Strengthening Public Health Preparedness Through Simulation: Experience From a Multi-Agency Field Hospital in Island Malaysia

What We Already Know

What This Article Adds

Introduction

In mid-2021, Malaysia experienced a severe COVID-19 surge driven by the Delta variant. The Federal Territory of Labuan—an island with fewer than 100 000 residents and only one minor specialist hospital—was the first region to face this wave. Rapid escalation in severe cases overwhelmed local capacity, prompting the Ministry of Health Malaysia, supported by multiple agencies, to establish a 100-bed COVID-19 field hospital within Dewan Labuan Corporation.^1,2

Field hospitals present unique challenges, including unfamiliar layouts, rapid timelines, and teams composed of personnel with diverse backgrounds. Without structured preparation, these factors can threaten patient safety and system functionality. Simulation, traditionally used for clinical training, can also serve as a public health intervention—to stress-test systems, reveal vulnerabilities, and align workflows in crisis conditions.^3,4,5 This report described the use of simulation to prepare the Labuan Field Hospital prior to patient admissions.

Methods

Simulation Procedures

Seven simulation exercises were conducted in the week before the hospital opened. These included fire drills, patient collapse and resuscitation scenarios, oxygen outage response, emergency intubation, specimen transport and infection control, portable x-ray deployment, and volunteer integration. All exercises were conducted in the operational space using actual equipment. Each drill was followed by structured debriefing sessions. Key scenarios and system improvements are summarized in Table 1.

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Table 1.

Simulation Scenarios, Identified Issues, and System Improvements at Labuan Field Hospital.

Simulation scenario	System vulnerability identified	Corrective measure implemented
Oxygen outage response	Delay in identifying oxygen depletion; staff uncertain about switching protocols; backup supply points poorly marked	Backup cylinders redistributed and labeled; clear oxygen rotation protocol established; visual indicators placed at each ward
Patient collapse and resuscitation (Code Blue)	Confusion over team roles; delayed initiation of chest compressions; lack of code team identification	Rehearsed code blue flow; staff briefings before each shift
Emergency intubation in ICU tent	Airway equipment scattered; lack of designated airway cart; delays in securing drugs and monitoring	Pre-packed airway kits prepared; airway trolley stationed in ICU tent; clear zone markings for emergency procedures
Fire drill and evacuation	Evacuation routes poorly understood; chain of command unclear; delays in patient movement	Evacuation maps posted at key points; fire marshals designated; command hierarchy clarified with incident commander
Specimen transport and PPE workflow	Risk of contamination during handover; inconsistent donning/doffing of PPE; unclear transport path	Specimen transfer zones defined; PPE checkpoints established; standardized handover log introduced
Portable x-ray deployment	Delay in mobilizing machine; unclear responsibility for infection control after imaging	Radiography liaison officer appointed; designated imaging areas mapped; disinfection protocol rehearsed
Volunteer integration into care teams	Non-clinical staff hesitant, uncertain about scope of tasks; duplication of efforts with clinical staff	Orientation briefings for volunteers; task allocation defined; volunteers included in simulation drills for confidence-building

Results

Discussion

This short report demonstrates that structured simulation exercises can strengthen public health preparedness in resource-constrained and geographically isolated settings. The Labuan Field Hospital achieved favorable outcomes—zero in-hospital mortality despite high patient acuity—following pre-opening rehearsals that exposed and corrected latent system vulnerabilities. Similar experiences have been reported internationally, where simulation-based drills improved readiness and coordination in disaster or outbreak contexts.^{1 -3}

The primary outcomes showed that a rapidly deployed multi-agency hospital can operate safely if critical workflows are rehearsed in advance. The secondary outcomes highlighted the value of simulation for workforce integration: staff reported improved role clarity, communication, and confidence, which are crucial when teams are assembled from diverse backgrounds with little prior collaboration. These findings align with literature identifying simulation as an effective tool to build shared mental models and improve interprofessional teamwork.^4,6,7

Importantly, the simulations were low-fidelity but high-functionality—emphasizing systems testing over technical realism. This practical approach is adaptable and scalable for other Asia-Pacific contexts facing public health emergencies, particularly in island or rural regions where health resources are limited.

Overall, simulation should be considered not only as an educational strategy but also as a public health intervention integral to disaster response and health systems resilience.

Conclusion

Pre-activation simulation exercises at the Labuan COVID-19 Field Hospital enabled early identification of system gaps, improved inter-agency collaboration, and contributed to safe patient care during a critical surge. By rehearsing workflows and building shared mental models, the hospital achieved favorable outcomes with no in-hospital mortality despite high clinical acuity. This experience demonstrates that low-resource, functional simulation can serve as a strategic public health intervention to strengthen preparedness in island and resource-limited settings. Integrating simulation into disaster planning frameworks may enhance resilience and operational safety across the Asia-Pacific region.