Quality care in hospital

The preceding chapter has addressed the quality of health care provided in the community by EMS personnel. Here we look at how the quality of care provided by healthcare professionals in the hospital setting can be improved.

A Lancet report in 2018 estimated that 8.6 million deaths per year in 137 low and middle-income countries (LMICs) were due to inadequate access to good-quality health care: 5.0 million were estimated to be due to poor-quality care and 3.6 million to non-utilisation of health care. This dismal scenario is far from applying only to less well-off economies: after the US Institute of Medicine landmark report in 1999, To Err is Human, estimated that medical errors in US hospitals might be causing up to 100,000 unnecessary deaths each year, healthcare quality has increasingly come into focus. And a 2016 study published in the British Medical Journal throws an even bigger spotlight on the issue: extrapolation from studies published since 1999 suggests that the figure exceeds 250,000, making medical error the third most common cause of death in the US.

Such poor-quality care is generally attributed to either poor initial training or failure to maintain and improve competencies of healthcare workers. However, having insufficient staff in a healthcare facility is felt by many to be also a significant factor.

Improving access

In 2016, the UN High Level Commission on Health Employment and Economic Growth issued its report and recommendations to the UN Secretary General, Ban Ki-moon, on the investments and actions needed to make progress towards achieving the SDG3 goal of Universal Health Coverage including access to quality essential healthcare services.

It estimated that without action there will be a shortfall, primarily in LMICs, of 18 million health workers needed to achieve and sustain Universal Health Coverage. But the UN report may have underestimated the shortfall by not considering fully the aspirations of healthcare systems in LMICs to go beyond minimum standards. This may also have been the case when the WHO estimated that there were 21 million nurses/ midwives worldwide with a global shortfall of 9 million.

64 Million Reasons to Change

The global shortage of nurses – no matter how skilled the others are – impacts quality of care. And there is an enormous disparity between HICs and LMICs regarding the numbers of nurses and midwives ranging from 18 per 1000 population in Norway to less than 1 per 1000 population in Ethiopia and Tanzania. For LMICs to get close to the HIC average of about 10 per 1000 by 2030 would require – with a projected global population of 8.5 billion – a global pool of about 85 million nurses and midwives, an increase of 64 million over the current estimate of 21 million. A seemingly impossible task. It just would not be affordable for LMICs if existing practices were followed. There is, unsurprisingly, a strong linear relationship between the number of nurses and the wealth of a country (see chart). A similar relationship applies for doctors. Waiting for countries to grow richer is not an option: economic growth of 3% per annum would only increase the global nursing pool by 35% over 10 years.

So how can the nurse shortages be addressed? Simply focussing on numbers entering nurse training is clearly not enough. The policy solutions must look to increasing productivity, for example through task shifting to assistants and the use of community health workers. And use of emerging technologies can play a big part as identified in the UN High Level Commission Report. The impact that technologies can have has been amply demonstrated in the field of personal communications with mobile phones now almost as common in China and India as in HICs. A similar revolution is needed in health care.

Sources: World Bank/OECD

The Patient Safety Movement

The Patient Safety Movement (PSM) Foundation was established in 2012 with a mission to reduce preventable deaths in hospitals from medical errors to zero by 2020, by working with all stakeholders to address the problems with actionable solutions. Although the goal has not been reached on this timescale, the Foundation still believes that it is the right goal and can be achieved with the right people, ideas and technology. It has focussed minds on the issue and resulted in the establishment of eighteen Actionable Patient Safety Solutions including on neonatal safety, optimal resuscitation, airway safety, and obstetric safety. Close to 5,000 hospitals worldwide and 100 professional societies, associations, and healthcare-related organisations have partnered with the PSM to help reach the goal. In 2018, Laerdal committed to contributing to the PSM goal by helping save 25,000 more lives that year through simulation-based educational programs. Including – with its partner the American Heart Association – 5,000 more lives through the Resuscitation Quality Improvement Program. Laerdal Global Health has committed to contribute 30,000 extra lives every year towards the PSM goal through programs described in the next chapter.

Crossing the Digital Divide

The UN Commission’s recommendations towards addressing the healthworker shortfall include:

harnessing the power of cost-effective information and communication technologies to enhance health education, people-centred health services and health information systems;
scaling up transformative, high-quality education and lifelong learning so that all health workers have skills that match the health needs of populations and can work to their full potential.

The Commission goes on to point out that technologies can be transformative if the digital divide – the uneven distribution across countries of access to Information and Communication Technologies (ICT) – can be crossed. But they must be properly resourced, regulated and in line with country ethics, principles and values. Opportunities mentioned include telemedicine, e-learning (see below), electronic health (e-health) and mobile health (m-health), social media, massive open online courses, webcasts, podcasts, high-fidelity simulation, decision-support tools, electronic medical records, electronic systems for disease surveillance, civil registration and vital statistics, and laboratory and pharmacy information systems. These technologies can
broaden the reach of health systems, even in the face of health worker shortages in remote and inaccessible areas. They can also strengthen collaborative teamwork and accountability and facilitate people-centred approaches to care.

The obstacles compromising technology’s full potential to remedy the health workforce gap and improve health services include: lack of proper evaluation of what works and what does not (an obstacle to moving from pilots to full-scale implementation), lack of internet access and ICT infrastructure, costs of connectivity, lack of electricity supply, data insecurity, and restrictive regulatory frameworks. Other challenges include lack of ICT and digital technology knowledge and resistance to change among educators, health system managers and health workers. Reaping the benefits of rapidly changing technologies will require internet/ICT infrastructure investments, especially in low- and middle-income countries.

An excellent example of how technology can transform healthcare delivery is the competence-based revolution in resuscitation from cardiac arrest (see below).

The Transformative Potential of e-Learning

E-learning enables education and training to become more learner centred, interprofessional, outcome and practice-focussed, workplace-based, equitable, collaborative across education and training providers, and scalable at greater efficiency without compromising effectiveness. E-learning can accelerate the development of the right skills at the required scale to achieve universal health coverage and respond to emerging disease threats. A global consortium of over 50 researchers and experts is conducting 12 systematic reviews. Preliminary findings suggest that e-learning is at least as effective as traditional forms of education for health professionals; and that, for example, serious gaming or gamification interventions and virtual reality environments have significant potential advantages over traditional methods in knowledge and skills acquisition. Further studies with more robust methodologies are required to determine the impact of e-learning on learning outcomes.

Working for Health and Growth. Investing in the Health Workforce. High-Level Commission on Health Employment and Economic Growth. World Health Organization 2016

A Long-Standing Partnership

Laerdal and the American Heart Association (AHA) have worked together for close to 50 years.

It was in 1974 that Laerdal supported the publication and distribution of the AHA’s first “Standards and Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care.” In 1997, a vital alliance was formed between the two organisations leading to the development of the HeartCode e-learning program and the Mini Anne kit for CPR training in schools and the community. In 2014 they introduced together the Resuscitation Quality Improvement (RQI) program to US hospitals. This program was based around the so-called Low-Dose, High-Frequency (LDHF) principle, moving health care away from big dose, infrequent training to focusing on continuous improvement of competence.

The Competence-Based Revolution

Research in the early 2010s had shown that the usual practice of two-year intervals between refreshing skills in both basic and advanced life support was inadequate because such skills often deteriorate within three to six months. Instead, allowing each healthcare worker to refresh skills every three months in a 10-minute session at a moment of their choosing at a skills testing station at their work-place was shown to be not only effective at counteracting skill decay but greatly improved skill performance over time. It also reduced the cost of refresher training for the hospital, avoiding the need to send people out for a course and fill in with replacement staff, and was also more convenient for both the hospital and healthcare worker. But most important, quality of care improved. As a result, at one of the early adopters, Texas Health Presbyterian Hospital in Dallas, survival doubled in the first year.

LDHF session to confirm RQI eCredential.

“This is probably the most exciting and important project that has come up in the AHA in the last twenty years, and it may be so also for the next ten years.”

Nancy Brown
CEO, American Heart Association

Nancy Brown presenting the AHA’s 2030 Impact Goals

RQI Partners

In June 2018, after the initial success of the Resuscitation Quality Improvement program (RQI), the AHA/Laerdal relationship grew even closer with the objective of rolling out the program across all hospitals, starting in the US. The best way to achieve this was felt to be the formation of a separate company, RQI Partners, owned jointly by the AHA and Laerdal with personnel from both organisations dedicated exclusively to the goal of helping save 50,000 lives every year. After less than two years of operation, RQI Partners is well on the way to achieving this goal with 20% of US hospitals having adopted RQI as their program of excellence in resuscitation.

The cognitive part of RQI uses the e-learning component of the AHA-Laerdal HeartCode program, which breaks down the curriculum into bite-size learning activities each quarter. In place of the two-year “course completion card”, the program has taken a big step forward by issuing an “e-Credential” verifying that the participant is competent in resuscitation skills.

The RQI eCredential

Healthcare providers who have verified their competence through active and ongoing participation in the RQI program are issued with an RQI eCredential card. This represents that the individual has achieved the gold standard exceeding any prior requirements for resuscitation training.

The American Heart Association’s Vision of RQI

Learn more about the American Heart Association’s vision of a world where no one dies from cardiac arrest.

Catrina’s Story

Catrina Brown was heading home from Texas Health Harris Methodist Hospital, South Worth, after a long day’s work, when she saw a motorcyclist had crashed and was lying unconscious by the side of the road. Another bystander called 911 and Catrina performed chest compressions until the ambulance arrived.

As a postpartum nurse, Catrina hadn’t performed CPR in years. She credits the regular training she receives through the RQI program at Texas Health for keeping her skills fresh.

“It really works,” she said. “When I came back to work, I told people two things: wear a helmet, and pay attention to CPR training.”

Catrina Brown
© Texas Health Resources

High-Fidelity Simulation

The benefits of quality improvement go beyond resuscitation to other hospital emergencies where patient safety is a serious concern such as trauma, sepsis, stroke and pediatric, neonatal and obstetric care. A well-drilled team is crucial – and this is where high-fidelity simulation comes to the fore using patient simulators with highly realistic and variable features to mimic as closely as possible various emergency scenarios.

In 2015, the US National Council of State Boards of Nursing recommended that high-fidelity simulation could gainfully substitute up to 50% of clinical practice across the nursing curriculum. And in 2017 the medical journal JAMA published a review and meta-analysis of simulation use in training health professionals. The authors listed best practice points for optimal effectiveness: facilitated debriefing, in situ refresher training, distributed practice, curriculum integration, clinical variation, range of difficulty, individualised learning, multiple learning strategies, defined outcomes, and valid simulator.

Whilst most institutions accept that simulation has a significant role to play in both education and refresher training of doctors and nurses, they may lack the capital to purchase simulators, the technicians to maintain them, or the faculty to run the programs. In some cases, all three. Laerdal’s Simulation as a Service program is intended to help such institutions.

Also, the advances in video capture and data processing increase substantially the feedback that can be provided to trainees on their performance during not only simulation practice but also in the clinical environment to help close the circle between training and therapy. The leading provider of such services, B-line Medical, has now joined the Laerdal group of companies.

Ashley’s Story

Newly out of residency, Ashley van der Zee Ormsby RN, BSN, had no idea late one evening that she would be relying on her simulation training to ensure a patient’s very survival. The patient, just after emergency surgery, suffered a pulmonary embolism that sent him into cardiac arrest.

Crediting an identical case in her simulation training at Children’s Hospital, Washington State University, Ashley called a code, took the lead, and directed the delivery of CPR for 30 minutes. The patient survived.

Ashley van der Zee Ormsby
Photo: Washington State University College of Nursing

“Sim-based training has brought a new dimension to medical education in the last decade.”

Doris Østergaard
Director of Copehagen Academy for Medical Education and Simulation (CAMES)

At Your Service

Laerdal offers its Simulation as a Service program to the US healthcare companies, HealthTrust and Audacia, as part of their educational packages for healthcare institutions. Simulators and task trainers, a technician to run them, and a facilitator to assist the clinical educator are part of the service.

The Health Trust program focuses on bringing new nurses on board for medical, surgery and obstetrics, and transitioning registered nurses to ICU and ED. 7,000 nurses have been through their simulation program to date.

With the Nursing Anne simulator, Audacia delivers their HERUSA program covering heart failure, respiratory, urinary, sepsis and anemia.

Simulation as a Service has also proved popular in the UK and Australia where it has been recently introduced.

Seeing is Believing

What do you get when an aerospace engineer joins up with a computer technologist? Initially something quite mundane albeit useful, but something truly innovative and potentially lifesaving quickly emerges and then matures into what today allows the collection and streaming of live video into the Cloud opening the way for analysis with deep machine learning. Technology designed to provide feedback to human learners to improve both the quality of their education and continuous quality improvement of the delivery of care in the patient environment.

It was in 2003 that Lucas Huang, who worked on the Hubble Space Telescope for NASA, met up with Chafic Kazoun, a technology leader at a consulting company called B-Line Express (as in the shortest distance between two points) in Washington DC, USA. In 2004, they were asked to build a custom solution for facilitating OSCEs (objective structured clinical examinations) – the type of examination used to test clinical skill performance and competence. The solution had to be 100% web-based and as reliable as the paper-based exams. They were tasked with automating data and video capture, assessment, and all associated reporting and tracking. They both wanted to create great products and together started a new company called B-Line Medical and their first product, Clinical Skills, was born.

Over the next 14 years, B-Line Medical grew from a small startup with three US medical school clients to become the world’s leading provider of video-driven healthcare education solutions for both simulated and live clinical care environments.

Thanks to a smart dedicated team committed to the mission, B-Line Medical has secured an impressive and loyal clientele that now consists of over 500 hospitals, medical schools and nursing programs throughout the world. Clients in its home country include Mayo Clinic, Children’s Hospital of Philadelphia, Boston Children’s Hospital, Cleveland Clinic, Stanford University, Johns Hopkins University, Harvard University, and Yale University. In 2018, B-Line Medical launched the new SimCapture Cloud Platform, a game changer for healthcare simulation that offers a fully cloud-based software platform with a remarkably small onsite audio-visual footprint and affordable subscription pricing. And in 2019 it joined the Laerdal family of companies with a shared goal of helping improve healthcare quality.

A Long and Evolving Partnership

The American Academy of Pediatrics (AAP), an organisation of over 67,000 child health providers, was amongst the early adopters of simulation-based training when their Neonatal Resuscitation Program (NRP) Steering Committee decided in 2007 to transition future education program initiatives to this methodology. The result was SimNewB.

The collaboration around the NRP program led AAP to invite Laerdal to the NRP Global Implementation task force in 2009. This brought about the Helping Babies Breathe program and the establishment of Laerdal Global Health, as described in the next chapter.

The success of the collaboration motivated the partners to address needs in other AAP life support programs leading to co-development of Pediatric Life Support Scenarios, and Pediatric Education for pre-hospital personnel with the SimJunior pediatric simulator (representing a 6-year old), and Premature Anne. Several self-directed programs followed including Simply NRP for parents and other family members, and an e-learning component for the NRP program.

This long partnership is still evolving with application of low-dose, high-frequency training to improve baby and infant programs.

Improving the Care of Mothers and Babies

Maternal and infant mortality has been reduced significantly over the last few years but there is room for further improvement. Saving the lives of mothers and babies in low-resource settings will be addressed in the next chapter. Here, the focus will be on what can be done in high-resource settings – there is room for improvement there as well. For example, although the USA spends 18% of its national income on health care, its maternal mortality rate has more than doubled from 10.3 per 100,000 live births in 1991 to 23.8 in 2014: over 700 deaths per annum, and of these, two thirds are preventable.

In the first decade of this millennium, Laerdal introduced its first high-fidelity infant and newborn simulators, SimBaby and SimNewB. These were developed in close collaboration with the AHA and the American Academy of Pediatrics (AAP) for their respective Pediatric Advanced Life Support (PALS) course and
Neonatal Resuscitation Program (NRP). The collaboration with the AAP led to the development of the 25-week old premature baby simulator, Premature Anne. When introduced in 2016, this was the first high-fidelity simulator for premature babies, focusing on improving the airway management skills that are critical to saving these tiny lives.

Substantial efforts have recently gone into developing second generation versions of both SimBaby and SimNewB to bring their features up to date with the latest needs. Highly realistic airways and external appearance, user feedback, and wireless operation improve the learning experience. SimBaby Tracheostomy has also been introduced to train parents and caregivers of children with compromised airways.

Over the last decade, Laerdal has worked with the UK Bristol-based company, Limbs & Things, to develop the SimMom birthing simulator. This evolved from combining two products – Laerdal’s ALS Simulator and Limbs & Things’ PROMPT birthing simulator – providing users with both anatomical accuracy and authentic simulation of emergencies such as postpartum haemorrhage, uterine inversion, and maternal collapse.

SimNewB, one of several newborn simulators developed in collaboration with representatives of the AAP newborn resuscitation committee.

“The Helping Babies Breathe program has helped save tens of thousands of newborns from birth asphyxia.”

Janna Patterson
SVP, Global Child Health & Life Support at American Academy of Pediatrics

From the Classroom to the Bedside

Doctors and nurses are commonly expected to step straight from school into practice with little subsequent attention to improving skills.

The shortcomings in training programs for “onboarding” new nurses have been glaring: a US study showed that 75% of new nurses were observed to commit medical errors. Nurses who lack confidence are more likely to leave their jobs – and in the US 34% of new nurses do so by the end of their second year. Replacing them is costly and patient safety is affected by this high attrition. To address this, in 2015 the US National League for Nursing (NLN) and Laerdal developed the Education Solution for Nursing program.

That same year, the NLN collaborated with the Ministry of Education in China to develop a multi-year plan for introducing simulation-based education in several hundred nursing schools. Also, in 2019 a Memorandum of Understanding was established between Laerdal Medical India, SAFER simulation centre in Stavanger, and the India Nursing Council to join forces to introduce simulation-based training initially in 2,500 of the nursing schools in India.

Another interesting dimension is inter-professional education. Students rarely have the chance to train with other professions, but the day they start working they are expected to work in teams in critical situations. Simulation training can help prepare them, improve their confidence and close the transition gap. Digital self-directed learning can significantly reduce the time required for campus and clinical training, supplemented by teamwork on patient cases and peer-to-peer learning. This process is an impressive cost cutter: whereas the faculty student ratio has traditionally been 1:3, the ratio for peer-to-peer simulation is 1:18. A comprehensive package of scenarios is now available for
nursing schools.

A woman pushing a Anne Simulator doll in a wheelchair.

Nursing Anne Simulator. Exchangeable parts allow it to be used for training in the care of patients of varying ages and ethnicity.

“The impact goal is better patient care, but the programe will also significantly reduce cost for
the employer.”

Beverly Malone
CEO of National League for Nursing

The International Year of the Nurse and Midwife

2020 has been designated by the World Health Organization (WHO) as the International Year of the Nurse and the Midwife. The WHO recognises that nurses and midwives play a vital role in providing health services. These are the people who devote their lives to caring for mothers and children giving lifesaving immunisations and health advice, looking after older people, and generally meeting everyday essential health needs. They are often the first and only point of care in their communities. The world needs 9 million more nurses and midwives if it is to achieve universal health coverage in accordance with SDG3 by 2030.

Safe Anaesthesia and Surgery

According to the Lancet Commission on Global Surgery, five billion people – two thirds of the global population – lack access to safe and affordable anaesthesia and surgery. Clinical conditions requiring surgical, obstetric, and anaesthesia services amount to 30% of the global disease burden; however, surgical care remains the most neglected area of global health with less than 1% of global health funding.

Laerdal is a global Impact Partner of the World Federation of Societies of Anaesthesiologists (WFSA). The Laerdal Foundation awarded a grant to the WFSA to introduce in 2017-18 its Safer Anaesthesia from Education (SAFE) program in Tanzania, Bangladesh, Nepal, and Zambia. The success of this initiative – with 320 anaesthesia providers trained – led to the Foundation providing further funding for WFSA to scale up implementation in India and Tanzania. This second phase also includes the VAST program in which WFSA is trialling new educational approaches including team-based simulation training in selected health facilities.

The Foundation has also supported a consensus meeting on metrics and reporting criteria for improving patient safety during surgery, obstetrics, and anaesthesia held at the Utstein Abbey, outside Stavanger, Norway. The participants concluded that the same evidence-based rigour and consensus that has been at the core of other Utstein topics such as out-of-hospital cardiac arrest is crucial.

A challenging setting for safe anesthesia.

“Two thirds of the global population lack access to safe and affordable anesthesia and surgery. WFSA is committed to change this situation.”

Jannicke Mellin-Olsen
WFSA President

A Shining Example

It was in 2005 that SAFER, the Stavanger Acute medicine Foundation for Education and Research, was founded around a simulation centre in a collaboration between Stavanger University Hospital (SUS), the University of Stavanger and Laerdal. During its first 15 years it has made great progress in meeting its prime goal to improve patient safety and strengthen competence among health workers. By 2020, over 250 facilitators are active in running more than 50 educational programs at the centre.

SAFER’s original purpose was to serve the needs of its founding partners. Indeed, it has proved an invaluable resource for SUS. In 2018 alone, there were over 45,000 hours of simulation training of SUS healthcare personnel – 27,000 at SAFER, 18,000 in the hospital itself. SUS now leads the league table for quality care in Norway. Its approach to healthcare quality improvement has simulation training at its core for a range of time critical emergencies. One example of this excellence is its approach to dealing with the victims of stroke. A revised treatment protocol in combination with on-site simulation-based team training sessions brought the time from entering the hospital to treatment down to a remarkable average of 13 minutes compared with the generally accepted standard of under 60 minutes.

This successful program with SUS has enhanced SAFER’s standing throughout Norway leading to a request from the Norwegian health authorities for SAFER to assume the role of the national centre of excellence in simulation.

Its research activities have gained scope and momentum, with a steady stream of PhDs and over 100 peer-reviewed publications. It has played a key role, and continues to do so, in the Safer Births research program with Haydom Lutheran hospital in rural Tanzania described in the next chapter.

Moreover, the roll-out of SAFER’s educational methodologies has started in South East Asia and several African countries. For example, in India, SAFER and Laerdal are implementing a cascade model for simulation training targeted at the 550 medical and 6000 nursing schools in the country in partnership with the Indian Nursing Council and SGT University in Delhi.

Elsa Søyland, Executive Director of SAFER, leads a simulation session.

A group of doctors preforming nurse training in India

India: The Seeds Have Been Planted

The sub-continent of India has close to 20% of the world’s population and is the world’s fifth largest economy. But it only spends about 3.7% of its national income on health care including private expenditure equating to $300 per person compared with the $6,000 that Norway spends per inhabitant. This difference in expenditure is reflected in the comparative numbers of nurses per thousand population – 1.4 in India vs 17.5 in Norway. But things are changing quickly. Over the last five years, India had the world’s fastest growing economy. Half of its population is under 25 years of age and India has the greatest number of software developers – exceeding 5 million. This will have a huge impact on its ability to deliver solutions that benefit the health of the population.

Laerdal’s involvement in India has also developed considerably over the last decade. Until then its products were sold through distributors in small quantities not tailored for local needs. The first Laerdal seed was planted in India in 2010 when Laerdal Medical India was established in Chennai with a small sales organisation, followed by Laerdal Global Health (LGH) setting up a small R&D team in Pune. With this closeness to the users, LGH was able to develop a product that met the needs of babies to survive and thrive – an innovative low-cost preterm wrap worn by the mother to keep her baby warm by skin-to-skin contact even whilst working. In 2016, LGH joined with Laerdal Medical India and opened offices in New Delhi and then Mumbai with a total staff now of 40. Partnerships followed with the Indian Nursing Council, Jhpiego and SGT University in Delhi to open the first National Reference Simulation Centre for Nursing in India; and with several medical and nursing universities promoting simulation-based education.

In 2017 a team of software engineers was established in Bangalore – the software capital of India – out of a co-operation with an established local software company, Impelsys. Laerdal Bangalore has since grown to about 200 developers with 35 directly employed by Laerdal, the others being a flexible resource from Impelsys. In addition to working on projects with other Laerdal companies, they have developed a new platform for the 2020 version of the Resuscitation Quality Improvement program of the AHA-Laerdal joint venture, RQI Partners.

Advanced programs for nurse training in India.

“India may be a land of over hundred problems, but it is also a place for a billion solutions.”

Kailash Satyarthi
Nobel Peace Laureate 2014

Responding to the Pandemic

As this book goes to press the world is in the middle of a pandemic of the new coronaviral disease, COVID-19. Although the disease has passed its peak in some countries, in others, especially in South Asia, Africa and South America, weekly cases and deaths are still increasing. LMICs now account for three-quarters of the 100,000 plus new cases per day. On current trends, deaths in cases where the presence of the virus has been confirmed will exceed 600,000 by end July, but this is almost certainly a significant underestimate of the impact because of underreporting, underdiagnosis and “indirect” deaths due to patients being unwilling to seek medical treatment during the pandemic for emergencies such as cardiac arrest and stroke. The true figure may well exceed one million.

Many countries went into lockdowns to limit the spread of the disease, but as they come out of these lockdowns there are concerns about subsequent waves of the disease. These are likely unless effective vaccines are developed, or the virus disappears naturally. For “herd immunity” to be achieved, it will be necessary to vaccinate billions of people. Gavi, the global vaccine alliance, is committed to helping make this happen and has partnered with Laerdal to make its training and quality assurance solutions more effective.

The economic impact of the lockdowns has been severe with many companies having to lay-off large numbers of staff. For Laerdal, its traditional training products have been seriously affected with classroom activities suspended, but this has been partially offset by a greater demand for respiratory therapy and training products. Also, the company’s RQI and e-learning solutions have proven beneficial to customers to limit social contact. Complimentary scenarios were developed very rapidly to assist healthcare personnel, especially those returning to clinical practice, in preparing for and dealing with COVID-19 patients. Given the severe effect of the coronavirus on the lungs of some patients, the ASL 5000 Lung Solution from Laerdal’s partner, Ingmar Medical, used in conjunction with its patient simulators and free training scenarios, has proved very valuable.

In the absence of face-to-face contact, webinars have been organised to assist users in implementing the new scenarios,
and on May 28th Laerdal hosted the first virtual Simulation User Network Conference. Over 3000 participants from 80 countries had presentations from experts from Stavanger, Copenhagen, London and New York on their experiences using simulation to address the challenges of COVID-19.

Enhancing Vaccination

On June 4th, 2020, Laerdal and Gavi, the global vaccine alliance, announced a new partnership to enhance and monitor frontline healthcare worker vaccination performance using innovative educational and digital technologies.

Gavi was formed in 2000 as the Global Alliance for Vaccines and Immunization and has since helped vaccinate nearly 800 million children and save more than 13 million lives. But it is estimated that 1.5 million children still die each year due to causes that could have been prevented if they were vaccinated. Gavi spends over $ 100m each year on training of frontline health professionals and implementing vaccine programs in low-resource countries, but despite these investments there is limited evidence of the impact on healthcare worker performance. Having taken note of the contributions of Laerdal Global Health to the Helping Babies Survive programs and the collaboration with the Global Finance Facility, Gavi invited Laerdal’s assistance to make its training and quality assurance solutions more effective. This will be achieved through simulation training and skills management, with digital solutions capturing data for quality assurance and needs-based refresher training. This overlaps a lot with solutions Laerdal has already made and wishes to develop further including the Safer Births and RQI programs.

Developing an Emergency Ventilator in Record Time

In the early phases of the pandemic in March 2020, there was a great concern that healthcare facilities would be overwhelmed and there would be insufficient ventilators for treating seriously ill patients. Several countries, including Norway, put out requests for companies to fast-track development and manufacture of emergency ventilators. Laerdal and Servi AS, another Norwegian company, responded to the request and with advice from clinical experts at Stavanger University Hospital, Oslo University and the Norwegian Armed Forces developed in record time an emergency ventilator based around a specification drawn up by the UK Department of Health. The system incorporates the widely-used Laerdal Silicone Resuscitator with O₂ reservoir system, a peep valve adjustable from 5 – 20 cm H₂0, a pressure relief valve and alarm, and a heat and moisture exchange filter. It includes a mechanical arm and high-quality motor and control electronics to compress the resuscitator bag and deliver accurately the required volume of oxygen at the appropriate rate.

The device has been designed for simple and safe operation to facilitate its use by the new categories of healthcare personnel that it was thought would be required, and may still be required in some countries, for assisting in the treatment of a growing number of COVID-19 patients. Together with the SAFER simulation centre in Stavanger, Laerdal also developed a specific training program.

Following recommendations from the clinical experts, the Norwegian health authorities placed an order for 1,000 units for deployment in hospitals throughout the country by June 1st. This effectively doubled the number of available ventilators in Norway.

As it turned out, actions taken in Norway to control the spread of the disease meant that the initial capacity of intensive care beds and ventilators was enough to meet the need. However, the ventilators remain available in the event of a second wave of the disease or for countries in greater need.

The ventilator has a lower production cost than traditional intensive care ventilators. Laerdal and Servi expect that further industrialization and higher-scale manufacture will make it more affordable for low-and middle-income countries where the pandemic has not yet reached its peak.