Taking ownership of occupational safety in theatre during COVID-19
By Dr Michelle Ananda-Rajah
Intubation is a highly skilled procedure but in the context of COVID-19 it takes nerves of steel. When adjusting a breathing tube down a difficult airway centimetres from the patient’s face, personal safety should be the last thing on your mind. Occupational safety is not an abstract construct for a group of anaesthetists in a Perth hospital who decided, at the start of the pandemic, to take ownership of their respiratory protection. Having dual appointments in major teaching hospitals in Perth and Hong Kong meant that David Kingsbury did not need to look far for best practice. He was in Hong Kong when his hospital started receiving first hand reports of an unusual pneumonia at the end of December 2019. The professional grapevine meant that this information did not have to come via state owned media or public health authorities including the WHO. When Hong Kong activated its pandemic response, David is matter of fact,
“The hospitals in Hong Kong literally pulled their pandemic manual off the shelf and turned to page one”.
He vividly recalls his first day of work at this hospital 8 years earlier. A whole day of induction was not sitting in dry lectures sipping instant coffee or watching an online video. The major part of induction was devoted to occupational safety and infection control. Such was the rigor of the process that “you could not enter the hospital as an employee until you had passed induction”.
So, what did it involve? Quantitative fit testing (with a Portacount, TSI Inc.) performed by trained nurses using a range of P2/N95 disposable respirators including the “Rolls Royce” of disposables the 3M, with a sticker of your respirator fit worn on your ID card; repeated donning and doffing of PPE “until you could do it without looking at the instructions” that “you did it over and over again until you got it right” he says with a laugh. A tour of the theatre and your office (PPE is stored in the office also) to show you where your respirator was stocked among the rest of the PPE. The “emphasis was on understanding the equipment and processes” rather than robotic compliance. They even covered contingencies for re-use of disposables in the face of critical shortage. This level of detail is so alien to us in Australian healthcare that it’s difficult to fathom. Why is it embedded in workplaces in Hong Kong? Simple, an institutional memory of SARS. Although they see more patients with tuberculosis, another SARS like crisis is always at the “back of their minds”.
When Hong Kong activated its pandemic response, he describes the bidirectional flow of information between state authorities and the frontline. The twice weekly webinars covered emerging clinical issues, lines of reporting with pre-delegated people identified, chains of command and detailed reports on PPE supply. The openness of data sharing meant that frontline clinicians were aware, as early as February, of the coagulation phenomena, autopsy findings and the multisystem nature of COVID-19 associated with atypical presentations including stroke. The comparisons to our own state and service level systems could not be more stark. Communication between Australian state agencies or indeed at local level to frontline staff has been a huge issue. Would sending all our health service CEOs and policy makers to Hong Kong turbo charge our pandemic response and attitude to occupational safety? It certainly wouldn’t hurt.
Interestingly in Hong Kong, hospitals are led by doctors who are experienced senior clinicians, plucked from the hospitals they have worked in. Chief executives have medical backgrounds bringing evidence-based practice to their own institutions. They have clearly put into action evidence that demonstrates the benefits to hospital performance when clinicians are installed into senior leadership positions.
This digression sets the scene for what followed. As early as January 2020, the anaesthetists in this Perth hospital took matters into their own hands. After initial requests for fit testing were rebuffed, they exploited a clause in the official guidelines that allowed it in certain high-risk groups. Guided by advice from the numerous Occupational Health and Safety groups established for Western Australia’s mining sector, as well as manufacturing giant 3M, they trained clinicians within their department in qualitative fit testing. It became apparent that 20-30% of people were failing the hospital model of respirator. It also became clear that solving this issue was not going to be easy because hospital management were themselves in uncharted waters and needed support.
The worldwide shortage of respirators was making headlines at the beginning of the pandemic. It was local businesses, from large mining supply companies to small paint and manufacturing shops, who approached the doctors with offers of support. Brand new re-useable 3M and Honeywell elastomeric masks exchanged hands along with expert advice on how to use them. Not satisfied with the looming critical shortages of 3M filter cartridges, they also bought powered air purifying respirators (PAPRs). A business case for 10 Cleanspace Halo PAPRs was successful thanks to a groundswell of support from clinicians backed by hospital administration. This insurance policy has “reassured them that they had a backup”, buffering them against supply shocks. David says,
“It’s better to reuse a re-usable than try to re-use a disposable mask that was never designed to be re-used”.
Their first mover initiative has spread to other hospitals in Perth who have also brought in fit testing. David counteracts the fit testing sceptics to “come and watch the process” where the respirator is stressed, during movement, talking and exercise looking for breaches or gaps opening up. He emphasises that respirator seal, stability and compatibility must be maintained sometimes for hours on end, during unpredictable events that are predictable in theatre (e.g. resuscitation) and during the often sweaty work of clinical care whether it be in theatre or on the wards.
Outliers whether they be individuals or systems are special. They don’t always hit the academic air waves but they hold a singular vision that they prosecute, navigating organisational barriers with pure determination. The benefits are indisputable. This department has certainty around their respiratory protection which has delivered peace of mind. A rare flower for many healthcare workers in Australia today.