Strategic Deployment of Cardiology Fellows in Training Using the Accreditation Council for Graduate Medical Education Coronavirus Disease 2019 Framework

Abstract

Coronavirus disease 2019 is a global pandemic affecting >3 million people in >170 countries, resulting in >200 000 deaths; 35% to 40% of patients and deaths are in the United States. The coronavirus disease 2019 crisis is placing an enormous burden on health care in the United States, including residency and fellowship training programs. The balance between mitigation, training and education, and patient care is the ultimate determinant of the role of cardiology fellows in training during the coronavirus disease 2019 crisis. On March 24, 2020, the Accreditation Council for Graduate Medical Education issued a formal response to the pandemic crisis and described a framework for operation of graduate medical education programs. Guidance for deployment of cardiology fellows in training during the coronavirus disease 2019 crisis is based on the principles of a medical mission, and adherence to preparation, protection, and support of our fellows in training. The purpose of this review is to describe our departmental strategic deployment of cardiology fellows in training using the Accreditation Council for Graduate Medical Education framework for pandemic preparedness.

Keywords: COVID‐19; education; fellows in training; health education.

Figure 1. Graphic representation of the number (N) of positive coronavirus disease 2019 (COVID‐19) patients in Beaumont Health (y axis) as a function of the day of crisis (x axis).

Layered on the graph are the Accreditation Council for Graduate Medical Education (ACGME) stages (red), deployment of cardiology fellows (F; blue), and mitigation strategies used by the state of Michigan (S; green), Beaumont Hospital–Royal Oak (H; orange), and the Department of Cardiovascular Medicine (C; purple). Statewide mitigation strategies include school closures (S1), prohibit public gathering >50 people (S2), orders to shelter at home (S3), permanent school closure (S4), and extend order to shelter at home (S5). Hospital mitigation strategies include cancel conferences, impose travel and visitor restrictions (H1), curbside testing (H2), on‐site testing, no meetings >10 people, cancel medical school rotations (H3), test hospitalized patients (H4), close outpatient offices (H5), suspend outpatient testing (H6), consolidate “clean” intensive care unit (ICU) (H7), expand personal protective equipment availability (H8), implement serologic testing (H9), and implement clinical study of serologic testing for employees (H10). Department mitigation strategies include cancel elective procedures and off‐site electives, change physician rounding to minimize patient contact (C1), nonessential fellows shelter at home (C2), COVID‐19 echocardiographic studies performed as “limited studies” (C3), develop acute coronary syndrome algorithm for COVID‐19 patients (C4), reduce outpatient noninvasive testing (C5), and implement telemedicine (C6). Deployment of cardiology fellows in training to COVID‐19 units include consultation service (F1), expand consultation service to 2 teams (F2), ICU‐line service (F3), internal medicine service (F4), and hybrid ICU service (F5). A indicates cancel the annual session of the American College of Cardiology; B1, first COVID‐19 patient in Beaumont Health; D1, first COVID‐19 death in Beaumont Health; and M1, first COVID‐19 patient in Michigan.

Figure 2. Rotations of cardiology fellows in training (FIT) during stage 1 to 3 of the coronavirus disease 2019 (COVID‐19) crisis (as indicated by the red boxes).

Stage 1 represents “business as usual.” Although stage 2 is characterized as minimal disruption of educational activities, hospital and departmental mitigation strategies required that FIT in “nonessential” activities shelter at home. Stage 3 is characterized by complete disruption of educational activities, mandated by the surge in COVID‐19 admissions that overwhelmed existing manpower. Cardiology FIT (C‐FIT) in the “pool” had several responsibilities, including backup for others in case of absence, remote services (adjudicate need for ECGs or echocardiograms and evaluate corrected QT interval for COVID‐19 patients), participate in C‐FIT deployment decisions, and participate in research or quality assurance projects. FIT assigned to coronary care unit (CCU) and inpatient service (IPS) were reassigned to COVID‐19 cardiology consultation teams (CCs) A and B. Blue indicates usual fellowship rotations; gray, inactive fellowship rotations; green, COVID‐19 patient care responsibilities; and yellow, pool. CCEP indicates clinical cardiac electrophysiology; CCL, cardiac catheterization laboratory; CT/MR, cardiac computed tomography/magnetic resonance imaging; ECHO, echocardiogram; HICU, hybrid intensive care unit; IC, interventional cardiology; ICU‐L, intensive care unit team for central lines (all intensive care units were COVID‐19 intensive care units); and IM‐AB, internal medicine teams A and B.

Figure 3. Deployment of cardiology attendings and fellows in training (FIT) during stages 2 and 3 of the coronavirus disease 2019 (COVID‐19) crisis.

A, “Usual” non–COVID‐19 cardiology services and new COVID‐19 cardiology consultation services (consultation teams A and B) during stage 2. Each service was assigned 1 cardiology attending and 1 FIT. B, Deployment of cardiology attendings and FIT during stage 3 of the COVID‐19 crisis. At this point, there was complete disruption of all usual cardiology rotations, and all 23 fellows had assigned roles on COVID‐19 services. By the peak of stage 3, cardiology attendings and FIT were assigned to roles on 1 of 4 COVID‐19 cardiology services or 1 of 2 COVID‐19 internal medicine services. The numbers in parentheses represent the number of physicians assigned to the rotation. *The attending and FIT on team B were fully deployed when the census on team A approached 25 patients. Before that time, team B was available as “backup.” **The pool included attendings and FIT who were not assigned to one of these clinical services, to serve as additional clinical needs or to replace others who were ill. Unlike the consultation services, members of internal medicine teams A and B had primary responsibility for the care of COVID‐19 patients. CC‐A and CC‐B indicate COVID‐19 cardiology consultation teams A and B; and CCU, coronary care unit.