Thrust into a pandemic unlike any other, health professionals today must continually adapt to an ever-changing environment. Protocols change at dizzying rates, while the physical and mental demands of our jobs increase exponentially. Both nursing and physician education has been interrupted and altered in ways that leave concerns about the quality of instruction.
To help health professionals with continued education and applied skills, we turned to medical simulation as both a content delivery tool and quality improvement aid at our institution as part of our adaptation to the pandemic. We aimed to provide high- quality medical education with a hands-on experience for the maximum number of learners while complying with infection control measures during an active pandemic. To this end, we implemented multi-disciplinary weekly simulation sessions at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas.
Design
Prior to the Session
Simulation sessions were targeted to an audience of health technicians, emergency department nurses, acute care nurses, critical care nurses, emergency medicine residents, and internal medicine residents. Simulation session participants were notified in advance of the session and provided with a pre-simulation orientation packet. The pre-session materials included guidance on the equipment expected to be utilized (eg, mechanical compressions device), institutional code blue procedural policy, and an overview of the session format. Each session was limited to 3 nurses, 2 physicians, 1 health technician, and 3 simulation session moderators. The number of participants was limited to those present in an actual cardiac arrest case in our hospital's standard operating protocol. No individual could participate in more than one scheduled simulation session in a 3-month period. Participants were expected to complete a pre-simulation assessment and survey on arrival to the session. Participants then engaged in COVID-19 or "Patient Under Investigation" (PUI) cardiac arrest simulations and associated debriefings.
Format of the Session
After a brief pre-simulation survey and assessment, participants were presented with a COVID/PUI cardiac arrest case in the setting of either the emergency department or the inpatient unit. Each case was approximately 14 minutes in duration. The participants had access to personal protective equipment (PPE) that was not intended for clinical use (eg, expired PPE). A high-fidelity simulation mannequin was utilized with a standard hospital simulation crash cart and airway box.
The case was run through initially with a structured debriefing led by simulation moderators and aimed at provoking self-reflection and areas for improvement. Next, participants were allowed a chance to incorporate feedback and rerun the same case. A second and more in-depth debriefing session followed. Debriefings were held as a group without separation of physicians and other team members. Participants completed a post-session assessment and survey.
After the Session
The final debriefing session included breakout sessions to discuss evidence-based protocols for COVID/PUI cardiac arrest care in detail and a formal review of infection prevention protocols. Participants were encouraged to ask questions and to review primary literature after the session. In addition, they received e-mails post-session initially 2 weeks after the session and then again one month after the initial session with additional content related to evidence-based cardiac arrest and COVID/PUI care.
Limitations
Given that these sessions were pre-scheduled, and participants were informed they would occur in advance, this compromised the level of fidelity of the simulation. In a more true-to-life scenario, participants would have an unannounced simulation case. However, given the strict infection control measures necessary during an active pandemic, it was crucial to announce the sessions beforehand to hold them in care areas with enough physical distancing possible. Additionally, the PPE utilized for these simulated cases was slightly different infection control grade and material compared to what is used in actual clinical practice. This was also necessary to allow us to evaluate appropriate donning and doffing protocols while being mindful of our limited PPE stores for clinical use. All assessments and surveys were anonymous except for identifying training level (eg, PGY-1 v PGY-3 resident), which limited the ability to provide personalized feedback to participants. In a realistic scenario, each individual would be identified and receive targeted goals for improvement.
Outcomes Measured
Three simulation moderators monitored each simulated case which comprised both simulation trained nurses and physicians. Objective metrics were noted during each simulated case to monitor for specific areas of improvement, such as but not limited to delays in defibrillation for appropriate rhythms, total hands-off time in regards to chest compressions, and time to backboard placement. Moderators also were expected to focus on effective communication, infection control measures, team dynamics, and care team-family interactions.
Survey and assessment data collected both before and after the sessions were monitored for trends for quality improvement efforts and targeted education for the hospital-at-large. The written surveys included whether participants felt comfortable with the donning and doffing protocols, equipment utilized in cardiac arrest care (eg, AutoPulse mechanical compressions device), and ACLS algorithms, as well as how their confidence changed in these areas after the session. Written assessments aimed to identify knowledge deficits that needed to be ameliorated and asked participants to identify interventions known to improve mortality outcomes in cardiac arrest care, list potentially reversible causes of cardiac arrest, and identify appropriate care measures post-return of spontaneous circulation (ROSC).
Discussion
We describe a novel multidisciplinary simulation program piloted at our tertiary care facility in the setting of an active and ever-evolving pandemic. Several modifications to usual medical education and simulation sessions were necessary. Medical simulation has long been utilized as a critical tool for providing hands-on clinical education, with its roots in the military, which first used such an instructional modality. From its inception, simulation has offered a risk-free and safe clinical practice environment for trainees. For this reason, we opted to use this as our instructional tool to address the educational and quality improvement needs of our institution and its health care team members.
The reception of this novel simulation program was exceedingly positive by multiple hospital departments and participants alike. Several departments, including anesthesia, respiratory therapy, and other clinical units (eg, primary care clinics, long-term acute care facilities, etc.), requested expansion of this simulation program to include their team members. In the event of rising positivity rates and the need to reconsider live time sessions, we are exploring virtual simulation sessions. This would allow us to build out longitudinal simulation goals, tailor objectives to the individual learner, meet night and weekend shift workers' educational needs, and adhere to all infection control precautions. It would also occur asynchronously, allowing for minimal disruptions in clinical care during scheduled work time hours. We have currently already employed virtual simulation as part of our BLS and ACLS recertification programs. We hope to continuously re-assess and improve our simulation efforts in response to the growing educational and quality improvement needs during the global COVID-19 pandemic. We anticipate the instructional modalities solidified during this time will be useful for years to come beyond the acute period of adapting to the pandemic.
Acknowledgments
We give special thanks to the Michael E Debakey Veterans Affairs Medical Center STAR Lab Staff, Dr. Hossam Safar, Dr. Charles Lan, and Dr. Glenn Levine, without whom these efforts would not have been possible.