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Table 3 Key themes and qualitative outcomes (highest impact and highest frequency) identified across simulations

From: Correction to: COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada

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 an 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
Key Outcomes:
• Remove visitor chairs, extra equipment and linens from room to avoid waste and additional cleaning between patients
• Keep transport routes clear
• Post signage for direction and decrease of clutter
• Creation of supply restocking checklist
• Creation of COVID-19 specific cart of required supplies
• Creation of small, labelled 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;
Key Outcomes:
• Test and walk through the route
• Use signage if COVID-19 routes differ from 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, wheel chairs, etc.)
• Emergency Medical Services should use a common pager Stem: “Possible/Confirmed COVID-19 patient”
• Upon arrival of out of hospital emergency medical services, ensure transport is ready and routes are prepared.
4. Theme: Maintenance of Isolation Environment/Prevention of Contamination Tools/Technology;
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: don’t 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
Key Outcomes:
• A runner role is needed across multi areas Operating Room, Emergency Department, Labour & 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
Key Outcomes:
• Use of dry erase markers on the shared glass walls between 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) or baby monitors
• 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 own professional role to cross teach about PPE
8. Theme: Critical Care Medicine Pre-Intubation Cognitive Aid People/Teams/Tasks;
Key Outcomes:
• Communicate a plan to ensure staff know their roles during intubation
• 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
• They should be clear, easy to use, adaptable to context, staff trained on prior to implementation and pilot tested prior to use on a real patient
• Examples: COVID-19 Airway pause checklist, checklists for buckets and carts/bins, IPAC Donning & Doffing Poster