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

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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

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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

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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.

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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

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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.

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.

Communicating with other Avatars: Text and Voice Chat

Avatar Movements: Walking, Running, Turning

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).

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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

watch Triage Tag Video

interact with notecards

make a notecard

listen to RumDum- assign ESI

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Instructors’ Guide

listen to RumDum- assign START color

sort a few RumDums by categories

At clothing/inventory teaching station

get some new clothes

put on new clothes with shoes

find a uniform

put on uniform

search for bought clothes in inventory

put on mask

put on goggles

put on gloves

put on HICS vest (behind uniforms)

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

decon showers (hint: they turn on!)

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

outdoor triage areas (series of tents)

HICS organizational chart

chemical spill (with fumes)

police car

helicopter

RL Hotwash

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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

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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

Wear Scrubs and PPE

Move mannequin patients

Listen to mannequin patient symptoms

Make Mannequin patient wear respiratory mask

Use Vitals Notecard

Use Triage Tags

Interact with Avatar Patients

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

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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

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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.

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

Recognize the two types of Patients: Mannequins and Avatar Patients

Interact with new resources

Interact with Oxygen tank

Interact with Heart Monitor

Use Hand Sanitizer: Gel in Gel Out

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)

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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/lesson-

2/HICS.ppt?attredirects=0

Lesson 2 – HICS quiz

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Instructors’ Guide

https://sites.google.com/a/play2train.us/private/va-pan-flu-exercise-script/lesson-

2/QuizQuestions2.doc?attredirects=0

Lesson2 – Web Quiz Set Up https://sites.google.com/a/play2train.us/private/va-pan-flu-exercise-script/lesson-

2/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/Lesson-

2Quiz_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/lesson-

6/MentalHealth.ppt?attredirects=0

Lesson 6 _vTrain Program Evaluation Instrument https://sites.google.com/a/play2train.us/private/va-pan-flu-exercise-script/lesson-

6/VTrainEval.doc?attredirects=0