Patients as partners in readiness for COVID‐19: using ‘live simulation’ to implement infection prevention and control procedures in the maternity operating theatre

Summary

Insitu simulation can be used to improve care within a particular setting and has specific value in developing and testing guidelines and procedures. However, it can be challenging to undertake simulation when clinical work is ongoing. Responding to the need to develop infection prevention and control procedures for coronavirus disease 2019 in the obstetric operating theatre, we asked three patients who required operative intervention to consent to be managed according to preliminary standard operating procedures as if they were severe acute respiratory syndrome‐coronavirus‐2 positive. With this method, we were able to run scenarios in real‐time without interrupting clinical work. As well as allowing us to develop and refine procedures, these ‘live simulations’ provided staff training and highlighted system problems that needed to be addressed as the first wave of the pandemic approached. In this case series, we describe our procedure for live simulation, report the learning points that this approach yielded, present the feedback from patient participants and reflect on the ethical implications of this technique.

Introduction

Simulation‐based training is increasingly used in healthcare to reproduce anything from standalone clinical skills to complex cases, depending on the learning objectives [1, 2]. Insitu simulation, delivered within the workplace, has an important role in improving care which is delivered within a particular setting, and can provide insights when developing institutional guidelines because human, system and environmental factors can be evaluated simultaneously [3, 4, 5]. Simulation has been employed in crises inside and outside of healthcare, notably in reproducing situations that would otherwise present risks to those involved, hence its widespread use in aviation. Historically, clinical work has posed little physical risk to healthcare professionals. However, coronavirus disease‐2019 (COVID‐19) has changed that situation for frontline staff, and also generated a sense of anxiety and uncertainty regarding what measures are required to protect staff and patients [6, 7].

Although pregnant women seem no more likely to be severe acute respiratory syndrome‐coronavirus‐2 (SARS‐CoV‐2) positive than the general hospital population, within the maternity setting there is a sometimes unpredictable risk of emergency operative intervention [8, 9]. This may increase the risk of SARS‐CoV‐2 transmission as a consequence of time pressure, increased staff exposure and aerosol‐generating procedures associated with general anaesthesia. In our busy consultant‐led maternity unit, the development of robust infection control processes at an early point in the pandemic was therefore of paramount importance.

We used ‘live’ insitu simulation (i.e. involving real patients) to assist with the development of standard operating procedures for managing patients with COVID‐19 in the obstetric operating theatre. By working with patients, we had the ability to explore scenarios in real‐time and assess the ability of the multidisciplinary team to implement preliminary standard operating procedures alongside the usual complexities of obstetric practice. In this case series, we describe our procedures for using live simulation and detail the learning points yielded by using this approach.

Report

Before commencing live simulations, we conducted preliminary manikin‐based simulations to develop draft standard operating procedures for the peri‐operative management of patients with known or suspected SARS‐CoV‐2 infection, based on resources available on icmanaesthesiacovid‐19.org. These took place ‘out of hours’ when workload was lower; all staff working on the delivery suite at the time were encouraged to participate where possible. This process highlighted issues including the importance of ready access to personal protective equipment (PPE), the need for a system by which to obtain equipment or assistance while minimising traffic into and out of the operating theatre, and the need to ensure the correct PPE was worn by attending teams such as neonatal specialists. Extensive discussion and problem‐solving was required at this stage, which would have been impractical during live simulation.

Following this preliminary work, three live in‐situ simulations were undertaken in the obstetric operating theatre. Patient care was delivered as planned, but with infection prevention and control procedures undertaken as per the draft standard operating procedures (with the exception that the patient’s birth partner was allowed to be present). These exercises were observed by a consultant anaesthetist, a consultant obstetrician and a senior midwife.

The aim of the live simulations was to refine the draft standard operating procedures in order to make them workable. The specific objectives included to evaluate the use of PPE and infection prevention and control procedures, the resultant impacts on human factors such as communication and to identify and mitigate system problems. The activity also provided the opportunity to provide infection prevention and control training for staff. The simulations were undertaken over a 9‐day period (18–27 March 2020), with the standard operating procedures undergoing development between simulations based on the learning points that were identified.

Informed consent was sought from both patients and staff following which the simulation process began (Figure 1). For patients, this was undertaken concomitantly with consent for anaesthetic and obstetric care. Criteria for abandoning or pausing the simulation (as appropriate) comprised: (1) withdrawal of patient or staff consent to participate; (2) occurrence of any clinical situation in which the simulation process may adversely impact the management provided; (3) requirement for any unanticipated aerosol‐generating procedure before which observing clinicians were unable to don PPE in a timely manner; (4) if the presence of PPE or new infection prevention and control practices was judged by the observing clinicians to pose a risk to the health or safety of any participant. Debriefing following the simulation was provided to all patients, and staff participated in a group debrief led by the observing clinicians.

Figure 1.

Live simulation management pathway. WHO, World Health Organization; PPE, personal protective equipment; i.v., intravenous; ODP, operating department practitioner.

Three patients with low case complexity (Table 1) were identified at times when greater than recommended staffing levels were available on delivery suite and invited then consented to participate.

Table 1.

Clinical details of the patient participants and potential problems. ODP, operating department practitioner; PPE, personal protective equipment.

Patient	Parity	Gestation	Patient details	Potential problems
1	0	Term + 2	35‐year‐old, instrumental delivery in delivery room followed by manual removal of placenta and repair of perineal tear under epidural top‐up anaesthesia in theatre. The epidural top‐up was commenced in the delivery room by a trainee anaesthetist and ODP wearing ‘airborne’ PPE who then transferred the patient to theatre. The receiving team in theatre wore ‘droplet’ PPE	Risk of conversion to general anaesthesia if the epidural top‐up was unsuccessful; increased risk of post‐partum haemorrhage
2	1	Term	36‐year‐old, elective caesarean section under spinal anaesthesia for previous emergency caesarean section. Anaesthesia undertaken by trainee and consultant, all staff in ‘droplet’ PPE	Potential requirement for neonatal team support (low risk)
3	1	39 + 6	29‐year‐old, elective caesarean section under spinal anaesthesia for previous traumatic vaginal delivery. Anaesthesia undertaken by consultant, all staff in ‘droplet’ PPE	Potential requirement for neonatal team support (low risk)

In patient 1, the patient became tachycardic and hypotensive during the procedure, most likely due to sepsis. The simulation element was therefore halted, the observing anaesthetist provided assistance, and the duty anaesthetic and obstetric consultants were called into theatre. The obstetric care of patient 2 proceeded uneventfully. In patient 3, the midwife was unable to auscultate the fetal heartbeat following spinal anaesthesia so the simulation was paused while the observing obstetrician and midwife provided assistance. Delivery was expedited and the baby was born in good condition; the simulation was resumed. No patients asked for the simulation to be stopped; in all cases the postoperative maternal and neonatal clinical course was uneventful.

Discussion

Much of the learning from live simulations centred on the use of PPE. In particular, we established that many staff were initially unfamiliar with the principles of infection prevention and control relating to high‐impact respiratory pathogens, and that effective leadership and clear briefing were therefore critical. This finding supported our organisation’s decision to implement 24‐hour senior clinician presence throughout the ‘surge’ of the pandemic. The standard operating procedures were revised to state that the likelihood of aerosol‐generating procedures should be assessed during the team brief, and that PPE should be donned according to this anticipatory assessment, an approach that has since been adopted in national guidelines [10]. Targeted training was also commenced in order to improve understanding of what type of PPE was appropriate in different circumstances.

Patient 1 in particular emphasises the unpredictable nature of obstetric practice and highlights that the pre‐operative team brief cannot account for all eventualities. In response to this, the standard operating procedures were modified to account for unanticipated deterioration. This case also demonstrated that during a busy emergency situation, ‘runners’ outside the operating theatre were unable to clearly hear requests through closed operating theatre doors. Portable radios were purchased to address this issue.

Initial patient comments regarding the live simulations were positive, but no formal early feedback was collected. However, at the time of seeking consent for this case series, written feedback was invited via email:

"Everyone wore gowns, masks and gloves… This really didn’t feel much different to what I would have expected in theatre… I found it really interesting to listen to the discussions about what was working well and the problems that were being highlighted to them during the simulation… I was made to feel like I was being helpful and that felt good.

Unfortunately, I became quite poorly during the procedure… When I was out of theatre [the anaesthetist] explained how things had taken a turn for the worse and they had to call in an emergency team… I apologised for spoiling the simulation. The anaesthetist was insistent that there was nothing to apologise for and said that… it had helped highlight issues with how to deal with emergent situations involving a potential COVID‐19 patient in theatre…

… The simulation had no negative effect on my experience…. it was nice to feel like I was giving something back to the people who had just helped to bring my precious baby into the world"—Patient 1

"… I saw this as a positive opportunity so agreed along with my partner… [Healthcare workers] coming into the room from that point on had to be fully PPE protected. Luckily my partner was still able to accompany me, this wouldn’t be the case in a real situation which I personally would find difficult… It was interesting to listen to the team communicating with each other through all the protection and hearing all procedures taking place to avoid contamination, also hearing what had gone wrong or could be improved on."—Patient 2

Myself and [my husband] were honoured to take part in the COVID‐19 training experience and do our bit to improve healthcare at such an unusual time. [The healthcare team] were amazing! The way they handled the whole experience was professional and fearless. Me and my husband felt at ease throughout the procedure and in very safe hands despite our nerves."—Patient 3

Though live simulation is perhaps an unorthodox approach, obstetric practice presented a unique challenge at the start of the pandemic. While other services could halt elective work, patient numbers in maternity remained constant and staff had little capacity to leave their usual roles to participate in training or development. By using live simulation, we were able to offer this in parallel with clinical work and democratise the process of standard operating procedure development.

Perhaps the most striking element of our experience is the patient feedback. We were concerned that live simulation may be intrusive and risk provoking anxiety at an already stressful time. However, patients volunteered eagerly and their feedback was universally positive. This appears to be due to a sense of collective solidarity with the health service: Patient 3 stated that she was "honoured to take part… and do [her] bit", Patient 2 "saw it as a positive opportunity", and Patient 1 worried about "spoiling the simulation" by becoming unwell, suggesting investment in the process. Participation did not appear to provoke anxiety, even though staff were heard discussing "what had gone wrong or could be improved on". The fact that patients found this interesting suggests that they were able to clearly identify which aspects of care were being simulated, highlighting the importance of clear briefing for patients as part of the consent process.

Though we utilised live simulation through necessity, we have found this to be a valuable technique with a high degree of acceptability to patients and staff. However, an impending pandemic is a unique circumstance and therefore the use of live simulation in other situations should be approached with caution. Nevertheless, it does offer the potential to embed training into routine practice, an attractive prospect in a health service grappling with a backlog of elective work in the face of an ongoing pandemic.

As the COVID‐19 pandemic approached, we needed to rapidly develop standard operating procedures and provide staff training in a busy maternity unit. Live simulation offered a pragmatic way to address these pressing needs at a challenging time and there is potential for the technique to be used in other circumstances. This case series provides an overview of how this might be done, based on the principles of prioritising patient safety, effective briefing and debriefing, and informed participant consent.