Advanced Performance Healthcare Design

April 7, 2020

Product Tested: Intubation Box

SUMMARY: We have identified multiple logistical and ergonomic issues associated with the use of the intubation box and based on this we cannot recommend this device at this time within an emergency department setting. 


We believe that the use of this box requires careful consideration and that unintended consequences may manifest. Appropriate 2nd order thinking, that follows and unravels the implications of a specific decision over time, is critical in the adoption of any new device and this is no different.  Additional complexity must be balanced with efficiency, ergonomic optimization and the shift in training required.  


We did not test the ability of the box to protect the team from contact/droplet and aerosol contamination. Unless there is evidence of nearly 100% exposure risk reduction to the team, the ergonomic impedances, logistical and application challenges far outweigh the infection control that might be provided (assuming that teams have appropriate airborne PPE). 



Participants: 2 emergency physician participants, 1 emergency physician facilitator/usability testing expert, 4 RNs and 4 RN observers, 2 RT participants and 1 RT observer, 1 equipment manager observer    


Usability Testing Methodology: Modified pluralistic walkthrough 

This approach asks participants and facilitators to withhold any product/device improvements until the completion of the session. Instead, feedback is focused solely on the product being tested in its current state. At the completion of the session, overall feedback, impressions and experiences were sought. 



58M, suspected COVID. Febrile, cough, O2 sats 85% on HiOx mask and altered mentation. The intubation team made the decision to intubate. 


Location: Large Canadian and urban academic emergency department 


We divided the testing into 3 stages: 

  1. Pre-intubation
  2. Peri-intubation
  3. Post-intubation


A variety of our staff tested and were able to transport it to the bedside without assistance.   

Placing the device onto our beds was possible by our taller staff though our shorter staff, even when beds were lowered found it challenging necessitating additional personnel.

We tested multiple positions of the bed. The device remained in place from 0 to 30 degrees without issue. In fact, it seemed more stable at 30 degrees.

Our beds are not perfect rectangles which allowed for tubing to effectively pass under the box to the wall connections without kinking.


We piloted the device with intubators of 3 different heights after bed height positioning was optimized 

  • Short (5ft1in): Visualization through the side of the box: Adequate 
  • Average (5ft7in): Visualization through the corner of the box : Problematic 
  • Tall (6ft2in): Visualization through the top of the box: Adequate

The glare from overhead lights is significant for the tall operators and visualization was impacted during the initial steps of intubation

All 3 intubators had their visors touch against the box. This may or may not be an issue but raises some concern regarding contamination and potential for visor dislodgement

We performed a bump test in multiple directions. Device exhibited head of bed instability falling into the intubator but lateral manipulation was stable.  


Difficulty manipulating the bougie.

Difficulty using a rigid stylet (non rigid stylet depicted here) 

Difficulty with suction use (with Yankauer)  

BVM (post-intubation) required to occur inline with patient rather than typical 90o

2 operators reported edges of the holes to cause substantial pressure points (though this was tested without Level 4 gown). Raises concern regarding risk of glove/PPE tears


Logistical plan for who is responsible for cleaning 


In a smaller room where it is placed on the ground, it may occupy valuable room space especially if resuscitation continues 


Moving to the floor/out of the room did not expose significant issues but required attention to patient circuits (a risk of disconnect cannot be discounted)