The purpose of this chapter is to describe the principles of training new poisons information staff (section A), and the principles of continuing education (section B). It is complemented by Chapter 1.2 Guidelines for Training Poisons Information Staff - Methods.

This document gives an outline of the subjects to be covered in a training programme for new poisons information staff. A detailed programme must be developed by each centre according to local circumstances, because the educational background of poisons information staff varies from centre to centre. The staff may be educated to university degree level in e.g. biochemistry, medicine, pharmacology, pharmacy, toxicology or they may be experienced, qualified nurses.

The main components in a poisons information system are the staff and the data bank. Neither by itself will ensure an optimal poisons information service; that is dependent on the smooth interaction between the two.

The competence of the staff, crucial for the quality of the information service provided, is dependent on several factors:

• basic education,
• personal qualities, and
• specific training provided ‘on the job’.

In this document some views are given on important issues in the training of poisons information staff. Inevitably the recommendations are of a general nature and may therefore seem self-evident to those who have long-since worked in well established centres.

The impact of a thorough training programme cannot be overemphasized, and the amount of time required for training should not be underestimated. This may sound like a truism. However, reality tells the following. Too short a training period, e.g. because of difficult circumstances or overestimation of the knowledge and skills of a certain new staff member, can prove devastating and unfair to the trainee. All new staff members, irrespective of background and personal qualities, need a solid and undisturbed training period, ensuring good basic knowledge and a sound self-confidence. The duration of the initial training period may vary, but it should ideally be around three months. It is, however, urgent to state that there is also need for continuous training of staff employed in a poisons centre (see below, Section B).

• 1. Main tasks and responsibilities of the centre, user groups
• 2. Organization and policies
• 3. Telephone service
• 4. Documentation of cases and call sheets
• 5. Information sources
• 6. Subject knowledge - general
• 7. Subject knowledge – specific
• 8. Up-dating the data bank

2.1 Main tasks and responsibilities of the centre, user groups
An explanation should be given of the purpose of the centre and its scope of activities; these are sometimes regulated by governmental instructions. It is important to clarify the legal aspects, what the centre is expected to achieve and, just as important, what is outside its mandate.

It is essential to clarify the authorized user groups, e.g. the general public, health care personnel, government authorities, the media, and to discuss their different requirements. It is crucial that poisons centre staff should not exceed their area of competence, and new staff members should be encouraged to consult with senior colleagues whenever there is uncertainty.

2.2 Organization and policies
The external and internal organization of the centre and its legal status should be described and discussed. Special attention should be given to policies related to confidentiality with regard to product information, enquiries received by the centre and patient data.

2.3 Telephone service
2.3.1 Policies
Each poisons centre must establish its own policy with regard to how enquiries should be handled. This is, in its turn, related to e.g. the basic education of the responding staff, internal procedures for seeking advice from senior colleagues, medical back-up, and the actual user groups.

Certain situations may recur quite frequently and it is practical to have a routine procedure ready for these situations. Examples are how to act and give priority to calls in case of a queue, advice on transportation of patients, how to act in cases of suicide attempts or threat of suicide where the toxic risk is not impending, how to handle common therapeutic errors e.g. double dose or ingestion of another patient’s medicine, how to deal with police and media when pharmaceuticals have been stolen, general questions from the public about toxic and lethal doses. These are some examples of situations where it has proven both rational and safe to have a standardized procedure for how to answer and act.

2.3.2 Training at the telephone.
It is a common conception that “learning by doing under supervision“ is the ideal way of training new staff for the telephone service. The following strategy is based on the experience in a number of centres and is therefore a suggestion that can be adapted to local circumstances.

• From the beginning of the training period the trainee should start listening to calls handled by a senior staff member, who explains the problem, demonstrates how to retrieve information, evaluate the situation and finally give advice. To start with the new staff member should stay at the telephone for only part of the day, in parallel with other training activities. Gradually longer periods can be spent at the telephone.

• In the beginning, when listening to calls, the trainee could be requested to complete the call form in order to become familiar with data recording. When familiar with the form the trainee can start to take the phone, interview the caller and discuss the proposed answer with the senior, supervising colleague.

• Discussing earlier calls, documented on tape, on paper or in a computer, may be useful and a ‘role-play’ can be arranged in answering and documenting these ‘calls’, that have the advantage of being authentic.

• When the new staff member has become familiar with the basic telephone routines and how to register the calls, it is time to start answering simple enquiries, gradually widening the responsibility to more complicated cases. All this time the trainee should be closely supervised and taught by a senior colleague. In the course of this process the trainee will be becoming increasingly independent.

• After a satisfying assessment of the training period and the competence of the trainee, he/she can start to take full responsibility for answering enquiries. This normally occurs after around three months. To check that there are no unforeseen shortcomings and as a support, the trainee should be accompanied for the first few night shifts. A medical back-up system running throughout the 24 hours is, in any case, mandatory.

• Training in telephone communication skills is important (see Chapter 2.1). Items of particular interest are questioning skills, listening skills, checking comprehension, empathy, dealing with angry, aggressive or upset people, and how to end a call. This training, as outlined above, can be provided internally, but some poisons centres consider additional external training courses, run by telephone communication specialists, to be very useful.

2.4 Documentation of cases and call sheets
Accurate and consistent documentation of cases is fundamental for legal reasons as well as for poisons centre statistics, follow-up studies and epidemiological research (see Chapter 3). A thorough understanding of how to use the enquiry record sheet and how to register the cases properly – whether on paper or on computer – is therefore mandatory. It is important to practice this, under supervision and using real cases.

2.5 Information sources
A poisons information centre may have access to many different information sources: internally produced files on the management of poisoning by chemical substances, pharmaceuticals and natural toxins, case data files, product information files, literature files, external data bases, relevant toxicology handbooks and external consultants for special cases. Self-evidently, one of the most important stages in the training period is to familiarise the trainee with these information sources and how to use them.

Each of the information sources must be explained separately in detail, and their use demonstrated through exercises using real cases. In addition the trainee could be given a list of questions to which they have to find the answers, referring to the respective information sources available at the centre.

2.6 Subject knowledge – general
An introduction to the principles of clinical toxicology should be given during the training period. For some categories of staff, depending on academic education, a basic understanding of human physiology and pharmacology is already at hand, but otherwise this competence must be provided for during the training period.

Apart from these basic requirements, there is a need for systematic education with regard to:

• routes of toxic exposure
• mechanisms of toxicity
• general management principles of poisoning: decontamination, symptomatic and supportive care, mechanisms of and indications for antidote treatment, methods for enhancing elimination of toxic substances
• the organization of antidote supply

It is important to discuss thoroughly actual controversies concerning treatment of poisoning, as many enquiries to a poisons centre relate to treatment issues that are under debate, have been re-evaluated and perhaps recently changed.

2.7 Subject knowledge – specific
With regard to the specific poisoning pattern in a country or region, the most important, dangerous and commonly occurring toxic substances should be identified. Based on this, selected pharmaceuticals, chemicals, chemical products and biological toxins should be subject to detailed teaching sessions, led by senior staff members. The basis for these sessions should, ideally, be the actual documents (substance monographs, treatment protocols) used in the information service, if necessary supplemented with other relevant material (handbooks, articles). The documents should be read under guidance and finally discussed in detail with the supervisor.

It may be helpful for the beginner to have a list of the most frequent chemical products, pharmaceuticals, plants etc, involved in calls from public and hospitals. Also a list of the most dangerous commercial products would be valuable in order to avoid wasting time (e.g. in spelling difficult names over the phone). Such lists may facilitate setting the priorities in the learning process.

It is advisable to introduce at an early stage special training on the most dangerous substances (such as chloroquine, paraquat, organophosphorus pesticides, cyanide), although some of these might occur only rarely.

Provide specific subject knowledge is one of the most important and time-consuming parts of the training period, and it must go on continuously also after this initial period.

2.8 Up-dating the data bank
The initial training should mainly aim at preparing new staff members for answering telephone enquiries in an adequate way, meeting the quality standards set by the centre. Preparing poisons information monographs also provides training opportunities in finding, evaluating and synthesizing toxicological information. However, it is not anticipated that the initial training period will include all the complex ingredients of the ‘background work’ such as writing poisons information monographs, collection and evaluation of product information, follow-up and evaluation of poisoning cases etc. All these aspects will be covered in the long run.

It is important to educate the trainee in the critical evaluation of literature references and information in different data bases (the British Medical Journal has published guidelines on this). Training in searching information in external data bases is essential, but this should include a critical approach and the awareness that data have to be adapted to the actual case.

3.1 Training methods
Theoretical knowledge may be conveyed to the trainees through different teaching activities. Training should involve a combination of formal techniques and experiential learning. Formal methods include lectures, study of papers and textbook chapters, clinical scenarios and tutorial sessions. Experiential learning is exemplified in sections 3.3 and 3.8.

The training should be organized and supervised by senior staff members.

3.2 Monitoring and evaluation
The progress of the trainee should be monitored during the course of training. There should be an objective observational evaluation of acquired skills and knowledge. The optimum would be formal examination, but this is not considered obligatory as long as adequate observational evaluation is undertaken by senior staff.

More information on both of these aspects is provided in the chapter “Guidelines for Training Poisons Information Staff - Methods”

Clinical toxicology is an area in rapid evolution and, as with all medical disciplines, there is a need for continuous training and education to maintain and expand knowledge. This is particularly true for recently established poisons information centres, but even senior clinical toxicologists - poisons information staff included - with many years of experience need to update their knowledge continuously.

Ways to accomplish continuous training
Some essential components of a programme for continuous training and education of poisons information staff are outlined below. Individual centres should apply these according to local needs and possibilities, as the types of calls handled and the educational background of poison information staff differs between centres.

1. Regular review of interesting, difficult, unclear and controversial cases is an essential part of a continuous training programme. This includes discussions on differential diagnoses, diagnostic procedures, treatment strategies and options, unexpected complications, discrepancy between the history and the clinical evolution etc. An integrated part of such a discussion should also be the role and responsibility of the poisons centre, and how it performed in the actual cases.

2. Regular briefing of staff about revisions of existing management protocols and substance monographs, highlighting any important changes.

3. Regular briefing of staff about new management protocols and substance monographs.

4. Regular briefing of staff about new problems, such as new types of poisoning observed, new products on the market and products of unknown composition.

5. Journal clubs for the critical review of new literature: staff members study new journal articles, book chapters, Internet information etc, evaluate the contents and discuss in plenum whether the new data/information should be integrated in the documents of the centre. All staff members should be updated on important news concerning the management of different poisonings.

6. Invited guest lectures/conferences, e.g. devoted to special topics of particular interest.

7. Toxicology ‘up-date’ lectures by internally recruited or invited lecturers.

8. Participation in applied research projects and publications will increase knowledge in a particular relevant field, stimulate staff members and enhance their motivation. The results of research projects undertaken should be reported back to the whole staff, and this is also true for poisons centre statistics.

9. Attendance at scientific meetings is crucial: it allows the staff member to share experience with others and provides immediate access to significant new observations and discoveries. The preparation and presentation of the staff member's own studies at scientific meetings also promotes personal development. Important news from the meeting should be reported back to those colleagues who did not attend the meeting.

10. Continuing education courses in clinical toxicology are organized more and more often. These specially designed courses offer valuable opportunities to increase personal competence as well as that of the poisons centre overall. Such courses may be available for distance learning or may take the form of short lecture-based courses.

11. Participation in international activities, such as the INTOX Programme of the International Programme on Chemical Safety (WHO, ILO, UNEP) broaden knowledge about toxicological issues and facilitate the creation of international networks.

12. A system for regular staff appraisal stimulates personal development and promotes positive attitudes.

It is obvious that much of the continuous training of poisons centre staff is closely related to the specific tasks and challenges of the daily work in the centre. It is important, however, that these day-to-day items are dealt with in a structured way and on a regular basis. In addition a number of specific activities to promote competence should, as shown above, be planned and performed. An important factor for the maintenance of quality in a poisons centre, and for ensuring quality and consistency of advice given, is also the capacity of the staff to work together as a team. The activities discussed above will promote this ambition.

Greenhalgh T. How to read a paper: The Medline database. Br Med J 1997;315:180-183

How to read a paper : getting your bearings (deciding what the paper is about). Br Med J 1997;315:243-246

How to read a paper: Assessing the methodological quality of published papers. Br Med J 1997;315:305-308

How to read a paper: Statistics for the non-statistician. I: Different types of data need different statistical tests. Br Med J 1997;315:364-366

How to read a paper: Statistics for the non-statistician. II: “Significant” relations and their pitfalls. Br Med J 1997;315:422-425

How to read a paper: Papers that report drug trials. British Medical Journal 1997;315:480-483

How to read a paper: Papers that report diagnostic or screening tests. Br Med J 1997;315:540-543

How to read a paper: Papers that summarise other papers (systematic reviews and meta-analyses). Br Med J 1997;315:672-675

Greenhalgh T, Taylor R. How to read a paper: Papers that go beyond numbers (qualitative research). Br Med J 1997;315:740-743

Hans Persson, Swedish Poisons Information Centre.
Additional comments from Martine Mostin, Belgian Poisons Information Centre

Daniela Pelclová, Poisons Information Centre, Prague, Czech Republic

Peer reviewed by members of the IPCS INTOX Poisons Centre Training Manual Working Group (R Awang, K Bakjaji, A Laborde, E Clarke, M Colbridge, W Daelman, A Dines, D Gotelli, M Hermanns-Clausen, T Jovaisa, J de Kom, M Kunde, I Makalinao, W Malas, R McKeown, M Mostin, D Pelclová, H Persson, L Panganiban, L Pinto Pereira, U Stedtler, W Temple)

Written for the INTOX Programme of the International Programme on Chemical Safety (WHO/ILO/UNEP), World Health Organization,
Geneva, Switzerland.

Finalized August 2005