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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 5  |  Page : 28-30

The Use of Simulation in Health-Care Response to COVID-19

1 Department of Intensive Care, Skills and Simulation Center, Ministry of National Guard Health Affairs, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
2 Department of Intensive Care, McGill University Health Centre, Montreal, Canada
3 Department of Intensive Care, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia

Date of Submission02-Sep-2020
Date of Acceptance28-Sep-2020
Date of Web Publication7-Dec-2020

Correspondence Address:
Sara S Aldekhyl
Department of Intensive Care, King Abdulaziz Medical City - Ministry of National Guard Health Affairs, Khasmal-an, P.O. Box 22490, Riyadh
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sccj.sccj_43_20

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In preparation for the COVID-19 pandemic, simulation came in handy in aiding health-care facilities around the world to establish strategies to manage its personnel, space, and processes through experiential learning. Simulation bloomed during the epidemic due to its flexibility and capacity to train large number of health-care professionals at different levels in a timely manner while maintaining high safety profile. This brief review aims at providing some examples of simulation use in the era of COVID-19 pandemic around the world. In addition, we will address some of the limitations that faced simulation-based learning and provide a glimpse to the future of simulation in addressing global pandemics.

Keywords: COVID-19, critical care, health care, medical education, pandemic, pandemic preparedness, simulation

How to cite this article:
Aldekhyl SS, Elbling DJ, Arabi YM. The Use of Simulation in Health-Care Response to COVID-19. Saudi Crit Care J 2020;4, Suppl S1:28-30

How to cite this URL:
Aldekhyl SS, Elbling DJ, Arabi YM. The Use of Simulation in Health-Care Response to COVID-19. Saudi Crit Care J [serial online] 2020 [cited 2023 Feb 8];4, Suppl S1:28-30. Available from: https://www.sccj-sa.org/text.asp?2020/4/5/28/302581

  Introduction Top

Simulation has demonstrated great potential in advancing health-care systems at various levels during the COVID-19 pandemic. It effectively facilitated the training of large number of health-care professionals at different levels in a timely manner either individually or in multidisciplinary teams through experiential learning.[1],[2],[3] In addition, simulation use has been associated with improved team morale and buy-in to adopt new or modified practice compared to traditional distribution of guidelines.[4],[5] From an educational theory prospective, the capacity of simulation to reduce cognitive load aided in optimizing the educational outcomes during this stressful period compared to classical bedside training/in-service presentations, by removing the risk of contracting the infection from patients and alleviating concerns of precipitating adverse outcomes during training.[6] At an operational level, well-equipped simulation centers were utilized as an overflow area for patient care as part of surge capacity management. Other centers mobilized their equipment and supplies to support acute care areas.[7]

  Examples of the Use of Simulation in COVID-19 Response Top

In preparation for the COVID-19 pandemic, simulation came in handy in aiding health-care facilities around the world to establish strategies to manage its personnel, space, and processes to provide a safe environment for its workers and high-quality care for patients. In this section, we will provide some examples of simulation use in the era of COVID-19 pandemic.

Locally, the Saudi Council for Health Specialties delivered multiple courses aimed at upscaling health-care professionals around the country in preparation for the pandemic. These courses were designed at multiple levels of complexity and tailored to target trainees from different levels and backgrounds.[8],[9] More details on these projects can be found in a dedicated review article in this special edition of the Critical Care Journal. King Abdulaziz City for Science and Technology developed a COVID-19 propagation simulation model that aims to simulate the dynamism of the disease behavior to provide an informed decision and policy-making process.[10]

At an international level, the World Health Organization developed multiple simulation-based exercises to aid the COVID-19 preparation efforts of different countries. The aim of these templates is to target as many areas of the pandemic as most countries have to deal with. Modules include areas such as (a) examining and enhancing the plans, procedures, and capacity to manage an imported COVID-19 case, (b) infection prevention and control measures, (c) point of entry exercise packages to review issues at the main airport, and (d) discussing critical issues in urban environments during the rapid spread of the disease.[11] On disease spread, intervention, and outcome prediction, numerous open and closed source simulation remodeling systems are currently available with variable complexity and functions.[12],[13]

Critical care in particular is an area that has used simulation in COVID-19 response. [Table 1] highlights some of the roles of simulation at different domains in health care.
Table 1: Examples of the use of simulations in critical care settings during COVID-19 pandemic

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  Limitations of Simulation Use during COVID-19 Pandemic Top

The widespread utilization of simulation-based activities was limited due to multiple factors. First, infection control and social distancing measures significantly lowered the maximum number of participants that could be accommodated at each simulation-based training session. The repurposing of simulation centers (converted to COVID-19 patient screening or care extension areas) and closure of centers added extra constraints to the availability of physical space for simulation use. Financial and manpower limitations are other factors that have further affected simulation utilization widely. Despite abiding with all infection control measures, attendance was suboptimal due to participants’ fear of contracting the infection during the sessions. The shortage of available personal protective equipment in nonpatient care areas did not help alleviate those fears nor did it help with the possibility of safely increasing the number of participants.

Second, the busy schedule of both the trainers and trainees limited the number of sessions scheduled, however this appears to have been compounded by the exhaustion and possible burnout of all staff, thereby limiting attendance further.

Finally, budget constraints and the limited availability of simulation technologists and support staff further exacerbated the aforementioned hindrances.

  Future Top

Simulation has shown its utility during this pandemic. In addition to being an educational tool, optimizing the individual, team, and process in the system, it can be utilized innovatively to support the work in the health-care facilities.[7]

Simulation has the potential to prepare the health-care system and the entire country to evaluate what has been done and provide insight to what can be expected. Pandemic data and different measures can be plugged into epidemiological remodeling simulators that assessment decision makers in making more informed decisions. Following needs assessment, simulation-based interventions can be designed to bridge the perceived gaps of the first wave to better prepare for a potential second wave. In addition, retraining and upscaling the skills of the health-care providers in anticipation for a surge in the needs.

Ingrassia et al. proposed a model for safe reopening of simulation centers based on national and international guidelines and flexibility. Reopening the simulation centers has to occur in a thoughtful and innovative approach as reopening does not mean “back to normal.”[26]

COVID-19 pandemic has brought simulation further into the spotlight. As more experience has been accumulated and more participants have participated in simulation-based activities, the black box and confusion have cleared around this modality.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Fregene TE, Nadarajah P, Buckley JF, Bigham S, Nangalia V. Use of in situ simulation to evaluate the operational readiness of a high-consequence infectious disease intensive care unit. Anaesthesia 2020;75:733-8.  Back to cited text no. 1
Dieckmann P, Torgeirsen K, Qvindesland SA, Thomas L, Bushell V, Langli Ersdal H. The use of simulation to prepare and improve responses to infectious disease outbreaks like COVID-19: Practical tips and resources from Norway, Denmark, and the UK. Adv Simul (Lond) 2020;5:3.  Back to cited text no. 2
Andreae MH, Dudak A, Cherian V, Dhar P, Dalal PG, Po W, et al. Healthcare simulation to prepare for the COVID-19 pandemic. J Clin Anesthesia 2020;66:109928.  Back to cited text no. 3
Gardiner C, Veall J, Lockhart S. The use of UV fluorescent powder for COVID-19 airway management simulation training. Anaesthesia 2020;75:964-5.  Back to cited text no. 4
Lockhart SL, Naidu JJ, Badh CS, Duggan LV. Simulation as a tool for assessing and evolving your current personal protective equipment: Lessons learned during the coronavirus disease (COVID-19) pandemic. Canadian J Anesthesia 2020;67:895-6.  Back to cited text no. 5
Díaz-Guio DA, Ricardo-Zapata A, Ospina-Velez J, Gómez-Candamil G, Mora-Martinez S, Rodriguez-Morales AJ. Cognitive load and performance of health care professionals in donning and doffing PPE before and after a simulation-based educational intervention and its implications during the covid-19 pandemic for biosafety. Infez Med 2020;28.  Back to cited text no. 6
Carlberg DJ, Chan TM, Ladkany D, Palmer J, Bradshaw K. Mobilization of a simulation platform to facilitate a system-wide response to the COVID-19 pandemic. Western J Emergency Med 2020;21:823-5.  Back to cited text no. 7
C Course. Available from: https://www.scfhs.org.sa/en/Gratitude/Pages/CriticalCareCrashCourse.aspx. [Last accessed on 2020 Aug 15].  Back to cited text no. 8
C Course. Available from: https://www.scfhs.org.sa/en/Pages/3C-Course.aspx. [Last accessed on 2020 Aug 15].  Back to cited text no. 9
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Simulation Exercise. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/training/simulation-exercise. [Last accessed on 2020 Mar 22].  Back to cited text no. 11
Biswas K, Khaleque A, Sen P. Covid-19 Spread: Reproduction of data and Prediction using a SIR Model on Euclidean Network; 2020. Available from: http://arxiv.org/abs/2003.07063. [Last accessed on 2020 Aug 15].  Back to cited text no. 12
About IHME Institute for Health Metrics and Evaluation. Available from: http://www.healthdata.org/about. [Last accessed on 2020 Aug 15].  Back to cited text no. 13
Choi GY, Wan WT, Chan AK, Tong SK, Poon ST, Joynt GM. Preparedness for COVID-19: In situ simulation to enhance infection control systems in the intensive care unit. Br J Anaesthesia 2020;125:e236-9.  Back to cited text no. 14
Workman AD, Welling DB, Carter BS, Curry WT, Holbrook EH, Gray ST, et al. Endonasal instrumentation and aerosolization risk in the era of COVID-19: Simulation, literature review, and proposed mitigation strategies. Int Forum Allergy Rhinol 2020;10:798-805.  Back to cited text no. 15
Malysz M, Dabrowski M, Böttiger BW, Smereka J, Kulak K, Szarpak A, et al. Resuscitation of the patient with suspected/confirmed COVID-19 when wearing personal protective equipment: A randomized multicenter crossover simulation trial. Cardiol J 2020.  Back to cited text no. 16
Foong TW, Hui Ng ES, Wee Khoo CY, Ashokka B, Khoo D, Agrawal R. Rapid training of healthcare staff for protected cardiopulmonary resuscitation in the COVID-19 pandemic. Br J Anaesthesia 2020;125:e257-9.  Back to cited text no. 17
Poor AD, Acquah SO, Wells CM, Sevillano MV, Strother CG, Oldenburg GG, et al. Implementing automated prone ventilation for acute respiratory distress syndrome via simulation-based training. Am J Crit Care 2020;29:e52-9.  Back to cited text no. 18
Aldekhyl S, Arabi Y. Simulation role in preparing for COVID-19. Ann Thorac Med 2020;15:134.  Back to cited text no. 19
  [Full text]  
Ramanathan K, Antognini D, Combes A, Paden M, Zakhary B, Ogino M, et al. Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases. Lancet Resp Med 2020;8:518-26.  Back to cited text no. 20
Alban A, Chick SE, Dongelmans DA, Vlaar APJ, Sent D, Study Group. ICU capacity management during the COVID-19 pandemic using a process simulation. Intensive Care Med 2020;46:1624-6.  Back to cited text no. 21
Andreae MH, Dudak A, Cherian V, Dhar P, Dalal PG, Po W, et al. Data and debriefing observations on healthcare simulation to prepare for the COVID-19 pandemic. Data Brief 2020;31:106028.  Back to cited text no. 22
Dharamsi A, Hayman K, Yi S, Chow R, Yee C, Gaylord E, et al. Enhancing departmental preparedness for COVID-19 using rapid-cycle in-situ simulation. J Hosp Infect 2020;105:604-7.  Back to cited text no. 23
Hedman LR, Felländer-Tsai L. Simulation-based skills training in non-performing orthopedic surgeons: Skills acquisition, motivation, and flow during the COVID-19 pandemic. Acta Orthop 2020:1-5.  Back to cited text no. 24
McKechnie T, Levin M, Zhou K, Freedman B, Palter VN, Grantcharov TP. Virtual surgical training during COVID-19: Operating room simulation platforms accessible from home. Ann Surg 2020;272:e153-4.  Back to cited text no. 25
Ingrassia PL, Capogna G, Diaz-Navarro C, Szyld D, Tomola S, Leon-Castelao E. COVID-19 crisis, safe reopening of simulation centres and the new normal: Food for thought. Adv Simul (Lond) 2020;5:13.  Back to cited text no. 26


  [Table 1]


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