Table 3 Highest impact and highest frequency outcomes
| Key themes and qualitative outcomes (highest impact and highest frequency) identified in simulation | Systems categories |
|---|---|
| 1. Theme: Safe doffing (removal of PPE safely and in correct order) |
People/teams/tasks; Tools/technology |
| Key outcomes | |
| Cross monitor team members during doffing | |
| Use and IPAC poster as a cognitive aid | |
| Ensure “1 to 1” doffing to avoid breaches observed when too many doffing at once (e.g., getting ahead or behind in doffing sequence) | |
| Consistent role of a “PPE Coach” to support safe doffing-ensure focus and intention with every step | |
| Implement “just-in-time” review of safe doffing to reduce cognitive load during long stressful periods in PPE. | |
| 2. Theme: Conducting environmental scans of care areas is crucial in anticipating, planning ahead, and developing area processes |
Environment; Tools/technology; People/Teams/Tasks |
| Key outcomes | |
| Remove visitor chairs, extra equipment and linens from room to avoid waste, and additional cleaning between patients | |
| Keep transport routes | |
| Post signage for direction and decrease of clutter | |
| Creation of supply restocking checklist white this | |
| Creation of COVID-19 specific cart of required supplies | |
| Creation of small, labeled packages of specific supplies, or medications for fast grab and go | |
| Ensure team members are aware of the responsibilities required to maintain the space | |
| Ensure cleaning processes for removal of equipment leaving COVID-19 rooms (e.g., stretchers, wheelchairs) | |
| 3. Theme: Conduct inter-departmental/inter-hospital transport routes to establish communication and process between departments and professions |
People/teams/tasks; Environment; Tools/technology |
| Key outcomes | |
| Test and walk through the route | |
| Use signage if COVID-19 routes differ from the usual process | |
| Clean hallways of clutter and reduce traffic if possible | |
| Consider dedicating elevator banks for COVID-19 patients, staff and carts | |
| Establish a designated clean person on transports to ensure surfaces are cleaned (e.g., floors, elevator buttons, stretchers, and wheel chairs) | |
| Emergency medical services should use a common Stem in communication and pages: This line is supposed to be with the one below to read: "Emergency medical services should | |
| “Possible/Confirmed COVID-19 patient” this goes afte the word "pages" in line above | |
| Upon arrival of out of external hospital emergency medical services, ensure transport is ready and routes are prepared. white this Should read; Upon arrival of externa;l hospital emergency medical services, ensure transport is ready and routes are prepared. | |
| 4. Theme: Maintenance of isolation environment/prevention of contamination |
Tools/technology; People/teams/tasks |
| Key outcomes | |
| Removal of stethoscopes, phones, ID badges, lanyards, watches, and earrings from person prior to donning. | |
| When items are on person, reinforce learnings re: do not reach below gown for ID badge/pager/mobile phone; or under visor to adjust goggles/mask. | |
| Creation of bins on an external cart in donning area for dropping items into | |
| Keep numbers of staff in the room low when possible | |
| Ensure cleaning process for roving items such as clipboards, ultrasound machines, etc. | |
| 5. Theme: Roles and responsibilities |
People/teams/tasks; Environment |
| Key outcomes | |
| A runner role is needed across multi areas: Operating Room, Emergency Department, Labor and Delivery Unit, Intensive Care Unit (team member to bring supplies between isolated COVID-19 care area and non-isolated area) | |
| Consider the involvement of HCAs and Unit Clerks to bring necessary equipment required for teams | |
| Establish “clean” and “dirty” sides between rooms and within rooms by taping the floors for a visual cue | |
| Establish CODE COVID-19 team to attend to all rapid deteriorating patients | |
| 6. Theme: Innovative approaches to communication |
Tools/technology; People/teams/tasks |
| Key outcomes | |
| Use of dry erase markers on the shared glass wall of isolation to ante room | |
| Use of a laminated page that can be flipped back and forth | |
| Use of white boards to communicate key messages to outside team members | |
| Use of two-way radios (e.g., walkie talkies) and baby monitors | |
| Limit the use of negative pressure rooms and use ante rooms where available | |
| Use of speaker phone setting | |
| Use of tape on floor to communicate ‘clean versus dirty’ zones | |
| Check that monitors and speakers on phones (especially with PPE on) can be heard | |
| Include name/role tag stickers on outer PPE to ensure role clarity and effective communication | |
| Reduce noise and ensure use of closed-loop communication (additional communication challenges with PPE on) | |
| Use of trigger scripts on pagers to signal a priority response. Scripts like “COVID airway” or “COVID transport” to alert a team and get the right people and the right equipment to the right place. | |
| 7. Theme: Psychological safety and speaking up | People/teams/tasks |
| Key outcomes | |
| Use critical language when breeches in PPE or when overcrowding in rooms occur | |
| Encourage all team members to speak up when they see breaches in safe PPE practices | |
| Removing hierarchical barriers can be challenging; promoting psychology safety is important for a cohesive team | |
| Go beyond your professional role to cross teach about PPE | |
| 8. Theme: Critical care medicine pre-intubation cognitive aid |
People/teams/tasks; Tools/technology; Organization |
| Key outcomes | |
| Communicate a plan ahead to ensure staff know their roles | |
| Double-check proper PPE during intubation | |
| Most experienced practitioner should perform the intubation | |
| Ensure the ventilator and video laryngoscopy device are in the room prior to start | |
| Consider back-up plan depending on available resources | |
| Ensure correct bagger filter is attached | |
| 9. Theme: Use of cognitive aids and checklists | Tools/technology |
| Key outcomes | |
| Consider human factors science in the development of new COVID-19 cognitive aids and checklists | |
| Cognitive aids can be made into posters, use larger font, central point of reference white this | |
| They should be clear, easy to use adaptable to context, trained prior to implement, and pilot tested prior to use on a real patient | |
| Examples: COVID-19 airway pause checklist, checklists for buckets, and carts/bins, IPAC donning and doffing poster white this |