User login
Atypical Cardiac Metastasis From a Typical Rectal Cancer
BACKGROUND: The heart is an unusual site of metastasis from any malignancy. The pericardium is the most frequently involved site of cardiac metastasis. Myocardial metastasis is rare and metastasis only to heart without evidence of spread anywhere else is extremely rare. Here we present a case of rectal cancer with metastasis only to heart.
CASE REPORT: A 64-year-old man was found to have a large ulcerated mass in the upper rectum, 15cm above the anal verge during colonoscopy. Biopsy of the mass revealed poorly differentiated invasive adenocarcinoma. After 5 weeks of neo adjuvant capecitabine with concurrent radiation, he underwent robotic low anterior resection (LAR) with coloanal anastomosis with loop ileostomy. Pathology revealed 5cm poorly differentiated adenocarcinoma of rectum invading through muscularis propria with 7/17 lymph nodes and margins involved with adenocarcinoma. He was staged as ypT3pN2bM0 (Stage IIIC, AJCC 8th edition, 2017). Adjuvant therapy was delayed until 12 weeks from surgery due to wound dehiscence/infection. After 5 cycles of adjuvant capecitabine and oxaliplatin, a follow up contrast CT chest/abdomen/pelvis revealed 2.3cm mass extending from pericardium to myocardium. Transesophageal echocardiogram(TEE) and cardiac MRI revealed 2 separate masses(1cm and 2cm) in the right ventricle (RV) free wall projecting into RV cavity concerning for free wall metastases. After 3 weeks, he presented to ED with shortness of breath. Transthoracic echocardiogram(TTE) showed large pericardial effusion with cardiac tamponade. 1250ml of pericardial fluid was removed by pericardiocentesis and cytology revealed metastatic colorectal adenocarcinoma. CT chest/abdomen/pelvis with IV contrast did not show any other site of metastasis. He was started on systemic chemotherapy with Fluorouracil and Irinotecan (FOLFIRI). He has tolerated FOLFIRI for a year without recurrence of pericardial effusion.
CONCLUSION: Most cardiac metastases are associated with widely metastatic disease, but this case is unique in having only cardiac metastasis from a previously resected rectal adenocarcinoma. Although often clinically silent, cardiac metastases should be considered in any patient with cancer and new cardiac symptoms. TTE is the initial imaging test but TEE, Cardiac CT and Cardiac MRI may help further characterize and delineate the extent of cardiac disease. A multidisciplinary team to evaluate and manage the patient with cardiac metastasis is recommended.
BACKGROUND: The heart is an unusual site of metastasis from any malignancy. The pericardium is the most frequently involved site of cardiac metastasis. Myocardial metastasis is rare and metastasis only to heart without evidence of spread anywhere else is extremely rare. Here we present a case of rectal cancer with metastasis only to heart.
CASE REPORT: A 64-year-old man was found to have a large ulcerated mass in the upper rectum, 15cm above the anal verge during colonoscopy. Biopsy of the mass revealed poorly differentiated invasive adenocarcinoma. After 5 weeks of neo adjuvant capecitabine with concurrent radiation, he underwent robotic low anterior resection (LAR) with coloanal anastomosis with loop ileostomy. Pathology revealed 5cm poorly differentiated adenocarcinoma of rectum invading through muscularis propria with 7/17 lymph nodes and margins involved with adenocarcinoma. He was staged as ypT3pN2bM0 (Stage IIIC, AJCC 8th edition, 2017). Adjuvant therapy was delayed until 12 weeks from surgery due to wound dehiscence/infection. After 5 cycles of adjuvant capecitabine and oxaliplatin, a follow up contrast CT chest/abdomen/pelvis revealed 2.3cm mass extending from pericardium to myocardium. Transesophageal echocardiogram(TEE) and cardiac MRI revealed 2 separate masses(1cm and 2cm) in the right ventricle (RV) free wall projecting into RV cavity concerning for free wall metastases. After 3 weeks, he presented to ED with shortness of breath. Transthoracic echocardiogram(TTE) showed large pericardial effusion with cardiac tamponade. 1250ml of pericardial fluid was removed by pericardiocentesis and cytology revealed metastatic colorectal adenocarcinoma. CT chest/abdomen/pelvis with IV contrast did not show any other site of metastasis. He was started on systemic chemotherapy with Fluorouracil and Irinotecan (FOLFIRI). He has tolerated FOLFIRI for a year without recurrence of pericardial effusion.
CONCLUSION: Most cardiac metastases are associated with widely metastatic disease, but this case is unique in having only cardiac metastasis from a previously resected rectal adenocarcinoma. Although often clinically silent, cardiac metastases should be considered in any patient with cancer and new cardiac symptoms. TTE is the initial imaging test but TEE, Cardiac CT and Cardiac MRI may help further characterize and delineate the extent of cardiac disease. A multidisciplinary team to evaluate and manage the patient with cardiac metastasis is recommended.
BACKGROUND: The heart is an unusual site of metastasis from any malignancy. The pericardium is the most frequently involved site of cardiac metastasis. Myocardial metastasis is rare and metastasis only to heart without evidence of spread anywhere else is extremely rare. Here we present a case of rectal cancer with metastasis only to heart.
CASE REPORT: A 64-year-old man was found to have a large ulcerated mass in the upper rectum, 15cm above the anal verge during colonoscopy. Biopsy of the mass revealed poorly differentiated invasive adenocarcinoma. After 5 weeks of neo adjuvant capecitabine with concurrent radiation, he underwent robotic low anterior resection (LAR) with coloanal anastomosis with loop ileostomy. Pathology revealed 5cm poorly differentiated adenocarcinoma of rectum invading through muscularis propria with 7/17 lymph nodes and margins involved with adenocarcinoma. He was staged as ypT3pN2bM0 (Stage IIIC, AJCC 8th edition, 2017). Adjuvant therapy was delayed until 12 weeks from surgery due to wound dehiscence/infection. After 5 cycles of adjuvant capecitabine and oxaliplatin, a follow up contrast CT chest/abdomen/pelvis revealed 2.3cm mass extending from pericardium to myocardium. Transesophageal echocardiogram(TEE) and cardiac MRI revealed 2 separate masses(1cm and 2cm) in the right ventricle (RV) free wall projecting into RV cavity concerning for free wall metastases. After 3 weeks, he presented to ED with shortness of breath. Transthoracic echocardiogram(TTE) showed large pericardial effusion with cardiac tamponade. 1250ml of pericardial fluid was removed by pericardiocentesis and cytology revealed metastatic colorectal adenocarcinoma. CT chest/abdomen/pelvis with IV contrast did not show any other site of metastasis. He was started on systemic chemotherapy with Fluorouracil and Irinotecan (FOLFIRI). He has tolerated FOLFIRI for a year without recurrence of pericardial effusion.
CONCLUSION: Most cardiac metastases are associated with widely metastatic disease, but this case is unique in having only cardiac metastasis from a previously resected rectal adenocarcinoma. Although often clinically silent, cardiac metastases should be considered in any patient with cancer and new cardiac symptoms. TTE is the initial imaging test but TEE, Cardiac CT and Cardiac MRI may help further characterize and delineate the extent of cardiac disease. A multidisciplinary team to evaluate and manage the patient with cardiac metastasis is recommended.
Association of Eosinophilia With Complete Response in Patients With Metastatic Solid Tumors Treated With Immunotherapy
BACKGROUND: Immune-related eosinophilia is a new immune related adverse effect associated with anti- PD-1 or anti-PD-L1 treatment (Bernard-Tessier, 2017). It appears to be a rare adverse effect with estimated frequency of 2.9% (Bernard-Tessier, 2017). There is evidence that changes in blood eosinophilia during anti- PD-1 therapy can be a predictor of long-term disease control in metastatic melanoma (Gaba, 2015). At least 3 studies have correlated immune mediated eosinophilia with high overall response rates up to 69% (Bernard- Tessier, 2017; Gaba, 2015; A, 2017). With this interesting observation, we retrospectively reviewed 36 patients in our center who were treated with PD-1 and anti PD-L1 agents. The Objective of our review was to assess the correlation of eosinophilia with the complete response rate.
METHODS: We retrospectively reviewed the medical records of 36 patients from May 2016 -May 2020 who had received anti PD-1 or anti PD-L1 treatment for metastatic solid tumors. Patients who had received consolidation immunotherapy were excluded from the review. Absolute Eosinophil Count (AEC) of over 500 per mm3 was used to define eosinophilia. Incidence rate of eosinophilia was estimated in comparison to the total number of patients who had received the above treatments.
RESULTS: In this small single center cohort of 36 male patients, eosinophilia was observed in 4/36 patients (11.11%). The median time to the absolute eosinophilia was 24 weeks (3 weeks - 52 weeks). Three out of the 4 patients had complete response. Complete response rates in patients with eosinophilia at any point after initiation of immunotherapy was 75% compared with 2.7% in the noneosinophila group. Overall response rate was 75% (3/4) in the eosinophilia group vs 12.5% (4/32) in the noneosinophilia group.
CONCLUSIONS: In our small retrospective cohort of patients, immune-related eosinophilia with anti-PD-1 and anti-PD-L1 treatments appear to be a biomarker and associated with beneficial clinical response. Additional, larger prospective studies are required to validate this. If validated in prospective studies, immune related eosinophilia could serve as a cost effective biomarker to identify responders likely to derive long-term disease control with immune therapies.
BACKGROUND: Immune-related eosinophilia is a new immune related adverse effect associated with anti- PD-1 or anti-PD-L1 treatment (Bernard-Tessier, 2017). It appears to be a rare adverse effect with estimated frequency of 2.9% (Bernard-Tessier, 2017). There is evidence that changes in blood eosinophilia during anti- PD-1 therapy can be a predictor of long-term disease control in metastatic melanoma (Gaba, 2015). At least 3 studies have correlated immune mediated eosinophilia with high overall response rates up to 69% (Bernard- Tessier, 2017; Gaba, 2015; A, 2017). With this interesting observation, we retrospectively reviewed 36 patients in our center who were treated with PD-1 and anti PD-L1 agents. The Objective of our review was to assess the correlation of eosinophilia with the complete response rate.
METHODS: We retrospectively reviewed the medical records of 36 patients from May 2016 -May 2020 who had received anti PD-1 or anti PD-L1 treatment for metastatic solid tumors. Patients who had received consolidation immunotherapy were excluded from the review. Absolute Eosinophil Count (AEC) of over 500 per mm3 was used to define eosinophilia. Incidence rate of eosinophilia was estimated in comparison to the total number of patients who had received the above treatments.
RESULTS: In this small single center cohort of 36 male patients, eosinophilia was observed in 4/36 patients (11.11%). The median time to the absolute eosinophilia was 24 weeks (3 weeks - 52 weeks). Three out of the 4 patients had complete response. Complete response rates in patients with eosinophilia at any point after initiation of immunotherapy was 75% compared with 2.7% in the noneosinophila group. Overall response rate was 75% (3/4) in the eosinophilia group vs 12.5% (4/32) in the noneosinophilia group.
CONCLUSIONS: In our small retrospective cohort of patients, immune-related eosinophilia with anti-PD-1 and anti-PD-L1 treatments appear to be a biomarker and associated with beneficial clinical response. Additional, larger prospective studies are required to validate this. If validated in prospective studies, immune related eosinophilia could serve as a cost effective biomarker to identify responders likely to derive long-term disease control with immune therapies.
BACKGROUND: Immune-related eosinophilia is a new immune related adverse effect associated with anti- PD-1 or anti-PD-L1 treatment (Bernard-Tessier, 2017). It appears to be a rare adverse effect with estimated frequency of 2.9% (Bernard-Tessier, 2017). There is evidence that changes in blood eosinophilia during anti- PD-1 therapy can be a predictor of long-term disease control in metastatic melanoma (Gaba, 2015). At least 3 studies have correlated immune mediated eosinophilia with high overall response rates up to 69% (Bernard- Tessier, 2017; Gaba, 2015; A, 2017). With this interesting observation, we retrospectively reviewed 36 patients in our center who were treated with PD-1 and anti PD-L1 agents. The Objective of our review was to assess the correlation of eosinophilia with the complete response rate.
METHODS: We retrospectively reviewed the medical records of 36 patients from May 2016 -May 2020 who had received anti PD-1 or anti PD-L1 treatment for metastatic solid tumors. Patients who had received consolidation immunotherapy were excluded from the review. Absolute Eosinophil Count (AEC) of over 500 per mm3 was used to define eosinophilia. Incidence rate of eosinophilia was estimated in comparison to the total number of patients who had received the above treatments.
RESULTS: In this small single center cohort of 36 male patients, eosinophilia was observed in 4/36 patients (11.11%). The median time to the absolute eosinophilia was 24 weeks (3 weeks - 52 weeks). Three out of the 4 patients had complete response. Complete response rates in patients with eosinophilia at any point after initiation of immunotherapy was 75% compared with 2.7% in the noneosinophila group. Overall response rate was 75% (3/4) in the eosinophilia group vs 12.5% (4/32) in the noneosinophilia group.
CONCLUSIONS: In our small retrospective cohort of patients, immune-related eosinophilia with anti-PD-1 and anti-PD-L1 treatments appear to be a biomarker and associated with beneficial clinical response. Additional, larger prospective studies are required to validate this. If validated in prospective studies, immune related eosinophilia could serve as a cost effective biomarker to identify responders likely to derive long-term disease control with immune therapies.
Assessing Pathologic Evaluation in Patients with DLBCL Within the Veterans Health Administration
INTRODUCTION: Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. Patients with DLBCL refractory to initial treatment or who experience relapse have low rates of prolonged disease-free survival. Fluorescence in situ hybridization (FISH) revealing rearrangements in the MYC gene along with either the BCL2 or BCL6 genes (double- and triple-hit lymphomas) demonstrate inferior outcomes when treated with standard front-line chemoimmunotherapy. Immunohistochemistry (IHC) testing for MUM1, CD10, BCL6, and MYC also provides important prognostic information and is used in the Hans algorithm to determine the cell of origin. We assessed how frequently these crucial tests were performed on DLBCL patients within the Veterans Health Administration (VHA).
METHODS: We performed a retrospective chart review of 1,605 randomly selected records of patients diagnosed with lymphoma seen within the VHA nationwide between 1/1/2011 and 12/31/2017. We included patients diagnosed with DLBCL. We excluded patients whose workup and treatment were outside of the VHA system, and patients with primary CNS lymphoma. We analyzed pathology reports. The proportion of patients who had IHC and FISH testing for each marker was assessed.
RESULTS: 725 patients were included in the study. Our patients were predominantly male (96.8%), with a median age of 67 years. Out of the patients analyzed, IHC to determine cell of origin was performed in 481 (66.3%). Out of those tested, 316 (65.7%) were of germinal center B-cell (GCB) origin, and 165 (34.3%) were non-GCB origin. FISH testing was performed in only 242 patients (33.4%). Out of the population tested, 25 (10.3%) were double- or triple-hit.
CONCLUSION: Pathological characterization is key to the diagnosis, prognosis, and treatment of DLBCL. It is recommended by the National Comprehensive Cancer Network (NCCN) to obtain IHC testing for MUM1, BCL6, CD10, and MYC, and FISH testing for MYC (with BCL2 and BCL6 if MYC is positive) in all patients with DLBCL. Our study shows that more than one half of patients did not have FISH testing, and that cell of origin was not determined in about one third of patients, indicating a need for improved testing of these protein expressions and gene rearrangements within the VHA.
INTRODUCTION: Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. Patients with DLBCL refractory to initial treatment or who experience relapse have low rates of prolonged disease-free survival. Fluorescence in situ hybridization (FISH) revealing rearrangements in the MYC gene along with either the BCL2 or BCL6 genes (double- and triple-hit lymphomas) demonstrate inferior outcomes when treated with standard front-line chemoimmunotherapy. Immunohistochemistry (IHC) testing for MUM1, CD10, BCL6, and MYC also provides important prognostic information and is used in the Hans algorithm to determine the cell of origin. We assessed how frequently these crucial tests were performed on DLBCL patients within the Veterans Health Administration (VHA).
METHODS: We performed a retrospective chart review of 1,605 randomly selected records of patients diagnosed with lymphoma seen within the VHA nationwide between 1/1/2011 and 12/31/2017. We included patients diagnosed with DLBCL. We excluded patients whose workup and treatment were outside of the VHA system, and patients with primary CNS lymphoma. We analyzed pathology reports. The proportion of patients who had IHC and FISH testing for each marker was assessed.
RESULTS: 725 patients were included in the study. Our patients were predominantly male (96.8%), with a median age of 67 years. Out of the patients analyzed, IHC to determine cell of origin was performed in 481 (66.3%). Out of those tested, 316 (65.7%) were of germinal center B-cell (GCB) origin, and 165 (34.3%) were non-GCB origin. FISH testing was performed in only 242 patients (33.4%). Out of the population tested, 25 (10.3%) were double- or triple-hit.
CONCLUSION: Pathological characterization is key to the diagnosis, prognosis, and treatment of DLBCL. It is recommended by the National Comprehensive Cancer Network (NCCN) to obtain IHC testing for MUM1, BCL6, CD10, and MYC, and FISH testing for MYC (with BCL2 and BCL6 if MYC is positive) in all patients with DLBCL. Our study shows that more than one half of patients did not have FISH testing, and that cell of origin was not determined in about one third of patients, indicating a need for improved testing of these protein expressions and gene rearrangements within the VHA.
INTRODUCTION: Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. Patients with DLBCL refractory to initial treatment or who experience relapse have low rates of prolonged disease-free survival. Fluorescence in situ hybridization (FISH) revealing rearrangements in the MYC gene along with either the BCL2 or BCL6 genes (double- and triple-hit lymphomas) demonstrate inferior outcomes when treated with standard front-line chemoimmunotherapy. Immunohistochemistry (IHC) testing for MUM1, CD10, BCL6, and MYC also provides important prognostic information and is used in the Hans algorithm to determine the cell of origin. We assessed how frequently these crucial tests were performed on DLBCL patients within the Veterans Health Administration (VHA).
METHODS: We performed a retrospective chart review of 1,605 randomly selected records of patients diagnosed with lymphoma seen within the VHA nationwide between 1/1/2011 and 12/31/2017. We included patients diagnosed with DLBCL. We excluded patients whose workup and treatment were outside of the VHA system, and patients with primary CNS lymphoma. We analyzed pathology reports. The proportion of patients who had IHC and FISH testing for each marker was assessed.
RESULTS: 725 patients were included in the study. Our patients were predominantly male (96.8%), with a median age of 67 years. Out of the patients analyzed, IHC to determine cell of origin was performed in 481 (66.3%). Out of those tested, 316 (65.7%) were of germinal center B-cell (GCB) origin, and 165 (34.3%) were non-GCB origin. FISH testing was performed in only 242 patients (33.4%). Out of the population tested, 25 (10.3%) were double- or triple-hit.
CONCLUSION: Pathological characterization is key to the diagnosis, prognosis, and treatment of DLBCL. It is recommended by the National Comprehensive Cancer Network (NCCN) to obtain IHC testing for MUM1, BCL6, CD10, and MYC, and FISH testing for MYC (with BCL2 and BCL6 if MYC is positive) in all patients with DLBCL. Our study shows that more than one half of patients did not have FISH testing, and that cell of origin was not determined in about one third of patients, indicating a need for improved testing of these protein expressions and gene rearrangements within the VHA.
Assessing Neutropenic Fever Management at Audie L. Murphy VA Medical Center (ALM VAMC)
BACKGROUND: Neutropenic fever poses a significant risk to cancer patients, with a major complication rate of 30% and mortality rate as high as 11%. Prompt evaluation with labs, imaging, and appropriate antibiotics are crucial to improving outcomes. In an attempt to reduce morbidity and mortality, the Infectious Disease Society of America (IDSA) and American Society of Clinical Oncology (ASCO) have set guidelines for the evaluation and treatment of neutropenic fever. The purpose of this project was to assess the management of neutropenic fever within our institution, and to identify potential areas for improvement in the care of these patients.
METHODS: We included patients seen at Audie L. Murphy VA Medical Center between September 1, 2018 and January 31, 2020 for neutropenic fever. We excluded patients without a diagnosis of malignancy and who had not received chemotherapy within the prior 4 weeks. We recorded the times of patient presentation, labs, imaging, and antibiotic administration. These were compared to the standards set forth by IDSA/ASCO. We also calculated average times to lab collection and to antibiotic administration. The proportion of patients who received unwarranted dose reductions of antibiotics also was assessed.
RESULTS: There were 35 unique encounters that met our inclusion criteria. All patients included in the study underwent all recommended diagnostic testing. 3 of 35 (8.6%) patients had CBC/CMP, 2 of 35 (5.7%) had urinalysis, 6 of 35 (17.1%) had blood cultures, and 3 of 35 (8.6%) had a chest x-ray (CXR) within the recommended 15 minutes from time of presentation. Only 3 of 35 (8.6%) patients received antibiotics within the recommended 1 hour from presentation. The average times to obtain CBC/CMP, urinalysis, blood cultures, CXR, and administration of antibiotics were 52.1 minutes, 162.4 minutes, 49.5 minutes, 96.1 minutes, and 308.4 minutes, respectively. 9 of 35 (25.7%) patients received unnecessary dose reductions of antibiotics.
CONCLUSIONS: Although patients received the appropriate evaluation according to IDSA/ASCO guidelines, the times to obtain appropriate diagnostic tests and administer recommend antibiotics were significantly prolonged. Establishing a standardized neutropenic fever protocol, prompt triaging, educational interventions, and identifying patients at risk for neutropenic fever may expedite care and improve outcomes for these high-risk patients.
BACKGROUND: Neutropenic fever poses a significant risk to cancer patients, with a major complication rate of 30% and mortality rate as high as 11%. Prompt evaluation with labs, imaging, and appropriate antibiotics are crucial to improving outcomes. In an attempt to reduce morbidity and mortality, the Infectious Disease Society of America (IDSA) and American Society of Clinical Oncology (ASCO) have set guidelines for the evaluation and treatment of neutropenic fever. The purpose of this project was to assess the management of neutropenic fever within our institution, and to identify potential areas for improvement in the care of these patients.
METHODS: We included patients seen at Audie L. Murphy VA Medical Center between September 1, 2018 and January 31, 2020 for neutropenic fever. We excluded patients without a diagnosis of malignancy and who had not received chemotherapy within the prior 4 weeks. We recorded the times of patient presentation, labs, imaging, and antibiotic administration. These were compared to the standards set forth by IDSA/ASCO. We also calculated average times to lab collection and to antibiotic administration. The proportion of patients who received unwarranted dose reductions of antibiotics also was assessed.
RESULTS: There were 35 unique encounters that met our inclusion criteria. All patients included in the study underwent all recommended diagnostic testing. 3 of 35 (8.6%) patients had CBC/CMP, 2 of 35 (5.7%) had urinalysis, 6 of 35 (17.1%) had blood cultures, and 3 of 35 (8.6%) had a chest x-ray (CXR) within the recommended 15 minutes from time of presentation. Only 3 of 35 (8.6%) patients received antibiotics within the recommended 1 hour from presentation. The average times to obtain CBC/CMP, urinalysis, blood cultures, CXR, and administration of antibiotics were 52.1 minutes, 162.4 minutes, 49.5 minutes, 96.1 minutes, and 308.4 minutes, respectively. 9 of 35 (25.7%) patients received unnecessary dose reductions of antibiotics.
CONCLUSIONS: Although patients received the appropriate evaluation according to IDSA/ASCO guidelines, the times to obtain appropriate diagnostic tests and administer recommend antibiotics were significantly prolonged. Establishing a standardized neutropenic fever protocol, prompt triaging, educational interventions, and identifying patients at risk for neutropenic fever may expedite care and improve outcomes for these high-risk patients.
BACKGROUND: Neutropenic fever poses a significant risk to cancer patients, with a major complication rate of 30% and mortality rate as high as 11%. Prompt evaluation with labs, imaging, and appropriate antibiotics are crucial to improving outcomes. In an attempt to reduce morbidity and mortality, the Infectious Disease Society of America (IDSA) and American Society of Clinical Oncology (ASCO) have set guidelines for the evaluation and treatment of neutropenic fever. The purpose of this project was to assess the management of neutropenic fever within our institution, and to identify potential areas for improvement in the care of these patients.
METHODS: We included patients seen at Audie L. Murphy VA Medical Center between September 1, 2018 and January 31, 2020 for neutropenic fever. We excluded patients without a diagnosis of malignancy and who had not received chemotherapy within the prior 4 weeks. We recorded the times of patient presentation, labs, imaging, and antibiotic administration. These were compared to the standards set forth by IDSA/ASCO. We also calculated average times to lab collection and to antibiotic administration. The proportion of patients who received unwarranted dose reductions of antibiotics also was assessed.
RESULTS: There were 35 unique encounters that met our inclusion criteria. All patients included in the study underwent all recommended diagnostic testing. 3 of 35 (8.6%) patients had CBC/CMP, 2 of 35 (5.7%) had urinalysis, 6 of 35 (17.1%) had blood cultures, and 3 of 35 (8.6%) had a chest x-ray (CXR) within the recommended 15 minutes from time of presentation. Only 3 of 35 (8.6%) patients received antibiotics within the recommended 1 hour from presentation. The average times to obtain CBC/CMP, urinalysis, blood cultures, CXR, and administration of antibiotics were 52.1 minutes, 162.4 minutes, 49.5 minutes, 96.1 minutes, and 308.4 minutes, respectively. 9 of 35 (25.7%) patients received unnecessary dose reductions of antibiotics.
CONCLUSIONS: Although patients received the appropriate evaluation according to IDSA/ASCO guidelines, the times to obtain appropriate diagnostic tests and administer recommend antibiotics were significantly prolonged. Establishing a standardized neutropenic fever protocol, prompt triaging, educational interventions, and identifying patients at risk for neutropenic fever may expedite care and improve outcomes for these high-risk patients.
Analysis of Oncology Telehealth Services in Veterans Health Administration
BACKGROUND: The purpose of this work is to assess the current utilization patterns of telehealth for oncology care and identify opportunities for increased utilization for underserved regions. In order to accurately and efficiently obtain this information a national data extraction and analysis was required to better understand the current needs. Approximately 33% of veterans are considered to live in rural America. A significant proportion of cancer patients must travel long distances to access cutting-edge VA cancer care. Some VAMCs provide academic subspecialized oncology care including next generation sequencing (NGS), genetic counseling, opportunities to enroll in clinical trials, and world-renowned clinical expert consultation. These services are not conveniently accessible for veterans therefore requiring a program which supports access to all.
METHODS: Baseline assessment measurements were identified to understand resource supply, demand, and telehealth utilization needs. Data were extracted from VA’s CDW and VSSCs Service Analysis Services cubes. 15 data measures from 8 data sources were pulled for 141 VAMCs spanning in time period from FY18 to March FY20.
Cluster Analysis, k-means clustering method, were used to classify VAMCs into distinct groups to identify facilities with the highest needs for oncology telehealth services. The evolutionary solving method was used to find the minimum sum of squared estimate of errors (SSE) allowing a more diversified approach in cluster assignment. Three cluster analysis were performed which include a combination of three variables specific to oncology staffing, telehealth usage, patient rurality, and community care consults (CCC).
RESULTS: Results show that 30 (21%) VAMCs are categorized as high need for TeleOncology. These facilities have low staff support, high CCC, and low telehealth usage. Of these, 11 (37%) VAMCs have high percent of rural patients. Eleven (8%) of all VAMCs are categorized as having high staff support, low CCC, and high telehealth usage; good hub site candidates for the National TeleOncology Program.
CONCLUSION: VA is expanding the National TeleOncology Program to offer oncology services to underserved VAMCs and Veterans across the United States. Results of this analysis are being applied to determine where to prioritize telehealth services for oncology care and which sites may serve as hubs.
BACKGROUND: The purpose of this work is to assess the current utilization patterns of telehealth for oncology care and identify opportunities for increased utilization for underserved regions. In order to accurately and efficiently obtain this information a national data extraction and analysis was required to better understand the current needs. Approximately 33% of veterans are considered to live in rural America. A significant proportion of cancer patients must travel long distances to access cutting-edge VA cancer care. Some VAMCs provide academic subspecialized oncology care including next generation sequencing (NGS), genetic counseling, opportunities to enroll in clinical trials, and world-renowned clinical expert consultation. These services are not conveniently accessible for veterans therefore requiring a program which supports access to all.
METHODS: Baseline assessment measurements were identified to understand resource supply, demand, and telehealth utilization needs. Data were extracted from VA’s CDW and VSSCs Service Analysis Services cubes. 15 data measures from 8 data sources were pulled for 141 VAMCs spanning in time period from FY18 to March FY20.
Cluster Analysis, k-means clustering method, were used to classify VAMCs into distinct groups to identify facilities with the highest needs for oncology telehealth services. The evolutionary solving method was used to find the minimum sum of squared estimate of errors (SSE) allowing a more diversified approach in cluster assignment. Three cluster analysis were performed which include a combination of three variables specific to oncology staffing, telehealth usage, patient rurality, and community care consults (CCC).
RESULTS: Results show that 30 (21%) VAMCs are categorized as high need for TeleOncology. These facilities have low staff support, high CCC, and low telehealth usage. Of these, 11 (37%) VAMCs have high percent of rural patients. Eleven (8%) of all VAMCs are categorized as having high staff support, low CCC, and high telehealth usage; good hub site candidates for the National TeleOncology Program.
CONCLUSION: VA is expanding the National TeleOncology Program to offer oncology services to underserved VAMCs and Veterans across the United States. Results of this analysis are being applied to determine where to prioritize telehealth services for oncology care and which sites may serve as hubs.
BACKGROUND: The purpose of this work is to assess the current utilization patterns of telehealth for oncology care and identify opportunities for increased utilization for underserved regions. In order to accurately and efficiently obtain this information a national data extraction and analysis was required to better understand the current needs. Approximately 33% of veterans are considered to live in rural America. A significant proportion of cancer patients must travel long distances to access cutting-edge VA cancer care. Some VAMCs provide academic subspecialized oncology care including next generation sequencing (NGS), genetic counseling, opportunities to enroll in clinical trials, and world-renowned clinical expert consultation. These services are not conveniently accessible for veterans therefore requiring a program which supports access to all.
METHODS: Baseline assessment measurements were identified to understand resource supply, demand, and telehealth utilization needs. Data were extracted from VA’s CDW and VSSCs Service Analysis Services cubes. 15 data measures from 8 data sources were pulled for 141 VAMCs spanning in time period from FY18 to March FY20.
Cluster Analysis, k-means clustering method, were used to classify VAMCs into distinct groups to identify facilities with the highest needs for oncology telehealth services. The evolutionary solving method was used to find the minimum sum of squared estimate of errors (SSE) allowing a more diversified approach in cluster assignment. Three cluster analysis were performed which include a combination of three variables specific to oncology staffing, telehealth usage, patient rurality, and community care consults (CCC).
RESULTS: Results show that 30 (21%) VAMCs are categorized as high need for TeleOncology. These facilities have low staff support, high CCC, and low telehealth usage. Of these, 11 (37%) VAMCs have high percent of rural patients. Eleven (8%) of all VAMCs are categorized as having high staff support, low CCC, and high telehealth usage; good hub site candidates for the National TeleOncology Program.
CONCLUSION: VA is expanding the National TeleOncology Program to offer oncology services to underserved VAMCs and Veterans across the United States. Results of this analysis are being applied to determine where to prioritize telehealth services for oncology care and which sites may serve as hubs.
A Rare Case of Triple Positive Inflammatory Breast Cancer in An Elderly Male
BACKGROUND: An 84-year-old male presented with a rapidly growing left breast mass associated with warmth, erythema, and serous discharge from left nipple for 2.5 months. Physical exam revealed ‘peau d’orange’ appearance of skin and a 3×7 cm, firm, irregular, fixed mass in left breast. Core needle biopsy of left breast revealed invasive ductal carcinoma and a computed tomography scan of chest showed multiple small pulmonary nodules. Patient was diagnosed with inflammatory breast carcinoma (Stage IV, cT4d cN1 cM1), ER/ PR positive, HER-2 positive. BRCA testing was negative. After a normal MUGA scan, patient was started on weekly paclitaxel and trastuzumab. After 4 cycles patient developed diarrhea and elected to stop paclitaxel. After 10 cycles of trastuzumab, patient developed signs of heart failure and a MUGA showed depressed left ventricular ejection fraction (LVEF). Trastuzumab was held and patient was started on tamoxifen. Patient had progression of primary mass into a fungating lesion and evidence of new pulmonary metastatic disease on tamoxifen. The primary lesion was treated with palliative radiation and after a subsequent MUGA scan showed normalization of LVEF; trastuzumab was resumed. Patient had stable disease on trastuzumab and continued to follow with oncology.
DISCUSSION: Male breast cancer is < 1% of all breast cancer but incidence is rising in the US. Risk factors include family history, BRCA2 > BRCA1, obesity, cirrhosis, and radiation exposure. Inflammatory breast cancer (IBC) is a rapidly progressive malignancy with a clinicopathological diagnosis. There are paucity of data of IBC in men due to rarity of the disease. Many patients initially are misdiagnosed with mastitis, unresponsive to antibiotics. At diagnosis, most patients have a higher age compared with females (by 5-10 years), and advanced stage, though have a similar prognosis by stage. Prognostic factors and treatment principles are same as females with multimodal approach of chemotherapy, radiation therapy, and hormone therapy.
CONCLUSIONS: IBC in men is very rare and awareness of its risk factors and presentation can lead to early diagnosis and better survival. Urgent referral to oncology is needed if index of suspicion is high. Further research is needed for defining best treatment modalities in elderly males.”
BACKGROUND: An 84-year-old male presented with a rapidly growing left breast mass associated with warmth, erythema, and serous discharge from left nipple for 2.5 months. Physical exam revealed ‘peau d’orange’ appearance of skin and a 3×7 cm, firm, irregular, fixed mass in left breast. Core needle biopsy of left breast revealed invasive ductal carcinoma and a computed tomography scan of chest showed multiple small pulmonary nodules. Patient was diagnosed with inflammatory breast carcinoma (Stage IV, cT4d cN1 cM1), ER/ PR positive, HER-2 positive. BRCA testing was negative. After a normal MUGA scan, patient was started on weekly paclitaxel and trastuzumab. After 4 cycles patient developed diarrhea and elected to stop paclitaxel. After 10 cycles of trastuzumab, patient developed signs of heart failure and a MUGA showed depressed left ventricular ejection fraction (LVEF). Trastuzumab was held and patient was started on tamoxifen. Patient had progression of primary mass into a fungating lesion and evidence of new pulmonary metastatic disease on tamoxifen. The primary lesion was treated with palliative radiation and after a subsequent MUGA scan showed normalization of LVEF; trastuzumab was resumed. Patient had stable disease on trastuzumab and continued to follow with oncology.
DISCUSSION: Male breast cancer is < 1% of all breast cancer but incidence is rising in the US. Risk factors include family history, BRCA2 > BRCA1, obesity, cirrhosis, and radiation exposure. Inflammatory breast cancer (IBC) is a rapidly progressive malignancy with a clinicopathological diagnosis. There are paucity of data of IBC in men due to rarity of the disease. Many patients initially are misdiagnosed with mastitis, unresponsive to antibiotics. At diagnosis, most patients have a higher age compared with females (by 5-10 years), and advanced stage, though have a similar prognosis by stage. Prognostic factors and treatment principles are same as females with multimodal approach of chemotherapy, radiation therapy, and hormone therapy.
CONCLUSIONS: IBC in men is very rare and awareness of its risk factors and presentation can lead to early diagnosis and better survival. Urgent referral to oncology is needed if index of suspicion is high. Further research is needed for defining best treatment modalities in elderly males.”
BACKGROUND: An 84-year-old male presented with a rapidly growing left breast mass associated with warmth, erythema, and serous discharge from left nipple for 2.5 months. Physical exam revealed ‘peau d’orange’ appearance of skin and a 3×7 cm, firm, irregular, fixed mass in left breast. Core needle biopsy of left breast revealed invasive ductal carcinoma and a computed tomography scan of chest showed multiple small pulmonary nodules. Patient was diagnosed with inflammatory breast carcinoma (Stage IV, cT4d cN1 cM1), ER/ PR positive, HER-2 positive. BRCA testing was negative. After a normal MUGA scan, patient was started on weekly paclitaxel and trastuzumab. After 4 cycles patient developed diarrhea and elected to stop paclitaxel. After 10 cycles of trastuzumab, patient developed signs of heart failure and a MUGA showed depressed left ventricular ejection fraction (LVEF). Trastuzumab was held and patient was started on tamoxifen. Patient had progression of primary mass into a fungating lesion and evidence of new pulmonary metastatic disease on tamoxifen. The primary lesion was treated with palliative radiation and after a subsequent MUGA scan showed normalization of LVEF; trastuzumab was resumed. Patient had stable disease on trastuzumab and continued to follow with oncology.
DISCUSSION: Male breast cancer is < 1% of all breast cancer but incidence is rising in the US. Risk factors include family history, BRCA2 > BRCA1, obesity, cirrhosis, and radiation exposure. Inflammatory breast cancer (IBC) is a rapidly progressive malignancy with a clinicopathological diagnosis. There are paucity of data of IBC in men due to rarity of the disease. Many patients initially are misdiagnosed with mastitis, unresponsive to antibiotics. At diagnosis, most patients have a higher age compared with females (by 5-10 years), and advanced stage, though have a similar prognosis by stage. Prognostic factors and treatment principles are same as females with multimodal approach of chemotherapy, radiation therapy, and hormone therapy.
CONCLUSIONS: IBC in men is very rare and awareness of its risk factors and presentation can lead to early diagnosis and better survival. Urgent referral to oncology is needed if index of suspicion is high. Further research is needed for defining best treatment modalities in elderly males.”
A Cognitive-Behavioral Stress Management Group for Men with Urologic Cancers: Pre- and Post-COVID
BACKGROUND: Urologic cancers and their treatments are associated with significant psychosocial challenges for veteran men, including sexual dysfunction, incontinence, fatigue, irritability, and depression. Although cancer support groups have been shown to be helpful for psychosocial distress, cognitive-behavioral stress management techniques have the capacity to directly address these challenges.
METHODS: A structured, open-enrollment, 6-session biweekly group was created in late 2017 as a cooperative effort between the urology department and comprehensive cancer center of a large VA medical center. Topics were selected based on their relevance to the population: (1) stress and the mind-body connection; (2) mindfulness; (3) sexual functioning and incontinence; (4) pain and sleep; (5) communicating with providers; and (6) managing anger and irritability. A clinical psychologist and/or psychology resident led the sessions, which include demonstration and practice of relaxation and mindfulness techniques, didactic presentations, and discussion. Medical providers received the group well and provides and a regular stream of referrals. Typical group size was between 2-6, and a total of 42 veterans have attended group sessions. The group was previously physically located in the urology clinic, reducing barriers and potentially stigma of access this type of service. After March 2020, the group transitioned to a weekly telephone- based group, continuing the same skills and topics, with good engagement and feedback from group members.
RESULTS: Group members have voiced increased confidence in managing their conditions and communicating with their providers, relief that they are not alone in their experience of potentially embarrassing side effects, and increased use of evidence-based stress management techniques.
CONCLUSION: Continuing this type of service during the COVID-19 pandemic has been important to help veteran manage the stress of postponed treatments (eg, radiation for prostate cancer), share information about hospital policies and procedures, and increase social connectedness with other similar patients.
BACKGROUND: Urologic cancers and their treatments are associated with significant psychosocial challenges for veteran men, including sexual dysfunction, incontinence, fatigue, irritability, and depression. Although cancer support groups have been shown to be helpful for psychosocial distress, cognitive-behavioral stress management techniques have the capacity to directly address these challenges.
METHODS: A structured, open-enrollment, 6-session biweekly group was created in late 2017 as a cooperative effort between the urology department and comprehensive cancer center of a large VA medical center. Topics were selected based on their relevance to the population: (1) stress and the mind-body connection; (2) mindfulness; (3) sexual functioning and incontinence; (4) pain and sleep; (5) communicating with providers; and (6) managing anger and irritability. A clinical psychologist and/or psychology resident led the sessions, which include demonstration and practice of relaxation and mindfulness techniques, didactic presentations, and discussion. Medical providers received the group well and provides and a regular stream of referrals. Typical group size was between 2-6, and a total of 42 veterans have attended group sessions. The group was previously physically located in the urology clinic, reducing barriers and potentially stigma of access this type of service. After March 2020, the group transitioned to a weekly telephone- based group, continuing the same skills and topics, with good engagement and feedback from group members.
RESULTS: Group members have voiced increased confidence in managing their conditions and communicating with their providers, relief that they are not alone in their experience of potentially embarrassing side effects, and increased use of evidence-based stress management techniques.
CONCLUSION: Continuing this type of service during the COVID-19 pandemic has been important to help veteran manage the stress of postponed treatments (eg, radiation for prostate cancer), share information about hospital policies and procedures, and increase social connectedness with other similar patients.
BACKGROUND: Urologic cancers and their treatments are associated with significant psychosocial challenges for veteran men, including sexual dysfunction, incontinence, fatigue, irritability, and depression. Although cancer support groups have been shown to be helpful for psychosocial distress, cognitive-behavioral stress management techniques have the capacity to directly address these challenges.
METHODS: A structured, open-enrollment, 6-session biweekly group was created in late 2017 as a cooperative effort between the urology department and comprehensive cancer center of a large VA medical center. Topics were selected based on their relevance to the population: (1) stress and the mind-body connection; (2) mindfulness; (3) sexual functioning and incontinence; (4) pain and sleep; (5) communicating with providers; and (6) managing anger and irritability. A clinical psychologist and/or psychology resident led the sessions, which include demonstration and practice of relaxation and mindfulness techniques, didactic presentations, and discussion. Medical providers received the group well and provides and a regular stream of referrals. Typical group size was between 2-6, and a total of 42 veterans have attended group sessions. The group was previously physically located in the urology clinic, reducing barriers and potentially stigma of access this type of service. After March 2020, the group transitioned to a weekly telephone- based group, continuing the same skills and topics, with good engagement and feedback from group members.
RESULTS: Group members have voiced increased confidence in managing their conditions and communicating with their providers, relief that they are not alone in their experience of potentially embarrassing side effects, and increased use of evidence-based stress management techniques.
CONCLUSION: Continuing this type of service during the COVID-19 pandemic has been important to help veteran manage the stress of postponed treatments (eg, radiation for prostate cancer), share information about hospital policies and procedures, and increase social connectedness with other similar patients.
A Case of Alectinib Cutaneous Toxicity and Results of a Desensitization Protocol
CASE REPORT: A male smoker aged 51 years with denovo metastatic NSCLC was treated with first-line chemoimmunotherapy. After 4 cycles, an EML4-ALK fusion was identified. At time of disease progression, alectinib 600mg BID was started after an 8-week washout period. Within 2 weeks, he developed a pruritic rash covering 90% of his BSA that required hospitalization and IV steroids. Biopsy confirmed a spongiotic and interface dermatitis with eosinophils consistent with a drug eruption. Rash was reported as an adverse event in the ALEX trial in 17% of patients treated with front-line alectinib but grade 3 rash was reported in only 1%.
A literature search demonstrated successful case reports of alectinib de-sensitization and thus a de-sensitization protocol was devised. Alectinib was started at 150mg daily and increased to 300mg BID over 2 weeks. His rash worsened resulting in a drug hold, treatment with oral prednisone, and a dose reduction to 300mg daily. The dose was increased to 300mg/450mg over 1 week when he developed painful mouth erosions. This resulted in a second dose hold and reduction to 300mg BID. After 2 weeks, alectinib was discontinued due to worsening rash with a plan to switch to an alternate ALK TKI, a strategy which has been successfully reported in the literature. Lorlatinib 100mg was recommended given phase 2 data demonstrating very low rates of rash (5% grade 1-2 and < 1% grade 3). While he did experience a facial rash within 2 weeks, a dose hold or reduction was not required. Nonetheless, lorlatinib was discontinued after 4 weeks due to other intolerable side effects and hypertriglyceridemia
DISCUSSION: Pembrolizumab has a terminal half-life of 22 days with steady state reached at 16 weeks with every 3-week dosing. It is therefore possible that prior exposure to pembrolizumab exacerbated the cutaneous toxicity of alectinib in this case. Multiple studies have shown that combining immunotherapy with alectinib leads to substantially more adverse events.
CONCLUSION: In patients with alectinib hypersensitivity, a de-sensitization protocol can be attempted. If hypersensitivity recurs, switching to an alternate ALK TKI is warranted. However, if immunotherapy has been previously administered without time for adequate washout, no TKI therapy may be tolerable.
CASE REPORT: A male smoker aged 51 years with denovo metastatic NSCLC was treated with first-line chemoimmunotherapy. After 4 cycles, an EML4-ALK fusion was identified. At time of disease progression, alectinib 600mg BID was started after an 8-week washout period. Within 2 weeks, he developed a pruritic rash covering 90% of his BSA that required hospitalization and IV steroids. Biopsy confirmed a spongiotic and interface dermatitis with eosinophils consistent with a drug eruption. Rash was reported as an adverse event in the ALEX trial in 17% of patients treated with front-line alectinib but grade 3 rash was reported in only 1%.
A literature search demonstrated successful case reports of alectinib de-sensitization and thus a de-sensitization protocol was devised. Alectinib was started at 150mg daily and increased to 300mg BID over 2 weeks. His rash worsened resulting in a drug hold, treatment with oral prednisone, and a dose reduction to 300mg daily. The dose was increased to 300mg/450mg over 1 week when he developed painful mouth erosions. This resulted in a second dose hold and reduction to 300mg BID. After 2 weeks, alectinib was discontinued due to worsening rash with a plan to switch to an alternate ALK TKI, a strategy which has been successfully reported in the literature. Lorlatinib 100mg was recommended given phase 2 data demonstrating very low rates of rash (5% grade 1-2 and < 1% grade 3). While he did experience a facial rash within 2 weeks, a dose hold or reduction was not required. Nonetheless, lorlatinib was discontinued after 4 weeks due to other intolerable side effects and hypertriglyceridemia
DISCUSSION: Pembrolizumab has a terminal half-life of 22 days with steady state reached at 16 weeks with every 3-week dosing. It is therefore possible that prior exposure to pembrolizumab exacerbated the cutaneous toxicity of alectinib in this case. Multiple studies have shown that combining immunotherapy with alectinib leads to substantially more adverse events.
CONCLUSION: In patients with alectinib hypersensitivity, a de-sensitization protocol can be attempted. If hypersensitivity recurs, switching to an alternate ALK TKI is warranted. However, if immunotherapy has been previously administered without time for adequate washout, no TKI therapy may be tolerable.
CASE REPORT: A male smoker aged 51 years with denovo metastatic NSCLC was treated with first-line chemoimmunotherapy. After 4 cycles, an EML4-ALK fusion was identified. At time of disease progression, alectinib 600mg BID was started after an 8-week washout period. Within 2 weeks, he developed a pruritic rash covering 90% of his BSA that required hospitalization and IV steroids. Biopsy confirmed a spongiotic and interface dermatitis with eosinophils consistent with a drug eruption. Rash was reported as an adverse event in the ALEX trial in 17% of patients treated with front-line alectinib but grade 3 rash was reported in only 1%.
A literature search demonstrated successful case reports of alectinib de-sensitization and thus a de-sensitization protocol was devised. Alectinib was started at 150mg daily and increased to 300mg BID over 2 weeks. His rash worsened resulting in a drug hold, treatment with oral prednisone, and a dose reduction to 300mg daily. The dose was increased to 300mg/450mg over 1 week when he developed painful mouth erosions. This resulted in a second dose hold and reduction to 300mg BID. After 2 weeks, alectinib was discontinued due to worsening rash with a plan to switch to an alternate ALK TKI, a strategy which has been successfully reported in the literature. Lorlatinib 100mg was recommended given phase 2 data demonstrating very low rates of rash (5% grade 1-2 and < 1% grade 3). While he did experience a facial rash within 2 weeks, a dose hold or reduction was not required. Nonetheless, lorlatinib was discontinued after 4 weeks due to other intolerable side effects and hypertriglyceridemia
DISCUSSION: Pembrolizumab has a terminal half-life of 22 days with steady state reached at 16 weeks with every 3-week dosing. It is therefore possible that prior exposure to pembrolizumab exacerbated the cutaneous toxicity of alectinib in this case. Multiple studies have shown that combining immunotherapy with alectinib leads to substantially more adverse events.
CONCLUSION: In patients with alectinib hypersensitivity, a de-sensitization protocol can be attempted. If hypersensitivity recurs, switching to an alternate ALK TKI is warranted. However, if immunotherapy has been previously administered without time for adequate washout, no TKI therapy may be tolerable.
A pandemic playbook for residency programs in the COVID-19 era: Lessons learned from ObGyn programs at the epicenter
The 2020 pandemic of coronavirus disease 2019 (COVID-19) has presented significant challenges to the health care workforce.1,2 As New York City and its environs became the epicenter of the pandemic in the United States, we continued to care for our patients while simultaneously maintaining the education and well-being of our residents.3 Keeping this balance significantly strained resources and presented new challenges for education and service in residency education. What first emerged as an acute emergency has become a chronic disruption in the clinical learning environment. Programs are working to respond to the critical patient needs while ensuring continued progress toward training goals.
Since pregnancy is one condition for which healthy patients continued to require both outpatient visits and inpatient hospitalization, volume was not anticipated to be significantly decreased on our units. Thus, our ObGyn residency programs sought to expeditiously restructure our workforce and educational methods to address the demands of the pandemic. We were aided in our efforts by the Accreditation Council for Graduate Medical Education (ACGME) Extraordinary Circumstances policy. Our institutions were deemed to be functioning at Stage 3 Pandemic Emergency Status, a state in which “the increase in volume and/or severity of illness creates an extraordinary circumstance where routine care, education, and delivery must be reconfigured to focus only on patient care.”4
As of May 18, 2020, 26% of residency and fellowship programs in the United States were under Stage 3 COVID-19 Pandemic Emergency Status.5 Accordingly, our patient care delivery and educational processes were reconfigured within the context of Stage 3 Status, governed by the overriding principles of ensuring appropriate resources and training, adhering to work hour limits, providing adequate supervision, and credentialing fellows to function in our core specialty.
As ObGyn education leaders from 5 academic medical centers within the COVID-19 epicenter, we present a summary of best practices, based on our experiences, for each of the 4 categories of Stage 3 Status outlined by the ACGME. In an era of globalization, we must learn from pandemics, a call made after the Ebola outbreak in 2015.6 We recognize that this type of disruption could happen again with a possible second wave of COVID-19 or another emerging disease.7 Thus, we emphasize “lessons learned” that are applicable to a wide range of residency training programs facing various clinical crises.
Ensuring adequate resources and training
Within the context of Stage 3 Status, residency programs have the flexibility to increase residents’ availability in the clinical care setting. However, programs must ensure the safety of both patients and residents.
Continue to: Measures to decrease risk of infection...
Measures to decrease risk of infection
One critical resource needed to protect patients and residents is personal protective equipment (PPE). Online instruction and in-person training were used to educate residents and staff on appropriate techniques for donning, doffing, and conserving PPE. Surgical teams were limited to 1 surgeon and 1 resident in each case. In an effort to limit direct contact with COVID-19 infected patients, the number of health care providers rounding on inpatients was restricted, and phone or video conversations were used for communication.
The workforce was modified to decrease exposure to infection and maintain a reserve of healthy residents who were working from home—anticipating that some residents would become ill and this reserve would be called for duty. Similar to other specialties, our programs organized the workforce by arranging residents into teams in which residents worked a number of shifts in a row.8-12 Regular block schedules were disrupted and non-core rotations were deferred.
As surgeries were canceled and outpatient visits curtailed, many rotations required less resident coverage. Residents were reassigned from rotations where clinical work was suspended to accommodate increased staffing needs in other areas, while accounting for residents who were ill or on leave for postexposure quarantine. Typically, residents worked 12-hour shifts for 3 to 6 days followed by several days off or days working remotely. This team-based strategy decreased the number of residents exposed to COVID-19 at one time, provided time for recuperation, encouraged camaraderie, and enabled residents working remotely to coordinate care and participate in telehealth without direct patient contact.
To minimize high-risk exposure of pregnant residents or residents with underlying health conditions, these residents also worked remotely. Similar to other specialties, it was important to determine essential resident duties and enlist assistance from other clinicians, such as fellows, nurse practitioners, physician assistants, and midwives.
To protect residents and patients, maximizing testing of patients for COVID-19 was an important strategy. Based on early experience at 1 center with patients who were initially asymptomatic but later developed symptoms and tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), universal testing was implemented and endorsed by the New York State COVID-19 Maternity Task Force.13 Notably, 87.9% of patients who were positive for SARS-CoV-2 at the time of admission had no symptoms of COVID-19 at presentation. Because the asymptomatic carrier rate appears to be high in obstetric patients, testing of patients is paramount.3,14 Finally, suspending visitation (except for 1 support person) also was instrumental in decreasing the risk of infection to residents.13
Resources for residents with COVID-19
This pandemic placed residency program directors in an unusual situation as frontline caregivers for their own residents. It was imperative to track residents with physical symptoms, conduct testing when possible, and follow the course of residents with confirmed or suspected COVID-19. As serious illness and death have been reported among otherwise healthy young people, we ensured that our homebound residents were frequently monitored.15 At several of our centers, residents with COVID-19 from any program who chose to separate from their families were provided with alternative housing accommodations. In addition, some of our graduate medical education offices identified specific physicians to care for residents with COVID-19 who did not require hospitalization.
Continue to: Deployment to other specialties...
Deployment to other specialties
Several hospitals in the United States redeployed residents because of staffing shortages in high-impact settings.12 It was important for ObGyns to emphasize that the labor and delivery unit functions as the emergency ward for pregnant women, and that ObGyn residents possess skills specific to the care of these patients.
For our departments, we highlighted that external redeployment could adversely affect our workforce restructuring and, ultimately, patient care. We focused efforts on internal deployment or reassignment as much as possible. Some faculty and fellows in nonobstetric subspecialty areas were redirected to provide care on our inpatient obstetric services.
Educating residents
To maintain educational efforts with social distancing, we used videoconferencing to preserve the protected didactic education time that existed for our residents before the pandemic. This regularly scheduled, nonclinical time also was utilized to instruct residents on the rapidly changing clinical guidelines and to disseminate information about new institutional policies and procedures, ensuring that residents were adequately prepared for their new clinical work.
Work hour requirements
The ACGME requires that work hour limitations remain unchanged during Stage 3 Pandemic Emergency Status. As the pandemic presented new challenges and stressors for residents inside and outside the workplace, ensuring adequate time off to rest and recover was critical for maintaining the resident workforce’s health and wellness.
Thus, our workforce restructuring plans accounted for work hour limitations. As detailed above, the restructuring was accomplished by cohorting residents into small teams that remained unchanged for several weeks. Most shifts were limited to 12 hours, residents continued to be assigned at least 1 day off each week, and daily schedules were structured to ensure at least 10 hours off between shifts. Time spent working remotely was included in work hour calculations.
In addition, residents on “jeopardy” who were available for those who needed to be removed from direct patient care were given at least 1 day off per week in which they could not be pulled for clinical duty. Finally, prolonged inpatient assignments were limited; after these assignments, residents were given increased time for rest and recuperation.
Ensuring adequate supervision
The expectation during Stage 3 Pandemic Emergency Status is that residents, with adequate supervision, provide care that is appropriate for their level of training. To adequately and safely supervise residents, faculty needed training to remain well informed about the clinical care of COVID-19 patients. This was accomplished through frequent communication and consultation with colleagues in infectious disease, occupational health, and guidance from national organizations, such as the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention, and information from our state health departments.
Faculty members were trained in safe donning and doffing of PPE and infection control strategies to ensure they could safely oversee and train residents in these practices. Faculty schedules were significantly altered to ensure an adequate workforce and adequate resident supervision. Faculty efforts were focused on areas of critical need—in our case inpatient obstetrics—with a smaller workforce assigned to outpatient services and inpatient gynecology and gynecologic oncology. Many ObGyn subspecialist faculty were redeployed to general ObGyn inpatient units, thus permitting appropriate resident supervision at all times. In the outpatient setting, faculty adjusted to the changing demands and learned to conduct and supervise telehealth visits.
Finally, for those whose residents were deployed to other services (for example, internal medicine, emergency medicine, or critical care), supervision became paramount. We checked in with our deployed residents daily to be sure that their supervision on those services was adequate. Considering the extreme complexity, rapidly changing understanding of the disease, and often tragic patient outcomes, it was essential to ensure appropriate support and supervision on “off service” deployment.
Continue to: Fellows functioning in core specialty...
Fellows functioning in core specialty
Anticipating the increased need for clinicians on the obstetric services, fellows in subspecialty areas were granted emergency privileges to act as attending faculty in the core specialty, supervising residents and providing patient care. On the other hand, some of those fellows, primarily in gynecologic oncology, were externally redeployed out of core specialty to internal medicine and critical care units. Careful consideration of the fellows’ needs for supervision and support in these roles was essential, and similar support measures that were put in place for our residents were offered to fellows.
In conclusion
The COVID-19 pandemic has presented diverse and complex challenges to the entire health care workforce. Because this crisis is widespread and likely will be lengthy, a sustained and organized response is required.16 We have highlighted unique challenges specific to residency programs and presented collective best practices from our experiences in ObGyn navigating these obstacles, which are applicable to many other programs.
The flexibility and relief afforded by the ACGME Stage 3 Pandemic Emergency Status designation allowed us to meet the needs of the surge of patients that required care while we maintained our educational framework and tenets of providing adequate resources and training, working within the confines of safe work hours, ensuring proper supervision, and granting attending privileges to fellows in their core specialty. ●
- Panahi L, Amiri M, Pouy S. Risks of novel coronavirus disease (COVID-19) in pregnancy; a narrative review. Arch Acad Emerg Med. 2020;8e34.
- Rasmussen SA, Smulian JC, Lednicky JA, et al. Coronavirus disease 2019 (COVID-19) and pregnancy: what obstetricians need to know. Am J Obstet Gynecol. 2020;222:415-426.
- Sutton D, Fuchs K, D'Alton M, et al. Universal screening for SARS-CoV-2 in women admitted for delivery. N Engl J Med. 2020;382:2163-2164.
- Accreditation Council for Graduate Medical Education. Three stages of GME during the COVID-19 pandemic. https://www.acgme.org/COVID-19/Three-Stages-of-GME-During-the-COVID-19-Pandemic. Accessed May 28, 2020.
- Accreditation Council for Graduate Medical Education. Emergency category maps/5-18-20: percentage of residents in each state/territory under pandemic emergency status. Percentage of residency and fellowship programs under ACGME COVID-19 pandemic emergency status (stage 3). https://dl.acgme.org/learn/course/sponsoring-institution-idea-exchange/emergency-category-maps/5-18-20-percentage-of-residents-in-each-state-territory-under-pandemic-emergency-status. Accessed May 28, 2020.
- Gates B. The next epidemic--lessons from Ebola. N Engl J Med. 2015;372:1381-1384.
- Pepe D, Martinello RA, Juthani-Mehta M. Involving physicians-in-training in the care of patients during epidemics. J Grad Med Educ. 2019;11:632-634.
- Crosby DL, Sharma A. Insights on otolaryngology residency training during the COVID-19 pandemic. Otolaryngol Head Neck Surg. 2020;163:38-41.
- Kim CS, Lynch JB, Seth C, et al. One academic health system's early (and ongoing) experience responding to COVID-19: recommendations from the initial epicenter of the pandemic in the United States. Acad Med. 2020;95:1146-1148.
- Kogan M, Klein SE, Hannon CP, et al. Orthopaedic education during the COVID-19 pandemic. J Am Acad Orthop Surg. 2020; 28:e456-e464.
- Vargo E, Ali M, Henry F, et al. Cleveland Clinic Akron general urology residency program's COVID-19 experience. Urology. 2020;140:1-3.
- Zarzaur BL, Stahl CC, Greenberg JA, et al. Blueprint for restructuring a department of surgery in concert with the health care system during a pandemic: the University of Wisconsin experience. JAMA Surg. 2020. doi: 10.1001/jamasurg.2020.1386.
- New York State COVID-19 Maternity Task Force. Recommendations to the governor to promote increased choice and access to safe maternity care during the COVID-19 pandemic. https://www.governor.ny.gov/sites/governor.ny.gov/files/atoms/files/042920_CMTF_Recommendations.pdf. Accessed May 28, 2020.
- Campbell KH, Tornatore JM, Lawrence KE, et al. Prevalence of SARS-CoV-2 among patients admitted for childbirth in southern Connecticut. JAMA. 2020;323:2520-2522.
- CDC COVID-19 Response Team. Severe outcomes among patients with coronavirus disease 2019 (COVID-19)--United States, February 12-March 16, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:343-346.
- Kissler SM, Tedijanto C, Goldstein E, et al. Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period. Science. 2020;368:860-868.
The 2020 pandemic of coronavirus disease 2019 (COVID-19) has presented significant challenges to the health care workforce.1,2 As New York City and its environs became the epicenter of the pandemic in the United States, we continued to care for our patients while simultaneously maintaining the education and well-being of our residents.3 Keeping this balance significantly strained resources and presented new challenges for education and service in residency education. What first emerged as an acute emergency has become a chronic disruption in the clinical learning environment. Programs are working to respond to the critical patient needs while ensuring continued progress toward training goals.
Since pregnancy is one condition for which healthy patients continued to require both outpatient visits and inpatient hospitalization, volume was not anticipated to be significantly decreased on our units. Thus, our ObGyn residency programs sought to expeditiously restructure our workforce and educational methods to address the demands of the pandemic. We were aided in our efforts by the Accreditation Council for Graduate Medical Education (ACGME) Extraordinary Circumstances policy. Our institutions were deemed to be functioning at Stage 3 Pandemic Emergency Status, a state in which “the increase in volume and/or severity of illness creates an extraordinary circumstance where routine care, education, and delivery must be reconfigured to focus only on patient care.”4
As of May 18, 2020, 26% of residency and fellowship programs in the United States were under Stage 3 COVID-19 Pandemic Emergency Status.5 Accordingly, our patient care delivery and educational processes were reconfigured within the context of Stage 3 Status, governed by the overriding principles of ensuring appropriate resources and training, adhering to work hour limits, providing adequate supervision, and credentialing fellows to function in our core specialty.
As ObGyn education leaders from 5 academic medical centers within the COVID-19 epicenter, we present a summary of best practices, based on our experiences, for each of the 4 categories of Stage 3 Status outlined by the ACGME. In an era of globalization, we must learn from pandemics, a call made after the Ebola outbreak in 2015.6 We recognize that this type of disruption could happen again with a possible second wave of COVID-19 or another emerging disease.7 Thus, we emphasize “lessons learned” that are applicable to a wide range of residency training programs facing various clinical crises.
Ensuring adequate resources and training
Within the context of Stage 3 Status, residency programs have the flexibility to increase residents’ availability in the clinical care setting. However, programs must ensure the safety of both patients and residents.
Continue to: Measures to decrease risk of infection...
Measures to decrease risk of infection
One critical resource needed to protect patients and residents is personal protective equipment (PPE). Online instruction and in-person training were used to educate residents and staff on appropriate techniques for donning, doffing, and conserving PPE. Surgical teams were limited to 1 surgeon and 1 resident in each case. In an effort to limit direct contact with COVID-19 infected patients, the number of health care providers rounding on inpatients was restricted, and phone or video conversations were used for communication.
The workforce was modified to decrease exposure to infection and maintain a reserve of healthy residents who were working from home—anticipating that some residents would become ill and this reserve would be called for duty. Similar to other specialties, our programs organized the workforce by arranging residents into teams in which residents worked a number of shifts in a row.8-12 Regular block schedules were disrupted and non-core rotations were deferred.
As surgeries were canceled and outpatient visits curtailed, many rotations required less resident coverage. Residents were reassigned from rotations where clinical work was suspended to accommodate increased staffing needs in other areas, while accounting for residents who were ill or on leave for postexposure quarantine. Typically, residents worked 12-hour shifts for 3 to 6 days followed by several days off or days working remotely. This team-based strategy decreased the number of residents exposed to COVID-19 at one time, provided time for recuperation, encouraged camaraderie, and enabled residents working remotely to coordinate care and participate in telehealth without direct patient contact.
To minimize high-risk exposure of pregnant residents or residents with underlying health conditions, these residents also worked remotely. Similar to other specialties, it was important to determine essential resident duties and enlist assistance from other clinicians, such as fellows, nurse practitioners, physician assistants, and midwives.
To protect residents and patients, maximizing testing of patients for COVID-19 was an important strategy. Based on early experience at 1 center with patients who were initially asymptomatic but later developed symptoms and tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), universal testing was implemented and endorsed by the New York State COVID-19 Maternity Task Force.13 Notably, 87.9% of patients who were positive for SARS-CoV-2 at the time of admission had no symptoms of COVID-19 at presentation. Because the asymptomatic carrier rate appears to be high in obstetric patients, testing of patients is paramount.3,14 Finally, suspending visitation (except for 1 support person) also was instrumental in decreasing the risk of infection to residents.13
Resources for residents with COVID-19
This pandemic placed residency program directors in an unusual situation as frontline caregivers for their own residents. It was imperative to track residents with physical symptoms, conduct testing when possible, and follow the course of residents with confirmed or suspected COVID-19. As serious illness and death have been reported among otherwise healthy young people, we ensured that our homebound residents were frequently monitored.15 At several of our centers, residents with COVID-19 from any program who chose to separate from their families were provided with alternative housing accommodations. In addition, some of our graduate medical education offices identified specific physicians to care for residents with COVID-19 who did not require hospitalization.
Continue to: Deployment to other specialties...
Deployment to other specialties
Several hospitals in the United States redeployed residents because of staffing shortages in high-impact settings.12 It was important for ObGyns to emphasize that the labor and delivery unit functions as the emergency ward for pregnant women, and that ObGyn residents possess skills specific to the care of these patients.
For our departments, we highlighted that external redeployment could adversely affect our workforce restructuring and, ultimately, patient care. We focused efforts on internal deployment or reassignment as much as possible. Some faculty and fellows in nonobstetric subspecialty areas were redirected to provide care on our inpatient obstetric services.
Educating residents
To maintain educational efforts with social distancing, we used videoconferencing to preserve the protected didactic education time that existed for our residents before the pandemic. This regularly scheduled, nonclinical time also was utilized to instruct residents on the rapidly changing clinical guidelines and to disseminate information about new institutional policies and procedures, ensuring that residents were adequately prepared for their new clinical work.
Work hour requirements
The ACGME requires that work hour limitations remain unchanged during Stage 3 Pandemic Emergency Status. As the pandemic presented new challenges and stressors for residents inside and outside the workplace, ensuring adequate time off to rest and recover was critical for maintaining the resident workforce’s health and wellness.
Thus, our workforce restructuring plans accounted for work hour limitations. As detailed above, the restructuring was accomplished by cohorting residents into small teams that remained unchanged for several weeks. Most shifts were limited to 12 hours, residents continued to be assigned at least 1 day off each week, and daily schedules were structured to ensure at least 10 hours off between shifts. Time spent working remotely was included in work hour calculations.
In addition, residents on “jeopardy” who were available for those who needed to be removed from direct patient care were given at least 1 day off per week in which they could not be pulled for clinical duty. Finally, prolonged inpatient assignments were limited; after these assignments, residents were given increased time for rest and recuperation.
Ensuring adequate supervision
The expectation during Stage 3 Pandemic Emergency Status is that residents, with adequate supervision, provide care that is appropriate for their level of training. To adequately and safely supervise residents, faculty needed training to remain well informed about the clinical care of COVID-19 patients. This was accomplished through frequent communication and consultation with colleagues in infectious disease, occupational health, and guidance from national organizations, such as the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention, and information from our state health departments.
Faculty members were trained in safe donning and doffing of PPE and infection control strategies to ensure they could safely oversee and train residents in these practices. Faculty schedules were significantly altered to ensure an adequate workforce and adequate resident supervision. Faculty efforts were focused on areas of critical need—in our case inpatient obstetrics—with a smaller workforce assigned to outpatient services and inpatient gynecology and gynecologic oncology. Many ObGyn subspecialist faculty were redeployed to general ObGyn inpatient units, thus permitting appropriate resident supervision at all times. In the outpatient setting, faculty adjusted to the changing demands and learned to conduct and supervise telehealth visits.
Finally, for those whose residents were deployed to other services (for example, internal medicine, emergency medicine, or critical care), supervision became paramount. We checked in with our deployed residents daily to be sure that their supervision on those services was adequate. Considering the extreme complexity, rapidly changing understanding of the disease, and often tragic patient outcomes, it was essential to ensure appropriate support and supervision on “off service” deployment.
Continue to: Fellows functioning in core specialty...
Fellows functioning in core specialty
Anticipating the increased need for clinicians on the obstetric services, fellows in subspecialty areas were granted emergency privileges to act as attending faculty in the core specialty, supervising residents and providing patient care. On the other hand, some of those fellows, primarily in gynecologic oncology, were externally redeployed out of core specialty to internal medicine and critical care units. Careful consideration of the fellows’ needs for supervision and support in these roles was essential, and similar support measures that were put in place for our residents were offered to fellows.
In conclusion
The COVID-19 pandemic has presented diverse and complex challenges to the entire health care workforce. Because this crisis is widespread and likely will be lengthy, a sustained and organized response is required.16 We have highlighted unique challenges specific to residency programs and presented collective best practices from our experiences in ObGyn navigating these obstacles, which are applicable to many other programs.
The flexibility and relief afforded by the ACGME Stage 3 Pandemic Emergency Status designation allowed us to meet the needs of the surge of patients that required care while we maintained our educational framework and tenets of providing adequate resources and training, working within the confines of safe work hours, ensuring proper supervision, and granting attending privileges to fellows in their core specialty. ●
The 2020 pandemic of coronavirus disease 2019 (COVID-19) has presented significant challenges to the health care workforce.1,2 As New York City and its environs became the epicenter of the pandemic in the United States, we continued to care for our patients while simultaneously maintaining the education and well-being of our residents.3 Keeping this balance significantly strained resources and presented new challenges for education and service in residency education. What first emerged as an acute emergency has become a chronic disruption in the clinical learning environment. Programs are working to respond to the critical patient needs while ensuring continued progress toward training goals.
Since pregnancy is one condition for which healthy patients continued to require both outpatient visits and inpatient hospitalization, volume was not anticipated to be significantly decreased on our units. Thus, our ObGyn residency programs sought to expeditiously restructure our workforce and educational methods to address the demands of the pandemic. We were aided in our efforts by the Accreditation Council for Graduate Medical Education (ACGME) Extraordinary Circumstances policy. Our institutions were deemed to be functioning at Stage 3 Pandemic Emergency Status, a state in which “the increase in volume and/or severity of illness creates an extraordinary circumstance where routine care, education, and delivery must be reconfigured to focus only on patient care.”4
As of May 18, 2020, 26% of residency and fellowship programs in the United States were under Stage 3 COVID-19 Pandemic Emergency Status.5 Accordingly, our patient care delivery and educational processes were reconfigured within the context of Stage 3 Status, governed by the overriding principles of ensuring appropriate resources and training, adhering to work hour limits, providing adequate supervision, and credentialing fellows to function in our core specialty.
As ObGyn education leaders from 5 academic medical centers within the COVID-19 epicenter, we present a summary of best practices, based on our experiences, for each of the 4 categories of Stage 3 Status outlined by the ACGME. In an era of globalization, we must learn from pandemics, a call made after the Ebola outbreak in 2015.6 We recognize that this type of disruption could happen again with a possible second wave of COVID-19 or another emerging disease.7 Thus, we emphasize “lessons learned” that are applicable to a wide range of residency training programs facing various clinical crises.
Ensuring adequate resources and training
Within the context of Stage 3 Status, residency programs have the flexibility to increase residents’ availability in the clinical care setting. However, programs must ensure the safety of both patients and residents.
Continue to: Measures to decrease risk of infection...
Measures to decrease risk of infection
One critical resource needed to protect patients and residents is personal protective equipment (PPE). Online instruction and in-person training were used to educate residents and staff on appropriate techniques for donning, doffing, and conserving PPE. Surgical teams were limited to 1 surgeon and 1 resident in each case. In an effort to limit direct contact with COVID-19 infected patients, the number of health care providers rounding on inpatients was restricted, and phone or video conversations were used for communication.
The workforce was modified to decrease exposure to infection and maintain a reserve of healthy residents who were working from home—anticipating that some residents would become ill and this reserve would be called for duty. Similar to other specialties, our programs organized the workforce by arranging residents into teams in which residents worked a number of shifts in a row.8-12 Regular block schedules were disrupted and non-core rotations were deferred.
As surgeries were canceled and outpatient visits curtailed, many rotations required less resident coverage. Residents were reassigned from rotations where clinical work was suspended to accommodate increased staffing needs in other areas, while accounting for residents who were ill or on leave for postexposure quarantine. Typically, residents worked 12-hour shifts for 3 to 6 days followed by several days off or days working remotely. This team-based strategy decreased the number of residents exposed to COVID-19 at one time, provided time for recuperation, encouraged camaraderie, and enabled residents working remotely to coordinate care and participate in telehealth without direct patient contact.
To minimize high-risk exposure of pregnant residents or residents with underlying health conditions, these residents also worked remotely. Similar to other specialties, it was important to determine essential resident duties and enlist assistance from other clinicians, such as fellows, nurse practitioners, physician assistants, and midwives.
To protect residents and patients, maximizing testing of patients for COVID-19 was an important strategy. Based on early experience at 1 center with patients who were initially asymptomatic but later developed symptoms and tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), universal testing was implemented and endorsed by the New York State COVID-19 Maternity Task Force.13 Notably, 87.9% of patients who were positive for SARS-CoV-2 at the time of admission had no symptoms of COVID-19 at presentation. Because the asymptomatic carrier rate appears to be high in obstetric patients, testing of patients is paramount.3,14 Finally, suspending visitation (except for 1 support person) also was instrumental in decreasing the risk of infection to residents.13
Resources for residents with COVID-19
This pandemic placed residency program directors in an unusual situation as frontline caregivers for their own residents. It was imperative to track residents with physical symptoms, conduct testing when possible, and follow the course of residents with confirmed or suspected COVID-19. As serious illness and death have been reported among otherwise healthy young people, we ensured that our homebound residents were frequently monitored.15 At several of our centers, residents with COVID-19 from any program who chose to separate from their families were provided with alternative housing accommodations. In addition, some of our graduate medical education offices identified specific physicians to care for residents with COVID-19 who did not require hospitalization.
Continue to: Deployment to other specialties...
Deployment to other specialties
Several hospitals in the United States redeployed residents because of staffing shortages in high-impact settings.12 It was important for ObGyns to emphasize that the labor and delivery unit functions as the emergency ward for pregnant women, and that ObGyn residents possess skills specific to the care of these patients.
For our departments, we highlighted that external redeployment could adversely affect our workforce restructuring and, ultimately, patient care. We focused efforts on internal deployment or reassignment as much as possible. Some faculty and fellows in nonobstetric subspecialty areas were redirected to provide care on our inpatient obstetric services.
Educating residents
To maintain educational efforts with social distancing, we used videoconferencing to preserve the protected didactic education time that existed for our residents before the pandemic. This regularly scheduled, nonclinical time also was utilized to instruct residents on the rapidly changing clinical guidelines and to disseminate information about new institutional policies and procedures, ensuring that residents were adequately prepared for their new clinical work.
Work hour requirements
The ACGME requires that work hour limitations remain unchanged during Stage 3 Pandemic Emergency Status. As the pandemic presented new challenges and stressors for residents inside and outside the workplace, ensuring adequate time off to rest and recover was critical for maintaining the resident workforce’s health and wellness.
Thus, our workforce restructuring plans accounted for work hour limitations. As detailed above, the restructuring was accomplished by cohorting residents into small teams that remained unchanged for several weeks. Most shifts were limited to 12 hours, residents continued to be assigned at least 1 day off each week, and daily schedules were structured to ensure at least 10 hours off between shifts. Time spent working remotely was included in work hour calculations.
In addition, residents on “jeopardy” who were available for those who needed to be removed from direct patient care were given at least 1 day off per week in which they could not be pulled for clinical duty. Finally, prolonged inpatient assignments were limited; after these assignments, residents were given increased time for rest and recuperation.
Ensuring adequate supervision
The expectation during Stage 3 Pandemic Emergency Status is that residents, with adequate supervision, provide care that is appropriate for their level of training. To adequately and safely supervise residents, faculty needed training to remain well informed about the clinical care of COVID-19 patients. This was accomplished through frequent communication and consultation with colleagues in infectious disease, occupational health, and guidance from national organizations, such as the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention, and information from our state health departments.
Faculty members were trained in safe donning and doffing of PPE and infection control strategies to ensure they could safely oversee and train residents in these practices. Faculty schedules were significantly altered to ensure an adequate workforce and adequate resident supervision. Faculty efforts were focused on areas of critical need—in our case inpatient obstetrics—with a smaller workforce assigned to outpatient services and inpatient gynecology and gynecologic oncology. Many ObGyn subspecialist faculty were redeployed to general ObGyn inpatient units, thus permitting appropriate resident supervision at all times. In the outpatient setting, faculty adjusted to the changing demands and learned to conduct and supervise telehealth visits.
Finally, for those whose residents were deployed to other services (for example, internal medicine, emergency medicine, or critical care), supervision became paramount. We checked in with our deployed residents daily to be sure that their supervision on those services was adequate. Considering the extreme complexity, rapidly changing understanding of the disease, and often tragic patient outcomes, it was essential to ensure appropriate support and supervision on “off service” deployment.
Continue to: Fellows functioning in core specialty...
Fellows functioning in core specialty
Anticipating the increased need for clinicians on the obstetric services, fellows in subspecialty areas were granted emergency privileges to act as attending faculty in the core specialty, supervising residents and providing patient care. On the other hand, some of those fellows, primarily in gynecologic oncology, were externally redeployed out of core specialty to internal medicine and critical care units. Careful consideration of the fellows’ needs for supervision and support in these roles was essential, and similar support measures that were put in place for our residents were offered to fellows.
In conclusion
The COVID-19 pandemic has presented diverse and complex challenges to the entire health care workforce. Because this crisis is widespread and likely will be lengthy, a sustained and organized response is required.16 We have highlighted unique challenges specific to residency programs and presented collective best practices from our experiences in ObGyn navigating these obstacles, which are applicable to many other programs.
The flexibility and relief afforded by the ACGME Stage 3 Pandemic Emergency Status designation allowed us to meet the needs of the surge of patients that required care while we maintained our educational framework and tenets of providing adequate resources and training, working within the confines of safe work hours, ensuring proper supervision, and granting attending privileges to fellows in their core specialty. ●
- Panahi L, Amiri M, Pouy S. Risks of novel coronavirus disease (COVID-19) in pregnancy; a narrative review. Arch Acad Emerg Med. 2020;8e34.
- Rasmussen SA, Smulian JC, Lednicky JA, et al. Coronavirus disease 2019 (COVID-19) and pregnancy: what obstetricians need to know. Am J Obstet Gynecol. 2020;222:415-426.
- Sutton D, Fuchs K, D'Alton M, et al. Universal screening for SARS-CoV-2 in women admitted for delivery. N Engl J Med. 2020;382:2163-2164.
- Accreditation Council for Graduate Medical Education. Three stages of GME during the COVID-19 pandemic. https://www.acgme.org/COVID-19/Three-Stages-of-GME-During-the-COVID-19-Pandemic. Accessed May 28, 2020.
- Accreditation Council for Graduate Medical Education. Emergency category maps/5-18-20: percentage of residents in each state/territory under pandemic emergency status. Percentage of residency and fellowship programs under ACGME COVID-19 pandemic emergency status (stage 3). https://dl.acgme.org/learn/course/sponsoring-institution-idea-exchange/emergency-category-maps/5-18-20-percentage-of-residents-in-each-state-territory-under-pandemic-emergency-status. Accessed May 28, 2020.
- Gates B. The next epidemic--lessons from Ebola. N Engl J Med. 2015;372:1381-1384.
- Pepe D, Martinello RA, Juthani-Mehta M. Involving physicians-in-training in the care of patients during epidemics. J Grad Med Educ. 2019;11:632-634.
- Crosby DL, Sharma A. Insights on otolaryngology residency training during the COVID-19 pandemic. Otolaryngol Head Neck Surg. 2020;163:38-41.
- Kim CS, Lynch JB, Seth C, et al. One academic health system's early (and ongoing) experience responding to COVID-19: recommendations from the initial epicenter of the pandemic in the United States. Acad Med. 2020;95:1146-1148.
- Kogan M, Klein SE, Hannon CP, et al. Orthopaedic education during the COVID-19 pandemic. J Am Acad Orthop Surg. 2020; 28:e456-e464.
- Vargo E, Ali M, Henry F, et al. Cleveland Clinic Akron general urology residency program's COVID-19 experience. Urology. 2020;140:1-3.
- Zarzaur BL, Stahl CC, Greenberg JA, et al. Blueprint for restructuring a department of surgery in concert with the health care system during a pandemic: the University of Wisconsin experience. JAMA Surg. 2020. doi: 10.1001/jamasurg.2020.1386.
- New York State COVID-19 Maternity Task Force. Recommendations to the governor to promote increased choice and access to safe maternity care during the COVID-19 pandemic. https://www.governor.ny.gov/sites/governor.ny.gov/files/atoms/files/042920_CMTF_Recommendations.pdf. Accessed May 28, 2020.
- Campbell KH, Tornatore JM, Lawrence KE, et al. Prevalence of SARS-CoV-2 among patients admitted for childbirth in southern Connecticut. JAMA. 2020;323:2520-2522.
- CDC COVID-19 Response Team. Severe outcomes among patients with coronavirus disease 2019 (COVID-19)--United States, February 12-March 16, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:343-346.
- Kissler SM, Tedijanto C, Goldstein E, et al. Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period. Science. 2020;368:860-868.
- Panahi L, Amiri M, Pouy S. Risks of novel coronavirus disease (COVID-19) in pregnancy; a narrative review. Arch Acad Emerg Med. 2020;8e34.
- Rasmussen SA, Smulian JC, Lednicky JA, et al. Coronavirus disease 2019 (COVID-19) and pregnancy: what obstetricians need to know. Am J Obstet Gynecol. 2020;222:415-426.
- Sutton D, Fuchs K, D'Alton M, et al. Universal screening for SARS-CoV-2 in women admitted for delivery. N Engl J Med. 2020;382:2163-2164.
- Accreditation Council for Graduate Medical Education. Three stages of GME during the COVID-19 pandemic. https://www.acgme.org/COVID-19/Three-Stages-of-GME-During-the-COVID-19-Pandemic. Accessed May 28, 2020.
- Accreditation Council for Graduate Medical Education. Emergency category maps/5-18-20: percentage of residents in each state/territory under pandemic emergency status. Percentage of residency and fellowship programs under ACGME COVID-19 pandemic emergency status (stage 3). https://dl.acgme.org/learn/course/sponsoring-institution-idea-exchange/emergency-category-maps/5-18-20-percentage-of-residents-in-each-state-territory-under-pandemic-emergency-status. Accessed May 28, 2020.
- Gates B. The next epidemic--lessons from Ebola. N Engl J Med. 2015;372:1381-1384.
- Pepe D, Martinello RA, Juthani-Mehta M. Involving physicians-in-training in the care of patients during epidemics. J Grad Med Educ. 2019;11:632-634.
- Crosby DL, Sharma A. Insights on otolaryngology residency training during the COVID-19 pandemic. Otolaryngol Head Neck Surg. 2020;163:38-41.
- Kim CS, Lynch JB, Seth C, et al. One academic health system's early (and ongoing) experience responding to COVID-19: recommendations from the initial epicenter of the pandemic in the United States. Acad Med. 2020;95:1146-1148.
- Kogan M, Klein SE, Hannon CP, et al. Orthopaedic education during the COVID-19 pandemic. J Am Acad Orthop Surg. 2020; 28:e456-e464.
- Vargo E, Ali M, Henry F, et al. Cleveland Clinic Akron general urology residency program's COVID-19 experience. Urology. 2020;140:1-3.
- Zarzaur BL, Stahl CC, Greenberg JA, et al. Blueprint for restructuring a department of surgery in concert with the health care system during a pandemic: the University of Wisconsin experience. JAMA Surg. 2020. doi: 10.1001/jamasurg.2020.1386.
- New York State COVID-19 Maternity Task Force. Recommendations to the governor to promote increased choice and access to safe maternity care during the COVID-19 pandemic. https://www.governor.ny.gov/sites/governor.ny.gov/files/atoms/files/042920_CMTF_Recommendations.pdf. Accessed May 28, 2020.
- Campbell KH, Tornatore JM, Lawrence KE, et al. Prevalence of SARS-CoV-2 among patients admitted for childbirth in southern Connecticut. JAMA. 2020;323:2520-2522.
- CDC COVID-19 Response Team. Severe outcomes among patients with coronavirus disease 2019 (COVID-19)--United States, February 12-March 16, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:343-346.
- Kissler SM, Tedijanto C, Goldstein E, et al. Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period. Science. 2020;368:860-868.
