Although we don’t talk about it much on the blog, one of the major research interests in Virchester is in the management of major incidents. Over the years we’ve published extensively on the epidemiology and response to major incidents, together with colleagues contributing to the MIMMS and HMIMMS1 courses from the Advanced Life Support Group2.
We are currently preparing for what may, or may not, be a forthcoming major incident in the form of coronavirus. Whilst we think that apocalypse predicted by some is unlikely, we do expect to receive unwell patients with suspected or real coronavirus. Here in Virchester we are already screening patients every day, but thus far they have all been well and can be managed in the community (as all are negative so far here).
However, it’s quite likely that a patient will turn up with what looks like a serious respiratory illness and a travel history to a high risk area. At the point when we see them it will not be possible to know whether it’s Covid19 or not and so we will have to presume that they are. I think all EDs should prepare for this scenario as it is really quite likely to happen in the coming weeks. My last experience of this was in the management of a suspected MERS CoV3 patient who turned out to have a straightforward nasty pneumonia, but we could not have know that at the time.
No doubt all EDs will have plans in place for these patients, but how can we test them? Some departments have performed departmental sims with mannequins/actors to test processes and these appear to work well, but are quite labour intensive and are difficult to repeat regularly.
A PEWC is a Practical Exercise Without Casualties. We use these on (H)MIMMS1,4 courses to teach and learn how to manage major incidents. It’s based on the military TEWT5 (Tactical Exercise Without Troops). Both involve giving a hypothetical situation to decision makers and asking them to formulate and articulate their plan that can then be discussed as a group. This takes place in the real clinical environment, so in a way it’s a form of in-situ simulation. However, there is no mannequin, no actor and no resus team. Instead you use the most powerful simulator on the planet – your own brain! (HT to @cliffreid).
For example you might do a PEWC on coronavirus patients in the ED. PEWCs generally work with a scenario followed by a series of prompts to tackle questions. The group then discuss these and then make a plan that leads into the next task. The role of the facilitator is to guide the discussions and to bring in any relevant information/tools/protocols as required.
Example tasking and scenarios
These are prompt statements which are then followed by discussion and then movement to the next area +/- preparation of areas, movement of staff, cordons etc. Each section is introduced over time and as the scenario develops (not all at once).
- You are the senior nurse/doctor in the ED. The triage nurse contacts you by phone. They have a 42 year old patient with pneumonia type symptoms and are they pretty sick. They have revealed that they have recently returned from a region where coronavirus is spreading in the community. Basic obs. RR 24, SaO2 89%, BP 105/65, HR 125, T 39.1C. They are sweaty and complain of shortness of breath. The department is very busy and there are no free cubicles at present.
- What are your actions at this point?
- How will you prepare the department?
- How will you manage your team?
- Following your initial actions. The patient has now been moved to the Amber area. They remain unwell with observations worsening.
- How are you going to provide clinical care to this patient?
- What investigations are possible in the ED?
- What level of treatments are possible in the ED?
- Preparations are being made for a negative pressure bed on HDU. However, the patient has deteriorated and in the opinion of the treating clinician will require ventilatory support.
- What ventilatory support is achievable in the ED?
- How would deliver this in the ED?
- Further aspects of the scenario are fed in as required to follow the patient journey.
Advantages of PEWCs.
We like the PEWC system as it is a way of testing decision making with few resources, repeatability and the ability to adjust the scenarios through iteration. You can also adjust the scenarios very easily. It also focuses on the command, control and communication aspects of infectious disease management rather than the clinical skills which may be better taught in skills specific training sessions (e.g. PPE application, intubation in PPE etc.).
I think they are similar to the ‘process testing’ sims as described by Chris Nickson and others.
In some ways a PEWC is simply a walk through of a process, the difference is in pre-determining the sequence of problems linked to the in-situ geography of the department/hospital.
Coronavirus is causing a great deal of anxiety at the moment. A lot of this appears to be related to uncertainty around systems and planning. We’d be really interested to hear of your preparations and if you use the PEWC method please get in touch and let us know how it goes.
- 1.Sammut J, Cato D, Homer T. Major Incident Medical Management and Support (MIMMS): A practical, multiple casualty, disaster-site training course for all Australian health care personnel. Emerg Med Australas. June 2001:174-180. doi:10.1046/j.1442-2026.2001.00206.x
- 2.ALSG . ALSG courses. Advanced Life Support Group. https://www.alsg.org/home/. Published 2020. Accessed 2020.
- 3.Baombe J. how to prepare your ed for a mers CoV patient. St Emlyn’s. https://www.stemlynsblog.org/how-to-prepare-your-ed-for-a-mers-cov-outbreak/. Published 2015. Accessed 2020.
- 4.Carley S. Major Incident Planning. St Emlyn’s. https://www.stemlynsblog.org/major-incident-planning-at-the-14th-accs-meeting-foamed/. Published 2017. Accessed 2020.
- 5.Maitland-Dougall WE Royal Arti. The Preparation of Tactical Exercises without Troops. Royal United Services Institution Journal. November 1938:805-810. doi:10.1080/03071843809422076