key: cord-1010302-esbob6ra authors: Daly Guris, Rodrigo J.; Elliott, Elizabeth M.; Doshi, Anushree; Singh, Devika; Widmeier, Keith; Deutsch, Ellen S.; Nadkarni, Vinay M.; Jackson, Kayleigh R.; Subramanyam, Rajeev; Fiadjoe, John E.; Gurnaney, Harshad G. title: Systems‐Focused Simulation to Prepare for COVID‐19 Intraoperative Emergencies date: 2020-07-19 journal: Paediatr Anaesth DOI: 10.1111/pan.13971 sha: 7ff9d37200b1760e72d42307ad123d8eb887aa27 doc_id: 1010302 cord_uid: esbob6ra Although intraoperative emergencies are uncommon,(1) we need to develop evidence‐informed and contextualized guidance for intraoperative emergencies involving patients with COVID‐19. At our academic pediatric hospital, we assembled a multi‐disciplinary team to examine and adapt intraoperative emergency workflows to ensure safety for patients with suspected COVID‐19 infection, and limit exposure for healthcare providers, with a focus on system improvement (rather than individual performance). Although intraoperative emergencies are uncommon, 1 we need to develop evidence-informed and contextualized guidance for intraoperative emergencies involving patients with COVID-19. At our academic pediatric hospital, we assembled a multi-disciplinary team to examine and adapt intraoperative emergency workflows to ensure safety for patients with suspected COVID-19 infection, and limit exposure for healthcare providers, with a focus on system improvement (rather than individual performance). This was achieved using in-situ simulation with experienced clinicians employing a modified Promoting Excellence and Reflective Simulation Framework (RFS), 2 and pause and reflect debriefing. 3 We aimed to identify potential failure and success points in our existing practice and establish safe COVID-19-related emergency response procedures. This project was determined to be non-human subjects research by the Children's Hospital of Philadelphia Institutional Review Board, and therefore exempt from informed consent. A ventilated high-technology manikin was used for an in-situ simulation of a healthy 25 kg seven-yearold with COVID-19, presenting for an urgent lower extremity fracture repair in a functional negative-pressure operating room (OR). The simulated child developed stable supraventricular tachycardia (SVT) while under general anesthesia. The SVT was unresponsive to vagal maneuvers and intravenous adenosine, and the patient developed hemodynamic instability after a synchronized cardioversion. This patient's cardiac rhythm deteriorated to ventricular fibrillation, which resolved following CPR and defibrillation according to appropriate algorithms. Two anesthesiologists, a circulating nurse, and a scrub nurse were inside the OR (hot zone) at the start of the simulation. A nurse trained in donning and doffing personal protective equipment (PPE) served as a PPE coach and supervised donning of PPE in the cold zone. This nurse also assisted with transferring additional supplies into the room. A second PPE coach was in the warm zone to help with PPE doffing and to redirect the flow of personnel to the cold zone prior to entering the OR. Two simulation educators, a simulation technician, and a senior patient safety and human factors scientist observed, took notes, and facilitated discussion and debriefing. We debriefed using three reflection techniques. Reflection-before-action encourages participants to think about potential consequences and plan around a clinical scenario. Reflection-in-action enables Accepted Article participants to reflect in the moment that a clinical decision is being made. Reflection-on-action allows participants to learn from a clinical action that has already occurred. The scenario was stopped each time a potential failure point or significant success was encountered. A mini-debriefing was performed, and workflow modifications were brainstormed. After each mini-debriefing, the scenario was resumed at a point that required overcoming the previously-identified hurdle, implementing the changes discussed, and assessing their success. At the end of the simulation, a final debriefing was conducted to organize discussed actions and concepts into themes and to translate lessons learned into prototype revised policy and procedures for managing intraoperative emergencies. A summary of the observed barriers, successes, and proposed workflows specific to our institution, related to pre-anesthetic preparation, emergency response activation, personnel management, information management, equipment management, and technical aspects of communication, appears in the Table. Discussion: Systems-focused in-situ simulation led by an experienced multi-disciplinary team helped us identify barriers and success points for optimal performance during emergencies involving patients with COVID-19. We tested our work-as-imagined by conducting work-as-simulated and modified our workflows in real-time based on our simulations ( Figure 1 ). During the same session, we tested, modified, re-tested, and repeated processes as needed until we arrived at acceptable safe workflows. This effort is not without limitations. While we have a better idea of how to translate our work-asimagined into work-as-done, we have continued to adapt our response based on in vivo experience taking care of patients with COVID-19. Further study will likely elucidate additional improvements as the COVID-19 landscape evolves and as institutions and clinicians gain more experience with new workflows. While our simulations were conducted in a well-resourced pediatric setting with the support of experienced simulation personnel, the overarching concepts can be adapted to individual institutions' capabilities. In all instances of workflow modification, it is vital to identify and preserve success points so that these are not inadvertently excluded from new practices. Involving a diverse group of front-line clinical staff in these endeavors provides useful insight into how work is actually done and may contribute to overall buyin and successful implementation. This article is protected by copyright. All rights reserved A two-way baby monitor with one-way video A Prospective Observational Cohort Study of Calls for Help in a Tertiary Care Academic Operating Room Suite Clinical Simulation: Education, Operations and Engineering Debriefing-on-Demand" A Pilot Assessment of Using a "Pause Button" in Medical Simulation Accepted Article