The highly virulent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rapidly spread through the New York Metropolitan area, overwhelming the local healthcare systems. In New York City alone, from its first documented case on March 1, 2020, there were 106,813 cases including 29,335 hospitalized patients and 7349 deaths by April 13, 2020.1 The NYC Health and Hospitals/Jacobi Medical Center and the Montefiore Health System, serving the Bronx and Westchester county communities, witnessed some of the highest SARS-CoV-2 case numbers and fastest surge in the United States from March to May 2020.2 In our hospital systems, the high acuity of the disease led to a rapid expansion of intensive care and inpatient treatment units, which was achieved by transforming previously nonclinical spaces such as lecture halls and conference rooms into makeshift patient care units. Demands for new treatment locations resulted in “disaster” privileges granted to visiting medical staff and travelers, the early graduation of final year medical students, and redeployment of medical residents, outpatient providers, and surgery teams into acute treatment areas. The nationwide lack of personal protective equipment (PPE) exacerbated this crisis,3 given that healthcare staff are at higher risk of acquiring infections during novel outbreaks.4
As the rate of new cases of SARS-CoV-2 presenting to our hospital had decreased, we began to reflect on our response to better prepare for a potential second wave. Our group recently completed a multicenter, quality improvement, in situ program focused on pediatric tracheostomy care5 and used this established network of simulation teams for an in situ program dedicated toward quality improvement as it relates to SARS-CoV-2. As of August 2020, we initiated the first phase of our program. We trained 30 medical staff members in systems-based debriefing and ran 36 in situ simulations, including 166 interprofessional medical staff members (4.6 participants per simulation; range = 3–9) across 5 emergency departments, both academic and community, adult and pediatric. Through this experience, we provide a rationale for the need for in situ simulation for systems improvement as it relates to SARS-CoV-2 along with recommendations on safety checks to consider before starting.
RATIONALE FOR IN SITU SIMULATION DURING THE SARS-COV-2
In situ simulation has demonstrated to be an effective tool for the detection of latent safety threats (LSTs), especially for medication errors, equipment functionality and availability, and resource/systems-based deficiencies.6 Our previous pediatric tracheostomy care program demonstrated the ability of in situ simulation to identify LSTs and use that data to gauge the effect of quality improvement (QI) interventions.5
Early studies of in situ simulation in SARS-CoV-2 demonstrated its use on infection control guidelines and detection of LSTs, including finding inappropriate intubation checklists for SARS-CoV-2 patients, the lack of proper proning procedures, and airway carts that did not fit into negative pressure rooms. Uncovering these LSTs led to corrective actions such as implementing a “walkie-talkie” to communicate easily to and from the negative chamber rooms and outside the rooms, obtaining a new airway cart suitable for transport into negative pressure rooms, and editing checklists to ensure staff safety during intubation.7–9
TABLE 1 -
Summary of Recommendations for In Situ Simulation in SARS-CoV-2 Settings
| Recommendations: |
| (1) Identify the immediate needs of the organization.
|
| (2) Minimize influx of participants to the “closed” units.
|
| (3) Limit the use of PPE during simulation
|
| (4) Minimize influx of external equipment into the “closed” units
|
| (5) Use electronic data collection software rather than paper forms.
|
In addition to its benefit in identification, our team used LSTs as benchmark data and a tool to evaluate the progression of QI interventions and change concepts being implemented. The full details of this simulation/QI merger are beyond the scope of this commentary but will be available on completion of our study. However, it is important to note that this merger, by offering hospitals data to measure on a continuous scale as QI interventions are put into place, played a significant role in rapid recruitment and implementation of our program across multiple sites.
Recommendation # 1:Identify the immediate needs of the organization
Prior to initiating simulations, identify and balance the needs of the patients, the staff, and the institution with your program's inherent risks.
In the middle of the overwhelming clinical load presented by this crisis, the need for training to properly equip staff and maintain patient safety became abundantly clear. Patients were dying at unprecedented rates, medical staff were falling ill at a higher rate than their non–health care worker counterparts, and hospitals were unable to accommodate the large high acuity volumes. However, educational gatherings also posed an increased risk of infection and spread of SARS-CoV-2. Therefore, before the initiation of any program, organizers should consider whether the risk of gathering is balanced by a clear benefit to the patient, the medical staff, and the community that we serve.
To assess the need for in situ simulation, we conducted internal surveys to ED staff at one of our sites, asking 2 open-comment questions related to their experience in the first wave: (1) “What are the biggest educational needs for our department specific to SARS-CoV-2?” and (2) “What quality improvement concerns do you have for our department specific to SARS-CoV-2.” Most responses mentioned need for further training, especially in the following: (1) ventilator management; (2) infection control measures including cross-contamination; (3) palliative care conversations; and (4) team communication during intubation. In meetings with key hospital stakeholders, including department leaders, these data and a proposed in situ program were discussed with wide support. When the project was brought to our larger in situ collaborative group, there was interest from all sites specific to airway management during SARS-CoV-2 including infection control and cross-contamination, team communication, and equipment availability.
Challenges for our sites included how to use our trainers, most of whom also worked clinically. Although some of our instructors had inherent administrative time built into their role, others did not. We could not continue our prior programs while also tackling the simulation needs of the organization during the peak of the pandemic, which included PPE training, airway management, development of proning teams, and resuscitation training for deployed staff. To allocate our resources appropriately, we took the mass casualty philosophy of “greatest good for the largest number,” canceling or postponing programs with no direct benefit during the peak of the crisis. Another concern was ensuring that our clinical educators were able to “step away” from the hospital. The crisis proved to bring about a high level of stress, exhaustion, and risk of psychological trauma.
It is difficult to gauge the impact on the learner from the change in direction of our programs. As of the writing of this commentary, some of our programs have been reinstated, others, such as airway management, have been edited to include SARS-CoV-2 management, while other simulation initiatives, including a large stroke in situ program, has been canceled to focus on the current SARS-CoV-2 in situ program.
Recommendation #2: Minimize influx of participants to the “closed” units.
To minimize nonessential traffic into and out of “closed” SARS-CoV-2 units, we recommend only inviting simulation participants who will already be placed in “closed” units as part of their job requirement.
Typically, in situ simulations use a range of personnel who are involved in the research, development, or production of the simulation. Our past in situ simulations have involved medical students, student observers, and simulation technicians. However, as of this date, our hospitals are limited to essential visitors such as parents of minors or a family member accompanying a dependent adult (such as in severe dementia or disability). Our volunteer services program is on hold until deemed safe to restart. Although many of our “closed units” have disbanded, there are many that will remain open, given that we are still actively managing new patients with SARS-CoV-2. In situ simulation in an acute care hospital taking care of SARS-CoV-2 patients would require personnel to participate in simulations inside the “closed” units. Although it is beneficial to run simulations inside these units to provide the multidisciplinary team learning and a system-level assessment of the unit, it is imperative that the people going into these units are limited to the participants of the simulation and others who would normally be working within the unit to minimize any unnecessary SARS-CoV-2 exposure.
During our peak, entrance into our “closed units” included removal of all personal belongings, changing into laundered scrubs and placing on PPE. Given the higher risk of transmission in a healthcare setting, let alone a designated unit specific for acute SARS-CoV-2 patients with likely a high viral load, we had concerns about allowing observers, students, or simulation technicians into such a clinical space. To decrease risk while still fostering multidisciplinary collaboration, our teams conducted virtual team meetings throughout the planning, implementation, and sustainability phases of the program. Simulations were performed by senior simulation educators on the days when they were working clinically to limit in-person group size. Educators were trained by simulation technicians on previous simulation programs and through structured virtual training sessions. The focus on low-fidelity mannequins allowed for ease of use of the technological components of the simulation by different team members.
In one of our hospitals, to plan for the in situ simulation program, simulation educators volunteered to primarily work in the “closed units” so that they could run in situ simulation during their shift when already in PPE during an appropriately designated time. Similarly, for other units, simulations were led by simulation educators who worked clinically as primary or consulting physicians on those units, thus decreasing any extra exposure or time within the “closed” units by our participants and educators.
By limiting personnel, the onus of scheduling, carrying equipment, running the program, and debriefing fell on a single individual who was also often working clinically in a high-stress environment. To decrease the load on this instructor and standardize the program across multiple sites, several techniques were implemented. (1) Virtual training sessions to calibrate all debriefers on the program included prerecorded simulations along with review of the Pearls for System Improvement framework used by our program10; (2) using a QR code, scripts were available on an online form and included description of program, analysis, and summary phase; (3) a questionnaire was placed on the form to ensure that “no go” criteria were being abided by and to assess the level of cognitive strain on the staff at time of simulation; (4) a prerecorded monitor with sound embedded in the online form played during the length of the simulation; (6) data entry in a plus/delta format per predetermined objectives was placed at the end of the online form for electronic data entry; and (7) medical students were used to help categorize and organize data and follow up with instructors postdebrief to ensure appropriate capturing of data. This method also allowed for resident physicians, medical students, QI committee members, and nurse educators to participate virtually in planning, development of QI tools and interventions, data management, and virtual walk-throughs to detect LSTs.
Recommendation #3: Limit the use of PPE during simulation
To preserve PPE and reduce cross-contamination, we found separating and marking simulation-based PPE to be a useful method in reducing the use of PPE.
With the nationwide shortage there has been a concerted effort to find ways to conserve PPE including the strategies for safe reuse of N95 respirators by UV-C and liquid disinfection11 as well as baking.12,13 The educator is now caught between a difficult decision, to train PPE use but also limit its disposal. Donning and doffing has been a particular area of educational need with studies demonstrating high contamination risk,14,15 with one study demonstrating a 90% risk of contamination with doffing.16 Aside from education on PPE, a recent SARS-CoV-2–related program discovered areas of contamination among medical staff performing a simulated intubation through use of fluorescent markers, suggesting the need for improved covering of high-risk exposure areas.17
In our institution, we performed PPE training in the simulation center outside of our clinical treatment areas. This allowed us to devote ample time to individual learning goals in the simulation laboratory and minimize in situ program time to focus on systems-based improvement in the clinical arena. All staff were screened before arrival in the hospital and were wearing surgical or N95 masks at all times. We used PPE gowns designated for training and labeled them as such with careful instruction to avoid the ripping of the gown on removal. For in situ, we purchased laundered level 2 infection control gowns and labeled them for simulation where they were cleaned and reprocessed to return to the unit without concern of unnecessary disposal of PPE. Using this hybrid system, we could evaluate initial education in a nonclinical environment, and then practice using laundered gowns in the clinical environment.
For our nonsimulation-based educational efforts, we stationed a trained safety officer to monitor donning/doffing in the department and give “just-in-time” feedback. This multipronged approach built a system where individuals were trained in the simulation center, then the system was assessed by in situ simulation, and consistent feedback was given by a trained safety officer to increase the safety of staff in a high-risk environment. While an emphasis on education and training is important, we found having structure in place to be critical. The lead author, an experienced emergency physician and simulation educator who led PPE training across his hospital and consulted on the building of a virtual reality donning/doffing program, was saved by an infection control safety officer who observed him making an error on doffing after a 12-hour shift in a closed SARS-CoV-2 unit.
Latent safety threats related to lack of a designated location for donning and doffing of PPE gowns were revealed across multiple hospital sites. Challenges included how to incorporate PPE given the limited time available for in situ simulation. When our “closed” units were no longer needed, rather than fully donning or doffing PPE during in situ, participants were asked to physically bring the PPE to the in-situ simulation without donning it and verbally explain how to doff it. The inclusion of PPE use in our simulation design allowed educators to identify numerous threats across hospital systems, particularly for location of PPE, areas of disposal, and proper disposal of gowns before leaving the patient room. This data also allowed teams at each site to brainstorm systems-wide improvements to tackle these LSTs.
Recommendation #4: Minimize influx of external equipment into the “closed” units.
To reduce the transport of equipment which can potentially be contaminated with SARS-CoV-2 virus particles and act as a vector of spread to participants and other locations, we recommend the use of low-fidelity equipment, which can be kept in each “closed” unit, meticulously cleaned and logged.
Early data on transmissibility for SARS-CoV-2 had demonstrated that aerosol particles can remain in the environment for hours and last on surfaces for many days,18 which is a significant concern when bringing staff and equipment together into a clinical treatment space. Although the simulations were performed in rooms that had been cleaned, much is unknown about this virus. We deemed the logistics of bringing equipment into and out of our “closed” unit to be too much of a safety threat for cross-contamination. For equipment housed inside “closed” units, the Center for Disease Control (CDC) recommends routine cleaning and disinfection procedures using an Environmental Protection Agency (EPA)-registered, hospital-grade disinfectant.13 Our team primarily uses high-fidelity mannequins, which do not come with instructions for cleaning for viruses. Laerdal, which makes a variety of simulation equipment, states that there are little data available on transmission using mannequin and instructs to remove the face of its cardiopulmonary resuscitation mannequin after each use and to disinfect using antiseptic with 70% alcohol.19 We also have concerns about the ability to thoroughly clean this equipment by a single educator, as well as concerns about the use of accessories, including the laptop needed to run the mannequin and the monitor. Ultraviolet C has been shown to be effective in disinfecting keyboards and computers, and we recommend this when possible.20
Given our concerns about the cleaning and transport of high-fidelity equipment, our simulation team decided to forego its use and use low-fidelity equipment only, including airway heads, test lungs, and cardiopulmonary resuscitation mannequins. Low-fidelity equipment, in some scenarios, has been shown to be comparable to high-fidelity equipment.21 We also used tablets in place of specialized monitors to reproduce vital signs and heart rhythms during the simulation. There are tablets stationed inside the “closed” units for patient and staff communication, video conference, and interpreter services at all times. These tablets were purchased specifically for SARS-CoV-2 to allow patients and medical staff to communicate with family members who were not allowed into the hospital. When not in use for communication, the tablets are able to be loaded with applications that allow them to function as monitors. Rather than using an application, we chose to have a link bookmarked for our online form with a prerecorded patient monitor. This prerecorded video could also be played on mobile phones and desktop computers already in the patient rooms to bypass the need for further external equipment.
Because of its lower cost and need for technical expertise to use, our low-fidelity equipment was kept in closed units to reduce potential transmission of the virus through the equipment. When closed units were shut down, they were easily stored within each department. An additional benefit of this is that simulation educators have more ready access to equipment for evening, weekend, and impromptu sessions while on shift and self-clean the equipment with training.
Challenges for our hospital sites included storage and access, along with ensuring that simulation equipment did not mix with actual clinical equipment. Given that this was a shared program across hospital sites, our network of simulation teams shared resources including airway heads while also distributing the workload required in developing online forms, debriefing scripts, and training videos for calibration. Storage of equipment was left to each individual site to place in a secure yet easily accessible location. Finally, each airway head, as well as equipment used during the simulation, was clearly labeled with bright pink tape. The instructor was responsible for ensuring that simulation items were not left in the clinical area and were placed back into the packable bag in which the airway head was transported. They were also instructed in the proper cleaning of all equipment before placing back into storage.
Recommendation #5: Use electronic data collection software rather than paper forms.
To decrease cross-contamination of inanimate objects that lead to transmission of the virus outside the “closed” unit, we recommend utilizing a fully electronic debrief and data collection structure.
Debriefing after simulation is essential to create a supportive and learning environment and to maximize benefits of simulation. There are many debriefing strategies that maximize learning and systems improvement after simulations.10,22 Though some debriefing strategies may use paper-based surveys and feedback forms, this increases the risk of cross-contamination if these forms are removed from the “closed” units.
We used the Pearls for System Improvement framework for debriefing, which includes a recommendation of flip charts or whiteboards cross-checked by participants in the summary phase to validate participant contributions and provide an accurate and transparent summary.10 Studies have shown a contamination rate as high as 80% to 90% of medical charts in the intensive care unit.23 This risk of contamination can spread to any paper form brought into the “closed” unit as a part of the simulation. Using online forms, our simulation educators transcribed findings and systems improvement notes directly into an electronic form while in the room upon conclusion of the debrief. We believe that these measures will reduce the cross-contamination footprint a simulation leaves behind in the “closed” unit and decrease the risk of transmission of the virus out of the unit.
When inputting simulation data via electronic data collection software, our educators sometimes used acronyms and other shorthand to refer to site-specific equipment and protocol. This required brief “check-ins” by the QI team shortly after each simulation to clarify LSTs collected during debrief sessions.
OTHER CONSIDERATIONS
Despite the focus on the current pandemic, one should keep in mind other factors critical for safe in situ simulation practices. We have used the previously published recommendations by Bajaj et al,24 to screen conditions before starting an in situ program. We recommend establishing “no go” criteria with unit managers ahead of time and not running the simulation if clinical load/acuity is too high, staffing needs are not met, workflow patterns deem simulation to not be feasible, equipment needs are not met, and if there are unanticipated event/threats to psychological safety. It is also important to maintain confidentiality to ensure that LSTs are reported without fear of reprisal. Lastly, it is important to work under the basic assumption “that everyone participating is intelligent, capable, cares about doing their best and wants to improve.”25
CONCLUSIONS
With the development of new treatment units, deployment of staff practicing outside of their normal routine, and the management of a novel coronavirus, our experience demonstrates that there is a demand for simulation-based programs, both in a designated center as well as in situ in the clinical arena. Balancing the demand for education and training with safety considerations requires innovative, thoughtful solutions. We have provided a rationale for performing systems-based in situ simulation at your institution while also having outlined anecdotal and evidence-based recommendations that we put into place to minimize this risk of SARS-CoV-2 transmission to staff and patients.
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