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To the Editor, We believe that protection of the well-being of healthcare providers while maintaining a workforce sufficient to respond to the coronavirus disease (COVID19) are fundamental to pandemic planning. In this letter, we describe how our hospital used low-fidelity airway simulation to assess and evolve the personal protective equipment (PPE) used for airway management of patients with COVID-19. We have now had 47 healthcare workers processed through the COVID-19 airway simulation scenario. During the first day of the simulation, we used our facility’s recommended PPE comprising a ‘‘yellow gown’’ (Eden Textile micro fibre isolation gown, Edmonton, AB, Canada), a N95 respirator, a visor integrated into a surgical mask, and non-sterile nitrile gloves (Figure A). When the practitioners changed the simple face mask to allow bagmask ventilation during the induction of anesthesia, a patient cough was simulated. We did this by using Glo Germ powder (Marlatek, Inc., Brockville, ON, Canada), a product designed to identify the simulated spread of microorganisms, which was brushed as powder onto the mannequin (contact) and forcefully expelled from the airway mannequin’s naris using a MAD Nasal intranasal mucosal atomization device (Teleflex, Morrisville, NC, USA) (droplet). Spread of the simulated nasal secretions was visualized with ultraviolet light. This technique revealed that the reusable yellow gowns were permeable to liquid; six out of the six first participants had visible soilage on their scrubs beneath their gowns. During the fifth simulation, an airway assistant wearing a disposable Association for the Advancement of Medical Instrumentation (AAMI) level-3 surgical gown (Sirus sterile nonreinforced surgical gown; Medline, Chicago, IL, USA) showed no contamination of scrubs beneath the gown. It also came to our attention that there was a significant amount of contamination on the practitioner’s neck, on the base of their wrist, as well as on their lower pants and shoes. While skin contamination is not a method of transmission for the severe acute respiratory syndrome coronavirus-2 responsible for causing COVID-19, these areas of soilage increase the risk for self-contamination (e.g., during doffing) via mucous membranes. We approached our institution’s Infection Control and Prevention Group with the findings of these first six participants; they indicated that the supplied yellow gowns lose their permeability protection after 25 washes. We have since upgraded our PPE to disposable surgical gowns or coveralls (Kleenguard A60; Kimberly-Clark, Roswell, GA, USA) of at least an AAMI level-3 protection consistent with US Food and Drug Administration recommendations for moderate to highly invasive procedures. We have also included neck protection in the form of either a coverall, or if a surgical gown is worn, S. L. Lockhart, MD, FRCPC (&) Department of Anesthesiology, St. Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada e-mail: slockhart@providencehealth.bc.ca

canadian journal of anaesthesia/canadian journal of anesthesia

Simulation as a tool for assessing and evolving your current personal protective equipment: lessons learned during the coronavirus disease (COVID-19) pandemic