key: cord-0820670-i093x35p
authors: Montauban, Pierre; Balakumar, Charannya; Rait, Jaideep; Zarsadias, Prizzi; Iqbal, Sara; Aravind, Biju; Shrestha, Ashish; Fernandes, Roland; Shah, Ankur; Basnyat, Pradeep; Harinath, Gandrasupalli; Basu, Sanjoy; Featherstone, Barry; Adams, Lawrence; Merh, Radhika; Nikolaou, Stella; Abdelrahim, Ahmed; Mangam, Sudhakar; Sebastian, Joseph; Mohamed, Hesham; Kawabata, Martin; Dmitrowicz, Aleksandra
title: The Important Role of In-Situ Simulation in Preparing Surgeons for the COVID-19 Pandemic
date: 2020-09-22
journal: Surgeon
DOI: 10.1016/j.surge.2020.08.013
sha: dc363b16b2b197a5fdd73af117843a1b6c4e9054
doc_id: 820670
cord_uid: i093x35p

Background Effective training is vital when facing viral outbreaks such as the SARS Coronavirus 2 (SARS-CoV-2) outbreak of 2019. The objective of this study was to measure the impact of in-situ simulation on the confidence of the surgical teams of two hospitals in assessing and managing acutely unwell surgical patients who are high-risk or confirmed to have COVID-19. Methods This was a quasi-experimental study with a pretest-posttest design. The surgical teams at each hospital participated in multi-disciplinary simulation sessions to explore the assessment and management of a patient requiring emergency surgery who is high risk for COVID-19. The participants were surveyed before and after receiving simulation training to determine their level of confidence on a Visual Analog Scale (VAS) for the premise stated in each of the nine questions in the survey, which represented multiple aspects of the care of these patients. Results 27 participants responded the pre-simulation survey and 24 the one post-simulation. The level of confidence (VAS score) were statistically significantly higher for all nine questions after the simulation. Specific themes were identified for further training and changes in policy. Conclusion In-situ simulation is an effective training method. Its versatility allows it to be set up quickly as rapid-response training in the face of an imminent threat. In this study, it improved the preparedness of two surgical teams for the challenges of the COVID-19 pandemic.

The SARS Coronavirus 2 (SARS-CoV-2) outbreak of 2019 (and subsequent COVID-19 disease) rapidly became a pandemic and is potentially the greatest threat humanity has faced in modern times. Its impact is virtually incalculable. The worldwide economy grinded to a halt. Experiences in the most affected regions tell of entire healthcare systems overrun in a matter of days, requiring disaster triaging of patients on a massive scale, particularly for access to Intensive Care [1] [2] [3] [4] .

As of August 2020, approximately 23 500 000 cases of COVID-19 and 812 000 deaths have been confirmed worldwide, with 333 000 and 41 500, respectively, occurring in the United Kingdom 5 ; these are likely to be gross underestimates, and will be higher by the time of publication of this study. It is vital that lessons rapidly be learnt in regions where there is still the chance to act proactively, rather than reactively, in the face of this crisis. -19 patients requiring mechanical ventilation, and the COVID-19 designated wards filled up at an increasing pace. At the time, it was expected that the peak caseload was yet to come, and therefore efforts to prepare had to continue.

The Surgical teams at both the WHH and QEQM were, as expected, seeing a reduction in their usual workload as only operations classified as 'Immediate' or 'Urgent' were being carried out a . While pathways were being explored to deal with 'Expedited' and 'Elective' operations, it was paramount to prepare the teams to deal with acutely unwell patients, particularly those requiring emergency surgery, who were concomitantly suspected/confirmed to have COVID-19.

A steering group designed a framework to implement measures to prepare for the challenges arising from the COVID-19 pandemic (Appendix A). It was initially designed for the WHH, but then expanded across the Trust. This was a quasi-experimental study with a pretest-posttest design. The simulation involved multi-disciplinary teams (Surgeons, Emergency Doctors, Anaesthetists, Theatre staff, Nursing staff) partaking in the scenarios as well as observing.

However, only the doctors within the Surgical teams, irrespective of grade, were invited to participate in surveys. The Consultants and Senior Registrars were interviewed to establish the key aspects of interest to be addressed during the simulation sessions.

In the initial stages of the crisis, when preparations for operating theatres were being planned and the Standard Operating Procedures (SOPs) drafted, a trial simulation was carried out at the WHH involving the surgical, anaesthetic and theatre teams. It was important to get the right balance between simplicity and covering all the desired learning objectives. These are listed in Table 1 , along with the skills being explored. (Table 1) The scenario was simulated to be set in the designated respiratory cohort area in the ED, which was unavailable due to clinical demands and the exposure risk, and hence an alternative vacant assessment area was used. The candidates were the on-call Surgical team. They were called by the ED team and on arrival would receive a more detailed briefing from the ED doctor, including investigations (CT findings and blood results). The candidates would proceed to assess the patient. The progression of the scenario is outlined in Figure 1 Table 2 . The instructions also clarified that responses remained anonymous and by filling out the survey the participants were consenting for responses to be included in the analysis and be disseminated in publications and/or presentations. Demographic data of the participants were not recorded due to lack of relevance and to avoid response bias arising from more senior team members sensing that they ought to appear more confident than their more junior colleagues.

Once the surveys closed, the quantitative data from the responses were transferred to a single database on Microsoft® Excel, which was also used to plot graphs. The statistical calculations were performed using R© version 3.6.1 6 . The pre-and postsimulation VAS scores were presented as medians and the Mann-Whitney U-test used to compare both datasets. The null hypothesis for each of the questions on the survey was that any difference between the pre-and post-simulation responses was the result of random chance, and hence not significant. This would be rejected if the p-value was equal to or less than 0.05.

Qualitative data was also collected in the form of observations made during the sessions, which would be synthesised and described.

There were 27 participants in the pre-simulation survey and 24 in the postsimulation. The median VAS Score, representing the level of confidence, for each of the questions in the pre-and post-simulation surveys are presented in Figure 3 . The simulation allowed specific themes for improvement to be identified and incorporated directly into the SOP for suspected/confirmed COVID-19 surgical patients. These are outlined in Table 3 . (Table 3 )

This study showed that in-situ simulation training significantly improved the level of virus outbreaks showcased the importance of training and preparing for these highly infective pathogens with the potential for pandemic propagation. However, we are seeing that countries are clearly still ill-prepared for this nature of menace.

There is evidence that simulation is an effective training method which is feasible across multiple specialties and clinical settings (7, 8) . Furthermore, it is suggested to improve clinical skills, teamwork and observed behaviours, as well as have a positive impact on patient safety (8, 9) . In-situ simulation has the virtue of being high-fidelity and cost-effective, as it can be carried out in real-life clinical settings as opposed to dedicated simulation centres, and an actor used, such as in this study, as opposed to high-tech, expensive mannequins. For this same reason, in-situ simulation can be very versatile and rapidly set up, and therefore used as a rapid response to prepare participants for an imminent threat. Similarly, additional human resources are not necessarily required. In this study, the teams participating in the session were those scheduled to be on-call. However, this may vary based on the daily workload at 16 . Though successful, these simulation programs were carried out in high-spec simulation centres, and recognised that reproducibility was a likely limitation.

There are far fewer studies on the use of simulation for the MERS 17, 18 and SARS 19, 20 epidemics. These are more pertinent to the current pandemic, having also been caused by viruses of the Coronavirus family and therefore also transmitted through droplets or aerosolization, which is relevant to the PPE and other preventive strategies required. Also, of note, all the referenced simulation-based training activities occurred several months or years after the outbreaks they relate to had finished with a view to future incidents. This study, on the other hand, has been carried out in the midst of the current pandemic, highlighting how in-situ simulation can be versatile and rapidly set up, and therefore used as a rapid response to prepare participants for an imminent threat. Wong et al. also successfully portrayed this by testing the preparedness of their operating theatre and procedures dedicated to known or suspected COVID-19 patients through in-situ simulation 21 . However, a quantitative analysis of this benefit was not carried out in that study.

A few challenges in carrying out this kind of training have been identified, however.

In this rapidly changing situation there has been a flurry of information, advice and guidance which, in turn, changes on almost a daily basis. The content of the simulation relies on this guidance, and hence the lessons gained from it can rapidly become obsolete if the changes in policy are significant. Following the aforementioned trial simulation, changes in guidance from governing bodies (NHS J o u r n a l P r e -p r o o f England, the Royal Colleges, etc) were taken into account for the simulation training.

This, in turn, allowed new guidance to be put into practice and incorporated into the SOP. Simulation training also requires that the team providing it be adequately trained in doing so, and particularly be confident in facilitating the debrief, which is the most essential aspect to achieve good learning outcomes. The authors recognise that this will not uniformly be the case across different centres, and would therefore advise that organisations encourage their staff to attend simulation trainer training courses.

Finally, there is the possibility that the simulation training was most beneficial to those directly involved in the simulation sessions in comparison to those merely observing. The design of this study did not account for this upon comparing the pretest-posttest scores assessing the impact of the simulation sessions, and given the anonymity of the surveys, it would have been impossible to adjust for this retrospectively. It is expected, however, that a thorough debrief with active participation of all the partakers, including the observers, would reduce that potential difference. The authors would also recommend that future studies regarding in-situ simulation training be designed bearing this limitation in mind.

In-situ simulation is an effective training method. Its versatility allows it to be set up quickly as rapid-response training in the face of an imminent threat. In this study, it improved the preparedness of two surgical teams for the challenges of the COVID-19 pandemic. It was also a key strategy in rapidly testing and adapting SOP in the assessment and operative management of emergency general surgical cases. Wider 

Communication -Escalation within Surgical team -Liaison with other teams (ED, anaesthetics, nurses, theatres) The team brief -Specific aspects to be discussed re: COVID-19 Logistics when preparing for surgery -Anaesthetic/theatre staff preparations -Timing to send for patient -Porters -transfer J o u r n a l P r e -p r o o f 

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Applying the current Standard Operating Procedures (SOP) for COVID-19 surgical patients 3. Selecting and applying the appropriate Personal Protective Equipment (PPE)

Considering specific investigations in initial management plan in relation to COVID-19, in addition to those of surgical condition 5. Exploring documentation, consenting and booking patient for surgery 6. Exploring the team brief dynamic with relation

Highlighting the logistical challenges of getting patient from the ED to the Operating Theatre 8. Exploring agreed PPE and role/location of surgeons during anaesthetic induction

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The authors of this research manuscript have no conflicts of interest to declare.

The Important Role of In-Situ Simulation in Preparing Surgeons for the COVID-19 Pandemic This is a scenario to simulate the journey of a young male patient presenting to the Emergency Department with a perforated duodenal ulcer. He has also displayed symptoms and has a contact history highly consistent with COVID-19. He has had bloods and a CT scan. The candidate will need to assess and manage the patient, and prepare for surgery.

J o u r n a l P r e -p r o o f