key: cord-0788030-zwdy1h7j authors: Kiely, Daniel J.; Posner, Glenn D.; Sansregret, Andrée title: Health care team training and simulation-based education in obstetrics during the COVID-19 pandemic date: 2020-05-30 journal: J Obstet Gynaecol Can DOI: 10.1016/j.jogc.2020.05.007 sha: d58d2bd0ad70cd554be34dbe1c63021f9eefe489 doc_id: 788030 cord_uid: zwdy1h7j ABSTRACT Health care team training and simulation-based education are important for preparing obstetrical services to meet the challenges of the COVID-19 pandemic. Priorities for training are identified in two key areas. First, the impact of infection prevention and control protocols on processes of care (e.g., appropriate and correct use of personal protective equipment, patient transport, preparation for emergency cesarean delivery with the potential for emergency intubation, management of simultaneous obstetric emergencies, delivery in alternate locations in the hospital, potential for increased decision-to-delivery intervals, and communication with patients). And second, the effects of COVID-19 pathophysiology on obstetrical patients (e.g., testing and diagnosis, best use of modified obstetric early warning systems, approach to maternal respiratory compromise, collaboration with critical care teams, and potential need for cardiopulmonary resuscitation). However, such training is more challenging during the COVID-19 pandemic because of the requirements for social distancing. This article outlines strategies (spatial, temporal, video-recording, video-conferencing, and virtual) to effectively engage in health care team training and simulation-based education while maintaining social distancing during the COVID-19 pandemic. virtual) to effectively engage in health care team training and simulation-based education while maintaining social distancing during the COVID-19 pandemic. RÉSUMÉ : La formation des équipes de soins et la formation par simulation sont importantes pour préparer les services d'obstétrique à relever les défis de la pandémie de COVID-19. Les priorités de formation sont définies dans deux domaines principaux : premièrement, les effets des protocoles de prévention et de contrôle des infections sur les procédures de soins (p. ex. utilisation adéquate de l'équipement de protection individuelle, transport des patientes, préparation des césariennes d'urgence en tenant compte du potentiel d'intubation d'urgence, gestion des urgences obstétricales simultanées, accouchement dans d'autres lieux à l'hôpital, augmentation potentielle du délai décision-extraction et communication avec les patientes) et deuxièmement, les effets de la physiopathologie de la COVID-19 sur les patientes obstétricales (p. ex. examens, analyses et diagnostics; utilisation optimale des systèmes modifiés d'avertissement précoce en obstétrique; stratégie de prise en charge de la gêne respiratoire maternelle; collaboration avec l'équipe de réanimation; risque de réanimation cardiopulmonaire). Toutefois, ce genre de formation est particulièrement difficile en temps de pandémie de COVID-19 en raison des exigences de distanciation physique. Cet article souligne des stratégies (spatiales, temporelles et virtuelles; enregistrement vidéo et vidéoconférence) pour se lancer efficacement dans la formation des équipes de soins et la formation par simulation tout en respectant la distanciation physique pendant la pandémie de COVID-19. The COVID-19 pandemic presents unprecedented challenges to healthcare teams. 1 There is an urgent need to effectively implement new and rapidly evolving protocols for clinical care and infection prevention and control (IPAC). There is accumulating evidence that simulation training in healthcare improves patient outcomes. 2 However, such training is more challenging during a pandemic due to the requirements for social distancing and the need for thoughtful utilization of scarce personal protective equipment (PPE). The stakes are high: breaks in IPAC protocol pose a risk of spreading COVID-19. Although pregnant patients do not appear to have a more severe course than the general population, the spectrum of disease in pregnancy is still concerning with some patients requiring critical care. 3 On balance, we believe that healthcare team training through simulation is important in the response to the COVID-19 pandemic. That being said, the training itself needs to be adapted to minimize risk of occupational spread of the virus. The necessity to prevent occupational spread of infection has multiple impacts on processes of care. Simulation training to practice these new processes may help to optimize care delivery. Insitu training in the clinical environment has the advantage of allowing for potentially complex logistical considerations of patient flow within the hospital and between teams to be determined. 4 Simulated "walk-throughs" are thus being used to both train healthcare providers and inform processes. If feasible, "just in time" training is another useful tool which involves an educational rehearsal a short time prior to an actual clinical event. 4 We propose training in the following areas: Practicing selection of appropriate PPE for the clinical circumstance -i.e. droplet vs airborne precautions. Practicing donning and doffing of PPE. Of note, PPE and certain types of medical equipment are currently in actual or anticipated short supply. Given this reality, using potentially scarce equipment for simulation may not be justifiable unless it is reusable (which poses its own transmission risks). Simulation scenarios need to take this into account, but there are many ways to achieve this during simulation: stating how PPE will be applied and where it is located in the facility, using PPE stickers which participants apply at appropriate moments, or using props or simulated PPE such as cloths with elastic bands to represent masks. Simulation allows these conversations to be explicitly practiced before they are faced in reality. Any of these themes lend themselves to the development of simulation exercises with several variations and which may be practiced repeatedly. Experiential learning followed by debriefing are the essential ingredients of simulation-based education, but how can we gather teams and learn from our simulated experiences without risking occupational spread of the virus? We propose four broad categories of social distancing which, alone or in combination, may allow healthcare team simulation training to continue. Spatial social distancing involves maintaining a two meter separation between participants. A person-free zone can be marked out on the floor of the room where simulation is occurring, for example with masking tape. A participant is confined to a zone and does not cross into the person-free zone. An obvious disadvantage is no physical contact or equipment transfers between participants, but this is offset by the ability for team members to communicate freely and in real time. Videoconferencing technologies allow simulation scenarios with participants in different locations, thereby decreasing the number of participants in any one site. Experiential learning is limited in this approach, but opportunities for others to participate in the debriefing are maximized. Virtual training allows participants to interact with a computer-based simulation exercises, often available online, allowing training off-site or from home. 9 Although this modality has great promise, the time necessary to develop such simulations (in the absence of significant investment of acceleratory resources) may not allow realization of its full potential in the context of a rapidly evolving pandemic. Healthcare team based simulation training is important during the COVID 19 pandemic. The value of this training is not limited to the acute phase of the pandemic but will likely also apply to second waves, chronic phases, and future outbreaks of other infectious diseases. However, careful thought is required about how to maintain social distancing while doing such training. By utilizing strategies to maintain social distancing during training such as spatial separation, temporal separation, video-recording, videoconferencing technologies, and virtual training, effective and safe team simulations can continue to occur and help to optimize the healthcare team response to this critical pandemic. As new recommendations are rapidly produced and updated at the national, international, and hospital leadership levels, simulation provides an opportunity to practice these directives on the ground, to work out potential problems of implementation, and to feedback lessons learned to inform possible fine-tuning of guidelines. 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