key: cord-316327-0hpthrjo
authors: Brar, Branden; Bayoumy, Mohamed; Salama, Andrew; Henry, Andrew; Chigurupati, Radhika
title: A Survey Assessing the Early Effects of COVID-19 Pandemic on Oral & Maxillofacial Surgery Training Programs
date: 2020-08-18
journal: Oral Surg Oral Med Oral Pathol Oral Radiol
DOI: 10.1016/j.oooo.2020.08.012
sha: 
doc_id: 316327
cord_uid: 0hpthrjo

The coronavirus disease 2019 (COVID-19) pandemic has specific implications for oral and maxillofacial surgeons due to an increased risk of exposure to the virus during surgical procedures of the aero-digestive tract. The objective of this survey was to evaluate how the COVID-19 pandemic affected oral and maxillofacial surgery (OMFS) training programs during the early phase of the pandemic. METHODS: A cross-sectional survey was sent to the program directors of 95 out of the 101 accredited OMFS training programs between April 3(rd) and May 6(th), 2020. The 35- question survey designed using Qualtrics software, to elicit information about the impact of COVID-19 on OMFS residency programs and the specific modifications made to clinical care, PPE and resident training/wellness to meet the response to the COVID-19 pandemic. RESULTS: The survey response rate from OMFS program directors was 35% (33/95) with most responses from states with high incidence of COVID19. All OMFS programs (100%) implemented guidelines to suspend elective and non-urgent surgical procedures and limited ambulatory clinic visits by third week of March, with an average date of March 16(th), 2020 (Date range March 8(th) -23(rd)). Programs used telemedicine (40%) and modified in-person visit (51%) protocols for dental and maxillofacial emergency triage to minimize exposure risk of HCP to SARS CoV2. PPE shortage was experienced by 51% of the programs. Almost two-thirds (63%) of the respondents recommended the use of a filtered respirator (i.e., N95 respirator) with full face shield as their preferred PPE, while 21% recommended Powered Air Purifying Respirators (PAPRs) during OMFS procedures. Only (73%) of the programs had resources for resident wellness and stress reduction. Virtual didactic training sessions conducted on digital platforms, most commonly “Zoom” formed a major part of education for all programs. CONCLUSION: All programs promptly responded to the pandemic by making appropriate changes to suspend elective surgery and, to limit patient care to emergent and urgent services. OMFS training programs should give more consideration to provide residents with adequate stress reduction resources to maintain their wellbeing and training to minimize exposure risk during an evolving global epidemic.

dental and maxillofacial emergency triage to minimize exposure risk of HCP to SARS CoV2. PPE shortage was experienced by 51% of the programs. Almost two-thirds (63%) of the respondents recommended the use of a filtered respirator (i.e., N95 respirator) with full face shield as their preferred PPE, while 21% recommended Powered Air Purifying Respirators (PAPRs) during OMFS procedures.

Only (73%) of the programs had resources for resident wellness and stress reduction. Virtual didactic training sessions conducted on digital platforms, most commonly "Zoom" formed a major part of education for all programs. Conclusion: All programs promptly responded to the pandemic by making appropriate changes to suspend elective surgery and, to limit patient care to emergent and urgent services.

OMFS training programs should give more consideration to provide residents with adequate stress reduction resources to maintain their wellbeing and training to minimize exposure risk during an evolving global epidemic.

our lives in every aspect including medical and surgical training programs and, disrupted the economy of our societies across the world. The first cases of atypical pneumonia due to the novel coronavirus were detected in Wuhan city, China and, reported to the World Health Organization (WHO) in December 2019. [1, 2] Subsequently, on January 8 th 2020, the Chinese Center for Disease Control and Prevention announced identification of SARS-CoV2 an enveloped, positive-sense, single-stranded RNA virus as the causative pathogen of COVID-19. [3] Since then it has spread rapidly within weeks to every part the world. The rapid spread of this virus to every continent was facilitated by ever-increasing international air travel, the integration of global supply chains, and in part, due to the greater transmissibility of the SARS-CoV2 virus. [4, 5] On January 30, 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a Public Health Emergency of International Concern and, shortly thereafter on March 11, 2020 classified it as a Pandemic at which point there were 130,000 confirmed cases in 118 countries. [6] Health Care Personnel (HCP), particularly dentists, oral and maxillofacial surgeons, otolaryngologists and head & neck surgeons, craniofacial surgeons and others who operate in the aero-digestive tract are at high risk for exposure to this virus. The primary mode of transmission of SARS-CoV-2 is via respiratory droplets (>5um) and through airborne transmission of droplet nuclei (<5um). Manipulation of the upper respiratory or oral mucosa or surgical procedures in aero-digestive tract can generate aerosol containing virus particles, increasing the risk to personnel operating in these anatomic areas. [7] [8] During the initial phase of the outbreak, data from Wuhan showed that healthcare personnel accounted for 29% of the patients, emphasizing the importance of appropriate PPE to reduce the risk of nosocomial transmission.

[2] [7] Around the same time in January 2020, communication from Stanford University revealed anecdotal evidence of nosocomial spread of COVID-19 among surgeons and other health care personnel involved in trans-sphenoidal pituitary surgery. [9] [10] Also, previous reports from Hong Kong during the first SARS outbreak in 2002-2003 revealed a high risk to Health Care Personnel (HCP) who accounted for 35% of the cases. [11] In the United States (US), the evolution of this outbreak started with the first reported case on January 19 th 2020 in Washington State. [12] Less than 2 months after the detection of this index case a national health emergency was declared in the US on March 13 th 2020. To date there are more than 5.5 million confirmed cases and 350,000 fatalities worldwide, with more than 1.6 million of these cases and over 100,000 deaths in the United States (US). [13] In the absence of a vaccine and, limited effective anti-viral therapies, the management of the COVID-19 pandemic has centered on supportive care for those with severe symptoms, and the use of physical means such as quarantine and "social distancing" for mitigation of spread. [14] In the first 2 weeks of March 2020, through personal communication and the news, we became aware of the changes that were already implemented in Washington State and other metropolitan areas like San Francisco. On March 13 th the American College of Surgeons (ACS) issued a statement based on the preceding events in Italy and China, recommending to reschedule elective surgeries and to shift inpatient procedures to outpatient settings, when feasible. Subsequently, on March 18 th 2020, the Centers for Medicare and Medicaid Services (CMS) issued a directive to halt all elective, and non-essential, nonemergent surgeries and preventive services. [15] This was done to reduce demands on hospitals and their resources including personnel, PPE, ventilators, beds, ICUs and to lower potential exposure of healthcare personnel. CMS also increased access to Medicare telehealth services for its beneficiaries under the Coronavirus Preparedness and Response Supplemental Appropriations Act. This rapid turn of events led to some urgent modifications to clinical care including surgery, by US health care providers in all specialties, to accommodate the critical shortages of hospital resources as the pandemic was evolving.

At this early stage (March 6th-18th, 2020) there was sparse information as to what other OMFS training programs in teaching hospitals were experiencing and, how they handled emergent procedures, and, what measures they instated to maintain the safety and wellness of the residents and faculty. This evoked the need to survey OMFS training programs and to start a discussion regarding some of the changes in emergency triage, urgent surgical procedures, and use of PPE to protect health care personnel. By the fourth week of March, most of the professional societies including the American Association of Oral and Maxillofacial Surgeons (AAOMS), the British Association of Oral and Maxillofacial Surgeons (BAOMS)-British Association of Oral Surgeons (BAOS) had issued guidance statements to minimize exposure risk to HCP. They suggested methods to avoid in-person encounters by using telemedicine triage, keeping emergency visits brief, having faculty or senior residents make definitive decisions for treatment to mitigate exposure risk. Further updates were provided, for high-risk procedures in aerodigestive tract such as, nasal endoscopy, and tracheostomy. [16] The aim of this survey was to assess the impact of COVID -19 on Oral and Maxillofacial Surgery (OMFS) training programs in the different regions of USA during the early phase of this pandemic between March 6 th to May 6 th 2020. As the pandemic was rapidly growing in the US, we wanted to know what changes were implemented by other OMFS training programs in the country to maintain the safety of their providers and patients, while accommodating for the surge of new infected patients. We specifically asked questions with respect to management of dental and maxillofacial emergencies, recommendations for PPE during clinical care, staffing changes, and resources used for resident didactic surgical training and wellness.

A questionnaire titled "National Survey Assessing the Impact of COVID-19 Pandemic on Oral and Maxillofacial Surgery Training Programs" was sent out via electronic mail on April 3 rd 2020 to the program directors of the 95 out of 101 accredited OMFS training programs throughout the United States. We had access to public email addresses of only 95 out of 101 accredited OMFS programs at the time the survey was distributed. The questionnaire was developed using Qualtrics software, which is a valuable online survey tool that allows one to build and distribute surveys, and analyze responses. The survey questions were reviewed by OMFS faculty and Boston University" Institutional Review Board (IRB) officer and a waiver was granted, as none of the questions requested identifiable information about the respondents. This allowed us to expedite the survey distribution during the early phase of this Pandemic. The survey was first sent to the 95 OMFS program directors on April 3 rd 2020 and subsequently a weekly follow-up reminder was sent to those who did not respond and to those who did not complete the survey over a 4-week period until the closing date of May 6 th 2020. shortage and type of PPE used during clinical encounters and surgical procedures; 4) Resident didactic training and wellness: resources used to maintain resident wellbeing. (Table I ) Descriptive statistics were automatically computed by Boston University" Qualtrics  software. We analyzed the data by region to compare the differences in West, Midwest, South, Northeast, and other territories. We compared the differences among the programs who suspended routine clinical activities earlier than March 16 th 2020 to those who did so on or after that date. Emergency Services: All participating programs implemented a modified dental and maxillofacial emergency triage protocol. These emergency services were primarily rendered in the hospital setting in the emergency department (37.8%) or OMFS ambulatory clinic (28.4%). Emergency services were provided less often (16.2%) in the dental school setting. Remote consultation for emergency care was also provided through telemedicine (17.6%) by a limited number of programs. During the COVID-19 pandemic, the majority of programs (76%) reported an average reduction of 63% in emergency department encounters. A few programs (6%) reported a 15% average increase in the number of emergency encounters and the remaining reported no change during the pandemic. When asked about the frequency of the emergency department encounters 82% of the programs reported less than 10 encounters per day, with the majority reporting having less than 5 encounters. Only 15% reported greater than 10 emergency department encounters daily. The type of emergency encounters are shown in Figure 6 .

Treatment: Emergent surgical procedures in the operating room were rendered by 93.9% of programs, whereas 6.1% provided no operating room services during this time. The emergent surgical procedures that were performed in the operating room during the pandemic are shown in Figure 7 . The emergency procedures conducted in the ambulatory (hospital or dental school) setting included clinical evaluation for dental emergencies, extractions, splinting dento-alveolar fractures, incision and drainage of dental abscesses and closed reduction of mandibular fractures. Almost all programs (97%) reported following guidelines established by their hospital with the exception of 3% who followed state health department guidelines. Of the 97% who followed hospital guidelines, (28.1%) used these guidelines alone, whereas 65% reported using them in combination with other guidelines including those from Center for Diseases Control (CDC), dental school (21.9%), and state dental society (3.1%). There were no major differences in the level of PPE recommended regardless of the clinical setting Operating Room vs. Ambulatory Clinic or ED for oral surgical procedures. There was a slight preference for using a Powered Air Purifying Respirator (PAPR) in the operating room.

Practitioners had a number of guidelines on appropriate PPE use while performing procedures. health care personnel to respond promptly with caution and valor, risking their lives; but the impact of this pandemic is unique for several reasons. Unlike the earlier outbreaks, which were largely regional epidemics/events, but in the same pattern, COVID-19 spread rapidly across the globe; disrupting the social, economic and emotional wellbeing of most societies. Health Care Personnel (HCP) were requested to make rapid changes within hours/days to adapt and work with the challenges of physical and social distancing, additional uncomfortable PPE, shortage of hospital resources, and to function under stressful conditions with limited assistance and many unknown facts about the virus. As the pandemic evolved the governing authorities had to rapidly modify plans from an "Emergency Preparedness" mode to the possibility of resorting to a "crisis standards of care" and make ethical decisions to accommodate the surge. [17] Specific to Oral and Maxillofacial Surgeons and other specialists working in the aero-digestive tract, is the concern regarding increased exposure risk due to aerosol generating procedures in the oral cavity, nose, and/or oropharynx. [7, 10, 16] We had 35% survey response rate with representation from 33/95 OMFS programs surveyed in all regions. The majority of our survey respondents were located in states with higher incidence of COVID-19 with (9/33) early survey responses from New York state. This is likely due to the rapidly changing situation in their region as well as the awareness of the OMFS program directors who were encountering many questions or dilemmas as we did, during this early phase of the Pandemic. The vast majority (79%) of the survey responses were received from Hospital based-University affiliated programs. We Our survey showed that 7 /33 programs (21%) reported having trainees or faculty members infected by SARS-CoV2. This is inevitable given the nature of our professional responsibilities and the type of procedures we perform, especially given the shortage of PPE during the pandemic. Lancaster et al reported on how the surgery department at an academic medical center optimized human resources. They identified key skills in each team member and ensured there were multiple team members with similar skill sets in order to accommodate for absences in case they were infected. They also limited faculty to single hospital sites and reduced the number of providers on-site each day, with contingency plans for section or department leadership. [29] Similarly other surgical departments rapidly redesigned and shifted workforce based on need. [30] A number of OMFS trainees and faculty were redeployed to other services during the surge/ height of the pandemic, based on need. More residents were redeployed in comparison to faculty. Fourteen out of the 33 programs reported reallocation of residents to other services including COVID-19 wards and 5 /33 programs reported redeployment of faculty. This may be a reflection of those trainees who were on their General Surgery or Medicine or Anesthesia rotations. Ten of these 14 programs were dual degree programs . Personal communication with program directors revealed one OMFS trainee fatality during the early phase of this pandemic. In their manual on how to protect health care personnel during global epidemics, the WHO has proposed recommendations to educate HCP to reduce exposure risk, to reduce anxiety and fear, and to promote health of wellbeing of responders. They also emphasized the importance of direct, face-face communication with HCP in a fair environment without blame. [26] Clinical operations: All programs directors responded that only urgent and emergent procedures were performed during the pandemic. About 9% of the participants continued to provide new patient consultations. It was not clear whether these were urgent and whether they were performed using telemedicine. About 63 % of the programs reported utilizing some form of telemedicine for patient care mainly postoperative follow up visits. Active participation in clinical care through telemedicine can complement residents" clinical training and facilitate emergency triage by decreasing exposure risk. On

March 17 th 2020 several temporary regulatory waivers and new rules were ordained to allow flexibility in the healthcare system to respond to the COVID-19 pandemic. This temporary relaxation in regulations helped many patients to seek care in non-traditional ways through telehealth, allowing hospitals to deal with any patient surges. [31] When in-person encounters were necessary, Institutions and professional organizations have recommended that the most experienced or skilled team member assess the patient to make definitive treatment decisions, in order to limit exposure of multiple individuals. As a result, surgical faculty in many institutions, as well as in the Boston area performed surgical procedures either independently or with another faculty member or senior resident when assistance was necessary.

Operating during these conditions can be difficult, stressful, and more prone to errors. It is important to make time to plan, delegate and make difficult decisions. [32] Many treatment decisions during the pandemic had to be modified even for emergent and urgent situations. Decisions to surgically intervene or choose a non-surgical alternative, to perform treatment immediately or delay treatment, admit or not to admit were some of the dilemmas faced by clinicians during the height of the pandemic while preparing for the surge. It is important to consider the risks and benefits from a societal standpoint as well as the individual patient"s perspective, when making these ethical decisions.

Reduction in volume of operating room procedures was difficult to estimate as our questionnaire did not specifically ask programs to quantify this. Based on the authors" institutional experience, we expected there would be an 80-85% reduction in operating room volume after CMS directive on March 18 th 2020 to suspend elective and non-essential surgery. [15] Most OMFS programs indicated about 62% reduction in emergency department patient encounters. Despite the significant reduction, deep neck infections and maxillofacial injuries continued and comprised the majority of OMFS emergency room encounters. The number of maxillofacial injuries due to assaults was higher than motor vehicular crashes (MVC) and falls.

One can expect this due to increase in violence, given the food and shelter insecurity and frustration from social distancing. The reduced road traffic may have also contributed to increased trauma from assault compared to MVC's during the pandemic. Increase in domestic violence, altercations among incarcerated and homeless individuals was reported during the pandemic. [33] Situations such as this pandemic require strong leadership providing direction to all, and cohesive teams that can work well and respond to take actions immediately. The 

The access to and use of PPE has been a major concern during this pandemic. We felt the choice of PPE may be influenced by the availability in their Institutions. Therefore, we questioned participants on what they would recommend rather than what PPE they used during the pandemic. A little over half of the participating programs (52%) reported PPE shortages. Of those experiencing a shortage, N95 respirators were the most commonly reported (94.1%), which led to the subsequent plan to recycle N-95 masks. There was an overwhelming consistency in the PPE recommendations for all oral and maxillofacial surgery procedures given the high-risk for exposure to SARS-CoV2. Most of the surgeons (62%) recommended N-95 respirator with full-face shield in conjunction with fluid resistant gown, gloves. Powered Air purifying Respirators (PAPRs) were recommended by a few (21%) for operating room procedures. All programs reported having hospital guidelines in place for the appropriate use of PPE. There is evidence that PAPRs provide greater protection due to higher microbial filtration efficiency than N-95 masks, however, these devices can be cumbersome and preclude use of head light and ability to communicate well with others during the operation. Surgeons in other sister specialties consider PAPRs as essential for optimal safety while performing Aerosol Generating Procedures. Otolaryngologists have recommended a higher level of PPE during aerosol generating procedures as a precautionary measure.

They also feel that further clarification is necessary to determine the type of PPE to reduce the risk of exposure. Resident Training: All training programs responded that their residents had access to virtual didactic training sessions and self-study resources. It is important to have some structure to the didactic training and continue their core activities using virtual classroom technology. Residents were resourceful and several education webinars. Programs such as COVID collaborative lecture series (three hours per week) hosted by the University of Michigan and, partner institutions has become popular. Such initiatives may be the beginning of a national curriculum. Other surgical specialties such as Otolaryngology and Urology have reported using similar collaborative lecture series. They also used surgical simulations models for training residents. [36] The most common digital platform used was "Zoom". Some others used "Microsoft teams", which has better security features and collaborative options. The cost, real-time collaborative features and, the number of participants allowed can vary in each of these video conferencing applications [37] Our survey did not address the question about resident research activities, but personal communication with a number of programs revealed that many residents and faculty were productive in research and scholarly activities.

Steadiness, compassion and resilience are important qualities to nurture during these demanding times.

Among the surveyed OMFS programs, 73% (24/33) reported that their residents had access to wellness programs, such as mindfulness and meditation seminars, yoga, and other exercise activities. Some programs reported access to tele-psychiatry services, if necessary, to relieve anxiety and stress. Some other specialties reported the benefits of virtual departmental social hours. In order to facilitate connecting with colleagues and faculty, they made time for social hours within their weekly schedules.

Practical issues affecting HCP include childcare, housing, and meals. Our survey revealed that many residents used food delivery, transportation and housing services.

Similar surveys have been conducted by most surgical specialties including Otolaryngology, Urology, Orthopedic surgery and General surgery. [30, [36] [37] [38] They reported more stringent schedules to manage the staffing shortages and, structured didactic training including virtual surgical simulation programs, seminars and access to video libraries as well as, time for virtual social hours with colleagues and faculty.

A qualitative study conducted by He et al. surveyed general surgery residents in 2 major Hospitals in the Boston area regarding their concerns about the COVID-19 outbreak. [26] Most residents responded that their main concern was health of their older family members and the possibility of transmitting infection to their family members. They did not worry as much about increased work load or even getting infected by the SARS-CoV-2 virus. [26] Their study also emphasized the recommendations of the World Health Organization (WHO) that HCP should be educated well about exposure risk through direct face-to-face communication in a blame free environment during these global epidemics. 

The paper titled "A Survey Assessing the Early Effects of COVID-19 Pandemic on Oral & Maxillofacial Surgery Training Programs is a current topic of interest for all dental specialty training programs during this Pandemic. This study highlights the importance of adequate wellness resources for trainees and the need for structured training for proper use of Personal Protective Equipment and infection control

Tables: Table I Figure 11 : Guidelines used to help implement changes in resident didactic activities during the COVID-19 pandemic. CODA = Commission on Dental Accreditation; ACGME = Accreditation Council on Graduate Medical Education; ADA = American Dental Association. Figure 13 : Video Conferencing platforms used by residency programs to conduct didactic activities during the COVID-19 pandemic.

Wellness initiatives offered to OMFS residents, faculty and staff during the COVID-19 pandemic. 

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