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Table 2 Focus areas and ways to address them

From: The use of simulation to prepare and improve responses to infectious disease outbreaks like COVID-19: practical tips and resources from Norway, Denmark, and the UK

Focus area(Learning) goalTarget groupSimulation/education modalityPractical considerationsImplications beyond training
Educational focus
 Infection prevention for healthcare professionalsUse appropriate personal protective equipment (PPE) and clinical equipment as per most recent guidelines.
Increase awareness of infection risk and highlight potential weak points in the protection.
Limit use of PPE to a minimum.
Optimise procedures to minimise infection risk.
All staff who may have patient or family contact• Teaching videos
• Demonstrations
• E-learning
• Skills training
• In situ training
• Peer-to-peer feedback during training and clinical work
• Checklists
For PPE, consider:
• Location of equipment
• Opening
• Donning/doffing
• Controlling correct use
• Hand hygiene
• Disposing
• Decontamination
Consider how to limit PPE use due to its limited availability (e.g. re-using equipment where infection risk allows, using mock-up equipment, combining several goals in one session).
Collaborate with infectious control to ensure up-to-date information is being taught.
Be aware of the time it takes to don PPE (6–7 min) in different settings (e.g. in an ambulance).
Inform other departments about this timing.
Consider how to disseminate learning points into the organisation including common errors observed in training, to avoid these occurring in clinical practise.
 Dealing with an agitated COVID-19 patientEnsuring identification and communication of infection status.
Ensuring own safety including use of PPE and positioning rooms next to exits.
Conflict management, de-escalation techniques, principles of self-defence.
Testing alarm response chains and timings.
All staff who may have patient or relative contact• Demonstration videos
• Role play with simulated patients
• Skills training
• Physical training
• Walkthroughs of rooms
Test resistance of PPE during physical activity before doffing.
Are there weak points that can be strengthened and who should you inform of this (e.g. ambulance services)?
Collaboration with psychiatry is essential.
Consider expert advisors as co-facilitators and set up a training rota.
 Increasing staffing to meet needsEnsure competency of all staff including those redeploying to clinical work.
Be aware of what the organisation requires from staff and consider that this might range from “perfect” to “good-enough”.
Consider additional COVID-19 related tasks, e.g. PPE use, screening, procedures such as airway related treatments.
Pre-graduate students
Professionals with other qualifications e.g. dentists
Retired ex-healthcare professionals
Redeployed external healthcare professionals
Volunteers
• E-learning group discussion
• Pre-recorded remote lectures
• Skills training with feedback
• Role play
• Simulation
• Clinical supervision with feedback
Do sharp needs analysis: what tasks need to be done?
What should your learners not do?
Ensure there is agreement on ways to escalate and call for help.
Attempt to create a cascading model through which information is disseminated.
Consider the quality assurance of your teaching; supervisors to quality control training and clinical practise, content experts (especially infectious control), rapid communication pathways for updates and quality checks.
Ensure organisation has methods of support for staff and clear ways of getting help.
Consider offering debriefs and other forms of support particularly if working with volunteers.
Consider assigning a well-being supervisor.
Show your appreciation in different ways (e.g. coffee and cake).
 Train for making decisions in the face of uncertainty and without regular support structuresBe aware of the new nature of decision making and that support structures may have changed.
Establish a way to make decisions that are satisfactory in terms of processes and outcomes.
Be aware of the emotional impact on decision makers, who may do so at a level they are not used to.
All staff who will be required to make decisions that would previously have been done by more senior or experienced staff.• Case discussions
• Full scale simulations
• Lectures
• E-learning
• Cognitive skills training, for example using the shadow box method [10]
Identify situations for specific target groups in which difficult decisions may be required.
Consider the different types of difficult decisions (e.g. distributing limited resources, selecting between courses of action, when to stop a specific course of action, refusing or withdrawing life supporting treatment, dealing with continuous reprioritising, and tackling conflict).
Clarify with organisational leaders what the legal and organisational frameworks are for the decisions taken.
Ask them to state their view on situations (verbal and non-verbal channels are important).
Prepare a clear and approved overview: who decides what?
 Ensure clear leadership and followership roles where neededUnderstand the pressures they will experience, including those arising from limited resources.
Prepare for their emotional stress and legitimise expression of concerns and acknowledge challenges.
Develop strategies to find leaders and followers and align their roles to organisational procedures.
All potential leaders and followers• Group discussions
• Case examples
• Full-scale simulation
• Presentations
• Sharing of previous experiences
• Cognitive skills training, for example using the shadow box method [10]
Consider an approach that will cater to individual difference, including the changing preferences of leaders and followers over time.
Consider how you will prepare learners for the unknown; they may not know how they will react in a crisis, and reactions between different crisis differ.
Consult with crisis intervention teams if possible.
Consider local customs, policies, and procedures.
System focus
 Optimise the layout and equipment available in COVID-19 rooms/wards
 Use simulation to test systems and improve processes which use these locations
Define equipment and space requirements.
Optimise room layout and equipment.
Optimise processes within the rooms and that use the equipment.
All staff who may have contact with patient on a ward:
• Health care professionals on the ward
• Housekeeping
• Porters
• Maintenance
• Volunteers
• Table top simulation
• Mockups
• Talk-through procedures
• Ceiling cameras to record and optimise walkways that are then replayed
During feedback and facilitation, consider that the needs, values, and attitudes of different professions may differ.
Ensure safety and infection control precautions are taken when borrowing and returning equipment from clinical areas.
Discuss findings with relevant departments and inform them of what does and does not work.
 Optimise flow of patients through the hospitalDesign procedures to minimise the risk of spreading infection by patients and healthcare professionals.All staff who may have patient contact, as well as:
• Site management
• Departmental leads
• Infection control
• Table top simulations
• Walk-throughs
Consider walking through each element so that no parts are overlooked and potential weak areas are highlighted.
Consider creating one way “streets” in patient flow to reduce infection risk.
Involve infectious disease experts.
Disseminate rapidly evolving changes; remember ambulance staff, clinics referring patients to hospital.
 Dealing with the lack of equipmentIdentify potential sources of equipment.
Determine how long and in what circumstances different equipment can safely be used.
Logistical staff e.g.
• Porters
• Receptionists
• Staff who know supply chains and processes
• Computer simulations with spreadsheets (consider COVID-19 patients/day, rate of spread, staffing/ equipment need etc. )[28]
• Physical Mock ups
• Table-top simulations
Support innovative thinking.
Ensure that borrowed equipment is marked so it can be easily returned, and if borrowed from a simulation centre, it is cleared for clinical use.
Consider making emergency level agreements with companies for the delivery of equipment and devices. Social media describe impressive examples.
Personal focus
 Taking care of the well-being of healthcare professionalsConsider ways to keep healthy (beyond avoiding infection).
Consider ways of dealing with fear and stress.
Consider situations in which PPE might lose protective properties.
All staff• Informal sharing of experiences
• Informative material
• Debriefing after certain incidents
• End-of-shift discussion to pass on information
This topic may generate resistance as it might be seen as less relevant. However, where a crisis may be prolonged, it can make a massive difference.
Ensure dedicated well-being staff are available.
Collaborate with staff usually responsible for psychological well-being and work conditions (psychologists, chaplains, occupational health).