Aerosol Box Use in Reducing Health Care Worker Contamination During Airway Procedures (AIRWAY) Study: Secondary Workload and Provider Outcomes in a Simulation-Based Trial.

OBJECTIVES: An aerosol box aims to reduce the risk of healthcare provider (HCP) exposure to infections during aerosol generating medical procedures (AGMPs), but little is known about its impact on workload of team members. We conducted a secondary analysis of data from a prospective, multicenter, randomized controlled trial evaluating the impact of aerosol box use on patterns of HCP contamination during AGMPs. The objectives of this study are to: 1) evaluate the effect of aerosol box use on HCP workload, 2) identify factors associated with HCP workload when using an aerosol box, and 3) describe the challenges perceived by HCPs of aerosol box use. DESIGN: Simulation-based randomized trial, conducted from May to December 2021. SETTING: Four pediatric simulation centers. SUBJECTS: Teams of two HCPs were randomly assigned to control (no aerosol box) or intervention groups (aerosol box). INTERVENTIONS: Each team performed three scenarios requiring different pediatric airway management (bag-valve-mask [BVM] ventilation, laryngeal mask airway [LMA] insertion, and endotracheal intubation [ETI] with video laryngoscopy) on a simulated COVID-19 patient. National Aeronautics and Space Administration-Task Load Index (NASA-TLX) is a standard tool that measures subjective workload with six subscales. MEASUREMENTS AND MAIN RESULTS: A total of 64 teams (128 participants) were recruited. The use of aerosol box was associated with significantly higher frustration during LMA insertion (28.71 vs. 17.42; mean difference, 11.29; 95% CI, 0.92-21.66; p = 0.033). For ETI, there was a significant increase in most subscales in the intervention group, but there was no significant difference for BMV. Average NASA-TLX scores were all in the "low" range for both groups (range: control BVM 23.06, sd 13.91 to intervention ETI 38.15; sd 20.45). The effect of provider role on workloads was statistically significant only for physical demand (p = 0.001). As the complexity of procedure increased (BVM → LMA → ETI), the workload increased in all six subscales (p < 0.05). CONCLUSIONS: The use of aerosol box increased workload during ETI but not with BVM and LMA insertion. Overall workload scores remained in the "low" range, and there was no significant difference between airway provider and assistant.

Aerosol Box Use in Reducing Health Care Worker Contamination During Airway Procedures (AIRWAY Study): A Simulation-Based Randomized Clinical Trial.

Importance: The aerosol box has been used during the management of patients with COVID-19 to reduce health care practitioner (HCP) exposure during aerosol-generating medical procedures (AGMPs). Little is known about the effect of aerosol box use on HCP contamination and AGMP procedure time. Objective: To investigate whether use of an aerosol box during AGMPs reduces HCP contamination or influences the time to successful completion and first-pass success rate for endotracheal intubation (ETI) and laryngeal mask airway (LMA) insertion. Design, Setting, and Participants: This multicenter, simulation-based, randomized clinical trial was conducted from May to December 2021 at tertiary care pediatric hospitals. Participant teams performed 3 simulated patient scenarios: bag-valve-mask ventilation, ETI, and LMA insertion. During the scenarios, aerosols were generated using Glo Germ. Teams of 2 HCPs were randomly assigned to control (no aerosol box) or intervention groups (aerosol box). Statistical analysis was performed from July 2022 to February 2023. Interventions: The aerosol box (or SplashGuard CG) is a transparent, plastic barrier covering the patient's head and shoulders with access ports allowing HCPs to manage the airway. Main Outcomes and Measures: The primary outcome was surface area of contamination (AOC) on participants. Secondary outcomes were time to successful completion and first-pass success rates for ETI and LMA insertion. Results: A total of 64 teams (128 participants) were enrolled, with data from 61 teams (122 participants) analyzed. Among the 122 participants analyzed, 79 (64.8%) were female and 85 (69.7%) were physicians. Use of an aerosol box was associated with a 77.5% overall decreased AOC to the torso (95% CI, -86.3% to -62.9%; P < .001) and a 60.7% overall decreased AOC to the facial area (95% CI, -75.2% to -37.8%; P < .001) in airway HCPs. There was no statistically significant difference in surface contamination after doffing personal protective equipment between groups. Time to completing ETI was longer in the aerosol box group compared with the control group (mean difference: 10.2 seconds; 95% CI, 0.2 to 20.2 seconds; P = .04), but there was no difference between groups for LMA insertion (mean difference: 2.4 seconds; 95% CI, -8.7 to 13.5 seconds; P = .67). Conclusions and Relevance: In this randomized clinical trial of aerosol box use in AGMPs, use of an aerosol box reduced contamination deposition on HCPs' torso and face predoffing; the use of an aerosol box delayed time to successful intubation. These results suggest that the incremental benefits of reduced surface contamination from aerosol box use should be weighed against delayed time to complete intubation, which may negatively affect patient outcome. Trial Registration: ClinicalTrials.gov Identifier: NCT04880668.

Validation of a 3-Dimensional-Printed Infant Tibia for Intraosseous Needle Insertion Training.

INTRODUCTION: Current bone models used for pediatric intraosseous (IO) placement training are expensive or lack anatomic and/or functional fidelity. This technical report describes the development and validation of a 3-dimensional printed (3DP) tibia from a pediatric lower extremity computed tomography scan for IO procedural training. METHODS: Multiple 3DP tibia models were printed using a dual-extrusion fused-filament fabrication printer. Models underwent iterative optimization until 2 final models, one of polypropylene (3DP clear) and the other of polylactic acid/polypropylene (3DP white), were selected. Using an exploratory sequential mixed-methods design, a novel IO bone model assessment tool was generated. Physicians then used the assessment tool to evaluate and compare common IO bone models to the novel 3DP models during IO needle insertion. RESULTS: Thirty physicians evaluated the provided pediatric IO bone models. Compared with a chicken bone as a reference, the 3DP white bone had statistically significantly higher mean scores of anatomy, heft, sense of being anchored in the bone, quality of bone resistance, and "give" when interfaced with an IO needle. Twenty-two of the 30 participants ranked the 3DP white bone as either 1st or 2nd in terms of ranked preference of pediatric IO bone model. A 3DP white bone costs $1.10 to make. CONCLUSIONS: The 3DP IO tibia models created from real-life computed tomography images have high degrees of anatomic and functional realism. These IO training models are easily replicable, highly appraised, and can be printed at a fraction of the cost of commercially available plastic models.

The Addition of Anaerobic Blood Cultures for Pediatric Patients with Concerns for Bloodstream Infections: Prevalence and Time to Positive Cultures.

Anaerobes are an important but uncommon cause of bloodstream infections (BSIs). For pediatric patients, routine inclusion of an anaerobic blood culture alongside the aerobic remains controversial. We implemented automatic anaerobic blood culture alongside aerobic blood cultures in a pediatric emergency department (ED) and sought to determine changes in recovery of obligate and facultative anaerobes. This was a cohort study in a pediatric ED (August 2015 to July 2018) that began in February 2017. Blood culture positivity results for true pathogens and contaminants were assessed, along with a secondary outcome of time to positivity (TTP) of blood culture. A total of 14,180 blood cultures (5,202 preimplementation and 8,978 postimplementation) were collected, with 8.8% (456) and 7.1% (635) positive cultures in the pre- and postimplementation phases, respectively. Of 635 positive cultures in the postimplementation phase, aerobic blood cultures recovered 7.6% (349/4,615), whereas anaerobic blood cultures recovered 6.6% (286/4,363). In 211/421 (50.0%) paired blood cultures, an organism was recovered in both cultures. The number of cases where organisms were only recovered from an aerobic or an anaerobic bottle in the paired cultures were 126 (30.0%) and 84 (20.0%), respectively. The TTP was comparable regardless of bottle type. Recovery of true pathogens from blood cultures was approximately 7 h faster than recovery of contaminants. Although inclusion of anaerobic blood cultures only recovered 2 (0.69%) obligate anaerobes, it did allow for recovery of clinically significant pathogens that were negative in aerobic blood cultures and supports the routine collection of both bottles in pediatric patients with a concern of bloodstream infections.