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Moving Knowledge, Not People: training India's health workforce during COVID-19

02 March 2021

The pandemic brought with it a set of challenges, several in fact. It was an overnight turn of events in the way of working, most interactions were forced to be taken virtually. Which pushed most of us to experiment until we found success.

A year has passed by, and while some of us have mastered the art of distant working, some are still grappling to find the balance. A must mention in the “what went right” domain is our ECHO Tele-mentoring Clinics, based on Project ECHO, a virtual knowledge-sharing and mentoring platform created for the most inaccessible health care providers and patients.

Even before the pandemic, Project ECHO’s motto was “Moving Knowledge, Not People”. Project ECHO aims to amplify the knowledge of health care workers to deliver best care practices for better patient outcomes. The emphasis is on reaching out to the most inaccessible and underserved communities. Project ECHO was launched in 2003 in New Mexico, USA by Dr. Sanjeev Arora, MD, a liver disease specialist at the University of New Mexico Health Sciences Center in Albuquerque. It is now a global movement implemented through partners sharing the vision of knowledge dissemination and learning through tele-mentoring. In 2018, Equalize Health partnered with Project ECHO, and since then, we have conducted more than 75 tele-mentoring sessions focused on training health workers.

Before the pandemic, Equalize Health employed the conventional ECHO model designed to foster peer-to-peer learning through small cohorts (~12 health care providers) who meet regularly online over a period of 6 months or more. During the sessions, participants shared and discussed cases while experts provided clinical support.

A screenshot taken from a recent ECHO Tele-mentoring Clinic for neonatologists in partnership with the Himalayan Institute of Medical Sciences (HIMS).

At the onset of the pandemic, it was imperative for pediatricians and neonatologists across India to be prepared to manage patients (including adults) on ventilators. Clinicians (pediatricians, intensivists, neonatologists, and staff nurses) were called upon to bridge the clinical resource gap irrespective of their areas of expertise, some never having tended to critical care patients. There was great need to train these clinicians quickly so they could be confident in their response and provide the best care possible to patients.

In order to meet this demand, we adapted the ECHO model, implementing rapid sessions on patient ventilation and respiratory management with larger learner cohorts than we had hosted before. The number of learners attending each session increased eight times, from an average of 20 to 160 clinicians per session. We held a total of 46 tele-mentoring sessions between April and August 2020, reaching 1,180 unique learners from 29 states and 3 union territories. Although each session had an average attendance of more than 150 learners, sessions covering topics such as ventilator operation, post-extubation care, and pediatric ventilation, saw more than 350 participants.

The numbers in terms of coverage was massive, unlike conventional ECHO clinics, and they created real impact, despite their limited duration.

Assessment of knowledge before and after the clinics showed a 70% improvement among participants on topics such as basic and advanced use of ventilators. On average, each of these participants was treating 20-25 patients per week, or approximately 80-100 patients per month. Over the six months following the training, each cohort of clinicians (average of 160 per cohort) would therefore reach 75,000 to 95,000 patients on average. Further study would be required to make inferential estimates about the application of knowledge to practice and practice to improved health outcomes, but the scale achieved provides evidence of knowledge amplification and potential improvement in clinical outcomes in the long run. Beyond knowledge improvement, the learners also provided very positive feedback on the mode of training and application of learning at the workplace.

“The sessions were very interactive, it helped

me understand the content more easily and
remember it for a longer period of time.”
- Staff Nurse, New Delhi

Equalize Health’s COVID tele-mentoring adapted to an emergent need to enhance Indian clinicians’ knowledge of critical care practice. tele-mentoring was critical to building capacities during the pandemic, but the greater takeaway is the fact that we need to be building capacities not just in response to emergencies but also in response to longstanding gaps in coverage and the future demand for more resilient health systems -- and we need to do it at scale. Tele-mentorings such as ours show that health care knowledge and practice gaps can be reduced with preparedness and collaboration and with equal capacity-building emphasis across tiers, facility segments, and clinician type.

The good news is that there are even more benefits to our ECHO program than just improved knowledge and confidence. Capacity-building platforms are supportive structures which health systems can use for collaboration, standardization, and resource sharing. These clinics strengthen knowledge ties and networks, building cohesive preparedness and morale among participants. Participants practice listening to each other, asking questions, sharing what they know, and supporting each other. If there is anything that we’ve learned from COVID, it’s that neither viruses nor knowledge is static, and health workers need continuing education, sharing, and learning, like that achieved through ECHO tele-mentoring, to adapt to our ever-changing world.