Infection Safety: In-Person Simulation Activities

Many simulation programs closed or limited their in-person simulation activities as the global Covid-19 pandemic began to spread throughout the world.  During this time, many simulationists provided invaluable service to their institutions via on-line, individual, advisory or other modalities.  In many places, in-person simulation activities are beginning to reopen, and the simulation community is developing and implementing safety plans to limit or prevent the spread of infection in their programs.  As simulation activities vary by locale, participant groups, institution type, location of activities, supplies and equipment it would be difficult for any one set of guidelines or protocols to satisfy every need.

The concepts of confidentiality contracts and fiction contracts are familiar to simulationists; we propose adding a safety contract. The educator or institution provides explicit information about what they are doing to maintain safety, and what is required of those who participate. The safety contract can be communicated via pre-course announcements, email or website postings, and reinforced at the start of the activity.

Here we attempt to present a framework for thinking about infection safety, especially with respect to the SARS-COV-2 virus, in the coming days. We have borrowed, in part, some of these ideas from an interview of Asaf Bitton, MD at Ariadne Labs and an article by Atul Gawande, also of Ariadne Labs at the Harvard School of Public Health in Boston.  Both articles were published in the New Yorker Magazine: Bitton and Gawande, respectively.

This framework is based on five elements each starting with the letter D :  Demographic, Density, Duration, Distance, and Disinfection.


One critical step in developing an infection safety strategy is to consider the characteristics of the participants and staff.   There may be people with vulnerabilities; how can you maintain safety while respecting their privacy? Are the people in this group living and working in a “hot spot” for covid-19?  How will you respond to an increase in community infection rate?  What factors will you consider when deciding whether to cancel or modify your program? How do you reliably and consistently check those thresholds and actualize a change in your program?   Are there factors such as sick leave policies or program deadlines that would inhibit staff and participants from staying home when they are not well? Are the participants working in places where they are at particular risk?  Which health screening method will you use and how will you respond to a positive screen? Are you checking temperature?Can you align your program with existing resources such as occupational health or student health services?

Density: Greater numbers of people involved in a simulation activity can create greater risk. Are there ways to minimize the density of people?  Will staggering the participants into smaller groups be helpful?  Can the physical space elements such as seats, tables, screens, stations be adapted to reduce density?

Duration:  The duration of exposure to potential sources of infection seems to be a critical variable in the risk equation.  Can you minimize the time that participants are in close contact?  Can some parts of the simulation be done remotely without losing effectiveness?

Distance:  Though six feet or two meters is the “social distance” standard, the actual transmission distance for SARS-COV-2 infections is situation dependent.  People speaking loudly or shouting is greatly different than people speaking softly through masks.  Can maximal distances between people be achieved and maintained for most of the simulation activity?  Are there particular parts of the event that naturally will decrease the safe distancing that could be mitigated by changes in layout, supplies, barriers, or other means?   Consider how to manage food and drink.  Since masks would be removed, do you prohibit consumption of coffee/ snacks when groups are gathered for briefing and debriefing?

Disinfection:  The current public health guidance suggests there are two major routes of transmission, respiratory droplets and fomite transmission (touching a contaminated surface and then moving that contamination to the mouth, nose, or eyes).  Masks reduce the risk of respiratory transmission and much has been written about the relative effectiveness of different kinds of mask technology.  What kinds of masks will people use for the simulation activity?  Will they be provided?  Many areas are experiencing shortages of masks and it is important to choose the right device to protect participants while assuring adequate supplies are available for clinical use.   How will wearing them be encouraged and enforced?  Fomite transmission, while thought to be less likely than respiratory droplet transmission, is best limited by hand hygiene, appropriate use of gloves, and cleaning common surfaces.  What disinfection measures are in place that are reliable and consistent in your simulation activity?  Is there handwashing readily available?  Is hand sanitizer available when hand washing is unavailable or impractical?  Are gloves available and is there guidance on when they are required or recommended?  By what mechanism, soap and water, chemical (hypochlorite, alcohol, peroxide, etc.), radiation (ultraviolet), temperature (sterilization) will each surface and simulation accoutrement be cleaned and how often?


The challenge of providing care in this pandemic have only amplified the existing opportunities for simulation to improve our work.  The importance of overcoming new barriers to delivering training are especially profound now where both the benefit and the risk are increased.  We hope to have provided useful prompts for help simulationists plan a new and safe model of training.



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