AETCOM.pptx

AETCOM in Microbiology

1. AETCOM in Microbiology 26-07-2022 1

2. Indian Medical Graduate (IMG) Healthcare needs of community keep changing - medical education system continuously evolves - adapt to changing needs To make existing traditional medical education system more relevant- IMG, MCI- introduced Competency-Based Medical Education (CBME) from the year 2019- the first major revision to the medical curriculum since 1997 after 20 long years 26-07-2022 2

3. Indian Medical Graduate (IMG) Overall goal of the undergraduate medical education program- by MCI, in the revised Graduate Medical Education Regulations- (2019) create an “ Indian Medical Graduate (IMG) ”- knowledge, skills, attitudes, values and responsiveness- function appropriately and effectively- physician of first contact- community while being globally relevant 26-07-2022 3

4. Roles of IMG 1. Clinician who understands, provides preventive care with compassion 2. Leader & member of the healthcare team & system - capabilities to collect, analyze, synthesize & communicate health data appropriately 3. Communicator with patients, families, colleagues and community 4. Lifelong learner - continuous improvement of skills and knowledge 5. Professional - committed to excellence, is ethical, responsive and accountable to patients, community and profession 26-07-2022 4

5. AETCOM Refers to the soft skills ‘ Attitude, Ethics & Communication ,’ that an IMG needs to learn along with the knowledge and clinical skills to provide holistic healthcare Assessment system in place- ensure that the learning about AETCOM has actually taken place 26-07-2022 5

6. AETCOM Essential components of AETCOM are as follows: Attitude Ethics: has the 4 pillars- Patient autonomy Beneficence Non-maleficence Social justice Communication 26-07-2022 6

7. Need for AETCOM Competencies Proficiency in AETCOM competencies- essential in carrying out routine healthcare activities- doctor-patient interactions, practicing informed decision making, breaking bad news, communication and documentation Lack of effective communication- medical errors, mistakes in diagnosis, inaccurate treatment, compromised patient safety, patient noncompliance- stressful legal and sociocultural issues 26-07-2022 7

8. AETCOM Learning in Current vs Previous Curriculum AETOM in earlier MBBS curriculum: Before CBME was introduced, medical education focused- gaining knowledge and clinical skills AETCOM competencies were neither formally taught nor assessed Some learning used to happen by observing seniors (role modelling) or with self-experience 26-07-2022 8

9. AETCOM Learning in Current vs Previous Curriculum AETCOM in current curriculum: aim at acquisition of minimum essential skills- communicating effectively & sympathetically with patients Longitudinally spread: AETCOM competencies relevant to each subject- defined in CBME- taught longitudinally- phases of MBBS Increasing complexity: topics/competencies are interlinked 26-07-2022 9

10. T-L Methods for AETCOM Competencies Teaching-Learning sessions: students are provided with opportunities to learn basic essential background knowledge, opportunities to learn by experiencing (mostly simulated) & reflect on experiences Innovative teaching-learning (TL) methods: more engaging & effective 26-07-2022 10

11. Problem-based Learning (PBL) Suggested by MCI as main TL method for AETCOM Helps students explore various facets of “real life issues” that will confront them in their careers, develop problem solving skills Case discussions promote collaborative learning and team work, reflection and self-directed learning 26-07-2022 11

12. Assessment of AETCOM Competencies Formative Assessment : d one during & along with day-to-day T-L sessions- to provide feedback to students and help them improve B ased on student participation in small group discussions, performance in assignments or internal assessment tests Summative Assessment : q ualifying examination which decides pass or fail status Questions on AETCOM competencies in theory & practical exams conducted at end of each professional year Student- maintain logbook as record of his performance 26-07-2022 12

13. Suggested AETCOM Topics in Microbiology Following competencies are specified in Microbiology subject: 1. Demonstration of confidentiality pertaining to patient identity on laboratory results 2. Demonstration of respect for patient samples sent to laboratory for performance of laboratory tests 26-07-2022 13

14. Competency-1: Demonstrate Confidentiality Pertaining to Patient Identity on Laboratory Results 26-07-2022 14

15. Sample Case Scenarios Case scenario 1 (Disclosing HIV result): A lady aged 20 years admitted for fever & breathlessness jumps from 4th floor of hospital & dies- recently diagnosed to be HIV reactive (one week ago) and “Retro positive” labels on her case file and bed. Family members- know about her HIV status. They became stressed & shouted at patient. Except her mother, all other family stopped visiting her 26-07-2022 15

16. Sample Case Scenarios Case scenario 2 (Not disclosing HIV result): A 33-year man- admitted to emergency ward with multiple limb fractures. His vitals stabilized, conscious & oriented. Emergency surgery- planned. His relative comes to lab to collect investigation reports, given all reports except HIV results. He is specifically asking if lab is not issuing only HIV report because it is reactive. Technician gets call from ward asking for HIV report immediately over phone, as t patient is being shifted to operating room 26-07-2022 16

17. Sample Case Scenarios Case scenario 3 (Patient refuses to provide samples): A nurse caring for admitted patient gets needle stick injury with syringe used for the patient. The patient’s HIV and HBV infection status unknown. To decide for PEP, nurse wants to get patient tested. Patient asks the nurse not to worry, refuses saying he has no such infection, hence no need to test & has financial constrain for performing the tests. The nurse is anxious. Nurse decides to use the patient’s blood sample collected for some other tests for testing for HIV and HBsAg and bear the cost by herself 26-07-2022 17

18. Sample Case Scenarios Case scenario 4 (Social stigma in COVID-19): A patient with influenza like illness (ILI) has come to the screening OPD. He had exposure to a confirmed COVID-19 case five days back. He wants to get tested and treated, as he is anxious. However, he does not want to be quarantined or discriminated, and has a fear of social stigma and losing the job. He is also the only caretaker of old parents at home 26-07-2022 18

19. Sample Case Scenarios Case scenario 5 (Occupational exposure): A medical intern comes to the infection control division , history of NSI 1 hour back. The source patient’s blood sample collected and tested for HIV, HBV and HCV. Intern is waiting in the reception to know about the test result of source. Test result is reactive for HIV but negative for hepatitis B and C. The infection control officer discloses the source result to the intern and provides appropriate counselling and PEP. He also forwards the source result to ICTC. The ICTC calls the source patient on next day and informs about the test result after providing counselling 26-07-2022 19

20. Essential Background Knowledge 1. Principles of medical ethics 2. Medicolegal aspects of confidentiality 3. Confidentiality & privileged communication related to lab. results 4. Modes of transmission & diagnostic approach for HIV or COVID-19 5. Sociocultural issues related to sensitive infections like HIV, COVID-19 or needle stick injury 6. PEP for NSI (needle stick injury) when source turns out to be positive for HIV or HBV 26-07-2022 20

21. Specific Learning Objectives 1. Discuss rights and responsibilities of patients (or healthcare worker in case scenario 5) 2. Discuss rights and responsibilities of laboratory with respect to confidentiality of laboratory results 3. Analyze ethical issues involved in confidentiality pertaining to patient identity 26-07-2022 21

22. Specific Learning Objectives 4. Describe medicolegal consequences of breach in confidentiality 5. Demonstration of sympathy when breaking through of result to healthcare workers, providing counselling and maintaining confidentiality pertaining to occupational hazards such as needle stick injury (in case scenario 5) 26-07-2022 22

23. Teaching-Learning Method 1. Introductory session: introduction of paper case in small group discussion, identification of various aspects involved, framing learning objectives and deciding assignments along with learning resources 2. SDL: self-directed learning by students 3. Anchoring learning sessions : involves one or more of following depending upon case scenario: Interaction with laboratory technician and counsellor of ICTC Interaction with Microbiology laboratory technician involved in HIV/COVID-19 testing and report dispatch Interaction with infection control officer involved in management of NSI 26-07-2022 23

24. Teaching-Learning Method 4. Concluding session: s mall group discussion of various possible approaches for case, their pros and cons, and justification for best approach selected by each student. However, it may be possible that there may not be single best approach 5. Writing narratives by the students about their learning experiences 26-07-2022 24

25. Assessment Formative: p articipation in group discussion, assignments, reflection writing, MCQs to assess relevant background knowledge, OSPE Summative (Theory): s hort notes and short answer questions Summative (Practical): OSPE with simulated patient–HIV pre-test/ post-test counselling, counselling following NSI, informing positive COVID-19 report to patient and informing NSI test result to the HCW 26-07-2022 25

26. Key Learning Points 1. Confidentiality 2. Informed consent 3. Counselling 4. Privileged communication 5. Method followed in ICTC for HIV testing 6. Method followed for other STDs (Syphilis, Gonorrhea) 7. Method followed for COVID-19 26-07-2022 26

27. Competency-2 Demonstration of Respect for Patient Samples 26-07-2022 27

28. Sample Case Scenarios Case scenario 1 (Rejection due to improper transport): Sequestrum from chronic osteomyelitis case was debrided and sent for culture and sensitivity. The sample was rejected by the laboratory mentioning that it was received in formalin, hence unsuitable for culture. There is no more sample available for culture now 26-07-2022 28

29. Sample Case Scenarios Case scenario 2 (Specimen did not reach laboratory): A critically ill 5-year-old child’s CSF report is awaited for 3 days. On enquiry laboratory says it did not receive the sample. On further probing it was found that the nursing staff had kept the small bottle with the sample in his pocket and mistakenly taken it outside the hospital and had dropped it somewhere, and did not submit it to the laboratory for testing. Now, the baby needs to undergo lumbar puncture again, results may not be the same as antibiotics are given and need to wait for some more days for the culture report 26-07-2022 29

30. Sample Case Scenarios Case scenario 3 (Misguided report due to inadequate information in requisition form): Urologist calls laboratory to discuss about “Insignificant bacteriuria” culture report of a pyelonephritis patient. He says it was a percutaneous nephrostomy sample and asks for the organism and antimicrobial sensitivity. Microbiologist says it was written as urine sample on the request form, some gram-negative bacillus had grown and the count was less than 10,000 CFU/mL, so it was thought to be a periurethral commensal and the isolate was discarded, and hence further testing cannot be done 26-07-2022 30

31. Sample Case Scenarios Case scenario 4 (Specimen kept at wrong place): Junior resident gets angry and yells at the patient on noticing a stool sample kept on the bedside. The patient’s attendant tries to explain that the container is covered in a plastic cover and all these days the junior resident herself used to keep collected blood and swab samples in that very same place, and he was not informed that stool sample was not to be kept on the side table 26-07-2022 31

32. Sample Case Scenarios Case scenario 5 (Rejection due to improper collection): A suspected pulmonary tuberculosis patient, who would travel 30 km from his village to the private hospital with the attached laboratory in the city, had submitted spot sputum sample the previous day and an early morning sample today for acid-fast staining. Reports of both the samples mentioned “many epithelial cells suggestive of excessive salivary contamination. Repeat with the proper sample”. Blood culture was also collected from the patient by the clinical team, the result of which came as contaminated blood culture specimen with patient’s skin flora 26-07-2022 32

33. Sample Case Scenarios Case scenario 6 (Sample collected for culture and sensitivity in unsterile container): Paired blood specimen (5 mL each) was sent to the laboratory in two vacutainers for blood culture. The laboratory rejected the specimen. The patient screams that he cannot allow to draw another set of blood specimen for investigation 26-07-2022 33

34. Sample Case Scenarios Case scenario 7 (Rejection due to lack of patient informations ) Microbiology lab rejects a bunch of specimens because one or the other relevant informations were missing in those specimens - patient’s name, age or gender, ward, hospital number, sample type, clinical diagnosis, or treatment history. Clinical team screams at the lab that they could have called the ward or the patient’s attendant and verified the details instead of rejecting 26-07-2022 34

35. Sample Case Scenarios Case scenario 8 (Rejection due to mismatch of name) Microbiology lab rejects a blood culture specimen collected in BacT /ALERT bottle because the patient’s name written on the bottle did not match with the requisition form. Clinical team asks the patient to pay again for a repeat blood culture investigation. The patient complains that he cannot afford the price for another test and neither he can give consent to draw another specimen 26-07-2022 35

36. Sample Case Scenarios Case scenario 9 (Prioritizing a sample requiring immediate processing and reporting over the others) In the midnight, the Microbiology laboratory receives three specimens (urine, sputum, CSF) from a patient for culture. The technician was already processing a huge load of investigations, therefore he informed the clinical team that these specimens can only be processed on the next day 26-07-2022 36

37. Essential Background Knowledge 1. Appropriate sample for the test planned: sample type, amount, collection procedure, preservative if any, container type used and its transportation and storage 2. Appropriate labelling for correct sample identification 3. Accompanying clinical information for correlation 26-07-2022 37

38. Essential Background Knowledge 4. Possible medicolegal issues following incomplete/incorrect sample identification 5. Sociocultural issues following incomplete/incorrect sample identification, relevant clinical information for correlation, improper storage/transportation 6. Ethical issues following incomplete/incorrect sample identification, relevant clinical information for correlation, improper storage/transportation 26-07-2022 38

39. Specific Learning Objectives 1. Choose appropriate container for sample collection 2. Demonstrate appropriate procedure for temporary storage & transportation of clinical sample 3. Discuss information that shall be written in request form & sample container, completely and legibly 26-07-2022 39

40. Specific Learning Objectives 4. Discuss judicious application of sample rejection criteria in best interest of patient care 5. Discuss importance of prioritizing specimen as relevant to clinical situation 6. Discuss medical, ethical & socio-economical considerations of errors in sample collection and submission process 26-07-2022 40

41. Teaching-Learning Methods 1. Introduction of scenarios with help of paper case/role plays/videos 2. Small group discussion : identification of clinical, medicolegal, sociocultural & ethical issues involved 3. Writing learning objectives 4. Writing narratives by students about their learning experiences 26-07-2022 41

42. Teaching-Learning Methods 5. Anchoring lecture and demonstration of appropriate procedure of sample collection, transportation and reception at laboratory Discussion with nursing staff, phlebotomist, laboratory technicians to gather first-hand information 6. Closing session with small group discussion 7. Writing narratives by students about their learning experiences 26-07-2022 42

43. Assessment Formative Summative (Theory) Summative (Practical): OSPE can be conducted covering: Sample collection with care and empathy, instructing patients on appropriate sample collection (e.g. urine, sputum, blood culture) Labelling sample containers and filling request form for the clinical scenario provided 26-07-2022 43

44. Key Learning Points Specimen rejection criteria: Reasons for sample rejection include: Improperly labelled or unlabeled sample Incomplete specimen-related or clinical information on sample Sub-optimal sample Duplicate microbiology samples received on same day Sample delayed in transit more than accepted limit 26-07-2022 44

45. Key Learning Points Specimen collection Prioritizing specimen for processing: certain precious specimens - CSF and sterile body fluids, ocular specimens, tissue specimens, suprapubic aspirate and bone specimen- processed immediately as soon as received, not more than 15 min delay Blood culture bottles should be immediately incubated upon receipt 26-07-2022 45