Adults Sim Scenario: COVID-19
The beginning of the COVID-19 pandemic was an incredibly challenging time for all of us. We were entering the ‘unknown’, fuelled with anxieties and apprehensions about working in the Emergency Department (ED). To help alleviate these feelings and prepare quickly for the rapidly evolving working conditions, we used translational simulation as an educational tool to identify safety issues for patients and staff [1].
To test our departmental and cross-specialty processes when dealing with a critically unwell COVID-19 patient, we designed and delivered a multidisciplinary adult simulation scenario. This took place in our Emergency Room (ER) involving approximately 100 interprofessional staff members across two sessions.
This was the first time for us as a team to facilitate a cross-specialty simulation in our ED. We took this opportunity to bring directorates together, enhance cohesive team working and generate rapid solutions [2].
This adult case scenario was based around a patient presented with acute respiratory failure after returning from Italy.
After stabilisation of the patient, we tested our transfer processes by allowing several other interprofessional staff groups (e.g. security, porters) to participate in transfer of the mannequin to the ICU.
Evaluation of verbal and written feedback from staff members identified the following key issues specific to the ED: lack of preparation prior to patient arrival; poor communication whilst wearing Aerosol-Generating Procedures (AGP) Personal Protective Equipment (PPE); and unsatisfactory donning/doffing procedures.
To act upon this, we generated the following immediate actions:
COVID-19 donning/doffing training hub available to hospital staff members
ER checklist that would help staff safely prepare for an unwell COVID-19 patient
Designate the use of smartphones (used on speakerphone) for communication between staff in the ER, and further work developing non-verbal communications.
Since our simulation, our IPC work has been ongoing and we have been able to run scenarios based on non-verbal communication whilst wearing AGP-level PPE.
References
- Brazil, V. (2017) Translational simulation: not ‘where?’ but ‘why?’ A functional view of in situ simulation. Adv Simul 2.
- Gordon, J.A., Wilkerson, W.M., Shaffer, D.W., Armstrong, E.G. (2001) “Practicing” medicine without risk: students’ and educators’ responses to high-fidelity patient simulation. Acad Med.76(5):469–72.
Pre-brief (instructor to read out)
“Welcome to Simulation. This experience is aimed at providing a safe, non-judgemental learning environment where you have the opportunity to practice clinical skills on a simulated patient (or Sim Man), before being faced with a real-life scenario. This is NOT a test!
We expect you to only undertake roles that you would perform in the clinical environment, and ask for help/escalate care appropriately. Thank you to the various specialties who have agreed to take part in this scenario.
The scenario will be run ‘real-time’, as if it were real-life. (For example, apply monitoring as usual, prescribe and ask for equipment). Any specialist equipment will be provided by the Education Team if requested.
We aim to run the scenario for approximately 30 minutes, followed by a detailed debrief session for another 30 minutes.
We would like: active participation from all candidates, honest verbal feedback about the team’s performance within the Simulation and written feedback about the Education Team running the scenario.
You will receive: immediate verbal feedback, assessments including a Mini-CEX, DOPS or log books signed (if requested) and a personalised certificate of attendance.”
Introduction to Sim Man
High fidelity mannequin, starting from head to toe…
Head: blink, talk, reactive pupils, airway care (e.g. intubation/surgical airways).
Chest: heart and breath sounds, chest will rise and fall, can attach defibrillator and use accordingly.
Arms: veins with blood therefore can cannulate, palpable radial pulses so can perform ABG.
Legs: can insert IO.
Feet: palpable peripheral pulses.
Monitoring: use your regular patient monitoring and the virtual monitor will display the observations as it is applied.
Information for the scenario
We will provide you with the relevant information prior to the scenario. Everything after this point you should discover, identify and address in real-time, as if this were a real-life patient.
If you are unsure, please ask the facilitator running the scenario for advice. Enjoy your Sim!
Scenario requirements
Case title: COVID-19
Setting: Emergency Room/Resus
Patient age/sex: 56/Male
Diagnosis: Acute Respiratory Failure secondary to COVID-19
Equipment required: Sim-Man mannequin (complete kit); Defibrillator with training leads; Training cannulation set; Emergency intubation drugs; Ventilator, HME filter, airway trolley, PPE trolley
Staff required: 1x Junior doctor, 1x Senior doctor, 1x Junior nurse, 1x Senior nurse, 1x ODP (Operating Department Practitioner), Anaesthetist/ITU team, 1x Radiographer, 2x Buddies
Learning objectives:
To demonstrate effective, structured A-E primary assessment & make a diagnosis of acute respiratory failure (with minimal investigations) with quick and rapid assessment of patient.
To demonstrate safe donning and doffing procedures.
Effective and appropriate clinical management of suspected COVID-19.
Safe and appropriate transfer (with risk assessment) of patient from ER to ITU.
Initial observations/setup
HR: 140
RR: 35
SpO2: 80% on Air, 88% on NRB mask
BP: 110/80
CRT: 2 seconds
Glucose: 10.5
GCS: E4 V4 M6 = 14/15
Pupils: Equal
Temp: 38.2°C
Weight: 95 kg
Arrival route: Ambulance (Red Call)
Additional info: Returned from Italy (Veneto region) 3 days ago; Hypertension; Type 2 Diabetes Mellitus (no insulin)
Equipment on arrival: NRB mask
Carers? None
Red Call sheet
Expected simulation progress for technician
After 5 mins, make these changes: (trending over the first 5 mins)
- If candidate(s) applies high flow oxygen (15 L non re-breathe mask), saturations to remain at 88%
- If candidate(s) does not apply high flow oxygen, saturations to fall to 80% and RR to increase to 40
After 10 mins, make these changes: (trending over another 5 mins)
If candidate(s) give medical therapy (e.g. IV fluids and antibiotics) observations to be as follows – saturations 86% on 15L NRB mask, RR 40, HR 145, BP 90/60, temperature 38°C If candidate(s) does not give medical therapy as above or inappropriate therapy (e.g. oxygen and antibiotics only) observations as follows – saturations 86% on 15L NRB mask, RR 45, HR 150, BP 85/60, temperature 38°C After 15-30 mins, make these changes: (trending over 15 mins) If candidate(s) successfully intubate and ventilate the patient, observations as follows: saturations 94% (on FiO2 100%), RR 16 (set on ventilator), capnography trace to be provided (see page 10), HR 110, BP 98/60, temperature 38°C If candidate(s) are unable to intubate/ventilate or do not make the decision to do so, patient will go into cardiorespiratory arrestAfter 5 mins, make these changes: (trending over the first 5 mins)
If candidate(s) applies high flow oxygen (15 L non re-breathe mask), saturations to remain at 88%
If candidate(s) does not apply high flow oxygen, saturations to fall to 80% and RR to increase to 40
After 10 mins, make these changes: (trending over another 5 mins)
If candidate(s) give medical therapy (e.g. IV fluids and antibiotics) observations to be as follows – saturations 86% on 15L NRB mask, RR 40, HR 145, BP 90/60, temperature 38°C
If candidate(s) does not give medical therapy as above or inappropriate therapy (e.g. oxygen and antibiotics only) observations as follows – saturations 86% on 15L NRB mask, RR 45, HR 150, BP 85/60, temperature 38°C
After 15-30 mins, make these changes: (trending over 15 mins)
If candidate(s) successfully intubate and ventilate the patient, observations as follows: saturations 94% (on FiO2 100%), RR 16 (set on ventilator), capnography trace to be provided (see page 10), HR 110, BP 98/60, temperature 38°C
If candidate(s) are unable to intubate/ventilate or do not make the decision to do so, patient will go into cardiorespiratory arrest
Instructions for patient
You are feeling extremely unwell and struggling to speak in sentences. If asked questions, you reply with only ‘Yes’ or ‘No’ answers.
Your condition will not stabilise so are able to give any history.
Collateral history from paramedic
6-hour history of SOB, unwell overnight and unable to lie flat. No fever. No recent admissions to hospital.
Patient travelled to Italy (Veneto region) two weeks ago, returned 3 days ago.
PMHx – Hypertension, type 2 diabetes mellitus
DHx – Lisinopril, metformin
SHx – Office worker, occasionally drinks alcohol, smoker
Prehospital interventions: IV cannulation has been unsuccessful. You have given Oxygen therapy only (15L NRB mask).
You are unaware of COVID-19 protocols.
Patient has: no NKDA, weight = 95 kg
Instructions for ITU SpR (over the phone)
You would like handover in a SBAR format.
You will come and review the patient in ER.
You request for the Operating Department Practitioner (ODP) to be contacted.
Donning
This video by Public Health England shows how to safely don (put on) the Personal Protective Equipment (PPE) specific to COVID-19. You can download a printable poster that provides a quick illustrated guide for donning PPE.
Doffing
This video shows how to safely doff (or remove) the Personal Protective Equipment (PPE) specific to COVID-19. You can download a printable poster that provides a quick illustrated guide for doffing PPE.
Supporting investigations
Capnography Trace
Generic debrief for scenario
There are lots of feedback models that can be used, but immediate feedback is essential to aid learning, to help analyse the process and create solutions.
For feedback to be effective and to improve patient safety overall, feedback should be:
S - Specific
M - Measurable
A - Achievable
R - Realistic
T - Timely
Example of a feedback model: (Pendleton’s Rules)
Clarify any points of information/fact
Ask the learner what s/he did well (ensure that they identify the strengths of the performance and do not stray into weaknesses).
Discuss what went well, adding your own observations (if there is a group observing the performance, ask the group what went well – focussing on their strengths).
Ask the learner to say ‘what went less well’ and ‘what they would do differently’ next time.
Discuss what went less well, adding your own observations and recommendations (if there is a group observing the performance, ask the group to add their observations and recommendations)
Debrief specific for this scenario
Non-technical skills:
Was the Team Leader Role well defined?
Were other roles allocated and followed? (e.g. Were names used? Stickers used?)
Did the team communicate well? Use of closed-loop communication?
Did the team leader give clear instructions?
Did team members prioritise tasks effectively?
Technical skills:
Safe and effective A-E assessment of patient, correctly identifying respiratory failure as diagnosis, suspected COVID-19
Initiating correct medical management (e.g Oxygen, IV fluids, IV antibiotics)
Correct donning and doffing procedures followed
Rapidity of decision-making and decision made to intubate (ITU colleagues)
Safe and appropriate transfer to ITU
