Lessons from the Frontlines Pandemic Response Among New York City Pediatric Emergency Medicine Fellowship Programs During COVID-19

SPECIAL FEATURE

Lessons From the Frontlines Pandemic Response Among New York City Pediatric Emergency Medicine Fellowship Programs During COVID-19

Selin Tuysuzoglu Sagalowsky, MD, MPH,* Cindy Ganis Roskind, MD,† Daniel M. Fein, MD,‡ David Teng, MD,§ and Nazreen Jamal, MD†

“ ” “ Abstract: were identified as either persons under investigation or persons The global pandemic novel coronavirus 2019 has upended under monitoring,” and our imperative was to protect trainees healthcare and medical education, particularly in disease epicenters such against unnecessary exposure, with attending-only patient evalua- as New YorkCity. In this piece, we seek to describe the collective experiences tions and procedures. and lessons learned by the New York City pediatric emergency medicine However, as coronavirus ravaged NYC, it became abundantly fellowship directors in clinical, educational, investigative, and psychologi- clear that the “education versus service” balance would shift in the cal domains, in hopes of engendering conversation and informing future direction of service. By mid-March, PEM volumes plunged by disaster response efforts. 50% to 80%, hospitals shut down elective and nonessential outpa- Key Words: COVID-19, fellowship education, disaster response, physician tient services, and clinical spaces were converted into dedicated wellness adult COVID-19 and intensive care units in need of staffing. Clin- – ical electives became unavailable and canceled, and nonessential (Pediatr Emer Care 2020;36: 455 458) activities likewise halted. As hospitals quickly increased capacity he global pandemic novel coronavirus 2019 (COVID-19) has for growing numbers of adult COVID-19 patients, the need to T upended healthcare and medical education, particularly in staff these areas led to redeployment strategies across New York. disease epicenters such as New York City (NYC). Program direc- Three of the NYC Fellowship Programs redeployed PEM tors and leaders in graduate medical education (GME) have made fellows to alternate units (such as the medical intensive care unit, iterative programmatic changes, responding to clinical requirements, adult emergency department, or medicine inpatient floors), and a educational needs, research expectations, and the personal tolls of fourth enlisted fellows in the institutional redeployment plan but disaster response. did not mobilize them. These programs, and their respective insti- As pediatric emergency medicine (PEM) fellowship program tutions, used variable approaches to forewarning and placement. directors, our responses to COVID-19 have been influenced by Redeployment strategies ranged from voluntary to mandatory leadership from GME Offices, the Accreditation Council for for all eligible fellows, with some institutions using a hybrid ap- Graduate Medical Education (ACGME), the American Board of proach in which a minimum number of volunteers were required. Pediatrics (ABP), and departmental leadership. The departmental Similarly, redeployment placement differed across institutions, institutional officers at all institutions represented here declared with some allowing trainee choice and others centrally assigning stage 3 pandemic emergency status under the ACGME's Extraor- placement to areas of highest need. In addition, most of our pedi- dinary Circumstances policy, which provides a framework for atric emergency departments increased patient age limits (ie, 30– response. Program directors from all 10 NYC PEM fellowship pro- 49 years), such that PEM providers, including fellows, were car- grams participated in an anonymous, electronic data sharing docu- ing for adult patients. In programs that did not redeploy, fellows ment about pandemic response efforts. Here, we seek to broadly were challenged by limited pediatric volumes and varying degrees describe our collective experiences and lessons learned in clinical, of bystander guilt. educational, investigative, and psychological domains, in hopes of The diversity of our experiences has resulted in the identifi- engendering conversation and informing future disaster re- cation of suggested principles to guide fellowship redeployment sponse efforts. plans. Many of these mirror the American Medical Association's (AMA) Council on Medical Education's “Guiding principles to ” CLINICAL RESPONSIBILITIES protect resident & fellow physicians responding to COVID-19 and the “ACGME's early adaptation to the COVID-19 pandemic: The most complicated and emotionally wrought program- principles and lessons learned.”1,2 We hope that subsequent peaks matic challenge has been adapting PEM fellows' clinical work to of COVID-19 will not require these measures and recognize that a highly contagious disease with extreme adult critical care needs. future outbreaks may not follow analogous epidemiologic patterns. In the pandemic's early days, patients with suspected infection However, outlining a general redeployment plan may ease logistics and create a shared mental model for PEM fellowship programs. From the *Departments of Emergency Medicine and Pediatrics, New York Uni- versityGrossmanSchoolofMedicine;†Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons; ‡Depart- ment of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY; and §Donald and Barbara Zucker School of Medicine Validation at Hofstra/Northwell, Hempstead, NY. Disclosure: The authors declare no conflict of interest. Practicing outside the immediate scope of one's training or Reprints: Selin Tuysuzoglu Sagalowsky, MD, MPH, Pediatric Emergency expertise, particularly when it involves placing oneself in danger, Medicine Fellowship Program, Departments of Emergency Medicine and challenges the core ethical principles of role fidelity and benefi- Pediatrics, New York University Grossman School of Medicine, Bellevue cence. It is critical for program directors to validate and empathize Hospital Center, Administration Bldg, Rm A528, 462 First Ave, New York, NY 10016 (e‐mail: [email protected]). with the range of emotional and ethical ambivalence associated Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. with redeployment. Some of us will feel excitement and duty in ISSN: 0749-5161 going “to battle,” whereas others will need to pass through a

Pediatric Emergency Care • Volume 36, Number 9, September 2020 www.pec-online.com 455

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. Sagalowsky et al Pediatric Emergency Care • Volume 36, Number 9, September 2020 process akin to the Kübler-Ross Stages of Grief before venturing allocated according to trainee comfort and competency, and to into a hazardous unknown.3 maximize patient safety. Many of our programs also obtained emergency privileges Expectation Management for fellows to assume attending roles as general pediatricians, to independently staff services such as urgent care or telehealth. When Although the specter of redeployment loomed from the such roles are not performed as part of a clinical rotation, the AMA pandemic's earliest days, none of us knew how or when to guidelines support pay commensurate with staffing level.1 operationalize. Universally, our redeployment mobilization efforts “ ” missed the mark by occurring too late to maximize gains. More- Safety over, the anticipatory grief from waiting with uncertainty was in itself a stress to many fellows. Ensuring satisfactory safety standards is fundamental to re- Although programmatic plans will need to be situationally deployment. During the COVID-19 response, limitations of per- modified, programs should aim to outline a transparent general sonal protective equipment (PPE), coupled with ambiguous and strategy to ensure that fellows can anticipate when and how they changing protocols, rendered this a difficult and emotionally try- might be redeployed. Allowing agency in placement serves the ing task. Ultimately, all fellows had full access and training to the additional benefit of providing fellows with some sense of control highest available standards of PPE. Despite extreme clinical de- in otherwise disorienting times. Given PEM fellows' skill set and mands, all programs prioritized continued compliance with work hour limitations and safeguards outlined by the ACGME's Com- educational objectives, our trainees demonstrated strong prefer- 4 ences for placement in adult emergency medicine sites at which mon Program Requirements During COVID-19. Other physical they rotate. We found it most effective to coordinate this placement safety methods used across institutions varied but included the through either institutional GME redeployment protocols and/or following: provision of personal equipment (ie, safety goggles, direct arrangement with departments of emergency medicine. bouffants, personal face masks, pulse oximeters); access to hospi- Finally, programs should make an early, clear plan for ex- tal scrubs and showers; dedicated housing for those wishing to emption criteria. Our institutions used various standards to release quarantine away from family members; and increases in life and healthcare workers from patient care during the COVID-19 outbreak, disability insurance. some of which were mandated by agencies like the New York Lastly, legal safeguards are also necessary when practicing in Health + Hospitals Corporation. The range of exemptions included extreme circumstances outside of one's expertise, even with super- such conditions as: underlying pulmonary disease, immunocom- vision. In NYC, Governor Cuomo issued an executive order provid- promise, older age (ie, >65 years), and pregnancy, among others. ing certain immunity to healthcare workers acting with good faith to Mental health concerns may also come into play when crafting render medical services for COVID-19 efforts. As program direc- such policies. Although details will vary, outlining a general plan tors, we all tried to ensure that our fellows had a protected environ- may expedite response efforts while allowing fellows to prepare ment to raise safety concerns without recrimination, though in educationally, logistically, and psychologically for redeployment. retrospect, anonymous channels for these grievances may be preferable. Transparency and Partnership EDUCATIONAL CONSIDERATIONS Throughout the redeployment process, transparency about mandates, processes, and potential next steps was key. Integrating Continuing to provide meaningful and relevant education for fellows into the planning process is central to transparency and PEM fellows throughout COVID-19 required innovative thinking. — partnership. In addition, redeployment was better received and ex- Enhanced communication with GME leadership in the form of — ecuted in collaboration with other trainees, faculty, and hospital weekly meetings, town halls, and e-mails occurred at most of leadership. Working alongside department chairs, division chiefs, our institutions, with a focus on policies dictating educational attending physicians, and program directors in redeployed units frameworks. This included changes in ACGME regulations, ro- created true camaraderie under the mantra of, “We're all in this to- tation cancellations, and best practices surrounding asynchro- gether.” Without collective redeployment across ranks, house staff nous learning. Partnering with other program directors at our may feel uniquely vulnerable, and we run the risk of exploiting own institutions, and frequent communication among PEM power differentials and collective bargaining restrictions inherent program directors across the country via digital texting plat- to training. Programs represented here counted adult EM rede- forms, also proved instrumental. ployment toward fellowship requirements in adult emergency All of our programs continued existing weekly educational medicine and other redeployments as clinical electives. As per AMA conferences using virtual platforms, with special attention to recommendations, special effort should be made to provide credit end-user encryption ensuring regulations compliance. Although — for work performed in redeployment. these platforms have obvious downsides including lack of inti- macy, technical learning curves, and limitations to in-group interaction—they also provided unexpected benefits. Conference Role Clarity and Preparation attendance universally increased, the net of invited speakers ex- Providing flexible coverage for fluctuating staffing needs is a panded, and the “chat” function allowed more timid participants primary purpose of redeployment. Nevertheless, fellows should to share thoughts readily and, if desired, privately, with group mem- be provided general guidelines, preparation, and adequate super- bers. We continue to improve active learning with these virtual vision for new roles. Ensuring adequate supervision for adult pa- platforms, integrating practices such as breakout rooms, interinsti- tients seen in pediatric departments (ie, through collaborations tutional conferences, audience response software, and video content. with adult EM preceptors) was just as important as supervision Subject matter shifted heavily to COVID-19 for the initial 4 outside the pediatric ED. Given the volume and risks of airway to 6 weeks of the pandemic, with a return to hybrid content by procedures during COVID-19, PEM fellows also benefited from April. Although we did not have time to prepare dedicated, explicit procedural guidelines. In some institutions, anesthesia high-level curricular content, we all used conference time to review teams performed all intubations, whereas others retained residents a broad spectrum of COVID-19–related epidemiology and pathol- and fellows for procedural roles. As always, procedures should be ogy, including internal medicine and adult critical care topics such

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. Pediatric Emergency Care • Volume 36, Number 9, September 2020 Lessons From the Frontlines as ventilator management, acute respiratory distress syndrome, in- time in the final stages of scholarly projects, including delays in terpretation of adult electrocardiograms, and anticoagulation pro- preparing materials for ABP submission before graduation. Fur- tocols. Programs also integrated education around general adult thermore, limited accessibility of biostatisticians (who were complaints, such as congestive heart failure and hypertension, largely reassigned to COVID-related projects) may have caused which were now being managed by pediatric providers in many delays for all phases of scholarly work. institutions. Partnering with internal medicine and intensivist col- Scholarly activity was also impacted by COVID-19–related leagues allowed us to effectively deliver such content, much of personal or family illness, changes in childcare responsibilities, which we were relearning alongside our fellows. Collating and and/or widespread emotional fatigue, which left many disinclined sharing asynchronous learning resources in emergency medicine to devote energy to non-COVID–related topics.12,13 One positive and critical care were likewise useful to this endeavor.5 byproduct of the COVID-19 pandemic is the promise of intriguing Continuing fellows' electives proved challenging. Trauma, new research questions and discoveries for generations of PEM toxicology, emergency medical services, orthopedics, obstetrics, physicians—particularly those in disease epicenters—in the do- and other off-site and internal electives were canceled. Faculty mains of clinical care, disaster preparedness, operations manage- and program directors quickly created novel, asynchronous, mod- ment, and education related to the pandemic. Institutions battling ular curricula to cover topics such as global health, emergency COVID-19 will need to centrally coordinate research efforts, creat- medical services, disaster preparedness, and radiology. Several ing and ensuring room for collaboration across disciplines, as we programs founded inventive telehealth electives for PEM fellows, have seen numerous duplicative studies and proposals in these ini- including Adult Emergency Medicine Follow-up and Virtual tial months. Involving fellows in COVID-19–related research early Urgent Care. The follow-up program incorporated novel, on will foster interdisciplinary collaboration, provide further oppor- fellow-driven guidelines to monitor for progression of symptoms tunities for scholarly activity, and ensure PEM input and expertise such as hypoxia or respiratory distress, and telehealth visits were in the estimation of COVID-19's impacts. supplemented with case discussions, asynchronous didactics, and Lastly, even as our hospitals and communities slowly reopen, independent reading in telemedicine. Granting emergency attend- travel to educational and research conferences remains limited ing privileges and focusing on follow-up visits allowed programs because of infectious and financial concerns. We encourage our to recuperate lost revenue because of trainee billing restrictions. fellows to continue drafting their work into research posters To limit additional COVID-19 exposure, all programs ceased and platform presentations, and programs will need to promote educational ultrasound scanning shifts and large-group simula- local and virtual opportunities to cultivate presentation and net- tions. Instead, hands-on ultrasound and simulation experiences working skills. were restricted to clinical shifts, with a focus on COVID-19–related applications such as cardiopulmonary ultrasound and individual- ized, in situ airway simulations. We compensated for these restric- WELLNESS tions with educational faculty rapidly generating asynchronous In 2017, the ACGME revised its common program require- curricula, using resources such as online image galleries and vir- ments to comprehensively address well-being. The pandemic tual patient simulation software.6–9 Although we pooled existing tested this mandate and highlighted the need for a robust infra- resources, developing and centralizing high-quality asynchronous structure to support trainee wellness, mitigate stress, and build re- elective, telehealth, ultrasound, and simulation content for PEM silience. Reflecting on the pandemic response, our programs fellows would benefit programs everywhere. faced 3 distinct psychological or emotional phases: preparation, Lastly, although COVID-19 has compelled us to reconfigure redeployment, and recovery. In the initial weeks of the pandemic, PEM fellows' clinical and educational curricula, the ACGME and as war analogies ran rampant in popular media, we struggled to we remain committed to ensuring that specialty-specific core com- prepare our trainees and ourselves for what lay ahead. Programs petencies are met, particularly for graduating fellows. As we discern focused on ensuring that fellows had adequate PPE and felt as safe the pandemic's longevity and effects on clinical training, we will as possible coming to work. Across NYC, fellows continued to further adapt with strategies such as expanding elective opportuni- see patients in the pediatric ED and joined faculty in the daily fear ties, enhancing simulation, or potentially increasing adult ED time of becoming ill or bringing infection home to loved ones. Programs to compensate if low patient volumes persist. attempted to counter this stress by constant communication, with most programs communicating with individual fellows daily, insti- tuting weekly or biweekly huddles, and engaging in frequent group RESEARCH AND SCHOLARLY ACTIVITY chats or text messages. Providing information, reassurance, and dis- Although the major ramifications of the COVID-19 pan- cussion about collective fears was the primary mechanism of sup- demic have been clinical, PEM fellows' scholarly activities were port during this first phase. As PPE concerns were laid to rest, the also impacted. Research is central to PEM fellowship; the ABP peak came upon us and redeployment became a reality for many requires completion of a scholarly project for board certification programs. eligibility, and the ACGME mandates 12 months of research for Although communication remained a cornerstone of support, fellows who have completed a pediatric residency.10,11 Fellows at with some programs adopting social zooms and formal psychiatric all stages of scholarly work were affected by the ongoing pan- counseling sessions, substantial mechanisms to support well-being demic. Many performed additional clinical responsibilities in lieu emerged from GME and departmental efforts. These included tan- of time originally dedicated for research. Fellows in preimple- gibles such as bonus or hazard pay, early transition of postgraduate mentation stages of their projects sustained delays in submission year salaries, loan forgiveness plans, free meals, free parking, travel to institutional review boards because of redeployment of men- reimbursement, childcare resources, and the safety resources cited tors or prioritization of COVID-19–related research. previously. Our programs allowed flexibility in scheduling vaca- Fellows actively enrolling patients in research studies had tions and electives, and the ABP provided allowances in elective significantly fewer opportunities for enrollment. At some institu- time for residents who become ill. tions, this was due to dramatic drops in pediatric ED volumes, Access to mental health services intensified, and resources whereas at others, there were institutional mandates to halt all for 24/7 psychiatric services were offered at divisional, departmen- non-COVID–related research activity. Senior fellows lost crucial tal, and institutional levels, including dedicated support groups for

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. Sagalowsky et al Pediatric Emergency Care • Volume 36, Number 9, September 2020 those uniquely affected by COVID-19 (ie, ill individuals, care- ACKNOWLEDGMENTS takers, parents, expectant parents, and those experiencing racial The authors thank Pediatric Emergency Medicine Fellowship or ethnic discrimination related to the pandemic). These mental Program Directors Stephen Blumberg (Jacobi Medical Center), health resources proved paramount, as trainees redeployed to Chris Kelly (NewYork-Presbyterian Brooklyn Methodist Hospi- adult units bore witness to unprecedented morbidity and mortality. tal), Ambreen Khan (SUNY Downstate & King's County Medical In the future, prospectively outlining and providing such compre- Center), Louis Spina (The Mount Sinai Hospital), Hector Vazquez hensive benefits will help programs and institutions ensure just (Maimonides Medical Center), and Yaffa Vitberg (NewYork- compensation, psychological safety, and a sense of appreciation. Presbyterian Cornell) for sharing their experiences and reviewing As our trainees have returned from redeployment, we refocus this article to ensure that it reflects the collective NYC PEM fel- our vision on adjusting to the new realities of prolonged social dis- lowship experience. tancing while processing the events of these past weeks. 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