Rapid upskilling through simulation to provide a safe COVID-19 inpatient mobile emergency rapid intubating team

The development of COVID-19 in-hospital mobile emergency rapid intubating teams (MERIT) was recommended to manage critically ill patients with COVID-19-associated respiratory failure. ¹ In our centre, availability from the cancellation of routine operating meant that the MERIT role was devolved to the anaesthetic workforce; developing the role raised unique and specific challenges for clinicians not usually caring for acutely unwell ward patients requiring admission to the intensive care unit (ICU) including daily variation in team members, multiple teams deployed simultaneously, lack of familiarity intubating outside of the operating theatre environment and the inherent difficulties performing the intervention in personal protective equipment (PPE).

Rapid upskilling to staff this MERIT service required significant culture shift. Educational reframing permitted adaption to a standard operating procedure (SOP)-driven model benefiting from commonality of language, decreased cognitive load and with a subsequent expectation of improvement in safety.^2,3 The full MERIT service was delivered two days after simulation commenced, so training and implementation were concurrent by necessity.

Training was delivered by a multidisciplinary team using high fidelity simulation of the full MERIT pathway, preceded by dissemination of a video recording of faculty members completing the simulation. The pathway was enacted in full to improve validity, including team briefing, use of a replica MERIT equipment trolley and ventilator, simulation of drawing up drugs, starting infusions, donning and doffing PPE, and intubation and subsequent moving of the patient to ICU.

Following initial training, additional focused MERIT simulation was repeated daily with the aim of improving team synergy, effective working and interpersonal communication, in addition to allowing protocol recapitulation and team specific post simulation debriefing.^4,5

MERIT providers provided feedback on the educational process relating to effectiveness and training model. Thirty-nine participants responded, of which 97% felt that the training process improved or significantly improved team working, and 100% felt that it improved safety. One-hundred percent of respondents felt well prepared to deliver the service and 97% felt that practice was effectively standardised. Interim analysis of 23 contemporaneously collected MERIT call datasets were additionally reviewed (March to May 2020). The mean time from MERIT activation to intubation was 26 min (13 to 36 min) and the entire MERIT process ending with handover to the ICU team took 43 min on average (27 to 75 min). Drugs used for induction of anaesthesia and subsequent sedation were uniform, and significant physiological instability during intubation was rare, with 87% maintaining pulse oximetry readings greater than 80%, and 91% maintaining systolic blood pressure over 90 mmHg. The marked homogeneity of the majority data points collected suggests that the use of an SOP model with appropriate training is able to reduce variation in practice.

Evaluation of our centre’s non-ICU MERIT service has validated the use of high fidelity simulation in delivering an SOP-based training programme despite barriers initially identified. It is effective in improving user’s reporting of preparedness, team working and safety, with development of a corresponding proficiency in delivering a complex intervention in a safe and timely manner to a defined standard. This model could be reinitiated rapidly to retrain MERIT providers in case of future COVID-19 peaks.