Download - Multidisciplinary simulation training for endotracheal

1So EHK, et al. BMJ Simul Technol Enhanc Learn 2021;0:1–9. doi:10.1136/bmjstel-2020-000766

Multidisciplinary simulation training for endotracheal intubation during COVID-19 in one Hong Kong regional hospital: strengthening of existing procedures and preparednessEric H K So,1 N H Chia,1 George W Y Ng,1 Osburga P K Chan,2 S L Yuen,3 David C Lung,4 W C Li,3 S S So,1 Victor K L Cheung 1

Original research

To cite: So EHK, Chia NH, Ng GWY, et al. BMJ Simul Technol Enhanc Learn Epub ahead of print: [please include Day Month Year]. doi:10.1136/bmjstel-2020-000766

► Additional supplemental material is published online only. To view, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjstel- 2020- 000766).

1Multi- Disciplinary Simulation and Skills Centre (MDSSC), Queen Elizabeth Hospital, Hospital Authority, Kowloon, Hong Kong2Quality & Safety Department, Hospital Authority Kowloon Central Cluster, Kowloon, Hong Kong3Central Nursing Division, Hospital Authority Kowloon Central Cluster, Kowloon, Hong Kong4Department of Pathology, Hospital Authority Kowloon Central Cluster, HKSAR, Hong Kong

Correspondence toVictor K L Cheung, Multi- Disciplinary Simulation and Skills Centre (MDSSC), Queen Elizabeth Hospital, Hospital Authority, Kowloon, Hong Kong; cheungklv. iop@ gmail. com

Accepted 12 May 2021

© Author(s) (or their employer(s)) 2021. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ.

ABSTRACTIntroduction In early 2020, our hospital responded with high alertness when novel coronavirus SARS- CoV-2 appeared. A hospital- based training programme was rapidly arranged to prepare staff for the imminent threat.Objective We developed a hospital- wide multidisciplinary infection control training programme on endotracheal intubation for healthcare workers to minimise nosocomial spread of COVID-19 during this high- stress and time- sensitive risky procedure.Methodology Major stakeholders (Quality & Safety Department, Infection Control Team, Central Nursing Division, high- risk clinical departments and hospital training centre) formed a training programme task group. This group was tasked with developing high- fidelity scenario- based simulation training curriculum for COVID-19 endotracheal intubation with standard workflow and infection control practice. This group then implemented and evaluated the training programme for its effectiveness.Results 101 training classes of 2- hour session were conducted from 5 February to 18 March 2020, involving 1415 hospital staff (~81% of target participants with training needs) either inside the hospital training centre or as in situ simulation training (intensive care unit or accident and emergency department). Learners’ satisfaction was reflected by overall positive response percentage at 90%. Opinions of participating staff were incorporated into the standard airway management and infection control practice for endotracheal intubation of adult patients with COVID-19. Thirty- five patients with COVID-19 were intubated with the current workflow and guideline without any nosocomial transmission.Conclusion An early planned and well- structured multidisciplinary hospital- wide simulation training programme was organised expeditiously to provide extensive staff coverage. The insight and experience gained from this project is valuable for future infectious disease challenges.

INTRODUCTIONHospital Authority, a statutory body established under the Hospital Authority Ordinance of Hong Kong Special Administrative Region in 1990, has been managing 43 public hospitals and 122 outpa-tient clinics with over 84 000 staff members and 29 000 beds for the 8 million population. After Hong

Kong suffered a great loss from severe acute respira-tory syndrome (SARS) outbreak in 2003,1 the Hong Kong Centre for Health Protection was established and policy was set up to face any similarly drastic and swift challenge because history repeats itself.2

After the first reported cases of pneumonia of unknown aetiology (SARS- CoV-2) detected in Wuhan City, the Government and Hospital Authority Head Office of Hong Kong SAR raised the response level to ‘serious’ on 4 January 2020. Queen Elizabeth Hospital (QEH) received the first confirmed case on 23 January 2020, and the region raised to the highest emergency response level on 25 January 2020. Without hesitation, our hospital chief executive and senior management proactively

What is already known on this subject

► COVID-19 poses a major threat for healthcare system and there are high causalities in healthcare workers (HCWs) which can cripple the system.

► Endotracheal intubation is the most consistently high- risk aerosol- generating procedure that causes the nosocomial spread of COVID-19 and other contagious acute respiratory diseases to HCWs.

► Simulation training can bridge the knowledge gap, enhance skill competency and alleviate anxiety of HCWs.

What this study adds

► Hospital- wide training programme for contagious disease like COVID-19 can still be implemented early in outbreak with coordinated effort.

► With limited resources and time, the focus of COVID-19 training should be on three areas: individual infection control practice optimisation, team work designation to minimise exposure and workflow reorganisation to contain contamination.

► Frontline HCWs opinions can be effectively and efficiently incorporated into hospital workflow through training for COVID-19 preparedness.

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2 So EHK, et al. BMJ Simul Technol Enhanc Learn 2021;0:1–9. doi:10.1136/bmjstel-2020-000766

Original research

launched a preparatory plan that included a comprehensive hospital- based training programme as part of it before WHO declared Public Health Emergency of International Concern for this disease. The training programme was aimed to be organ-ised as soon as possible with extensive coverage at all frontline staff level within a short period in anticipation of COVID-19 patient surge. Hospital Quality & Safety Department convened a multidisciplinary training programme task group composed of relevant stakeholders.

High- fidelity scenario- based simulation training has been used as an educational tool to improve individual and team perfor-mances through deliberate practice.3–8 It can enhance staff preparedness, improve systems and protocols and ultimately patient safety.9 Simulation is an excellent method to prepare healthcare workers (HCWs) and systems for disaster response.10

Close airway contact of critical patients during aerosol gener-ating procedures with failure of infection control practice was proven to increase risk of SARS transmission to HCWs.11 Bag mask ventilation and endotracheal intubation are deemed as aerosol- generating procedure. The evidence suggests that performing or exposure to endotracheal intubation, either by itself or combined with other procedures (eg, cardiopulmonary resuscitation or bronchoscopy), is the most consistently associ-ated risk factor of nosocomial transmission of acute respiratory infections.12 13 Viral load of the patient with COVID-19, contam-inated environment together with aerosol generating nature of the procedure account for its high infectivity to HCWs. Chris-tian et al14 recommended in addition to provision of proper personal protective equipment (PPE) for staff performing this ‘high- risk’ procedure, the administrative controls and envi-ronmental controls should also be included in the systematic approach to this problem. Caputo et al15 also suggested that protection guidelines alone failed to prevent SARS transmission to HCWs. Mission of this training programme task group was to prepare the simulation training scenario for COVID-19 endo-tracheal intubation, define the role of different teams, modify the guidelines and workflow logistics and integrate feedback and opinions of trained staff into the hospital standard of practice.

The desired outcome was a critical mass of hospital HCWs to go through the training programme. They would be trained with endotracheal intubation practice with proper infection control measures for critical patients with COVID-19 to provide safe, timely and quality patient care. Moreover, the proper and up- to- date infection control principles, measures and skills in general practice could also be promoted and conveyed in the training programme. This paper records the preparation, arrange-ment, process, impact and the outcome of the hospital training programme in face of COVID-19 disease.

METHODSThe training programme task group for critical COVID-19 endotracheal intubation was convened by the Quality & Safety Department. Members included representatives from Accident & Emergency Department, Central Nursing Division, Infec-tion Control Teams, Department of Anaesthesiology & Oper-ation Theatre Services, Intensive Care Unit, Multi- disciplinary Simulation and Skills Centre and Resuscitation Committee. These departments were either involved in the treatment of crit-ical patients with COVID-19 or responsible for hospital staff training. The training programme was subsequently coordi-nated, prepared and implemented by Central Nursing Division and training centre, as well as supported by Infection Control Teams.

Emergency airway management outside the operating theatre involves multidisciplinary collaboration in an unfavourable physical environment under great time stress. After the training, the learners were expected to perform proper donning and doffing of PPE, to practice the procedure under standard guide-lines and to work as a team with clear role delineation defined by protocol. The task group reviewed the WHO guideline on respiratory infections,16 Hospital Authority Head Office infec-tion control guideline,17 expert opinion of hospital Infection Control Teams and literature on nosocomial SARS transmission and its related training.

WHO clinical management of 2019-nCoV infection is suspectedIn the table of ‘How to implement infection prevention and control measures for patients with suspected or confirmed 2019- nCoV’ and section on ‘Management of hypoxemic respiratory failure and acute respiratory distress syndrome’,16 recommen-dations are:1. Contact precaution for protection against transmission from

contact with contaminated surfaces or equipment in contam-inated environment like airborne infection isolation room. – Use PPE when entering and remove it when leaving the

room. – Use either disposable or dedicated equipment (eg, stetho-

scopes, blood pressure cuffs, and monitors). – Avoid patient movement or transport.

2. Airborne precaution against infective aerosol generated during procedures like endotracheal intubation – All HCWs performing aerosol- generating procedures use

PPE, including gloves, long- sleeved gowns, eye protec-tion, fit- tested N95 or higher level of protection respi-rators.

– Avoid the presence of unnecessary individuals in the room.

– Endotracheal intubation should be performed by a trained and experienced provider using airborne precau-tions.

Hospital Authority Head Office infection control guideline and toolkitAccording to Hospital Authority,17 recommendations are:1. N95 respirators, face shield/goggles for eye protection, dis-

posable isolation gown (Association for the Advancement of Medical Instrumentation, Level 3), gloves with proper hand hygiene for aerosol- generating procedures in both high- risk patient areas and other patient areas (recommended PPE un-der serious response (S2) and emergency level, 81 of 126 slides).

2. Assign trained staff with full PPE for the procedure and limit the number of staff in the room during the procedure (man-agement of aerosol- generating procedures in general ward).

Development of scenario designCOVID-19 training scenario prototype was prepared by nurse educators with input of simulation training experts and other clinical specialists. It was set as a deteriorating patient with COVID-19 requiring endotracheal intubation. Details of role delineation, responsibility and collaboration of Parent Team and Central Resuscitation Team, clean and non- clean zone segregation to minimise staff and environmental contamina-tion were included. Learners were required to work as a team to manage this patient under proper infection control measures

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against infectious respiratory droplets and fomites in a rela-tively closed environment. Airway management workflow was based on the ‘Measures for Intubation in General Ward/ Air- borne Infection Isolation Room) during nCoV (Novel Corona-virus which was subsequently named as COVID-19 by World Health Organisation on 11 February 2020) Period’ for emer-gency endotracheal intubation formulated by Department of Anaesthesiology & Operation Theatre Services. At the same time, the department had also promulgated the ‘Recommended safety measures for emergency intubation in General/ Isolation Wards during COVID-19’ (online supplemental appendix A) to all hospital medical and nursing staff in early February. By the time the learners joined the training courses, they already had some ideas of the latest arrangement and this recommendation. The scenario prototype was then vetted by the task group and finalised after a trial run observed by major stakeholders (online supplemental appendix B, scenarios of COVID-19 simulation training for isolation ward).

The training goals were to enhance the knowledge and skills of learners and different teams to help them protect themselves, work more collaboratively and use valuable resources rationally. Cognitive, procedural, communication and team work domains were covered in the training courses. The simulation instructors ensured that every step of donning and doffing of appropriate PPEs for airborne/droplet protection including test- fit N95, face shield±goggle, cap, gloves and water- proof gown were properly practiced in the training. Mistakes in infection control practice by HCWs were noted and corrected.

Just before the activation of the emergency response level, Hospital Authority Head Office announced cancellation of corporate training courses up to June 2020. This move gave the training centre maximal flexibility for training resources allocation to prepare and organise COVID-19 training classes instantly. The curriculum was designed with the aim to enhance staff protection, minimise staff exposure and environmental contamination with patient safety secured. The training class titled ‘Infectious Disease Practice Drill and Refresher Training (Novel Coronavirus)’ rolled out from 5 February to 18 March 2020. A standardised and unified workflow was developed in the training programme and adopted for subsequent clinical practice.

Considerations in procedures and setting of simulation trainingSupported by experienced simulation educators with profes-sional certificate in train- the- trainer programme accredited by Monash University, simulation training was conducted either in simulation lab for isolation ward and general ward staff or in the real clinical environment as in situ simulation inside accident and emergency (A&E) department and intensive care unit (ICU) for respective teams. The duration of each training session was 2 hours, covering: (1) briefing/familiarisation, (2) scenario- based simulation, (3) skills practice on doffing (and return demo), (4) debriefing, (5) discussion and sharing of common pitfall in caring of patient during aerosol generating procedures, as well as (6) evaluation/questionnaire (as in online supplemental appendix B, P.2 duration).

For each session, there were three to four trained instructors observing and recording notes in real time. After each training session, instructors held a debriefing with the participating team members and observers. Instructors led the discussion and reflection of participants on infection control performance, team work, compliance to protocol and other observed issues. Concerns and great ideas of the trained staff were shared

during debriefing. These were collected and communicated with relevant stakeholders, including hospital senior manage-ment. Simulation was thus used both for training and process modification.

Training in the simulation lab, A&E and ICU proceeded simul-taneously so that more staff could be trained within a limited period of time with minimal disturbance to service. Priority of training in simulation lab was given to staff working in isola-tion ward who took care of confirmed patients with COVID-19. Training of general ward staff who took care of asymptom-atic patients commenced after training of isolation ward staff had accomplished. As different types of HCWs were infected in SARS, training was not limited to one profession but to all HCWs in close proximity to patients with COVID-19 in the ‘high- risk’ procedure (see figure 1).

In order to conserve the PPE, which was in shortage for frontline clinical use, the genuine PPE was replaced by simu-lated PPE for training purpose. Examples included the use of industrial N95 masks, training centre three- dimensional printed visors and house- made face shields by centre simula-tion technicians, with the considerations of scientific evidence and cost- effectiveness.

Target participants and coverageWith the support of more than 700 doctors and 2500 nurses, QEH is one of the major hospitals providing acute and tertiary referral services for the community. Between financial year of 2019/2020, the amount of annual patient uptake in QEH was more than 113 thousand (table 1). According to a snapshot of hospital statistics (as of 31 March 2020) provided by statistical officer of QEH, 119 and 171 medical and nursing staff were hired in the ICU and A&E Department, respectively. Target participants for training of ‘general wards’ and ‘isolation wards’ (kept rotating staff from a department/ward to another one) were recruited from department of medicine (N=680, 39%), surgery (N=247, 14%), specialist outpatient (N = 83, 5%) and others (N=454, 26%). Of the 3200 doctors and nurses in QEH, 1754 (55%) from departments stated above were all our potential target participants. Coordinated by the Central Nursing Division, all participants were recruited through nomi-nation received from department heads, department operation managers, nurse consultants and ward managers. Our aim of training coverage for potential target participants was 1400 (about 80%) within 6 weeks.

Figure 1 Training in proper personal protective equipment gear.

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Ethical considerationsEthical approval of the Research Ethics Committee of Hospital Authority was not necessary for medical and nursing education program initiated by high management of Hospital Authority. All participants were asked to complete a written informed consent on confidentiality issues and use of data from course evalua-tion, questionnaire, formal and informal feedback in written or verbal format, formative or summative assessment approved by respective steering committee, as well as audio- visual recording for internal audit, education and research purposes prior to commencement of each simulation training session.

Procedures and measurementsIn line with quality assurance measures for accreditation stan-dards of the Society of Simulation in Healthcare,18 all simulation training courses organised by the Multi- disciplinary Simula-tion and Skills Centre required participants and instructors completing standardised course evaluation forms. By the end of each training session, one set of questionnaires with 35 items (30 rating scales and 5 open- ended follow- up questions) and another set with 13 items (related to training quality of simu-lation session) were distributed to participants and instructors, respectively. Each item was measured on a 5- point Likert scale ranging from 1 ‘strongly disagree’ to 5 ‘strongly agree’. Positive response percentage is operationally defined as the proportion in counts for rating 4 ‘agree’ or 5 ‘extremely agree’ (figure 2).

With excellent interitem reliability (Cronbach’s alpha=0.92), average of summary content validity index (S-CVI/Ave=0.96) and scale content validity index with universal agreement (S- CVI/UA=0.87) reviewed by multidisciplinary committee members, participants’ questionnaire can be categorised into six domains: (1) training needs, (2) training design, (3) simulation, (4) debriefing, (5) feedback on instructor and (6) satisfaction.

Statistical and data analysisTraining deliverables and their distributions were covered with a demographic table prior to inferential statistical analysis. Partic-ipants were stratified by two groups with respective mode of simulation: (1) in situ and (2) lab based. Independent sample t- tests were used for between- group comparison of their popu-lation means of six domains, including: (1) training needs, (2) training design, (3) simulation, (4) debriefing, (5) feedback on instructor and (6) satisfaction. All significant levels of alpha were set at 0.05 (two tailed), if not otherwise indicated. The data were analysed using IBM SPSS Statistics (V.25.0, IBM Corp, 2017).

If there were no significant between- group differences, positive response percentage of different domains would be presented as basic descriptive statistics. On top of that, quan-titative and qualitative feedback from instructors was roughly addressed in order to monitor the quality of simulation training in the lens of professional members in the field. Furthermore, qualitative contents drawn from feedback and opinions from stakeholders throughout the simulation training and debriefing sessions would be included as supplementary information to evoke further discussion.

RESULTSTraining deliverablesOf 101 sessions carried out between 5 February and 18 March 2020, about one- third of simulation classes (A&E=20%;

Figure 2 Questionnaire for participants in COVID-19 simulation training in Queen Elizabeth Hospital. CRM, Crew Resources Management.

Table 1 Hospital size and potential target participants in Queen Elizabeth Hospital (QEH)

Potential target forCOVID-19 sessions

Target departments

Medical staff, n (%)

Nursing staff, n (%)

Annual patient uptake(1 April 2019 to 31 March 2020)(as of 31 March 2020)

In situ – ICU Intensive Care Unit

14 (4) 105 (7) 162

In situ – A&E Accident & Emergency

46 (14) 125 (9) 172 435

Simulation lab- based - ’Isolation Ward’ or‘General Ward’

Medicine 116 (34) 564 (40) 39 916

Surgery 59 (18) 188 (13) 17 260

Specialist Outpatient*

/ 83 (6) 619 131

Others 98 (30) 356 (25) 56 326

QEH inpatients(n=1754)

333 (19) 1421 (81) 113 664

‘Others’ included anaesthesiology and operation theatre service, orthopaedics and traumatology, obstetrics and gynaecology and clinical departments otherwise not specified.*Unlike nurses, doctors who worked for Specialist Outpatient Department were those actually working in other relevant clinical departments (eg, consultants from specific department would spend time on outpatients session according to their clinical schedule). Patient intake from Accident & Emergency and Specialist Outpatient will be excluded from Annual Patient Uptake of QEH Inpatients between 1 April 2019 and 31 March 2020.

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ICU=14%) was in situ in respective departments and two- thirds (isolation ward=30%; general ward=36%) was lab based in the training centre. Within this period under intense time and resources constraint, 1415 hospital staff members, including 1167 nurses, 163 doctors and 85 other professionals, were trained (see table 2 for ‘demographic table’). As a result, the number of trained potential target in crash courses, in either in situ or simulation lab- based mode was 1415 out of 1754 (81%). Total 1186 evaluation forms were collected from participants (response rate=84%).

Quantitative feedbackRegarding modes of simulation training, no significant mean differences between in situ and lab- based mode of simulation training were found (p>0.05) for all components in the ques-tionnaire, in terms of training needs, training design, simulation, debriefing, instructor feedback and satisfaction. For participants, mean scores of positive response percentage ranged from 88% to 91% for all domains (table 3). For instructors, 74 evaluation forms were received from training of isolation ward (31%) and general ward (69%). Mean scores of positve response percentage ranged from 96% to 100% for all items (table 4).

Qualitative feedbackOn top of rating scores, instructors from both isolation and general ward expressed their appreciation of teamwork, communication and support from all involved departments. They reflected on observations and correction of learners’ non- adherence to hospital recommendation on doffing of PPE just in time before actual outcome. Learners and instructors recognised

the importance of on- site support from Infection Control Teams to respond with professional advice, especially on stan-dard procedures of donning and doffing of PPE and proper case transfer management. Under evolving conditions of the pandemic, learners unanimously agreed that their knowledge, skills and confidence were greatly enhanced by the training.

Insight from debriefing sessionsPost- training debriefing session served as an open discussion platform to incorporate bidirectional opinions into the standard airway management and infection control practice for endotra-cheal intubation in adult patients with COVID-19. Examples of

Table 2 Demographics table of COVID-19 simulation training course

Based on attendance record Number of session Number of attendance Simulation setting

Trained groups Counts (%) Counts (%) In situ Lab based

Accident & Emergency 20 (20) 129 (9) ✓ ✗

Intensive Care Unit 15 (14) 116 (8) ✓ ✗

Isolation Ward 30 (30) 544 (38) ✗ ✓

General Ward 36 (36) 626 (45) ✗ ✓

Based on attendance record In situ Lab- based

Counts (%) Counts (%)

Type of HCWs Doctors 59 (24) 104 (9)

Nurses 176 (72) 991 (85)

Others 10 (4) 75 (6)

Based on evaluation forms returned In situ Lab- based

Counts (%) Counts (%)

Gender Female 108 (66) 725 (70)

Male 56 (34) 311 (30)

Year(s) of clinical experience <3 32 (20) 322 (31)

3–6 50 (30) 186 (18)

7–10 54 (33) 318 (31)

11–15 18 (11) 85 (8)

>15 10 (6) 124 (12)

Department of participants Accident & Emergency 73 (45) / /

Intensive Care Unit 91 (55) / /

Anaesthesiology & Operation Theatre Service / / 87 (8)

Medicine / / 454 (44)

Surgery/Neurosurgery / / 245 (24)

Others / / 250 (24)

‘Others’ included Orthopaedics & Traumatology, Obstetrics & Gynaecology and otherwise not specified.HCW, healthcare worker.

Table 3 Learners positive response percentage on COVID-19 simulation training for all trained groups

Trained group: A&E ICUIsolation ward

General ward Overall

Domains PR% PR% PR% PR% PR%

Training needs 95 86 90 92 91

Training design 98 84 88 91 90

Simulation 96 83 85 91 88

Debriefing 97 89 90 92 91

Feedback on instructor

97 84 87 97 89

Satisfaction 96 83 88 91 89

Overall 97 85 88 91 90

A&E, Accident & Emergency Department; ICU, Intensive Care Unit; PR%, Positive Response Percentage.

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reflection included: (1) proper hairdressing to avoid breaching infection control principles in doffing of PPE, (2) clarifica-tion of handling clinical waste for patients with COVID-19 in different clinical areas, (3) minimised circuit disconnection by preconnecting the bag- mask device or ventilator circuit with necessary components like viral/bacterial filter and closed circuit suction set; (4) putting prepacked resuscitation items on top of emergency- trolley in general ward and keeping one defibrillator in non- clean zone; and (5) raised staff awareness of how proper donning and doffing of PPE could build up patient safety climate from personal level to community level. Some of these opin-ions and feedbacks were conveyed to stakeholders, which were adopted and integrated into the standards of clinical practice.

DISCUSSIONCOVID-19 pandemic has struck almost every part of the world with heavy casualties. The impact is colossal with faster, wider and deeper spread compared with SARS. It has also imposed tremendous burden on healthcare system in different coun-tries. Millions of people have been infected and thousands have succumbed. Hong Kong is one of the first batches of affected regions. Up to 12 August 2020, Hong Kong has recorded more than 4200 confirmed cases with 58 deaths after 6 months. HCWs are the highest risk profession due to nosocomial transmission. In the USA, over 130 000 HCWs are infected with reported death over 600.19 Over 600 nurses died from COVID-19 worldwide.20 Every single HCW occupationally acquired COVID-19 was demoralising and was a dangerous source of nosocomial spread to other hospital patients and staff. SARS- CoV-2 was transmitted

in hospitals through contact, respiratory droplet spread as well as certain aerosol- generating procedures. With the agonising SARS experience and the initial inconspicuous nature of this COVID-19, our hospital decided to prepare early for the anticipation of COVID-19 disease. Training was one of the best approaches to engage and mobilise staff, to standardise our practice and to effectively use our resources within the tight time constraint. Our hospital adopted the just- in- time simulation training, enabling healthcare workers to rehearse infection control measures and entire workflow in teams prior to performing aerosol- generating procedures with confirmed or suspended COVID-19 patients in designated wards.21

We decided to strengthen our staff preparedness and process through high- fidelity simulation training. Simulation provides an opportunity for deliberate practice in a safe environment.18 It can rapidly facilitate hospital preparation and education of large number of HCWs with proven values.3 13 A ‘relatively small’ amount of education with the correct and well- chosen objectives was believed to be associated with a significant increase in adher-ence to infection control practice and provide safety benefits.11 22 The workforce capacity, workflow logistics and processes can be optimised through simulation training even in healthcare organisation under pressure.13. In 6 weeks’ time, a large group of staff from both high risk and general ward areas were trained up with standard infection control and endotracheal intubation practice guidelines under clear role delineation to scale up the workforce. American Heart Association recently complied and published an interim guidance to address the gap in its cardio-pulmonary resuscitation guidelines for providing resuscitation of patients with COVID-19.23 Most, if not all, of its recommended new measures echo our hospital intubation protocol for patients with COVID-19 released in February.

Policy and guidelines that were well planned and well written must combine with appropriate training to achieve optimal effect. A study of questionnaires from HCWs who performed endotracheal intubation in SARS revealed that staff concerns changed over time.15 Staff concerns gradually shift from the need for PPE to the need for better training and patient care proto-cols. HCWs also perceived that their experiences were ineffec-tively integrated into guidelines and protocols. The participating HCWs in our training programme were encouraged to provide feedback to policy makers on the protocols and treatment guide-lines in the debriefing. In this way, their valuable experience and input were rapidly incorporated into treatment guidelines for endotracheal intubation of patients with COVID-19. As a result, learners showed high positive rating percentage in the post- training evaluation.

Three training objectives were met: first, reinforce proper infection control practice; second, contain contamination of staff, environment and equipment; and third, minimise HCWs exposure to highly infectious SARS- CoV-2 during endotracheal intubation for patients with COVID-19. Patients were cared by Parent and Central Resuscitation Teams with close communica-tion for this emergency procedure. Up to early Aug 2020, of the 377 patients with COVID-19 admitted into QEH, 35 were intu-bated due to critical conditions from collected data of A&E, ICU and Anaesthesiology & Operation Threatre Services department. All intubation adopted the workflow and practice being taught in the training programme. The feedback from the Parent Team staff, Central Resuscitation Team members and ICU colleagues were positive, and they had great confidence in adopting the protocol that gave them great sense of safety. According to compilation of hospital statistics from the ICU as of 10 August 2020, there were no adverse events reported on intubation

Table 4 Instructors positive response percentage on COVID-19 simulation training for isolation and general wards

Trained groups: Isolation ward General ward Overall

Items of questionnaire PR% PR% PR%

1) The objectives of the course are clearly stated.

100 100 100

2) The course content is appropriate.

100 100 100

3) The course manuals or materials are clear and useful.

96 100 99

4) The amount of course material is sufficient.

100 100 100

5) The scenarios are properly set. 100 100 100

6) The modalities used in the scenario are appropriate.

100 100 100

7) Learners performed well and actively involved in the scenarios.

100 94 96

8) Learners performed well and actively involved in the debriefing session.

100 94 96

9) The level of course to the learners is about right.

100 100 100

10) The course length is appropriate.

100 100 100

11) The venue is appropriate and well organised.

100 100 100

12) Overall quality of the course is good and recommended.

100 100 100

13) You are willing to teach next time.

96 100 99

Overall 99 99 99

PR%, positive response percentage.

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procedures after training. So far, no single HCW in our hospital has acquired COVID-19 through nosocomial transmission.

The arts of scenario design: how different context affects the way the scenario is set up?There are discrepancies between airway management in isola-tion ward in different contexts when a standard workflow and protocol is applied as indicated in online supplemental appendix A (see 3. Indications and location of intubation). For example, intubation procedures (and application of high- flow oxygen therapy) is not recommended in general ward for patient with suspected nCoV infection. Subsequent arrangement and prepar-ative procedures for patient transfer from general ward to isolation ward would specifically apply to simulation training for ‘general wards’. Such procedures have been included in the set- up of simulation scenarios (see online supplemental appendix B, P.2 scenarios and P.3 checklist remarks).

Any differences in staff perception on simulation training, in terms of ‘mode’ and ‘role’?Our study found that there was no significant difference in staff perception between modes of in situ and lab- based simu-lation. Regardless of mode of simulation training and clinical backgrounds, most participants felt satisfied with the simula-tion training, in terms of training needs (91%), training design (90%), simulation (88%), debriefing (91%) and instructor feed-back (89%).

In order to facilitate learning and reflective process in rela-tively passive role, staff proficiency checklists were distributed to all observers in advance (see online supplemental appendix C). Observers involved in scenario- based simulation and subsequent debriefing session could gain insights from the scenario and enhanced knowledge as much as their counterparts by reflecting on their observation and enhance personal experience in clinical setting.

Distribution of in situ and lab-based simulation: golden ratio or by chance?The distribution of 2/3 in simulation lab and 1/3 in real work-place resulted from maximum capacities in operating simulation training within 6- week duration. To take all factors, such as operation needs, manpower issues, availability of training venues and clinical safety into considerations, the training programme task group decided to implement some management strategies:

► Use parallel mode of simulation (lab- based and in situ). ► Accept quotas for observers.At the time of planning phase of simulation training, A&E

and ICU staff have already been occupied with clinical duties, whereas staff from other departments were awaiting rotation to isolation ward and/or change of ward setting to suspected cases of COVID-19. For A&E and ICU training, in situ simulation could achieve the highest degree of environmental fidelity and provide optimal flexibility for instructors and trainees based on their availability. For training of general ward and isolation ward, simulation lab was considered as an appropriate venue that could balance the risk of infection and occupancy of clinical operation.

Training effect of healthcare simulation on organisation sustainabilityOur simulation training centre and Central Nursing Division were able to rapidly mobilise and conduct appropriate hospital- based training courses to cover a large proportion of relevant

hospital staff within a 6- week period. This type of response is not possible without an investment in simulation educators, techni-cians and robust simulation infrastructure. The training outcome speaks to the value and benefits of the simulation training centre to the organisation. Healthcare simulation had also been used in several healthcare organisations and training centres to evaluate the preparedness in their institutions during the Ebola crisis.10 It can be one of the organisational factors, which may improve safety climate in healthcare setting and help the hospital manage-ment advance service quality by sharpening the focus on patient and system outcomes.

Based on our experience of using simulation for training and modification of the process, we summarise a recommendation list to be considered when faced with an acute need for simulation in a disaster preparedness situation (box 1). ‘Box 1. 4. Implemen-tation of Post- training measures’ served as sustainable measures following the simulation training, including balance between needs/manpower issues and demonstration videos accessible by staff. On top of captioned measures, Central Nursing Division used regular cardiopulmonary resuscitation drills (with checklist regarding PPE proficiency, N95 and hand hygiene) to remind staff of skills related to patients with COVID-19. The retaining intervals for infection control related refreshing course were 2 years.

LIMITATIONSUnder frequent staff rotation and heavy clinical duty of HCWs handling patients with COVID-19, obtaining post- training feedback from participants through structured interview and focus group became unfeasible. With restrictive time for plan-ning of simulation training in 1 week and clinical duty of both participants and instructors, no formal qualitative analysis with anecdotes or themes were conducted, not to mention structural debriefing models. There was no specific model of debriefing considered in the planning phase, given all instructors are quite experienced in healthcare simulation education.

Without formal structured interview or focus group for content analysis, we have only drawn meaningful feedback from open- ended questions, shared opinions during debriefing sessions and informal responses from trained staff who had performed intubation with patients with COVID-19 by the authors under limited time, resources and infection control measures. In addi-tion, post- training feedback from the Parent Team staff, Central Resuscitation Team members and ICU colleagues were collected informally via Department Operation Manager Meeting and Quality & Safety forum with staff at all levels and added to summary table at the back of this paper.

Regarding quantitative analysis on simulation training, results were based on self- report questionnaire from participants, which may be subjective at certain time point. They could neither eval-uate the degree of change in knowledge and skills just after the training nor track the translational effect of clinical effective-ness on high- risk procedures in real clinical practice. Owing to anonymity in rating for all active participants and observers, we could no longer be possible to differentiate their identity in data analysis. Therefore, we have no way to verify whether two popu-lations were homogeneous through subgroup analysis.

Fourthly, healthcare simulation training is only one of all aspects in strengthening preparedness yet connecting frontline worker with up- to- date knowledge and closing gap of knowl-edge and skills. Ongoing monitoring by proficiency assessment of infection control teams is not feasible when hospital service retained normalcy on and off among waves of COVID-19

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pandemic. Accountability for monitoring clinical outcomes and safety issues were shouldered by respective departments, not by coordinators of simulation training.

Lastly, the service flow or procedure change of COVID-19 management could not be evaluated through our training because the main purpose of our simulation was for education, not for ‘stress test’. Other research questions beyond service workflow, such as gadgets for airway intervention using florescence stain to visualise spread of virus, could not be examined through this study as well.

CONCLUSIONSUnder the COVID-19 pandemic threat, we have demonstrated how simulation- based training contributed significantly to prepare the hospital staff, strengthen the protocols and work-flow for endotracheal intubation as part of our hospital response plan. The programme has trained 1415 hospital HCWs (~81% of target participants with training needs) with overall positive feedback within limited time frame. There was zero nosocomial transmission to HCWs during subsequent endotracheal intuba-tion of patients with COVID-19. The insight and experience gained from this training programme is valuable for future infec-tious disease challenges.

Acknowledgements We would like to express our gratitude to the Hospital Authority Head Office and Queen Elizabeth Hospital top management for their operational support to simulation training: Quality & Safety Department for their initiation for workforce establishment; Infection Control Teams, especially Ms S Y

Box 1 Summary of change in strengthening of existing procedures and preparedness plan for COVID-19 pandemic after simulation training

1. Reinforce Infection control practice to improve staff personal protection knowledge and skills

– Correct personal protective equipment (PPE) donning and choose right equipment (like videolaryngoscope) before procedure.

– Proper PPE doffing sequence of contaminated PPE after procedure.

– Understand the importance of buddy system and mutual protection during the procedure.

– Unify the minor variations of different practice for high- risk aerosol- generating procedures in different clinical areas into one standard infection control practice.

2. Contain contamination by reorganising workflow process – Formulate guidelines ‘Measures for Intubation in

General Ward/AIIR during nCoV Period’ for emergency endotracheal intubation by Department of Anaesthesiology & Operation Theatre Services.

– Consolidate workflow for intensive care unit (ICU) transfer of intubated patients to minimise transit time and contamination.

– Minimise circuit disconnection by preconnection of the bag- mask device or ventilator circuit with necessary components like viral/bacterial filter and closed circuit suction set.

– Segregate equipment from clean and non- clean zones to reduce environmental contamination.

3. Minimise staff exposure by designation of team work – Familiarise designated roles and responsibilities of Parent

Team and Central Resuscitation Team in the procedure. – Early recognition of deteriorating patient with COVID-19

by Parent Team to alert Central Resuscitation Team and ICU of potential endotracheal intubation for more preparatory time and lower the risk of transmission.15

– Central Resuscitation Team led by an experienced anaesthesiologist specialist for intubation to minimise the number of attempts and exposure time.

– Active and backup team assigned to limit the number of healthcare workers and avoid unnecessary exposure.

4. Implementation of post- training measures – Follow up with feedback from frontline staff during

debriefing session. – Organise additional COVID-19 related in situ multipurpose

simulation training coordinated by senior nurse management.

– Arrange in situ simulation drills for newly converted isolation ward following the increasing service needs, supported by hospital Quality & Safety Department and Central Resuscitation Team.

– Prepare video clips on COVID-19 proper doffing procedures and endotracheal intubation on hospital intranet accessible to all hospital staff for review and refreshment.

– Strengthen accountability of clinical staff in general practice by promoting the culture that ‘Proper donning and doffing of PPE is every staff responsibility to protect themselves, to protect colleagues, to protect patients, to protect family and community’.

5. Practical tips for effective COVID-19 simulation training

Continued

Box 1 Continued

– Summon relevant stakeholders and experts of the field early to form a multidisciplinary task group.

– Initiate planning of high- fidelity simulation training of infectious disease protocol and practice as an invaluable asset for staff and patient safety in early phase of the outbreak.

– Identify gap of existing practice based on empirical evidence from literature search, expert opinions and/or root- cause analysis (if applicable).

– Stay focus on limited number of well- defined dangerous procedure(s) and its associated workflow(s).

– Take individual and team work, knowledge and skills, complex and context- specific system issues,24 safety issues of the patients and healthcare professionals into accounts.

– Anticipate a number of days needed to train enough staff for a critical mass to achieve a reasonable impact on staff empowerment.

– Listen to the learners as they usually have the solutions for their issues. Collective wisdom is important in this kind of challenge.

– Allow over time for debriefing session to address learners’ level of anxiety, concerns for their own safety and direct relevant questions to Infection Control Team.

– Mitigate HCWs’ pressure and emotional stress by acknowledging their concerns and building sense of being supported and protected in work environment.

– Act as a bridge to bring the learners’ feedback to senior management for consideration, follow- up and incorporate into protocol if appropriate.

– Engage staff into the preparation and implementation phase of new measures or protocols if possible.

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Lee, Mr W K Lo and Ms Naomi Yeung, for their knowledge in up- to- date infection control standards; Central Nursing Division for overall coordination and scenario proposal; Resuscitation Committee, especially Dr K C Lui, for formulation of standard algorithm of aerosol- generating procedures and other high- risk procedures; and all administrative and technical staff members in Multi- disciplinary Simulation and Skills Centre for their active involvement and intellectual input in converting conceptual ideas into feasible plan throughout the training and data management processes.

Collaborators Eric H K So, N H Chia, George W Y Ng, Osburga P K Chan, S L Yuen, David C Lung, W C Li, S S So and Victor K L Cheung.

Contributors Conceptualisation: all authors. Methodology: EHKS, NHC, GWYN, SLY, SSS and VC. Software: EHKS, SLY, SSS and VC. Validation: all authors. Formal analysis: EHKS, SLY, SSS and VC. Investigation: EHKS, SLY, SSS and VC. Resources: SLY, SSS and VC. Data curation: EHKS, SLY, SSS and VC. Writing – original draft preparation: EHKS, SLY, SSS and VC. Writing – review and editing: all authors. Visualisation: VC. Supervision: EHKS, NHC and GWYN. Project administration: SSS and VC. Funding acquisition: EHKS, NHC, GWYN and SSS. All authors have read and agreed to the published version of the manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not- for- profit sectors.

Competing interests None declared.

Patient consent for publication Not required.

Ethics approval For review on training on education purpose, ethical approval from institutional research ethics committee is not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement The data of this study are available from the corresponding author on reasonable request.

Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.

ORCID iDVictor K L Cheung http:// orcid. org/ 0000- 0001- 5381- 1091

REFERENCES 1 World Health Organisation. Summary of probable SARS cases with onset of illness

from 1 November 2002 to 31 July 2003. Available: https://www. who. int/ csr/ sars/ country/ table2004_ 04_ 21/ en/ [Accessed 08 Apr 2020].

2 Yuen KY. The SARS attack on Hong Kong. Hong Kong Med J 2003;9:302–3. 3 Abrahamson SD, Canzian S, Brunet F. Using simulation for training and to change

protocol during the outbreak of severe acute respiratory syndrome. Crit Care 2006;10:R3.

4 Chopra V, Gesink BJ, de Jong J, et al. Does training on an anaesthesia simulator lead to improvement in performance? Br J Anaesth 1994;73:293–7.

5 Holcomb JB, Dumire RD, Crommett JW, et al. Evaluation of trauma team performance using an advanced human patient simulator for resuscitation training. J Trauma 2002;52:1078–86.

6 Howard SK, Gaba DM, Fish KJ, et al. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 1992;63:763–70.

7 Larbuisson R, Pendeville P, Nyssen AS, et al. Use of anaesthesia simulator: initial impressions of its use in two Belgian university centers. Acta Anaesthesiol Belg 1999;50:87–93.

8 Ericsson KA, Krampe RT, Tesch- Römer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev 1993;100:363–406.

9 Dieckmann P, Torgeirsen K, Qvindesland SA, et al. The use of simulation to prepare and improve responses to infectious disease outbreaks like COVID-19: practical tips and resources from Norway, Denmark, and the UK. Adv Simul 2020;5:3.

10 Biddell EA, Vandersall BL, Bailes SA, et al. Use of simulation to gauge preparedness for Ebola at a free- standing children’s Hospital. Simul Healthc 2016;11:94–9.

11 Raboud J, Shigayeva A, McGeer A, et al. Risk factors for SARS transmission from patients requiring intubation: a multicentre investigation in Toronto, Canada. PLoS One 2010;5:e10717.

12 Tran K, Cimon K, Severn M, et al. Aerosol- generating procedures and risk of transmission of acute respiratory infections: a systematic review. CADTH Technol Overv 2013;3:e3101.

13 World Health Organisation. Infection prevention and control of Epidemic- and Pandemic- Prone acute respiratory infections in health care. Available: https://www. who. int/ csr/ bioriskreduction/ infection_ control/ publication/ en/ [Accessed 08 May 2020].

14 Christian MD, Loutfy M, McDonald LC, et al. Possible SARS coronavirus transmission during cardiopulmonary resuscitation. Emerg Infect Dis 2004;10:287–93.

15 Caputo KM, Byrick R, Chapman MG, et al. Intubation of SARS patients: infection and perspectives of healthcare workers. Can J Anaesth 2006;53:122–9.

16 World Health Organisation. Clinical management of severe acute respiratory infection when novel coronavirus (2019- nCoV) infection is suspected: interim guidance, 28 January 2020, 2020. Available: https:// apps. who. int/ iris/ handle/ 10665/ 330893 [Accessed 01 Jun 2020].

17 Hospital Authority. HAHO infection control guideline and toolkit, 2020. Available: https://www. ha. org. hk/ haho/ ho/ pad/ Comkit. pdf [Accessed 08 May 2020].

18 Society for Simulation in Healthcare. Accreditation standards, 2016. Available: https://www. ssih. org/ Credentialing/ Accreditation/ Full- Accreditation [Accessed 11 Mar 2021].

19 Centers for Disease Control and Prevention (CDC). Cases in the US. Available: https://www. cdc. gov/ coronavirus/ 2019- ncov/ cases- updates/ cases- in- us. html [Accessed 12 Aug 2020].

20 International Council of Nurses (ICN). More than 600 nurses die from COVID-19 worldwide. Available: https://www. icn. ch/ news/ more- 600- nurses- die- covid- 19- worldwide [Accessed 01 Jun 2020].

21 Agency for the Healthcare Research and Quality. Healthcare simulation dictionary, 2020. Available: https://www. ahrq. gov/ news/ second- edition- healthcare- simulation- dictionary. html [Accessed 11 Mar 2021].

22 Shigayeva A, Green K, Raboud JM, et al. Factors associated with critical- care healthcare workers’ adherence to recommended barrier precautions during the Toronto severe acute respiratory syndrome outbreak. Infect Control Hosp Epidemiol 2007;28:1275–83.

23 Edelson DP, Sasson C, Chan PS, et al. Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19: from the emergency cardiovascular care Committee and get with the Guidelines- Resuscitation adult and pediatric task forces of the American heart association. Circulation 2020;141:e933–43.

24 Brazil V. Translational simulation: not ’where?’ but ’why?’ A functional view of in situ simulation. Adv Simul 2017;2:20.

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jstel-2020-000766 on 25 May 2021. D

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http://creativecommons.org/licenses/by-nc/4.0/

http://orcid.org/0000-0001-5381-1091

https://www.who.int/csr/sars/country/table2004_04_21/en/

https://www.who.int/csr/sars/country/table2004_04_21/en/

http://www.ncbi.nlm.nih.gov/pubmed/12904622

http://dx.doi.org/10.1186/cc3916

http://dx.doi.org/10.1093/bja/73.3.293

http://dx.doi.org/10.1097/00005373-200206000-00009



http://dx.doi.org/10.1037/0033-295X.100.3.363

http://dx.doi.org/10.1186/s41077-020-00121-5

http://dx.doi.org/10.1097/SIH.0000000000000134

http://dx.doi.org/10.1371/journal.pone.0010717

http://dx.doi.org/10.1371/journal.pone.0010717



https://www.who.int/csr/bioriskreduction/infection_control/publication/en/

https://www.who.int/csr/bioriskreduction/infection_control/publication/en/

http://dx.doi.org/10.3201/eid1002.030700

http://dx.doi.org/10.1007/BF03021815

https://apps.who.int/iris/handle/10665/330893

https://www.ha.org.hk/haho/ho/pad/Comkit.pdf

https://www.ssih.org/Credentialing/Accreditation/Full-Accreditation

https://www.ssih.org/Credentialing/Accreditation/Full-Accreditation

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html

https://www.icn.ch/news/more-600-nurses-die-covid-19-worldwide

https://www.icn.ch/news/more-600-nurses-die-covid-19-worldwide

https://www.ahrq.gov/news/second-edition-healthcare-simulation-dictionary.html

https://www.ahrq.gov/news/second-edition-healthcare-simulation-dictionary.html

http://dx.doi.org/10.1086/521661

http://dx.doi.org/10.1161/CIRCULATIONAHA.120.047463

http://dx.doi.org/10.1186/s41077-017-0052-3


1

Appendix A. “Recommended safety measures for emergency intubation in General/Isolation

Wards during COVID-19”

_____________________________________

Measures for Intubation in General Ward/AIIR during the Novel Corona Virus (nCoV)

Period Department of Anaes & OTS, QEH (as at 4 Feb 2020)

Attention to all levels of staff in Dept of Anaes & OTS

1 Background:

1.1 Standard Precautions should be undertaken for all patients.

1.2 All intubation procedures are labeled as high risks aerosol - generating procedures,

hence Air Borne, Droplet, Contact Precautions and Full PPE should be undertaken.

2 When will the following measures be adopted or stand down:

2.1 The following measures should be followed when:

2.1.1 HKSAR Government /HA declares/activates S1 (Serious Response Level)

level or above

2.1.2 OR the patient’s clinical conditions suggest a serious respiratory disease possibly of infective origin.

2.2 The following measures can stand down when HKSAR Government /HA declares

the response level to “Alert Response level” or below.

3 Indications and Location of Intubation:

3.1 Airborne Infection Isolation Room (AIIR)

3.1.1 Parent team consults Intensivist to access patient if oxygen requirement reaches

4L/min through nasal cannula but clinically stable.

3.1.2 Parent team consults Anaesthetist through “911” activation to intubate the

patient in AIIR if oxygen requirement reaches 4L/min through nasal cannula

and clinically indicated. Parent team should inform Anaesthetist about patient’s nCoV infection status (e.g. suspected/ confirmed/ enhanced surveillance done).

After intubation, parent team consults Intensivist to assess for ICU admission.

3.1.3 If patient develops cardiac arrest, parent team should start CPR in AIIR first and

consult Anaesthetist through “911” activation for intubation. Parent team should inform Anaesthetist about patient’s suspected/confirmed nCoV infection status. Parent team consults Intensivist for ICU assessment.

3.2 General Ward

3.2.1 No intubation should be performed in general ward for patient with suspected

nCoV infection. Parent team should arrange AIIR admission.

3.2.2 Intubation should be performed in AIIR.

3.2.3 Other cases should be intubated in a controlled environment like single room or

side room.

3.2.4 Anaesthetist may call back ward or contact parent team doctor for further

clinical details.

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any relianceSupplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Simul Technol Enhanc Learn

doi: 10.1136/bmjstel-2020-000766–9.:10 2021;BMJ Simul Technol Enhanc Learn, et al. So EHK

2

4 Steps to be undertaken when an intubation request is received:

4.1 When intubation procedures are to be performed for patients who are confirmed or

suspected with air borne / droplet transmission diseases, all staff has to comply with

infection control practice, including eye protection, face shield, suitable N95 mask,

AAMI level 3 protective gown and gloves. Refer to recommended sequence by

Infection Control.

4.2 PPE should be done in the designated “Gown Up” area of the ward. 4.3 All staff must wear N95 mask, the model of which should has been verified by prior

Fit Test.

4.4 Upon arrival to the ward making the request for intubation:

4.4.1 The OTA/AA should leave the intubation case and the DRUG BOX OUTSIDE

the main ward proper e.g. ward corridor to prevent contamination.

4.4.2 The OTA/AA should prepare at “Gown Down” area

4.4.2.1 A big pink plastic bag for placement of contaminated / used equipment

(e.g. laryngoscope blade, bougie) that are to be send to CSSD for

disinfection

4.4.2.2 A big transparent plastic bag for placement of contaminated / used

equipment (e.g. laryngoscope handle, TuoRen video laryngoscope,

Capnograph monitor) that are to be brought back to OT sluice room for

disinfection

4.4.3 OTA/AA should communicate with attending Anaesthetist for additional airway

items (e.g. Videolaryngoscope / Capnograph), otherwise standard items

consisting of:

4.4.3.1 Laryngoscope and blade, usually McCoy size 3,

4.4.3.2 COETT size 7.0mm/8.0 mm or 6.0mm/7.0mm,

4.4.3.3 Intubation stylet,

4.4.3.4 Bougie,

4.4.3.5 Oropharyngeal airways size 2 and 3,

4.4.3.6 Syringe for cuff inflation,

4.4.3.7 Plain gauze,

4.4.3.8 Durapore,

4.4.3.9 Two packs of single use sterile lubricant.

The above items will be brought to the bedside of the patient to avoid

contamination of the intubation case. They are to be placed in a clear plastic

bag with Zip Lock for transport into the ward

4.4.4 The DRUG BOX is to be left OUTSIDE the main ward proper together with the

intubation case. A Zip-Lock bag, with drug labels, containing the following

drugs will be brought along:

4.4.4.1 Propofol 200mg x 1

4.4.4.2 Etomidate 20mg x 1

4.4.4.3 Suxamethonium 100mg x 2

4.4.4.4 Rocuronium 50mg x 1



3

4.4.4.5 Cisatracurium 10mg x 1

4.4.4.6 Atropine 1.2 mg x 1

4.4.4.7 Ephedrine 30mg x 1

4.4.4.8 0.9% NS injection, 10mL x 3

The Anaesthetist should arrange extra drugs if required.

4.4.5 After procedure is completed

4.4.5.1 The syringe for cuff inflation and ALL single-use items (used or unused)

should be discarded appropriately in the ward.

4.4.5.2 Reusable items that will be sent to CSSD (mainly the laryngoscope blade

and bougie) should be placed in the original plastic bag with Zip Lock

and then placed in the big pink plastic bag WITHOUT touching any parts

of the pink bag.

4.4.5.3 Reusable items that will be brought back to OT for disinfection (mainly

the laryngoscope handle, VL and Capnograph monitor) should have the

protective shields removed and then placed into the big transparent plastic

bag WITHOUT touching any parts of the transparent bag.

4.4.6 The drugs, used or unused, should be discarded appropriately in the ward by the

Anaesthetist before leaving.

4.4.7 Gown Down - can only be done in the designated “Gown Down” area.

Procedures of Gown Down:

4.4.7.1 Take off the gloves

4.4.7.2 Wash hands

4.4.7.3 Take off the goggle/ face shield

4.4.7.4 Take off the protective gown

4.4.7.5 Wash hands

4.4.7.6 Take off N95 mask

4.4.7.7 Wash hands

4.4.7.8 Put on surgical mask

4.4.8 Put on gloves and then seal / tie the opening of the pink and transparent plastic

bags tightly. Remove the gloves and WASH HANDS before leaving the ward.

5 After care upon returning to OT:

5.1 Inform Duty Nursing Officer / APN of arrival and return of contaminated equipments

so that nobody will enter the sluice room without PPE.

5.2 Put the transparent bag in the sluice room.

5.3 Bring the large pink bag containing contaminated items to CSSD.

5.4 Go back to OT, gown up full PPE according to proper sequence.

5.5 Clean the intubation case and drug box with large alcohol wipes.

5.6 Go into sluice room and carefully open the transparent bag. Use special disinfection

wipes to disinfect the items e.g. laryngoscope handle, TuoRen VL, Capnograph

monitor etc.

5.7 Put the disinfected items into a plastic box.

5.8 Use large alcohol-wipe to clean the table surface where the transparent bag has been



4

placed.

5.9 Take off PPE according to recommended sequence as above and put on surgical

mask.

5.10 Return the disinfected items to their respective locations.

5.11 The OTA/AA should replenish stocks in the intubation case.

5.12 The drugs in the DRUG BOX should be refilled by Nursing Staff

Labels for use

Airway items placed in Zip Lock bag:

1. Laryngoscope + blade, McCoy size 3

2. Cuffed ETT, 2 sizes

3. Intubation stylet

4. Airways, size 3 and 4

5. Bougie

6. Syringe for ETT cuff inflation

7. Plain gauze

8. Durapore

9. Two packs of single use lubricant

The Anaesthetist should arrange extra items if

required.

DRUGS placed in Zip Lock bag:

1. Propofol 200mg x 1

2. Etomidate 20mg x 1

3. Suxamethonium 100mg x 2

4. Rocuronium 50mg x 1

5. Cisatracurium 10mg x 1

6. Atropine 1.2 mg x 1

7. Ephedrine 30mg x 1

8. 0.9% NS injection, 10mL x 3

The Anaesthetist should arrange extra drugs if

required.

6 Intubation Procedure:

6.1 Plan ahead

6.2 Anaesthetist and OTA/AA wear full PPE

6.3 One Ward Nurse wears full PPE and assists Anaesthetist for drug administration

6.4 One Parent Team Doctor wears full PPE and standby to perform aftercare of patient

after intubation

6.5 Preoxygenation with oxygen through Laerdal bag or nasal cannula

6.6 Anaesthetist performs rapid sequence induction

6.7 Avoid manual bagging (manual bagging without a filter and a tight fit face mask to



5

prevent air leak will result in high risk of disease transmission to staff)

6.8 Intubate and confirm correct position of tracheal tube

6.9 Administer one dose of medium acting muscle relaxant

6.10 Institute mechanical ventilation

6.11 Anaesthetist handovers patient to Parent Team Doctor

6.12 Anaesthetist and OTA/AA perform proper gown down in designated “Gown Down” area before packing up the used items.

6.13 Anaesthetist should perform proper documentation after gown down.

6.14 Anaesthetist and OTA/AA should go back to D3 changing room to take shower as

soon as possible after leaving the AIIR/general ward

7 Cardiopulmonary Resuscitation:

7.1 Follow ACLS algorithm, avoid manual bagging

7.2 Apply Oxygen 6L/min through a nasal cannula during CPR before intubation.

8 Recommendations to Parent Team:

8.1 Sedation: ensure adequate sedation to prevent patient agitation, tube buckling and

accidental self extubation. This is crucial for patient safety and avoid disease

transmission to staff.

8.2 Use close suction system



1

Appendix B. Scenarios of the COVID-19 Simulation Training in Queen Elizabeth Hospital

Infectious Disease Practice Drill and Refresher Training (Novel Coronavirus) 2020

Queen Elizabeth Hospital, Hospital Authority, HKSAR

COVID-19

Simulation

Training

Program

Development

Committee

Accident and Emergency Department (A&E), Queen Elizabeth Hospital

Central Nursing Division (CND), Queen Elizabeth Hospital

Infection Control Team (ICT), Queen Elizabeth Hospital

Intensive Care Unit (ICU), Queen Elizabeth Hospital

Isolation Ward, Queen Elizabeth Hospital

Kwong Wah Hospital Multi-disciplinary Simulation Training Centre

Multi-disciplinary Skills Simulation Centre (MDSSC), Queen Elizabeth Hospital

Quality and Safety (Q&S) Department, Queen Elizabeth Hospital

Learning

Objectives

1. To increase awareness in using appropriate Personal Protective Equipment in performing

Aerosol Generated Procedure

2. To recognize basic hazards in Aerosol Generated Procedure

3. To describe the appropriate Personal Protective Equipment required in Aerosol Generated

Procedure

4. To demonstrate doffing of Personal Protective Equipment (PPE) properly

5. To communicate with relevant people and units for transfer of suspected Novel Coronavirus

Infectious case

6. To provide relevant information to the receiving unit

7. To identify lapse in infection control – buddy system

8. To recognize clean and dirty zone concept

Contents

Pre-requisite/

Pre-reading:

Before the training, all participants should:

complete basic infection control training within 24 months

complete the Proficiency Test on Personal Protective Equipment within 24

months

watch education video on “Transportation of Critically Ill Patient using Portable Ventilator”

read hospital guideline and workflow on inter-hospital transportation of

confirmed case and intra-hospital transfer suspected case

Scenario-based simulation training to increase staff awareness on the importance to use

appropriate Personal Protective Equipment in Aerosol Generated Procedure (AGP) and perform

doffing of PPE appropriately

Briefing of scenario, post-training de-briefing and discussion

Sharing common pitfall in caring of patient during aerosol generated procedure

Assessment Direct observation by instructors ± observers

Evaluation

Evaluation forms (by Multi-disciplinary Simulation and Skills Centre)

Personal Feedback

Instructor’s Feedback

Certificate of

Achievement

Electronic Certificate of Attendance would be awarded to participants after completion of the

training class

Format of

Training

In-situ: A&E, ICU

Simulation lab based: Isolation Ward, General Ward

Participants

(HOT Seats)

A&E ICU Isolation Ward General Ward

A&E Doctor

A&E Nurse in-charge

A&E Nurse x 2

Supporting Staff

Nurse in-charge

Case Nurse

Ward Nurse x2

Parent Team

Doctor

Nurse in-charge

Case Nurse

+/- Ward Nurse

Parent Team

Doctor

Anaesthetist & OT

assistant

Case Nurse

Ward Nurse

Parent Team

Doctor

Anaesthetist and

OTA

No confederate + Patient Care Assistant

(as confederate)

+ Patient Care Assistant

(as confederate)

+ Parent Team Doctor

(as confederate)

+ 2 Observers + 6 Observers + 12 Observers + 6 Observers

Instructor 1. Certified simulation instructors (completed Train-the-trainer program from Monash University)

2. Skills instructors (Infection Control Link Nurse specialized in Infection Control)



2

Duration

Duration Content

10 mins Briefing/ Familiarization

25 + 15 mins Scenario + Skills Practice on Doffing and Return Demo

40 + 20 mins Debriefing, discussion and sharing of common pitfalls in caring of patient

during AGPs

10 min Evaluation & Questionnaire

Scenarios

(Respective

Training

Groups)

Background for A&E

1. A 72-year-old man with history of Diabetes Mellitus on regular Diamicron and Metformin

2. Triage

2.1. TOCC history was negative

2.2. Vital signs BP 128/70, P 110/min, Temp 37.9℃, SpO2 94% in room air, RR 24/min

2.3. Verbalized cough for 2 days without sputum. He had mild shortness of breath since the morning

3. Scenario

3.1. Waiting for doctor assessment in cubicle

3.2. Patient told the staff that he had travel history to China

3.2.1. sought medical advice and diagnosed as chest infection

3.2.2. refuse admission and return to HK

3.3. Increasing shortness of breath, desaturation

3.4. Elective intubation

3.5. Contact relevant staff and unit for arrangement patient transfer

3.6. Perform doffing

Background for ICU


2. On admission




2.4. Histix HHH, urine ketone +++, ABG 7.02/4.5/10/24/-10 on 2L/min

2.5. RFT 130/4.5/3.4/78

3. Inserted two large bores IV for insulin 2 units/hr infusion and 100ml/hr plasmalyte

4. He told the staff that he had increasing SOB and some sweating

5. Patient in Air-borne Infection Isolation Room and on 2L/min Oxygen via nasal cannula

Background for Isolation Ward (Air-borne Infection Isolation Room)


2. On admission

2.1. TOCC (Travel Occupation Contact Clustering) history was positive, visited relatives in Wuhan, China

one week ago

2.2. Vital signs BP128/70, P 110/min, Temp 37.9℃, SpO2 94% in room air, RR 24/min

2.3. Cough for 2 days without sputum and mild shortness of breath since morning

2.4. Awaiting Nasopharyngeal aspirates result.

3. Patient in Air-borne Infection Isolation Room and on 2L/min Oxygen via nasal cannula

Background for General Ward


2. On triage / admission / transfer-in




2.4. ** Surgical Stream General Ward: Abdominal Pain; Back Pain; Head injury

3. Pre-Scenario

3.1. Patient in a 4-bed cubicle, bed 7, IV access available at right upper limb

3.2. Conscious and alert GCS 15, On 4L/min oxygen therapy via nasal cannula, tiredness

3.3. Case Nurse go to bedside to take Blood Pressure

3.4. Patient verbalize shortness of breath, SpO2 88% (no sputum, dry cough), RR 24/min

3.5. Case Nurse Informed Medical Officer for desaturation

3.6. Phone order prepare for elective intubation

4. Scenario

4.1. Case Nurse activate resuscitation

4.2. Nurse B transferred patient to designated single room then prepare equipment



3

Checklist of Simulation Training

Items of the Checklist Compliance

/ Remarks

Personal

Protective

Equipment

Put on appropriate PPE for

Suspected/ Confirmed Case

- Hand Hygiene

- N95 /

- Face Shield

- Level III Gown /

- Cap (Optional)

- Latex Gloves /

Doffing of PPE

- Hand Hygiene

- Remove gloves

- Hand Hygiene

/

- Remove Face Shield

- Remove Cap

- Hand Hygiene

/

- Remove Gown

- Hand Hygiene

- Remove N95

- Hand Hygiene

For A&E, remove

N95 outside

Resuscitation

Room

Bathing after Aerosol Generated Procedure /

Buddy System /

Resuscitation –

Airway

High Flow

Oxygen therapy

- Connect all parts including bacterial filter For General

ward, avoid

high flow

oxygen therapy

- Full PPE before high flow oxygen

- Monitor for any leakage

- Surgical Mask for patient over the nasal cannula or

oxygen mask

Intubation

- Video-assisted laryngoscope

- Disposable blade

N/A for General

ward

- Sedation and muscle relaxant

- Inflate the cuff of ET tube before connecting to

ventilator

Communication

and

Information

Communication

- Alert others for suspected case identified

- Alert others to put on Full PPE

For A&E,

activate

engagement

light outside

Resuscitation

Room

- Closed loop communication

- SBAR: Situation, Background, Assessment,

Recommendation

/

- inform relevant parties for patient transportation /

Information

- Patient condition

- Suspected or confirmed case /

- Precaution

- Designated passage away from overcrowded area /

- Required equipment

- Environmental decontamination after transportation /

Other

Infection

Control

Concept of

Clean and

Dirty Zone

- Proper documentation

- Resuscitation trolley and equipment pool outside AII

Room

- For ICU and

Isolation ward,

document

outside AII

Room

- For A&E and

General ward,

document by

“clean” nurse

- Dirty Zone provide care

- Clean Zone for record and external communication /



Staff proficiency (Review Date: 1 Jan 2020)

Staff Record – Infection Control Practice - Readiness & Competence

Name of staff:

Rank:

Department:

Workplace:

Staff ID:

N95 Fit Test

Date of Test: Suitable Model:



Infection Control Practice – Competence: N95 Fit Check

Yes No Remarks

1. Putting on the mask

1.1 Cover nose and mouth

1.2 Place the uppermost rubber band over the head

1.3 Place the lowermost rubber band at back of neck

1.4 Shape the metal stripe of mask over nose bridge with fingers (both hands)

2. Fit Check

2.1 Inhale – the mask will collapse

2.2 Exhale – no leakage from side of mask




Staff Record – Infection Control Practice – Readiness & Competence

Infection Control Practice – Competence:

PPE Trainer:

Degowning – Sequence and Key Procedures

Yes No Remarks

1. Remove gloves

1.1 Grasp outer surface of glove near wrist of one hand

1.2 Peel glove away turning inside -out and hold the glove in hand

1.3 Slide ungloved fingers beneath the glove of the remaining hand

1.4 Peel off the glove inside-out, bagging the first glove inside

1.5 Hand hygiene

2. Remove face shield / cap/ goggles

2.1 Hold the side strips / hands of face shield / goggles

2.2 Slide forward and away from face

2.3 Grasp the rim of cap, pull backward & sideward

3. Remove gown

3.1 Loosen the ties of the waist

3.2 Hold the tapes at neck on each side, pull apart and peel the gown away, turning

sleeves inside-out one by one

3.3 Roll / fold up the gown inside-out slowly

3.4 Hand hygiene

4. Remove N95 mask

4.1 Lift the lowermost rubber band from back of neck, crossing over the head to the

front

4.2 Lift the uppermost rubber band from head to the front and remove mask

4.3 Hand hygiene

Hand Hygiene – Key Procedures

Yes No Remarks

1. Hand washing with soap & water

1.1 Hands are wet under running water

1.2 Washing agent is applied to all surfaces

1.3 Hands are rubbed vigorously, covering all surfaces, for at least 20 seconds

1.4 Hands are rinsed thoroughly under running water

1.5 Hands are dried well with paper towel

1.6 Water flow is operated without using the washed hands

2. Hand rub with antiseptic lotion

2.1 All surfaces of hands are covered with recommended volume of product

2.2 Hands are rubbed thoroughly till dry

Staff signature: Date:

Verified by: Name: Signature: Date:




Key / Checklist:

1. Training record on infection control should be kept in workplace

Training courses conducted by QEH ICT

Date of training

Title of training course

2. Record of N95 mask Fit Test should be kept in workplace

Date/ Year of last test

Model of N95 mask

Marked “F” in the “yes” column for the staff who failed the test.

3. N95 Fit Check – Key Procedures

Putting on the mask

Cover nose and mouth

Place the uppermost rubber band over the head

Place the lowermost rubber band at back of neck

Shape the metal stripe of mask over nose bridge with fingers (both hands)

Fit Check

Inhale – the mask will collapse

Exhale – no leakage from side of mask

4. Degowning – Sequence and Key Procedures

Remove gloves

Grasp outer surface of glove near wrist of one hand

Peel glove away turning inside-out and hold the glove in hand

Slide ungloved fingers beneath the glove of the remaining hand

Peel off the glove inside-out, bagging the first glove inside

Remove face shield / goggles/ cap

Hold the side strips / hands of face shield / goggles

Slide forward and away from face

Grasp the rim of cap, pull backward & sideward

Remove gown

Loosen the ties of the waist

Hold the tapes at neck on each side, pull apart and peel the gown away, turning sleeves

inside-out one by one

Roll / fold up the gown inside-out slowly

Remove N95 mask

Lift the lowermost rubber band from back of neck, crossing over the head to the front

Lift the uppermost rubber band from head to the front and remove mask

5. Hand Hygiene – Key Procedures

Hand washing with soap & water

Hands are wet under running water

Washing agent is applied to all surfaces

Hands are rubbed vigorously, covering all surfaces, for at least 20 seconds

Hands are rinsed thoroughly under running water

Hands are dried well with paper towel

Water flow is operated without using the washed hands

Hand rub with antiseptic lotion

All surfaces of hands are covered with recommended volume of product

Hands are rubbed thoroughly till dry



香港一所地區醫院在 2019冠狀病毒期間的氣道插管綜合模擬訓練: 強化現有程序及應變措施

摘要

[引言] 廿零二零年初，伊利沙伯醫院由發現嚴重急性呼吸系統綜合症冠狀病毒二型 (SARS-CoV-2) 個案開始高度

戒備。透過迅速安排駐院訓練課程，醫護人員能為逼近眉睫的威脅作好準備。[目標] 我們開發全醫院跨部門感染控

制模擬訓練，從而減低醫護人員在高壓及時效性風險下處理氣道插管程序院內感染。[方法] 主要服務持份者 (包括

質素及安全部、感染控制組、中央護理部、臨床部門及本院培訓中心) 建立了訓練課程專案小組。該小組參照標準

工作流程及感染控制指引，針對 2019 冠狀病毒期間氣道插管程序訂立高仿真度的情景模擬訓練課程大鋼，進而推

行及評估訓練課程的有效程度。[結果] 於 2020年 2月 5日至 3月 18日期間，我們於本院培訓中心及 (深切治療部

及急症室) 實地舉辦了 101回長達 2小時的模擬訓練課程，合共 1,415名 (逾 8成有訓練需求) 的醫護人員受惠。

高達九成參加者對該課程的整體滿意程度給予正面評分。他們的意見被採納於 2019 冠狀病毒期間氣道插管程序標

準氣道管理及感染控制指引。在符合現行標準工作流程及醫院指引下，三十五名確診個案完成氣道插管程序，並沒

有造成院內傳播。 [結論] 迅速地組織有計劃及結構良好的全醫院跨部門模擬訓練，能有效伸延受訓醫護人員的整

體覆蓋率。所得見解及經驗，有助我們面對未來傳染疾病的挑戰。



Download - Multidisciplinary simulation training for endotracheal

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