Prospective observational study of gender and ethnicity biases in respiratory protective equipment for healthcare workers in the COVID-19 pandemic.

OBJECTIVE: To describe success rates of respiratory protective equipment (RPE) fit testing and factors associated with achieving suitable fit. DESIGN: Prospective observational study of RPE fit testing according to health and safety, and occupational health requirements. SETTING: A large tertiary referral UK healthcare facility. POPULATION: 1443 healthcare workers undergoing quantitative fit testing. MAIN OUTCOME MEASURES: Quantitative fit test success (pass/fail) and the count of tests each participant required before successful fit. RESULTS: Healthcare workers were fit tested a median (IQR) 2 (1-3) times before successful fit was obtained. Males were tested a median 1 (1-2) times, while females were tested a median 2 (1-2) times before a successful fit was found. This difference was statistically significant (p<0.001). Modelling each fit test as its own independent trial (n=2359) using multivariable logistic regression, male healthcare workers were significantly more likely to find a well-fitting respirator and achieve a successful fit on first attempt in comparison to females, after adjusting for other factors (adjusted OR=2.07, 95% CI): 1.66 to 2.60, p<0.001). Staff who described their ethnicity as White were also more likely to achieve a successful fit compared with staff who described their ethnicity as Asian (OR=0.47, 95% CI: 0.38 to 0.58, p<0.001), Black (OR=0.54, 95% CI: 0.41 to 0.71, p<0.001), mixed (OR=0.50 95% CI: 0.31 to 0.80, p=0.004) or other (OR=0.53, 95% CI: 0.29 to 0.99, p=0.043). CONCLUSIONS: Male and White ethnicity healthcare workers are more likely to achieve RPE fit test success. This has broad operational implications to healthcare services with a large female and Black, Asian and minority ethnic group population. Fit testing is imperative in ensuring RPE effectiveness in protecting healthcare workers during the COVID-19 pandemic and beyond.

Emergency Airway Management in Patients with COVID-19: A Prospective International Multicenter Cohort Study.

BACKGROUND: Tracheal intubation for patients with COVID-19 is required for invasive mechanical ventilation. The authors sought to describe practice for emergency intubation, estimate success rates and complications, and determine variation in practice and outcomes between high-income and low- and middle-income countries. The authors hypothesized that successful emergency airway management in patients with COVID-19 is associated with geographical and procedural factors. METHODS: The authors performed a prospective observational cohort study between March 23, 2020, and October 24, 2020, which included 4,476 episodes of emergency tracheal intubation performed by 1,722 clinicians from 607 institutions across 32 countries in patients with suspected or confirmed COVID-19 requiring mechanical ventilation. The authors investigated associations between intubation and operator characteristics, and the primary outcome of first-attempt success. RESULTS: Successful first-attempt tracheal intubation was achieved in 4,017/4,476 (89.7%) episodes, while 23 of 4,476 (0.5%) episodes required four or more attempts. Ten emergency surgical airways were reported-an approximate incidence of 1 in 450 (10 of 4,476). Failed intubation (defined as emergency surgical airway, four or more attempts, or a supraglottic airway as the final device) occurred in approximately 1 of 120 episodes (36 of 4,476). Successful first attempt was more likely during rapid sequence induction versus non-rapid sequence induction (adjusted odds ratio, 1.89 [95% CI, 1.49 to 2.39]; P < 0.001), when operators used powered air-purifying respirators versus nonpowered respirators (adjusted odds ratio, 1.60 [95% CI, 1.16 to 2.20]; P = 0.006), and when performed by operators with more COVID-19 intubations recorded (adjusted odds ratio, 1.03 for each additional previous intubation [95% CI, 1.01 to 1.06]; P = 0.015). Intubations performed in low- or middle-income countries were less likely to be successful at first attempt than in high-income countries (adjusted odds ratio, 0.57 [95% CI, 0.41 to 0.79]; P = 0.001). CONCLUSIONS: The authors report rates of failed tracheal intubation and emergency surgical airway in patients with COVID-19 requiring emergency airway management, and identified factors associated with increased success. Risks of tracheal intubation failure and success should be considered when managing COVID-19.

healthcareCOVID: a national cross-sectional observational study identifying risk factors for developing suspected or confirmed COVID-19 in UK healthcare workers.

OBJECTIVE: To establish the prevalence, risk factors and implications of suspected or confirmed coronavirus disease 2019 (COVID-19) infection among healthcare workers in the United Kingdom (UK). DESIGN: Cross-sectional observational study. SETTING: UK-based primary and secondary care. PARTICIPANTS: Healthcare workers aged ≥18 years working between 1 February and 25 May 2020. MAIN OUTCOME MEASURES: A composite endpoint of laboratory-confirmed diagnosis of SARS-CoV-2, or self-isolation or hospitalisation due to suspected or confirmed COVID-19. RESULTS: Of 6,152 eligible responses, the composite endpoint was present in 1,806 (29.4%) healthcare workers, of whom 49 (0.8%) were hospitalised, 459 (7.5%) tested positive for SARS-CoV-2, and 1,776 (28.9%) reported self-isolation. Overall, between 11,870 and 21,158 days of self-isolation were required by the cohort, equalling approximately 71 to 127 working days lost per 1,000 working days. The strongest risk factor associated with the presence of the primary composite endpoint was increasing frequency of contact with suspected or confirmed COVID-19 cases without adequate personal protective equipment (PPE): 'Never' (reference), 'Rarely' (adjusted odds ratio 1.06, (95% confidence interval: [0.87-1.29])), 'Sometimes' (1.7 [1.37-2.10]), 'Often' (1.84 [1.28-2.63]), 'Always' (2.93, [1.75-5.06]). Additionally, several comorbidities (cancer, respiratory disease, and obesity); working in a 'doctors' role; using public transportation for work; regular contact with suspected or confirmed COVID-19 patients; and lack of PPE were also associated with the presence of the primary endpoint. A total of 1,382 (22.5%) healthcare workers reported lacking access to PPE items while having clinical contact with suspected or confirmed COVID-19 cases. CONCLUSIONS: Suspected or confirmed COVID-19 was more common in healthcare workers than in the general population and is associated with significant workforce implications. Risk factors included inadequate PPE, which was reported by nearly a quarter of healthcare workers. Governments and policymakers must ensure adequate PPE is available as well as developing strategies to mitigate risk for high-risk healthcare workers during future COVID-19 waves.

A prospective, observational, cohort study of airway management of patients with COVID-19 by specialist tracheal intubation teams.

PURPOSE: Because of the anticipated surge in cases requiring intensive care unit admission, the high aerosol-generating risk of tracheal intubation, and the specific requirements in coronavirus disease (COVID-19) patients, a dedicated Mobile Endotracheal Rapid Intubation Team (MERIT) was formed to ensure that a highly skilled team would be deployed to manage the airways of this cohort of patients. Here, we report our intubation team experience and activity as well as patient outcomes during the COVID-19 pandemic. METHODS: The MERIT members followed a protocolized early tracheal intubation model. Over a seven-week period during the peak of the pandemic, prospective data were collected on MERIT activity, COVID-19 symptoms or diagnosis in the team members, and demographic, procedural, and clinical outcomes of patients. RESULTS: We analyzed data from 150 primary tracheal intubation episodes, with 101 (67.3%) of those occurring in men, and with a mean (standard deviation) age of 55.7 (13.8) yr. Black, Asian, and minority ethnic groups accounted for 55.7% of patients. 91.3% of tracheal intubations were performed with videolaryngoscopy, and the first pass success rate was 88.0%. The 30-day survival was 69.2%, and the median [interquartile range] length of critical care stay was 11 [6-20] days and of hospital stay was 12 [7-22] days. Seven (11.1%) MERIT healthcare professionals self-isolated because of COVID-19 symptoms, with a total 41 days of clinical work lost. There was one reported incident of a breach of personal protective equipment and multiple anecdotal reports of doffing breaches. CONCLUSION: We have shown that a highly skilled designated intubation team, following a protocolized, early tracheal intubation model may be beneficial in improving patient and staff safety, and could be considered by other institutions in future pandemic surges.

RéSUMé: OBJECTIF: En raison de l'augmentation anticipée du nombre de cas nécessitant une admission à l'unité de soins intensifs, du risque élevé de génération d'aérosols de l'intubation trachéale et des exigences spécifiques aux patients atteints du coronavirus (COVID-19), nous avons créé une équipe mobile dédiée pour l'intubation trachéale rapide (MERIT - Mobile Endotracheal Rapid Intubation Team) afin de garantir qu'une équipe hautement qualifiée puisse être déployée pour prendre en charge les voies aériennes de cette cohorte de patients. Notre objectif était de rapporter l'expérience et l'activité de notre équipe d'intubation ainsi que les devenirs des patients pendant la pandémie de COVID-19. MéTHODE: Les membres de l'équipe MERIT ont suivi un modèle d'intubation trachéale précoce basé sur un protocole. Pendant sept semaines autour du pic de la pandémie, des données prospectives ont été colligées concernant l'activité de la MERIT, les symptômes et diagnostics de COVID-19 parmi les membres de l'équipe, ainsi que les données démographiques, procédurales et les devenirs cliniques des patients. RéSULTATS: Nous avons analysé les données de 150 épisodes d'intubations trachéales initiales, dont 101 (67,3 %) survenus chez des hommes, avec un âge moyen (écart type) de 55,7 (13,8) ans. Les personnes noires, asiatiques et de minorités ethniques représentaient 55,7 % des patients. Au total, 91,3 % des intubations trachéales ont été réalisées par vidéolaryngoscopie, et le taux de réussite au premier essai était de 88,0 %. Le taux de survie à 30 jours était de 69,2 %, et la durée médiane (écart interquartile) de séjour aux soins intensifs était de 11 (6-20) jours et de 12 (7-22) jours à l'hôpital. Sept (11,1 %) professionnels de la santé de l'équipe MERIT se sont mis en auto-isolement en raison de symptômes de la COVID-19, pour un total de 41 jours de travail clinique perdus. Un incident de bris de stérilité de l'équipement de protection individuelle a été rapporté, et de multiples bris lors du déshabillage ont également été rapportés de façon anecdotique. CONCLUSION: Nous avons démontré qu'une équipe d'intubation désignée et hautement qualifiée, respectant un modèle d'intubation trachéale précoce basé sur un protocole, pourrait contribuer à améliorer la sécurité des patients et du personnel. La création d'une telle équipe est envisageable dans d'autres établissements lors de futurs épisodes pandémiques.

Developing and validating subjective and objective risk-assessment measures for predicting mortality after major surgery: An international prospective cohort study.

BACKGROUND: Preoperative risk prediction is important for guiding clinical decision-making and resource allocation. Clinicians frequently rely solely on their own clinical judgement for risk prediction rather than objective measures. We aimed to compare the accuracy of freely available objective surgical risk tools with subjective clinical assessment in predicting 30-day mortality. METHODS AND FINDINGS: We conducted a prospective observational study in 274 hospitals in the United Kingdom (UK), Australia, and New Zealand. For 1 week in 2017, prospective risk, surgical, and outcome data were collected on all adults aged 18 years and over undergoing surgery requiring at least a 1-night stay in hospital. Recruitment bias was avoided through an ethical waiver to patient consent; a mixture of rural, urban, district, and university hospitals participated. We compared subjective assessment with 3 previously published, open-access objective risk tools for predicting 30-day mortality: the Portsmouth-Physiology and Operative Severity Score for the enUmeration of Mortality (P-POSSUM), Surgical Risk Scale (SRS), and Surgical Outcome Risk Tool (SORT). We then developed a logistic regression model combining subjective assessment and the best objective tool and compared its performance to each constituent method alone. We included 22,631 patients in the study: 52.8% were female, median age was 62 years (interquartile range [IQR] 46 to 73 years), median postoperative length of stay was 3 days (IQR 1 to 6), and inpatient 30-day mortality was 1.4%. Clinicians used subjective assessment alone in 88.7% of cases. All methods overpredicted risk, but visual inspection of plots showed the SORT to have the best calibration. The SORT demonstrated the best discrimination of the objective tools (SORT Area Under Receiver Operating Characteristic curve [AUROC] = 0.90, 95% confidence interval [CI]: 0.88-0.92; P-POSSUM = 0.89, 95% CI 0.88-0.91; SRS = 0.85, 95% CI 0.82-0.87). Subjective assessment demonstrated good discrimination (AUROC = 0.89, 95% CI: 0.86-0.91) that was not different from the SORT (p = 0.309). Combining subjective assessment and the SORT improved discrimination (bootstrap optimism-corrected AUROC = 0.92, 95% CI: 0.90-0.94) and demonstrated continuous Net Reclassification Improvement (NRI = 0.13, 95% CI: 0.06-0.20, p < 0.001) compared with subjective assessment alone. Decision-curve analysis (DCA) confirmed the superiority of the SORT over other previously published models, and the SORT-clinical judgement model again performed best overall. Our study is limited by the low mortality rate, by the lack of blinding in the 'subjective' risk assessments, and because we only compared the performance of clinical risk scores as opposed to other prediction tools such as exercise testing or frailty assessment. CONCLUSIONS: In this study, we observed that the combination of subjective assessment with a parsimonious risk model improved perioperative risk estimation. This may be of value in helping clinicians allocate finite resources such as critical care and to support patient involvement in clinical decision-making.

Causal inference in perioperative medicine observational research: part 1, a graphical introduction.

Graphical models have emerged as a tool to map out the interplay between multiple measured and unmeasured variables, and can help strengthen the case for a causal association between exposures and outcomes in observational studies. In Part 1 of this methods series, we will introduce the reader to graphical models for causal inference in perioperative medicine, and set the framework for Part 2 of the series involving advanced methods for causal inference.

Causal inference in perioperative medicine observational research: part 2, advanced methods.

Although RCTs represent the gold standard in clinical research, most clinical questions cannot be answered using this technique, because of ethical considerations, time, and cost. The goal of observational research in clinical medicine is to gain insight into the relationship between a clinical exposure and patient outcome, in the absence of evidence from RCTs. Observational research offers additional benefit when compared with data from RCTs: the conclusions are often more generalisable to a heterogenous population, which may be of greater value to everyday clinical practice. In Part 2 of this methods series, we will introduce the reader to several advanced methods for supporting the case for causality between an exposure and outcome, including: mediation analysis, natural experiments, and joint effects methods.

SNAP-2 EPICCS: the second Sprint National Anaesthesia Project-EPIdemiology of Critical Care after Surgery: protocol for an international observational cohort study.

INTRODUCTION: The admission of high-risk patients to critical care after surgery is a recommended standard of care. Nevertheless, poor compliance against this recommendation has been repeatedly demonstrated in large epidemiological studies. It is unclear whether this is due to reasons of capacity, equipoise, poor quality clinical care or because hospitals are working creatively to create capacity for augmented care on normal surgical wards. The EPIdemiology of Critical Care after Surgery study aims to address these uncertainties. METHODS AND ANALYSIS: One-week observational cohort study in the UK and Australasia. All patients undergoing inpatient (overnight stay) surgery will be included. All will have prospective data collection on risk factors, surgical procedure and postoperative outcomes including the primary outcome of morbidity (measured using the Postoperative Morbidity Survey on day 7 after surgery) and secondary outcomes including length of stay and mortality. Data will also be collected on critical care referral and admission, surgical cancellations and critical care occupancy. The epidemiology of patient characteristics, processes and outcomes will be described. Inferential techniques (multilevel multivariable regression, propensity score matching and instrumental variable analysis) will be used to evaluate the relationship between critical care admission and postoperative outcome. ETHICS AND DISSEMINATION: The study has received ethical approval from the National Research Ethics Service in the UK and equivalent in Australasia. The collection of patient identifiable data without prior consent has been approved by the Confidentiality Advisory Group (England and Wales) and the Public Privacy and Patient Benefit Panel (Scotland). In these countries, patient identifiable data will be used to link prospectively collected data with national registers of death and inpatient administrative data. The study findings will be disseminated using a multimedia approach with the support of our lay collaborators, to patients, public, policy-makers, clinical and academic audiences.

Expression of the regeneration-associated protein SPRR1A in primary sensory neurons and spinal cord of the adult mouse following peripheral and central injury.

Small proline-rich repeat protein 1A (SPRR1A) is expressed in dorsal root ganglion (DRG) neurons following peripheral nerve injury but it is not known whether SPRR1A is differentially expressed following injury to peripheral versus central DRG projections and a detailed characterization of expression in sensory neuron subpopulations and spinal cord has not been performed. Here we use immunocytochemical techniques to characterize SPRR1A expression following sciatic nerve, dorsal root, and dorsal column injury in adult mice. SPRR1A was not detected in naïve spinal cord, DRG, or peripheral nerves and there was minimal expression following injury to the centrally projecting branches of DRG neurons. However, following peripheral (sciatic) nerve injury, intense SPRR1A immunoreactivity was observed in the dorsal horn and motoneurons of the spinal cord, in L4/5 DRG neurons, and in the injured nerve. A time-course study comparing expression following sciatic nerve crush and transection revealed maximum SPRR1A levels at day 7 in both models. However, while SPRR1A was downregulated to baseline by 30 days postlesion following crush injury, it remained elevated 30 days after transection. Cell-size and double-labeling studies revealed that SPRR1A was expressed by DRG cells of all sizes and colocalized with classical markers of DRG subpopulations and their primary afferent terminals. High coexpression of SPRR1A with activating transcription factor-3 and growth-associated protein-43 was observed, indicating that it is expressed by injured and regenerating neurons. This study supports the hypothesis that SPRR1A is a regeneration-associated gene and that SPRR1A provides a valuable marker to assess the regenerative potential of injured neurons.