Much has already been written about the speed and force with which the coronavirus disease 2019 (COVID-19) pandemic has struck countries around the world. Healthcare providers have scrambled to reconfigure their systems and redeploy staff to deal with the rapidly rising demand for hospital beds and ventilators. Similarly, research into areas of uncertainty in COVID-19 has had to move just as rapidly. So much about the disease, and the SARS-CoV-2 virus that causes it, still remains unknown.

Motivations

At Guy’s and St Thomas’ NHS Foundation Trust in the United Kingdom, we found ourselves in the middle of the COVID-19 storm, as patients started presenting to the emergency department at the beginning of March. As one of the largest hospitals within central London, we were in the thick of the action. And while we were intubating patients with deteriorating respiratory failure, we did not know what sorts of risks we were being exposed to as healthcare providers. The process of initiating patients onto mechanical ventilation theoretically exposes airway managers to aerosolized secretions, which can be inhaled by those closest to the patient during airway manipulation.

This project has also demonstrated ... that collaboration, novel thinking, and responsiveness to the needs of the healthcare community are not only feasible, but likely critical to the future success of research in anesthesia.

We thus felt compelled to begin collecting data about our airway procedures in order to audit the intubation activities we were performing, as well as to track whether any of us subsequently developed symptoms of COVID-19 or worse.

Technical Solutions

At the beginning, we considered collecting data on paper or via simple spreadsheets maintained on a central computer somewhere in our department, but these options were quickly discarded in favor of more flexible digital data capture tools, which allow for decentralized data collection. A number of options for creating online databases were available, including REDCap or an online Google Sheets spreadsheet. However, none of these had the flexibility, security, or ease of deployment that we were looking for.

Finally we settled on a self-designed database solution supplied by Knack.com, which allowed a quick prototype to be designed within two days and trialed on a small scale within our hospital department. Knack’s software also allowed us to keep the database accessible to all users, facilitated mobile devices users with the ability to enter data from their own devices, and permitted password-protected logins to be quickly generated.

After the initial prototype was deployed, quick cycles of iterative improvements were made to the database capture tool. We then realized that there would likely be interest in the registry from other hospitals, both within the U.K. and internationally, as the pandemic would ultimately become a ubiquitous problem faced by health workers worldwide. Often in clinical academia, researchers are obsessed with perfection and “getting things perfect the first time.” This approach may result in an arrest of progress and may not be appropriate in highly dynamic scenarios. We therefore decided to adopt principles more usually associated with software engineering: to present a minimally-viable product first, then iteratively improve upon that to drive our progress along.

Scaling through Collaboration

Using research contacts available within our group, we contacted other anesthetic and intensive care colleagues within the United Kingdom and abroad to gauge interest in participating in data collection. We engaged the Royal Colleges of Anaesthesia, Surgery and Emergency Medicine, as well as national societies to help dissemination. Crowdsourcing of data and open collaboration has often been a feature of U.K. anesthesia research (pioneered by such initiatives as the National Audit Projects and Sprint National Anaesthesia Projects) and has successfully delivered research that is both compelling to frontline clinicians and cost-effective to conduct.

Uptake within the U.K. anesthesia, intensive care, and emergency medicine communities for the project was swift and increased rapidly on an international stage via careful social media engagement (Twitter) and endorsements from societies and other influential member organizations. We maintained contact with all participants through weekly reminder emails and innovative use of data dashboards to engage users using the data they provided. The publicly accessible IntubateCOVID dashboard contains information on the number of intubations logged on the site, personal protective equipment use, airway management methods, and new symptoms reported by users. A dynamic map provides participants with opportunities to see active locations and compare database use across sites. For participating sites, country- and site-level dashboards permit national and local benchmarking for intubation practices related to COVID-19.

IntubateCOVID in North America and Beyond

Since its successful launch in the United Kingdom on March 23, IntubateCOVID has grown to become a global registry, with participation from clinicians in 14 countries spanning 5 continents. This spread from a national to an international registry leveraged both formal and informal professional networks within and across participating countries. In the United States, the first country outside of the United Kingdom to join IntubateCOVID, engagement of participating hospitals first took place via an established research network developed for REGAIN, an ongoing multicenter trial of spinal versus general anesthesia for hip fracture surgery (Regional versus General Anesthesia for Promoting Independence after Hip Fracture, NCT02507505). The U.S. component of the project subsequently received operational funding from the American Society of Anesthesiologists, the Anesthesia Patient Safety Foundation, and the International Anesthesia Research Society, along with additional endorsement by the Foundation for Anesthesia Education and Research and the Association of University Anesthesiologists. Member outreach from each of these organizations enabled the rapid dissemination of IntubateCOVID in the United States, with more than 180 hospitals currently participating. Spread beyond the United States has similarly taken advantage of a combination of established and grassroots networks, with each national site lead identifying networks within their country best equipped to disseminate information on the unique collaborative opportunity that IntubateCOVID presents.

The outcomes of IntubateCOVID extend beyond just the critical results that we believe they will publish. This project has also demonstrated locally, nationally and internationally, that collaboration, novel thinking, and responsiveness to the needs of the healthcare community are not only feasible, but likely critical to the future success of research in anesthesia.

Twitter: @dannyjnwong, @elboghdadly, @ neumanmd, @c_johnstone1980, @dr_imranahmad, @IntubateCovid