Resus Today Autumn 2020

Volume 7 No. 2
Autumn 2020
Resuscitation Today
A Resource for all involved in the Teaching and Practice of Resuscitation
See reverse for Simulation Today

Just breathe
PENTHROX 99.9%, 3 ml inhalation vapour, liquid: Please refer
to the Summary of Product Characteristics (SmPC) before
prescribing. Abbreviated Prescribing Information.
Presentation: Each bottle of PENTHROX contains 3 ml of
methoxyflurane 99.9%, a clear, almost colourless, volatile liquid,
with a characteristic fruity odour. Each PENTHROX combination
pack consists of one bottle of 3 ml PENTHROX, one PENTHROX
Inhaler and one Activated Carbon (AC) chamber. Indications:
Emergency relief of moderate to severe pain in conscious adult
patients with trauma and associated pain. Dosage and
administration: PENTHROX should be self-administered under
supervision of a person trained in its administration, using the
hand held PENTHROX Inhaler. It is inhaled through the custombuilt
PENTHROX inhaler. Adults: One bottle of 3 ml PENTHROX
as a single dose, administered using the device provided. A
second bottle should only be used where needed. The frequency
at which PENTHROX can be safely used is not established. The
following administration schedule is recommended: no more than
6 ml in a single day, administration on consecutive days is not
recommended and the total dose to a patient in a week should
not exceed 15 ml. Onset of pain relief is rapid and occurs after
6-10 inhalations. Patients are able to titrate the amount of
PENTHROX inhaled and should be instructed to inhale
intermittently to achieve adequate analgesia. Continuous
inhalation of a bottle containing 3 ml provides analgesic relief for
up to 25-30 minutes; intermittent inhalation may provide longer
analgesic relief. Patients should be advised to use the lowest
possible dose to achieve pain relief. Renal impairment:
Methoxyflurane may cause renal failure if the recommended dose
is exceeded. Caution should be exercised for patients diagnosed
with clinical conditions that would pre-dispose to renal injury.
Hepatic impairment: Cautious clinical judgement should be
exercised when PENTHROX is to be used more frequently than
on one occasion every 3 months. Paediatric population:
PENTHROX should not be used in children and adolescents under
18 years. For detailed information on the method of administration
refer to the SmPC. Contraindications: Use as an anaesthetic
agent. Hypersensitivity to methoxyflurane, any fluorinated
anaesthetic or to any of the excipients. Patients who are known
to be genetically susceptible to malignant hyperthermia. Patients
or patients with a known family history of severe adverse reactions
after being administered with inhaled anaesthetics. Patients who
have a history of showing signs of liver damage after previous
methoxyflurane use or halogenated hydrocarbon anaesthesia.
Clinically significant renal impairment. Altered level of
MAT-PEN-UK-000310 Date of preparation: October 2020
Look familiar?
It’s TIME for change...
71 MINUTES FASTER DISCHARGE 1 ON AVERAGE &
SUPERIOR PAIN RELIEF 2,3 FOR MODERATE TO SEVERE
TRAUMA PAIN WITH PENTHROX VS SAT *
Penthrox is indicated for the emergency relief of moderate to severe pain in conscious adult patients with trauma and associated pain. 4
consciousness due to any cause including head injury, drugs or
alcohol. Clinically evident cardiovascular instability. Clinically
evident respiratory depression. Warnings and Precautions: To
ensure the safe use of PENTHROX as an analgesic the lowest
effective dose to control pain should be used and it should be
used with caution in the elderly or other patients with known risk
factors for renal disease, and in patients diagnosed with clinical
conditions which may pre-dispose to renal injury. Methoxyflurane
causes significant nephrotoxicity at high doses. Nephrotoxicity is
thought to be associated with inorganic fluoride ions, a metabolic
breakdown product. When administered as instructed for the
analgesic indication, a single dose of 3 ml methoxyflurane
produces serum levels of inorganic fluoride ions below 10
micromol/l. In the past when used as an anaesthetic agent,
methoxyflurane at high doses caused significant nephrotoxicity,
which was determined to occur at serum levels of inorganic
fluoride ions greater than 40 micromol/l. Nephrotoxicity is also
related to the rate of metabolism. Factors that increase the rate
of metabolism such as drugs that induce hepatic enzymes can
increase the risk of toxicity with methoxyflurane as well as subgroups
of people with genetic variations that may result in fast
metaboliser status. Methoxyflurane is metabolised in the liver,
therefore increased exposures in patients with hepatic impairment
can cause toxicity. PENTHROX should be used with care in patients
with underlying hepatic conditions or with risks for hepatic
dysfunction. Previous exposure to halogenated hydrocarbon
anaesthetics (including methoxyflurane when used as an
anaesthetic agent), especially if the interval is less than 3 months,
may increase the potential for hepatic injury. Potential effects on
blood pressure and heart rate are known class-effects of high-dose
methoxyflurane used in anaesthesia and other anaesthetics.
Caution is required with use in the elderly due to possible
reduction in blood pressure. Potential CNS effects such as
sedation, euphoria, amnesia, ability to concentrate, altered
sensorimotor co-ordination and change in mood are known classeffects.
The possibility of CNS effects may be seen as a risk factor
for potential abuse, however reports are very rare in postmarketing
use. PENTHROX is not appropriate for providing relief
of break-through pain/exacerbations in chronic pain conditions
or for the relief of trauma related pain in closely repeated episodes
for the same patient. PENTHROX contains the excipient, butylated
hydroxytoluene (E321) which may cause local skin reactions (e.g.
contact dermatitis), or irritation to the eyes and mucous
membranes. To reduce occupational exposure to methoxyflurane,
the PENTHROX Inhaler should always be used with the AC
Chamber which adsorbs exhaled methoxyflurane. Multiple use of
PENTHROX Inhaler without the AC Chamber creates additional
risk. Elevation of liver enzymes, blood urea nitrogen and serum
uric acid have been reported in exposed maternity ward staff
when methoxyflurane was used in the past at the time of labour
and delivery. Interactions: There are no reported drug interactions
when used at the analgesic dosage (3 – 6 ml). Methoxyflurane is
metabolised by the CYP 450 enzymes, particularly CYP 2E1 and
to some extent CYP 2A6. It is possible that enzyme inducers (such
as alcohol or isoniazid for CYP 2E1 and phenobarbital or rifampicin
for CYP 2A6) which increase the rate of methoxyflurane
metabolism might increase its potential toxicity and they should
be avoided concomitantly with methoxyflurane. Concomitant use
of methoxyflurane with medicines (e.g. contrast agents and some
antibiotics) which are known to have a nephrotoxic effect should
be avoided as there may be an additive effect on nephrotoxicity;
tetracycline, gentamicin, colistin, polymyxin B and amphotericin
B have known nephrotoxic potential. Sevoflurane anaesthesia
should be avoided following methoxyflurane analgesia, as
sevoflurane increases serum fluoride levels and methoxyflurane
nephrotoxicity is associated with raised serum fluoride.
Concomitant use of PENTHROX with CNS depressants, such as
opioids, sedatives or hypnotics, general anaesthetics,
phenothiazines, tranquillisers, skeletal muscle relaxants, sedating
antihistamines and alcohol may produce additive depressant
effects. If opioids are given concomitantly with PENTHROX, the
patient should be observed closely. When methoxyflurane was
used for anaesthesia at the higher doses of 40–60 ml, there were
reports of drug interaction with hepatic enzyme inducers (e.g.
barbiturates) increasing metabolism of methoxyflurane and
resulting in a few reported cases of nephrotoxicity; reduction of
renal blood flow and hence anticipated enhanced renal effect
when used in combination with drugs (e.g. barbiturates) reducing
cardiac output; and class effect on cardiac depression, which may
be enhanced by other cardiac depressant drugs, e.g. intravenous
practolol during cardiac surgery. Fertility, pregnancy and
lactation: No clinical data on effects of methoxyflurane on fertility
are available. As with all medicines care should be exercised when
administered during pregnancy especially the first trimester. There
is insufficient information on the excretion of methoxyflurane in
human milk. Caution should be exercised when methoxyflurane
is administered to a nursing mother. Effects on ability to drive
and use machines: Methoxyflurane may have a minor influence
on the ability to drive and use machines. Patients should be
advised not to drive or operate machinery if they are feeling
Before administering PENTHROX, make sure you have read and fully understood the SmPC and educational materials, which provide important information about how to safely use the device to minimise risk of serious side effects.
PENTHROX educational materials and training on its administration are available from Galen on request.
*SAT = Standard Analgesic Treatment: In the St. Mary’s Hospital service evaluation, SAT consisted of IV opioids or procedural sedation in the majority of cases. 1 In the MEDITA trial, SAT consisted of IV paracetamol (1 g) or IV ketoprofen
(100 mg) for moderate pain and IV morphine (0.1 mg/kg) for severe pain, 2 and in the InMEDIATE trial, SAT varied among sites but most frequently comprised of NSAIDs for moderate pain and IV locally approved opioid and non-opioid
analgesics for severe pain. 3
drowsy or dizzy. Undesirable effects: The common non-serious
reactions are CNS type reactions such as dizziness and somnolence
and are generally easily reversible. Serious dose-related
nephrotoxicity has only been associated with methoxyflurane
when used in large doses over prolonged periods during general
anaesthesia. The following adverse drug reactions have either
been observed in PENTHROX clinical trials in analgesia, with
analgesic use of methoxyflurane following post-marketing
experience or are linked to methoxyflurane use in analgesia found
in post-marketing experience and in scientific literature (refer to
the SmPC for further details): Very Common (≥1/10): dizziness;
common (≥1/100 to

CONTENTS • Incurved face seal
4 EDITORS COMMENT
6 FEATURE COVID-19 pandemic patient’s preparation: ears using simulation
for systems-based learning to prepare the largest
healthcare workforce and system in Canada
18 FEATURE Penthrox Can Outperform Morphine
COVER STORY
Quality, innovation and choice
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Visit our dedicated website page www.intersurgical.com/info/iview to view the video,
download the information sheet or make an enquiry.
Access to the article can be found on the Dave Airways blog: https://daveairways.
Subscription Information – Autumn 2020
Resuscitation Today is a tri-annual publication
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wordpress.com/2020/06/21/the-i-view-videolaryngoscopy-and-tracheal-intubationfor-patients-with-suspected-or-confirmed-covid-19/
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Contact information:
Intersurgical
Crane House
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Tel: 0118 9656 300
Email: info@intersurgical.com
Website: www.intersurgical.com
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This issue edited by:
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MSc Paramedic
c/o Media Publishing Company
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RESUSCITATION TODAY - AUTUMN 2020
3

EDITORS COMMENT
EDITORS COMMENT
With the focus for so many of us having been Covid 19 for many many months
we decided to maintain the Covid 19 theme here in the Autumn edition of
Resuscitation Today.
We have some new scientific articles, including a fascinating article from Professor Sir Keith Porter
who discusses penthrox.
“...it has been
fascinating to
share experiences
and best practices
with practitioners
from around the
world during these
Both the American Heart Association and the ERC are set to release new resuscitation guidelines
in the new year and have been asking for comments on the scientific advice before it is provided
to us via the Resuscitation Council UK.
There have been many “on line resuscitation congresses”, in both Adult and Child Resuscitation
and it has been fascinating to share experiences and best practices with practitioners from
around the world during these events.
If you have interesting articles you would like to put forwards for publication in this journal during
2021 please send them to info@mediapublishingcompany.com
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RESUSCITATION TODAY - AUTUMN 2020
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Quality, innovation and choice
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FEATURE
COVID-19 PANDEMIC PREPARATION: USING
SIMULATION FOR SYSTEMS-BASED LEARNING
TO PREPARE THE LARGEST HEALTHCARE
WORKFORCE AND SYSTEM IN CANADA
Mirette Dubé 1* , Alyshah Kaba 1,2 , Theresa Cronin 1 , Sue Barnes 1 , Tara Fuselli 1 and Vincent Grant 1,3,4
Dubé et al. Advances in Simulation (2020) 5:22 https://doi.org/10.1186/s41077-020-00138-w © The Author(s). 2020
Abstract
Healthcare resources have been strained to previously unforeseeable
limits as a result of the COVID-19 pandemic of 2020. This has prompted
the emergence of critical just-in-time COVID-19 education, including
rapid simulation preparedness, evaluation and training across all
healthcare sectors. Simulation has been proven to be pivotal for both
healthcare provider learning and systems integration in the context
of testing and integrating new processes, workflows, and rapid
changes to practice (e.g., new cognitive aids, checklists, protocols)
and changes to the delivery of clinical care. The individual, team,
and systems learnings generated from proactive simulation training
is occurring at unprecedented volume and speed in our healthcare
system. Establishing a clear process to collect and report simulation
outcomes has never been more important for staff and patient safety
to reduce preventable harm. Our provincial simulation program in the
province of Alberta, Canada (population = 4.37 million; geographic
area = 661,848 km 2 ), has rapidly responded to this need by leading
the intake, design, development, planning, and co-facilitation of
over 400 acute care simulations across our province in both urban
and rural Emergency Departments, Intensive Care Units, Operating
Rooms, Labor and Delivery Units, Urgent Care Centers, Diagnostic
Imaging and In-patient Units over a 5-week period to an estimated
30,000 learners of real frontline team members. Unfortunately, the
speed at which the COVID-19 pandemic has emerged in Canada may
prevent healthcare sectors in both urban and rural settings to have
an opportunity for healthcare teams to participate in just-in-time in
situ simulation-based learning prior to a potential surge of COVID-19
patients. Our coordinated approach and infrastructure have enabled
organizational learnings and the ability to theme and categorize a mass
volume of simulation outcome data, primarily from acute care settings
to help all sectors further anticipate and plan. The goal of this paper
is to share the unique features and advantages of using a centralized
provincial simulation response team, preparedness using learning and
systems integration methods, and to share the highest risk and highest
frequency outcomes from analyzing a mass volume of COVID-19
simulation data across the largest health authority in Canada.
Keywords: Simulation, COVID-19; debriefing, Systems integration,
Pandemic preparation, Quality, Safety, Organizational learning
Introduction
RESUSCITATION TODAY - AUTUMN 2020
With the emergence of the COVID-19 pandemic of 2020, healthcare
resources have been strained to unforeseeable capacities, promoting
the need for rapid, effective, and efficient preparedness. This has
prompted the emergence of just-in-time preparedness strategies,
including simulation for systems evaluation and healthcare provider
(HCP) learning to support planning across healthcare sectors [1–9].
Simulation has been pivotal for systems testing and integrating new
and improved components such as novel workflows, protocols, and
cognitive aids with rapid changes to practice and care delivery. Finding
clear approaches to rapidly collect and report what is working well and
what needs to change is urgently required for HCP and patient safety to
ultimately reduce preventable harm.
The provincial simulation program, named eSIM (educate, simulate,
innovate, motivate) in the province of Alberta, Canada (population
= 4.37 million; geographic area = 661,848 km2, [10]), has rapidly
responded to preparedness training by establishing a central eSIM
provincial COVID response team (similar to an emergency command
center operations team for simulation) to facilitate a large-scale
project managing the initiation, planning, execution, and performance/
monitoring of a provincial COVID-19 simulation response [11]. Over just
5 weeks, this response team enabled a harmonized intake process,
design, and development of a robust COVID-19 simulation curriculum,
mobilized a data collection/outcome reporting team, and a response
plan to facilitate over 400 acute care simulation session requests across
Alberta’s broad geographical zones. This coordinated approach and
infrastructure enabled an integrated provincial multi-site simulation
response, allowing the ability to rapidly theme and categorize a mass
number of simulation findings (over 2,500 systems issues) from over
30,000 learners (HCP) on the frontline. The simulation “command
center” served to disseminate the outcomes across a large single health
authority to further support ongoing planning, develop and refine the
curriculum, and remain a specialized contact team of simulation experts
for all health sectors (primarily acute care; urban and rural).
The goal of this paper is to share the unique features and advantages of
using a centralized provincial simulation response team, preparedness
using learning and systems integration methods, and to share the
6
*
Correspondence: mirette.dube@ahs.ca
1
eSIM Provincial Simulation Program, Alberta Health Services, Alberta Health Services, 1403 29th Street NW, Calgary, Alberta T2N 2 T9, Canada
Full list of author information is available at the end of the article

FEATURE
highest risk and highest frequency outcomes from analyzing a mass
volume of COVID-19 simulation data across the largest health authority
in Canada.
Background
Alberta Health Services: largest integrated healthcare system in
Canada
Alberta Health Services (AHS) has a centralized approach to its
leadership and core operational functions (e.g., human resources
and information technology) and provides medical care at over 650
facilities across the province, including 106 acute care hospitals and
25,653 continuing care beds/spaces, five stand-alone psychiatric
facilities, 2723 addiction and mental health beds and 243 community
palliative and hospice beds. AHS has over 125,000 employees and
over 10,000 physicians and service accountability zones are divided
into five geographical areas: North, Edmonton, Central, Calgary,
and South [10]. There are few organizations in the world, which are
comparable to AHS’ integrated healthcare system relative to its size
and capacity [12], making it a unique opportunity to glean insights and
lessons learned from COVID-19 pandemic preparedness.
Pandemic preparedness and planning: role of simulation for
team training and systems integration
While disaster planning has become core content within some training
curricula, the majority of health professionals remain ill prepared to
deal with large scale disasters and will not encounter these critical
scenarios in practice [13, 14]. Simulation is one method that has been
identified to improve readiness and preparedness in times of disaster
through deliberate practice and exposure to rare situations [15–18].
Simulation-based learning has historically focused on individual and
team training of practicing HCPs [19–25], although it has evolved to
include just-in-time in situ training within the actual clinical environment
[26–28] including simulation for systems integration (SIS), targeting
the testing and integration of systems and processes (e.g., workflows,
care pathways) that are uniquely important to disaster preparedness
[29–32].
the literature [8, 9, 26–28]. Pandemics place high demands on clinical
care and potential risk of contamination for HCP, which increases
the fear of spread to others [1, 36, 37]. Deliberate practice through
simulation can reduce the cognitive load of HCP involved in direct
frontline patient care, potentially mitigating latent safety threats (LSTs)
(e.g., errors in design, organization, and/or training that may have a
significant impact on patient safety) in times of extended pressure,
exhaustion, and burnout [38].
As recently illustrated in both Italy [2] and Singapore [3], simulation is
key to preparedness by optimizing work flow structures, developing
new processes, managing staffing levels, procuring equipment, bed
management, and enforcing consistency of medical management of
patients. In those ways, simulation can be used as both a learning and
evaluation tool (e.g., SIS/SFD) [32]. Diekmann et al. also described
the potential of using simulation to improve hospital responses to the
COVID-19 crisis [6]. Recently published COVID-19 simulation papers
[8, 9] share lessons learned in an attempt to support organizations
that may seek to use simulation for diagnosing, testing, and
embedding these approaches within pandemic constraints. While
these papers do not provide specific outcomes from their system
simulations, they share practical tips, tools, scenarios, debriefing
questions, and resources which can be used to analyze the current
needs and responses to potentially mitigate the negative impacts
of the COVID-19 crisis. Similarly, Chan and Nickson [7], published
an example of practical considerations for organizations in the
development for just-in-time simulation training, including the scenario
development, prebriefing, and debriefing, using system and process
simulation for the testing of airway management for suspected/
confirmed cases of COVID-19. While many of the findings in the
emergent literature above glean insights into the use of simulation
as both a learning and evaluation tool to prepare for COVID-19, a
key gap identified is that many of these outcomes are unique to the
experience of one specific site or one unique institution, which limit
the generalizability and scalability of the findings. This is especially
important when using simulation for pandemic preparedness to rapidly
test systems and processes and prepare frontline teams to care for
potential COVID-19 patients.
The eSIM COVID-19 response team has been involved in pioneering
work in SIS [11, 32, 33] systems integration, an engineering term
defined as bringing many subsystems together into one better
functioning system, has the potential to improve the safety and
quality of care through re-engineering of the processes and systems
in which HCP work [34]. The system engineering initiative for patient
safety (SEIPS) 2.0 model provides a framework outlining how the
work system components (e.g., tools/technology, tasks, environment,
people/teams) provide a matrix for thematically categorizing system
focused debriefing (SFD) outcomes in a complex adaptive healthcare
system [35]. SIS/SFD allows testing of new processes within
healthcare systems to inform design and utility, and to identify system
issues proactively to prevent harm [15, 19–21].
The rapid onset of the COVID-19 crisis is having a profound impact
on global health, increasing demand, and risks on healthcare systems
due to rapidly changing and unpredictable circumstances. The use
of in situ simulation as a proactive risk mitigation strategy to prepare
healthcare organizations for pandemic planning is well supported in
Therefore, an identified need in the literature is the ability to proactively
identify systems issues, while testing new pandemic processes in real
time, and sharing these organizational learnings and system-level
outcomes on a mass scale to both anticipate and plan for COVID-19.
This is an invaluable opportunity to support healthcare organizations’
preparedness during a global pandemic.
COVID-19 simulation project approach
Our provincial simulation program rapidly mobilized to respond to
our organization’s need by establishing a central simulation COVID
response team and a large-scale evaluation project to manage the
initiation, planning, execution, and performance/monitoring for all
simulation-based requests. The following sections will summarize our
project evaluation approach based on common project phases [39]:
(A) project initiation and planning; (B) project execution; (C) project
performance and monitoring; (D) organizational learning; and (E)
reporting of outcomes.
RESUSCITATION TODAY - AUTUMN 2020
7

FEATURE
Project initiation and planning
Rapidly designating the eSIM COVID-19 response team allowed
a centralized contact and triage system across the province for all
simulation-based requests coming from hundreds of centers, allowing
coordination, planning, and resource oversight for simulation training.
Team members included a team lead, geographically dispersed
eSIM consultants (clinicians whose workplace role is to lead the
design, delivery, faculty development, and evaluation of simulation
methodologies and projects at AHS) and a designated data and
outcomes team solely responsible for theming and categorizing
thousands of simulation data points from COVID-19 simulations.
The simulation infrastructure in place in AHS prior to COVID-19 (e.g.,
eSIM consultants positioned in every zone (rural, urban, and mobile
program) and > 1300 eSIM-trained simulation educators across
AHS) ensured every geographical zone was supported. The intake
process was maintained through a central spreadsheet accessible to
the entire provincial team and a needs assessment facilitated by an
eSIM consultant (Additional file 1 intake form) to ensure the needs and
objectives aligned with established simulation-based methodologies
and capacity. Requests were prioritized as they were processed and
whenever possible, prior relationships with simulation-trained educators
comfortable with the use of simulation-based methods were leveraged
to help facilitate the large number of sessions. eSIM consultants either
fully led the sessions, initiated sessions while mentoring others to
replicate delivery on an on-going basis (especially when large numbers
of HCP were involved), and/or shared resources with faculty who had
the capacity and experience to lead sessions independently.
The first wave of intake requests (and patients) in Alberta, organically
flooded from Emergency Departments, followed by Intensive Care
Units, Operating Rooms, Labor and Delivery Units, and Neonatal
ICUs in Calgary. Simulations were triaged for COVID-19 training and
preparedness for the highest risk locations and activities across acute
care. A second wave of requests included diagnostic imaging and
inpatient medical units (including newly created inpatient units for
COVID-19, among others). A similar pattern of requests followed from all
of the five geographic zones in Alberta in concordance with the number
of COVID-19 cases starting to move through the system. Daily response
team meetings ensured strategic planning with eSIM consultants to then
specifically target and reach out to acute care sites with no simulation
trained champion, those who had not made any requests, and to ensure
simulation support and curriculum resources were shared across all
zones.
Curriculum development
A novel part of our approach was the creation of a robust, centrally
located simulation curriculum, which was rapidly developed and
mobilized over a 10-day period at the onset of the COVID-19 simulation
response. Curriculum content was vetted through medical experts,
clinical leaders, Infection Prevention and Control consultants, and
the organization’s Emergency Command Center to ensure accuracy,
alignment, and validity before application. New emerging curriculum
resources for COVID-19 were reviewed daily to ensure the most relevant
up-to-date information was reflected within current best practice
recommendations. The curriculum included COVID-19 simulation
scenarios for all sectors, and included a prebriefing script, debriefing
tools [32], cognitive aids, “how-to” guides and shared webinars.
Curricular materials were shared over the 5-week period with over 600
teams across AHS.
Objectives for the COVID-19 simulation scenarios were based on the
highest risk and highest impact system issues identified and prioritized
by integrated interprofessional teams of clinicians, managers, and
educators—based on their units/departments greatest needs. Table
1 provides samples of frequently used scenario objectives across all
simulations and their related work system categories [35].
Project execution
Central to our unique approach was the planning and execution of
three common simulation-based methods to prepare teams and the
healthcare system during COVID-19 preparedness (Table 2). These
methods include (1) surge planning and table top debriefing;
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Table 1 Sample COVID-19 simulation scenario objectives (highest risk and highest frequency)
Examples of some COVID-19 scenario objectives (pre-determined to be highest risk and highest frequency)
Equipment: Implement creation of carts for personal protective equipment/intubation
Cognitive aids: Apply airway pause with COVID-19 additions
Paging systems: Assess addition of “COVID-19” stem to pages to ensure HCP safety and priority response
Task complexity: Prepare smaller specialized teams for intubation (e.g., airway response team)
Prepare smaller teams to anticipate and prepare for any aerosol-generating medical procedure
Designate and prepare personal protective equipment (PPE) coach for donning and doffing
Organize clean runner role to help with cognitive overload
Signage: Evaluate plan for new areas for COVID-19 vs non-COVID-19 patients (surge specific phases)
Transport routes: Assess, plan, testing of dedicated hallways and elevators
Assess staffing during day and night with Intensive Care Unit surge bed plans and escalating to 2 patients per room
Site capacity and triggers: Evaluate pandemic surge exercises identifying triggers, bed capacity, flow restrictions, and
continuity across the site
Communication pathways: Apply testing of handover tools and new alerts
Workflow: Identify appropriate number staff/roles caring for patient(s)
Policies (testing of new or existing): Appraise any unnecessary and preventable delays in care and/or process
System issue categories
[35]
Tools and technology
People and tasks
Environment
Organization
Processes
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Table 2 Method, objective, and examples of intake requests
Method Objective(s) Sample of intake requests
Table top exercises
Process walk-through/
environmental scan
with debriefing
Rapid cycle simulation
and debriefing
• Surge planning
• Bed capacity allocation
• Identify LSTs, new workflows, new processes, using a
systems approach to debriefing
• Training small groups of interprofessional teams in rapid
cycle simulation training and debriefing (once processes
are established). Most often 20-min simulations followed
by 20-min debriefings.
• Assess a hospital’s emergency response operational plan
related to current bed capacity and pandemic surge
planning phases 1 through 4.
• Align organizational pandemic policies with current local
current state resources to bridge expectations of front line
staff and pandemic policy makers.
• Determine new processes for a COVID stroke patient from
CT (computed tomography) scan to emergency intubation
to angiography.
• Determine workflow process from the emergency room
triage through to an isolation room for a team COVID-19 intubation
process.
• Determine the environmental layout and associated
workflows, including LSTs when ventilating two patients in
one Intensive Care Unit room (new processes, staffing
ratios), testing of IT-related issues and central alarm bank.
• Determining new and unique processes and educational
needs within indigenous health centers and communities
to ensure safety of vulnerable populations and ensuring
preparedness.
• Apply new processes of patient flow from triage to isolation
room including intubation, safe PPE processes for all
emergency departments in Calgary over 2 days (4 adult
sites). a
• Apply COVID-19 medical management to a complex medical
scenario.
a Approximately 250 interprofessional team members per site (including physicians, nurses, respiratory therapists, infection prevention and control (IPAC) staff,
environmental services, clinical leaders, and other non-clinical team members such as protective services)
(2) process walkthrough and environmental scans; and (3) rapid cycle
simulation and debriefing. Both learnerfocused and system-focused
debriefing approaches were used across these three methods [22, 32].
Surge planning and table top debriefing
In some instances, eSIM consultants and human factors (HF)
specialists led the co-facilitation and debriefing of table top surge
planning exercises. These exercises allowed for proactive pandemic
surge planning assessment of facility, departments, programs,
and services related to COVID-19 patient flow. eSIM and HF were
then utilized for designing decision algorithms, observation of new
work processes and work environments, and identifying further
improvement opportunities.
Rapid cycle simulation and debriefing
Once final COVID-19 processes and workflows were established,
departments/clinical areas progressed to rapid cycle simulation training
followed by debriefing [41]. This involved rapid training sessions
(average 20-min scenario duration followed by 20-min debriefings) to
ensure small groups of interprofessional team members were able to
apply new processes in the live clinical environment prior to use with
actual patients. All questions related to medical management, infection,
prevention and control (IPAC) and process were also debriefed during
these sessions.
Project performance and monitoring
Process walkthrough and environmental scans
Early preparatory work focused on using a systems approach to
co-design new COVID-19 processes and spaces. These physical
walkthrough simulations were based on day-to-day movement,
case-specific patient presentations, and workflows that would be
impacted by COVID-19. They were also used to train multiple HCPs
to orientate them to the new COVID-19 response for their areas (see
Additional file 2 for key points to consider in a process walkthrough
environmental scan planning exercise). The primary focus was on
identifying LSTs prior to the first patient experience which allowed for
application of a new processes in a plan, do, study, act (PDSA) cycle
[40]. The team moved through a department/clinical area, doing an
environmental scan for barriers, identification of missing equipment,
testing of communication pathways, and identification of new tasks/
roles/responsibilities. Any changes to the space and processes were
actioned to leadership.
Data collection and analysis
A data outcomes team was designated to rapidly process and analyze
data collected from all provincial COVID-19 simulations. Figure 1
outlines a systematic iterative process developed for intake and entry of
data. An initial coding scheme for categorization of data was created.
Data analysis included the theming of system-focused debriefing
outcomes [32] based on the SEIPS 2.0 system categories (e.g., tools/
technology, tasks, environment, people/teams) [35]. All outcome data
were analyzed to determine convergence of themes and repeated
expression of reoccurring constructs. Discrepancies in the codes and
labeling of themes were discussed by the core project team regularly
and resolved; with themes simplified and altered accordingly until
complete agreement was reached. Saturation of emergent themes was
reached across > 400 simulation sessions provincially. The number
of learners/participants and simulation sessions was collected using a
standardized intake spreadsheet and was collated biweekly.
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Fig. 1 Systematic process for intake and entry of data
Organizational learning
Fig. 1 Systematic process for intake and entry of data
When using a simulation for systems integration approach, the
collection and sharing of systems issues and learnings is key to
informing a parent organization. The eSIM program’s infrastructure and
approach was critical in a pandemic situation, as the information and
learnings from the SIS were used to iteratively make improvements
and help teams across the organization anticipate and plan for issue
mitigation and process improvement. The timely analysis of large
volumes of data that was being collated and themed in real time by the
eSIM response team proactively informed and enabled scaling up of
quality improvement activities across sites, departments, and zones.
Our organizational learning included broad sharing of weekly dashboard
updates of key outcomes, webinars (local and international webinars
shared across the entire AHS organization and beyond resulting in over
4000 unique views; recording shared with > 100, 000 email addresses)
[4, 42], and key COVID-19 resources developed for simulation.
COVID-19 simulation project key outcomes
Highest impact and highest frequency outcomes
The provincial eSIM COVID-19 simulation response team facilitated
simulation session requests by leading the intake, design, development,
planning, and facilitation of over 400 acute care simulation sessions
across all sectors of our provincial health program. In under a 5-week
period, an estimated 30,000 learners participated in simulation in both
rural (17%) and urban (83%) centers across the province (Fig. 2).
There was a wide variance in the number of sessions/learners per
request ranging from 1-3 days of simulation training and 10-400
people requiring training per request. Well over 2500 systems issues,
including LSTs, have been proactively identified and mitigated through
> 400 simulation sessions. Systems issues across all sessions were
categorized into processes (61%), tools and technology (14%), persons
and tasks (14%), environment (7%), and organization (4%).
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Fig. 2 Estimated number of participants in COVID-19 preparedness simulation by department
Fig. 2 Estimated number of participants in COVID-19 preparedness simulation by department
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Table 3 highlights the highest priority themes discussed in the
debriefings (impact) and the highest reported outcomes (frequency)
that emerged from all COVID-19 simulations.
In analyzing the nine themes, it is clear that the rapid knowledge
translation of best practices, new guidelines, and processes
following system simulation events can potentially serve other
organizations that may seek to learn from our centralized,
coordinated approach to using system integration simulation for
pandemic planning and preparedness.
In synthesizing the learnings from the highest impact and highest
frequency outcomes of the 9 themes reported in Table 3, there are
several reasons on why these salient themes came together based on
our unique context and organizational level approach to SIS. Each of
these themes informed our organization as to what was working well
at one site, department, and zone and what needed to be improved
and scaled up across the organization. For example, although we
had an IPAC team, and multiple related resources and cognitive aids
designed to support IPAC processes; it became clear, as identified
by the frontline through simulation, that more needed to be done to
address the nuances and unique clinical practices of IPAC specific
to the pandemic. While hundreds of learners continued to struggle
with safe doffing, simulation was able to inform the development of
emerging best practices surrounding 1:1 doffing, what questions were
repeatedly being discussed; why breaches were happening; and
ensuring one person guided and supported individuals during doffing.
Observing the trending of process-related systems issues enabled
our team to share this finding broadly and focus our simulation tools
and approaches to further address systems issues that impacted
not just one unit, site or department enabling the learnings identified
through simulation to be scaffolded and shared across the entire
province. This led to further development of a systemsbased process
walk through approach, with debriefing, to ensure a systematic
identification of process issues.
Repeated SIS debriefings where frontline team members asked
about personal items such as watches, earrings, and identification
badges in COVID rooms allowed us to share rapidly evolving
strategies to address proper maintenance of isolation environments
and the prevention of contamination. For teams who were struggling
with effective ways to communicate outside of COVID rooms, we
were able to rapidly share innovations on a large scale to any other
teams who were in the same position in preparing their unit and
staff to respond to the evolving nature of the global pandemic. This
involved designing, through simulation, innovative approaches
necessary to keep staff and patients safe by communicating using
dry erase markers on glass between rooms, as one example. As
protected COVID-19 intubations were identified as a high anxiety
and high-risk time for healthcare workers, as shown by repeated
simulation requests from healthcare staff targeting these objectives,
having the ability to test these processes in simulation and refine a
critical care medicine cognitive aid for pre-intubation and then share
these findings on such a large scale was essential to successful
preparation and safety of staff. As a result of multiple simulations
on intubation, a COVID-19 cognitive aid was developed, which was
then contextualized for rural sites and then broadly shared across the
province using our coordinated system.
Discussion
Our use of simulation for systems integration involved taking a project
approach to the initiation, planning, execution, and reporting [39] (e.g.,
shared learnings) to enable proactive improvement work for safer, more
efficient, and reliable care processes for patients and healthcare teams
[43–50]. This paper adds to the emerging literature on using simulation
for pandemic planning and preparedness [8, 9] as it describes a
highly coordinated COVID-19 pandemic simulation response using a
centralized team, robust valid curriculum, and data outcomes team to
analyze and rapidly share an unprecedented volume of simulation data
for a large-scale SIS project across the largest single health authority in
Canada.
Unfortunately, the speed at which the COVID-19 pandemic has emerged
in Canada may prevent every acute care center in both urban and
rural settings in having healthcare teams participate in “just-in-time”
in situ simulation-based learning and systems/process. The ability to
test new pandemic processes, and share organizational learnings to
be disseminated on a mass scale has been pivotal in preparing our
healthcare system to respond to the emergent threat of COVID-19.
The importance of using simulation as a “first choice” strategy for
ensuring individual, team, and system readiness in times of crisis is
supported by multiple publications in the literature [5, 51–53], and
highlights that a sustained investment in simulation programs will
have immeasurable impacts across healthcare systems following
the pandemic. Many of these papers [3, 6–9] indicate a single site or
unit approach to pandemic preparation, although do not specifically
highlight using a coordinated and centralized simulation team,
development of robust valid curriculum, and real time data analysis
of emerging themes from hundreds of simulations. Although “more”
may not necessarily always be better, we advocate that during times of
pandemic where time sensitivity and reliable information are of utmost
importance, a coordinated organizational-wide simulation response
approach allows for broader and faster sharing, scalability, and
generalizability of the findings. The validation of these 9 themes from
simulations across multiple sites and teams outweighs the findings at
only one.
One of the emerging findings that differed our project from other
COVID-19 system simulations experiences both nationally and globally
in using simulation as both a learning and evaluation tool to prepare [3,
6–9], was recognizing the critical importance of embedding simulation
as a central part of the organizational learning, and the overall pandemic
preparedness strategy. Similar to an operational “Emergency Command
Center,” simulation programs (regardless of the size) need to situate
themselves to be members “at the table” with key programs informing
decision-making, and influencing organizational planning and pandemic
preparedness from the beginning. Many factors influence the ability of
simulation programs to “take this seat” including how the program is
established prior to pandemic and how well it may be recognized by
hospital administration staff in informing the organization of the needs
and challenges coming directly from the frontline care providers. We
situated ourselves as key informants to leaders and the organization’s
administration, through planning and executing a large-scale simulation
for systems integration project. Our outcomes, which identified over
2500 systems issues, including LSTs, had meaning to the organization
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Table 3 Highest impact and highest frequency outcomes
Key themes and qualitative outcomes (highest impact and highest frequency) identified in simulation
Systems categories
1. Theme: Safe doffing (removal of PPE safely and in correct order) People/teams/tasks;
Key outcomes
Tools/technology
Cross monitor team members during doffing
Use and IPAC poster as a cognitive aid
Ensure “1 to 1” doffing to avoid breaches observed when too many doffing at once (e.g., getting ahead or behind in
doffing sequence)
Consistent role of a “PPE Coach” to support safe doffing-ensure focus and intention with every step
Implement “just-in-time” review of safe doffing to reduce cognitive load during long stressful periods in PPE.
2. Theme: Conducting environmental scans of care areas is crucial in anticipating, planning ahead, and
developing area processes
Key outcomes
Remove visitor chairs, extra equipment and linens from room to avoid waste, and additional cleaning
between patients
Keep transport routes
Post signage for direction and decrease of clutter
Creation of supply restocking checklist white this
Creation of COVID-19 specific cart of required supplies
Creation of small, labeled packages of specific supplies, or medications for fast grab and go
Ensure team members are aware of the responsibilities required to maintain the space
Ensure cleaning processes for removal of equipment leaving COVID-19 rooms (e.g., stretchers, wheelchairs)
3. Theme: Conduct inter-departmental/inter-hospital transport routes to establish communication and process
between departments and professions
Key outcomes
Test and walk through the route
Use signage if COVID-19 routes differ from the usual process
Clean hallways of clutter and reduce traffic if possible
Consider dedicating elevator banks for COVID-19 patients, staff and carts
Establish a designated clean person on transports to ensure surfaces are cleaned (e.g., floors, elevator buttons, stretchers,
and wheel chairs)
Emergency medical services should use a common Stem in communication and pages: This line is supposed to be with
the one below to read: "Emergency medical services should
“Possible/Confirmed COVID-19 patient” this goes afte the word "pages" in line above
Upon arrival of out of external hospital emergency medical services, ensure transport is ready and routes are prepared.
white this Should read; Upon arrival of externa;l hospital emergency medical services, ensure transport is ready and routes
are prepared.
Environment;
Tools/technology;
People/Teams/Tasks
People/teams/tasks;
Environment;
Tools/technology
4. Theme: Maintenance of isolation environment/prevention of contamination Tools/technology;
Key outcomes
People/teams/tasks
Removal of stethoscopes, phones, ID badges, lanyards, watches, and earrings from person prior to donning.
When items are on person, reinforce learnings re: do not reach below gown for ID badge/pager/mobile phone; or under
visor to adjust goggles/mask.
Creation of bins on an external cart in donning area for dropping items into
Keep numbers of staff in the room low when possible
Ensure cleaning process for roving items such as clipboards, ultrasound machines, etc.
5. Theme: Roles and responsibilities People/teams/tasks;
Key outcomes
Environment
A runner role is needed across multi areas: Operating Room, Emergency Department, Labor and Delivery Unit, Intensive
Care Unit (team member to bring supplies between isolated COVID-19 care area and non-isolated area)
Consider the involvement of HCAs and Unit Clerks to bring necessary equipment required for teams
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Table 3 Highest impact and highest frequency outcomes (Continued)
Key themes and qualitative outcomes (highest impact and highest frequency) identified in simulation
Establish “clean” and “dirty” sides between rooms and within rooms by taping the floors for a visual cue
Establish CODE COVID-19 team to attend to all rapid deteriorating patients
because they were widespread and converged data from several sites
including both urban and rural centers and across the continuum of
care. In addition, we could equally share and reach all sites within
our organizational structure for the new emerging themes we were
uncovering in real time.
We informed our organization on multiple levels through our webinars,
dashboards, and relationships built across a large health authority.
Queueing IPAC team members of ongoing concerns with best practices
for safe doffing to enable targeted approaches; sharing weekly questions
still arising from the frontline to the IPAC team; and then supporting
the development of a “doffing buddy” program are a few examples.
This example highlights that while the emerging literature on COVID-19
simulations [3, 6-9] differ in their approach and scale of SIS, there is
overlapping outcomes and triangulation of findings specific to IPAC
across the different systems, countries, and jurisdictions. Essentially, this
underlines the validity and robustness of the use of simulation for systems
integration methodology for organizational learning.
Systems categories
6. Theme: Innovative approaches to communication Tools/technology;
Key outcomes
People/teams/tasks
Use of dry erase markers on the shared glass wall of isolation to ante room
Use of a laminated page that can be flipped back and forth
Use of white boards to communicate key messages to outside team members
Use of two-way radios (e.g., walkie talkies) and baby monitors
Limit the use of negative pressure rooms and use ante rooms where available
Use of speaker phone setting
Use of tape on floor to communicate ‘clean versus dirty’ zones
Check that monitors and speakers on phones (especially with PPE on) can be heard
Include name/role tag stickers on outer PPE to ensure role clarity and effective communication
Reduce noise and ensure use of closed-loop communication (additional communication challenges with PPE on)
Use of trigger scripts on pagers to signal a priority response. Scripts like “COVID airway” or “COVID transport” to alert
a team and get the right people and the right equipment to the right place.
7. Theme: Psychological safety and speaking up People/teams/tasks
Key outcomes
Use critical language when breeches in PPE or when overcrowding in rooms occur
Encourage all team members to speak up when they see breaches in safe PPE practices
Removing hierarchical barriers can be challenging; promoting psychology safety is important for a cohesive team
Go beyond your professional role to cross teach about PPE
8. Theme: Critical care medicine pre-intubation cognitive aid People/teams/tasks;
Key outcomes
Tools/technology;
Organization
Communicate a plan ahead to ensure staff know their roles
Double-check proper PPE during intubation
Most experienced practitioner should perform the intubation
Ensure the ventilator and video laryngoscopy device are in the room prior to start
Consider back-up plan depending on available resources
Ensure correct bagger filter is attached
9. Theme: Use of cognitive aids and checklists Tools/technology
Key outcomes
Consider human factors science in the development of new COVID-19 cognitive aids and checklists
Cognitive aids can be made into posters, use larger font, central point of reference white this
They should be clear, easy to use adaptable to context, trained prior to implement, and pilot tested prior to use on a
real patient
Examples: COVID-19 airway pause checklist, checklists for buckets, and carts/bins, IPAC donning and doffing poster white this
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We realized that process-related systems issues were widespread
and the requests for environmental scans with debriefing prompted
hundreds of teams to start redesigning their COVID care spaces after
one of our “shared learnings” webinars. Seeing the rapid uptake of
teams developing checklists and cognitive aids in isolation of each
other, and with limited human factors experience, led us to establish
collaborative human factors tools on how to develop an effective
cognitive aid and principles of safe use. We believe all of these
developments were the result of a swift and purposeful largescale
centralized approach.
Recognizing that not all health authorities have opportunity to coordinate
or operationally support a centralized team and curriculum across sites;
we recommend the explicit effort of simulation programs to align with
other programs in meaningful ways to analyze and share emerging
data in real-time to support validation for broader sharing and scalability
when possible.
The simulation methods and outcomes used in the COVID-19 response
have had a profound impact on our teams, processes, and system
functioning. Our experience offers other organizations’ learnings
to glean and consider the importance of establishing a centralized
simulation response team for scale, spread and speed of knowledge
translation, implementation, and change management effectiveness.
With on-going use of SIS sessions informing cycles of improvement,
the simulation will continue to be a key organizational tool we will use
to further manage this evolving crisis, as well as future needs of our
healthcare organization. Our pandemic preparedness highlighted the
essential use of simulation as both an evaluation tool capable of testing
systems and processes, and identifying and mitigating LSTs, as well
as an education tool capable of rapidly preparing frontline teams in
terms of the changes identified above. This project has identified how
the dissemination and broadcasting of curriculum and lessons learned
(e.g., emerging themes, innovations, systems-based approaches) from
simulation can rapidly help a large organization over a large geographic
area be adequately prepared for an evolving situation like the COVID-19
pandemic of 2020.
Supplementary information
Supplementary information accompanies this paper at https://doi.
org/10.1186/s41077-020-00138-w.
Abbreviations
AHS: Alberta Health Services; COVID: Coronavirus disease; COVID-19:
Coronavirus disease 2019; eSIM: educate Simulate Innovate Motivate;
HCA: Health care aides; HCP: Healthcare provider; HF: Human factors;
ID: Identification badge; IPAC: Infection prevention and control; LST:
Latent safety threat; PPE: Personal protective equipment; SEIPS: System
engineering initiative for patient safety; SFD: System focused debriefing; SIS:
Simulation for systems integration
Acknowledgements
The authors would like to recognize the many partnerships and people that
enabled an impressive simulation response to the COVID-19 pandemic.
This project, considering its scope and scale, would not have been possible
without the efforts of many team members from the Alberta Health Services’
eSIM Provincial Simulation Program, KidSIM Pediatric Simulation Program,
and Covenant Health Authority. The authors would like to acknowledge the
following people for their contributions to the project curriculum design,
delivery, data entry, manuscript review, and input throughout the COVID-19
simulation response project: Mark Allen, Ken Brisbin, Helen Catena, Jennifer
Chatfield, Amy Cripps, Christina Eichorst, Andrea Faid, Monika Johnson,
Erica Meunier, Annamaria Mundell, Albert Phung, Andrew Reid, Rob
Ritchie, Jennifer Semaka, Cherie Serieska, Michael Sidra, Kristin Simard, Jill
Soderstrom, Nadine Terpstra.
The authors would also like to recognize Dan Duperron, Darren Steidl,
and Sheneel Lal for biomedical engineering support; Juanita Clark for
administrative support; AHS Design Lab Team (Ali Abid); AHS Infection
Prevention and Control Team (Gwyneth Meyers); and the many simulation
champions across the province of Alberta, including Drs. Gord McNeil,
Jonathan Gaudet, Andrea Boone, Stuart Rose, Simon Ward, and Sharon
Reece.
Authors’ contributions
MD, AK, TC, SB, TF, and VG were involved in the conceptualization, analysis,
and interpretation of the data, drafting of the manuscript, and development of
all figures and tables. The authors read and approved the final manuscript.
Authors’ information
MD is a Masters certified critical care Registered Respiratory Therapist with
24 years of experience in healthcare. She has over thirteen years’ experience
in simulation and debriefing; training hundreds of interprofessional teams,
faculty development, simulation for systems integration and debriefing,
undergraduate education, global health, human factors, design thinking,
research, project and change management, former provincial Director of
Quality and Patient Safety education, and leading provincial simulation
and quality improvement projects. She is passionate about patient safety,
improving healthcare systems, and has multiple peer-reviewed publications
on interprofessional collaboration, team training, and using simulation and
debriefing for systems improvement. During the COVID-19 pandemic of
2020, MD was the eSIM Provincial Simulation Response Team Lead for the
province of Alberta, Canada.
Funding
No funding was required for the development of this manuscript.
Ethics approval and consent to participate
No ethics approval or consent was needed for this manuscript.
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Author details
1
eSIM Provincial Simulation Program, Alberta Health Services, Alberta
Health Services, 1403 29th Street NW, Calgary, Alberta T2N 2 T9, Canada.
2
Department of Community Health Sciences, Cumming School of Medicine,
University of Calgary, Calgary, Canada. 3 Departments of Pediatrics and
Emergency Medicine, Cumming School of Medicine, University of Calgary,
Calgary, Canada. 4 KidSIM Pediatric Simulation Program, Alberta Children’s
Hospital, 28 Oki Dr NW, Calgary, Alberta T3B 6A8, Canada.
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FEATURE
PENTHROX CAN
OUTPERFORM MORPHINE
Unless you have had personal experience of using Penthrox this
statement will come as a complete surprise. Two prospective
studies, MEDITA (1) and InMEDIATE (2) , from Italy and Spain
respectively and published in 2019 both reported the provision
of better analgesia when Penthrox was compared with Standard
Analgesic Treatment (SAT).
The study reported that methoxyflurane was superior to SAT. The
median time for onset of pain relief was 9 minutes in the methoxyflurane
group and 15 minutes in the SAT group. Healthcare professionals in an
overall assessment rated methoxyflurane good, very good or excellent in
90.3% of cases compared with 64.4% in the SAT group. Methoxyflurane
had no serious adverse effect on any of the patients.
RESUSCITATION TODAY - AUTUMN 2020
Penthrox is the trade name of methoxyflurane. As a handheld, selfadministered
volatile inhalational analgesic it has had approximately
7 million uses worldwide. Methoxyflurane was originally used as an
anaesthetic agent but it was withdrawn because of reported cases
of renal and liver toxicity. It was however observed that patients
receiving methoxyflurane had excellent post-operative pain relief and
it was therefore recognised in sub-anaesthetic dosage to have potent
analgesic properties.
Penthrox has a rapid onset, within 6-10 inhalations (3) and a rapid offset.
Importantly, since its licensing in the UK in 2016 by the Medicines and
Healthcare products Regulatory Agency (MHRA) for moderate to severe
pain in adults due to trauma and related conditions, there have been
no reported drug interactions and adverse events are usually mild and
transient.
Supplied in a 3ml vial, the device (often known as the green whistle)
can be charged ready for use in under a minute and when used
continuously will last 25-30 minutes. Most patients use it intermittently
where it will last for approximately one hour. A second 3ml dose is
permissible.
Very importantly, Penthrox has minimal effect on the cardiovascular or
respiratory system which makes it more suitable than opioids in certain
patient groups (4) . Furthermore, it can be administered to patients with a
potential pneumothorax, unlike nitrous oxide – oxygen gas. Whilst it can
make some patients drowsy, they are fully rousable.
The MEDITA study (Methoxyflurane versus Standard Analgesic
Treatment for Acute Trauma Pain in the Emergency Setting) was a
randomised, open label, active controlled multi-centre trial undertaken
in Italy (1) involving 15 Emergency Medical Centres (both prehospital
and ED settings). The study used a Visual Analogue Scale (VAS) to
record changes in pain scores at baseline, 3, 5 and 10 minute intervals
in patients receiving either methoxyflurane or Standard Analgesic
Treatment (SAT). SAT was either intravenous paracetamol 1g or
intravenous ketoprofen 100mg for moderate pain and morphine for
severe pain.
Two thirds of the patients had moderate pain where 80 patients received
paracetamol and 11 received ketoprofen. Of the remaining third with
severe pain 42 patients received morphine.
At around the same time the InMEDIATE study (Inhaled Methoxyflurane
Provides Greater Analgesia and Faster Onset of Action Versus Standard
Analgesia in Patients with Trauma Pain) was taking place in Spain
(2)
. Once again this was a randomised controlled, open label, study
comparing methoxyflurane with SAT. In this study standard analgesic
treatment included intravenous, intramuscular and oral non-opioids,
intravenous opioid and trans mucosal opioids. The study reported
superior efficacy of methoxyflurane over SAT including better pain relief,
speed of action (3.17 minutes methoxyflurane, 10 minutes SAT) and
greater patient satisfaction (77% methoxyflurane, 38% SAT). In addition,
patients prescribed methoxyflurane required less rescue medication
(8.5% methoxyflurane, 12.1% SAT).
A recent service evaluation at St Mary’s Hospital in London showed a 71
minute mean reduction time is spent in the Emergency Department (ED) for
patients receiving Penthrox compared to other analgesia and in particular
for shoulder dislocations the mean reduction time was 183 minutes (5) .
Specifically, to pre-hospital care there have been three ambulance service
evaluations. When collated there were 155 patients where a significant
reduction in pain scores was recorded. A more in-depth prospective study
is due to report from the East Midlands Ambulance Service any time now.
In relation to pre-hospital care Penthrox can provide fast, effective
analgesia at the time of first patient contact avoiding the need for
immediate cannulation and if necessary, it can be used as a bridging
analgesia before the administration of an opioid. Its effectiveness in
pre-hospital care is demonstrated in the paper by Forrest et al (6) where
it has been used in a number of patients with multiple injuries.
Like all drugs there are contraindications. The main ones are reduced
level of consciousness, history of malignant hyperthermia and aged
below 18 years (a requirement of the current product license) though
it should be noted in the Republic of Ireland it is being used in the
pre-hospital setting in children over the age of 5 years old. It should
not be used in cases of severe cardiovascular instability, respiratory
impairment, known clinically significant renal disease or liver impairment.
There should be no concern about occupational exposure where a
900-fold safety margin has been demonstrated (7) . Its sweet taste is
detectable and Penthrox use should be discontinued prior to patient
transportation by helicopter.
18

FEATURE
around the mouthpiece. Immediate deep inspiration could potentially
initiate coughing.
In summary, Penthrox may be considered a non-narcotic, easy to
administer, safe and rapid acting first line alternative to currently
available analgesic options for trauma related pain in both the prehospital
and Emergency Department settings.
References
1. Mercandante S et al Adv Ther 2019 November; 36(11):3030-3046
In terms of in-hospital use for fracture management it has favourable
costings when combined with staffing costs for conscious sedation,
intravenous anaesthesia and regional nerve blocks.
Penthrox, is currently used by all hospitals and national pre-hospital
services in Ireland and in the UK in 108 hospitals for ED usage with
pending approval in 60 hospitals. It is used by the majority of Major
Trauma Centres, approved for use in the military, used by a number of
firearms units, St John Ambulance and sporting organisations including
the Football Association (FA) and Rugby Football Union (RFU).
Finally, under the current circumstances it is worth noting that the
delivery of Penthrox is not by aerosol generation, it is a volatile liquid.
Patients need coaching before its use and should be advised to initially
take gentle breaths prior to breathing normally maintaining a good seal
2. Borabia AM et al Ann Emerg Med
https://doi.org/10.1016/j.annemergmed.2019.07.028
3. Coffey F et al. Emerg Med J 2014; 31:613-618 doi: 10.1136/
emermed-2013-202909.
4. Oxer HF Jornal of military and veterans health 2016;24(2):14-20
5. Young L et al ADV Ther.2020 doi:10.1007\s1235-020-01294-1
6. Forrest M et al Journal of Paramedic Practice 2019;11(2):54-60
7. Frangos J et al Regul Toxicol Pharmacol.2016:80:210-25
Professor Sir Keith Porter
Professor of Clinical Traumatology
Queen Elizabeth Hospital Birmingham
OStJ, MD, MBBS, FRCS(Eng), FRCS(Ed), FIMC RCS(ED), FFSEM(Ed),
FCEM, FRSA, FRCGP(Hon)
Resuscitation Today
Volume 7 No. 2
Autumn 2020
Resuscitation Today
A Resource for all involved in the Teaching and Practice of Resuscitation
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