Performance of Resuscitation Skills by Paramedic Personnel in Chemical Protective Suits

Resilience and Protection of Health Care and Research Laboratory Workers During the SARS-CoV-2 Pandemic: Analysis and Case Study From an Austrian High Security Laboratory

The SARS-CoV-2 pandemic has highlighted the interdependency of healthcare systems and research organizations on manufacturers and suppliers of personnel protective equipment (PPE) and the need for well-trained personnel who can react quickly to changing working conditions. Reports on challenges faced by research laboratory workers (RLWs) are rare in contrast to the lived experience of hospital health care workers. We report on experiences gained by RLWs (e.g., molecular scientists, pathologists, autopsy assistants) who significantly contributed to combating the pandemic under particularly challenging conditions due to increased workload, sickness and interrupted PPE supply chains. RLWs perform a broad spectrum of work with SARS-CoV-2 such as autopsies, establishment of virus cultures and infection models, development and verification of diagnostics, performance of virus inactivation assays to investigate various antiviral agents including vaccines and evaluation of decontamination technologies in high containment biological laboratories (HCBL). Performance of autopsies and laboratory work increased substantially during the pandemic and thus led to highly demanding working conditions with working shifts of more than eight hours working in PPE that stressed individual limits and also the ergonomic and safety limits of PPE. We provide detailed insights into the challenges of the stressful daily laboratory routine since the pandemic began, lessons learned, and suggest solutions for better safety based on a case study of a newly established HCBL (i.e., BSL-3 laboratory) designed for autopsies and research laboratory work. Reduced personal risk, increased resilience, and stress resistance can be achieved by improved PPE components, better training, redundant safety measures, inculcating a culture of safety, and excellent teamwork.

Impact of Clinician Personal Protective Equipment on Medical Device Use During Public Health Emergency: A Review

The aim of this systematic review is to evaluate the impact of personal protective equipment (PPE) on medical device use during public health emergency responses. We conducted a systematic literature search of peer-reviewed journals in PubMed, Web of Science, and EBSCO databases. Twenty-nine of 92 articles published between 1984 and 2015 met the inclusion criteria for the review. Although many medical device use impacts were reported, they predominantly fell into 3 categories: airway management, drug administration, and diagnostics and monitoring. Chemical, biological, radiological, and nuclear (CBRN)-PPE increased completion times for emergency clinical procedures by as much as 130% and first attempt failure rates by 35% (anesthetist) versus 55% (non-anesthetist). Effects of CBRN-PPE use depend on device, CBRN-PPE level, and clinician experience and training. Continuous clinical training of responders in CBRN-PPE and device modifications can improve safety and effectiveness of medical device use during public health emergency response.

Limiting factors for wearing personal protective equipment (PPE) in a health care environment evaluated in a randomised study

Pandemics and re-emerging diseases put pressure on the health care system to prepare for patient care and sample logistics requiring enhanced personnel protective equipment (PPE) for health care workers. We generated quantifiable data on ergonomics of PPE applicable in a health care setting by defining error rates and physically limiting factors due to PPE-induced restrictions. Nineteen study volunteers tested randomly allocated head- or full body-ventilated PPE suits equipped with powered-air-purifying-respirators and performed four different tasks (two laboratory tutorials, a timed test of selective attention and a test investigating reaction time, mobility, speed and physical exercise) during 6 working hours at 22°C on one day and 4 working hours at 28°C on another day. Error rates and physical parameters (fluid loss, body temperature, heart rate) were determined and ergonomic-related parameters were assessed hourly using assessment sheets. Depending on the PPE system the most restrictive factors, which however had no negative impact on performance (speed and error rate), were: reduced dexterity due to multiple glove layers, impaired visibility by flexible face shields and back pain related to the respirator of the fully ventilated suit. Heat stress and liquid loss were perceived as restrictive at a working temperature of 28°C but not 22°C.

Hospital resuscitation teams: a review of the risks to the healthcare worker

Background

“Code blue” events and related resuscitation efforts involve multidisciplinary bedside teams that implement specialized interventions aimed at patient revival. Activities include performing effective chest compressions, assessing and restoring a perfusing cardiac rhythm, stabilizing the airway, and treating the underlying cause of the arrest. While the existing critical care literature has appropriately focused on the patient, there has been a dearth of information discussing the various stresses to the healthcare team. This review summarizes the available literature regarding occupational risks to medical emergency teams, characterizes these risks, offers preventive strategies to healthcare workers, and highlights further research needs.

Methods

We performed a literature search of PubMed for English articles of all types (randomized controlled trials, case-control and cohort studies, case reports and series, editorials and commentaries) through September 22, 2016, discussing potential occupational hazards during resuscitation scenarios. Of the 6266 articles reviewed, 73 relevant articles were included.

Results

The literature search identified six potential occupational risk categories to members of the resuscitation team—infectious, electrical, musculoskeletal, chemical, irradiative, and psychological. Retrieved articles were reviewed in detail by the authors.

Conclusion

Overall, we found there is limited evidence detailing the risks to healthcare workers performing resuscitation. We identify these risks and offer potential solutions. There are clearly numerous opportunities for further study in this field.

Mapping the use of simulation in prehospital care - a literature review

Background

High energy trauma is rare and, as a result, training of prehospital care providers often takes place during the real situation, with the patient as the object for the learning process. Such training could instead be carried out in the context of simulation, out of danger for both patients and personnel. The aim of this study was to provide an overview of the development and foci of research on simulation in prehospital care practice.

Methods

An integrative literature review were used. Articles based on quantitative as well as qualitative research methods were included, resulting in a comprehensive overview of existing published research. For published articles to be included in the review, the focus of the article had to be prehospital care providers, in prehospital settings. Furthermore, included articles must target interventions that were carried out in a simulation context.

Results

The volume of published research is distributed between 1984- 2012 and across the regions North America, Europe, Oceania, Asia and Middle East. The simulation methods used were manikins, films, images or paper, live actors, animals and virtual reality. The staff categories focused upon were paramedics, emergency medical technicians (EMTs), medical doctors (MDs), nurse and fire fighters. The main topics of published research on simulation with prehospital care providers included: Intubation, Trauma care, Cardiac Pulmonary Resuscitation (CPR), Ventilation and Triage.

Conclusion

Simulation were described as a positive training and education method for prehospital medical staff. It provides opportunities to train assessment, treatment and implementation of procedures and devices under realistic conditions. It is crucial that the staff are familiar with and trained on the identified topics, i.e., intubation, trauma care, CPR, ventilation and triage, which all, to a very large degree, constitute prehospital care. Simulation plays an integral role in this. The current state of prehospital care, which this review reveals, includes inadequate skills of prehospital staff regarding ventilation and CPR, on both children and adults, the lack of skills in paediatric resuscitation and the lack of knowledge in assessing and managing burns victims. These circumstances suggest critical areas for further training and research, at both local and global levels.

Comparison of techniques for securing the endotracheal tube while wearing chemical, biological, radiological, or nuclear protection: a manikin study

OBJECTIVE

The objective of this study was to assess the impact of chemical, biological, radiological, nuclear personal protective equipment (CBRN-PPE) on the ability to secure an endotracheal tube (ETT) with either the Thomas Tube Holder™ or cotton tape tied in a knot.

METHODS

Seventy-five clinicians secured an ETT in a previously intubated manikin with the Thomas Tube Holder™ and cotton tape. A mixed quantitative and qualitative research design was used to gauge actual performance times and perceptions of difficulties. Following completion of the study, 25 clinicians were interviewed to gauge their experiences of securing the ETT with both devices while wearing CBRN-PPE.

RESULTS

The mean time to apply the Thomas Tube Holder was 29.02 seconds, compared with tape which took a mean of 58 seconds (p=0.001). Clinicians rated the Thomas Tube Holder as easier to use than tape (Mann-Whitney z=9.934; p<0.001), which was confirmed during interviews. Of the clinicians interviewed, 92% perceived that the Thomas Tube Holder provided the better method for securing an ETT, none of the clinicians identified the tape as the best method for securing the endotracheal tube while wearing CBRN-PPE. Clinicians identified that the design of the Thomas Tube Holder facilitated the gross motor movement required for application.

CONCLUSIONS

The Thomas Tube Holder is easier and faster to apply when wearing CBRN-PPE when compared with cotton, and the Thomas Tube Holder is perceived by the participants as being more effective at preventing accidential extubation.

Does position of the patient adversely affect successful intubation whilst wearing CBRN-PPE?

INTRODUCTION

Following a CBRN incident attending medical personnel will be required to instigate life saving airway interventions whilst wearing CBRN-PPE. CBRN-PPE is known to adversely affect fine motor skill but little is known about whether the position of the patient compounds this problem.

METHODS

Seventy-five clinicians were recruited and performed intubation and insertion of a LMA in to a manikin whilst wearing CBRN-PPE. Both skills were completed twice with the manikin positioned on a bench and once on the floor. Following completion of the study 25 participants (a minimum of 2 participants from each professional group) were interviewed to ascertain their experiences. The recruitment of a non-homogenous group allowed for subgroup analysis with regards the potential impact of professional background on skill performance.

RESULTS

9.33% first attempts at intubation at waist height ended in failure but this reduced to 4% on the second attempt. This improvement was reversed with the manikin on the floor where the failure rate was 26.67%. Intubation on the floor took significantly longer to perform, being 45.9 s slower than the first attempt at intubation in the optimal position [95% CI (30.7 s, 61.1 s); p<0.001] and 62.4 s longer than the second [95% CI (48.4 s, 76.3 s); p<0.001]. LMA insertion was successful at all attempts, regardless of the manikins position. LMA placement on the floor was no slower than the second attempt at waist height (p=0.231) and faster than the first attempt at waist height (by 4.8 s [95% CI (3.4 s, 6.1 s); p<0.001]). Anaesthetists were consistently the fastest at performing all airway skills regardless of the position of the manikin but previous exposure to wearing CBRN-PPE had no statistically significant impact on skill performance. All 25 clinicians interviewed had difficulty in viewing the larynx with the manikin positioned on the floor regardless of being an experienced 'on floor' intubator with the movement of the CBRN-PPE hood being the principle reason. This is in contrast to only three participants noting issues with vision whilst standing-up.

CONCLUSION

the position of the patient is likely to be an independent factor when choosing to either intubate or insert a LMA whilst wearing the current NHS CBRN-PPE.

The effect of physical exertion in chemical and biological personal protective equipment on physiological function and reaction time

OBJECTIVES

The primary objective of this study was to describe and compare changes in heart rate, venous pH, venous partial pressure of carbon dioxide (pCO(2)), venous bicarbonate level, lactate level, oxygen saturation (SpO(2)), and tympanic membrane (TM) temperature occurring in a group of healthy volunteers during 20 minutes of physical exertion, both with and without chemical and biological personal protective equipment (PPE). A further aim was to establish whether any significant prolongation of reaction time occurred after physical exertion in chemical and biological PPE, compared to baseline values without the protective equipment.

METHODS

Nineteen highly fit volunteers were subjected to a baseline reaction time test and measurement of physiological variables. They were then subjected to physical exertion on a treadmill: once while wearing a short-sleeved t-shirt, shorts, and running shoes and once while wearing chemical and biological PPE. Repeat measurements of the physiological variables were made after 10 and 20 minutes of physical exertion in both groups, after which repeat reaction time tests were conducted.

RESULTS

Results showed that physical exertion of 20 minutes undertaken by highly fit volunteers wearing PPE resulted in a higher heart rate response and TM temperature compared with control measurements. Decreased venous pH and increased venous pCO(2) were also observed during exertion in the PPE group. Although differences in these variables between the control and PPE groups were statistically significant, they were not of clinical relevance in the sample of volunteers studied. No significant difference in reaction time before and after exertion in PPE was identified.

CONCLUSIONS

This study did not identify any effect of 20 minutes of heavy exercise in highly fit volunteers wearing level C chemical and biological PPE on reaction time. Heart rate response and TM temperature were higher during exertion in PPE. These differences, along with other physiological alterations observed, were not of clinical relevance. Further studies using arterial blood gas analysis and a more accurate measure of core body temperature are needed to better assess the physiological effect of this level and duration of exercise on subjects wearing similar PPE. Other aspects of cognition also require investigation under these conditions, in order to assess their effect on patient and rescuer safety.

Physiological responses during graded treadmill exercise in chemical-resistant personal protective equipment

BACKGROUND

As the likelihood of terrorist acts increases, prehospital personnel have been forced to train in the proper use of chemical-resistant personal protective equipment (PPE). This protective ensemble has been reported to be physiologically taxing for the wearer, imposing an additional thermal load resulting in hypohydration, hyperthermia, and reduced work time. Victim extrication, the rescue-the-rescuer role of the rapid intervention team and rapid self-extrication, typically requires high-intensity work that can be maintained only for short time intervals. The additional physiological burden imparted by the level C PPE during high-intensity work is unknown.

OBJECTIVE

We hypothesized that the added thermal burden resulting from work in PPE would shorten work time and result in a higher core temperature during incremental treadmill exercise.

METHOD

In this prospective, crossover, laboratory study, EMS providers (n = 8, 5 male) completed a Bruce treadmill test on two occasions: once in a chemical-resistant coverall and air-purifying respirator (PPE) and once in shorts and t-shirt (CON). Oxygen consumption, vital signs, core and skin temperature, and perceptual measures of exertion, thermal sensation, and comfort were monitored throughout the test.

RESULTS

Subjects achieved maximal oxygen consumption and more than 90% of age-predicted maximum heart rate in both conditions. Heart rate, skin temperature, and measures of perceived exertion, comfort, and thermal sensation increased during the treadmill exercise but did not differ between the PPE and CON conditions. Core temperature increased in both the CON and PPE conditions (0.8 +/- 0.5 vs. 0.7 +/- 0.3, p = 0.40).

CONCLUSION

High-intensity work in level C PPE is primarily limited by cardiovascular capacity. The thermal burden associated with this short bout of work in PPE (approximately 10 minutes) is not different than high-intensity work in short pants and cotton t-shirt. Consideration should be given to cardiorespiratory fitness when assigning providers to work in chemical-resistant PPE, especially on tasks that require high-intensity work.