key: cord-283900-4pa93xqi
authors: Khan, M. Ali; Sivalingam, Arunan; Haller, Julia A.
title: Perceptions of Occupational Risk and Changes in Clinical Practice of U.S. Vitreoretinal Surgery Fellows during the COVID-19 Pandemic
date: 2020-05-22
journal: Ophthalmology. Retina
DOI: 10.1016/j.oret.2020.05.011
sha: 
doc_id: 283900
cord_uid: 4pa93xqi

Abstract Purpose To assess perceptions of occupational risk and changes to clinical practice of ophthalmology trainees in the United States during the COVID-19 pandemic. Design An anonymous, non-validated, cross-sectional survey was conducted online. Data was collected from April 7-16, 2020. Participants 2019-2020 second year U.S. vitreoretinal surgery fellows in two-year vitreoretinal surgery training programs were invited to participate. Intervention Online survey. Main outcome measures Survey questions assessed policies guiding COVID-19 response, known or suspected exposure to SARS-CoV-2, changes in clinical duties and volume, and methods to reduce occupational risk including availability of personal protective equipment. Results Completed responses were obtained from 62 of 87 eligible recipients (71.2% response rate). Training settings included academic (58.1%), hybrid academic/private practice (35.5%), and private practice only settings (6.5%). Overall, 19.4% of respondents reported an exposure to a COVID-19 positive patient, 14.5% reported self-quarantining due to possible exposure, and 11.3% reported being tested for COVID-19. In regards to PPE, N95 masks were available in the emergency room (n=40, 64.5%), office (n=35, 56.5%), and operating room settings (n=35, 56.5%). Perceived comfort level with PPE recommendations was significantly associated with availability of an N95 respirator mask in the clinic (p<0.001), emergency room (p<0.001) or operating room (p=0.002) settings. Additional risk mitigation methods outside of PPE were: reduction in patient volume (n=62, 100%), limiting patient companions (n=59, 95.2%), use of a screening process (n=59, 95.2%), use of a slit lamp face shield (n=57, 91.9%), temperature screening of all persons entering clinical space (n=34, 54.84%), and placement of face mask on patients (n=33, 53.2%). Overall, 16.1% reported additional clinical duties within the scope of ophthalmology, and 3.2% reported being re-deployed to non-ophthalmology services. 98.4% of respondents expected a reduction in surgical case volume. No respondents reported loss of employment or reduction in pay or benefits due to COVID-19. Conclusion and Relevance: Suspected or confirmed clinical exposure to COVID-19 positive patients occurred in approximately one-fifth of trainee respondents. Perceived comfort level with PPE standards was significantly associated with N95 respirator mask availability. As surgical training programs grapple with the COVID-19 pandemic, analysis of trainees’ concerns may inform development of mitigation strategies.

patients (n=33, 53.2%). Overall, 16 .1% reported additional clinical duties within the scope of 52 ophthalmology, and 3.2% reported being re-deployed to non-ophthalmology services. 98.4% of 53 respondents expected a reduction in surgical case volume. No respondents reported loss of 54 employment or reduction in pay or benefits due to . In all, 87 eligible fellows from 62 training programs were identified and received the 105 survey via email. Survey questions assessed training program environment, policies guiding 106 COVID-19 response, changes in fellow duties and clinical volume, and methods to reduce 107 occupational risk including availability of PPE. The survey was open from April 7 to April, 16, 108 2020. Eligible recipients received an invitation email followed by 2 reminder emails. 109

Participation was voluntary and no compensation was offered.

Data was exported to Microsoft Excel and descriptive characteristics were obtained. With 111 a population size of 87, a sample size of 61 would be required to achieve a 95% confidence 112 interval at a 7% margin of error. A Fisher's exact test was used to determine, when applicable, 113 associations between two categorical variables, with a p value of <0.05 deemed statistically 114 significant. 115

Completed responses were obtained from 62 of 87 eligible recipients (71.2% response 118 rate) from April 7-16, 2020 ( Figure 1 ). Two fellows chose to opt-out of the survey, and the 119 remaining 23 eligible fellows were non-responders. 120 58.1% (n=36) reported training at an academic center, 35.5% (n=22) in a hybrid 121 academic/private practice setting, and 6.5% (n=4) in a private practice setting. Overall, 50% 122 reported that re-deployment is possible in coming weeks. Ten respondents (16.1%) reported reassignment to duties within the scope of ophthalmology, including staffing of a non-retina 140 related urgent care clinic, staffing of general ophthalmology clinics, participation in tele-141 medicine visits, and being granted full attending privileges in the field of retina. 142

Respondents who trained in a metro area considered high risk for COVID-19 were not 143 more likely to be re-deployed (p=0.23) than those who did not. Respondents who trained in a 144 metro area considered high risk for COVID-19 were more likely to be assigned additional duties 145 within the scope of ophthalmology compared to those who did not, but this difference was not 146 statistically significant (p=0.08). 147

Availability and use of PPE: 148 58 respondents (95.1%) reported they are required to wear, at minimum, a surgical mask 149 for all patient contact. In regards to N95 respirator masks, 35 (56.5%) respondents reported their 150 availability in the office setting, 40 (64.5%) in the emergency room setting, and 35 (56.5%) in 151 the operating room setting. 47 respondents (75.8%) reported their institution has a policy of 152 sterilizing N95 respirator masks for reuse. Of surveyed PPE items -including N95 respirator 153 masks, surgical masks, eye protection, gloves, and gowns -the least available PPE item in the 154 emergency room or operating room setting was an N95 respirator mask (n=35, 56.5% available). 155

In the clinic setting, the least available PPE item was a gown (n=15, 24.2% available). 156 57 respondents (91.9%) stated that they believed current PPE recommendations at their 157 training institution were influenced by current or anticipated PPE shortages. 56.5% (n=35) of 158 respondents expressed being comfortable with the PPE recommendations at their institution 159 (n=28, 45.2% somewhat comfortable and n= 7, 11.3% extremely comfortable). 16 

significantly associated with availability of N95 masks in the clinic (p<0.001), emergency room 164 (p<0.001), and operating room setting (p=0.002). 165

A total of 7 respondents (11.3%) reported they had no access to an N95 respirator mask. 166

Of these 7, two trained at an academic institution, two trained in a private practice setting, and 167 three trained at a hybrid academic/private practice program. 168

Reported occupational risk is depicted in Figure 2 . 19.4% of respondents (n=12) reported 170 a clinical exposure to a COVID-19 positive patient, 14.5% (n=9) reported self-quarantining due 171 to possible exposure, and 11.3% (n=7) reported being tested for COVID-19. Fellows who train in 172 metro areas considered high risk for COVID-19 were not more likely to be exposed to (p=0.11), 173 tested for (p>0.99), or self-quarantined (p>0.99) due to COVID-19. Fellows who train in 174 academic institutions were not more likely to be exposed to (p=0.11), tested for (p=0.39), or self-175 quarantined (p=0.46) due to COVID-19 than who did not. 176

Risk mitigation strategies utilized at fellow respondent work places are depicted in Figure  177 3. Risk mitigation strategies included: reduction in patient volume/scheduling (n=62, 100%), expected volume reduction by 30%, 18 (29.0%) expected volume reduction by 20%, and 7 (11.3%) expected a volume reduction by 10% or less. One respondent (1.6%) expected an 208 increase in total surgical case volume. 209

A majority of respondents (n=35, 56.5%) reported concern about the effect of COVID-19 210 on their surgical training. 14.5% of respondents (n= 9) were extremely concerned and 41.9% 211 (n=26) were somewhat concerned. 24.2% (n=15) reported having no concerns regarding the 212 effect of COVID-19. 213

No respondents reported reduction in pay or benefits, or being unemployed or furloughed 214 due to COVID-19. A total of 59 respondents (95.2%) stated they had accepted a position of 215 employment to start after completion of fellowship training. Of these, 3.4% (n=2) reported their 216 employment contract was revoked (n=1) or start date delayed (n=1) due to COVID-19. 217

Health care professionals are at increased risk during the COVID-19 pandemic. 16 Access to N95 respirator masks, in particular, has been a flashpoint for risk perception. 243

Many institutions are following current CDC guidelines that do not call for routine use of N95 244 respirator masks for lower risk interactions, instead reserving them to protect workers in higher 245 risk settings. In this study, the lone factor significantly associated with perceived comfort level 246

with PPE recommendations during the study period was the availability of an N95 respirator 247 mask, and further found that 91.9% of respondents stating they believe their institutional PPE 248 recommendations were influenced by PPE shortages. 11.3% reported they had no access to an 249 practice. Two respondents (3.2%) reported being re-deployed to non-ophthalmology services 280 with an additional 19 (30.6%) reporting that this may be imminently possible. Moreover, 16.1% 281 of respondents reported that they have been tasked with additional duties within the scope of 282 ophthalmology, including being granted higher level clinical privileges. The ACGME, in 283 addition, has conveyed that furloughs of trainees are "unacceptable." 22 No respondents reported 284 reduction in pay or benefits, or being unemployed or furloughed due to COVID-19.

The clinical education of trainees in the face of reduced clinical care volume, particularly 286 as the need to limit care to emergent or urgent indications continues, is deserving of special 287 attention and effort. All but one respondent (n=61, 98.4%) in this study expected a reduction in 288 surgical case volume due to COVID-19, with 45.2% (n=28) expecting a reduction by 50% or This study has several limitations. While the survey achieved a 71.2% response rate, non-297 response bias may be present. To limit this effect and improve response rates we utilized email 298 addresses that were recently listed as the primary contact address on fellowship application files 299 and no 'bounce-back' emails were generated from the survey software. Grouping of question 300 topics was utilized to avoid order bias. Allowing anonymity and avoiding organizational (e.g. 301 ASRS, AUPO) sponsorship were utilized to reduce any response bias. All results are self-302 reported, so validity of exposure perceptions, institutional policies, and other variables cannot be 303 ascertained. This survey assessed perceptions of occupational risk, and true risk cannot be 304 inferred by these responses. Risk tolerance and comfort levels regarding institutional policies 305 may differ from physician to physician and thus influence the perceptions described herein. 306

Discussion of data regarding differential reduction of SARS-CoV-2 or other coronavirus 307 transmission with surgical or N95 respirator masks is outside the scope of this study assessing ophthalmology trainee perceptions of occupational risk. Although PPE availability was assessed, 309 more specific technical questions regarding precise PPE details (such as results of fit testing, size 310 of eye protection, use of a surgical versus standard N95 respirator masks, PPE manufacturer, 311 etc.) were not asked. Vitreoretinal surgery fellows were selected for survey as their specialty 312 often requires urgent and emergent care, and their experience, exposure rates, and perceptions 313 may not be applicable to vitreoretinal surgery attendings or residents or fellows of different 314 subspecialties. Conversely, since vitreoretinal fellows may be more clinically active during 315 COVID-19, they may be less likely to be re-deployed to non-ophthalmology settings that could 316 influence their overall exposure risk. Lastly, as the COVID-19 pandemic continues to press on, 317 respondent sentiments should be taken in context of the study period evaluated as risk 318

perceptions and national, local, and institutional policies will continue to evolve, particularly as 319 guidance to re-open surgical facilities for elective and semi-elective surgery in May, 2020 are 320

In conclusion, COVID-19 has, in a period of months, resulted in unprecedented stresses 322 on the US healthcare system and healthcare workers, including trainees. This study reports 323 occupational risk perceptions, currently utilized risk mitigation strategies, and surgical volume 324 training concerns for second year US vitreoretinal surgery fellows mid-pandemic escalation. 325

Elucidating the concerns of ophthalmic surgical trainees, both physical and psychological, can 326 guide mitigation strategies aimed not only to alleviate concerns and enhance work force health, 327 but also optimize this key period of training, despite its challenges. 328 329

Approximately one-fifth of U.S. vitreoretinal surgery fellows had suspected or confirmed clinical exposure to COVID-19 positive patients. Risk mitigation and support strategies were varied and were guided by a combination of institutional and national recommendations.

A survey was sent to current, 2019-2020 senior U.S. Vitreoretinal Surgery Fellows to assess perceptions of occupational risk during COVID-19 and was open from April 7-16, 2020. A total of 62 of 87 eligible fellows responded (71.3% response rate). Distribution of survey responses over the course of survey duration is presented above. Respondents were asked if they had known clinical exposure to a COVID-19 positive patient, if they self-quarantined due to possible exposure, and if they had been tested for COVID-19 (serologic or viral polymerase chain reaction methods). Results of these indicators of occupational risk are depicted above. A survey was sent to current, 2019-2020 senior U.S. Vitreoretinal Surgery Fellows to assess perceptions of occupational risk during COVID-19.

Respondents were asked what strategies are being utilized to reduce their occupational risk. Common risk mitigation strategies not related to use of personal protective equipment are summarized above.

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