Bioterrorism and Health System Preparedness, Issue Brief No. 7
The Agency for Healthcare Research and Quality is holding a series of Web-assisted conferences on bioterrorism and the health care system.
Archived online, each audioconference on bioterrorism is also distilled into
an issue brief. This brief examines education and training efforts that are used to create and maintain the readiness of a qualified workforce to respond to a sudden increase in surge capacity needs.
Select for the downloadable print version (PDF file 140 KB). PDF Help.
Contents
Introduction
CDC Funding for Education and Training
HRSA's National Bioterrorism Hospital Preparedness Program
Non-Contiguous Training
Preparing Volunteer Nurses for Public Health Emergencies
Discussion
Conclusion
For More Information
Introduction
| Surge capacity is a health care
system's ability to expand
quickly beyond normal services
to meet an increased demand
for medical care in the event of
bioterrorism or other large-scale
public health emergencies. |
A health system's ability to expand its
services rapidly depends on the
availability of qualified personnel and
their ability to perform tasks assigned to
them. Building a qualified workforce
requires that disaster planners recruit
previously untapped resources, such as
non-active nurses, and provide training to
ensure that these personnel are prepared
to respond to significantly increased surge
capacity requirements.
On March 2, 2004, the Agency for
Healthcare Research and Quality (AHRQ)
sponsored a Web-assisted audioconference that examined how education
and training efforts are being used to
create and maintain the readiness of an
appropriately trained workforce that can
respond to a sudden increase in surge
capacity needs. Presentations were made
by the following researchers and
practitioners:
- Joan P. Cioffi, Ph.D., Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, GA.
- Terri Spear, Ed.M., Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, MD.
- Michael Allswede, D.O., University of Pittsburgh Medical Center Health System, Pittsburgh, PA.
- Betsy Weiner, Ph.D., R.N., B.C., FAAN, Vanderbilt University, Nashville, TN.
This issue brief summarizes those
presentations and the question and answer
period that followed. Dr. Cioffi and Ms.
Spear described education and training
initiatives sponsored by the Centers for Disease Control and Prevention (CDC)
and the Health Resources and Services
Administration (HRSA), respectively. Dr. Allswede described his AHRQ-funded
project to develop noncontiguous
training that teaches
hospital personnel the skills they need
to respond to bioterrorism or other
large-scale public health emergencies.
Dr. Weiner discussed her project, also
funded by AHRQ, to develop and
evaluate Web-based and face-to-face
training modules to prepare volunteer
nurses to respond to public health
emergencies.
A recurring theme of the
audio conference was the importance of
competency-based training.
Return to Contents
CDC Funding for
Education and Training
One of CDC's top strategic
imperatives is to build a competent
and sustainable public health
workforce that can respond to a
bioterrorist event or other public health
emergency. "CDC has developed a
national public health strategy for
terrorism preparedness and response
that will guide our agency's efforts
over the next five years," said the
CDC's Joan Cioffi. Dr. Cioffi
described education and training
activities in three broad categories:
-
The first category is State and local
education and training, which is
mandated by CDC's Cooperative
Agreement on Public Health
Preparedness and Response for
Bioterrorism. The Cooperative
Agreement provides grants to 50
States, the District of Columbia, eight
territories, and three cities. Grantees
are expected to conduct needs
assessments, develop training plans,
and have some capacity to maintain
data on who has been trained. CDC
plans to disseminate best practices on
a regional and national basis and is
currently developing system
performance indicators and exercises
and drills to help grantees refine their
training activities.
-
The second category is partnerships.
The Centers for Public Health
Preparedness program includes 23
schools of public health and 13
specialty centers, including schools of
medicine, nursing, veterinary
medicine, and law. The Centers work
with state and local partners to meet
identified community needs. For
example, the University of Illinois at
Chicago is working with the Illinois
Department of Health and the City of
Chicago to provide needs assessments
for training of all public health staff
and to develop customized training.
CDC has also formed partnerships
through outreach to clinicians. In
response to clinicians' desire for
guidance from their professional peers
and the organizations they typically
work with, CDC has established
relationships with the Association of
American Medical Colleges and eight
specialty societies. They are working
collaboratively to develop customized
information for more than 300,000
clinicians and health care professionals
who have links to these organizations.
-
The third broad category is as a direct
provider of education and training,
both internally and externally.
Internally, CDC must train its
emergency operations staff and field
staff for terrorism preparedness.
External training is provided through
nine different CDC offices, centers,
and agencies. The Office of Terrorism
Preparedness and Emergency
Response coordinates the various
education and training programs to
identify gaps and avoid duplications.
Dr. Cioffi summarized CDC's role in
providing critical health information as
being part of a continuum from
communication to professional
education. CDC has learned from its
experience with the anthrax attacks,
the spread of SARS, and other
emerging health threats that two
strategies are needed.
CDC's "just in
case" strategy involves making
educational information available to
frontline public health professionals
and clinicians, helping to prepare them
to recognize illnesses that might be
caused by a terrorist agent. A good
example of that strategy is the wealth
of information on smallpox that is
available on CDC's Web site.
The second strategy, "just in time,"
involves being able to provide
information that can be immediately
accessed by public health professionals
and clinicians when they are presented
with a case that may have been
affected by a bioterrorist event.
Clinical guidance and medical
management protocols can be made
available through hotlines, health alerts
and advisories, emergency satellite
videoconferences, and other means.
The starting point for both strategies is
CDC's Web site (www.cdc.gov).
Return to Contents
HRSA's National
Bioterrorism Hospital
Preparedness Program
The purpose of HRSA's National
Bioterrorism Hospital Preparedness
Program is to "ready hospitals and
supporting health care systems to
deliver coordinated and effective care
to victims of terrorism and other
public health emergencies." Guidance
in the first year of the program, FY
2002, made education and training a secondary priority, and program
guidance for FY 2003 made it
optional. Nevertheless, HRSA's
detailed review of applications for
continuation funding found that 100
percent of its grantee hospitals are
addressing education and training for
bioterrorism and other public health
emergencies.
HRSA's analysis of the education and
training being provided by grantee
hospitals included who was being
trained, what topics were being
addressed, and what educational
methodologies were being used.
Because it is a hospital-based
program, the training of laboratory
personnel and medicine, mental
health, nursing, and allied health
professionals was expected. Hospital
training has also targeted fire, police,
and emergency medical personnel.
The topic most frequently addressed
during training is worker safety, which
focuses on how to use personal
protective equipment and how to
perform basic activities while wearing
it.
The second most frequently
addressed topic is psychosocial issues
for both patients and providers.
Other
topics include:
- Responding to biological, chemical, and radiological events.
- Incident command.
- Risk communication.
- Treating special populations.
Grantees reported using several
different educational methodologies:
- 69 percent reported using face-to-face training, either "one on one" or "one to many."
- 61 percent are using distance learning approaches such as Web-based training and video and other tape.
- 55 percent are using field exercises or drills
- 52 percent have distributed written learning materials.
While it is clear that hospitals are
engaged in education and training for
bioterrorism preparedness, neither the
hospitals nor HRSA can answer one
overriding question today. That
question is: "What percentage of the
Nation's health care workforce is
prepared to respond competently to a
public health emergency?"
To help
answer that question, HRSA is
assisting awardees in shifting from
content-focused training toward
competency-based training. Instead of
acquiring content knowledge about
smallpox, anthrax, or radiation illness,
for example, hospital employees
would be expected to be able to
describe and demonstrate their
emergency response role.
"Competency-based education
increases the relationship between
training and workplace applicability,"
said HRSA's Terri Spear. "Health care
providers will have a measure to
assess for themselves that they are as
prepared as they can be in response to
an event and to be able to provide the
best care possible for the population
that they are serving."
By offering a
clearer definition of provider
preparedness, competency-based
training also improves the
transferability and comparability of
training across health care facilities.
Further information about HRSA's
National Hospital Bioterrorism
Program is available at
www.hrsa.gov/bioterrorism/.
Return to Contents
Non-Contiguous Training
Dr. Michael Allswede is the principal
investigator on an AHRQ-sponsored
project to develop a competency-based
training approach called "noncontiguous
training" as a method of
teaching hospital personnel the skills
needed to respond to bioterrorism or
other large-scale public health
emergencies. Biological or chemical
or radiation events are different from
other emergencies because they place
the medical caregiver at risk. They may
place patients already in the hospital at
risk and may place the facility itself at
risk. Keeping caregivers, patients, and
the facility safe requires new skill
development and adaptation of other
technical skills.
Those new skills are better taught on
an individual level rather than in a
general drill. Non-contiguous training
divides the hospital disaster plan into
key capacities and key skills that are
then assigned to individual staff
members. The skill level of each staff
member is assessed and needed skills
are tracked as they are acquired to
give each person an individualized
training program. Training is divided
into segments so that the staff member
can learn the skills during down-time
or on regular CME training days. In
effect, each person has his or her own
individual disaster plan. When a
general drill is then held, or if an
emergency event occurs, each
individual knows what he or she is
supposed to do.
The concept of non-contiguous
training has been borrowed from the
U.S. Navy's Afloat Training Exercise
and Management System (ATEAMS).
A Navy ship is similar to a hospital in
disaster emergency training, said
Allswede, in that "you cannot just stop
a ship and have it go through a
training day and then start it going
again." Similarly, hospitals cannot stop
their normal functions to take part in a
drill.
Moreover, drills are often
scheduled at the convenience of
individuals from other sectors of the community, such as the police. (For
example, drills may be scheduled in the
morning, which is optimal for the
police force but almost always very
busy for hospitals.) In addition, drills
are costly and consume significant staff
time. At the University of Pittsburgh
Medical Center, for example, a disaster
drill in the emergency department costs
$3,000 per hour in staff salary alone.
Non-contiguous training is intended to
disseminate knowledge and skills prior
to a disaster drill, thereby making the
drill more effective and efficient.
The program being developed by Dr.
Allswede and his colleagues has also
borrowed a concept from the U.S. Army
called the "FAPV" sequence, which
stands for Familiarize, Acquire,
Practice, and Validate. The first two
components lend themselves to noncontiguous
training.
- The Familiarize
component includes classic classroom
teaching, distance learning, video
interface, and memory enhancement
tools like mnemonics.
-
The Acquire
component employs two
methodologies. One is virtual interface
using an interactive computer program.
The second is a training room
containing approximately 40
physiologic mannequins that have
pulses, can talk, and can exhibit a wide
range of symptoms. Medical staff can
practice treating symptoms in a
controlled environment.
The Practice component is best done in
a standard drill format. The focus of the
drill is not on whether the individual
knows what to do, but whether
individuals and groups together can
apply the skills they have acquired to
accomplish their objective.
- The Validate
component may be "the real thing" or
an unannounced drill, but can also be
done in a non-contiguous way. The
University of Pittsburgh Medical
Center, for example, validates the
training of their microbiology
technicians by occasionally submitting
a slide containing a biological pathogen
among normal slide sets. The objective
is to validate the ability of the
technician to identify the pathogen and
respond in an appropriate manner.
The non-contiguous training program
will be published by AHRQ. Until that
time, additional information is available
from Project Director Lucy Savitz,
Ph.D., at the Research Triangle
Institute: savitz@rti.org.
Return to Contents
Preparing Volunteer Nurses for Public Health Emergencies
With support from an AHRQ grant, the
Vanderbilt University School of
Nursing is developing and will evaluate
modules that are intended to prepare
volunteer and non-active nurses to
respond to events of bioterrorism or
other public health emergencies. The
evaluation will compare online with
face-to-face training to determine the
effectiveness and efficiency of each
approach. The project will also attempt
to define user characteristics that
predict selection and completion of
training by each method, and to
determine the adequacy of technology
integration in learning emergency
response skills.
The project is targeted at inactive
nurses who have volunteered for the
Medical Reserve Corps (MRC) in their
local communities. MRC volunteers
must be trained to know what their role
is in an organized response to a mass
casualty event. The Vanderbilt project
will provide that training. Furthermore,
the Vanderbilt team believes that nurses
who have volunteered will be more
motivated to learn.
The training modules that are being
developed under the project are based
on competencies created by the
International Nursing Coalition for
Mass Casualty Education (INCMCE),
which is hosted by the Vanderbilt
University School of Nursing. Those
competencies are now available on the
INCMCE Web site, http://wwwincmce.org.
The first module is called "The Tipping
Point," because a large public health
emergency may require value shifts. For
example, the nurse's traditional approach
to triage may need to change. A mass
casualty event requires that the triage
nurse's decisions must be based on what
will do the most good for the greatest
number of people. Thus, the critically ill
person may not be the one who should
be treated first—a value shift.
Each of what will ultimately be seven
modules will be posted on the INCMCE
Web site as they become available.
Return to Contents
Discussion
Following the presentations the
audience was invited to submit
questions to the panelists. Five major
subjects emerged from the ensuing
discussion.
Sources of Information About Competencies
In addition to the nursing competency
for mass casualty education, other
competencies have been developed by
several professional organizations. Also,
CDC has sponsored the development of
competency sets for public health. A
listing of Web sites where competencies
can be found is provided as part of this
issue brief.
Public Health Emergencies Other than Bioterrorism
One question raised was whether surge
capacity education and training was
being approached from a total health
perspective, with the range of
microorganisms and infectious diseases
that health care workers may face.
Michael Allswede responded by
describing the "trifurcated response"
disaster plan at the University of
Pittsburgh Medical Center (UPMC).
The trauma response maximizes
personnel, equipment, beds, and
medications, all concentrated on
victims, or the emergency department.
The hazmat response starts with the
fundamental understanding that
something bad has happened outside
the hospital and must be kept outside
the hospital; this applies to a chemical
event or a radiation event. The
quarantine response involves
configuring the hospital to take in
potentially infectious or hazardous
patients by segregating staff and
contaminated patients from noncontaminated
patients.
Joan Cioffi noted that CDC's dual
strategy of "just in case" and "just in
time" applies not just to a potential
bioterrorism event, but has been proved
to be effective in response to recent
outbreaks of SARS and monkey pox
and the potential of avian flu. Betsy
Weiner pointed out that the broader
term to describe the response to a mass
casualty incident is an "all-hazards"
approach.
Competency-based Training
In response to a question about
decontamination training, Michael
Allswede described how UPMC has
moved from time-based to objective-based, or competency-based, training.
UPMC started with the Occupational
Safety and Health Administration's
certified four-hour, eight-hour sequence for decontamination training. That
approach was useful for familiarization
with the decontamination system, but
did not necessarily demonstrate the
acquisition of actual skills.
The
questions to be answered are:
- Can you or can you not get into your decontamination suit in two minutes or less?
- Can you or can you not operate the decontamination system?
- Can you or can you not, in a four-person team, decontaminate one patient every six minutes?
The answers to those
questions can be measured by
observation. When the desired skill
level is reached, the hospital can be
confident that staff will be able to
respond to an actual emergency.
Medical Reserve Corps
Vanderbilt's use of nurses who had
volunteered for the Medical Reserve
Corps elicited additional information
about the MRC. Betsy Weiner
explained that each MRC unit is
configured according to the needs of
the community it serves. Thus, units
may include expected professionals like
physicians, nurses, pharmacists, and
emergency medical technicians, but
also veterinarians, for example, because
some infectious diseases may appear
first in animals.
In addition, April Kidd
called from the National Office of the Medical Reserve Corps to provide the
program's Web site, where more
information can be found. That Web
site is http://wwwmedicalreservecorps.gov.
Incident Command System
Another caller raised the issue of the
importance of incorporating the
Incident Command System and
incident management system principles
into the training modules that are being
developed. This includes creation of
integrated training opportunities among
health care, public safety, emergency
medical services, and other public health
entities as part of the team training
process.
Betsy Weiner responded that,
indeed, one of the lessons learned in
development of the mass casualty
education modules for nurses was that
incident management system principles
had to be included at the outset. Mass
casualty response, she said, is a process
that must be well integrated.
Michael Allswede, on the other hand,
pointed to the experience of the UPMC
Health System, which includes 20
hospitals and approximately 7,000
doctors. They have learned that the
hospital component of the Incident
Command System involves too many
people without enough decisionmaking
power. The UPMC Health System has
thus reduced the number of physicians
in the command center to three higher-level
people with better decisionmaking
power.
Return to Contents
Conclusion
Stakeholders, including decisionmakers at the Federal, State, and local
levels; health system emergency
planners; and providers, all have an
essential role in ensuring sufficient
surge capacity within their
communities and regions. To guarantee
a rapid response in the event of a
public health emergency, they must
have sufficient staff available to
respond, and those staff must
understand their roles and perform
them effectively.
Workforce education
and training—including the
competency-based training approach
described in this issue brief—will be
critical to ensuring health systems'
successful response to significantly
increased surge capacity requirements.
Return to Contents
For More Information
The complete audioconference on
"Surge Capacity—Education and
Training for a Qualified Workforce" is available as a text transcript on the
AHRQ Web site at http://www.ahrq.gov/prep/ and will be made available as a streaming presentation.
Additional Resources Related to Bioterrorism, Surge Capacity, and
Health System Preparedness |
| http://www.hsrnet.net/ahrq/surgecapacity/event1/materials/competency_training.htm |
This site provides a helpful compilation of resources on
competency-based training for bioterrorism and other public
health emergencies. |
| http://www.nursing.hs.columbia.edu/institute-centers/chphsr/btcomps.pdf |
This link offers a CDC brochure for all public health workers on core
competencies related to bioterrorism and emergency. This link offers
a CDC brochure for all public health workers readiness. |
| http://www.incmce.org/competenciespage.html |
The INCMCE Web site offers a description of education needed by registered nurses responding to mass casualty incidents. |
| http://www.hrsa.gov/bioterrorism/ |
HRSA's Web site provides information on the National Bioterrorism Hospital Preparedness Program including detailed guidance on HRSA's regional surge capacity benchmarks. |
| http://www.medicalreservecorps.gov |
The Medical Reserve Corps' Web site offers information on its
mission and activities, including access to a LISTSERV™ for MRC
communities. |
Return to Contents
| This issue brief was prepared for AHRQ by AcademyHealth under
contract No. 290-98-0003. |
AHRQ Publication No. 04-P028
Current as of October 2004
Internet Citation:
Surge Capacity—Education and Training for a Qualified Workforce. Bioterrorism and Health System Preparedness, Issue Brief No. 7. AHRQ Publication No. 04-P028, October 2004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ulp/btbriefs/btbrief7.htm
540 Gaither Road Rockville, MD 20850