key: cord-0974288-tmk2c9eh authors: Alhaj, Ahmad Kh.; Al-Saadi, Tariq; Mohammad, Fadil; Alabri, Said title: Neurosurgery Residents Perspective on the COVID-19: Knowledge, Readiness, and Impact of this Pandemic. date: 2020-05-16 journal: World Neurosurg DOI: 10.1016/j.wneu.2020.05.087 sha: a3bae4f5fdfa1087faad4cd07d2149d09fc1d949 doc_id: 974288 cord_uid: tmk2c9eh Abstract Background The novel Coronavirus disease (COVID-19) is a life-threatening illness, which represents a challenge to all the health-care workers. Neurosurgeons around the world are being affected in different ways. Objectives This is the first study regarding the readiness of neurosurgery residents towards the COVID-19 pandemic and its impact. The aim is to identify the level of knowledge, readiness, and the impact of this virus among neurosurgery residents in different programs. Methods A cross-sectional analysis in which 52 neurosurgery residents from different centers were selected to complete a questionnaire-based survey. The questionnaire comprised of three sections and 27 questions that ranged from knowledge to impact of the current pandemic on various features. Results The median knowledge score was 4 out of 5. The proportion of participants with satisfactory knowledge level was 60%. There was a statistically significant difference between the knowledge score and location of the program. Around 48% of the neurosurgery residents dealt directly with COVID-19 patients. Receiving a session about personal protective equipment (PPE) was reported by 57.7%. The neurosurgery training at the hospital was affected. About 90% believed that this pandemic influenced their mental health. Conclusion Neurosurgery residents have a relatively good knowledge about COVID-19. The location of the program was associated with knowledge level. Most of the participants did not receive a sufficient training about PPE. Almost all responders agree that their training at the hospital was affected. Further studies are needed to study the impact of this pandemic on neurosurgery residents. The novel Coronavirus disease (COVID-19) is a respiratory tract viral infection, caused by the newly emergent, severe acute respiratory syndrome coronavirus (SARS-COV-2). 1, 2 It is a life-threatening viral illness, which represents a challenge to all health-care workers over the globe. The World Health Organization (WHO) reports that this viral infection confers a 3% to 4% crude mortality rate. 3 This pandemic has affected everyone in all aspects of daily life, especially in the healthcare. The quality of residency training is negatively influenced as a result of the recent pandemic. As the number of individuals infected with this virus rapidly increases, neurosurgeons from different nations are significantly affected in multiple ways. 4, 5, 6, 7 Neurosurgery residents are now facing a major challenge, especially for those who work in hospitals with a high number of COVID-19 patients. In addition, some residents are fully responsible for patients with this infection. The strategies to increase the regional intensive care unit (ICU) allowance included the reduction of all surgical activities, starting with elective, to ultimately, also, include some urgent cases. 6 Currently, most of the neurosurgical centers postponed their elective surgeries due the burden of this infection. 4, 5, 8 Furthermore, several programs have reduced the number of residents by 50% of normal, thus keeping the remainder of the residents at home. 7 Almost all neurosurgery programs around the world have changed their academic meetings to online communication in an attempt to reduce physical contact. To our best knowledge, this is the first study regarding the readiness of neurosurgery residents towards the COVID-19 pandemic and the impact it has on their training. The aim of this study is to identify the level of knowledge, readiness, practices, as well as the impact of this virus among neurosurgery residents in various neurosurgical programs. This cross-sectional study involves the assessment of neurosurgery residents through a questionnaire-based survey. The study was conducted during the pandemic, from the 14 th until the 28 th of April 2020. The sample size "n" is represented by a total of 52 respondents from different neurosurgical programs. They completed the survey (Appendix A) on the awareness, knowledge, practices, and safety measures about COVID-19. The questionnaire was mainly adapted from the current interim guidance and information for healthcare workers, published by the US Centers for Disease Control and Prevention (CDC). 10 Several editorial studies published recently about the impact of the virus on neurosurgery residents was also utilized to create the questionnaire. 5, 7, 8 The target population consists roughly of around 300 residents, comprised of neurosurgery residents from various neurosurgical centers that we chose. A representative sample from Canada, United Stated of America (U.S.A.), Kuwait, Saudi Arabia, Serbia and Italy were selected. We divided the regions into North America, which includes Canada and U.S.A. In addition, Saudi Arabia and Kuwait represent the programs in the Arabian Gulf Cooperation Council (GCC) countries. Regarding the European programs, we reached out to residents from Serbia and Italy. Residents from different centers where selected from three different regions, with the number of participants from each region being close to one another. Moreover, we communicated with senior neurosurgeons from these regions, and they provided us with lists of residents with their contacts, which we selected randomly from. Therefore, our sampling procedure comprised of random selection of the participants. In addition, each resident was reached in person via a direct phone call or a text message in order to restrict the data to our inclusion criteria, which involved only neurosurgical residents. Moreover, this method of direct contact facilitated a very high response rate. All neurosurgeons who finished their training or were above the sixth year of the program were excluded from our data. An informed consent was obtained from each subject. The study objectives were explained to the residents. They were also assured regarding confidentiality of the collected information, and that they were free to decline participation in the study. One participant who refused to complete the survey was excluded. The questionnaire consisted of three sections and 27 questions. The first section (8 items) involves the baseline information: gender, age, location of the program, year of training, and current health condition. The next section (13 items) contains inquiries about basic biological and microbiological knowledge of this virus 11, 12 , hand hygiene, as well as personal protective equipment (PPE). 10 Additionally, we evaluated whether the subjects received any formal training in hand hygiene, PPE, and N-95 mask handling. The final section (6 items) focuses on the impact of this pandemic on the resident in terms of neurosurgical training, studying, mental health, as well as whether their social life was affected or not. 5, 7, 8 Convenient sampling method was used for data collection, and the distribution of qualitative responses was presented as frequency and percentages. Sub-groups were classified on the basis of gender, age, location of the program, and year of residency training. The Statistical Package for Social Sciences (IBM SPSS Statistics 23, IBM Corporation, Armonk, NY, USA, 2016) was used for data entry and analysis. First, univariate analysis was conducted, and qualitative variables were described by frequency and percentage. The quantitative variable (total knowledge score) was calculated by adding the points for the five knowledge items (each item equals one point). This variable, with a non-normal frequency distribution, was summarized by a median and inter-quartile range. We determined that the cut-off of the satisfactory knowledge level is a total knowledge score ≥ median. Also, a logistic regression model was used to identify the determinants of low knowledge level. At that point, p-value ≤ 0.05 was used as the cut-off level for statistical significance. Pearson's Chi-square test was utilized to assess the association between the qualitative variables. Mann-Whitney U test was used to compare two groups with a non-normal frequency distribution, while Kruskal-Wallis one-way analysis of variance test was used to compare more than two groups. We tested the association of our questions in relation to age, gender, location of the program, and year of residency training. In the present cross-sectional sample survey, 53 neurosurgery residents attending different centers around the world were contacted directly from the six countries mentioned earlier. Out of this number, 52 participants returned a completed self-administered questionnaire, and hence, the analysis was based on this number (response rate = 98.1%). Table 1 depicts the descriptive analysis of self-reported baseline information and the current health status of the residents with regard to COVID-19 virus. The majority of the participants were male (73.1%). Concerning the age, 69.2% were below 30 year old, and 30.8% were 30 year-old or above. Regarding the location of the neurosurgery program, the percentage of residents representing each country in our sample were as follow: Canada 36.5%, U.S.A. 9.6%, Kuwait 9.6%, Saudi Arabia 23.1%, and from the European countries (Italy and Serbia) 21.1%. The frequency of participants from each year of the residency (R) training were: (R1) 26.9%, (R2) 11.5%, (R3) 23.1%, (R4) 17.3%, (R5) 15.4% and (R6) 5.8%. Besides, table 1, also shows the current situation of residents in terms of this pandemic: 17.3% were under stay home order by their institution or the government; however, 82.7% are resuming their work at the hospital. In addition, according to our results, 21.2% of the neurosurgery residents were under quarantine or isolation. From our sample, only one resident from Europe tested positive for COVID-19. Furthermore, about 36.5% were negative, the rest, which represent the majority, 61.5%, were not tested for the infection. Almost half of the responders, 48.1%, dealt directly with COVID-19 patients, while the rest did not. Table 2a shows the frequency of correct responses to the five items of the knowledge score about the virus and the safety measures in relation to the location of the program. The number of residents who answered the questions correctly were as follows: 76.9% knew that the virus type, 90.4% knew the main mode of transmission, and 86.5% recognized the most common symptoms. The most accurate estimation of the incubation period of this virus was answered by only 40.4% of participants. Concerning the preferred hand hygiene method in the healthcare settings; unexpectedly, only 51.9% knew the correct answer. The first section of the table also displays the responses according to each location of the program in details, and some of the items showed statistically significant results. In table 2b, we recorded the responses about the training of safety measures, the safe practices, and the strategies of infection control. As expected, receiving a formal hand hygiene training was reported by 78.8%. In addition, receiving formal session of the correct sequence of PPE donning and doffing was stated by 57.7%. Only 50% of our sample knew their correct size of N-95 mask prior to this pandemic. Likewise, only 50% knew how to correctly obtain a nasopharyngeal swab sample. Most of the results in the previously mentioned items were significantly associated with the location of the program. The distribution of the total knowledge score was shifted to the right with left skewness (figure 1). The maximum total knowledge score was five, and the median knowledge score of our participants was four out of five, representing a good knowledge level. Table 3 demonstrates the association of this score about the virus with gender, age, year of residency training, location of the neurosurgery program. The table also depicts the association between the knowledge score and whether the participant was taking care of COVID-19 patients. The median for male residents was four, compared to three in females. There was neither a difference in medians nor statistical significant association of the knowledge score with regard to age and year of residency training. The median in each location was as follow: four, four, and three in North America, GCC countries, and Europe region, respectively. The difference in medians was statistically significant between Europe and North America, as well as between Europe and GCC countries (p-value = 0.049). Figure 2 shows the boxplot of the knowledge score based on the region of the program. The cut-off of the satisfactory knowledge level was four, which is the median. In our results, 59.6% had satisfactory knowledge about the virus, while 40.4% had a non-satisfactory level. The impact of this pandemic among neurosurgery residents is shown in table 4. Almost all of the residents found that their training at the hospital was affected. When asked about their opinion regarding the neurosurgical procedures during this pandemic, roughly 42% desired to resume their elective surgical procedures. Additionally, the daily studying hours was affected by about 80%, while the remaining did not face a change in the studying hours per day. The social life of all residents in our sample was influenced by the current situation. Shockingly, this pandemic affected the mental health of 90% of the participants. In table 5, the association of the impact on mental health of COVID-19 and year of training revealed that the mental health of all residents in the first, third, and sixth year of training was affected. Although the percentage of fifth year residents was also high (62.5%), they were the lowest group in this aspect. This association was significant (p-value 0.006), but other confounders' effect could not be eliminated. Our study is the first regarding the readiness of neurosurgery residents towards the COVID-19 pandemic and the impact it has on their training. This pandemic is evolving rapidly worldwide, disrupting personal and professional life, including that of neurosurgeons and neurosurgical residents. 4 Most programs have seen a significant drop in elective or nonessential surgical volume, impacting the functional neurosurgery cases foremost. 7 Regarding surgeries, around 57.7% in our study agreed that elective neurosurgical procedures should not be resumed during this pandemic ( figure 3-A) . In another editorial, authors stated the following "we have halted all elective cases, but will continue to schedule urgent and emergent cases, involving head and spine trauma, cauda equina syndrome, embolic stroke, ruptured aneurysms, and acute hydrocephalus are relatively noncontroversial; however, urgent cases such as malignant brain tumors and progressive cervical spondylotic myelopathy may require a more nuanced discussion." 4 Responses from our analysis disclosed that only 23% think that brain tumor or compressive spinal cord tumor surgeries should be postponed. In terms of skillset, a trustworthy neurosurgical team should have the ability to treat patients with infectious diseases who also require emergency operations. 8 At the same time, in our survey, most of the residents (≈ 80%) will only do emergency surgery on a confirmed COVID-19 patient if there are appropriate PPE, while a minority (≈ 20%) will perform it regardless the presence or absence of PPE; none of the participants refused to perform this surgery in either way ( figure 3-C) . Access to and training on proper PPE use are critical to the safety of workers. 14 When asked about the residents' opinion, if neurosurgical programs should involve a session about PPE every year, around 73% agreed that this session is essential ( figure 3-B) . Overall, programs report a significant decrease in the volume of cases. Clinic visits have transitioned to telemedicine where possible, decreasing resident exposure to outpatient encounters. 7 Similarly, all in-person conferences such as grand rounds, resident education conferences, and multidisciplinary meetings have been replaced by video teleconferences. 4 In concordance with our expectations, almost all of the residents found that their training at the hospital was affected. Certainly, once this pandemic has concluded, careful retrospective analysis of its impact on resident case volume will be necessary to ensure we are prepared for any future event. 7 The American Board of Neurological Surgery has postponed both primary and oral examinations. 7, 15 The Royal College of Physicians and Surgeons of Canada has also decided to postpone the written exam, while the oral component will no longer be required. 16 In our sample, the daily studying hours was affected in about 80%. Nonetheless, the studying hours might be affected positively or negatively. A study, about involving physicians in patients' care during epidemics, advised of possible alternatives to real patient-physician interaction as to avoid placing trainees at risk. 17 Less than half of the neurosurgery residents (46.2%) feel competent in taking care of COVID-19 patient, most of those who feel capable have already dealt with COVID -19 patients (figure 4) . Due to increasing number of COVID-19 patients who require hospitalization, some radiology residents have been reassigned to internal medicine and ICU as to care for the high influx of patients. 17 Similarly, almost half of the neurosurgery residents in our sample, 48.1%, dealt directly with COVID-19 patients in the previously mentioned settings. On the other hand, some neurosurgery residents might gain intensive care skills. In the end, working temporarily in the ICU or internal medicine department will benefit any physcians in one way or another. "Social distancing measures have circumvented the traditional trainee-faculty member workstation teaching, which is especially disadvantageous for residents who may be rotating on a service for the first or second time in their training." 14 Our survey revealed that 96.2% of the sample followed social distancing in a daily manner, while only two of the participants found it difficult to stick to this practice. "Work-related stress is a potential cause of concern for health professionals. It has been associated with anxiety including multiple clinical activities, depression in the face of the coexistence of countless deaths, long work shifts with the most diverse unknowns and demands in the treatment with patients with COVID-19." 18 In our data, this pandemic negatively affected the mental health of 90% of the participants. However, this influence is not specific, and might affect the residents mental health either positive or negative way. The median knowledge score about COVID-19 pandemic and infection control measures was four out of five (80%) with a range from one to five. The correct answers to the knowledge questions were the following: 76.9% knew that the virus type is an RNA virus single-stranded 11 and 90.4% knew that the main mode of transmission is via respiratory droplets. 12 Moreover, the most common two symptoms of the virus are fever and cough 12 , which 86.5% got correct. The most accurate estimation of the incubation period of this virus is 5 days 12 , and it was answered by only 40.4% of participants. Concerning the preferred hand hygiene method in the healthcare settings, which is hand rub for at least 20 seconds with 70% Ethanol 10 ; unexpectedly, only 51.9% knew the correct answer. On the other hand, 42.3% think that hand rub for at least 20 seconds with soap and water is the preferred method. Only 50% of the residents knew their correct N-95 mask size, as it is required to safely manage any suspected or confirmed cases. This study has some limitations. Temporal association of the knowledge score with the aspects discussed above cannot be definitely established due to the nature of the cross-sectional study design. Besides, the pandemic has affected the whole world in diverse degrees at different times. We have reached the neurosurgery residents in only six countries with different academic settings and resources. Therefore, the ability to generalize the results of this study to all neurosurgery programs may be limited. Our study suggested that neurosurgery residents have as a relatively good level of knowledge about COVID-19 pandemic, despite that a significant number of the participants did not reach the satisfactory level of the knowledge score. The location of the program was independently and significantly associated with knowledge score after adjusting for confounding between variables. Concerning the infection control, most of the neurosurgery residents received a formal hand hygiene training prior to the pandemic. However, receiving a formal training of the correct sequence of PPE donning and doffing was not sufficient. Most of the responders agree that their training at the hospital was affected. Larger retrospective studies that include a representative sample of neurosurgical residents with a wide range of regions is essential in order to generalize the results to the target population. It is recommended that health authorities provide infection control sessions to prepare the residents for any future events. Neurosurgery program directors may consider sharing experiences with other programs to enhance education and decrease the infection rate among surgeons. Regarding surgery, delay of elective procedures but proceeding with semi-elective, urgent, and emergency surgeries is advised. That being said, surgeons should also be provided with sufficient quantities of PPE so as procedures can be performed safely. Due to increased stress and decrease studying hours, we urge to provide the residents with adequate time to prepare for any upcoming evaluation. According to the reviewed editorials about this pandemic, we also encourage that the academic training should be continued with social distancing measures with a minimal number of attendees, or even online communication. Furthermore, ease of access of residents to mental health professional to prevent any psychological traumatic event, and provide them with stress-management sessions is also suggested. • % = column % • p-values were generated using Pearson's chi-square test (≤ 0.05 is statistical significant) Figure 1 . Frequency distribution of the total knowledge score among the neurosurgery residents in our sample. Coronavirus disease (COVID-2019) Situation Report-57 The outbreak of COVID-19: an overview Coronavirus disease (COVID-2019) Situation Report-46 Letter: Academic Neurosurgery Department Response to COVID-19 Pandemic: The University of Miami/Jackson Memorial Hospital Model Neurosurgical priority setting during a pandemic: COVID-19 Neurosurgery in the storm of COVID-19: suggestions from the Lombardy region, Italy (ex malo bonum) Impact of COVID-19 on neurosurgery resident training and education Response to COVID-19 in Chinese neurosurgery and beyond And Chiocca EA. Editorial. COVID-19 and academic neurosurgery Information for healthcare professionals Coronaviruses post-SARS: update on replication and pathogenesis Q&A on coronaviruses (COVID-19) COVID-19 awareness among healthcare atudents and professionals in Mumbai Metropolitan region: A questionnairebased survey The Impact of COVID-19 on Radiology Trainees The American Board of Neurological Surgery The Royal College of Physicians and Surgeons of Canada Involving Physicians-in-Training in the Care of Patients During Epidemics Supporting the Health Care Workforce During the COVID-• GCC: Arabian Gulf Cooperation Council (GCC) countries • p-values were generated using the Mann-Whitney U test for comparing two groups, and *Kruskal-Wallis one-way analysis of variance test for comparing more than two groups & Canada GCC: Arabian Gulf Cooperation Council countries (Kuwait & Saudi Arabia). European country: Data selection from Italy & Serbia We thank all the participants in this project for their time and effort. We also thank Dr. Dragan Savic and Dr. Jacquelyn Corley, for providing us the contacts of some neurosurgery residents. In addition, we would like to thank all the health-care workers in the front lines against COVID-19 pandemic. This is the first study regarding the readiness of neurosurgery residents towards the COVID-19 pandemic and its impact. The aim is to identify:• The level of knowledge about the novel Coronavirus among neurosurgery residents in different programs. • We also studied and discussed the readiness of the neurosurgery residents.• The impact of this virus on the neurosurgery was illustrated in order to give a general picture of the effect of this pandemic on the training in the hospitals, studying, and the general well-being of the residents. • Neurosurgery residents have a relatively good knowledge about COVID-19.• The location of the program was associated with knowledge level.• Most of the participants did not receive a sufficient training about personal protective equipment (PPE).• Almost all responders agree that their training at the hospital was affected.• About 90% believed that this pandemic influenced their mental health.• Further studies are needed to study the impact of this pandemic on neurosurgery residents.