Lessons Learned at a COVID-19 designated hospital

Highlights

• •Surgical training during the COVID-19 Pandemic required restructuring.
• •Surgical Services can meet hospital needs as an access and procedure team.
• •Videoconferencing platforms can be utilized for continued communication and education.

Early 2020, coronavirus disease 2019 (COVID-19) became prevalent in New York City.¹ The New York State Governor designated University Hospital of Brooklyn (UHB) as a COVID-19 hospital. The faculty, residents, and students that serve it reflect the diverse cultures and nationalities of Brooklyn. State University New York (SUNY) Downstate Health Sciences University is the sole academic medical center in Brooklyn, training 59 General Surgery residents. Residents rotate at five hospitals: UHB (the primary teaching hospital), Kings County Hospital, Brooklyn Campus of the Veterans Affairs NY Harbour Healthcare System, Coney Island Hospital, and Richmond University Medical Center. We are also responsible for the surgical education of SUNY Downstate Health Sciences University College of Medicine.

The COVID-19 pandemic dramatically changed the daily activities of the Department of Surgery. All elective surgeries and clinics were canceled per the American College of Surgeons guidelines.² The number of emergency surgeries also decreased. Consequently, we saw a rapid decline in the surgical service census. As NYC became a COVID-19 epicenter, our Department of Surgery was challenged with how to ensure resident and faculty safety while mitigating supply shortages and providing care for the surplus of critically ill patients.

Residents were told to remain at their current clinical assignments because of familiarity with that hospital’s safety protocols and prevent potential COVID-19 contamination across the residency. The Graduate Medical Education (GME) Office declared Pandemic Emergency Status with the Accreditation Council for Graduate Medical Education (ACGME),³ which allowed flexibility for residents’ redeployment. In response to the pandemic, all vacation requests for its faculty and residents rescinded. The UHB research resident was redeployed to active clinical duties. Residents received a refresher course on resuscitation and ventilator management. Appropriate use of personal protective equipment (PPE) was emphasized, and the GME Office provided additional training on PPE donning and duffing.

UHB filled quickly with hundreds of patients with COVID-19. Many had a complicated course requiring interventions, including intubation, pressor support, and hemodialysis. The residents rotating at UHB were restructured into three teams (Fig. 1 .). (1) A Call team with responsibilities including routine floor work, support of medical services by assisting in proning patients and performing emergency resuscitations and covering the Transplant Surgery service. (2) A Surgical Emergency Advanced Line Service (SEALS) team, composed of residents and a supervising attending, was assigned to assist with procedural solutions for all inpatients, including placement of arterial, central venous, dialysis, and midline catheters. The SEALS team was also responsible for thoracostomy, pigtail catheter insertion, and wound management. (3) The remaining surgical residents were redeployed to the medical floors, emergency department and ICUs. Throughout redeployment, residents adhered to the ACGME Big Four governance under the Stage 3 Pandemic Emergency status: duty hour regulations, having faculty supervision, and adequate resources including PPE. All other common program and specialty-specific requirements were suspended.³

Fig. 1.

General surgery resident groups during COVID-19 pandemic.

Additionally, program-wide phone message group to discuss issues, announce changes and help create a cohesive community despite physical distances. We had a Rapid Response Leadership Team consisting of chief residents and site directors, which met via teleconferencing regularly to address ongoing concerns. Direct patient contact was ideally limited to one person during rounds. Every morning, PPE was distributed from a carefully controlled inventory. We used an N95 respirator when at risk for aerosolization it is covered by a surgical mask that is changed according to CDC guidance.⁴ Face shields were reused after cleaning.⁵ Gowns were issued daily and not changed between patients with COVID-19 in the same unit, unless soiled. We were instructed to report immediately if experiencing any symptoms with isolation at home for 7 days if symptomatic. Residents had to be asymptomatic for three days before medical clearance for return to duty.^{6 , 7} From mid-April, eleven residents were isolated due to COVID-19-like symptoms, and two tested positive. Additionally, free mental health services were offered by the GME Office and UHB.

Despite suspension of the ACGME didactic requirements, our department continued to maintain educational sessions to provide continuity of the curriculum and engage with residents for both wellness and training (Table 1 .). This may have been even more important for residents with families in other states and countries. All of our group educational activities were converted to videoconferencing.^{8 , 9} Weekly grand rounds, morbidity and mortality conference, guest speakers, and journal club were held during the daytime. Core Curriculum and board exam preparation continued but were moved to evening and recorded, due to the demands of ongoing clinical duties. For continued care of patients without COVID-19 requiring outpatient follow-up and consultation, telemedicine platforms were initiated.

Table 1.

Summary of general surgery residency structure during COVID-19 pandemic.

Workforce Adjustments
Anticipation of significantly decreased routine workload
Optimization of workforce (rescheduling of vacation/research)
Contingencies for temporary reduction of residents due to illness
Creation of a dedicated access/procedure service (SEALS)
Safety
Physical separation of resident subgroups
Limitation of direct interaction with COVID-19 patients
Guidance of conservative PPE use
Distribution of PPE to all residents and staff
Escalation protocol for PPE shortage
Isolation and Return to Duty protocols of symptomatic residents and staff
Easy access to mental health support services and wellness activities
Abide by ACGME duty hours regulations
Academic Activities
Refresher course on ventilator management, with emphasis on COVID-19 related lung injury, and resuscitation
PPE donning and duffing training
Continuation of academic curriculum
Use of web-based platforms for education and residency community engagement
Flexibility of teaching hours to include evening sessions
Recording of academic activities for self-study

By assigning residents to a multitude of medical services, we risked losing our surgery department’s identity, yet they kept our general surgery residency as a cohesive unit. Our procedure service (SEALS) allowed primary teams to focus on medical care without the burden of procedures and surgical residents to practice their skills and manage critically ill patients with COVID-19.

Caring for patients suffering from COVID-19 infection is as novel as the disease itself. There were no guidelines on how to treat patients, much less ourselves. The trepidation exhibited by both patients and healthcare workers was palpable. We witnessed death on a massive scale. We lost many of our patients, and even some of our colleagues and loved ones. Morale significantly increased because we understood that our department underscored our safety, cohesiveness, physical and mental well-being, as well as maintenance of resident education while meeting the overwhelming needs of UHB. We have endured massive devastation during this crisis. Yet, we remained unified, not despite our different backgrounds and perspectives but precisely because of them. It is paramount that as physicians, we understand the importance of caring for not just our patients and families but also ourselves and each other.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

None of the authors have conflicts to disclose.