10 POISON CENTRE STAFF TRAINING AND QUALITY
10.2 TRAINING OF POISONS INFORMATION STAFF
10 POISON CENTRE STAFF
A thorough training programme consisting of presentations (usually covering both common poisoning agents and less commonly encountered agents), clinical scenarios, directed reading and, most importantly, time to gain the important skills of telephone communication and triage, is essential. Training methods are discussed in more detail in the WHO poison centre training manual (1).
Once the training period is completed, trainees’ skills and competence should be tested before they are allowed to answer telephone enquiries unsupervised.
In addition to basic training of new staff, all staff should have continuous training and professional development to ensure that their knowledge of poisoning and the treatment of poisoned patients is up to date with current practice. Such training could take the form of in-house case discussions and journal clubs, meetings with other poison centres, attendance at international meetings and other forms of continuing professional development as identified by the poison centre.
10.2.1 AREAS TO BE COVERED IN TRAINING
The training programme for new poisons information staff should encompass the following:
• local policies and procedures
• principles of clinical toxicology
• assessment of a poisoned patient
• knowledge about different agents
• information sources
• provision of telephone advice and communication skills
• documentation
• assessment.
These topics are described briefly below. Most of the subjects listed in subsection 10.4.1 for medical toxicologists are also relevant to the training of specialists in poisons information, although the subjects may be covered in less depth.
LOCAL POLICIES AND PROCEDURES
New staff and trainees should, as part of their induction, be made aware of local policies and procedures, such as operating procedures, how the centre handles enquiries from specific groups (for example, from the police, public, media, legal teams) and the usual working practices that the new trainee will be expected to follow. This training will also cover procedures for referring enquiries to more senior colleagues (including clinicians) or external experts or escalating enquiries that may have wider implications, such as on chemical incidents and deliberate release of toxic substances.
New trainees must know what is expected of them in their role and that in-house policies or standard operating procedures are in place to enable them to deal calmly and methodically with any expected or unexpected situation.
PRINCIPLES OF CLINICAL TOXICOLOGY
The principles of clinical toxicology should be introduced during the training period. Some staff, depending on their background, may already have a basic understanding of human physiology and pharmacology.
Otherwise, this will be developed during the training period.
In addition to these basic requirements, the trainee should understand, and be familiar with routes of exposure, mechanisms of toxicity, recognition of common toxidromes and the principles of general management of poisoning, including decontamination, symptomatic and supportive care, antidotes and methods for enhancing elimination.
ASSESSING THE POISONED PATIENT
The depth of training included in these sessions may vary from centre to centre, but trainees should understand “normal” physiological parameters and how different poisons may affect them, particularly in relation to potential “red flags” (for example, symptoms of severe toxicity) that should alert them to refer a case to a senior colleague or clinician. Basic understanding of electrocardiography and typical electrocardiographic abnormalities seen in cases of poisoning with cardiotoxic agents would be useful.
Similarly, interpretation of blood gas results, how different poisons affect them, and the common investigations used in the management of poisoned patients should be covered.
SUBJECT KNOWLEDGE
Acquiring a good understanding of the toxicity and management of the most common types of poisoning that the poison centre deals with is one of the most important parts of training. According to the pattern of poisoning in the country or region, selected pharmaceuticals, chemicals, chemical products and biological toxins should be covered in detail in teaching sessions led by senior staff members. Training should also cover toxic substances known to cause serious harm but which may be less commonly encountered.
In addition to the teaching sessions, relevant directed reading should be given, such as recent literature or book chapters. Shortly after each teaching session, clinical scenarios or mock calls involving the poisons covered should be organized, both to give the trainee an example of the types of calls they will be dealing with and to identify any gaps in knowledge, which can be rectified with additional training.
INFORMATION SOURCES
A poison centre should have access to many sources of information (see also section 9). These can include internally produced documents on the management of poisoning, product information files, scientific journals (electronic and hard copy), internal and external databases, relevant toxicology handbooks and external consultants for specific cases such as snake envenoming. The trainee should become familiar with the available sources used at their poison centre and should also be able to identify those sources that are best for specific enquiries.
If the poisons information centre produces its own documents on the management of poisoning, the trainee should become familiar with how they are produced, particularly if part of their role will be to assist in their production.
The trainee should be able to find specific information and management recommendations relevant to a particular case in a timely manner. While databases and books may describe the entire management of a case, the poisons information specialist must develop the particular skill to understand what information the caller requires and tailor the information accordingly.
As the primary data sources in a poisons information centre are usually electronic, the trainee should be familiar with the back-up arrangements in case of power outage or unavailability of the Internet.
TELEPHONE SERVICE AND COMMUNICATION SKILLS
Each poisons information centre must establish its own policy for how enquiries should be handled and also identify target user groups. For instance, some poisons information centres take calls only from medical professionals, while others also take calls from members of the public.
A standard internal operating procedure may be in place for dealing with situations that occur frequently, such as:
• answering and giving priority to calls;
• dealing with requests for antidotes and requests for laboratory services;
• managing calls from people who are suicidal or have attempted suicide;
• handling common therapeutic errors, such as double doses of medication;
• identification of plant material;
• dealing with queries from the police and media; and
• general questions from the public about toxic and lethal doses.
The trainee should listen in to calls taken by senior staff, ideally through a dual headset so that the trainee can hear both sides of the conversation. If a computer work station is available nearby, the trainee could also try to find information in “real time” during an enquiry, which will give them additional practice.
Training in telephone communication skills is extremely important. These include questioning the caller and taking an accurate history, having good listening skills, showing empathy and checking that they have correctly understood the information provided. The trainee should also learn how to deal with angry, aggressive or upset people and how to end a call. Such training is usually provided internally, but some poison centres may use external training courses run by telephone communication specialists. Telephone communication skills are particularly important in taking calls from members of the public, which might require some additional training in counselling or conflict resolution.
The most efficient, practical way of training new staff for the telephone service is experiential learning under supervision. A suggested strategy involves a step-by-step process, in which the trainee takes increasing responsibility for answering and documenting poisons information enquiries. The objectives are to:
• ensure that the trainee is familiar with the typical telephone dialogue between callers and poisons information staff;
• allow trainees to build their skills in telephone triage and the principles of risk assessment; and
• familiarize trainees with the centre’s enquiry record form, how to complete it and the documentation standards required for all enquiries.
The trainee should understand the limitations of telephone conversations, such as mishearing letters, words or numbers and be able to identify common mistakes, such as confusion of agent names, and should double-check their spelling.
As trainees gain experience by answering “mock” calls, they should have the opportunity to take real calls, under the supervision of a senior member of staff, who listens in, gives prompts when necessary and gives feedback. Before answering the caller, trainees will discuss their findings with the senior staff member, and once the staff member is satisfied, the trainee can relay the information to the caller.
Once trainees have successfully completed training and demonstrated competence, they can begin to take full responsibility for answering enquiries. Some centres may consider that a short probationary period of supervised calls is appropriate.
DOCUMENTATION
Poisoning cases must be accurately, consistently documented. This is often a requirement for medico- legal reasons and is also important for epidemiological research, toxicovigilance, collection of follow-up data and compiling statistics. Each centre has its own method for recording enquiries, usually in a computer database. Enquiries may be logged live, as the call is taking place, or initially recorded on paper and the information entered into a database at a later stage, ideally soon after the enquiry is complete.
Trainees should be shown how to complete the enquiry record accurately, ensuring that the document is clear, scientifically accurate and completed in a timely manner. Training should include an explanation of the reasons for entering particular information and the importance of an accurate, complete record of each case.
10.2.2 ASSESSMENT AND EXAMINATION
After completion of the training programme, the poisons information centre should have some form of assessment of trainees’ skill before they answer calls unsupervised. This is important for clinical governance. The competence of trainees can be assessed by:
• a formal examination;
• a detailed checklist that indicates a minimum level of competence in each training objective; or
• by setting a threshold number of calls or of calls about specific poisons that the trainee has to answer while under supervision.
The training period may be regarded as a probation for the new member of staff until they are certified as competent by the assessment method selected. Once trainees are established as competent, they will be able to participate in the staff rota and answer telephone enquiries unsupervised.