COVID-19 Emergency Department Protocols: Experience of Protocol Implementation Through in-situ Simulation

Figures & data

Figure 1 Various zones in the Emergency Department before COVID-19 outbreak.

Figure 2 Re-designated triage and ARI areas in the Emergency Department.

Figure 3 (A) Triage officer interviewing a simulated patient. (B) The multidisciplinary ED staff discussing the triage algorithm for COVID-19.

Figure 4 Instructor familiarizing the multidisciplinary staff with protected intubation protocol.

Figure 5 Debriefing session after the protected intubation protocol ISS.

Table 1 Participants’ Details, N= (38)

Variables	n (%)
Gender
Female	17 (44.7)
Male	21 (55.3)
Department
ED	33(86.8)
Non-ED	5(13.2)
Profession
Physician	18 (47.4)
Nurse/paramedic	20 (52.6)
Topic
Triage	5 (13.2)
Both	33 (86.8)

Abbreviations: n, number of participants; ED, emergency department.

Table 2 Pre- and Post-Simulation Responses to Individual Triage Scenarios (N= 38)

Triage Case Scenarios ^a	Pre-Simulation, n (%)		Post-Simulation, n (%)
	Correct	Incorrect	Correct	Incorrect
Case 1	28 (73.7)	10 (26.3)	37 (97.3)	1 (2.7)
Case 2	17 (44.7)	21 (55.3)	35 (92.1)	3 (7.9)
Case 3	14 (36.8)	24 (63.2)	36 94.7)	2 (5.3)
Case 4	10 (26.3)	28 (73.7)	37 (97.3)	1 (2.7)
Case 5	25 (65.8)	13 34.2)	37 (97.3)	1 2.7()
Case 6	24 (63.2)	14 36.8)	34 (89.5)	4 (10.5)
Case 7	21 (55.2)	17 (44.8)	30 (78.9)	8 (21.15)
Case 8	23 (60.5)	15 (39.5)	34 (89.5)	4 (10.5)
Case 9	19 (50.0)	19 (50.0)	32 (84.2)	6 (15.8)
Case 10	20 (57.1)	18 (42.9)	33 (86.8)	5 (13.2)

Note: ^aSupplement 3a.

Abbreviation: n, number of participants.

Figure 6 Box plot of pre- and post-simulation score for triage simulation sessions.

Table 3 Examples of LSTs and Opportunities for Improvement Identified by in situ Simulations for Protected Airway Management

Latent Threat Category	Examples of Threat	Identifying Sources
Medication	Rocuronium missing Vasopressors missing Inventory of emergency medication not maintained	Nurse Paramedic
Equipment	Resuscitation set-up not user friendly Inappropriate size of bougie Freshly relocated manual defibrillator lacks compatible electricity port Infusion set/pump missing Correct sized BVM bag and masks missing LMAs missing Portable Xray unit missing Fogging of the goggles/visor	Physician Nurse
Resources/System	Lack of mechanism to deliver samples to the lab Proper waste disposal from the suction unit unclear	Physician
Individual	Faulty airway maneuvers Wrong dose calculation of Rocuronium Inadequate donning	Physician Nurses
Miscellaneous	Knowledge gap regarding when and how to properly don and doff PPE Additional human resources when the number of critically ill suspected cases increase with the progress of pandemic not identified. Additional surge capacity for the ARI zone not identified	Physician

Abbreviations: BMV, bag mask ventilation; LMA, laryngeal mask airway; PPE, personal protective equipment.

Table 4 Self-Reported Pre- and Post-Simulation Change in Skills and Confidence Level

	Pre-Simulation, Median (IQR)	Post-Simulation, Median (IQR)	P value ^a
Triage skill, n=38	1(1–2)	4(4–5)	<0.001
Airway skill, n=33	2(1–2)	4(3–4)	<0.001
Triage confidence level, n=38	1(1–2)	4(3–4)	<0.001
Airway confidence level, n=33	1(1–2)	4(3–4)	<0.001

Note: ^aWilcoxon signed rank test.

Abbreviations: IQR, interquartile range; n, number of participants.

Figure 7 Participants’ evaluation of ISS (on a Likert scale of 5; 1 denoting “disagree” and 5 denoting “agree”).