A Protocol for COVID-19 Transmission During Tracheostomy

In This Article

Abstract and Introduction

Abstract

Background: Tracheostomies are highly aerosolizing procedures yet are often indicated in patients with COVID-19 who require prolonged intubation. Robust investigations of the safety of tracheostomy protocols and provider adherence and evaluations are limited.

Objectives: To determine the rate of COVID-19 infection of health care personnel involved in COVID-19 tracheostomies under a multidisciplinary safety protocol and to investigate health care personnel's attitudes and suggested areas for improvement concerning the protocol.

Methods: All health care personnel involved in tracheostomies in COVID-19–positive patients from April 9 through July 11, 2020, were sent a 22-item electronic survey.

Results: Among 107 health care personnel (80.5%) who responded to the survey, 5 reported a positive COVID-19 test result (n = 2) or symptoms of COVID-19 (n = 3) within 21 days of the tracheostomy. Respondents reported 100% adherence to use of adequate personal protective equipment. Most (91%) were familiar with the tracheostomy protocol and felt safe (92%) while performing tracheostomy. Suggested improvements included creating dedicated tracheostomy teams and increasing provider choices surrounding personal protective equipment.

Conclusions: Multidisciplinary engagement in the development and implementation of a COVID-19 tracheostomy protocol is associated with acceptable safety for all members of the care team.

Introduction

Since the first report of a novel coronavirus in Wuhan, China,^[1] the persistence of the ensuing COVID-19 pandemic has created massive global challenges for public health, research, and health care.^[2] Although many cases of COVID-19 are mild, patients with severe illness often require intensive care because of acute hypoxemic respiratory failure,^[3] necessitating prolonged mechanical ventilation in up to approximately 12% of patients.^[4] The increase in respiratory failure has resulted in an increased need for tracheostomies in patients with COVID-19.^[5]

Because tracheostomies are highly aerosolizing procedures,^[6,7] many authorities have raised concerns regarding the potential for transmission of COVID-19 to health care personnel during the procedure and have established recommendations to enhance patient and provider safety.^[8–12] The data on rate of infection of health care personnel in association with tracheostomies have largely demonstrated limited viral transmission; however, most reports are anecdotal^[13–16] or from cohorts of small teams of proceduralists, without consideration of the broader health care team.^[17–24]

Researchers have advocated for health care personnel–centered studies to investigate the risk for COVID-19 transmission during tracheostomy,^[25] yet few studies have included the entire complement of physicians, nurses, surgical technologists, and respiratory care practitioners involved in the procedure. In the current study, we describe the COVID-19 tracheostomy protocol implemented at our institution and investigate the rate of transmission of COVID-19 to health care personnel involved in tracheostomy procedures as well as the beliefs and attitudes of health care personnel concerning their own safety.

Table 1. Survey response by health care provider group
Health care provider group^a	No. of survey Responders	No. of survey Nonresponders
Physicians	46	4
Proceduralist	22	1
Anesthesiologist	6	1
Resident or fellow	18	2
Nonphysicians	61	22
Nurse	34	15
Respiratory care practitioner	25	6
Surgical technologist	2	1

^aχ² by individual group was 8.8 (P = .12); χ² by physician vs nonphysician was 8.4 (P = .04).

Table 2. Characteristics and outcomes of health care personnel who responded to the survey
Role	No. (%) of 107 respondents		No. of tracheostomies performed, median (range)	Performed tracheostomy using proper PPE, No. (%) of respondents	No. of respondents with
Role	Total	With prior tracheostomy experience	No. of tracheostomies performed, median (range)		Positive COVID-19 test result within 21 days of Procedure	Symptoms of COVID-19 within 21 days of procedure
Proceduralist	22 (21)	22 (100)	2 (1–28)	22 (100)	1	1
Anesthesiologist	6 (6)	6 (100)	3 (1–14)	6 (100)	0	0
Resident or fellow	18 (17)	17 (94)	2 (1–10)	18 (100)	1	0
Nurse	34 (32)	30 (88)	2 (1–11)	34 (100)	0	1
Respiratory care practitioner	25 (23)	21 (84)	2 (1–14)	25 (100)	0	1
Surgical technologist	2 (2)	2 (100)	2 (2)	2 (100)	0	0

Abbreviation: PPE, personal protective equipment.

Table 3. Qualitative content analysis of attitudes and areas for improvement of health care personnel who responded
Category	% of respondents^a	Sample excerpt
Provider safety
Proper PPE	67	"Appropriate PPE by all staff members is critical to safety of the procedure."
Communication	18	"Working with a team that can communicate and work AS A TEAM."
Improvements
PAPRs for all health care personnel	25	"PAPR for all in room
Dedicated teams performing tracheostomy	25	"Consider tracheostomy team approach which is done in other institutions

Abbreviations: PAPRs, powered air-purifying respirators; PPE, personal protective equipment.
^aResponses were included in more than one category if both categories were represented in a single response; percentages were calculated based only on those who had responded.