key: cord-0019110-bbidztej authors: Matthews, Jeffrey B.; Blair, Patrice Gabler; Ellison, E Christopher; Andrew Elster, CAPT Eric; Nagler, Alisa; Schwaitzberg, Steven D.; Shabahang, Mohsen M.; Sidawy, Anton N.; Spanknebel, Kathryn; Stain, Steven C.; Britt, L.D.; Sachdeva, Ajit K. title: Checklist Framework for Surgical Education Disaster Plans date: 2021-07-12 journal: J Am Coll Surg DOI: 10.1016/j.jamcollsurg.2021.06.015 sha: ffaec478af0c18dc8c958fe90c76f089cecbc82d doc_id: 19110 cord_uid: bbidztej nan The COVID-19 pandemic disruptedand, as of this writing, continues to disruptsurgical training programs across the United States and around the globe. Reductions in operative procedures, due first to the nationwide moratorium on non-essential surgery and then to multiple subsequent "waves" of the pandemic that strained hospital capacity, jeopardized the ability of many trainees, especially those in their Chief Resident years, to achieve required case minimums. Social distancing policies interfered with the workflow of care teams as well as the ability to gather for in-person didactic conferences. Trainee safety and wellness were compromised by factors ranging from redeployment to non-operative assignments such as ICUs, emergency departments, and wards overrun with COVID-19 patients to shortages of personal protective equipment (PPE) that risked viral transmission to self, family, and loved ones. The response of surgical educators and their trainees has been nothing short of extraordinary. The organizations responsible for institutional and program accreditation and certification of freshly minted graduates have also demonstrated nimbleness and flexibility to address the crisis. Yet the pandemic also illustrated how much of the response to this educational disaster was improvisational and reactive. Overall, surgical educators and the institutions they represent were generally unprepared to address a disaster of this magnitude. The Accreditation Council for Graduate Medical Education (ACGME) requires institutions to maintain a policy that addresses "support" for each of their ACGME-accredited programs and for the residents/fellows in the event of a disaster occurrence that imparts substantial disruptions in patient care or education. 1 This policy must include information about assistance for continuation of salary, benefits, liability coverage, and educational assignments. While such a J o u r n a l P r e -p r o o f rudimentary policy may protect residents in the case of program closure, there is no requirement that an institution consider a more comprehensive approach to educational program disruption. Disasters that can potentially disrupt patient care and education range from natural disasters (eg hurricane, earthquake) to manmade disasters (eg mass casualty events, ransomware) and can affect a single hospital, a region, or (as in the current pandemic) the world. The Academy of Master Surgeon Educators (AMSE) of the American College of Surgeons (ACS) Division of Education appointed a Special Committee in March 2020 to address the impact of the COVID-19 pandemic on surgical training. Among the efforts of this Special Committee have been periodic surveys of program directors, surgical department chairs, clerkship directors, and learners to assess topics ranging from clinical experience to wellness over time. 2 3 Based on the early and severe disruptions to surgical education reported by programs particularly in the Northeast during the first wave, the Special Committee recognized that most institutions did not have sufficiently detailed disaster plans for surgical education to draw upon to be able to meet the impending challenges they would face. The Special Committee appointed a subcommittee to specifically address the question of whether there may be common themes that (should?) run through potential institutional disaster policies (specifically with respect to surgical education) that could potentially improve preparedness for future, unspecified events. The subcommittee members reviewed and compared institutional disaster plans from their own institutions and found, as expected, that the responses to educational disasters lacked sufficient detail and scope to be of any practical value in the context of the pandemic. The safety and wellbeing of residents and faculty members are essential to the provision of highquality health care as well as to the development of resilient physicians and surgeons. 7 The ACGME mandates that programs include resident education in self-care and assessment of trainee wellbeing. 8 As surgeons are known to be at increased risk for depression, burnout, and suicide, 9 it is critical that general surgery trainees be nurtured and supported to achieve competency in foundational self-care and wellness skills with the same rigor and prioritization as other aspects of training. Such baseline resident competencies, program assessments and infrastructure must be in place before a disaster strikes. For many general surgery residents surveyed during the COVID-19 pandemic, wellness resources were either unknown, underutilized or not provided. Lack of wellness resources (and female gender) was associated with new depression and burnout symptoms among residents surveyed, while the provision of J o u r n a l P r e -p r o o f wellness resources and PPE were protective of burnout symptoms. 3 Another survey of general/specialty surgery program directors and department chairs showed a significant negative impact on physical, emotional, and mental health of respondents as institutional operations progressed from usual operations to an emergency ACGME-declared stage under the burden of increasing numbers of COVID-19 patients. 2 This underscores the importance of not only matching the individual and organization wellness needs and resources to the specific crisis at hand, but also ensuring resource utilization. Safety of learners in the context of a disaster is also paramount. An institutional disaster response plan must consider safety of all employees, caregivers, and learners. There may be some specific additional considerations for learner safety in the context of a disaster plan for education but this is more likely to depend on the specific nature of the disaster. While it is clear that safety is fundamental to wellness, attention to wellness requires a great deal more than addressing safety. Nevertheless, in the context of a disaster, physical safety and psychological safety are quite deeply intertwined. For example, during the COVID-19 pandemic, the lack of PPE was found to be a major disruptor of trainee wellness. 2 3 Institutional disaster plans for education should ideally anticipate the need to scope and scale wellness resources and support, to address safety concerns specific to the threat at hand, and to adapt to individual resident and program needs in real time. In the setting of disease outbreaks, epidemics and pandemics such as COVID-19, the evidence to support the selection of various interventions beneficial to mental health and resilience of health care providers, remains unproven. However, interventions successfully utilized by the military during times of combat J o u r n a l P r e -p r o o f have been adapted for use in civilian populations and emergency response teams/workers with favorable outcomes. 10 11 Recently, the ACGME has also provided a comprehensive COVID-19 wellness resource guidebook that details specific recommendations for wellness and resiliency knowledge, skills and abilities, including links to national organizations and resource banks. The guidebook also details organizational strategies and tactics by which programs may inventory, plan, communicate, and educate during "usual" operations, as well as ways to implement expanded and proactive wellbeing support services during times of increased clinical demand and during emergency declaration periods when patient care concerns are paramount. 12 Safety and wellness considerations for an educational disaster plan should include both institutional and programmatic resources. Institutional resources may include a crisis hotline, bereavement response, occupational health resources including post-exposure policy and procedures, a plan to acquire and provide PPE and to mitigate needs identified, a range of virtual and in-person counseling and mental health services, grief counseling, and a central repository of wellness and mental health resources to address basic and community needs specific to the area and program. 7 Program resources may include a resident wellness committee with peer support and faculty mentoring, defined contingency plans for extended leave due to injury or illness, comprehensive wellness and resiliency skills training, and self-care including self-and peerassessments at baseline with means to monitor during the course of disaster emergencies. The COVID-19 pandemic has rapidly accelerated the adoption of telemedicine in routine surgical practice and has illustrated its ongoing relevance to surgical education in the response to future unanticipated disasters. 20 In order to be able to utilize telemedicine in a crisis, it is important to have trained the faculty, staff, and learners on the use of the technology and to have been familiarized in normal circumstances. That makes it essential for every surgical learner to have experience in assessing patients using telemedicine. Telemedicine needs to become part of the curriculum starting at the junior level of residency and continue through the more senior years. Only then will a learner be able to use telemedicine with ease at the time of crisis. There are two important reasons for the use of telemedicine in times of crisis. In order to have a relatively smooth increase in the utilization of telemedicine in times of crisis, it is important to have all the necessary equipment and software in place. 21 A private room with stations for telemedicine is essential. As new platforms arise for telemedicine, the leadership needs to keep the learners, staff, and faculty appraised of those developments. In addition, guidelines should be written for the use of telemedicine in times of crisis: what types of patients should be seen using this technology in the outpatient and inpatient settings. 22 As a national event, the COVID-19 pandemic disrupted surgical education throughout the world in general and in the United States in particular. Such major disruption necessitated resident redeployment that was in large part institutional in nature to account for various factors such as the PPE stock at the institution, patient care, resident safety, and resident education. 23 24 25 National disruptions are rather rare; several factors determine the type of disruption and the extent of resident redeployment necessary to maintain continuity of resident education. Such factors include: the magnitude of the disruption and whether it is institutional, regional, or national; the length of the disruption and whether the event is time-limited or protracted; and the nature of the event and whether it is a natural disaster, cyberattack, physical attack on population or infrastructure, or infectious in nature, to state a few. Based on such factors, the type and magnitude of redeployment can vary. Institutional redeployment occurs within the same institution, either from one residency rotation structure to another within the surgery department, or from one service line to another, as example, surgical residents providing ED/ICU coverage or changes in team structure for redundancy or consolidation to allow for on-and-off rotations and periods of rest while working in highintensity environments. Regional redeployment occurs within the same region redeploying residents from one institution to another. National redeployment takes place when residents are redeployed from one state or one region of the US to another. An event, such as Hurricane Katrina that hit New Orleans in August 2005, may disrupt the health system in a region for a protracted period of time that necessitates residency program closure either for a few years or permanently. 26 In such a situation, the pram needs to be prepared to arrange for the residents to complete their training in other programs, regionally or even nationally. 27 Preparation for any kind of disruption and redeployment is of paramount importance and requires a predetermined plan. Consideration should be given to specific program policies, a predetermined group that can be assembled instantly in case of a disruption including the department's educational leadership (as represented by the Program Director and Chair), and a plan that can be put into action in case of a disaster event. Such a plan should consider factors J o u r n a l P r e -p r o o f engages the employees (and learners), motivates them, and communicates the goals. At time of crisis, leaders need to be seen and they need to be present. Finally, alignment of goals, accountability, and empowerment are essential. It is important to empower the frontline workers but establish and communicate the overall objective. The goalposts are determined by the leader, communicated effectively, autonomy is given at the local level, and everyone is held accountable. 30 The purpose of providing instruction on these concepts is that they become more natural in times of crisis. Part of the preparedness of educational programs for crisis situations is the ability of the entire educational leadership team to incorporate the principles above into their practices at times of disaster. These principles should be part of the drills that are run for dealing with sudden events that can affect the educational mission. This checklist is intended to provide program directors, department chairs, and their educational teams a framework within which to consider the elements that might comprise an optimal disaster plan for surgical education. Given the nationwide and global experience with the COVID-19 pandemic and its disruption of surgical training, it is recommended that surgical departments review the performance of their training programs during the COVID-19 pandemic, consider "lessons-learned" from their institutional experiences, and develop a more comprehensive disaster plan for surgical education to enhance preparedness. Surgery departments and institutions may find value in sharing their approaches to the categories defined J o u r n a l P r e -p r o o f within the checklist in order to continually learn from each other and be better prepared for future crises. 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