key: cord-0718047-5stovb8d authors: Diaz, Maria Carmen G.; Dawson, Kimberly title: Use of Simulation to Develop a COVID-19 Resuscitation Process in a Pediatric Emergency Department date: 2020-08-04 journal: Am J Infect Control DOI: 10.1016/j.ajic.2020.07.032 sha: 711c4c79f192b70e172f52870f5575f4e5dcefdc doc_id: 718047 cord_uid: 5stovb8d The Coronavirus Disease 2019 (COVID-19) pandemic has created many challenges for healthcare providers. At the forefront is the need to balance optimal patient care with the safety of those providing that care. This is especially true during resuscitations where life-saving procedures cause widespread aerosolization of the virus. Efforts to mitigate this exposure to front-line providers are therefore paramount. We share how we used simulation to prepare our Pediatric Emergency Department for COVID-19 resuscitations. The authors certify that to the best of our knowledge, no conflict of interest, financial or other, exists. -MD and KD Highlights:  Simulation may be used to augment infection prevention and control initiatives  Simulation may be used to help develop COVID-19 processes, spaces and workflows  Simulation may be used to help educate teams about COVID-19 nuances The American Heart Association's (AHA) Coronavirus Disease 2019 (COVID-19) guidelines emphasize the need to balance timely, high-quality resuscitation with healthcare provider safety. 1 Safely and rapidly implementing these guidelines may be challenging as the inherent stress that accompanies new algorithms may be compounded by fears of disease transmission and impede understanding and effective execution of new processes. Simulation may help teams with systems integration. 2, 3, 4, 5 Through collaboration and bi-directional feedback, simulation creates a safe analytic lens into spaces and processes so that flow may be optimized and risk minimized. And, by encouraging deliberate practice with facilitated feedback prior to actual patient care, simulation educates participants, decreases cognitive load 6 and mitigates errors by increasing individual and team comfort and confidence with high stakes events such as COVID-19 resuscitations. We used simulation to iteratively develop a COVID-19 resuscitation process for our pediatric emergency department (PED), a 47 bed, Level I Pediatric Trauma center with approximately 60,000 annual PED visits and housed in a free-standing, suburban children's hospital. Our simulations allowed us to collaborate, leverage different perspectives and devise an easily understood, unified resuscitation process that helps protect our team. Simulation to Define the Current State: Our first step was to assess our current PED space, teams, flow and processes. We consulted subject matter experts (SMEs) and devised a COVID-19 pediatric resuscitation simulation scenario. Our SMEs and administrative leadership joined our simulation as silent observers. Our standard resuscitation We discovered that our current resuscitation space and path for EMS into that space was not optimal for COVID-19 resuscitations. EMS' aerosol generating procedures (AGP) would contaminate personnel, equipment and supplies along the path into our resuscitation rooms. Additionally, these rooms contain copious equipment and supplies that need to be terminally cleaned or discarded after resuscitative AGPs leading to prolonged room turnover time. Also, these rooms are positive pressure. This is not optimal as naturally ventilated or negative pressure rooms are preferred for COVID-19 AGPs. 7, 8 Our simulation also showed that we had to reduce exposure risk, decrease our resuscitation team size, and monitor the number of staff within the resuscitation room. Individual team members had to take on more tasks than usual and we had to be creative within our space. And we needed to do this as quickly as possible prior to our anticipated peak of COVID-19 patients. We summarized and sorted our simulation findings and feedback according to methods, equipment, supplies and associates. Our key stakeholders assigned criticality to each item and together we developed potential mitigation options. Based on this, we conducted further simulations to leverage work as imagined with work as done 9 to ensure that our mitigation strategies translated to the frontline. We had to limit contamination from AGPs along EMS' path into and within our PED. None of our existing negative pressure rooms are near our ambulance entrance. Our decontamination space was ideal as it's next to the ambulance entrance, is physically closed off from the rest of the PED, and has minimal equipment. Since it contained several positive pressure rooms, our facilities team changed airflow into and within one area so that it had negative pressure airflow. We ran simulations trialing different algorithms of bringing in equipment and supplies versus strategically stocking the room. We decided to stock the room with vital airway and vascular access supplies placed in labeled, encased plastic basins pre-sorted according to patient weight following Broselow tape recommendations ( Figures 1 and 2) . We chose this method as it was the easiest and quickest to reliably clean post-resuscitation and still allowed for the use of appropriate weight based pediatric equipment. We also used simulation to determine our optimal number of staff around the head of the bed, within the room and outside of the room (Table 2) . At the head of the stretcher Airway provider Manages airway. May also function as team lead if PED + physician. Conducts primary survey. Places patient on monitor, assists with airway procedures/management and assists with bedside nurse procedures as needed. Obtains access, labs, performs procedures. Together with airway provider completes secondary survey as needed. We utilized simulation as a vehicle to help us better understand COVID-19 resuscitation related infection prevention and control issues within our PED. Simulation allowed us to understand barriers within our current space and helped us develop and refine a new process that would allow us to effectively resuscitate pediatric COVID-19 patients while minimizing personnel risks. And we used simulation to educate staff about our new space, processes and workflows. Buy in from leadership stakeholders was key as they invested in our process, supported our journey and ensured that we were aligned with our organization's goals. Interprofessional input, willingness of staff to participate and learn new processes, timely and effective bi-directional feedback and loop closure of issues brought up during the simulations also led to our success. Further analysis is needed to ensure that these efforts translate to actual patient care within our PED. We encourage the use of simulation to augment infection prevention and control initiatives. We hope that our journey may help inspire other teams to maximize the potential of simulation during the COVID-19 pandemic. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the High-reliability emergency response teams in the hospital: improving quality and safety using in situ simulation training The study of factors affecting human and systems performance in healthcare using simulation Preparedness for COVID-19: in situ simulation to enhance infection control systems in the intensive care unit The use of simulation to prepare and improve responses to infectious disease outbreaks like COVID-19: practical tips and resources from Norway, Denmark, and the UK. Adv Simul (Lond) Using cognitive load theory to inform simulation design and practice Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected: interim guidance Pediatric Airway Management in COVID-19 Patients: Consensus Guidelines From the Society for Pediatric Anesthesia's Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society Reflections on work as done (WAD) and work as imagined (WAI) in an emergency response organization: A study on firefighters training exercises Impact of Simulation-Based Closed-Loop Communication Training on Medical Errors in a Pediatric Emergency Department