Improving Emergency Department Airway Preparedness in the Era of COVID-19: An Interprofessional, In Situ Simulation.

Audience: The target audience for this airway simulation includes all emergency department (ED) staff who are potential members of a COVID-19 intubation team, including emergency medicine attendings, emergency medicine residents, nurses, respiratory therapists, pharmacists, and ED technicians. Introduction: As of May 7, 2020 there were 1,219,066 diagnosed cases of COVID-19 in the U.S. and 73,297 deaths.1 A special report from the Centers for Disease Control and prevention on infections in healthcare personnel reported 9,282 cases between February 12th and April 9th.2 Sars-CoV-2 is a novel virus that requires a careful, coordinated approach to airway management given the high risk of aerosolization.3 It is essential to train ED staff (1) to appropriately care for patients with suspected COVID-19 disease and (2) to provide an organized, safe working environment for providers during high-risk, aerosolizing procedures such as intubation. In addition to providing a set of airway management guidelines, we aimed to educate the staff through participation in a simulation activity. Due to the multiple team members involved and the array of equipment needed, an in-person in situ strategy was implemented. The goals of the simulation were to optimize patient care and minimize viral exposure to those involved during intubation. Educational Objectives: At the conclusion of the simulation session, learners will be able to: 1) Understand the need to notify team members of a planned COVID intubation including: physician, respiratory therapist, pharmacist, nurse(s), and ED technician. 2) Distinguish between in-room and out-of-room personnel during high-risk aerosolizing procedures. 3) Distinguish between in-room and out-of-room equipment during high-risk aerosolizing procedures to minimize contamination. 4) Appropriately select oxygenation therapies and avoid high-risk aerosolizing procedures. 5) Manage high risk scenarios such as hypotension or failed intubation and be prepared to give push-dose vasoactive medications or place a rescue device such as an I-gel ®. Educational Methods: This is a high-fidelity, interprofessional, in-situ simulation used to train a team of providers that would normally participate in the management of a patient with suspected COVID-19 requiring endotracheal intubation. Participants might include emergency medicine attendings, emergency medicine residents, nurses, respiratory therapists, pharmacists, and ED technicians. The patient is best represented by a high-fidelity mannequin such as Trauma HAL® (Miami, FL USA) https://www.gaumard.com/products/trauma/trauma-halr), with a monitor displaying vital signs and voice-response capabilities. The simulation includes an interprofessional debriefing session, during which an airway checklist, communication strategies, and best practices are reviewed. Research Methods: Airway management guidelines were developed by an interdisciplinary team at our institution. We used these guidelines from Stanford Health Care and best practices from a literature review to create a checklist of recommended steps. Two assessors used the checklist to track team actions. Any missed items were discussed in the team debrief and participants were encouraged to ask questions. At the end of the session, to check for understanding, participants were provided with a brief anonymous online survey accessed by a QR code. These assessments allowed the simulation team to iteratively edit the case before future simulations. Results: From 3/23/20-4/23/20, we held 12 in-situ simulations with 62 participants, including emergency medicine physicians, nurses, technicians, respiratory therapists, and pharmacists. Two individuals observed each simulation and compared team performance to the checklist of recommended steps. The actions that were not completed during the simulation served as teaching points during the simulation debrief. The debrief discussions helped to identify misconceptions regarding oxygenation strategies, difficulties in staff communication due to physical barriers, and various other quality or safety concerns. Participant reactions following the simulation and debriefs were overwhelmingly positive. Discussion: This simulation was an effective, easy-to-implement method of interprofessional team training for a risk-inherent procedure in the ED. We learned that the deliberate simulation of each step of the COVID19-specific intubation procedure with all team members provided opportunities to identify safety challenges in communication, equipment, and approach. Each debrief stimulated an excellent discussion among team members, and allowed for interprofessional feedback, clarification of questions, and recommendations for areas of improvement. Our main take-away from the pilot of this novel simulation case is that new, high-risk procedures require a coordinated team effort to minimize risks to patients and staff, and that team training is feasible and effective using frequent in situ simulations. Topics: Medical simulation, in-situ simulation, interprofessional, COVID-19, novel coronavirus, SARS-CoV-2, intubation, medical education, health professions education, team training, airway management.

Day of Ascent Dosing of Acetazolamide for Prevention of Acute Mountain Sickness.

Background: Acetazolamide is the most common medication used for prevention of acute mountain sickness (AMS), usually administered the day or night before ascent. The objective of this study was to evaluate the efficacy of day of ascent dosing of acetazolamide for AMS prevention. Methods: Double-blind, randomized, controlled noninferiority trial of acetazolamide 125 mg twice daily beginning either the night before or the morning of ascent. Healthy low altitude adults ascended from 1240 m (4100 ft) to 3810 m (12,570 ft) during summer 2018 on White Mountain, California. Primary outcome was incidence of AMS with the two different dosing patterns, assessed by the 1993 Lake Louise Questionnaire (LLQ) of ≥3 with headache and a minimum of 1 for other symptom. Results: One hundred four participants completed the study, with 54 (52%) randomized to night before acetazolamide and 50 (48%) to day of ascent dosing, without differences in baseline characteristics. There was 9% greater incidence of AMS in the day of ascent acetazolamide group (48.0% vs. 39%, 95% confidence interval [CI] -11.8 to 30, p = 0.46, number needed to treat [NNT] = 5.6 vs. 3.7), with the CI just surpassing the predetermined 26% noninferiority margin. There was a lower incidence of severe AMS (1993 LLQ >5) in the day of ascent group (n = 5, 10%, NNT = 2.3) compared with night before dosing (n = 12, 22%, NNT = 3.1) (95% CI -28 to 3.6), and lower average symptom severity in the day of ascent group (3 vs. 3.5, 95% CI -0.5 to 1.4). Conclusions: Day of ascent acetazolamide demonstrated higher rates of AMS compared with traditional dosing by a small margin. With similar rates of severe AMS and overall symptom severity, the potential for improved convenience and compliance may support day of ascent use.

Altitude Sickness Prevention with Ibuprofen Relative to Acetazolamide.

BACKGROUND: Acute mountain sickness is a common occurrence for travel to high altitudes. Although previous studies of ibuprofen have shown efficacy for the prevention of acute mountain sickness, recommendations have been limited, as ibuprofen has not been compared directly with acetazolamide until this study. METHODS: Before their ascent to 3810 m on White Mountain in California, adult volunteers were randomized to ibuprofen (600 mg, 3 times daily, started 4 hours before the ascent), or to acetazolamide (125 mg, twice daily, started the night before the ascent). The main outcome measure was acute mountain sickness incidence, using the Lake Louise Questionnaire (LLQ), with a score of >3 with headache. Sleep quality and headache severity were measured with the Groningen Sleep Quality Survey (GSQS). This trial was registered at ClinicalTrials.gov: NCT03154645 RESULTS: Ninety-two participants completed the study: 45 (49%) on ibuprofen and 47 (51%) on acetazolamide. The total incidence of acute mountain sickness was 56.5%, with the incidence for the ibuprofen group being 11% greater than that for acetazolamide, surpassing the predetermined 26% noninferiority margin (62.2% vs 51.1%; 95% confidence interval [CI], -11.1 to 33.5). No difference was found in the total LLQ scores or subgroup symptoms between drugs (P = .8). The GSQS correlated with LLQ sleep (r = 0.77; 95% CI, 0.67-0.84)=%. The acetazolamide group had higher peripheral capillary oxygen saturation than the ibuprofen group (88.5% vs 85.6%; P = .001). CONCLUSION: Ibuprofen was slightly inferior to acetazolamide for acute mountain sickness prevention and should not be recommended over acetazolamide for rapid ascent. Average symptoms and severity were similar between drugs, suggesting prevention of disease.