Setting and Study Design
As the largest tertiary hospital in the province with 1000 bed capacity, the [***] had participated in receiving many COVID-19 critically ill patients. The hospital’s surge plan increased by up to 3-fold for its 25-intensive care unit (ICU) bed capacity.
All hospital trainees and physicians were invited to attend the training program. The entire course was composed of 2 parts: 1) virtual, and 2) hands-on. The virtual part focused on introducing candidates to basic theoretical aspects on COVID-19, basic elements of critical care management, and concepts of infection control and prevention. Moreover, it included pre-recorded webinars and lectures covering guidelines and best practice strategies in managing critically Ill patients with suspected or confirmed COVID-19. This included basic airway management and respiratory support (initial non-invasive and invasive ventilator settings), early risk communications and inter professional teamwork. The virtual part was designed and developed by the Health Academy of the Saudi Commission for Health Specialties (SCFHS). [7] All candidates must successfully complete the virtual part before registering for the hands-on part of the course. Thereafter, the practical component was a focused 1-day hands-on course conducted at the [***]- Clinical Skills and Simulation Center (KAU-CSSC).
Hand-on Course development
The Clinical Skills and Simulation Center at the [***] had been designated (by the Saudi Commision for Health Specialties) as a location to conduct the hands-on part of the course. This single day focused course was developed carefully by senior anesthesiologists, emergency physicians and critical care physicians with extensive teaching experience. This program was designed to allow candidates to practice basic airway management techniques on airway manikins, to operate and change initial invasive and non-invasive mechanical ventilator settings, to practice donning and doffing of personal protective equipment, and applying theoretical knowledge in a high-fidelity simulation session (see supplementary file 1 for program agenda). Trainees and physicians from non-critical care specialties who completed the online part were eligible to register for the hands-on part. Physical distancing and strict hygiene precautions were implemented for participant and instructor safety.
Instructors were board-certified physicians in anasthesia, critical care and emergency medicine. Additionally, respiratory practitioners and nursing educators were carefully recruited as instructors. Moreover, course director and instructors were certified in item writing analysis and train the trainer program. The course director ensured standardization of course content among instructors to meet candidate needs. Moreover, supplementary ID-sized cards were created and distributed to candidates as cognitive aids for use at the bedside (supplementary file 2 and 3). These cards were attached to badge holders for speedy access (as a cognitive aid) and help candidates make the right decisions quickly when it comes to critical medication dosage, initial mechanical ventilator settings, and personal protective equipment sequencing.
Knowledge Assessment tool
A multiple-choice question test was developed by a group of active clinical faculty from anasthesia, critical care and emergency medicine with expertise in education and testing. Multiple choice questions (MCQs) were developed following best practices for construction and phrasing. The MCQs tested knowledge on basic airway management, the use of personal protective equipment, initial mechanical ventilator settings, vasopressors and hemodynamic parameters, and team dynamics. Four faculty members met to decide on items relevant for the purpose of the program. Consensus was reached on 20 MCQs after two iterations. Each question had one best answer and three wrong answers. The surviving sepsis campaign guidelines on the management of adults with coronavirus disease 2019 in the ICU were used as the primary reference for writing MCQs. The pre-test was distributed and completed electronically via Google form on the day of the course prior to starting. While the post-test was distributed and completed immediately after course completion.
Competency assessment
A competency checklist was developed by the Saudi Commission for Health Specialties (SCFHS) for each hands-on station. Residents and physicians participating in the course are expected to demonstrate basic skills. The purpose of these hands-on stations is to assess candidate competency (supplementary file 3) and re-enforce skills, while ensuring candidates ability to perform independently, while awaiting for more advanced help in real clinical practice.
Performance assessment Tool
A single simulation-based scenario was case implemented using a high-fidelity manikin in a simulated environment (supplementary file 4). This scenario was developed by the SCFHS and reviewed by the site course director and instructors at the clinical skills and simulation center. The scenario was modified and adopted to our institution’s established diagnostic and therapeutic protocols. Candidates self-reported confidence levels (on a scale of 0-10) were used to assess candidate confidence before and after simulation-based scenario.
Statistical analysis
Summary statistics and skill competency were performed using frequencies and means, where appropriate. Pre- and post-training tests, and self-reported confidence levels were compared using paired T-test. A p < 0.05 was considered as statistically significant.