ABSTRACT
INTRODUCTION: The COVID-19 pandemic has provided many obstacles for healthcare providers. One challenge has been ensuring safety during high risk procedures such as Emergency Department (ED) intubations. The risks include: little preparation time, aerosolizing nature of the procedure, and unknown COVID status. Video review has shown effectiveness in quality improvement in critical care scenarios. We aimed to determine the feasibility of using video review of ED intubations in order to gather data about these events and enact change to improve provider safety. METHODS: We captured select videos of intubations that occurred in the COVID-19 pandemic in an audiovisual capable critical care bay. Each video was captured in real time and reviewed for intubation characteristics, intubator characteristics, exposure risk, and PPE compliance. RESULTS: The majority of the intubations were emergent (88.9%). Five patients (55.6%) were in cardiac arrest. The final COVID status was negative in 8 patients (88.9%). In most cases, a senior resident or attending was the intubating provider (77.8%). The mean number of intubation attempts was 1.1 (SD 0.33). The mean number of providers present at intubation was 3.9 (SD 1.97). The mean number of nurses and technicians present was 3 (SD 0.67) and 1.4 (SD 0.97), respectively. On average, the door to the room was opened 13.67 times (range: 1-40). Provider PPE compliance was 100%. All intubating providers wore a powered air purifying respirator. All others present wore an N95 mask, gloves, gown, and eye protection. CONCLUSIONS: Video review of emergency intubations was a feasible means of evaluating provider safety and quality assurance during a global pandemic. Video review is an effective manner of evaluating adherence to PPE guidelines. It can also identify areas for improvement, such as limiting the number of providers in the room and limiting exposure to others by minimizing door-opening. These data were used to improve our intubation process. We implemented the use of pre-prepared airway boxes for each critical care bay, and walkie-talkies to communicate to those outside of the room to minimize door opening. Video review remains a fruitful and open space for quality improvement innovation and furthering the safety of patients and providers.
ABSTRACT
INTRODUCTION: High-flow nasal cannula oxygen therapy (HFNC) has gained attention as an alternative respiratory support for critically ill COVID-19 patients, however, the evidence behind HFNC has been unbalanced as it covers various comorbidities in hypoxic and hypercapnic respiratory failure. We sought to identify what group of patients needed HFNC and to assess whether its use impacted length of stay and survival. METHODS: A retrospective cohort study was performed at a single center urban academic center. Data collected included age, gender, BMI, medical comorbidities, length of hospital stay and mortality for all patients hospitalized with COVID-19. We compared the characteristics of the patients who received HFNC at any point during their hospitalization to all patients hospitalized with COVID-19. RESULTS: The total number of COVID-19 patients was 363. HFNC was used in 115 admitted patients, of which, 74 were in the ICU with a mean length of stay of 7 days. Overall this group had an average hospital length of stay of 15 days in total as opposed to 10.2 days in non-HFNC utilizers. The most common comorbidities seen in the cohort were hypertension (76.4%), diabetes mellitus (37.4%), asthma (14.6%), COPD (11.24%), and obstructive sleep apnea (4.5%). In patients who received HFNC, 41.2% survived compared to 71.8% of all COVID-19 patients. CONCLUSIONS: Factors determining the outcome of patients using HFNC are not well understood. Our patients who received HFNC were more likely to have underlying cardiopulmonary disease than non-HFNC utilizers. Furthermore, they had a longer length of stay and a higher mortality rate in comparison to all COVID-19 patients. While we specifically identified patients who received HFNC, some of these patients received other forms of supplemental oxygen therapy during their hospital stay which may confound the characteristics of this group. It is also possible that patients receiving HFNC were sicker in general, which may explain their disparity in mortality and hospital stay duration. Further research needs to be done in order to clarify if HFNC in COVID-19 patients, particularly those with cardiopulmonary comorbidities, is beneficial in delaying escalation of oxygen therapy and potentially prolonging survival.
ABSTRACT
INTRODUCTION: Early in the COVID-19 pandemic, hypoxic patients were immediately intubated for fear of decompensation and aerosolizing the virus with non-invasive ventilation (NIV). Reports revealed a high mortality for intubated patients, prompting NIV such as high flow nasal cannula (HFNC) or noninvasive positive pressure ventilation (NIPPV). The literature lacks description of the outcomes between patients who were intubated immediately versus only after failing NIV. We describe the characteristics of patients who were intubated ?early,? defined as being intubated without NIV attempts, versus ?delayed?, defined as intubated after failed initial NIV use. METHODS: A prospective registry was created of all COVID-19 patients admitted to our urban academic medical center from March 2020 to July 2020. We analyzed this database to investigate escalation of respiratory support. Variables of interest included intubation, use of HFNC, NIPPV, and mortality. Logistic regression explored associations with mortality. RESULTS: A total of 109 patients were initiated on NIV. 102 began on HFNC and 7 on NIPPV. A total of 47 patients were intubated early. Of those started on HFNC, 24 (23.5%) were escalated directly to intubation. 23 (22.5%) received NIPPV, of which 16 (69.6%) required intubation. Of those started on NIPPV initially, 5 required intubation and 2 were downgraded to HFNC. Comparing early versus delayed intubation, the odds ratio for surviving intubation, adjusted for age and BMI, with a trial of NIV prior to intubation was 0.057 (0.002 - 0.562). For NIPPV, 94.4% (17 of 18) of patients intubated ?delayed? died, while 69.2% (27 of 39) patients intubated ?early? died. Unadjusted odds ratio for surviving intubation when having HFNC prior to intubation was 0.289 (0.081- 0.923), but lost statistical significance when adjusted for age and BMI. 64 patients (58.7%) who were started on NIV were never intubated during admission. CONCLUSIONS: This study suggests that NIV may be useful in the treatment of hypoxemia secondary to COVID-19 to prevent intubation, however the likelihood of survival decreases in those who fail NIV. Delayed intubations are associated with mortality when adjusted for age and BMI. Further research is needed to investigate who may benefit most from NIV as a supportive measure to prevent intubation.