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Since the WHO declared covid-19 pandemic on 11 March 2020, Hamad Medical Corporation (HMC), the leading healthcare provider in Qatar, has taken unprecedented measures to streamline service provision, to prevent transmission of the virus and to protect healthcare workers (HCWs) in its participating hospitals.1
The contagion nature of the novel coronavirus and the confirmed human-to-human transmission means that HCWs and in particular anaesthesia care providers are at enhanced risk of infection.2
Airway management is a core anaesthesia skill and is particularly hazardous as it leads to aerosolisation of large number of viral particles.
Anaesthetists are competent to perform these skills in routine practice; however, during the current pandemic, they are dealing with patients with highly contagious disease. They are required to apply strict infection control measures to combat the spread of the virus and to protect themselves while providing care for patients with covid-19. In preparation to meet these challenges, anaesthesia care providers must undergo structured training to deal with such an unfamiliar situation.
The purpose of this article is to present an experience from our Anaesthesia Department at Al Khor Hospital, HMC, to use simulation to rehearse skills training pertinent to providing general anaesthesia (GA) to patients with covid-19.
A metric-based checklist was developed (table 1). Steps of induction of GA, tracheal intubation, intraoperative management, tracheal extubation and patient recovery were identified and clearly defined in the context of treating patient with covid-19. Three anaesthesia consultants reviewed available literature and best practice guidelines to form the comprehensive checklist. Steps of donning and doffing personal protective equipment (PPE) were also included.3
The checklist was then posted to all members of the department (14 anaesthesia physicians and 15 anaesthesia technicians). Members were asked to review and familiarise themselves with the individual items in the checklist. In our department, we assigned one operating room (OR) to receive all potential patients with covid-19. All non-essential equipment were removed from OR. Anaesthesia machine and related equipment were all covered in transparent plastic sheet to reduce risk of contamination. Anaesthesia station ergonomics is arranged so that infection control measures are adhered to and for easy disposal of contaminated equipment.
Subsequently, training is established so that each pair of the members, often an anaesthesia physician and an anaesthesia technician, was asked to undertake a simulated session of conducting GA for patient with covid-19 in OR.
A video (video attached online supplementary file 1) recording was acquired for entire session and subsequently scored using the checklist by the three consultants who initially developed the checklist.
The video recording was then played prior to commencing each subsequent simulation learning session to aid prebriefing. Errors in performance were identified and discussed. Candidates were given time to reflect on their own performance during debriefing, and all questions were answered. The process continued until every member of the anaesthesia team has participated in at least one session.
Simulation training is well known to the specialty of anaesthesia, and in this particular pandemic, there is little doubt that it can play an important role.4 It helps anaesthesia care providers to rehearse airway management skills before approaching patients with covid-19. This will minimise the chance of transmitting infection. Simulation also gives opportunity to analyse the existing system, identify weaknesses and develop solutions to these issues.
Aerosol generation during airway management is a major concern for anaesthesia care providers. During previous outbreak of coronavirus, tracheal intubation conferred a 13-fold higher relative risk ratio for acquiring respiratory infection for those who were participating in the procedure compared with those who were not.5 This will have huge implications for the practice of anaesthesia during the current covid-19 pandemic. Training must be provided to anaesthesia care providers including donning and doffing PPE as they do not practise these skills regularly.
We propose that anaesthesia departments develop their own local protocols and engage all members in structured training modules with objective assessment. It is important to realise that simulation is most powerful when integrated in a carefully designed curriculum. The developed checklist though not validated gives a detailed and unambiguous description of what to do and what not to do and may help prepare anaesthesia care providers to deal with the outbreak if integrated on simulated learning platform. We envisage a huge role for simulation training in the current and future potential pandemics. Anaesthesia training bodies may consider including simulation-based training for pandemic as a competency requirement during training and for recertification.
Authors would like to thank all members of the Department of Anaesthesiology, Al Khor Hospital, for participating in simulation sessions. Special thanks go to our anaesthesiology technical staff who prepared all required equipment, Chiraz Soltani, Amel Tayari, Aida, Jawdat, Ibrahim, Mohamed Ali Khan, Ismahen and Houari.
Contributors All authors: conception, design and application of methodology. All authors participated in drafting and approval of manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
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