Immunology and Immunotherapy Caring for Healthcare Professionals during COVID-19 Crisis: Integrating Simulation Training with Hospital System towards Actualizing Occupational Safety, Health and Well-being

In January 30, 2020 the World Health Organization (WHO) declared the outbreak COVID-19 as a Public Health Emergency of International Concerns (PHEIC) to later, in March 11, 2020, declared it as a global pandemic, Hong Kong Special Administrative Region (HKSAR), a densely populated city where approximately 8-million people are residing, has been at high stake of large-scale spread in the serial waves of COVID-19 attacks. Lessons that healthcare workers (HCWs, roughly defined as “medical, nursing, and patient-care or operational staff in hospital”) learned from painful experience in the battle with Severe Acute Respiratory Syndrome (SARS) have

triggered excessive distress and fear of workplace infection, sequela of infection, and death [1]. Without considering alternative approach like herd immunity by natural infection, Queen Elizabeth Hospital (QEH), one of the major local public hospitals under the governance of Hospital Authority (HA), has been dedicated to providing all-rounded preventive measures to keep HCWs safe from harm in high risk areas, such as Accident & Emergency Department (AED), Intensive Care Unit (ICU), and Isolation and general wards.
In this short commentary, we would like to share with readers our reflection on how healthcare simulation training contributed to system integration and its translational effect on personal strengths as well as occupational well-being.

What is Healthcare Simulation Training?
Society for Simulation in Healthcare (SSiH) defined "Simulation training" as: i) the imitation or representation of one act or system by another; and ii) a bridge between traditional medical education and real-life clinical experience [2]. In healthcare setting, "simulation training" can serve as: i) an educational methodology, ii) an assessment tool for knowledge or skills acquisition, iii) a modality of hypothesis testing for how human factors, device on training, and conditions modified within training affect the effectiveness or any clinical outcomes, and iv) a system integration measure [3][4][5][6]. "Running on the fly", an impromptu type of simulation training, is the least preferred approach during an outbreak [7]. When a "justin-time" simulation-based infection control training for healthcare workers is being called for, comprehensive and systematic plan of curriculum and training objectives on which healthcare simulation and subject matter experts are involved in giving professional advice plant a seed for success. [6,8].

Integrating Healthcare Simulation with Hospital System
The COVID-19 outbreak triggered our defense mechanism, where infection control was identified by high management as the primary strategic direction. On the 23 rd of September 2020, a multidisciplinary taskforce against COVID-19 was established to unify and standardize hospital-wide practice and procedures to minimize cross-contamination hazard during high risk procedures, such as aerosol generating procedures (AGPs) and endotracheal intubation ( Table 1). Through proactive discussion and post-trial modification (Figure 1), the taskforce finalized specific training objectives (e.g., Self-awareness of basic hazards, understanding of level of personal protective equipment (PPE) in performing AGPs, donning/doffing procedures of PPE; identification of clean and dirty zone; lapse in infection control with buddy system) and prioritized the training program for high risk departments(for details of curriculum and content of scenarios, please refer to Cheung et al.) [9].

Training Center where Personal Strengths of Healthcare Workers Blossom
Healthcare simulation training could bring prosperity to HCWs by i) refreshing knowledge in up-to-date hospital guideline and practical skills for participants and educators within or outside of their high-risk departments, and ii) facilitating the buy-in process of resilience and well-being in a professional manner [10]. As energy flows where attention goes, practical techniques, such as meditation and appreciative inquiries, could help HCWs embrace both positive and negative emotions with rational optimism to reach and maintain a serenity state of mind [11,12]. Through briefing and familiarization, simulation educators help participants suspend their disbelief on stimulated environment and mannequins for more immersive experience in scenario-based simulation. Debriefing session after the training allowed educators and participants to review their performance in line with learning objectives, reflecting on what they observe, think, feel, and learn during the scenarios on a here-andnow basis. Feedback from participants would be adopted to improve overall logistics or workflow of high-risk procedures, making the internal service guideline down to earth [4]. To mobilize the change towards system integration, our training center played a major role in handling human factors, system monitoring, psychometrics, and technical issues (Table 2).

Training Deliverables, Outcomes, and Sustainable Measures
Between February 5 and March 18, 2020, 1,415 HCWs in QEH underwent our crash courses on either "in-situ" (at their own departments, real ward environment) or lab-based (at simulation center, simulated ward environment) mode. The training coverage for HCWs, who have worked or were working in isolation wards from Jan 25, 2020 to Aug 3, 2020, was over 80% (158/195).Of 749 nursing staff from the Department of Medicine or Surgery, 547 (73%) have completed the training. Strengthening infection control practice through the simulation training resulted in zero case fatality rate (CFR) and infection rate of HCWs via AGPs or other procedures handling confirmed and suspected cases of COVID-19 under Hospital Authority. Financial benefits have been reflected by cost-effectiveness analysis on costs unspent on medical treatment for infected staff, loss of manpower, and medical claims for malpractice in managing COVID-19 patients at organization level.

Clinical Departments
-Estimate training needs and release manpower for the training

Centre (MDSSC)
-Contribute to intellectual inputs in converting conceptual ideas into feasible plan throughout the training and data management processes -Incorporate healthcare simulation training into hospital system for patient safety    To maintain sustainability of infection control measures, a bidirectional feedback system keeps all stakeholders informed of the evaluation of training effect, clinical and operational outcomes, and sharing on subsequent strategic direction. For instance, a monitoring mechanism for staff proficiency records on regular basis, expansion of training scope from adult wards to pediatric wards, and videos of endotracheal intubation for suspected or confirmed case of COVID-19 circulated to all internal staff have been on the list of action plan or implemented already. Our seamless collaboration demonstrates the spirit of Gestalt principle: The whole is always greater than sum of its parts.

Translational Effect of Healthcare Simulation on of Healthcare Simulation on Occupational Safety, Health Psychology and Well-being
Identifying the extent to which a simulation training program yields positive outcomes of personal strengths has high theoretical and practical values in the fight against COVID-19, and can be translational to clinical management of Aerosol-generating Procedures (AGPs) with other pathogens comparable to the SARS-CoV-2 [13,14]. One of our studies provided evidence that COVID-19 specific simulation training statistically significantly enhanced HCWs' level of assertiveness, mental preparedness, self-efficacy, internal locus of control, and internal locus of responsibility, and such improvement could lead to satisfactory clinical and organization outcomes [9].
Stress-induced syndromes are highly associated with infection rate of HCWs due to compromised immune system, and can be exacerbated by organizational and political issues, exposure to highly stressful situations, and poor team experiences [10]. As a result, our simulation training prevented HCWs from suffering occupational and moral distress, burnout, and infection for several reasons: i. Bi-directional feedback system with all-level communication and transparency throughout the COVID-19 workgroup development and implementation of simulation training reduced misunderstanding, reluctance to change, and potential political concerns at organization level timely.
ii. Effective manpower management from high management and respective head of department and flexibility in mode of simulation training ("lab-based" for isolation and general wards; "in-situ" for staff from ICU and AED with high intensity of work) reduced excessive stress from extra time for training.
iii. Inter professional simulation (IPS) enabled doctor, nurse, and supporting workers to strengthen core competencies of their own roles and understand functionalities of other disciplines under highly realistic controlled environment [7]. Situational awareness of the unexpected deterioration of patients under care, close-loop communication with teammates, assertiveness and mutual support in practicing doffing of PPE under buddy system and procedural guideline could be largely enhanced through IPS.
In a long term, strengthening resilience and well-being through simulation training may probably fulfill HCWs' needs of occupation health and safety, as well as transformation from work engagement to employee engagement reflected by positive change in vigor (enthusiastic, energetic and persistent despite setbacks), dedication (maintaining significant driveto goals), and absorption (concentrating on tasks with positive emotions) [15]. Future scientific studies, such as addressing occupational aspects of HCWs to predict psychological well-being and patient safety climate using structural equation models, could be a silver lining of COVID-19 pandemic in a favorable light of contemporary lifestyle medicine and positive occupational health psychology.