By SimGHOSTS Board Member Scott Crawford, MD, FACEP, CHSOS
COVID-19 has disrupted nearly every aspect of our lives, but especially the delivery of experiential learning. Simulation-based education relies on the ability to interact with medical tools and communicate with patients and other care providers. This experience is especially important when training skills where tactile feel and human factors about grip, positioning, and muscle memory are required for the effective transfer of a skill. Distance learning and online video courses are a poor surrogate for many of these activities.
Simulation also has the long-held tenet that learning should be safe, both psychologically and physically. Simplified, learners shouldn’t do things that are dangerous to others, and learners should be allowed to make mistakes in a controlled learning environment without fear of retribution. It is with these concepts in mind that the importance of direct observation of skills is paramount. A skill that is being performed improperly can be dangerous to the learner. For example: a transfer or lift performed with improper technique, use of an instrument that puts the learner or a colleague at risk for a sharps injury, or putting a future patient at risk by not fully observing and correcting improper procedural technique before a skill becomes ingrained and performed incorrectly later.
Healthcare providers have encountered a new health risk this year and that is one of potential contamination and transmission of illness to themselves or their family members. Stories of care providers staying at hotels or stripping down to their underwear before entering a house are commoni,ii. Simulation programs have largely remained closed and safe from this risk, but as states and campuses relax rules about isolation and distancing, many simulation programs will welcome learners back to continue training. How do we make sure staff and students remain safe, especially as the risk of transmission from hospital and clinic environments by learners and educators is very possible?
Strict enforcement of hand hygiene and screening practices prior to entry can help and, although potentially controversial as a blanket public use requirement, providing or requiring simple face coverings is a prudent first step. Simple masks made of several layers of cloth may provide some benefit to the wearer, according to a study published by the American Chemical Societyiii. However, conflicting evidence about reduction of viral transmission risk to those around someone with a simple face mask has called the practice into questioniv. While the magnitude of benefit for wearing a mask may be unclear, it is a common requirement in healthcare environments and incorporating this practice into training will improve acceptance and add realism. It also provides a constant visual and physical reminder not to touch your face, mouth, or nose. Just make sure you have an addition to your dress-code policy for appropriateness of masks.
The question will undoubtedly come up of what to do if someone doesn’t want to wear a face mask. This brings forward a question about the Americans with Disabilities Act (ADA). Some guidance is provided by the U.S. Equal Employment Opportunity Commission (EEOC). A document discussing pandemic preparedness originally prepared for the H1N1 outbreak in 2009, but updated for current reference on March 21, 2020, discusses some of these pointsv.
Here is a greatly simplified interpretation, not intended to constitute legal guidance: If a “direct threat” that “cannot be eliminated or reduced by reasonable accommodation”vi is present (and a pandemic counts), employers and businesses may require employees to wear masks or other personal protective equipment (PPE). The concept of direct threat, however, can change, and as Centers for Disease Control and Prevention (CDC) guidelines and local public health regulations change, so may the ability to require masks.
If someone states that they cannot wear a mask, it requires engagement of the ADA interactive process. It is acceptable to only ask general information related to this, and not ask questions that would release information about a disability. A request for medical documentation can be requested for employees and to identify what accommodations could be considered (ex. unpaid leave until mask requirement is lifted, provide alternative work environment, or provide alternative face covering that is allowed).
Acceptable: Do you have symptoms of cold or flu? (Anyone can have these symptoms) Specifics currently should be limited to COVID-19-related symptoms: ex. fever, chills, cough, shortness of breath, or sore throat. Do you have a condition/disability that prevents you from being able to wear a mask? (A yes or no question that provides no detail about the nature of the condition)
NOT acceptable: Do you have a weakened immune system? (Could imply HIV or cancer) Do you have claustrophobia, COPD, or asthma? (Provides specific information about a medical condition)
Here is an example of an ADA compliant employee screening form from the EEOC website:
ADA-COMPLIANT PRE-PANDEMIC EMPLOYEE SURVEY
Directions: Answer “yes” to the whole question without specifying the factor that applies to you. Simply check “yes” or “no” at the bottom of the page.
In the event of a pandemic, would you be unable to come to work because of any one of the following reasons:
• If schools or daycare centers were closed, you would need to care for a child;
• If other services were unavailable, you would need to care for other dependents;
• If public transport were sporadic or unavailable, you would be unable to travel to work; and/or;
• If you or a member of your household fall into one of the categories identified by the CDC as being at high risk for serious complications from the pandemic influenza virus, you would be advised by public health authorities not to come to work (e.g., pregnant women; persons with compromised immune systems due to cancer, HIV, history of organ transplant or other medical conditions; persons less than 65 years of age with underlying chronic conditions; or persons over 65).
Answer: YES______ , NO_______
The final test for accommodation is: Could the employer or business provide “reasonable accommodation” without “undue hardship?” Reasonable accommodation: A change in the work environment to allow opportunity to perform the job; for example, working from home. Undue Hardship: A significant difficulty or expense to make an accommodation, but other accommodations could still be considered and implemented.
This standard related to ADA accommodation can also be applied to customers and the general publicvii.
Can an employer require a medical examination (including temperature monitoring)? – Yes, if it is conducted on everyone performing the same job function, and if supported by CDC and public health recommendations (and currently it is).
At a minimum, policies for simulation center re-opening should address:
•Number of learners allowed to be in the room(s)
•How and when equipment and spaces will be cleaned and disinfected
•Screening practices for building entry/participation
•A method for notification of exposure if a learner or staff member tests positive for COVID-19
•Modifications to group training and debriefing practices
•How to handle an employee/learner who either has COVID symptoms and wants to work, or who is asymptomatic but does not want to return.
Some programs that will not have students return in the summer or fall have looked into the creation of kits for home use to demonstrate skills via video conference sessions. This may include sutures and skin pads, needles for injection, or phlebotomy training. Distribution of sharps has generated a lot of discussion about not only safe use, but also disposal. The following resources may be useful in supporting the safe dispensing, collection and processing of sharps.
Some programs have incorporated this into a home health teaching activity by allowing the learner to understand how patients with needles and lancets may be able to safely collect and dispose of these devices either through individually distributed commercially made sharps collection devices, or through a homemade containment device.
Some state government agencies even advocate homemade sharps containers. For example, the Texas Commission on Environmental Quality created a fact sheet describing best practices for the collection and disposal of sharps at home. This guide describes the use of a hard plastic opaque bottle with a screw top that is clearly labeled “sharps” or “needles.” They also provide a list of disposal sites in Texas.
The Food and Drug Administration (FDA) offers the following resource for collection and disposal or sharpsviii. It summarizes that rules vary between communities, but suggests calling 1-800-643-1643, emailing firstname.lastname@example.org, or going to https://safeneedledisposal.org/ for state specific information. This site describes that many states even allow homemade sharps containers to be appropriately disposed of in the household trash, but emphasizes NEVER with the recycling.
In addition to disposal concerns, it is a recommended practice to create a brief policy sheet to collect a student signature at the time of kit pickup acknowledging that sharps are included. Plan to provide instructions like those from the National Institute for Occupational Safety and Health (NIOSH) and the CDC about ‘How to prevent needle stick and sharps injuries.’ ix Even though many items may seem like common sense statements, such as “Store sharps containers out of the reach of children, pets, and others not needing access,” many individuals may not have thought about what having sharps in the house may mean.
The student should understand that he or she is expected to follow applicable rules and regulation for safe handling and disposal. As no biologic material should be present with home training, infection and needle stick risks should be low. However, simple consideration of needle stick first-aid and instructions for what to do in the event of a potential off-site needle stick – whether clean, contaminated, or unknown – should be included.
•Wash needle sticks and cuts with soap and water.
•Do not squeeze the area of a needle stick or cut. And don't wash the area with antiseptics or bleach.
•Ensure tetanus has been updated in the past 10 years (5 years if cut by an object contaminated with dirt, soil or saliva)
Existing needle-stick policies may still be applicable for follow-up, but if the injury occurs at off-hours (nights or weekends), instruction about notification and follow-up at an emergency department or clinic may be warranted, but only if there is concern about a contaminated exposure. While there should be no animal or human contamination of needles or other sharps in the home simulated environment, the reason the sharps policies exist is to evaluate for potential infectious exposure to and to offer prophylactic medications if HIV or Hepatitis contamination were a concern.
iii Konda, A., Prakash, A., Moss, G. A., Schmoldt, M., Grant, G. D., & Guha, S. (2020). Aerosol filtration efficiency of common fabrics used in respiratory cloth masks. ACS nano.
iv Bae, S., Kim, M. C., Kim, J. Y., Cha, H. H., Lim, J. S., Jung, J., ... & Sung, M. (2020). Effectiveness of surgical and cotton masks in blocking SARS–CoV-2: a controlled comparison in 4 patients. Annals of Internal Medicine.