DEVELOPMENT, IMPLEMENTATION AND OUTCOMES OF A TRAINING PROGRAM FOR RESPONDERS TO ACTS OF TERRORISM Geoffrey T. Miller, NREMT-P, Joseph A. Scott, MD, S. Barry Issenberg, MD, Emil R. Petrusa, PhD, Angel A. Brotons, EMT-P, David Lee Gordon, MD, William C. McGaghie, PhD, Michael S. Gordon, MD, PhD community. The potential for mass-casualty incidents that cross broad geographic areas, and medical, political, criminal and public-safety issues dictate that training for the emergency-response community be standardized across all disciplines, agencies and regions3−5 All responders must be able to react appropriately to these events, protect themselves, initiate command, communicate, perform appropriate triage and decontamination, and render medical care, in and out of the traditional healthcare delivery venues.6−9 The range of those expected to respond to these events is expanding to include many different professionals, all of whom will be required to adapt rapidly to specific incident demands in a unified approach. The knowledge, skills and attitudes needed to respond to these threats are unfamiliar to most of these populations. In addition, it is unlikely emergency responders will encounter many of these high-impact, low-frequency events after their initial training. Studies demonstrate that if providers are not exposed to critical events on a regular basis, their knowledge and skills in responding to such events decline 6–12 months after initial training.10 Simulation-based education has been shown to be a practical and valid approach to prepare responders to these events.11,12 It is generally agreed that a fundamental core of knowledge and essential skill set is necessary for anyone involved in response to acts of terrorism.13−17 Training in this area has increased in the past few years but continues to vary in content, methods and availability. Most available programs are lecture based and lack skill training and opportunity for practice.13 Usually, only highly specialized teams of responders (hazardous materials [HAZMAT], bomb disposal, special response teams, etc.) participate in programs that include skills practice and simulation training.13 Major challenges to the widespread implementation of intensive, hands-on training programs to a larger number of responders include program duration, required prerequisites, high cost and a lack of literature regarding the effectiveness of this type of training. This report describes how the University of Miami Center for Research in Medical Education (UM CRME) addressed these challenges through the development, implementation and evaluation of a multidisciplinary, interactive and simulation-enhanced course to prepare responders to acts of terrorism.
ABSTRACT Introduction. Responding to acts of terrorism requires the effective use of public-safety and medical-response resources. The knowledge, skills and attitudes necessary to respond to future threats is unfamiliar to most emergency responders. Objectives. The purpose of this report to describe the development, implementation and evaluation of a multidisciplinary, interactive and simulation-enhanced course to prepare responders to acts of terrorism. Methods. We used a 5-step systematic process to develop a blendedlearning, simulation-enhanced training program. Learners completed a self-confidence questionnaire and written examination prior to the course and a self-confidence questionnaire, written examination and course evaluation when they finished the course. Results. From July 7, 2003 to March 8, 2005, 497 consenting learners completed the course. After course completion, learners demonstrated significant increases in their knowledge of terrorism response (t = −64.3, df = 496, p < 0.05) and their confidence in responding to terrorist events (t = −45.5, df = 496, p < 0.05). Learner feedback about the course was highly positive. Conclusions. We successfully implemented a two-day course for professionals likely to respond to terrorist acts that included scenario-based performance training and assessment. Course participants increased their knowledge and were more confident in their ability to respond to acts of terrorism after participating in this course. Key words: disaster; EMS; simulation; terrorism; training. PREHOSPITAL EMERGENCY CARE 2006;10:239–246
INTRODUCTION Complex and increasing threats such as terrorism, biological disease outbreaks (Marburg1 and Severe Acute Respiratory Syndrome [SARS]),2 catastrophic natural disasters (hurricanes, tsunamis, mud slides, earthquakes) and other emergencies are driving the need for a better prepared and sustainable emergency-response
Received September 9, 2005 from the University of Miami Miller School of Medicine, (GTM, JAS, SBI, AAB, DLG, MSG) Duke University School of Medicine (ERP), and Northwestern University Feinberg School of Medicine (WCM). Accepted October 12, 2005. Address correspondence and reprint requests to: Geoffrey T. Miller, NREMT-P, Center for Research in Medical Education, University of Miami Miller School of Medicine, PO Box 016960 (D-41), Miami, FL 33101. e-mail:
[email protected] doi:10.1080/10903120500541191
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METHODS The UM CRME convened a curriculum development advisory committee (CDAC) to conduct an extensive review of existing terrorism, HAZMAT, military and disaster-response curricula in response to the events of September 11, 2001. UM CRME faculty members participated in several existing courses as a prelude to developing the new curriculum. The goal was to create a standardized, interdisciplinary curriculum for targeted learner groups. The CDAC adopted a modified ADDIE (Analysis, Design, Development, Implementation and Evaluation)18 model for curriculum development and benefited from the UM CRME’s experience in creating courses such as Emergency Management of Acute Myocardial Infarction19 and Emergency Management of Acute Stroke.20
Needs Analysis The CDAC collaborated with subject matter experts (SMEs) from different regions, agencies and municipalities that represented our target audiences (emergency medical technicians, paramedics, firefighters, nurses and physicians) to identify their unique learning needs. The geographic target audience included emergency responders in the state of Florida. We reached this audience through Florida’s community colleges and vocational-technical schools that provide initial and continuing public-safety and medical education. The CDAC deliberated often to determine the optimal duration of the training program. Most existing curricula for terrorism and disaster response ranged from 4 hours to more than 40 hours in length depending on technical specialty. In many cases, the content for these curricula was delivered only through lectures and reading materials, limiting learner time for handson skill training and deliberate practice of core competencies. Additional curriculum delivery methods included CD-ROM, web-based eLearning and self-study programs. The CDAC felt that lengthy courses incur a significant financial and workforce burden on agencies and are often impractical or prohibitive. As a result, the CDAC recommended a course length of 16 hours over 2 days to provide a balance between training needs and scheduling constraints in the community.
Design of Course The curriculum design was based on (1) UM CRME expertise19−21 ; (2) the input of an international consortium of experts in medical education and assessment from 12 medical centers; and (3) the input of the CDAC and SMEs, including emergency physicians, trauma surgeons, toxicologists, infectious disease experts, members of the U.S. military, emergency medical services (EMS) and fire-rescue experts in haz-
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TABLE 1. UM Emergency Response to Terrorism Global Learning Outcomes (1) Recognize a potential terrorist incident and initiate incident operations. (2) Implement personal and public safety protective measures. (3) Perform appropriate decontamination procedures. (4) Implement the Incident- and Unified-Command systems and perform effective intra- and interagency communication. (5) Provide triage and emergency medical care specific to incident type(s).
ardous materials and urban search and rescue, and law-enforcement officers. Global learning outcomes (Table 1) were established focusing on desired competencies that all learners should master by the end of the course. We then adapted specific learning objectives from existing curricula and ensured they were in congruence with existing state and federal guidelines. Redundancies and omissions of content for the core competencies were noted and modified. These core competencies provided the framework for a curriculum and evaluation process that adhered to the principles of Instructional System Design.22 These include: providing clear goals and instructions, keeping individuals motivated to learn, and providing opportunities for self-assessment and immediate and constructive feedback. All adopted strategies were guided by evidencebased literature.23−25 We introduced each topic in an interactive, casebased, lecture format that contains embedded videos and questions to engage learners and provides them with opportunities to respond and receive instructor feedback. Some lectures are followed by interactive sessions, such as a game show, large-group tabletop, and triage exercises, which allow learners to quickly apply and practice the material. During afternoon sessions, learners practice hands-on emergency-response skills that were presented in the lectures while working in their personal protective equipment. Learners practice skills with manikins, task trainers (airway management, antidote administration, IV therapy) and standardized patients (ambulatory decontamination, triage, communication). Multidisciplinary team building concepts are practiced by having the learners participate in team-based scenario exercises. These exercises allow learners to recognize and analyze the incident, communicate information, evaluate the patient, practice team and individual skills, and receive specific, immediate feedback that corrects omissions and errors.
Development of Course With the assistance of the CDAC, we adopted educational strategies intended to facilitate learner mastery of curricular objectives. Content and delivery methods included the development of modular, interactive PowerPoint presentations to present core knowledge,
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TABLE 2. University of Miami Emergency Response to Terrorism Course Agenda Day 1 Topic
Precourse Assessments Terrorism Response Concepts Incident Operations Personal Protective Equipment (PPE) Mass Decontamination Incident and Unified Command PPE Donning Exercise Skills Stations • Ambulatory Decontamination • Incapacitated Decontamination • Medical Management • Specialized Equipment
Day 2 Time
Format
Topic
Time
Format
30 min. 30 min. 45 min. 50 min. 60 min. 45 min. 45 min.
MCE, SRF CBL CBL EGE CBL CBL SE
60 min. 45 min. 45 min. 45 min. 45 min.
CBL CBL CBL TTE VBE
45 min. 45 min. 45 min. 45 min.
SE SE SE SE
Chemical Agents Biological Agents Radiological and Explosive Agents Managing the Incident Triage Team-Based Scenario Exercises • Case 1 (Nerve Agent) • Case 2 (Vesicant Agent) • Case 3 (Cyanide) • Case 4 (Radiological Device) Postcourse Assessments
45 min. 45 min. 45 min. 45 min. 30 min.
OSCE OSCE OSCE OSCE MCE, SRF, CE
CBL: Case-Based Lecture; CE: Course Evaluation; EGE: Educational Gaming Exercise; MCE: Multiple-Choice Examination; OSCE: Objective Structured Clinical Evaluation; SE: Skills Exercise; SRF: Self-Rating Form; TTE: Tabletop Exercise; VBE: Video-Based Exercise.
reinforced with case presentations, instructional games, video demonstrations, large- and small-group exercises, scenario-based skill stations, and discussion and feedback sessions. We then developed a student learning manual that included a course syllabus and agenda, explicit learning objectives for each module, and written curricular materials such as slides, case studies, skills checklists, and resources for additional learning and reference. We also developed an instructor manual and comprehensive curricular training materials that included annotated instructor slide sets emphasizing key teaching points, detailed instructional materials for teaching skills, checklists, teaching posters (Figure 1), scripted scenarios, team building projects and learner evaluation forms. Finally, we developed curricular evaluation tools: pre- and postcourse learner examinations, pre- and postcourse annotated instructor evaluations, formative psychomotor skills checklists, affective (behaviors and attitudes) evaluations and course effectiveness surveys. We developed course content to be delivered via a variety of instructional methods. These include lectures, small-group sessions, independent study, skillbuilding exercises and team training. We incorporated a high degree of realism into the skills stations to represent actual working conditions including the use of specialized equipment and medical simulators (Figure 2). Significant course time was devoted to hands-on skill training and simulation exercises (Table 2). This al-
lowed for deliberate practice26 of core competencies with the intent to promote transfer of knowledge and skill. Prior to implementing the new course, we pilottested all classroom presentation materials, the learner manual, skills station instructional posters and checklists, scenario/Objective Structured Clinical Examination (OSCE)27 guides and assessment materials, and a comprehensive instructor training manual. We elicited instructor, learner and CDAC feedback to refine these materials. The SMEs reviewed and approved all final curricular materials.
IMPLEMENTATION OF COURSE Participants We first implemented the course at the UM CRME. A pilot phase allowed the CDAC to determine the necessary administrative structure and support. We set the class size at 24-30 students to allow for optimal instructor-learner ratios and hands-on time for the students to practice skills. Course registrants were from South Florida fire-rescue departments, hospitals and other healthcare agencies (Table 3). Although most of the fire-rescue department personnel receive mandatory training while on-duty, a small percentage attended courses on their own time. All of the nurses and physicians attended the course voluntarily. None
TABLE 3. Study Population Demographics Group
Paramedic EMT RN Other∗ MD Total ∗
N (%)
Age
Male
Female
Years of experience
313 (63.0%) 137 (27.6%) 24 (4.8%) 16 (3.2%) 7 (1.4%) 497
39.1 (23–58) 40.8 (24–58) 40.4 (25–59) 34.7 (26–49) 35.1 (28–50) 39.4 (23–59)
268 (85.6%) 122 (89.1%) 7 (29.2%) 9 (56.3%) 4 (57.1%) 410 (82.5%)
45 (14.4%) 15 (10.9%) 17 (70.8%) 7 (43.7%) 3 (42.9%) 87 (17.5%)
9.4 (1–30) 7.7 (1–31) 13.3 (1–27) Not Reported 6.0 (2–12) 9.1 (1–31)
Law enforcement, first responder, ER technician, dispatcher, physician assistant.
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FIGURE 1.
Teaching posters for nerve agent antidote administration.
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FIGURE 2.
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Learners practice incapacitated victim decontamination in level C personal protective gear.
of the learners received any compensation for their participation in the course. EMTs, paramedics and nurses received continuing professional education credit towards their re-licensure. Instructors All of the instructors attended a training course and participated in the pilot program. Full- and part-time faculty from the UM CRME presented lectures, facilitated group discussions and skills development exercises, and gave feedback to the instructor-learners. The instructor course included delivery of comprehensive training materials and individual instructor training. To facilitate statewide dissemination, we replicated the instructor-development process at partner EMS training centers throughout the state of Florida, resulting in more than 200 trained instructors at 29 locations. Implementation Plan From the beginning, we involved stakeholders from key state organizations to ensure that the training was appropriate for their constituents and that the evaluation data addressed their needs.28 Prior to wide-scale implementation of our curriculum, we met with these groups to minimize potential barriers such as competing demands, nonsupportive attitudes, and scheduling
concerns. Sixty days prior to each planned course, the UM CRME identified local agencies, training officers, medical directors, coordinators and managers to advise them of the program and provide them information for recruitment purposes. We also maintained a website that publicized the course and allowed for on-line registration.
Course Evaluation A course-evaluation process is essential to demonstrate need for the course and how it contributes to the goals and objectives of agencies, departments and individuals who participate. Program evaluation typically includes feedback from instructors, learners and other stakeholders. This information may be collected during the development of the program (formative), when a final program is delivered (summative) or both. For this study, we evaluated learners’ attitudes (confidence), cognitive knowledge gain and learners’ perception of course effectiveness. Design This was a prospective, cross-sectional, before-andafter study designed to measure the effectiveness of the ERT training program. The study was approved by the University of Miami Miller School of Medicine Human Subjects Research Office (IRB Protocol #03/300).
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TABLE 4. Results of Self- and Cognitive Assessments Group
N (%)
Pre-self
Post-self
Change
Pre-cog
Post-cog
Change
Paramedic
313 (63.0%)
3.0 (± 0.7)
4.5 (± 0.5)
54.4 (± 10.2)
88.5 (± 7.9)
EMT
137 (27.6%)
2.7 (± 0.8)
4.2 (± 0.5)
49.7 (± 9.5)
82.5 (± 9.5)
RN
24 (4.8%)
2.4 (± 0.9)
4.5 (± 0.5)
49.0 (± 12.4)
91.5 (± 6.2)
Other
16 (3.2%)
2.1 (± 0.8)
4.1 (± 0.5)
42.8 (± 11.4)
78.0 (± 10.4)
7 (1.4%)
2.7 (± 0.8)
4.6 (± 0.4)
60.0 (± 15.0)
90.9 (± 5.5)
497 (100%)
2.9 (± 0.8)
4.4 (± 0.5)
1.5 (± 0.7) p < 0.001 1.5 (± 0.8) p < 0.001 2.1 (± 0.9) p < 0.001 2.0 (± 0.8) p < 0.001 1.9 (± 0.8) p < 0.001 1.5 (± 0.8)
52.7 (± 10.6)
86.7 (± 8.9)
34.1 (± 11.4) p < 0.001 32.8 (± 11.9) p < 0.001 42.5 (± 13.2) p < 0.001 35.3 (± 16.2) p < 0.001 30.9 (± 13.6) p < 0.001 34.0 (± 11.8)
MD Total
Outcome Measures Demographic Data We developed a database (Microsoft Access 2000; Microsoft Corp., Redmond, WA) to document each trainee’s contact information, professional classification, current position and employer, primary job function, experience in the position, previous experience/education and performance on evaluations. Learners completed a registration form at the beginning of each course. Learners also read and signed a consent form that permitted us to use their information for quality improvement and academic purposes.25 Knowledge Participants completed a 25-question multiple-choice examination before and after the course that measured learners’ knowledge in responding to terrorist events.25 All examination items were linked to course objectives and reviewed by the CDAC and SME groups following a rigorous 8-step process to ensure item reliability and validity.29 Confidence Participants completed a 10-item survey regarding their confidence in responding to a terrorist event. Participants indicated their confidence for each question using a five-point scale (1 = not confident, 5 = very confident). If a participant ranked themselves low (1 or 2), they were asked to explain in an open-ended response area. The same ten questions and scale were used at the end of the course. This provided data on participants’ achievement of affective outcomes.25 Learner Satisfaction A 22-item program-evaluation questionnaire solicited feedback from learners regarding the effectiveness of the course and suggestions for improving the curriculum. Learners ranked each component of the course on a five-point scale (1 = strongly disagree, 5 = strongly
agree). Learners were also invited to provide additional comments. Analytical Methods Data were extracted from the database and entered into SPSS (Ver. 12; SPSS Inc., Chicago, IL) for analysis. We analyzed pre- and postcourse written tests and the self-confidence questionnaires with a t-test for paired groups. We used a probability of 0.05 to determine statistical significance.
RESULTS From July 7, 2003 to March 8, 2005 we conducted 33 courses involving 497 consenting study participants (829 total course registrants). Most learners were male and the majority was either paramedics or EMTs. Learners gained a significant amount of new information by the end of the course (52.7% to 86.7%, t = −64.3, df = 496, p < 0.05) (Table 4). A pass mark of 84% was used for cognitive pre- and postcourse examinations, modeled after the standards of the American Heart Association(AHA).30 This has been our typical pass score and used for the past decade with more than 50,000 learners. Seventy-three percent of learners scored greater than or equal to the pass mark. Learners who did not achieve the pass mark completed mandatory remediation. All learners received feedback on all items of the assessment. Learners also demonstrated a significantly higher confidence in responding to terrorist events after the course (2.9 to 4.4 out of 5), (t = −45.5, df = 496, p < 0.05) (Table 4). Course evaluation was highly positive, with an average rating of 4.51 of 5. The most highly rated component was the hands-on skill station for emergency personal protective equipment donning. Learners highly agreed with the following statements: • “I would recommend this course to others,” • “this program is useful for me in my occupation,”
and
• “a positive learning environment was maintained
during the course.”
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Written comments supported the positive ratings— no items were rated less than 4.3.
primary and continuing education for emergency medical services, allied-health professionals, and publicsafety officers. The primary limitation of the study is the lack of demonstrated skill acquisition by the learner population. This, however, is being addressed in a separate study that evaluates both individual and team acquisition of the core skills necessary for a terrorism response. A limitation to the successful implementation of this course is the constant need to train more first-time learners while also providing refresher training 12 months or more postcourse. Another challenge to its implementation is the lack of sufficient training time provided by departments and agencies. To address these challenges, we plan to develop an online precourse program followed by a 1-day, eight-hour, hands-on course. We will convert the present course into individual modules that will be large enough to support learning, but flexible and free-standing enough for re-use in different contexts for different populations. We will convert all existing learning and testing materials (lectures, tabletop exercises, skills stations and scenario-based exercises) to digital resources for efficient and quick online delivery. We will develop a website to provide a single location for all e-learning course material that will be accessible to all registrants for both initial cognitive-based training and refresher training. Our goal is to reduce the time responders are away from their active duties and reduce the training-time burden on departments, agencies and municipalities. We will measure the time saved for faculty instruction and learner training and establish a continuous quality improvement process that includes evaluating outcomes and modifying the course to achieve our performance goals.
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DISCUSSION We successfully incorporated the latest scientific knowledge related to disaster and terrorism events into a dynamic and interactive 2-day, sixteen-hour course for emergency responders caring for victims of disasters and terrorism. We adopted a standardized yet flexible, hands-on, competency-based curriculum for a wide range of healthcare and public-service providers. Participants who attended the course demonstrated improved knowledge on a 25-item written examination and improved selfconfidence on an affective questionnaire. Since its inception, the course has been implemented statewide through a grant and partnership with the State of Florida Department of Health. As of August 2005, we have trained more than 2,200 learners in the ERT course, demonstrating the practicality of its widespread implementation. We provided learners not only with the opportunity to learn new principles regarding an effective response to acts of terrorism, but also the opportunity to engage in deliberate practice26 of core skills necessary for such a response. Deliberate practice involves (a) repetitive performance of psychomotor skills in a focused domain, coupled with (b) rigorous skill assessment, that provides learners (c) specific, informative feedback, that results in (d) better skills performance in a controlled setting. The use of standardized patients as victims of multiple types of terrorism events facilitated the training and practice of critical skills. Learners actually practiced the proper technique for ambulatory decontamination and burn-victim care and demonstrated their competence. The use of a wide range of task trainers and simulator manikins enhanced the “psychological fidelity”31 of all skills stations and scenarios for training and testing. Interactive, multimedia video exercises portrayed a wide range of causalities, enabling learners to practice triage. Throughout the course, we repeatedly emphasized and evaluated crisis-resource-management principles32 with emphasis on cross-disciplinary communication. Perhaps the most important process that led to the course’s success was establishing the necessary relationships with local, state and federal organizations to facilitate the dissemination of this training. The UM CRME currently trains more than 10,000 course registrants annually in a variety of acute clinical care courses through our Division of Emergency Medical Skills Training. Participants in these courses come from a variety of fire-rescue, emergency-medical-services, hospital, and public-health departments and agencies. We disseminate programs throughout Florida and the southeastern United States, primarily via community colleges and vocational technical centers that provide
CONCLUSIONS We successfully integrated didactic and performance sessions into a two-day course for professionals likely to respond to terrorist acts. We integrated state-of-theart training with objective assessments of all learners in four terrorism scenarios. Results from the pre- and postcourse self-assessments and examinations indicate that course participants are more confident in their ability to respond to acts of terrorism and increase their knowledge as a result of their participation in this course. This project demonstrated that it is possible to develop and implement a successful terrorism-response training program using a five-step, systematic approach (ADDIE) with special attention to cultivating essential resources such as personnel; time; facilities; political and financial support; and community, regional and state support. The authors would like to thank Robert B. Tober, MD, Nabil El Sanadi, MD, members of the Curriculum Development Advisory Committee,
246 and the Miami International Alliance for Medical-education Innovation (“the M.I.A.M.I. Group”) for their expert input; Eva Blanco, Jill Hershbein, Maria Lorenzo, Dori McLean, Obed Frometa, EMT-P and the paramedic-instructor staff of the University of Miami Center for Research in Medical Education for their valuable contributions; the Florida Department of Health for financial support and the expert guidance of Sandra Schoenfisch, RN, PhD, and Mark O’Neill, PhD; the Miami Urban Area Security Initiative, Florida Department of Education, Friends For Life nonprofit volunteer organization, W. George and Ethel M. Kennedy Family Foundation, and Health Foundation of South Florida for their financial support; and the U.S. Army for providing invaluable educational resources.
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