key: cord-278341-pnrh3r2j
authors: Monzani, Alice; Genoni, Giulia; Binotti, Marco; Tagliaferri, Francesco; Rabbone, Ivana; Ingrassia, Pier Luigi
title: Management of a suspected case of 2019 novel coronavirus infection in a 4‐year old child: A simulation scenario
date: 2020-08-10
journal: J Paediatr Child Health
DOI: 10.1111/jpc.15022
sha: 
doc_id: 278341
cord_uid: pnrh3r2j

nan

Monitors required: Thermometer, pulse oximeter.

Other equipment required: Paediatric patient simulator (SimBaby, Laerdal, Wappingers Falls, NY, USA), oxygen tank, nasal prongs, intravenous (IV) normal saline and giving sets, IV cannulas, drugs: paracetamol.

• Chest X-ray: interstitial changes, mainly at the lung basis 

You are a paediatrician working at a university-based paediatric emergency department. You are visiting outpatients. A mother brings her 4-year-old child for fever, cough and breathing difficulty. A paediatric nurse is undergoing the triage in another room (Table 1 ).

Participants are handed over the case of a 4-year-old girl brought by her mother for fever, cough and breathing difficulty. The first part of the scenario is the pre-triage where the paediatric nurse/ learner should take a full medical history of the child, showing that the child went with her family to visit some relatives in Codogno, Lombardy area, 10 days before, and her aunt is now hospitalised for a COVID-19 infection. The paediatric nurse should promptly inform the paediatrician and the pre-triage should be completed in the 'red room', dedicated to patients with Key Points 1 A disease-specific scenario for COVID-19 allows testing of local guidelines. 2 Learning personal protective equipment donning/doffing in a simulation scenario would be effective in the perspective of a just-in-time training. 3 A disease-specific scenario for COVID-19 could implement and test the management of a multi-disciplinary cooperation. After the correct identification of the suspected paediatric case, learners should evaluate the patient and call for the help of the infectious disease medicine consultant (embedded participant).

The patient shows dry cough, mild tachycardia, mild tachypnoea, oxygen saturation of 95% and a core temperature of 38.5 C. The learners should decide to deliver oxygen with nasal prongs and to administer paracetamol; adequate fluid support can be started. Following primary evaluation a basic blood count, CRP, PCT, blood gas analysis, and a chest X-ray can be requested. Nucleic acid testing by RT-PCR of throat swabs should be performed after discussing the case with the infectious disease medicine consultant. The RT-PCR will confirm the COVID-19 infection. The participants should then decide the Department of hospitalisation for the patient.

You are visiting outpatients at the emergency department. A mother brings her 4-year-old child for fever, cough, and breathing difficulty from 2 days. Laboratory, radiology, and other relevant studies CBC: WBC 6.4 × 10 9 /L, neutrophils 84%, lymphocytes 12%, PCR 0.82 mg/dL (reference value <1 mg/dL), PCT 0.3 ng/mL. Chest X-ray: Interstitial changes, mainly at the lung basis. Throat swab: Tested positive for COVID-19 nucleic acid using RT-PCR. 

This simulation case provides a way to test and implement procedures for prompt identification, isolation, and management of a suspected COVID-19 infection in a paediatric patient.

In the case of COVID-19, the proper adherence to guidelines often represents a challenge for frontline staff because they are different from usual procedures and rapidly evolving. Simulated cases offer the opportunity to practice using the most updated guidelines and identify issues that are preventing staff from adhering to them. Differently from medical simulation about well-established algorithms, we strongly recommend reviewing the most recent guidelines with learners before running the simulation.

The scenario offered the opportunity to discuss some essential aspects of a suspected COVID-19 case during the debriefing. The following technical skills were reviewed:

• Early identification, early isolation, early diagnosis, and early treatment are all essential and sequential steps to be fulfilled for the proper management. • Proper donning/doffing of PPE. The team should be able to wear the PPE, in strict accordance with the recommended onoff procedure. • In the contingency of COVID-19 outbreak, differential diagnoses in a paediatric patient with mild respiratory distress and fever should not be lost sight of and should be discussed with the learners. The case also offered insights to test important non-technical skills.

• Clear role definition and communication between team members, with the peculiarity of a multi-disciplinary staff. • Call for the help of the consultant. This resource should be promptly used, in order to discuss with the consultant the timely isolation of the patient and the best options for the hospitalisation, according to local guidelines. • Effective communication with the child's parent, aimed at collecting essential information about possible sources of infection and at providing clear notions about isolation procedures, in a reassuring but firm way. When we ran this simulation scenario at the SIMNOVA simulation centre, we showed, from a technical point of view, an improvement in the rapidity and appropriateness of PPE wearing procedures as the learners repeated the scenario. The implementation of the skills in PPE use is of paramount importance to prepare health-care workers to proficiently and safely work departments dealing with suspected COVID-19 cases. Actually, an extremely high rate of secondary infections among healthcare workers has been reported in Italy, suggesting inadequate infection control protections in clinical practice. Simulated scenarios could fulfil the need for a just-in-time training, preferably if precociously implemented. In this regard, it would be particularly useful in Countries not already critically involved in the pandemic, and to address not only residents but also paediatric emergency practitioners, in the front line of the management of suspected COVID-19 cases. Moreover, this simulation scenario offers the opportunity to test how the most updated guidelines fit with the local resources and personnel. Regarding crisis resource management and teamwork, it matches the opportunity to stress some organisational clues that are typical of uncommon and stressful situations and to identify latent safety threats, including fixable problems with teamwork, systems issues and adherence to guidelines.

The design of this scenario was mainly based on the principles of Kolb's Theory of Experiential Learning 5 and andragogy. 6 Actually, we aimed to apply experiential learning along with critical reflection, in order to increase residents' engagement in simulation, assist them in discovering strengths and weaknesses and in gaining self-confidence. We used a true-to-life simulated clinical setting, trying to replicating the reality of the workplace, even if it was not possible to provide an in-situ simulation, due to the critical involvement of the emergency departments during COVID outbreak. Finally, we aimed to provide a good-judgmental and nonthreatening learning environment, in order to reduce residents' anxieties and stress and to encourage sharing of thought and ideas. Indeed, it is known that residents' engagement and interest in simulation education is high, particularly because simulation could represent the way to move from a culture of blame around an error to a new culture of safety, where errors are disclosed in the debriefing. 7, 8 In conclusion, this scenario aims at providing a holistic training exercise to prepare paediatric residents and physicians for practice in the challenging settings of COVID-19 outbreak but can be easily used for any highly contagious respiratory disease training.

A novel coronavirus outbreak of global health concern

COVID-19) Situation Reports

A case series of children with 2019 novel coronavirus infection: Clinical and epidemiological features

Diagnosis and treatment of 2019 novel coronavirus infection in children: A pressing issue

Experiential Learning: Experience as the Source of Learning and Development

The Theory into Practice Database

Barriers to use of simulation based education

Simulation-based medical training for paediatric residents in Italy: A nationwide survey