Workshop to Develop and Deliver a Core Curriculum on Clinical Toxicology

Held at the Royal Infirmary of Edinburgh, Edinburgh, UK, 19-21 July 2006

1 Welcome and introductory remarks
1.1 Mrs Alison Good from the Scottish Poisons Information Bureau welcomed the participants to the meeting.

2 Selection of officers and approval of agenda
2.1 It was decided that there would be a rotating Chair. Professor Balali Mood chaired the meeting on the first day and Dr Fountain chaired for the remaining 1.5 days. Ms Tempowski took the meeting record. The agenda is given at Annex 1. The list of participants is given at Annex 2.

3 Background and purpose of the workshop
3.1 Clinical toxicology was not a recognized specialty is most countries and, consequently, was little taught. One obstacle to better teaching was the lack of accessible, good quality teaching materials. This was particularly true in developing and in-transition countries, yet these were the countries that saw large numbers of poisoning cases with a high morbidity and mortality. If frontline health professionals were better educated in clinical toxicology this would improve the management of poisoning and contribute to reducing morbidity and mortality.

3.2 WHO was committed to assisting Member States to improve the training of their health professionals, in particular by making innovative use of information and communication technology. These activities were coordinated through the technical unit for E-Health in the Department of Knowledge Management and Sharing.

3.3 The Global Plan of Action agreed under the Strategic Approach to International Chemicals Management (SAICM) included the need to improve capacities in countries to manage poisonings, and to access and use scientific knowledge. The Quick Start Programme would provide funds to countries, and possibly to non-governmental organizations, for activities directed towards meeting these needs.

3.4 Professor Andrew Dawson of the South Asian Clinical Toxicology Research Collaboration (SACTRC) approached IPCS with a proposal for developing and delivering teaching materials on clinical toxicology using the Internet. The purpose of the meeting was to explore Dr Dawson's proposal and to agree a plan for putting the proposal into practice.

4 Proposal for developing and disseminating a clinical toxicology curriculum
4.1 Professor Dawson's proposal was to use a web-based open-source platform such as a wiki site for the compilation and delivery of teaching materials. Contributors would upload their teaching materials to the site and these could then be freely used by anyone wishing to teach themselves or others. Contributors would, for the most part, use pre-existing materials rather than be expected to create new materials.

4.2 There was already a lot of material on the Internet, however, it was difficult for the user to judge its quality. This project would offer a collection of high quality material for teaching, as well as links to other vetted websites.

5 Experiences in developing clinical toxicology education and in e-learning
5.1 Six presentations were given:

Ø Ms Tempowski spoke about the WHO Health Academy and the Global Public Health Platform. The Health Academy provided interactive teaching packages aimed at changing behaviours that contributed to bad health (http://www.who.int/healthacademy/courses/en/). WHO was collaborating with the Department of Public Health, University of Iowa to explore the use of advanced telecommunication tools for distance learning through the Global Public Health Platform http://www.who.int/kms/events/Events/en/index.html

Ø Dr Besbelli presented the WHO/UNEP Multi-Level Resource Tool for the Safe Management of Pesticides. This included information on safe handling of pesticides and on management of poisoning, as well as links to authoritative websites. The teaching materials were stratified into basic, intermediate and advanced. The resource tool was available on CD-ROM.

Ø Dr Groszek presented the results of a survey of clinical toxicology teaching in Central and Eastern Europe. Only four countries: Poland, Bulgaria, Serbia and Russia had formal post-graduate specialization and training in clinical toxicology.

Ø Professor Faiz spoke about the profile of poisoning in Bangladesh, and the teaching of clinical toxicology. This was not a recognized specialty, but some teaching modules had been developed for both undergraduate and postgraduate teaching. Poisoning was usually managed by forensic medicine specialists.

Ø Professor Balali Mood described clinical toxicology training in Iran. There were three teaching centres: Shiraz, Mashhad and Tehran. Clinical toxicology had been incorporated into national medical boards for internal, forensic and industrial medicine. A curriculum for a formal fellowship and sub-specialty Board in Clinical Toxicology was submitted last year to the Ministry of Health and Medical Education.

Ø Dr Thompson described the Medical Toxicology diploma and masters course taught by distance learning from the University of Wales College of Medicine. This course was taken by a range of health professionals. He also demonstrated the web-based platform used to provide learning materials and to enable students to submit their work.

5.2 These presentations highlighted the fact that different types of health professionals would require teaching materials, and that the priorities in terms of subject varied from country to country, according to the different patterns of poisoning.

6 Definition and prioritization of the key elements of the curriculum content
6.1 Teaching materials were needed for the education of professionals from a range of specialties and backgrounds e.g. forensic medicine, emergency medicine, nursing, poisons information. Materials were needed for both undergraduate and postgraduate teaching. They were also needed at different levels of content (basic, intermediate and advanced). It was decided, however, that contributors should not be required to adapt their existing materials for different levels of teaching. The aim was to provide a package of materials that was sufficiently comprehensive that it could be adapted by the user for these different target and levels. On the other hand, if a contributor had materials aimed at a specific target group, they could identify this group when they submitted their material.

6.2 It was felt that priority should be given to dealing with the issues that caused the highest morbidity and mortality. While the needs, in terms of substance-specific materials varied in different countries, there was core material that would be needed by everyone e.g. diagnosis of poisoning, initial patient management. There were also some poisonings that were common to many developing and in-transition countries e.g. pesticides and snake bite.

6.3 A priority list of topics was agreed, and this is given in Annex 3. The aim was to populate this 'skeleton' with teaching materials during the pilot phase of site development. The priority list was a cut-down version of the curriculum developed by the American Board of Emergency Medicine. It was not intended to be exclusive: if contributors had materials on topics not included in the cut-down list they could still submit these to the site. Professor Dawson would add the 'skeleton' to the site and would provide instructions for contributors.

7 Structure and content of the site
7.1 For each topic there would be 3 sections: section 1 would provide additional information on the topic that could be added to, or edited by, contributors. Section 2 would be the teaching package. The third section would be a discussion board.

7.2 The teaching package would comprise: PowerPoint slides (as .ppt so that they could be adapted by the user) and supporting background text to the slides, either as a .pdf or as notes attached to the slides in the PowerPoint file. If appropriate the contributor could indicate the level or target group towards which their material was aimed. Test questions and answers could also be provided. There would be links to materials on other sites though it was preferable to have as much supporting material as possible provided in one place. This was particularly important if the site was going to be downloaded to a CD-ROM or other stand-alone medium for dissemination.

7.3 The possibility was raised of adding an image library in the future.

8 Issues of quality, intellectual property rights
8.1 The quality of the teaching content would be assured by inviting contributions from experienced and well-regarded clinical toxicologists and by peer review. The Home page of the site would list the people, and also possibly the institutions, that had contributed material to the site. In addition the names of steering group members would be listed. This would enable users to make a judgment about the quality and credibility of the teaching materials.

8.2 Peer review would be carried out by fellow contributors. It was also suggested that a small number of external experts be identified who, though they might not be willing to submit materials themselves, would be willing to carry out peer review. Before approaching people for this task some information about the concept and the tasks of the external reviewers needed to be written. This should probably wait until the project group had gained some experience in the process themselves, but could nevertheless start within the pilot phase of the project.

8.3 After the start-up phase the pool of contributors would widen, as users of the website would also be invited to submit their materials. How these materials should be peer-reviewed was yet to be decided in detail. One proposal was to provide a list of peer reviewers of the website from which the contributor could select one individual to carry out the peer-review. It was agreed that when the project group had gained more experience in the process of submitting and reviewing materials this procedure would be further developed.

8.4 It was recognized that there were many uncertainties in clinical toxicology and there could therefore be a range of views on best management. Moreover, in many parts of the world 'best management' was determined by the availability of resources. It was important to reflect these different positions in the teaching materials. Section 1 of each topic provided a medium through which controversies could be discussed.

The process of moderating submitted materials would ensure that those containing information that was a long way from accepted norms would be excluded. The Home page would alert the user to the fact that they might find differing views expressed, and would explain why this was.

8.5 There was an audit trail, in that the wiki site enabled contributors to see where changes had been made, and old versions of documents were retained.

8.6 A draft procedure for submitting materials is given at Annex 4. A code of conduct for authors would also be written.

8.7 The decision whether to put their name on their materials was left to the contributor. The site would in any case list the contributors. Contributors would be advised about the possible need to remove institutional logos or other identification.

8.8 Authors should remove any material from their slides that was copyrighted to others unless they had permission to use the material for the purpose of putting it on the website. A copy of the permission document should be sent to the site moderator. This issue needed further clarification, however, and Professor Dawson would consult with a copyright lawyer about liability for the use of copyrighted material, since this could happen inadvertently.

8.9 Photographs of patients should only be included if they added to the understanding of the subject being described. Such photographs should be anonymised as far as possible and the use of such pictures should comply with the standard requirements of medical journals, e.g. with respect to patient permission.

8.10 Contributors to the site should understand that acceptance of their submissions was on the basis that the materials would have unrestricted use for educational purposes.

8.11 There would need to be a disclaimer on the site. This would incorporate the usual text about not accepting liability for the way in which the site content was used and interpreted, and would also draw attention to the fact that users might find a number of different views expressed about the same subject.

9 Promotion of the site
9.1 In order to be promotable, the site needed to have an attractive and appropriate name. The choice might be limited by the availability of domain names. The name would be decided at the next meeting but could be discussed on the wiki site.

9.2 A number of means for promoting the site were suggested. It was important to repeat promotional activities at intervals. Possible means included:

Ø Asking toxicological and medical societies and associations to include a link on their websites.

Ø Sending information via list serves e.g. INTOX-general, those belonging to medical/toxicological societies.

Ø Identifying a 'champion' in each country who could publicize the site nationally and encourage its use.

Ø Asking medical journals, both those with an international and those with a primarily national readership, to include information about the site.

Ø Informing medical schools and medical libraries.

Ø Giving presentations at congresses and writing papers about the initiative.

Ø Asking websites used for continuing professional development to include a link.

9.3 In addition, users would be asked to acknowledge the source of their materials by means of a slide about the site that would be provided for them.

10 Functional requirements
10.1 A wiki site would be used in the first instance, though it was possible that this might change as the site developed. Some functionality requirements identified so far were:

Ø Ability to track changes made to materials

Ø Ability to have threaded discussions about topics

Ø Back-up functionality

Ø Assignment of differential rights to users e.g. for uploading, editing, read-only

Ø Ability to download the entire content onto another website or into a different medium such as a CD-ROM or the eGranary Digital Library [1]

11 Evaluation of the site
11.1 A number of evaluation methods were agreed:

Ø Check that all the priority topics have materials

Ø Monitor of web hits – look at country/region and the topics downloaded

Ø Number of new contributions offered by users

Ø Check Comments/Discussion section

Ø Ask a trainee e.g. a Fellow or MSc student to develop a presentation using materials on the site and get their feedback

Ø Invite users to provide feedback

Ø Put a survey form on the website

Ø If the website becomes heavily used, consider requiring registration before materials can be downloaded – use this for evaluation surveys

Ø Organize a research project to evaluate the site from different perspectives e.g. penetrance, effectiveness

Ø Ask the external reviewers to provide comments on the overall site

12 Possibilities of translation into other languages
12.1 There was a need for teaching materials in languages other than English. This could be achieved in a number of ways. The pool of contributors could be widened to include those in other countries who would be invited to submit materials in their own language. In addition users of the site who translated materials for their own use would be asked to submit these for use by others. Translated materials would need to be reviewed by a clinical toxicologist who was a native speaker of that language.

13 Costs and possible sources of funding
13.1 The costs for the pilot phase of the project were low: around US$1000 p.a. to use the wiki site without advertisements. At the end of the pilot phase it would be useful to have a meeting of contributors in order to evaluate how the project had progressed and to decide on next steps. It was suggested that this meeting could be held back-to-back with the Toxicology Update course in Cardiff, UK in November. A meeting in the UK would cost approximately $20,000. Other cost items are listed in Annex 5.

13.2 In terms of possible sources of funding for the longer term, it was possible that the E-Health unit of WHO could contribute up to $10,000, depending on the platform chosen. In addition it might be possible to apply to the SAICM Quick Start Programme (QSP). An application would have to be made through the SAICM focal point in a country. Since SACTRC was in Sri Lanka, Dr Fernando would explore the possibility of an application from there. This would be for the second wave of QSP funding.

13.3 Other possible sources included donor agencies and other UN bodies, such as UNESCO. Dr Fountain said some funds might be available from TOXINZ in return for contributions to the database. An additional possible source was to present the website as a research project and to seek funding for its implementation and evaluation of its usage.

13.4 It was felt that it would be better to approach potential funders once the pilot site had been established. Thus the issue of funding would be considered again at the next meeting.

14 Next steps and timeline
14.1 It was agreed that there would be a three-month pilot phase when the site would only be open to contributors. This period would be used to test the process of populating the site and to identify problems e.g. with conflicting information, overpopulation of some topics and lacunae in others, quality issues etc. A meeting would take place after that time, preferably in association with an existing meeting, the outcome of the pilot phase would be reviewed, and a decision be taken about next steps.

14.2 The following actions and timelines were agreed:

15 Further business
15.1 During the discussions it became clear that there were a number of terms and roles that would need to be defined. This could be carried out during the next 3 months through the wiki site. The terms/roles identified at the meeting were:

Ø Contributors
Ø Core contributors
Ø Invited contributors
Ø Unsolicited contributions
Ø Steering group
Ø Site moderator
Ø Users
Ø Target group
Ø Package
Ø Topic area

16 Closure of meeting
16.1 Ms Tempowski closed the meeting by thanking Mrs Good and colleagues at the Scottish Poisons Information Bureau for organizing and hosting the workshop. She also thanked the participants for their active contribution to the workshop.

World Health Organization IPCS/INTOX/Clin Tox Curric/ Agenda-final
International Labour Organization
United Nations Environment Programme
International Programme on Chemical Safety

Workshop to Develop and Deliver a Core Curriculum on Clinical Toxicology. Held at the Royal Infirmary of Edinburgh, Edinburgh, UK. 19th to 21st July 2006.

1 Welcome and introductory remarks
2 Selection of officers and approval of agenda
3 Background and purpose of the workshop
4 Proposal for developing and disseminating a clinical toxicology curriculum
5 Experiences in developing clinical toxicology education and in e-learning
6 Definition and prioritization of the key elements of the curriculum content
7 Structure and content of the site
8 Issues of quality, intellectual property rights
9 Promotion of the site
10 Functional requirements
11 Evaluation of the site
12 Possibilities of translation into other languages
13 Costs and possible sources of funding
14 Next steps and timeline
15 Further business
16 Closure of meeting

Professor Madhi BALALI-MOOD
Medical Toxicology Center, Imam Reza hospital, Mashhad, 91735-348, Islamic Republic of Iran
Tel: + 98 511 8819301 Fax: +98 511 8813714 E-mail: mbalalimood@hotmail.com

Dr Nida BESBELLI
World Health Organization, Avenue Appia 20, CH-1211 Geneva 27, Switzerland
Tel: +41 22 791 4287 Fax: +41 22 791 E-mail: besbellin@who.int

Professor Peter BLAIN*
Chemical Hazards and Poisons Division (Newcastle), Health Protection Agency, Wolfson Unit, Claremont Place, Newcastle upon Tyne NE2 4AA, United Kingdom
Tel: +44 191 222 7195 Fax: +44 191 222 6442 E-mail: p.g.blain@newcastle.ac.uk

Dr Paul DARGAN
Guy's & St Thomas' Poisons Unit, Guy's & St Thomas' Hospital Trust, Avonley Road, London SE14 5ER, United Kingdom
Tel: +44 20 7771 5315 Fax: +44 20 7771 5306 E-mail: paul.dargan@gstt.nhs.uk

Professor Andrew DAWSON
Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
Tel: +94 814479822 Fax: +94 814479822 E-mail: adawson@hypertox.com

Professor Abul FAIZ
Dhaka Medical College, Dhaka-1000, Bangladesh
Tel: +88 02 8616780 Fax: +88 031 610029 E-mail: mrg@spnetctg.com ; mafaiz@dbn-bd.net

Dr Ravindra FERNANDO
National Poisons Information Centre, Faculty of Medicine, Kynsey Road, Colombo 8, Sri Lanka
Tel: +94 11 2694016 / 2693266 Fax: +94 11 2691581 E-mail: ravindrafernando@hotmail.com

Dr John FOUNTAIN
New Zealand National Poisons Centre, University of Otago, PO Box 913, Dunedin, New Zealand
Tel: +64 3 467 5168 Fax: +64 3 477 0509 E-mail: john.fountain@otago.ac.nz

Dr Barbara GROSZEK
Department of Clinical Toxicology, Collegium Medium Jagiellonian University, Rydygier's Hospital, Os. Zlotej Jesieni 1, 31 826 Krakow, Poland
Tel: +48 12 646 89 85 Fax: +48 12 646 89 85 E-mail: mfgrosze@cyf-kr.edu.pl

Dr Bob HOFFMAN
New York City Poison Control Center, 455 First Avenue, Room 123, New York, NY 10016, USA
Tel: +1 212 447 8153 Fax: +1 212 447 8223 E-mail: bobhoff@pol.net

Professor Ratnam KOTEA*
Faculty of Science, Department of Health Sciences, Level 7, New Academic Complex Building, University of Mauritius, Réduit, Mauritius
Tel: +230 454 1041 Fax: +230 454 9642 E-mail: kotear@uom.ac.mu

Dr John THOMPSON
Academic Centre, Llandough Hospital, Penlan Road, Vale of Glamorgan, CF64 2XX, United Kingdom
Fax: +44 2920 703454 E-mail: thompsonjp@cardiff.ac.uk

Dr Nick BATEMAN
NPIS Edinburgh (Scottish Poisons Information Bureau), Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, United Kingdom
Tel: +44 131 242 1391 / 1383 Fax: +44 131 242 1387 E-mail: nick.bateman@luht.scot.nhs.uk

Ms Alison GOOD
NPIS Edinburgh (Scottish Poisons Information Bureau), Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, EH16 4SA United Kingdom
Tel: +44 131 242 1391 / 1383 Fax: +44 131 242 1387 E-mail: alison.good@luht.scot.nhs.uk

Dr Michael EDDLESTON
NPIS Edinburgh (Scottish Poisons Information Bureau), Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, United Kingdom
Tel: +44 131 242 1383 Fax: +44 131 242 1387 E-mail: eddlestonm@eureka.lk ; michael.eddleston@luht.scot.nhs.uk

Dr Ruben THANACOODY
NPIS Edinburgh (Scottish Poisons Information Bureau), Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA, United Kingdom
Tel: +44 131 242 1391 / 1383 Fax: +44 131 242 1387 E-mail: ruben.thanacoody@luht.scot.nhs.uk

Ms Joanna TEMPOWSKI
International Programme on Chemical Safety, World Health Organization, Avenue Appia 20, CH-1211 Geneva 27, Switzerland
Tel: +41 22 791 3571 Fax: +41 22 791 4848 E-mail: tempowskij@who.int

(Based upon the American Board of Emergency Medicine (ABEM) curriculum for medical toxicology. NB numbering of sections does not correspond to that of ABEM curriculum)

Teaching materials can be introduced at any level in this listing:

1 Pharmacology/Toxicology
1.1 Pharmacokinetics/Toxicokinetics
1.2 Pharmacodynamics/Toxicodynamics

2 Therapeutics
2.1 ABCs: Resuscitation

3 Initial Management
3.1 Differential Diagnosis
3.2 Toxidromes
3.3 Decontamination Strategies

4. Enhanced Elimination Techniques

5. Supportive and Other Care
5.1 Seizures
5.2 Arrhythmias
5.3 Control of Agitation
5.4 Control of Temperature
5.5 Correct Electrolyte and Acid-Base Disturbances
5.6 Fluid Resuscitation
5.7 Patient Monitoring
5.8 Pressor Agents and Control of Blood Pressure
5.9 Protect Airway/Ventilation/Manage Airway Injury
5.10 Psychiatric Issues
5.11 Social Issues
5.12 Transplantation

6 Drugs
6.1 Analgesics, Anti-inflammatory Drugs
6.1.2 Acetaminophen/paracetamol
6.1.3 Nonsteroidal Anti-inflammatory Drugs
6.1.4 Opioids
6.1.5 Salicylates
6.1.6 Others (e.g., antigout drugs, gold), colchicine

6.2 Drugs that Affect the Cardiovascular System
6.2.1 Antidysrhythmics
6.2.2 Calcium channel blockers
6.2.3 Cardiac glycosides
6.2.4 Antihypertensives
6.2.5 Adrenergic (and mixed) antagonists

6.3 Drugs that Affect the Nervous System
6.3.1 Anticonvulsants

6.4 Drugs that Affect Autonomic Homeostasis
6.4.1 Anticholinergics
6.4.2 Antihistamines
6.4.3 Sympathomimetics (e.g., amphetamines, cocaine)

6.5 Ethanol

6.6 Psychoactive Drugs and Hallucinogens (e.g., marijuana, lysergic acid diethylamide [LSD])

6.7 Psychotropics
6.7.1 Anxiolytics and sedative-hypnotics
6.7.2 Antidepressants
6.7.3 Antipsychotics
6.7.4 Mood stabilizers

7 Pesticides
7.1 Fumigants and Sterilants
7.2 Fungicides
7.3 Herbicides

7.4 Insecticides and Repellents
7.4.1 Carbamates
7.4.2 Organochlorines
7.4.3 Organophosphates
7.4.5 Pyrethrins and pyrethroids

7.5 Rodenticides
7.5.1 Anticoagulant
7.5.2 Non-anticoagulant

8. Cleansers and Caustics
8.1 Acids
8.2 Alkali
8.3 Bleach

9. Hydrocarbons/Solvents/Fuels
9.1 Alcohols and Glycols
9.1.1 Diethylene glycol
9.1.2 Ethylene glycol
9.1.3 Glycol ethers
9.1.4 Isopropanol
9.1.5 Methanol

10 Natural Products
10.1 Plants
10.1.1 Cardiovascular Toxic Plants (e.g. Aconitum napellus, Nerium oleander)
10.1.2 Cutaneous/Mucus Membrane Toxic Plants (e.g. Toxicodendron sp, Dieffenbachia sp)
10.1.3 Gastrointestinal Toxic Plants (e.g. Phytolacca Americana, Solanum sp)
10.1.4 Hepatotoxic Plants (e.g. Bilghia sapida, Symphatum sp)
10.2.5 Multisystem Toxic Plants (e.g. Prunus sp, Ricinus communis)
10.2.6 Neurotoxic Plants (e.g. Datura sp, Nicotiana tabacum)

10.2 Fungi

10.3 Envenomations
10.3.1 Arthropods
10.3.2 Marine Creatures
10.3.3 Reptiles/Amphibians

11. Metals/Metalloids

Provisional procedures for submission and review

Start-up phase – approx. 3 months

(Site will be open to small group of contributors only - the purpose of this phase is to identify problems and issues needing clarification)

1. Each contributor will post their package of materials to the website. A topic skeleton will be provided into which the contributor can slot their materials.

2. Others in the group will look at and comment on the materials. Each package will be looked at by another contributor or external reviewer at least once and preferably a second time after a few weeks to check any changes. This will be ensured by the site moderator.

3. The author will make the changes judged to be necessary (NB only the author can change their own materials)

4. The package will be accepted for subsequent public use.

Live phase - provisional procedure

(This will be revised in the light of experience during the pilot phase)

1. Existing contributors will simply post their materials to the site without the need for review, provided that this has been shown to be acceptable in the start-up phase.
2. New, external contributors will be asked to send their materials to a reviewer chosen from a list established by the project group. This list will be on the website with short information about each member’s areas of expertise.
3. Once the reviewer has ‘passed’ the materials these will be posted to the site.

Cost items for clinical toxicology curriculum site

[1] The eGranary Digital Library provides millions of digital educational resources to institutions lacking adequate Internet access. Web site content is downloaded (with permission) and delivered to intranet Web servers at partner institutions in developing countries, enabling millions of multimedia documents to be instantly accessed by users over their local area networks at no cost.

*Invited but unable to attend