key: cord-1008647-fegkacyz
authors: Luc, Jessica G.Y.; Archer, Michael A.; Arora, Rakesh C.; Bender, Edward M.; Blitz, Arie; Cooke, David T.; Elde, Stefan; Guy, T. Sloane; Halpern, Alison L.; Harrington, Caitlin; Hlci, Tamara Ni; Kidane, Biniam; Olive, Jacqueline K.; Ouzounian, Maral; Stamp, Nikki; Vervoort, Dominique; Varghese, Thomas K.; Antonoff, Mara B.
title: The Thoracic Surgery Social Media Network Experience During the COVID-19 Pandemic
date: 2020-05-18
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2020.05.006
sha: f862a99f4145c5ce6889c585a0f7388f15b6b831
doc_id: 1008647
cord_uid: fegkacyz

[Figure: see text]

The Thoracic Surgery Social Media Network (TSSMN) was formed in 2015 as a collaborative effort between the Annals of Thoracic Surgery and The Journal of Thoracic and Cardiovascular Surgery [1] . The primary goals of the initiative were to bring social media attention to key publications from both journals and to highlight major accomplishments in cardiothoracic surgery. TSSMN has established a presence in the social media community, achieving its goals through the activity of delegates who tweet content related to recent journal publications, live-tweet the specialty's annual meetings, and host live TweetChats featuring key articles published in cardiothoracic surgery to engage manuscript authors, readers, and the virtual community in scholarly discussion [2] [3] [4] [5] .

Given the unprecedented global impact of the novel coronavirus disease 2019 (COVID-19), TSSMN pivoted from our usual TweetChats focusing on manuscript discussion to focus on supporting cardiothoracic surgeons during the pandemic (declared March 11, 2020). A one-hour TweetChat was held on March 29, 2020, at which time, there were over 750,000 confirmed cases worldwide with a death toll of over 36,000. Themes and questions for discussion were crowdsourced during the preceding days from the TSSMN community through social media and were then summarized into topics to be addressed during the TweetChat. The TweetChat drew a total of 7.5 million impressions, 2,587 tweets, and 273 participants, with the majority of respondents from the United States (56%), followed by Canada (25%), Europe (13%), and Asia (6%) ( Table 1) .

TweetChat topics included (1) triaging of patients for cardiothoracic surgery; (2) surgical education during COVID-19; (3) overcoming limited resources and personal protective equipment (PPE); (4) tips and tricks to keep one's home and family safe from COVID-19; and (5) the role of the cardiothoracic surgery community in combatting the COVID-19 pandemic. Given the debatable aspects of issues raised, 24 separate Twitter polls (Table 2) were utilized during the TweetChat to form a consensus and generate discussion surrounding practice patterns and opinions as we navigate these uncharted waters together.

We aim to share the key content from this chat with the readership of the Annals of Thoracic Surgery, and, herein summarize the discussion of each of the crowd-sourced TweetChat topics, along with the collectively generated potential solutions to the challenges encountered by the cardiothoracic surgical TSSMN online community. Those findings and ideas which are reported reflect those of the online chat participants, and may include anecdotal comments or suggestions which lack evidence and warrant further study.

Depending on the phase of COVID-19 prevalence in hospitals (preparatory, potential or real surge, or overwhelmed), we have needed to evaluate methods for triaging and scheduling patients for cardiothoracic surgery.

In response to questions regarding how cardiothoracic surgeons were conducting their ambulatory clinics, the majority stated that they were utilizing telehealth (65%), whereas, the remaining respondents were still conducting clinic as usual (12%) or had canceled clinic completely (17%) (n=60 respondents for poll). Some surgeons indicated that they were taking urgent referrals only, deferring all non-urgent referrals. Further comments from surgeons during the chat addressed the utility of telehealth in successfully shifting patient care to be more patient-centered and safe during COVID-19.

For patients with stage I-II lung cancer, the majority of cardiothoracic surgeons addressing this question (n=35) opted to delay surgery for 2-3 months (20/35, 57%). 29% (10/35) felt that surgery should not be postponed, with most (7/10, 70%) operating at their next available slot, while the remaining would advocate diversion to alternative treatment modalities (i.e. stereotactic body radiation therapy, etc). Comments from surgeons include the importance of multidisciplinary discussions and shared decision making to ensure that the treatment approach selected aligns with the patients' values and wishes, taking into account heightened risk for contracting COVID-19 if operating now versus progression of oncologic disease if delayed versus risks and benefits of nonstandard of care. More information regarding thoracic oncology surgery triage was cited from the consensus statement from the Thoracic Surgery Outcomes Research Network [6] .

Regarding the scenario of a postoperative patient with continued air-leak who develops COVID-19, respondents recognized that this would be high-risk with potential for aerosol-generation. Options proposed by respondents include early discharge home with chest tube drain and reservoir with outpatient chest tube removal with full (PPE), or utilization of digital chest drainage systems with built-in hydrophilic filters.

Thirty-two respondents provided their recommendations for patients with left-main coronary artery disease, the majority of whom (20, 63%) would opt for urgent coronary artery bypass grafting surgery, followed by percutaneous coronary intervention (19%), elective surgery (9%), and medical management (9%). Responses were more disparate regarding management of patients with symptomatic valvular disease: among 41 respondents, 39% preferred urgent surgery, while 32% suggested transcatheter therapy, 20% delayed surgery, and 10% opted instead for medical management. Similar responses were provided for symptomatic aortic aneurysms, for which, among 37 surgeons, 60% continued with urgent surgical repair, whereas 32% picked transcatheter therapy if feasible and 8% waited for elective surgery.

In terms of heart and lung transplantations, a majority (67/113, 59%) of poll respondents opted to put these operations on hold. For those respondents who felt that transplantations should continue during the COVID-19 pandemic, additionally provided comments hit on key nuances, addressing the need to prioritize only the most urgent of patients, taking into consideration the risks posed to the healthcare team during the procurement and operation as well as those to the recipients during their postoperative recoveries in an immunocompromised state and concomitant obligate use of intensive care facilities and resources. More information regarding adult cardiac surgery and congenital surgery triage is available in consensus statements published in The Annals [7, 8] .

The need for physical distancing has led to the discontinuation of in-person medical school courses, cancellation of educational conferences and licensing examinations, decline in operative volumes, and modifications to resident scheduling to both limit exposure of personnel as well as re-deployment of trainees to areas of need. As the impact of COVID-19 permeates throughout the healthcare system, surgical education has been put in a state of flux and uncertainty.

Participants responded that, in terms of residency, fellowship, and job interviews, most activities are now held virtually (62%) with the remaining having been canceled (n=34).

Among 21 individuals commenting on licensing examinations, 76% stated that their exams had been put on hold, with fewer number continuing on the original timeline (10%) or being held virtually (5%). When trainees were polled regarding the modality and timeline they would prefer for licensing examinations amidst the COVID-19 pandemic, 33% wished to take the exams remotely on the regular timeline, 33% preferred remotely but with a >3 month delay, 23% would rather delay for 1 year until next sitting, while only 11% desired the exams to be held in person as usual (n=18 respondents for poll).

Academic session have either been put on hold (54%) or are held virtually (43%), according to 35 respondents on this poll. Comments provided touched on the benefit of technology for streaming didactics, as well as for providing modified clinical educational experiences, such as virtual rounds to engage remote learners and patient families, while minimizing exposure for all. Among 32 poll participants, 25 (78%) stated that operative experience had decreased due to either lessened case-volume and/or modification to trainee schedule to minimize exposure with the remaining trainees having been re-deployed to areas of need in the care of patients with COVID-19. A number of additional comments were provided, and the needs for re-education and proper training for those in new or alternative roles, care and protection of those who become ill, flexibility and adaptation of current educational milestones, and providing psychosocial support to trainees were emphasized.

The pandemic raises concerns regarding limited resource allocation including the rationing of resources. These carry significant implications for the well-being of patients and providers alike.

The majority of 34 respondents stated that there was a perceived lack of PPE at their institutions (62%), while those who denied experiencing a shortage still indicated that their institutions were rationing resources. PPE policies at the institutions of poll participants varied greatly, with 45% (22/49) needing to wear surgical masks everywhere in the hospital and 37% indicating that N95 use was reserved for aerosol-generating procedures. Respondents also had varying experiences with regard to routine preoperative testing of cardiothoracic surgical patients. Among 38 respondents to this poll, 42% emphasized the importance of testing, given the high rates of asymptomatic carriers, while 50% reported inadequate availability of such tests. However, others cautioned that false negatives could be inappropriately reassuring and that the sensitivity of the test may be affected by the low viral load of asymptomatic carriers. Ultimately, the need to protect healthcare workers through availability of N95 masks and full PPE for aerosol generating procedures for all patients regardless of COVID-19 status was emphasized.

Methods to re-sterilize contaminated PPE with UV radiation, heat, and vaporized hydrogen peroxide, among other methods, were discussed, though it remains to be determined whether these strategies are effective, and the evidence is rapidly evolving.

More information regarding mask re-use strategies was cited from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES, https://www.sages.org/n-95-re-use-instructions). In addition, the members of the TweetChat community commented on an evolving role for the use of smoke evacuation systems or air-seal devices in the use of cautery and any carbon dioxide insufflation due to potential of aerosol generation, with possible transitions away from minimally invasive procedures among some chat participants. For open airway procedures, there was a clear consensus to avoid the use of TA staplers, or to use a "double stapling" technique if the TA stapler was deemed necessary. Again, we note that those were opinions of participants, and evidence supporting the avoidance of minimally invasive procedures such as robotic lung surgery in the setting of COVID-19 has not been demonstrated.

The majority of respondents (72% of 32) stated that there was concern regarding the number of key hospital resources required in the treatment of patients with COVID-19 including ventilators, hospital beds, and ICU beds. Participants highlighted the need for transparency in reporting of availability of healthcare resources as well as prediction of healthcare resource utilization for COVID-19 in order to identify capacity constraints and need for support. In addition, they emphasized the importance of a coordinated response to prepare for the surge, to secure access to the various supply chains as well as utilizing innovative ways to augment hospital capacity (e.g., repurposing of public facilities). Furthermore, the need to protect healthcare workers to ensure sustainability of our workforce as well as early detection, isolation, and testing were highlighted to combat COVID-19's rapid spread.

More information regarding infection mitigation strategies in the operating room and surgical recovery is available in a consensus statement published in The Annals [9] .

In our care of patients with COVID-19 as healthcare providers, we inadvertently risk exposing our families to the virus. When asked how one's living situation has changed with COVID-19, the majority of respondents stated that it had not changed (65%), though a large proportion stated that they self-isolate in their own room (31%), and a small minority (4%) were choosing to stay at the hospital or live in a hotel (n=26 respondents for poll). Interestingly, responses shifted significantly when participants were asked what they would do if they were exposed to a patient with COVID-19 with no PPE and were asymptomatic. Among 68 respondents, 41% would self-isolate within their home, 32% would quarantine away from home, and the remainder choosing to use PPE at home if unable to self-isolate. Ultimately, participants echoed that one's response to exposure depends on context and consequences. If one had a high-risk exposure or lived with vulnerable individuals at home, then one ought to weigh those issues into their consideration of self-isolation. Overarching chat recommendations included making contingency plans if physicians or their family members were to become infected and, further, to have advanced care directives in place.

In terms of decontamination routines after working at the hospital, anecdotal tips shared included bringing only disposable containers, changing and/or showering before going home (or immediately upon arrival), wiping down all personal belongings, distancing from high-risk family members, leaving shoes outside, and setting up a contaminated and non-contaminated area in one's home, if possible. In addition, participants stated the need to minimize use of any personal items that may act as fomites for COVID-19 transmission, including but not limited to, use of the laptops, bags, white coat, stethoscope, ties, and personal accessories, and to utilize telemedicine modalities if appropriate.

pandemic.

The following themes emerged during the TweetChat in the discussion regarding the role of TSSMN in the COVID-19 pandemic.

1. Community support and collaboration: TSSMN has a role in uniting the global cardiothoracic surgery community to foster collaboration and sharing of information, resources, and research opportunities. Given the potential physical, emotional, and mental stress of this pandemic, it may be advantageous to rely on the collective experience of our cardiothoracic surgical community to learn together from each other, rather than apart. Healthcare is a team sport.

To mitigate harm to population health, TSSMN serves a role to combat misinformation through the dissemination of critical post-publication scholarly peer-reviewed literature on COVID-19. This includes, but is not limited to, those put forth in cardiothoracic surgical journals and from cardiothoracic surgical societies, including ethical guidelines [10] and tiered triage guidelines for adult cardiac surgery [7] , congenital cardiac surgery [8] , and thoracic malignancies [6] . The promotion of transparent and trustworthy information can aid in public education, empowerment, and ultimately, individual responsibility in the treatment and prevention of COVID-19. surgeons across the globe are leading by example and finding ways to contribute their skills. Opportunities include serving on the team to perform much-needed procedures to expedite patient care, assuming or assisting in alternative roles, and to dynamic health system restructuring within the ever-evolving hospital environment. We are ultimately serving humanity. Everyone is in a unique battle against COVID-19. One very important role of a surgeon in a pandemic is to help grow hospital capacity by triaging elective operations and thereby preserving personnel and hospital resources.

Disseminate content that is data-driven and evidence-based: Social media is useful for disseminating and promoting not only evidence-based practices but also tools for collecting and reporting data relating to COVID-19. TSSMN can encourage greater utilization of the Society's National Database tracking surgical outcomes of cardiothoracic surgery patients with and without COVID-19, as well as distribute resource utilization prediction tools.

This study is subject to a number of limitations that should be considered. Due to the nature of Twitter polls and their anonymous and voluntary nature, they are subject to responder bias as well as lack internal and external validity. In addition, TSSMN is an online community, thereby excluding those who are not engaged in social media.

We have demonstrated the feasibility of TSSMN to facilitate communication among the global cardiothoracic surgery community in an unprecedented time of public health crisis, enabling us to join forces, collaborate, and find strength from our collective experiences with COVID-19, even when we must physically be apart. 

Thoracic Surgery Social Media Network: Bringing Thoracic Surgery Scholarship to Twitter

Participating in TweetChat: Practical Tips from The Thoracic Surgery Social Media Network (#TSSMN)

Live Tweet The Society of Thoracic Surgeons Annual Meeting: How to Leverage Twitter to Maximize Your Conference Experience

Thoracic Surgery Social Media Network: Early Experience and Lessons Learned

The Trainee Thoracic Surgery Social Media Network: A Pilot Study in Social Media Use

Thoracic Surgery Outcomes Research Network, Inc. COVID-19 Guidance for

Triage of Operations for Thoracic Malignancies: A Consensus Statement from Thoracic Surgery Outcomes Research Network

Adult cardiac surgery during the COVID-19 Pandemic: A Tiered Patient Triage Guidance Statement

COVID-19: Crisis Management in Congenital Heart Surgery

Adult Cardiac Surgery and the COVID-19 Pandemic: Aggressive Infection Mitigation Strategies are Necessary in the Operating Room and Surgical Recovery

Cardiothoracic Surgeons in Pandemics: Ethical Considerations