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Competency and Training for Health Practitioners Working in Remote Oil and Gas Operations

A Consensus Document

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Contents

List of Abbreviations 4

Introduction 5

Purpose 5

Who is this document for? 5

Disclaimer 5

Definitions 6

Responsibility 7

Mindset 8

Registration and Experience 8

Competency and Training 9

Training Delivery and Competence Evaluation 9

Training Duration 9

Skills Maintenance 9

Emergency Medicine 10

Primary Healthcare 12

Preventive Medicine 12

Health Administration 13

Extreme Remote Locations 14

References 14

Appendix A: Recommended RHCP Training Contents 15

Appendix B: Abstract: Developing Consensus on Remote Healthcare Practitioners’ Competency for Oil and Gas Operations: A Delphi Study 18

Appendix C: Workshop Participants and Contributors 20

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List of Abbreviations

Introduction

AED Automated external defibrillation ACLS Advanced cardiac life support ALS Advanced life support ATLS Advanced trauma life support BLS Basic life support CPD Continuous professional development DFA Designated first aiders DKA Diabetic ketoacidosis ECG/EKG Electrocardiogram ENT Ear, nose and throat FRM Fatigue risk management FTW Fitness to work HACCP Hazard analysis critical control point HCP Hearing conservation program HRA Health risk assessment HSSE Health, Safety, Security and the

Environment GCS Glasgow Coma Scale GMC General Medical Council IRHC Institute of Remote Healthcare MER Medical emergency response MERP Medical emergency response plan MI Myocardial infarction MSDS Material safety data sheet NMC Nursing and Midwifery Council PHLTS Pre-hospital trauma life support RHC Remote healthcare RHCP(s) Remote healthcare practitioner(s) RTW Return to work WFA Workplace first aid WHPP Workplace health promotion program

Remote Healthcare Practitioners (RHCPs) working in oil and gas operations are responsible for providing on-site emergency, primary and preventive care1 with minimum medical supervision and support. As such, the competency of RHCPs is vital in protecting the health of those working and living in these remote environments. However, there is currently no universally accepted “standard” for RHCP competency and training. Although there are a number of training providers offering courses specifically aimed at RHCPs, their contents, prerequisite qualifications, and exit standards vary widely. These courses are also not accessible to all RHCPs globally. In recognition of this gap, the Institute of Remote Healthcare (IRHC) organised a Remote Healthcare Competency Workshop as part of their 2014 Conference (“Delivering Competent Healthcare in Remote and Rural Environments”), at Olympia, London, on 7-8th October 2014. This workshop was attended by 79 professionals and subject matter experts from around the world representing: energy and maritime industries; academic institutions, technology providers, remote healthcare service providers and emergency medical providers. A key reference for the discussion is the paper “Developing Consensus on Remote Healthcare Practitioners’ Competency for Oil and Gas Operations: A Delphi Study”2.

Purpose

This document is designed to support the IRHC document “Remote Healthcare for Energy and associated Maritime activities (IRHC, 2013)”. It represents a consensus of expert opinion and aims to define the competency expectations and training requirements for RHCPs working in remote oil and gas operations around the globe. It serves to assist: (1) training providers in developing RHCP training and assessment; (2) RHCPs in clarifying expectations on their competency, and (3) Company Health / Health, Safety, Security and the Environment (HSSE) advisors in planning for health support in their respective remote locations. It provides a benchmark for objectively determining the suitability of RHCP candidates, and those who are already in operational appointments. This document does not attempt to prescribe a single competency expectation for each remote site, as the exact requirement must be shaped by the prevailing risks and situation specific to the workplace, company and country. It does, however, offer guidance on a structured approach to RHCP competency.

Who is this document for?

This document is aimed at professionals involved in implementing health in remote oil and gas operations, including:

➔ Company Health/HSSE professionals ➔ Medical training providers ➔ Emergency assistance providers ➔ Remote Healthcare Practitioners (RHCP)

Disclaimer

This document is based on the workshop participants’ individual views, derived from their expertise in providing healthcare in remote locations in the oil and gas industry. The views presented in this document do not necessarily represent the views of the participants’ organisations. Please check that anything you take from this document meets local regulatory or business requirements, and is appropriate for your particular location, activities and risks.

1. Includes occupational health, and public health. 2 Developing Consensus on Remote Healthcare Practitioners’ Competency for Oil and Gas Operations: a Delphi Study. Klein, S.

Mohamed, H. 2014 IRHC Conference, Olympia London, 7-8th October 2014.

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Definitions

➔ Remote Healthcare Practitioner (RHCP): A health professional who is responsible for providing healthcare in remote locations.

➔ Remote Healthcare (RHC): The prevention, diagnosis, and treatment of illnesses and injuries for those who work in remote locations.

➔ Competency3 (Health Professional): The habitual and judicial use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflections in daily practice for the benefit of the individual and community being served.

➔ Remote Location: Sites where the medical evacuation of an injured or ill person to a hospital cannot be guaranteed to be achieved within 4 hours in foreseeable circumstances (e.g. inclement weather). A common example in the oil and gas industry is the offshore platform.

➔ Extreme Remote Location: Sites where medical evacuation to a hospital can never be achieved within 4 hours, even in the best of circumstances. Examples include seismic vessels operating beyond helicopter flying range. In these sites, evacuation times may exceed 24 hours.

➔ Advanced Life Support (ALS): A set of life-saving protocols and clinical skills that extend Basic Life Support (BLS) to further support the circulation and provide an open airway and adequate ventilation (breathing).

➔ Advanced Cardiac Life Support (ACLS): A set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.

➔ Advanced Trauma Life Support (ATLS): A training program for medical providers in the management of acute trauma cases, developed by the American College of Surgeons, as the

➔ Tier 2: Provide assessment and stabilisation by a health professional within 1 hour of any injury or illness that requires it.

➔ Tier 3: Provide admission to and care at the nearest local hospital within 4 hours of any injury or illness that requires it.

➔ ALARP: When response times or requirements above cannot reasonably be met, perform a risk assessment and provide medical emergency response risk mitigation measures5 to ensure that the risks are kept as low as reasonably practicable (ALARP).

➔ Remote Medical Support (“Topside”):6 Real-time specialist medical advice by emergency medical professionals (usually doctors) to the RHCP via telecommunication and/or information technologies. It is also commonly known colloquially as “topside support” in the energy industry. Topside needs to be available to the RHCP on demand, 24/7.

➔ Remote Site Clinic (Tier 2): A site health centre at a remote location for the provision of casualty resuscitation in transit to a (Tier 3) hospital. A remote site clinic has extended capabilities in view of the need to provide Tier 2 support beyond 4 hours. (See also “Site Clinic”).

➔ Site Clinic: A site health centre for resuscitation by a RHCP and the provision of advanced life support (i.e. Tier 2 medical emergency response). (See also “Remote Site Clinic”).

Responsibility

The RHCP is responsible for providing: ➊ Emergency management of ill or injured workers in remote locations; ➋ Frontline delivery of primary healthcare; ➌ F rontline delivery of preventive care (e.g. occupational health, public health, health promotion,

etc.), and standard of care for initial assessment and treatment in trauma centres. ➍ H ealth administration (e.g. managing a site clinic, managing a pharmacy, record keeping,

➔ Fitness to Work (FTW): The certification of an individual that their current level of health is suitable for the safe completion of normal tasks expected of them in the workplace.

➔ Health Risk Assessment (HRA): A process of identifying workplace health hazards, evaluating their risks to health and determining appropriate workplace control and recovery measures in order to prevent acute and chronic health effects to the workers in that work location. It is not the same as FTW (see “FTW”).

➔ Incident: An unplanned event, or chain of events, that has, or could have, resulted in injury or illness to people or damage to assets, the environment or reputation.

➔ Medical Evacuation (“Medevac”): The emergency transfer of ill or injured personnel to a health facility for the purpose of obtaining medical care. It has priority over all normal operations. A medevac may be pursued using various transportation modes (e.g. helicopter, boat, off- road vehicle, or a crew change flight). The term “medevac” is not restricted to those where air transportation is used, or to those where a health professional provided medical support during transfer.

➔ Medical Emergency Response (MER) Standard:4 Various standards of care during medical emergencies exist, with most utilising a time-based tiered approach. A typical example of an MER Standard is as follows:

➔ Tier 1: Provide first aid treatment, including defibrillation, by a designated first aider within 4 minutes of any injury or illness.

communications skills, implementing health programs, etc.)

3. Defining and Assessing Professional Competence. Epstein R, Hundert E, JAMA. 2002 Jan 9;287(2):226-35. 4. Remote Healthcare for Energy and associated Maritime activities. Institute of Remote Healthcare, 2013.

5. Risk mitigation measures include increased medical capability from additional equipment, drugs, telecommunications, as well as enhanced RHCP competency (as described in this document). .

6 Further details on Topside expectations are outlined in IRHC document “Remote Healthcare for Energy and associated Maritime activities (2013)”.

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Mindset

Providing healthcare in a remote location requires the RHCP to adopt a different approach to work than that of working in a hospital setting. RHCP training and assessment must ensure that the RHCP is aware of the need to adopt this differing mindset, which includes:

➊ A ccountability. The RHCP is responsible for delivering health to the individuals on site. The RHCP’s behaviours and actions impacts not only on patient’s safety, but also the site’s operational readiness, business continuity, reputation and legal liability.

➋ B readth. The RHCP needs to possess a broad range of knowledge and skill relating to health. In addition to knowledge of the usual branches of medicine and surgery, the RHCP will also need to utilise his/her knowledge and skills in areas such as pharmacy, dentistry, mental health, public health, occupational health, health management, human factors and operational medicine7. In addition to health, the RHCP will also need to understand safety and engineering issues that are relevant to the workers’ health (e.g. water systems, exhaust fumes, engineering controls for noise and chemicals, etc.).

➌ F lexibility. There are many factors inherent to working in remote locations which require adaptability, flexibility and resilience on the part of the RHCP. This includes a fast-changing

Competency and Training

➊ T o ensure competent practice, the RHCP must complete formal RHCP training, and a formal competency evaluation/assessment process.

➋ T he formal RHCP training and assessment must cover: a. Emergency Medicine b. Primary Healthcare c. Preventive Medicine (including Occupational Health, Public Health and Health Improvement) d.Health Administration (e.g. managing a site clinic, communications skills, record keeping,

implementing health programs, etc.) ➌ I n addition to the baseline RHCP training and assessment, RHCPs who are deployed to extreme

remote locations are required to complete additional training and assessment relevant to this environment.

Training Delivery and Competence Evaluation

operational tempo, sudden crises, extreme environments (e.g. heat, cold, security, altitude), ➊ W hilst the mainstay of RHCP training delivery remains face-to-face, some (but not all) RHCP and limited supplies and support. training components can be delivered via distance learning (e.g. computer-based training).

➍ L eadership. Successful health delivery in remote locations requires the RHCP to be able to ➋ W hilst the mainstay of RHCP evaluation remains face-to-face, some (but not all) RHCP influence without formal authority.

➎ C ollaboration. In order to successfully deliver health, the RHCP requires support from workers, supervisors, and managers, topside, and their back-to-back colleagues. A collaborative mindset helps the RHCP to build trust, establish strong working relationships, and influence.

➏ C uriosity (Enquiring). A mindset of curiosity encourages risk identification, assessment, exploration of opportunities and problem solving.

competence evaluation components can be delivered via distance learning (e.g. computer aided assessment).

Training Duration

No consensus was achieved on RHCP training duration. However, the majority of subject matter ➐ M oral Courage. RHCPs often need to make difficult clinical decisions in difficult circumstances, experts endorsed the view that RHCP training (including distance learning) should typically take 120

with limited treatment options and limited access to information. In addition, RHCPs may often need to hold difficult conversations with employees, supervisors and management.

Registration and Experience

To ensure competent practice, prior to working in remote locations, the RHCP must possess the following:

hours or more. The actual duration required will depend on the individual’s baseline competency and experience. The critical factor is that the achievement of outcomes of the learning is demonstrated by the learner.

Skills Maintenance

➊ T o prevent skills decay the RHCP must: ➊ A current professional registration with a relevant national regulatory body (e.g. medical a. Complete ATLS and ACLS training (or their equivalents) every 3 years, OR complete a series

council, nursing council, a. healthcare professional council, etc.), in order to indicate the RHCP’s baseline competency

and good standing. b. At least 3 years’ of clinical working experience in an Emergency Medicine setting. c. In addition to the above, a one-year working experience in a Primary Healthcare setting is

desirable (but not vital). It is not considered an absolute requirement, as the combination of prior experience (3 years in Emergency Medicine and 1 year in Primary Healthcare) is rare amongst health practitioners in many countries.

Typical RHCP professional backgrounds include Nurse, Physician, Paramedic, Physician’s Assistant, and Military Medic. Any health professional who (a) possess a current professional registration from a relevant national regulatory body, (b) possess the working experience outlined above, and (c) have successfully completed the RHCP competency and training outlined in this document, are suitable for practice from those perspectives.

of shorter, modular, more frequent skills maintenance training in ATLS and ACLS (or their equivalents) as part of a continuous professional development (CPD) approach.

b. Meet CPD requirements of the national regulatory body with whom he/she is registered. No consensus was obtained on experiential training involving real patients (e.g. via hospital attachments) at regular intervals (e.g. every 2 years). However, most participants view this to be highly valuable in maintaining the RHCP’s clinical skills.

7 Basic understanding of the health impacts of onsite work activities (e.g. those relating to diving medicine, tropical medicine, aviation medicine, travel medicine, etc.).

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Emergency Medicine ➑ M anage common dental emergencies (e.g. dental abscess, cellulitis, tooth fracture).

RHCP training and assessment in Emergency Medicine must ensure that the RHCP is able to: ➊ Provide Advanced Cardiac Life Support and Advanced Trauma Life Support.8

RHCP training and assessment emergencies must ensure that the RHCP is able to: a. Manage dental pain. b. Administer dental filling/dressing.

➋ M anage multiple casualty incidents (including: develop and communicate an initial scene c. Replant avulsed front tooth. report, perform primary triage, apply immediately necessary lifesaving treatment and perform secondary triage).

➌ C learly communicate relevant medical information with other medical and rescue personnel

d. Administer local dental anaesthesia. e. Perform dental extraction. f. Manage dental infection (including those involving fascial spaces).

during an emergency. ➒ M anage common psychiatric emergencies (e.g. attempted suicide, acute depression, psychosis, ➍ M anage common medical emergencies (e.g. myocardial infarction, acute asthma, diabetic violent behaviours, etc.). RHCP training and assessment in managing common psychiatric

ketoacidosis, etc.). RHCP training and assessment in managing common medical emergencies must ensure that the RHCP is able to: a. Identify life-threatening electrocardiogram changes. b. Perform the pre-hospital delivery of thrombolytic drugs9 (for acute myocardial infarction)

under the supervision of a topside physician. c. Perform intraosseous access and infusion. d. Perform needle cricothyrotomy. e. Perform needle thoracostomy for a tension pneumothorax. f. Interpret a peak expiratory flow rate (PEFR) result.

emergencies must ensure that the RHCP is able to: a. Assess and communicate suicide risk (including the use of mini-mental health scoring systems). b. Manage acute psychosis and acute confusional states (e.g. delirium tremens). c. Identify and manage severe depression, alcohol withdrawal syndrome, acute anxiety

and panic. ➓ T raining others. Train staff (laypersons) in providing workplace first aid and automated

external defibrillation (AED). To ensure competent training provision, the RHCP must be a certified instructor in: a. Workplace first aid.

➎ M anage common surgical emergencies (e.g. acute abdomen, acute appendicitis, strangulated b. Automated external defibrillation (AED). hernia, acute urinary retention, etc.). RHCP training and assessment in managing common surgical emergencies must ensure that the RHCP is able to: a. Identify signs of an acute abdomen. b. Perform transurethral catheterisation for acute urinary retention.

➏ M anage common traumatic injuries (e.g. fractures, head injury, eye injuries etc.). RHCP training and assessment in managing common traumatic emergencies must ensure that the RHCP is able to: a. Assess and document level of consciousness using the Glasgow Coma Scale (GCS). b. Identify the signs of skull fracture through examination. c. Carry out neurological examination. d. Manage head injuries in the field. e. Manage spine injuries in the field. f. Administer local infiltration anaesthesia (including a nerve block). g. Administer sedation. h. Wound suturing, debridement, and dressing. i. Manage burns.

➐ M anage patient transfer and medical evacuation (including the preparation of a patient prior to movement and medical evacuation).

8 The workshop participants are of the view that the current available Advanced Cardiac Life Support (or equivalent) and Advanced Trauma Life Support (or equivalent) training (e.g. ALS, ACLS, ATLS, ITLS and PHTLS) only partially meet RHC requirements. They do not adequately address industry specific issues (e.g. prolonged field care, aviation medicine, etc.) Until such a bespoke, internationally recognised, industry-specific course becomes available - any of these training can be used as an interim standard.

9 Whist the RHCP is expected to possess the competency to deliver thrombolytic drugs under supervision, the actual implementation of thrombolytic therapy at in specific location will require careful assessment of risks related to the location and the case.

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Primary Healthcare

RHCP training and assessment in Primary Health Care10 must ensure that the RHCP is able to: ➊ Perform primary healthcare consultations ➋ I dentify and manage common and significant complications arising from common chronic

illnesses (e.g. cardiovascular, respiratory, endocrine, gastrointestinal, urological, musculoskeletal, neurological, dermatological, infectious, ENT, ophthalmological, sexual health and mental illnesses)11.

➎ Food and Drinking Water Safety.

a. Describe the principles of food safety and food safety management systems. b. Conduct food safety audits and report findings. c. Participate in outbreak investigations (e.g. norovirus, food poisoning etc.). d. Implement and maintain a food safety management system (e.g. Hazard Analysis Critical

Control Point [HACCP]). e. Describe principles of drinking water safety.

➌ M anage common minor injuries and illnesses (e.g. contact dermatitis, foreign object in the eye, f. Implement procedures to help ensure drinking water safety (e.g. potable water testing). minor burns, etc.). ➏ Ergonomics. Provide basic advice on workplace ergonomics.

➍ Perform minor surgery (e.g. local anaesthesia, wound care, etc.). ➐ H earing Conservation. Participate in the implementation of Hearing Conservation Program ➎ D ispense, and demonstrate awareness of pharmacology and polypharmacology of

chronic illnesses.

(HCP). ➑ Fatigue Risk Management. Describe the fatigue risk management (FRM) process. ➒ W orkplace Health Promotion Program (WHPP). Implement a WHPP, focusing on behavioural

Preventive Medicine

RHCP training and assessment in Preventive Medicine must ensure that the RHCP is competent in respect of:

change including: a. Nutrition and diet. b. Exercise. c. Smoking cessation.

➓ S tress, Resilience and Healthy Workplace. Implement stress management programs, resilience ➊ H ealth Risk Assessment (HRA). training, and promote positive psychology in the workplace.

a. Describe the HRA process. This includes an awareness of the HRA identification techniques, assessment techniques (e.g.using risk ratings and registers), hierarchy of controls, and ALARP (“as low as reasonably practicable”) concept.

b. Use the HRA results12 to implement and monitor workplace health controls.

Infectious Disease Outbreak Prevention. Identify common communicable disease symptoms, understand and implement local isolation procedures, escalate outbreaks of infectious disease appropriately, implement hygiene, sanitation and other containment measures, and initiate contact tracing.

➋ M edical Assessment for Fitness to Work (FTW). Operational Medicine. Basic understanding of the health impacts of onsite work activities that a. Describe FTW requirements in relation to the jobs/tasks undertaken of the location. b. Identify individuals who may not be fit for work due to recent changes in health status. c. Identify when a return to work (RTW) reassessment is required for individuals at risk.

➌ Incident Investigation and Reporting. a. Describe the incident investigation process. b. Describe the industry’s occupational illness and injury reporting requirements. c. Able to apply the industry’s classification of illness and injuries. d. Provide support to an incident investigation team. e. Act as a member of an incident investigation team. f. Apply medical confidentiality whilst supporting the incident investigation and reporting.

➍ Substance Abuse. Describe the common elements of a drug and alcohol policy (e.g. clear rules, awareness/training, assistance, testing, disciplinary actions, etc.)

a. Describe health effects of alcohol and commonly abused substances. b. Able to identify signs and symptoms of alcohol and substance abuse. c. Able to describe drug testing procedure (e.g. collection, screening, chain-of-custody,

confirmatory testing, Medical d. Review Officer’s verification, etc.)

may be beyond his/her training (e.g. those relating to diving medicine, tropical medicine, aviation medicine, travel medicine, etc.).

Health Administration

RHCP training and assessment in Health Service Administration must ensure that the RHCP is able to: ➊ Manage a remote Site Clinic pharmacy. ➋ Manage clinic record keeping. ➌ Manage medical equipment (including managing equipment maintenance and calibration). ➍ Plan, communicate, and coordinate health programs (e.g. HCP, WHPP). ➎ U se IT tools (e.g. word processors, spreadsheets, electronic presentations, electronic

communications, etc.). ➏ P ractice public speaking to communicate and influence people (e.g. to implement

health programs). ➐ Communicate effectively using Telemedicine. ➑ I mplement clinical governance (includes participating in clinic audit, and significant

event reporting).

10 The workshop participants observed that most current RHCP training courses lacked Primary Care element.

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Extreme Remote Locations

Sites where medical evacuation to a hospital can never be achieved within 4 hours (even in the best of circumstances) pose significant challenge to healthcare provision. In addition to the baseline RHCP training and assessment above, RHCPs who are deployed to extreme remote locations are required to: ➊ Possess at least 3 years of experience of working in remote locations. ➋ Complete additional training and assessment.13

➌ Manage common medical and surgical emergencies as follows: a. Perform surgical cricothyrotomy. b. Insert a chest drain for a tension pneumothorax c. Rapid sequence intubation d. Mechanical ventilation during transport e. Perform emergency ultrasound14 (at the point of care, for immediate patient-care decisions)

➍ Manage common dental emergencies as follows: a. Manage traumatic tooth luxation and avulsion by reducing, repositioning and fixation. b. Manage dislodged crowns and bridges.

References

1. Developing Consensus on Remote Healthcare Practitioners’ Competency for Oil and Gas Operations: a Delphi Study. Klein, S. Mohamed, H. 2014 IRHC Conference, Olympia London, 7-8th October 2014.

2. Remote Healthcare for Energy and associated Maritime activities. Institute of Remote Healthcare,

2013. Defining and Assessing Professional Competence. Epstein R, Hundert E, JAMA. 2002 Jan 9;287(2):226-35.

Appendix A: Recommended RHCP Training Contents

The following table outlines the RHCP training contents. They can be delivered either face-to-face, virtually, or a combination of both. However, where the authors are of the opinion that a face-to- face mode is significantly more effective than virtual training, the topic is marked with an asterisk (*).

The recommended total training time is 120 hours, with 80 hours spent on theory, and 40 hours in practical sessions. However, the actual required duration will depend on the individual’s baseline competency and experience. Whilst all of the following skills need to be evaluated, not all of them need to be taught.

11 The greatest challenge in terms of Primary Care and the RHCP is chronic disease management – due to changing worker demographics (i.e. older workers).

12 The HRA itself may be performed by a specialist HRA practitioner (e.g. an industrial hygienist). 13 No consensus was achieved on the exact content and details of the additional training assessment for extreme remote locations.

Exact requirements must be shaped by the prevailing risks and situation specific to the workplace, company, and country. 14 If necessary, utilizing telemedicine, under Topside direct supervision.

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Module 1: Introduction Theory Practical 1. RHCP roles and responsibilities X

2. Mindset X

Module 2: Emergency Care Theory Practical 1. Advanced Cardiac Life Support (or equivalent) and Advanced Trauma Life

Support (or equivalent). X X*

2. Multiple casualty incidents (including: develop and communicate an initial scene report; perform primary triage; apply immediately necessary lifesaving treatment and perform secondary triage).

X X

3. Emergency communication X 4. Common medical Emergencies (includes myocardial infarction, acute

asthma, diabetic ketoacidosis, etc.) X

5. Electrocardiogram (ECG/EKG) (includes the identification of normal and abnormal ECG/EKG changes)

X X

6. Thrombolysis X X 7. Common surgical emergencies (includes acute abdomen, acute

appendicitis, strangulated hernia, acute urinary retention, etc.) X

8. Emergency ultrasound† X X* 9. Common traumatic emergencies (includes fractures, head injury, spine

injuries, eye injuries, etc.) X

10.Traumatic emergency skills

a. Wound suturing, debridement and dressing. X X* b. Intraosseous access X X* c. Needle cricothyrotomy X X* d. Needle thoracostomy X X* e. Peak flow measurement X X* f. Transurethral catheterisation X X* g. Glasgow Coma Scale (GCS) X X* h. Neurological examination X X* i. Local infiltration anaesthesia (including nerve block) X X* j. Sedation X

k. Nasal packing X

l. Burns X

m. Surgical cricothyrotomy† X X* n. Chest drain insertion† X X* o. Transcutaneous pacing† X X*

11.Infectious disease outbreak prevention X

12.Operational medicine X

Module 5: Health Administration Theory Practical 1. Managing a remote site pharmacy X

2. Clinic record keeping X

3. Managing medical equipment X

4. Implementing health programs (including planning, communicating, and coordinating)

X

5. Communications (including public speaking skills, and telemedicine communication)

X X*

6. Using IT tools (e.g. word processor, spreadsheets, electronic mail, etc.). X 7. Clinical governance X

*Face-to-face mode may be significantly more effective than virtual training

†Remote locations only *Face-to-face mode may be significantly more effective than virtual training

Module 3: Primary Healthcare Theory Practical 1. Primary healthcare consultation X X 2. Common chronic illnesses (includes common cardiovascular, respiratory,

endocrine, gastrointestinal, urological, musculoskeletal, neurological, dermatological, infectious, ear, nose and throat, ophthalmological, sexual health and mental illnesses)

X

3. Common minor injuries and illnesses (e.g. contact dermatitis, foreign object in the eye, minor burns, etc.).

X

4. Primary healthcare procedures and minor surgery (e.g. removal of foreign object in eye, wound suturing, debridement, dressing, etc.).

X X*

5. Prescribing, pharmacology and polypharmacology X

Module 4: Preventive Medicine Theory Practical 1. Health risk assessment (HRA) X

2. Fitness to work (FTW) X

3. Incident investigation and reporting X

4. Substance abuse policy and controls X

5. Food and drinking water safety X

6. Ergonomics and lifting X

7. Hearing conservation program (HCP) X

8. Fatigue risk management (FRM) X

9. Workplace health promotion program (WHPP) X

10.Stress, resilience and healthy workplace X

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p. Suprapubic catheterisation for acute urinary retention† X X* q. Rapid sequence intubation† X X* r. Mechanical ventilation during transport† X X*

11.Patient transfer and medical evacuation X

12.Dental pathology: prevention, diagnosis and management X

13.Dental procedures

a. Temporary dental filling and dressing X X* b. Local dental anaesthesia: Landmarks and techniques X X* c. Dental extraction: basic principles and techniques X X* d. Traumatic tooth luxation and avulsion: assessment, reduction,

repositioning and fixation†

X X*

e. Manage dislodged crowns and bridges† X X* 14.Common psychiatric emergencies (e.g. attempted suicide, acute

depression, anxiety psychosis, violent behaviours, etc.) X

15.Mental state examination and suicide risk (includes communication of Suicide Risk)

X X

16.Instructor qualification in workplace first aid provision and automated external defibrillation (AED)

X X*

Appendix B: Abstract: Developing Consensus on Remote Healthcare Practitioners’ Competency for Oil and Gas Operations: A Delphi Study

Background

Ensuring that the skills set and competencies of Remote Healthcare Practitioners (RHCPs) working in oil and gas operations are at an appropriate standard is a continual challenge. Despite increasing activity in remote locations both within the Energy industry and its associated Maritime activities, there are no universally accepted standards, with wide variation in training and stakeholder’s expectations. In recognition of these challenges, and the potential limitations around the generalizability of the 2013 Institute of Remote Healthcare Guidance Document (“IRHC: “Remote Healthcare Guidance Document for Energy and associated Maritime activities”) in representing the global view of key stakeholders, the IRHC Council commissioned an independent research team based at Robert Gordon University (RGU)15 to conduct a Delphi Study. The Delphi methodology was originally developed as a decision making tool by the RAND corporation1, the Delphi method of enquiry recognises the value of experts’ opinions and experience when full scientific knowledge is lacking2. It is a well-established method used for guideline development within a range of policy settings, including that pertaining to occupational health physicians3 and occupational health4. Comprising an iterative process, it is commonly used to determine whether consensus is possible by asking experts to indicate the level to which they agree or disagree with statements presented in a questionnaire format in two or more rounds.

Aims

To: (i) achieve international consensus of expert opinion on basic statements pertaining to the skills set and competencies of RHCPs upon which a universally accepted standard can be built, and (ii) inform the training and practice of RHCPs internationally on the basis of the best available advice from experts and practitioners in the field.

Method

Within the context of the Energy industry and its associated Maritime activities, a modified Delphi study was conducted using seven inter-related phases. Phase I – Generation of statements: A list of items for subsequent translation into statements and appropriate topic areas were generated by means of: (i) a literature review and (ii) collaboration with Dr Halim Mohamed as the Principal Author of the “IRHC: “Remote Healthcare Guidance Document for Energy and associated Maritime activities” (2013). Phase II – Validation of statements: To validate the clarity and comprehensibility of the statements, a select sample of individuals were invited to comment as representatives of the target categories identified for the sampling frame from which the Delphi Study participants were drawn. Phase III – Development of an online questionnaire: The outcome of Phases I and II informed the development of the questionnaire comprising 116 statements, which were allocated to 22 topic areas in total. Snap Survey Software was used to deliver the statements in the form of an online questionnaire in order to: (i) facilitate administration; (ii) reduce burden on participants, and (iii) expedite the process to ensure completion in time for presentation at the IRHC 2014 Conference. Phase IV –Selection of a panel of experts: As the composition of the sample relates to the validity and generalizability of the outcome, careful consideration was given to key issues pertaining to sampling and selection of the panel of experts including the sampling criteria (i.e., who qualifies as an expert) and the sample size. Potential “expert” panel participants were identified from a sampling frame designed to ensure a heterogeneous sample such that the entire

15 *RGU Research Team (Institute for Health & Wellbeing Research (IHWR), Faculty of Health & Social Care): Professor Susan Klein (Director, Aberdeen Centre for Trauma Research); Dr Hector Williams (Senior Research Fellow, IHWR); Dr David Robertson (IHWR Member, Lecturer, School of Health Sciences); Ed Watson (Web & E-Learning Resource Editor, School of Pharmacy & Life Sciences).

spectrum of opinion is determined and comprised the four target populations, viz: (i) Oil & Gas representatives; (ii) Service Provider representatives; (iii) Subject Matter Experts, and (iv) RHCPs. Phase V – Conduct of a “modified” Delphi Study: Participants were provided with pre-selected issues upon which to make a judgement (as determined in Phase I). Two rounds were conducted to reduce the occurrence of panel fatigue. Phase VI – Content and statistical analysis: Between each round, content analysis was conducted to condense the data for the subsequent round, and facilitated by employing the Snap Survey Software. Phase VII – Dissemination of findings: The findings were: (i) presented on Day 1 of the 2014 IRHC Annual Conference “Delivering Competent Healthcare in Remote and Rural Environments” (7th-8th

October, 2014, Olympia, London) and (ii) provided a basis for discussion at the RHCPs Competency Workshops on Day 2 in order to enhance consensus of agreement where necessary.

Results

Based on a sample of N=315, 86 (27%) valid responses were achieved for Round 1 and 75 (24%) for Round 2 respectively. Participants derived from 105 organisations with the majority pertaining to the Oil and Gas industry (46%). Most participants were Health Advisers (40%) who currently worked on a daily basis in remote healthcare (65%), particularly within the geographical regions of Europe and Eurasia (65%). Of the 30 RHCPs who participated, the majority were physicians (80%). Overall, consensus was achieved for the 61% of statements, with the majority pertaining to 16 of the 22 topic areas as follows: RHCP Responsibility; Mindset; RHCP Competency and Training; Formal RHCP Training and Assessment for Prevention of Skill Decay; RHCP Training and Assessment in: Emergency Medicine; Advanced Life Support (ALS); Common Medical Emergencies; Common Surgical Emergencies; Common Psychiatric Emergencies; Common Traumatic Emergencies; Training Staff in First Aid and Defibrillation; Extreme Remote Locations; Primary Health Care; Preventative Medicine, and Health Service Administration. Examples of consensus of agreement include: RHCPs should possess a current registration with a relevant governing body and complete formal RHCP training and assessment (particularly in respect of 3-yearly ALS training an components relating to emergency care, preventative care and primary care) Topic areas that received least consensus with regards to their respective statements were most notably in relation to: Training Duration; Training Delivery; Skills Maintenance; Competence Evaluation/ Assessment, and RHCP Training and Assessment in Common Dental Emergencies. Examples of an absence of consensus of agreement include: RHCP professional background; training and assessment in the administration of anaesthetics, and ability to undertake certain dental procedures such as performing a tooth extraction.

Conclusion

In light of the high level of consensus achieved, and in concert with potential for the subsequent RHCPs Competency Workshops to resolve those topic areas currently lacking in consensus, recommendations based on the findings of this modified Delphi study provides a robust evidence- base on which to: (i) build continued industry collaboration on competency and training standards; (ii) develop an industry guidance document, and (iii) enable global implementation.

References

1Dalkey N, Helmer O (1962). An Experimental Application of the Delphi Method to the Use of Experts. Memorandum No RM-727/1-Abridged. The RAND Cooperation, Santa Monica, California. 2Linstone HA & Turoff M (1975). The Delphi Method: Techniques and Applications. Addison-Wesley. 3Reetoo KN, Harrington JM, Macdonald EB (2005). Required competencies of occupational physicians: a Delphi survey of UK customers. Occup Environ Med, 62, 406-413. 4Loney T, Aw TC (2014). Development of Occupational Health in the Gulf Cooperation Council Countries: The UAE Experience. The Journal of The Institute of Remote Health Care, 5(1), 18-24.

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Appendix C: Workshop Participants and Contributors

Name Organisation

1. Prof Graham Page Aberdeen Royal Infirmary 2. Prof James Ferguson Aberdeen Royal Infirmary 3. Dr Nahyan Helal Abu Dhabi National Oil Company (ADNOC) 4. Mr Ahmed Al Kaabi Abu Dhabi National Oil Company (ADNOC) 5. Mr Ajith George Abu Dhabi National Oil Company (ADNOC) 6. Dr Ciaran O’Shea Atlantic Offshore Medical Services 7. Dr Colville Laird BASICS Scotland 8. Mr Burjor Langdana BASMU (British Antarctic Survey Medical Unit) & AdventureMedic 9. Dr David Flower BP 10. Prof Alasdair Munroe Centre for Health Science, Inverness 11. Mr Joseph McMenamin CTeL Innovations 12. Mr Chris Cooper East of England Ambulance Service 13. Mr AbdullaAl Qubaisi Emirates Institute Health & Safety 14. Dr Stephen Jones Esso UK Limited 15. Mr Ged Healy Exmed UK Ltd 16. Mr Shaun Taylor Exmed UK Ltd 17. Mr Shane Prevost Exmed UK Ltd 18. Mr David Swann Exmed UK Ltd 19. Mrs Karilyn Secker Exmed UK Ltd 20. Mr Chris Morris Exmed UK Ltd 21. Mrs Louise Shaw-Jones Exmed UK Ltd 22. Miss Casey Payne Exmed UK Ltd 23. Mr Anthony Pugsley Exmed UK Ltd 24. Mr Dai Jones Exmed UK Ltd 25. Mr Dan Bridges Exmed UK Ltd 26. Dr Philip Sharples FrontierMEDEX 27. Miss Marie Watkins FrontierMEDEX 28. Mr Stewart Milne FrontierMEDEX 29. Dr Syed Nasir FrontierMEDEX 30. Dr Stephen Milnes FrontierMEDEX 31. Mr Ryan Steil FrontierMEDEX 32. Mr Paul Woodhouse FrontierMEDEX 33. Miss Hannah Norman FrontierMEDEX 34. Prof Nelson Norman Institute of Remote Healthcare 35. Dr Malcolm Valentine Institute of Remote Healthcare 36. Mr Alan Bolam Institute of Remote Healthcare 37. Ms Kathy Bolam Institute of Remote Healthcare 38. Mr Jerry Overton International Academies of Emergency Dispatch 39. Dr Lars Petersen International SOS 40. Dr Jonathan O’Keeffe International SOS 41. Dr William Freeland International SOS / Abermed

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Name Organisation 42. Mr Ali Hammoud John Hopkins Aramco Healthcare 43. Mr Angus Cowan John Hopkins Aramco Healthcare 44. Mr Michael Dolan Maersk Oil & Gas 45. Prof William McKerrow NHS Education for Scotland 46. Dr Hannah Evans NHS Highland 47. Dr Glenn Hammack NuPhysicia 48. Ms Diana Smith NuPhysicia/InPlace Medical 49. Mr Michael Szafron NuPhysicia/InPlace Medical 50 Dr Graham Furnace Oil and Gas UK 51. Dr Susan Schunder- OMV AG

Tatzber 52. Dr Norsayani Yaakob PETRONAS 53. Ms Susan Helliwell PRAXES Medical Group 54. Mr Nicholas Dillon Remote Medic UK 55. Prof Valerie Maehle Robert Gordon University 56. Prof Cherry Wainwright Robert Gordon University 57 Prof Ian Murray Robert Gordon University 58. Prof Susan Klein Robert Gordon University 59. Mr Stephen Benbow Robert Gordon University 60. Mr Kennedy Osakwe Robert Gordon University 61. Mr Phillip Nel Royal College of Surgeons Edinburgh 62. Dr Alistair Fraser Royal Dutch Shell Plc 63. Dr Frano Mika SAIPEM 64. Dr Rudiger Stilz Shell International 65. Ms Sharyn Toner Shell International B.V. 66. Dr Hans Berg Shell International B.V. 67. Dr Halim Mohamed Shell Malaysia Ltd 68. Dr Eduard Gevorkian Shell Russia 69. Dr Helen Griffith Shell UK Upstream 70. Mr Chris Cook Shell UK Upstream 71. Mr Steve Bray SP Services (UK) Ltd 72. Dr Brian Fitzsimmons Tain and District GP Practice Scotland 73. Prof Joseph Rappold Temple University School of Medicine 74. Dr Bob Mark TSG Associates 75. Prof Tar-Ching Aw United Arab Emirates University 76. Dr Tim Carter University of Bergen 77. Prof Sandra MacRury University of the Highlands and Islands 78. Dr Brian Wells Wells Offshore 79. Dr Joseph Pearson XstremeMD 80. Dr Louis Corne XstremeMD

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Institute of Remote Health Care