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Factors affecting providers’ comfort and fear during intubations of patients with COVID-19
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  1. Esther Lee1,
  2. Reem Qabas Al Shabeeb2,
  3. Muhammad El Shatanofy3,
  4. Collin F Mulcahy4,
  5. David P Yamane5,6,
  6. Marian L Sherman5,
  7. Eric R Heinz5
  1. 1Western University of Health Sciences, Pomona, California, USA
  2. 2Internal Medicine, Inova Fairfax Hospital, Falls Church, Virginia, USA
  3. 3The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
  4. 4Division of Otolaryngology–Head and Neck Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
  5. 5Department of Anesthesiology and Critical Care, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
  6. 6Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
  1. Correspondence to Esther Lee, Western University of Health Sciences, Pomona, CA CA 91766, USA; esther.lee1{at}westernu.edu

Abstract

Background Providers performing endotracheal intubation are at high risk of contracting SARS-CoV-2. The objective was to assess various demographic, exposure and institutional preparedness factors affecting intubators’ comfort and fear level during COVID-19 intubations.

Methods We conducted a cross-sectional, survey-based study during the COVID-19 pandemic from September 2020 to January 2021 at a single academic medical centre in Washington, DC, USA. Inclusion criteria were healthcare providers who had an experience in intubating patients confirmed with or suspected of COVID-19. The survey assessed various factors related to the providers’ comfort with intubation and fear during COVID-19 intubations.

Results A total of 329 surveys from 55 hospitals were analysed. Of the respondents, 173 (52.6%) were from emergency medicine providers. Factors that were associated with a higher comfort level of intubating patients with COVID-19 included attending physician position (adjusted OR (aOR)=2.6, 95% CI 1.4 to 4.8; p=0.003), performing more than 20 COVID-19 intubations (aOR=3.3, 95% CI 1.5 to 6.6; p=0.002), participation in an intubation team (aOR=1.6, 95% CI 1.1 to 2.7; p=0.031) and adequate levels of personal protective equipment (PPE) (aOR=4.3, 95% CI 2.0 to 8.8; p<0.0005). Compared with emergency physicians, anaesthesiology providers had higher fear levels of contracting SARS-CoV-2 during both first and subsequent SARS-CoV-2 intubations (first: OR=1.7, 95% CI 1.1 to 2.6, p=0.006; subsequent: OR=2.0, 95% CI 1.4 to3.2, p<0.0005).

Conclusion A higher degree of comfort in intubating patients suspected of or confirmed with COVID-19 was demonstrated in more senior physicians, members of intubation teams, providers who performed a higher number of intubations and providers who reported adequate PPE. These findings highlight potential targets for improving the experience of providers in this setting.

  • COVID-19

Data availability statement

No data are available.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Among the various healthcare workers during the COVID-19 pandemic, providers performing intubations are likely at an increased risk of contracting the virus due to the proximity of the provider to the patient’s airway. Recent studies have evaluated factors associated with front-line provider stress and wellness during the COVID-19 pandemic; however, to our knowledge, no studies have specifically investigated provider distress associated with intubation.

WHAT THIS STUDY ADDS

  • Our study suggests that providers who are more experienced with COVID-19 intubations and specialise in emergency medicine have a higher comfort level of intubating patients with COVID-19 and have a lower fear level of contracting COVID-19. Older age and more years in practice were also associated with greater comfort and less fear during intubations.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • Interventions such as being part of a dedicated intubation team, participating in simulation exercises and access to adequate personal protective equipment may improve intubators’ self-perceived risk of contracting COVID-19.

Introduction

Recent studies have evaluated factors associated with front-line provider stress and wellness during the COVID-19 pandemic; however, few studies have specifically investigated provider distress during intubations.1 2 The purpose of this study was to explore risk factors for intubation-related distress and describe comfort and fear levels of intubating physicians throughout the pandemic.

Methods

We conducted a cross-sectional, survey-based study during the COVID-19 pandemic from September 2020 to January 2021. An anonymous online survey was emailed to anaesthesiology and emergency medicine programme directors in the USA. The programme directors were asked to disseminate the survey to attending physicians, fellow physicians, resident physicians, certified registered nurse anaesthetists (CRNAs) and physician assistants (PAs) across their department. The survey assessed various demographic, exposure and preparation factors affecting providers’ comfort of intubating and fear of contracting SARS-CoV-2 during confirmed or suspected COVID-19 intubations using a 0–10 Likert scale (0 represents lowest fear/comfort and 10 represents highest fear/comfort). We excluded providers who had not intubated a patient with confirmed or suspected COVID-19. There was no patient and public involvement.

The effects of each demographic, exposure and preparedness factor on comfort and fear levels were evaluated by the Mann-Whitney U test and the Kruskal-Wallis test. Three ordinal logistic regression models were created to assess independent associations of these predictors with comfort level, fear level during first intubation and fear level during subsequent intubation. Factors that were statistically significant in bivariate comparisons were included in the ordinal logistic regression models. Results of the regressions are presented as adjusted OR (aOR) with 95% CIs. Statistical analyses were performed using SPSS V.27. Statistical significance was declared at p<0.05.

Results

We analysed 329 responses collected between September 2020 and January 2021. Demographic information, preparation factors, and comfort and fear levels of each group of all categorical variables are described in table 1. A total of 329 surveys from 55 hospitals were analysed. Of the respondents, 173 (52.6%) were from emergency medicine/critical care and 156 (47.4%) were from anaesthesia/critical care. Nearly half of the responses were from attending physicians (44.1%); 40.4% were from resident or fellow physicians; and 51 (15.1%) were from CRNAs and PAs. Factors that were statistically significant in bivariate comparisons included age (years), specialty, position, time in practice (years), number of confirmed or suspected COVID-19 intubations, intubation team and personal protective equipment (PPE) adequacy. These factors were included in the ordinal logistic regression model (table 2).

Table 1

Demographic information and preparation factors affecting intubation experience (n=329)

Table 2

Factors associated with intubator comfort and fear level following ordinal logistic regression4

In multivariate analysis, participants over 56 years old had a lower fear level for contracting COVID-19 compared with the age group of 25–35 years old during their first intubation of patients suspected of or confirmed with COVID-19 (aOR)=0.3, 95% CI 0.1 to 0.8; p=0.048). (table 2). Participants from anaesthesiology or anaesthesiology/critical care had a higher fear level of contracting COVID-19 compared with those in emergency medicine or emergency medicine/critical care during both first and subsequent intubations (first: aOR=1.7, 95% CI 1.1 to 2.6, p=0.006; subsequent: aOR=2.0, 95% CI 1.4 to 3.2, p<0.0005). Compared with the attending physician group, the resident or fellow physician group had a lower comfort level of intubating patients with COVID-19 (aOR=0.4, 95% CI 0.2 to 0.7; p=0.003). Additionally, providers with more than 16 years of practice had a higher comfort level of intubating patients with COVID-19 compared with providers with 5 years of practice (aOR=3.0, 95% CI 1.0 to 8.1; p=0.047)

Participants who were part of a dedicated intubation (DI) team and declared adequacy of PPE reported greater comfort intubating patients with COVID-19 (‘DI’ aOR=1.6, 95% CI 1.1 to 2.7, p=0.031; ‘PPE’ aOR=4.3, 95% CI 2.0 to 8.8, p<0.0005). Participants who reported adequacy of PPE were also more likely to have a lower level of fear of contracting SARS-CoV-2 during their first and subsequent intubations of patients suspected of COVID-19 (‘first’ aOR=0.2, 95% CI 0.1 to 0.4, p<0.0005; ‘subsequent’ aOR=0.2, 95% CI 0.1 to 0.3, p<0.0005) (table 2).

Discussion

Our study found that rank and number of COVID-19 intubations were positively associated with comfort levels during COVID-19 intubations. Similarly, older providers and emergency medicine physicians reported lower fear levels of contracting SARS-CoV-2 compared with younger age groups and anaesthesiologists, respectively. Collectively, these findings suggest that greater experiences with managing emergency airways dictated both comfort and fear levels during COVID-19 intubations.

Our study also suggests that institutional preparedness such as having a DI team and adequate PPE positively influenced providers’ experiences during COVID-19 intubations. Several institutions have developed COVID-19 intubation teams for safe, efficient and protocolised airway management.3 In this study, we found that providers with access to adequate PPE during COVID-19 intubations experienced greater comfort levels as well as reduced fear levels of contracting SARS-CoV-2 during first and subsequent intubation attempts of patients suspected of COVID-19.

Our study has several limitations that are inherent to a survey-based study. The intubators’ experience of comfort and fear level during COVID-19 intubations could have varied, depending on the trajectory of the pandemic as well as the institutions’ level of preparedness during the course of the pandemic. Second, recall bias is inherent to the self-reported retrospective survey studies that limit accuracy of their experiences. For example, the intubators were asked about the fear level during their first intubation that may have been many months previously. Third, we sent our survey to programme directors who were then requested to distribute the survey among faculty and residents within their departments. It is possible that some programme directors did not distribute the survey either altogether or to everyone who could have qualified to participate in this study. Additionally, those who were less affected by intubations perhaps were less likely to respond. This could have resulted in a non-response bias (and we are unable to report a response rate). Lastly, we must acknowledge that there is some level of interaction between the level of experience, number of intubations performed, and self-perceived fear and comfort levels. This is particularly true in teaching programmes where resident fear levels may have been driven by the expectation to perform above a certain standard rather than from a lower level of experience performing intubations. Questionnaires should explore the reasons why residents reported heightened fear levels during intubations, and similar studies across the globe are recommended to improve the generalisability of our study.

Conclusion

A higher degree of comfort in intubating patients suspected of or confirmed with COVID-19 was demonstrated in more senior physicians, members of intubation teams, providers who performed a higher number of intubations and providers who reported adequate PPE. These findings highlight potential targets for improving the experience of providers in this setting.

Data availability statement

No data are available.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by the George Washington University Institutional Review Board (NCR 202652). Participants gave informed consent to participate in the study before taking part.

References

Footnotes

  • Handling editor Ed Benjamin Graham Barnard

  • Contributors DPY is the guarantor and the corresponding author of this work. All authors substantially contributed to the study design and reviewed and commented on the manuscript. All authors have full access to the data in this study. EL, IB and ERH analysed the data and take responsibility for the integrity of the data and the accuracy of the data analysis. RQAS, EL and CFM wrote the first draft of this article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.