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Transcript of Web Conference (continued)

Cindy DiBiasi: So how do you teach the skills so people show up, that you are hitting the right people?

Dr. Michael Allswede: We have adopted again from the military the FAPV sequence, which stands for Familiarize, Acquire, Practice and Validate. The "familiarize" skill we use a number of modalities from classic classroom-sorts of teaching to distance learning, video interfaces, various memory tools, mnemonics, those sorts of things so that people understand where their disaster drill might be.

We also use this as a, in the disaster, a personal disaster drill as a small fact sheet. There is a segment in our disaster plan for individual people that gives you the numbers that you are supposed to get called, where the equipment is supposed to be, those sorts of things, quick reference sorts of things.

For acquisition of skills, we use various practice, muscle memory methodologies by using either a virtual interface so we have an interactive computer program that you can interface with or a training room. In our case, our training room is inhabited by about 40 or so physiologic mannequins that have pulses and can talk and can exhibit all sorts of symptoms and things. So we actually train people not only in the knowledge acquisition in the classroom, but we also then toss them into a controlled environment where they can actually give medications in Level A and that sort of thing to feel how it would be.

These two sections, familiarize and acquire, are the two functions or the two skill levels that we feel the non-contiguous training program is especially good at doing.

Practicing skills is best done in the standard drill format where the focus is not does the individual know what to do, but the focus is do individuals and groups of individuals work well enough together to be able to at the other end of the process have an objective capability, something that actually works.

Lastly, for validation. Validation of course is the real thing, but can also be done in non-telegraphed and no-advance-warning sorts of drills. We do that also on a non-contiguous basis. For example, we have started in our microbiology department to slide in biological pathogens in the normal slide sets such that a microbiology tech reading urine slides for the day might come upon a, [unclear] bathobacilusanthrasis slide and we want that person, without advance warning, without knowledge, to be able to do and respond in an appropriate manner, to validate that in fact they are trained and they know what their plan is and that the system will in fact work.

Cindy DiBiasi: So what kind of reaction have you been getting to this training program?

Dr. Michael Allswede: Well, I don't have any official satisfaction numbers, but the ability for a group of trained physicians and nurses, allied health professionals, to hone in on the disaster skills that they need and not do all the rest of it is a tremendous advantage. For those of you involved in disaster drills, the usable portion of a three-hour disaster drill is generally about 15 minutes of your actual time doing something or learning something and the rest of the time is standing around drinking coffee and complaining about how this is so screwed up. So what we try to do is take that 15 minutes and expand it out, integrate it into the normal C&E cycle that you have already paid for in terms of staff training time and to create actual acquisition of skills to focus on the WMD challenges.

Cindy DiBiasi: Well, let's tell our audience where they can find out more about what seems to be a very interesting training program.

Dr. Michael Allswede: Absolutely. This project has ran through the Research Triangle Institute through Lucy Savitz is the project officer. You can find it on the AHRQ Web site and if you are interested enough to call me at the University of Pittsburgh, I would be happy to receive your call.

Cindy DiBiasi: Wonderful. Thank you Michael. We will be back with lots of questions, I am sure. In a moment, we would like to open up the discussion for questions from our listening audience, but first I would like to turn to Dr. Betsy Weiner from the School of Nursing at Vanderbilt University. Betsy and her group are currently working on an AHRQ-supported project that is developing and evaluating online and face-to-face training modules that aim to prepare volunteer and non-active nurses to respond to events of bioterrorism or other public health emergencies. Betsy, your group has recently been awarded an AHRQ grant for your work in education and training. Can you start by telling us a bit about this project?

Dr. Betsy Weiner: Surely. Well, you know Terri already talked about educational outcomes, but most people are really surprised to know that many of the educational activities they have been a part of have not been thoroughly evaluated. This is very true with the emergency preparedness and response. I have a research team that actually has 20+ years of experience in developing multi-media so I am aging us when I talk about that, but we believe we can bring our skills in online development through this education and training issue that we have.

We decided to look at nurses that have volunteered for Medical Reserve Corps at the local level and compare face-to-face training versus online training. We are looking at several areas when we do that. One relates to effectiveness and we have a number of variables associated with that. Secondly, we are looking at efficiency. Everybody wants to know what is more expensive and is it going to work? We are also defining user characteristics that select whether they would like to learn things online versus a face-to-face class, which also does become costly when you keep transporting these faculty different places.

Finally, we want to determine the adequacies of technology integration. Is this a good place to use technology? Because technology shouldn't be thrown at a problem unless it is going to help come to some sort of solution.

Cindy DiBiasi: Why are you focusing on volunteer and non-active nurses?

Dr. Betsy Weiner: We really did not want to pull active nurses out of a response workforce that were already connected with other health care organizations. We are going after those who are retired, those who have chosen to be soccer moms or dads for a period of time, and we are going to offer them the training so that they also fit into an organized response. There is nothing worse than a bunch of people showing up to help, but you don't know their credentials, you don't know what they are capable of doing and you don't know if they understand the entire response plan.

The Medical Reserve Corps has been funded for the last two years for various communities to set up their own medical reserve response corps, but they can validate what those competencies are. They can provide educational and training programs for them so that when they show up, when there is some public response, they know what their job is.

I know what I left out. We believe strongly that those people are going to head the initiative to learn because they volunteered.

Cindy DiBiasi: What is the key message about surge capacity? What is the key message that you are trying to get out to these nurses?

Dr. Betsy Weiner: I think, while we don't have one single module that has that in the title, it is a recurring theme. It is a very strong theme for us. What we are saying to the nurses is you may find yourself in a situation that suddenly has outstripped the resources you know are around you. That time will come. You will know that. Suddenly you will look around and have to come to grips with the fact that I may have to do some shifting in my values. I may have to rethink this. I am not sure how I am going to get out of this situation.

Cindy DiBiasi: You are mentioning that there are some value shifts that nurses must make. Give us an example of one of those required changes.

Dr. Betsy Weiner: Probably the biggest value change, a good example of that would be in the method of triage. You look around you and your realize you have limited resources and this particular picture I have I am showing a part of our online program where it is a mock set up outside Vanderbilt it is clear that there is not a place for everybody. There is not a slot to fit them in to evaluate them and they are there and you are the nurse in the middle of all this realizing, "Whoa. I want to go home." You can't go home. That is not an option. You have to realize that what you have to do is the most good for the greatest number of people. Sometimes that is not the most critically ill person that you are taking care of for the first time. So to have a chance to talk about that, our nursing think tank people, when they organized the online modules felt so strongly about this value shift that the first module, it is called The Tipping Point.

Cindy DiBiasi: How does your work differ from other training programs?

Dr. Betsy Weiner: Well, when Terri talked about competency-based training, we are very fortunate to have an international nursing coalition for mass-casualty education that is hosted by Vanderbilt. Colleen Conway-Welch, Dean of the Vanderbilt School of Nursing, started that group prior to 9/11. It consists of schools of nursing, nursing accrediting body, specialty organizations and governmental agencies. We are up to about 80 representatives now.

The first thing they really wanted to do was to develop these competencies that could be used by everyone. I have taken those things in my online development work and actually put them out into a grid. I will show you a Web site later you can go to look at that. There are a large number of those competencies and so it is somewhat unwieldy, but we know we are going to be very thorough in what it is that we are turning out.

Secondly, our online work is based on something called The How People Learn Framework. This framework was developed by a study for the National Research Council that actually evaluated all of the educational research that was out there to try to ascertain what is the best way. How do people learn? If we don't know how they learn, we don't know how to teach them.

So in The How People Learn Framework there are some things that sound like they are so common sense you wonder why we haven't thought about them. First, students come with preconceptions. They all have a different background, but they come with something and we need to go to where they come from. This sounds like common sense too, but if you are going to develop these competencies, students have to have a foundation; they have to have a conceptual framework, a place to put the items that you are asking them because if they don't know where to put them, they don't know where to retrieve them later, particularly when you are stressed out. Students have to take control of their own learning. We can't push it on them. Finally, we have to come up with teaching/learning environments that are learner-centered, knowledge-centered, assessment-centered and part of the community of scholars.

Now you might wonder, OK, so what do you do with all that? We put it into a learning cycle. In our learning cycle, in each module that we develop, it starts out with a challenge question and so after the challenge questions, the person takes down notes about what does this mean to me? If I had to answer these questions right now, with nothing to look at, what am I going to say? They get a chance to later, after the resource section, which is quite massive with wonderful interviews and resources, they are going to compare that and say, "Well, I did know a little bit about what I needed to do to begin with. Probably more than I ever thought I knew."

Cindy DiBiasi: Are any of these modules available?

Dr. Betsy Weiner: I wish I could say they all were, but we are currently in production for the first three that for me is a frustration of the time it takes to get these things developed. We hoped to have the first three available in late April. The next two should be ready by early fall and then I am still looking for funding dollars to do the last two modules.

Cindy DiBiasi: OK, that was your commercial. (Laughs.)

Dr. Betsy Weiner: There you go. As soon as each module is available, we will be posting that on the International Nursing Coalition Web site for people to use. These were all done through federal funding and so they are available. We are not charging for any of these products. We might later if a learning management system is put on top of some of those modules.

Cindy DiBiasi: OK, and you can see the slide is now up. Is that where they can get information on the modules?

Dr. Betsy Weiner: That is it, www.incmce.org.

Cindy DiBiasi: OK, thank you Betsy. We will be back to you. In a moment we are going to open the lines for questions from our listening audience, but first let me tell you how to communicate with us.

There are two ways you can send in your questions. The first is by telephone. If you are already listening on a phone, all you have to do is press "*1" to indicate that you have a question. If you are listening through your computer and want to call in with a question, dial 1-888-496-6261 and use the password "surge capacity", and then press "*1." Remember that while you are asking your question on the air, please don't use the speakerphone or cell phone to ask your question. Be sure to speak loudly and clearly. If you are listening through your computer, it is important that you turn down the volume after speaking with the operator. There is a significant time delay between the Web and telephone audio.

If you want to send a question in by the Internet, simply click the button marked "Q&A" on the event window on your computer screen, type in your question and then click the "Send" button. One important thing, if you prefer not to use your name when you speak with us that is fine, but we would like to know what state you are from, the name of your department or organization, so please provide those details regardless of whether your question comes in by phone or by the Internet.

As you are formulating your questions and queuing up on the phone lines, I would like to say a few words about our sponsor. The mission of AHRQ is to improve the quality, safety, efficiency and effectiveness of health care for all Americans. Two of AHRQ's operating components helped to produce this series of audio conferences. First, AHRQ's User Liaison Program serves as a bridge between researchers and state and local policymakers. ULP not only brings research-based information to policymakers so that you are better informed, but we also take your questions back to AHRQ researchers so they are aware of priorities at the state and local level. Hundreds of state and local officials participate in ULP workshops every year.

Secondly, AHRQ's Center for Primary Care, Prevention and Clinical Partnerships provides expertise and leadership on primary care practice and research, both within AHRQ and throughout the Department of Health and Human Services. The Center supports extramural and intramural research that informs a wide range of issues related to primary care practice and policy.

I'd like to take a quick moment to thank Dr. Sally Phillips, Director of AHRQ's Bioterrorism Preparedness Research Program in the Center for Primary Care, Prevention and Clinical Partnerships. She has been instrumental in helping to produce this series.

ULP and the Center for Primary Care, Prevention and Clinical Partnerships hope that today's Web-assisted audio conference and the remaining events in this series will provide a forum for a productive discussion between our audience of policymakers and researchers.

We'd appreciate any feedback you have on this Web-assisted audio conference and at the end of today's broadcast a brief evaluation form will appear on your screen with easy to follow instructions on how to fill it out. Please be sure to take the time to complete the forms. For those of you who have been listening by telephone only and not using your computer, we ask that you stay on the line. The operator will ask you to respond to the same evaluation questions using your telephone keypad. Your comments on this audio conference will provide us with a valuable tool in planning future events that better suit your needs. Also you could E-mail your comments to the AHRQ User Liaison Program at https://info.ahrq.gov.

OK, well why don't we go to our questions from the audience. The first question is from Beth Neeley for Mike. The question is, "Have you ever considered the use-modeling simulation in the validation phase of your approach, in conjunction with the drills, for example?"

Dr. Michael Allswede: I am not familiar with the use-modeling simulation as a piece of software, but I think that...

Cindy DiBiasi: I think it is the use of modeling simulation.

Dr. Michael Allswede: Oh, the use of modeling. All right.

Cindy DiBiasi: Just in general.

Dr. Michael Allswede: All right. I thought that was a proprietary name.

Cindy DiBiasi: It will be now that you have (unclear).

Dr. Michael Allswede: Exactly. And my IPO will be coming up in a while. (Laughing.) We use a number of simulation-sorts of scenarios that are developed, usually in planning with our city and in planning within our health care system.

If you have listened to AHRQ Webcasts in the past, you have heard me speak about the Pittsburgh Matrix. The Pittsburgh Matrix is a rather large study, again funded by AHRQ that provides a response-sided model for bioterrorism response analyzing the response key capacities and key resources to bioterrorism with its two primary variables, which to me and then we feel that we have validated that, are the timeline of the event, when in the course of an event the health care system has a chance to learn about what is happening and respond to it and then how big the victim load is relative to capacity.

We have focused on our non-contiguous training program on acquisition of basic skills. But one of the adaptations of the non-contiguous training program is because all these training modules are electronic, they can be sent through the Web. So if we are receiving a volunteer corps or a cadre of individuals from another area, they can train up on our facility, what it looks like, where to stand, how to operate the various features of the facility prior to actually getting there. One of the key features in a surge capacity, integrating volunteers are people that don't normally work in a facility are all the basic "finding my way around" sorts of problems.

So by using the non-contiguous training module not only can we make our staff better but we can mail it to folks who may in fact be our assistants in time of crisis so that they become skilled before they even get there, in a just-in-time format.

Cindy DiBiasi: A question for the panel. "Are there competencies already developed that could be used as templates for developing them at our hospital and how can people ask us these?"

Terri Spear: There are a number of competencies that are already in existence. Unfortunately, each set is in a different area. [interference]

Terri Spear: The nursing competencies are available on Vanderbilt's?

Dr. Betsy Weiner: Yes, they are on that incmce.org Web site and the difference with those competencies is we actually had members of the nursing coalition begin the authoring of these. It went through a research process and we finally reached agreement from everybody around the table and it took almost twelve months to do that, which is surprising. Again, we say that there are a large number of them, but they are agreed-upon competencies.

Joan Cioffi: Excuse me, Cindy? This is Joan Cioffi. Can I add? Actually if someone is interested in getting copies of the Competency Sets for Public Health, and those would include core competencies for emergency response and then BT-specific ones, I can provide a link and send it to the folks at AHRQ that they can make available to the participants. That is some work that we have sponsored in the past and has formed the, if you will, guiding framework for the work that our centers for preparedness have been doing and information that we have shared with our grantees. So I can get some specific Web sites to folks...

Terri Spear: Is that the work out of Columbia?

Joan Cioffi: Yes, it is the work out of Columbia and it is on their, it is on a couple of their Web sites including the Center for Public Health Preparedness at the mailman School Public Health Web site.

Terri Spear: And if anybody would like the competencies for the other health professions, if they E-mail me, I can send them all of the links that I have to the various Web sites where they exist. I have a sheet on that.

Joan Cioffi: But you are working from bioterrorism competencies for the hospital setting, right?

Terri Spear: As well as some of the professional ones, yes ma'am.

Dr. Michael Allswede: If anybody is interested in a list of professional incompetencies, I would be happy to provide that, a list of that as well. (Laughter.)

Joan Cioffi: This is Joan again. Just another comment because I can share this with the AHRQ folks as well. I was able to get one of our research assistants to really shop the Internet and find for some of the other disciplines as well what might be out there, so between Terri and myself we think we probably can get most folks on this broadcast with as much as available electronically.

Cindy DiBiasi: Great, great. Thank you. OK, on the phone with us from Massachusetts we have Steven, it is either Weinstein or Weinsteen.

Steven Weinstein: Right, thank you. The presentation, which was great by the way, seemed to have focused on bioterrorism agents. I was wondering if there is equal attention being played to emerging pathogens and emerging infectious diseases? We all saw what happened with the recent SARS outbreak and of course it could be other emerging issues if avian flu ever crossed over to human-to-human transmissions. So the question is, are we looking at this from a total public health perspective with the range of microorganisms and infectious diseases that health care workers may face?

Cindy DiBiasi: Michael?

Dr. Michael Allswede: Yeah, when we look at our plan from hospital response, we are not very pathogen based. In fact, we write our treatment protocols based on bioterrorism pneumonia, not what we are going to do for tularemia, what we are going to do for plague. We take a global approach with the presumption that you don't know what the agent is and you have to make a decision in that environment. Secondly, you don't know how many agents that you are dealing with. You just know the one that you know about so there are unknown unknowns.

In order to make a hospital work, what we have done in our disaster plan is we have trifurcated it. We have a disaster plan that is written for trauma response, which maximizes personnel, equipment, meds, beds and drugs, all concentrated on the victim field, which is the emergency department. We have a hazmat response in which we use as a fundamental understanding something bad outside the hospital that we are keeping outside the hospital which is applicable for a chemical weapon event; applicable for a chemical spill, an accident; applicable for a radiation event.

Then we have a quarantine plan, which we know, the hospital configures itself such that we will be taking in potentially infectious or hazardous patients. By doing so we need to segregate our staff and our patients in our care areas from the non-contaminated patients because we have a dual responsibility. We have a responsibility to those individuals who are sick with SARS or whatever the outbreak might be, but we also have a responsibility for those individuals that are getting better from surgery or having a heart attack or whatever else to not get SARS in the hospital. And if you are a fan of infectious diseases, as I can tell you are, that I feel that that is a significant problem with hospital response because generally in an infectious disease outbreak there is communicable event, the hospital makes it worse because the concentration of victims infects other people.

Cindy DiBiasi: Joan, is there anything you would like to add to that?

Joan Cioffi: Yes. Just again, the strategies I spoke about broadly, the just-in-time, just-in-case strategies would really very much fit into the notion that we are looking beyond just the terrorist, bioterrorism-type of agent and certainly one of the ways we have been able to test our systems most recently here at the agency have been with things like monkey pox and SARS, etc. and avian flu and so forth. So the being prepared, we got a lot of practice with emerging infections as well as the bioagents that actually really stimulated a lot of hard thinking about reaching the frontline clinician community with the end first responding community, etc., with the information it needed just in time.

Dr. Betsy Weiner: I think the other terminology that you hear is an all-hazards approach as a process that certainly we are trying to address. I think we overuse the term "bioterrorism" because many of the funding sources we went after used that lingo. Terri can certainly speak to that, but it is certainly broader than just bioterrorism.

Cindy DiBiasi: We have on the phone from Tennessee Clara Hare. Hello?

Clara Hare: My question is regarding decontamination training in competencies. Is there a process that you have used in your institutions that have worked well and is there certification required to do this decontamination training or can you use a train-the-trainer course?

Dr. Michael Allswede: In our perspective, experience doing decontamination training, we started with the OSHA-certified sequence which is a four-hour, eight-hour combination. But those were wonderful for familiarization of the decon system, but really didn't do very much for us in terms of acquisition of actual skills. So what we have done in our system is we have gone away from the OSHA time-based training and we have gone toward an objective-based training, which is a can-you, can-you-not get in and out of your suit inside of whatever, two minutes? Can-you, can-you-not operate the disaster, our decontamination system? Can-you, can-you-not decontaminate in a four-person team one patient every six minutes? When you are at that skill level, we think that you actually have a facile capability that you can use in a time of emergency as opposed to a bunch of people that have had a lecture a year ago on decontamination and they are trying to figure out whether the boots go on first or whether the suit goes on first. We actually think that doing it is a much better way to do it. So we have started with what is already out there, a time-based and gone to objective-based training.

Terri Spear: And through their work, we are working on with competency-based education, that is the whole point of moving towards competency-based education. It is to move from simply seat time being the indicator of performance to actual behaviors and performance. I am over here clapping as Michael is talking.

Cindy DiBiasi: A practical question for the panel from Scott Nelson. "Do you have a list of funding resources for training aids? Sometimes it is difficult to get funding when working for private, for-profit hospital systems. Terri?

Terri Spear: We all ask the question that way. (unclear) (Laughter.)

Dr. Michael Allswede: Well, the University of Pittsburgh is not going to fund your hospital. (Laughter.)

Terri Spear: Our funds go directly to the state to be distributed to the hospital and each state pretty much various states and jurisdictions have utilized different formulas and methodologies for distributing the national hospital BT money. I would recommend you speak with your state health department to find out how they are distributing their dollars and to see if there are resources available for you there either through the National Bioterrorism Hospital Preparedness Program or the CDC's program as well.

Cindy DiBiasi: A question for Joan from Countess Hudson. "Which specialty societies are partnered with CDC as part of clinician outreach? I am hoping AAFP and ACOEM are two of them." Joan, are you there?

Joan Cioffi: I'm sorry. I had to remind myself to hit that mute button. Yes, I do have the name of the societies and this might only be the beginning. Clearly, and I think Dr. Dan Baden, who is in the Office of Communications and has been on these calls before could even speak more broadly, but the ones through AAMC, dermatology, family physicians, the American College of Physicians, the Osteopathic Society, the emergency room physicians, infection control and emergency medical technicians are some of the key ones, but the AAMC has over 90 professional societies that are linked with that so we have even broader outreach just through the AAMC itself, and that is the Association of American Medical Colleges but it represents not just the schools but a broad range of professional societies.

Cindy DiBiasi: And Joan, another partner in question for you from Richard Calcoat. "Is the CDC partnering with HSA, CMAC to provide information on best practices regarding mental health and substance abuse responses to bioterrorism in conjunction with other public health services?

Joan Cioffi: Yes. Clearly the partnerships at the federal level are very important and within our center for injury prevention and control there are some staff who have a specialized interest in mental health issues and who are knowledgeable about the activities of some of the other agencies. While CDC does not have a lead on the mental health component, it certainly is a very important component in the work that we do and certainly have recognized that that was a very important piece of response so yes, the answer to the question is yes, we are partnering with those groups as well.

Cindy DiBiasi: A question for Betsy from Sharon Longshore from South Carolina. "How many states have a Reserve Medical Corps and are they active and how can we contact them?"

Dr. Betsy Weiner: You can go to the Medical Reserve Corps site. I think just do a Google search because I might give you the wrong address related to that. But there were about 50 Medical Reserve Corps who were funded in the first year's initiative. Primarily the successful ones have been able to connect their Medical Reserve Corps with their overall regional response plan. Those grants were only for $50,000, which is not a lot of money. Perhaps a half of FTE for someone to organize that and make sure that the correct kind of publicity is out about the Medical Reserve Corps. The second year funding was also for about $50,000. So they are listed by state on that site to be able to see if there are ones that are funded.

Now there are additional ones that are coming up that don't have funding, but again have them as part of their regional response plans. To my knowledge, I don't think those are listed on that site. My suggestion would be to contact your local public health department because they should be the center of any of those sorts of plans that are existing, so there are funded Medical Reserve Corps and those that are unfunded.

Cindy DiBiasi: We have Dawn McKinney on the phone from Washington, DC. Hello?

Dawn McKinney: Yes, I am with the National Association of Community Health Centers and I had a question for Terri Spear at HRSA. I was wondering, I guess, if you have a sense from your grantees about the level of involvement or to the extent they have been able to involve health centers and surge capacity as well as education and training?

Terri Spear: When we did our review of the applications, which is what I am relying upon for the 2003, there was evidence that community health centers were strong partners in the education and training activities. We, however, are working with our awardees to continue to push in that direction and will hopefully see greater activity in that area as the programs mature.

The program is called the Hospital Preparedness Program, but we have increased efforts on hospitals and health care systems, of which community health centers are very much a part of that.

Dawn McKinney: Thank you.

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