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COVID 19 struck us all like a bolt of lightning and for the past 10 months, it has tested our resilience, agility, creativity, and adaptability in all aspects of our lives and work. Simulation centers and simulation-based educational programs have not been spared. Rather than wait for the pandemic to be over before commencing operations and training, we have been actively looking at programs, reviewing alternative methods such as e-learning, use of virtual learning platforms, decentralization of training using in situ simulation (ISS) modeling, partnerships with relevant clinical departments, cross-training of staff to attain useful secondary skills, and many other alternatives and substitutes. It has been an eye-opening journey as we maximize our staff's talent and potential in new adoptions and stretching our goals beyond what we deemed was possible. This paper shares perspectives from simulation centers; The SingHealth Duke NUS Institute of Medical Simulation which is integrated with an Academic Medical Center in Singapore, The Robert and Dorothy Rector Clinical Skills and Simulation Center, which is integrated with Thomas Jefferson University, Oakhill Emergency Department, Florida State University Emergency Medicine Program, Florida, USA and The Wellington Regional Simulation and skills center. It describes the experiences from the time when COVID 19 first struck countries around the world to the current state whereby the simulation centers have stWWarting functioning in their "new norm." These centers were representative examples of those in countries which had extremely heavy (USA), moderate (Singapore) as well as light (New Zealand) load of COVID 19 cases in the nation. Whichever categories these centers were in, they all faced disruption and had to make the necessary adjustments, aligning with national policies and advisories. As there is no existing tried and tested model for the running of a simulation center during an infectious disease pandemic, this can serve as a landmark reference paper, as we continue to fine-tune and prepare for the next new, emerging infectious disease or crisis., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Emergencies, Trauma, and Shock.)

Introduction: Medical clearance is required to label patients with mental illness as free of acute medical concerns. However, tests may extend emergency department lengths of stay and increase costs to patients and hospitals. The objective of this study was to determine how knowledgeable emergency and psychiatric providers are about the costs of tests used for medical clearance., Materials and Methods: We surveyed the department of psychiatry (Psych) and department of emergency medicine (EM) faculty and residents to obtain their estimates of the costs of 18 laboratory/imaging studies commonly used for medical clearance. Survey responses were analyzed using the Wilcoxon signed-rank test to compare the median cost estimates between residents and faculty in EM and Psych., Results: A total of 99 physicians (response rate, 47.8%) completed the survey, including 47 faculty (EM = 28; Psych = 20) and 52 residents (EM = 29; Psych = 23). Across all the groups, cost estimates for tests were inaccurate, off by several hundred dollars for three tests, and by $13-$80 for 15. Significant differences between EM and Psych providers for estimated median costs of specific tests included between residents for urine drug screens (EM: $800; Psych: $50; P < 0.0001) and ECG (EM: $25; Psych: $75; P = 0.004); between faculty for urinalysis (EM: $40; Psych: $18; P = 0.020) and urine drug screen (EM: $100; Psych: $10; P < 0.0001); and between all physicians for urine drug screen (EM: $500; Psych: $50; P < 0.0001)., Conclusion: Further education on the financial costs of medical clearance is needed to inform workup decisions and consensus between emergency and psychiatric providers., Competing Interests: There are no conflicts of interest.

Context: Over 6% of all emergency department (ED) visits in the United States involve primary mental health or behavioral issues. The patients are stabilized in the ED but frequently require admission to an inpatient psychiatric unit or institution for longer term treatment and management. To facilitate this process, an emergency physician (EP) must first "medically clear" the patient as stable for transfer. At present, there is no interdisciplinary consensus regarding the necessary elements of the medical clearance or stability assessment process. In addition to satisfy the vague requirement for medical clearance, the EP must abide by the rules of the inpatient facilities before his/her patient is accepted., Settings and Design: This manuscript summarizes the admission exclusionary criteria of inpatient psychiatric units in the Houston-Galveston metro area., Subjects and Methods: we pooled the exclusionary criteria of all the facilities patients with mental illness can be sent to in the Houston-Galveston metropolitan area, and divided those criteria by categories., Results: Pooled exclusionary criteria congregate into 1. preexisting or current medical condition and capabilities (e.g. hypertensive urgency, pregnancy, acute alcohol intoxication), 2. exclusionary criteria related to administrative burdens that may impact staffing or require advanced equipment/training e.g. autism spectrum disorders, intellectual disabilities, respiratory isolation or daily hemodialysis, 3. laboratory and ancillary testing required by inpatient facilities before acceptance of the patient., Conclusions: Of the inpatient units in the Houston-Galveston area, facilities lack a unified staffing model, ancillary services, but the various challenges (e.g., limited staffing and ancillary services) and different skills offered (e.g., geriatric care) are reflected in exclusionary criteria in a partially overlapping, but not fully uniform, way. The variation in number and kinds of exclusionary criteria further complicate the admission process and often serve as a bottleneck in the securing an inpatient bed., Competing Interests: There are no conflicts of interest.