Using simulation for training and to change protocol during the outbreak of severe acute respiratory syndrome

Corresponding author: Simon D Abrahamson 0 Professor of Medicine, Department of Medicine and Division of Critical Care, University of Toronto, St. Michael's Hospital , 30 Bond Street, Toronto, M5W 1W8 , Canada 1 Clinical Leader Manager, Trauma and Neurosurgery Intensive Care Unit, St. Michael's Hospital , 30 Bond Street, Toronto, M5W 1W8 , Canada 2 Assistant Professor of Anesthesia, Department of Anesthesia and Division of Critical Care, University of Toronto, St. Michael's Hospital , 30 Bond Street, Toronto, M5W 1W8 , Canada Introduction During the 2003 severe acute respiratory syndrome (SARS) crisis, we proposed and tested a new protocol for cardiac arrest in a patient with SARS. The protocol was rapidly and effectively instituted by teamwork training using high-fidelity simulation. Methods Phase 1 was a curriculum design of a SARS-specific cardiac arrest protocol in three steps: planning the new protocol, repeated simulations of this protocol in a classroom, and a subsequent simulation of a cardiac arrest on a hospital ward. Phase 2 was the training of 275 healthcare workers (HCWs) using the new protocol. Training involved a seminar, practice in wearing the mandatory personal protection system (PPS), and cardiac arrest simulations with subsequent debriefing. - Introduction Severe acute respiratory syndrome (SARS) is a newly identified atypical pneumonia that can be life threatening. Attention was drawn to the disease in February 2003 when a physician and subsequently 12 other hotel guests staying in a hotel in Hong Kong became ill [1]. One of these hotel guests returned to Toronto, Canada, died on 5 March 2003, and became the index case for Toronto. The Morbidity and Mortality Weekly Report published a description of the SARS outbreak on 21 March 2003 [2]. The SARS virus seemed to be highly contagious in the hospital setting. A case report suggested that intubation of patients produced a high risk for transmission of SARS to healthcare workers (HCWs) [3]. SARS created a crisis in healthcare in Toronto. The lack of literature, uncertainty about treatment, and fear of the disease caused great concern among HCWs. In late April 2003, our Critical Care Department was asked to urgently develop and implement a protocol for the management of cardiac arrest in the SARS patients. At the time there were directives from the Ontario provincial government mandating the use of a personal protection system (PPS) during the intubation of SARS patients [4]. A PPS was defined as 'an apparatus consisting of head, face and neck protection with or without enclosed body protection'. An example of a PPS cited in the directive was the Stryker T4 system (Stryker Instruments, Kalamazoo, MI, USA). ACLS = advanced cardiac life support; CBS = Code Blue Special; HCW = healthcare worker; ICU = intensive care unit; PPS = personal protection system; SARS = severe acute respiratory syndrome. fSourmamSaArRySofpaalgtioernithm for cardiac arrest protocol (Code Blue Special) for a SARS patient. The cardiac arrest scenario was of great concern because care had to be delivered immediately. We knew from previous simulation experience that a HCW required 1 1/2 minutes to dress in the Stryker T4 [5]. Hence, application of a PPS would increase the time before resuscitation could begin. We needed to develop a protocol that ensured HCW safety as well as timely patient care. We used simulation to perfect the protocol as well as to train the cardiac arrest team. Simulation has been used to improve individual and team performances [6-9]. It has also been used as an evaluative tool [10,11]. We used the simulated cardiac arrest scenarios to provide an opportunity for deliberate practice, an important concept in effective learning [12]. The rationale for this approach was that simulation improved the retention of advanced cardiac life support (ACLS) guidelines in comparison with textbook review [13]. Materials and methods Simulation was used to design a protocol and then to train over a two-week period all HCWs who might be involved in a SARS cardiac arrest. Phase 1: Cardiac arrest protocol A modified ACLS protocol was designed and referred to as 'Code Blue Special' (CBS). We were aware that there was minimal scientific evidence, and there were no guidelines, for decisions related to having HCWs apply protective equipment that would delay time to definitive ACLS care. The Critical Care Department convened committee meetings involving experts representing the disciplines involved in the treatment of cardiac arrest (anesthesia, cardiology, critical care, emergency medicine, nursing, and respiratory therapy). The infection control service provided consultants to the committee. An initial protocol was developed by this committee. A group of educators then assessed this protocol in a teaching area by repeated simulations. The infection control service monitored the simulations for breaches of infection control. After these simulations, discussions between educators and infection control personnel resulted in a modified protocol that was accepted by the multidisciplinary committee (Figure 1). During these simulations we recognized the need for a SARSspecific equipment cart. Finally, the group of educators conducted a cardiac arrest simulation with a manikin (Laerdal, SimMan) placed in a bed in an empty negative-pressure patient room on a ward. In preparation, all necessary equipment to manage a SARS cardiac arrest was placed outside the room and all HCWs that would respond to an actual SARS cardiac arrest (nurses, physicians and respiratory therapists) were present. A full arrest scenario was then simulated, including the transport of the resuscitated patient to the intensive care unit (ICU). During this simulation an educator and the director of infection control noted any flaws. Phase 1, the protocol development, took 4 days to complete. Phase 2: Team training program The goal of Phase 2 was to train the on-call cardiac arrest teams in CBS. We acquired a dedicated training area in the hospital consisting of five adjoining rooms with computer and Internet access. We obtained call schedules for the arrest teams and began the training with the team members who were on call during the next two days. Using our experience in Phase 1, we decided to train HCWs in groups of eight. We planned to train HCWs in the use of the PPS in groups of two, and because four educators were available daily we decided that the maximum number of HCWs for each session was eight. A two-hour training session proceeded as follows: 1. All HCWs attended a PowerPoint presentation highlighting pertinent principles for the care of the SARS cardiac arrest patient. Each received a handout and had time for questions and answers. We stressed all the modifications to the (HPePaSlt)hcare worker dressed in T4 Stryker personal protection system (PPS). The PPS is worn over a disposable gown. In addition, goggles, an N95 respirator and two pairs o (...truncated)