Training Workshop for Health Care Workers

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Welcome to the
Training Workshop for Health Care Workers
For the Care and Isolation Unit (CIU) of St.
Patrick Hospital
George Risi, MD, Msc Infectious Disease
Specialists, PC 614 West Spruce Street Missoula,
MT www.infectionspecialists.org grisi_at_saintpatrick
.org
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Purpose of This Course

• To familiarize the Health Care Professional with
  the fundamental aspects of Biosafety and
  Biocontainment
• To introduce the concept of Biosafety Levels
• To describe the role of the health care community
  and St. Patrick Hospital in support of research
  activities at the Rocky Mountain Labs
• To replace fear of the unknown with respect for
  the known
• To establish confidence that the proper use of
  established methods to prevent transmission of
  familiar infectious diseases will also protect
  against infection by exotic or high hazard agents.

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Lets Do This Right

• The National Research Council has recently
  published a comprehensive review of the state of
  knowledge regarding how people learn
• Fundamental concepts about how people learn arose
  from this, along with the realization that many
  established methods of education are inconsistent
  with what is now known about effective learning.
• The fundamental concepts of learning apply to
  children as well as adults, and are irrespective
  of ones level of educational achievement

From How People Learn, National Research
Council, 2000
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How People Learn

• Students come to a learning situation with
  preconceptions about how the world works. If
  these initial preconceptions, correct or
  incorrect, are not engaged, the student will
  either
• Fail to grasp new concepts or
• Will learn them just for an exam and then revert
  to the preconception outside the learning
  environment
• To develop competence in an area of inquiry,
  students must
• Have a deep foundation of factual knowledge
• Understand facts and ideas in the context of a
  strong conceptual framework, which allows them to
  organize information into meaningful patterns
• Students need to take control of their own
  learning by defining goals and monitoring their
  progress in achieving them (metacognition)

From How People Learn, National Research
Council, 2000
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Application of Novel Teaching Methods to
Medical Education (in a one day workshop..?)

• What are the preconceived ideas one has when
  walking into a lecture?
• What are the essential facts to be conveyed and
  how to convey them within a frame of reference?
• How does one determine what the listener is
  absorbing?
• Is the listener engaging and self evaluating
  whether or not they are learning the material?

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Essentials for Learning

• Identify the common misconceptions that learners
  have about this topic and rectify them
• Provide information that is relevant
• Engage the learner in the process
• Query the learner in novel ways to determine
  their mastery of the material
• Provide feedback

Whats wrong with this picture?
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Objectives of This Workshop
At the Completion of this Workshop the Health
Care Worker Will be Able to

• List the essential elements of standard and
  transmission based isolation guidelines
• Demonstrate proper technique of donning and
  doffing personal protective equipment
• Illustrate proper technique of hand hygiene

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Objectives Contd

• Apply proper technique for cleanup of infectious
  body fluids within the CIU
• Cite which of the Biosafety Level 4 agents have
  demonstrated person to person transmission in the
  health care environment
• Utilize the information in the pathogen specific
  modules to decide the appropriate type of PPE to
  don for a disease and the stage of illness

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Agenda for the Day

• You have already
• Taken the pretest
• Read the Lassa education module
• Viewed the videos
• Introduction to BSL-4 research
• Techniques for donning and doffing
• Techniques for spill cleanup
• Isolation guidelines

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Agenda

• Lecture Viral Hemorrhagic Fevers
• Interactive sessions. Patient care scenarios
  utilizing the Lassa module
• B. Radley scenario
• Ravenwood scenario
• Potter scenario
• Lecture Hand Hygiene and PPE
• Lunch- on your own

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Agenda II

• Hospital SOP Jeopardy!!! (with prizes)
• Break out sessions
• Duran learning center
• Spill cleanup
• Hand hygiene
• Blood drawing and use of the I-Stat
• CIU if room available
• Donning and Doffing of PPE
• Mannequin training
• Post test and evaluation form
• Group Discussion on further improvements to the
  training

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Feedback

• Workshops are intentionally being kept small
• This is a work in progress
• Your feedback and assistance in improving this
  course will
• Help you
• Help your colleagues
• Help provide optimal care to an exposed individual

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What is the Response of the Medical Community
when a New Disease Emerges?

• Bubonic plague, Surat, India 1994
• Monkeypox, US, 2003

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Surat, India

• State of Gujarat, NE India
• September 1993 earthquake strikes a nearby region
  known to be endemic for plague
• 10,000 deaths, 106 homes destroyed. Survivors
  evacuate but store grain before leaving
• Stored grain results in an explosion of rats and
  fleas
• By mid September, 1994 at least 35 residents of
  the village of Mamala had developed bubonic
  plague

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Bubonic Plague Surat, India, 1994

• A farmer whose bubonic plague had progressed to
  pneumonia travels to Surat to attend the festival
  of Ganesh on 9/18/03, unknowingly transmits
  disease to others
• On 9/21 there are 7 cases of pneumonic plague, 6
  more the next day
• On 9/22 the BBC reports an outbreak resulting in
  panic and mass exodus
• Within 12 hours 100,000 had fled, 300,000 more
  the next day
• By 9/24 600,000 or half the population of Surat
  had fled

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The Worlds Reaction

• 9/28 the Gulf states ban all flights, goods and
  citizens from India
• Pakistan and Sri Lanka follow the next day, then
  China, Russia, Egypt, Malaysia, Bangladesh
• North Korea denies docking privileges to all
  ships of any nationality that had previously been
  in Indian waters
• The U.S. attempts to screen all arriving
  passengers from India
• Stock Market in Bombay crashes
• Estimated loss from trade and tourism 1.3
  billion

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Actual Toll of Cases

• 6300 reported, only a few confirmed and using
  invalidated techniques
• Total deaths 56
• No convincing transmission outside of Surat
• No tourists contracted plague
• No patients with plague are known to have
  actually left India during the outbreak

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And the Medical Response?

• On the one hand
• Ministry of health seems to lack good
  information. Recommendations were late
• Of 137 private physicians, 80 fled the city,
  closing their clinics and abandoning their
  patients
• On the other hand
• Hundreds of physicians and nurses in the
  community and at the Civil Hospital stayed on the
  job and cared for hundreds of patients

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The Gambian Giant Pouch Rat
Up to 32 inches long Up to 2 ½ pounds
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Monkeypox, US Midwest, 2003

• April 9, 2003 a Texas animal importer received a
  shipment of 800 small mammals from Ghana, West
  Africa with 6 different genera of rodents
  including Gambian giant rats.
• The rats were sold to an Iowa vendor who then
  sold them to a vendor in Chicago, Illinois. The
  Chicago vendor housed the rats in a cage near a
  cage of domestic prairie dogs.
• Prairie dogs from the Illinois vendor were sold
  or traded at swap meets to persons from
  Illinois, Ohio, Wisconsin and Indiana.
• Many of the prairie dogs became ill and died from
  what was later recognized as monkeypox.
• 72 cases of monkeypox were reported to CDC from
  Wisconsin, Illinois, Indiana, Ohio, Kansas and
  Missouri.

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HCW Response

• In Rockford, Illinois a 10 year old girl is
  admitted with fever and rash, suspected diagnosis
  of monkeypox
• All but one physician and 4 nurses refused to
  provide care for the patient. Over 4 days they
  worked in shifts
• Marshfield Clinic, Wisconsin. Similar case, but
  no HCW reluctance. No occupational transmission

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Rockford Explanation

• Globalization has resulted in the recognition of
  several serious emerging infectious agents in the
  US during the past year, including SARS, WNV, and
  monkeypox. The tempo of this infectious disease
  assault combined with the lack of time for the
  professional health care community to acquire
  knowledge and come to terms with the handling of
  these frightening diseases has uncovered an
  apparent change in the traditional professional
  values of some medical practitioners.

Anderson MG, Ped. Infect Diseases 2003221093
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Lessons Learned Why SOME HCW are Reluctant and
How to Address

• Has there been a change in the medical culture ?
• HCW have always had differing responses to a
  disease outbreak
• A recent survey of US physicians revealed that
  80 would continue to care for patients in the
  event of an outbreak of an unknown but
  potentially deadly illness, but that only 21
  felt prepared for doing so.
• Issues raised
• Ignorance of the disease and methods of avoidance
• Fear, for themselves and for their loved ones

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What Do HCWs Need?

• Sense that risks are shared equally. Lead from
  the front
• Ready access to information
• For RML, knowledge of what agents are being
  studied in advance
• A well engineered healthcare facility that
  enhances safety
• Detailed knowledge of and confidence in
  transmission based isolation guidelines and their
  correct application
• Reliable PPE and knowledge of proper use
• The confidence that is instilled by frequent
  testing and drilling

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READY?