Editors’ Note: This article was accepted on March 11, 2020, and was accurate at that time. Because information about SARS-CoV-2 and COVID-19 is evolving rapidly, please verify these recommendations and information.
As chief residents, we are proud to lead a group of residents who provide around-the-clock staffing for three busy hospitals. Additionally, our residents travel internationally to provide medical care, travel to conferences to disseminate their scholarly work, and raise families. The recent spread of SARS-CoV-2, the novel coronavirus that causes COVID-19, has raised a series of challenges over the last few days and weeks that have caused us to consider how we might prepare as a residency for this and other pandemics.
Our immediate concern was the possibility of increased need for sick call, particularly in the event of resident quarantine. Routinely, we have daily sick call coverage, and the shift is later repaid by the person activating. If a second absence requires coverage beyond initial sick call activation, the on-call chief solicits same-day availability from the resident pool with chief resident coverage as a backstop. Our solution was to develop a second string of sick call. The upcoming schedule was already published, so we relied on volunteers for this and successfully filled our backup sick call schedule.
The decision to develop a backup sick call system was not easy. We had concerns about whether this was a resident responsibility. How many layers of coverage are residents responsible for providing? When do we consider mechanisms like altering shift times and duration or having gaps in coverage? When do we pull residents from electives? What happens when we run out of additional sick call volunteers?
Resident Safety, Well-Being, and Health
As emergency medicine residents, we are part of the team on the front line of patient care. This station puts the emergency department team at particularly high risk in an infectious outbreak. Keeping residents safe and healthy is an important goal itself and because they are an integral part of the workforce. We had added concerns about our residents who were pregnant, immunocompromised, or otherwise at increased risk.
Treating affected patients requires safety measures like special triage procedures and use of personal protective equipment (PPE). It is important that programs ensure team members are educated on how to appropriately use PPE and new departmental protocols. Simulation is a powerful training tool when infectious rates are low. We are currently implementing a simulation to model these issues.
We also considered how to involve residents in care of these patients. Residents are not generally excluded from taking care of any patient population, including patients with infectious diseases. However, there are practical issues to consider like the limited availability of PPE, limiting the number of individuals who come into contact with an identified case, and the fact that all patients are seen by an attending. Currently, we are limiting direct resident involvement in identified ED cases of COVID-19.
Finally, there is the issue of educational activities. Limiting large gatherings can be helpful to prevent transmission of a disease, but certain educational requirements like conference and journal club are organized as large in-person gatherings. We are moving to teleconferencing educational programming where possible.
In the event a resident had to miss a substantial period of work, whether for illness or quarantine, our residents wondered how this time would be compensated and how it would affect their academic progression. Questions of compensation and academic promotion largely fall outside the purview of chief residents; however, we did give consideration to these issues.
Our initial thought was to use leave under the Family and Medical Leave Act (FMLA). Residents at our institution are entitled to additional paid FMLA on top of vacation. With regard to academic progression, there are several factors that affect this, including ensuring the resident has completed required educational rotations. Programs could change a resident’s assigned block during leave to electives to avoid delaying graduation. Other options include working from home. For example, we have electives that allow residents to work remotely, permitting them to progress through the academic curriculum without needing to take an absence. An accommodation like this is particularly helpful in the event of quarantine.
We confronted two issues around work-related travel. The first was the issue of international electives. Several residents were scheduled to leave for global health electives that were canceled under a moratorium on work-related international travel. The second issue was resident travel to national conferences, as there were also restrictions placed on domestic travel. Often these preemptive travel restrictions are in excess of government recommendations, making it difficult for residents to obtain refunds for their travel expenses. Where programs issue travel restrictions in excess of government recommendations, we encourage programs to defray the costs associated with those cancellations.
When residents plan global travel, they could consider obtaining trip insurance, international medical insurance, and medical evacuation insurance—although coverage in settings like pandemics may be limited
Many of our residents have families that include working spouses and small children. To prepare for possible day care and school closures, an emergency list of temporary, trusted adult babysitters was built to provide our resident parents more childcare options and further protect our sick call.
We also encouraged residents to consider how they might best protect their families should they become ill or require quarantine. Some residents felt their family would be safe to stay in quarantine with them at home, while others considered short-term lodging for their families with relatives or friends.
We have found that we cannot treat a pandemic the same as other disaster preparedness events, such as natural disasters or acts of terrorism. Factors contributing to this include the duration of the event and the infectious nature. Residencies need sustainable solutions that could last for an unforeseeable amount of time without placing an unmanageable burden on residents. The role of residents is a unique one in the health care team. They are both learners and integral members of the patient care team. Our solutions may not be practical for smaller programs, given our size of 73 residents. However, we hope that this article will help prompt further discussion about residency preparedness.
Dr. Chernoby, Dr. Doos, Dr. Purpura, and Dr. Wagner, are chief residents in the department of emergency medicine at Indiana University School of Medicine in Indianapolis.