Comparison of Three Video Laryngoscopes and Direct Laryngoscopy for Emergency Endotracheal Intubation While Wearing PPE-AGP: A Randomized, Crossover, Simulation Trial

Background: The COVID-19 pandemic has necessitated changes in the safety protocols of endotracheal intubation at every level of care. This study aimed to compare the first-pass success rates (FPS) and intubation times (IT) of three video laryngoscopes (VL) and direct laryngoscopy (DL) for simulated COVID-19 patient emergency intubation (EI). Methods: The study was a prospective, randomized, crossover trial. Fifty-three active paramedics performed endotracheal intubation with the I-viewTM VL, UESCOPE® VL, ProVu® VL and Macintosh direct laryngoscope (MAC) wearing personal protective equipment for aerosol-generating procedures (PPE-AGP) on a manikin with normal airway conditions. Results: The longest IT was noted when the UESCOPE® (29.4 s) and ProVu® (27.7 s) VL were used. The median IT for I-view was 17.4 s and for MAC DL 17.9 s. The FPS rates were 88.6%, 81.1%, 83.0% and 84.9%, respectively, for I-view, ProVu®, UESCOPE® and MAC DL. The difficulty of EI attempts showed a statistically significant difference between UESCOPE® and ProVu®. Conclusions: The intubation times performed by paramedics in PPE-AGP using UESCOPE® and ProVu® were significantly longer than those with the I-view and Macintosh laryngoscopes. The use of VL by prehospital providers in PPE did not result in more effective EI than the use of a Macintosh laryngoscope.

Risk of Dehydration Due to Sweating While Wearing Personal 2 Protective Equipment in COVID-19 Clinical Care: A Pilot Study

Objective: The objectives of this study were (a) to determine the physical impact of the personal protective equipment (PPE) used in COVID-19 care, specifically the impact on the hydration state of the temperature and the comfort of the healthcare workers who use it, and (b) to show the high-fidelity simulated environment as an appropriate place to test the experimental designs to be developed in real environments for COVID-19. Background: All healthcare staff use full PPE in the care of COVID-19 patients. There are problems, such as excessive sweating, which have not been quantified thus far. Methods: A descriptive pilot design was used in a simulated high-fidelity setting. There was paired activity, with mild–moderate physical activity, between 45 and 60 min continuously, with the COVID-19 PPE. Sixteen intensive care nurses were selected. The before–after differential of weight, thirst, weight use of the PPE, body temperature, thermal body image, general and facial warmth sensation, and perspiration sensation were measured. Results: All subjects lost weight in the form of sweat with both PPEs during the simulation scenario, with a mean of 200 g (0.28% of initial weight), and increased thirst sensation. Body thermal image increased by 0.54 °C in people using the full COVID-19 PPE. Conclusions: The use of PPE in the management of critically ill COVID-19 patients generates weight loss related to excessive sweating. The weight loss shown in this pilot test is far from the clinical limits of dehydration. The use of ventilated PPE, such as PAPR, reduce the body temperature and heat sensation experienced by the users of it; at the same time, it improves the comfort of those who wear it. The simulated environment is a suitable place to develop the piloting of applicable research methodologies in future studies in a real environment.

Life-Saving Procedures Performed While Wearing CBRNe Personal Protective Equipment: A Mannequin Randomized Trial

INTRODUCTION

Chemical-biological-radiological-nuclear-explosive (CBRNe) are complex events. Decontamination is mandatory to avoid harm and contain hazardous materials, but can delay care. Therefore, the stabilization of patients in the warm zone seems reasonable, but research is limited. Moreover, subjects involved in biological events are considered infectious even after decontamination and need to be managed while wearing personal protective equipment (PPE), as seen with Ebola and COVID-19 pandemic. With this simulation mannequin trial, we assessed the impact of CBRNe PPE on cardiopulmonary resuscitation and combat casualty care procedures.

METHODS

We compared procedures performed by emergency medicine and anesthesiology senior residents, randomized in 2 groups (CBRNe PPE vs. no PPE). Chest compression (CC) depth was defined as the primary outcome. Time to completion was calculated for the following: tourniquet application; tension pneumothorax needle decompression; peripheral venous access (PVA) and intraosseous access positioning; and drug preparation and administration. A questionnaire was delivered to evaluate participants' perception.

RESULTS

Thirty-six residents participated. No significant difference between the groups in CC depth (mean difference = 0.26 cm [95% confidence interval = -0.26 to 0.77 cm, P = 0.318]), as well as for CC rate, CC complete release, and time for drugs preparation and administration was detected. The PPE contributed to significantly higher times for tourniquet application, tension pneumothorax decompression, peripheral venous access, and intraosseous access positioning. The residents found simulation relevant to the residencies' core curriculum.

CONCLUSIONS

This study suggests that cardiopulmonary resuscitation can be performed while wearing PPE without impacting quality, whereas other tasks requiring higher dexterity can be significantly impaired by PPE.Trial Registration Number: NCT04367454, April 29, 2020 (retrospectively registered).

Influence of respiratory protective equipment on simulated advanced airway skills by specialist tracheal intubation teams during the COVID-19 pandemic

Background

The COVID-19 pandemic has highlighted the importance of respiratory protective equipment for clinicians performing airway management.

Aim

To evaluate the impact of powered air-purifying respirators, full-face air-purifying respirators and filtering facepieces on specially trained anaesthesiologists performing difficult airway procedures.

Methods

All our COVID-19 intubation team members carried out various difficult intubation drills: unprotected, wearing a full-face respirator, a filtering facepiece or a powered respirator. Airway management times and wearer comfort were evaluated and analysed.

Results

Total mean (SD) intubation times did not show significant differences between the control, the powered, the full-face respirator and the filtering facepiece groups: Airtraq 6.1 (4.4) vs. 5.4 (3.1) vs. 6.1 (5.6) vs. 7.7 (7.6) s; videolaryngoscopy 11.4 (9.0) vs. 7.7 (4.3) vs. 9.8 (8.4) vs. 12.7 (9.8) s; fibreoptic intubation 16.6 (7.8) vs.13.8 (6.7) vs. 13.6 (8.1) vs. 16.9 (9.2) s; and standard endotracheal intubation by direct laryngoscopy 8.1 (3.5) vs. 6.5 (5.6) vs. 6.2 (4.2) vs. 8.0 (4.4) s, respectively. Use of the Airtraq achieved the shortest intubation times. Anaesthesiologists rated temperature and vision significantly better in the powered respirator group.

Conclusions

Advanced airway management remains unaffected by the respiratory protective equipment used if performed by a specially trained, designated team. We conclude that when advanced airway skills are performed by a designated, specially trained team, airway management times remain unaffected by the respiratory protective equipment used.

Orotracheal tube versus supraglottic devices in biological, chemical and radiological disasters: meta-analysis in manikin-based studies

OBJECTIVE

To compare the mean time of orotracheal intubation and insertion of supraglottic airway devices, considering healthcare providers wearing waterproof overall, gloves, boots, eye protection and mask at the Chemical, Biological, Radiological and Nuclear context in simulation setting.

METHODS

Six databases were searched. The selected studies were put in a pool of results using a random-effects meta-analysis, with standardized mean differences and calculation of 95% confidence intervals.

RESULTS

Nine observational studies were included. Regarding reducing time to provide ventilatory support, subgroup analyses were made. The emergency setting subgroup: -12.97 [-16.11; -9.83]; I2 = 64%. The surgery setting subgroup: -14.96 [-18.65; -11.27]; I2 = 75%. Another analysis was made by reproductive methodology subgroups. Ophir's subgroup: -15.70 [-17.04; -14.37]; I2 = 0%. All meta-analyses had orotracheal tube as comparator.

CONCLUSION

Moderate level of evidence was in favor of insertion of supraglottic devices because of fast application.

Staff perceptions of military chemical-biological-radiological-nuclear (CBRN) air-purifying masks during a simulated clinical task in the context of SARS-CoV-2

Air-purifying full-face masks, such as military chemical-biological-radiological-nuclear masks, might offer superior protection against severe acute respiratory syndrome coronavirus 2 compared to disposable polypropylene P2 or N95 masks. In addition, disposable masks are in short supply, while military chemical-biological-radiological-nuclear masks can be disinfected then reused. It is unknown whether such masks might be appropriate for civilians with minimal training in their use. Accordingly, we compared the Australian Defence Force in-service chemical-biological-radiological-nuclear Low Burden Mask (AirBoss Defense, Newmarket, Canada) with polypropylene N95 masks and non-occlusive glasses worn during simulated tasks performed by civilian clinicians in an Australian tertiary referral hospital intensive care unit. After brief training in the use of the Low Burden Mask, participants undertook a simulated cardiac arrest scenario. Previous training with polypropylene N95 masks had been provided. Evaluation of 10 characteristics of each mask type were recorded, and time to mask application was assessed. Thirty-three participants tested the Low Burden Mask, and 28 evaluated polypropylene N95 masks and glasses. The Low Burden Mask was donned more quickly: mean time 7.0 (standard deviation 2.1) versus 18.3 (standard deviation 6.7) seconds; P = 0.0076. The Low Burden Mask was rated significantly higher in eight of the 10 assessed criteria, including ease of donning, comfort (initially and over a prolonged period), fogging, seal, safety while removing, confidence in protection, and overall. Visibility and communication ability were rated equally highly for both systems. We conclude that this air-purifying full-face mask is acceptable to clinicians in a civilian intensive care unit. It enhances staff confidence, reduces waste, and is likely to be a lower logistical burden during a prolonged pandemic. Formal testing of effectiveness is warranted.

Aircrew Performance and Safety While Using Protective Masks in Response to Coronavirus Disease

INTRODUCTION: In response to the urgent need for safe aircrew respiratory protection due to the COVID-19 pandemic, three small descriptive evaluations were conducted with aircrew and air traffic controllers (ATC) that assessed the impact of mask use on safety and performance onboard rotary wing aircraft.METHODS: A series of evaluations assessed aircrew performance using the 3M^TM Model 1860 N95 respiratory protection mask, two aviation-specific cloth mask prototypes, and a commercial off-the-shelf aviation-specific cloth mask. The series of evaluations included different sets of subjects consisting of up to five Black Hawk helicopter aircrew members, air traffic control (ATC), and 12 CH-47 aircrew members. The Modified Rhyme Test was used to measure speech intelligibility and was administered in the UH-60 among crewmembers of the same aircraft, between pilots of different aircraft, and between the pilots and ATC. Measures of workload, usability, comfort, and pulse oximetry were also administered.RESULTS: Results from the Modified Rhyme Test indicated that all subjects scored greater than 80% accuracy given the proper microphone positioning relative to the mask. With respect to workload, NASA-TLX total scores for the perform radio communications task was 50.83.DISCUSSION: Despite an elevated perceived degree of workload on the communications flight task, results from the speech intelligibility test indicated that performance was maintained within the acceptable range as defined by MIL-STD-1474E, Design Criteria Standard Noise Limit. This abbreviated evaluation suggests that the face masks tested are safe for use by helicopter aircrew under the conditions tested.Cave KM, Kelley AM, Feltman KA, Gerstner JA, Stewart JL, Crowley JS. Aircrew performance and safety while using protective masks in response to coronavirus disease. Aerosp Med Hum Perform. 2021; 92(4):274280.

Use of powered air-purifying respirator(PAPR) as part of protective equipment against SARS-CoV-2-a narrative review and critical appraisal of evidence

BACKGROUND

The last 2 decades have seen an increasing frequency of zoonotic origin viral diseases leaping from animal to human hosts including Severe Acute Respiratory Syndrome Coronaviruses (SARS-CoV-2). Respiratory component of the infectious disease program against SARS-CoV-2 incorporates use of protective airborne respiratory equipment.

METHODS

In this narrative review, we explore the features of Powered Air Purifying Respirators (PAPR) as well as logistical and evidence-based advantages and disadvantages.

RESULTS

Simulation study findings support increased heat tolerance and wearer comfort with a PAPR, versus decreased communication ability, mobility, and dexterity. Although PAPRs have been recommended for high-risk procedures on suspected or confirmed COVID-19 patients, this recommendation remains controversial due to lack of evidence. Guidelines for appropriate use of PAPR during the current pandemic are sparse. International regulatory bodies do not mandate the use of PAPR for high-risk aerosol generating procedures in patients with SARS-CoV-2. Current reports of the choice of protective respiratory technology during the SARS-CoV-2 pandemic are disparate. Patterns of use appear to be related to geographical locations.

DISCUSSION

Field observational studies do not indicate a difference in healthcare worker infection utilizing PAPR devices versus other compliant respiratory equipment in healthcare workers performing AGPs in patients with SARS-CoV-2. Whether a higher PAPR filtration factor translates to decreased infection rates of HCWs remains to be elucidated. Utilization of PAPR with high filtration efficiency may represent an example of "precautionary principle" wherein action taken to reduce risk is guided by logistical advantages of PAPR system.

Speech intelligibility in respiratory protective equipment - Implications for verbal communication in critical care

Respiratory protective equipment (RPE) such as filtering facepiece respirators, elastomeric respirators and powered air-purifying respirators are routinely worn in the critical care unit as a component of personal protective equipment (PPE) when caring for patients with coronavirus disease 2019 (COVID-19). It is the authors' anecdotal experience that RPE may, however, inadvertently interfere with verbal communication between critical care staff. The literature pertaining to the effects of RPE wear on verbal communication was therefore reviewed. A literature search returned 98 articles, and 4 records were identified from other sources; after screening for content relevancy, 15 experimental studies were included in the narrative synthesis. Previous studies in both healthcare and other occupational settings suggest a detrimental impact on speech intelligibility, varying according to RPE type and test conditions. The effects of background noise and potential for increased cognitive load through compensatory behaviours are also identified. The clinical significance of these effects remains uncertain though, as evidence measuring clinical outcomes or errors is lacking. Mitigating strategies include increasing speech intelligibility through environmental changes and technology; modifying verbal communication strategies; and decreasing reliance on verbal communication where possible.

Predicting Health Care Workers' Tolerance of Personal Protective Equipment: An Observational Simulation Study

BACKGROUND

More recently, due to the coronavirus disease 2019 pandemic, health care workers have to deal with clinical situations wearing personal protective equipment (PPE); however, there is a question of whether everybody will tolerate PPE equally. The main objective of this study was to develop a risk model to predict whether health care workers will tolerate wearing PPE, C category, 4B/5B/6B type, during a 30-minute simulation.

METHODS

A nonexperimental simulation study was conducted at the Advanced Simulation Center, Faculty of Medicine, Valladolid University (Spain) from April 3rd to 28th, 2017. Health care students and professionals were equipped with PPE and performed a 30-minute simulation. Anthropometric, physiological, and analytical variables and anxiety levels were measured before and after simulation. A scoring model was constructed.

RESULTS

Ninety-six volunteers participated in the study. Half the sample presented metabolic fatigue in the 20 minutes after finishing the simulation. The predictive model included female sex, height, muscle and bone mass, and moderate level of physical activity. The validity of the main model using all the variables presented an area under the curve of 0.86 (95% confidence interval: 0.786-0.935), and the validity of the model had an area under the curve of 0.725 (95% confidence interval: 0.559-0.89).

CONCLUSIONS

Decision-making in biohazard incidents is a challenge for emergency team leaders. Knowledge of health care workers' physiological tolerance of PPE could improve their performance.

Systematic review and meta-analysis comparing ventilatory support in chemical, biological and radiological emergencies

Objective:

to compare the mean development time of the techniques of direct laryngoscopy and insertion of supraglottic devices; and to evaluate the success rate in the first attempt of these techniques, considering health professionals wearing specific personal protective equipment (waterproof overalls; gloves; boots; eye protection; mask).

Method:

meta-analysis with studies from LILACS, MEDLINE, CINAHL, Cochrane, Scopus and Web of Science. The keywords were the following: personal protective equipment; airway management; intubation; laryngeal masks.

Results:

in the “reduction of the time of the procedures” outcome, the general analysis of the supraglottic devices in comparison with the orotracheal tube initially presented high heterogeneity of the data (I²= 97%). Subgroup analysis had an impact on reducing heterogeneity among the data. The “laryngeal mask as a guide for orotracheal intubation” subgroup showed moderate heterogeneity (I²= 74%). The “2^ndgeneration supraglottic devices” subgroup showed homogeneity (I²= 0%). All the meta-analyses favored supraglottic devices. In the “success in the first attempt” outcome, moderate homogeneity was found (I²= 52%), showing a higher proportion of correct answers for supraglottic devices.

Conclusion:

in the context of chemical, biological or radiological disaster, the insertion of the supraglottic device proved to be faster and more likely to be successful by health professionals. PROSPERO record (CRD42019136139).

Use of powered air-purifying respirator (PAPR) by healthcare workers for preventing highly infectious viral diseases-a systematic review of evidence

BACKGROUND

Healthcare workers (HCWs) are at particular risk during pandemics and epidemics of highly virulent diseases with significant morbidity and case fatality rate. These diseases include severe acute respiratory syndrome coronaviruses, SARS-CoV-1 and SARS-CoV-2, Middle Eastern Respiratory Syndrome (MERS), and Ebola. With the current (SARS-CoV-2) global pandemic, it is critical to delineate appropriate contextual respiratory protection for HCWs. The aim of this systematic review was to evaluate the effect of powered air-purifying respirators (PAPRs) as part of respiratory protection versus another device (egN95/FFP2) on HCW infection rates and contamination.

METHODS

Our primary outcomes included HCW infection rates with SARS-CoV-2, SARS-CoV-1, Ebola, or MERS when utilizing PAPR. We included randomized controlled trials, non-randomized controlled trials, and observational studies. We searched the following databases: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two reviewers independently screened all citations, full-text articles, and abstracted data. Due to clinical and methodological heterogeneity, we did not conduct a meta-analysis. Where applicable, we constructed evidence profile (EP) tables for each individual outcome. Confidence in cumulative evidence for each outcome was classified according to the GRADE system.

RESULTS

We identified 689 studies during literature searches. We included 10 full-text studies. A narrative synthesis was provided. Two on-field studies reported no difference in the rates of healthcare workers performing airway procedures during the care of critical patients with SARS-CoV-2. A single simulation trial reported a lower level of cross-contamination of participants using PAPR compared to alternative respiratory protection. There is moderate quality evidence that PAPR use is associated with greater heat tolerance but lower scores for mobility and communication ability. We identified a trend towards greater self-reported wearer comfort with PAPR technology in low-quality observational simulation studies.

CONCLUSION

Field observational studies do not indicate a difference in healthcare worker infection utilizing PAPR devices versus other compliant respiratory equipment. Greater heat tolerance accompanied by lower scores of mobility and audibility in PAPR was identified. Further pragmatic studies are needed in order to delineate actual effectiveness and provider satisfaction with PAPR technology.

SYSTEMATIC REVIEW REGISTRATION

The protocol for this review was prospectively registered with the International Register of Systematic Reviews identification number CRD42020184724 .

The Multiple Casualty Scenario: Role of the Anesthesiologist

Purpose of Review

Mass casualty disasters (natural and man-made) present an acute, critical situation that taxes healthcare resources and clinician acumen. This review summarizes the characteristics and management skill sets that anesthesiologists possess that make them valuable clinicians during mass casualty events and why we as anesthesiologists must continually educate ourselves on this important topic.

Recent Findings

Anesthesiologists should be involved in all aspects of emergency preparedness—mitigation, planning, response, and recovery. The anesthesia department should have a plan for how it will deal with managing patients during natural and man-made (unintentional or intentional) disasters, one that takes into account a risk hazard analysis and institutional goals. Unfortunately, most practicing anesthesiologists have not had training and ongoing education for such events, and few academic centers train anesthesiology residents and staff to prepare for mass casualty scenarios.

Summary

The everyday clinical practice of anesthesiologists involves the utilization of some of the skills (vascular access, tracheal intubation) commonly required to successfully manage mass casualty scenarios. Anesthesiologists’ knowledge of anti-cholinesterases makes them subject matter experts on nerve agent poisoning, and their experience managing trauma patients will serve them well, depending on the nature of the mass casualty event. Practicing anesthesiologists however need to continually educate themselves on their role during mass casualty events. and current anesthesiology residency programs should develop a curriculum and incorporate simulation training to better prepare future generations of anesthesiologists.

The impact of respiratory protective equipment on difficult airway management: a randomised, crossover, simulation study

The current international COVID‐19 health crisis underlines the importance of adequate and suitable personal protective equipment for clinical staff during acute airway management. This study compares the impacts of standard air‐purifying respirators and powered air‐purifying respirators during simulated difficult airway scenarios. Twenty‐five anaesthetists carried out four different standardised difficult intubation drills, either unprotected (control), or wearing a standard or a powered respirator. Treatment times and wearer comfort were determined and compared. In the wearer comfort evaluation form, operators rated mobility, noise, heat, vision and speech intelligibility. All anaesthetists accomplished the treatment objectives of all study arms without adverse events. Total mean (SD) intubation times for the four interventions did not show significant differences between the powered and the standard respirator groups, being 16.4 (8.6) vs. 19.2 (5.2) seconds with the Airtraq™; 11.4 (3.4) vs. 10.0 (2.1) seconds with the videolaryngoscope; 39.2 (4.5) vs. 40.1 (4.8) seconds with the fibreoptic bronchoscope scope; and 15.4 (5.7) vs. 15.1 (5.0) seconds for standard tracheal intubation by direct laryngoscopy, respectively. Videolaryngoscopy allowed the shortest intubation times regardless of the respiratory protective device used. Anaesthetists rated heat and vision significantly higher in the powered respirator group; however, noise levels were perceived to be significantly lower than in the standard respirator group. We conclude that standard and powered respirators do not significantly prolong simulated advanced intubation procedures.

Resuscitation of the patient with suspected/confirmed COVID-19 when wearing personal protective equipment: A randomized multicenter crossover simulation trial

BACKGROUND

The aim of the study was to evaluate various methods of chest compressions in patients with suspected/confirmed SARS-CoV-2 infection conducted by medical students wearing full personal protective equipment (PPE) for aerosol generating procedures (AGP).

METHODS

This was prospective, randomized, multicenter, single-blinded, crossover simulation trial. Thirty-five medical students after an advanced cardiovascular life support course, which included performing 2-min continuous chest compression scenarios using three methods: (A) manual chest compression (CC), (B) compression with CPRMeter, (C) compression with LifeLine ARM device. During resuscitation they are wearing full personal protective equipment for aerosol generating procedures.

RESULTS

The median chest compression depth using manual CC, CPRMeter and LifeLine ARM varied and amounted to 40 (38-45) vs. 45 (40-50) vs. 51 (50-52) mm, respectively (p = 0.002). The median chest compression rate was 109 (IQR; 102-131) compressions per minute (CPM) for manual CC, 107 (105-127) CPM for CPRMeter, and 102 (101-102) CPM for LifeLine ARM (p = 0.027). The percentage of correct chest recoil was the highest for LifeLine ARM - 100% (95-100), 80% (60-90) in CPRMeter group, and the lowest for manual CC - 29% (26-48).

CONCLUSIONS

According to the results of this simulation trial, automated chest compression devices (ACCD) should be used for chest compression of patients with suspected/confirmed COVID-19. In the absence of ACCD, it seems reasonable to change the cardiopulmonary resuscitation algorithm (in the context of patients with suspected/confirmed COVID-19) by reducing the duration of the cardiopulmonary resuscitation cycle from the current 2-min to 1-min cycles due to a statistically significant reduction in the quality of chest compressions among rescuers wearing PPE AGP.

First responder communication in CBRN environments: FIRCOM-CBRN study

INTRODUCTION

Recent terror attacks and assassinations involving highly toxic chemical weapons have stressed the importance of sufficient respiratory protection of medical first responders and receivers. As full-face respirators cause perceptual-motor impairment, they not only impair vision but also significantly reduce speech intelligibility. The recent introduction of electronic voice projection units (VPUs), attached to a respirator, may improve communication while wearing personal respiratory protection.

OBJECTIVE

To determine the influence of currently used respirators and VPUs on medical communication and speech intelligibility.

METHODS

37 trauma anaesthetists carried out an evaluation exercise of six different respirators and VPUs including one control. Participants had to listen to audio clips of a variety of sentences dealing with scenarios of emergency triage and medical history taking.

RESULTS

In the questionnaire, operators stated that speech intelligibility of the Avon C50 respirator scored the highest (mean 3.9, ±SD 1.0) and that the Respirex Powered Respiratory Protective Suit (PRPS) NHS-suit scored lowest (1.6, 0.9). Regarding loudness the C50 plus the Avon VPU scored highest (4.1, 0.7), followed by the Draeger FPS-7000-com-plus (3.4, 1.0) and the Respirex PRPS NHS-suit scored lowest (2.3, 0.8).

CONCLUSIONS

We found that the Avon C50 is the preferred model among the tested respirators. In our model, electronic voice projection modules improved loudness but not speech intelligibility. The Respirex PRPS NHS-suit was rated significantly less favourably in respect of medical communication and speech intelligibility.

Emergency Department Response to Chemical, Biological, Radiological, Nuclear, and Explosive Events: A Systematic Review

Introduction

A Chemical, Biological, Radiological, Nuclear, and explosive (CBRNe) event is an emergency which can result in injury, illness, or loss of life. The emergency department (ED) as a health system is at the forefront of the CBRNe response with staff acting as first receivers. Emergency departments are under-prepared to respond to CBRNe events - recognizing key factors which underlie the ED CBRNe response is crucial to provide evidence-based knowledge to inform policies and, most importantly, clinical practice.

Problem

Challenges in detection, decontamination, and diagnosis are associated with the ED CBRNe response when faced with self-presenting patients.

Methods

A systematic review was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). An in-depth search strategy was devised to identify studies which focused on the ED and CBRNe events. The inclusion criteria were stringent in terms of the environment (ED), participants (first receivers), situation (CBRNe response), and actions (detection, decontamination, and diagnosis). Fifteen databases and topic-specific journals were searched. Studies were critically appraised using the Mixed Methods Appraisal Tool (MMAT). Papers were thematically coded and synthesized using NVivo 10 (QSR International Ltd, Melbourne, Australia).

Results

Sixty-seven full-text papers were critically appraised using the MMAT; 70% were included (n = 60) as medium- or high-quality studies. Data were grouped into four themes: preparedness, response, decontamination, and personal protective equipment (PPE) problems.

Discussion

This study has recognized the ED as a system which depends on four key factors - preparedness, response, decontamination, and PPE problems - which highlight challenges, uncertainties, inconsistencies, and obstacles associated with the ED CBRNe response. This review suggests that response planning and preparation should be considered at three levels: organizational (policies and procedures); technological (decontamination, communication, security, clinical care, and treatment); and individual (willingness to respond, PPE, knowledge, and competence). Finally, this study highlighted that there was a void specific to detection and diagnosis of CBRNe exposure on self-presenting patients in the ED.

Conclusion:

The review identified concerns for both knowledge and behaviors which suggests that a systems approach would help understand the ED response to CBRNe events more effectively. The four themes provide an evidence-based summary for the state of science in ED CBRNe response, which can be used to inform future policies and clinical procedures.

RazakS,HignettS,BarnesJ.Emergency department response to chemical, biological, radiological, nuclear, and explosive events: a systematic review.Prehosp Disaster Med.2018;33(5):543–549.

Informing decisions on the purchase of equipment used by health services in response to incidents involving hazardous materials

Accidents involving release of chemical, biological, radiological or nuclear substances may prompt the need to decontaminate exposed casualties prior to further medical treatment. Health service workers who carry out decontamination procedures wear protective suits to avoid direct contact with contaminants. We developed an analytical framework based on queueing theory to inform UK Department of Health's decisions on the stock of protective suits that ambulance services and hospitals with emergency departments in England should hold. Our aim was to ensure that such allocation gave an accepted degree of resilience to locally identified hazards. Here we give an overview of our work and describe how we incorporated information in the public domain about local hazards with expert opinion about the patterns of demand for decontamination associated with different types of incident. We also give an account of how we worked with decision makers to inform national guidance on this topic.