# Presentation: 064977

## Just-in-Time Training for Point-of-Dispensing (POD) Staff: The NYC Experience

- Anne Rinchiuso, MPH
- Medical Reserve Corps Coordinator/Emergency Planner
- New York City Department of Health
- and Mental Hygiene

## Overview

- Definition of Just-in-Time (JIT) training
- Overview of NYC’s POD layout, operations, and staffing model
- Evolution and components of NYC’s JIT training plan
- Results from JIT training completed to date
- Implications for planning and future directions

## What is “Just-in-Time” (JIT) Training?

- Evolving concept in human resources/ training literature
- “...real time creation of knowledge and solutions that cannot be separated from job function.”1
- For NYC, JIT Training refers to training that POD staff will receive at time of an emergency
- 1Advances in Developing Human Resources Vol. 5, No. 3 August 2003 308-320

## NYC POD Layout

- *May be outside of the physical POD layout

## Triage Station

- Use Triage script to identify individuals who:
- Have contraindication to available prophylaxis
- On medication which interacts with prophylaxis
- Have medical conditions which require dose adjustment of prophylaxis or existing medications
- If any of the above, send patient to **Medical Evaluation**
- If none of the above, send patient to **Dispensing **to receive prophylaxis

## Dispensing Station

- Provide antibiotic or vaccine to patients
- Direct public to **Exit**

## Medical Evaluation Station

- Evaluate individuals who:
- Have contraindications to prophylaxis
- Are on medications which interact with prophylaxis
- Have medical conditions affecting prophylaxis
- Determine:
- Which prophylaxis patient should receive/if patient should receive prophylaxis
- Send patient to **Dispensing** or **Exit** as appropriate

## Pharmacy Station

- Antibiotic or vaccine is prepared for **Dispensing** Station
- Re-packaging/color-coding of antibiotic doses
- Reconstitution of vaccine, as appropriate
- No public interaction

## Exit Station

- Provide additional forms if needed, and if available
- Informational signs about prophylaxis will be posted at exits

## Flow Monitors

- Direct patients into, through, and out of the POD
- Provide information and/or distribute any available info sheets to patients waiting in line
- Critical to POD operations

## Medical Greeters

- Clinicians will be stationed outside of the POD to screen patients and refer persons who may be ill with the disease for which we are providing prophylaxis to a hospital

## Command/Personnel Stations

- Planning centers of the POD
- Supplies
- Phones, faxes, computers for communication
- Dedicated Personnel Officer to manage staff assignments, breaks, etc.

## POD Organizational Structure

## POD Resource Center

- Centralized POD command center
- Staffed and managed by DOHMH staff; located at DOHMH
- All supply, facility, and staffing requests from POD teams to come in to Resource Center
- All data to be reported to, and collected by, Resource Center
- Supply and staff arrival times
- Supply and staffing levels
- Patient flow and throughput during POD operation
- Significant problems encountered

## NYC’s JIT Training Plan

- DOHMH employees to make up Core Staff of top 6 leadership positions in POD
- POD Team Leader, Operations Chief, Logistics Chief, Flow Monitor Chief, Triage Chief, and Medical Evaluation Chief
- Core staff centrally-trained and assigned by DOHMH “Master Trainers” and Assignment Officers
- Approximately 2.5-3.0 hours

## NYC’s JIT Training Plan (2)

- Core staff assigns and trains all other staff at POD sites
- MRC volunteers, spontaneous health professional volunteers, city workers, and non-medical volunteers through MOU with NY Cares
- Medical volunteers credentialed at 1 of 5 sites (1 per borough)

## Core Staff Training-Didactic

- Situation report/briefing
- General POD overview
- POD layout
- POD stations and operating procedures
- POD organizational chart
- Data collection and reporting protocols

## Core Staff Training-Practical

- Role-play triage and medical evaluation scripts
- Review medication prep for Pharmacy Station
- Color-code antibiotics for easy dispensing
- Reconstitute vaccine, if necessary
- Prepare syringes for dispensing, as appropriate

## Core Staff Training-Practical (2)

- Review placement of Flow Monitors
- Discuss set-up of each station
- Demonstrate staff prophylaxis procedures
- Practice run-through of “patients” for all staff to watch/ask questions
- Go over general staff assignment protocols for POD sites

## Core Staff Responsibilities at POD Site

- Report in to POD Resource Center upon arrival
- Report arrival times of medical and non-medical supplies, as well
- Ensure proper physical set-up of POD
- Get the POD ready for operation (i.e., place all algorithms on tables, select secure medical supply area, etc.)
- Check ID and assign all volunteers who arrive at POD
- Train all general POD staff

## General POD Staff JIT Training: Shift 1

- Arrive at POD site and receive assignment from Personnel Officer
- Report to assigned Station for briefing and training
- Meet Station Chief and obtain staff identification clothing/materials
- JIT training conducted by POD Team Leader and/or Station Chiefs
- Approximately 45 minutes

## General POD Staff JIT Training: Shift 1 (2)

- Didactic
- Situation report/briefing
- General POD overview
- Practical
- Role-play triage and medical evaluation scripts
- Review medication prep for Pharmacy Station
- Go over placement of Flow Monitors
- Discuss set-up of each station

## General POD Staff JIT Training: Shift 1 (3)

- A few staff members run through POD to role-play patients so that all may watch
- Specific station-related questions addressed by Station Chiefs
- All staff members receive prophylaxis before they begin work
- Approximately 15-20 minutes

## General POD Staff JIT Training: Shift 2

- Arrive at POD site and receive assignment from Personnel Officer
- Report to Briefing Area for situation report and POD overview
- Report to Station for practical training
- Meet Station Chief and obtain staff identification clothing/materials
- Partner with Shift 1 staff member to learn specific role
- When comfortable, take over from Shift 1 worker

## Why JIT Training?

- We will never be able to pre-identify or be able to pre-train all 40,000 staff needed for citywide activation
- Turnover of DOHMH staff and volunteers leads to loss of knowledge
- Extensive and repetitive pre-training can be costly and time-consuming

## Why JIT Training? (2)

- Every staff member would need to be re-trained at the time of the emergency because it is not expected that they will retain the information over long periods of time without constant re-training
- Scenario-specific information will always need to be provided to staff

## Why JIT Training? (3)

- No matter how much pre-training you do, it is unlikely that all of your pre-trained volunteers will be available at the time of an emergency
- Spontaneous volunteers will certainly be used, and you must have a simple and efficient way of training them when they report to assist you

## Trainings/Drills Completed to Date

- MRC Trainings (5)
- Citywide drill (4 PODs opened)
- CDC drill (1)
- Trainings with medical students (2)
- DOHMH staff trainings (3)
- Participants alternate between being staff and being patients

## Trainings/Drills Completed to Date (2)

- Although these trainings were held with various populations, they all have roughly the same accuracy rate
- Each also demonstrated that we can provide prophylaxis at the rate of ~1000/hour for antibiotics, and ~550/hour for smallpox vaccine
- Our plans are based on these throughput numbers

## MRC Trainings

- 5 trainings held June 2004-February 2006
- 3 for antibiotic dispensing; 2 for smallpox vaccination
- Volunteers play all roles, as per licensures
- Additional POD training for smallpox vaccination planned for Summer 2006

## JIT Training Results

| 

POD Staff
Prophylaxis
Date | 
MRC Volunteers
Smallpox Vaccine 
June 2004 | 
MRC Volunteers
Smallpox Vaccine
March 2005 | MRC Volunteers and Hospital-Based Providers
Antibiotics
 June 2005 | MRC Volunteers Antibiotics 
Feb 2006 |
| --- | --- | --- | --- | --- |
| Total Patients Seen | 527 | 349 | 401 | 295 |
| Uncomplicated | 376 (71%) | 278 (80%) | 371 (93%) | 273 (93%) |
| Correct |  359 (95%) | 277 (99%) | 360 (97%) | 264 (97%) |
| Incorrect | 17 (5%) | 1 (1%) | 11 (3%) | 9 (3%) |
| Complicated | 151 (29%) | 71 (20%) | 30 (7%) | 22 (7%) |
| Correct | 127 (84%) | 31 (44%) | 27 (90%) | 16 (73%) |
| Incorrect | 24 (16%) | 40 (56%) | 3 (10%) | 6 (27%) |
| Correctly Triaged | 93% | 88% | 97% | 95% |

## PODEX Citywide Drill

- 4 PODs opened simultaneously in Queens, NY-June 2005
- DOHMH Medical-Clinical IMS section staffed leadership positions (Core Teams)
- MRC staffed Medical Evaluation and Pharmacy Stations
- NY Cares and Red Cross volunteers, as well as CERT teams, staffed all other positions, including Triage
- Train-the-Trainer model used for 3 of 4 PODs

## JIT Training Results (2)

| 

POD Staff
Prophylaxis
Date | 
POD A
MRC, DOHMH staff, and non-medical volunteers
Antibiotics
June 2005 | 
POD B
MRC, DOHMH staff, and non-medical volunteers
Antibiotics
June 2005 | 
POD C
MRC, DOHMH staff, and non-medical volunteers
Antibiotics
June 2005 | 
POD D
MRC, DOHMH staff, and non-medical volunteers
Antibiotics
June 2005 |
| --- | --- | --- | --- | --- |
| Total Patients Seen | 687 | 125 | 776 | 221 |
| Uncomplicated | 601 (87%) | 114 (91%) | 709 (91%) | 197 (89%) |
| Correct | 583 (97%) | 104 (91%) | 693 (98%) | 183 (93%) |
| Incorrect | 18 (3%) | 10 (9%) | 16 (2%) | 14 (7%) |
| Complicated | 86 (13%) | 11 (9%) | 67 (9%) | 24 (11%) |
| Correct | 65 (76%) | 5 (45%) | 42 (63%) | 17 (71%) |
| Incorrect | 21 (24%) | 6 (55%) | 25 (37% | 7 (29%) |
| Correctly Triaged | 94% | 87% | 95% | 90% |

## CDC Drill

- POD drill held April 2004 at NYU College of Dentistry
- SNS receipt, storage and staging-focused drill to which we added a POD
- DOHMH public health nurses staffed Triage
- Dental faculty members staffed Medical Evaluation
- Dental students staffed all other roles

## JIT Training Results (3)

| 

POD Staff
Prophylaxis
Date | 

NYU Dental Students and Faculty and School Health Nurses
Antibiotics April 2004 |
| --- | --- |
| Total Patients Seen | 269 |
| Uncomplicated | 199 (74%) |
| Correct | 195 (98%) |
| Incorrect | 4 (2%) |
| Complicated |  70 (26%) |
| Correct | 47 (67%) |
| Incorrect | 23 (33%) |
| Correctly Triaged | 90% |

## Trainings with Medical Students

- Mt. Sinai School of Medicine-March 2004
- SUNY Downstate Medical School-October 2004
- Medical students staffed all positions

## JIT Training Results (4)

| 

POD Staff
Prophylaxis
Date | Mt. Sinai Medical Students 
Antibiotics
March 2004 | 

SUNY Downstate Medical Students
Antibiotics
October 2004 |
| --- | --- | --- |
| Total Patients Seen | 324 | 484 |
| Uncomplicated | 199 (61%) | 349 (72%) |
| Correct | 187 (94%) | 342(98%) |
| Incorrect | 12 (6%) | 7 (2%) |
| Complicated | 125 (39%) | 135 (28%) |
| Correct | 113 (90%) | 119 (88%) |
| Incorrect | 12 (10%) | 16 (12%) |
| Correctly Triaged | 92% | 95% |

## DOHMH Staff Trainings

- School Health physicians and nurses-April 2004
- Physicians staffed Medical Evaluation; nurses staffed all other positions
- Bureau of TB clinical staff-June 2004
- Physicians staffed Medical Evaluation; balance of clinic team members staffed all other positions

## JIT Training Results (5)

| 

POD Staff
Prophylaxis
Date | 

School Health  Physicians and Nurses 
Smallpox Vaccine
April 2004 | 

DOHMH TB Clinical Staff
Antibiotics
June 2004 |
| --- | --- | --- |
| Total Patients Seen | 242 | 321 |
| Uncomplicated | 184 (76%) | 258 (80%) |
| Correct | 182 (99%) | 245 (95%) |
| Incorrect | 2 (1%) | 13 (5%) |
| Complicated | 58 (24%) | 63 (20%) |
| Correct | 49 (84%) | 54 (86%) |
| Incorrect | 9 (16%) | 9 (14%) |
| Correctly Triaged | 95% | 93% |

## Flu POD Drill-November 2005

- Tested procedures and transition time for a shift change
- “Train-the-trainer” model used for second shift workers
- Received briefing and assignment, then watched staff member they were relieving do their job, taking over when ready
- Evaluated worker comfort level regarding: instructions, energy level, ability to perform function based on shift change and suggestions for improvement
- With POD adequately staffed, patient flow ~410/hour
- Multiple patient forms that we would not have during citywide event

## Most Common Mistakes Observed

- Confusion between side effects and allergies
- Some true allergies not recognized (e.g., hives)
- Some side effects incorrectly treated as allergies (e.g., GI upset)
- For antibiotic dispensing, children are sometimes incorrectly given doxycycline

## Implications for Planning

- Results from the JIT trainings conducted among varied populations to date demonstrate that medical and non-medical people may be trained to staff PODs if algorithms are simple and straight-forward and training method used is successful at communicating information

## Implications for Planning (2)

- Ensure that scopes of practice are expanded and/or licensure waivers are in place to allow health professionals enhanced practice capability in the PODs
- e.g., NY State has drafted an order to expand scopes of practice for dentists, podiatrists, and LPNs to perform the Triage function, which is not normally in their respective scopes of practice
- Draft emergency orders to allow for non-licensed health professionals to perform Triage function
- Set guidelines for educational status, civil service title, etc.

## Implications for Planning (3)

- Must balance need to drill JIT training materials and format with benefits that may be reaped from extensive pre-training of MRC volunteers
- e.g., training MRC volunteers in POD set-up even though it is not part of the JIT training for general staff

## Implications for Planning (4)

- Must continue to hone algorithms after each exercise to ensure that accuracy rate will be as high as possible
- What common points need to be emphasized for all staff and what extra training, if any, is required for clinicians?
- Must define acceptable level of accuracy
- Trainings and drills often use higher than normal percentages of complicated patients

## Future Directions

- Explore different training models
- Does every staff member need to be trained in all roles?
- How much general POD information is necessary for staff, especially Shift 2 workers?

## Future Directions (2)

- Exercise different models, including “Train-the-Trainer”
- DOHMH staff and MRC volunteers
- Continue to refine training materials
- Pre-position Core Staff training materials
- Training “Go Bags” stored at DOHMH containing all materials and equipment needed to get Core Staff training up and running within 2 hours

## Acknowledgements

- Stephanie Factor, MD, MPH
- Former Medical Director, Bureau of Emergency Management,
- NYC DOHMH
- NYC DOHMH Bureau of Emergency Management Staff
- Special thanks to: Daniel Bunker and Ethan Cramer-Flood for their assistance with the POD data
- NYC Office of Emergency Management
- Partners with DOHMH in POD Planning