Residents in Anaesthesia and Intensive Care: their role in times of emergency

Chief editor’s note: With this paper, we intend to open a new rubric: The residents’ corner, hoping that our readers and members will gladly contribute to it and take this opportunity to share information on their work conditions, research activities and future plans.

Alberto Barbieri¹, Enrico Giuliani², Gabriele Melegari³, Elisabetta Bertellini³

1. School of Anaesthesia and Intensive Care of University of Modena and Reggio Emilia, Italy
2. Department of Medical, Surgical, Maternal-Child and Adult Sciences, University of Modena and Reggio Emilia, Italy
3. Department of Anaesthesia and Intensive Care, Azienda Ospedaliero-Universitaria di Modena, Italy

enrico.giuliani@unimore.it

The COVID-19 emergency has highlighted that a critical part of an effective response is the availability of trained healthcare workers to cope with an increased volume of patients, often requiring advanced medical attention. Training healthcare workers is a complex and long process which makes coping with global emergencies, like the COVID-19 pandemic, challenging as, with most nations being affected, international help is significantly diminished.

The Italian Government, on March 9^th, at the beginning of the exponential phase of the epidemic in the Northern Regions of Lombardy, Veneto and Emilia-Romagna, with a special law (d.l. 14/2020) made it possible for residents in their last two years of specialisation in anaesthesiology and intensive care to start working in hospitals as temporary staff physicians for the duration of the COVID-19 emergency. The months served as temporary staff physicians count towards the completion of the residency program. The deployment of residents as temporary staff physicians was a decision taken by each regional administration on the basis of the local severity of the epidemic and the need for additional medical personnel.

This has led to a prompt and massive response by the senior residents that have contributed to reinforcing the staff of existing and newly created intensive care units (ICUs). From the School of Anaesthesiology and Intensive Care of the University of Modena and Reggio Emilia, 19 residents have started working in 8 hospitals across the Emilia Romagna region over a total of 96 residents within a few days from the enactment of the decree by Italian authorities. The whole fifth year and the vast majority of the fourth year were employed: 8 in COVID-19 ICUs and operating rooms, 5 in COVID-19 ICUs and occasionally in conventional ICUs, 3 exclusively in COVID-19 ICUs, 1 in operating rooms and 1 across the whole spectrum of activities to cover for an increased workload of the existing staff.

At the start of the COVID-19 emergency and for all its duration the director coordinated with the residents’ representatives the reorganisation of the rotations so that all essential services were maintained and non-essential resources reallocated where needed. The day-to-day training of the remaining residents has been updated to cope with the deployment of their more senior colleagues to other hospitals, with respect to the advancement of their core-curricula. No delay in the training of residents is expected from the COVID-19 emergency.

In recent years our residency program had to face two local emergencies, a double seismic event in 2012 ¹ and one of largest concerts of recent history, that called for the development and refinement of prompt re-deployment strategies to meet rapidly and radically changing healthcare needs, work environments. As a result, senior residents, quickly responded to the call for the help of several regional facilities, while

a minority of the fourth-year residents and third and second-year residents were dynamically reorganised to cover for their senior colleagues’ redeployments both in COVID-19 ICUs (12), regular ICUs (13), anaesthesia for general surgery (11) and anaesthesia per speciality surgery (3) across the training network with the aim of both supporting the COVID-19 response and continuing their training ². First-year residents (28), who had just begun their training, were not affected by the reorganisation: they were assigned to anaesthesia rotations. The remaining residents were either on maternity leave or involved in international exchange programs.

The digital log-book was updated to allow residents deployed in response to the COVID-19 to record their activities under the supervision of the local clinical leads, it also helped to keep track of the changes made to the remaining residents training programs so that, once the emergency is over, conducting a training gap analysis is possible.

The activities of residents returning from the COVID-19 deployment will be reviewed and a personalised training program created to cover any missing areas in order to guarantee that training standards are met. Fifth-year residents are expected to graduate at the end of October as planned.

Residency programs involved a relatively high number of young professionals, 8776 in Italy in 2019 ³, with a wide-ranging number of skills to cover all medical specialities; anaesthesiology and intensive care have the highest number of residents, 926 that corresponds to the 10.5% of the total. Skills and capabilities grow very steeply during the years to reach a plateau in the last years of residency, where the focus is in consolidating the knowledge and independence ⁴, which is why this group of residents can be considered an optimal reserve clinical force to rapidly deployed in case of necessity.

Out of past experiences, our residency program developed the flexibility to reshape itself to respond to rapidly changing needs, while maintaining its core aim: training future specialists. A modular program is a key to flexibility, as modules can be easily interchanged which facilitates the emergency reassignment of residents to essential structures, guaranteeing as much as possible the achievement of the yearly training targets.

This structure has been effective in our local context in becoming a “reservoir” of physicians with specialised competencies that could be quickly mobilised in case of emergency. Legislators and directors of residency programs should work on making this option a stable element of the healthcare policy, including specific early training in emergency management strategy, adding this subject to the residency curriculum. Simulation, both digital and live, can play an important role in training for an emergency. To keep track in real-time of the level of training of each resident for this specific purpose a digital online log-book ⁵ would be the most effective tool, allowing directors to precisely know who can be immediately deployed in case of emergency, based on the actual skills and capabilities of each professional.

The COVID-19 emergency could become the opportunity for assessing the status of the residency programs globally, to facilitate the drafting of a common emergency response plan. In fact, residency programs can therefore play an important role in the emergency preparedness strategy of national healthcare systems as reservoirs of medical personnel with an adequate level of advanced training.

References:

1. Barbieri A, Melegari G, Lob V, et al.. Prehosp Emerg Care 2018; 22:353-360.
2. https://edition.cnn.com/2020/03/21/world/health-workers-doctors-photos-coronavirus-italy-wuhan-trnd/index.html (accessed 13 May 2020)
3. Ministry of University and Research – Medical Residency Programs Available from https://www.miur.gov.it/web/guest/-/specializzazioni-mediche-decreto-di-distribuzione-dei-posti-a-a-2018-2019 (accessed 16 April 2020)
4. Kietaibl S, Blank A, De Robertis E.. Eur J Anaesthesiol 2019; 36: 473-476.
5. Barbieri A, Melegari G, Giuliani E. Eur J Anaesthesiol 2020; 37:515.

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