Play2Train instructor guide

vTrain Instructors’ Guide

The objective of this manual is to provide support for instructors and facilitators who teach and guide students through a Virtual Pandemic Flu Triage Exercise in our 3D MultiUser Virtual Learning Environment.

Instructors’ Guide

Contents Introduction ........................................................................................................................ 3 Purpose of Course ............................................................................................................ 3 Learning Objectives ......................................................................................................... 3 Confidentiality & Security ............................................................................................... 4 Student Access to Help .................................................................................................... 4 Orientation Sessions 1-3...................................................................................................... 4 Session One ......................................................................................................................... 4 Objective .......................................................................................................................... 4 Orientation in RL (~55 mins) .......................................................................................... 4 Orientation in Virtual Environment ............................................................................... 5 RL Hotwash ..................................................................................................................... 5 Session Two ......................................................................................................................... 5 Objectives ......................................................................................................................... 5 Learning objectives .......................................................................................................... 5 Orientation and HICS didactic in Virtual Environment (~55 mins) .............................. 5 RL Hotwash ..................................................................................................................... 6 Session Three....................................................................................................................... 6 Objectives ......................................................................................................................... 6 Activities in the Virtual Environment (~55 mins) .......................................................... 6 RL Hotwash ..................................................................................................................... 7 Drills and Exercise: Sessions 4-5 ........................................................................................ 8 Session Four ........................................................................................................................ 8

1 Instructors’ Guide

Objectives ......................................................................................................................... 8 Scenario(~60 mins): ........................................................................................................ 8 Scenario Narrative .......................................................................................................................................8

Activities in Virtual Environment: HICS set up and Triaging ........................................ 8 Debrief in Virtual Environment ...................................................................................... 9 Session Five ......................................................................................................................... 9 Objectives ......................................................................................................................... 9 Scenario (~60 mins): ....................................................................................................... 9 Scenario Narrative ..................................................................................................................................... 10

Activities in Virtual Environment: Pan Flu Triage Exercise in the ED of Hospital ...... 11 Debrief in Virtual Environment ..................................................................................... 11 Session Six - Evaluation ..................................................................................................... 11 Objective ......................................................................................................................... 11 Activities ........................................................................................................................ 12 Results & Follow Up .......................................................................................................... 12 Resources........................................................................................................................... 12 Lesson 2 –HICS Slides .................................................................................................. 12 Lesson 2 – HICS quiz .................................................................................................... 12 Lesson2 – Web Quiz Set Up .......................................................................................... 13 Lesson 2 - Proctor Guide ............................................................................................... 13 Lesson 4 & 5 - H1N1 Plan for ED ................................................................................... 13 Lesson 6 – Mental Health Slides ................................................................................... 13 Lesson 6 _vTrain Program Evaluation Instrument ...................................................... 13

2 Instructors’ Guide

Introduction This manual outlines each session of the training. It describes the purpose and objectives of the course. It is intended to support you in your endeavor to manage the course and help the students complete the course successfully. At the end of the manual you will find links to a collection of resources. This instructor’s guide is designed to complement the Student manual.

Note that this manual is a dynamic tool, not a static document. It will continue to be updated as improvements are made or as the context changes.

Purpose of Course To provide an opportunity to test a concept of operation for an unexpected surge in healthcare need in the event of a Pandemic Influenza event within the Emergency Department of the VA SD and to test, get feedback and insights on this innovative training approach in an online 3-D Multi User Virtual Learning Environment (MUVLE).

Participants: ED personnel, vTrain Team

Learning Objectives The students will learn when and how to utilize different triage systems for patients presenting to the hospital during a pandemic influenza event.

1. Function in current job class (ED triage nurse) as an avatar in a virtual learning environment.

2. Demonstrate expected role in response to a pandemic influenza at the VA San Diego Healthcare System.

3. Demonstrate ability to provide reliable and accurate communication to patients, coworkers, and administrators using the principles of the Hospital Incident Command System (HICS).

4. Demonstrate ability to appropriately utilize the Emergency Severity Index (ESI) and START (simple triage and rapid transport) triage methods (including the use of Triage Tags) within a virtual learning environment.

5. Demonstrate ability to change from one triage system to another as appropriate within a pandemic flu scenario.

6. Demonstrate ability to use proper infection control practices within a pandemic flu scenario.

7. Demonstrate ability to utilize proper personal protective equipment (PPE) within a pandemic flu scenario.

8. Demonstrate the process of identifying and managing stress and anxiety associated with emergency events.

3 Instructors’ Guide

Confidentiality & Security Ensure that all data collected including personal student data and other research data meet the IRB requirements and, all consent forms are signed.

Student Access to Help Inform students who to contact to get technical and content help.

Orientation Sessions 1-3 Session One Several things need to be accomplished in the first class session; define the objectives, discuss student and instructor expectations, demonstrate skills and allow student to practice. It is important to remember that much of the tone of class is established during that session.

Objective: Primary focus will be introduction to 'technology' i.e. familiarization with the Virtual Environment utilizing orientation stations.

There will be one facilitator in RL and another in the Virtual Environment. Session starts in Real Life (RL) for 10-15 minutes with introductions and goals for the session. At the end, the evaluator will carry out a debrief in RL.

Orientation in RL (~55 mins)           

Sign all informed consents and HIPPA forms Welcome & thank you Explain what we are doing Explain why their participation is important Show pandemic flu machinima to give trainees sense of "end game" goal Overview: explain general curriculum x 6 weeks Explain about avatars and customizing in open lab or even at home. At this stage the technical staff will have already created avatars for the students and the students can log in with their passwords.

Caution about wandering & permissions needed Encourage to think aloud and ask for help Overview of online 3-D Multiuser Virtual Learning Environment (detailed in Student’s Manual) Overview of the course : HICS, EIS, START Triage, Pandemic Flu Exercises 4 Instructors’ Guide

Orientation in Virtual Environment Virtual Environment session instructions are provided in the Student Manual (Section 1.0 through 2.3). 

Explanation of VLE navigation and features and tools availability. An overview of the viewer interface is also given.

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complete some of the common tasks, such as walking, communicating, viewing and interacting to facilitate the sessions/exercises in the virtual environment Please note that the basic ways to achieve these skills are provided, and advanced alternatives are considered as being optional. The student can explore these when they have time.

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Communicating with other Avatars: Text and Voice Chat

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Avatar Movements: Walking, Running, Turning

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Interacting with Objects: stretchers, gurneys, wheel chairs

RL Hotwash After the Virtual Environment session, a 10~15 mins debrief will be conducted by the evaluator.

Session Two Session starts in Real Life (RL) for 10-15 minutes with an introduction and goals for the session.

There will be one facilitator in RL and another in the Virtual Environment. At the end a debrief will be carried out in RL by the evaluator.

Objectives: Primary focus will be on the HICS didactic in the Virtual Environment and taking of the HICS quiz. Student will also learn new advanced skills such as camera control and looking around and viewing objects, and advanced Communications such as direct voice chats.

Learning objectives   

Describe the Hospital Incident Command System (HICS) Identify the HICS sections using "CFLOP" Determine where you fit into HICS as an Emergency Department team member.

Orientation and HICS didactic in Virtual Environment (~55 mins) Virtual Environment session instructions are provided in the Student Manual (Section 2.4 through 2.68).

5 Instructors’ Guide

Review and re-experience skills from Lesson 1 in Virtual Environment. Participants will receive HICS didactic in virtual conference room and they will utilize pollster for quick quiz on HICS. The HICS slides, questions and the Quiz engine user guides are available in the resources section at the end of the manual.

RL Hotwash After the Virtual Environment session, a 10~15 mins debrief will be conducted by the evaluator.

Session Three Objectives: Primary focus will be introduction to ESI, START, utilization of Triage Tags (more info can be found at triagetags.com) and infection control measures and PPE. Participant will learn how to use the virtual resources in the triaging area (triage tags, PPE, mannequins, note cards) and, how to wear uniforms and clothing and change appearances within the virtual environment.

As with the previous lessons session will begin in RL with introduction and goals for session (10-15 mins) and then to the Virtual Environment. Some of the content from the previous lesson will be revisited and an overview of ESI, START, and utilization of Triage Tags presented by facilitator. Participants then proceed to the triage training area, and the uniform and clothing stores.

Additionally an overview of the inventory will be given in the student manual. It is not an exhaustive exploration of the Inventory, but rather an overall look at how participants are going to use the Inventory during the session. Virtual Environment session instructions are provided in the Student Manual (Section 3.0 through 3.2).

Activities in the Virtual Environment (~55 mins) In field outside hospital 

get triage helper

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watch Triage Tag Video

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interact with notecards

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make a notecard

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listen to RumDum- assign ESI 6 Instructors’ Guide

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listen to RumDum- assign START color

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sort a few RumDums by categories

At clothing/inventory teaching station 

get some new clothes

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put on new clothes with shoes

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find a uniform

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put on uniform

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search for bought clothes in inventory

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put on mask

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put on goggles

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put on gloves

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put on HICS vest (behind uniforms)

If there is some time, explore Play2Train Island and find the following 

decon showers (hint: they turn on!)

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bottled water (take one so you are not dehydrated later)

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outdoor triage areas (series of tents)

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HICS organizational chart

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chemical spill (with fumes)

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police car

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helicopter

RL Hotwash 7 Instructors’ Guide

After the Virtual Environment session, a 10~15 mins debrief will be conducted by the evaluator.

Drills and Exercise: Sessions 4-5 Session Four Session starts in Real Life (RL) for a few minutes with introduction and goals for the session.

Then the drill scenario will commence. There will be facilitators in RL and in the Virtual Environment. At the end of triaging, the Incident Commander will reconvene a meeting in the triaging area for feedback and debrief. The H1N1 Plan for ED is available in the resources section at the end of the manual.

Objectives: The main focus is to do triage using ESI and START in the Triage area set up outside the virtual hospital. The participants will be required to play their role within the Hospital Incident Command System (HICS) and then figure out how to appropriately and correctly use the triage systems available to them to manage the increasing number of patients that will be presenting for care.

Scenario(~60 mins): The Scenario will start in the conference room, where the Incident Commander will address the participants. They will then be asked to proceed to the Triage area set up outside the hospital. Participants will wear their scrubs and PPE. Further team leaders will be assigned and will need to wear appropriate ICS vests. Participants will be using the skills they learned in the previous lessons to participate in the Pandemic Flu drill such as camera skills, pushing cart or wheelchairs, wearing clothing and objects and interacting with their inventory.

Scenario Narrative The VA San Diego Healthcare System in collaboration with the regional emergency support function partners is responding to an outbreak of a novel strain of influenza A (H1N1) virus. The Department of Public Health in cooperation with the Centers for Disease Control & Prevention (CDC) has been on high alert as the emerging pandemic has reached Phase 6 (internationally widespread) levels. Regional and hospital Emergency Operations Plans have been standing by, but have yet to be activated as the current increased numbers of patients seeking care have been similar to seasonal flu surges. However, a few recent, influenza-related deaths have occurred in the community, resulting in increasing concern both among the general public and among healthcare providers.

There are two types of patients the mannequin ones and a few avatars. They are all recognizable by their triage Tags.

Activities in Virtual Environment: HICS set up and Triaging 8 Instructors’ Guide

Virtual Environment session instructions are provided in the Student Manual (Section 4.0 through 4.1.9). A few new skills and the previously learned skills will be revisited during the exercise. 

Assume role in HICS

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Wear Scrubs and PPE

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Move mannequin patients

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Listen to mannequin patient symptoms

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Make Mannequin patient wear respiratory mask

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Use Vitals Notecard

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Use Triage Tags

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Interact with Avatar Patients

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Label Triage Tents

Debrief in Virtual Environment At the end of triaging, the Incident Commander will reconvene a meeting in the triaging area for feedback and debrief.

Session Five Session starts in Real Life (RL) for a few minutes with introduction and goals for the session.

Then the virtual exercise scenario will commence. There will be facilitators in RL and in the Virtual Environment. At the end of triaging, the Incident Commander will reconvene a meeting in the triaging area for feedback and debrief.

Objectives: Participants will be required to do triage during a Pandemic Flu event in the Triage Emergency Department of the virtual hospital using ESI and START. The participants will be required to play their role within the Hospital Incident Command System (HICS) and then figure out how to appropriately and correctly use the triage systems available to them to manage the increasing number of patients that will be presenting for care. They will deal with additional injects such as a media reporter and lack of resources.

Scenario (~60 mins): The Scenario will start in the conference room, where the Incident Commander will address the participants. They will then be asked to proceed to the Emergency Department. Participants will wear their scrubs and PPE. Further team leaders will be assigned 9 Instructors’ Guide

and will need to wear appropriate ICS vests. Participants will be using the skills they learned in the previous lessons to participate in the Pandemic Flu drill such as camera skills, pushing cart or wheelchairs, wearing clothing and objects and interacting with their inventory.

Scenario Narrative The multiple cases of novel H1N1 reappear in Scripps Ranch in late September. Early cases are not recognized as influenza, and are treated conservatively, affording the opportunity for transmission to schoolmates and family.

The vaccine for the novel H1N1 will not be ready for distribution in large volumes until late October. Vaccine for the novel H1N1 will require two injections, at least two weeks apart, to stimulate immunity. Immunity will not be sufficient to protect subjects from infection until two weeks after the second injection.

Local officials hesitant to implement community mitigation strategies early in an outbreak, especially school closure so close to the beginning of the school year. The media continue to fuel the public sentiment that health officials over-reacted to the spring wave and are doing likewise to the fall cases. There is political pressure to keep schools open because of large numbers of workers without “time off” benefits to care for their children. The Federal government does not have solutions in place, such as emergency wage replacement, to mitigate that pressure. Because of economic pressures and high value placed on jobs in a weakened economy, workers will continue to work when sick, exacerbating transmission in the most contagious stage of their illness.

After a few weeks of this fall wave, the prevalence in affected parts of the county increases. The first few deaths are reported, some in young individuals. Emergency departments begin to see large volumes of people who are not ill with the flu, but are concerned that they or their children “might have it.” They are requesting screening and prescriptions for antivirals. The VA Emergency Departments experiences a 150% increase in chief complaints with respiratory symptoms.

By mid-October, 15,000 cases will be reported across the country, with hot spots in urban areas that have not employed community mitigation strategies. The highest prevalence is among children and young adults, but during this wave, there is a 5-fold increase in mortality, with 250 deaths by late-October, mostly in school-age children and those in late teens in Southern California.

The CDC documents the increased virulence, and communities begin to close schools. Health guidance is provided encouraging those with fever, cold symptoms, sore throat or respiratory symptoms to remain at home and wear masks in public, and to go to their doctor or the emergency department if acutely ill. This is concurrent with fall allergy season, when a large proportion of people report nasal symptoms in a normal year, and many of those will normally have sore throat and cough. The highest concentration of people who have no doctor or health 10  Instructors’ Guide

coverage is the same population at greatest risk for becoming ill with novel H1N1: children and young adults.

Even though the prevalence of illness is less than 2%, some public officials are discouraging the use of public transportation or participating in other close gatherings. There is increased demand on emergency medical services for transport of patients to the hospital who would normally see a doctor via public transportation. As the prevalence of disease increases, deaths of children is in the news regardless of the case fatality rate, and concerned parents want their children checked if they have any related symptoms. Primary care providers who may have the capacity to see only a few extra people per day, will be overbooked and will be referring patients to the emergency department.

Activities in Virtual Environment: Pan Flu Triage Exercise in the ED of Hospital Virtual Environment session instructions are provided in the Student Manual (Section 5.0 through 5.1.10). 

A few new skills and the previously learned skills will be revisited during the exercise.

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Communicate with an avatar who is far from you e.g. in another room

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Recognize the two types of Patients: Mannequins and Avatar Patients

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Interact with new resources

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Interact with Oxygen tank

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Interact with Heart Monitor

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Use Hand Sanitizer: Gel in Gel Out

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Virtual hand washing

Debrief in Virtual Environment At the end of exercise the Incident Commander will reconvene a meeting in the triaging area for feedback and debrief.

Session Six - Evaluation Objective : Focus is on evaluation and feedback from participants on the whole course via different modalities.

Course Evaluation held in RL (~60 mins)

11  Instructors’ Guide

The Mental health slides and the vTrain Program Eval form are available in the resources section at the end of the manual.

Activities Provide information on how to dealing with stress as a caregiver after a disaster. The protocol is to discuss with ED CSD who then notifies ELT (executive leadership team) who then involves the Disaster Stress Relief Team.

Assorted written evaluations and discussions with evaluators Objective-based questions pre/post Course evaluations Review preparedness questionnaire results from Lesson five Review performance using recorded machinimas from Lesson Four drill & Lesson Five drill At the end, relax and talk and share our experiences

Results & Follow Up Results Follow-Up Discussions and feedback on the sessions and prepare a presentation to discuss our findings and draft a manuscript.

30-day follow-up interview with Nancy to explore how vTrain knowledge has been implemented by staff.

30-day follow-up with ED CSD to explore "learning" has been applied to the ED setting

Resources Lesson 2 –HICS Slides https://sites.google.com/a/play2train.us/private/va-pan-flu-exercise-script/lesson2/HICS.ppt?attredirects=0

Lesson 2 – HICS quiz 12  Instructors’ Guide

https://sites.google.com/a/play2train.us/private/va-pan-flu-exercise-script/lesson2/QuizQuestions2.doc?attredirects=0

Lesson2 – Web Quiz Set Up https://sites.google.com/a/play2train.us/private/va-pan-flu-exercise-script/lesson2/Lesson2_WebQuizSetUp_Instructor.pdf?attredirects=0

Lesson 2 - Proctor Guide https://sites.google.com/a/play2train.us/private/va-pan-flu-exercise-script/lesson-2/Lesson2Quiz_Intro_Proctor.pdf?attredirects=0

Lesson 4 & 5 - H1N1 Plan for ED http://www.acep.org/WorkArea/DownloadAsset.aspx?id=45781

Lesson 6 – Mental Health Slides https://sites.google.com/a/play2train.us/private/va-pan-flu-exercise-script/lesson6/MentalHealth.ppt?attredirects=0

Lesson 6 _vTrain Program Evaluation Instrument https://sites.google.com/a/play2train.us/private/va-pan-flu-exercise-script/lesson6/VTrainEval.doc?attredirects=0

13  Instructors’ Guide