As part of the national COVID-19 response, an NHS Nightingale Hospital was established for our region. An initial cohort of patients was admitted with resource allocation, demanding that limitation of care be clearly defined, including avoidance of invasive ventilation. Within weeks, an increasing bed capacity need drove preparation to admit patients who might require escalation to mechanical ventilation. This shift in admission criteria demanded significant change to the hospital’s service provision, including the ability to stabilize and transfer critically ill patients from this satellite location to an acute partner trust 
The aim of this study was to perform a rapid, prospective analysis of the critical care patient pathway and surrounding environment at a novel Nightingale Hospital using high-fidelity simulation.
Following a need assessment and discussion with stakeholders, in situ
simulation was undertaken using a Hal® (Gaumard) manikin with a multi-disciplinary team. The immersive scenario, requiring intubation of a deteriorating COVID-19 patient, was undertaken in real time, debriefed and then repeated to assess interventional safety improvements. A demonstration video narrative was produced as a learning aid for dissemination to all supporting staff who may be involved with this clinical scenario, potentially at short notice.
The internal environment and infrastructure were adequate to perform the task. A significant number of latent threats were identified and actioned during the simulation (Table 1
). Qualitative feedback demonstrated that simulation was a useful and effective experience to increase confidence in performing this high-risk procedure in a remote location. Feedback on the video was positive and it was approved for dissemination to staff who may be involved in managing these patients.
Latent threats found at the Exeter Nightingale hospital during simulated intubation of a critically unwell COVID-19 patient
|Safety||Intubation checklist||Adopted and amended by members of the visiting teams. A video was created for demonstration purposes.|
|Equipment||Unfamiliar ventilators Breathing circuits incompatible Arterial lines Central lines Sterile packs Pressure bags Ultrasound probe covers Sterile gloves Theatre hats Tapered high-volume low-pressure endotracheal tubes, with integrated above cuff suction port Size 3 face masks Yanker suckers CPAP masks compatible with the ‘Jenny’ ventilator||A training video for use on the ventilator was made with information sought from the company representative. Boxes were unpacked and checked. Any additional equipment requested by the team was documented and ordered. Nightingale clinical lead informed of the extra requirements.|
|Drugs||Lack of critical care drugs||Intensivist involved with the investing team liaised with the Nightingale pharmacist to order any additional drugs.|
|General||Equipment unchecked and boxed identified.||The team unpacked and checked equipment and set it up for clinical use.|
|Staffing||Requirements for operation department practitioners, anaesthetists on near standby Transfer to the main hospital site||Transfer simulation planned with the ambulance service to test the multi-disciplinary components. The clinical lead was informed of the findings.|
|Resource planning||Ability to manage patients prone at the remote site||Staffing requirements were reported back to Nightingale lead consultant|
Implications for practice:In situ
simulation with a high-fidelity manikin proved to be a useful and reproducible tool in developing and testing the systems involved in managing critical care patients at a novel hospital. In accurately simulating a real-time clinical scenario, the care pathway is experienced and contextualized within the team. It offers an opportunity to expose deficits in the system without causing harm (Kaba and Barnes, 2019). Evidence gathered can be easily and rapidly reported to operational leaders allowing timely decision-making, change implementation and mitigation of preventable risk. This makes simulation a cost- and resource-effective quality improvement method. In addition to patient safety process testing, in situ
simulation offers a valuable individual and collective training opportunity, providing realistic orientation for clinicians and staff. In recording the simulation, educational tools have been created, extending their reach to both clinical and non-clinical staff.