Table 1 The Safety Model on clinical aspects and crisis resource management
From: In-situ simulations for COVID-19: a safety II approach towards resilient performance
Department | Safety I | Latent safety threat identified | Observed participant behavior | Recommended solutions | Observed improvements | Explanations of good performance |
|---|---|---|---|---|---|---|
Clinical aspects | ||||||
PICU, ICU | -PPE donning/doffing technique | -Inadequate staff preparedness in infection control | -Inexperience in donning/doffing PPE -Delay in donning and doffing PPE -Multiple contamination hazards due to lack of prior training in PPE | -Donning and doffing posters at room entrances and exits -Colleagues in the room assist in donning/doffing PPE -Sharing videos of proper donning/doffing technique -Simulations for practicing donning/doffing | -Recognizing the need for additional PPE | -The infection control team and the simulation team led the effort throughout the hospital on the correct donning/doffing protocols. -Donning/doffing videos were produced and e-mailed to the staff; posters were placed on every door to remind healthcare workers of the proper techniques. This not only helped healthcare workers, but patients/families as well. |
-Using non-rebreather mask at a high flow -bag-mask ventilation -Using non-invasive ventilation outside negative pressure rooms | -Increasing the chances of viral aerosolization | -Lack of knowledge of aerosol generating procedures | -Guideline adjustments to include warnings about aerosol generating procedures -Simulations targeting oxygen supplementation | -Choosing non-rebreather facemask as first line oxygen supplementation -Use of MDI instead of nebulizers -Identifying respiratory failure signs | -Participants exhibited adequate knowledge in regard to respiratory therapy due to knowledge dissemination by intensivists and subsequent attendance of skill-specific simulation part-task training sessions organized by the simulation program. -In pre-COVID simulations, timely and accurate oxygenation had been prioritized, participants were aware of the needs and methods, however, were slow in adapting these needs to the nuances of COVID-19 patients. | |
-Aggressive fluid resuscitation in case of shock | -Risk of fluid overload | -Lack of knowledge of fluids restriction guidelines | -Simulations targeting management of shock | -Early inotropic support | -Pre-COVID simulations stressed on the importance of recognizing low cardiac output and the need for early ionotropic support. -Displaying adherence to the “Precautionary Principle” | |
-Inexperience in intubation -Unfamiliar with intubation equipment -Improper rapid sequence intubation (RSI) medication doses -Unfamiliar with proper sequence of connections | -Delay in intubation -Intubation procedure interruptions -Aerosolization of viral particles -Increased risk of aspiration | -Uncomfortable with intubation and its equipment -Unfamiliar with detailed RSI concepts | -RSI training sessions -Simulations targeting intubation | -Recognizing the need for RSI -Proper RSI medications -Not using bag-mask ventilation for pre-oxygenation | -Skills-specific RSI sessions were conducted throughout the hospital and for all residents by the simulation team. When faced with a COVID-19 scenario, residents recognized the need for RSI and followed the new recommendations. | |
-Presence of unnecessary staff in the room -Getting the emergency cart inside the room -In the L&D suite: small space when the infant incubator was placed in the room | -Increase risk of contagion and contamination | -Contamination hazards due to lack of knowledge of proper infection control measures | -Guidance on proper role assignment and environment control -Reorganizing the environment to distance the labor bed from the infant incubator by removing unnecessary furniture from the room | -Preparing necessary medications and equipment outside the room -Obs. team tried their best to avoid contamination -Timely arrival of neonatal COVID team to the room | -Multiple sessions provided by infection control on a weekly basis communicated to the staff the hazards of overcrowding in rooms, the importance of following prevention and contamination protocols. These elements were also alluded to during pre-briefing. -Over time, hospital staff became familiar and comfortable with simulation, calls were not disregarded, and consults arrived to the simulations in a timely manner. | |
CRM | ||||||
PICU | -Disorganization due to lack of leadership and proper role assignment | A fraught atmosphere | -Residents felt stressed, confused and disorganized during the simulation R: Stressful. Very stressful.” “R: We weren’t organized. Multiple people were giving orders at the same time. We should have asked who the leader was, who was making the decisions. -N: It was confusing at first because there was not a clear leader. I did not know who to listen to.” | -Longer pre-briefings, allowing the participants to truly get comfortable in the simulated environment Simulations and subsequent debriefings focused on non-technical skills and teamwork emphasizing timely role assignment, closed-loop communication and sharing mental models -Build a culture of teamwork, flatten the hierarchy, encourage personnel to step up, take charge and speak up without fear -Developing an equipment check list for a more timely and efficient management of resources. Implementing skills training in situ, e.g., CPR in a patient room to familiarize personnel with the positioning of the bed, the location of the board, etc. -Send expecting parents a detailed description of what to expect ahead of labor and follow institutional guidelines | -Closed-loop communication | -This is the result of having participated in multiple high-fidelity simulations in the past and working in multidisciplinary teams. This was particularly helpful in COVID-19 simulations because healthcare workers from different teams were not always necessarily familiar with working together. |
-Inadequate allocation and management of human resources | -At times there were more personnel in the room than needed “R: So many faces! There should not have been that many people. Only essential personnel.” | |||||
-Hierarchical culture, failure to take charge/lead | -The initial leader often took a step back after a senior physician came in, and allowed them to take control without clearly vocalizing and reassigning the role. “F: When I entered I noticed that they were a bit lost and confused so since I am the fellow I decided to take over, but I did not say that I just assumed that leadership was handed to me” | |||||
ICU | -Slow, inefficient response | -Lack of situational awareness | -Residents had difficulty locating and setting up the needed equipment, which delayed their response. -“R: The problem was that we could not find the needed medication on time. The key is to find the proper response at the proper time. That was the stressful part” Residents did not take the necessary measures which would have facilitated their delivery of care such as lowering side rails, using CPR board or lowering the bed -“D: Why weren’t you comfortable doing the CPR? R: Because of our positioning. It was uncomfortable. D: How could you have made it more comfortable for yourself? - R: Maybe lowering or better positioning the bed. We also forgot the board.” | -Residents often rely of nursing staff to be situationally aware of the location of medications, equipment, etc., and in critical instances when they ought to fend for themselves, they are lost. It is imperative that everyone is familiar with the location of the medical carts on the floors, which are identically equipped, and this must be included in the orientation week of all new personnel and refreshers should be given every 6 months. -Often resuscitation or intubation trainings take place on part-task trainers, either places on tables or the floor; therefore, personnel are not as familiar with the most comfortable positioning of the bed when performing life saving measures on actual patients. We propose trainings using the patient bed, and the mechanisms of lowering the rails, the bed, positioning of the board, etc. | -Good role assignment | -This is also is the result of having participated in multiple simulations in the past, prior to this pandemic. So, leaders properly assigned roles and tasks according to the skills, experience, and comfort of available personnel. He/she gave every team member in the room a clear role, reminded them of it in case they got distracted doing something else, and re-shuffled when necessary. |
Obstetrics (L&D) | -Unfamiliarity with in situ simulation in the labor and delivery suite -Disorganization in a small room when the pediatric team arrived -Poor communication with the mother as to what to expect when baby was born | -Need for more hospital-wide multidisciplinary simulation exercises | -During the debriefing session, participants expressed how important and beneficial the hands-on practical aspect of the simulation was. -“R: I feel like this was very important for everyone. It shows you what you need to work on and reminds you of the information that you need to remember. Really every one of us should go through this. Now I feel like I know and understand the guidelines more -R: Everyone should participate in one. It would be good if we can repeat this. Can we do another one next week?” | -Openness and willingness to learn and improve | -Participants acknowledged the shortcomings of their performance and the areas they need to work on. They were quick to ask for help especially that the system supports seeking guidance from seniors or more experienced health providers with no judgment or jeopardy. They showed an aptitude for constructive criticism and readiness to learn and improve their delivery of care in future cases. Being able to admit the times when one is at fault is in itself a positive notion that can be placed under the umbrella of safety II | |