Training Workshop for Health Care Workers

For the Care and Isolation Unit (CIU) of St. Patrick Hospital

Welcome to the

George Risi, MD, MscInfectious Disease Specialists, PC614 West Spruce StreetMissoula, MTwww.infectionspecialists.orggrisi@saintpatrick.org

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.

Let’s 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 one’s level of educational achievement

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

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

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?

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 What’s wrong with this picture?

Objectives of This Workshop

• 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

At the Completion of this Workshop the Health Care Worker Will be Able to:

Objectives Cont’d

• 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

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

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

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

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

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

• Bubonic plague, Surat, India 1994

• Monkeypox, US, 2003

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

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

The World’s 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

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

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

The Gambian Giant Pouch Rat

Up to 32 inches longUp to 2 ½ pounds

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.

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

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 2003;22:1093

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

What Do HCW’s 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

READY?