key: cord-0886476-y3cro0q3
authors: El Tahan, Mohamed R.; Wilkinson, Kirstin; Huber, Jonathan; Schreiber, Jan-Uwe; Forner, Anna-Flo; Diprose, Paul; Guarracino, Fabio; Erdoes, Gabor
title: Challenges in the Cardiothoracic and Vascular Anesthesia Fellowship Program since the COVID-19 pandemic: An electronic survey on potential solutions
date: 2021-08-10
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2021.08.008
sha: 8cef5a45266ebc341e217f8a904029b5aa92f27d
doc_id: 886476
cord_uid: y3cro0q3

OBJECTIVE: We explored the current practice of fellowship training in cardiothoracic and vascular anesthesia and surveyed the acceptability of potential solutions to mitigate the interrupted fellowship training during the severe acute respiratory syndrome coronavirus disease (COVID-19) pandemic. DESIGN: A prospective electronic questionnaire-based survey. SETTING: The survey was initiated by the Education Committee of the European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC) PARTICIPANTS: EACTAIC fellows, EACTAIC and non-EACTAIC subscribers to the EACTAIC newsletter and EACTAIC followers on different social media platforms. INTERVENTIONS: After obtaining the consent of participants, we assessed the peri-operative management of COVID-19 patients, infrastructural aspects of the workplace, local routines for preoperative testing, the perceived availability of personal protective equipment (PPE) and the impact of COVID-19 on fellowship training. In addition participants rated suggested solutions by the investigators to cope with the interruption of fellowship training using a traffic light signal scale. MEASUREMENTS AND MAIN RESULTS: We collected 193 responses from 54 countries. 82.4% of respondents reported cancelling or postponing elective cases during the first wave. Of the respondents, 89.7% had provided care for COVID-19 patients, 75.1% reported staff in their center being reassigned to work in the Intensive Care Unit (ICU), and 45% perceived a shortage of PPE at their centers. Most respondents reported the termination of local educational activities (79.6%) and fellowship assessments (51.5%) because of the pandemic (although 84% of them reported having time to participate in online teaching), and 83% reported a definitive psychological impact. More than 90% of the respondents chose green and/or yellow traffic lights to rate the importance of the suggested solutions to cope with the interrupted fellowship training during the pandemic. CONCLUSIONS: The COVID-19 pandemic led to the cancellation of elective cases, deployment of anesthesiologists to intensive care units, involvement of anesthesiologists in perioperative care for COVID-19 patients, and interruption of educational activities and trainees’ assessments. There is some consensus on suggested solutions for mitigation of the interruption in fellowship training.

Since 2020, the world has been subject to the effects of the global pandemic secondary to COVID-19, with multiple waves affecting different countries at different times. 1 We have previously reportedsimilarly to others -that some of the CTVA fellows were required to take over the direct care of COVID-19 patients in the Intensive Care Unit (ICU) while their original duties caring for patients undergoing cardiothoracic and vascular surgeries and interventions could not be completed as per the requirements of the EACTAIC CTVA Fellowship Curriculum. 3, 4 We also reported that during the first wave of the COVID-19 pandemic, EACTAIC fellowship program directors stated that training of their fellows was interrupted in 55.6% of the hosting centers. 3 Consequently, a significant proportion of fellows were unable to meet the required basic and advanced rotations in cardiothoracic and vascular anesthesia. The Accreditation Council for Graduate Medical Education (ACGME) has divided the response to the COVID-19 pandemic into three levels of management of fellowship programs. Level 1 occurs when the health system's response to the pandemic does not overstretch the continuity of the fellowship program activities. Level 2 would result in a slight to moderate interruption of fellowship activities so that significant adjustments would have to be made to the fellowship operations to meet the pandemic requirements at this intermediate intensity level. At level 3, the response to the pandemic overtaxes the contingency planning and reserves of the fellowship program with a moderate to severe interruption of the everyday activities of the community, leading to the suspension of the program. 4 The negative impact of the pandemic on the continuity of the formal training of the fellowships is likely to be prolonged in the case of subsequent waves.

The purpose of this survey was to examine the impact of the pandemic on the EACTAIC CTVA fellowship program and to explore local changes and adjustments in the CTVA fellowship program to overcome the limitations and necessary structural changes. The present survey results will help EACTAIC trainers develop consensus-based recommendations for decision-making. We believe that the some of the proposed mitigating measures could help to take the pressure off both fellows and host centers concerned about meeting fellowship requirements.

We performed an internet-based, global survey regarding the CTVA fellowship program after the measures, and the number of cardiac, thoracic, and vascular procedures performed before and after the COVID-19 pandemic. Furthermore, the questionnaire included a screening of the acceptability to respondents of potential solutions proposed to cope with the interrupted fellowship program during the COVID-19 pandemic. These solutions had been theoretically proposed previously. 3 This survey used a traffic light system (green-yellow-red) for respondents to evaluate whether these proposed solutions should be considered in the final recommendations. These could then potentially be approved by the EACTAIC Education Committee and Board of Directors after a subsequent quantitative survey. The traffic light system was defined as; "green" is highly recommended, "yellow" may be recommended, and "red" is not recommended. The respondents were asked to choose only one traffic light symbol for each suggested solution. Successful solutions will require at least 2/3 rd green and/or yellow rating to be considered as a consensus opinion for the EACTAIC Education

Committee. Addressees received written information about the aims and objectives of the survey, data handling and management, and privacy rights.

All participants provided consent for participation and data analysis. Participation in this study was voluntary and anonymous. The survey was uploaded to the Survey Monkey ® platform, and the survey link was distributed to all CTVA fellows from the EACTAIC fellow database and other subscribers to the EACTA newsletter and social media platforms. Reminders were sent until the end of the collection period. All data collected was anonymized, secured and will remain confidential in the EACTAIC archiving system for five years following the general data protection regulations (accessible at https://eugdpr.org/).

Data management and descriptive statistics (number, percentages, median and interquartile range) 

The initial survey period was set from December 9, 2020, to February The use of a powered air-purifying respirator (PAPR) and plastic apron was reported by only 1.6% of respondents ( Figure 2 ). Perceived shortages of personal protection equipment (PPE) were reported by 45.4% of respondents, including FFP2 or FFP3 respirators (33.3%), surgical masks (15.9%), N95 masks (12.7%), protective suits (11.1%), gowns or aprons (9.6%), hair cover (6.3%), goggles (1.6%), face shield (6.3%), shoe cover (6.3%), gloves (4.8%), or hood (1.6%) ( Table 2 ). The perceived shortage of PPE was reported by 11.1% of respondents as occurring at the beginning of the pandemic ( Table 2 ). Availability of negative-pressure operating theaters was reported by 51.9% respondents ( Table 2) . Preoperative routine COVID-19 testing was utilized in the centers of 97.2% of respondents. Testing was reportedly considered in all cases by centers from 89.7% respondents, compared with only in elective cases by centers from 9.6% respondents ( It has been recognized in other specialties that the COVID-19 pandemic has negatively impacted on operative volumes experienced by training-grade doctors in general surgery. 5, 6 The adverse effects on clinical training following on from the cancellation or curtailment of usual clinical services has been recognized in other sub-specialty areas including neuroanesthesia, cardiology, radiology and plastic surgery. [7] [8] [9] [10] [11] The results from this survey are in line with these findings in that the COVID-19 pandemic has negatively impacted on the case load available for the EACTAIC CTVA fellows in training.

Furthermore, this survey has also demonstrated that teaching and training opportunities have been reduced, as were opportunities for training evaluation. This is consistent with a study of residents and fellows in a nationwide study in Saudi Arabia in 2020 which showed 84.6% of respondents reported a reduction in training activities. 12 The significant impact of the pandemic on sub-specialty fellowship training has also been reported from the United States of America. 13, 14 Whilst it is positive that preoperative COVID-19 testing of patients was reported by the majority of respondents, worryingly, 45% of respondents perceived a shortage of PPE in their centers. Moreover, this survey also highlights the presence of the adverse psychological impact of COVID-19 on the survey respondents. These results are consistent with previously published studies regarding the adverse mental health and well-being effects of the pandemic upon both surgical and non-surgical residents within a large hospital, and, upon radiology trainees. 9, 15 Despite these challenges, most respondents in the current survey found some time to participate in educational activities, either regularly or intermittently.

The current EACTAIC curriculum for CTVA fellows is based on a pre-definitions of training duration, case numbers and competencies levels. This survey supports the notion that the COVID-19 pandemic has limited the ability of EACTAIC fellows to successfully meet these training requirements.

An important focus for this study was to attempt to understand the perceived value of some proposed solutions that might be employed by the EACTAIC Education Committee in due course. The respondents of this survey positively rated a number of proposed solutions to mitigate the negative effects of COVID-19 on training. Strategies such as moving towards a competency-based curriculum,

waiving the requirement to complete TEE certification until the next possible date, recognizing the time in ICU during the COVID-19 pandemic towards ICU training time, or extending training periods to allow fellows to fulfill training requirements, were either recommended or highly recommended by respondents using the traffic light system. These aspects require consideration by the EACTAIC Education Committee and Board of Directors. Indeed, in recent times in many European countries, there has been a move towards a competency-based curriculum, 16 and therefore these solutions may have particular merit.

Within the United States of America, the ACGME has highlighted that the "…visits/case logs of a program"s graduates who were on duty during this pandemic… will be judiciously evaluated in light of the impact of the pandemic on that program." 17 Further, the National Board of Echocardiography have temporarily given trainees more time to fulfill logbook requirements considering interruptions that occurred to training during the pandemic. 18 These measures mirror some of those most highly recommended within this current survey.

There are a number of limitations to this survey. Firstly, the actual response rate is difficult to assess given the multiple platforms and modalities used to generate invitations to the survey. In this respect only a low percentage of respondents from North America were completed the survey -probably because of its marketing mainly through the subscribers of EACTAIC newsletter and related social media platforms. Data are presented as number (percentage). The low number of COVID-19 patients in the country 3 (11.5%)

The availability of routine preoperative PCR-testing and number of intensive care beds 2 (7.7%)

Administrative decision due to having a dedicated COVID-19 pathway in an isolated building 3 (11.5%)

The hospital has no COVID-19 infected patients 2 (7.7%)

The hospital is a reference high-volume center for cardiac and cancer patients 2 (7.7%)

Cardiac surgery was classified as an "urgent surgery 1 (3.9%)

The proportion of patients with "suspected" or "diagnosed" COVID-19 presenting in your center 

Most respondents to this survey reported a termination of local educational activity during the Covid-19 pandemic Most respondents to this survey reported an adverse psychological impact of the Covid-19 pandemic. Potential solutions for mitigating the effects of interruptions to fellowship training have been proposed and rated by respondents. These data will assist the EACTAIC Educational Committee to come to informed decisions on the mitigation of the impact of future pandemics.

WHO Coronavirus disease (COVID-19)

Multiwave pandemic dynamics explained: how to tame the next wave of infectious diseases

Interruption of the European Association of Cardiothoracic Anaesthesiology (EACTA) Fellowship Program During the Coronavirus Disease

Pandemic: Consequences and Solutions

The Fellowship Experience in Adult Cardiothoracic Anesthesiology-Strategies for Applicants and Fellows to Navigate the Coronavirus Crisis

Paradox of resident case numbers. Is there a number that qualifies competence? JAMA Surg

Factors associated with general surgery residents" operative experience during the COVID-19 Pandemic

The Impact of the Global SARS-CoV-2 (COVID-19) Pandemic on Neuroanesthesiology Fellowship Programs Worldwide and the Potential Future Role for ICPNT Accreditation

The Impact of the COVID-19 Pandemic on Cardiovascular Fellows-in-Training: A National Survey

Impact of COVID-19 Pandemic on Training and Well-Being in Radiology Residency: A National Survey of Diagnostic Radiology Trainees in Saudi Arabia

A Snapshot of Radiology Training During the Early COVID-19 Pandemic

Impact of the COVID-19 Pandemic on the Education of Plastic Surgery Trainees in the United States

Impact of COVID-19 pandemic on residency and fellowship training programs in Saudi Arabia: A nationwide cross-sectional study

The impact of the COVID-19 pandemic on fellowship training: A national survey of pediatric otolaryngology fellowship directors

Effects of COVID-19 on Facial Plastic and Reconstructive Surgery Fellowship Training and Director Practices

The impact of COVID-19 pandemic on training and mental health of residents: a cross-sectional study

Variations in assessment and certification in postgraduate anaesthesia training: a European survey

Accreditation Council for Graduate Medical Education

Covid-19 Temporary Extended Certification Pathways

We appreciate the assistance provided by Ms. Noemi Albanese, EACTAICThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

The precise demographics of all respondents are unknown due to the wide-ranging nature of the survey. There were multiple platforms used to approach potential participants meaning that it was not possible to identify the precise response rate.

Identification of differences in the experience of pandemic conditions between trainees/fellows and trainers. Bench-testing of some of the proposed mitigation solutions in real-world conditions.Identification of the impact of future pandemic waves and the impact of vaccination roll-out on the fellowship program.EACTAIC -European Association of Cardiothoracic Anaesthesiology and Intensive Care