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.

The Comparative Effectiveness of Virtual Reality Versus E-Module on the Training of Donning and Doffing Personal Protective Equipment: A Randomized, Simulation-Based Educational Study.

Introduction Preventing errors in donning and doffing of personal protective equipment (PPE) is critical for limiting the spread of infectious diseases. Virtual reality (VR) has demonstrated itself as an effective tool for asynchronous learning, but its use in PPE training has not been tested. The objective of this study was to compare donning and doffing performance between VR and e-module PPE training. Methods A prospective randomized open-blinded controlled trial was conducted to determine differences in donning and doffing performance after VR and e-module PPE training among medical staff and medical students at a single institution. The primary outcome was donning and doffing performance with real PPE, assessed using a 64-point checklist. The secondary outcome was participant preparedness and confidence level after training.  Results Fifty-four participants were randomized, mostly consisting of medical students (n=24 {44%}) or emergency medicine and otolaryngology residents (n=19 {35%}). The VR group (n=27 {50%}) performed better than the control in the overall PPE scores but this was not statistically significant (mean {SD}, VR: 55.4 {4.4} vs e-module: 53.3 {8.1}; p = 0.40). VR participants also reported higher levels of preparedness and confidence after training. Residents as a subgroup achieved the highest increases after VR training compared to their counterparts in the control training group (mean {SD}, VR: 55.6 {4.9} vs e-module 48.4 {5.5}, p = 0.009).  Conclusion In this randomized trial, VR training was found to be non-inferior to e-module for asynchronous PPE training. Our results suggest that in particular residents may benefit most from VR PPE training. Additionally, VR participants felt more confident and prepared to don and doff PPE after training compared to e-module participants. These findings are particularly relevant given the ongoing coronavirus disease 2019 (COVID-19) pandemic. Future studies need to focus on VR integration into residency curriculum and monitoring for long-term skill retention.

Predictors for inpatient mortality during the first wave of the SARS-CoV-2 pandemic: A retrospective analysis.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic overwhelmed healthcare systems, highlighting the need to better understand predictors of mortality and the impact of medical interventions. METHODS: This retrospective cohort study examined data from every patient who tested positive for COVID-19 and was admitted to White Plains Hospital between March 9, 2020, and June 3, 2020. We used binomial logistic regression to analyze data for all patients, and propensity score matching for those treated with hydroxychloroquine and convalescent plasma (CP). The primary outcome of interest was inpatient mortality. RESULTS: 1,108 admitted patients with COVID-19 were available for analysis, of which 124 (11.2%) were excluded due to incomplete data. Of the 984 patients included, 225 (22.9%) died. Risk for death decreased for each day later a patient was admitted [OR 0.970, CI 0.955 to 0.985; p < 0.001]. Elevated initial C-reactive protein (CRP) value was associated with a higher risk for death at 96 hours [OR 1.007, 1.002 to 1.012; p = 0.006]. Hydroxychloroquine and CP administration were each associated with increased mortality [OR 3.4, CI 1.614 to 7.396; p = 0.002, OR 2.8560, CI 1.361 to 6.160; p = 0.006 respectively]. CONCLUSIONS: Elevated CRP carried significant odds of early death. Hydroxychloroquine and CP were each associated with higher risk for death, although CP was without titers and was administered at a median of five days from admission. Randomized or controlled studies will better describe the impact of CP. Mortality decreased as the pandemic progressed, suggesting that institutional capacity for dynamic evaluation of process and outcome measures may benefit COVID-19 survival.

Safety Considerations for In Situ Simulation in Closed SARS-CoV-2 Units.

SUMMARY STATEMENT: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic placed a tremendous strain on the healthcare system, which led to the deployment of new personnel into acute care settings, early graduation of medical students, and development of new treatment spaces. Education teams at the Montefiore Health System and New York Health and Hospitals/Jacobi Medical Center found simulation, both laboratory-based and in situ, critical to the training of medical staff and investigation of latent safety threats. Through our experience, we encountered unique infection control concerns based on in situ sessions, which prompted us to redesign our programs for the treatment of SARS-CoV-2. Using this experience, we outline our rationale for the use of in situ simulation for newly developed SARS-CoV-2 spaces along with recommendations on safety checks to consider before starting.