The COVID-19 Graduate Medical Education Pandemic Response: Innovation, Agility and Collaboration By Woodson “Scott” Jones, MD

The COVID-19 Graduate Medical Education Pandemic Response: Innovation, Agility and Collaboration

By Woodson “Scott” Jones, MD

At the beginning of the COVID-19 pandemic in March 2020, the Office for Graduate Medical Education (OGME) at the Long School of Medicine, University of Texas Health San Antonio (UT Health) began to plan for an anticipated rapid rise in hospitalized patients at University Hospital. At the same time, the state of Texas restricted elective medical procedures. This significantly reduced training opportunities for some residents and fellows in their assigned medical specialties. The OGME implemented a comprehensive plan to employ residents and fellows outside of their training specialty to support critical patient care needs at University Hospital (UH) and the Audie L. Murphy Memorial Veterans Hospital (VA).

The OGME, in close coordination with several GME Program Directors (PD), the Chief Medical Officer at UT Health physicians and key unit medical directors, administrators and nursing leadership at UH and the VA, developed and implemented the Cross-Department Deployment Program (CDDP) to address COVID-19 patient care needs (i.e., palliative care, intensive care, inpatient wards, etc.). Clinical “Bucket Managers” at the VA and UH were also identified for each of these anticipated care-lines needing additional support. Their PDs classified all residents and fellows according to the level of supervision they would need in each clinical setting, should they be deployed. Department Deployment Managers (DDM), often a PD, were identified to oversee each department's cross-deployments. Further educational resources, a just-in-time training intranet site and shadowing opportunities were developed. The OGME ensured 100% of residents and fellows received personal protective equipment (PPE) training. OGME conducted virtual “town halls” to discuss the deployment preparations and resources available. UT Health, UH and the VA worked cohesively to develop similar PPE protocols, health care provider participation in COVID-19 patient care, testing and return to work protocols.

UH, our largest training site, began to experience a rapid rise in COVID-19 hospitalizations in June, with a 400% increase in admissions, leading to the activation of the CDDP. Palliative care team support began on June 19, followed by ward and intensive care team support within a few days. Our second largest participating site, the VA, likewise saw rapidly rising COVID-19 hospitalizations, activating the CDDP to support additional hospitalist teams on June 22. At its peak, the CDDP supported 16 new patient care teams and existing services that required additional physician support. 197 deployed residents and fellows supported UH and the VA during the duration of the CDDP for the first surge. Internal medicine residents provided over 1,500 hours of additional support through their jeopardy coverage. The Surgery Program provided up to seven residents at a time to provide 24/7 COVID ICU support. UH successfully cared for the surge in patients without exceeding hospital capacity. There was no evidence of COVID-19 transmission to the cross-deployed residents or fellows, which is a testament to the thorough training and equipping of our GME residents and fellows.

Banner Celebrating Summer 2020 GME COVID Deployers.

In a post-event survey administered to participating residents and fellows, the overall deployment experience was viewed as positive for two-thirds of residents, and onehalf of the respondents stated they would be willing to deploy again if the need arose. Ninety percent felt their personal safety was important to the care team. We also learned from the feedback that we had insufficiently highlighted the additional COVID coverage our UTHSA physician faculty had provided during the first surge. So, as we entered into a second surge of COVID patients in November of 2020, we better communicated when our internal medicine subspecialists began supporting inpatient teaching teams. Freeing our internal medicine hospitalists enabled them to manage the increased COVID patients. This was before any residents were yet cross-deployed. We also better communicated when our trauma faculty expanded our COVID ICU capabilities by opening up the COVID ICU Green Team for a second time, initially without resident support. We had faculty from at least five different specialties cross-deploy to help with our palliative care services. Finally, beginning mid-December 2020, we activated the GME CDDP again through mid-March 2021. We deployed 187 residents and fellows from 26 different GME programs, as well as the oralmaxilofacial surgery residents from the dental school and physician assistant, occupational therapy, physician therapy and respiratory therapy trainees from the School of Health Professions. The physician support was so remarkable that only a very limited number of locums or other external physicians (i.e., deployed military) contributed to either COVID surge. In the end, more than one-third of our GME trainees deployed from their routine training to help directly to meet the demands of caring for COVID-19 patients.

The UTHSA, UH and VA demonstrated remarkable agility, collaboration and innovation during the COVID-19 pandemic. Regarding innovation, new processes for assigning and tracking residents and fellows to support clinical activities at UH and the VA were created as deployments that had never been considered before. Best practices were adopted from our own programs and other institutions and tailored to our unique situation while maintaining compliance with the key tenets and accreditation standards of the Accreditation Council for Graduate Medical Education (ACGME). We were contacted and shared our practices with at least four different institutions during the surges. Our efforts were also presented in an

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invited workshop at the ACGME annual meeting in February 2021.

While innovation is a domain in which academic medical centers excel, agility and collaboration are not often considered inherent strengths. However, agility was crucial to success. The team worked quickly to implement a process, where none had existed before, to evaluate residents’ capability to support several different areas of patient care. Each resident and fellow who participated in the CDDP utilized skills that were part of their core education and training as physicians. However, these were often outside the scope of their specialty training. Dyad teams were created with UH and VA Hospital Medicine to enhance supervision. Finally, the challenge with managing residents deployed from different programs to multiple teams for varying time periods required on-the-fly changes in the implementation process to create “threads” of program-level ownership. Each program would ensure resident or fellow coverage to a specific team daily until clearly transitioning to another program. There were no reported drops in coverage. Further, 100% of residents reported appropriate supervision on the survey mentioned earlier, unlike reports in the press from other areas of the county.

With the varied missions of clinical care, research and education, academic health systems can drift towards operating in silos at times. The Office of GME worked in coordination with over 30 GME Program Directors and the clinical, nursing and administrative leaders from UT, UH and the VA to establish and administer the CDDP. UT GME leadership did COVID Clinical Learning Environment Walks (CLEW) with UH leadership, checking in resident workrooms for wellness checks (i.e., candy, cookies), ensuring they had PPE, hand sanitizer and reminding them about staying masked in the often confined workspaces. Regular meetings (daily during peak) and virtual meetings with CDDP leadership (DDM and Bucket Managers) ensured all patient care requirements were satisfied with properly trained and supervised providers. GME attended and reported daily in the COVID response team of UTHSA and within the COVID Bed Management Committee, as well for VA and UH, coordinated by the UT Health Physicians Chief Medical Officer. Faculty set the tone for academic medical centers. Departments and divisions outside of general internal medicine lead by example, stepping forward early to help support the COVID mission, which was critical to our success. For instance, the trauma surgeons leading the COVID-19 ICU expansion efforts set a tone for an “all in” environment within the institution, creating a “culture of engagement” in meeting the needs of Bexar County and the Region. The efficiencies and improved communication and coordination across specialties and with our partnering hospitals during this pandemic have provided models for us to build upon to enhance patient care for years to come.

Two residents “Cross-Deployed” to COVID Hospitalist Service with Internal Medicine Attending.

Woodson “Scott” Jones, MD is Vice Dean, GME & DIO and Professor of Pediatrics at the UT Health Long School of Medicine. He is a member of the Bexar County Medical Society.