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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 7  |  Page : 72-75

Role of simulation in COVID-19 management

Department of Pediatric Intensive Care, Rainbow Children's Hospital, Marathahalli, Bengaluru, Karnataka, India

Date of Submission20-Apr-2020
Date of Decision24-Apr-2020
Date of Acceptance29-Apr-2020
Date of Web Publication29-May-2020

Correspondence Address:
Dr. Rakshay Shetty
Department of Pediatric Intensive Care, Rainbow Children's Hospital, Marathahalli, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JPCC.JPCC_65_20

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Simulation is a method of teaching which uses simple and/or sophisticated technology to educate the target audience through guided experience and interactions that evoke real-world scenarios, which is being increasingly used in the field of medicine. Specifically, in situ simulation that is designed using specific scenarios within environments that replicate real-world clinical issues, to train multidisciplinary teams to test systems, and improve outcomes. Although it is routinely used for supplementing medical education, the current COVID-19 pandemic gives us a perfect opportunity to use simulation to test the preparedness of health-care facilities for managing COVID-19 patients and also to train health-care workers (HCWs) in the skills necessary to protect themselves from the infection while taking care of the infected patients. The HCWs can be trained in various aspects of personal safety, as well as modifications to their existing protocols needed to take care of COVID-19 patients. Here, we present how the health facilities can adopt simulation to prepare for the current pandemic and identify gaps in the systems and processes that can be corrected. We also share our experience of using this methodology for COVID-19 preparedness in a tertiary care pediatric facility.

Keywords: COVID-19, hospital preparedness, simulation

How to cite this article:
Deepak R, Shetty R. Role of simulation in COVID-19 management. J Pediatr Crit Care 2020;7, Suppl S1:72-5

How to cite this URL:
Deepak R, Shetty R. Role of simulation in COVID-19 management. J Pediatr Crit Care [serial online] 2020 [cited 2022 Dec 8];7, Suppl S1:72-5. Available from: http://www.jpcc.org.in/text.asp?2020/7/7/72/285375

  Introduction Top

Simulation is a method of teaching which uses simple and/or sophisticated technology to educate the target audience through guided experience and interactions that evoke real-world scenarios. It is being used by varied industries to train staff as well as a quality assessment tool. In the past two decades, this methodology is being increasingly used in medicine to train nurses and young doctors, right from undergraduate courses, and on simple procedures up to specific skill training at a super-specialist level. It also provides scope for multidisciplinary training of various teams. Simulation-based learning can develop health professionals' knowledge, skills, and attitudes, all while protecting real patients from any real harm. At an organizational level, simulation helps to test system preparedness and identify gaps in specific areas that need to be fixed. The benefits of using simulated environments for learning allow participants to “learn by doing” and observe the outcomes of their actions. We can provide “just-in-time training” when and where it is needed to prepare health-care providers with the desired skill to manage unfamiliar situations. Cook et al., in their meta-analysis, have shown that, in comparison with no intervention, technology-enhanced simulation training in health professions education is consistently associated with large effects for outcomes of knowledge, skills, and behaviors and moderate effects for patient-related outcomes.[1] Another meta-analysis by Beal et al. suggested that simulation-based medical education is more effective for teaching critical care medicine to students than other teaching methods.[2]

COVID-19 has been declared as a pandemic by the World Health Organization and to prepare for this pandemic, hospitals need to develop strategies to manage their resources for optimum care of the patients. Communicable diseases such as COVID-19 that are not frequently encountered by health-care workers (HCWs) require specialized training to master the competency to avert transmission to staff and other patients. Transmission within health-care facilities to health-care workers has been documented: 3.8% of COVID-19 cases have occurred in health-care workers, causing five deaths in China.[3] This pandemic provides a perfect setting to use this methodology to train HCWs and ensures hospital preparedness to take care of the patients affected by COVID-19 as well as protect themselves from the infection. The goal of this simulation exercise will be to practice assessing and caring for a patient of COVID-19 while maintaining personal and team safety against a potential droplet/airborne infection using appropriate personal protective equipment (PPE).

  Evidence for Role of Simulation for Epidemic Preparedness Top

Abualenain and Al-Alawi conducted a pre- and post-interventional study on simulation-based training (SBT) program in Ebola PPE for all HCWs in a hospital in Saudi Arabia and found that the participant competency in PPE improved from 65% to 87% after ten sessions of SBT program.[4]

Manuel et al. had designed a simulation-based curriculum to deal with the Ebola epidemic for nursing students, which aimed at the need to be able to recognize Ebola virus disease-compatible symptoms and implement the relevant protocols, including properly donning and doffing of PPE and reducing the risk of transmission of the virus through appropriate decontamination [Figure 1].[5] Wong et al. stated that during their preparation for COVID-19 pandemic in a busy hospital in Singapore, conducted a series of simulations and “walk-throughs” of various scenarios with different surgical disciplines. Their objectives were to proactively seek latent threats and potential breaches in infection control during stressful moments of crisis. They identified and addressed personnel, equipment, and system issues.[6]
Figure 1: Simulated Ebola case scenario frame. A template for progressive training HCW for an infectious disease (lessons from Ebola epidemic). (From: Manuel et al., Ebola Virus Hemorrhagic Fever: A Simulation-based Clinical Education Experience Designed for Senior Undergraduate Nursing Students)

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  Application of Simulation Training Top

Roussin and Weinstock at Boston Children's Hospital have introduced SimZones innovation, a system where simulation is divided into four Zones (0–3) to help cater to the needs of trainees for a specific skill or clinical scenario [Figure 2].[7] Translation of this training system into clinical practice is sometimes referred to as Zone 4.
Figure 2: SimZones: An Organizational Innovation for Simulation Programs and Centres Academic Medicine 92(8):1114-1120, August 2017

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Simulation training for the current scenario can be based on what we learned during the Ebola epidemic in Africa during 2014–2017 and involves the following three main stages:

  1. Identification of key elements from real clinical settings
  2. Presentation of these elements in a lightweight, inexpensive, and portable environment, and
  3. The ability to recreate and replay clinical scenarios.

The above template for the Ebola epidemic can be used for the skill training of individual personnel using Zone 0–1 simulations. The HCW is given equipment for a specific task and observed with feedback being given to them after completion of the task. This can be done repeatedly until adequate competency is achieved by the trainee. This technique is useful to train personnel in skills of:

  1. Effective flow of a suspected patient from triage to intubation
  2. Limiting exposure of hospital staff and other patients, by appropriately isolating high-risk patients in a designated area
  3. Technique of donning/doffing of PPE
  4. Airway management of a COVID-19 patient
  5. Resuscitating a patient of COVID with minimum staff and taking appropriate precautions.

Health-care facilities coming up with individualized protocols for handling a potential COVID patient need to identify a suspect COVID-19 during initial triage, management of a suspect and confirmed COVID-19 based on the level of acuity, intrahospital, and on resuscitation policies. Once individual skill training is achieved, and personnel is familiar with the local protocols, system testing of patient flow, team dynamics, and human factors assessment can be done using Zones 2 and 3 simulation exercises. This will require elaborately scripted scenarios with definitive learning objectives and be run in a high-fidelity manner, either using high- or low-technology manikins.

Appropriate facilitator driven debriefing to reflect once practice is done either during (pause and debrief) for Zone 1–2 scenarios or after the scenario (advocacy and enquiry-AI) for Zone 3 scenarios.

Generally, Zone 3 scenarios would involve multidisciplinary teams. The following are some examples, where a Zone 3 simulations can be conducted:

  • Stabilizing a suspect COVID patient in the emergency room (ER) – this scenario involves multiple learning objectives learned individually from triage nurse identifying the patient to be a COVID suspect and guiding them to the designated area, the ER nurse and doctor donning PPE before attending to the patient and stabilizing the patient following the hospital protocol. We can also extend the scenario to test the doffing of PPE as well as decontamination of the area after the patient has been shifted
  • Transporting of a patient from ER to the designated ward area– this scenario tests the coordination of the ER team, security personnel, and the receiving team of the ward. This can be used to identify difficulties in transporting the patient though a clear path preventing exposure to other staff and patients, facilities like elevators, and also preparations of the ward team (PPE/isolation room, etc.) to receive the patient
  • Resuscitating or intubating a patient in cardiac/respiratory arrest in ER/intensive care unit/Ward– this scenario addresses the environmental limitations of the respective area, unsatisfactory equipment setup, communication difficulties of different team members of multiple specialties, lack of familiarity with protective equipment of the team, infection control breaches during a crisis, and inadequate support during a resuscitation.

  Our Experience Top

We, at Rainbow Children's Hospital, Marathahalli, Bengaluru, formulated a team of doctors and management and prepared a draft protocol for managing a suspect or proven case of COVID-19, and the protocol was conveyed to all the departmental in charges for knowledge sharing. Since mid-March to 2nd week of April 2020, preparatory exercises for a hypothetical scenario of receiving a COVID-19 patient were carried out. The number of simulations that were progressive and involved initial screening through admission to an inpatient unit, and also scenarios involving resuscitation in the ER and pediatric intensive care unit (PICU) were conducted by a team led by PICU consultants, fellows, and infectious disease specialist.

We started with Zone 0 skill-based training on proper donning and doffing technique of PPE and droplet precautions by HCW and security personnel at all possible entry points for patients. In addition, PICU and anesthetic teams underwent Zone 0–1 training in the use of positive pressure ventilation (PPV) using viral filters and modifications to the existing resuscitation protocol. We subsequently ran Zone 1–3 scenarios to cover various aspects preparedness of the ER teams, the constraints of the existing space, and logistics of transport as well as resource requirements of different areas. Potential issues, breaches, and key observations were identified and communicated with our administration through verbal reports within hours of completing the simulations and rectified where possible following the Plan-Do-Study-Act cycle. We finally admitted non-COVID patients as COVID in PICU to explore the practical feasibilities of the current protocol and ran A–I Zone 4 debriefing method to rectify any deficiencies.

  • The points that were identified during these scenarios were as follows:
  • The lack of familiarity and knowing the importance of proper donning and doffing of PPE
  • The amount of time taken for wearing PPE
  • The number of PPE required for each area
  • Space constraints in the ER and resus bay
  • Lack of familiarity with using the viral filter
  • Avoiding PPV during resuscitation before the arrival of the team in full PPE
  • Ensuring familiarity with isolation, intubation, and resuscitation protocols.

These points were addressed with modifications of the draft protocol over a period of 2 weeks, and a final protocol was prepared and disseminated.

  Conclusion Top

Simulation offers an excellent opportunity to train on various aspects of preparing a medical team to take care of COVID 19 children in the hospital. Understanding of simulation methodology is important in designing appropriate scenarios and using correct debriefing methods to get the most out of this technique. Experience with the Ebola epidemic does suggest that it increases the confidence of medical teams and potentially allows the team to provide effective care without endangering themselves.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang MT, et al. Technology-enhanced simulation for health professions education. JAMA 2011;306:978-88.  Back to cited text no. 1
Beal MD, Kinnear J, Anderson CR, Martin TD, Wamboldt R, Hooper L. The effectiveness of medical simulation in teaching medical students critical care medicine: A systematic review and meta-analysis. Simul Healthc 2017;12:104-16.  Back to cited text no. 2
Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA 2020;323:1239-42. doi: 10.1001/jama.2020.2648.  Back to cited text no. 3
Abualenain JT, Al-Alawi MA. Simulation-based training in ebola personal protective equipment for healthcare workers: Experience from King Abdulaziz University Hospital in Saudi Arabia. J Infect Public Health 2018;11:796-800.  Back to cited text no. 4
Manuel A, Macdonald S, Alani S, Moralejo D, Dubrowski A. Ebola Virus Hemorrhagic Fever: A Simulation-Based Clinical Education Experience Designed for Senior Undergraduate Nursing Students. Cureus 2014;6:e228. doi:10.7759/cureus.228.  Back to cited text no. 5
Wong J, Goh QY, Tan Z, Lie SA, Tay YC, Ng SY, et al. Preparing for a COVID-19 pandemic: A review of operating room outbreak response measures in a large tertiary hospital in Singapore. Can J Anaesth 2020;1-14. doi:10.1007/s12630-020-01620-9c.  Back to cited text no. 6
Roussin CJ, Weinstock P. SimZones: An Organizational Innovation for Simulation Programs and Centers. Acad Med 2017;92:1114-20.  Back to cited text no. 7


  [Figure 1], [Figure 2]


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