Simulation Operations COVID-19 Considerations - This is Not a Simulation
by SimGHOSTS Board Member, Scott Crawford MD, FACEP, CHSOS
Much of a simulation center’s function is related to simulated disease processes and many are unsure how to prepare for or adjust when an actual illness or infection risk is present.
With mass hysteria of a viral pandemic and fears of financial turmoil ruling the daily news discussions, this article attempts to bring forward a pragmatic approach on how to realistically review and adjust daily functioning of a simulation center. The primary mission for simulation centers should be to support healthcare education, patient (and learner) safety, and serve as a resource for training all aspects of patientcare including communication, technical skills training, and promoting best practices in patient safety. While it is still debated if the Coronavirus COVID-19 can be contained or if sustained transmission is inevitable, it should be a consideration for all education and training programs to review and revise plans that would modify daily function.
Coronaviruses are a group of viruses (named for their appearance on electron microscopy) that cause respiratory symptoms ranging from the features of a ‘common cold’ to severe respiratory diseases. Unfortunately, there is currently no vaccine for the illness caused by COVID-19 and antibiotics are not of use in the treatment of those infected. The primary focus from a public health standpoint is prevention. While there is always a concern for transmission, standard ‘contact’ and ‘droplet precautions’ appear sufficient to prevent this. In addition, review of current trends and monitoring of outbreak locations from reputable sources like Johns Hopkins (global map) and University of Washington (detailed US map by county) available to provide healthcare workers the most up to date information on the spread of the virus. The CDC remains one of the best sources for information for healthcare providers and the public. These resources include recommendations for use PPE, facial hair, patient testing guidelines and clinical care guidelines. While patient care recommendations have been made, the simulation community has been working to identify what should be considered for the delivery of experiential learning is a safe manner.
Sick Leave Policies:
A first step recommendation is to stay at home if anyone has signs or symptoms of acute respiratory illness and/or a fever. One can return to work once they are symptom free, including fever free (100.4° F) for 24 hours. Many human resource programs require a note to return to work. We suggest that each employer consider modifying this requirement. Also consider implementing a screening process upon arrival asking participants and staff about the presence of symptoms before being allowed to participate in or facilitate an activity or a session.
Workplace safety: (CDC infographic)
The first item on every simulation checklist should be handwashing, so make sure that hand hygiene stations have hand sanitizer and a method for restocking as supply will likely be used more than in the past. Omit the formality of hand shaking; an elbow bump or head nod can still show you care. If standard cleansers are unable to obtained, consider the CDC alternative of a dilute chlorine-based hand washing solution (~1/3 cup to 1 gallon ratio of household bleach to water – final concentration ~0.05%).
Solid surfaces and commonly used workspaces should be wiped down with standard disinfectant cleaners, or the ‘strong’ solution from the link above. The CDC has these surfaces to clean listed as tables, desks, and doorknobs. Unique aspects to the simulation environment that should also be disinfected include headsets, microphones, keyboards, manikins, code cart draws, medical equipment devices, and task trainers.
Simulation-based Training Instructional Pearls:
Since respiratory distress is the largest concern in patients with severe infection, those with an acute respiratory distress syndrome (ARDS) type disease pattern may require intubation and ventilatory support. Several recommendations have been put forth to minimize the risk of disease transmission. (Intubation Infographic)
- Perform procedure in negative pressure room
- Minimize personnel in room
- Wear N-95 mask and face shield
- Preoxygenate with a non-rebreather and avoid bag-valve mask use to minimize droplet formation
- Use paralytics to prevent cough/gag
Current patient testing is still only recommended for:
- Hospitalized patients who have signs and symptoms compatible with COVID-19 in order to inform decisions related to infection control.
- Other symptomatic individuals such as, older adults (age ≥ 65 years) and individuals with chronic medical conditions and/or an immunocompromised state that may put them at higher risk for poor outcomes (e.g., diabetes, heart disease, receiving immunosuppressive medications, chronic lung disease, chronic kidney disease).
- Any persons including healthcare personnel, who within 14 days of symptom onset had close contact with a suspect or laboratory-confirmed COVID-19 patient, or who have a history of travel from affected geographic areas (see below) within 14 days of their symptom onset.
But other guidelines have also suggested that we assume the disease exists in all communities and not wait until positive testing to institute countermeasures.
Remote learning options:
Many programs have Audio/Video systems available for recording of small group or simulation sessions. One method of supporting experiential learning, while decreasing transmission risk, is to schedule a single small group activity and then assign review of the recording at home. A virtual online debrief using a web-based conferencing application can also be done outside of the simulation center.
There are many such applications available including:
If a program is only interested in streaming of content such as a simulation or demonstration, and doesn’t need (or want) lots of talk from viewers, live-streaming options from Facebook Live, or YouTube can also be considered. A previous presentation discussing the specific requirements of configuring these systems and can be downloaded (here).
Virtual simulations have already been written by the Global Network for Simulation in Healthcare (GNSH) that can be used for free to train patient safety topics. These are free web-accessible vignette and video-based programs that could be used to support remote training. Debriefing documents are provided for the educational support of each simulation.
These simulations cover topics such as:
- Medication Errors
- Healthcare Associate Infections (HAIs)
- Care Teams
Use of VR training:
Education and training are still important even in a pandemic. Some may argue that it is even more important than it was before. Simulation programs are the best prepared for adaptive learning strategies and can help to support education in a safe manner.
Virtual reality training programs exist that can allow users to practice outside of large group settings (just be sure to clean the headset and controllers).
Some virtual reality programs such as Patient Communication Simulators (PCS) can work on standard computer systems and allow training of history taking skills using a natural voice language system. Although it still has some improvements to be made in speech recognition this could be reviewed as an alternative to many SP interactions.
Many VR systems demonstrated at IMSH this year allow for multiple users to interact in the same virtual room. Systems like SimX, UbiSim and Oxford Medical Simulation all showcased this ability, but some will require specialty systems that can use a VR headset. A special offer was put forth by Oxford Medical Simulation to allow use of their platform free for 60 days to support training during the pandemic.
Although a physical exam can be difficult to demonstrate virtually, don’t underestimate the importance of a phone call or video call session for practicing and demonstrating communication and history taking skills. SP training can still be conducted as a group to review a case in an online meeting system and then individual call-ins can occur to meet with an SP virtually. Most web conferencing systems should have the ability to record sessions for later review by students or educators.
While this is likely already common practice, sheets and gowns may pose a contamination risk and should be washed between users, alternatively paper gown and sheets that are disposable may be easier.
Standard precautions for patient interaction should be used, and many simulation programs may wish to continue using SPs because they are 1-on-1 interactions that do not use large class gatherings. Plan to avoid central gathering of SPs in lounge areas and perform surface disinfection of exam rooms between SPs. SPs may be asked to help with these procedures.
Some programs describe having breakout room functionality to have all members join a single meeting link and then separate individuals into smaller rooms without cross-talk.
Webex Breakout sessions (‘Webex Training’)
GoToMeeting Breakout (GoToTraining)
As you find good solutions and sites, please share them in the discussion forums (here).
Stay safe and healthy!
World Health Organization, Q&A on Coronaviruses 9COVID-19), Published March 9, 2020 at https://www.who.int/news-room/q-a-detail/q-a-coronaviruses, Accessed March 11, 2020