Background: COVID-19 has taken the world by surprise; even the most sophisticated healthcare systems have been unable to cope with the volume of patients and lack of resources. Yet the gradual spread of the virus in Lebanon has allowed healthcare facilities critical time to prepare. Simulation is the most practical avenue not only for preparing the staff but also for troubleshooting system's latent safety threats (LSTs) and for understanding these challenges via Hollnagel's safety I-II approaches. Methods: This is a quality improvement initiative: daily in situ simulations were conducted across various departments at the American University of Beirut Medical Center (AUBMC), a tertiary medical care center in Beirut, Lebanon. These simulations took place in the hospital with native multidisciplinary teams of 3-5 members followed by debriefing with good judgment using the modified PEARLS (Promoting Excellence and Reflective Learning in Simulation) for systems integration. All participants completed the simulation effectiveness tool (SET-M) to assess the simulation. Debriefings were analyzed qualitatively for content based on the Safety Model and LST identification, and the SET-Ms were analyzed quantitatively. Results: Twenty-two simulations have been conducted with 131 participants. SET-M results showed that the majority (78-87%) strongly agreed to the effectiveness of the intervention. We were able to glean several clinical and human factor safety I-II components and LSTs such as overall lack of preparedness and awareness of donning/ doffing of personal protective equipment (PPE), delayed response time, lack of experience in rapid sequence intubation, inability to timely and effectively assign roles, and lack of situational awareness. On the other hand, teams quickly recognized the patient's clinical status and often communicated effectively. Conclusion: This intervention allowed us to detect previously unrecognized LSTs, prepare our personnel, and offer crucial practical hands-on experience for an unprecedented healthcare crisis.

Introduction Working under extreme stress can cause medical professionals to deviate from clinical guidelines even if they know of their existence, let alone in situations such as COVID-19 where guidelines are unclear, fluid, and resources limited. In situ simulation has been proven an effective tool for training medical professionals during previous healthcare crises, eg, Ebola, influenza, as well as for assessing the preparedness of centers by identifying potential latent safety threats. In this article, we describe our ongoing simulation activities to ensure that our staff is best prepared to adapt to the challenges of COVID-19. Methods This is a prospective preparedness assessment and training intervention at a tertiary care academic center in Lebanon during the COVID-19 pandemic. In situ simulations followed by debriefing with good judgment occur daily involving native teams of 3 to 5 professionals in the newly established COVID intensive care unit and wards, the adult and pediatric intensive care unit and wards, and the emergency department. The simulations are assessed by the instructor using the Simulation Team Assessment Tool and by the participants using the Simulation Effectiveness Tool. Transcripts of recorded simulation debriefings are analyzed for content for latent safety threats using the SHELL Framework (Software-Hardware-Equipment-Liveware). Results In 2 weeks, we conducted 15 simulations with 106 participants and 47 observers. Simulation Team Assessment Tool scores show an overall improvement across the hospital over time [101.5 ± 13 (80–134)]. Participants' feedback on the Simulation Effectiveness Tool has been predominantly positive on the educational and practical benefits of the simulation activity. Data from debriefings and observations demonstrated the following categories of latent safety threats: inadequate preparedness on infection control, uncertainty of guidelines on oxygen supplementation and intubation protocols, lack of leadership and communication, overall panic, and others. Conclusions Our single-center preparedness intervention demonstrated multiple latent safety threats in relation to COVID-19, which can be recognized through simulation before translating into actual patient care.

Objectives The Do-Not-Resuscitate (DNR) order is part of most hospitals’ policies on the process of making and communicating decisions about a patient's resuscitation status. Yet it has not become a part of our society's ritual of dying in the Middle East especially among children. Given the diversity of pediatric patients, the DNR order continues to represent a challenge to all parties involved in the care of children including the medical team and the family. Methods This was a retrospective review of the medical charts of patients who had died in the pediatric intensive care unit (PICU) of a tertiary academic institution in Beirut, Lebanon within the period of January 2012 and December 2017. Results Eighty-two charts were extracted, 79 were included in the analysis. Three were excluded as one patient had died in the Emergency Department (ED) and 2 charts were incomplete. Most patients were male, Lebanese, and from Muslim families. These patients clinically presented with primary cardiac and oncological diseases or were admitted from the ED with respiratory distress or from the operating room for post-operative management. The primary cause of death was multiorgan failure and cardiac arrest. Only 34% of families had agreed to a DNR order prior to death and 10% suggested “soft” resuscitation. Most discussions were held in the presence of the parents, the PICU team and the patient's primary physician. Conclusions The DNR order presents one of the most difficult challenges for all care providers involved, especially within a culturally conservative setting such as Lebanon. As the numbers suggest, it is difficult for parents to reach the decision to completely withhold resuscitative measures for pediatric patients, instead opting for “soft” resuscitations like administering epinephrine without chest compressions.