A Sustained Medical Simulation Response to the COVID-19 Pandemic
By: Brian Kaufman MD, FCCP, FCCM
Director VA NY Harbor Simulation Laboratory (Manhattan)
VA NY Harbor (Manhattan)
Sunil Nair MD
Simulation Fellow / Division of Pulm / Critical Care Medicine
NYU Grossman School of Medicine
New York, NY - Novel Coronavirus Disease 2019 (COVID-19) placed strains on the New York City intensivist workforce unprecedented in recent times. Realizing that rapid up-staffing of intensive care units would be needed as COVID-19 surged, VA NY Harbor Healthcare undertook to expand its numbers of intensive care physicians and physician-extenders using medical simulation. Any physician or advanced practice provider (nurse practitioners and physician assistants) expected to occupy a critical care leadership or critical care responder (e.g. rapid response team) role underwent rapid-cycle training at the Manhattan Veterans Affairs Simulation Laboratory. Training focused on performing critical care assessments and procedures in biohazard conditions; scenarios presented included respiratory failure and cardiac arrest, both unfortunately common throughout the pandemic. Observing infection control practices, participants were encouraged to interact with each other, simulation staff, the advanced patient simulator, as well as ultrasound simulators; decisions and outcomes were debriefed immediately after each scenario. Two-hundred critical care fellows, pulmonary-only faculty, and non-traditional ICU physician and advanced practice providers were up-trained in this manner over 6 weeks, contributing to the critical care workforce at a key time during the surge.
The up-training occurred in two phases: phase one was directed to those with some prior advanced intensive care unit training who would need to be rapidly deployed to augment our existing critical care faculty as the number of intensive care unit beds/units increased in early March 2020. Phase one participants included all our pulmonary/critical care fellows, and pulmonary faculty with prior ICU training but no ICU experience since completing their fellowship training. In addition, all the current critical care faculty participated in phase one training sessions. Participants were presented with two simulation scenarios: 1) Acute respiratory deterioration of a patient with COVID-19 (scenario 1); and 2) cardiac arrest of a COVID-19 patient in an isolation room (scenario 2). Participants had to don appropriate personal protective equipment and demonstrate principles such as minimizing unnecessary staff exposure by bringing only necessary personnel to the bedside, choose the appropriate equipment and perform appropriate procedures (such as intubation) following guidelines that existed in early March. Debriefing immediately followed the completion of each scenario.
Because rapid escalation of ICU capacity in New York City, there was a huge need for additional intensivist staffing. This could only be accomplished by utilizing non-critical care trained physicians and Advanced Practice Providers (APPs). Many helped as volunteers but without adequate up-training, their efforts when deployed could have been inefficient or potentially disruptive. Phase two focused on trying to improve the medical knowledge and comfort level of these providers in critical care medicine. A total of 39 three hour simulation-based sessions were held with a maximum of 6 learners per session. Participants were asked to manage various scenarios including cases of circulatory shock and acute respiratory failure. Critical care point of care ultrasound was integrated into each of the scenarios including the evolution of lung sonographic findings in worsening COVID-19 respiratory failure. A survey completed after the return of this workforce to their normal locations documented improvement and knowledge and comfort after completing these sessions.
We concluded that the use of simulation can be a safe and effective adjunct to improve intensivist workforce preparedness during pandemic conditions.