Controlling Infection Transmission In The Hospital Environment.

“All the world’s a stage, and the men and women merely players”
William Shakespeare, As you Like it (2. 7.139-140)

Rehearse, rehearse!

This month, the team has been working on clinical scenario grids for the simulation training sessions. The layout for the scenario has been defined as the Emergency Room or Accident and Emergency, a point of first patient contact for many health workers. The plot for the ‘story’ has been created and we are currently rehearsing the scenario to ensure that all necessary cues to guide the research participant are communicated in a timely and appropriate fashion.

A medical simulation session is run like a well-orchestrated theatre play. Much like a play, a medical simulation exercise involves setting up a scene, furnishing a stage, assigning roles and scripted lines to actors (research personnel). As in the theatere, there is a lot of improvisation because of the varied paths that a research participant can decide to take in response to events simulated during a scenario.

Some scenarios require the use of costumes to confer the right setting e.g. an operating room scenario will require the use of operating room garments and relevant personal protective equipment.
There is often a simulation coordinator, akin to a stage manager who makes sure that everything is working, the lighting is perfect, the characters are in place and all materials are assembled. Sometimes, there’s even a camera rolling, to capture actions/events that may not be noticed and documented in real time.

As you can imagine, a successful simulation session requires a lot of rehearsal to run smoothly. So you see, creating a medical simulation scenario is much like a theatrical production.
When used for the purposes of research though, seemingly minor changes in script, stage set up, costumes, props etcetera, could have an impact on your data, ranging from negligible to catastrophic. And so it’s important to define your research objectives, explore usable and measurable data, and to make sure that your research scenario depicts the appropriate circumstances that would lead your research participant to the desired outcome, and then rehearse,

While mapping out the flow of events and the script for interaction with research participants, a few cogent factors have come to light:
1. Time management: The duration of the scenario should be kept as brief as feasibly possible. Study participants are clinically engaged hospital staff whose clinical commitments should be prioritized during the course of the project.
2. Manpower: As this training session will be replicated by local trainers, the scenario is being designed to require as little manpower as possible. This will increase the chances of reproducibility in the field and minimize the disruption that scheduling conflicts in a large training team can produce.
3. Standardized simulation layout: This project has 3 partnering sites in West Africa and it is important that the spatial arrangement of the simulator and simulation materials are consistently reproducible regardless of location, room shape and structure.
4. Efficient use of resources: During an early practice session, we realized that the routine use of personal protective equipment at the training station using rapid cycle deliberate practice, could potentially result in significant waste of personal protective equipment. We have devised a strategy to maximize simulation materials and minimize waste during the training session.
Where we are now
• Research protocols have been drafted and are in the process of submission at Johns Hopkins and partnering institutions in Abuja, Nigeria and Tamale, Ghana.
• Simulation grids focused on infection control during a clinical encounter have been created and are currently being tested in simulation session rehearsals with volunteering clinicians.
• Simulation performance checklists have been crafted and are being reviewed by clinicians and simulation experts.
• A first draft of the infection control simulation training manual for trainers is under construction.

Last month, we shared a link to a video showing a clinical encounter that resulted in cross contamination. To watch a video that depicts how such an event can escalate across a hospital population (staff, patients, visitors), click the link below.
https://www.youtube.com/watch?v=_o9SxDFPUiA

Please look for our monthly updates on this blog to read more about our use of simulation to train health workers on preventative infection control measures. Please feel free to contact us with questions you may have by sending an email to Adaora M. Chima, MBBS, MPH ([email protected]) or Benjamin H Lee, MD, MPH ([email protected])