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Simulation as a Critical Resource in the Response to Ebola Virus Disease

Gaba, David M. MD

Simulation in Healthcare: Journal of the Society for Simulation in Healthcare: December 2014 - Volume 9 - Issue 6 - p 337–338
doi: 10.1097/SIH.0000000000000068

From the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA.

Reprints: David Gaba, 1871 Austin Ave, Los Altos, CA 94024 (e-mail:

The author declares no conflict of interest.

As I write this on the last day of October, the United States and the rest of the world have been bracing for the possibility of the onset of cases of Ebola virus disease (EVD) in our health care institutions. This comes on the heels of our watching a humanitarian catastrophe in certain West African countries that have had substantial outbreaks of the disease. Although the world response to these outbreaks has possibly been “too little, too late,” I commend the valiant work of both local clinicians and lay people as well as of volunteer clinicians from all over the world in tending to the needs of afflicted patients and in trying to stem the disease at or near its source.

Here in the United States, I have been observing—through some direct connections and through the “rumor mill”—the major role that simulation facilities and personnel have been assuming in the preparations for and occasionally the actual conduct of patient care for those with symptomatic EVD. Although it is far too early to collect or understand even a fraction of the various stories of how this is transpiring across the country, I would like to reflect on some of the bits and pieces I am personally aware of. As it stands today, the response to EVD here is a quintessential example of a situation that is ripe for the application of simulation. Treating patients with symptomatic EVD in a safe fashion is a complex process that—except in a handful of sites—requires equipment, processes, skills, and an unwavering attention to small details that are unfamiliar to clinical personnel. As of today, there have been patients with symptomatic EVD in very few places in the United States, yet nearly all major medical centers are preparing to handle such cases, and many outpatient facilities are also planning for what to do. All of us sincerely hope that the situation will stay this way. Hence, simulation plays a major role in such preparations, as there is no other way to get ready and to train personnel for a challenge that may never come. As such, it is much like the common clinical scenarios for which we frequently use simulation—serious, rare, patient care events, which any clinician or clinical team/site may never see but for which we all need to be prepared to handle effectively should the need arise.

So far, I have observed a number of things about the use of simulation for EVD preparedness. These can be considered random observations at this point, and no doubt, there will be scholarly articles that summarize and review such activities and offer lessons learned. At this early stage however, it seems reasonable to mention a few:

  • Simulation facilities and simulation experts—clinicians, technical, and administrative staff—have become substantially involved in the response to this challenge.
    • Here at Stanford for example, our Immersive Learning Center has become the site for a purpose-built (in only a few days) physical site for strict isolation training. This site was built in a portion of a large room that had been devoted to simulation for safe patient handling (ie, ergonomics of lifting and moving patients). Although we have simulation rooms that mimic hospital rooms, they do not have the same design and size as do the isolation rooms with anteroom Stanford Hospital that will be used to host patients with EVD if necessary. Given the difficulty of working while wearing cumbersome personal protective equipment and of the doffing process, it was clear that a replica of the physical site would be important for such clinical simulations. The ability to create such a replica obviated the disruption that frequent in situ simulations in the actual rooms might create and simplified the ability to schedule and handle training for volunteer staff, and it also allowed us to use all our current simulation facilities for their usual purposes.
    • The Center for Medical Simulation through its Institute for Medical Simulation in Boston has organized a group of hospitals with graduates of IMS programs to collaborate and share information about their EVD response planning (Jeff Cooper, personal communication).
  • Simulation has been used for many different purposes—again, these are early observations, and many variants or completely different applications will surface over time.
    • Systems probing of the characteristics and use of the Personal Protective Equipment (PPE) available to and chosen for use by the institution
    • Systems probing of the application of the protocols, checklists, and ergonomics of PPE donning and doffing procedures
    • Systems probing in replica sites or in situ locations (or both) of the multilevel coordination between direct caregivers in full PPE, safety monitoring personnel, infectious disease experts, and staff from environmental management, clinical laboratory, and others
    • Systems probing on the feasibility of and issues with attempting surgery (including cesarean delivery and neonatal resuscitation) in full PPE either in the patient’s isolation room or in a sequestered operating room
    • Systems probing of how best to handle unexpected events with caregivers in full PPE (eg, handling a fainted/unresponsive caregiver in full PPE) while maintaining full safety
    • Table-top simulations for hospital leadership and managers on incident command and higher-level coordination of efforts and resources
    • Use of surreptitious standardized patient actors (unknown to nearly all clinical staff) to test the readiness of first-line clinical sites (eg, clinics, emergency department) to handle an unexpected patient with possible symptomatic EVD (described in a webinar given by the Society for Simulation in Healthcare with faculty from the Health and Hospitals Corporation of New York City,
    • Finally and perhaps most challenging in terms of logistics, the direct training of a multitude of individual clinicians, dyads, and teams in the complex processes of donning and doffing PPE as well as in the use of protocols for clinical care and performing procedures in full PPE.

For sites that are already doing these or other simulation-based activities, I urge them to continue the efforts to yield maximal learning and optimal preparation of facilities, processes, and personnel. For sites that are not yet using simulation to develop and hone their readiness, I urge them to find ways to do so, and I trust that the simulation community will strive to assist them however we can.

It is too early to say whether these preparations at so many sites across the country will actually be put to the test in large numbers for real clinical care; we surely hope not. However, even if there should not be a single additional patient with EVD, these efforts will not have been in vain. Many experts in infectious diseases believe that we have largely dodged bullets and been very lucky in our unsystematic worldwide response to many other highly infectious diseases such as SARS, MERS, or the virulent forms of influenza (we are also reminded that even “ordinary” seasonal influenza is far more contagious than EVD, kills thousands of people every year, and for which the often effective immunization is skipped by millions of people). Thus, the lessons learned from preparing for the handling of EVD will likely be valuable for the health care community as a whole and for each site in particular. We need to retain these lessons even after the current wave of interest, fear, and necessity wanes. Unfortunately, that is rarely the fate of such preparations for infectious diseases or indeed for many patient safety initiatives. The one thing we can say for sure is that there will almost surely be another time in the future. If we lose the lessons learned this time in real patient care and via simulation, we will only have our collective self to blame. The simulation community will need to do its utmost to see that this does not happen.

© 2014 Society for Simulation in Healthcare