The coronavirus disease 2019 (COVID-19) pandemic resulted in a rapid influx of critically ill patients, necessitating adding intensive care unit (ICU) beds and redeploying non-ICU clinicians to critical care areas. New York City Health + Hospitals (NYC H+H) applied the Kern's Six Steps Curriculum Design framework to deploy a ventilator simulation course across the system to build preparedness for ventilator management in non-ICU providers. In this article we describe how our quality improvement initiative prepared the largest public hospital system in the country to take care of intubated COVID patients for the “second wave” by applying Kern's Six Steps. Through this description, we offer how applying a framework, like Kern's Six Steps, is a model that structures interventions for success and can be applied to future disaster preparedness educational strategies.

Audience:This case is meant for senior emergency medicine (EM) resident physicians as a preparatory tool for the American Board of Emergency Medicine Certifying Exam. However, it is applicable for EM residents at all levels of training. Introduction:Difficult conversations are an integral part of the practice of emergency medicine. Competent EM physicians routinely engage in challenging conversations with patients and their families (eg, delivering bad news, disclosing medical errors, providing death notifications).1 Despite their importance, communication skills are often not formally taught in residency training.2 Instead, learners frequently rely on role modeling to develop the skills necessary to navigate these difficult situations.3 Incorporating structured education and training around these challenging encounters has the potential to significantly enhance both learner preparedness and patient care.2,4,5. Educational Objectives:This Observed Structured Clinical Examination (OSCE) is intended to cover the topic of Difficult Conversations. The overarching educational goal of this case is to assess learners' communication skills, emotional responsiveness, and ability to facilitate a death notification conversation. Participants will be evaluated on their ability to communicate in an empathic, patient-centered manner while leading a difficult discussion. Successful participants will establish rapport, actively listen, disclose sensitive information clearly and compassionately, and respond appropriately to emotional reactions. By the end of the session, learners should be able to: (1) establish rapport with the patient's family by initiating introductions and creating a supportive environment, (2) assess the family's baseline understanding of the patient's condition by using open-ended questions and active listening to elicit their perspective, (3) communicate the patient's death clearly and compassionately, using concise, non-technical language, (4) demonstrate empathy by responding appropriately to emotional reactions, validating concerns, and addressing questions thoughtfully, and (5) provide closure to the conversation by summarizing key points, offering emotional support, and clarifying the next steps in the patient's care. Educational Methods:We designed a single-station OSCE focused on the delivery of a death notification. This format is aligned with the Difficult Conversations module of the newly implemented ABEM Certifying Exam, which emphasizes communication skills and emotional responsiveness in a challenging simulated clinical encounter. In this OSCE, the learner is presented with a brief case summary describing the unsuccessful resuscitation of a patient in cardiac arrest and is tasked with delivering the bad news to the patient's family. The family member is portrayed by a standardized participant who follows a structured script and provides standardized emotional and verbal cues. The examiner assesses learner performance using a detailed, behaviorally anchored checklist that includes both verbal and nonverbal communication skills. This OSCE structure mirrors the ABEM Certifying Exam to promote realism, consistency, and educational relevance. Research Methods:This simulation case was initially developed by three subject matter experts with backgrounds in EM and simulation-based education. To ensure clinical accuracy, coherence, and educational relevance, the case underwent a structured peer review process. Using the Simulation Scenario Evaluation Tool (SSET),6 a panel of three external reviewers evaluated the case and provided targeted feedback on elements such as case realism, scenario progression, clarity of learning objectives, and alignment with assessment metrics. Following peer review, the case was pilot-tested at two EM residency programs and a national EM academic conference. These pilot implementations aimed to evaluate the case's clarity, feasibility, and instructional design within authentic educational environments. During these sessions, faculty facilitators and learners engaged with case materials, including a standardized participant script, examiner overview, and critical actions checklist. Feedback from this beta testing phase guided revisions to enhance standardized actor prompts, case logistics, and assessment materials. Results:Expert reviewers reported strong agreement that the learning objectives of the simulation case were specific, measurable, action-oriented, relevant, time-bound, and appropriately aligned with the experience level of the intended learners. They also noted that the clinical context, scenario progression, and integrated critical actions effectively supported these learning objectives. Faculty facilitators expressed strong agreement that the accompanying case materials and resources offered adequate guidance to support independent implementation of the case at their own institutions. Learner feedback indicated that both the written and verbal instructions were easy to follow and that the experience was valuable for preparing them for the ABEM Certifying Exam. Discussion:This simulation case effectively met its educational goals and proved to be a useful resource for preparing learners for the Difficult Conversations module of the ABEM Certifying Exam. Facilitators gave high ratings across key areas, emphasizing the clarity and quality of the learning objectives, scenario flow, and supporting materials. Learners consistently noted that the case offered valuable practice in communication skills and emotional engagement. These results support the use of structured OSCEs within EM residency curricula. Through simulation, this case contributes to closing educational gaps, fostering standardization, and improving learner readiness for board certification. Topics:Death notification, delivering bad news, communication, difficult conversations, American Board of Emergency Medicine, Certifying Exam.

BACKGROUND:Patient safety science and debriefing approaches have historically tended to focus most heavily on Safety-I or "why things go wrong" and learning from unfavorable performance, root cause of adverse outcomes, and improvement opportunities learned from failures. Consequently, rich opportunities for analysis and learning from "why things go right," successful performance, and exploration of how systems succeed, adapt, and perform effectively regardless of outcome-Safety-II-are often underrepresented. METHODS:Open-access videos of healthcare debriefing were sought by searching Google and YouTube via search terms "healthcare debriefing," "healthcare debrief," "healthcare debriefing video," "healthcare debrief video," "healthcare debriefing example," "healthcare debrief example," "simulation debriefing," and "simulation debrief." Additionally, a search of major professional organization websites was utilized. Included videos were reviewed to score all utterances on the following: (1) phase of debriefing; (2) question or statement; (3) by facilitator or participant; (4) if utterance was neutral, related to positive performance/ "what went well" or negative performance/"what could be improved"; (5) if facilitator utterance was general or a follow-up, reflective utterance building upon previous discussion; (6) if participant utterances were general or specific reflective, insight offering comments; (7) all facilitator follow-up/ specific reflective type utterances were further analyzed and coded as exploration into Safety-I (e.g., exploration of why error occurred) or Safety-II (e.g., adaptability, variation, reproducing success) concepts. RESULTS:A review of open-access video examples of healthcare debriefing demonstrates disproportionate emphasis on Safety-I and highlights the opportunity for open-access examples of healthcare debriefing to include additional language and techniques that promote and role model inclusion of Safety-II discussion. CONCLUSIONS:While there is always room for improvement and we must all strive to do the best we can, we are missing a major opportunity to build resilience by Safety-II exploration into analyzing why things go positively. Those designing such instructional videos should intentionally include debriefing focused on both Safety-I and Safety-II aspects of performance, regardless of outcome, as they are both important, complimentary, and result in a more holistic understanding of improvement opportunities and success. Future study on the impact of Safety-II debriefing should focus on context-specific promotion of quality and patient safety, as well as impact on participant wellbeing and overall safety culture.

Healthcare debriefing is a cognitively demanding conversation after a simulation or clinical experience that promotes reflection, underpinned by psychological safety and attention to learner needs. The process of debriefing requires mental processing that engages both “fast” or unconscious thinking and “slow” intentional thinking to be able to navigate the conversation. “Fast” thinking has the potential to surface cognitive biases that impact reflection and may negatively influence debriefer behaviors, debriefing strategies, and debriefing foundations. As a result, negative cognitive biases risk undermining learning outcomes from debriefing conversations. As the use of healthcare simulation is expanding, the need for faculty development specific to the roles bias plays is imperative. In this article, we hope to build awareness about common cognitive biases that may present in debriefing conversations so debriefers have the chance to begin the hard work of identifying and attending to their potential detrimental impacts.

The COVID-19 pandemic necessitated rapid innovations in distance learning.1 Simulation is a valuable medical education strategy for learners to translate abstract knowledge to clinical application and can be facilitated remotely. This AM Last Page presents common challenges in delivering remote simulation, practical solutions, and unique opportunities afforded by this novel educational format.

Introduction A large-scale in situ simulation initiative on cardiac arrest in pregnancy was implemented across NYC Health + Hospitals. In situ simulation must be safely balanced with clinical conditions such as through application of no-go considerations or standardized reasons to cancel or postpone the simulation. Our objective is to describe our findings on the application of no-go considerations during this simulation initiative. Methods NYC Health + Hospitals/Simulation Center developed an in situ simulation program focused on cardiac arrest in pregnancy, implemented at 11 acute care facilities. The program's toolkit included no-go considerations for in situ simulation safety: situations prompting a need to cancel, reschedule, or postpone a simulation to ensure patient and/or staff safety. Results Data were collected from June 2018 through December 2019. The simulation sites reviewed the 13 established no-go considerations before each simulation event to assess if the simulation was safe to “go”. After the conclusion of the initiative, all data related to no-go considerations were analyzed. Two hundred seventy-four in situ simulations were scheduled and 223 simulations (81%) were completed. Fifty-one no-go events were reported, with 78% identifying a reason by category. Twenty-two percent did not report a reason or category. Four of the 13 suggested no-go considerations were not reported. Conclusions The no-go considerations framework promotes standardized and strategic scheduling of in situ simulation. Analysis of no-go consideration application during this system-wide initiative provides a model for the usage of tracking no-go data to enhance safety and inform future simulation planning.

Background:The last few years have seen an increased focus on diversity, equity, and inclusion (DEI) initiatives across organizations. Simulation has been used in varying degrees for teaching about DEI topics with emergency medicine; however, there are no established best practices or guidelines on this subject. To further examine the use of simulation for DEI teachings, the DEISIM work group was created as a collaboration between the Society of Academic Emergency Medicine (SAEM) Simulation Academy and the Academy for Diversity and Inclusion in Emergency Medicine (ADIEM). This study represents their findings. Method:This qualitative study was conducted using a three-pronged approach. Initial literature search was conducted followed by a call for submission of simulation curricula. These were then followed by five focus groups. Focus groups were recorded, transcribed by a professional transcription service, and then subjected to thematic analysis. Results:Data were analyzed and organized into four broad categories including Learners, Facilitators, Organizational/Leadership, and Technical Issues. Challenges within each of these were identified, as were potential solutions. Select pertinent findings included focused faculty development, a carefully planned approach that utilized DEI content experts and the use of simulation for workplace microaggressions or discriminations. Conclusions:There appears to be a clear role for simulation in DEI teachings. Such curricula, however, should be undertaken with careful planning and input from appropriate and representative parties. More research is needed on optimizing and standardizing simulation-based DEI curricula.

Objectives:Debriefing is an integral component of simulation education, and effective debriefing education is required to maintain effective simulation programs. However, many educators report financial and logistical barriers to accessing formal debriefing training. Due to limited educator development opportunities, simulation program leaders are often compelled to utilize educators with insufficient debriefing training, which can limit the impact of simulation-based education. To address these concerns, the SAEM Simulation Academy Debriefing Workgroup authored the Workshop in Simulation Debriefing for Educators in Medicine (WiSDEM), a freely available, concise, and ready-to-deploy debriefing curriculum with a target audience of novice educators without formal debriefing training. In this study, we describe the development, initial implementation, and evaluation of the WiSDEM curriculum. Methods:The Debriefing Workgroup iteratively developed the WiSDEM curriculum by expert consensus. The targeted level of content expertise was introductory. The curriculum's educational impact was assessed by surveying participants on their impressions of the curriculum and their confidence and self-efficacy in mastery of the material. Additionally, facilitators of the WiSDEM curriculum were surveyed on its content, usefulness, and future applicability. Results:The WiSDEM curriculum was deployed during the SAEM 2022 Annual Meeting as a didactic presentation. Thirty-nine of 44 participants completed the participant survey, and four of four facilitators completed the facilitator survey. Participant and facilitator feedback on the curriculum content was positive. Additionally, participants agreed that the WiSDEM curriculum improved their confidence and self-efficacy in future debriefing. All surveyed facilitators agreed that they would recommend the curriculum to others. Conclusions:The WiSDEM curriculum was effective at introducing basic debriefing principles to novice educators without formal debriefing training. Facilitators felt that the educational materials would be useful for providing debriefing training at other institutions. Consensus-driven, ready-to-deploy debriefing training materials such as the WiSDEM curriculum can address common barriers to developing basic debriefing proficiency in educators.

Debriefing is a critical element in healthcare, both in the clinical environment and in the simulation lab. Often, what is said at a debriefing is not recorded, leading to loss of critical data that could be used to inform future simulations, education, and systems improvement. In this perspective piece, we explain the powerful role that capturing debriefing data can have for identifying themes to improve learners’ knowledge and skills, as well as inform data-driven systems change and initiatives.

Background The Promoting Excellence and Reflective Learning in Simulation (PEARLS) Healthcare Debriefing Tool is a cognitive aid designed to deploy debriefing in a structured way. The tool has the potential to increase the facilitator’s ability to acquire debriefing skills, by breaking down the complexity of debriefing and thereby improving the quality of a novice facilitator’s debrief. In this pilot study, we aimed to evaluate the impact of the tool on facilitators’ cognitive load, workload, and debriefing quality. Methods Fourteen fellows from the New York City Health + Hospitals Simulation Fellowship, novice to the PEARLS Healthcare Debriefing Tool, were randomized to two groups of 7. The intervention group was equipped with the cognitive aid while the control group did not use the tool. Both groups had undergone an 8-h debriefing course. The two groups performed debriefings of 3 videoed simulated events and rated the cognitive load and workload of their experience using the Paas-Merriënboer scale and the raw National Aeronautics and Space Administration task load index (NASA-TLX), respectively. The debriefing performances were then rated using the Debriefing Assessment for Simulation in Healthcare (DASH) for debriefing quality. Measures of cognitive load were measured as Paas-Merriënboer scale and compared using Wilcoxon rank-sum tests. Measures of workload and debriefing quality were analyzed using mixed-effect linear regression models. Results Those who used the tool had significantly lower median scores in cognitive load in 2 out of the 3 debriefings (median score with tool vs no tool: scenario A 6 vs 6, p =0.1331; scenario B: 5 vs 6, p =0.043; and scenario C: 5 vs 7, p =0.031). No difference was detected in the tool effectiveness in decreasing composite score of workload demands (mean difference in average NASA-TLX −4.5, 95%CI −16.5 to 7.0, p =0.456) or improving composite scores of debriefing qualities (mean difference in DASH 2.4, 95%CI −3.4 to 8.1, p =0.436). Conclusions The PEARLS Healthcare Debriefing Tool may serve as an educational adjunct for debriefing skill acquisition. The use of a debriefing cognitive aid may decrease the cognitive load of debriefing but did not suggest an impact on the workload or quality of debriefing in novice debriefers. Further research is recommended to study the efficacy of the cognitive aid beyond this pilot; however, the design of this research may serve as a model for future exploration of the quality of debriefing.

Health SecurityVol. 20, No. S1 CommentaryOpen AccessCreative Commons licenseInnovations in Fatality Management During the COVID-19 PandemicInga Furuness, Madeline M. Tavarez, Meghan D. McGinty, Kim Mendez, Oliver Demree, Charles Aviles, Mohammed Salahuddin, Jennifer Coard, Jenna Mandel-Ricci, Suzanne Bentley, Eric Wei, Christine Flaherty, Manuel Saez, Mahendranath Indar, and Laura IavicoliInga FurunessAddress correspondence to: Inga Furuness, MPA, BSN, RN, Assistant Director of Emergency Management, NYC Health + Hospitals, 50 Water St, 2nd Floor, 206, New York, NY 10004 E-mail Address: furunesi@nychhc.orgInga Furuness, MPA, BSN, RN, is Assistant Director, Emergency Management, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Madeline M. TavarezMadeline M. Tavarez, MPA, CHEP; is Senior Director, Emergency Management Planning and Operations, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Meghan D. McGintyMeghan D. McGinty, PhD, MPH, MBA, was Director, Emergency Management, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Kim MendezKim Mendez, EdD, ANP, RN, is Senior Vice President/Corporate Chief Information Officer, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Oliver DemreeOliver Demree, BSN, is Associate Director, Emergency Management, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Charles AvilesCharles Aviles is Associate Director of Safety Management, NYC H+H/Lincoln, Bronx, NY.Search for more papers by this author, Mohammed SalahuddinMohammed Salahuddin, SSBB, CHEP, is Director, Emergency Management, NYC H+H/Queens, NY.Search for more papers by this author, Jennifer CoardJennifer Coard, LCSW, is Associate Director of Executive Administration, NYC H+H/Queens, NY.Search for more papers by this author, Jenna Mandel-RicciJenna Mandel-Ricci, MPH, MPA, is Senior Vice President, Healthcare Systems Resilience, Greater New York Hospital Association, New York City, NY.Search for more papers by this author, Suzanne BentleySuzanne Bentley, MD, MPH, FACEP, CHSE, is Medical Director of Simulation Center and Attending Physician Emergency Medicine, NYC H+H/Elmhurst, NY.Search for more papers by this author, Eric WeiEric Wei, MD, MBA, is Senior Vice President, Chief Quality Officer, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Christine FlahertyChristine Flaherty is Senior Vice President, Office of Facilities Development, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Manuel SaezManuel Saez is Assistant Vice President, Facilities Administration, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, Mahendranath IndarMahendranath Indar is Senior Director, Office of Facilities Development, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this author, and Laura IavicoliLaura Iavicoli, MD, FACEP, is Senior Assistant Vice President, Emergency Management, New York City Health + Hospitals (NYC H+H)/Central Office, New York City, NY.Search for more papers by this authorPublished Online:31 May 2022https://doi.org/10.1089/hs.2021.0154AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail IntroductionOf the innumerable challenges faced during the first surge of the COVID-19 pandemic, fatality management was among the most widely publicized. COVID-19 led to an unprecedented number of deaths in New York City—both in healthcare facilities and at home—taxing every aspect of the fatality management continuum. Inpatient healthcare facilities, medical examiner offices, and funeral homes faced excessive challenges finding adequate staffing, space, and supplies, which made it impossible to manage the workload with the existing processes. In response, New York City Health + Hospitals (NYC H+H) worked as an integrated healthcare system to develop and implement solutions to challenges related to resource management, staffing, workplace injuries, situational awareness, and the mental health of staff. These innovations can be used by other health systems to develop more robust fatality management capabilities in the future.NYC H + H is the largest municipal healthcare system in the United States, with more than 40,000 staff providing care to more than 1 million New Yorkers across 11 acute care hospitals, 5 postacute long-term care facilities, 7 diagnostic and treatment centers, and more than 70 community-based primary care sites. NYC H + H provides healthcare to a diverse population of patients regardless of insurance, immigration status, or ability to pay. Throughout the COVID-19 pandemic, NYC H + H has worked to provide care to a vulnerable population while navigating complex challenges with acquiring and managing critical resources including staff, space, and supplies.Mass Fatality Management PreparednessThe US Centers for Disease Control and Prevention defines the core capability of fatality management as: the ability to coordinate with other organizations ([eg, public health], law enforcement, healthcare, emergency management, and medical examiner/coroner) to ensure the proper recovery, handling, identification, transportation, tracking, storage, and disposal of human remains and personal effects; certify cause of death; and facilitate access to mental/behavioral health services to the family members, responders, and survivors of an incident.1Prior to the pandemic, coordination and planning efforts took place with key partners such as the New York City Office of the Chief Medical Examiner (OCME), which provided hospitals across New York City with the Biological Incident Fatality Surge Plan for Managing In- and Out-of-Hospital Deaths.2 NYC H + H also collaborated with the New York City Department of Health and Mental Hygiene and the New York City Emergency Management to stockpile essential fatality management supplies and identify infrastructure capabilities for morgue surge space. From December 2018 to March 2019, NYC H + H assembled an internal planning committee of emergency managers, morgue directors, facility managers, security, and clinicians from its 11 hospitals to identify, plan, and coordinate processes for mass fatality operations in accordance with the guidance provided by the OCME Biological Incident Fatality Surge Plan.2 This effort was part of the 2018-2019 Hospital Preparedness Program network initiatives,3 a cooperative agreement funded by the Assistant Secretary for Preparedness and Response. The committee's goals were to: Confirm current morgue capacity within NYC H+H's 11 hospitalsDetermine space and infrastructure resources necessary to accommodate Body Collection Point (BCP) assets at each of the 11 hospitalsUse an electronic data gathering application to document BCP information should these assets need to be deployed across the cityDevelop an incident response guide within the electronic incident command system to reflect the 2016 OCME Biological Incident Fatality Surge Plan2Despite the extensive intra-agency planning that took place prior to COVID-19, the elasticity of the fatality management system across New York City had never been exercised or tested to the magnitude COVID-19 demanded. Since the beginning of the pandemic, NYC H + H has worked with other city agencies to rapidly strengthen the fatality management system to support the ongoing crisis and prepare for future citywide mass fatality incidents.SpaceOne of the most pressing fatality management concerns during COVID-19 pandemic surges has been space. In early March 2020, New York City Emergency Management began deploying BCPs to hospitals and postacute facilities in need of surge morgue space. Although a BCP could be any space where decedents are stored in a mass fatality incident, New York City used refrigerated trailers, which are commonly used to extend mortuary space. On March 21, 2020, New York City Emergency Management deployed the first BCP in New York City.4 Two weeks later, at the height of the pandemic, 83 BCPs were deployed throughout the city, presenting numerous logistical and operational challenges. Fatality management plans developed before COVID-19 had envisioned that hospitals would manage one BCP at a time. Because of delays in citywide systems, some hospitals were forced to house multiple BCPs onsite at once. Determining the location for multiple onsite BCPs proved to be a challenge and emphasized the need to plan for the placement of more than a single BCP, should the need arise. Unlike internal morgues, BCPs do not have predetermined spaces for decedents. For example, fixed morgues have labeled individual spaces. During the first wave of COVID-19, temporary shelves were installed that helped maintain organization. However, the ongoing need to rapidly construct shelves was challenging. An ideal solution would be supplemental morgue space specifically designed as such, akin to the medical ambulance buses emergency medical services use to respond to mass casualty incidents.Situational AwarenessThe paper-based documentation process used in morgues prior to the pandemic was cumbersome and could not provide key situational awareness metrics, such as real-time decedent census, location, and planned disposition. To gain real-time information and simplify mortuary logistics, NYC H+H's systemwide Office of Emergency Management worked with electronic medical record (EMR) information technology leads, site emergency managers, and morgue directors to leverage the electronic medical record system for situational awareness of fixed and surge morgue capacity. The team created an electronic morgue flowsheet in a virtual unit, modeled after a clinical unit (Figure 1). They then developed a dashboard from the flowsheet data that illustrated, among other data points, the decedent location, time in morgue, hours since death, and planned disposition (Figure 2).Figure 1. Mortuary documentation flowsheet in patient electronic medical record. Note: No real patient data were used in this figure; only example data for demonstration.Figure 2. Mortuary Situational Awareness Dashboard. Note: No real patient data were used in this figure; only example data for demonstration. Actual dashboard only viewable by mortuary staff caring for those decedents.Using the EMR for morgue operations solved a number of logistical problems. The fields in the flowsheet autopopulate to the documents required by funeral homes or the medical examiner's office, simplifying paperwork. Death certificates are scanned into the EMR for easy interdepartmental access. Using the EMR especially enhanced situational awareness through a color-coded field denoting time spent in morgue. Where appropriate and possible, fields in the flowsheet have selectable responses instead of free text, so data points are extractable and can generate reports in a dashboard format for enhanced decisionmaking.StaffingBetween March and June 2020, New York City hospitals experienced severe staffing shortages, and fatality management operations were no exception. During this period, morgues at hospitals and postacute care facilities saw a rapid surge in decedents. On March 22, 2020, New York City reported 63 deaths attributed to coronavirus.5 Eight weeks later, that number had risen to 15,888 cumulative deaths (Figure 3). The NYC H + H systemwide logistics section activated emergency contracts to supply temporary mortuary technicians and worked to rapidly cross-train and redeploy staff with transferrable skills. For example, patient transport personnel were reassigned to assist with transporting decedents to BCPs, while doctors whose specialty was not currently impacted by patient surge processed death certificates. One barrier to the effectiveness of reassigning staff was training. During the first surge of COVID-19, just-in-time training took place; to maximize resilience, future planning should preidentify surge staff and build the infrastructure to pretrain or rapidly train staff.Figure 3. Daily confirmed and probable COVID-19-related deaths in New York City from February 29, 2020, to August 5, 2021. Data source: New York City Department of Health and Mental Hygiene.6Mortuary staff also reported an increase in injuries while performing an unprecedented volume of work and the unfamiliar task of moving and handling decedents in BCPs. To address mortuary staff injuries associated with a high volume of heavy lifting in a complex and potentially unfamiliar environment, NYC H + H developed a toolkit to rapidly train staff on ergonomic principles for lifting and moving decedents to and within a BCP. The toolkit includes a training video that demonstrates proper lifting and moving techniques and an educational booklet with an algorithm to help staff determine the safest way to move a decedent given different situations and equipment available. The algorithm has a tiered set of recommendations that includes keeping the heaviest decedents in the fixed morgue if possible, using a lift if available, and using friction-reducing devices like emergency medical service-style slide boards and slip sheets. To develop this toolkit, Emergency Management conducted site visits, talked to staff about the challenges they experienced, and enlisted the help of an ergonomist. Involving mortuary staff and a subject matter expert were key components of this intervention's success, as was ensuring that the content of the training was flexible enough to accommodate different situations mortuary staff might face in a mass fatality incident.SuppliesDuring the pandemic, essential supplies were limited, and processing resource requests promptly was essential to maintain operations. Initially, resource requests were submitted via phone or email and added to an Excel spreadsheet for tracking. This manual process made it difficult to manage, track, and provide status updates on resource requests, particularly those related to fatality management. NYC H + H leveraged our information technology department's day-to-day service delivery platform to create an electronic resource request process (Figure 4) and created user guides that outlined step-by-step processes for entering and managing requests. The logistics section decedent management unit leader oversaw requests. To address supply shortages, resources were balanced and allocated across the health system to meet acute demand. For example, when one acute care hospital ran out of human remains pouches, they placed a request in the service delivery platform, and another hospital with surplus sent over their available supply. Sharing supplies between sites within the system has been a crucial aspect of successful resource management for COVID-19.Figure 4. Digital resource request form on service delivery platform.Mental Health ServicesFamilies of the deceased faced exceptional difficulty navigating the process of putting their loved ones to rest during the first surge of the pandemic. Additionally, those who lost loved ones had limited opportunity to seek social support, an important factor in bereavement.7 Funeral costs skyrocketed, and many families could not afford to have a funeral home burial. Family support teams were assembled to assist families coordinate the burial of their loved one, connect them to funding sources available to decrease the financial burden, and provide psychological support. The teams varied but often consisted of psychiatry, guest relations, and social work staff members whose departments experienced decreased patient volume due to the pandemic. These teams provided key family support and were essential in improving fatality management operations.Fatality management staff faced very stressful conditions as they worked to manage the surge of decedents. In additional to the emotional stress, workers contended with a dramatic increase in work volume and rapidly changing national guidance regarding personal protective equipment. To address the emotional and psychological toll associated with providing such service, NYC H + H significantly expanded its systemwide Helping Healers Heal (H3) program. H3 is a peer support program that was originally initiated to acknowledge the burden healthcare delivery places on healthcare workers themselves and to work to combat “second victim syndrome.”8 This syndrome is the trauma some healthcare providers experience after an adverse patient outcome or practice error, which manifests as psychological (shame, guilt, anxiety, grief, depression), cognitive (compassion dissatisfaction, burnout, secondary traumatic stress), and/or physical reactions. The overarching goal of the program is to provide support and bear witness to, validate, and share experiences. H3 provides a psychological safety net for healthcare workers and has never been as crucial as during the struggles of providing care during the COVID-19 pandemic.The H3 program includes 3 tiers aimed at addressing second victim syndrome. The first tier involves training all staff about second victim syndrome, the stress continuum, and the importance of debriefing after difficult cases or anytime someone is struggling. Debriefing is a reflective, facilitated discussion about an event, in this case inclusive of any and all aspects of the COVID-19 crisis. H3 is led by peer support champions, the second tier of the program, who are trained to provide psychological support, lead individual or group debriefings, and identify stages of the stress continuum. The third tier involves training peer support champions to recognize behavioral cues indicative of mental health issues and make expedited referrals to trained mental health professionals to provide critical and timely intervention. Overall, the H3 program aims to ensure that staff do not feel alone in their unique experiences as healthcare workers, and that all staff have access to crucial mental health resources. Staff found it cathartic to talk to someone about their experiences.ConclusionThe COVID-19 pandemic has tested the ability of healthcare system to manage massive surges in decedents. NYC H + H adapted to this challenge by supplementing fixed morgue space, augmenting and cross-training personnel to expand staffing capacity, sharing supplies across the health system, leveraging information technology systems for resource management and situational awareness, and offering psychological support for involved staff. The innovations that enabled NYC H + H to manage the decedent surge were a result of interdepartmental collaboration, which proved to be a key principle of success that will inform future emergency response efforts.AcknowledgmentsThe authors wish to acknowledge and thank Jose Calderon, Curtis Ritchens, Curtis Ritchens Jr., Dheeraj Mathew, Guillermo Lozada, Melvin Morgan, Nicole Decarmine, David Lowe, Eric Denham, Kenneth Williamson, Michaelo Vega, Mike Montague, Hector Lopez, Lawrence Ohene-Asa, Ramel Simmons, Rashad Smith, Zaire Bowen, Aapri Cummings, Aaron Riley, Alex Guillaume, Alicia Noel, Alix C. Vernet, Andrew Brown, Beatrice Gilles, Breanna Marcus, Carol Mosley, Christopher Giddings, Clena Fleurelus, Dalliant Edouard, Daniel A. Mitchell, Dave Campbell, David Tejada Jr., Dennis Flores, Derrick Weaver, Dilson L. Pichardo, Doanhe Yludora Matthews, Dorian Browne, Edward J. Rodriguez, Eric E. Anderson, Eroline Stewart-Billingy, Estefani Heredia Arana, Eucharia A. Iwuchukwu, Eva Gallimore, Faye Escourse, Genli M. Marte, Haoua Traore, Ikeda Romeo, Jason Shine, Jean M. Edmond, Jeffrey Bradshaw Jr., Jonathan Clemons, Jose Holgun, Jose R. Gonzalez, Joseph Jean Marie, Joseph Reis, Joshua Morgan, Keifer Enniss, Keriesha McDonald, Knolly St. Lewis, Malaika Morris, Marc Arthur, Marcia Moe, Marcos Chavez, Marie Sabine Felix, Marsha Martins, Michere Brittlebank, Mustapha Azeez, Natasha C. Francis, Noel M. Scarlett, Omari Daniels, Raymond Hill, Richard James, Richard Rios, Rita Frederick, Roger De Peza, Ronald Swan, Sabrina De Los Santos, Sagine Laroche, Sandra S. Morency, Shandeka Hunter, Sharis Jn Baptise, Stemela Jean, Tajhare L. Henry, Terell Alexander, Trinity Galindo, Wilbert Harris Jr., Wyane Ingram-Harrison, Alvin Figueora, Sigourney Slocumb-Warlick, Victor Rodriguez, Danielle Coles, Melonee Winter, T'iara-Ruby Damon, Angel Rosario, Ahaila Mohabir, Andres Thomas, Anthony Harper, Anthony Rodriguez, Ashley Digirolamo, Bethsilda Watson, Cachita Smith, Carlos Rios, Charles Perry, Daniel Vaught Jr., Eddie Alicea, Evert Gonzalez, Farooq Mirza, Gabrielle Johnson, Gregory Rios, Hazel Mattei, Jose Nieves, Kymeshia Heyliger, Lakeisha Smith, Marquis Brown, Narobie Jenkins, Neil Singh, Raelle Watts, Royce Stephens, Shruti Dimri, Stephen Jackson, Travis Lynch, Tyler Chan, and Christopher Thompson for their tireless dedication and heroic work in caring for the New Yorkers we lost during the COVID-19 pandemic. We also thank the operations, incident command, admitting, facilities, and H3 teams at all NYC H + H sites. Finally, we thank Andrea Cohen and Catherine Patsos for their insight and review of this article.References1. US Centers for Disease Control and Prevention (CDC). Public Health Emergency Preparedness and Response Capabilities: National Standards for State, Local, Tribal, and Territorial Public Health. Updated January 2019. Atlanta, GA: CDC; 2018. Accessed August 4, 2021. https://www.cdc.gov/cpr/readiness/00_docs/CDC_PreparednesResponseCapabilities_October2018_Final_508.pdf Google Scholar2. The City of New York Office of the Chief Medical Examiner (OCME). Biological Incident Fatality Surge Plan for Managing In- and Out-of-Hospital Deaths. New York: OCME; 2016. Accessed February 24, 2022. https://www.documentcloud.org/documents/6827234-2016-Biological-Incident-Fatality-Surge-Plan-for Google Scholar3. Public Health Emergency. Hospital Preparedness Program (HPP). Page last reviewed September 23, 2021. Accessed March 23, 2022. https://www.phe.gov/Preparedness/planning/hpp/Pages/default.aspx Google Scholar4. Greater New York Hospital Association (GNYHA). GNYHA Lessons Learned/Preparation for Future COVID-19 Waves. Topic: Fatality Management in New York City Hospitals. New York: GNYHA; 2020. Accessed August 4, 2021. https://www.calhospitalprepare.org/sites/main/files/file-attachments/lessonslearned_fatalitymanagement.pdf Google Scholar5. New York City Department of Health and Mental Hygiene. 2019 novel coronavirus (COVID-19) SurvEpi Branch daily data summary. Published March 22, 2020. Accessed August 4, 2021. https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-daily-data-summary-deaths-03222020-1.pdf Google Scholar6. New York City Department of Health and Mental Hygiene (DOHMH). GitHub. New York, NY; 2020. Updated December 13, 2020. Accessed August 4, 2021. https://github.com/nychealth/coronavirus-data/blob/master/trends/data-by-day.csv Google Scholar7. Burke LA, Neimeyer RA, Young AJ, Bonin EP, Davis NL. Complicated spiritual grief II: a deductive inquiry following the loss of a loved one. Death Stud. 2014;38(1-5):268-281. Crossref, Medline, Google Scholar8. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726-727. Crossref, Medline, Google ScholarFiguresReferencesRelatedDetails Volume 20Issue S1Jun 2022 Information© Inga Furuness et al., 2022; Published by Mary Ann Liebert, Inc.To cite this article:Inga Furuness, Madeline M. Tavarez, Meghan D. McGinty, Kim Mendez, Oliver Demree, Charles Aviles, Mohammed Salahuddin, Jennifer Coard, Jenna Mandel-Ricci, Suzanne Bentley, Eric Wei, Christine Flaherty, Manuel Saez, Mahendranath Indar, and Laura Iavicoli.Innovations in Fatality Management During the COVID-19 Pandemic.Health Security.Jun 2022.S-90-S-96.http://doi.org/10.1089/hs.2021.0154creative commons licensePublished in Volume: 20 Issue S1: May 31, 2022Online Ahead of Print:April 22, 2022KeywordsCOVID-19Fatality managementHospital preparedness/responseSecond victim syndromeEpidemic management/responseOpen accessThis Open Access article is distributed under the terms of the Creative Commons License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.PDF download

Background During the COVID-19 pandemic, a substantial number of emergency health care workers (HCWs) have screened positive for anxiety, depression, risk of posttraumatic stress disorder, and burnout. The purpose of this qualitative study was to describe the impact of COVID-19 on emergency care providers' health and well-being using personal perspectives. We conducted in-depth interviews with emergency physicians, emergency medicine nurses, and emergency medical services providers at 10 collaborating sites across the United States between September 21, 2020, and October 26, 2020. Methods We developed a conceptual framework that described the relationship between the work environment and employee health. We used qualitative content analysis to evaluate our interview transcripts classified the domains, themes, and subthemes that emerged from the transcribed interviews. Results We interviewed 32 emergency HCWs. They described difficult working conditions, such as constrained physical space, inadequate personnel protective equipment, and care protocols that kept changing. Organizational leadership was largely viewed as unprepared, distant, and unsupportive of employees. Providers expressed high moral distress caused by ethically challenging situations, such as the perception of not being able to provide the normal standard of care and emotional support to patients and their families at all times, being responsible for too many sick patients, relying on inexperienced staff to treat infected patients, and caring for patients that put their own health and the health of their families at risk. Moral distress was commonly experienced by emergency HCWs, exacerbated by an unsupportive organizational environment. Conclusions Future preparedness efforts should include mechanisms to support frontline HCWs when faced with ethical challenges in addition to an adverse working environment caused by a pandemic such as COVID-19.

BACKGROUND:Cardiac arrest resuscitation requires well-executed teamwork to produce optimal outcomes. Frequency of cardiac arrest events differs by hospital location, which presents unique challenges in care due to variations in responding team composition and comfort levels and familiarity with obtaining and utilizing arrest equipment. The objective of this initiative is to utilize unannounced, in situ, cardiac arrest simulations hospital wide to educate, evaluate, and maximize cardiac arrest teams outside the traditional simulation lab by systematically assessing and capturing areas of opportunity for improvement, latent safety threats (LSTs), and key challenges by hospital location.METHODS:Unannounced in situ simulations were performed at a city hospital with multidisciplinary cardiac arrest teams responding to a presumed real cardiac arrest. Participants and facilitators identified LSTs during standardized postsimulation debriefings that were classified into equipment, medication, resource/system, or technical skill categories. A hazard matrix was used by multiplying occurrence frequency of LST in simulation and real clinical events (based on expert opinion) and severity of the LST based on agreement between two evaluators.RESULTS:Seventy-four in situ cardiac arrest simulations were conducted hospital wide. Hundreds of safety threats were identified, analyzed, and categorized yielding 106 unique latent safety threats: 21 in the equipment category, 8 in the medication category, 41 in the resource/system category, and 36 in the technical skill category. The team worked to mitigate all LSTs with priority mitigation to imminent risk level threats, then high risk threats, followed by non-imminent risk LSTs. Four LSTs were deemed imminent, requiring immediate remediation post debriefing. Fifteen LSTs had a hazard ratio greater than 8 which were deemed high risk for remediation. Depending on the category of threat, a combination of mitigating steps including the immediate fixing of an identified problem, leadership escalation, and programmatic intervention recommendations occurred resulting in mitigation of all identified threats.CONCLUSIONS:Hospital-wide in situ cardiac arrest team simulation offers an effective way to both identify and mitigate LSTs. Safety during cardiac arrest care is improved through the use of a system in which LSTs are escalated urgently, mitigated, and conveyed back to participants to provide closed loop debriefing. Lastly, this hospital-wide, multidisciplinary initiative additionally served as an educational needs assessment allowing for informed, iterative education and systems improvement initiatives targeted to areas of LSTs and areas of opportunity.

Introduction According to the Institute of Medicine, 98,000 annual deaths are caused by preventable errors. Speaking up about patient safety or professionalism concerns when they arise allows medical staff to move from bystanders to active participants in the prevention of patient harm. This study assesses the current climate around speaking up for patient safety and unprofessional behavior by Emergency Medicine (EM) resident physicians and compares it to previously published data from other specialties. Methods A multi-site, descriptive, cross-sectional design was utilized based on previously published Speaking Up Climate Safety and Professionalism Scales. EM residents at 3 programs in the United States were surveyed, and their responses were compared to previously published responses from other specialties. Results 102 residents from 3 EM residency programs responded to the survey, yielding a response rate of 54.3%. Responses on the survey fell close to the neutral response (3 on a 5-point Likert scale) on all measures, indicating opportunity for improvement. However, EM responses were significantly more favorable than responses from other specialties on several questions. Conclusion This assessment demonstrates room for improvement on speaking up behaviors among EM residents but also suggests that unique features of EM may contribute to a relatively more positive speaking up climate compared to other specialties, which may inform strategies to increase speaking up behaviors. For example, deliberate practice of situations requiring strong teamwork and strategies to reduce traditional hierarchies may help emulate the climate that tends to occur organically in EM.

Introduction: In 2017, approximately 295,000 women died during and immediately following pregnancy and childbirth worldwide, with 94% of these deaths occurring in low-resource settings. The Dominican Republic (DR) exhibits one of the highest maternal mortality ratios in the region of Latin America and the Caribbean despite the fact that 99% of registered births in the country are reportedly attended by a skilled birth attendant. This paradox implies that programs to support healthcare worker knowledge and skills improvement are vital to improving maternal health outcomes in the DR. Helping Mothers Survive (HMS) is a provider training program developed by Jhpiego and global partners. The goal of HMS is to combat maternal mortality by contributing to quality improvement efforts that reinforce maternal health skills of local healthcare workers. Methods: An international, multisectoral group of stakeholders collaborated in the implementation of two HMS curricula, Bleeding After Birth (BAB) and pre-eclampsia & eclampsia (PE&E). Demographic information as well as pre- and post-training knowledge scores were recorded for each participant. Knowledge score improvement was assessed in order to support effectiveness of the program on knowledge acquisition of healthcare workers. Results: Three hundred and twenty healthcare workers participated in the HMS training workshops between October 2016–August 2020. Of the 320 participants, 132 were trained as master trainers. The majority of participants identified as attending physicians, followed by residents/interns, nurses, students, and “other.” A significant improvement in knowledge scores was observed for both the BAB and PE&E curricula, with a 21.24 and 30.25% change in average score (pre- to post-test), respectively. In response to COVID-19 pandemic restrictions, flexibility of the local team led to a PE&E virtual training pilot workshop in August 2020. Discussion/Conclusions: Simulation-based training improved the knowledge levels of healthcare workers for both HMS curricula. These results suggest that simulation-based workshops have an impact on knowledge acquisition and skills of healthcare workers immediately following training. For the PE&E curriculum, no significant difference in knowledge acquisition was observed between in-person and virtual training sessions. The ongoing pandemic poses challenges to program implementation; however, these preliminary results provide evidence that conducting virtual workshops may be a viable alternative to in-person training.

INTRODUCTION:Treatment of acute ischemic stroke is challenging because it requires prompt management, interdisciplinary collaboration, and adherence to specific guidelines. This resource addresses these challenges by providing in situ simulated practice with stroke codes by practicing clinicians at unannounced times.METHODS:An emergency department team was presented with a 55-year-old simulated patient with speech difficulty and right-sided weakness. The team had to assess her efficiently and appropriately, including activating the stroke team via the hospital paging system. The stroke team responded to collaboratively coordinate evaluation, obtain appropriate imaging, administer thrombolytic therapy, and recognize the need for thrombectomy. Learners moved through the actual steps in the real clinical environment, using real hospital equipment. Upon simulation completion, debriefing was utilized to review the case and team performance. Latent safety threats were recorded, if present. Participants completed an evaluation to gauge the simulation's effectiveness.RESULTS:Six simulations involving 40 total participants were conducted and debriefed across New York City Health + Hospitals. One hundred percent of teams correctly identified the presenting condition and assessed eligibility for thrombolytic and endovascular therapy. Evaluations indicated that 100% of learners found the simulation to be an effective clinical, teamwork, and communication teaching tool. Debriefing captured several latent safety threats, which were rectified by collaboration with hospital leadership.DISCUSSION:Impromptu, in situ simulation helps develop interdisciplinary teamwork and clinical knowledge and is useful for reviewing crucial times and processes required for best-practice patient care. It is particularly useful when timely management is essential, as with acute ischemic stroke.