Just-in-time in-situ simulation for high stakes success in viral haemorrhagic fever (VHF)
Authors: Scaffardi Suzanne , Wiltshire Michaella , Moores Rachel , Adlakha Amit , Taylor Caroline , O’Shea Michelle , Dunning Jake , Hanton Sinead 
Published: November 2022

Success of just-in-time in-situ simulation to find new ways of working, test processes, and uncover latent error to promote patient and staff safety is well documented from the COVID-19 pandemic [1,2]. We used just-in-time simulation in a unique situation where imminent transfer of a critically unwell patient with VHF was required to our high-level isolation unit (HLIU). The Trexler isolator tent is custom made for treating high consequence infectious diseases (HCID), requires specific training. Staff provide care by ‘stepping’ into ‘suits’ in the plastic walls. Transfers into the tent are time-critical to reduce potential exposure risk to staff. This was the first time ever an intubated, ventilated patient was to be transferred into the tent.
Simulation, Infectious Diseases, and Intensive Care teams collaborated within a few hours’ notice to simulate in-situ the mechanism of transferring a patient (using a Laerdal SimMan 3G) intubated and ventilated with multiple drug infusions running, headfirst from a transport trolley into the foot end of the isolator tent. This was repeated subsequently in several Plan-Do-Study-Act (PDSA) cycles to refine the process and reduce transfer time taken. There were multiple pauses as problems, latent threats, and potential failure points were identified, and time outs to discuss solutions.
Transfer teams informally reported increased confidence being able to troubleshoot and rehearse the transfer process before patient arrival. Key learning related to leadership, communication, highlighting safety steps, and sharing mental models between teams such as airway management, significance during transfer and ergonomics of airway-trained personnel positioning in the tent. This was written up as a visual aid for the transfer team. Environmental latent threats found included safe ventilator mounting, IV pump management, emergency drug preparation, and allowed for enhanced consideration of the practicalities of caring for an intensive care patient in the HLIU tent. The actual transfer of the patient went smoothly and without incident. Further simulations were run during the patient care episode to rehearse and potential anticipate airway and ventilation management issues.
Just-in-time in-situ simulation provided a valuable opportunity to rehearse a high-stakes, never done before activity, and facilitated identification of environmental latent threats before patient arrival. It created a shared mental model between different specialities of patient needs contributing towards an increased situational awareness and ability to forward plan and project, ultimately increasing patient and staff safety.
1. Guris RJ, Doshi A, Boyer DL, Good G, Gurnaney HG, Rosenblatt S, McGowan N, Widmeier K, Kishida M, Nadkarni V, Nishisaki A. Just-in-time simulation to guide workflow design for coronavirus disease 2019 difficult airway management. Pediatric Critical Care Medicine. 2020;21(8):e485.
2. Zucco L, Chen MJ, Levy N, Obeidat SS, Needham MJ, Hyatt A, Keane JR, Pollard RJ, Mitchell JD, Ramachandran SK. Just-in-Time In Situ Simulation Training as a Preparedness Measure for the Perioperative Care of COVID-19 Patients. Simulation in Healthcare: Journal of the Society for Simulation in Healthcare. 2022 Feb 10; Published Ahead of Print. doi: 10.1097/SIH.0000000000000635
We acknowledge the hard work and expertise of the Infectious diseases and Intensive care medical and nursing leads and team who supported the delivery of this simulation, and the clinical and support staff who maintain and run the HLIU, and the NHS England Contact High Consequence Infectious Diseases Network.