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Education to Move Knowledge, Not Patients

Advances in Skin & Wound Care: June 2022 - Volume 35 - Issue 6 - p 303
doi: 10.1097/01.ASW.0000829480.81286.f7
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The world has changed dramatically over the past few years. We need to revise education methods and accelerate knowledge transition into clinical practice. Project ECHO (Extension for Community Healthcare Outcomes)1 was designed by Dr Sanjeev Arora at the University of New Mexico to provide virtual education to healthcare professional teams in their own community for the purposes of “moving knowledge, not patients.” The Ontario ECHO Skin & Wound Project is designed to provide new knowledge to interprofessional teams across Ontario, Canada (population nearly 15 million), through weekly broadcasts arranged in two 8-session cycles. Topics include leg and foot ulcers as well as pressure injuries and miscellaneous wounds. Each 2-hour session includes an interactive didactic portion combined with case presentations from the interprofessional team (spokes) and the facilitators (hubs). The spokes each present at least one case during a Zoom-enabled cycle. Each case is discussed for 20 to 40 minutes and the hubs facilitate two or three case presentations. The cases are deidentified and presented in the Wound Bed Preparation 2021 format.2 After the submitting spoke presents the case, the other spokes and interprofessional hubs offer recommendations prior to the team providing a one-page consultative report for patient recommendations.

In this issue of Advances in Skin & Wound Care, medical student volunteer Angela Fan interviewed healthcare professionals who presented cases at ECHO to obtain follow-up data on the team recommendations for patient care. Here are the five themes from the study and why they are generalizable to most wound care interprofessional practices.

Care Coordination. Each team needs a coordinator. The mutual respect between physicians, nurses, and allied health providers should reflect recognition of complementary expertise to write an interprofessional plan that encompasses the whole person.

Patient Empowerment

Every patient deserves appropriate pain management: On a numbered pain scale of 0 to 10, pain levels should not exceed 3 or 4. Pain should be categorized and treated as nociceptive or neuropathic. For patient comprehension, giving finite anchors is often helpful: 10 for slamming their finger in the car door, 5 for a bee sting, and 0 for no pain. Patient empowerment may also include giving options for wound care and linking form to function so the patient can assess changing wound characteristics. Comprehensive assessments should also include a patient's financial status, living conditions, and available support system. All of these factors require good communication between healthcare providers and patients based on mutual trust.

Practitioner-Related Factors

In the study by Fan and colleagues, one practitioner did not appreciate the need for a biopsy to diagnose pyoderma gangrenosum. Applying the new criteria by Maverakis et al,3 50% of the published case studies without the diagnostic neutrophilic infiltrate biopsy do not have the diagnostic criteria for a probable diagnosis of pyoderma gangrenosum. This complication needs to be recognized, and most patients had their biologic agent dropped in favor of alternative treatment.

Barriers to Accessibility

This is a big problem in rural and remote areas, especially in Ontario. Some family doctors may not have access to noninvasive vascular studies, less common laboratory studies, wound specialists, and timely medical specialist consultations. Remote telemedicine consultants may not be familiar with local resource availability.

Beyond the Single Case

Project ECHO provided a very useful case-based learning opportunity for five of six interviewed teams in the Fan study. This type of education was not available locally and many of the principles were generalizable. The submitted cases served as a continued needs assessment through the cycles of the program.

Successful education links knowledge (interactive didactic presentations) with skills (instructive videos with student video and written assignments) to modeling of coordinated, integrated interprofessional team education with responsiveness to patient-centered concerns. We challenge the reader to develop interprofessional teams and model education to improve patient outcomes.

R. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM

Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN


1. Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med 2011;364:2199–207.
2. Sibbald RG, Elliott JA, Persaud-Jaimangal R, et al. Wound bed preparation 2021. Adv Skin Wound Care 2021;34(4):183–95.
3. Maverakis E, Ma C, Shinkai K, et al. Diagnostic criteria of ulcerative pyoderma gangrenosum: a Delphi consensus of international experts. JAMA Dermatol 2018;154:461–6.
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