As the first in a series on bioterrorism offered in 2004, this Web Conference was broadcast March 2, 2004. It was designed to share with State, local, and health system policymakers the latest information on research findings and strategies related to education and training that may improve planning for hospital and health system surge capacity.
Cindy DiBiasi: Good afternoon. Welcome to Surge Capacity: Education and Training for a Qualified Workforce. This is the first event in a series of free Web-assisted audio conferences on surge capacity and health system preparedness. These events are designed for State and local health policymakers and health system decision makers. The series is sponsored by the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality, often referred to by the acronym A-H-R-Q. My name is Cindy DiBiasi and I will be your moderator for today's session.
The context for this series is clear and compelling. Bioterrorism continues to be a significant threat to the health and well-being of our nation. Efforts to address this threat have focused considerable attention on the need to improve and strengthen the U.S. health care and public health infrastructures to be sufficiently prepared to respond to a major public health emergency.
An important aspect of bioterrorism preparedness is that of surge capacity. Surge capacity is a health care system's ability to rapidly expand beyond normal services to meet the increased demand for qualified personnel, medical care and public health in the event of bioterrorism or other large-scale public health emergencies or disasters.
A number of important stakeholders, including policymakers, planners, and other decision makers at the Federal, State and local levels, program administrators, health system decision makers and providers all have an essential role in ensuring that sufficient surge capacity exists within their own jurisdiction, region or delivery system. To be effective in their planning efforts, it is critical that they have information about the latest research, tools and models focusing on surge capacity available to them. Today's event is the first one in the 2004 series on surge capacity and health system preparedness. I will tell you more about this series later in the broadcast, but right now let's turn to today's call.
We will be exploring the key issues, research findings and strategies related to education and training for surge capacity. Let me begin by introducing today's panelists. In the studio with me I have Terri Spear, Bioterrorism Education and Training Specialist in the Emergency Preparedness Evaluation and Specialty branch of the Special Programs Bureau of the Federal Health Resources and Services Administration. Dr. Michael Allswede, Associate Professor of Emergency Medicine and Section Chief of the Special Emergency Medical Response in the Department of Emergency Medicine at the University of Pittsburgh Medical Center. Betsy Weiner, Senior Associate Dean for Educational Informatics and Professor in Nursing and Biomedical Informatics in the School of Nursing at Vanderbilt University and Joan Cioffi, Senior Service Fellow in the Public Health Practice Program Office at the Centers for Disease Control and Prevention and Joan will be joining us remotely. Welcome everyone.
Before we begin our discussion, I would like to tell the audience a bit about the format of this audio conference. First we will talk with our four panelists and then open the lines to take your question. We will give you instructions on how to send questions to us later in the program. Although we don't anticipate that you will experience any technical problems, I would like to give you a few tips on dealing with them just in case they come up. If you are on the Web and experience any problems viewing your slides, click the "Help" button in the bottom right-hand corner of your screen to troubleshoot your Web connection. If it appears that the slides are not advancing, you may need to restart your browser and log on again. If you experience any difficulty with the audio stream, you may access the audio by phone by dialing 1-888-496-6261 and using the password "surge capacity." These dial-in instructions are posted on the right-hand side of your screen in the small, black box. If you are on the phone and need technical assistance, dial "*0." For people who are listening by phone but watching the slides on the Internet, please be aware that you will notice a delay in the slide changes because they are timed to match the Internet broadcast.
Now I think we are ready to discuss today's topic and let's begin with Joan Cioffi from the Federal Centers for Disease Control and Prevention, the CDC. There Joan has been working on education and training initiatives related to bioterrorism and health system preparedness. Joan, what is the CDC doing to address the education and training needs in terrorism and health system preparedness?
Joan Cioffi: Cindy, the preparedness and response capabilities of our community depend on health care, public health and the responder workforce. 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.
The Office of Terrorism Preparedness and Emergency Response here at CDC reports to the CDC director and is responsible for overall strategic coordination in the agency. One of the 11 strategic imperatives is a competent and sustainable workforce and it is very important that this has been cited specially in the plan because this enables us to focus on increasing the number and type of professionals in the response workforce, developing and delivering competency-based education and training, strengthening recruitment into the workforce and evaluating the impact of our efforts. Lynn Steele, who was to be on this conference call, is the Senior Advisor for Education and Training.
Generally speaking, I can categorize our activities in three broad areas, the first being the State and local program, which is OUR grant program to 50 States, the District of Columbia, eight territories and three cities. The second are CDC-directed education and training efforts and these can be focused internally or externally. In 2003 alone we estimated that there were 427 distinct educational activities in that category. We also view our Web site as a very important tool and in an average month we reach four million Web viewers and certainly in emergencies more than that. The other would be leveraging partnerships and there are two examples I will discuss today. One is our Centers for Public Health Preparedness Program, which is a national network of approximately 36 centers located in academic institutions, most of which are directly involved in training to meet state, local and national needs. The second partnership is our clinician outreach where we are working with medical specialty groups.
Cindy DiBiasi: How are states using CDC funds from bioterrorism preparedness and planning cooperative agreements for education and training?
Joan Cioffi: The cooperative agreement includes detailed guidance in specific focus areas, one of which is education and training. The focus areas like planning, epidemiology surveillance, laboratory capacity, information technology, risk communications, strategic stockpile, almost all of those include an education and training effort, but in the section that is finally referred to as "Focus Area G", there is guidance to the states around how to ensure integration and coordination of training across the focus areas. Generally speaking, we have expected the states to conduct needs assessments, develop training plans and have some capacity to maintain data on who has been trained with these funds.
Taking a look at the grantee-provided information, we estimate that 52% of the grantees have completed their needs assessment in 2003. For 2004, a review of their plans indicated that although the range of training varied from ten to 67, most states average planning at least 40 distinct training interventions sort of across the board on different categories. We are looking forward to making sure that best practices are disseminated on a regional and national basis and currently in the process of developing some system performance indicators and exercises and drills that will help the grantees test their system performance and we believe that this will help them in the future refine and better align their proposed training activity.
Cindy DiBiasi: Joan, you mentioned working with partners to address increasing public health capacity for preparedness and response. Can you tell us a little bit more about that?
Joan Cioffi: Yes. There are two things that I think would be relevant, especially relevant for today's presentation. The first is our Centers for Public Health Preparedness Program. We started that in 2000 with four awardees and are up to 23 accredited public schools of public health. These are complemented by 13 specialty sites, which are also in academic institutions but are more often in schools of medicine, law, veterinary medicine and nursing.
The Centers work with state and local partners in meeting identified needs, community needs. An example would be the University of Chicago in Illinois is working with the Illinois Department of Health and also the City of Chicago and has worked to provide needs assessments for all the public health staff, is developing customized training and helping with the learning management system. UIC has also developed a certification program for emergency response coordinators in that state.
The Centers program in schools of public health we know have at least 300 courses that vary from general to very specific topics that are available and we are really working to enhance the collaboration among those centers so that although we are looking for national standardization, we understand there needs to be some local customization. We anticipate that these groups will be well positioned to provide things more nationally as we move forward with the programs. We certainly believe that our academic institutions are natural partners for addressing pipeline issues and designing certification program to assure a prepared workforce.
One thing we also learned too is the importance of working directly with the clinician community. CDC is a credible source of information for health care professionals and while they see us as a credible source, they also want their information and guidance also from professional peers and organizations that they normally work with. So to foster those kinds of relationships, we have worked with the Association of American Medical Colleges and eight specialty societies and have a relationship with them that we are working on the development of customized information for those groups. We estimate that that relationship alone brings us in direct contact with over 300,000 frontline clinicians.
Cindy DiBiasi: Now the CDC is a direct provider of education and training for terrorism preparedness. How is the agency coordinating these efforts?
Joan Cioffi: Yes, you are right. CDC itself directs and provides education, not only internally but also externally and recently we determined that just in 2000 alone, there were about 600 education and training activities that were either developed or delivered by CDC staff for internal or external audiences. An example of a program that the audience may even be aware of is our Forensic Epidemiology course, which was developed in response to the events of 9/11, and anthrax bringing public health and law enforcement together. This has been disseminated nationally and since August of 2003 we estimate that more than 50 communities have used the program and the program has reached about 3,500 nationally.
We have an internal committee that is working to assure that we have better internal coordination and that we better identify gaps and avoid duplications. Certainly for our own surge capacity needs we have to train our emergency operation staff, field staff, etc. So this is an issue for both what CDC can do directly to an external audience but equally importantly for our own internal audience.
Cindy DiBiasi: Joan, how would you summarize the CDC strategy for surge capacity needs?
Joan Cioffi: Well, as a result of our experiences with anthrax and SARS and other emerging health threats, we view our role in providing critical health information as being part of a continuum from pure communications to more formal professional education. We often speak of needing "just in time" and "just in case" strategies. The "just in case" means providing frontline health professionals and clinicians with what they need to recognize illness that might be caused by a terrorist agent. This is an ongoing process and certainly takes advantage of Web-based and distance learning formats. An example of this would be the availability of smallpox information in multiple formats. The "just in time" strategy means that we need to be able to provide information that can be accessed by public health and clinicians when they are presented with a specific person or case that may have been affected by terrorism. This means developing capabilities for real time and continuous updates. We need to have immediate clinical guidance and medical management protocols available through hotlines, health alerts and advisories, emergency satellite videoconferences, etc.
In summary, we will work with other federal agencies and state and local academic partners as well as internally to assure that we have a response-capable frontline workforce.
Cindy DiBiasi: Joan, could you please tell our listeners how they can find more information on the CDC's initiatives in this area?
Joan Cioffi: Well, we would recommend that the best place is we try to have our Web site be a one-stop shop so I would direct everyone to our main Web site and use the search capabilities there which is the www.cdc.gov and also Lynn Steele, who is our Senior Advisor for Education and Training, would be more than happy to assist partners in any specific questions that they might have on this issue.
Cindy DiBiasi: Great. Joan, thank you. We will be back to you but first I would like to turn to Terri Spear from the Federal Health Resources and Services Administration, also known by the acronym H-R-S-A. Terri is working on a number of HRSA-sponsored initiatives that focus on education and training including the National Bioterrorism Hospital Preparedness Program. Terri, tell us what HRSA hopes to achieve through the National Bioterrorist Hospital Program.
Terri Spear: The National Hospital Bioterrorism Preparedness Program exists to prepare hospitals in supporting health care systems to deliver a coordinated and competent response in the case of an emergency, bioterrorism or other public health emergency.
Cindy DiBiasi: What is currently being done by HRSA awardees in the area of education and training for hospital preparedness?
Terri Spear: Well, this program is a two-year old program. In the first year it became very clear to us that our awardees were, let me say, planning to plan. In the second year, which it recently has gone through its second funding, we became able to tell what forms of training had already been done and who were looking at it. The training aspect for awardees is an optional area. So we initially thought that only a portion of them would be moving in that direction. When we surveyed the 2003 applications that came in, we found that roughly 80% of them were actively reporting that they were participating in education and training. However, when we looked in the other areas such as laboratory capacity and many of the other areas, scoured the applications very closely, we found that 100% of our programs, even though it is an optional area, were addressing education and training.
Cindy DiBiasi: You said it was sort of like the "who", "what" and "how".
Terri Spear: Yes.
Cindy DiBiasi: Let's start by talking about the "who".
Terri Spear: OK. When we did that review we found out that because we are a hospital-based program, we had hoped that a wide range of professionals were being focused on or targeted for training. We actually found that that was the case, that they included such disciplines as laboratory personnel, first responders and the like. We were very pleased with the fact that they were working with fire and EMTs, again showing that they are not only training the in-hospital personnel, but those that interact with that hospital personnel helping to coordinate the whole system across.
Cindy DiBiasi: Let's talk about some of the topics you will be focusing on.
Terri Spear: Sure. The programs told us that the number one area that they were looking at, most of the programs were on worker safety. That probably comes from OSHA requirements and a number of other functions, but under "worker safety" we were looking at personal protective equipment, they were teaching their employees and others how to use that equipment, when to use it, how to perform basic activities while encased in personal protective equipment and which ones were good. They also showed that they were looking at psychosocial issues which has to do not only with the responses of the community or their patients themselves, but also the providers, the EMS, the fire and the like as they were coming in as well as their own staff in response to an issue of terrorism.
They also then had the ones we could predict, the biological, the chemical, the nuclear; the explosive activities also were underway along with a host of other activities.
Cindy DiBiasi: Let's talk a bit about how you approached the training.
Terri Spear: OK. We were curious as to what were the most common methodologies that our hospitals and our states were using to provide the training and we were able to break that out. We saw that the most common methodology was face-to-face training, most of our programs. That is the one-to-one or the one-to-many kind of training.
The second one, which we were glad to see, was that distance education, that roughly 81% of our training programs were done through distance education and that could be Web-based, such as how this program is being displayed. Or it could be enduring entities such as tapes, videotape, and other forms of tape. The other piece of information we were really concerned about had to do with the dissemination of written materials. How many of them were sending out books and pamphlets and examples of posters that they were utilizing to try to educate and serve as reference materials to those providers. We found that a wide range of methods were being utilized.
Cindy DiBiasi: Now this sounds like such a huge undertaking. Is there anything left to do?
Terri Spear: Actually there are. As we look across the country, we can find that there is a lot of education going on. However, when we ask simple questions such as, and Congress asks us these questions on a regular basis, what percentage of the nation's health workforce is prepared to respond competently to a public health emergency? This sounds like a pretty simple question. We were unable to answer it. If we look at our federal response, we not able to answer that question today.
If you look at local and state responses, they are not able to answer that question accurately either. And when they turned to the professionals themselves and they say, "Are you prepared?" a recent study that was conducted found that even the providers themselves can't say, "I am ready to respond." That only roughly 20% of them indicated in a survey that they were able to respond. So if the federal government can't answer that question accurately and the state and local people can't and the providers themselves can't, we need to begin looking at that area.
Cindy DiBiasi: Let's talk a bit about the future direction. Where is this program headed?
Terri Spear: Well, we are going to be working with our awardees. We have 62 awardees in the states and various jurisdictions and the territories. To assist them in moving from content-focused alone training, which was considered traditional training to, and examples of that are strictly smallpox training, strictly anthrax training, strictly radiation illness alone. Those have a role, that content has a role in the education, but to utilize that along in the determination of a prepared workforce is a little risky. So we are moving from that traditional method towards competency-based models. Competency is where you bundle together the skills, knowledge and abilities of an individual in a given context do you actually demonstrate a behavior. So we will begin working in that area.
Cindy DiBiasi: Why did you decide to do this now?
Terri Spear: Well, first of all we are not alone in saying that health professional education needs to move in this direction. As we look around, we see that there are many activities moving in competency-based education. We know that there are existing bioterrorism competencies for a host of professions. We know that public health has a listing; medicine is working on that area but also has a listing of competencies; nursing, EMS, hospital-based employees and hospital administrators. So one of the reasons we are moving in this direction is the health professions themselves are telling us we need to.
Cindy DiBiasi: Let's talk some about the benefits of competency-based education.
Terri Spear: I would love to. Competency-based education allows for programmatic definition and differentiation. It allows for folks to clearly focus on what is being done. It also increases the focus on the questions of what percentage of the health care workforce is prepared to respond. It will begin to allow us to get outcome measures that will begin to answer that question. It also increases the relationship between training, the actual act of training, and workplace applicability so that it can be measured. Then the training outcomes are observable and therefore measurable.
We also hear stories of health professionals who tell us that they have taken four classes, were required to take four classes in anthrax training when that initially came out. There was no way to check off whether that content knowledge had been achieved so that people were finding themselves in the same classes over and over again. Our hospitals were frustrated with that. Release time became a major issue for health professionals and moving towards standardized competency-based training would allow for transferability and comparability of training, so that you would be able to tell apples are apples and oranges are oranges. And people would be able to indicate that they have already received that training and are able to demonstrate that skill and utilize their resources to obtain skills they hadn't been able to identify.
It also allows for efficiency in resource utilization. We won't be repeating much of the educational lessons unless it is necessary. There may be cases where it is necessary to repeat training. We are not saying that repetition in itself is an evil thing; we know that there are cases where that is very necessary but at least you will know it is needed and not just simply being done.
It also will allow for a clearer definition of health care provider preparedness. The health care providers themselves, I use the term "will have a dipstick", much like you test your oil. They will have a measure to be able 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 their population that they are serving.
The last thing that it will hope to do, and this is something that I harp on pretty regularly, is it will allow expensive drills and exercises to have added utilization. One of the ways, only one of the ways will be evaluating whether a competent workforce exists, is through exercises and drills. It would allow that tool to be utilized for additional activities.
Cindy DiBiasi: Terri, how can our listeners find out more about your program?
Terri Spear: Well, for more about the National Hospital Bioterrorism Program, you can go to the Web site that will appear on the screen soon, but it is www.hrsa.gov/bioterrorism/ or they can contact me. I would be happy to answer any questions they may have and my E-mail address is tspear@hrsa.gov.
Cindy DiBiasi: Great, thank you Terri. We will be back with some questions for you, but now lets turn to Dr. Michael Allswede from the University of Pittsburgh Medical Center. He is currently working on an AHRQ-sponsored project that has developed an innovative training program to help health care systems adequately and effectively train hospital personnel. Michael, your group; I am sorry, can you start by giving us a brief overview of what the non-contiguous training program is?
Dr. Michael Allswede: Absolutely Cindy. I run a large health care system and I do a lot of the disaster management. One of the key pieces that I wonder about is the same thing that Terri Spear discussed in her presentation, which is the question of will we actually respond? If you look at a bioterrorism or a chemical terrorism or a radiation event, they are different than normal disasters because they place the medical caregiver at risk. They may place patients at risk within the hospital; they may place the facility itself at risk, depending on the sort of event that you are managing. To keep the patients safe and the facility safe it requires new skill development on the part of the personnel and adaptation of rather technical skills.
What our realization was was that skills are not adequately taught in drills and that to acquire these sorts of skills we needed to develop an innovative program. So what we have done is create a non-contiguous training program where our disaster plan is broken up into key capacities and key skills which are then assigned to our various personnel and tracked to our various personnel such that we can follow up with new nurses or nurses that have been there for a while and get a skill profile. What sort of training would be needed and then be able to individualize that training for each person. The non-contiguous training is chopped up into segments such that downtime or normal CME training days can be utilized in order to transmit those skills instead of having a remote, all-staff sort of lecture, which is expensive and relatively inefficient.
Cindy DiBiasi: Well let's talk about the key advantages to training the workforce in this manner.
Dr. Michael Allswede: Absolutely. If you think about is, weapons of mass destruction cause several challenges. First off, there is a triage inversion that occurs because those who can get away from a site will in fact get away from the site so the least injured people present first. Well, it doesn't seem reasonable to turn away people from a disaster event, but in fact that may be the correct decision. Training our people in how to conceive of that is a reasonable thing to do. Also, if you follow the sorts of weapons of mass destruction disasters like the Tokyo sarin event, they had a contamination of hospital personnel so in the midst of this disaster, if you don't respond appropriately, you start subtracting people from your staff.
What we attempted to do with our non-contiguous training project is to disseminate individual knowledge and skills prior to the drill and prior to the disaster and allow people to familiarize themselves, acquire those skills and then be able to practice them such that each individual person has their own individual disaster plan. I am somewhat embarrassed to report that I am the author of a 300-page disaster plan. It sits as the holy book in my office and in the office of the medical director and no one would ever read it, and particularly in a time of emergency. What we try to do with our disaster training is make that document come alive so that the doctors know what they are supposed to do, the security guards know what they are supposed to do and there is not a lot of wasted effort.
Cindy DiBiasi: Has this method of skill acquisition maintenance ever been used in other industries?
Dr. Michael Allswede: Yes Cindy, we have blatantly borrowed it from the United States Navy. The United States Navy has a great deal of similarity in disaster emergency training to a hospital in that you cannot just stop a ship and have it go through a training day and then start it going again. You have to have a way that those individuals on a ship can practice their disaster skills, their fire skills, their flood skills, their battle stations, whatever.
The Navy concept is called the Afloat Training Exercise and Management System and it is a methodology by which different skills are segmented and assigned to different personnel and trained in a normal but non-contiguous cycle such that if you are a cook and your job is to man a fire hose, at the end of your day when you have your hour of training period, you go to the training room and you learn how to operate a fire hose and then you go to your bunk and rack-out for the rest of the night. We have basically taken that approach to a hospital because we think that there are enough similarities between their system and the cross-challenges of hospital training that we think we can adapt the architecture.
Cindy DiBiasi: Why should a hospital adopt a non-contiguous training concept when they are already doing drills?
Dr. Michael Allswede: Well there are three basic reasons. First off, hospitals can't stop their normal function. Because hospital drills are generally scheduled at the convenience of the community, they generally happen in the morning, which if you think about a hospital is when all the elective surgery happens, admissions and discharges happen so there is only a limited area within the hospital and limited number of personnel to actually be able to play in the drill.
Secondly, and as any of us who have been through disaster drills understands, if you are senior enough to have been through a few of these things, you schedule important meetings or perhaps out of town trips because you don't want to be part of this thing. It is generally a large amount of standing around with people telling other people what to do and a lot of misinformation and confusion.
The second reason is that shifting, if you were to actually do competently a disaster drill, you need to layer on an additional shift of people in the hospital to play the drill as well as take care of the patients and that is expensive. In our hospital system, we will spend $3,000 an hour in salary alone to play a drill in our emergency department. That is not including the administrative staff. That is not including the rest of the hospital. That is just the emergency department staff. I would refer you to the $16 million that the United States spent on TOPOFF II to train for a day or two a shift or two of individuals throughout the United States. It is just expensive.
Lastly, if you chose to make that investment, you ought to be able to get something for it, but if you layered on an extra shift at our emergency department, one shift of nurses is actually 8% of our total nursing staff; 5% of our total attending physicians. Because residents have educational duties, etc., you won't get any of the residents. So at great expense, at great disruption to the hospital, you actually end up training a minority of people and what is worse is that you don't actually acquire skills during the disaster drill because the disaster drill doesn't allow or the format of the disaster drill doesn't allow for skill acquisition in a training environment.