Article 8

Original Research—Research Article

Management of the Clinical and Academic Mission in an Urban Otolaryngology Department During the COVID-19 Global Crisis

Otolaryngology– Head and Neck Surgery 2020, Vol. 163(1) 162–169 � The Author(s) 2020

Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599820929613 http://otojournal.org

Pete S. Batra, MD 1 , Phillip S. LoSavio, MD

1 , Elias Michaelides, MD

1 ,

Peter C. Revenaugh, MD 1 , Bobby A. Tajudeen, MD

1 ,

Samer Al-khudari, MD 1 , Inna Husain, MD

1 ,

Peter Papagiannopoulos, MD 1 , Ryan Smith, MD

1 ,

Kerstin M. Stenson, MD 1 , and R. Mark Wiet, MD

1

Abstract

Objective. The objective of this study was to assess the strate- gic changes implemented in the departmental mission to con- tinue safe delivery of otolaryngology care and to support the broader institutional mission during the COVID-19 pandemic response.

Study Design. Retrospective assessment was performed to the response and management strategy developed to trans- form the clinical and academic enterprise.

Setting. Large urban tertiary care referral center.

Results. The departmental structure was reorganized along new clinical teams to effectively meet the system directives for provision of otolaryngology care and support for inpatient cases of COVID-19. A surge deployment schedule was devel- oped to assist frontline colleagues with clinical support as needed. Outpatient otolaryngology was consolidated across the system with conversion of the majority of visits to tele- health. Operative procedures were prioritized to ensure throughput for emergent and time-critical urgent procedures. A tracheostomy protocol was developed to guide manage- ment of emergent and elective airways. Educational and research efforts were redirected to focus on otolaryngology care in the clinical context of the COVID-19 crisis.

Conclusion. Emergence of the COVID-19 global health crisis has challenged delivery of otolaryngology care in an unparal- leled manner. The concerns for preserving health of the work- force while ethically addressing patient career needs in a timely manner has created significant dilemmas. A proactive, thought- ful approach that reorganizes the overall departmental effort through provider and staff engagement can facilitate the ability to meet the needs of otolaryngology patients and to support the greater institutional mission to combat the pandemic.

Keywords

COVID-19, novel coronavirus, pandemic, otolaryngology, telehealth, tracheostomy

Received April 22, 2020; accepted May 5, 2020.

C oronavirus is a single-stranded RNA virus that has

the potential to cause a spectrum of clinical symp-

toms, ranging from the common cold to more severe

lower respiratory symptoms, including pneumonia, respira-

tory failure, and death. 1

Typically, these viruses are found in

animals worldwide, with few instances of human disease.

The World Health Organization used the term 2019 novel

coronavirus (COVID-19) to refer to the December 2019 out-

break in Wuhan, China, that affected the lower respiratory

tract of patients and resulted in pneumonia. 2

The reference

name for the virus resulting in this disease has been termed

severe acute respiratory syndrome coronavirus 2 (SARS-

CoV-2). Given the rapid spread of COVID-19 globally over

a matter of 2 months, the World Health Organization dubbed

this a pandemic on March 11, 2020. 3

As of April 19, 2020,

the disease had spread to 185 countries, with 2,394,291

reported cases worldwide and 164,937 deaths. 4

After the initial clustering of cases in China and subse-

quently Europe, the United States now sits in the epicenter

of the pandemic. On April 19, 2020, the United States had

the most cases in the world with 722,761, including 33,903

attributed deaths. 4

As COVID-19 has reached the shores of

our country, the impact of the evolving pandemic to otolar-

yngology has been profound. Within a matter of a few

weeks, the specialty has seen a drastic decline in outpatient

clinic volumes and the cessation of elective surgical proce-

dures. Moreover, given the invasive nature of our diagnostic

and therapeutic procedures, otolaryngologists have been

1 Department of Otorhinolaryngology–Head and Neck Surgery, Rush

University Medical Center, Chicago, Illinois, USA

Corresponding Author:

Pete S. Batra, MD, Department of Otorhinolaryngology–Head and Neck

Surgery, Rush University Medical Center, 1611 W Harrison St, Suite 550,

Chicago, IL 60612, USA.

Email: [email protected]

deemed high risk for viral exposure, despite not being a tra-

ditional frontline specialty in battling the disease. Per anec-

dotal experience, colleagues in China, Italy, and Iran have

reported high rates of COVID-19 transmissions to otolaryn-

gologists, including deaths.

This article details the efforts of the otorhinolaryngology

department at a large tertiary care referral center in Chicago

that was designed to handle a pandemic. We hope to disse-

minate the strategies employed and lessons learned to con-

tinue to meet the tripartite otolaryngology mission under

difficult circumstances and to support the greater mission of

the organization to focus on managing cases of COVID-19.

Setting

Rush University Medical Center is a 664-bed tertiary care

referral hospital in the near west side of Chicago. The new

hospital that opened in 2012 was designed with the capabil-

ity to treat patients in particular crisis settings, such as a

bioterrorism attack or a pandemic. The facility is 1 of 35 fed-

erally designated hospitals for treating infectious diseases. It

houses 40 negative-pressure rooms to control airflow to

entire sections of the building to prevent cross-contamination

by airborne pathogens and the ability to expand bed capacity at

short notice to manage a surge of potentially infected patients.

The otorhinolaryngology department is composed of 14 full-

time and 3 part-time otolaryngology faculty, 2 part-time oral

maxillofacial surgeons, 9 audiologists, 7 ENT residents (ear,

nose, and throat), and 4 advanced practice providers.

Methods

Retrospective assessment of the management strategy of the

Department of Otorhinolaryngology–Head and Neck Surgery

at Rush University Medical Center to the evolving pandemic

was conducted through review of daily institutional briefings,

weekly departmental briefings, email communications from

institution and department, and institutional and departmental

written policies. The study was exempt from approval by the

Rush University Medical Center Institutional Review Board.

Results

Institutional Response

Rush University Medical Center activated resources in late

February to prepare for COVID-19, though an initial cluster-

ing of cases in the greater Chicago area was not seen until

March 10, 2020. 5

It is important to note that on April 16,

2020, the Illinois Department of Public Health notified the

State Emergency Operations Center that hospitals may need

to implement crisis standards of care pursuant to their

disaster response plans. The changes in the hospital incident

command structure were implemented 6 weeks prior to the

invocation of crisis standards of care; thus, this represents a

proactive emergency response to the looming crisis.

Strategic institutional directives included development of a

centralized command center, complete reorganization

of the emergency department (ED) to triage patients with

COVID-19, and implementation of the surge plan to handle

floor and intensive care unit (ICU) cases.

A central COVID-19 hospital command center was acti-

vated with a team of 90 key hospital clinical and nonclinical

leaders to coordinate the overall effort across the system of 3

hospitals and affiliated regional sites. Twice-daily hour-long

briefings were initiated to review the caseload of system

COVID-19 cases and system readiness in regard to personnel

and resources, as well as local, regional, and national infec-

tion trends. The institution started daily system updates to

apprise all employees on case numbers and related critical

updates.

The ED was converted to handle coronavirus cases to

mitigate risks to providers and patients in the direct line of

initial exposure. The ambulance bay was converted into a

COVID-19 triage center to manage any patients exhibiting

coronavirus-like symptoms. Potentially infected patients

were assessed in private screening tents for vitals, medical

history, and COVID-19 testing. Any potential cases requir-

ing admission to the general floor or ICU were directed to

the 20-bed ED pod with private negative-pressure rooms,

which were cordoned from the non–COVID-19 cases.

A separate coronavirus clinic in a stand-alone building, a

telehealth provider pool, and a drive-through testing site

for COVID-19–related care and testing were also implemen-

ted early to mitigate ED strain and potential staff and patient

exposures. Testing capabilities were quickly increased

through development of in-house testing as well as other pri-

vate and institutional partnerships. Testing triage and indica-

tions were reviewed daily and expanded as testing capacity

increased gradually over the course of the month. The intro-

duction of point-of-care (POC) testing greatly expanded the

capabilities by mid-April, especially in the ambulatory and

operative setting. As of April 28, 16,223 patients have been

screened across the Rush system since the beginning of the

COVID-19 outbreak, with 4243 (26.2%) testing positive.

A surge capacity plan was implemented on March 2 to

ensure adequate floor and ICU bed availability with the evo-

lution of the pandemic. Through optimization of physical

spaces and opening patient care units in nontraditional areas,

such as postanesthesia care units, the hospital increased addi-

tional beds by 73% for critical care patients and by 58% for

noncritical care patients. The total surge maximum capacity

included 142 ICU and 460 non-ICU dedicated COVID-19

beds. This enhanced ability to treating patients with

COVID-19 led to a significant increase in requests for trans-

fers across the greater Chicago area. The organization has

worked with hospitals across the region to selectively accept

referrals where expertise and resources at Rush could be

leveraged to handle difficult cases and to positively affect

patient outcomes. However, these transfers had to be care-

fully balanced to preserve an appropriate level of capacity

for incoming emergencies and non–COVID-19 cases within

the system. As of April 8, 2020, Rush has accounted for

18% of ICU COVID-19 beds and 68% of vented ICU cases

in the city of Chicago.

Batra et al 163

Departmental Reorganization

The entire otolaryngology department was reorganized into a

2-team structure, with each team being composed of 7 full-

time ENT faculty, 1 oral maxillofacial surgeon attending, 3

residents, and 1 inpatient advanced practice provider (Table 1). Call responsibilities were handled by each team, alternat- ing every other day, with a primary faculty member on call

and the remaining team members providing backup as

needed for subspecialty consults and emergent cases. A

single pager number was assigned to the rotating attendings

on call, and sign-out was performed attending to attending

each morning to maintain continuity of care on the service.

This strategy would mitigate the need to have 1 individual

on call for a long stretch of days. Furthermore, this would

allow 2 fully staffed subspecialty services to work clinically

apart to ensure continuity of services and redundancy within

the department, in case there was any viral exposure to the

providers. The lead team would also provide coverage for

surge capacity to the ED, inpatient floors, and ICUs as

needed to support frontline providers. Communication was

strengthened across the department to ensure alignment

among faculty, residents, administrators, and staff. Weekly

web-based faculty meetings were implemented in addition to

regular email communications from the chair, medical direc-

tor, program director, and practice administrator.

Surgical Case Management and Inpatient Care

In accordance with guidance from the Centers for Disease

Control and Prevention, the American College of Surgeons,

and the Illinois Department of Public Health, all nonemer-

gent or elective surgery was canceled starting March

16, 2020, at Rush. From an institutional perspective, this

would allow physicians and nurses to focus on the pandemic

response. In addition, this would allow operating rooms

(ORs) and perioperative spaces to be repurposed during the

potential surge of patients with COVID-19 and to conserve

personal protective equipment (PPE) and redeploy ventila-

tors to other patient care areas as needed. A departmental

surgical prioritization list was developed to classify cases

into emergent (next available OR, 3-6 hours) and time criti-

cal urgent (1-2 weeks; Table 2). When oncologic cases were scheduled, the surgical plan and potential adjuvant treatment

implications were carefully reviewed at the weekly multidis-

ciplinary tumor board. Treatment preceded with a focus on

complete and efficient care while limiting utilization of

inpatient resources, patient length of stay, and potential

exposure risks to this immunocompromised population. This

process was also in accordance with the American College

of Surgeons’‘‘COVID-19 Guidelines for Triage of Cancer

Surgery Patients.’’ 6

The final list was circulated to the perio-

perative services leadership to ensure timely access to care

for critical cases emerging during this period. All other

patients from previously scheduled elective cases were per-

sonally contacted by their surgeon to postpone or reschedule

these procedures.

All urgent and time-critical elective cases were reviewed

by the chair, vice chair, and patient safety officer to ensure

that they were deemed appropriate for personnel and

resource utilization and subsequently forwarded to the insti-

tutional surgical leadership for posting. Given the high risk

of viral shedding in the upper aerodigestive tract, all patients

with mucosal cases involving the nose, paranasal sinuses,

nasopharynx, oral cavity, oropharynx, larynx, and hypophar-

ynx would undergo preoperative COVID-19 testing 2 to 3

days prior to surgery. By April 9, POC testing was available

in the OR for all surgical cases and would facilitate the abil-

ity to perform 2 sequential tests and confirm negative results

2 to 3 days apart prior to surgery. This was deemed manda-

tory for all upper aerodigestive tract cases with high risk of

aerosolization. Despite negative test results, all surgeons,

anesthesia, and staff would wear N95 respirators in addition

to standard PPE for invasive mucosal cases with high risk

of aerosolization. PPE recommendations were reviewed

daily; video demonstrations were created and posted for

hospital-wide access; and provider simulation of PPE don-

ning and doffing was offered. Prior to clustering of cases in

the community, our department adjusted PPE recommenda-

tions and endoscopy indications for inpatient consultations

in anticipation of unrecognized admitted cases. Rounding

teams were split, and personnel limitations were created for

patient interactions to mitigate potential exposures.

Tracheostomy Protocol Development

The department also developed a tracheostomy protocol in

conjunction with key stakeholders across the institution,

including general surgery, critical care, anesthesia, infection

control, OR nursing, and respiratory therapy. This was

implemented on April 1, 2020, to provide a standardized

care pathway, maintenance of infection control, safety of

Table 1. Departmental Reorganization Structure to Manage the COVID-19 Crisis.

Team A Team B

Department chair and lead coordinator

Team leader 1 Team leader 2

Faculty

Rhinology 1 Rhinology 2

Head and neck 1 Head and neck 2

Otology/neurotology 1 Otology/neurotology 2

Facial plastics 1 Facial plastics 2

General main campus 1 General main campus 2

General off-site 1 General off-site 2

General/peds oto 1 General/peds oto 2

Oral surgery 1 Oral surgery 2

Residents/APPs

Senior resident 1 Senior resident 2

Junior resident 1 Junior resident 2

Junior resident 1 Junior resident 2

Inpatient PA 1 Inpatient PA 2

Abbreviations: APP, advanced practice provider; PA, physician assistant; peds

oto, pediatric otolaryngology.

164 Otolaryngology–Head and Neck Surgery 163(1)

providers, and optimization of patient care outcomes for

intubated patients with COVID-19. Percutaneous and bed-

side/OR open tracheostomy was part of the care pathway,

dependent on patient factors and provider considerations.

Given the high risk of aerosolization in these potentially posi-

tive cases of COVID-19, a specific type of powered air-

purifying respirator, termed controlled air-purifying respirator

(CAPR; MAXAIR), was utilized. The CAPR integrates the

motor, fan, filter, and controlled air flow mechanism directly in

a lightweight helmet, thus eliminating the need for the breath-

ing tube connected to a belt-mounted unit. This minimizes the

need for rigorous cleaning procedures required with the pow-

ered air-purifying respirator and improves physician maneuver-

ability during the procedure. The Rush University Medical

Center tracheostomy protocol is available as Table 3.

Ambulatory Practice Management

By March 1, 2020, all patients presenting to the ambulatory

sites, including the main campus and 3 regional sites, were

thoroughly screened for symptoms and foreign travel.

With progressive community outbreak, this screening was no

longer considered reliable. By mid-March, all elective in-

person clinic visits and office procedures were gradually

converted to virtual video or telephone visits for new and

established patients to maintain continuity of patient care.

All physicians reviewed their upcoming schedules and

marked appointments to be rescheduled, converted to a tele-

health visit, or seen in person (if critical). During the base-

line week prior to implementation, 730 in-person office

visits were conducted at the main campus and regional sites.

After a 3-week transition period with conversion to digital

video and telephone visits, 297 total visits were performed,

including 43 in person (14.5%), 97 by telephone (32.7%),

and 157 by video (52.9%). In-person outpatient visits were

available to patients deemed important for urgent examina-

tion, especially for the vulnerable head and neck cancer pop-

ulation or patients in the immediate postoperative period.

Audiology services were significantly curtailed, with provi-

sion only when testing outcome could significantly affect

care decisions, such as sudden sensorineural hearing loss.

Prior to conversion to the virtual platform and continued

throughout were strategies to protect providers and support

and administrative staff. These included twice-daily symp-

tom and temperature checks, spacing of work stations, social

Table 2. List of Emergent and Time-Critical Urgent Cases During the COVID-19 Crisis for Adult and Pediatric Patients.

Emergent (next available OR) � Acute airway obstruction � Airway foreign body � Angioedema � Deep space neck abscess with airway involvement � Free flap compromise � Neck hematoma � Necrotizing fasciitis � Orbital hematoma � Penetrating neck trauma � Postoperative hemorrhage with hemodynamic instability � Posttonsillectomy hemorrhage

Emergent (to OR in 3-6 h) � Acute invasive fungal sinusitis � Acute mastoiditis with complications � Bilateral mandible fracture with instability � Esophageal foreign body � I&D deep neck abscess � Orbital abscess � Orbital fracture with entrapment

Time-critical urgent

surgery (1-2 wk)

� Advanced-stage head and neck cancer ablative and reconstructive surgery � Benign skull base/head and neck tumors with significant symptoms or concern for permanent

neurologic injury (eg, acoustic neuroma, pituitary adenoma, paraganglioma)

� CSF leaks/encephaloceles repair with complications � Maxillofacial trauma � Pending or progressive airway compromise � ENT surgery where delay .1 mo may cause permanent neurosensory deficit (eg, sinus disease

causing orbital/skull base compression, chronic ear disease with facial weakness or inner ear

erosion)

� Other clinical scenarios where delay in care could cause significant compromise of patient health, to be approved by departmental surgery review team

Abbreviations: CSF, cerebrospinal fluid; ENT, ear, nose, and throat; I&D, incision and drainage; OR, operating room.

Batra et al 165

Table 3. Rush University Medical Center COVID-19 Tracheostomy Protocol.

Background Due to the COVID-19 pandemic, a dedicated tracheostomy protocol is being implemented for the

purposes of a standardized care pathway, maintenance of infection control, provider safety, and

optimization of patient care outcomes.

Protocol development Coordination and development of the protocol done after consultation with representatives from

otolaryngology, general surgery, critical care, anesthesia, infection control, OR nursing, and

respiratory therapy. Additional literature review of SARS experience conducted by team.

Unpublished data from Wuhan hospitals reviewed.

Indications for surgery Currently there is no available evidence to support early or aggressive tracheostomy for patients

with COVID-19. In fact, early anecdotal evidence from China demonstrates a very low rate of

tracheostomy overall in patients with COVID-19. Concerns about the procedure center on

intra- and postoperative infection control, care provider safety, post–hospital care setting

availability (LTAC), patient safety related to prone positioning, and ultimate effect on mortality

outcomes. Therefore, initial protocols will focus on limited consideration of tracheostomy after

careful individual patient consideration.

� Mechanical ventilation .14-21 d � FiO2 \50% � PEEP \8-10 � PIP \ 30 � Not requiring high-dose vasoactive agent and/or .1 vasopressor � Absence of uncontrolled dysrhythmia � Absence of severe acidosis � INR \1.5 � Platelets .100k � No anatomic contraindications � Availability of recommended PPE � COVID-19 PCR testing that is negative 2 times before surgery. If testing is positive,

surgical and medical teams will discuss risks and benefits of surgery, taking into account all

medical, safety, and infection control factors.

Setting/technique � Initial technique consideration will be to perform percutaneous tracheostomy. � If contraindicated medically or due to other limitations, open technique will be performed. � Bedside technique vs OR after consideration of medical status, including COVID-19 testing.

Staff (bedside): percutaneous

tracheostomy

� Attending physician � Resident/fellow physician � Unit nurse inside room � Clean RT inside room for postoperative care

Staff (bedside): open tracheostomy � Anesthesia � Attending surgeon � Resident surgeon � OR scrub nurse in room � Clean nurse unit nurse outside room � Clean RT outside room for postoperative care

Staff (OR): open tracheostomy � Anesthesia � Attending surgeon � Resident surgeon � OR scrub nurse in room � Circulating RN in room

Preoperative preparation � Overhead lights and portable headlight inside hood � Neck extension with shoulder roll � Paralyzed, 100% FiO2 � Inject site with 1% lidocaine with 1:100,000 epinephrine � Neck: sterile preparation with face exposed for ETT access � Enhanced PPE: surgical gowns, double gloves, PAPR hoods, shoe covers � Tracheostomy tray, Bovie machine and equipment, OR pack

(continued)

166 Otolaryngology–Head and Neck Surgery 163(1)

distancing of breakroom activities, staggering of examina-

tion room utilization to allow for cleaning, movement of

high-risk employees (immunosuppression, comorbidities)

away from patient-facing interactions, and frequent review

of PPE and protocols for any patients suspected of having

COVID-19. Additionally, through the institutional command

center structure, select staff volunteered and were reassigned

to other clinical areas as needs for COVID-19–related care

increased.

With a significant drop in outpatient clinic volume (40%

of baseline), provider schedules and templates were consoli-

dated to our main campus with focused access at regional

sites to more effectively utilize clinic personnel and to limit

foot traffic to clinical areas. Upper airway endoscopy was

performed only when deemed absolutely necessary to guide

clinical decision making. Full PPE with N95 respirator was

utilized for endoscopy, irrespective of the COVID-19 status

of the patient.

Clinical providers were able to successfully engage

patients via the video platform for most elective and many

urgent issues. The initial screening allowed for subsequent

in-person visit for pressing urgent matters as needed. With

more widespread availability of COVID-19 testing at the

POC, within 1 month of implementation of the virtual plat-

form, the faculty practice has now designated 2 off-sites, in

the city (Rush South Loop) and a suburb (Rush Oak Brook),

as ‘‘safe sites’’ to allow for in-person evaluations for urgent

patient care issues. These patients undergo COVID-19 symp-

tom screening at the time of appointment scheduling, 24

hours prior to appointment, and on the day of appointment.

All ENT patients also undergo POC testing for COVID-19

and are evaluated in person if testing is negative. This strat-

egy will allow for more optimal management of urgent

patient issues while maintaining rigorous safeguards for pro-

vider and patient safety. Several email communications were

sent to our entire patient base and referring physicians,

informing them of their options for care and consultations

during the pandemic.

Residency Program/Education

The substantial decrease in surgical cases and outpatient

volume has adversely affected the overall training opportu-

nity for residents. However, the overall engagement into a

departmental and institutional response to an evolving global

pandemic provided an unparalleled opportunity to engage

trainees in a system-based practice format for disaster man-

agement. As mentioned, all residents were designated to

teams A and B in conjunction with the faculty. One senior

resident would lead each resident team and provide night-

time backup coverage to the junior residents on call. The

off-call team would not be required to be on-site to reduce

potential exposure to patients at the institution and the other

team. The postgraduate year 1 and 2 residents (PGY-1 and

PGY-2) were also available to assist in the ED and ICU set-

ting as required during the surge plans.

All teaching sessions, including lectures, morbidity and

mortality conference, and tumor board, were transitioned to

a virtual format via the WebEx platform. Over the initial

month, weekly faculty/resident sessions were conducted to

communicate the reorganized departmental structure, review

newly implemented clinical and OR policies, and address

provider concerns. These educational sessions integrated

review of the most recent literature and recommendations

regarding COVID-19 diagnosis, treatment, safety, and dis-

ease course to ensure dissemination of the highest available

scientific evidence. These sessions also served to promote

engagement, to allay anxiety due to the rapid changes, and

to build camaraderie among the team members. Quality ini-

tiative projects were also implemented to support the overall

organizational effort for COVID-19. Simulation training was

conducted for faculty, residents, and nurses to guide proper

donning and doffing of CAPR for airway procedures and

proper technique for nasal and nasopharyngeal swabbing for

COVID-19 testing.

On March 27, 2020, the institution declared a stage 3 pan-

demic status under the existing extraordinary circumstances

policy of the ACGME (Accreditation Council for Graduate

Table 3. (continued)

Intraoperative considerations � FiO2 \30% when incising trachea � Ventilation held when cuff is deflated or when incising trachea � Consider Steri (1010) drape coverage when incising trachea

Postoperative respiratory care � HME . T-piece . tracheostomy collar � T-piece preferred over tracheostomy collar � Inline suction only � Maintain cuff pressure 25-30 cm H2O � Minimize bronchial hygiene: no HyperSal � No prone position

Transfers from outside hospitals Transfers with ‘‘reason for transfer: tracheostomy in COVID-19’’ will be accepted from outside

hospitals only if they meet the indications for surgery after consultation with the surgeon and

ICU attending.

Abbreviations: ETT, endotracheal tube; HME, heat moisture exchanger; ICU, intensive care unit; INR, international normalized ratio; LTAC, long-term acute

care; OR, operating room; PAPR, powered air-purifying respirator; PCR, polymerase chain reaction; PEEP, positive end expiratory pressure; PIP, peak inspira-

tory pressure; PPE, personal protective equipment; SARS, severe acute respiratory syndrome; RN, registered nurse; RT, respiratory therapy.

Batra et al 167

Medical Education) with a 30-day expiration to be reconsid-

ered for extension at that time. Rush was the first institution

in the Chicago region to make this declaration due to the

high volume of patients with COVID-19 being treated at the

medical center. This declaration allowed for great flexibility

in the training environment—most notably, the redeploy-

ment of residents to the COVID-19 surge units. All ACGME

program requirements were temporarily waived, with the

exception of PPE resources/training, supervision, and work

hour requirements. During the initial 3 weeks, 4 otolaryngol-

ogy residents were deployed to a surge unit in the ED with

the purpose of providing direct otolaryngology-related care

to offload the ED staff to primarily care for patients with

COVID-19. This need quickly reduced and shifted toward

inpatient needs after the first week of the patient surge.

Critical care platforms soon became the most utilized

resource across the institution. Medical specialty residents

were fully utilized on inpatient hospital medicine units and

existing medical critical care units. The hospital quickly con-

verted additional surge ICU beds that were staffed by surgi-

cal residents under supervision by a critical care attending.

Two otolaryngology residents have participated in 1-week

rotations on these units to date.

Research Efforts

Research remains a core component of our academic mis-

sion. At the time of the pandemic, the department had more

than a dozen head and neck oncology, rhinology, sleep, and

otology clinical trials in different phases of progression. To

mitigate risks to patients, all in-person visits were postponed

and follow-up transitioned to telephone visits. New clinical

trials and new patient enrollment were temporarily halted

until stabilization of the pandemic and to allow providers to

focus on COVID-19–related efforts. Multiple retrospective

and prospective clinical studies were designed in close colla-

boration between departmental faculty and residents to

investigate the impact of coronavirus on otolaryngology

care. Specific efforts include investigations into smell and

taste dysfunction in COVID-19 as well as detailed analysis

of innovative workflow changes involving POC COVID-19

testing. Additionally, results of simulation-based training

initiatives were formalized and submitted for publication.

Discussion

The evolving pandemic has challenged the provision of oto-

laryngology care globally in an unmatched manner. The

elective nature of much of our specialty has resulted in a

drastic reduction of the ambulatory clinic and operative

volumes so that personnel and resources can be appropriately

diverted to support providers on the frontline of battling the

COVID-19 pandemic. However, this also represents a

unique opportunity to recalibrate the clinical and academic

goals of departments to align with the mission of their home

institutions and local communities to meet the greater needs

of the population in this extraordinary time. Most academic

medical centers represent complex matrixed organizations

where change management can be difficult and often slow

due to multiple stakeholders and complex rules and regula-

tions. Within 3 weeks, the entire health care system was able

to transform the physical space and repurpose personnel to

meet the challenges of the emerging pandemic. In parallel,

the department was reorganized with a complete shift in focus

to continue to provide essential ENT services but also meet

the institutional needs in the broader context of the COVID-

19 pandemic. The key departmental initiatives included (1)

reorganization of the department into a 2-team structure for

call and surge redeployment, (2) cessation of elective surgery

and creation of an emergent and time-critical urgent case list,

(3) transition of in-person visits to the virtual video platform

and creation of safe regional sites, (4) adaptation of a web-

based platform for weekly departmental meetings and edu-

cational conferences, (5) maintenance of patient engage-

ment with close frequent communication to existing and

potentially new patients on availability for telehealth and

in-person options, and (6) refocus of research efforts to

COVID-19–related projects.

Despite the rapid nature of the required changes, the over-

all engagement of the faculty, trainees, and staff has

remained high as they have shifted their efforts to meet the

new demands and challenges posed by the health crisis. This

magnitude of change is possible only through continuous

involvement and input from all stakeholders and constant

communication through formal meetings and informal touch

points. As it stands, this study is largely process driven and

lacks data on specific outcomes of the implemented changes.

Five studies are currently underway to assess the impact of

the myriad changes, including the aforementioned simulation

projects and POC testing in the operative and ambulatory

environment. Two manuscripts have already been submitted

to Otolaryngology–Head and Neck Surgery: one on simula-

tion training to guide proper donning and doffing of CAPR

for airway procedures and the other on the impact of POC

testing in the OR.

Conclusion

This article outlines the implementation strategy of changes

required to the departmental structure and delivery of care

during the emerging pandemic. The changes implemented

weighed the competing priorities of the departmental provi-

sion of otolaryngology care with the institutional priorities

for pandemic management, with the prime directive being to

preserve the health and safety of the workforce. This can

serve as a template for other academic departments and

group practices nationally and internationally to meet these

new unmet challenges, since the infection will peak at differ-

ing times in various parts of the world and thus disrupt deliv-

ery of care in an asynchronous manner.

Author Contributions

Pete S. Batra, substantial contributions to conception and design,

drafting the manuscript, final approval, and accountability for all aspects

of the work; Phillip S. LoSavio, critical review/revision, final approval;

Elias Michaelides, critical review/revision, final approval; Peter C.

Revenaugh, critical review/revision, final approval; Bobby A.

168 Otolaryngology–Head and Neck Surgery 163(1)

Tajudeen, critical review/revision, final approval; Samer Al-khudari,

critical review/revision, final approval; Inna Husain, critical review/revi-

sion, final approval; Peter Papagiannopoulos, critical review/revision,

final approval; Ryan Smith, critical review/revision, final approval;

Kerstin M. Stenson, critical review/revision, final approval; R. Mark

Wiet, critical review/revision, final approval.

Disclosures

Competing interests: None.

Sponsorships: None.

Funding source: None.

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