“Building the plane as you fly”: Simulation during the COVID-19 pandemic

Abstract

The 2019 coronavirus disease pandemic is challenging our Canadian emergency departments (EDs) in unparalleled ways. As part of the frontline response, EDs have had to adapt to the unique clinical difficulties associated with the constant threat of COVID-19, developing protocols and pathways in the setting of limited and evolving information. In addition to the disruption of routine clinical care practices, an underlying perception of danger has resulted in a challenging clinical environment in which to make time-sensitive, high-stakes decisions. This has created an urgent need for targeted and adaptive training for all members of the emergency medicine healthcare team. The following commentary reflects the perspective of four emergency medicine simulation educators during the Canadian response to COVID-19. Recognizing that local needs and resources will vary, we highlight three key roles that simulation can play in the adaptive response to COVID-19: protocol development and system testing, provider education, and team-based training. The disruption to our practice as a result of COVID-19 has required us to "build the plane as we fly," and we believe simulation to be a key tool in this process. SIMULATION FOR PROTECTED PROTOCOL DEVELOPMENT AND TESTINGThis pandemic has brought us to uncharted waters and has required the creation of new processes and protected protocols for intubation, code blue responses, and workflows within the ED. Our familiar and reliable system 1 thinking (fast, automatic, unconscious thought processes) frequently applied during high risk events has been supplanted by system 2 thinking (slow, effortful, and deliberate thought processes) due to team safety risks related to viral exposure and infection. 1 For example, the cognitive load required to perform common tasks, such as endotracheal intubation, has increased considerably, creating opportunities for error. In order to support system 2 thinking and mitigate error, protocols and corresponding checklists are required. Simulation allows for a safe, controlled, and iterative approach to protocol design and is well established in this context. 2,3 It seems only natural to apply our experience using simulation for systems testing to ED preparedness for COVID-19.Much like crash testing a car, simulation affords an opportunity for ED and simulation leaders to observe, reflect, and refine proposed protocols without risking harm to the healthcare team (or patient). This process is important to ensure a consistent approach and anticipate downstream implications prior to operationalization. Integrating the Plan-Do-Study-Act conceptual framework for systems improvement into pandemic simulation activities allows for a rapid analysis of novel protocol development. In turn, this enhanced simulation strategy serves to identify the safest and most efficient and pragmatic approach to various emergent situations. Novel pandemic-related protocols and various critical event checklists (e.g., COVID-19 intubation checklist) are From the

Resident learning during a pandemic: Recommendations for training programs

“…Many departments have accelerated their in situ simulation programs in response to COVID-19 for protocol development and revision, provider training, and teambased training. 13 Resident involvement has been variable, but our sites have embraced the opportunity to incorporate trainees, especially since many will be working independently on the front line in the near future. Virtual simulation is another option for simulationbased training.…”

Context: How COVID-19 exposed key factors of emergency medicine education

“…Educators have rapidly pivoted to virtual academic days, virtual teaching sessions, and novel wellness initiatives. 1 Interest in in situ simulation has expanded, 2,3 and novel educational techniques, such as the use of mental practice, 4 have been embraced. Collectively, these innovations highlight the importance of context in education, an increasing focus on collective competence, and the synergy of education and quality improvement.…”

“…6 Instead of engaging with just residents or attending physicians, multiple innovations described in this issue focus on healthcare teams. [2][3][4] While it has long been recognized that we do not practise in a vacuum and team-based simulation is not uncommon, our historic educational paradigms continue to centre around physicians. COVID-19 has given us the nudge we needed to shift this focus from individuals to teams.…”

“…The arrival of the pandemic has stressed the potential danger of incompetence that can result from team members with misaligned mental models and facilitated engagement of clinicians in emergency department educational initiatives. Specifically, Chaplin et al 2 described the impetus for the use of team-based in situ simulation at their centres, whereas Hanel 3 and Riggs 4 used virtual and mental simulations to engage their entire department.…”

“…In one example, the input from participants in simulation education initiatives was used to improve the final process of identifying latent safety threats. 2 In another, the power of mental practice was leveraged to provide virtual repetition of donning and doffing without wasting precious personal protective equipment. 4 Applying mental practice to an immediate patient safety threat with limited resources empowered providers with the skills to be safe in their new day-to-day work.…”