key: cord-323008-xk89ew1b
authors: Rama, Asheen; Murray, Andrea; Fehr, James; Tsui, Ban
title: Individualized simulations in a time of social distancing: Learning on donning and doffing of an COVID-19 airway response team
date: 2020-08-30
journal: J Clin Anesth
DOI: 10.1016/j.jclinane.2020.110019
sha: 
doc_id: 323008
cord_uid: xk89ew1b

nan

We read the article by Zhang et al. [1] regarding strategy of using protective personal equipment (PPE) during the COVID-19 pandemic with great interest. We concur that "personnel education and experience play important roles in efficacy of PPEs". Recently, common biosafety breaches during donning and doffing of protective personal equipment (PPE) have been reported [2] .

In the midst of pandemic, simulation not only may play a vital role in supplementing both education and experience needed with minimizing the risk of infecting healthcare workers (HCWs), but also allows educators to provide constructive feedback to providers. With the approval and wavier of institutional IRB, we report here our findings of examining our staff training regarding the common biosafety breaches in donning and doffing for aerosols generating medical procedures (AGMPs) based on key areas identified by Munoz-Leyva and Niazi [2] . Prior to reviewing the findings, we also encourage the reader to participate in gamification to enhance their learning [3] by viewing the drawing on the left in Fig. 1 , and determine if the drawing represents optimal PPE. The reader may then refer to the summary table on the right which highlights optimal PPE. COVID-19 airway response team consists of experienced anesthesiologists that are interested and knowledgeable in managing airway of COVID-19 patients. Ten participants from our division's COVID-19 airway response team were presented with a simulation scenario in which a COVID-19 patient required urgent intubation. Participants donned PPE in an anteroom before entering the patient's adjoining room to prepare for a potential intubation. Then, participants were instructed to doff their PPE and exit the patient's room. The entire process was recorded, and personalized video-playback was given during debriefing. Of note, participants on numerous occasions were at risk for or did in fact self-contaminate. Some anesthesiologists only utilized equipment provided at the donning station while others requested additional PPE: (a) Eye protection;

During the donning process, a variable amount of time was spent hand sanitizing, thus debriefers emphasized the 20 s rule [4] with alcohol-based sanitizer. A variable amount of sanitizer was used, often of insufficient volume to last for the recommended 20 s. The time required to don PPE ranged from 2 to 4.5 min which emphasized the need for process familiarity as emergent intubations are commonplace, such as in cases of self-extubations which occurs in up to 22.5% of patients in the ICU [5] . Several participants did not double glove and several participants wore the N95 mask incorrectly.

The doffing process was seen as more challenging by participants and was critiqued, referring to CDC and institution guidelines for best practices. Many participants contaminated the anteroom by doffing in this room rather than inside the patient's room. Participants were recommended to stand more than 6 ft away from the patient during doffing and removing the gown in a leaning forward, rolling inside and out fashion. Several individuals self-contaminated themselves by touching the door handle after removing their gloves while others contaminated their scrubs below the knees as they attempted to maneuver over patient monitoring cables. During debriefs, it was possible to critique donning and doffing practices and collectively brainstorm improvements to the COVID-19 airway response system. The debriefs further emphasized the need for a buddy system in which a spotter could read off a PPE equipment list. Only until recently, individual-based, personalized coaching simulation has reemerged and utilized for physician training in our institution. Instead of group learning format, this personalized simulation system allows single participants, under the guidance of two simulation debriefers, to use the aforementioned guidelines and learn proper donning and doffing of PPE.

Given the vast number of HCWs who are becoming infected with COVID-19 [6] , it is of vital importance that we not only distribute knowledge on PPE in the form of protocols, guidelines, demonstrations, and videos, but also provide simulations with personalized feedback which improves staff safety in anticipation of potential second wave infection as the world reopens [6] . Indeed, "equipment and protocols will surely briskly in the current crisis [1] ."

None.

Strategy of using personal protective equipment during aerosol generating medical procedures with COVID-19

Common breaches in biosafety during donning and doffing of protective personal equipment used in the care of COVID-19 patients

Simulation-based ultrasound-guided regional anesthesia curriculum for anesthesiology residents

Quantifying the effect of hand wash duration, soap use, ground beef debris, and drying methods on the removal of Enterobacter aerogenes on hands

Minimizing self-extubation

Beware of the second wave of COVID-19