====== 6.1.1 Chapter 1.2 Guidelines for Training Poisons Information Staff - Methods ====== ===== OBJECTIVES ===== The purpose of this chapter is to provide a guide to methods for training new poisons information staff. This complements information provided in [[:wikitox:6.1.1_guidelines_for_training_poisons_information_staff_principles|Chapter 1.1 Guidelines for Training Poisons Information Staff - Principles.]] ===== INTRODUCTION ===== As discussed in the chapter "//Guidelines for Training Poisons Information Staff - Principles//", each poisons centre must devise a training programme tailored to the needs of the service and the educational background of the staff. There will be numerous strands to the training and strategies will differ locally, but the broad categories under which a training programme should be devised are as follows: a. Ethos and scope of the service\\ b. Policies and procedures\\ c. Operations e.g. handling of telephone enquiries\\ d. Subject knowledge The objectives of the training programme are to ensure that the trainee: • understands their role and obligations as part of the poisons centre team;\\ • is confident in the operational procedures of the poisons centre;\\ • knows how to handle poisons telephone enquiries (including how to find the relevant information);\\ • understands the toxicology of the most common types of poisoning that make up enquiries to the poisons centre; and\\ • understands the basic principles involved in the management of the poisoned patient. ===== METHODS ===== ==== Introduction ==== Devising a training programme and preparing training materials takes considerable thought and time. Carrying out the training itself is also time-consuming and, if possible, should be a task shared with other experienced members of the poisons centre. The involvement of staff external to the centre, e.g. from related services such as Medicines Information, or the local Emergency Department could also be considered. Since staff involved in training will usually have their normal work, e.g. in answering poisons calls, there is a need for flexibility on all sides to accommodate the exigencies of the service. At the beginning of the training, the objectives, methodology and time frame should be explained to the trainee, and a written programme provided. Each day should be broken up into different types of training activity and as far as possible, training should be planned so that each part builds upon what went before. It is important that the training programme and the progress of the trainee are monitored, and some suggested methods are described below. While there is no need for elaborate equipment for training, certain equipment does facilitate the process and this is described below. **a. Ethos and scope of the service** \\ This information should be provided in one or more introductory talks between the trainer and the trainee, perhaps citing examples of situations that illustrate the important points. Colleagues who are assisting with training (e.g. by allowing the trainee listen in to their calls) should also use real-life situations to reinforce this information. Ideally there should also be a written document that can be referred to and given to the trainee to read. Issues that might be covered include the mission statement of the centre, the obligation of confidentiality, authorized and non-authorized users, individual accountability and responsibility, and working as part of a team. **b. Local policies and procedures** \\ All of the important policies and procedures in place for the running of the poisons centre should be covered. These could include work practices (e.g. the staff rota), the organizational structure of the poisons centre and its host institution if relevant, making contacts with internal and external groups (e.g. manufacturers). The information could take the form of a written statement. The trainer could explain the main sections and then give the trainee time to read it through themselves and to come back with any questions. Important activities should have their own standard operating procedure (SOP) agreed internally and, in some instances, externally. **c. Operations** \\ **//Handling telephone enquiries// ** \\ This is the most important aspect of a poison centre's work, and there should be a carefully thought-out operating procedure for dealing with enquiries. A written SOP can be used as the basis for training. The training should include the following components: • How the enquiry should be answered; whether it is routinely voice-recorded; how the data is documented at the time of the call; how to source the information needed (including accessing relevant databases, textbooks, internal data) and how to convey this information back to the caller in a clear and concise way. • What happens to the data subsequently e.g. is it written down at the time of the enquiry and then entered onto a database, or is it entered into the database “live” or “near live”. Why documentation is important and what the information is used for e.g. for toxicovigilance or to produce an annual report, as a medico-legal record. • How to deal with specific situations, such as those listed under section 2.3 in "Guidelines for Training Poisons Information Staff - Principles". • Consideration should be given to organizing a training session specifically on telephone communication skills (see chapter 2.1). This training will, of course, go in parallel with the teaching of subject knowledge, and should be used, as much as possible, to reinforce this knowledge. A suggested step-by step approach to telephone training is as follows: 1. Initially the trainee should listen to enquiries as they are answered by a senior member of staff. They should listen to the type of information asked of the caller regarding caller details, circumstance and patient details etc and note how this data is transcribed. The trainer should then explain to the trainee where to access the information in order to answer the query. How a risk assessment is made and how information is relayed to the caller are also important. Role play could also be used, based on records of real calls. The trainee should take the history, find the information to reply and document the enquiry as if it were real. They should be prompted and given feedback as required. The cases selected for the role play could refer to agents that the trainee has recently learned about. Also this method can be useful for portraying less common types of poisoning that may not occur during the training process but whose toxicology it is important for the trainee to know e.g. methanol poisoning or snake bite (use of and availability of antidotes/antivenoms). 2. The next stage is for the trainee to take real calls with a senior member of staff listening in, prompting, guiding and giving feedback. Each call record completed by the trainee should be checked for completeness, accuracy and legibility (if it is handwritten). 3. As the trainee gains experience the level of supervision can be reduced so that eventually there is simply a senior member of staff present and available to give guidance but not actively listening to the call. When, and only when, both the trainer and the trainee are fully confident, can the trainee start to take calls unsupervised. ===== FINDING INFORMATION ===== Familiarisation with information sources is largely built up through experience. Senior colleagues can assist the trainee by pointing them to appropriate sources for answering specific enquiries. In addition, the trainee can be given a list of the main information sources with a note about the types of enquiry they are most useful for, and can be given time to browse through these sources. For some computerized databases specific training may be required on how to use them. Another approach is to give the trainee a list of questions that they must answer using the available information sources. These questions should cover all the categories of agent that the poisons centre may be called about and should be representative of the types of question that a poisons information specialist could be asked. The trainee should note which source they used for each question and this can be discussed subsequently when the trainer is checking the answers. ===== SUBJECT KNOWLEDGE ===== The trainee will be dealing with all aspects of clinical toxicology involving a wide range of agents, from non-toxic exposures to fatal exposures, the use of specific treatment regimens and the availability and use of antidotes. The knowledge that must be acquired is therefore very large. At the same time the trainee usually needs to be trained rather quickly so that they can start taking their share of the poisons centre's workload. It will therefore be necessary to prioritize the subject knowledge that must be acquired in the short-term, for example by initially focusing on the ‘top 20’ enquiries to the poisons centre and the more complicated treatment regimens e.g. antifreeze poisoning. Training could involve: 1. Seminars on aspects of the management of poisoning and on specific agents or categories of agent, supported by visual aids, study notes and background reading material. Some centres use videos, DVDs, or tape recordings of lectures made by staff that the trainee can watch/listen to at their own pace. 2. Quizzes or tests, such as multiple choice questions (MCQs), with feedback and follow-up discussion as appropriate. 3. Departmental discussion groups, where any confusion or differences of view can be aired. 4. Visits to an acute medical unit or emergency department to see poisoned patients in a medical setting and to better understand the information needs of medical callers to the service. 5. If the poisons centre receives written enquiries about aspects of toxicology then asking the trainee to draft a reply can help them to build subject knowledge as well as familiarity with information sources. ==== Assessing the progress of training ==== A training checklist is useful to ensure that all important subjects are covered and also to monitor that planned training sessions have actually taken place (an example is given in the appendix) It is important that the trainer and trainee have regular meetings to discuss how the training is progressing. Giving constructive feedback is essential. Other ways for assessing progress include: • Formal test of knowledge. Some poisons centres set their trainees a pre-training test and a post-training test. • Counting the number of poisons calls that the trainee has answered. A threshold number could be set before the trainee can work independently. • Use of a training log: the trainee could be asked to keep a daily or weekly record of the different types of training activity that they have participated in. This log can be discussed at regular meetings with the trainer. • Systematic checking of call records completed by the trainee for accuracy and correct response. • If facilities allow, the trainer and the trainee should listen to calls taken by the trainee. The trainee can self-critique and the trainer can also provide feedback about whether the correct information was taken from the caller, the sources of information used were appropriate and up to date, the trainee's manner was appropriate, and the advice given was specific and correct. This can be done at intervals during the training period. An example of a checklist that could be used to assist this process can be found in the appendix. • The trainer can ask experienced colleagues for their observations on the competence of the trainee. • The trainee can be asked about their own feelings of competence and confidence in working independently. • The use of evaluation and self-evaluation checklists can help to maintain consistency and objectivity. Examples can be found in the appendix. Even when this stage of training is complete, it is important to recognize that there are always new things to learn and that training is a continuous and unending process. Opportunities for continuing education should be provided, as suggested in section B of "[[:wikitox:6.1.1_guidelines_for_training_poisons_information_staff_principles|Guidelines for Training Poisons Information Staff - Principles]]". There should also be a continuing system of appraisal, where a designated senior member of staff can discuss with the new staff member their achievements, any training needs that are not being met, future work and direction etc. ==== Training equipment ==== For training on the telephone it is a good idea to have a second ear piece that can be fitted to the telephone. A less convenient alternative is to use the telephone's loudspeaker facility, though it will be necessary to remember to mute the telephone while the trainer is giving guidance to the trainee. A further useful piece of equipment is a tape recorder that can be connected to the telephone: recorders used for dictation often have this facility. This will allow the trainer and the trainee to listen to calls taken by the trainee so that these can be discussed and feedback given. Training needs should be taken into account when buying new telephones for the poisons centre. Audio-visual equipment is also useful, such as a data projector, overhead projector or slide projector. ===== MATERIALS AND RESOURCES ===== Examples of evaluation checklists are attached at Appendix 1. The following toxicology reference sources provide useful background reading material for the trainee: Bryson PD. General Management of The Overdosed Patient IN: Bryson PD Comprehensive Review in Toxicology for Emergency Clinicians 3rd ed, Taylor and Francis, USA Goldfrank LR, Flomenbaum NE, Lewin et al. Principles of Managing the Poisoned or Overdosed patient. IN: Goldfrank LR, Flomenbaum NE, Lewin NA et al (eds) (2002) Goldfrank’s Toxicologic Emergencies 7th ed; McGraw-Hill, USA Hack JB and Hoffman RS. General Management of Poisoned Patients IN: Tintinalli JE, Kelen GD and Stapczynski JS (eds) Emergency Medicine A Comprehensive Study Guide 6th Ed (2004), McGraw-Hill, USA Jones AL and Dargan PI. Basic Principles IN: Churchill’s Pocketbook of Toxicology (2001), Churchill Livingstone, Edinburgh Keyes DC and Dart RC. Initial Diagnosis and Treatment of The Poisoned Patient IN: Dart RC (Ed) (2004) Medical Toxicology 3rd Ed, Lippincott, Williams and Wilkins, USA Kirk M. An Overview Use of the Intensive Care Unit for Poisoned Patients, IN: Goldfrank LR, Flomenbaum NE, Lewin NA et al (eds) Goldfrank’s Toxicologic Emergencies 7th ed, (2002) McGraw-Hill, USA Olsen KR (ed) Emergency evaluation and treatment. IN: Poisoning and Drug Overdose (4th ed) (2004), McGraw-Hill Companies, USA ===== AUTHOR(S) ===== Mark Colbridge, Medical Toxicology Unit, Guy's & St Thomas' Foundation NHS Trust, London, UK Joanna Tempowski, International Programme on Chemical Safety (WHO/ILO/UNEP), Geneva, Switzerland Not yet peer reviewed Written for the INTOX Programme of the International Programme on Chemical Safety (WHO/ILO/UNEP), World Health Organization, Geneva, Switzerland. Finalized xxx 2005 ==== Appendix 1 ==== Examples of evaluation checklists and log sheets 1. Examples of training log sheets and checklists 2. Examples of evaluation and self-evaluation checklists