Improving safety and communication for healthcare providers caring for SARS-COV-2 patients.

BACKGROUND: Decreasing healthcare provider (HCP) exposure to the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) virus in emergency departments (EDs) is crucial. Approaches include limiting the HCP presence and ensuring sealed isolation rooms, which can result in communication difficulties. This quality improvement (QI) initiative aimed to decrease by 50% duration of isolation room door opening and increasing HCP-perceived communication clarity by one point on a five-point Likert scale. METHODS: This was a prospective, multi-stage project with three Plan-Do-Study-Act (PDSA) cycles between May and July 2020: (1) an educational intervention, (2) the introduction of a novel transceiver communication device, and (3) utilizing a clinical champion. Statistical Process Control XbarR charts were used to assess for special cause variation, and two-tailed Mann-Whitney U tests were used for statistical significance between Likert survey means. Qualitative responses underwent thematic analysis. RESULTS: Observation of 174 patient encounters was completed over 33 days, with 95 meeting the inclusion criteria. Door opening decreased from baseline (n=40; mean 72.97%) to PDSA 3 (n=21; mean 1.58%; p<0.0001). HCP-perceived communication clarity improved from baseline (n=36; mean 3.36) to PDSA-3 (n=49; mean 4.21; p<0.001). Survey themes included positive effects on communication and workflow, with some challenges on the integration of the new device into the clinical workflow. HCP-perceived errors, workarounds, and workflow pauses showed significant improvements. CONCLUSION: This QI initiative with a novel transceiver showed significant decreases in isolation room door opening and increases in communication clarity. Future work will expand to operating rooms and intensive care units.

Rapid deployment of a virtual simulation curriculum to prepare for critical care triage during the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic in Ontario, Canada, an Emergency Standard of Care for Major Surge was created to establish a uniform process for the "triage" of finite critical care resources. This proposed departure from usual clinical care highlighted the need for an educational tool to prepare physicians for making and communicating difficult triage decisions. We created a just-in-time, virtual, simulation-based curriculum and evaluated its impact for our group of academic Emergency Physicians. METHODS: Our curriculum was developed and evaluated following Stufflebeam's Context-Input-Process-Product model. Our virtual simulation sessions, delivered online using Microsoft Teams, addressed a range of clinical scenarios involving decisions about critical care prioritization (i.e., Triage). Simulation participants completed a pre-course multiple-choice knowledge test and rating scales pertaining to their attitudes about using the Emergency Standard of Care protocol before and 2-4 weeks after participating. Qualitative feedback about the curriculum was solicited through surveys. RESULTS: Nine virtual simulation sessions were delivered over 3 weeks, reaching a total of 47 attending emergency physicians (74% of our active department members). Overall, our intervention led to a 36% (95% CI 22.9-48.3%) improvement in participants' self-rated comfort and attitudes in navigating triage decisions and communicating with patients at the end of life. Scores on the knowledge test improved by 13% (95% CI 0.4-25.6%). 95% of participants provided highly favorable ratings of the course content and similarly indicated that the session was likely or very likely to change their practice. The curriculum has since been adopted at multiple sites around the province. CONCLUSION: Our novel virtual simulation curriculum facilitated rapid dissemination of the Emergency Standard of Care for Major Surge to our group of Emergency Physicians despite COVID-19-related constraints on gathering. The active learning afforded by this method improved physician confidence and knowledge with these difficult protocols.

RéSUMé: CONTEXTE: Au cours de la pandémie de COVID-19 en Ontario, au Canada, une norme de soins d'urgence pour les poussées majeures a été créée afin d'établir un processus uniforme pour le " triage " des ressources limitées en soins intensifs. Cette proposition d'écart par rapport aux soins cliniques habituels a mis en évidence la nécessité d'un outil éducatif pour préparer les médecins à prendre et à communiquer des décisions de triage difficiles. Nous avons créé un programme d'études virtuel, juste à temps, basé sur la simulation et avons évalué son impact sur notre groupe de médecins urgentistes universitaires. MéTHODES: Notre programme d'études a été développé et évalué selon le modèle Contexte-Intrant-Processus-Produit de Stufflebeam. Nos sessions de simulation virtuelle, réalisées en ligne à l'aide de Microsoft Teams, ont abordé une série de scénarios cliniques impliquant des décisions sur la priorisation des soins intensifs (c.-à-d. le triage). Les participants à la simulation ont rempli un test de connaissances à choix multiples avant le cours et des échelles d'évaluation concernant leurs attitudes à l'égard de l'utilisation du protocole de soins d'urgence standard avant et deux à quatre semaines après leur participation. Des commentaires qualitatifs sur le programme ont été sollicités par le biais d'enquêtes. RéSULTATS: Neuf sessions de simulation virtuelle ont été dispensées sur trois semaines, touchant au total 47 médecins urgentistes titulaires (74 % des membres actifs de notre service). Dans l'ensemble, notre intervention a conduit à une amélioration de 36 % (IC 95 % 22,9-48,3 %) de l'auto-évaluation du confort et des attitudes des participants en matière de décisions de triage et de communication avec les patients en fin de vie. Les scores au test de connaissances se sont améliorés de 13% (IC 95% 0,4-25,6%). 95 % des participants ont donné une évaluation très favorable du contenu du cours et ont également indiqué que la session était susceptible ou très susceptible de modifier leur pratique. Le programme d'études a depuis été adopté à plusieurs endroits dans la province. CONCLUSION: Notre nouveau programme de simulation virtuelle a facilité la diffusion rapide des normes de soins d'urgence en cas de crise majeure à notre groupe d'urgentistes, malgré les contraintes de rassemblement liées au COVID-19. L'apprentissage actif que permet cette méthode a amélioré la confiance et les connaissances des médecins concernant ces protocoles difficiles.

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.

Bougie-assisted cricothyroidotomy: Delphi-derived essential steps for the novice learner.

OBJECTIVE: A cricothyroidotomy is a life-saving procedure, performed as a final option to emergency airway algorithms, and is essential for all clinicians who perform emergency airway management. The bougie-assisted cricothyroidotomy (BAC) is a novel technique that may be performed faster and with fewer complications than other traditional approaches. There is no established standard set of steps to guide the instruction of BAC performance. This study sought to systematically develop a BAC checklist for novice instruction using a modified Delphi methodology and international airway experts. METHODS: A literature review informed the creation of a preliminary BAC checklist. A three round, modified Delphi method was used to establish a BAC checklist intended for novice-level instruction. The consensus level for each step and the final checklist were predefined at 80%. Participants were international airway experts identified by study personnel and snowball sampling. RESULTS: Fourteen international airway experts across six acute care specialities participated in the study. The checklist was refined using a seven-point rating scale for each item and participant comments. A 17-item checklist was developed with expert consensus achieved after three rounds. Internal consistency, measured with Cronbach's α, was 0.855 (95% confidence interval 0.73-0.94). CONCLUSION: This modified Delphi-derived checklist is the first systematically developed list of essential steps for guiding BAC instruction for novice learners. This tool serves to standardize BAC skill instruction and provide learners with a structured and consistent set of steps for deliberate practice.

Endoscopic management of inverted papillomas: long-term results--the St. Paul's Sinus Centre experience.

OBJECTIVES: To demonstrate that computer-assisted endoscopic management of inverted papillomas yields excellent long-term results in terms of preventing recurrence and minimizing significant morbidity and mortality. METHODS: A retrospective chart review of patients who are being followed up for tumour recurrence or have undergone tumour removal between 2000 and 2008. All cases were undertaken using the GE Instatrak 3500+ navigation system. RESULTS: Inverted papillomas are the most common tumour managed endoscopically (57% of all sinonasal tumours) with 76 patients seen over the last 8 years. Approximately 50% of these cases had undergone previous surgery in another centre where the tumour was either not recognized or the resection was incomplete. Twentynine percent of these patients had a recurrence but only three required a revision procedure using an open approach; otherwise recurrences were successfully managed endoscopically. Endoscopic recurrence during the first half was 32% (versus 14% for open procedures), dropping to a recurrence rate of 11% in the latter period. CONCLUSIONS: Endoscopic management of inverted papillomas allows good control of the disease and avoids unnecessary morbidity associated with open procedures. Although there is a higher initial recurrence rate, these recurrences can be successfully managed endoscopically, and computer navigation can be a useful adjunct in achieving this.