key: cord-258916-jbdz1pk0 authors: Andreae, MH; Dudak, A; Cherian, V; Dhar, P; Dalal, PG; Po, W; Pilipovic, M; Shah, B; Hazard, W; Rodgers, DL; Sinz, EH title: Data and Debriefing Observations on Healthcare Simulation to Prepare for the COVID-19 Pandemic: Healthcare Simulation for COVID-19 date: 2020-07-15 journal: Data Brief DOI: 10.1016/j.dib.2020.106028 sha: doc_id: 258916 cord_uid: jbdz1pk0 We report on data and debriefing observations in the context of an immersive simulation conducted to (a) train clinicians and (b) test new protocols and kits, developed in table-top exercises without prior clinical experience to fit anticipated clinical encounters in the setting of the rapidly expanding COVID-19 pandemic. We simulated scenarios with particular relevance for anesthesiology, perioperative and critical care, including (1) cardiac arrest, (2) emergency airway management, (3) tele-instruction for remote guidance and supervision, and (4) transporting an intubated patient. Using a grounded theory approach, three authors (MHA, DLR, EHS) developed emergent themes. First alone and then together, we sought consensus in uncovering overarching themes and constructs from the debriefings. We thus performed an informal qualitative thematic analysis based in a critical realist epistemological position - the understanding that our findings, while real, are affected by situational variables and the observer's perspective.[1,2] We compared data from videos and triangulated the data by member checking. All participants and course instructors volunteered to participate in this educational project and contributed as co-authors to this manuscript. During debriefing, we applied crisis resource management concepts including situation awareness, prioritization of tasks, and clear communication practices, conducting the debriefing with emphasis on current TeamStepps 2.0 terminology and concepts. [3,4] In addition, we re-evaluated formerly familiar processes, as shortcomings of protocols, kits, and interdisciplinary cooperation became apparent. The data provide detailed observations on how immersive simulation and debriefing among peers mitigated the unfamiliarity of individual clinicians and the organization at large with the demands of an unprecedented healthcare crisis. We also observed and report on the anxiety caused by resource constraints, risk to clinicians in the face of limited personal equipment, and the overall uncertainty surrounding COVID-19. We began to summarize, interpret, critique, and discuss our data and debriefing observations in a rapid co-publication in the Journal of Clinical Anesthesia. [Healthcare Simulation to Prepare for the COVID-19 Pandemic][5] Anesthesiology and Pain Medicine Specific subject area Immersive healthcare simulation in perioperative medicine for process improvement and pandemic preparedness Type of data Tables How data were acquired We converted a previously scheduled MOCA (Maintenance of Certification in Anesthesiology) simulation course [6, 7] in our American Society of Anesthesiologists Endorsed simulation program to train internal clinicians in scenarios related to COVID-19 [8, 9] and to vet Covid- 19 • Immersive healthcare simulation employing anticipated clinical encounters may be useful to test COVID-19 [8, 10, 11] and other airborne contagious disease hospital protocols, developed with limited clinical experience, to detect shortcoming before such gaps become apparent in clinical care and threaten patient or provider safety. [12] [13] [14] • Our report is geared towards other simulation professionals, [6, 15, 16] especially in anesthesiology, [17] critical care, and perioperative medicine, who want to leverage immersive simulation to vet their airborne precaution care protocols before the arrival of an epidemic. [12] [13] [14] • The purpose of our detailed simulation protocols ( Table 2 ) is allow replication of typical airborne contagious disease simulation scenarios and the summary of the emergent themes and key learning points allow others to anticipate, contrast, and triangulate simulation debriefings with participants. • Given the limited recent experience of healthcare providers in industrialized countries with airborne contagious disease, simulation fill a void not only to train providers in anticipated scenarios, but to test protocols developed in table top exercises without prior clinical exposure, and to augment the organizational response, by improving interdisciplinary coordination. [13, 14, 18] with a view to training our providers and testing our COVID-19 protocols in realistic simulation scenarios prior to the arrival of COVID-19 cases at our institution. Case number and Title are in the first and second column on the left, respectively. The Scenario presented to the participant is sketched in the next column and the Central Themes and Key Lessons elicited during our debriefings in the column can be found in the column on the right. Table 3 Table 3 offers a detailed description of the enacted four clinical scenarios of anticipated COVID-19 encounters with objectives, equipment and supplies as well as resources needed, a description of the roles, and the sequential development of the scenario to allow for an easy replication of the reported healthcare simulation scenarios. When we conducted our simulations in March 2020, hospitals resources were already stretched in New York City. Penn State teams had started to develop protocols to guide clinicians in expected COVID-19 scenarios, based on the sparse medical literature available at that time. However, no one on our teams had gained any personal experience managing patients with COVID-19, [8, 9, 11] as no COVID-19 patients had been yet admitted at our institution, the Penn State Health Milton S. Hershey Medical Center (MSHMC), in Hershey, Central Pennsylvania. We converted a previously scheduled MOCA (Maintenance of Certification in Anesthesiology) simulation course [6, 7, 19] in our American Society of Anesthesiologists Endorsed simulation program to train internal clinicians in scenarios related to COVID-19. The simulations were hence geared towards experienced anesthesiology, perioperative and critical care physicians. Several authors (MHA, ES, DLR, VC and AD) designed four cases for seven participating physician anesthesiologists, who would each be in the "hot seat", (the critical central active role of the scenario), at least once. [20] All participants and course instructors were employed by the Medical Center and contributed as co-authors to this manuscript. The sequence of our simulations was as follows. All participants initially participated in three skills practice sessions expected to be relevant to patient care: 1) donning and doffing of PPE; 2) emergency surgical airway; and 3) intraosseous access. [9, 21] This was followed by case scenarios beginning with a code blue/cardiac arrest in a patient with a history consistent with COVID-19 infection, but without confirmatory or exclusionary test results available. One participant was given the role of the team leader and the rest were expected to act as the response team. [20] This case was debriefed first on the teamwork and communication aspects of the code response along the lines of usual CRM (Crisis Resource Management) debriefing [22, 23] and then the entire group discussed aspects of the case specifically relevant to changes in practice specific to managing a cardiac arrest patient in the context of possible COVID-19 infection. [12] The same case was repeated with a different team leader and the group practiced the protocol that had been designed for COVID-19 patients for management of cardiac arrest. The debriefing that followed focused primarily on how the protocol worked and what needed to be changed or refined in the protocol. The team is called to the emergency department to assist with a patient in respiratory distress. During evaluation, patient experiences respiratory arrest and cardiovascular collapse. Goal -Participants will adapt Advanced Cardiovascular Life Support (ACLS) algorithms for a possible COVID-19 patient in cardiac arrest. Focus is on situation awareness during the first minutes of the event, with emphasis on teamwork to provide CPR, defibrillation, airway management, and the first epinephrine administration with modifications for a COVID-19 positive situation. The central theme is the concept of "Protected Code Blue" where team member safety is emphasized. Procedures are altered to protect the resuscitation team in the context of airborne transmission. Participants are called to assist with the airway management of a known COVID-19 patient in acute respiratory distress to facilitate intubation. The scenario unfolds into an anaphylaxis with a difficult airway. Goal -Participants will modify their approach to securing an emergency airway due to respiratory failure in a positive COVID-19 patient with difficult airway due to anaphylaxis. Focus Is on planning and preparation to provide initial oxygenation and ventilation, management of anaphylaxis, and intubation after respiratory failure. The central theme is provider safety and containment of airborne transmission during airway management of a COVID-19 patient. 3 Transport of a A known COVID-19 patient needs an in-hospital transport from the ICU to the OR. The patient is intubated on high PEEP and FiO2. He is on multiple infusions including pressors to maintain blood pressure, sedatives, and epoprostenol to improve V/Q mismatch. Participants must prepare the patient for transport and move the patient from the room and down the hall. Goal -Participants will prepare for and transport a COVID-19 positive patient from the Intensive Care Unit to the Operating Room for emergency surgery taking necessary actions to limit virus exposure during the transport while protecting the patient from acute Focus is on establishing clear roles for multiprofessional team members and taking actions to reduce potential of virus spread during the transport. consider intubation prior to transport to avoid bag mask ventilation and exposure of OR personnel and bystanders. • Coordination between "clean" and "contaminated" personnel is paramount. for Remote Procedural Guidance and Supervision The participants are tasked to place a chest-tube, but there is no provider available who has experience in placing a chest tube. A provider with experience in chest tube placement remotely directs the bedside clinician on performing the procedure using a Tele-ICU unit or other similar two way-audio/visual system. Goal -Remote team leader will provide instruction and coaching to team members using a two-way audio/visual link (telehealth) to instruct bedside participant how to perform chest tube placement in a patient with a tension pneumothorax that has been temporized with needle thoracotomy. ICU: intensive care unit, OR: operating room, PEEP: positive end expiratory pressure, FiO2: fraction of inspired oxygen, V/Q: ventilation/perfusion (lung function) Participants are asked to discuss goals of care with the family of an elderly COVID-19 patient with a poor prognosis, in the face of an acute shortage of ventilators. The central theme is the distress of family and providers facing a grim ethical dilemma of resource allocation in the context of a pandemic.  He is a sales manager with a 30-year history of one pack a day smoking.  He recently flew back from a company conference attending by over 200 people from around the world.  He does not recall being exposed to anyone who was sick.  Patient is in respiratory distress stating he is having a "hard time breathing." Depending on simulation program and manikin capabilities, patient (manikin) may respond to questions or information can be supplied by in scenario actor. Physical examination - • what equipment should be brought into the room (with regards to decontamination or destruction afterward), • how to maintain communication between the "dirty" and "clean team members to solicit assistance and additional equipment, • how the code algorithm should be altered in the setting of COVID-19, • what resources need to be activated to bring the patient to the final disposition, ideally a negative pressure room in the intensive care unit. The scenario may evoke feelings of anxiety and distress in the participants, which may come up in the discussion. Contingent on the familiarity of the participants with each other, it may be challenging to lead a discussion about concerns that touch on personal safety, professional ethics, and professional identity. Distress may be caused by: • prioritizing care in the setting of insufficient hospital or ICU beds, • the delay in providing care (due to the cumbersome process of donning personal protective equipment), • the inability to assist in the code, or • the stress of performing cardio-vascular resuscitation with limited clinicians in the room. • the uncertainty surrounding COVID-19 and its fatality rate, • confusing and unclear communication by leadership, • the lack of healthcare resources and absent coordinated action to confront the situation, or • the lack of personal protective equipment and resulting concerns for participants health or the health of family members who may be at risk due to immunocompromise, co-morbidities, simply or old age. Goal -Participants will modify their approach to securing an emergency airway due to respiratory failure in a COVID-19 positive patient with difficult airway due to anaphylaxis. Objectives -Participants will… 1. Employ CRM techniques including role assignments (e.g., team leader, "dirty" and "clean" team members, task assignments) and communication practices that enhance the team's shared mental model (e.g., huddle prior to room entry, closed loop communication). that has been unresponsive to initial medication therapy for anaphylaxis. 7. Communication between "dirty" team in room and "clean" team in out-of-room support roles is maintained. Debriefing Guide - The participants discuss their response with the facilitator focusing the discussion on the COVID-19 relevant aspects of the scenario. In particular, the group discusses: health or the health of family members who may be at risk due to immunocompromise, co-morbidities, simply or old age. Goal -Participants will prepare for and transport a COVID-19 positive patient from the Intensive Care Unit to the Operating Room for emergency surgery taking necessary actions to limit virus exposure to team members and others during the transport. Objectives -Participants will… 1. Employ CRM techniques including role assignments (e.g., team leader, "dirty" and "clean" team members, task assignments) and communication practices that enhance the team's shared mental model (e.g., huddle prior to room entry, closed loop communication). • Intubation prior to transport versus intubation to the operating room with a view to reduce exposure of OR personnel and hallway bystanders by avoiding bag mask ventilation outside the negative pressure environment. Goal -Remote team leader will provide instruction and coaching to team members using a two-way audio/visual link (telehealth) to instruct bedside participant how to perform chest tube placement in a patient with a tension pneumothorax that has been temporized with needle thoracotomy. This scenario requires the "Hot Seat" participant in the role of the remote team leader to be experienced in the procedure and the bedside clinician to be relatively inexperienced or not current in practice of the procedure. For this reason, participant roles were specially designated. Note -This section details the telehealth interaction between the remote team leader and the bedside clinician(s). This section was preceded by the bedside team assessing and intervening with a patient presenting with possible tension pneumothorax. The "Hot Seat" participant was the remote team leader. The first part of this scenario was conducted to provide another training opportunity for participants to cover key objectives presented in other simulation scenarios regarding team management in COVID-19 patients. Objectives (specific to telehealth interaction for chest tube placement) - Briefing (to remote team leader) -"You have been asked to do a teleconsultation with a physician at another hospital who is managing a COVID-19 positive patient who now requires a chest tube after successful needle thoracotomy in the right chest. The provider has done the procedure before but is out of practice and requesting assistance. The patient was in the ICU and had been diagnosed with ARDS related to COVID-19 diagnosis. A central line had been placed immediately before patient deterioration due to tension pneumothorax." Simulation 2. Remote team leader assesses situation to determine urgency. 3. Remote team leader optimizes field of view by either moving camera location or moving patient into field of view. This scenario focused on a remote telehealth situation. The same techniques could be employed locally when the clinician at the patient's bedside needs assistance and due to limiting the number of people in the COVID-19 patient room or inability of the supervising physician to enter the room (e.g., on home quarantine, underlying health issue that places the senior provider at high risk). 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