Variations in COVID-19 airway management and preparedness among Victorian hospitals

Recommended Citation Jordan, Kaylee A.; Sindoni, Teresa M.; Segal, Reny; Lee, Keat; Krieser, Roni B.; Mezzavia, Paul; Chen, Yinwei; and Ng, Irene (2021) "Variations in COVID-19 airway management and preparedness among Victorian hospitals," Journal of Perioperative Nursing: Vol. 34 : Iss. 4 , Article 3. Available at: https://doi.org/10.26550/2209-1092.1142 https://www.journal.acorn.org.au/jpn/vol34/iss4/3


Variations in COVID-19 airway management and preparedness among Victorian hospitals Summary
The COVID-19 pandemic presents significant concerns surrounding the risk of transmission to health care workers involved in airway management of patients with suspected or known infection. Limited evidence has been available to guide the preparation of staff, intubation environments, team structure and personal protective equipment. Our study invited Victorian hospitals to complete a survey on their airway management practices and protocols, in order to assess the degree of variability in practice and preparedness. Twenty hospitals responded in September 2020, during Victoria's second wave of COVID-19. Forty percent had dedicated COVID-19 intubation teams, all including consultant anaesthetists. Seventy-five percent had negatively pressured dedicated intubation rooms. All provided airborne precautions including N95 masks for airway and cardiac arrest management of suspected or confirmed COVID-19 positive patients, with 35 per cent providing N95 mask fit testing and 15 per cent providing powered air purifying respirators or elastomeric respirators. Thirty-five percent provided airborne precautions for cardiac arrest management of patients not suspected to be COVID-19 positive. Significant inter-hospital variations were reported in airway management practices, such as preoxygenation, bag-mask ventilation, medications and techniques to minimise aerosolisation. Although some of this variation was likely due to individual hospital infrastructure and resource limitations, it would be ideal to achieve a more consistent, standardised approach across Victorian hospitals. This study may highlight areas for improvement for some hospitals. These areas for improvement may include consideration of the establishment of COVID-19 intubation teams in at least major metropolitan hospitals, N95 mask fit testing and the use of airborne precautions for cardiac arrest management during times of increased community prevalence of COVID-19.

Introduction
The World Health Organization (WHO) declared the 2019 novel coronavirus (COVID-19) to be a pandemic on 11 March 2020 1 . Despite recent experiences with disease outbreaks, such as influenza, EBOLA and Middle East Respiratory Syndrome Coronavirus (MERS-CoV), the combination of high transmission and mortality rates of COVID-19 made this pandemic an unprecedented event, for which most health care systems in the world were not adequately prepared 1,2 .
Health care workers are at increased risk of developing the infection, due to their close contact with patients and each other, and their involvement in procedures that may increase the dispersion of contaminated fluid or aerosols 3,4 . One study showed that one in ten health care workers who were involved in tracheal intubation of patients with suspected or confirmed COVID-19 subsequently reported a COVID-19 outcome, defined as either being diagnosed with new COVID-19 infection or requiring self-isolation or hospitalisation with new symptoms 5 . Hospitals around the world, including those in Australia, had to promptly develop airway management guidelines and protocols with very limited supporting literature at the beginning of the pandemic 6 . Several guidelines then gradually became available as new information emerged, to guide medical professionals on airway management of suspected and confirmed COVID-19 positive patients, including those released by the Safe Airway Society 7 , the Anesthesia Patient Safety Foundation 8 , the Australian Society of Anaesthetists 3 and the Australian and New Zealand Intensive Care Society 9 . However, variations in practice among hospitals have been reported 10 .
Recent concerns have been raised about particular features of Victoria's health system, and whether this may play a role in the significantly higher incidence of COVID-19 that has been observed in comparison to other states 11 . Most of the states in Australia have overarching health structures and central sources of guidelines and standards. In contrast, in Victoria there are six Primary Health Networks (PHNs) and 88 Local Health Care Authorities 12 . Each of the PHNs operates as its own separate entity, making it challenging to integrate and share information and resources across different networks. The aim of this study was to examine how different hospitals in Victoria prepare, coordinate and conduct the airway management of patients with suspected or confirmed COVID-19. This information can be used as a reference for hospital staff who are involved in planning COVID-19 airway management.

Methods
After obtaining approval from Melbourne Health Human Research Ethics Committee (QA2020128), we invited the hospitals that are affiliated with the University of Melbourne to participate in this study 13 . We included all the adult hospitals that have both an anaesthetic department and an emergency department (ED). We excluded hospitals whose ED only caters for psychiatric patients. These inclusion and exclusion criteria were selected in order to encompass hospitals that would be expected to manage the airway of a COVID-19 positive patient requiring intubation. Twenty-nine hospitals were invited to be included.
An invitation email was sent to the directors of the anaesthetic departments of each of the 29 selected hospitals. They then nominated the most appropriate person to complete the predesigned survey regarding the airway management of suspected or confirmed COVID-19 patients in their hospital. The nominated person was considered to be the leader or one of the leaders in the hospital, involved in the planning and development of the hospital COVID-19 airway management policies or guidelines. The survey consisted of questions regarding the presence and components of COVID-19 intubation teams, intubation environments, personal protective equipment (PPE), airway management equipment, staff preparation and airway management practices (see supplemental material). These questions were designed to allow comparison across these areas, in order to assess inter-hospital variation in practice. We contacted the nominated person via email. The survey was then completed via their preferred method (a phone call from one of the investigators or self-completion and return by email). Consent was implied by their response to our email and the completion of the survey.
The survey took place during September 2020, coinciding with the declining phase of the second wave of COVID-19 cases in Victoria. There were 723 daily cases at the peak in July 2020. The first wave occurred in March 2020. Most hospitals had developed a policy on airway management of suspected or confirmed COVID-19 patients by the time the study was conducted.
Results from the survey were transferred to a standard spreadsheet (Excel; Microsoft, Redmond, WA, USA), and descriptive statistics were used to present all of the data.

Results
Of the 29 hospitals contacted, we received responses from 20 hospitals, giving a response rate of 69 per cent. This included 18 public hospitals (12 metropolitan, six regional) and two private hospitals (both metropolitan). All of the surveys were completed by consultant anaesthetists, three of whom were the director of the anaesthetic department. They were all involved in the development of local COVID-19 airway management policies.
Preparation of the intubation team staff for airway management of suspected or confirmed COVID-19 patients is shown in Table 1. Eight hospitals had established dedicated COVID-19 intubation teams, all of which included consultant anaesthetists, during both in-hours and after-hours periods. Of these eight teams, seven included one nurse only. Three included an ICU nurse, three included an anaesthetic nurse, one included an Emergency Department (ED) nurse and one included two nurses from either ICU, anaesthetics or ED. Ninety-five percent of hospitals provided formal training for personnel involved in COVID-19 airway management, with 85% of hospitals using simulation for this purpose (Table 1). Ninety percent of hospitals used a cognitive aid to assist with airway management of these patients.
Most hospitals (18 of 20; 95%) provided dedicated COVID-19 intubation rooms, with 75 per cent of hospitals (15 of 20) having negatively pressured rooms for this purpose, frequently in the intensive care unit (ICU) and ED ( Table 2). The median number of dedicated intubation rooms per hospital was three (ranging between 1 and 12). Seventyfive percent of hospitals reported the use of a dedicated COVID-19 airway trolley (or other transport means such as a container or bucket).
All of the hospitals had oropharyngeal airways, alternative facemasks/laryngeal masks/ endotracheal tubes and equipment for front-of-neck access either immediately available in the room or closely available outside the room. Ninety-five percent of hospitals (19 of 20) had their videolaryngoscope and bougie inside the room. Only one hospital did not have a hyper-angulated laryngoscope available. However, six of the hospitals (30%) did not have immediate access to a fibreoptic bronchoscope if required. A variety of protocols were used in different hospitals for both intubation and extubation procedures, as shown in Table 3.
In terms of PPE, all of the hospitals provided gowns, gloves, hats, N95 particulate respirator masks and face shields for the staff who were involved in COVID-19 airway management. Three hospitals (15%) provided the option of using powered air purifying respirators (PAPRs) or elastomeric respirators as an alternative to N95 masks. Neck covers were only used by three hospitals. Seven hospitals (35%) provided N95 mask fit testing (Table 1).
In regard to the cardiac arrest team for suspected or confirmed COVID-19 patients, 11 hospitals (55%) included an anaesthetic registrar or consultant. All of the 20 hospitals provided the same PPE that was worn by staff intubating suspected or confirmed COVID-19 positive patients. Only seven out of 20 hospitals (35%) had a similar requirement for airborne precautions including the use of N95 masks at the attendance of cardiac arrests of patients not suspected or known to be COVID-19 positive. All of these seven hospitals were metropolitan hospitals.  Moreover, the lack of an overarching health care structure, which would assist in the integration of resources and sharing of information among different health care networks in Victoria, may also have been a potential contributing factor.
It has been suggested that dedicated and experienced COVID-19 intubation teams, such as those using anaesthetists or anaesthetic registrars as lead intubators, may improve patient outcomes and staff safety 14 . This is understandably challenging for some regional hospitals, where the case load is low and resources are limited.
Nonetheless, major metropolitan hospitals should consider establishing a COVID-19 intubation team, absent in more than half of the metropolitan hospitals in this study.
Several consensus guidelines specific to airway management of suspected and confirmed COVID-19 positive patients recommend that negative pressure rooms should be BMV not allowed 3 Allowed if low SpO2 11 • SpO 2 < 80% 3 • Anaesthetist's discretion 7 • Life threatening situation 1 Medication protocol 10 (50%) 10 (50%) Induction agent protocolised 7 • Ketamine 4 • Propofol 3 NMB protocolised 9 • Rocuronium 6 • Suxamethonium 3 Opioid protocolised 5 • Fentanyl 3 • Alfentanil 2 In the management of cardiac arrest of patients suspected or known to be COVID-19 positive, it is reassuring that every hospital provided the equivalent PPE as that worn during airway management of this patient cohort, which is in keeping with recommendations from the DHHS 23 . Unless there is clear evidence to the contrary, the Australian College of Emergency Medicine (ACEM) recommends that while there are high rates of community transmission of COVID-19 any collapsed or unresponsive patient should be assumed to be high-risk for COVID-19, and that airborne PPE should be worn 24 . The significantly higher adaptation of this recommendation for airborne precautions in this setting in metropolitan hospitals, compared to regional hospitals, potentially reflects the higher prevalence of COVID-19 in the metropolitan regions.
One of the potential factors leading to variations in the COVID-19 airway management among different hospitals is the lack of evidence in literature to guide practices. One major uncertainty or controversy is the degree of aerosolisation of COVID-19 during airway manipulation. This may have contributed to the inter-hospital variability seen in the limitation of oxygen flows for preoxygenation, the decision path and trigger for bag-mask ventilation, the protocolisation of drugs used on induction, the mandated clamping of the endotracheal tube for circuit disconnections, extubation practices and the use of high-flow nasal prongs and non-invasive ventilation. This cross-sectional study highlights a large variation in practice among hospitals, despite increasing numbers of publications that are emerging to provide more understanding about aerosol generation during airway management 25,26 .

Limitations
There are several limitations in this study. It involved only 20 Victorian hospitals, which is a small sample size. However, we included all of the major metropolitan hospitals and many regional hospitals and we believe this is a reasonable representation of Victorian hospitals. There was a selection bias, as we included only the hospitals that responded to our email invitation.
Inter-hospital variation in who was nominated to complete the survey and how this decision was made may be present. There is an assumption that individual hospital airway management practices align with their policies, where this may not be the case. Finally, this study is only a snapshot of practices across different Victorian hospitals in September 2020. There are constant changes in COVID-19 management guidelines and practices as new information continues to emerge. Nonetheless, this cross-sectional study highlights a large variation across different hospitals.

Conclusion
In conclusion, this study compared how different hospitals in Victoria prepare, coordinate and conduct the airway management of patients with suspected or confirmed COVID-19. We found inter-hospital variability in many areas. This study can be used as a reference and may potentially highlight areas for improvement for some hospitals. Further studies would be beneficial to investigate the reasons behind the variations, and to examine whether there is less variation in other states which have an overarching health care structure. We should also consider the implications of these differences, for example, potential differences in the quality of care of COVID-19 positive patients, potential differences in transmission risk within hospitals and staff wellbeing impacts regarding conflicting information and management of these patients in different locations.

Declaration of conflicting interests
There are no potential conflicts of interest with respect to this research, authorship, and/or publication of this article.