Challenges and Balances
Challenges to meeting the emergency preparedness continuing education needs of New York clinicians include both content and process elements. The NYCEPCE intends to work collaboratively with HRSA, the project advisory board and the various groups represented on that board to find resolutions that work. Among the challenges are balance in content, time for participation in education, balance between distance-based and in person training, coordination with other training efforts, and sustained competency of seldom used skills.
Balance in content
Perhaps the biggest challenge facing anyone providing education on emergency preparedness to clinicians is finding a balance between the clinicians’ natural interest in diagnosis and management of specific conditions and the NIMS requirement that individuals first know and understand that their response is part of an overall system that can support and sustain a community through the challenge of an emergency, beginning with initial response within his/her usual setting and then deployment as needed elsewhere through planned assignment or volunteer activities. In developing the modules prepared under the current Bioterrorism Curriculum Development Program (BTCDP), the project staff has been able to engage clinicians by using clinical experts in each type of emergency to assure accuracy and inclusion of vivid details appreciated by clinicians. In addition, each module has been carefully reviewed to assure that key messages about response under ICS (or HEICS within a hospital) are reinforced at every possible opportunity, drawing upon the expertise of individuals responsible for hospital emergency planning, and for integration of hospital response into the wider community’s preparedness. For example, use of chain of command (in contrast to the clinician’s typical individual professional authority) is a repeated lesson, as is the development of personal and family emergency plans to facilitate readiness to respond. Course evaluations and post-tests indicate that while hospital emergency coordinators want HEICS emphasized, it is essential to continue this mixed approach or the interest of clinicians cannot be sustained.
Time for participation in education
First responders and first receivers are in some form of emergency response mode for at least part of every working day and thus are motivated to think about needed education on a regular basis. They are also the health professionals most likely to be involved in any emergency drill or exercise, which are also educational opportunities. However, clinicians who might be first detectors, the staff of smaller settings such as community pharmacies or health centers not under Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements, and the clinicians in specialties and units away from the emergency department do not receive such motivating stimuli. For this enormous group of clinicians, web-based courses that are relatively short and engaging make training more accessible. In addition, these web-based courses may be taken at times and places convenient to the clinician. Developing interactive approaches to allow demonstration of competency in at least the organizational competencies of emergency response also increases the likelihood that clinicians will advance from awareness towards reasonable proficiency.
Balance between distance-based and in person training
Absent the expensive laboratories for full-scale simulation of clinical interventions with patients, courses that require demonstration of some specific skill (performance of a patient care task while wearing Level B personal protective equipment, for example) will require face-to-face interaction. Given the size of New York and the travel challenges in the densely populated New York City area, face-to-face training will be minimized, and the Project Advisory Board and representatives of target audiences will be used to determine what can be done via distance methods and what will require in-person training. For instance, where a more hands-on demonstration may be required, the project will use a hybrid approach with the didactic portion of the training conducted via a distance learning methodology with the opportunity to practice the skill in the local setting and to demonstrate proficiency to a local partner or by submitting a videotaped performance to a central site.
Coordination with other training efforts
With a state as big as New York, the rich array of resources available in New York City, and the level of interest in emergency preparedness since 1999, multiple groups including universities, hospitals, associations and government agencies, have been developing and offering training. Some of this training has focused on clinical training, whereas other trainings have focused on certain aspects of response, such as surge capacity in a mass distribution site, or have been offered at specific sites, such as the Chemical-Biological-Radiological-Nuclear-Explosive (CBRNE) Academy established by the NYC DOHMH and New York University at Bellevue Hospital. The number of clinicians to be educated, however, far exceeds the number of clinicians that have successfully completed currently available training. This project will focus on filling an unmet need (e.g., pharmacists and veterinarians), penetrating more deeply into an audience that is currently only partially engaged (e.g., community physicians who have not volunteered with a medical reserve unit), or surge responder groups. The project will continue to refer potential students to existing course material, when curricula appear to be duplicative.
Sustained competency of seldom used skills
It is highly unlikely that every clinician who takes emergency preparedness training or bioterrorism preparedness will encounter an emergency within the immediate time frame of what he or she learned in a single course. The commitment to an all-hazards approach as recommended by Department of Homeland Security increases the likelihood that general emergency response competencies will be practiced at some interval, especially with the occurrences of extreme weather conditions and other emergency incidents from transportation or industry. In addition, training that emphasizes ICS and the expectation of being assigned a specific functional role with just-in-time refresher training increases the likelihood that important lessons will be remembered and that confidence in response will increase. An important part of this consortium is the plan for evaluation that includes a longer time frame to assess learning, gathering information from participants at 6 and 9 month intervals. The interactive exercise will also make maintaining competency in response easier for the busy clinician.