Intubator Performance and Contamination with the Use of Barrier Enclosure Devices: Results from a Simulated COVID-19 Resuscitation.

INTRODUCTION: Medical institutions are using barrier enclosure devices during intubation procedures and other aerosol-generating medical procedures without evidence of their effectiveness or usability, potentially compromising patient care, and provider safety. Our objective was to determine the degree of protection offered by these devices and explore other usability factors for two popular barrier systems. METHODS: A simulated trial comparing an intubation box, a frame and plastic tarp system, and unprotected intubation was performed in an academic emergency department. Ten emergency physicians were recruited to participate. Our primary outcome was the degree of contamination from secretions measured by average surface area exposed to phosphorescent material. Secondary outcomes included: laryngoscopy time and time to barrier application, unsuccessful intubation attempts, and usability ratings for each system. Descriptive statistics were reported for all variables of interest and a linear mixed model was used to analyze contamination and laryngoscopy time. Usability was captured through electronic questionnaires using a five-point Likert scale. RESULTS: Contamination was more prevalent with the box, compared to the frame and tarp, and no device, however, this did not achieve statistical significance (13.2% versus 8.1% versus 12.2%, P = 0.17). A barrier system delayed intubation when compared to using no system (no system = 24.4 s [95% CI 17.3-27.5], frame = 54.4 s [95% CI 13.8-95.0], box = 33.8 s [95% CI 21.4-46.1], P = 0.02). In assessing usability, 30% of users preferred the use of a box barrier, 40% of users preferred the frame, and 30% would not use either in future intubation. CONCLUSIONS: Compared to no barrier protection, an intubation box enclosure offers limited additional protection. A frame and tarp system reduces exposure at the expense of visibility and operator comfort. Finally, barrier systems do not appear to have a clinically significant impact on airway management.

Barrier enclosure use during aerosol-generating medical procedures: A scoping review.

INTRODUCTION: Barrier enclosure devices were introduced to protect against infectious disease transmission during aerosol generating medical procedures (AGMP). Recent discussion in the medical community has led to new designs and adoption despite limited evidence. A scoping review was conducted to characterize devices being used and their performance. METHODS: We conducted a scoping review of formal databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, CENTRAL, Scopus), grey literature, and hand-searched relevant journals. Forward and reverse citation searching was completed on included articles. Article/full-text screening and data extraction was performed by two independent reviewers. Studies were categorized by publication type, device category, intended medical use, and outcomes (efficacy - ability to contain particles; efficiency - time to complete AGMP; and usability - user experience). RESULTS: Searches identified 6489 studies and 123 met criteria for inclusion (k = 0.81 title/abstract, k = 0.77 full-text). Most articles were published in 2020 (98%, n = 120) as letters/commentaries (58%, n = 71). Box systems represented 42% (n = 52) of systems described, while plastic sheet systems accounted for 54% (n = 66). The majority were used for airway management (67%, n = 83). Only half of articles described outcome measures (54%, n = 67); 82% (n = 55) reporting efficacy, 39% (n = 26) on usability, and 15% (n = 10) on efficiency. Efficacy of devices in containing aerosols was limited and frequently dependent on use of suction devices. CONCLUSIONS: While use of various barrier enclosure devices has become widespread during this pandemic, objective data of efficacy, efficiency, and usability is limited. Further controlled studies are required before adoption into routine clinical practice.