Implementing healthcare professionals’ training during COVID-19: a pre and post-test design for simulation training

ABSTRACT BACKGROUND: Coronavirus disease-19 (COVID-19) has imposed a new reality that presents several challenges for healthcare professionals. The main challenge has been the lack of proper training in relation to an unknown disease. OBJECTIVE: To investigate healthcare professionals’ acquisition of knowledge of a new airway management protocol for COVID-19 through their participation in simulation training. DESIGN AND SETTING: Pre and post-test study with purpose sampling, carried out in a tertiary-level hospital in the city of Campinas, state of São Paulo, Brazil. METHODS: This was a cross-sectional pre and post-test intervention among healthcare professionals working in the intensive care unit and emergency department of a large hospital. The training was carried out using an in situ simulation scenario and the participants answered pre and post-tests consisting of a 20-item questionnaire about the new protocol. RESULTS: The paired-sample t test demonstrated that there was a significant increase in test score (t = −19.06; P < 0.001), from before the training (M = 8.62; standard deviation, SD = 3.53) to after the simulation training (M = 17.02; SD = 1.76). CONCLUSIONS: The simulated training had a positive impact on the healthcare professionals’ acquisition of the COVID-19 protocol. We also demonstrated that in situ simulation training was an efficient tool for implementing new protocols, thus bringing benefits to healthcare systems, professionals and patients.

Healthcare professionals have become protagonists in this new reality. For safe and effective care to be developed, it necessary to train these professionals in large numbers, in settings ranging from primary care to quaternary-level hospitals. Given the high rate of transmissibility of COVID-19, simulation training can ensure individual, team and system readiness 17 while increasing patient and professional safety.

OBJECTIVE
To investigate healthcare professionals' acquisition of knowledge of a new airway management protocol for COVID-19 through their participation in simulation training.

METHODS
This was a pre and post-test study with purpose sampling that was conducted between March 31 and April 14, 2020. The data for this study came from an institutional training protocol for healthcare professionals working in the intensive care unit and emergency department of a large hospital. The simulated training was carried out in situ using PPE and a high-fidelity simulator.
Participants answered a pre-test and a post-test consisting of 20 questions with very short answers, on donning and doffing (five questions), oxygen therapy for patients with acute respiratory distress syndrome (ARDS) due to COVID-19 (four questions), orotracheal intubation (five questions), and choice of medication for starting mechanical ventilation (six questions) (Appendix 1).
The maximum possible score for the test was 20.
The training offered to the participants consisted of the following steps: 1. Pre-test.  from before to after the simulation training were also found in the subdomains ( Table 1).

DISCUSSION
In this study, we investigated healthcare professionals' acquisition of a new airway management protocol for COVID-19 in a large hospital. We found evidence of a significant and considerable improvement from before to after training, which was in line with previous data in the literature. [4][5][6][7] Our data also corroborated studies that showed that simulation was essential for developing, testing, refining and implementing new workflows and protocols in healthcare. 8,10,11,18,19 This was also essential in the context of the COVID-19 pandemic, in which we trained healthcare professionals on the new protocol for safe and effective care of patients with COVID-19.
We chose in situ simulation because of the necessity to train healthcare professionals while they continued to do their clinical work. Thus, we organized training sessions in the mornings, afternoons and nights. In situ training also decreased the circulation of healthcare professionals throughout the university, thus avoiding exposing vulnerable people to the risks of COVID-19.
Furthermore, these healthcare professionals remained close to their units, which allowed them to respond to any emergency when necessary. In situ simulation is a fast and efficient way for training a multidisciplinary team because training takes place during the team's hours of service, using the workplace resources. 19 In this study, we decided to use questions with very short This study had some limitations. First, the purposing sample may have limited the generalizability of our findings. Another limitation was that we used a one-group pre and post-test design.
Both the sampling and the study design were selected because of the importance of training frontline workers and we designed the simulation training based on the best evidence available.
Most importantly, we demonstrated the possibility and usefulness of simulation training during COVID-19. Lastly, we focused mostly on knowledge acquisition, since all the frontline workers were skillful with regard to airway management but lacked expertise relating to the new protocol.

CONCLUSIONS
The simulated training had a positive impact on the healthcare professionals' acquisition of the COVID-19 protocol. We also demonstrated that in situ simulation training was an efficient tool for implementing new protocols, thus bringing benefits to healthcare systems, professionals and patients.