Table 2.

Descriptions of the identified issues and proposed solutions for responding to a medical emergency or cardiac arrest call for a patient with suspected COVID-19

IssueSolution
Communication
1. Distance between the door and the patient led to further communication issues, participants who had relevant information (eg from documentation or imaging) outside the room felt unable to effectively communicate that information as they were not heard clearly or at times not acknowledged.1. To help overcome the significant delays in being able to access the notes, we propose that a ‘red’ summary sheet for each query COVID-19 patient should remain inside the ‘red zone’, as a copy of a version from the full notes. This sheet could include current diagnosis, current plan, significant past medical history, allergies, current treatment, escalation plan and can be used as a proforma in the notes to exclude duplicating work.
2. Given the fact that the notes must remain outside the side room in the ‘green zone’, it was reported that the door was a significant barrier to communicating information clearly.2. We advise that on arrival to an emergency for a query COVID-19 patient, the team announce their arrival to the in-room team, assess what equipment they currently have inside, what equipment they require and how many people are currently in the room.
3. The FFP3 masks make it more difficult to communicate clearly, with numerous participants reporting that they found it challenging to understand instructions.3. We would like to stress the fact that clear closed-loop communication will be essential in these stressful situations, and to encourage the use of names and confirmations.
4. It was noted to be important that any calls placed be specific, ie to include ‘COVID-19’ and ‘male/female’, also to clarify whether it was a MET call or cardiac arrest call, and what PPE was required on arrival of the MET team.4. This can be achieved through training and education of staff.
Equipment
1. The notes and drug chart were often taken into the room (‘red zone’) and were therefore contaminated. This obviously provides significant challenges to any further management of this patient. If the notes are left outside the room, this limits their usefulness and requires one individual to read the notes from outside, and possibly requires an individual close to the door on the inside to receive the information.1. See Communication solution 1 for discussion of the COVID proforma which may aid the decision-making of the in-room team.
2. There were numerous concerns about what equipment could be taken into the room. Examples included computers, resuscitation trolleys, emergency medication and defibrillators.2. A list of items can be placed on each resuscitation trolley to identify which items can be taken into the side room and which cannot.
3. Challenges arose in transferring the essential equipment for investigation and resuscitation (eg ABGs) in a timely fashion and avoiding having to doff and re-don. There was also an absence of bags to safely hand over ‘red’ ABG bottles to ‘green’ individuals outside the room.3. ‘Transfer bags’ for the safe transfer of samples should be stored on the top of the resuscitation trolley.
4. It was often found that the candidate's first instinct was to enter the room once donned without identifying any equipment needs in the room (eg defibrillator). Once they entered the room, they were unable to exit to grab any equipment and they had to rely on the team outside, which led to delays.4. Creating a ‘grab bag’, containing useful items for a MET call (eg ABG, cannula, blood bottles, gauze, tourniquets), to be stored on the resuscitation trolley or outside all side rooms containing patients with possible or confirmed COVID-19. Any individual entering the room should ask the in-room team what equipment they have and what else they require. This individual should bring in that equipment at that point to avoid having to doff and re-don.
5. It was difficult to safely dispose of sharps as there were no sharps bins in the room. There were no bins in the side room / outside the room for doffing of kit.5. Provide the appropriate kit inside for doffing and disposal of equipment within ‘red’ areas.
6. It was reported that nursing staff are being advised that the MET team will arrive with their own PPE (confirmed source from an actual MET call), despite no MET members being made aware of this or having the provision to do so.6. Ensure the same information is communicated to all teams.
Procedures
1. Transfer of any material from inside the room to outside (eg sending of an ABG) was found to be complicated. In both situations, an ABG was handed from the ‘red’ team to the ‘green’ individual outside the room. In both cases, this resulted in potential contamination of the individual and other members of staff.1. We recommend that in order to safely send investigations, the following protocol should be applied. A ‘red’ individual should label the bottle and put the cap on it in the room. They should then communicate with the ‘gatekeeper’ or ‘runner’ to ask them to open a ‘transfer bag’. Using non-touch technique (both individuals), the ABG bottle should be dropped into the ‘transfer bag’ before being sealed by the ‘green’ team. The ‘runner’ should then take the ABG to the nearest appropriate machine and run it without touching the inside of the bag. It is imperative that bloods are labelled with stickers while in the ‘red’ zone.
2. In scenario two, the initial MET call converts into an arrest call, requiring the complete doffing and re-donning of PPE to ensure that all members of the team were in AGP PPE before starting chest compressions. The delay as a result of doing this was ~4 minutes (therefore without chest compressions).
Staff reported a lack of confidence and preparation in donning and doffing safely, as was evidenced by the fact that many participants contaminated themselves.
2. Provision of training for staff on donning and doffing.
3. The nurse who had been part of the simulation when non-AGP PPE was required had not passed his fit test, which led to a replacement needing to be found as the scenario proceeded to a cardiac arrest; this increased delays.3. Provision of adequate fit testing and awareness of a team's fit-test status.
4. There was much uncertainty as to which ABG machine the blood from a patient with suspected COVID-19 could be run on.4. Education of staff and dissemination of information.
5. There was also uncertainty as to when the MET/arrest team had arrived as they began to start donning and this led to anxiety among the clinical staff inside the room.5. MET team to announce their presence on arrival by knocking and also to begin identifying equipment and personnel needs (as per Equipment solution 4).
Personnel
1. Given that there were significant communication challenges due to a combination of masks, distance and barriers, one individual was often required to hover close to the door / peel away from the arrest to relay information out of the room or receive any relevant information.1. Our simulation highlighted the fact that it may be challenging and unsafe to run a cardiac arrest call with only four individuals in the room. One member of the team needs to be relatively free inside the room to relay information from outside the room (eg documentation, imaging) to the team. Then, among the remaining three members of the team, the following roles need to be fulfilled: chest compressions, airway management (eg bag-valve mask), defibrillation, timing, procedures (eg ABGs and cannulation) and one member leading the team.
2. In both simulations there was occasionally no one immediately outside the room, and therefore no access to notes, imaging, drug chart, medications or any other equipment. In both simulations, a participant ended up doffing and standing outside the room to support.2. Additionally, it is imperative that there is a ‘gatekeeper’ outside the room at all times to coordinate the flow of people and equipment into the room and to communicate information from the notes or previous investigations. This person should not leave their post under any circumstances, as doing so would isolate the in-room team from further support.
3. When any investigations needed to be run (eg ABG), the person outside the room in both simulations became unavailable, meaning that there was no one to relay information to the ‘red’ team.3. We also advise that there is an additional runner outside the room to collect any further equipment or send any investigations.
4. Not all staff attending arrest calls have been fit tested.4. We recommend that there be a list of staff on every ward who is on shift and has passed fit testing for rapid identification if additional support is required.