Impact of COVID-19 on pediatric emergency fellowship training in Saudi Arabia

Objectives To assess the impact of the COVID-19 pandemic on the academic and clinical processes of pediatric emergency medicine (PEM) fellowship training held by the Saudi Commission for Health Specialties (SCHS). Methods A cross-sectional, nationwide, survey-based study was conducted between June and December 2020. PEM program directors as well as fellowship trainees were eligible. The collected data were under the following domains: (1) sociodemographic and work-related characteristics; (2) impact of the COVID-19 pandemic on patient flow and PEM procedures; (3) impact on emergency skills and competence; (4) impact on academic performance; and (5) attitudes toward PEM practice and potential solutions. Monthly reports of PEM visits and procedures were also collected from program directors. Results A total of 11 PEM program directors and 42 fellows responded. During the pandemic, the number of total ED visits decreased by 70.1%, ED inpatient admissions fell by 57.3%, and the number of intraosseous need insertion and lumbar puncture procedures fell by 76.7% and 62.3%, respectively; the temporal differences in the median frequencies were statistically significant. The pandemic has influenced the knowledge acquisition and leadership skills of one-third of program directors (36.4% and 27.3%, respectively) and the skills and competence of fellows (31.0%). The majority of directors and fellows showed that online classes/webinars were useful (100% and 95.2%, respectively), and there was no need to extend the current fellowship training to compensate for learning deficits (62.7% and 78.6%, respectively). The importance of dedicated modalities to fill in the training gap increased by 62.5% of program directors and 35.7% of fellows. Conclusion The COVID-19 pandemic had significant effects on clinical procedures and academic activities in the PEM fellowship program. The impact was consistently perceived across PEM program directors and fellows. Technology-driven solutions are warranted to mitigate the expected learning and clinical deficits due to reduced clinical exposure.


Introduction
The COVID-19 pandemic has dramatically influenced the behavior and actions of individuals, organizations, and communities worldwide, and health care organizations are no exception.Multiple operational changes have been made in hospitals, academic health centers, and medical practice institutions in response to the pandemic.For example, in Saudi Arabia, national authorities have undertaken measures to optimize health capacity and care for the surge in COVID-19 patients, extend services to private organizations, and instruct health care providers about the optimal use of personal protective equipment (PPE) [1][2][3].The Ministry of Health has stressed the importance of implementing adequate hospital response measures, such as monitoring daily occupancy rates, reallocating isolation beds, transferring patients who do not experience COVID-19 symptoms to other hospitals, and suspending nonurgent and routine services in health care settings [4].Furthermore, outpatient visits have transitioned to telemedicine [5], and clinical exposure has substantially decreased in multiple medical specialties.These pervasive changes have also entailed the redeployment of health care trainees to new roles, altered clinical exposure, and changes in targeted educational activities, such as lectures and conferences.
As a consequence, directors and leaders in academic medical education programs have adopted operational changes to respond to new clinical requirements and educational needs.Although scarce, data from Saudi Arabia revealed the effects of COVID-19 on residency and fellowship training programs for ophthalmology, internal medicine, and radiology [6][7][8].However, little is known about the impact of these changes on pediatric emergency medicine (PEM) practice and training.The PEM fellowship program was established by the Saudi Commission for Health Specialties (SCHS) to improve the clinical experience of trainees in the management of critically ill children.This 2-year program helps achieve key competencies in triage, diagnosis, decision-making, case management, and follow-up care by providing a comprehensive academic curriculum and hands-on training sessions using models and/or equipment.PEM residents and trainees are required to be well prepared to deal with urgent cases in acute care facilities.Such capabilities are predominantly based on experience and clinical exposure.and hands-on training sessions might have been affected by shifts in health care modalities during the COVID-19 pandemic.The present study aimed to explore the impact of the COVID-19 pandemic on PEM fellow training programs across Saudi Arabia from the perspectives of program directors and trainees.The results of this study will help tailor a dedicated program with mitigation measures to compensate for the deficient aspects in the current program.

Study setting and ethical considerations
The study team at King Abdullah bin Abdul-Aziz University Hospital (KAAUH), which is located at Princess Nourah Bint Abdulrahman University (PNU), Riyadh, carried out a cross-sectional, survey-based study involving PEM program directors and fellows across the Kingdom of Saudi Arabia.The study was conducted between June and December 2020.The study protocol was approved by the institutional review board (IRB) of PNU [H-01-R-059#].The collected data were kept confidential and were solely used for research purposes.

Study population
The directors of the PEM program of the SCHS were eligible.In addition, first-and second-year PEM trainees who were enrolled during the post-pandemic period (from March to June 2020) were included.We excluded service PEM specialists who were not enrolled in the SCHS fellowship program and fellowship program trainees who were not enrolled in the post-pandemic period.

Study procedure
Data collection was based on two main themes: (1) monthly reports of PEM visits and procedures as reported by program directors, and (2) survey-based data to collect self-perceptions of program directors and PEM fellows regarding the impact of COVID-19 on PEM fellowship training.Monthly PEM activities and procedures were collected for the period from March to June 2019 (the pre-pandemic reference period) and the same period in 2020 (during the pandemic) using dedicated data collection sheets on SurveyMonkey ® (Momentive Inc.).These included the monthly number of PEM visits, the number of PEM inpatients admitted, and the number of the following PEM procedures: intubation, intraosseous needle insertion, and lumbar puncture.In addition, data on a number of resuscitation procedures were collected, including neonatal resuscitation, pediatric resuscitation, and major trauma resuscitation.
Two structured questionnaires were created on the SurveyMonkey ® platform (one for program directors and another for PEM fellows).Survey items were retrieved from validated investigations [9][10][11][12][13], and the items were modified and adapted to be applicable in the context of the PEM fellowship program.Survey links were distributed to eligible participants via email and social media platforms.
The program director questionnaire comprised five domains (for the total 25 items listed in Appendix 1): (1)

Statistical analysis
Categorical variables were presented as frequencies and percentages, whereas continuous variables were demonstrated as medians and interquartile ranges (IQRs).The percent changes in ED visits between both pre-and post-pandemic periods were computed, and comparisons of numbers of ED visits were performed using the Mann-Whitney test.Statistical analysis was performed using the Statistical Package for Social Sciences version 26.0 (SPSS Inc., Chicago, IL, USA).

Temporal changes in the number of visits, admissions, and selected procedural and managemental parameters across PEM training centers
The changes in the total number of ED visits and admissions as well as the number of ED procedures and resuscitation interventions are shown in Table 1, and the monthly changes are visually depicted in Fig. 1.The total number of ED visits in 2020 was 61,048, which was 70.1% lower than that in 2019 (203,948 visits).Similarly, ED admissions fell by 57.3% from n = 7345 in 2019 to n = 3138 in 2020.The total number of emergent procedures performed at pediatric emergency departments has consistently dropped, with the largest decline for intraosseous needle access (76.7%), followed by intubation (62.7%) and lumbar puncture (62.3%).The differences between the pre-and post-pandemic periods were statistically significant for the median values of ED visits (p < 0.0001), ED admissions (p = 0.005), and two emergency procedures, including intraosseous needle access (p = 0.029) and lumbar puncture (p = 0.048).The number of resuscitation interventions showed modest reductions from March to June 2020, with no statistically significant temporal differences compared to the same month in 2019 (Table 1).

Sociodemographic and work-related characteristics
A total of 11 PEM program directors responded to the survey.The respondents indicated that their training programs were primarily located in Riyadh (36.4%) or Jeddah (27.3%) and that the number of fellows enrolled in the programs ranged between 4 and 6 (54.5%) or less than 4 fellows (27.3%).Three program directors (27.3%) stated that their PEM departments had been converted to COVID-19 inpatient units to increase bed capacity.Furthermore, PEM fellows were redeployed from rotations to other PEM training centers or other planned pre-COVID-19 rotations, as indicated by 45.5% and 63.6% program directors, respectively.

The impact of the pandemic on patient flow and PEM procedures and duties
Regarding the impact of the COVID-19 pandemic on patient flow at PEM departments, the majority of program directors (who responded to the survey as "a lot" or "a great deal") underscored a significant reduction in the number of major pediatric trauma resuscitation cases (72.8%) and the average number of visits to the PEM department per shift (63.7%,Fig. 2A).

The impact of the pandemic on knowledge acquisition during shifts and emergency skills and competence
Regarding the aspects relevant to workload and competence, 36.4% of program directors stated that while the pandemic might have influenced knowledge acquisition during shifts, it has decreased leadership and teamwork skills as well as PEM  procedural skills and competence, as revealed by 27.3% and 18.2% of respondents, respectively (Fig. 2B).

The impact of the pandemic on academic performance
The most significant effects on academic performance were primarily related to reducing simulation activities (72.8%) and negatively affecting PEM fellowship master plans (36.4%), whereas research activities were minimally affected (9.1%, Fig. 2C).

Attitudes of program directors toward PEM practice during the pandemic and the potential solutions
Generally, the impact of the pandemic on PEM fellow training was rated as minimal to moderate by the program directors (as declared by 36.4% and 63.6% of respondents, respectively).Interestingly, online classes and webinars held during the lockdown period were appreciated by all respondents.Only one respondent agreed that trainees would not be able to achieve the optimal technical competence as an independent practitioner, while three participants (27.3%) felt that it is important to extend the current training period of mentorship for PEM fellows.In addition, eight program directors (62.5%) acknowledged the role of these proposed modalities to fill the training gap, particularly for extending simulation sessions (100%) and providing multiple hands-on courses (62.5%).

Responses of PEM fellows Demographic, psychological, and COVID-related characteristics
A total of 51 PEM fellows responded to the questionnaire; however, the responses of nine participants were excluded due to lack of primary outcomes.Out of the remaining respondents (n = 42), there were 24 males (57.1%), 26 firstyear fellows (61.9%), and 30 participants aged 31-35 years (71.4%,Table 2).Most PEM fellows dealt with patients with a suspected or confirmed COVID-19 infection (97.6%), and thought that they had received adequate training on the proper use of personal protective equipment (PPE, 78.6%).Approximately three-quarters of PEM fellows (76.2%) declared that the pandemic had increased stress/anxiety levels, while 33.3% of fellows were satisfied with the psychological support provided by the SCFHS.Thirty-one participants (73.8%) were aware of the "DAEM" initiative intended for the psychological support of trainees during the pandemic; however, only two participants (4.8%) had enrolled in the program (Table 2).

The impact of the pandemic on patient flow and PEM procedures and duties
Regarding the impact of the pandemic on patient flow, eight participants (19.0%) indicated that the number of shifts/duties decreased during the COVID-19 pandemic.Approximately one-third of PEM fellows have an estimated a greater than 50% reduction in PEM visits (31.0%), and a more than 50% reduction in PEM procedures (35.7%) at the training centers.

The impact of the pandemic on emergency skills and competence
Approximately one-third of the PEM fellowship program trainees (31.0%) agreed that the pandemic has affected their PEM skills, competence, and performance.In addition, 19.0% of the trainees indicated that their teamwork, decision-making, and communication skills were affected.

The impact of the pandemic on academic performance
Concerning academic performance, 12 PEM fellows (28.6%) perceived negative effects on their academic activities in the post-pandemic period.Theoretical learning, PEM training, and educational rounds during shifts were the most negatively affected, as indicated by 56.1%, 47.6%, and 40.5% of the participants, respectively (Fig. 3A).Among those who perceived negative effects on academic performance, the effects were rated "high" to "very high" by 17.3% of participants for theoretical learning/classroom training (Fig. 3B), 20.0% for PEM fellowship training (Fig. 3C), and 25.0% for PEM fellowship academic activities in general (Fig. 3D).Interestingly, 31 PEM fellows (73.8%) indicated a negative influence of COVID-19 on didactical and practical training activities, which impacted self-professional growth.

Attitudes of PEM fellows toward PEM practice during the pandemic and the potential solutions
A large proportion of respondents agreed that online classes and webinars were useful during the lockdown period (95.2%) but indicated that there was no urgent need to extend the training period or the period of mentorship to compensate for the negative effects of COVID-19 on PEM training (78.6%).To fill the training gap, 15 PEM fellows (35.7%) corroborated the importance of conducting distinct modalities during the training.Of them, 13 (86.7%)and 9 (60.0%)participants acknowledged the impact of extensive simulation sessions and multiple hands-on courses to address the training gap (shown in Fig. 4).

Discussion
The global COVID-19 pandemic has caused significant changes in various clinical settings, resulting in iterative programmatic changes in the academic medical niche.Consistent with the increased burden among adults compared with children, pediatric emergency departments responded differently than adult emergency units.In our study, the number of PEM visits plunged by 70.1%, and ED admissions plunged by 57.3%.In New York City, Sagalowsky et al. [14] also reported a significant reduction in PEM volume by 50-80% due to the shutdown of elective and nonessential procedures and the conversion of clinical spaces into intensive care units (ICUs) and adult COVID-19 departments.The authors indicated that PEM fellows in three different programs were redeployed to ICUs, medicine inpatient units, and adult emergency departments [14].The present analysis also showed that the frequencies of lumbar puncture and intraosseous access procedures were greatly reduced in the post-pandemic period; this trend may be attributed to concerns about the highly contagious nature of the virus.The loss of volume in cases may be academically detrimental for fellows, particularly for those with casevolume requirements.Therefore, future plans should be tailored to meet the graduating criteria, whether by having a case-by-case competence assessment program for individual fellows or by extending the fellowship period [15].Concerning the responses of PEM directors and fellows, we showed similar patterns of self-perception regarding the post-pandemic reduction of PEM flows and procedures as well as the respondents' attitudes toward the necessity of online classes/webinars.Additionally, approximately three-quarters of directors and fellows agreed that there is no need to extend the training period of PEM mentorship.While rapidly evolving circumstances have influenced the leadership and teamwork skills of program directors, the pandemic has also impacted the skills and performance of fellows.Compared to fellows, a higher proportion of program directors (62.5% versus 35.7% for program directors and fellows, respectively) appreciated the role of alternative modalities to fill in the gap in fellows' training.
The findings of this study are generally in line with other findings in the literature regarding the negative effects on the learning process in fellowship programs.Indeed, approximately half of PEM fellows reported a significant impact on theoretical learning, PEM training, and educational rounds during shifts.In a recent study involving medical residents and fellows in Saudi Arabia, the majority of fellows (85.2%) and senior residents (81.8%) indicated a reduction in training activities during the pandemic [8].
Additionally, similar to our findings, more than half of the fellows felt stressed, anxious, or worried about the situation during the pandemic [8].This is in agreement with the fact that depression and anxiety are commonly reported among medical staff of first-line units, such as emergency departments, infectious diseases, and intensive care units, who are frequently in close contact with potentially infected patients [16].Furthermore, the psychological burden is prominent among junior staff, fellows, and residents who are not prepared with appropriate mental health care training and not equipped with relevant coping strategies [17,18].
Of note, approximately one-third of PEM directors (36.4%) stated that knowledge acquisition has significantly reduced during the post-pandemic period.Furthermore, a considerable proportion of fellows indicated a 50% reduction in PEM training activities, which affect their skill development, competence, and performance.Similarly, the majority of ophthalmology trainees in multiple countries reported a 50% reduction in clinical activity and a more than 75% reduction in surgical activities [19].
In this study, the importance of online classes and webinars was emphasized by all program directors and most fellows.Indeed, the pandemic has caused many training programs to modernize their educational content and update their method of delivery in a way that is familiar to residents and fellows.For example, in the USA, videoconferencing has been used as an alternative to on-site visits that had originally been utilized in selecting an otolaryngology fellow or fellowship programs [20].A working group of the Coalition for Physician Accountability also recommended that all fellowship programs should commit to virtual visits and online interviews for all students for the entire residency interview cycle [21].
Importantly, extensive simulation sessions and handson courses were suggested by approximately two-thirds of PEM directors and one-third of fellows as potential solutions to COVID-19-related learning deficits in the present analysis.Likewise, homemade and online simulation models, surgical videos, and webinars have been proposed as sources for important skill training for obstetrics and gynecology trainees, as indicated by a recent systematic review of the relevant literature [22].The positive attitudes of program directors and fellows toward online solutions and simulation paradigms reflect the importance of these technology-driven methods in different fellowship processes to guarantee the continuity of education and ensure a sustained learning curve for fellows [23].
The present study has some limitations.Variation in the perceptions of PEM program directors and fellows regarding different outcomes was not statistically assessed because the questions were not consistent in either the director or fellow questionnaires.For example, program directors were asked to rate their perceptions regarding the volume of PEM visits, whereas fellows responded to a question regarding a more than 50% reduction in PEM visits.The limited number of respondents might have also impacted the robustness and reliability of the data.Consequently, the implications of our results may not be generalizable to other regional settings.Finally, the cross-sectional nature of our study might have been affected by response bias in which some respondents may have accidentally or intentionally provided false responses.
In conclusion, the COVID-19 pandemic had devastating effects on patient flow and the frequency of inpatient admission to PEM departments, with significant declines in distinct emergency procedures, including intraosseous needle access and lumbar puncture.Self-reported stress/ anxiety levels were high among the majority of PEM fellows, indicating a need for psychological support via dedicated multidisciplinary health care teams that involve social workers, psychiatrists, and other mental health workers.PEM program directors and fellows reported similar patterns of self-perception regarding post-pandemic changes in patient volume at PEMs and knowledge and skills acquisition during shifts.Both groups equally appreciated the importance of online classes/webinars, and the majority of them showed no need to extend the training period to compensate for learning deficits.A higher proportion of program directors acknowledged the importance of implementing corrective modalities, especially extensive simulation sessions and hands-on courses, to fill training gaps.Future large-scale, longitudinal studies are required to corroborate the negative impact of reduced clinical exposure and academic activities during fellowship training.Smart technology should be widely adopted in national fellowship programs to account for the expected slowdown of PEM fellows' learning curve in the post-pandemic period.

Appendix 1
The domains, items, and the available choices of the PEM director questionnaire.

Fig. 2
Fig. 2 The responses of PEM program directors regarding the impact of the COVID-19 pandemic on selected parameters related to patient flow and PEM procedures and duties (A), knowledge acquisition during shifts and emergency skills and competence (B), and academic performance (C)

Fig. 3
Fig. 3 The responses of PEM fellows regarding their perceived effects of the COVID-19 pandemic on their academic activities and PEM training (A) and the degrees of negative effects on theoretical learning/classroom training (B), PEM fellowship training (C), and PEM fellowship academic activities (D)

Fig. 4
Fig. 4 The responses of PEM fellows regarding the proposed solutions to address the training gap

Table 1
Descriptive statistics of ED visits and admission as well as the pediatric emergency procedures and resuscitation interventions performed in the PEM training centers in selected months in 2019 and 2020 * Significant differences were assessed using the Mann-Whitney U test