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AHRQ Evidence reports and summaries AHRQ Evidence Reports, Numbers 1-60 51. Training of Clinicians for Public Health Events Relevant to Bioterrorism Preparedness Evidence Report/Technology Assessment Number 51 Prepared for: Contract No. 290-97-006 Prepared by: AHRQ Publication No. 02-E011 The Johns Hopkins University Evidence-based Practice Center expresses its appreciation to Saba Syed, B.A., Kirk A. Harris, Jr., B.A., Xiaoyan Song, M.D., M.S., Neel Patel, and Neil R. Powe, M.D., M.B.A., M.P.H., for their contributions to this project. This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied. AHRQ is the lead Federal agency charged with supporting research designed to improve the quality of health care, reduce its cost, address patient safety and medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps health care decisionmakers -- patients and clinicians, health system leaders, and policymakers -- make more informed decisions and improve the quality of health care services. This document is in the public domain and may be used and reprinted without permission except for any copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders. AHRQ appreciates citation as to source, and the suggested format is provided below: Catlett C, Perl T, Jenckes M, et al. Training of Clinicians for Public Health Events Relevant to Bioterrorism Preparedness (Evidence Report/Technology Assessment No. 51 (Prepared by Johns Hopkins Evidence-based Practice Center under Contract No. 290-97-006). AHRQ Pub. No. 02-E011. Rockville, MD: Agency for Healthcare Research and Quality. January 2002. ISBN 1-58763-072-9 The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-Based Practice Centers (EPCs), sponsors the development of evidence reports and technology assessments to assist public- and private-sector organizations in their efforts to improve the quality of health care in the United States. The reports and assessments provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies. The EPCs systematically review the relevant scientific literature on topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to developing their reports and assessments. To bring the broadest range of experts into the development of evidence reports and health technology assessments, AHRQ encourages the EPCs to form partnerships and enter into collaborations with other medical and research organizations. The EPCs work with these partner organizations to ensure that the evidence reports and technology assessments they produce will become building blocks for health care quality improvement projects throughout the Nation. The reports undergo peer review prior to their release. AHRQ expects that the EPC evidence reports and technology assessments will inform individual health plans, providers, and purchasers as well as the health care system as a whole by providing important information to help improve health care quality. We welcome written comments on this evidence report. They may be sent to: Director, Center for Practice and Technology Assessment, Agency for Healthcare Research and Quality, 6010 Executive Blvd., Suite 300, Rockville, MD 20852.
Objectives. Recent terrorist attacks have increased concerns about the Nation's vulnerability to terrorism, including the potential use of biological weapons. The purpose of this evidence report is to identify and review data on the most effective ways to train clinicians to respond to a bioterrorist attack or other public health events that may pose similar threats to the health care system, including infectious disease outbreaks, toxidromes or mass poisonings, catastrophic events that incite public fear, and events that call for use of hospital disaster plans. Search strategy.The Johns Hopkins University Evidence-based Practice Center (EPC) searched electronic literature databases, including MEDLINE and the Educational Research Information Clearinghouse (ERIC), using separate strategies for each database. The EPC also searched Internet Web sites and conducted a hand search of references and selected journals. The search covered articles published through May 2001. Search terms included biological warfare, bioterrorism, communicable disease, disease outbreaks, epidemic, disaster planning, catastrophe, toxins, toxidromes, poison, disease notification, surveillance, education, and evaluation. Selection criteria.Paired investigators independently reviewed the titles and abstracts of citations identified by the search to exclude articles that were not written in English, did not include human data, had no original data, had only a meeting abstract, did not include health care professionals, did not address bioterrorism or a relevant public health model, did not include training or education, or did not include evaluation data. Data collection and analysis.The paired reviewers evaluated study quality in terms of representativeness of study population, methodologic bias, description of the educational intervention, outcomes, and statistical analysis. The reviewers also extracted information on learning objectives, targeted learners, educational methods, results, and conclusions. The EPC team synthesized information qualitatively because the studies were too heterogenous to support quantitative synthesis. Main results.The search identified 1,942 unique citations, of which 60 were eligible for complete review. Of these, 53 evaluated the training of clinicians for detection and management of an infectious disease outbreak, 1 evaluated training of clinicians in how to detect and manage toxidromes or mass poisonings, 5 addressed training in how to respond to events that call for the use of hospital disaster plans, and 1 evaluated training of clinicians to report infectious diseases to a central agency. None of the studies evaluated the training of clinicians in how to use Web- or telephone-based central information resources or to communicate with other health professionals during a public health event. Many of the studies had low study quality scores. However, several pertinent findings emerged from some of the studies: 1) use of standardized patients was an acceptable and effective way to train physicians in detection and management of infectious disease outbreaks; 2) satellite broadcasting was an effective way to train large numbers of clinicians and to standardize training across geographically separated groups; 3) a tabletop exercise may be useful for training health care professionals about management of a bioterrorist attack; 4) disaster drill training improved clinicians' knowledge of hospital disaster plans and allowed identification of problems; and 5) a didactic program can help train infection control nurses to report certain infectious disease symptom complexes to a central agency. Conclusions.Modest evidence exists about effective ways to train clinicians to detect and manage an infectious disease outbreak. Very little evidence exists about how to effectively train clinicians to respond to other types of public health events deemed relevant to bioterrorism preparedness. Almost no evidence exists on training clinicians in aspects of response such as using central information resources, communicating with other professionals, and reporting events to a central agency. This gap in evidence warrants an increased commitment to developing and evaluating educational programs relevant to bioterrorism preparedness, infectious disease outbreaks, and other public health events. SummaryOverview Recent terrorist attacks against the United States have increased awareness of the Nation's vulnerability to terrorism. One particularly serious form of terrorism involves the use of biological weapons that could cause devastating epidemics. To minimize the risks of bioterrorism, the United States has made bioterrorism preparedness a priority for government and military agencies, public health advocates, law enforcement, first responders, and health care professionals. Based on the recommendation of a working group led by the Centers for Disease Control and Prevention (CDC), preparation efforts are concentrating on smallpox, anthrax, plague, botulism, tularemia, and the viral hemorrhagic fevers. These agents have been chosen as areas of focus due to their ease of dissemination and transmission, high mortality rates, ability to cause public panic, and need for special public health preparedness. Until recently, the public and private health care sectors had been largely excluded from the Nation's bioterrorism preparatory efforts. The very group that would handle the consequences of an attack has yet to receive widespread education on the topic. Fortunately, the value of bioterrorism education has been recently recognized, leading to a significant question: How does one effectively train clinicians for such an unusual public health crisis? The purpose of this evidence report is to identify and review data on the most effective ways to train clinicians to respond to a bioterrorist attack or other public health event posing similar challenges to the health care system. Reporting the EvidenceThe target population addressed in the studies reviewed in this evidence report consists of clinicians including physicians, physician assistants, nurses, nurse practitioners, and community health workers. The target audience for the report consists of policymakers and others developing educational strategies for health care professionals that could be involved in the assessment and management of victims of a bioterrorist attack. To identify the most effective methods to train clinicians to respond to a bioterrorist attack, the Johns Hopkins University Evidence-based Practice Center (EPC) addressed the following key questions: Q1a. What are effective methods for the initial training of clinicians for detection and management of a bioterrorist attack or other public health event? Q1b. What are effective methods for updating and reinforcing the training of clinicians for detection and management of a bioterrorist attack or other public health event? Q2. What are effective methods for training clinicians to use Web- or telephone-based central information resources in response to a bioterrorist attack or other public health event? Q3. What are effective methods for training clinicians to report events to a central agency in response to a bioterrorist attack or other public health event? Q4. What are effective methods for training clinicians to communicate with other health care professionals in response to a bioterrorist attack or other public health event? Due to the paucity of literature pertaining specifically to the education of health professionals in bioterrorism preparedness, the EPC sought to include evidence on the effectiveness of training clinicians for other types of public health events with similar training requirements. Distinctive requirements include the ability to rapidly identify unusual disease syndromes, to contact public health officials, and to communicate with disease control agencies as well as other health professionals. The relevant public health events considered in this report were infectious disease outbreaks, toxidromes or mass poisonings, catastrophic events that incite public fear, and events that call for use of hospital disaster plans. MethodologyTo identify all studies potentially relevant to the key questions, the EPC team searched electronic databases and Web sites and conducted hand searching of references. The databases searched were: MEDLINE; the Educational Research Information Clearinghouse (ERIC); HealthSTAR; the Specialized Register of Effective Practice and Organization of Care Cochrane Review Group (EPOC); the Research and Development Resource Base in Continuing Medical Education (RDRB/CME); the Social, Psychological, Educational and Criminological Trials Register (SPECTR); and PsychINFO. The team also searched the database of the National Technical Information Service of the United States Government. Hand searching focused on journals that were most likely to have eligible studies, as well as reference lists in key articles. The Internet was searched using the metasearch engine Copernic 2000. The search covered articles published through June 2001. For the first step in the review process, two members of the EPC team independently reviewed the titles identified by the search for relevance to the project. All titles deemed irrelevant by both reviewers were excluded from the abstract review process. Each potentially relevant abstract was circulated to two members of the study team who independently reviewed the abstract and indicated which, if any, of the key questions the article addressed. For articles found not relevant, the reviewers indicated a reason for exclusion. The exclusion criteria were: not written in English; did not include human data; no original data; meeting abstract only; did not include health care professionals; did not address bioterrorism or a relevant public health model; and did not include training or education. Each relevant article was read by a pair of reviewers using a form to assess study quality and a form to extract information from the article. At least one reviewer had advanced training in research methods and at least one had relevant advanced clinical training. The reviewers evaluated study quality in terms of educational methods, reporting of representativeness, bias and confounding, description of outcomes, and statistical quality. Study quality scores were calculated for each of the five categories based on the percentage of study quality items that were adequately addressed. An overall quality score was calculated as an average of the five category scores. On the content form, the reviewers abstracted the following types of information from each eligible study: learning objectives, characteristics of targeted health care professionals, educational methods, results for each type of learning objective, and conclusions. Data from the article review process were entered into a relational database. Findings
This evidence report highlights the lack of strong published evidence about how to train clinicians for bioterrorism preparedness. Furthermore, there is a paucity of well-designed studies pertaining to the training of clinicians in management of public health events relevant to bioterrorism preparedness. This has significant implications for future research in training health professionals in this area. To determine the most effective way to train clinicians on how to respond to a bioterrorist attack or other serious public health event, future work will need to give more attention to evaluating the effectiveness of educational programs. Evaluation methods should include pretesting and posttesting, as well as at least one comparison group. The use of measurable outcomes will be critical to ensure unbiased determination of the efficacy of educational strategies. Furthermore, targeted outcomes should be linked to well-defined learning objectives. The following specific questions are areas for future research. They are vitally important questions to answer and are currently without published evidence.
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