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Resuscitation during the COVID-19 pandemic: Lessons learnt from high-fidelity simulation

  • Wan Yen Lim
    Correspondence
    Corresponding author.
    Affiliations
    Department of Anaesthesia, Sengkang General Hospital, 110 Sengkang E Way, Singapore 544886, Singapore
    Division of Anaesthesiology and Perioperative Sciences, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
    Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore
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  • Patrick Wong
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  • Li-Ming Teo
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  • Vui Kian Ho
    Affiliations
    Department of Anaesthesia, Sengkang General Hospital, 110 Sengkang E Way, Singapore 544886, Singapore
    Division of Anaesthesiology and Perioperative Sciences, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
    Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore
    Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore 117597, Singapore
    Department of Intensive Care, Sengkang General Hospital, 110 Sengkang E Way, Singapore 544886, Singapore
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      To the Editor
      The coronavirus disease 2019 (COVID-19) pandemic has caused an unprecedented global healthcare crisis, creating challenges to resuscitative efforts. Cardio-pulmonary resuscitation (CPR) confers additional risks to healthcare workers due to exposure to aerosol generating procedures (AGPs) like chest compressions, face mask ventilation and intubation. The emergent and high-intensity situation may also result in lapses in infection control practices.
      • Edelson D.P.
      • Sasson C.
      • Chan P.S.
      • et al.
      Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed cOVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians.
      High-fidelity simulation sessions were conducted in our institution to identify latent threats in existing workflows, and to formulate modified life support protocols focusing on: protection of healthcare workers (HCW) and patients, minimizing aerosolization and reducing delays in resuscitation.
      Sengkang General Hospital, one of Singapore's largest regional hospitals, comprises an acute care 1000-bedded facility and a 400-bedded community care hospital. Suspected or confirmed COVID-19 patients are managed in negative pressure, single-bedded rooms in the acute care hospital. In the community hospital, such patients are managed in cohort wards (4–6 bedded bays) with natural cross ventilation through large open windows. A single code blue team, based at the acute hospital, provides resuscitation services at both facilities. Due to geographical reasons, the mean (SD) code blue response time to the acute and community care wards were 3.28 (1.76) and 6.67 (2.06) min, respectively. These timings were validated from actual code blue events pre-COVID-19.
      In simulations, we adhered to hospital and COVID-19 guidelines of full PPE (including N95 mask or powered air-purifying respirator (PAPR), gown, gloves, goggles and face shield or visor).
      • Cook T.M.
      • El-Boghdadly K.
      • McGuire B.
      • McNarry A.F.
      • Patel A.
      • Higgs A.
      Consensus guidelines for managing the airway in patients with COVID-19.
      A donning and doffing supervisor, or a buddy system can reduce self-contamination amongst HCW.
      • Bricknell M.
      • Hodgetts T.
      • Beaton K.
      • McCourt A.
      Operation GRITROCK: the Defence Medical Services’ story and emerging lessons from supporting the UK response to the Ebola crisis.
      The mean (SD) time taken by 19 HCW during simulations, for donning full PPE including CleanSpace® PAPR was 3.33 (0.73) min. Our timings were comparable to donning full PPE that included N95 mask, which were 3.28 (1.15) min.
      • Suen L.K.P.
      • Guo Y.P.
      • Tong D.W.K.
      • et al.
      Self-contamination during doffing of personal protective equipment by healthcare workers to prevent Ebola transmission.
      We identified two latent threats on two separate simulation sessions: (1) A participant, designated as the second responder, entered the resuscitation room without eye protection; (2) A participant tripped and fell while retrieving equipment, possibly contributed by impaired peripheral vision when wearing goggles. Learning points from these include adopting a buddy system for donning and doffing of PPE, removing hazardous items and ensuring adequate resuscitation space.
      From our simulations in the community hospital where isolation facilities are unavailable, we observed that precautions to protect surrounding patients in the cohorted wards were required. These include use of waterproof shields or partitions to cordon off the resuscitation area, prompt evacuation of ambulant patients and minimizing aerosol generating procedures. Due to the potential delay in response times, manual ventilation via SAD
      • Cook T.M.
      • El-Boghdadly K.
      • McGuire B.
      • McNarry A.F.
      • Patel A.
      • Higgs A.
      Consensus guidelines for managing the airway in patients with COVID-19.
      (preferred if HCW is trained and competent in SAD insertion) or a well-fitting mask with a good seal may be required prior to code blue team arrival. We summarized our recommendations for resuscitation in acute and community hospital settings in Table 1.
      Table 1Summary of our recommendations between acute and community hospitals.
      Acute care hospitalCommunity hospital
      Set upIsolation, negative pressure roomCohorted ward with 4–6 beds
      Physical barriers to reduce aerosolization and exposurePlacement of a non-porous sheet (e.g. plastic drape) or a wet gauze over the patient's mouth and noseWaterproof shields/partitions to cordon off the resuscitation area and evacuate ambulant patients within the same area
      Placement of a non-porous sheet (e.g. plastic drape) or a wet gauze over the patient's mouth and nose
      Limit staff presentMaximum of 5 HCW to minimize exposure; dedicated staff (with PPE) outside the room to render immediate assistance
      Donning & doffing of PPEBuddy system or supervisor
      First responderPPE including N95 (leave resus scene once CB team arrives)PPE including PAPR
      Second responderPPE including PAPR
      Code blue teamFull PPE including PAPR
      CPRCompression-only CPR till code blue team arrivesCPR including face mask or SAD ventilation till code blue team arrives
      IntubationEarly intubation by experienced personnel using videolaryngoscope
      EquipmentAttachment of a HEPA filter to the resuscitation ventilator bag; capnography to confirm tracheal tube placement; use 2nd generation SAD if required
      Patient transferClamp tracheal tube prior to disconnection; dedicated transport ventilator with appropriate filters attached
      CommunicationConcise, closed-loop communication, especially via intercom
      CB, code blue; HCW, healthcare worker; HEPA, high efficiency particulate air; PAPR, powered air-purifying respiratory; PPE, personal protective equipment; SAD, supraglottic airway device
      Frequent training and simulation sessions including PPE familiarization minimizes delays in resuscitation, reduces risk of viral transmission, enhances communication, teamwork and coordination, and allows latent threats identification and workflow refinement.

      Conflicts of interest

      None declared.

      Funding

      Not applicable.

      Ethics approval

      Not applicable.

      Author's contribution

      WYL and PW: Conception of work, acquisition of data, drafting manuscript and revisions. LMT and VKH: Conception of work, acquisition of data, revision of manuscript.

      References

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        • Sasson C.
        • Chan P.S.
        • et al.
        Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed cOVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric Task Forces of the American Heart Association in Collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: Supporting Organizations: American Association of Critical Care Nurses and National EMS Physicians.
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        • McCourt A.
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