Optimizing healthcare professional performance in COVID-19 airway management: The role of interprofessional simulation training

TO THE EDITOR During the coronavirus disease 2019 (COVID-19) pandemic, tracheal intubation was stressful because it combined an urgent and potentially difficult procedure with a significant risk of aerosol contamination.[1] Interprofessional full scale in situ translational simulations (IFSTS) could help teams apply best practice and improve safety of care they deliver.[2] IFSTS is a full-scale simulation methodology in which interprofessional team are exposed in their own work environment, in order to help simulation training to be directly applicable to future real clinical situations. Just before the pandemic, intensive care unit (ICU) physicians and nurses from 4 teaching hospitals in Lyon and Paris were invited to IFSTS sessions to train for the specific COVID-19 patient airway management procedure. Their stress level was recorded before the IFSTS session and if it occurred, after being exposed to airway management of a real COVID-19 patient. We hypothesized that IFSTS sessions could help professionals to manage the stress of this new procedure. The herein protocol was approved by the French-Society-of-Anesthesia-and-Intensive-Care Ethical committee (IRB 00010254-2020-047, March 25, 2020). Participants received study information and gave written consent. IFSTS sessions involved teams of one physician and two nurses. Each session started with a general briefing about the training objectives and the demonstration of the use of the procedure checklist that has been previously prepared. Then, a 1-min case scenario briefing was performed and ended with “You have just decided to intubate the patient”. Each scenario started outside the resuscitation room and lasted 10-15 min. The procedure checklist was displayed on the intubation trolley. The first item described materials and medications to be prepared before entering the room. The next item proposed a distribution of roles among the physicians and nurses from the teams. The physician and one nurse had to enter in, while the other nurse stayed behind the glass door available for any need. The latter nurse read out loud and check the protective clothing procedure. Once in the room, the team followed the checklist displayed close-by the ventilator to guide the airway management (preparation/intubation). The scenario ended once endotracheal tube position was controlled. The debriefing focused on professionals’ collaboration, communication, and checklist use. The level of stress was rated by participants on visual analog scales (VAS) rating from 0 to 100 and cognitive appraisal ratio (CAR) before the scenario.[3] In case the professionals had to deal with intubation of a real COVID-19 patient during the whole pandemic period of time, they also rated their stress (VAS and CAR) and filled a VAS-satisfaction and VAS-perceived impact of IFSTS on their performance. The stress-VAS scores and CAR were compared between males/females and between physicians/nurses using the Mann-Whitney test. Variables were expressed as count, or median [25th-75th]. A P < 0.05 was considered statistically significant. Between March and June 2020, 142 professionals benefited from a IFSTS session. Table 1 describe the key characteristics of the participants. Among them, 16 also participated to a real COVID-19 patient intubation procedure afterwards. Participants exposed both to IFSTS and intubation for real COVID-19 patient (n = 16) rated baseline Stress VAS for the latter non-statistically different to Stress VAS before IFSTS, respectively 40 (23-70) vs. 28 (10-52), P = 0.24. However, they reported improved CAR scores before intubation of a real COVID-19 compared to before IFSTS, respectively 1.00 (0.95-1.19) vs. 0.90 (0.68-0.96), P < 0.01. For participants exposed to IFSTS (n = 142), the stress-VAS score was significantly higher for females compared to males and for nurses compared to physicians, however the CAR was not different between groups [Figure 1]. No other difference was observed. The VAS-satisfaction score was 68 (49-82) and the VAS-perceived impact of IFSTS on performance score was 86 (82-88) with no difference between gender or profession. IFSTS rapidly enabled a high number of professionals to benefit from training for this specific COVID-19 procedure with new incoming patient with specific new airway management to implement to limit the risk of aerosolization and contamination. More than 10% of participants experienced a real COVID-19 patient intubation situation during the study period with a reported significant positive impact of IFSTS on performance. The quantitative stress level was high, and higher before IFSTS among females and nurses, however the qualitative perception (CAR) was not reported different among physicians/nurses. Figure 1.: Quantitative and qualitative stress level before IFSTS. Subgroup snalysis. N, number of participants (number of women for nurse and physician subgroups, or number of nurses for female and male subgroups); Y, median (IQR) age (graduated since/experience in intensive care); years. VAS, visual analog scales; CAR, cognitive appraisal ratio; IFSTS, interprofessional full scale in situ translational simulations; IQR, interquartile range. Table 1. - Key characteristics of the included participants Characteristics Exposed to IFSTS Exposed to COVID-19 patient Number of participant 142 16 Age, year 32 34 Female 80 (56%) 9 (56%) Nurse 83 (58%) 13 (81%) Graduated since, year 7 5 Experience in intensive care, year 5 6 Stress VAS 42 40 Cognitive appraisal ratio 0.98 (0.82-1.21) 1.00 (0.96-1.20) Satisfaction VAS - 68 Impact of IFSTS on performance VAS - 86 Data are presented as n (%) or median (IQR). COVID-19, coronavirus disease 2019; VAS, visual analog scale; IFSTS, Interprofessional full scale in situ translational simulations; IQR, interquartile range. It is being suggested that females and nurses cope differently with stress, even if a high stress level can have an impact on individual performance,[4] its management may depend on gender[5] or their position within the team. To conclude, knowing that to improve team performance, one should reach an ideal individual stress level, we suggest implementing IFSTS to help healthcare-professionals to deal with urgent and stressful procedures, and individualizing the IFSTS debriefing according to stress levels in order to help individuals to better cope with their contextual and professional stress.