Providing safe, high-quality patient care with optimization of resident education and wellness remains the mission of our program, regardless of a pandemic. Accomplishing this task in the setting of the Centers for Disease Control and Prevention’s (CDC) recommendations for social distancing and a two-week self-quarantine10, however, required restructuring for risk mitigation as well as the implementation of protocols to ensure the safety of physicians and patients alike. While similar residency programs adapted a 2-team system4,5, it was felt that a 3-team strategy provided an option that led to even less exposure risk for residents and faculty. This system gave all members a 14-day period away from patient care for symptom surveillance which is beyond the estimated range for symptom presentation11. Countries affected early by COVID-19 demonstrated a nearly 20% infection rate in healthcare workers12. Since widespread testing remains in short supply, the safest way to ensure a healthy workforce is an appropriate quarantine period. Therefore, three physically separate teams composed of faculty and residents were formed to function as independent pods with all levels of training present. To accomplish the mission, these teams would rotate weekly between three different roles: Inpatient-Team, Back-up Team, and Quarantine-Team (Fig. 1).
The Inpatient-Team was tasked with managing all acute inpatient care. We continued our night float call system with one junior resident covering all overnight consults. To ensure the safety of both the Inpatient-Team and patients, residency leadership seamlessly implemented a virtual checkout which occurs each morning in accordance with Accreditation Council for Graduate Medical Education (ACGME) standards13. Virtual checkout utilized a Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant platform (Microsoft Teams, Microsoft, Redmond, WA) to share radiographs, advanced imaging, and relevant clinical photographs with members of the care team to include Attending orthopaedic trauma faculty, subspecialty faculty members, trainees of all levels, advanced practice providers, and nurse leaders. In addition to the clinical utility of a virtual checkout, the process allowed us to continue to provide consistent feedback and resident education, while adhering to physical distancing rules. Including the operating room orthopaedic nurse manager allowed this to further serve as the daily TeamSTEPPS14 huddle with review of case priority, special concerns, surgical plan, equipment needs, and case duration. Inclusion of subspecialty faculty members in virtual checkout allowed efficient triage and transfer of care for isolated injuries to Ambulatory Surgery Centers (ASCs) thereby limiting the impact on our tertiary/quaternary center. Further, technology was leveraged to conduct virtual Emergency Department (ED) consults to limit exposure to residents performing consults on straightforward musculoskeletal injuries. In addition, program leaders worked directly with the ED to streamline the process for direct admission of certain operative injuries like hip fractures.
While system leadership launched several initiatives to prevent shortages of personal protective equipment (PPE) like respirators and gowns, face shields for orthopaedic procedures were difficult to obtain and maintain. These are of particular importance in orthopaedic surgery due to the splash and aerosol created by common musculoskeletal techniques and tools11. Additionally, this was a major concern for our junior residents managing consults in the ED and trauma bay. To fill this gap, program leadership partnered with engineers from Hendrick Motorsports (one of the top NASCAR racing teams) to repurpose 3D printers and laser cutters to create high-quality, improvised PPE in the form of face shields15. Approval for the use of these shields was obtained through the appropriate channels to ensure safety and consistency. Within days, prototypes were given to the operative room (OR) team and residents working in the ED; thereafter, shields were available to all orthopaedic staff and offered to other surgical services. Open communication and rapid response helped to not only provide safety to our teams, but also keep the focus on patient care. An anonymous survey (Supplementary File 1) revealed that 100% of residents felt that these strategies gave them the tools necessary to ensure their safety while delivering high quality patient care; moreover, 94% felt that it demonstrated program leadership’s care for their safety and well-being.
While the Inpatient-Team managed all acute inpatient care for the orthopaedic service, the Back-up Team served as a ready force to replace infected team members if necessary. In addition, the Back-up Team ran the virtual clinic. The current COVID-19 pandemic has served as a catalyst for integration of telemedicine for outpatient virtual clinics, and telemedicine will likely be incorporated into more practices in the future16. This 3-team system not only ensured education on telemedicine logistics, but limited exposure and risk for practitioners, staff, patients and their families while still providing quality care. While the Quarantine-Team remained out of patient contact, they took the lead on virtual education and wellness initiatives. Taken together, after spending one week as the Inpatient-Team delivering high-quality patient care, residents and faculty alike spent a total of two weeks outside of the hospital to focus on education, research, wellness, and virtual clinic.
Overall, 76% of residents surveyed felt that the forced adaptions brought on by the Covid-19 pandemic including cancellation of elective surgery and subspecialty rotations due to the COVID-19 pandemic did not negatively impact their training or preparedness for their career. While most felt it did not negatively impact their career, 53% of surveyed residents did feel that they missed important subspecialty exposure. Interestingly, of PGY4’s surveyed, 75% felt that they missed important subspecialty exposure and 50% felt that the COVID-19 pandemic did negatively impact their training, indicating that those in the midst of deciding upon career and fellowship opportunities felt more negatively affected than junior residents or those already matched into fellowship.