key: cord-0747632-rnxbd5r6
authors: Myers, Sage R.; Abbadessa, Mary Kate; Gaines, Shannon; Lavelle, Jane; Ercolani, Jenna; Shotwell, Collin; Ainsley, Matthew; Pettijohn, Kevin; Donoghue, Aaron J.
title: Repurposing Video Review Infrastructure for Clinical Resuscitation Care in the Age of COVID-19
date: 2020-08-25
journal: Ann Emerg Med
DOI: 10.1016/j.annemergmed.2020.08.030
sha: 6a92472f5ec06efdea93a2870a20e9607f257714
doc_id: 747632
cord_uid: rnxbd5r6

nan

Within the context of the COVID-19 pandemic, minimizing healthcare worker exposure to the novel coronavirus has become a paramount part of the provision of healthcare in all settings across the world. Limited supply of personal protective equipment (PPE), personnel shortages as a result of exposure, and ensuring the safety and health of our workers, have all dictated the need to minimize the number of providers with direct patient contact. In resuscitation events, there is high likelihood of multiple aerosol-generating procedures, and increased risk of viral transmission, therefore limiting personnel is of particular importance. The development of creative solutions to allow vital team contributions to occur outside of the direct patient care space whenever possible is critical.

The use of video recording and video review during resuscitative care has been described in several recent studies from pediatric emergency departments (ED). [1] [2] [3] Members of our group have reported on the use of video review as a means of assessing performance during cardiopulmonary resuscitation (CPR) and tracheal intubation (TI). 4-7 Since 2012, the ED at the Children's Hospital of Philadelphia has maintained a robust video-based quality improvement (QI) program. All resuscitations (both medical and trauma) are recorded using a multicamera video system (B-Line Medical, Washington, DC, USA), which uses a combination of three video angles, two audio feeds, and the vital sign monitor. (Figure 1 ) These can be reviewed in simultaneously streaming windows. To allow for capture of video assisted laryngoscopy, one video feed is replaced with the laryngoscope view when actively in use. As part of the Resuscitation QI program, we collect prospective data from the resuscitation physician leader immediately after each event. Primarily, this creates a complete database of demographics, diagnoses, and procedures, but also allows the leader to self-identify a given video to be reviewed. Using a learning health care system approach, videos are reviewed every two weeks in an open meeting focused on objective, systematic data collection with simultaneous goals of 1) identification of near-misses, safety events or areas for improvement in care delivery, 2) evaluation of workflows to determine interventions likely to impact identified areas of weakness, and 3) assessment of changes in care delivery after identified interventions are implemented.

Within secure firewalls, B-Line LiveCapture software can be used in a livestream fashion to view the events in real time. This functionality has been essential to the set-up of a Resuscitation Command Center in the ED in the era of COVID-19. Given that medical and trauma resuscitation patients are considered COVID-19 unknown and are at high risk of requiring aerosol-generating procedures, team members not providing direct patient care have been moved into the Resuscitation Command Center ( Figure 2 ) to minimize exposure as appropriate. The following roles have been transitioned to work remotely from the Command Center:

• Patient care associates: Completes registration, prepares identification bands and patient labels, and pages consultants. • Charge Respiratory Therapist: Assists in gathering necessary equipment and supporting movement of the patients on respiratory support to their subsequent care area. Can be called into the direct patient care area as needed to support the first responding respiratory therapist.

• Social work: Provides remote assistance to family members via tablet video chat or face-to-face assistance to family members who may choose to leave the resuscitation room.

• Child life: Provides support to the patient via tablet video chat or transitions to in room support when appropriate based on age-associated coping. (Table 1 ) Although we did not prospectively set up data collection to monitor reliability of the livestream-based command center system, overall since the transition to the command center set-up, we have had very few technical difficulties requiring command center team members to enter the resuscitation room due to lack of adequate audio/video connection. Built-in redundancies in communication have aided this, with tablet, cell phone, hospital-phone, two-way J o u r n a l P r e -p r o o f radio, and nurse-call options available as needed. In comparing data between the number of patients cared for in the our resuscitation room with the command center structure from 3/19/20-7/20/20, and the number of video-captured events (signaling that video was available and running in livestream during the event) we found only 5 of the 88 total events that did not have available video, further supporting the reliability of the system.

We recognize that our ED is uniquely situated given our pre-existing audio/video capability. However, similar strategies are possible without this substantial infrastructure. While our main resuscitation space was previously outfitted with a permanent audio/video system, we also created a back-up resuscitation space to allow for simultaneous resuscitation of two unrelated patients. In this area, we used a B-Line ultraportable system which only involves placement of two digital video cameras with built-in microphones connected to a laptop bearing the B-Line software. This allowed for temporary set up of livestream capabilities to support team members located in the command center when the back-up space was in use and can still be controlled remotely from computers within the command center.

have been trialed can be found in Table 2 . Some EDs may have window visibility into resuscitation areas which could allow for some "outside room" knowledge and support of the bedside team, especially if augmented by a two-way audio communication method. A video-based system like the one described here, however, adds the additional benefit of allowing that outside room team to be in a As an aside, the use of video review in this way has allowed us to have accurate contact tracing for all those involved in resuscitation events where the patient ultimately was found to be COVID-19 positive, since staff in the room may not otherwise be found listed in the medical record (such as technicians performing compressions, or supporting respiratory therapists setting up the ventilator).

To evaluate difference in clinical care outcomes associated with this new staffing model, we performed unadjusted univariate comparisons of intubation first-pass success and adverse events during intubation. In addition, to evaluate differences in clinical care processes, we performed unadjusted univariate comparisons of time to first blood pressure measurement, which had been a quality metric being tracked prior to the pandemic. We found that the decrease in staff present in the resuscitation room was not associated with obvious changes in clinical process or outcomes, as evidenced by supporting data listed in Table 2 . As with the data presented above evaluating the impact of our intervention on number of providers present, data on intubation and vital sign metrics was collected via our ongoing video review process. The use of video for data collection has been shown to have superior accuracy to chart review 3 and is more feasible than in-person observation.

Therefore, if video is implemented as a real-time feed to support out-of-room team support, it also bring the possibility of a secondary benefit of adding a rich data source for quality improvement through review or recorded videos.

Overall, by re-purposing our video review QI program to augment live, direct patient care, we have been able to limit the number of providers exposed to patients undergoing resuscitation, without deleterious effects on patient care processes or outcomes, thereby supporting the overarching goal of limiting staff contact with procedures at high risk of transmission in patients with unknown COVID-19 status.

Though we benefit from a pre-existing audio/video set-up within our resuscitation space, the principal of allowing for clinical work by resuscitation team members outside of the closed resuscitation space through the use of audio and video communication can be adapted to other environments using the alternative methods discussed. In the ED we face the unique risk combination of a patient population that is COVID-status unknown and yet relatively frequently requires aerosol-generating procedures, including resuscitation. We should continue to strive to implement creative solutions to decrease staff exposure. Evaluation of similar strategies implemented in emergency departments, including critical analysis of actual decrease in staff exposure and impact on clinical care should continue as we are able to gather more data as this pandemic wears on. In addition, adaptation of methods developed in the setting of COVID-19 should be considered as possible strategies for treatment of other high-risk patients such as Ebola and chemical exposure. 

Factors associated with oxyhemoglobin desaturation during rapid sequence intubation in a pediatric emergency department: findings from multivariable analyses of video review data

The effect of a checklist on advanced trauma life support task performance during pediatric trauma resuscitation

Rapid sequence intubation for pediatric emergency patients: Higher frequency of failed attempts and adverse events found by video review