In Situ Simulation as a Quality Improvement Tool to Identify and Mitigate Latent Safety Threats for Emergency Department SARS-CoV-2 Airway Management: A Multi-institutional Initiative

Background : In situ simulation has emerged as a powerful quality improvement (QI) tool in the identification of latent safety threats (LSTs). Following the first wave of SARS-CoV-2 at an urban epicenter of the disease, a multi-institutional collaborative was formed to integrate an in-situ simulation protocol across five emergency departments (EDs) for systems improvement of acute airway management. Methods : A prospective, multi-institutional QI initiative using two Plan-Do-Study-Act (PDSA) cycles was implemented across five EDs. Each institution conducted simulations involving mannequins in acute respiratory failure requiring definitive airways. Simulations and systems-based debriefs were standardized. LSTs were collected in an online database, focused on: (1) equipment availability, (2) infection control, and (3) communication. Results : From June 2020 through May 2021, 58 of 70 (82.9%) planned simulations were completed across five sites with 328 unique individual participants. Overall LSTs per simulation (7.00–4.69, p < 0.001) and equipment LSTs (3.00–1.46, p < 0.001) decreased from cycle 1 to cycle 2. Changes in mean LSTs for infection control and communication categories varied among sites. There was no correlation between total LSTs or any of the subcategories and team size. Number of beds occupied was significantly negatively correlated with total and infection control LSTs. Conclusion : This study was unique in simultaneously running a structured in situ protocol across numerous diverse institutions during a global pandemic. This initiative found similar categories of threats across sites, and the protocol developed empowered participants to implement changes to mitigate identified threats.

In Situ Simulation as a Quality Improvement Tool to Identify and Mitigate Latent Safety Threats for Emergency Department SARS-CoV-2 Airway Management: A Multi-Institutional Initiative.

BACKGROUND: In situ simulation has emerged as a powerful quality improvement (QI) tool in the identification of latent safety threats (LSTs). Following the first wave of SARS-CoV-2 at an urban epicenter of the disease, a multi-institutional collaborative was formed to integrate an in situ simulation protocol across five emergency departments (EDs) for systems improvement of acute airway management. METHODS: A prospective, multi-institutional QI initiative using two Plan-Do-Study-Act (PDSA) cycles was implemented across five EDs. Each institution conducted simulations involving mannequins in acute respiratory failure requiring definitive airways. Simulations and systems-based debriefs were standardized. LSTs were collected in an online database, focused on (1) equipment availability, (2) infection control, and (3) communication. RESULTS: From June 2020 through May 2021, 58 of 70 (82.9%) planned simulations were completed across five sites with 328 unique individual participants. Overall LSTs per simulation (7.00-4.69, p < 0.001) and equipment LSTs (3.00-1.46, p < 0.001) decreased from cycle 1 to cycle 2. Changes in mean LSTs for infection control and communication categories varied among sites. There was no correlation between total LSTs or any of the categories and team size. Number of beds occupied was significantly negatively correlated with total and infection control LSTs. CONCLUSION: This study was unique in simultaneously running a structured in situ protocol across numerous diverse institutions during a global pandemic. This initiative found similar categories of threats across sites, and the protocol developed empowered participants to implement changes to mitigate identified threats.

In Situ Simulation as a Tool to Longitudinally Identify and Track Latent Safety Threats in a Structured Quality Improvement Initiative for SARS-CoV-2 Airway Management: A Single-Center Study.

BACKGROUND: In situ simulation has emerged as a powerful tool for identifying latent safety threats (LSTs). After the first wave of the SARS-CoV-2 pandemic, an urban community emergency department (ED) identified opportunities for improvement surrounding acute airway management and particularly focused on infection control precautions, equipment availability, and interprofessional communication during acute resuscitation. Using the Model for Improvement, a hybrid in situ/quality improvement initiative was implemented using Plan-Do-Study-Act (PDSA) cycles to enhance systems for intubating patients with SARS-CoV-2. METHODS: Three PDSA cycles consisting of 10 simulations each were conducted from June 2020 through February 2021. Latent safety threats (LST) were identified through an in situ simulation scenario involving a patient with SARS-CoV-2 in acute respiratory failure. LSTs were collected through structured debriefs focused on (1) infection control, (2) equipment availability, and (3) communication. The SAFER-Matrix was used to score LSTs according to frequency and likelihood of harm by members of the ED QI team (SAFER score). The research team worked with the same QI leaders to implement action plans based on scored threats using cause-and-effect and driver diagrams. The Donabedian model was used to conceptually evaluate the quality of interventions upon conclusion of the third PDSA cycle. RESULTS: The median SAFER score decreased from 10.94 in PDSA cycle 1 to 6.77 in PDSA cycle 2 to 4.71 in PDSA cycle 3. Across all identified LSTs, the SAFER score decreased by 3.114 for every additional PDSA cycle (P = 0.0167). When evaluating for threats identified as being primarily structure based, there was a decrease in SAFER score of 1.28 per every additional PDSA cycle (P = 0.001). There was a decrease in total count of LST of 0.20 per additional simulation run (P = 0.02) after controlling for shift type, census, perceived workload, team size, and prior attendance in simulations across all PDSA cycles. CONCLUSIONS: This study presents a blueprint for the utilization of in situ simulation through multiple waves of the SARS-CoV-2 pandemic to identify LSTs and use the SAFER score as a surrogate marker to monitor the impact of interventions for a safer environment for both medical staff and patients.

Answering the Call to Action: A Multimodal Wellness Response to Psychological Distress in Health Care Workers During the COVID-19 Pandemic in the Bronx.

The emotional and psychological toll of the COVID-19 pandemic has been characterized as a parallel pandemic, disproportionately affecting health care workers when compared to the general population. Recognizing the tragic effects that the pandemic was having on the psyche of our health care workers, a multidisciplinary peer-support program called Helping Healers Heal was augmented to address these complex needs in a large, urban, academic medical center in the Bronx, NY. A multimodal approach including wellness events, emotional support rounds, fast-tracked connections with therapeutic support, and coalition building was used to reach 80% of staff from May through August, 2020. The multidisciplinary team planned events and interventions to appeal to the myriad ways people cope and build resilience, and by utilizing existing resources, it proved extremely cost-effective. In a survey of the program's participants, 94% of respondents "agreed" or "strongly agreed" that their participation helped alleviate stress.

Early lessons learnt using simulation to rapidly deploy a trained observer programme during the COVID-19 pandemic in New York City.

New York City became one of the epicentres of the COVID-19 pandemic in 2020. Simulation was used to establish the COVID-19 trained observer programme to mitigate healthcare workers' infection risk during patient care. The members of the trained observer group consisted of 32 staff members. At the start of the training programme, they were provided donning and doffing guides with a step-by-step description of personal protective equipment (PPE) usage, followed by in-situ PPE simulation training. Later on, as PPE protocols evolved, additional educational modalities were used and included training videos, picture demonstrations of common PPE mistakes and repeated in-situ simulations. The early lessons which emerged from using simulation to train observers during the COVID-19 pandemic were the following: address PPE shortages during presimulation planning, prepare to perform updates for trained observers and use multiple educational modalities to train observers. Adequate amounts of PPE should be available to train observers. Repeated simulations are necessary to update observers on PPE protocols. Multiple learning modalities should educate the trained observers and equip them for their role in COVID-19 units.