Table 1.
Evaluation of the Performance of 22 Skills during 20 Mock Codes for Managing Suspected Cases of COVID-19 at the Hospital ED
| Item | Not Done N (%) |
Partially Done N (%) |
Done N (%) |
Score a Mean (95% CI) |
|---|---|---|---|---|
| 1. Correct sequence and procedure of PPE with hand hygiene: 1-N95 respirator; 2-Goggles/face shield; 3-Gown; 4-Gloves (tuck gown cuffs securely under gloves) | 1 (3.0%) | 12 (36.4%) | 20 (60.6%) | 79.0% (69.4%-88.6%) |
| 2. Limit to three-person intubation team “when possible” (MD, RT, RN) | 7 (21.2%) | 15 (45.5%) | 11 (33.3%) | 56.0% (43.4%-68.6%) |
| 3. If suctioning required, use close suctioning system and standby ventilator while suctioning | 20 (62.5%) | 6 (18.8%) | 6 (18.8%) | 28.0% (14.1%-41.9%) |
| 4. Pre-oxygenation with O2 flows <6L/min, with correct face mask selection, for five minutes | 6 (18.2%) | 7 (21.2%) | 20 (60.6%) | 71.0% (57.5%-84.5%) |
| 5. Optimize position and instruct assistant to optimize equipment +/- early call for assistance | 6 (18.2%) | 9 (27.3%) | 18 (54.5%) | 68.0% (54.7%-81.3%) |
| 6. Try to refrain from BMV unless urgently needed; use of two hand technique to ensure good seal in case of BMV | 11 (33.3%) | 13 (39.4%) | 9 (27.3%) | 47.0% (33.6%-60.4%) |
| 7. If there is any difficulty in ventilation, consider early conversion to LMA (up to clinician preference) | 25 (75.8%) | 3 (9.1%) | 5 (15.2%) | 19.5% (6.8%-32.2%) |
| 8. Nasal cannula at 5L/min left in place for apneic oxygenation | 21 (63.6%) | 1 (3.0%) | 11 (33.3%) | 35.0% (18.7%-51.3%) |
| 9. Preparation of airway plan and clear communication of plan to assisting staff, including steps to minimize aerosolization of particles | 7 (21.2%) | 12 (36.4%) | 14 (42.4%) | 60.5% (47.2%-73.8%) |
| 10. Preparation of airway equipment, including: video laryngoscope and appropriate size blade, closed suctioning system | 9 (27.3%) | 10 (30.3%) | 14 (42.4%) | 57.5% (43.3%-71.7%) |
| 11. Give appropriate drugs for rapid sequence intubation; make sure to use high dose of paralytic agents | 8 (24.2%) | 7 (21.2%) | 18 (54.5%) | 65.0% (50.6%-79.4%) |
| 12. Standby ventilator before removal of face mask for intubation | 16 (48.5%) | 11 (33.3%) | 6 (18.2%) | 35.0% (21.9%-48.1%) |
| 13. Intubation to be done by the most experienced ED physician | 2 (6.3%) | 6 (18.8%) | 24 (75.0%) | 84.5% (74.2%-94.8%) |
| 14. Intubate using video laryngoscopy, only after adequate onset of paralysis, with aim at first pass success without patient coughing | 7 (21.2%) | 8 (24.2%) | 18 (54.5%) | 66.5% (52.6%-80.4%) |
| 15. In case of intubation attempt failure: resume BMV with two-hand technique with tight seal | 9 (28.1%) | 9 (28.1%) | 14 (43.8%) | 58.0% (43.3%-72.7%) |
| 16. Ensure cuff inflated before positive pressure ventilation (bagging or ventilator) | 11 (33.3%) | 7 (21.2%) | 15 (45.5%) | 56.0% (40.8%-71.2%) |
| 17. Assure correct intubation by ETCO2 | 13 (39.4%) | 3 (9.1%) | 17 (51.5%) | 56.0% (39.6%-72.4%) |
| 18. Auscultate again to confirm tube position | 8 (24.2%) | 1 (3.0%) | 24 (72.7%) | 74.0% (59.1%-88.9%) |
| 19. Request chest x-ray | 3 (9.1%) | 2 (6.1%) | 28 (84.8%) | 88.0% (77.5%-98.5%) |
| 20. Follow gown down steps correctly and appropriately: 1-Remove gloves; 2-Remove (top) cap and eye protection; 3-Remove gown; 4-remove mask; 5-remove particulate respirator | 4 (12.1%) | 13 (39.4%) | 16 (48.5%) | 68.0% (56.0%-80.0%) |
| 21. Perform hand hygiene | 11 (33.3%) | 5 (15.2%) | 17 (51.5%) | 59.0% (43.3%-74.7%) |
| 22. Proper disposal of used consumables and equipment | 6 (18.2%) | 8 (24.2%) | 19 (57.6%) | 69.5% (56.1%-82.9%) |
| Overall Performance Score | 211 (29.2%) | 168 (23.2%) | 344 (47.6%) | 59.2% (53.3%-65.0%) |
Abbreviations: BMV, bag mask ventilation; ED, emergency department; LMA, laryngeal mask airway; MD, medical doctor; PPE, personal protective equipment; RN, registered nurse; RT, respiratory therapist.
a
Higher score means better performance. Individual score was calculated as the sum of evaluation with two points recorded if the item was done, one point recorded if the item was partially done, and zero points recorded if the item was not done. The percentage represents observed score (actual performance) relative to maximum possible score (best performance).