key: cord-0794558-v7by6dnp
authors: Kessler, Remi A.; Oermann, Eric K.; Dangayach, Neha S.; Bederson, Joshua; Mocco, J.; Shrivastava, Raj K.
title: Changes in Neurosurgery Resident Education During the COVID-19 Pandemic: An Institutional Experience from a Global Epicenter
date: 2020-05-08
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.04.244
sha: b1e37a7e5dafbb86ee3de40e78e20ec99a17712e
doc_id: 794558
cord_uid: v7by6dnp

nan

To the Editor:

The first case of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its associated coronavirus disease in New York State was diagnosed on March 1, 2020. It was declared a global pandemic by the World Health Organization (WHO) shortly thereafter on March 11, 2020. 1 As it rapidly spread across New York City (NYC), the city's major teaching hospitals underwent unprecedented changes to re-organize resources, make space for the massive surge in COVID-19 positive patients who would require hospitalization and ventilatory support, and to re-deploy physicians of all specialties to aid in the effort. Given that NY is leading the nation in the number of patients diagnosed with COVID-19 (277,606 cases as of April 25, 2020), 2 coupled with the cancellation of all elective surgeries, the comprehensive redeployment of attending neurosurgeons and residents to assist in covering a COVID-19 intensive care unit (ICU) became a necessity. Here we present our detailed institutional experience -from an 1,141-bed, tertiary care academic center and six other affiliate hospitals of the Mount Sinai Health System in NYC-on how the re-organization efforts changed our neurosurgical graduate medical education program from the heart of the pandemic.

On March 23, 2020, the Department of Neurosurgery at Mount Sinai issued its first version of changes to resident practice. The inciting event for this was the conversion of the new neurosurgical ICU (NSICU) into a dedicated 35-bed COVID-ICU, requiring full-time staffing from all four of our faculty neuro-intensivist physicians. At this juncture, neurosurgery departmental leadership re-deployed residents and attendings to provide 24/7 neuro-critical care coverage, and mid-level providers were assigned to coverage in the emergency department and COVID-ICU. The old neurosurgical ICU was re-activated, and all neurosurgical patients were Resident Education from the Pandemic Epicenter transferred there. One of the first changes made was expanded resident coverage to staffing this older neurosurgical ICU and junior residents responsible for call every third night. The four chief residents (PGY-7s and PGY-6s) rotated on a weekly basis between the NSICU, the standard ICU and two neurosurgery operating rooms (ORs). The NSICU chief supervised the neurosurgical service, neurosurgery floor patients, NSICU patients, oversaw neurosurgery consults, and rounded with the ICU team in the morning to build expertise in critical care. They were also responsible for preparing the biweekly radiology conference. The ICU chief neurosurgery resident worked closely with the ICU physician and rounded in the ICU on all patients, supervised ICU management day-to-day, and was in-house during the day with home call at night. The first OR chief had primary OR responsibility, and the second OR chief was to remain home unless the second OR was running. Both PGY-5 residents were exclusively assigned to the cerebrovascular neurosurgery service and functioned at the Fellow level. This change was in response to the seven-fold increase in stroke admissions related to COVID-19 seen at Mount Sinai within recent weeks. 3 All junior residents were re-assigned to a minimum of six weeks of neurocritical care and six weeks of neurosurgery. The neurocritical care junior residents were scheduled for 24-hour in-house call every third day. The juniors assigned to the neurosurgery service were scheduled for 24-hour call every fourth day. Their responsibilities include prepping patients for the OR, preparing the radiology list, and covering the surgical cases. One other junior resident was considered backup for covering cases, otherwise was to stay at home. Interns were assigned to the NSICU through July 2020. The same principles applied to the residents covering the other Mount Sinai affiliate hospitals. All resident weekly teaching conferences and Grand Rounds were held virtually via video conferencing. On April 6, 2020, changes were made to this aforementioned version of the department staffing by introducing a dedicated senior and Resident Education from the Pandemic Epicenter junior resident to staffing the COVID-19 ICU, due to increased need. The chiefs were also reassigned to four, one-week rotations consisting of the NSICU, the ICU, the OR, and the hospital floor/neurosurgical consults. The reason for this change was that the low volume of surgical cases did not require a second chief resident and that physician staffing was better utilized in other areas of the hospital dedicated to COVID-19.

The changes to neurosurgery resident education at Mount Sinai were borne out of a necessity for re-deployment of our physicians to assist in the fight against COVID-19, given the sheer abundance of positive patients in NYC. The Emory University Department of Neurosurgery reported similar changes for residents covering their neurosurgical service and each resident is to spend one week during the month of April caring for COVID-19 patients. 4 A number of programs have reported reducing resident staffing by 50% with teams rotating one week at a time, while the rest of the residents remain at home. Cases that ultimately go to the OR are typically limited to a single resident to both reduce exposure and preserve PPE. 5 The Massachusetts General Hospital/Brigham and Women's programs has re-deployed attendings and residents on a voluntary basis. 6 The shutting down of research facilities for residents completing their research years has also led to delays in scientific productivity for those involved in wet bench research. 7 Emory, along with many other programs, have similarly used videoconferencing for live-streaming Grand Rounds, educational didactic sessions, and case conferences. 8 The COVID-19 pandemic has dramatically transformed the clinical neurosurgery residency training program at Mount Sinai due to the need to treat the unprecedented high numbers of >1,600 COVID-19 positive patients currently admitted to our hospital. The COVID-19 pandemic has required our department to change resident education to an exceptional degree, but we are continuing neurosurgical learning in innovative ways while heeding the call to care for NYC's sickest patients.

Keywords: resident education, neurosurgery, pandemic, virus

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