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Year : 2023  |  Volume : 17  |  Issue : 2  |  Page : 195-204

Formulating interprofessional anesthesiology and operating room clinical management pathway during COVID-19 pandemic using experiential learning theory in a university hospital in Saudi Arabia

1 Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University; Anesthesiology Services Section, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
2 Department of Nursing, Faculty of Medicine, King Abdulaziz University Hospital; Clinical Skills and Simulation Center, Vice-Presidency of Development, King Abdulaziz University, Jeddah, Saudi Arabia
3 Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University; Anesthesiology Services Section, King Abdulaziz University Hospital; Department of Nursing, Faculty of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
4 Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University; Anesthesiology Services Section, King Abdulaziz University Hospital; Clinical Skills and Simulation Center, Vice-Presidency of Development, King Abdulaziz University, Jeddah, Saudi Arabia

Correspondence Address:
Abdulaziz M A. Boker
Consultant and Professor, Department of Anesthesia and Critical Care, Director, Clinical Skills and Simulation Center, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia, P.b. Box 80215, Jeddah – 21589
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sja.sja_480_22

Rights and Permissions
Date of Submission01-Jul-2022
Date of Decision05-Jul-2022
Date of Acceptance10-Jul-2022
Date of Web Publication10-Mar-2023


As the number of COVID-19 cases is rapidly increasing internationally, management, recommendations and guidelines of COVID-19 are rapidly evolving and changing. Formulating local clinical management policies among institutions adopting these recommendations is vital to staff as well as the patients' safety. Also, training multidisciplinary teams on these policies is an important, yet challenging, part of the process. The purpose of this paper is to present the process that has been followed to formulate COVID-19-specific response anesthesiology and operating room (OR) policies at King Abdulaziz University Hospital, by applying David A. Kolb's experiential learning theory during simulation-based training. This project had a total of six simulation-based sessions (four simulation scenarios and two clinical drills) designed to test the efficacy and efficiency of the then current practice in the hospital, facing the COVID-19 pandemic. Qualitative data analysis was completed using qualitative thematic data analysis. To apply experiential Kolb's theory, session's checklist (two raters per session), outcomes, and participants' feedback to develop and improve clinical management pathway in the department were used. The 12 reports and participants' feedback highlighted three main areas for improvement. These are Personal Protective Equipment implementation, team dynamics, and airway management. This process then guided in creating a new understanding of the multidisciplinary clinical management pathway, in addition to enhancing viability of the current practice and clinical management guidelines and protocols, which were already established and adapted at the hospital before the COVID-19 pandemic crisis. The alignment with Kolb's experiential theory helped formulate anesthesiology and OR effective clinical management pathway has been demonstrated. Applying experiential learning theory by a clinical institute using interprofessional, multidisciplinary simulations and clinical drills can guide the process of formulating clinical management pathways during pandemic outbreaks.

Keywords: COVID-19, experiences, experiential learning, framework, Kolb's theory, multidisciplinary, outbreaks, simulation, teams

How to cite this article:
Bahaziq W, Noaman N, AlHazmi A, Tayeb B, Boker AM. Formulating interprofessional anesthesiology and operating room clinical management pathway during COVID-19 pandemic using experiential learning theory in a university hospital in Saudi Arabia. Saudi J Anaesth 2023;17:195-204

How to cite this URL:
Bahaziq W, Noaman N, AlHazmi A, Tayeb B, Boker AM. Formulating interprofessional anesthesiology and operating room clinical management pathway during COVID-19 pandemic using experiential learning theory in a university hospital in Saudi Arabia. Saudi J Anaesth [serial online] 2023 [cited 2023 Mar 27];17:195-204. Available from:

  Introduction Top

As of March 11, 2020, the World Health Organization (WHO) officially announced the Coronavirus outbreak as a pandemic.[1],[2] A pandemic is a disease outbreak that spreads across countries—wide geographic area—at the same time. Dr. Tedros Adhanom Ghebreyesus, Director-General of WHO, said that he was “deeply concerned” by the “alarming levels of inaction.”[1] WHO affirmed that the world nations have to take “urgent and aggressive action” to reverse the outbreak's course.[2]

Based on these recommendations, the Saudi Arabian Ministry of Health (MOH) has taken operational movements to provide guidance and information to be followed by health-care workers (HCWs) during this crisis. The first case of COVID-19 in the Kingdom of Saudi Arabia was reported on March 2, 2020. This was followed by immediate actions and precautions taken by the country, including the temporary suspension of Umrah (Islamic sites ritual visitation), all travel, and social gatherings. Moreover, the MOH announced that everybody should practice heightened self-responsibility during this time.[3] Therefore, it became essential to provide a framework to prepare the Department of Anesthesia and Critical Care at King Abdulaziz University Hospital (KAUH) to develop a comprehensive care plan for COVID-19 response.

To develop such a plan, the experiential learning theory of David A. Kolb was applied, which is a fundamentally different view of the learning process, using simulation-based interventions.[4],[5] Experiential learning represents behavioral theories of learning based on an empirical epistemology.

The cooperation with the Clinical Skills and Simulation Centre (CSSC) was crucial to plan, achieve, and overcome the challenges with the clinical institute and departmental pathways and policies for the COVID-19 response governing protocol. Training the operating room (OR) multidisciplinary teams can constitute a significant challenge especially during a crisis. On March 19, 2020, the COVID-19 Crisis Plan Committee at the Department of Anesthesia and Critical Care was established to prepare for the pandemic response. Thereafter, the KAUH COVID-19 Committee was established on March 24, 2020. On the same day, the KAUH committee decided to limit the number of OR to 5 functioning ORs out of 20 ORs in total.

Hence, the COVID-19 Crisis Response Plan Committee at the Department of Anesthesia and Critical Care has divided the department staff into two groups; alternating each week to decrease the potential exposure and COVID-19 transmission between the two teams. On April 9, 2020, airway team was established across the hospital. Other administrative measures were implemented, such as N95 masks fitting test, acquiring Personal Protective Equipment (PPE),[6] mandating PPE courses, and formulation of various clinical guidelines for ORs and airway management for suspected or confirmed COVID-19 cases.

The first PPE course for HCWs was held on March 15, 2020. On the following day, first, clinical simulation scenario series was started. The aim of the simulation-based sessions, clinical simulation/clinical drills, was to begin a sequence of clinical cases using Kolb's Experiential Theory as a continuous process to evaluate and improve the existing framework of the Department of Anesthesia and Critical Care's COVID-19 response protocols that can deliver a department-centered and a comprehensive management for the Coronavirus pandemic and to initiate and strengthen the collaboration with other departments.

Up until the time of writing this paper, only suspected, but no confirmed, COVID-19 patients have required surgery at KAUH. This is expected to change shortly as the number of cases is increasing globally and nationally, and more COVID-19 patients present to the hospital every day. This study is aimed at describing the implementation of experiential learning theory to create clinical management pathways at the Department of Anesthesiology and Critical Care at KAUH. This was achieved through the transformation of experiences and knowledge during the simulation and drill sessions organized. The continuity of creating awareness and expertise throughout training sessions can help create a pathway for clinical management during the COVID-19 pandemic crisis.

  Methods Top

This project included a total of six simulation-based sessions: four clinical simulations, and two clinical drills that took place in the period between March 16, 2020 and April 23, 2020 [Figure 1]. The sessions were designed to test the effectiveness and efficiency of the current practices in the hospital in response to the COVID-19 pandemic and to use feedback to improve clinical practice.
Figure 1: Simulation and drills timeline and location

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The project was guided by Kolb's experiential learning theory. This theory was chosen to conduct the project, as it allows instructors to be active partners in the learning process, facilitate group activities and interactions, and use knowledge acquired through such methods as simulation and drills. Besides, the theory provides a framework for interprofessional education research, followed by, abstract conceptualization, a concept of critical thinking based on clinical results, which have been reported to the departmental meeting to implement changes in clinical pathways and start protocols for the odds result with the OR director. By the subsequent session, the experiential cycle was followed by active experimentation, with all the newly developed clinical guidelines being implemented.

The cases are described in detail in [Table 1] and [Table 2]. The sessions' checklist was inspired and developed based on COVID-19 induction in the operation theaters at Sir Charles Gairdner Hospital, Perth, Australia.[7] They were categorized into six main subsections as a tool to monitor performance during the simulation-based session, with more than one participant involved [Table 3]. The checklist served as a tool to provide a formative feedback to gain insight and assess the feasibility or practicality of a new approach for broader implementation in the hospital and departmental clinical pathways; guide the discussion with the participants during the debriefing after each session (simulation scenario/clinical drill), and identify areas of strength and/or weakness.
Table 1: Summary of the clinical simulation scenarios

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Table 2: Summary of the clinical drills

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Table 3: Checklist for simulation and clinical drills

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The checklist provides the raters with the options to place a checkmark in the cell corresponding with their answers (Yes/No/Not Applicable). Two instructors/raters per session were observing the performance of the participants and each filled in the checklist independently. The raters did not participate in the simulation-based sessions (simulation scenario/clinical drill) as they were observing the performance of the participating team. The raters were tasked to evaluate six areas during the simulation namely: (1) room preparation, (2) staff preparation, (3) early patient assessment, (4) preparation for drugs and airway management, (5) donning procedures and (6) doffing practices.

At the end of the scenario, a round table debriefing with instructors/raters was conducted. Participants were given equal chances to express their feelings and thoughts about the experience. During the debriefing, the participants were first asked, “What was the simulation about? And why is it important?,” to navigate through their thoughts and concerns, in addition to expectations.

All comments, debriefing notes, and discussion were noted and documented throughout the study. This process involved the fragmentation of data to allow for conceptualization beyond the obvious. Using open, selective, and theoretical coding processes was performed to conceptualize possible links between categories and to move data analysis beyond the descriptive level. After each session, the documented findings were used to modify the hospital procedures between different sessions. These modifications were incorporated in the following sessions for training and system testing.

Data collection procedures and analysis

A total of six simulation-based sessions were completed (four clinical simulations and two clinical drills) had been implemented. Each session was rated by two independent raters. A total of 12 checklists (2 per session) were collected, where each item was scored as Yes/No/Not Applicable (NA) depending on team completion of the given tasks. The sum of the scores given for each subset of skills (room preparation, staff preparation, early patient assessment, donning, preparation for drugs and airway management, and doffing) and the percentage of completion of the possible marks were presented in graphical form.

Qualitative data analysis was performed from observations aided by the checklist, group discussions, and individual interviews during the debriefing. Furthermore, the agreement and variation among raters were analyzed and presented at the departmental meeting during the groups' discussion.

  Results Top

Characteristics of raters and participants

Six simulation-based sessions were conducted with a total of 81 participants [Table 4]. Twelve checklists were collected from the raters. The findings from the checklists are illustrated in [Supplementary 1] and [Supplementary 2].
Table 4: Characteristics of raters and participants

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The data showed variable differences between the results obtained by the two raters examining the same material. [Table 4] elaborates on the differences between the raters' backgrounds.

Outcomes of simulation scenarios

The debriefing feedback showed general agreement among the participants on the need for more training sessions to improve their performance in the future and to increase the interdepartmental collaboration to ensure practical dynamics and a safe environment for work. Also, the participants focused on the importance of having a clear understanding of the clinical pathway for suspected/confirmed COVID-19 cases coming to the OR [Supplementary 1]. A clear pathway would change the practice and improve the patients' care, while maintaining the safety of the staff. “Effective practice,” “safe practice,” “team dynamic,” and “understanding the importance of clinical pathways and guidelines” were frequently mentioned by the participants throughout all the sessions. They indicated the need for a framework to guide them as health-care workers. In the first two simulation-based sessions, staff wondered about the best traffic flow to transfer patients with COVID-19 to the OR and the labor and delivery (L&D) to minimize the site contamination. In response, a clear traffic pathway for COVID-19 cases was developed by the OR committee [[Supplementary 1] outcomes sim-1, sim-2].

The results of the checklists collected from the four clinical simulation-based sessions [Supplementary 1] showed that the PPE trolley was always available outside the room; however, the N95 respirators were not available at all times. Moreover, no visual aids guiding the proper sequence of donning and doffing were present. This was reflected in the participants' performance, as they did not show a proper understanding of the principles of PPE. Such failure to adhere to the proper PPE protocols was more noticeable during the first two clinical simulation sessions as the participants had not yet attended any course on PPE protocol, in comparison with participants in the subsequent two clinical simulation sessions (3 and 4), who had attended a course on proper PPE use prior to the session, and thus scored higher in proper PPE donning and doffing checklists.

For all clinical simulation sessions, no visual aids for donning or doffing were available to assist the participants. This was changed after clinical simulation 4; since visual aids were affixed on all PPE trolleys and walls near the donning/doffing area to help guiding HCWs on the proper protocol. In addition, during the clinical simulations 1 and 2 in OR and L&D, the participants did not show an incompetent team dynamic performance, in terms of no clear role assignment among the team, no closed-loop communication, and the number of HCWs in the room was not minimized to prevent any potential contamination. As a result, the importance of team dynamics was clarified during the OR departmental meeting [Figure 2]. The participants' understanding of this concept has been manifested in clinical simulations 3 and 4 as they showed improvement in team dynamics.
Figure 2: Team dynamics

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Patient assessment took place inside the designated room for COVID-19 cases, with all staff wearing the appropriate PPE, as all site coordinators and head nurses were informed about the simulation and drills except for the second clinical simulation in the L&D. On the request of the obstetric instructor, the unit was not notified to test the readiness of the staff, which increased the stress of the health-care providers, as they have not expected a COVID-19 pregnant patient. On hearing this, a nearby patient in the holding area had a panic attack. The instructors had to brief and reassure this patient about the simulation. As a result, the head nurse of the L&D unit insisted on the importance of being notified about the simulation in future sessions. This had shown that other departments, away from the OR, needed more guidance. The team later addressed their concern regarding handling such cases offsite for better outcomes, while maintaining the safety of the staff and other patients.

Outcomes of clinical drills

For airway management, in the first clinical simulation, the anesthesiologist tried to recall the COVID-19 intubation guidelines as no visual aids were available. The video-assisted laryngoscopy was always utilized, but the COVID-19 airway trolley was not prepared yet. This caused delays in the management during simulation. This concern was later addressed to the Department of Anesthesia and Critical Care, which resulted in continuous development, revision, and modification of clinical guidelines for airway management for COVID-19 cases along with the preparation of the airway trolley for all COVID-19 cases and COVID-19 Airway-Specific checklist. This has been implemented within the Department of Anesthesia and Critical Care, which can be noticed during the onward sessions [Supplementary 1] and [Supplementary 2].

By the time the clinical drills (last two simulation-based sessions) were conducted, most of the OR staff had attended the PPE course, and clinical guidelines for anesthetic management for suspected/confirmed COVID-19 cases had been established by the department. Later debriefings demonstrated an improvement in the overall performance of anesthesia and OR teams to handle COVID-19 suspected/confirmed cases in terms of understanding the principles of PPE, team dynamics, and comprehension of the clinical management protocols [Supplementary 2]. The staff had reported ease in dealing with such situations and awareness of their role, besides the need for the multidisciplinary team including surgeons, nurses, and housekeeping departments to be actively involved in future drills for better results.

With a better understanding of the mode of transmission of the disease and mandatory PPE courses, the staff improved dramatically with the donning/doffing techniques. Visual aids have been utilized in many areas of the hospital. Also noted was the need to emphasize a buddy check during donning and doffing, which was reflected in the last three sessions [Supplementary 1], [Supplementary 2].

The checklist helped to identify the problems in the OR and document their improvement over time. The availability of the PPE trolley outside each OR and the presence of COVID-19 alert signs on every entrance to all rooms started to be displayed. Assigning roles and minimizing the number of personnel inside the room shows progress in the clinical drills, which reflects the staff understanding of team dynamics at this point.

Interestingly, an essential concern surfaced regarding how to maintain the proper PPE while attending complex OR cases during the clinical drills [Supplementary 2]. The participants reported difficulty in communication, breathing, and subjective feelings of discomfort and excessive perspiration increasing with time while wearing the full PPE along with N95 mask, which adds to stress-related case complexity. As a result, a letter was sent to the infection control team to supply the Department of Anesthesia and Critical Care with a powered air-purifying respirator (PAPR) [[Supplementary 2], drill 1]. An intercom communication system was suggested to be implemented inside the room to establish efficient communication with the runner outside for any missing/needed items. Furthermore, the importance of the patient trolley policy needs to be written at this time after the patient is transferred to the OR table.

In clinical drill 1, an uncuffed endotracheal tube (ETT) had to be changed for a cuffed one, which resonated that we have no thoughts of a plan in regard to airway management in case of ETT exchange. As mentioned earlier, the algorithm and protocol for airway management for suspected/confirmed COVID-19 cases had been developed in the Department of Anesthesia and Critical Care. This is being demonstrated in [Supplementary 2], as many anesthesiologists have implemented the pathway and are becoming efficient over time with repeated measures, teaching during morning meetings and the utilization of visual aids.

Implementation of experiential learning theory

Overall, incorporation of the modifications resulted in an overall improvement of performance in all subsequent sessions; donning 59%-100%, doffing 25%-100%, room preparation 33% up to 100%, staff preparation 17% up to 100%, early patient assessment 50%-67% and drug and airway management 68%-100%) [Figure 3]. Also, the staff became more oriented about the changes implemented in the OR as it is being noticed throughout the sessions (simulation scenario/clinical drill) [Figure 4].
Figure 3: Percentage of tasks completion in the checklist across the sessions

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Figure 4: Implementation of experiential learning theory in developing clinical pathways and management

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  Discussion Top

Simulation has been adopted by health-care teaching after 90 years of experience in many other professional fields like military, aviation, astronauts, and nuclear industry.[8] In health care, simulation-based medical education facilitates knowledge, skills, and attitudes transfer and modification in a psychologically safe manner.[9] The collaborations of the Department of Anesthesia and Critical Care and the Clinical Simulation Centers in Saudi Arabia for simulation-based activities have been well established in undergraduate, postgraduate, and anesthesia staff development.[10]

Kolb's cycle guided the design of this project, which included the four stages of the experiential cycle: concrete experience, reflective observation, abstract conceptualization, and active experimentation.[11] Simulation-based sessions (clinical simulation/clinical drills) of this project presented a concrete experience in the process of collaboration and formulating clinical and administrative management pathways during the Department of Anesthesia and Critical Care's COVID-19 response planning, which can be applied to vast different quality improvement projects as well.[12]

In the first stage of the experiential learning theory cycle, “concrete experience,” the first session was conducted in the main OR isolation room with the cooperation of the CSSC to avoid affecting patients care, minimize workplace distractor, and keep the confidentiality of the simulation-based sessions and participants. For the first clinical simulation scenario, such arrangement was established between the consultant anesthesiologist on-call and the OR head nurse to find the available participants to be called to the first OR simulation scenario. With the second simulation scenario, at the L&D OR, the consultant anesthesiologist on-call was informed, but the unit manager was not notified as per the request of the obstetric instructor to test the readiness of the unit. With all the other simulation-based sessions (simulation scenarios/clinical drills), all site coordinators were notified before starting the case operation to arrange for the best timing and participants availability without patient distraction. Health-care workers who participated in the session appreciated the simulation scenario along with the group debriefing of the case, after the simulation session. No pre-brief session was conducted at the initial four clinical simulation scenarios. With the last two clinical drills, participants were pre-briefed regarding a clinical drill conducted with the assumption of COVID-19 disease encounter. At the end of each clinical drill, instructors debriefed the participants to address their inputs for the management of the COVID-19 cases.

In the second stage of the learning theory, “reflective observation,” observations from the sessions' checklist of the study at the time of the department and hospital readiness for the national epidemic crisis were correlated. One of the important observations was the lack of effective PPE donning and doffing progress in the first two simulation scenarios. As a result, the Department of Anesthesia and Critical Care enrolled its staff in a PPE course at the CSSC to enhance their understanding and performance of the donning/doffing principles, which resulted in improved outcome measures after the second simulation scenario. Another observation is the lack of the role assignment among the participants in the team. The issue of staff dynamic inside the OR has been addressed to the Department of Anesthesia and Critical Care. This observation highlighted the importance of staff dynamics planning inside the OR with COVID-19 patient management.

Inter-rater variations have been reported and correlated with different outcomes in simulation-based sessions 1, 2, and 4. Such variations could be due to the different backgrounds, experience, and expectations of each rater. This is a very common phenomenon in such complex learning and evaluation scenarios. The variation brings out multiple and diverse learning points and can be leveraged to create a broader perspective. If desired to reduce this variation, rater training and further standardized calibration using videos or other methods can be utilized.[13] The latter is mostly needed during high-stakes certification exams.

Nevertheless, there has been an overall improvement in the outcome of the checklists, with the subsequent simulation-based sessions, and that could be related to departmental teaching progress through teaching rounds, lectures, and social media updates with the COVID-19 and the infection control guidelines literature update.

In the third stage of the experiential learning theory, “abstract conceptualization,” the clinical aspect of each simulation-based session (simulation scenario/clinical drill) was addressed. Each session's outcome was reported to the Department of Anesthesia and Critical Care's Quality and Accreditation unit, nursing department, and obstetric department. The six simulation-based sessions were organized in a parallel timeframe with the multidisciplinary approach of the clinical pathway and the hospital's COVID-19 response policies and plans. Looking into that outcome, one of the first observations was the importance of standardizing the policies to transfer COVID-19 cases in and out of the OR and which corridor to be used to minimize site contamination and endorsement sites. The staff registration sheet (anesthesia team involved during case management) and the COVID-19 alert signs to the OR were implemented during this stage of the cycle. Consequently, staff dynamic improvement plans have been implemented after this issue was addressed to the Department of Anesthesia and Critical Care. According to the department's COVID-19 airway management plan, there was no consideration regarding airway rescue management in case of ETT exchange until the first clinical drill experience, when the team had to handle ETT exchange. This was reported to the department's COVID-19 committee. By the time of the second clinical drill, at the stage of abstract conceptualization, the intercom communication system was suggested to be implemented inside the room to establish efficient communication with the runner outside of any missing/needed items. On connecting the patient to the portable monitor, as in the institute, patients were intubated at the recovery negative pressure room and then transferred to the OR, to lessen the time of transfer and cross-contamination. The importance of “patient trolley policy” needed to be written at this time after the transfer of patient to the OR table. Observing the experiment's reports at this stage of the experiential theory cycle was an eye-opener to various blind spots in the process of developing and implementing clinical pathways by activating the experiential learning theory cycle.

The fourth stage of the experiential learning theory cycle, namely the “active experimentation”, has been achieved by implementing new changes in the process of writing the institutional clinical pathway. When it comes to balancing regional and national approaches, no matter what the scale of action—local, state, regional, or national—true preparedness extends far beyond the walls of an individual jurisdiction or health-care organization.[14] In this study, after every session, the local committees were updated to implement the necessary changes in the developed COVID-19 response protocols for efficient and accurate implementation. This stage did help in finding shortcomings of the clinical pathways. In order to address and minimize the participants' fatigue, the final two sessions of the experiment witnessed implementing strategies designated to maintain PPE, minimize donning and doffing, and decrease stress among staff. This came in light of the importance of the safety of patients and the staff's well-being in the OR, where COVID-19 case management takes place.

What the world learned from Italy is the need for a higher level of preparedness during hospital management of their presenting cases. Given the little experience in dealing with the new virus, strategic mistakes are unavoidable. The novel COVID-19 pandemic, because of its scale, constitutes a massive threat to health-care workers.[14] The rise in infection rates among medical personnel could be explained by hospitals being overcrowded. As of March 30, 2020, as much as 8,920 medical personnel had been infected with COVID-19 in Italy, leading to further loss of capacity for hospitals to respond. Furthermore, 9% of infections in Italy occurred among health-care personnel, which highlights the importance of proper PPE plans and strict hygienic procedures in the hospital environment.[15],[16] Sadly, attention to health-care worker's safety has languished at a far too low level of priority for decades, and now it is evident how unwise that has been. Without a physically and psychologically safe workforce, excellent health care is not attainable.[17] A letter was sent to the infection control unit to demonstrate the need to supply the Department of Anesthesia and Critical Care with PAPRs, since it would provide the best protection when attending a COVID-19 patient for more than 1 hr. High-efficiency particulate air filtration system was requested from the infection control unit to be available in the OR as well to ensure the operation field is clean and well sterilized.

The role of health-care workers in the COVID-19 pandemic is, at the first glance, clear. However, our data documents lack off the needed response framework and protocols guiding actions during such crises. During drills in which the guidelines were known, participants showed increased confidence in dealing with patients. Moreover, data show concerns for patient and staff safety in situations where the needed equipment is limited, especially PPE. However, the findings are similar to the reports by Michalec B and Lamb Gm in that all simulation activities, team dynamics, role clarity, and some panic and stress perception were a concern for interpersonal skills.[18]

This work has a few limitations. There ought to be more cases, but this will result in a loss of the depth of the simulation cases. Due to the limitation of time, focus on debriefing the staff at the end of each scenario was preferred to have better outcomes in terms of staff comprehension of the current situation, and to respond to the existing epidemic accordingly. In addition, the whole multidisciplinary team, including surgeons, nurses, and the housekeeping department (team members and leaders) should be actively involved in future drills to guarantee better results.

Kolb's experiential learning theory is considered the continuity of creating knowledge by transforming simulation experiences into a cognitive framework in clinical pathways' development and management. In this project, three main areas for improvement have been identified: (1) PPE implementation, (2) team dynamics, and (3) airway management. These results demonstrate the applicability of alignment with Kolb's experiential theory during the process of formulating the anesthesiology and OR clinical management pathway. Further simulations could guide in designing workplace-based strategic clinical plans.

  Conclusion Top

From the Wuhan and Italy experiences, there is a need to act faster as the rates of infection are increasing dramatically. Therefore, the institute's clinical pathways and guidelines need testing for efficiency and effectiveness. This can be done through simulation and clinical drills. The results and data can be observed, reported, and analyzed to propose modifications of current pathways and guidelines, and develop new ones that will fit the institute and the region's needs to respond to epidemics more effectively.

For years, the Kolb's experiential learning theory had been used to develop new curricula and models for teaching. This theory was demonstrated in simulation and clinical drills by promoting critical thinking to reflect on the already established clinical pathway. The theory has proven to be an excellent theoretical foundation for developing and improving the current practice. Furthermore, by identifying vulnerabilities and areas that need improvement, a new management plan was developed. This had resulted in the enhancement of the overall performance of the institution, and more specifically, in the OR, dealing with the new disease.

For future efforts, applying the experiential learning theory as a framework by multidisciplinary clinical institutes using simulations and clinical drills would actively promote and guide the process of developing and implementing new clinical management pathways, protocols, and guidelines while simultaneously providing the patients with better care services during the pandemic outbreaks.


We would like to acknowledge the COVID-19 Crisis Response Plan Committee and Department of Anesthesia and Critical Care at King Abdulaziz University Hospital, Jeddah, Saudi Arabia for their responsiveness and help in developing the guidelines in response to simulation. We extend our special appreciation to Dr. Auhood Bukhary and Dr. Haifa Algethmi for their contribution and outstanding support. We would also like to thank KAUH and the King Abdulaziz University Clinical Skills and Simulation Center (KAU CSSC) staff and leadership for their commitment and support to conduct this work.

Author contributions

Conceptualization was shared by W.B., A.B. Writing the original draft, review and editing the final version were done by N.N., A.A., B.T. Supervision was conducted by A.B. All authors have read and agreed to the published version of the manuscript.

Institutional review board statement

The biomedical research ethics committee at the Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia has exempted this study from getting a formal approval as it is non-intervention - retrospective record review study. The reference No for exemption: (22-12). We also confirmed that the guidelines outlined in the Declaration of Helsinki were followed in this study.

Informed consent statement

An informed consent was obtained from all the study participants.

Data availability statement

The data presented in this study are available on request from the corresponding author.

Financial support and sponsorship

This study was funded by the Deanship of scientific research at King Abdulaziz University, Jeddah, Saudi Arabia.

Conflicts of interest

There are no conflicts of interest.

  References Top

Bedford J, Enria D, Giesecke J, Heymann DL, Ihekweazu C, Kobinger G, et al. COVID-19: Towards controlling of a pandemic. Lancet 2020;395:1015-8.  Back to cited text no. 1
Sohrabi C, Alsafi Z, O'neill N, Khan M, Kerwan A, Al-Jabir A, et al. World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). Int J Surg 2020;76:71-6.  Back to cited text no. 2
Shah SG, Farrow A. A commentary on “World Health Organization declares global emergency: A review of the 2019 novel Coronavirus (COVID-19)”. Int J Surg 2020;76:128-9.  Back to cited text no. 3
Dhital R, Subedi M, Prasai N, Shrestha K, Malla M, Upadhyay S. Learning from primary health care centers in Nepal: Reflective writings on experiential learning of third year Nepalese medical students. BMC Res Notes 2015;8:1-9.  Back to cited text no. 4
Claramita M, Ekawati FM, Gayatri A, Istiono W, Sutomo AH, Kusnanto H, et al. Preparatory graduate professional training in general practice by using the'experiential learning'framework. Asia Pac Fam Med 2018;17:1-13.  Back to cited text no. 5
Fiorillo M, Verre AF, Iliut M, Peiris-Pagés M, Ozsvari B, Gandara R, et al. Graphene oxide selectively targets cancer stem cells, across multiple tumor types: Implications for non-toxic cancer treatment, via “differentiation-based nano-therapy. Oncotarget 2015;6:3553-62.  Back to cited text no. 6
Sir Charles Gairdner Hospital, Perth, Australia. COVID Induction in the operating theatres at Sir Charles Gairdner Hospital, Perth, Australia Demonstration video. YouTube. Available from: [Last accessed on 2022 Jul 30].  Back to cited text no. 7
Satava RM. Role of simulation in postgraduate medical education. J Health Spec 2015;3:12-6.  Back to cited text no. 8
  [Full text]  
Aggarwal R, Mytton OT, Derbrew M, Hananel D, Heydenburg M, Issenberg B, et al. Training and simulation for patient safety. BMJ Quality and Safety 2010;19:i34-i43.  Back to cited text no. 9
Arab A, Alatassi A, Alattas E, Alzoraigi U, AlZaher Z, Ahmad A, et al. Integration of simulation in postgraduate studies in Saudi Arabia: The current practice in anesthesia training program. Saudi J Anaesth 2017;11:208-14.  Back to cited text no. 10
Kolb DA. Experiential learning: Experience as the source of learning and development. FT press; 2014.  Back to cited text no. 11
Farsi S, Noaman N, Bukhary A, Bahaziq W, Sabbahi A, Abushoshah I, et al. Anaesthesia and critical care department at a major academic centre's adaptation to face the COVID-19 pandemic. Int J Gen Med 2021;14:3539-52.  Back to cited text no. 12
Cash AH, Hamre BK, Pianta RC, Myers SS. Rater calibration when observational assessment occurs at large scale: Degree of calibration and characteristics of raters associated with calibration. Early Child Res Q 2012;27:529-42.  Back to cited text no. 13
Berwick DM, Shine K. Enhancing private sector health system preparedness for 21st-century health threats: Foundational principles from a national academies initiative. JAMA 2020;323:1133-4.  Back to cited text no. 14
Boccia S, Ricciardi W, Ioannidis JP. What other countries can learn from Italy during the COVID-19 pandemic. JAMA Intern Med 2020;180:927-8.  Back to cited text no. 15
Omboni S. Telemedicine during the COVID-19 in Italy: A missed opportunity? Telemed J E Health 2020;26:973-5.  Back to cited text no. 16
Berwick DM. Choices for the “new normal”. JAMA 2020;323:2125-6.  Back to cited text no. 17
Michalec B, Lamb G. COVID-19 and team-based healthcare: The essentiality of theory-driven research. J Interprof Care 2020;34:593-9.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3], [Table 4]


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