Journal Logo

Highly Communicable Disease Management Theme Issue

Simulation as a Tool to Facilitate Practice Changes in Teams Taking Care of Patients Under Investigation for Ebola Virus Disease in Spain

Rojo, Elena RN; Oruña, Clara RN; Sierra, Dolores RN; García, Gema RN; Del Moral, Ignacio MD, PhD; Maestre, Jose M. MD, PhD

Author Information
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: April 2016 - Volume 11 - Issue 2 - p 89-93
doi: 10.1097/SIH.0000000000000139
  • Free


The West African Ebola outbreak began December 2013 in Guinea. The first European victim, a 75-year-old missionary treating patients with Ebola in the Liberian capital of Monrovia, was evacuated to Spain on August 6, 2014. He was transferred to Hospital La Paz-Carlos III in Madrid where he subsequently died on August 12. A second Spanish citizen, a 70-year-old medical doctor, had been infected while helping patients in Sierra Leone. He was evacuated to Madrid on September 22. He died on September 25, 2014.

Following International Health Regulations (IHR), the National IHR Focal Point in Spain and the Early Warning and Response System of the European Commission informed the World Health Organization (WHO)1 on October 6, 2014, of the first confirmed case of Ebola virus disease (EVD) transmitted in Spain. The case was a 44-year-old female nurse assistant with no travel history to West Africa. She had participated in the medical care of the second patient previously mentioned in Hospital La Paz-Carlos III. She had been in contact with the patient twice, and on both occasions, she reported that she wore appropriate personal protection equipment (PPE). This case represented the first human-to-human transmission of EVD outside Africa.

As of September 27, 2015, countries with widespread transmission have reported 28,388 cases of EVD with 11,296 deaths. Other affected countries have reported 36 laboratory-confirmed cases of EVD with 15 deaths. This is currently the largest EVD outbreak ever recorded according to the Centers for Disease Control and Prevention in the affected countries in conjunction with the WHO and based on information reported by their ministries of health.2

The director general of IHR convened the first meeting of the emergency committee on EVD outbreak on August 6, 2014. Ebola virus disease outbreak was declared a public health emergency of international concern because of (1) intensive community and health facility transmission patterns, (2) the case-fatality ratio reaching 90%, and (3) the possibility of sporadic imported cases similar to the ones described earlier. In addition, providing medical care for patients under investigation or infected patients greatly increased physical and psychological stress (eg, anxiety, depression, hesitation, or social isolation).3

In response to these threats, several measures were deployed for infection, prevention, and control. These measures were meant to ensure that appropriate and coordinated international support reached affected areas rapidly while combating the international spread of outbreaks. The WHO, together with its partners, has developed standard operating protocols and training material. These can be used worldwide to contribute to epidemic preparedness as well as to strengthen public health emergency response systems and structures.1,4

Simulation-based medical education translational science shows that results achieved in the educational laboratory (T1) transfer to improved patient care practices (T2) and improved patient and public health (T3).5 Simulation has played a major role in the preparation of teams equipped to care for patients with suspected EVD. These teams can prevent the spread of the disease while simultaneously ensuring that staff, health care providers, and patients stay safe and secure. Given that EVD incidence remains very low, most clinical personnel outside West Africa are unfamiliar with the complex processes, equipment, and unwavering attention to the small but necessary details.

One advantage of clinical simulation is in the re-creation of a safe and realistic environment where trainees can gain and maintain essential skills. Not surprisingly, clinical simulation has been used for many different purposes and in many variants.6 As previously stated by Gaba,7 “Lessons learned in preparation for this outbreak will likely be valuable for both the health care community as a whole and for each site in particular in anticipation of other highly infectious diseases that may come. These include virulent strains of influenza, severe acute respiratory syndrome (SARS), and Middle East respiratory syndrome.”

In this context, we analyzed the impact of simulation-based training on clinical practice and work processes on teams caring for patients in Cantabria, Spain, under observation for possible EVD.


Management of EVD in Spain

On October 10, 2014, the Government of Spain created a special committee for the management of EVD. The objectives were as follows: (1) monitor the health of infected people and those at risk of infection, (2) coordinate mobilization of the necessary resources to aid health care professionals, (3) coordinate actions related to controlling EVD with international agencies, and (4) establish informative policy protocols to ensure maximum protection for professionals.

Together with foreign health services, the Spanish Ministry of Health has drawn up an action protocol for all points of entry into Spain. This protocol governs the actions that should be taken by health care professionals managing suspected cases of EVD. Under this protocol, the monitoring of people who have come into direct contact with patients with Ebola is mandatory. A person who has been in direct contact with an EVD patient is considered a case under investigation if the body temperature is 37.7°C or higher and if the patient has intense cephalgia, abdominal pain, diarrhea and vomiting, and any form of unexplained hemorrhaging or if the patient has multiple-organ failure.

In Spain, any patient with this combination of symptoms has to be transferred to the designated hospital of reference for the particular autonomous region. Valdecilla University Hospital is the designated hospital in the Cantabria Region. After the emergency department triage team identifies a patient as a potential EVD case, the patient has to be immediately brought to an isolation facility located close to the emergency department. A designated team is responsible for taking care of these patients, and all laboratory-confirmed cases have to be transferred to the Carlos III Health Institute in Madrid by an air medical transport team.

Technical Guidance Documents for Teams Responsible for Managing Suspected EVD Cases

In collaboration with health councils of the various regional governments, the Carlos III Health Institute, scientific societies, the Spanish Ministry of Health, and Social Services and Equality have all implemented a protocol for EVD in Spain. This protocol is aimed at ensuring the early detection and diagnosis of any possible Ebola cases as well as immediately adopting the appropriate control measures. Elaborated in accordance with the recommendations issued by international bodies, the protocol document is publically available and has been revised periodically.8

Training of Teams Responsible for Managing Suspected Cases of EVD

Each autonomous region in Spain is responsible for selecting a reference hospital and an in-house care team. Predeployment training and follow-up support are required to help personnel work safely and effectively. Thus, when the Ebola problem erupted, 1 member of the team in each hospital was selected as the person responsible for the training. Those people attended a 6-hour “train the trainer” course organized by the Medical Brigade of the Spanish Army Corps at the Epidemiology Division of the Carlos III Health Institute in Madrid. Training of actual teams had to be conducted at each particular hospital.

Instructional design at Valdecilla Hospital had 4 phases, which included 1 for knowledge acquisition, and consisted of basic self-online learning and lectures. This first phase offered guidelines and protocols on how medical personnel could protect themselves from the virus, perform procedural skills, isolate and transport the patient, manage waste, and clean facilities. The second phase featured a review of critical steps, workshops with hands-on practice, and several case discussions. The third phase of application covered simulation scenarios that gave staff the opportunity to practice before encountering a patient in a real-life situation. During this phase, nurses and physicians wore required PPE. The last phase included a debriefing to sustain and improve performance in the future.

Needs Assessment and Learning Objectives for Simulation-Based Training

This module focused on the following 3 areas central to the management of a patient with Ebola, highlighted by WHO: (1) implementation of safety protocols including disinfectant and waste removal guidelines along with proper doffing/donning of PPE, (2) patient care, and (3) teamwork and interprofessional communication. Triage and symptom management were not objectives for this training. A committee formed by the person responsible for training, the operations director of the simulation center, an educator, and an infectious disease specialist selected the specific objectives and designed the scenarios.

Lessons Learned and Practice Change Analysis

A debriefing between instructors and trainees followed each simulation. It was used as a formative assessment tool with the goal of helping participants understand, analyze, and synthesize what they thought, felt, and did during the simulation to improve future performance in similar situations. The debriefing also detected changes that might be incorporated into the workflow and system. It was conducted using the good judgment approach described by the Center for Medical Simulation by a lead debriefer and a content expert in EVD serving as an associate debriefer.9

Lessons learned by each team during debriefings were listed. Clinical decision making was not part of the learning objectives. Three months after the simulations took place, a survey was sent to team members to learn what practice and system changes had been implemented.


A total of 44 staff members participated in 7 training sessions that included 9 critical care registered nurses, 6 registered general nurses, 12 nurse assistants, 4 infectious disease specialists, 7 staff members from hospital cleaning services, and 6 nurse supervisors.

Each session started with an introduction to clarify goals and expectations, establish and maintain an engaging context for learning, and attend to logistic details. Each session focused on 3 clinical scenarios where an actor was used as the patient.

Learning goals for each scenario are summarized in Table 1. Lessons learned during debriefings are listed in Table 2. All groups discussed the number of people needed for each task, for example, changing the bed or cleaning the patient to minimize exposure time. Teamwork-related issues such as anticipating and planning, distributing workload, communicating effectively, and speaking up were found essential to optimize safety. Changes translated to clinical practice and actual settings 3 months after the initial simulation-based training sessions are listed in Table 3. Practice changes were grouped in 3 categories. The first category was related to clinical practice and mainly included the implementation of general teamwork principles to manage patients and prevent errors. Participants in the first training session reported signs of psychological distress (eg, anxiety, depression, and fatigue) with an impact on physiologic, cognitive, emotional, and behavioral levels. Team members also demanded support to cope with these issues, and a psychologist was recruited after the first course. The second category was related to protocol implementation. Several sections of the guidelines were found to be confusing, and some processes were not addressed. Participants took action to rewrite confusing sections and add new processes to the protocol. The last category was related to system and workflow. The team changed their shift schedule to cross-monitor each other during shifts and rearrange isolation room equipment.

Learning Goals for Each Simulation Scenario
Lessons Learned During Debriefings After Clinical Scenarios
Practice and System Changes Translated to Clinical Practice and Actual Settings 3 Months After the Initial Simulation-Based Training Sessions


Patients with suspected or confirmed EVD need to be cared for using very specific and highly specialized procedures, special isolated facilities, protective wear, and differentiated work processes. It is a very uncommon situation that puts patients, health care providers, and the general population at risk and, at the same time, requires the coordinated effort of an interprofessional team. In response to these threats, WHO is making efforts to provide up-to-date information, and many countries worldwide have used this information to implement protocols to guide safe patient care.1

Simulations have been widely used to familiarize staff with the meticulous steps and details involved in keeping the staff and patients safe. Local teams can take advantage of the reflective practice from the training scenarios and incorporate valuable learning and insights into planning and practice.10

Participants self-reported signs of high levels of psychological distress and requested support during the first training session. A psychologist was recruited after the first course to serve as a content expert during the debriefings. Only one other group highlighted psychological distress in the subsequent sessions. Three months after the training, however, the team implemented no further measures in this regard. Psychological distress seemed to be alleviated by consistent, repetitive, hands-on simulation-based training. These findings are consistent with a cross-sectional controlled study comparing the stress response of providers in direct contact with a patient with Ebola with providers taking care of terminally ill patients and patients with reduced consciousness. No significant differences were found between the 2 groups with respect to the severity of somatic symptoms, anxiety, depression, and fatigue.11 Both previous research and our own results suggest that a well-trained and dedicated team may be able to cope well with the stress of caring for a severely ill patient with Ebola. In our opinion, this underlines the high level of motivation within these types of teams. The fact that there were no confirmed cases in Spain might have reduced the distress sensation. However, health care professionals who had direct contact with a patient with Ebola reported significantly greater social isolation and felt a more dramatic need for shorter shift hours. The team in Spain felt that their video surveillance shifts were too long and consequently decided to shorten the length. Implementing this particular change may potentially increase the safety of all health care personnel involved in direct patient contact.

Teamwork-related issues were a constant during the debriefing sessions and are consistent with any type of team training in acute care settings. Caring for critically ill patients requires the coordinated efforts of an interprofessional team. Numerous reports have confirmed that human errors are very common in this context, with communication being more frequently highlighted as a barrier to teamwork and as having a negative impact on patient safety.12 Many reports have found that team training improves team performance and results in improved efficiency of patient care.13 Our local team has decided to do monthly drills to practice crisis resource management skills.

Successful management of patients with Ebola is difficult and complex. There is growing evidence supporting checklist use to improve adherence to best practices. In a high-fidelity simulation study, checklist use was associated with significant improvements in the management of operating room crises.14 Protocols and guidelines have been released to govern actions that should be taken by the health care professionals involved in managing suspected cases of Ebola. However, participants found some of the information provided confusing. Health care professionals also found that the materials do not provide answers to individual concerns and to the queries of those working in direct contact with patients. As a result, these professionals took action to rewrite some checklists and sections provided by the National Health Service. This suggests that simulation may be useful for testing and validating action protocols before actual implementation in the actual context of care.

Participants decided to reorganize the material needed in the isolation room. Taking care of patients with Ebola is a dynamic system with complex interactions, and identifying inefficiency and redundancy that can be removed from the system may be of help. Simulation can facilitate the evaluation of infrastructure changes and policy changes before implementing them with actual patients as well as evaluate the processes and systems involved within the organization.15

Practice change updates usually focus on changes that may have significant and broad impact on clinical practice. Some of the changes listed here are minor, such as the change of video surveillance time, but health care workers treating people with Ebola are at greatest risk of infection. Ebola virus disease spreads by direct contact, and paying attention to small details and staying focused and methodical when taking care of patients with high infectious diseases can prevent the spread of the disease.

There are several limitations as to how this study can guide the use of simulation to enhance effective workflow adaptation of protocols and guidelines. One is the low number of participants in the study that can prevent generalization of the results. Another is the absence of a comparative group from a different context to assess transferability.


Simulation-based training can play an important role in detecting what parts of a protocol or guidelines need to be adapted or changed to meet the needs of a specific team and to decide which changes should be carried out to make it more efficient. The identification of patterns of changes or adaptations the implementation of a protocol requires may help design team training exercises.


1. World Health Organization. Publications and Technical Guidelines. Available at: Http://Apps.Who.Int/Ebola/Publications-And-Technical-Guidelines. Accessed October 1, 2015.
2. Centers For Disease Control And Prevention. Ebola Case Counts. Available at: Http://http://Www.Cdc.Gov/Vhf/Ebola/Outbreaks/2014-West-Africa/Case-Counts.Html. Accessed October 1, 2015.
3. Imai H, Matsuishi K, Ito A, et al. Factors associated with motivation and hesitation to work among health professionals during a public crisis: a cross-sectional study of hospital workers in Japan during the pandemic (H1N1) 2009. BMC Public Health 2010; 10: 672.
4. World Health Organization. Technical Guidance Documents For Medical Staff. Available at: Http://Who.Int/Csr/Disease/Ebola/Protective-Measures-Staff/En. Accessed October 1, 2015.
5. McGaghie WC, Draycott TJ, Dunn WF, et al. Evaluating the impact of simulation on translational patient outcomes. Simul Healthc 2011; 6(Suppl 6): S42–S47.
6. Del Moral I, Maestre JM. A view at the practical application of simulation in professional education. Trends In Anaesthesia And Critical Care 2013; 3: 146–151.
7. Gaba DM. Simulation as a critical resource in the response to Ebola virus disease. Simul Healthc 2014; 9: 337–338.
8. Ministerio De Sanidad, Servicios Sociales E Igualdad, España. Protocolo De Actuación Frente A Casos Sospechos De Enfermedad Por Virus Ebola. Available at: Http://http://Www.Msssi.Gob.Es/Profesionales/Saludpublica/Ccayes/Alertasactual/Ebola/Docs/13102014protocolodeactuacioneve_CISNS.Pdf. Accessed October 1, 2015.
9. Maestre JM, Rudolph J. Theories and styles of debriefing: the good judgment method as a tool for formative assessment in healthcare. Rev Esp Cardiol (Engl Ed) 2015; 68: 282–285.
10. Maestre JM, Szyld D, Del Moral I, et al. The making of expert clinicians: reflective practice. Rev Clin Esp (Engl Ed) 2014; 214: 216–220.
11. Lehmann M, Bruenahl CA, Löwe B, et al. Ebola and psychological stress of health care professionals. Emerg Infect Dis 2015; 21: 913–914.
12. Hicks CM, Bandiera GW, Denny CJ. Building a simulation-based crisis resource management course for emergency medicine, phase 1 results from an interdisciplinary needs assessment survey. Acad Emerg Med 2008; 15: 1136–1143.
13. Capella J, Smith S, Philp A, et al. Teamwork training improves the clinical care of trauma patients. J Surg Educ 2010; 67: 439–443.
14. Arriaga AF, Bader AM, Wong JM, et al. Simulation-based trial of surgical-crisis checklists. N Engl J Med 2013; 368: 246–253.
15. Maestre JM, Manuel-Palazuelos JC, Del Moral I, et al. Clinical simulation as a tool to facilitate culture change in healthcare. Rev Colomb Anestesiol (Engl Ed) 2015; 42: 124–128.

Ebola virus disease; Highly communicable disease; Simulation; Practice change

© 2016 Society for Simulation in Healthcare