key: cord-272182-5lunidrs
authors: Lim, Wan Yen; Wong, Patrick; Teo, Li-Ming; Ho, Vui Kian
title: Resuscitation during the COVID-19 pandemic: Lessons learnt from high-fidelity simulation
date: 2020-05-22
journal: Resuscitation
DOI: 10.1016/j.resuscitation.2020.05.024
sha: 
doc_id: 272182
cord_uid: 5lunidrs

nan

The coronavirus disease 2019 (COVID-19) pandemic has caused an unprecedented global healthcare crisis, creating challenges to resuscitative efforts. Cardio-pulmonary resuscitation (CPR) confers additional risks to healthcare workers due to exposure to aerosol generating procedures (AGPs) like chest compressions, face mask ventilation and intubation. The emergent and high-intensity situation may also result in lapses in infection control practices 1 . High-fidelity simulation sessions were conducted in our institution to identify latent threats in existing workflows, and to formulate modified life support protocols focusing on: protection of healthcare workers (HCW) and patients, minimizing aerosolization and reducing delays in resuscitation.

Sengkang General Hospital, one of Singapore's largest regional hospitals, comprises an acute care 1000-bedded facility and a 400-bedded community care hospital. Suspected or confirmed COVID-19 patients are managed in negative pressure, single-bedded rooms in the acute care hospital. In the community hospital, such patients are managed in cohort wards (4-6 bedded bays) with natural cross ventilation through large open windows. A single code blue team, based at the acute hospital, provides resuscitation services at both facilities. Due to geographical reasons, the mean (SD) code blue response time to the acute and community care wards were 3.28 (1.76) and 6.67 (2.06) minutes, respectively. These timings were validated from actual code blue events pre-COVID-19.

In simulations, we adhered to hospital and COVID-19 guidelines of full PPE (including N95 mask or powered air-purifying respirator (PAPR), gown, gloves, goggles and face shield or visor) 2 . A donning and doffing supervisor, or a buddy system can reduce selfcontamination amongst HCW 3 . The mean (SD) time taken by 19 HCW during simulations, for donning full PPE including CleanSpace ® PAPR was 3.33 (0.73) minutes. Our timings were comparable to donning full PPE that included N95 mask, which were 3.28 (1.15) minutes 4 .

We identified two latent threats on two separate simulation sessions: 1. A participant, designated as the second responder, entered the resuscitation room without eye protection; 2. A participant tripped and fell while retrieving equipment, possibly contributed by impaired peripheral vision when wearing goggles. Learning points from these include adopting a buddy system for donning and doffing of PPE, removing hazardous items and ensuring adequate resuscitation space.

From our simulations in the community hospital where isolation facilities are unavailable, we observed that precautions to protect surrounding patients in the cohorted wards were required. These include use of waterproof shields or partitions to cordon off the resuscitation area, prompt evacuation of ambulant patients and minimizing aerosol generating procedures. Due to the potential delay in response times, manual ventilation via SAD 2 (preferred if HCW is trained and competent in SAD insertion) or a well-fitting mask with a good seal may be required prior to code blue team arrival. We summarized our recommendations for resuscitation in acute and community hospital settings in Table 1 .

Frequent training and simulation sessions including PPE familiarization minimizes delays in resuscitation, reduces risk of viral transmission, enhances communication, teamwork and coordination, and allows latent threats identification and workflow refinement.

None. 

Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the

Consensus guidelines for managing the airway in patients with COVID-19

Operation GRITROCK: the Defence Medical Services' story and emerging lessons from supporting the UK response to the Ebola crisis

Self-contamination during doffing of personal protective equipment by healthcare workers to prevent Ebola transmission