key: cord-327394-mwbmi88i
authors: Edwards, Jodi-Ann; Breitman, Igal; Kovatch, Irina; Dresner, Lisa; Smith, Teresa Y.; Brunicardi, F. Charles; Schwartzman, Alexander
title: Lessons Learned at a COVID-19 designated hospital
date: 2020-08-04
journal: Am J Surg
DOI: 10.1016/j.amjsurg.2020.07.029
sha: 
doc_id: 327394
cord_uid: mwbmi88i

During early 2020, New York City became an epicenter for coronavirus disease 2019. The University Hospital of Brooklyn, which is the primary teaching hospital for the State University of New York Downstate Health Sciences University, became the only COVID-19 designated hospital in Brooklyn. The Department of Surgery implemented drastic changes to address the hospital's needs while remaining committed to the education of surgical residents. They ensured resident safety, continued surgical education, participation and contribution to the care of COVID-19 patients. We were able to accomplish these goals using an access and procedure team and program-wide use of video-conferencing platforms. Here, we have shared our experiences and solutions to the challenges that our department faced during this pandemic.

hemodialysis. The residents rotating at UHB were restructured into three teams (Figure 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 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 J o u r n a l P r e -p r o o f 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.

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. 

World Health Organization. Coronavirus disease 2019 (COVID-19)

COVID-19: Recommendations for Management of Elective Surgical Procedure. United States

Stage 3 Pandemic Emergency Status Guidance. United States

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Surviving Sepsis Guidelines for COVID-19. United States

Criteria for Return to Work for Healthcare Personnel with Suspected or Confirmed COVID-19. United States

Overcoming distance: video-conferencing as a clinical and educational tool among surgeons

Use of Telemedicine in Surgical Education: A Seven-Year Experience