International Journal of Obstetric Anesthesia (2020) 43, 89–90
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CORRESPONDENCE
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Resilience of the restructured (including those about clinical management, resource
obstetric anaesthesia training management, communications and interprofessional
programme during the COVID-19 collaborations) were posed to the residents during these
outbreak in Singapore sessions and were discussed with the consultant facilitat-
ing the session over the webcast.
We would like to report our experience from the restruc- Unfortunately, procedural skills training on epidural
turing of our obstetric anaesthesia training programme trainers, and simulation sessions involving obstetric dif-
in order to mitigate the impact of infection control mea- ficult airway management on mannequins in clinical
sures during the COVID-19 outbreak in Singapore. Our areas, could not be replaced with webcast lectures. To
institution, KK Women’s and Children’s Hospital, is overcome this, we looked into using a pilot virtual real-
responsible for obstetric anaesthesia training for the Sin- ity difficult airway gaming scenario to practice decision-
ghealth Anaesthesiology Residency Program and has making at critical junctures of the crisis scenario.5,6 Vir-
about 90 residents rotating through three different insti- tual reality sets were readily available and portable but
tutions under the Singhealth cluster of healthcare needed disinfection after each use. The results from this
institutions. form of learning are being analysed.
Our national ‘Disease Outbreak Response System In addition to staff segregation, there were other edu-
Condition’ alert level was escalated to the second highest cational impacts. Clinical learning decreased due to can-
of ‘Orange’ on February 7 2020, signifying severe dis- cellation of non-essential surgery. Increased clinical and
ease with limited community spread.1 From that time, psychological stress from managing ‘high infection risk’
a team-based segregation roster was implemented. Spe- cases superseded the clinical teaching that might other-
cialists and residents were divided into two teams, with wise occur in a non-outbreak setting.7 It was also natu-
each team rostered to clinical areas that were located ral for our consultants to manage ‘high infection risk’
on two separate levels within the hospital. Staff per- patients intra-operatively themselves, so as to minimise
forming overnight duties were also from the same team. resident exposure.2 Nonetheless, we encouraged the con-
The purpose was to minimise staff interactions and sultant-resident pair, assigned to the same clinical area,
reduce the impact of mandatory staff quarantine orders to do a clinical and well-being debrief at the end of every
in the event of an outbreak in our healthcare system. shift.
These measures had a significant impact on the delivery The robustness of resident assessment and feedback
of curricular training, which required interactions was significantly impacted. As only consultants in the
between learners and consultants. These included class- same team could assess the resident, the number of
room-based teaching, clinical supervision, procedural available assessors was reduced, which may have
skills and simulation-based training, as well as trainee resulted in less robust or suboptimal feedback on perfor-
assessment and feedback. In the absence of routine mance. Moreover, performance could be affected in the
face-to-face meetings, we anticipated and experienced direct observation of procedural skills competency
difficulties in each of these educational elements. assessments by the added psychological stress of addi-
Consequently, our department drew on the chal- tional infection control measures, such as the need for
lenges learnt with respect to providing continuing med- personal protective equipment. Thus, we limited the per-
ical education during the SARS-virus crisis in 2003, and formance of the direct observation of procedural skills
modified and implemented some of these measures.2 We assessments to patients who had been assessed, using
hope that describing these measures will be useful to the our institutional guidelines, as of ‘low infection risk’.
readership in times of current and future outbreaks. This required co-ordination between the surgical, anaes-
With the suspension of classroom-based teaching, we thetic and infection control teams.
selected a video-conferencing platform to conduct the Movement of residents within the different institu-
webcast lectures.3,4 The real-time display of presentation tions was restricted and thus their planned rotation in
slides, ease of internet connectivity, ease of use on lap- obstetric anaesthesia was extended. This necessitated
tops and mobile phones, as well as the ability to record curricular adjustments, as some residents had already
for subsequent playback, all enhanced the learning expe- completed the requisite training and achieved the com-
rience of the residents and consultants. The latter was petencies required at their level of residency training.
essential as the shift roster and clinical duties did not We put in place learning and developmental pro-
always allow for protected teaching time for residents grammes for the residents that allowed them to progress
to join in the teaching session. Reflective questions to the next level of obstetric anaesthesia training. The
90 International Journal of Obstetric Anesthesia
Table 1 Impact of COVID-19 on training and mitigating measures
Impact Mitigating measures
Classroom teaching Insufficient tutorial rooms to allow team segre- Use of videoconferencing platform for webcast lectures
gation for teaching that are accessible from home and different areas at
Lack of well-ventilated tutorial rooms work
Lack of protected teaching time from team Accessibility of webcast lectures from mobile devices
segregation roster Easy playback of webcast lectures
Clinical teaching Insufficient caseload from cancellation of elec- Focusing more on ‘quality’ than ‘quantity’, with resi-
tive cases dent-consultant debriefing of cases after every shift
Minimising number of staff from managing Progression of obstetric anaesthesia training to the
‘high infection risk’ cases next residency year once current competencies have
Suspension of cross-institutional rotation, con- been met
sequent prolonged obstetric anaesthesia rota- Introducing concepts such as protective measures
tion and potential loss of learning required during aerosol-generating procedures in ‘high
opportunities infection risk’ cases, which are common in anaesthesia
practice but not covered in the residency curriculum
Procedural training Difficulties with performing regional anaesthe- Conducting training on performing regional anaesthe-
sia with personal protective equipment (loss of sia with personal protective equipment and aseptic
dexterity, need for sterility and increased psy- technique on epidural trainers
chological stress) Conducting virtual reality difficult airway gaming sce-
Cancellation of difficult airway simulation ses- narios for residents
sions in clinical areas Conducting case-based discussions on obstetric diffi-
cult airway management
Assessment and feedback Decreased number of assessors Focusing more on qualitative rather than quantitative
Clinical and psychological stress can impact feedback from consultants
performance Increased number of assessments from peers and
Lack of effective mentorship for mentor–men- nursing
tee pairs should they be placed in different Performance of direct observation of procedural skills
teams on ‘low infection risk’ patients
Placing mentor–mentee in the same team
impact on the COVID-19 outbreak on training and mit- References
igating measures is summarised in Table 1.
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B.L. Sng JAMA 2020 Feb 20. [Link]
Department of Women’s Anaesthesia, KK Women’s and
Children’s Hospital, Singapore
E-mail address: [Link].s.e@[Link]