key: cord-0046398-4o9vft91
authors: Lababidi, Hani M S; Alzoraigi, Usamah; Almarshed, Abdullah Abdulaziz; AlHarbi, Waleed; AlAmar, Mohamad; Arab, Amer A; Mukahal, Mahmoud A; AlAsmari, Faisal A; Mzahim, Bandar Y; AlHarastani, Husam A M; Alammi, Salem S; AlAwad, Yousef I
title: Simulation-based training programme and preparedness testing for COVID-19 using system integration methodology
date: 2020-05-27
journal: BMJ Simul Technol Enhanc Learn
DOI: 10.1136/bmjstel-2020-000626
sha: ea6e26df28db201a7cdce79acafa0f598d9b52a9
doc_id: 46398
cord_uid: 4o9vft91

BACKGROUND: COVID-19 pandemic is presenting serious challenges to the world’s healthcare systems. The high communicability of the COVID-19 necessitates robust medical preparedness and vigilance. OBJECTIVE: To report on the simulation-based training and test preparedness activities to prepare healthcare workers (HCWs) for effective and safe handling of patients with COVID-19. METHODOLOGY: Two activities were conducted: simulation-based training to all HCWs and a full-scale unannounced simulation-based disaster exercise at King Fahad Medical City (KFMC). The online module was designed to enhance the knowledge on COVID-19. This module was available to all KFMC staff. The five hands-on practical part of the course was available to frontliner HCWs. The unannounced undercover simulated patients’ full-scale COVID-19 simulation-based disaster exercise took place in the emergency department over 3 hours. Six scenarios were executed to test the existing plan in providing care of suspected COVID-19 cases. RESULTS: 2620 HCWs took the online module, 17 courses were conducted and 337 frontliner HCWs were trained. 94% of learners were satisfied and recommended the activity to others. The overall compliance rate of the full-scale COVID-19 disaster drill with infection control guidelines was 90%. Post-drill debriefing sessions recommended reinforcing PPE training, ensuring availability of different sizes of PPEs and developing an algorithm to transfer patients to designated quarantine areas. CONCLUSION: Simulation-based training and preparedness testing activities are vital in identifying gaps to apply corrective actions immediately. In the presence of a highly hazardous contagious disease like COVID-19, such exercises are a necessity to any healthcare institution.

Simulation-based training programme and preparedness testing for COVID-19 using system integration methodology

The novel coronavirus pandemic has presented serious challenges to the world's healthcare systems' infrastructure. 1 The high communicability of the COVID-19 disease necessitates robust medical preparedness and vigilance. 2 Detailed practices and precautions need to be applied throughout the spectrum of care of patients with COVID-19. 3 Routine testing of preparedness remains an integral step in assuring effective and safe handling and treatment of patients with highly hazardous contagious disease. The Center of Research, Education and Simulation Enhanced Training (CRESENT) at King Fahad Medical City (KFMC) in Riyadh, Saudi Arabia, has been conducting simulation exercises for performance improvement and to test operational preparedness for many years. CRESENT conducted simulation training exercises for mock codes, bed sores in intensive care unit, 4 Ebola virus disease preparedness, speaking up as well as operational preparedness of new emergency department (ED) and bronchoscopy suite. 5 This article reports on the simulation-based training and test preparedness activities to prepare KFMC healthcare workers (HCWs) for effective and safe handling of patients with COVID-19.

KFMC is the largest tertiary care medical centre under the Ministry of Health (MOH) in Saudi Arabia. The KFMC campus includes four hospitals with 1200-bed capacity and nine apartment towers for nursing staff and more than 400 living quarters. The course followed the blended learning approach. The online self-learning module was designed to enhance the knowledge of the learners on COVID-19 definition, epidemiology, signs, symptoms and transmission as per Saudi MOH. This module was made available to all KFMC staff (around 4500 HCWs) and was followed by an online examination. An electronic certificate was generated indicating completion of the theoretical part. The practical part of the course was made available to front-line staff (around 950 HCWs). It consisted of five hands-on skill stations: donning and doffing of PPE, PAPR, equipment cleaning, nasopharyngeal swab and one group discussion session on speaking up (table 1) .

On the other hand, the full-scale COVID-19 simulation-based disaster exercise objectives were the following: 1. To test Emergency Medical Services (EMS) response in a prehospital setting as per KFMC epidemic protocol. 2. To evaluate ED response dealing with suspected COVID-19 cases as per newly developed algorithms.

COVID-19 cases. Ancillary hospital departments at KFMC whose services were critical to the success of caring for patients with COVID-19 were involved in the unannounced exercise. These were: ED, EMS, patient affairs, security staff and Nursing Administration. The full-scale COVID-19 simulation-based disaster exercise took place in the ED over 3 hours with participation of around 70 staff from those departments. A total of six scenarios, using six standardised patients (SP) and one full body manikin, were executed to test the existing plan in providing care of the six patients with suspected COVID-19 disease (table 2) . Compliance with infection control procedures was measured by computing the rate of fulfilments of the 'expected actions' from table 2. Plus-delta debriefing methodology was used for postexercise debriefing (table 2). The cited information and/or identifiable in table 2 are not from an actual patient. Any resemblance to real person living or deceased will be coincidence. In one hybrid scenario, the SP was switched to a manikin after he asked for a urinal and the HCW left the room.

A total of 2620 HCWs at KFMC took the online module. Until the writing of this manuscript, a total of 17 courses were conducted with a total of 337 frontliner HCWs trained (table 3) . Post-course evaluations were collected and presented in table 4. Around 94% of learners were satisfied or highly satisfied and recommended the simulation-based educational activity to the others.

A total of 14 members from Disaster Management, ICD, Nursing Administration and CRESENT, 6 evaluators and 6 SPs conducted the full-scale COVID-19 simulation-based disaster exercise on the 11 March 2020. The overall compliance rate of the HCWs with infection control guidelines was 90%. Post-drill debriefing sessions with all participating departments/administrations were conducted to empower the strength points and identify the gaps in the triage system, infection control and flow of patients (table 5) . Table 5 Strengths and challenges of the full-scale COVID-19 simulation-based disaster exercise 

The Nursing Administration at KFMC developed a robust algorithm for screening and triage of all patients arriving to ED (figure 1). Two main strengths of this full-scale COVID-19 simulation-based disaster drill worth mentioning. First was the identification of all undercovered (mystery) simulated patients as possible COVID-19 cases early on at arrival to the main door and namely by the so-called 'visual nurse'. Second, the integration of Canadian Triage and Acuity Scale 9 and the Visual Triage Checklist for Acute Respiratory Illness (figure 2) in the screening and triage process. No challenges reported under this domain.

All HCWs who participated in the full-scale COVID-19 simulation-based disaster drill practised strict infection control measures. Many strengths were described by the observation team. Hand hygiene was universally applied by all HCWs. There was limited access to the ED and hospital security played a noticeable role to achieve it. The challenges included: one nurse was not wearing the proper PPE, no proper cleaning of the queuing machine and linen used by EMS was taken back to the ambulance.

The prehospital transfer of symptomatic HCWs from their living quarters to ED was adequate. The flow of patients within the ED was well controlled by hospital security and triage nurses. As for the confirmed patients with COVID-19 who require hospitalisation, they were transferred by EMS to the MOH-designated COVID-19 hospital outside KFMC as per protocol. Undercovered simulated HCWs with COVID-19 were supposed to be transferred to one of the KFMC housing towers that was designated by the ICD for home quarantine. Three challenges were identified: lack of written instructions for home isolation, no designated party to transfer back quarantined HCWs and lack of training of security staff in HCWs' quarantine areas on infection control measures.

The major recommendations that were included in the final report: reinforcing PPE training regularly and registration in the COVID-19 course, ensuring availability of different sizes of PPEs and developing a clear algorithm to transfer patients to designated quarantine areas.

Evaluating healthcare facilities performance in disasters remains a major challenge to healthcare administrators. Advanced healthcare systems, such as Italy, Spain and China, were overwhelmed with patients with COVID-19. [10] [11] [12] Full-scale exercises and drills have been widely used to assess hospital readiness for effective and safe performance during highly contagious outbreaks. [13] [14] [15] [16] Violations of infection control practices by HCWs can be a major factor in facilitating the transmission of pathogens and outbreak. 17 Infection control measures like hand hygiene require relentless efforts to secure a high level of awareness and compliance among HCWs. 18 This study showed very high compliance of KFMC HCWs in applying written protocols when dealing with suspected cases of COVID-19. It also discovered gaps that were remediated immediately. The high compliance rate we encountered is due to the high awareness level of the KFMC HCWs as well as the unprecedented global effect of COVID-19. People around the world are exercising extreme measures like social distancing, disinfection of belongings and home quarantine to limit the spread of this highly communicable disease.

A key element in the success of any quality improvement and system integration project is the support from higher administration. 19 The CRESENT System Integration Committee at KFMC, formed from leaders in high positions, has the mission to apply consistent, planned, collaborative and integrated interventions, in conjunction with systems engineering and risk management, to address KFMC healthcare system issues and needs and achieve excellent clinical care, enhanced patient safety and improved outcome metrics across the healthcare system. It represents an organised bidirectional feedback loop between CRESENT and the healthcare system at KFMC to integrate simulation programmes within the whole KFMC healthcare system. 20 Many accelerated precautions decisions were taken at higher levels during the period of conducting the course, like stopping all training activities which might increase the risk of disease outbreak. The COVID-19 training course was excluded and precautions were arranged with the ICD to provide safe training to attendees and instructors. These precautions included reducing the number of participants per session, spacing the skill stations and frequent hand washing.

Protecting HCWs from getting infected remains an essential weapon in defeating COVID-19. Physicians, nurses, respiratory therapists, EMS personnel, environmental services personnel are all vulnerable and need to be protected both physically 21 and psychologically. 22 By the end of February 2020, China reported more than 3000 infected HCWs in Hubei alone. 23 In a single designated hospital in Wuhan, 28 physicians and nurses contracted COVID-19. 24 The figures from Italy have been more alarming given the difference in population and healthcare workforce. Around 9% (2609) of the COVID-19 cases are among HCWs. 25 We included HCWs in four out of the six scenarios in the full-scale COVID-19 simulation-based disaster exercise with various risks to COVID-19.

The full-scale COVID-19 simulation-based disaster drill was unannounced with injected undercovered simulated patients. Unannounced or no-notice drills provide added realism and produce more realistic data when compared with scheduled drills. In Ebola preparedness no-notice drills, 40% of hospitals failed to ask patients about travel history, occupation, contact history and cluster information compared with 90% compliance rate during regular inspection. 26 Furthermore, 49 New York City EDs were evaluated regarding their response to communicable diseases through unannounced undercovered simulated patient drills. 27 These drills generated valuable information to the hospitals to improve on identifying and isolating patients with a potentially highly infectious disease. 27 During this experience, we faced a few challenges. The main challenge was related to limited time in planning and execution of training and exercise. The COVID-19 has been spreading fast all over the world and immediate training and preparedness testing is of utmost importance. Another challenge is the balance of using PPE for training and saving hospital resources like N95 masks for the real pandemic. Such decisions need to be discussed properly with the institution's supply chain and may affect course design and execution. The drills were carried out by members of Disaster Management, CRESENT and ICDs. Most of them are known by the hospital staff and this can affect performance and evaluation.

Simulation-based training and preparedness testing activities are vital in identifying gaps to apply corrective actions immediately. In the presence of a highly hazardous contagious disease like COVID-19, such exercise is a necessity to any healthcare institution. It identifies gaps and improves the HCWs' preparedness. The main three areas worth of emphasising for COVID-19 preparedness simulation training include triage system, infection control measures and flow of patients.

The drill was endorsed by Chief Executive Officer and KFMC COVID-19 taskforce

Presence of all related department/administrations leaders

Security presence was optimal in controlling traffic

A special quarantine area for HCWs has been allocated

Having a clear IC, EMS and ED algorithms and pathways

Excellent social media monitoring during the drill

EMS followed proper procedure in transporting patients to ED

Dispatch response (activation time) was optimal

Terminal cleaning was done for ambulances. Challenges 1. Linen used by EMS was taken back to the ambulance. 2. ED nurse not wearing proper PPE. 3. No proper cleaning of the queuing machine

Training of security staff in HCWs quarantine areas on IC

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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.Competing interests None declared.Patient consent for publication Not required.ethics approval This research was approved by the KFMC Institutional Review Board.Provenance and peer review Not commissioned; externally peer reviewed. data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. None. This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

Hani M S Lababidi http:// orcid. org/ 0000-0002-9737-9832