INTRODUCTION
As many locations around the world pass through or emerge from the initial wave of
the COVID-19 pandemic, lessons learned are being collected, analyzed, and implemented
across clinics, hospitals, and health systems.[1
2] The toll on health-care providers (HCPs), both physical and psychological, has
been tremendous.[2
3] The prospect of contracting the illness while providing care to those who are acutely
ill, combined with the repeated sight of death and suffering, creates a significant
psychological burden on frontline personnel.[4
5
6] There is also growing recognition that many HCPs were simply unprepared for what
they had to see, process, and cope with. Experiences from previous epidemics suggest
that there is a significant associated risk of posttraumatic stress disorder.[7]
Many of the same health-care professionals will still be working on the frontline
into the near-to-intermediate term, dealing with airway management of critically ill
patients suffering from COVID-19, whether during the current or potential future waves
of the disease.[1] It is crucial to ensure that HCPs have the tools, the education,
the skills, as well as adequate levels of confidence to safely carry out critical
high-risk procedures such as endotracheal intubation (ETI).[8
9] The amount of aerosol generated during procedures like intubation poses a significant
threat to HCPs battling pandemic.[10
11] Of importance, there is also a relatively steep learning curve in terms of performing
ETIs, while wearing full personal protective equipment is often modified “aerosol
box” intubation settings.[12
13
14] Both the psychological and procedural aspects of ETI in COVID-19 patients can
be addressed with proper airway management training and purposeful simulation, incorporating
both cognitive and technical considerations.
The authors of this article see a pivotal role for simulation in preparing HCPs for
high-pressure, high-risk work environments.[15
16
17] Accordingly, the development of the simulation process needs to be deliberate
and appropriate structured so that it can make a difference by helping to improve
systems and processes of patient care. As such, we have developed a methodical 10-step,
streamlined simulation scenario (SSS) and checklist as a training tool to help to
prepare trainees for COVID-19 intubations and minimize the risk of viral exposure.
In this manuscript, we outline a simulation-based exercise in ETI for COVID-19 patients.
SIMULATION EXERCISE LOGISTICS AND STRUCTURE
As in other simulations, critical to this exercise is the proper definition of roles
and closed-loop communication between participating stakeholders.[18] The simulation
package for ETI consists of several key elements including:
A 20-min video demonstration of the pre-recorded simulation with role-playing to support
the facilitation of the exercise and its subsequent debriefing [Figure 1] (Video-Assisted
Learning for Standardization)
A checklist to explain all the processes of the exercise
Debriefing and troubleshooting of the process
Psychological preparedness module to help “place the trainee” mentally in a high-risk,
high-pressure environment ahead of any actual clinical ETI scenario takes place.
Figure 1
Image from the video that was used for training
The role and allocation of the team members involved in the intubation were preassigned
[Table 1].
Table 1
The role and allocation of the team members involved in the intubation were preassigned
Personnel
Responsibility
Team leader
Most experienced airway expert available
Registered respiratory therapist
Airway equipment in charge
Registered nurse
Intravenous lines/drug in charge
Infection control nurse
Oversees procedure and protocols
The in situ simulation was carried out in the simulation laboratory at the Department
of Emergency Medicine (EM) during the general outbreak preparedness campaign at our
institution. The EM team to prepare the SSS collated the inputs from the Hospital
Infection Control Committee and Disaster Preparedness team. All the processes were
critically observed and managed by two dedicated simulation staff – one experienced
simulation manager (observer) outside the simulation room through a glass panel and
one from within the room.
The sessions were conducted daily for all those who are likely to be involved in the
airway management of suspected or confirmed COVID-19 patients. A high-fidelity human
patient simulator (SimMan®) was used to simulate a patient suffering from severe hypoxemic
respiratory failure due to COVID-19, further complicated by hypotension, who presented
to the emergency department. Within this general theme, four different clinical situations
were utilized during SSS training, with consideration given to the estimated competency
of the group. There were four teams based on the competencies of the team leader as
follows: (in the order of least to most experienced).
Resident <1-year experience
Resident more than 1-year experience
Junior consultant
Senior consultant.
However, there were no significant changes in the sequence of ETI steps.
SIMULATION GROUPS AND IMPLEMENTATIONS
Each SSS group consisted of a 3-member ETI team. In all, we completed 14 individual
simulations involving 56 participants (14 Team Leader (TL) and 42 Registered Nurse
Registered Respiratory Therapist RN/RRT) [Figures 2 and 3]. Each SSS lasted between
45 min to 1 h. An additional 30–45 min time allocation was devoted to the prerecorded
video [Figure 1] and post-SSS debriefing and troubleshooting session. Some of the
components could be staggered if multiple groups participate in the exercise. Overall,
it took nearly 2 h to train each group of trainees.
Figure 2
Training of the in-hospital residents, followed by a demonstration on the high-fidelity
human patient simulator
Figure 3
Demonstration of the tracheal intubation by the trainees on the high-fidelity human
patient simulator
Health-care workers involved in patient care during an acute infectious outbreak have
reported severe psychological stress due to multiple factors, including fear of contracting
and spreading the disease, witnessing the death in colleagues and family members.
There are documented accounts of the same during the Ebola and SARS epidemic in different
parts of the world.[19
20
21] There is a need to provide physical and emotional care to HCPs during an infectious
epidemic/pandemic. It is also expected that HCPs may experience psychosomatic symptoms
with the progression of time during such a crisis.[22] A personal focus area as one
of the domains in crisis simulation that hinges on taking care of the well-being of
HCPs is being highlighted more now. Psychological well-being is an important tenet
which is gaining prominence in simulation exercises where, in addition to knowledge
and skills, well-being of the learners is also taken into account.[23] One of the
goals of our simulation exercise was to prepare the HCPs to work optimally in a high-stress,
high-risk environment adhering to the principles of crisis resource management.[24]
Psychological safety during simulation-based learning
Psychological safety during simulation-based learning (SBL) can be even more critical
than physical wellness. This is because in SBL, there is “performance” involved and
learners can be more self-conscious among themselves. Thus, facilitators of these
sessions need to have an “eagle eye” to observe even the slightest nuances from the
learner's perspectives. They must be aware of these and also assist to nurture and
urge participation in a neutral and nonthreatening way. Once learners feel comfortable,
they may then start to share and talk more openly, for example, during debriefing.
Being nonjudgmental is critical. Just one statement, which is offensive to one learner,
can throw us back many steps. Thus, preparedness from the faculty and facilitators
is important. Psychological wellness affects performance during SBL in a similar way
stress does. Thus, the impact of making learners feel at ease must never be underestimated.
In Asia, culture plays an essential role as well. In general, Asian learners may tend
to be less vocal, less confrontational, and may thus appear to be less participatory
and quiet. Hierarchy plays a critical role as well, whereby respect for teachers and
faculty is still something still held very strongly. Thus, for faculty working in
cross-cultural settings, there is a need to be aware of this. Giving our learners
second chances and opportunities are also important. At times, a more personalized
approach may even be needed for someone who is extremely shy and fearful of “public
speaking.”
ADDITIONAL RECOMMENDATIONS AND FEEDBACK
The intended participants of the SSS include all HCPs who may be called upon to provide
airway management in the setting of a known or suspected COVID-19 patient. This includes
clinicians from different areas and levels of training (faculty, residents of those
specialties expected to provide airway management, RN, and RRT). Similar to other
simulation exercises,[18] predesigned focused feedback rubric was used to debrief
the participants at the end of each session. Feedback and suggestions were obtained
from the participants to improve the subsequent implementation of knowledge and skills
learned into individual clinical practice. After each debriefing and critical analysis,
appropriate revisions were made in the guidelines and incorporated into subsequent
SSS exercises. In all, our entire institutional team was able to be trained within
2 weeks.
The main goals of the simulation were defined as follows:[18
25
26
27]
To improve the preparedness of TL, RN, RRT, and Infection Control Nurse (ICN) for
managing suspected or confirmed cases of COVID-19 with “just-in-time training”
To focus on the rapid acquisition of skills through “mastery learning” to optimize
both patient care and clinician safety
To disseminate key learning points to all members, including common errors observed
in training, to avoid these in clinical practice
To examine the system and operational issues related to institutional infection control
guidelines
To prepare HCPs for working sustainably in a high-stress, high-risk environment.
SUMMARY AND CONCLUSIONS
As a response to occupational concerns over COVID-19 exposure risk, we chose to eliminate
or minimize any perceived threats to provider safety. Thus, we implemented biosafety
barrier devices that serve to reduce the risk of airborne virus transmission [Figure
4]. Following our institutional adoption of biosafety barrier devices, the training
session was also modified accordingly. This included the incorporation of the use
of the barrier devices into the SSS processes. The next steps in our evolving SSS
implementation include the process of using and comparing different barrier devices
in the simulated setting.
Figure 4
Emergency physician intubating with modified steps of intubation using the barrier
device
In summary, we strongly recommend the in situ simulation methodology as a valuable
tool to evaluate and improve the performance of frontline HCPs involved in the management
of COVID-19. Repeated simulations appear useful, with new insights learned by exercise
participants who may not have been aware of specific nuances without the active implementation
of our iterative process. The latter paradigm also serves to maintain operational
readiness and should be embraced during times with fewer-than-expected COVID-19 ETIs
to ensure appropriate levels of preparedness during patient surge scenarios.[28]
With the rapid and often unpredictable progression of the COVID-19 pandemic, all frontline
HCPs must be prepared for high-risk, high-stress procedures such as ETI. With the
in situ simulation training, as described in our manuscript, we were able to achieve
such preparedness. In addition, we were able to ensure ongoing high quality of the
process by implementing real-time learning, appropriately revising pertinent (e.g.,
ETI) guidelines, and by providing HCPs with a realistic set of expectations for working
with COVID-19 patients in respiratory distress. We believe that in situ simulation
can be used to train HCPs involved with high-risk procedures and to efficiently delineate
the process so that institutional guidelines and practice patterns can be optimized
in the event of an emerging infectious disease such as COVID-19.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.