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Lots of people asking about the #COVID19 #Simulations we have been doing. Here’s a thread of thoughts and advice

1. We already have an established process for low acuity patients. We’ve not done simulation with walk ins.
2. We’ve focused on significantly unwell patients arriving by ambulance or as walk ins.
3. We have robustly defended our plans to test what might happen and not just what the plans say will happen. So we have tested what we would do if we later discover someone is covid +ve as well as when we already know/highly suspect.
4. You must rest your plans at their best and when they fail, for example when a patient arrives unexpectedly or when you have a PPE failure
5. Our usual scenario is a 👨‍🦳 70 yo with a 4/7 hx of cough and fever. Deteriorates in last 12 hours. Now HR 120, BP 105/60, SaO2 90% on 15L, RR 28, GCS 14.
6. We walk through the sim slowly, allowing learners to ask questions as we go along. This is essential as there are LOTS of questions.
7. Initial tasks are in setting up our isolation resus room which we have created by moving parts of our department around. We now have a resus space for these patients separate to main resus
8. Familiarising the team with this new area and how we get into and out is vital. It’s these little practival elements that really count. Eg putting on PPE is a generic skill, but where, how and when in a particular environment needs practice
9. We get our colleagues in radiology/ICU/Anaes involved too. We physically get the X-ray machine in and practice how we move things like cassettes in and out of the room (and bloods/gases/swabs etc)
10. We talk about what assessment can take place whilst in PPE and the use of USS etc. We talk about how comms in and out of hot zone is hard and how it has to be managed
11. In our usual scenario the patient requires IPPV so we talk through how that will be slightly differently to avoid aerosol generating procedures.
12. We then practice moving the patient out of the ED and the complexities of that.
13. We spend a lot of time talking about decisions.
Should we do CPR?
Is NIV possible?
Alternatives to nebs?
Thresholds for IPPV?
Ceilings of care?
Treating a sick colleague?
Self isolation?
14. So having done this many times the outcomes of our sims have changed.

It helps us practice (eg PPE)
It answers colleagues questions and anxieties.
It tests our processes (we have changed almost everything as a result of the simulations)
It shows that we own the problem

It shows that we want people to be trained and we value their work and skills.
It shows where we still have gaps and concerns.
16. A few cautions.

Ensure that any external visitors are well briefed. They may not understand how sim works or how an ED works. That can be problematic if they don’t understand.

Don’t allow late walk ins (see point above)

Make sure that you allow 1:1 conversations later as
Some people will want to raise questions outside of a group setting. Everyone has personal circumstances that affect how they feel about this pandemic. Make yourself available after the sim session.
17. Does it work?


We’ve had suspected patients similar to our regular sim patient. We still have much to learn, refine and adapt, but I’m so grateful to my colleagues (esp Siv and Nandini) who have taken a grip of local training such that we are getting prepared.
18. Should you be doing this or similar?

Absolutely. Get started today with a walk through (process) sim.

Time is short and you, your patients and most importantly you colleagues need it.

19. You don’t need any fancy kit btw. Use a real person and stick some obs on a monitor. You can do it all with basically nothing.
20. Happy to answer any questions, but the bottom line is to follow the rules of @stemlyns
21. But not NMFP because it ‘is’ our problem and we need to own it.

More here…
22. We can’t get everyone through Sim, but we aim to get enough to ‘contaminate’ every shift with someone who has done it. That way we can ‘spread’ the learning beyond the actual sessions.
Clarification. Nebs are not aerosol generating if used with normal face mask.

Not sure if used in anaesthetic circuits. Thoughts?
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