Extubation Simulation during COVID-19: lessons learnt on “low stakes” simulation between adult and pediatric critical care units (1090-004188) (Research Abstract Professor Rounds: Group 3)
Start time: Thursday, January 28, 2021, 11:30 AM End time: Thursday, January 28, 2021, 12:30 PM Session Type: Research Abstracts (Completed Studies)
The Coronavirus disease 2019 pandemic has required that hospitals rapidly adapt workflows and processes to limit disease spread and optimize the care of critically ill adults and children. As part of our institution’s Coronavirus disease 2019 critical care workflow design process, we developed and conducted a number of simulation exercises. Being an institution with adult and pediatric patients, an airway team was established(1) as an emergency response to assist the critical care units with the surge. The simulations in the adult units were all focused on the intubation procedure and lessons learnt during the procedure were disseminated amongst staff with continuous workflow enhancements. We (pediatric simulation program) hypothesized that simulation education of a “low hanging fruit” process such as extubation could provide more lessons learnt than a high stakes procedure such as intubation in a COVID-19 patient.
In situ simulation took place in a fully operational PICU isolation room designated for COVID-19 patient care. For aerosol generating procedure (extubation), personal protective equipment. The goal of the simulation was to identify potential patient care and system failure points in extubating a child with suspected COVID-19. We used a modified Pediatric HAL; Gaumard, Miami, FL to simulate a 8-year-old who was ready by extubation readiness protocols to be extubated. The extubation scenario was developed by two simulation educators. Data Collection: Two simulation educators (one of them a pediatric intensivist), and an anesthesiologist observed the simulation in addition to participating in the debriefing (done using the PEARLS framework) (2). When possible, potential solutions using human factors principles were sought throughout the debriefing. Feedback was obtained from all participants and observers during an immediate verbal debriefing process.
The systems issues identified through all the COVID-19 simulations including the intubation and cardiac arrest simulation provided opportunities to learn under the themes of personnel in the room, donning, doffing, a procedure during the scenario itself. The latent safety threats identified during the extubation simulation scenario were clamping of the endotracheal tube (ETT), availability of the viral filter attached bag prior to disconnecting the circuit. The attachment of the inline end-tidal carbon dioxide monitor and the inline suction to the port before attachment to the ETT. These stress points during the workflow could be identified as part of the low stakes simulation and led to significant workflow changes that were employed not only during the process of extubation but also were deployed in a pediatric COVID19 suspected or confirmed patient during events that needed bagging, a high-risk event in COVID-19 patients.
Extubation is an aerosol-generating procedure in a COVID-19 patient(3). Our experience suggests that simulation by experienced practitioners in a “low stakes situation” is a useful component in developing workflows pertaining to the COVID-19 population. The totality of these experiences led to the creation of a patient-specific COVID-19 airway contingency (intubation, disconnection from the ventilator and extubation) planning bundle. Our group deployed simulation-based methodology to conduct feasibility tests and tests of change (end tidal carbon dioxide monitoring as opposed to our adult critical care patients) during the time-sensitive creation of new workflows for low risk processes such as extubation. We identified stress points in a mission-critical workflow as it was being designed. Incorporating simulation allowed us to be one step closer to demonstrating “work as done” compared to our “work as imagined.”