COVID-19 Anesthesia Teams Simulation-Based Training: Objectives & Simulation Instructor Notes

1. Discuss personal strategies for reducing fomites that may contribute to the spread of COVID-19.
2. Demonstrate donning and doffing of PPE for the care of a patient in the OR during the COVID-19 crisis.
3. Discuss techniques to minimize aerosols while intubating in the OR setting.
4. Review emergence and extubation techniques that minimize aerosols in the OR.
5. Discuss TeamSTEPPS communication strategies utilized in the care of an OR patient.
6. Identify self-care techniques to optimize the well-being of healthcare professionals.

Faculty Outline

1. Three core principles
   1. Self-safety is the highest principle. Froedtert Health Enterprise and the Medical College of Wisconsin is committed to your personal safety.
   2. Patient care must be delivered at the highest level.
   3. Resource allocation and stewardship of PPE remains crucial to managing the crisis.
2. Personal gear suggestions and rationale
   1. Get rid of face hair—it makes N95 masks sit poorly on your face
   2. No jewelry—it acts as a fomite, difficult to clean, traps pathogens
   3. No makeup-attracts airborne particles, in particular to your eyes, where transmission can occur
   4. No lanyards that aren’t hard plastic that can be disinfected
   5. No tennis shoes or porous shoes without a shoe cover
   6. No undershirts or clothes from home—avoid wearing clothes you can’t have laundered here
   7. No logo jackets, wear the one provided by hospital that is laundered here or wear two scrub tops
   8. No bags in ORs-even with purple bag, your straps are contaminated
   9. Phone in plastic bag or wiped down
   10. Be able to wipe down everything on your person (phone, ID badge, pager, pens, stethoscope, etc.)
3. Managing your N95
   1. Keep Ziploc on your person with name and date
   2. Keep N95 open to air
   3. Don’t bend it
   4. Don’t touch the inside ever
   5. Avoid touching the outside, handle it by the edges or wear gloves
   6. Keep the outside of the mask covered with droplet mask
   7. Store it…just in case.  In three days, virus is dead.
   8. Get a new mask daily and a new plastic bag.
   9. If shortages increase, can use UV sterilization or other measures approved by Infection Control
4. Washing hands
   1. Remains one of the most important things you can do to stop the spread of this virus
   2. Lots of friction and time with soap, up to forearms if you can.
   3. OR sinks have timers, use them.  20-30 seconds is great.
   4. Use lotion at home at night, coconut oil, Vaseline, Aquaphor are good choices. The goal is to protect the skin from breakdown.
   5. Keep your nails trimmed.
   6. Cover a cut with dermabond, a bandaid just won’t work with the massive handwashing. See RAAPs attending for help with this.
5. Staying well and teamwork in the OR
   1. Faculty must come into the OR often to break the resident, CAA or CRNA. They need to get liquids to stay hydrated and use the restroom.
   2. Pulmonary toilet is key, hot liquids are best, overall hydration is necessary.
   3. In true exposure when not protected (face splatter of blood, airway secretions, vomit, etc), leave the OR, wash face with soap and water, gargle mouth, and consider saline stick nasal rinse and wash it out that way. Depending on exposure, consider full body shower and change scrubs and under clothes. Contact occupational health.
   4. Bring a change or two of underclothes so if you are showering you have clean socks, underwear, etc. Place one full set into a Ziploc bag so you can easily grab it.  Consider bringing your own soaps.
   5. Use closed loop communication while in the operating room.
   6. Keep the operating room quiet when inducing and emerging.
   7. Debrief with the team any unexpected problems or adverse events.
   8. Practice mutual support by identifying specific things your team is doing that fosters high levels of patient care.
   9. Remember, everyone is stressed and fearful about the unknowns of this pandemic. Everyone is doing their best. Despite working together, maybe even for years, realize you may not know your colleagues that well or the stress or pressures they are dealing with.  Be kind and supportive.
6. Review PPE donning and doffing (faculty only demonstrates to conserve PPE)
7. Intubating Regular patients who are not COVID-19 positive or PUI-(faculty demonstrates key principles on mannequin)
   1. Wear the proper PPE-understand the virus and infection risk.
   2. Business as usual except:
      1. Wear an N95 (or PAPR), gown, head cover, shoe cover, and gloves for all intubations
      2. Surgical mask over N95 to help protect it and conserve PPE
      3. Double glove when going in the mouth
      4. Glove your laryngoscope and place it on the floor or proper holding receptacle
      5. Clean your workstation often
      6. Careful induction and emergence plans to avoid/reduce coughing.
      7. Consider covering the patient with a clean sheet (plastic/cloth) during these procedures
   3. Keep the patient in the OR longer than you might normally to avoid having them cough in hallways or on the PACU RN.
   4. Faculty must be present for all inductions, intubations, emergence, extubation and PACU transfers.  This may mean we go slower than usual.
   5. Keep RNs, techs and surgeons past the foot of the bed when inducing and emerging.
   6. Do not allow anyone in the OR to take their mask off at the end of the case.

8. Intubation and extubation considerations. These are not mandates, just things for the OR teams to consider:
   1. See list of Aerosol Generating Procedures (AGPs) and use PPE when doing any of these.
   2. To avoid nosocomial spread, you must control the items that are used inside the patient’s body so they don’t contaminate you or the work area.
   3. Please keep your workstation clean, especially the Pyxis and supply closets. Do not go into them with dirty gloves or potentially contaminated gown sleeves.
   4. Regional and neuraxial anesthesia are good choices when appropriate.
   5. RSI with or without cricoid pressure are good choices when appropriate.
   6. Extubation is never an emergency, so take your time and be thoughtful. Options to reduce coughing include: deep extubation (caution!), high opioid extubation, dexmedetomidine, lidocaine, etc.
   7. KEY PRINCIPLE: Avoid doing things that are too far outside your normal practice. This is not the time to be trying new equipment or techniques as you are more likely to make an error.
   8. Keep garbage close by so that when you pull the ETT, OGT, etc it quickly goes into the trash.
   9. Consider placing a sheet over the patient’s chest on extubation to reduce contamination of their body. When leaving the OR, fold it up and place in the laundry.
   10. You can doff your gown, gloves and N95 mask and return to OR with regular mask during maintenance phase. If case is short, consider leaving it on.
   11. Wear gloves all the time in the OR, you can hand sanitize the gloves
9. COVID patients
   1. See the document created by the Department. It covers how patients will transfer to the OR, where they will be intubated, specific techniques etc.
   2. The care of this patient is not really different than any other, we still provide the highest level of care.
   3. COVID-19 positive patients are coming to the OR only for life-threatening emergencies.
   4. Consider taking these patients back to the ICU to be extubated, in particular if their oxygen requirement or ventilatory support settings increased during the case.
   5. Do an extensive sign out with the ICU team on return.
10. Home and Self-Care
    1. Allergy season is coming—continue medications if on them to keep airways patent.
    2. Can use neti pot to wash out sinuses at home.
    3. Gargle saltwater if you don’t like drinking hot liquids.
    4. If you eat food from restaurants, reheat the food.  Do not get cold food (salads, etc) as takeout.
    5. If you get your groceries delivered, put them away, wash your hands, and sanitize the counter.
    6. Wash your home handles, light switches, counters, sinks and such frequently. Regular home cleaners are great.
    7. Keep your toilet seat lid down before you flush (fecal-oral transmission).
    8. Consider wiping down your car steering wheel, handles, etc
    9. Get fresh air, exercise, and do things that make you feel good while practicing social distancing.
    10. Sleep a little more than you think you need.
    11. Avoid behaviors that weaken your immune system.
    12. Consider a multivitamin daily.
    13. Pay attention to government orders for increasing lock down.
    14. Shower fully before leaving work or when you get home from work before you interact with your family.
    15. Leave your hospital shoes in the locker room.
    16. If you live alone, please make an action plan now for how you will get cares, who will check in on you, etc should you contract this illness. Have two people lined up who can bring you food, medication, etc.
    17. Consider how close you will get to your family. Some suggest sleeping in different rooms and keeping 6 feet away.  This is a personal decision each person needs to consider.
    18. All healthcare workers with an NPI number can get the Headspace App for free—it allows you to do meditation, sleep stories, background music, etc.
    19. Consider Slivercloud subscription for managing stress.
    20. The Employee Assistance Program (EAP) is available to all employees who are in need of free and confidential support.
11. Professionalism
    1. Keep your pager on and be ready to help during this crisis
    2. Check your email frequently
    3. Avoid “reply all” to emails so that everyone can manage the barrage of data better
    4. Know how to get on the A*net to look up protocols
    5. Use the donning and doffing checklists, as things change so will the checklist. Cognitive aids are meant to unburden the mind and keep you doing best practice in a fluid environment.