A Multimodal Approach to Training COVID-19 Processes Across Four Intensive Care Units

Highlights•

COVID-19 required urgent clinical changes to promote Intensive Care Unit staff safety

Information dissemination and high-volume team training demands a multimodal approach

We employed videos, webinars, superusers, small-group simulation and cognitive aids

Abstract

Coronavirus disease (COVID-19) required innovative training strategies for emergent aerosol generating procedures (AGPs) in intensive care units (ICUs). This manuscript summarizes institutional operationalization of COVID-specific training, standardized across four ICUs. An interdisciplinary team collaborated with the Simulator Program and OpenPediatrics refining logistics using process maps, walkthroughs and simulation. A multimodal approach to information dissemination, high-volume team training in modified resuscitation practices and technical skill acquisition included instructional videos, training superusers, small-group simulation using a flipped classroom approach with rapid cycle deliberate practice, interactive webinars, and cognitive aids. Institutional data on application of this model are presented. Success was founded in interdisciplinary collaboration, resource availability and institutional buy in.

KeywordsAbbreviations: COVID-19 (Coronavirus disease), ICU (intensive care unit), AGPs (aerosol generating procedures), HCPs (health care providers), PPE (personal protective equipment), CPR (cardiopulmonary resuscitation), ECMO (Extracorporeal membrane oxygenation), CRM (crisis resource management)IntroductionCoronavirus disease (COVID-19) has high morbidity and mortality and is highly transmissible via respiratory droplets or direct contact (CDC
Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.; WHO
Naming the coronavirus disease (COVID-19) and the virus that causes it.). Aerosol generating procedures (AGPs) such as bag mask ventilation, intubation and non-invasive ventilation increase health care providers’ exposure (HCPs) to pathogens. To maintain HCP safety, specific infection control measures, procedural and systems-based modifications are recommended for AGPs in patients with confirmed/suspected COVID-19 infection (Abulebda K. Ahmed R.A. Auerbach M.A. Bona A.M. Falvo L.E. Hughes P.G. Gross I.T. Sarmiento E.J. Barach P.R. National preparedness survey of pediatric intensive care units with simulation centers during the coronavirus pandemic.; Balikai S.C. Badheka A. Casey A. Endahl E. Erdahl J. Fayram L. Houston A. Levett P. Seigel H. Vijayakumar N. Cifra C.L. Simulation to Train Pediatric ICU Teams in Endotracheal Intubation of Patients with COVID-19.; CDC
Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.; Edelson D.P. Sasson C. Chan P.S. Atkins D.L. Aziz K. Becker L.B. Berg R.A. Bradley S.M. Brooks S.C. Cheng A. Escobedo M. Flores G.E. Girotra S. Hsu A. Kamath-Rayne B.D. Lee H.C. Lehotzky R.E. Mancini M.E. Merchant R.M. Topjian A. 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 t.; Feldman O. Meir M. Shavit D. Idelman R. Shavit I. Exposure to a Surrogate Measure of Contamination From Simulated Patients by Emergency Department Personnel Wearing Personal Protective Equipment.). Emergent AGPs present unique challenges: teams must implement effective clinical care while minimizing spread of aerosolized viral particles; personal protective equipment (PPE) adversely impacts verbal and non-verbal communication; providers must learn modified technical skills; and risk of personal exposure heightens stress inherent to resuscitation negatively influencing teamwork. The evolving global pandemic required HCPs, especially those in intensive care units (ICUs) where emergent AGPs are commonly performed, to make these significant practice changes and rapidly train to competency in new technical skills and team-based practices while adhering to social distancing regulations and simultaneously provide uninterrupted patient care (Bialek S. Boundy E. Bowen V. Chow N. Cohn A. Dowling N. Ellington S. Gierke R. Hall A. MacNeil J. Patel P. Peacock G. Pilishvili T. Razzaghi H. Reed N. Ritchey M. Sauber-Schatz E. Severe outcomes among patients with coronavirus disease 2019 (COVID-19) - United States, February 12-march 16, 2020.; CDC
Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.; Edelson D.P. Sasson C. Chan P.S. Atkins D.L. Aziz K. Becker L.B. Berg R.A. Bradley S.M. Brooks S.C. Cheng A. Escobedo M. Flores G.E. Girotra S. Hsu A. Kamath-Rayne B.D. Lee H.C. Lehotzky R.E. Mancini M.E. Merchant R.M. Topjian A. 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 t.).A literature review revealed the application of numerous pedagogical innovations to meet urgent training needs during the COVID-19 pandemic involving technology and simulation-based teaching. Internationally, simulation was relied upon to both prepare HCP and identify latent safety threats in COVID-19 care processes and environments (Dubé M. Kaba A. Cronin T. Barnes S. Fuselli T. Grant V. Correction to: COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada.). Adult centers in Saudi Arabia and France reported use of online modules, practical skill stations and an in-situ training program using a modified Peyton's approach with rapid cycle deliberate practice (RCDP) (Buléon C. Minehart R.D. Fischer M.O. Protecting healthcare providers from COVID-19 through a large simulation training programme.; Lababidi H.M.S. Alzoraigi U. Almarshed A.A. Alharbi W. Alamar M. Arab A.A. Mukahal M.A. Alasmari F.A. Mzahim B.Y. Alharastani H.A.M. Alammi S.S. Alawad Y.I. Simulation-based training programme and preparedness testing for COVID-19 using system integration methodology.). Similarly, tabletop exercises, structured in-situ simulation sessions and debriefing resulted in improved performance and compliance with protocol modifications and increasing procedural confidence (Balikai S.C. Badheka A. Casey A. Endahl E. Erdahl J. Fayram L. Houston A. Levett P. Seigel H. Vijayakumar N. Cifra C.L. Simulation to Train Pediatric ICU Teams in Endotracheal Intubation of Patients with COVID-19.; Daly Guris R.J. Doshi A. Boyer D.L. Good G. Gurnaney H.G. Rosenblatt S. McGowan N. Widmeier K. Kishida M. Nadkarni V. Nishisaki A. Wolfe H.A. Just-in-Time Simulation to Guide Workflow Design for Coronavirus Disease 2019 Difficult Airway Management∗.; Sharara-Chami R. Sabouneh R. Zeineddine R. Banat R. Fayad J. Lakissian Z. Situ Simulation: An Essential Tool for Safe Preparedness for the COVID-19 Pandemic.). In a national preparedness survey of 22 US pediatric ICUs with simulation capabilities, reported training modalities included ‘simulation-based’ (82%), video (73%), didactic (55%) and online modules (45%) (Abulebda K. Ahmed R.A. Auerbach M.A. Bona A.M. Falvo L.E. Hughes P.G. Gross I.T. Sarmiento E.J. Barach P.R. National preparedness survey of pediatric intensive care units with simulation centers during the coronavirus pandemic.). The International Pediatric Simulation Society maintains a collaborative document of simulation efforts relating to COVID-19 (https://www.ipssglobal.org/community_resources_covid). However, we identified no published overarching description of practical implementation and integration of multiple modalities in a pediatric center.This manuscript outlines the multimodal approach established at our large urban academic quaternary pediatric institution to develop safe approaches to emergent AGPs and to train large numbers of staff in new practices across four ICUs (Figure 1). The goal was to provide high-quality care without compromising HCP safety (Edelson D.P. Sasson C. Chan P.S. Atkins D.L. Aziz K. Becker L.B. Berg R.A. Bradley S.M. Brooks S.C. Cheng A. Escobedo M. Flores G.E. Girotra S. Hsu A. Kamath-Rayne B.D. Lee H.C. Lehotzky R.E. Mancini M.E. Merchant R.M. Topjian A. 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 t.).Figure 1

Figure 1Summary of the institutional approach to developing new processes related to both technical skills and systems-based changes to facilitate safe execution of aerosol generating procedures in response to the COVID-19 pandemic. The multimodal strategy included a flipped classroom approach, rapid cycle deliberate practice, traditional hands-on simulation, and webinar-style trainings successful through strong interdisciplinary collaboration, partnership with a well-established hospital-based Simulator Program, and harmonizing of work across 4 ICUs.

Implementation Team

The work of developing new care processes for safe conduct of emergent AGPs and subsequent training of front-line team members was conducted by a multidisciplinary team made up of clinical experts (ICU nurses, physicians, respiratory therapists), Simulator Program personnel (curriculum developer, simulation engineers), representatives from OPENPediatrics (a web-based, educational platform), and unit-based clinical educators with specific expertise in simulation and debriefing. Implementation of training built on the established culture of in-situ simulation and strong foundation in crisis resource management principles present across all 4 ICUs in the institution.

Development of COVID-19 Safe AGP Practices for ImplementationTo standardize the institutional ICU approach to emergent AGPs, key interdisciplinary stakeholders from four ICUs (cardiac, medical, medical/surgical and neonatal) partnered with the Simulator Program to address three high-risk scenarios: intubation, cardiopulmonary resuscitation (CPR) and extracorporeal membrane oxygenation (ECMO) cannulation. The collaborative response addressed modified team resuscitation practices and acquisition of new technical skills to provide high-quality care, effective teamwork and overcome COVID-19 related challenges (CDC
Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.; Edelson D.P. Sasson C. Chan P.S. Atkins D.L. Aziz K. Becker L.B. Berg R.A. Bradley S.M. Brooks S.C. Cheng A. Escobedo M. Flores G.E. Girotra S. Hsu A. Kamath-Rayne B.D. Lee H.C. Lehotzky R.E. Mancini M.E. Merchant R.M. Topjian A. 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 t.). Draft procedures were developed based on emerging literature, recommendations from prior pandemics and interdisciplinary clinical expertise. Process maps were created and subsequently refined via procedural walkthroughs in the clinical space and room diagrams were constructed (Figure 2). Cycles of high-fidelity in-situ simulation, debriefing, process modification, and repeat simulation and debriefing were leveraged to test and refine processes, optimize sequences of steps, team roles, provider physical location in the room, and order as well as timing of entry of equipment into the room. Debriefings focused on identifying and solving challenges to implementation of processes using the Promoting Excellence and Reflective Learning in Simulation framework (Balikai S.C. Badheka A. Casey A. Endahl E. Erdahl J. Fayram L. Houston A. Levett P. Seigel H. Vijayakumar N. Cifra C.L. Simulation to Train Pediatric ICU Teams in Endotracheal Intubation of Patients with COVID-19.; Daly Guris R.J. Doshi A. Boyer D.L. Good G. Gurnaney H.G. Rosenblatt S. McGowan N. Widmeier K. Kishida M. Nadkarni V. Nishisaki A. Wolfe H.A. Just-in-Time Simulation to Guide Workflow Design for Coronavirus Disease 2019 Difficult Airway Management∗.; Edelson D.P. Sasson C. Chan P.S. Atkins D.L. Aziz K. Becker L.B. Berg R.A. Bradley S.M. Brooks S.C. Cheng A. Escobedo M. Flores G.E. Girotra S. Hsu A. Kamath-Rayne B.D. Lee H.C. Lehotzky R.E. Mancini M.E. Merchant R.M. Topjian A. 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 t.; Sharara-Chami R. Sabouneh R. Zeineddine R. Banat R. Fayad J. Lakissian Z. Situ Simulation: An Essential Tool for Safe Preparedness for the COVID-19 Pandemic.). Specific process-based changes included alterations to standard intubation (immediate cuff inflation and direct ventilator connection prior to initiation of positive pressure) and CPR (use of a mechanical CPR device) (Balikai S.C. Badheka A. Casey A. Endahl E. Erdahl J. Fayram L. Houston A. Levett P. Seigel H. Vijayakumar N. Cifra C.L. Simulation to Train Pediatric ICU Teams in Endotracheal Intubation of Patients with COVID-19.; Edelson D.P. Sasson C. Chan P.S. Atkins D.L. Aziz K. Becker L.B. Berg R.A. Bradley S.M. Brooks S.C. Cheng A. Escobedo M. Flores G.E. Girotra S. Hsu A. Kamath-Rayne B.D. Lee H.C. Lehotzky R.E. Mancini M.E. Merchant R.M. Topjian A. 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 t.; Sharara-Chami R. Sabouneh R. Zeineddine R. Banat R. Fayad J. Lakissian Z. Situ Simulation: An Essential Tool for Safe Preparedness for the COVID-19 Pandemic.). Each unique ICU setting also instituted population specific modifications; for example, the neonatal ICU used inline suction due to endotracheal tube size.Figure 2

Figure 2Room diagram depicting clinical zones. During an emergent response in the ICU setting, the surrounding clinical space was organized into three distinct zones based on patient proximity and exposure risk. 1) the “hot zone” inside the patient's room, required PPE including N95 or powered air-purifying respirator (PAPR), eye protection, gown and gloves, worn prior to any entry; 2) the “warm zone” including the anteroom and/or area immediately outside the patient's hallway door defined by temporary barriers; and 3) the “cold zone” outside the room. For early iterations, “warm zone” PPE included only a surgical ear-loop mask and eye protection. Observed frequent door openings for equipment entry in high-fidelity simulations raised concern about risk to nearby staff leading to adjustments to include same PPE as the “hot zone”. “Full PPE = gown, gloves, N95 or powered air purifying respirator (PAPR), eye protection”. Computer on wheels (COW), Respiratory Therapist (RT), Medical Doctor / clinician (MD), Nurse (RN), Nurse Practitioner (NP), cardiopulmonary resuscitation (CPR), Event Manager (EM), Clinical Assistant (CA).

Three key systems-based changes were also devised and implemented to facilitate safe execution of AGPs: 1) Three distinct clinical care zones with differing PPE requirements were designated based on proximity to AGPs (Figure 2); 2) teams were divided into sub-teams and roles based on clinical care zones (Table 1); and 3) novel communication strategies were implemented to facilitate communication between teams inside and outside the room when room doors were closed (Table 1) (Howard S.K. Gaba D.M. Fish K.J. Yang G. Sarnquist F.H. Anesthesia crisis resource management training: Teaching anesthesiologists to handle critical incidents.).

Table 1COVID-19 Safe Aerosol Generating Procedures

Multimodal training strategiesImplementation of the newly developed technical and system-based changes into clinical practice across four ICUs faced important challenges. Coordinated distribution of information and trainings of such processes needed to: 1) adhere to social distancing requirements; 2) rapidly train large numbers of practitioners to acquire ‘muscle memory’ in new physical skills while simultaneously engaged in active patient care; 3) provide asynchronous training opportunities for staff infrequently on-site; 4) make just-in-time or refresher training available for high-risk procedures; 5) revise Crisis Resource Management (CRM) principles with novel applications in the context of the pandemic and 6) harmonize across ICU settings, as many staff work across multiple ICUs. A multimodal strategy was applied including video-based training modules for introduction of new skills and processes (Moynihan K. Zackin B. Agus M. Bullock K. Imprescia A. Kleinma n M. Allan C Cardiopulmonary Resuscitation in the ICU with COVID-19 Considerations.; Moynihan K. Zackin B. Agus M. Bullock K. Imprescia A. Kleinma n M. Allan C Cardiopulmonary Resuscitation in the ICU with COVID-19 Considerations.), hands-on simulation using rapid cycle deliberate practice (RCDP) (Lemke D.S. Fielder E.K. Hsu D.C. Doughty C.B. Improved Team Performance During Pediatric Resuscitations After Rapid Cycle Deliberate Practice Compared With Traditional Debriefing: A Pilot Study.; Perretta J.S. Duval-Arnould J. Poling S. Sullivan N. Jeffers J.M. Farrow L. Shilkofski N.A. Brown K.M. Hunt E.A. Best Practices and Theoretical Foundations for Simulation Instruction Using Rapid-Cycle Deliberate Practice.) for development of proficiency in new technical skills, webinar-style training, creation of durable cognitive aids, and hands-on refresher trainings (Figure 1). The design and conduct of in situ simulations conformed to INACSL Healthcare Simulation Standards (Watts P.I. McDermott D.S. Alinier G. Charnetski M. Ludlow J. Horsley E. Meakim C. Nawathe P.A. Healthcare Simulation Standards of Best PracticeTM Simulation Design.). Simulation activities were preceded by a structured pre-brief. Super-users trained in the new protocols facilitated operationalization of practical training to large numbers of staff.Instructional Videos

Instructional videos introduced large numbers of staff to new practices and processes, overcoming social distancing restrictions and permitting asynchronous and just-in-time learning. Developed as a collaboration between clinicians, the Simulator Program, and OPENPediatrics, three separate narrated videos of high-fidelity simulations performed in situ by experienced multidisciplinary teams provided instruction on intubation, resuscitation (including use of a mechanical CPR device), and emergency ECMO cannulation. Videos were made available on the OPENPediatrics platform and through links provided to all staff. Clinicians were encouraged to view videos both on their own time or at the bedside for just-in-time review of practices prior to anticipated high risk events.

Rapid Cycle Deliberate PracticeNew technical skill acquisition requires hands-on practice. Applying a flipped classroom approach, nurses, attending physicians, fellows, and respiratory therapists watched instructional videos then received training from super-users using a RCDP approach (Lemke D.S. Fielder E.K. Hsu D.C. Doughty C.B. Improved Team Performance During Pediatric Resuscitations After Rapid Cycle Deliberate Practice Compared With Traditional Debriefing: A Pilot Study.; Perretta J.S. Duval-Arnould J. Poling S. Sullivan N. Jeffers J.M. Farrow L. Shilkofski N.A. Brown K.M. Hunt E.A. Best Practices and Theoretical Foundations for Simulation Instruction Using Rapid-Cycle Deliberate Practice.). These sessions focused on technical aspects of intubation with COVID-19 precautions and mechanical CPR device use. To maintain social distancing, participants were trained in groups of 4 at an off-site simulation center, replicating ad-hoc team structure for real-life intubation events. Training sessions progressed from hands on instruction in technical skill components of modified COVID-specific intubation with a competency learning approach followed by a high-fidelity team simulation for consolidation. Training sessions began with hands on instruction in technical skill components of modified COVID-specific intubation protocols, with the expectation that learners would demonstrate competency in the skills before progressing to a scenario-based team simulation for consolidation of skills.Structured Interactive Webinars and Video-based Simulation

To train large numbers of staff in new team-based approaches to intubation, resuscitation/CPR and emergent ECMO cannulation in the COVID-19 era webinar-style trainings were offered. Staff were encouraged to view instructional videos prior to participation. Webinars were run using a ‘live’, interactive zoom platform with a proportion of participants on site in a conference room maintaining social distancing, and others dialing in. Webinars encompassed brief revision of CRM principles, didactic instruction on care zones, roles of team members “inside” and “outside” room, and communication strategies followed by viewing of a video-recorded crisis simulation demonstrating these concepts. Learners participated in a debriefing focused on enhancing understanding of COVID-specific practices and trouble-shooting challenges of implementation of these practices. The rich interdisciplinary nature of participants was leveraged to troubleshoot practical implementation challenges and identify solutions.

Durable Cognitive AidsTo facilitate care at the bedside, cognitive aids were created and distributed throughout the ICUs providing streamlined instructions related to COVID-specific safety practices for intubation and team-based care for just-in-time reference. Visual references were laminated for decontamination available on all code carts also included room maps demonstrating zones of care (Figure 2) and associated PPE requirements.Hands on Refresher Trainings

Following initial live and virtual trainings, in situ simulation-based mock codes were run on a weekly basis, emphasizing rapid correct donning of PPE, utilization of clinical care zones, and management of communication strategies between inside and outside the patient room. Simulations adhered to all institutional social distancing guidelines. The majority of staff arrived at simulation events with PPE allotted for that day of work. For those who responded without PPE, N95 masks and face shields crafted by simulation center engineering staff for simulation use only (not approved for patient use) were provided to avoid depletion of hospital PPE resources. A prebrief oriented participants to the specific objectives of the simulation. Novel COVID-19 protocols were reviewed, including use of designated zones of care, protocols for communication from inside to outside the room, and expectations for PPE use during an emergency. Finally, team member roles were assigned and participants were given ample time to ask clarifying questions regarding new COVID-19 protocols. Simulations were facilitated by multidisciplinary clinical faculty with specific training in simulation and debriefing. In each one-hour session staff completed the same simulation scenario twice followed by debriefing to reinforce and clarify safety practices. Debriefing applied a systems improvement lens to identify strategies for managing challenges to adhering to COVID-19 best practices and application of CRM principles as relevant to clinical modifications for the pandemic.

Uptake of Training Opportunities

HCP were required to be well-versed in procedures/protocols around AGPs, infection control, safety and appropriate use of PPE. Our multimodal approach was designed to allow access to training to the largest number of staff possible through either virtual or live interactive activities while adhering to social distancing policies. RCDP training on intubation procedures were assigned to all attending ICU physicians and respiratory therapists, the group most likely to engage in these activities and face risk of exposure during clinical practice. In situ simulations were offered to ICU nurses, physicians, and respiratory therapists as part of their workdays in order maximize opportunities for participation. Online learning modules and webinars were available to individuals and allowed for both participation by greater numbers and opportunity to repeatedly reinforce new material.

Clinical Applications, Limitations and Future DirectionsOverall, 169 ICU staff, including nurses, nurse practitioners, respiratory therapists and physicians, trained with in-person small group skills-based simulations. Post-training surveys of participants revealed they perceived increased preparedness and reduced anxiety. Additionally, 145 interdisciplinary staff participated in webinars, with surveys confirming increased perceived preparedness and improved clarity on application of CRM principles during COVID-19 safety protocols. Finally, 87 staff (nurses, nurse practitioners, respiratory therapists and physicians) participated in simulation-based refresher trainings. Intubation and resuscitation training videos were also made available beyond our institution through OPENPediatrics, the free, on-line, open access knowledge exchange platform, recording greater than 283,000 views across 53 countries (

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