COVID-19 Emergency Department Protocols: Experience of Protocol Implementation Through in-situ Simulation

Anmol Shrestha; Abha Shrestha; Taylor Sonnenberg; Roshana Shrestha

doi:10.2147/OAEM.S266702

COVID-19 Emergency Department Protocols: Experience of Protocol Implementation Through in-situ Simulation

Open Access Emerg Med. 2020 Oct 16:12:293-303. doi: 10.2147/OAEM.S266702. eCollection 2020.

Authors

Anmol Shrestha¹, Abha Shrestha², Taylor Sonnenberg³, Roshana Shrestha¹

Affiliations

¹ Department of General Practice and Emergency Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal.
² Department of Community Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal.
³ Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, USA.

Abstract

Purpose: During the outbreak of Coronavirus disease of 2019 (COVID-19), the preparedness of emergency departments (EDs) for triaging of the patients and safety of staff is of utmost importance. The aim of our study was to develop and implement COVID-19 ED triage and protected intubation protocols for COVID-19 patients with in-situ simulation (ISS) training. The latent safety threats (LST) detection also served as a platform to test new system amendments and refine the protocols and workflows with infection control issues. We also explored the effectiveness of this approach based on Kirkpatrick's model of evaluating training outcomes.

Participants and methods: The protocols and simulation scenarios were developed and validated. A total of 22 triage and 13 intubation simulation sessions were conducted in the ED with multidisciplinary staff (physicians=18, nurses=20) during a period of four months. Each simulation was followed by a debriefing session to discuss the team performance. Pre- and post-simulation performances were compared. LSTs were identified and remediated. An online voluntary feedback was collected from the participants to explore the opinion about the ISS sessions and confidence level using a 5-point Likert scale.

Results: There was a significant improvement in triage knowledge score after ISS [5.5/10 (IQR 4-6) versus 8.5/10 (IQR 8-9), p<0.001]. There was a desirable proportion of correct responses (>75%) following the ISS for triage case scenarios. A pre-designed checklist was used during protective intubation simulations. Some important LSTs were missing medications, lack of mechanism to deliver patient samples to lab and faulty airway maneuvers. The participants' feedback on ISS showed increased skills and confidence level on triaging and protected intubation (p<0.001). They found the protocols easy to follow and they recommended for more such modules in future.

Conclusion: ISS is a quick and efficient tool to implement the ED protocols for preparation of outbreaks like COVID-19. It helps the ED staff to triage and manage the airway safely. We recommend such an approach to train the multidisciplinary staff and continue to improve ourselves through ISS addressing the changing nature of the pandemic.

Keywords: airway management; emergency department; in situ simulation; intubation; latent safety threats; triage.

Grants and funding

Funding is provided under the project titled “Emergency Medicine Protocol Development and Implementation Through Simulation in Nepal” by the Sustaining Technical and Analytic Resources (STAR) Collaboration Laboratory, a project of the Public Health Institute, in collaboration with the Consortium of Universities for Global Health (CUGH), through funding from the United States Agency for International Development (USAID).