Intubation in the Time of COVID-19

↸ Care Optimization, ⟹ Efficiency

Objective. 

Redesign airway management at Michigan Medicine for intubation of critically ill patients to (1) reduce aerosolized viral particles, (2) protect the intubating physician from high viral load exposure, (3) optimize for patient safety, and (4) reduction of unnecessary equipment waste and cost.

The Problem.

The World Health Organization (WHO) declared SARS-COV2 a global pandemic on March 11, 2020.  In the era of a droplet transmitted contagion, airway management equipment could no longer safely remain in patient rooms for fear of contamination between patients. In an effort to preserve personal protective equipment (PPE), nurses, tech, respiratory therapists, and physicians needed to minimize number of times entering a room.  This pandemic changed not only the process by which we manage patient airways, but also the organization of the equipment needed to do the job effectively.

 Redesigning the airway table and rethinking airway management to include all job families was essential, consequential, and time-sensitive.  

The redesigned airway management workflow included a new airway algorithm or protocol, necessary equipment and organization to carry out the protocol, and education for protocol implementation.

Faculty and residents worked together to create a workflow that included appropriate PPE as well as the necessary operational changes. Data from best practices and recommendations from academic institutions across the world were incorporated into the final airway algorithm.

Design features of the final algorithm included:

• Reduction in equipment waste

• Appropriate donning and doffing of PPE

• Reduction of aerosolized of viral particles

  • Increased sedative and paralytic dosing to prevent cough and gag reflex

  • Limited preoxygenation methods: Heated high flow nasal cannula (HHFNC) limited to 40L, nasal cannula up to 6L, and 2 person bagging through a viral filter.

  • Avoidance of non-invasive positive pressure ventilation (NIPPV).

  • Endotracheal (ET) tube clamping when hooking up to ventilator

• Limiting provider exposure

  • Limiting the number of people in the room.

  • Video laryngoscopy rather than direct laryngoscopy

• Easy to read, electronically accessible algorithms to all providers

To implement these changes, educational simulations for nurses and physicians were held 30 minutes prior to shift changes. Simulation sessions provided a time for feedback and helped drive iterative cycles to improve both the algorithm and the organization of care equipment.

Equipment and Organization: Current state.

In order to use the algorithm, the storage and organization of equipment needed to be redesigned. Rather than an airway or crash cart, at Michigan Medicine, emergency medicine (EM) providers use an innovative airway table in which most commonly used and critical airway equipment is organized on a table , for easy access and restocking.  This schematic was printed on airway tables in each resuscitation bay. 

However, when COVID-19 pandemic preparations began, it was quickly realized that having all equipment laid out and exposed was wasteful and an infection control issue. For patient and provider safety all items on the table would need to be discarded after each patient in droplet precautions.

The Process.

Using a series of rapid iterative cycles with frequent testing, educational simulations, and user feedback, the team quickly generated and revised management algorithms. Changes in the airway algorithm drove changes in equipment and vice versa. 

The core design principles dictating prototypes for the new airway management system were creating a system that was portable, user-friendly, comprehensive, and preserved resources/reduced waste.

Iteration 1 – Airway Bag

The initial prototype was an airway bag. Patient belongings’ bags were repurposed, and all equipment needed by the intubating physician, nursing, and respiratory therapy was placed into the bag. The goal was to limit the number of entries and exits from the patient room from start to finish.

 Testing and Feedback:

• The bag was cumbersome and required all articles to be dumped from the bag in order to find the items needed. This slowed down the overall airway management.

• Everything in the bag had exposure to droplets when opened and was thrown away even if not used. This resulted in increased waste of precious resources and increased cost.

 Iteration 2 – MD, RN, and RT Airway Table

Based upon the feedback received, a new airway table was piloted next– a modification on the popular, existing airway table. The old model included only physician equipment. The new model included items for physicians, nursing, and respiratory therapy much like the airway bags. However, the items were already laid out for ease of use and accessibility.

Please note that providers were shifted to exclusively using video laryngoscopy. Direct laryngoscopy (DL) blades were no longer an option, but to preserve the mechanics of traditional DL, preferred method by some attendings, a Glidescope Go was purchased to be used with a Mac 4 blade.  Equipment selected for the table reflects the change in practice.

 Testing and Feedback:

• Table is crowded, but it is an improvement from the bag

• Unused items with plastic backings could be wiped down and used again. Items with paper backing that were exposed to the environment needed to be thrown away following each aerosolization procedure. This reduced waste, but still resulted in waste of high cost items such as laryngeal mask airways (LMAs).

• Limitations on the number of available tables

 Iteration 3 – Airway Pack

The Airway Pack system was the next dramatic iteration. The airway packs represent a modular organization of equipment based upon job family (MD, RN, RT). There is further subdivision of physician equipment (Plan A, B, and C) for a step-wise airway management approach.

Highlights

• Modular, take-what-you-need design

• Inventory on the side of pack storage locker to increase visibility and help with restocking

• Color coding on the front of the storage bins in the c-locker corresponding to the label colors.

The initial proposal for airway packs included 3 different prototypes (figure 9-11). Each prototype differs in the number of options (varying sizes of ET tubes, VL blades, and LMA sizes) for Plan A and Plan B.

The team decided to push prototype 2 forward to allow room for user preference and availability of two of the most commonly used sizes of equipment (7.0 and 7.5 ET tubing). This helped limit the options without sacrificing appropriate equipment.

Further discussion was had about having a separate respiratory therapy bag. Although it would require providers to bring another bag in the room, this would allow for concurrent preparation between 2 users and could potentially reduce the time to intubation. It would also further subdivide equipment for ease of use.

 Testing and Feedback:

• Unopened airway packs can be sanitized with oxivir and items inside are safely able to be reused. Waste significantly reduced.

• Easy to find equipment because it is subdivided by job family and further divided into plan A, B, C for physicians.

• Color coded system allows for user recognition and easy selection of equipment from c-locker.

• Packs are easily carried by one person and can be used in smaller rooms with ease.

Implementation

The final airway system includes 5 discrete airway packs: Plan A, Plan B, and Plan C, Nursing, and Respiratory.  With the radical change in equipment storage and organization a new workflow, pictured below, was laid out for physicians. Resident physicians are expected to grab one of each bag and take all packs into the room.  The items from the packs can be laid out on a procedure table in the room if desired. Plan C bags containing surgical airway equipment can remain outside the room until needed.

Simulation sessions and wide distribution of the finish algorithm allowed for relatively smooth implementation of each prototype and the final product.

Final airway pack graphics and workflow graphic featured directly above are developed by MCIRCC’s talented graphic designer, Kateyln Murphy. All other images featured are original creations by the author.

This incredible work would not have been possible without an outstanding Critical Care Airway Team.