Protocols and Simulation
Simulation drills have been proven to be essential in testing protocols and providing effective training for multi-disciplinary teams. (22–24) In the setting of COVID-19, the key areas of concern are in infection containment during labour and delivery, and during transfer of the patient to operating theatre for caesarean deliveries. Our dry run and in-situ simulation identified deficiencies such as gaps in communication and co-ordination and breaches in infection prevention. This led to an unacceptable delay of up to 45 minutes from time of decision to transfer to operating theatre. Reviewing and improving the effective communication mechanisms between teams will be important step in improving this time interval. Simulation has also taught us that urinary catheterisation should be done in the ward prior to transfer to operating theatre. Simple measures such as steering clear of the operating theatre during aerosol generating procedures such as intubation and extubation were only uncovered as a result of simulation.
Further changes arising from the debrief sessions, included developing a checklist of the steps, a laminated preparation list (Table 1) and a list of contacts of personnel for easy referencing. These were attached to a pre-prepared trolley with contained the necessary equipment for obstetric care. This allowed expeditious transfer to the isolation ward or emergency department if a vaginal birth was anticipated.
Dedicated personnel should be on site to guide and remind the attending team of the correct steps in donning and doffing off the PPE and PAPR, where missteps and errors can be easily committed in the heat of the moment, leading to potential breaches in infection containment. In addition, infographics (Figures 1 and 2) were put up on the walls in designated gowning and degowning stations for staff as guides to staff and reminders on the correct steps of the donning and doffing of PPE.
With such a rapidly changing situation, it is vital that the latest changes in protocols are rapidly and effectively disseminated to all staff. The best laid plans can easily go awry with poor communication. Staff were regularly updated via encrypted healthcare messaging applications (eg. TigerConnect) and emails.