedics about their experiences with ECHO. Methods: Semi-structured interviews were conducted with eight ambulance clinicians who took part in the end-of-life care (EoLC) ECHO programme. Thematic analysis and coding was undertaken to identify and develop the emerging themes. Results: This study identified three key themes: programme structure, factors influencing engagement and professional impact. The provision of a virtual community of practice through Project ECHO was a unique and highly valued experience, which was accessible and allowed for networking, peer support and sharing of practice. The concept of a ripple effect was reported in disseminating learning across the wider team. Conclusion: The development of virtual communities of practice as a novel educational intervention has the potential to transform clinical supervision and ongoing education for ambulance clinicians who are often isolated by the nature of ambulance services that cover large regions.

Emergency department presentations in palliative care patients: a retrospective cohort study.

OBJECTIVES: To map the patient journey for individuals known to palliative care presenting to the emergency department (ED). METHODS: A linked dataset from the CUREd database and palliative care services in a region in the North of England was used. The study describes day and time of presentations, events occurring in the ED, mode of leaving the department and length of hospital admissions for presentations occurring within 90 days of a contact with palliative care. Findings were compared with the wider population in the CUREd database. RESULTS: A significant proportion of individuals known to palliative care (29.4%) presented to the ED. Presentations typically occurred in working hours. Most presented by ambulance (84.4%) and were admitted to hospital (75.1%); these observations persisted across age groups. Most presentations involved investigations (88.5%) and/or treatment (84.1%). CONCLUSIONS: Palliative patients exhibit significant use of the ED; some have the potential to benefit from attendances, but there is a minority for whom ED is unlikely to have improved their care. Advance care planning and communication between services are important for empowering those who stand to benefit from ED, while ensuring appropriate care is planned for those who prefer to avoid presenting.

Mobile technology and delegated work in specialist community services: the EnComPaSS Integration project.

OBJECTIVES: The current UK healthcare workforce crisis is particularly severe in community services. A key limitation with traditional service-delivery models is the reliance on practitioners with levels of training and experience to enable them to operate independently. This paper describes a real-world evaluation of the implementation of digital health technology designed to provide remote, real-time support and task delegation in community palliative care services. It explores the ability of technology to support sustainable community workforce models and reports on key indicators of quality and efficiency. METHODS: The study was a mixed-methods, theory-driven evaluation, incorporating interviews, observations and analysis of routine data. The focus of this paper is the reporting of findings from pre-post implementation comparison and interrupted time series analysis. Data include community hospice service visits, hospital use by hospice patients and patient reported experiences. RESULTS: The digital health intervention allowed the service to include a more junior workforce (p<0.001, Cramer's V=0.241), requiring fewer joint visits (p<0.001, Cramer's V=0.087). No negative changes in hospitalisation were observed and patient reported experiences improved (p=0.023). Changes in hospital non-emergency bed days were inconclusive. However, emergency department admissions reduced significantly (-76.9 /month at 17 months, p=0.001). The cost per hour for visits reduced from £16.71 to £16.23 and annual savings of £135 153 are estimated for reduced emergency admissions. CONCLUSIONS: The evaluation demonstrates the value of digital innovation to support programmes of service redesign and begin to address the healthcare workforce crisis, while having a positive economic effect and indicating an improvement to patient experiences.

Evaluating a palliative care education programme for domiciliary care workers.

BACKGROUND: Many domiciliary care workers have reported low confidence and isolation when delivering end of life care in patients' homes. Project Extension for Community Healthcare Outcomes (ECHO) is an initiative that has demonstrated success in increasing confidence and knowledge of end of life care in UK nursing home and community hospice workers, but it has not been evaluated with domiciliary care workers. AIM: To test the acceptability of Project ECHO to domiciliary care workers as a means of increasing their knowledge of, and confidence in, delivering palliative care, and its effectiveness in reducing their isolation by developing a community of practice. METHOD: A service evaluation, involving one domiciliary care agency delivering care in the community, was conducted from May 2018 to April 2019. The participants were 25 home care workers who were employed by the agency. Participants were invited to attend an event at which gaps in their knowledge were identified, and a curriculum of learning on the Project ECHO programme was developed. The learning involved 12 educational sessions over 12 months, with each session teaching a different component of palliative care. Questionnaires were completed by the participants before and after the educational sessions to assess their effect. In addition, a focus group was conducted with four of the participants. RESULTS: Comparison of the questionnaires completed before and after participating in the education sessions revealed an increase in self-reported knowledge across all 12 topics of the curriculum and an increase in confidence in seven of the 12 topics. However, attendance across the 12 sessions was variable, with no more than nine being attended by any one participant. CONCLUSION: Palliative care education for domiciliary care staff using ECHO methodology was well received, relevant and accessible, and may have the potential to improve self-assessed knowledge and confidence. However, finding an ideal time for as many staff to attend as possible may be challenging.

Aprepitant for the management of refractory emesis in a patient with a small bowel carcinoid tumor.

Nausea and vomiting are common distressing symptoms with multiple etiologies. Serotonin and substance P can induce nausea and vomiting by binding to specific receptors (5-hydroxytryptamine3 [5HT3] and neurokinin-1 [NK-1] receptors respectively). Carcinoid tumors, which originate from enterochromaffin cells of the neuroendocrine system, secrete several biologically active amines and peptides, including serotonin and substance P, that are responsible for the distant effects of this tumor. The authors present an 88-year-old lady with metastatic carcinoid tumor, with evidence of carcinoid syndrome. She had nausea and vomiting that became unresponsive to 5HT3 receptor antagonists and other antiemetics. As substance P is released from carcinoid tumors and has a role in the pathogenesis of emesis, the NK-1 receptor antagonist aprepitant was trialed. This provided complete and sustained improvement of the nausea and vomiting until her death 2 months later. This case demonstrates the potential role and rationale of NK-1 receptor antagonists in the management of resistant emesis in patients with carcinoid tumors. Clinical trials are needed to evaluate the efficacy and toxicity of these drugs in the management of emesis in patients with carcinoid syndrome.