Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc
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Original Article

Volume 14, Number 9, September 2022, pages 377-387

A Newly Developed Interprofessional In-Situ Simulation-Based Training for Airway Management of COVID-19 Patients: Identification of Challenges and Safety Gaps, and Assessment of the Participants’ Reaction


Figure 1.
Figure 1. Study flow for in-situ simulation to train interprofessional adult emergency, pediatric emergency, and anesthesiology teams in airway management for suspected or confirmed COVID-19 patients. COVID-19: coronavirus disease 2019.


Table 1. Teams’ Characteristics
ParticipantsPediatric, N (%)Adult, N (%)Anesthesia, N (%)Total, N (%)
Total participants7199129299
Physician specialists1233449
Anesthesia technologist--3333
Respiratory therapists620-26


Table 2. Participants’ Satisfaction With the Session’s Objectives, Materials, Content Relevance, and Facilitator’s Knowledge, Delivery, and Style
In-situ simulation session itemAgree, N (%)Strongly agree, N (%)
Program objectives
  I understood the learning objectives.40 (14.39%)235 (84.53%)
  I was able to relate each of the learning objectives to the learning I achieved.45 (16.19%)230 (82.73%)
  I was appropriately challenged by the material.50 (17.99%)225 (80.94%)
Course materials
  I found the course materials easy to navigate.65 (23.38%)205 (73.74%)
  I felt that the course materials will be essential for my success.64 (23.02%)208 (74.82%)
Content relevance
  I will be able to immediately apply what I learned.59 (21.22%)216 (77.70%)
Facilitator knowledge
  My learning was enhanced by the knowledge of the facilitator.42 (15.11%)232 (83.45%)
  My learning was enhanced by the experiences shared by the facilitator.40 (14.39%)234 (84.17%)
Facilitator delivery
  I was well engaged during the session.43 (15.47%)232 (83.45%)
  It was easy for me to get actively involved during the session.45 (16.19%)230 (82.73%)
  I was comfortable with the pace of the program.47 (16.91%)228 (82.01%)
  I was comfortable with the duration of the session.47 (16.91%)227 (81.65%)
Facilitator style
  I was engaged during the session.42 (17.52%)234 (84.17%)
  I was given ample opportunity to get answers to my questions.39 (14.03%)236 (84.89%)
  I was given ample opportunity to practice the skills I am asked to learn.39 (14.03%)236 (84.89%)
Program evaluation
  I was given ample opportunity to demonstrate my knowledge.44 (15.83%)231 (83.09%)
  I was given ample opportunity to demonstrate my skills.43 (15.47%)232 (83.45%)
Pre-course reading and video
  It was helpful to review knowledge and skills related to the simulation objectives.51 (18.35%)219 (78.78%)
  I found the room atmosphere to be comfortable.62 (22.30%)209 (75.18%)
  I was pleased with the room set-up.67 (24.10%)205 (73.74%)
  I experienced minimal distraction during the session.67 (24.10%)203 (73.02%)


Table 3. Absolute Frequencies of Codes for Each Theme
ThemeCategorySubcategoryNumber of codesExample of facilitators’ summaries of participants’ comments
PPE: personal protective equipment; PEEP: positive end-expiratory pressure; HEPA: high-efficiency particulate air; COVID-19: coronavirus disease 2019; PAWP: pulmonary artery wedge pressure; ETT: endotracheal tube; RSI: rapid sequence intubation; CDC: Centers for Disease Control and Prevention; AGPs: aerosol-generating procedures; PAPR: powered air-purifying respirator.
Airway managementAnticipationAnticipation of difficult airway33Anticipated difficult airway
PreparationPreparation of intubation equipment29Equipment checks before intubation
Connection of the catheter (extension) device in pediatric patients6Use the catheter (extensor)
Connection of the bag-mask ventilation device to the PEEP valve device5Do not forget the PEEP valve
Pre-oxygenationPre-oxygenation using two-handed bag-mask ventilation technique (V-E) for 3 - 5 min18Pre O2 with two hands technique, V shape holding the mask
Administration of low flow O2 in case desaturation with minimal pressure < 20 mm Hg15Low flow O2
Application of high flow nasal cannula in case of desaturation6Need to improve oxygenation for COVID-19 patients by using high flow nasal cannula and minimize using Ambu bag
Application of high flow non-rebreathing mask in case desaturation
Avoidance of non-invasive ventilation
ProtectionClosure of the suction system19Close suction
PlacementAssignment of the expert to intubate14Intubation need to be done by a most expert in the room
Usage of video laryngoscopy9Order video laryngoscope
Performance RSI9RSI medication
Post-intubation managementInflation of the cuffed endotracheal tube 5 mm Hg > PAWP9Inflating the cuff before the ventilation
Assure of the placement of the endotracheal tube12Check the tube position
Assure clamping of ETT22Clamp ETT
Infection controlEquipmentFamiliarization with the equipment placement in the emergenct room5Need to be more familiar with equipment place
Prepare all the needed equipment outside the intubation room33Bring all the needed equipment inside to prevent going outside and inside the room, or assign a runner to prepare equipment from outside
Crowd controlMinimization the number of personnel inside the room24Limit the number of personnel in the room to limit exposure
COVID-19 protectionConsideration of use of plastic cover for pediatric patients or plastic box for adults23Order the plastic cover for pediatric or the plastic box for adult
Attachment of viral filter24Need to use a viral filter for the Ambu bag
Follow CDC/institutional guidelines for AGPs13Follow KFMC protocol
Application of surgical mask on the patient to minimize aerosolization5Keep an eye to minimize aerosolization by applying a mask
Prioritization of healthcare workers safety12Check with the team and make sure everyone is wearing a proper mask, and request PAPR if needed.
DonningAdherence to the proper sequence of donning25The sequence of donning and doffing
Do not wear a surgical mask under N95
DoffingAdherence to the proper sequence of doffing30Doffing is done outside
PPEAssignments of compliance observer during the procedure15Having a person outside to monitor appropriate donning and doffing
Room ventilationAssure the presence of HEPA filter maximum power5Check if filter inside the room
Assure closure of the door during intubationClosing the door throughout the procedure
Team dynamicsClear ordersLoudness and clearness of the team leader voice15Avoid floating order
Raise voices
Speaking upSpeaking up29The team needs to speak up if they have suggestions for the team leader.
Role assignmentAssignment of the team members and roles clarity23Know your role
Share mental modelA shared mental model with the team members17Share mental model
CommunicationInsure closed-loop communication20Close the loop of communication
LeadershipSynchronous communication between the team leader and team14Avoid floating order and assign it to a specific person
AnticipationAnticipation of the challenges25Anticipate and act properly
Situation awarenessAcquaintance with the equipment11The team leader needs to make sure that his team is familiar and knows how to use the equipment


Table 4. Top Three Challenges Encountered During the In-Situ Simulation Training by Specialty
Pediatric emergencyAdult emergencyAnesthesia
CDC: Centers for Disease Control and Prevention; PPE: personal protective equipment.
Airway managementAnticipation of difficult airwayPreparation of intubation equipmentAnticipation of difficult airway
Assignment of the most expert provider to perform intubationUsing non-rebreathing mask/using high flow nasal cannula/avoidance non-invasive ventilationClosure of the suction system
Use of video laryngoscopyAnticipation of difficult airwayAdministration of low flow O2 in case desaturation with minimal pressure < 20 mm Hg
Infection controlMinimization of the total number of personnel inside the roomAdherence to the proper sequence of doffingPreparation of all needed equipment outside the intubation room
Prioritization of healthcare workers safetyAvoidance of incomplete donning or doffing of the PPEAttachment of a viral filter
Adherence to the proper sequence of donningConsideration of using plastic cover for the pediatric or plastic box for adultFollowing CDC/institutional guidelines in aerosol-generating procedure
Team dynamicSpeaking upAssure closed-loop communicationSpeaking up
Assignment of the team and clarity of rolesSpeaking upAssignment of the team and clarity of roles
Loudness and clarity of the team leader voiceSynchronous communication between the team leader and teamLoudness and clarity of the team leader voice