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Competency and Training for Health Care Practitioners Working in Remote Environments Revised January 2017

A Revised Consensus Document 1


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Contents Contents 

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List of abbreviations

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Introduction5 Purpose5 Who is this document for?

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Definitions

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RHCP Roles and Responsibility

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Mindset8 Experience, Certifications, and Training

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Competency and Education

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Education Delivery and Competence Evaluation

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Training Duration

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Skills Maintenance

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Emergency Medicine

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Primary Healthcare Care

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Occupational Medicine

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Clinical Governance and Administration

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Extreme Remote Locations

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References

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Appendix A: Emergency Medicine

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Appendix B: Primary Care/Preventative Medicine/Health Administration

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Appendix C: Delphi Study

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List of Abbreviations

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AED

Automated external defibrillation

HSSE Health, Safety, Security and Environment

ACLS

Advanced cardiac life support

GCS

Glasgow Coma Scale

ALS

Advanced life support

GMC

General Medical Council

ATLS

Advanced trauma life support

IRHC

Institute of Remote Healthcare

BLS

Basic life support

MER

Medical emergency response

CPD

Continuous professional development

MERP Medical emergency response plan

DFA

Designated first aiders

MI

Myocardial infarction

DKA

Diabetic ketoacidosis

SDS

Safety data sheet

ECG/EKG Electrocardiogram

NMC

Nursing and Midwifery Council

ENT

Ear, nose and throat

PHLTS

Pre-hospital trauma life support

FRM

Fatigue risk management

RHCP(s) Remote healthcare practitioner(s)

FTW

Fitness to work

RTW

Return to work


Introduction The Institute of Remote Health Care (IRHC) has recognised the continual growth of clinical work in remote and extremely remote environments and has engaged stakeholders across the various clinical professions (doctors, nurses, medics and paramedical personnel). This was followed by a Delphi Study completed by Professor Susan Klein (attached as Appendix 3) From this consultation, the consensus document was constructed, which is intended to inform practitioners, healthcare providers, industry and educational institutions and other interested parties of the IRHC’s opinion concerning the evolving areas in remote clinical practice. The document was not intended to be complicated or difficult to read but to be a practical, steering paper that aligns the core clinical competencies for remote healthcare practitioner (RHCP™) globally. The key issues identified were: ➊ What are the health challenges of working in remote locations, and what are the common ways of overcoming these challenges? ➋ What are the competency requirements for Health Professionals working at these remote locations? ➌ What are the communication technologies, tele-health and telemedicine capabilities required to deliver health in these settings? ➍ What medical equipment and medical supplies are required to support health delivery in these locations? ➎ What preventive controls and planning considerations are needed to optimize health and minimise injuries and illnesses in these locations? The IRHC published “IRHC Remote Healthcare for Energy and associated Maritime activities©” in October 2013” A Delphi Study “Developing Consensus on Remote Healthcare Practitioners’ Competency for Oil and Gas Operations” was completed by Professor Susan Klein in 2014 followed by a further workshop at the IRHC Conference “Delivering Competent Healthcare in Remote and Rural Environments “held at Olympia London 7th-8th October 2014, the IRHC published “Competency and Training for Health Practitioners working in Remote Oil and Gas Operations” Further IRHC workshops were facilitated by Drs Richard Hooper and Jayson Eversgerd at the “Remote Healthcare Conference “held 16th -17th February 2016 in Abu Dhabi to further develop the competency and training document to reflect a more global approach and extend the target audience to all remote healthcare practitioners. In total, over 200 professionals from around the world involved in remote healthcare have contributed to this document. The current version of the IRHC Consensus document provides clear and concise guidance, in modular format, of the educational requirements to produce a professional and competent remote healthcare practitioner. The evolution of this document has now reached a stage that it is ready for curricular development by the various capable training organisations around the globe. It is also suggested and in current development that a series of IRHC CPD courses would be ideal to allow the material to be covered in appropriate bites. Training organisations are now encouraged to produce appropriate courses to be accredited by IRHC. The IRHC envisions the way forward is to provide CPD credit points to members to justify an award of recognition as a fully competent international remote healthcare practitioner (RHCP™). The intention is to align CPD education to the consensus themes and supply members with demonstrable CPD Units. CPDUs provide the initial foundations for course development and lead the standardisation process for RHCP education.

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Further collaborative international research will be undertaken to determine whether modifications and amendments are required to take account for the different disease patterns, environmental, geographical and government and legal systems across the world. This will allow a suite of CPD courses and programs that will be produced to provide appropriate content for different geographical locations.

Purpose This document is designed to support the IRHC document “Remote Healthcare for Energy and associated Maritime activities (IRHC, 2013)”. It represents a consensus of expert opinion and aims to define the competency expectations and training requirements for RHCPs working in remote oil and gas operations around the globe. It serves to assist: (1) training providers in developing RHCP training and assessment; (2) RHCPs in clarifying expectations on their competency, and (3) Company Health / Health, Safety, Security and the Environment (HSSE) advisors in planning for health support in their respective remote locations. It provides a benchmark for objectively determining the suitability of RHCP candidates, and those who are already in operational appointments. This document does not attempt to prescribe a single competency expectation for each remote site, as the exact requirement must be shaped by the prevailing risks and situation specific to the workplace, company and country. It does, however, offer guidance on a structured approach to RHCP competency.

Who is this document for? This document is aimed at professionals involved in implementing health care in remote environments. ➔ Company Health/HSSE professionals ➔ Medical / RHCP training providers ➔ Emergency assistance providers ➔ Remote Healthcare Practitioners (RHCP) ➔ Government agencies and legislative bodies ➔ Allied emergency medical services combat agencies as well as recognition from other EMS providers e.g. ambulance coastguard etc.

Disclaimer This document is based on the workshop participants’ individual views, derived from their expertise in providing healthcare in remote locations in the oil and gas industry. The views presented in this document do not necessarily represent the views of the participants’ organisations. Please cross reference to your individual legislation and regulatory frameworks that anything you take from this document meets local regulatory or business requirements, and is appropriate for your particular location, activities and risks.

Definitions ➔ Remote Healthcare Practitioner (RHCP): A health professional who is responsible for providing healthcare in remote locations. ➔ Remote Healthcare (RHC): The prevention, diagnosis, and treatment of illnesses and injuries for those who work in remote locations.

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➔ Competency1 (Health Professional): The habitual and judicial use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflections in daily practice for the benefit of the individual and community being served. ➔ Remote Location: Sites where the medical evacuation of an injured or ill person to a hospital cannot be guaranteed to be achieved within 4 hours in foreseeable circumstances (e.g. inclement weather). A common example in the oil and gas industry is the offshore platform. ➔ Extreme Remote Location: Sites where medical evacuation to a hospital can never be achieved within 4 hours, even in the best of circumstances. Examples include seismic vessels operating beyond helicopter flying range. In these sites, evacuation times may exceed 24 hours. ➔ Advanced Life Support (ALS): A set of life-saving protocols and clinical skills that extend Basic Life Support (BLS) to further support the circulation and provide an open airway and adequate ventilation (breathing). ➔ Advanced Cardiac Life Support (ACLS): A set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions. ➔ Advanced Trauma Life Support (ATLS): A training program for medical providers in the management of acute trauma cases, developed by the American College of Surgeons, as the standard of care for initial assessment and treatment in trauma centres. ➔ Fitness to Work (FTW) (aka FFD-Fitness for Duty): The certification of an individual that their current level of health is suitable for the safe completion of normal tasks expected of them in the workplace. ➔ Health Risk Assessment (HRA): A process of identifying workplace health hazards, evaluating their risks to health and determining appropriate workplace control and recovery measures in order to prevent acute and chronic health effects to the workers in that work location. It is not the same as FTW (see “FTW”). ➔ Incident: An unplanned event, or chain of events, that has, or could have, resulted in injury or illness to people or damage to assets, the environment or reputation. ➔ Medical Evacuation (“Medevac”): The emergency transfer of ill or injured personnel to a health facility for the purpose of obtaining medical care. It has priority over all normal operations. A medevac may be pursued using various transportation modes (e.g. helicopter, boat, off-road vehicle, or a crew change flight). The term “medevac” is not restricted to those where air transportation is used, or to those where a health professional provided medical support during transfer. ➔ Medical Emergency Response (MER) Standard:2 Various standards of care during medical emergencies exist, with most utilising a time-based tiered approach. A typical example of an MER Standard is as follows: o Tier 1: Provide first aid treatment, including defibrillation, by a designated first aider within 4 minutes of any injury or illness. o Tier 2: Provide assessment and stabilisation by a health professional within 1 hour of any injury or illness that requires it. o Tier 3: Provide admission to and care at the nearest local hospital within 4 hours of any injury or illness that requires it. o ALARP: When response times or requirements above cannot reasonably be met, perform a risk assessment and provide medical emergency response risk mitigation measures3 to ensure that the risks are kept as low as reasonably practicable (ALARP).

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Defining and Assessing Professional Competence. Epstein R, Hundert E, JAMA. 2002 Jan 9;287(2):226-35. Remote Healthcare for Energy and associated Maritime activities. Institute of Remote Healthcare, 2013.

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➔ Remote Medical Support (“Topside”): 4 Real-time specialist medical advice by emergency medical professionals (usually doctors) to the RHCP via telecommunication and/or information technologies. It is also commonly known colloquially as “topside support” in the energy industry. Topside needs to be available to the RHCP on demand, 24/7. ➔ Remote Site Clinic (Tier 2): A site health centre at a remote location for the provision of casualty resuscitation in transit to a (Tier 3) hospital. A remote site clinic has extended capabilities in view of the need to provide Tier 2 support beyond 4 hours. (See also “Site Clinic”). ➔ Site Clinic: A site health centre for resuscitation by a RHCP and the provision of advanced life support (i.e. Tier 2 medical emergency response). (See also “Remote Site Clinic”).

RHCP Roles and Responsibility The consensus document has identified themes relating to the role and competency required to be a RHCP and as such The RHCP is responsible for providing: ➊ Emergency management of ill or injured in remote locations; ➋ Frontline delivery of primary healthcare; ➌  Frontline delivery of occupational medicine (e.g. occupational health, public health, vector control, health promotion, education and training), and ➍ Clinical governance and health administration (e.g. managing a site clinic, managing a pharmacy, recordkeeping, communications skills, implementing health programs, etc.)

Mindset Providing healthcare in a remote location requires the RHCP to adopt a different approach to work than that of working in a traditional hospital setting where available multiple speciality physician consultations are readily available and medical evacuations are typically less than 1 hour from request. RHCP training and assessment must ensure that the RHCP is aware of the need to adopt this differing mindset, which includes: ➊  Accountability. The RHCP is responsible for delivering health to the individuals on site for extended periods. The RHCP’s behaviours and actions impact not only on patient’s safety, but also the site’s operational readiness, business continuity, reputation and legal liability including but not exhaustive Ethics, data protection and confidentiality ➋  Knowledge and Breadth. The RHCP needs to possess a broad range of knowledge and skill relating to health and safety. In addition to knowledge of the usual branches of medicine and surgery, the RHCP will also need to utilise his/her knowledge and skills in areas such as pharmacy, dentistry, public health, occupational health, health management, human factors and tactical/operational medicine. In addition to health, the RHCP will also need to understand safety and engineering issues that are relevant to the worker’s health (e.g. Water systems, exhaust fumes, engineering controls for noise and chemicals etc.). ➌  Flexibility. There are many factors inherent to working in remote locations, which require adaptability, flexibility and resilience on the part of the RHCP. This includes a fast-changing operational tempo, sudden crises, extreme environments (e.g. heat, cold, security, altitude), and limited supplies and support. ➍  Leadership. Successful health delivery in remote locations requires the RHCP to be able to influence without having formal authority. ➎  Collaboration. In order to successfully deliver health, the RHCP requires gaining support from workers, supervisors, and managers, topside, and their back-to-back colleagues. A collaborative mindset helps the RHCP to build trust, establish strong working relationships, and influence.

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➏  Curiosity (Inquiring). A mindset of curiosity encourages risk identification, assessment, exploration of opportunities and problem solving. ➐  Moral Courage. RHCPs often need to make difficult clinical decisions in difficult circumstances, with limited treatment options and limited access to information. In addition, RHCPs may often need to hold difficult conversations with employees, supervisors and management.

Risk mitigation measures include increased medical capability from additional equipment, drugs, telecommunications, as well as enhanced RHCP competency (as described in this document). 4 Further details on Topside expectations are outlined in IRHC document “Remote Healthcare for Energy and associated Maritime activities (2013)”. 3

Experience, Certifications, and Training To ensure competent practice, prior to working in remote locations, the RHCP must possess the following: a. A current professional registration with a relevant national or governmental regulatory body (e.g. medical council, nursing council, healthcare professional council, etc.), in order to indicate the RHCP’s baseline competency and good where relevant and pertaining to the country of practice. b. At least 3 years’ of clinical working experience in an Emergency Medicine setting.

In addition to the above, a one-year working experience in a Primary Healthcare setting is desirable (but not essential). It is not considered an absolute requirement, as the combination of prior experience (3 years in Emergency Medicine and 1 year in Primary Healthcare) is rare amongst health practitioners in many countries. Typical RHCP professional backgrounds include Nurse, Nurse Practitioner, Physician, Paramedic, Physician’s Assistant, and Military Medic. Any health professional that (a) possess a current professional registration from a relevant national regulatory body, (b) possess the working experience outlined above, and (c) have successfully completed the RHCP competency and training outlined in this document, are suitable for practice from those perspectives.

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Competency and Education ➊  To ensure competent practice, it is recommended the RHCP complete RHCP training where available e.g. HSE (or equivalent) and a competency evaluation/assessment process. ➋ The RHCP training and assessment recommended based on consensus should cover: a. Emergency Medicine (Appendix A: Themes 1-4) b. Primary Care (Appendix B- Theme 5) c. Occupational Medicine (Appendix B: Theme 6) d. Clinical Governance and Administration (Appendix B: Theme 7) ➌  In addition to the baseline RHCP training and assessment, RHCPs who are deployed to extreme remote locations are required to complete additional training and assessment relevant to this environment.

Education Delivery and Competence Evaluation ➊ Whilst the mainstay of RHCP training delivery remains face-to-face, some (but not all) RHCP training components can be delivered via distance learning (e.g. computer-based training) or hybrid model. ➋  Whilst the mainstay of RHCP evaluation remains face-to-face, some (but not all) RHCP competence evaluation components can be delivered via distance learning (e.g. computer aided assessment).

Training Duration No consensus was achieved on RHCP training duration. However, the majority of subject matter experts endorsed the view that RHCP training (including distance learning) should typically take 120 hours or more. The actual duration required will depend on the individual’s baseline competency and experience. The critical factor is that the achievement of outcomes of the learning is demonstrated by the learner.

Skills Maintenance ➊ To prevent skills decay the RHCP must: a.  Complete ACLS training every 2 years, ATLS (or its equivalent) every 4 years, OR complete a series of shorter, modular, more frequent skills maintenance training in ATLS and ACLS (or their equivalents) as part of a continuous professional development (CPD) approach. b.M  eet CPD requirements of the IRHC, national or governmental regulatory body with whom he/she is registered or meet the CPD standards to be determined by the IRHC e.g. must complete 100 points per year from a series of workshops, literature reviews conferences etc. No consensus was obtained on experiential training involving real patients (e.g. via hospital attachments) at regular intervals (e.g. every 2 years). However, most participants view this to be highly valuable in maintaining the RHCP’s clinical skills.

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Emergency Medicine RHCP training and assessment in Emergency Medicine must ensure that the RHCP is able to perform the following: ➊ Understand the various roles and responsibilities that entail being a RHCP and how they may differ from one location or environment to another. The RHCP needs to learn the mindset it requires and the various important attributes the remote environment requires to be successful. ➋  To be up to date on the minimum certifications and training that is required and formally maintains CPD on the following as well as areas pertinent to their scope of practice. • ACLS ATLS, ITLS, PhEC Basics, PHTLS or equivalent. • Mass Casualty Incident (MCI): understanding the key concepts in performing START triage (Simple Triage and Rapid Treatment), establishing an Incident Command System (ICS), and secondary triage (e.g. MIMMS, SALT, START+) • Emergency Communications Training (2-way radio, Email, Satellite Phone) • Instructor qualification in workplace first aid provision and automated external defibrillation (AED) ➌ Diagnosis and Patient Management. • Core principles of Pre-Hospital medicine to include: Scene size up, Patient Assessment & Stabilisation, and Emergency Transport. • Conduct appropriate history and physical examination and provide initial or definitive management for common medical chief complaints and their associated differential diagnosis such as fever, weakness, dizziness, numbness, headache, vision changes, dyspnoea, chest Pain, abdominal pain, endocrine emergencies, and allergic Reactions. • Conduct appropriate history and physical examination and provide initial or definitive management for common orthopaedic chief complaints and their associated differential diagnosis such as back pain, neck pain, hand Injuries, sprains, strains, fractures, and dislocations. • Identify and provide initial management of common surgical emergencies such as acute appendicitis, cholecystitis, perforated viscous, bowel obstruction, diverticulitis, testicular torsion, strangulated hernia etc. • Identify and provide initial management of common psychiatric emergencies such as acute depression, anxiety psychosis, mania, suicidal ideations and violent behaviours. • Recognise and manage logistical challenges associated with each patient’s illness or injuries in relations to their remote environment and access to definitive care. • Core principles in the initial evaluation and treatment of Environmental, Toxicological, and Dive Emergencies including indications for emergency hyperbaric medicine. ➍ Procedures and Skills – see details outlined in Appendix A: Theme 4

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Primary Healthcare RHCP training and assessment in Primary Health Care10 must ensure that the RHCP is able to: • Perform primary healthcare consultations • Identify and manage common and significant complications arising from common chronic illnesses (e.g. cardiovascular, respiratory, endocrine, gastrointestinal, urological, musculoskeletal, neurological, dermatological, infectious, ENT, ophthalmological, sexual health and mental illnesses)11. • Manage common minor injuries and illnesses (e.g. rashes, upper respiratory tract infections, contusions, abrasions) captured within the scope of emergency medicine. • Perform minor surgery (e.g. local anaesthesia, wound care) captured within the scope of emergency medicine. • Dispense, and demonstrate awareness of pharmacology and polypharmacology of chronic illness.

Occupational Medicine RHCP training and assessment in Occupational Medicine must ensure that the RHCP is competent in respect of: ➊ Health Risk Assessment (HRA). be successful. a. Describe the HRA process. This includes an awareness of the HRA identification techniques, assessment techniques (e.g. using risk ratings and registers), hierarchy of controls, and ALARP (“as low as reasonably practicable”) concept. b. Use the HRA results5 to implement and monitor workplace health controls. ➋ Medical Assessment for Fitness to Work (FTW) (aka. Fitness for Duty (FFD). a. Describe FTW requirements in relation to the jobs/tasks undertaken of the location. b. Identify individuals who may not be fit for work due to recent changes in health status. c. Identify when a return to work (RTW) reassessment is required for individuals at risk. ➌ Substance Abuse and Misuse. a. Describe the common elements of a drug and alcohol policy (e.g. clear rules, awareness/ training, assistance, testing, disciplinary actions, etc.) b. Describe health effects of alcohol and commonly abused substances. c. Able to identify signs and symptoms of alcohol and substance abuse. d. Able to describe drug testing procedure (e.g. collection, screening, chain-of-custody, confirmatory testing, Medical Review Officer’s verification, etc.) ➍ Food and Drinking Water Safety. a. Describe the principles of food safety and food safety management systems. b. Conduct food safety audits and report findings. c. Participate in outbreak investigations (e.g. norovirus, food poisoning etc.). d. Implement and maintain a food safety management system (e.g. Hazard Analysis Critical Control Point [HACCP]). e. Describe principles of drinking water safety. f. Implement procedures to help ensure drinking water safety (e.g. potable water testing). ➎ Ergonomics. Provide basic advice on workplace ergonomics. ➏ Hearing Conservation. Participate in the implementation of Hearing Conservation Program (HCP). ➐ Fatigue Risk Management. Describe the fatigue risk management (FRM) process.

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➑ Workplace Health Promotion Program (WHPP). Implement a WHPP, focusing on behavioural change including: a. Nutrition and diet. b. Exercise. c. Smoking cessation. ➒ Infectious Disease Outbreak Prevention. Identify common local and global communicable disease symptoms, understand and implement appropriate infection control procedures, escalate outbreaks of infectious disease appropriately, implement hygiene, sanitation and other containment measures, and initiate contact tracing. ➓ Incident Investigation and Reporting. a. Describe the incident investigation process. b. Describe the industry’s occupational illness and injury reporting requirements. c. Able to apply the industry’s classification of illness and injuries. d. Provide support to an incident investigation team. e. Act as a member of an incident investigation team. f. Apply medical confidentiality whilst supporting the incident investigation and reporting.

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The HRA itself may be performed by a specialist HRA practitioner (e.g. an industrial hygienist).

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Clinical Governance and Administration RHCP training and assessment in Health Service Administration must ensure that the RHCP is able to: ➊ Manage a remote Site Clinic pharmacy. ➋ Remote Clinic Management (recordkeeping, scheduling, Waste, Inventory, Controlled Substance management). ➌ Communications (public speaking, telemedicine communications). ➍ IT Intelligence (Word processing, Spreadsheets, Email, Internet, Electronic Health Record). ➎  Operational Medicine for Various Remote Settings (Humanitarian, Industrial, Tactical, Extreme Remote). This includes a basic understanding of the health impacts of onsite work activities that may be beyond his/her training (e.g. those relating to diving medicine, tropical medicine, aviation medicine, travel medicine, etc.). ➏  Implement clinical governance (includes participating in and conducting clinical audits).

Extreme Remote Locations Sites where medical evacuation to a hospital can never be achieved within 4 hours (even in the best of circumstances) pose significant challenge to healthcare provision. In addition to the baseline RHCP training and assessment above, RHCPs who are deployed to extreme remote locations are required to: ➊ Possess at least 3 years of experience of working in remote locations. ➋ Complete additional training and assessment.6 ➌ Perform the following emergency procedures : a. Insert a chest drain for a tension pneumothorax b. Rapid Sequence Induction (RSI) followed by Endotracheal intubation c. Suprapubic catheterisation for acute urinary retention d. Plain Radiography: Safety, Imaging, Interpretation (Chest, Pelvis, C-spine, Extremity) † e. Emergency ultrasound† (Basic Physics and eFAST exam)

References ➊ Developing Consensus on Remote Healthcare Practitioners’ Competency for Oil and Gas Operations: a Delphi Study. Klein, S. Mohamed, H. 2014 IRHC Conference, Olympia London, 7-8th October 2014. ➋ Remote Healthcare for Energy and associated Maritime activities. Institute of Remote Healthcare, 2013. ➌ Defining and Assessing Professional Competence. Epstein R, Hundert E, JAMA. 2002 Jan 9;287(2):226-35.

No consensus was achieved on the exact content and details of the additional training assessment for extreme remote locations. Exact requirements must be shaped by the prevailing risks and situation specific to the workplace, company, and country. 6

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Appendix A: Emergency Medicine (Theme 1-4) Theme 1: Introduction 1. RHCP roles and responsibilities (see details in Framework Doc). 2. Mindset of the RHCP (see details in Framework Doc). Theme 2: Required Certifications & Training 1. Advanced Cardiac Life Support (ACLS) or equivalent. 2. Advanced Trauma Life Support (ATLS), PreHospital Trauma Life Support (PHTLS), International Trauma Life Support (ITLS) PhEC Basics UK or Equivalent. 3. Mass Casualty Incident (MASCAL): understanding the key concepts in performing primary triage, establishing an Incident Command System (ICS), and secondary triage (eg. MIMMS, SALT, START+, ). 4. Emergency communications Basics (2-way Radio, Email, Satellite Phone) 5. Instructor qualification in workplace first aid provision and automated external defibrillation (AED). Theme 3: Diagnosis & Patient Management 1. Core principles of Pre-hospital medicine to include: Scene Size-up, Patient Assessment & Stabilization, and Emergency Transport. 2. Conduct appropriate history and physical examination and provide Initial or definitive management for common medical chief complaints and their associated differential diagnosis such as Fever, Weakness, Dizziness, Numbness, Headache, Eye Pain, Dyspnoea, Chest pain, Abdominal Pain, Endocrine Emergencies, Allergic Reactions. 3. Conduct appropriate history and physical and provide Initial or definitive management for common orthopaedic chief complaints and their associated differential diagnosis such as Back pain, Neck pain, Hand Injuries, Sprains, Strains, Fractures, and Dislocations. 4. Identify and provide initial management of common surgical emergencies such as acute appendicitis, cholecystitis, perforated viscus, bowel obstruction, diverticulitis, testicular torsion, strangulated hernia etc. 5. Identify and provide initial management of common psychiatric emergencies such as acute depression, anxiety psychosis, mania, suicidal ideations, and violent behaviours. 6. Recognition and management of logistical challenges associated with each patient’s illness or injuries in relation to their remote environment and access to definitive care. 7. Core principles in the initial evaluation and treatment of Environmental, Toxicological, and Dive emergencies including indications for emergency Hyperbaric medicine. Theme 4: Procedures Competencies 1. Corneal Anaesthesia and Fluorescein Staining of the Cornea. 2. Epistaxis management: Nasal packing and Cautery. 3. Wound care, Suturing, Debridement and Dressing. 4. Incision and Drainage of a simple and complex superficial abscess.

Theory X X Theory X X

Practical

X

X

X X

X X*

Theory X

Practical

Practical X* X

X

X

X

X

X

X

Theory X X X X

Practical X* X* X* X*

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5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

Local Wound Anaesthesia & Hand Nerve blocks Nail Trephination & Nail Removal. Intraosseous access- Lower & Upper Extremity. Peripheral Venous access. Surgical Cricothyroidotomy. Needle Thoracostomy. Performance and Interpretation of a 12 lead electrocardiogram. Administration of Acute Myocardial Thrombolytic Medications. Fractures management- Splinting of all extremities. Indications and Methodology of Tourniquet Applications. Joint Dislocation Stabilization and Reduction Modalities: Jaw, Shoulder, Elbow, Digits, Hip, Knee, and Ankle. Conscious Sedation (Mild to Moderate) for Procedures and Intubated patient management. Techniques and Modalities in Physical and Chemical Restraints of the Acute Psychotic and Violent patient. Chest drain/tube insertion and management†. Transurethral catheterization. Suprapubic catheterisation for acute urinary retention†. Rapid Sequence Induction(RSI) followed by Endotracheal Intubation†. Mechanical ventilation initiation and prolonged management. Insertion of a Supraglottic Device (LMA, King Airway, Combitube). Laryngoscopy with Miller and Macintosh blade for endotracheal intubation. Application of temporary dental filling. Local dental anaesthesia: Landmarks and techniques. Traumatic tooth luxation and avulsion: assessment, reduction, repositioning, and basic stabilization. Basic management of dislodged crowns and bridges. Plain Radiography: Safety, Imaging, Interpretation (Chest, Pelvis, C-spine, Extremity) †. Emergency ultrasound† (Basic Physics and eFAST exam).

*Face-to-face mode may be significantly more effective than virtual training

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X X X X X X X X X X X

X* X* X* X* X* X* X* X* X* X*

X X X X X X X X X

X* X* X* X* X* X* X*

X X X

X* X*

X X

X

X

X*


Appendix B: Primary Care/Preventative Medicine/Health Administration (Themes 5-7) Theme 5: Primary Healthcare 1. Primary healthcare consultation. 2. Identify and manage common and significant complications arising from common chronic illnesses management (includes common cardiovascular, respiratory, endocrine, gastrointestinal, urological, musculoskeletal, neurological, dermatological, infectious, ear, nose and throat, ophthalmological, sexual health and mental illnesses). 3. Prescribing pharmacology & Polypharmacy awareness. Theme 6: Occupational Medicine 1. Health risk assessments (HRA). 2. Fitness to work (FTW)/(aka. Fitness for Duty-FFD). 3. Substance abuse policy and controls. 4. Food and drinking water safety monitoring. 5. Ergonomics and lifting. 6. Hearing Conservations Programs. 7. Fatigue Risk Management (FRM). 8. Work Place Health Promotion Program (WHPP). 9. Infectious Disease Outbreak Prevention. 10. Incident Investigations. Theme 6: Occupational Medicine 1. Managing a remote site pharmacy. 2. Remote Clinic Management (recordkeeping, scheduling, Waste, Inventory, Controlled Substance management). 3. Communications (public speaking, telemedicine communications). 4. IT Intelligence (Word processing, Spreadsheets, Email, Internet, Electronic Health Record). 5. Operational Medicine for Various Remote Settings (Humanitarian, Industrial, Tactical, Extreme Remote). 6. Implement clinical governance (includes participating in and conducting clinical audits).

Theory X X

X Theory X X X X X X X X X X Theory X X

Practical X

Practical

Practical

X X X X

*Face-to-face mode may be significantly more effective than virtual training

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Appendix C Abstract: Developing Consensus on Remote Healthcare Practitioners’ Competency for Oil and Gas Operations: A Delphi Study Background Ensuring that the skills set and competencies of Remote Healthcare Practitioners (RHCPs) working in oil and gas operations are at an appropriate standard is a continual challenge. Despite increasing activity in remote locations both within the Energy industry and its associated Maritime activities, there are no universally accepted standards, with wide variation in training and stakeholder’s expectations. In recognition of these challenges, and the potential limitations around the generalizability of the 2013 Institute of Remote Healthcare Guidance Document (“IRHC: “Remote Healthcare Guidance Document for Energy and associated Maritime activities”) in representing the global view of key stakeholders, the IRHC Council commissioned an independent research team based at Robert Gordon University (RGU)1 to conduct a Delphi Study. The Delphi methodology was originally developed as a decision making tool by the RAND corporation1, the Delphi method of enquiry recognises the value of experts’ opinions and experience when full scientific knowledge is lacking2. It is a well-established method used for guideline development within a range of policy settings, including that pertaining to occupational health physicians3 and occupational health4. Comprising an iterative process, it is commonly used to determine whether consensus is possible by asking experts to indicate the level to which they agree or disagree with statements presented in a questionnaire format in two or more rounds. Aims To: (i) achieve international consensus of expert opinion on basic statements pertaining to the skills set and competencies of RHCPs upon which a universally accepted standard can be built, and (ii) inform the training and practice of RHCPs internationally on the basis of the best available advice from experts and practitioners in the field. Method Within the context of the Energy industry and its associated Maritime activities, a modified Delphi study was conducted using seven inter-related phases. Phase I – Generation of statements: A list of items for subsequent translation into statements and appropriate topic areas were generated by means of: (i) a literature review and (ii) collaboration with Dr Halim Mohamed as the Principal Author of the “IRHC: “Remote Healthcare Guidance Document for Energy and associated Maritime activities” (2013). Phase II – Validation of statements: To validate the clarity and comprehensibility of the statements, a select sample of individuals were invited to comment as representatives of the target categories identified for the sampling frame from which the Delphi Study participants were drawn. Phase III – Development of an online questionnaire: The outcome of Phases I and II informed the development of the questionnaire comprising 116 statements, which were allocated to 22 topic areas in total. Snap Survey Software was used to deliver the statements in the form of an online questionnaire in order to: (i) facilitate administration; (ii) reduce burden on participants, and (iii) expedite the process to ensure completion in time for presentation at the IRHC 2014 Conference. Phase IV –Selection of a panel of experts: As the composition of the sample relates to the validity and generalizability of the outcome, careful consideration was given to key issues pertaining to sampling and selection of the panel of experts including the sampling criteria (i.e., who qualifies as an expert) and the sample size. Potential “expert” panel participants were identified from a sampling frame designed to ensure a heterogeneous sample such that the entire spectrum of opinion is determined and comprised the four target populations, viz: (i) Oil & Gas representatives; (ii) Service Provider representatives; (iii) Subject Matter Experts, and (iv) RHCPs. Phase V – Conduct of a “modified” Delphi Study: Participants were provided with pre-selected issues upon which to make a judgement (as determined in Phase

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I). Two rounds were conducted to reduce the occurrence of panel fatigue. Phase VI – Content and statistical analysis: Between each round, content analysis was conducted to condense the data for the subsequent round, and facilitated by employing the Snap Survey Software. Phase VII – Dissemination of findings: The findings were: (i) presented on Day 1 of the 2014 IRHC Annual Conference “Delivering Competent Healthcare in Remote and Rural Environments” (7th-8th October, 2014, Olympia, London) and (ii) provided a basis for discussion at the RHCPs Competency Workshops on Day 2 in order to enhance consensus of agreement where necessary. Results Based on a sample of N=315, 86 (27%) valid responses were achieved for Round 1 and 75 (24%) for Round 2 respectively. Participants derived from 105 organisations with the majority pertaining to the Oil and Gas industry (46%). Most participants were Health Advisers (40%) who currently worked on a daily basis in remote healthcare (65%), particularly within the geographical regions of Europe and Eurasia (65%). Of the 30 RHCPs who participated, the majority were physicians (80%). Overall, consensus was achieved for the 61% of statements, with the majority pertaining to 16 of the 22 topic areas as follows: RHCP Responsibility; Mindset; RHCP Competency and Training; Formal RHCP Training and Assessment for Prevention of Skill Decay; RHCP Training and Assessment in: Emergency Medicine; Advanced Life Support (ALS); Common Medical Emergencies; Common Surgical Emergencies; Common Psychiatric Emergencies; Common Traumatic Emergencies; Training Staff in First Aid and Defibrillation; Extreme Remote Locations; Primary Health Care; Preventative Medicine, and Health Service Administration. Examples of consensus of agreement include: RHCPs should possess a current registration with a relevant governing body and complete formal RHCP training and assessment (particularly in respect of 3-yearly ALS training an components relating to emergency care, preventative care and primary care) Topic areas that received least consensus with regards to their respective statements were most notably in relation to: Training Duration; Training Delivery; Skills Maintenance; Competence Evaluation/Assessment, and RHCP Training and Assessment in Common Dental Emergencies. Examples of an absence of consensus of agreement include: RHCP professional background; training and assessment in the administration of anaesthetics, and ability to undertake certain dental procedures such as performing a tooth extraction. Conclusion In light of the high level of consensus achieved, and in concert with potential for the subsequent RHCPs Competency Workshops to resolve those topic areas currently lacking in consensus, recommendations based on the findings of this modified Delphi study provides a robust evidence-base on which to: (i) build continued industry collaboration on competency and training standards; (ii) develop an industry guidance document, and (iii) enable global implementation. References Dalkey N, Helmer O (1962). An Experimental Application of the Delphi Method to the Use of Experts. Memorandum No RM-727/1-Abridged. The RAND Cooperation, Santa Monica, California. 2 Linstone HA & Turoff M (1975). The Delphi Method: Techniques and Applications. Addison-Wesley. 3 Reetoo KN, Harrington JM, Macdonald EB (2005). Required competencies of occupational physicians: a Delphi survey of UK customers. Occup Environ Med, 62, 406-413. 4 Loney T, Aw TC (2014). Development of Occupational Health in the Gulf Cooperation Council Countries: The UAE Experience. The Journal of The Institute of Remote Health Care, 5(1), 18-24. 1

*RGU Research Team (Institute for Health & Wellbeing Research (IHWR), Faculty of Health & Social Care): Professor Susan Klein (Director, Aberdeen Centre for Trauma Research); Dr Hector Williams (Senior Research Fellow, IHWR); Dr David Robertson (IHWR Member, Lecturer, School of Health Sciences); Ed Watson (Web & E-Learning Resource Editor, School of Pharmacy & Life Sciences). 1

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IRHC Competency and Training for Health Practitioners  
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