Creating Effective Virtual Trainings for Medical Examiners and Coroners

July 31, 2023 | Rachel Redding, Ellen Gurung

Overdose deaths in the United States have risen significantly in the wake of the COVID-19 pandemic. There were more than 106,699 overdose deaths in 2021—a 14% increase from the previous year—putting immense pressure on medical examiners and coroners (ME/Cs) to effectively manage overdose death investigations, potentially leading to errors in death certificates and incorrectly attributed ICD-10 codes.

ME/Cs are vital to U.S. public health surveillance, certifying and reporting more than 20% of total deaths. One study found that 20.3% of death certificates indicating an overdose death in 2016 did not include a specific drug as the cause of death. Since death reporting informs local, state, and national mortality data, these inaccuracies and omissions can make it challenging for public health agencies to improve overdose prevention efforts and identify emerging trends.

As the overdose epidemic continues, it is imperative for the medicolegal death investigative community to engage in continuous training that acknowledges the role they play in protecting the nation’s health. It is especially important to provide ME/Cs with effective educational resources to ensure that their communities are adequately supported.

In response to these needs, ASTHO and CDC partnered with six subject matter experts (SMEs), including medical examiners, coroners, and a toxicologist to pilot the Extension for Community Healthcare Outcomes (ECHO) model with ME/Cs with the goal of improving overdose death reporting accuracy. This pilot became known as Project ECHO: Overdose Fatality Investigative Techniques (OD-FIT).

Project ECHO: OD-FIT Overview

Project ECHO: OD-FIT is based on the ECHO model, an innovative way to engage practitioners through web-based sessions, didactic presentations, and case discussions. The model uses a panel of facilitators and speakers (i.e., SMEs) and practitioners who participate in the ECHO sessions. This model creates a virtual space for participants to share information, get real time feedback, connect with colleagues, and build capacity, which is particularly helpful for those with less access to resources such as those working in rural areas or with hard-to-reach populations.

Project ECHO: OD-FIT discussions have focused on suspected overdose scene investigations, the role of forensic autopsy in overdose cases, and determining whether overdoses were accidental or suicide. Initially, participants rarely brought cases to sessions and discussion was limited, possibly due to multi-tasking, virtual meeting fatigue, lack of familiarity with content, or lack of access to a comfortable and quiet environment for verbal sharing. To address these issues, Project ECHO: OD-FIT pivoted to have the SMEs present session topics and case studies and include multiple-choice polls and chat prompts to spark participant engagement. Overall, more than nine out of ten evaluation respondents reported an increase in knowledge, skills and/or capability.

Recommendations for Implementation

With the conclusion of Project ECHO: OD-FIT, local or state ME/C offices as well as state and/or national associations may be interested in creating virtual training series. Here are several recommendations and lessons learned from sessions hosted to date.

Be mindful of audience needs.

• Survey your audience so you can tailor the information for attendees.
• SMEs tailored each session to include didactic presentations that improved overdose investigations and death reporting.
• Evaluation results indicated that topic applicability often varied by role, with investigators finding topics related to overdose fatality reviews and data more applicable to their work, whereas coroners found greater application in topics related to autopsy and mental well-being.
• Be aware of time constraints, virtual meeting fatigue, and other barriers to participation.
• Virtual breakout rooms did not initially yield robust case discussion, which may have been due lack of familiarity with the medical model of case presentations, adjusting to teleworking, and/or confidentiality concerns.

Promote a safe environment for peer-to-peer sharing.

• Attendees are more likely to participate in conversations, information sharing, and present questions to the group if they feel they are in a supportive, comfortable environment.
• During Project ECHO: OD-FIT sessions, SMEs shared personal stories of fatal overdoses within the family, cases where they made a mistake, difficult cases that stuck with them throughout their careers, and the effects of vicarious trauma. SME’s vulnerability opened the conversation to participants and allowed them to feel comfortable sharing their own struggles and ask their colleagues for advice.
• Ensure that attendees have the necessary tools to fully participate in the virtual trainings, including access to a strong Wi-Fi connection, a laptop/computer with both a camera and microphone, and a quiet place where they can attend sessions.
• Be willing to accept silence and understand participants may have various reasons for not participating verbally.

Keep sessions fresh and enjoyable.

• Add engagement tools to increase participation during sessions.
• Participant polls, word clouds, breakout rooms, and engaging with the chat feature can increase participant engagement and idea sharing.
• If participation and conversation are low, ask participants what types of engagement options they would prefer. This is an all-teach, all-learn environment and participants should be engaged in the planning process.

Ask for feedback and use it to improve.

• Create and implement an evaluation plan.
• Implement anonymous, aggregated post-session surveys using Likert scales and open responses so participants can rate the quality of information and topics provided and offer suggestions for improvement.
• Use the feedback from participants to inform content and improve future sessions.