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\begin{document}

\title{Development of clinical care guidelines for faculty and
residents in the era of COVID-19}



\author[1]{Steven D. Pletcher, MD}%
\affil[1]{University of California San Francisco School of Medicine}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\begin{abstract}
\textbf{Background~}The global COVID-19 pandemic brings new challenges
to otolaryngology resident education. Surgical volume and clinic visits
are curtailed, personal protective equipment for operating room
participation is restricted, and the risk of COVID-19 disease
transmission during heretofore routine patient care is the new
norm.~\textbf{Methods~}We describe a small-team ``cohorting'' protocol
including guidelines for faculty and resident in common clinical
scenarios with attention paid to the risk of common otolaryngologic
procedures.~\textbf{Results~}A rotating small-team approach was
implemented at each clinical site, limiting interaction between
Department members but providing comprehensive coverage. Faculty were
involved at the earliest phase of clinical interactions. Guidelines
delineated faculty and resident roles based on risk stratification by
patient COVID status and anticipated procedures. Special consideration
was given to high-risk procedures such as endoscopy and
tracheotomy.~\textbf{Conclusions~}A small-team based approach with
guidelines for faculty/resident roles may mitigate risk while optimizing
patient care and maximizing education.%
\end{abstract}%



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Abstract content goes here

Jason S. Park, MD, PhD\textsuperscript{1}; Ivan H. El-Sayed,
MD\textsuperscript{1}; VyVy N. Young, MD\textsuperscript{1}; Steven D.
Pletcher, MD\textsuperscript{1,*}

\textsuperscript{1}Department of Otolaryngology--Head and Neck Surgery,
School of Medicine, University of California San Francisco, San
Francisco, CA, USA

\textsuperscript{*}Corresponding author: Steven D. Pletcher, MD
Professor, Residency Program Director Department of Otolaryngology --
Head and Neck Surgery University of California San Francisco School of
Medicine 2233 Post Street, 3\textsuperscript{rd} Floor, San Francisco,
CA 94115 e-mail: Steven.Pletcher@ucsf.edu

No grant support to report. This work has not been presented at any
meetings or conferences.

Brief running title:

COVID-19 era guidelines for faculty and residents

Key words:

COVID-19, guidelines, cohorting, residency, trainee, education,
aerosol-generating procedures

\emph{Abstract}

\textbf{Background}

The global COVID-19 pandemic brings new challenges to otolaryngology
resident education. Surgical volume and clinic visits are curtailed,
personal protective equipment for operating room participation is
restricted, and the risk of COVID-19 disease transmission during
heretofore routine patient care is the new norm.

\textbf{Methods}

We describe a small-team ``cohorting'' protocol including guidelines for
faculty and resident in common clinical scenarios with attention paid to
the risk of common otolaryngologic procedures.

\textbf{Results}

A rotating small-team approach was implemented at each clinical site,
limiting interaction between Department members but providing
comprehensive coverage. Faculty were involved at the earliest phase of
clinical interactions. Guidelines delineated faculty and resident roles
based on risk stratification by patient COVID status and anticipated
procedures. Special consideration was given to high-risk procedures such
as endoscopy and tracheotomy.

\textbf{Conclusions}

A small-team based approach with guidelines for faculty/resident roles
may mitigate risk while optimizing patient care and maximizing
education.

\textbf{Introduction}

Even in the best of times, providing excellent resident education
involves many challenges. Ensuring outstanding surgical care while
training residents in surgery, maintaining appropriate balance between
service and education, and designing a graduated experience that allows
a natural transition of trainees from Resident to Faculty are some of
the baseline conundrums faced by all surgical training programs. The
introduction of the global COVID-19 pandemic has disrupted our practices
and added additional dimensions to these challenges.

As Educators, our first step in responding to this pandemic must be to
understand its potential areas of impact on our trainees. Hands-on
surgical exposure for trainees has been dramatically curtailed by a
decreased volume of surgical procedures. On March
23\textsuperscript{rd}, the American Academy of Otolaryngology -- Head
and Neck Surgery officially recommended limiting patient interactions to
``time-sensitive and emergent problems'' and resident surveys
demonstrate that, during the same time frame, nearly all programs
surveyed had enacted policy changes to decrease COVID-19
spread\textsuperscript{1,2}. Additionally, risk of infection
restrictions on personal protective equipment (PPE) can limit operating
room participation to only essential personnel.

The role of the head and neck surgeon and trainees with whom we work,
however, extends beyond the operating room. Much of the risk we face is
presented during inpatient management and consultations. Training and
patient care in this environment presents a different set of challenges.
The ``routine'' examinations and procedures that make up much of the
daily life of a resident now require a careful assessment of risk to
trainees, faculty, and staff. Medicine is a team sport and we also face
the risk of infecting each other. Early results from contact tracing of
infected health care workers at our institution demonstrate that
transmission between health care providers is almost as likely as
transmission from patients\textsuperscript{3}. Many clinics have started
using telehealth for initial ambulatory visits and limiting the people
in the room during clinic assessments to mitigate ambulatory risk, but
in-hospital consultations remain a source of concern.

The COVID-19 pandemic required restructuring of faculty and resident
assignments to protect the safety of healthcare workers and patients
alike. In this paper, we describe the creation and implementation of
guidelines delineating resident and faculty responsibilities in
accordance with safety mandates to reduce the risk (to providers, other
health care workers, and patients) while preserving resident education.

\textbf{Methods}

We describe the conception and implementation of a small-team
``cohorting'' protocol. A literature search was performed to assess and
categorize risk of common procedures performed by Otolaryngology -- Head
and Neck Surgery residents. An iterative process with resident, faculty,
and department leadership input was used to create guidelines for
faculty and resident roles in common clinical scenarios.

\textbf{Results}

\emph{Institutional and regional mandates}

Large faculty gatherings and conferences were not permitted and were
converted to online teleconferences according to university guidelines.
In-person encounters between clinicians and patients were limited to the
minimum necessary. Elective surgery and patient care activities were
curtailed according to state mandate and medical center guidance, with a
resultant significant decrease in clinical and surgical volume for
trainees. Surgical teams were restructured.

\emph{Team cohorting}

In order to limit patient exposure and team risk, we introduced a team
cohort approach: a rotating small-team approach designed for each
clinical site in our residency program as described by other surgical
subspecialties \textsuperscript{4}. Each cohort team is prevented from
physical interaction with the other teams and cover separate days in the
hospital. Faculty-resident partnerships were assigned to limit
interaction between Department members but provide comprehensive
coverage at each clinical site. Residents were assigned to physician
teams and they worked as a unit, being on call the same days and off the
others. Attending teams were sequestered as well. This reduced the
chance of spread of infection throughout the program should one resident
or attending become infected.

\emph{New paradigm for faculty and resident clinical care roles}

Continuing resident involvement in clinical activities is considered a
critical aspect of ongoing resident education. This priority has been
previously described by the head and neck surgery department in
Lombardy, Italy \textsuperscript{5}. The traditional hierarchy of junior
residents performing primary assessment of patients guided by a senior
resident is disrupted for two reasons. First the cohort system requires
more manpower for daily assignments. Second, in order to reduce the
number of at risk exposures, involvement of an experienced clinician is
critical at the earliest phase of clinical interactions. In the new
paradigm, detailed management of urgent otolaryngologic issues could be
discussed as they arose through one-on-one discussion, in small groups,
and in group video conferences, with special attention paid to the
unique impact of the ongoing pandemic on clinical decision-making.
Certain activities once considered routine for a head and neck surgeon,
such as bedside endoscopy or tracheotomy change, now pose potential risk
to the surgeon and trainee. Consideration is given to which patients
require such procedures and who should be present. There were also
opportunities to discuss evolving appropriate use and re-use guidelines
as well as proper donning and doffing of personal protective equipment.

\emph{Risk Stratification}

In order to define the working relationship for these small group
partnerships, common otolaryngologic procedures were identified and
risk-stratified based on existing evidence. Faculty and resident patient
care roles were assigned based upon patient status, clinical care
requirements, and mitigation of provider risk. Patients were categorized
into three groups based on risk: COVID-positive patients, patients under
investigation (PUI), and non-COVID/non-PUI. For this third category
which may include asymptomatic carriers, a shared model of
faculty/resident care was devised based upon provider experience and
procedure risk.

Drawing from available evidence for the SARS-CoV-2 virus and related
viral infections including SARS-CoV and
MERS-CoV,\textsuperscript{6--10}clinical patient encounters and
procedures were divided into low risk and high risk categories. Special
consideration was given to procedures with high potential for viral
transmission by aerosol generation: endoscopy (nasal and laryngoscopy)
and tracheotomy (Table 1). Levels of faculty and resident involvement
were defined as faculty only direct patient care, direct supervision,
and consultation followed by indirect supervision (Figure 1).

\textbf{Discussion}

The field of Otolaryngology -- Head and Neck Surgery has an intimate
relationship with the primary anatomic regions associated with high
viral load in the upper aerodigestive tract. With this realization comes
a critical responsibility to ensure that we are not placing our trainees
at risk in the name of education or as part of ``business as usual.''
Early publications and social media interactions have highlighted the
concerns for COVID-19 transmission in our field\textsuperscript{11--16}.
A full understanding of our roles as physicians, however, lays bare the
fact that we cannot avoid risk.

Residents are routinely the front-line provider of care for inpatients
and emergency department consultations. The new infectious risk
associated with each clinical interaction threatens resident wellbeing
-- both physical and mental\textsuperscript{17,18}. As a group, faculty
are older and carry more comorbidities than residents, placing them at
significantly higher risk if infected with the novel coronavirus.
Faculty also carry the ultimate responsibility for both patient care and
resident training and well-being; faculty are financially compensated
for these responsibilities. Ultimately we are all physicians who have
accepted the responsibility to care for our patients. We must also
accept the responsibility to care for each other.

Treating patients during a pandemic setting has resulted in a
significant reduction of existing resident learning opportunities such
as in-person conferences, surgical volume and assessment of patients in
clinic and on the floor. The cohorting system was implemented to
diminish risk of spreading infection within our department, but also
created an intimate team atmosphere with enhanced opportunity for
individualized teaching. Each clinical encounter now results in a
careful assessment of risk and determination of the appropriate extent
of evaluation prior to performing an examination. During daily team
discussions, a focus on the determinants of the optimal extent of
evaluation for each patient provides an ideal opportunity for in-depth
discussion of symptoms, pathology, diagnostic tests and treatment
options.

While we are focused on trainee safety, we also recognize that
restricting junior residents from traditional clinical activities may
restrict their ascension to the next training level. The traditional
approach to clinical training has the least experienced trainee
performing the initial evaluation of a patient and reporting those
findings to more senior team members who subsequently repeat the
critical portions of the exam. Clearly, this repeated exposure is
inappropriate for patients with known COVID disease\textsuperscript{19}.
Further, the significant rate of asymptomatic carriers of disease and
limitations with availability and sensitivity of testing require changes
to this protocol for all patient encounters. Development of guidelines
which account for risks presented by both patients and clinical
scenarios facilitates team care by identifying optimal care providers
for each scenario.

The guidelines presented here are neither comprehensive nor universally
applicable, but represent our experience at a major academic center at a
time when viral testing and treatment are limited. There certainly will
be specific patient scenarios in which clinical judgement demands
deviation from guidelines. One example is a true airway emergency in
which delay for the sake of guideline compliance could result in
disastrous patient care consequences. The potential risk of evaluations
as simple as oral cavity examination merits discussion with a faculty
member prior to clinical interaction. In some scenarios, however,
faculty approval may be implied or carried forward. With an inpatient
following oral cavity resection and reconstruction, for example, daily
examinations by the rounding team would be expected. The specifics of
these guidelines are likely not appropriate for all programs. Variations
in geography, practice settings, and most importantly endemic rates of
COVID infection will dictate ideal guideline details for individual
sites. Adapting and adopting guidelines for management of these common
patient interactions, however, provides an opportunity to mitigate risk
to the healthcare team without compromising the quality of patient care.

Our categorization of procedural risk was based on an estimation of the
likelihood of aerosol generation and resultant short-distance airborne
transmission of infectious viral particles during each procedure in
question. While epidemiologic and experimental data is limited, studies
from the 2002-2003 SARS outbreak support that there was a significant
increased risk of transmission of infection to health care workers
performing or involved in aerosol-generating procedures
(AGPs)\textsuperscript{6,10}. In particular, 2014 WHO guidelines note
consistent evidence for increased risk with tracheal intubation,
tracheotomy, non-invasive ventilation, and manual ventilation before
intubation as AGPs based on work including a systematic review published
in 2012 of ten low-quality studies from the SARS
epidemic\textsuperscript{6,7}. The data also support that there is a
hierarchy of risk among aerosol-generating procedures included in these
studies, which is reflected in our categorization\textsuperscript{6}.
Significantly, the viral load of SARS-CoV-2 is known to be very high in
both the upper and lower respiratory tract in an infected patient, with
somewhat higher viral loads in the nose than in the
oropharynx\textsuperscript{20--22}. We supplemented the conclusions of
the above studies with additional cohort studies, case reports, expert
opinion, and practical judgment in categorizing procedures for which
either little to no data currently exists (e.g. nasal endoscopy,
laryngoscopy, skull base surgery, control of epistaxis, and drainage of
peritonsillar abscess)\textsuperscript{7,10,12,23}.

Tracheotomy and endoscopic examinations are among those specifically
called out as high risk procedures in our protocol. In the case of
tracheotomy, there is consistent evidence for increased risk of viral
transmission from the SARS epidemic\textsuperscript{7}, presumably due
to likelihood of aerosolization of a high concentration of virus for a
prolonged period. Whenever possible, this procedure should be performed
by the minimum number of experienced providers to complete the procedure
expeditiously. Endoscopy, while frequently thought of as simply an
extension of the Otolaryngologist's physical exam, carries significant
risk for the clinician as well as staff and technicians who support the
exam and process instrumentation. In our protocol, early faculty
involvement is vital in evaluating the initial request or indication for
the procedure, as they are in a position to efficiently and effectively
decline this procedure in favor of alternative diagnostic evaluations
whenever appropriate. In emergent or urgent scenarios where endoscopy is
required, having faculty perform or directly supervise the exam ensures
efficient and comprehensive evaluation in a single setting.

We have found that a small-team cohorting model with established
guidelines delineating clinical roles and responsibilities can serve to
strengthen the bond between faculty and residents. Strengthening this
bond may be the most critical component of the COVID-19 response in
residency training. Both faculty and residents are at risk; our early
institutional data demonstrates a similar number of faculty and resident
infections\textsuperscript{3}. Recent resident surveys suggest that the
amount of risk perceived by a resident correlates with the trust they
have in their Department administration\textsuperscript{1}. Faculty
should be involved at the earliest stages of patient care including
initial consultation. We are uniquely positioned to decline
non-critical, aerosol-generating scope exams and identify streamlined
evaluations to limit clinician exposure while maintaining patient care.
When faculty join residents on the frontlines of patient care we model
the physicianship central to managing a crisis, diminish risk to health
care providers, and empower residents to remain engaged in meaningful
patient care.

\textbf{Conclusions}

The COVID-19 pandemic has inexorably altered patient care for the
Otolaryngologist -- Head and Neck Surgeon. As we remain hopeful for a
return to normalcy in residency training, adopting a small-team based
approach and guidelines for patient exams and interactions has the
potential to mitigate risk while preserving patient care and maximizing
education.

\textbf{References}

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