Translational Simulation on Steroids in COVID-19

Professor Victoria Brazil & Dr Swapnil Pawar

• What is Translational Simulation? It is a terminology which refers to a subset of simulation activities that are directly focused on a patient or institutional level outcomes and focusing on those outcomes through at least two ways. One is through diagnosing system issues at the individual team or system level and then also seeking to address those issues through simulation. It involves testing new systems or embedding new systems or re-evaluating existing systems. Steroids are a two-edged sword, and we have to think before commencing any patient on steroids carefully. Similarly, translational simulation during COVID-19 pandemic is challenging. As an educator, we recommend asking yourself “what do you want to achieve through simulation in COVID-19 pandemic?” before committing to intense simulation activities.
• Why do we need Translational simulation for COVID-19 pandemic? A simulation that’s more purely education is good e.g. simulation for our medical students. Translational simulation in the context of pandemic refers to the subset, which is often but not always in-situ simulation activity. This is targeting a particular service outcome and involves going through virtually a quality improvement cycle of studying it, planning, doing something, restudying it, acting on that, and so hence translational simulation. COVID-19 pandemic offers a unique opportunity to simulation craft group to step up to implement urgent and high stakes change. Most of the facilities have existing processes and infrastructure to ramp up the simulation programmes to match the needs of their organisation. In simple words, it is a process testing and rectifying exercise and not just a teaching modality. E.g. Trauma scenario – we all know how to run trauma scenario in NON-COVID era. However, the process will look completely different now when we don’t know which patient is COVID-19 positive or suspected. That means we need to adapt and change the whole organisational aspects of trauma management which will involve –1) Buy-in from all stakeholders 2) Redesigning the response process 3) training all relevant staff members 4) rehearsing till we get perfect. And most importantly, we have to achieve this in a relatively narrow timeframe. This will apply to many more scenarios, and the efforts needed will just multiply exponentially. Some of those things can take years to change, and the pandemic gives an urgency, which we know is essential in any change management strategy, but it doesn’t necessarily give us a nice template as to how to approach that change. Translational simulation is one of several plans that we have to do while at the same time being very conscious that human beings haven’t changed even if the urgency and the high stakes nature of the change are there.
• Prepare COVID-Simulation team in your organisation —Central co-ordination of Simulation activities is essential –
  getting together once or twice a week with people from operating theatre, ICU, the medical emergency team, after-hours care unit, ed, maternity.
• Prioritise the list of simulation activities
• Prepare the roster of simulation faculty and participants
• Tap into skillset available within and outside your organisation –
  different departments have different skillsets and this is a chance for people to share those a lot more, and also to examine those interfaces. This is potentially a time when we feel like particularly those of us in critical care; we are going to need to work together even more than usual and be able to have a lot of to and fro about where some of the traditional boundaries are drawn, about when people are transferred between different units and indeed the skillsets. There may be, amidst just doing ICU type activity, there might be other people in the hospital doing ed type activity. So we do think the opportunity is also for collaboration in the simulation area just as it is in the clinical area.
• We do acknowledge that not everyone has a hospital-wide simulation capability or outlook. So this is probably a reason to make sure that there is one, whether that’s a network solution or whether it’s overarching governance or whether it’s merely a resource that people can draw upon. Obviously depends on how you set up things at your own institution.
• Does Simulation modality matter? The short answer is NO. The simulation faculty need to choose the modality that is appropriate to learning objectives. Pay attention to details and don’t deviate from standard practices such as pre-briefing and debriefing.
• Unlearning can be challenging for Translational simulation during Pandemic
  It’s complicated. It’s so far from what we usually do. It may make pretty good sense about what we should do, but people aren’t going to do it because they’re not used to it. It’s not part of the habit. It’s not part of a reflex. If for instance, you want to stop doctors and nurses doing CPR on a patient until they get PPE on, you’re going to have to think hard about what’s going to get in the way of them doing that. How are you going to create forcing functions and how you are going to get sufficient experience in simulation or elsewhere that staff have got a new normal. And we think that’s challenging when so many of us work on reflexes that we’ve built up over many years.
• It can trigger more anxiety –
  This is already a time of high stress both for the people initiating changes and for the staff who are trying to come on board with those. We think if you just then drop in a simulation that people aren’t used to that can only heighten anxiety and illustrate just how far and how severe the aim is from where we’re usually practising. So We do think this is not the time to stop doing good pre-briefing
• Cleaning of equipment & Reducing the risk of transmission –Maintaining social distancing while running simulations is critical. If one of the participants or faculty is affected, that will force all attendees to go in quarantine for the next two weeks and has a significant impact on workforce morale and service provision.

• PPE burn rate vs training people how to use PPE correct – This has been a real challenge during the pandemic. There is no right or wrong answer. However, we suggest coming up with innovative educational approaches to achieve the balance between training how to wear PPE and reducing PPE burn rate.
• Cultural Sensitivity – Translational simulation has a relational and affective element as you proceed with any of these things. There are groups who are culturally more comfortable with change, with followership, and then there are groups who aren’t. And a different approach that recognizes that maybe a different tack in the pre-briefing, the debriefing and a different point in their phase.

• Educator Burnout – Be aware of faculty burnout, when the entire programme is on “steroids”. It’s important to look after the faculty and participant as “simulation fatigue” is not uncommon during stressful times such as COVID-19. One of the strategies of preventing burnouts is frequent Check-in–> what is everyone doing? Who needs help today? What sort of sims are you doing? What are the areas do you feel like we need to target? What have you learnt about communicating between different rooms? What have you learnt about disseminating through infographics?

• Moving forward – It’s important how do we take that same agility and flexibility that we took into this being able to rapidly do a large number of sims and now move back towards the kind of processes we had, but maybe still hang on to some of the things that we changed because, in fact, they’re better. So there are some things we don’t want to do post-pandemic, but there are some things that maybe were streamlined very nicely that are useful to us. We think hopefully we can select out some of those and retain them.