May 21, 2021By Dr. Kim Baily

Rapid Deployment of In Situ Simulation during COVID-19 for Caregiver Safety

As we look forward to a loosening of COVID-19 restrictions, we should also review how the healthcare system and, in particular, simulation programs responded to the pandemic. During the 2021 IMSH conference, Ian Doten, Daniel Robinson, Christina Mason, Michelle Walters and Benjamin Wilson from Swedish Health Services (SHS) in Seattle, Washington, shared how their healthcare system rapidly deployed simulation during the early days of the COVID-19 pandemic to protect caregivers.

In 2008, when the SHS simulation program began, simulation mostly involved single disciplines and education. Their early simulation work gained a reputation for excellence in pediatric emergencies, sepsis, postpartum hemorrhage, system-wide mass casualty responses and preparing for Ebola in 2014. The program expanded to the larger Providence Health Services and to over 100 other facilities. Dr. Doten noted the SHS simulation program views itself as a “translational multidisciplinary macro system which connects experts at the bedside with institutional goals”.

By early 2020, pre-COVID-19 simulation at SHS was divided into two main programs. The first program was involved in more traditional educational services, such as nurse onboarding and regulatory requirements. The second program was focused more on safety and systems, and centered around in situ simulation for experienced multidisciplinary team development.

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In situ simulation was found to be an effective process for staff improvement, confidence building and engagement. The pre-COVID-19 program had time to plan and discuss simulation interventions, expose 80% of the staff to two hours of team-based simulations, and also had enough time to assess outcomes and staff engagement. Detailed deliverables and gaps solutions and opportunities were clearly presented to simulation clients. The SHS looked to their simulation program for solutions to various issues. Note that SHS has multiple campuses spread out over the greater Seattle area.

And Then COVID-19 Struck…

Originally, the first COVID-19 case was thought to be a patient hospitalized in Everett about 30 miles north of Seattle. Both senior administrators and the simulation team had the forethought to realize that simulation could likely play a critical role in the response of the organization to the COVID-19 pandemic. The larger system turned to simulation for solutions. Initial requests came in for assistance with the intubation of likely COVID-19 patients.

There was initially hope that all COVID patients could be sequestered in Issaquah where an existing Ebola isolation unit was already in existence, but the rapid increase in cases necessitated the development of a system-wide response. Within one day of a high-level review of existing policies, the first simulation was conducted in one emergency department (Feb. 25). Word spread quickly between facilities and departments, and requests poured in for assistance from the simulation program.

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By March 12, pediatric, ICU intubation and seven emergency departments had participated in simulation; and by March 26, in situ simulation had begun in eight ORs and several inpatient units. Michelle Walters noted that high-level stakeholders from all departments were seconded to help with scheduling, organization, ensure participation and obtain equipment supplies. She noted that although it was an incredibly busy time and somewhat “crazy” trying to bring simulation to so many campuses and departments, the simulation staff were able to meet the department’s requests.

Any staff likely to come into contact with COVID patients were encouraged to participate, including medical staff, nurses, respiratory care, transport and environmental support. Pre-COVID levels of participation (80-100%) were not achieved, but information by word-of-mouth helped spread critical information among the staff. Nearly all the barriers to simulation prior to COVID dissolved.

Walters was solely responsible for all scheduling, which prevented overlaps or unwanted downtime. Walters was able to ensure there was sufficient time for the sim teams to travel to the different facilities. Emergency departments and those areas where staff were most likely to be exposed were considered a priority for scheduling. Twenty departments were covered in 30 days, using three to four variations of the simulation. Senior administrative support from the facilities and departments made a critical difference in scheduling and implementation.

Christina Mason noted that prioritization, planning and organization were key to the program’s success. Answers from bedside teams and debriefs were shared rapidly throughout the system. Flexibility as a team and the ability to rapidly adapt were vital, as guidelines sometimes changed on a daily basis. PPE donning and doffing was identified as a key issue.

Ben Wilson, the lead simulation technology specialist for the SHS simulation program, noted that the program already had various accreditations for the simulation program and simulation staff. Since so little was known about transmission during the early stages of the pandemic, staff were concerned about transporting equipment between facilities.

The simulation method transitioned from high-level adult and pediatric mannequins, to airway torsos and smaller pieces of equipment, to use of standardized patients (sim staff), to telesimulation where only one simulation facilitator traveled to sites to manage the scenario. In addition,various pieces of equipment were developed to protect learners; for example, Plexiglas boxes to screen learners during intubation scenarios.

Feel the Pain…

Rapid process improvement during the early pandemic was challenging and at times stressful, but the SHS team, while acknowledging the challenge, pushed forward with projects, accepting that pre-COVID simulation practices were sometimes too lengthy. The team adapted their preexisting Ebola preparation as a starting point. For example, initial ED process flow improvement simulation began as tabletop exercises, but quickly transitioned into the ED.

Due to the number of staff and shifts, Mason reported that people and ideas were left out. Repetition of the same scenario helped reveal issues with workflow, role assignments, transport and the ED response process itself, and generated many questions which ultimately led to improved processes. PPE equipment supply was challenging, and PPE alternatives for simulation were developed. During codes, staff tended to jump into patient care without remembering to don PPE, so many staff had to be reeducated to ensure that they were fully protected prior to patient care.

Each department had their own unique challenges, especially as Centers for Disease Control and Prevention guidelines were rapidly changing. For example, deciding who could stay with a laboring mother, and whether a newborn should stay in the room with the mother. Reducing code team members in the ED was investigated to prevent unnecessary staff exposure. Simulation helped to determine policies and workflow.

Dan Robinson noted that one of the problems early in the pandemic was the lack of a single reliable source of information. Initially, a COVID information portal was created which was regularly updated and every shift participated in huddles. However, with new suggestions for process improvement coming from simulation activities, staff were sometimes confused about which information to use.

SHS created a “Source of Truth” in real time which relied on the latest CDC and World Health Organization information and simulation data. When possible, content experts were present at simulation offerings, guiding staff with the latest information. Since department leads were well-informed, they could initiate rapid change and reduce barriers, and often attended simulations. Robinson noted that having the right staff present during simulation was important.

Key staff present during the simulations included infection experts, simulation experts, heads of departments for nursing, respiratory care and environmental care, etc. Real-time changes could be initiated rapidly and managers felt supported. Following simulation, department-specific “Action Item Lists” were generated and initiated as soon as possible.

Summary of Accomplishments:

  • Rapid creation of a framework for safe practice during a scary, unprecedented time.
  • Development of written department-specific and simulation-tested policies that staff could follow.
  • Improved staff confidence levels, which in turn led to reduced anxiety.
  • No workplace illness in staff most at risk including the environmental staff during the first six weeks of the pandemic (2,500 patient COVID days of exposure).
  • Enhanced ability and confidence of simulation team members.
  • Improved confidence of bedside clinician experts to face and solve issues related to care of COVID patients.
  • Clinicians were able to see that hospital leadership heard and responded to their concerns.

The preexisting successful SHS simulation program and hospital leadership support enabled the SHS to respond rapidly to the COVID pandemic, keep their staff safe and improve clinician confidence in a large multi-facility organization. The use of clinical simulation to test, change and initiate policies played a key role in their success story. The SHS simulation program is likely an exemplar for the role of healthcare simulation in the clinical practice of the future.

COVID-19 Healthcare Simulation Resources

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