Factors affecting providers' comfort and fear during intubations of patients with COVID-19.

BACKGROUND: Providers performing endotracheal intubation are at high risk of contracting SARS-CoV-2. The objective was to assess various demographic, exposure and institutional preparedness factors affecting intubators' comfort and fear level during COVID-19 intubations. METHODS: We conducted a cross-sectional, survey-based study during the COVID-19 pandemic from September 2020 to January 2021 at a single academic medical centre in Washington, DC, USA. Inclusion criteria were healthcare providers who had an experience in intubating patients confirmed with or suspected of COVID-19. The survey assessed various factors related to the providers' comfort with intubation and fear during COVID-19 intubations. RESULTS: A total of 329 surveys from 55 hospitals were analysed. Of the respondents, 173 (52.6%) were from emergency medicine providers. Factors that were associated with a higher comfort level of intubating patients with COVID-19 included attending physician position (adjusted OR (aOR)=2.6, 95% CI 1.4 to 4.8; p=0.003), performing more than 20 COVID-19 intubations (aOR=3.3, 95% CI 1.5 to 6.6; p=0.002), participation in an intubation team (aOR=1.6, 95% CI 1.1 to 2.7; p=0.031) and adequate levels of personal protective equipment (PPE) (aOR=4.3, 95% CI 2.0 to 8.8; p<0.0005). Compared with emergency physicians, anaesthesiology providers had higher fear levels of contracting SARS-CoV-2 during both first and subsequent SARS-CoV-2 intubations (first: OR=1.7, 95% CI 1.1 to 2.6, p=0.006; subsequent: OR=2.0, 95% CI 1.4 to3.2, p<0.0005). CONCLUSION: A higher degree of comfort in intubating patients suspected of or confirmed with COVID-19 was demonstrated in more senior physicians, members of intubation teams, providers who performed a higher number of intubations and providers who reported adequate PPE. These findings highlight potential targets for improving the experience of providers in this setting.

Impact of COVID-19 specific simulation training in improving intubators' level of comfort during intubations of COVID-19 patients - Results from a USA national survey.

Background: Tracheal intubation is a hazardous aerosolizing procedure with a potential risk of spreading SAR-CoV-2 between patients and physicians. Aim: The purpose of this study was to explore the impact of COVID-19 specific simulation training in improving provider level of comfort during the intubation of COVID-19 patients. Methods: In this cross-sectional national study, an electronic survey was disseminated using a snowball sample approach to intubators from 55 hospitals across the United States. The survey assessed providers' comfort of intubating and fear of contracting the virus during COVID-19 intubations. Results: A total of 329 surveys from 55 hospitals were analyzed. Of 329 providers, 111 providers (33.7%) reported participating in simulation training. Of those, 86 (77.5%) reported that the simulation training helped reduce their fear of intubating COVID-19 patients. Providers in the simulation training group also reported a higher level of comfort level with intubating both general patients (median [range] no-simulation training group 9 [3-10], simulation training group 9 [6-10]; p = 0.015) and COVID-19 patients (no-ST 8 [1-10], ST group 9 [4-10]; p < 0.0005) than providers in the no-simulation training group. Conclusions: Our study suggests that COVID-19 specific intubation simulation training promotes provider comfort. Simulation training may be implemented as part of airway management training during the current and novel pandemic situations.

An Equitable Electronic Scheduling System for Anesthesiology Residents: A Quality Improvement Project.

BACKGROUND: Most postgraduate medical education occurs in hospitals in an apprenticeship model with actual patients. Creating a work shift schedule must account for complex factors, including hospital needs, work-hour restrictions, trainee qualifications, and case distribution in order to fairly allocate the resident workload. In this study, we report the first successful implementation of an equitable, computer-generated scheduling system for anesthesiology residents. METHODS: A total of 24 residents at a single, urban training program were surveyed in 2015 to rank work shift difficulty. Shifts were categorized and translated into a weighted point system by program leadership based on the survey results. An automated and modifiable scheduling system was created to incorporate rule-based assignment of prerequisites and evenly distribute points throughout the academic year. Point values were retrospectively calculated in 2014, and prospectively calculated from 2015 to 2018. The equality of variance test was used to evaluate the variation of the SD of monthly average point distributions year-over-year and within each class of trainees. RESULTS: Year-over-year analysis revealed that post-point system implementation, call point distribution trended toward reduced variance in all 4 years, with significant reductions of 63% in 2016 (SD 4.9, P < .01), and 57% in 2017 (SD 5.8, P < .01). Analyzed by class, first-year trainees' SD decreased by 73% in 2016 (SD 2.5, P < .01), by 67% in 2017 (SD 3.1, P < .04), and 65% in 2018 (SD 3.3, P < .02) compared with the pre-point system year in 2014. The second year clinical anesthesia resident class SD decreased by 56% in 2015 (SD 5.9, P < .01), 41% in 2016 (SD 7.9, P < .02), and 49% in 2017 (SD 6.9, P < .01). CONCLUSION: The computerized point system improved work distribution equity year-over-year and within trainee cohort groups.

Trauma in Obstetrical Patients.

INTRODUCTION: Pregnant trauma patients are an underdescribed cohort in the medical literature. Noting injury patterns and contributors to mortality may lead to improved care. METHODS: Female patients between 14 and 49 years of age were identified among entries in the 2017 National Trauma Data Bank. Data points were compared using Chi-square test, Fisher's exact test, Student's t-test, Mann-Whitney rank-sum, or multiple logistic regression as appropriate. P < 0.05 was used to determine the findings of significance. RESULTS: There were 569 pregnant trauma patients identified, which was 0.54% of the 105,507 women identified. Overall, mortality was low among all women and not different between groups (1.2% for pregnant women vs. 2.2% for nonpregnant, P = 0.12). Pregnant women with head injuries had a higher mortality rate than pregnant women without (4.2% vs. 0.47%, P < 0.01). Head injuries (Abbreviated Injury Severity Score [AIS] head >1) were associated with an increased risk for mortality (odds ratio: 3.33, 95% confidence interval: 3.0-3.7, P < 0.01). CONCLUSION: There was no increase in mortality for trauma patients who are pregnant when controlling for covariates. Factors such as head injuries, the need for blood, and comorbid diseases appear to have a more significant contribution to mortality. We also report the prevalence of head, cervical spine, and extremity injuries in pregnant trauma patients. Multidisciplinary simulation, jointly crafted protocols, and expanding training in regional anesthesia may be the next steps to improving care for pregnant trauma patients.

Overcoming Communication Barriers: An evaluation of communication devices for healthcare providers wearing powered air-purifying respirators (PAPRs).

Introduction: The COVID-19 pandemic has resulted in an increased use of Powered Air Purifying Respirators (PAPRs), by health care providers to mitigate the risk of viral transmission, especially for aerosol-generating procedures. In this study, we evaluate communication devices that could be used concurrently with PAPRs to promote improved communication. Methods: We tested two devices, a Bluetooth earpiece and a throat microphone that operated over mobile networks, against a control scenario in a simulated operating room environment with participants donning PAPRs. Participants read a short paragraph to each other, transcribed short phrases, and evaluated the scenarios according to speech intelligibility, ease of use, and comfort. Results: There were 30 participants of varying PAPR experience. The Bluetooth headset had the most accurate transcriptions, followed by control, and lastly the neckpiece (94.7%vs 88.4%vs 76%, p<0.001). Conclusion: Communication devices have the potential to bridge but also worsen communications barriers between providers donning PAPRs.

COVID-19 Intubation Safety: A Multidisciplinary, Rapid-Cycle Model of Improvement.

The COVID-19 pandemic has forced the health care industry to develop dynamic protocols to maximize provider safety as aerosolizing procedures, specifically intubation, increase the risk of contracting SARS-CoV-2. The authors sought to create a quality improvement framework to ensure safe practices for intubating providers, and describe a multidisciplinary model developed at an academic tertiary care facility centered on rapid-cycle improvements and real-time gap analysis to track adherence to COVID-19 intubation safety protocols. The model included an Intubation Safety Checklist, a standardized documentation template for intubations, obtaining real-time feedback, and weekly multidisciplinary team meetings to review data and implement improvements. This study captured 68 intubations in suspected COVID-19 patients and demonstrated high personal protective equipment compliance at the institution, but also identified areas for process improvement. Overall, the authors posit that an interdisciplinary workgroup and the integration of standardized processes can be used to enhance intubation safety among providers during the COVID-19 pandemic.

Evaluation of Knowledge Acquisition with a Practice Management Course for Anesthesiology Residents: A Pilot Study.

Physicians routinely rely on nontechnical skills-including leadership ability, managerial skills and financial considerations-when delivering patient care. Efficient practice management is a commonplace expectation of attending anesthesiologists, but there is no uniform residency training to foster the expertise required to succeed in this endeavor. The purpose of this study is to evaluate a novel practice management course for anesthesiology residents. METHODS: Senior anesthesiology residents (Clinical Anesthesia-3) at The George Washington University were eligible to participate in a 1-month Ambulatory Anesthesiology-Practice Management Rotation focusing on the acquisition of nontechnical skills and knowledge applicable to becoming an effective clinical leader. The rotation included 1-week service as operating room manager, completion of an online module, assigned readings with follow-up discussions, and completion of a billing and reimbursement exercise. The interventions, in aggregate, were measured with a preknowledge and a postknowledge test. RESULTS: Twelve residents out of 14 (86%) completed the preknowledge and postknowledge tests. Residents scored significantly higher on the postcourse exam (61.49%, SD 18.65%) than the pretest (42.7%, SD 12.7%) (P < .004). CONCLUSION: A curriculum designed to develop the practice management skills required of a physician anesthesiologist is feasible and effective at improving knowledge within a 1-month, senior resident rotation.

Report on Implementation, Use, and Sustainability of a Labor Epidural Service in Georgetown, Guyana.

BACKGROUND: The use of epidural analgesia for laboring women is generally unavailable at public hospitals in Guyana despite favorable utilization rates in private institutions. In 2014, a healthcare team completed a targeted mission aimed at neuraxial analgesia training of providers at the preeminent public hospital in Georgetown, Guyana. This study evaluates the impact of the training, including provider attitudes, use, and barriers. METHODS: A prospective, mixed methods study of all obstetric, nursing, and anesthesiology providers at Georgetown Public Hospital Corporation was completed. Quantitative assessment of the posttraining use of epidural analgesia at 2 and 6 months was documented. Provider surveys were distributed anonymously at 2 months posttraining. Targeted interviews were completed from a random sampling of providers at 6 months; qualitative analysis of interviews formulated the basis for reporting limitations and barriers. RESULTS: Providers surveyed included 7 anesthesia providers and 24 obstetrics providers. Respondents believed Guyanese women should be offered epidural analgesia (93%), epidurals could be performed safely (87%), and Guyana has the resources necessary for routine use (81%). In assessing epidural knowledge, anesthesia providers achieved 60% correct response rate compared to 84% among obstetrics providers. Nurse anesthetists placed 16 epidurals following training. However, placement ceased after 2 months. The largest barriers to placement were unavailable anesthesia staff (63%), lack of supplies (16%), and insufficient nursing staff to monitor patients with epidurals (11%). CONCLUSIONS: A 1-week mission achieved widespread Guyanese provider acceptance despite a lack of previous experience. However, barriers proved insurmountable to achieving a sustainable, independently functioning epidural analgesia program.

Anesthesiology Residents-as-Teachers Program: A Pilot Study.

BACKGROUND: The role of residents as teachers has grown over time. Programs have been established within various specialties to formally develop these skills. Anesthesiology residents are frequently asked to provide supervision for novice learners and have numerous opportunities for teaching skills and clinical decision making. Yet, there are no educational programs described in the literature to train anesthesiology residents to teach novice learners. OBJECTIVE: To explore whether a resident-as-teacher program would increase anesthesiology residents' self-reported teaching skills. METHODS: An 8-session interactive Anesthesiology Residents-as-Teachers (ART) Program was developed to emphasize 6 key teaching skills. During a 2-year period, 14 anesthesiology residents attended the ART program. The primary outcome measure was resident self-assessment of their teaching skills across 14 teaching domains, before and 6 months after the ART program. Residents also evaluated the workshops for quality with a 9-item, postworkshop survey. Paired t testing was used for analysis. RESULTS: Resident self-assessment led to a mean increase in teaching skills of 1.04 in a 5-point Likert scale (P < .001). Residents reported the greatest improvement in writing/using teaching objectives (+1.29, P < .001), teaching at the bedside (+1.57, P  =  .002), and leading case discussions (+1.64, P  =  .001). Residents rated the workshops 4.2 out of 5 (3.9-4.7). CONCLUSIONS: Residents rated their teaching skills as significantly improved in 13 of 14 teaching domains after participation in the ART program. The educational program required few resources and was rated highly by residents.