key: cord-1018876-xag08e8h authors: Dharamsi, A.; Hayman, K.; Yi, S.; Chow, R.; Yee, C.; Gaylord, E.; Tawadrous, D.; Chartier, L.B.; Landes, M. title: Enhancing departmental preparedness for COVID-19 using rapid cycle in situ simulation date: 2020-06-13 journal: J Hosp Infect DOI: 10.1016/j.jhin.2020.06.020 sha: 094c57a5e7174d9d7eb9897a5b53315a592fe4aa doc_id: 1018876 cord_uid: xag08e8h In response to COVID-19, we developed a rapid-cycle in situ simulation (ISS) programme to facilitate identification and resolution of systems-based latent safety threats. The simulation involved a possible COVID-19 case in respiratory failure, using a manikin modified to aerosolize phosphorescent secretions. 36 individuals participated in and 20 observed five ISS sessions over six weeks. Debriefing identified latent safety threats from four domains: personnel, PPE, supply/environment, and communication. These threats were addressed and resolved in later iterations. 94% of participants felt more prepared to care for a potential COVID-19 patient after the ISS. In early 2020, the World Health Organization declared a public health emergency of international concern in regard to an emerging novel respiratory pathogen, known as COVID-19. COVID-19 is among the family of zoonotic coronaviruses, from which Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) have emerged. While much still remains unclear as to the transmission dynamics of this novel coronavirus, it does appear that it may spread via aerosolization during procedures [1] . As with previous novel respiratory pathogens, such as SARS and MERS, the spread of this virus is anxiety provoking and tests our health care system's agility to protect both our patients and our health care workers. The first documented case of COVID-19 in Canada created a sense of urgency locally to ensure preparedness for more potential cases [2] . In situ simulation (ISS) is a process in which simulation exercises are conducted in the clinical workspace, by care providers who are on clinical duty, using equipment and resources in that workspace [3, 4] . Such exercises can aid clinical units in improving team functioning, identifying latent safety threats, informing processes, as well as guiding clinical protocols and care [4] [5] [6] . Rapid cycle simulation has been described previously in medical education as a way of providing real time feedback and opportunities for learners to practice [7] , and there are examples of in situ simulation being used in an iterative fashion to find solutions to latent safety threats over months to years [7, 8] . We present a hybrid of these two methods, a rapid-cycle ISS programme, developed for emergency departments (EDs) in the wake of an emerging respiratory pathogen. We evaluated this programme's ability to uncover and address departmental, organizational, and system gaps that present latent safety threats to both patients and providers in an urgent and timesensitive fashion. Leaders of the physician, nursing, and respiratory therapist staff were familiar with the ISS programme at our institution and highly supportive of utilizing this novel ISS programme to test our ED preparedness, particularly since Toronto has historically been a potential area of spread of pathogens from China as was evidenced by the SARS 2003 epidemic [9] . The study was conducted at an academic, tertiary care academic centre in Toronto, Canada which includes two EDs, collectively seeing over 126,000 patients per year. Simulations were conducted in the ED negative pressure rooms. The ISS team includes three physician simulationists, a simulation education specialist, as well as the nurse educators and nurse managers from each site. The case was created using aggregate data from previous febrile respiratory illness outbreaks, namely local data captured from the 2003 SARS outbreak [8] . Given our experience from SARS, our ISS team understood that the highest risk of this emerging respiratory pathogen would be in the case of a critically-ill patient presenting to triage and ultimately requiring aerosol-generating procedures in the ED [8, 9] . The rapid-cycle ISS programme was created to identify latent safety threats (LST) to staff and mitigate these with innovative solutions that could subsequently be tested in the next simulation. Although there is no established frequency of simulations to be considered a "rapid cycle", previous iterative ISS studies have been completed on much longer timelines (months to years) [7, 8] . We planned to facilitate one session per week, with time between sessions dedicated to solution generation and implementation. The case features a febrile, haemodynamically unstable patient in severe respiratory distress, who screens positive at triage for potential COVID-19 exposure based on travel history. A manikin was modified to aerosolize phosphorescent droplet secretions. At the end of the case, these secretions were visualized on providers using black light. Full details of the case, including the phosphorescent moulage, are published on EMSimCases [10] . Simulation sessions were conducted in standard negative pressure rooms, congruent with institutionally established full personal protective equipment (PPE) (eye protection, N95 mask, gown, gloves) and isolation protocols (airborne, droplet and contact) for a critically ill COVID-19 patient. The simulations were conducted in real time with clinical staff on duty that day. In accordance with infection control guidelines to minimize team size in potential COVID-19 cases, one physician, one registered nurse, and one respiratory therapist participated. Key stakeholders contributed to subsequent formalization and improvement of existing ED processes, including Infection Prevention and Control, Infectious Diseases, anesthesia, and the ISS team. Following each session, an ISS physician team member facilitated a 15-minute debriefing session. A second ISS team member took notes during the debriefing session, which were utilized to drive solutions between sessions. Each participant also completed a brief mixedmethods survey via a Google Form. Participants were asked to identify key safety threats, major learning points, and outstanding questions via open-ended short answer questions. The survey also included Likert-type questions about perceived preparedness and attitudes towards the ISS programme. Two investigators (EF, KH) independently coded and thematically analyzed openended survey responses and facilitator debriefing notes to identify emerging themes. These themes were organized by simulation session date to identify persistence and/or resolution of safety threats. We planned to continue the ISS sessions until no new major modifiable safety threats were identified, and thematic saturation was reached. This quality improvement initiative received an exemption from the Research Ethics Board at our institution. Between January 25th and March 5th, five COVID-19 ISS sessions were completed in a rapid cycle format as the epidemic was emerging. 36 people participated in the simulation and evaluation, representing a broad team of hospital-wide stakeholders informing guidelines and addressing latent safety threats that were identified after each simulation. An additional 20 individuals observed the session but did not fully participate in the debrief or complete the survey. Infographics, email notifications, video recording of the simulation and invitations to participate as observers helped broaden the reach of these simulations. Results were also presented at two monthly ED team meetings, as well as at morning safety huddles. After the March 5th session, investigators reached a consensus that thematic saturation had been achieved, with no new safety threats identified. This also coincided with a marked increase in patients in our department requiring isolation precautions, given concern about imminent community circulation of COVID-19 in Toronto. The first critically ill suspected COVID-19 case arrived at our institution less than one week after the most recent ISS. The team believed that ISS had adequately prepared them to care for the patient without breaching PPE. Participants rated the ISS process very positively. 97% of participants agreed the simulation was relevant to their practice and 94% felt more prepared to care for a potential COVID-19 patient. Only 11% of participants believe that the simulation distracted from patient care. Debriefing identified latent safety threats from four domains: PPE, personnel, supply/environment, and communication. The identified safety threats and iterative solutions are detailed in Table I . While asked separately, the responses to the three open-ended survey questions were highly similar, thus were thematically analyzed together. The majority of survey results reflected common themes identified in the debriefing sessions. The survey demonstrated that most safety threats were adequately addressed by later iterations, as early issues did not reemerge in subsequent surveys. PPE remained a concern for participants across sessions, but evolved from general (e.g., order of donning/doffing) to specific (e.g., wearing shoe covers) over time. Only one respondent remarked explicitly on the emotional response to a novel risk such as COVID-19, yet provider concern about the specifics of personal protection was a dominant theme in debriefing and the survey. Safety threats in the PPE domain generally required only a single session to resolve after identification. Survey responses highlighted the specific value of practicing in interprofessional teams, for example, by identifying different standard operating procedures between the respiratory therapy group and the nursing staff for the same task. Team-based strategies to address threats were identified in both the debriefings and survey, for example pre-selection of a specific staff member to gather any additional supplies for the team inside the isolation room. Latent safety threats in this domain were largely resolved with improved signage and preparation of materials (See Appendix 1 for materials signage). The stakeholder analysis for our simulation was an iterative process, and some team members (e.g., housekeeping staff) were invited to participate later in the process, which led to identification of and solutions for new safety threats after several sessions had already occurred. Safety threats in this domain required multiple iterations to address. Several of the solutions trialed posed large new issues, for example, contamination of the user with a portable phone. The team members found the baby monitor (hands-free communication system) provided sufficient clarity of communication with minimal risk of contamination. ISS allows users to design context and location-specific scenarios that address specific behaviours (i.e., teamwork, communication), identify system vulnerabilities and implementation challenges, and shape processes of care [3] . Our model of rapid-cycle ISS was particularly helpful as it allowed us to iteratively modify the simulation based on feedback and evolving guidelines, which allowed for incremental improvements over a very short period of time. As new solutions were implemented, we were able to quickly disseminate updates to the group via infographics, emails, morning departmental safety huddles, and team meetings. As these solutions were trialed in clinical care, we were also able to ascertain feedback from the group, inform further iterative changes in subsequent simulations. The systemization of these changes provide a structure for other sites to navigate changes to their departmental infrastructure and practices. This structure can aid in not only implementing changes, but also rationalizing the specific solutions to the care team. Demonstrating how and why these changes have been implemented has aided in the uptake and acceptance of these innovations into clinical practice. Personal safety, maintained primarily through proper PPE, was a major theme of this case. The phosphorescent aerosol moulage changed providers' perception of their risk during the resuscitative scenario and led to high commitment to maintaining infection prevention precautions in the simulated exercise. This high commitment likely uncovered latent safety threats more quickly than a lower commitment from stakeholders, and we may have had very different results without this critical component of the simulation. ISS in a team environment, rather than performing preparedness drills, led to key improvements particularly in the communication domain. This finding emphasizes the strength and agility of an interprofessional training environment. While our sample size is relatively small, we met our endpoint of thematic saturation/no major new safety threats identified in our final ISS session. Knowledge translation in ISS can be challenging owing to the low ratio of participants to overall care providers in the group, yet we were able to disseminate findings to stakeholders rapidly. Continued sessions may yield new or different results; we balanced this with the relative urgency to share our findings in an expedited fashion. The timing of these ISS was expedited while allowing for procurement of supplies and within limitations of scheduling the various facilitators and sessions; however, preparedness for COVID-19 could have been further accelerated and condensed over a shorter time period. This rapid-cycle ISS programme provides an opportunity to identify and iteratively address latent safety threats in caring for patients with possible COVID-19 in a time-sensitive fashion. Rapidcycle ISS is a valuable model to augment departmental preparedness in the wake of emerging epidemics. E m a i l u h n s i m c o m @ g m a i l . c o m S C R E E N I N G T O O L C L I N I C A L N O T E S A N D A C O D E B L U E R E S U S R E C O R D ( I N A P L A S T I C C O V E R ) 1 L N S I V A N D B L O O D W O R Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anesth Can Anesth First imported case of 2019 novel coronavirus in Canada, presenting as mild pneumonia. The Lancet In situ simulation in emergency medicine: Moving beyond the simulation lab: IN SITU SIMULATION IN EMERGENCY MEDICINE Using Simulation to Improve Patient Safety: Dawn of a New Era Detecting latent safety threats in an interprofessional training that combines in situ simulation with task training in an emergency department Quality improvement utilizing in-situ simulation for a dual-hospital pediatric code response team Situ Simulated Cardiac Arrest Exercises to Detect System Vulnerabilities SARS: A Local Public Health Perspective Illness in Intensive Care Staff after Brief Exposure to Severe Acute Respiratory Syndrome The authors would like to acknowledge the efforts of Dr. Peng Yinhua, who alerted the world to the potential dangers of COVID-19, and ultimately succumbed to the disease. We would also like to thank Kathy Bates, Deborah Davies, Elayna Fremes, and Camilla Parpia for their assistance in propelling this project forward. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. None to declare.