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

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

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 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;

Environment;

Tools/Technology

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;

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: 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

Environment

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

People/Teams/Tasks

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;

Tools/Technology;

Organization

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