|Year : 2021 | Volume
| Issue : 2 | Page : 24-32
Readiness of respiratory therapists in Saudi Arabia to manage patients with COVID-19: A cross-sectional study
Hassan M Al Refaee, Mohammed K Al Shehri
Respiratory Care administration, King Fahad Medical City, Riyadh, Saudi Arabia
|Date of Submission||08-Mar-2021|
|Date of Acceptance||25-Apr-2021|
|Date of Web Publication||24-Jun-2021|
Hassan M Al Refaee
Respiratory Care Administration, King Fahad Medical City, Riyadh
Source of Support: None, Conflict of Interest: None
Background: Respiratory therapists (RTs) are one of the frontline healthcare workers fighting the coronavirus disease 2019 (COVID-19) in the clinical areas, such as intensive care units, and emergency rooms. There are no data to measure the current practice of RTs in Saudi Arabia toward COVID-19 patient management. This study aimed to measure the current practice of RTs to manage COVID-19 patients. Materials and Methods: A cross-sectional, self-administered online survey comprising 29 questions. The survey comprised two sections: A demographic focusing on participants' data and a section to measure the knowledge of practitioners about the proper management of patients with COVID-19. None of the RTs who completed the survey were excluded. Results: A total of 247 RTs from different regions of Saudi Arabia were included. Men RTs were (65.6%), and the mean age was 30.52 ± 2.1 years. The majority of the RTs answered the questionnaire questions correctly. Answering the questions correctly was associated with more years of experience and working in the central and eastern regions. More than 50% of the RTs answered three questions inaccurately; those questions pertained to the suitable tidal volume, the acceptable SpO2 for critically ill patients, and the recommended trial period for noninvasive ventilation. Conclusions: Our cross-sectional study showed that RTs working in Saudi Arabia conformed to the current guidelines and recommendations for dealing with patients with COVID-19. The accurate knowledge in dealing with these patients was increased with years of experience. Future studies are required that recruit additional RTs from different countries and educational backgrounds.
Keywords: COVID-19, frontline healthcare workers, respiratory therapists, SARS-CoV-2, Saudi Arabia, SpO2
|How to cite this article:|
Al Refaee HM, Al Shehri MK. Readiness of respiratory therapists in Saudi Arabia to manage patients with COVID-19: A cross-sectional study. Saudi Crit Care J 2021;5:24-32
|How to cite this URL:|
Al Refaee HM, Al Shehri MK. Readiness of respiratory therapists in Saudi Arabia to manage patients with COVID-19: A cross-sectional study. Saudi Crit Care J [serial online] 2021 [cited 2021 Jul 27];5:24-32. Available from: https://www.sccj-sa.org/text.asp?2021/5/2/24/319312
| Introduction|| |
The ongoing coronavirus disease 2019 (COVID-19) pandemic has affected many people since its identification in Wuhan, China, in December 2019. Over the last few months, the number of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, the causative agent of COVID-19, and related deaths has increased exponentially; as of September 18, 2020, the number of infections exceeded 30.2 million globally, while the number of reported deaths surpassed 940,000 On January 30, 2020, the World Health Organization (WHO) declared COVID-19 a public health emergency of international concern. At that time, four countries in addition to China reported human-to-human transmission of the virus. Since then, the WHO announced that COVID-19 is spread via direct, indirect, and close contact with the respiratory secretions of an infected person.
Healthcare workers, including respiratory therapists (RTs), who are at the frontline of the management of the pandemic are at high risk of contracting the SARS-CoV-2. RTs provide oxygen therapy, respiratory medications, invasive and non-invasive ventilation, and airway management, and participate in advanced modalities of treatment, such as the prone positioning of patients and extracorporeal membrane oxygenation (ECMO). Moreover, the procedures performed by RTs that lead to the generation of aerosolized airborne particles, such as endotracheal suction or endotracheal intubation, may increase the chances of contracting the SARS-CoV-2.,
Although several guidelines have been developed nationally and internationally to unify the management of patients with COVID-19, the actual practices of respiratory care (RC) still vary. As the need for RC continues to advance in Saudi Arabia, the number of RTs is also increasing. Nonetheless, the guidelines for COVID-19 management by RTs remain unclear. This study aimed to describe the current practices of the RTs managing patients with COVID-19 in different hospital departments, including emergency rooms (ERs), intensive care units (ICUs), and general care wards, in Saudi Arabia.
| Materials and Methods|| |
Ethics approval was obtained from the Ethics Committee of the King Fahad Medical City (No. 20-241). Participation in the survey was voluntary. Furthermore, the participants were informed about the confidentiality of the responses and provided informed consent by agreeing to complete the survey.
Survey design and administration
The study was designed as a cross-sectional, self-administered online questionnaire survey that consisted of 29 questions. The survey comprised two sections: (1) a demographic section focusing on subject data (questions 1–13) and (2) a section that measured practitioners' knowledge about the proper management of patients with COVID-19 (questions 14–29). The questionnaire was developed based on the latest guidelines of the WHO concerning the progression of the COVID-19 crisis. Five experts in the field validated the format and content of the questionnaire, confirming that the survey is a realistic measure reflecting RT knowledge about the safe management of patients with COVID-19. The survey was completed by study participants between May 21, 2020, and June 21, 2020, using Google Docs.
The following demographic data were collected using the survey: age, gender, nationality (Saudi, non-Saudi), region (Central, Eastern, Northern, Southern, or Western), years of experience (≤5 years, 6–10 years, 11–15 years, 16–20 years, and >20 years), qualification (Diploma, Bachelor's degree, Master's degree, or Ph. D.), Saudi Commission for Health Specialties Classification (consultant, senior specialist, specialist, or technician), working-shift hours (8, 9, or 12 h), hospital position (administrative or clinical staff), and working area (critical care, ER, general care, or pulmonary function test laboratory). In addition, data regarding the knowledge of RTs regarding the practices related to the evidence-based management of patients with COVID-19 were collected in the second part of the survey.
The study participants included RTs working at a hospital in Saudi Arabia. A total of 247 RTs from five regions of Saudi Arabia (Central, Eastern, Northern, Southern, and Western regions) were contacted for the survey via RT groups on social media (Facebook, Twitter, WhatsApp, and LinkedIn). None of the RTs who completed the survey were excluded from the study.
A descriptive summary and a frequency analysis were performed on all variables included in the survey questions. We reported the mean ± standard deviation for continuous variables and counts and frequencies for categorical variables (gender, nationality, region, survey response, etc.). Moreover, depending on whether the expected cell frequency was smaller than 5, the Chi-squared and Fisher's exact tests were used to determine the significance of the association between categorical variables and correct as well as incorrect answers. Significance was set at P < 0.05. All analyses were conducted in SPSS version 25 (SPSS Inc., Chicago, IL, USA) and MedCalc version 18.11.6. (MedCalc Software Ltd, Ostend, Belgium)
| Results|| |
Our cross-sectional study included 247 RTs working in different regions within Saudi Arabia. The male gender was predominant among survey takers, with a percentage of 65.6%, and the mean age of the subjects was 30.52 ± 2.1 years. Moreover, 89.9% of the study participants were Saudi, and 46.2% were working in the central region of Saudi Arabia. The majority of the RTs that completed this questionnaire had ≤5 years of experience (54.7%), had a bachelor's degree qualification (87.9%) and were classified as specialists according to the Saudi Commission For Health Specialties Classification (81.8%). Furthermore, the RTs included in this study worked 12 h shifts (80.2%), were regular staff members (83%) and worked in a variety of hospital settings (ICUs, ERs, and general-care wards) (40.9%). Moreover, the RTs included here worked in alternating night and day shifts (65.6%), were employed by governmental hospitals (90.7%), and their hospitals had a bed capacity of 300–599 beds (35.6%). [Table 1] lists the baseline characteristics of the RTs included in our study.
|Table 1: Demographic and professional characteristics of the participants (n=247)|
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Description of the current practices of respiratory therapists working in Saudi Arabia who manage COVID-19 cases
Two-hundred and forty-five (99.2%) RTs believed that the recommended personal protective equipment (PPE) while dealing with patients with COVID-19 included gloves, a gown, a mask, and an eye shield. Moreover, 238 (96.4%) of the RTs included in this study thought that they should wear fitted respirator masks (N95 respirators, FFP2, or equivalent masks) while performing aerosol-generating procedures, 205 (83%) agreed that the nebulization of medications is the method that most increases the risk of particle transmission, and 163 (66%) believed that performing a bronchoscopy procedure in patients with COVID-19 should only be implemented in emergency cases.
Two hundred and two (81.8%) study participants stated that inflating the cuff and clamping the endotracheal tube (ETT) ought to be done before connecting the ETT to the mechanical ventilator in COVID-19 cases. In addition, 236 (95.5%) RTs believed that placing viral filters between the resuscitator bag and the ETT is highly recommended, while 245 (99.2%) RTs thought that the closed suction system is the recommended suction system for ventilated patients with COVID-19, and 138 (55.9%) said that the tidal volume suitable for those patients was 4–6 ml/kg.
Furthermore, 216 (87.4%) RTs said that the use of a high positive end-expiratory pressure method is the recommended strategy for ventilated COVID-19 cases, 197 (79.8%) believed that the plateau pressure in those patients should be kept below 30 cmH2O, and 131 (53%) thought that the prone position time for COVID-19 patients with severe acute respiratory distress syndrome (ARDS) should be 12–16 h per day.
One hundred and sixty-nine (68.4%) of the interviewed RTs reported that an SpO2 value of 90%–92% is acceptable for critically ill patients with COVID-19. Ninety-four (38.1%) RTs in our survey reported that, if they ran out of treatment options in a hypoxemic patient, they would choose Veno-venous ECMO (VV-ECMO).
Among the RTs included in the study, 127 (51.4%) thought that noninvasive ventilation (NIV) is not recommended for patients with COVID-19, 178 (72.1%) said that the American Heart Association recommended keeping arrested patients on a mechanical ventilator during chest compression, and 153 (61.9%) believed that a high flow nasal cannula is required if the target SpO2 cannot be achieved using conventional oxygen therapy. [Table 2] shows the response to our questionnaire regarding dealing with COVID-19 patients. [Figure 1] shows the percentages of correct answers among the survey questions.
|Table 2: Descriptive analysis of coronavirus disease 2019 survey items (n=247)|
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|Figure 1: The percentages of correct and incorrect answers among the survey questions|
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Answering the questions of this survey correctly was associated with more years of experience [Table 3] and working in the central and eastern regions of Saudi Arabia [Table 4].
|Table 3: Association between years of experience and correct answers to the survey questions|
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|Table 4: Association between region in Saudi Arabia and correct answers to the survey questions|
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| Discussion|| |
The current practices of RTs showed that RTs in Saudi Arabia believed that the recommended PPE while dealing with patients with COVID-19 included gloves, a gown, a mask, and an eye shield. Moreover, they stated that fitted respirator masks (N95 respirators, FFP2, or equivalent) should be worn while performing aerosol-generating procedures. In addition, the majority of the study subjects believed that bronchoscopy for COVID-19 cases should be performed in emergencies only, that a viral filter should be placed between the resuscitator bag and the ETT, that the closed suction system is the recommended one for patients with COVID-19, and that the tidal volume of the mechanical ventilator should be kept at a range of 4–6 ml/kg. Most of the RTs who participated in this survey agreed that patients with COVID-19 should be kept on a mechanical ventilator during chest compression.
The majority of RTs in this study answered the questionnaire questions correctly. Answering the questions correctly was associated with more years of experience and working in central and eastern Saudi Arabian regions. Most of the old and first RT schools are located in those regions, which may explain this result. The central and eastern regions of Saudi Arabia have the biggest RT department in the kingdom.
Conversely, more than 50% of the study sample inaccurately answered three questions. Those questions pertained to the suitable tidal volume for mechanically ventilated patients with COVID-19, the acceptable SpO2 for critically ill patients with COVID-19, and the recommended trial period for NIV in patients with COVID-19. The correct answers to these questions were 4–8 ml/kg, 92%−96%, and 1–2 h, respectively. This is a clear indicator that much knowledge, courses, training, and competencies are required to improve the performance of the RTs according to the recently updated guidelines.
The results of our study were in accordance with the guidance of a recent Chinese consensus regarding the suitable management of critically ill patients with COVID-19 in the ICU. In this consensus, 16 Chinese respiratory medicine experts were invited to provide an expert statement concerning critically ill patients with COVID-19. They recommended the use of continuous monitoring and supportive treatment for those patients.
The European Society of Intensive Care Medicine, together with the Society of Critical Care, published guidelines concerning the appropriate management of critically ill patients with COVID-19. Their recommendations included the use of fitted respirator masks (N95 respirators, FFP2, or equivalent) during aerosol-generating procedures and assigning senior practitioners to the insertion of ETTs. Interestingly, the panel of experts in this guidance recommended starting oxygen supplementation if the SpO2 was <90% in addition to early intubation if the condition of the patients with COVID-19 deteriorated. Regarding mechanically ventilated patients with COVID-19 who developed ARDS, the guidance recommends the use of low tidal ventilation volumes (4–8 ml/kg) and keeping the plateau pressure below 30 cmH2O, which are similar to the values that were chosen as being correct in our study.
A review by Navas-Blanco and Dudaryk showed that multiple clinical centers worldwide have highlighted the importance of avoiding intubation and mechanical ventilation in hypoxemic patients with COVID-19. However, if a patient develops ARDS, invasive methods should be used. The Chinese consensus advised that endotracheal intubation should be performed by senior practitioners, NIV ought to be used in COVID-19 with induced ARDS, and close monitoring should be continual while providing mechanical ventilation for COVID-19 cases. A study reported by Price et al. argued that the use of NIV, particularly continuous positive airway pressure (CPAP), was not associated with an increased risk of COVID-19 transmission if health care providers took the necessary precautions. Moreover, in a randomized controlled trial, the use of CPAP was linked to early improvement in oxygenation in cases with acute hypoxemic non-hypercapnic respiratory insufficiency. Nonetheless, using CPAP did not lessen the rates of the need for intubation or improved patient outcomes.
Study strengths, limitations, and implications for future research
To the best of our knowledge, this was the first cross-sectional study to assess the current practices of RTs managing patients with COVID-19 in different hospital settings within Saudi Arabia and globally. We also provided an insight into the current practices of RTs managing patients with COVID-19 in different regions in Saudi Arabia. The limitations of this study include the relatively small number of included participants. Moreover, only a small percentage of the participating RTs were working in the northern Saudi Arabian area, and a small percentage had a Ph.D. degree. Future studies should recruit additional RTs from various working regions and educational backgrounds. Similar studies should be implemented in different countries.
| Conclusions|| |
Our cross-sectional study showed that RTs working in Saudi Arabia conformed to the current guidelines and recommendations regarding the management of patients with COVID-19. Accurate knowledge in dealing with patients with COVID-19 increased with years of experience. Future studies are required to recruit additional RTs from different countries and educational backgrounds.
This review was supported by King Fahad Medical City, Research Center. The authors thank the Research Center for all the help and support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]