Human factors
Human factors training suggests that key to reducing error is maintaining usual practice as much as possible in times of adversity [2]. Therefore only minor modifications were made to standard surgical and anaesthetic techniques for tracheostomy in order to minimise risk of aerosol generation (Figure 1). The relative merits of undertaking the procedures in a positive pressure operating theatre versus a negative pressure side room in critical care were discussed and it was felt that the safety benefits of the theatre environment outweighed the potential risks. We simulated our tracheostomy protocol on two SARS-CoV-2 negative patients prior to our first COVID-19 case.