In-situ simulations for COVID-19: a safety II approach towards resilient performance

Zavi Lakissian,Rami Sabouneh,Joe Fayad,Rim Banat,Rana Sharara-Chami,Rida Zeineddine

doi:10.1186/s41077-020-00137-x

Abstract

BackgroundCOVID-19 has taken the world by surprise; even the most sophisticated healthcare systems have been unable to cope with the volume of patients and lack of resources. Yet the gradual spread of the virus in Lebanon has allowed healthcare facilities critical time to prepare. Simulation is the most practical avenue not only for preparing the staff but also for troubleshooting system’s latent safety threats (LSTs) and for understanding these challenges via Hollnagel’s safety I–II approaches.MethodsThis is a quality improvement initiative: daily in situ simulations were conducted across various departments at the American University of Beirut Medical Center (AUBMC), a tertiary medical care center in Beirut, Lebanon. These simulations took place in the hospital with native multidisciplinary teams of 3–5 members followed by debriefing with good judgment using the modified PEARLS (Promoting Excellence and Reflective Learning in Simulation) for systems integration. All participants completed the simulation effectiveness tool (SET-M) to assess the simulation. Debriefings were analyzed qualitatively for content based on the Safety Model and LST identification, and the SET-Ms were analyzed quantitatively.ResultsTwenty-two simulations have been conducted with 131 participants. SET-M results showed that the majority (78–87%) strongly agreed to the effectiveness of the intervention. We were able to glean several clinical and human factor safety I–II components and LSTs such as overall lack of preparedness and awareness of donning/doffing of personal protective equipment (PPE), delayed response time, lack of experience in rapid sequence intubation, inability to timely and effectively assign roles, and lack of situational awareness. On the other hand, teams quickly recognized the patient’s clinical status and often communicated effectively.ConclusionThis intervention allowed us to detect previously unrecognized LSTs, prepare our personnel, and offer crucial practical hands-on experience for an unprecedented healthcare crisis.

Highlights

COVID-19 has taken the world by surprise; even the most sophisticated healthcare systems have been unable to cope with the volume of patients and lack of resources
Latent safety threats were derived from incidents classified as safety I, and we reviewed the debriefings and organized these based on clinical and human factor issues (Table 1)
Clinical incidents pertained to (1) incorrect donning and doffing of the protective equipment (PPE), which led to safety hazards to both the patient and the healthcare staff; (2) oxygenation: whether it was the use of non-rebreather masks at high flow or bag mask ventilation outside negative pressure rooms, the staff’s lack of knowledge of the changing guidelines with regard to the appropriate choice of oxygen supplementation increased the chances of viral aerosolization; (3) general unfamiliarity and experience with intubation and lack of knowledge of rapid sequence intubation (RSI) procedures and Department Safety I

Summary

Introduction

COVID-19 has taken the world by surprise; even the most sophisticated healthcare systems have been unable to cope with the volume of patients and lack of resources. The gradual spread of the virus in Lebanon has allowed healthcare facilities critical time to prepare. The Washington Post recently reported that “somehow, this messed-up country [Lebanon], teetering on the brink of economic ruin and political chaos, has done something right when it comes to the coronavirus.” [1]. How has a country amid crippling protests since October 2019, soaring food prices, lack of healthcare resources, and a currency in free-fall managed to nearly plateau the COVID-19 curve? The gradual spread of the infection in Lebanon allowed healthcare facilities time to prepare and expand hospital capacity, to the point that there are more beds available than patients to fill them [4]

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Conclusion