|LETTER TO THE EDITOR
|Year : 2016 | Volume
| Issue : 2 | Page : 156-157
Simulation and lessons learned from the Ebola epidemic
Cameron R Wangsgard1, Damian V Baalmann2, Virginia R Keaveny2, Pritish K Tosh3, Deepi G Goyal2, Byron I Callies4, Torrey A Laack1
1 Department of Emergency Medicine, Mayo Clinic College of Medicine; Mayo Clinic Multidisciplinary Simulation Center, Rochester, MN, USA
2 Department of Emergency Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
3 Department of Medicine, Division of Infectious Disease, Mayo Clinic College of Medicine, Rochester, MN, USA
4 Mayo Clinic, Rochester, MN, USA
|Date of Web Publication||19-Aug-2016|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Wangsgard CR, Baalmann DV, Keaveny VR, Tosh PK, Goyal DG, Callies BI, Laack TA. Simulation and lessons learned from the Ebola epidemic. Educ Health 2016;29:156-7
The West African Ebola epidemic that began in 2014 has exposed the vulnerability of medical facilities when a patient presents with a life-threatening and highly contagious infectious disease. The transmissibility and extremely high morbidity and mortality of Ebola Virus Disease (EVD) make it unique among infectious diseases. This epidemic has specifically been more challenging than prior threats due to the high infection risk of all those in contact, requiring multidisciplinary coordination to minimize risk to other patients, staff and the community. This is not the first time that an epidemic has created a time-sensitive and complex task for hospitals across North America and the world. Previous epidemics, including novel influenza A/H1N1 in 2009 and Severe Acute Respiratory Syndrome (SARS) in 2003, have demonstrated that there are significant barriers to developing these strategies. Disaster planning and training remains a complex process, and implementation of hospital-wide plans can be daunting, especially when information and responses need to change daily.
Hospital-wide drills are a mainstay of disaster training and preparedness. In situ simulation is the use of simulation-based training within an actual clinical environment, rather than in a simulation center used for training but not patient care. Drills and in situ simulation may be viewed as different tools, but for the purpose of Ebola preparedness the concepts and execution are fundamentally the same and we consider the terms synonymous. In situ simulation can not only educate staff members, but also identifies process gaps to iteratively improve planning models before these are implemented in a real-life scenario.  In addition, the knowledge, skill, attitudes and behaviors of those involved in a simulation predict how individuals would act in a real clinical situation.  In situ simulation has been helpful in preparing for the current Ebola epidemic and holds great potential for future epidemics.
In September 2014, a multidisciplinary institutional group was formed at our academic medical center in Rochester, Minnesota, USA to develop plans to screen and care for patients at risk of having EVD. This multidisciplinary team included members from multiple departments and disciplines including Critical Care, Disaster Preparedness, Emergency Medicine, Housekeeping, Infection Prevention and Control, Infectious Disease, Lab Medicine, Transport/EMS (Emergency Medical Services), and Security. This group developed care process guidelines for our organization. However, it was not known how well this process would be implemented in actual practice. Because the care of these patients is complex and involves multiple groups, and because of the importance of preventing any potential breaches in protocol, in situ simulation was felt to have the potential to aid in identifying gaps and making iterative improvements in our processes.
We developed several in situ simulation scenarios throughout our hospital to model the process of care for a patient who was screened to be at risk for EVD. This included the steps required of all the stakeholders, from those directly involved in patient care to ancillary staff whose work also impacts the screening process and subsequent care of these patients. These simulations included the work of EMS personnel; the transport, screening and activation of protocols by our admission coordinating office that received simulated phone-calls from outside hospitals; the registration and care of the patient in the Emergency Department; the collection, transport and processing of lab studies; housekeeping and waste disposal; care of the patient in the intensive care unit; and the handling of patients following death. One of our institution's infectious disease attending physicians portrayed the patient in the simulation, termed 'Smart Simulated Casualties,' i.e., when physicians assume the roles of patients to better understand the medical care being provided in these types of complex scenarios. 
The lessons learned from our initial series of in situ simulations proved invaluable in more ways than can be presented in this letter. We highlight two examples that illustrate the benefits that in situ simulation holds for other hospitals across the US and worldwide that must prepare for potential EVD cases or other novel pathogens. First, through our simulation, we discovered the need to restructure the format of our entire care process guidelines from an original text-based guide into a role-specific flow-chart and checklist illustrative format. Through an iterative scenario, we found that clinicians were better able to adhere to all required steps using this graphical format even when they were unfamiliar with the entirety of the multi-step processes. Secondly, our simulation found that using personal protective equipment (PPE) is not as simple as we believed. It is easy to contaminate oneself or one's surroundings if careful technique is not followed. In accordance with updated US Centers for Disease Control (CDC) recommendations, training was modified to use of a buddy system with a colleague closely watching to identify breaks in protocol and prevent contamination, and this was added to our care process guidelines. As a follow-up to the initial simulation scenarios, a working group of 15 facilitators trained approximately 600 staff members, both clinicians and non-clinicians, from the Emergency Department, Medical ICU, Pediatric ICU, and support services in the proper use of PPE. Following the success of these initial scenarios, our institution continued to run Ebola in situ simulations every three weeks; these contineud through the Spring of 2015. Iterative process improvements were made to our institutions care process guidelines following each simulation.
In situ simulation can be run with little experience in simulation and disaster preparedness training; however, there is great benefit to understanding the basic structure of simulation design, implementation and debriefing. If an institution does not have an individual formally trained or experienced in simulation or disaster preparedness, we recommend at least one individual at that institution take a formal course in simulation. There are many multi-day continuing education simulation courses offered in the US and perhaps elsewhere.  Our institution became comfortable with in situ simulation through the prior experience of its practice leaders and through the use of on-going simulation testing and training throughout design and construction of a new Emergency Department. Our hospital's simulation efforts have been critical to its ablity to now rapidly deploy the resources necessary to respond to an emerging threat like EVD.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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