Heather Murray is Associate Professor and Deputy Head in the Department of Emergency Medicine at Queen’s University.
Eve Purdy is a PGY5 in emergency medicine and and anthropologist who completed a fellowship in translational simulation in Australia.
Simulation is playing an important role in helping us at Kingston Health Sciences Centre prepare for COVID19. We’ve turned to simulation like never before to enhance our staff’s knowledge and skills, to rework spaces and improve processes.
Groups that normally train and work separately have come together to practice and plan, creating positive changes in our working environment and culture. Here are some examples of what we have done.
Improving knowledge and skills:
Donning and doffing of personal protective equipment (PPE) is an essential skill that must be practiced. This has been done extensively with daily deliberate practice in the Emergency Department (ED) for on-shift nurses, doctors and respiratory therapists. To conserve resources we are reusing PPE and employing mental rehearsal techniques during these simulations. Videos and visual prompts have been developed and used to improve performance and prevent mistakes.
Practicing specific intubation and ventilation techniques has been another focus. This has occurred in the ED, OR, ICU and off site in simulation labs, and has involved all team members including different medical specialists, nurses, respiratory therapists and infection control personnel. The ability to do so has been facilitated by online sharing of resources and experience from across the country and around the world (EM Sim Cases, St. Emlyns, LITFL, Sim-One). This worldwide cooperation and information transfer from places with lived experience has facilitated high quality training at Canadian institutions. This training method, developed and refined with use by front line providers, will be essential if we need to train non-traditional staff to do these tasks.
Reworking spaces and changing processes:
We have used simulation to trial procedures and patient care in non-traditional spaces. Anticipating an influx of infected patients, we road-tested procedures for patient care in new environments.
Using this process Kingston Health Sciences Centre was able to create a COVID assessment centre outside the ED. The same has been done at St. Michael’s in Toronto.
These simulations have positively impacted our culture. Practicing together bonds the team and creates a sense of community and increased confidence in each other. This week at Kingston Health Sciences Centre we ran a simulation scenario of a code blue COVID patient – walking through the process and directly addressing concerns from the group. Residents, bedside nurses, environmental services staff, administrators and senior ICU attendings listened to each other and brainstormed together. Many of these individuals are not at the usual decision-making tables. The process broke down traditional hierarchal barriers, allowing people on the front lines to feel heard and empowering those at the top to listen. When people feel safe and supported, they will be honest about ongoing fears and concerns, allowing further problem-solving and refinement.
As the pandemic evolves, so will the simulation approach. It may become impractical to gather groups of people. Perhaps we will move to a quick team mental rehearsal just before heading into that room together to intubate a sick patient and a structured simulation style debriefing after the event. The specific knowledge, space, process and cultural objectives of the simulations might also change. We may need to focus on simulating end of life discussions and decisions to palliate, if the resource constraints mirror the experience of other countries.
Simulation has been front and centre in our preparation for the COVID19 pandemic. We used to plan on paper and hope for the best. Simulation has allowed us to do much more than that.