As doctors, nurses, and hospital administrators watched, another emergency-department team took a patient from paramedics and wheeled him behind the closed glass doors of the resuscitation room, sealing in themselves and the air around them.
Sweat running down behind face shields with the strain of masked breathing, the team started a full resuscitation, performing CPR, inserting IVs, hooking up monitors, and eventually inserting a breathing tube and putting the patient on a ventilator, taking precautions to avoid the spray of airway droplets. An X-ray machine was summoned to the emergency department; the patient was later moved to the ICU.
While all this was happening, those watching asked such questions as: What do we do with the paramedic’s bed now that it is contaminated? Why was that health-care provider reaching for his pager beneath his gown? Is everything in the room, including unused equipment, now contaminated? Should she be wearing earrings? Should their hair not be pulled back? Did the tube insertion expose the team to aerosolized COVID-19? Do the team members have to leave the room during X-rays, which would mean they’d have to remove personal protective equipment and then put it back on? What about all those people they passed in the hallways on the way to the ICU — could they be at risk?
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The questions were precisely the point: this was a medical-simulation exercise. The patient? A sophisticated mannequin.
Scenes such as this played out in hospitals across the country in the early weeks of March. Doctors, nurses, respiratory therapists, porters, and even housekeepers were rehearsing. And medical leaders and simulation experts were watching, noting the various issues that could arise during the treatment of infectious patients.
In Ottawa, almost 300 people were trained over the course of two days in two scenarios: intubating a suspected COVID-19 patient in the emergency department and caring for an infected patient who needs emergency surgery.
“We’re truly using simulation to guide the health-care system,” says Glenn Posner, an obstetrician and the medical director of the simulation patient-safety program at the Ottawa Hospital.
The goals of the program are two-fold: to allow real teams of professionals from different disciplines to train together in a clinical environment, and to help reveal latent threats. “We’re discovering problems we wouldn’t have otherwise known about,” Posner says.
Catherine Varner, an emergency-department physician and clinician-scientist at Mount Sinai Hospital in Toronto, says that front-line workers have been required to take in an overwhelming amount of COVID-19 information: “It is like drinking from a fire hose.” The rehearsals, she says, allow them to apply the information and have a template for what to do when the real situation arises: “This time of the calm before the storm has allowed for this to happen. It has given us the opportunity to hone our skills and protect our staff.”
After a simulation exercise, teams discuss how they did.
“It’s really the debrief where a lot of the reflection and learning happens,” says Jennifer Dale-Tam, a nurse and simulation educator at the Ottawa Hospital. In 10 to 15 minutes, she says, the team can discuss what went well, how they functioned as a team in a crisis situation, and what challenges came up.
Varner says that simulations were common practice in her hospital even before COVID-19 but that these scenarios have helped establish new processes for patients with infections.
One question that arose: how the “dirty” team inside the room could communicate with the “clean” team outside without opening the glass doors.
In Varner’s hospital, they solved the problem by placing baby monitors in the room so that those outside could hear what was happening. In other hospitals, the solution was to use markers to write messages on the glass doors.
Posner says that, as COVID-19 could affect any department in the hospital, simulations have been run in the obstetrical unit and the diagnostic-imaging department and for housekeeping staff. “It’s not just docs who are on the front line,” he says.
By late March, it was no longer appropriate to have groups of health-care workers gathering to run simulation exercises, Posner says. So his program started running the scenarios with a small group: the sessions were filmed with a virtual-reality camera and then made available for remote viewing. “I am now a part-time obstetrician and part-time video editor,” he says. “I can’t provide an in situ experience, but I’m trying to give an immersive experience.”
Posner’s team has now uploaded more than 10 different videos, some of which have been viewed more than 2,000 times and from as far away as New Zealand.
Some health-care providers have told him that they watch the videos in order to prepare for their upcoming shifts. Dale-Tam notes that nurses are using them to educate themselves and to teach others.
As Ontario’s experience of the COVID-19 pandemic has developed and changed, so, too, have the simulation scenarios. Varner says that, in her hospital, they are just about to start simulating palliative care for COVID-19 patients.
“We need to practise because, typically, these patients don’t come in all at the same time. We may need to manage a complex airway and have difficult conversations about end-of-life care at the same time," she says. "This situation is fairly unprecedented in modern-era medicine.”