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 field11–16. 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 mental17,18. 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 disease19. 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)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 epidemic6,7. The data also support that there is a hierarchy of risk among aerosol-generating procedures included in these studies, which is reflected in our categorization6. 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 oropharynx20–22. 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)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 epidemic7, 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 infections3. Recent resident surveys suggest that the amount of risk perceived by a resident correlates with the trust they have in their Department administration1. 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.