CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 3, September – October 2024 156 AFRICA We set out to determine the impact of COVID-19 on patient contact in ambulatory and interventional procedures; to assess the impact on fellows’ didactic training episodes; and to determine the adaptive changes that have been introduced either proactively or reactively in order to mitigate these changes. Methods We reviewed hospital statistics and clinical training logbooks to establish the volume of out- and in-patient cardiovascular care and training episodes, both prior to and after the introduction of government measures. To account for seasonal variation, we chose two identical time points, one year apart (March–May 2019 vs March–May 2020). The AKUHN training programme is organised in six blocks, including (1) in-patient consultations and critical care unit coverage, (2) out-patient service, (3) ambulatory diagnostics, (4) invasive cardiology to include coronary and device therapy, (5) cardiovascular radiology, and (6) research. Rotations (1) to (4) are fixed blocks and have permanent fellow presence. Rotations (5) and (6) have fellows rotating intermittently. To ensure consistency, we evaluated the fixed blocks in which fellows rotated throughout every day of the year. The following characteristics were evaluated for each month for total cases versus trainee cases for the pre- and post-COVID-19 era: internal medicine out-patient episodes, cardiovascular out-patient episodes, cardiovascular admission numbers, cardiovascular consultations, transthoracic echocardiograms (TTE), coronary angiography, coronary intervention, device implantation, transoesophageal echocardiography, treadmill electrocardiography (ECG), tilt-table testing and 24-hour Holter ECG monitoring. Lecture and clinical presentation logs, research and journal club and clinical rounds logs were interrogated to identify the number of didactic teaching sessions delivered and to determine total attendance. Fellow training logs for each rotation were recorded. We looked only at hands-on exposure. We evaluated fellows in years two and three of the three-year fellowship programme. All fellows completed a questionnaire to determine changes in their rota structure (whether they had been redeployed) and to determine their views on whether the COVID-19 pandemic had a positive or negative impact on their training. Statistical analysis Data are presented as numbers and were analysed using Microsoft ExcelTM. Results The total number of in- and out-patient episodes in the cardiology service and the number of cardiac procedures performed during both periods are presented in Table 1. Both in- and out-patient clinical cardiovascular episodes dropped significantly (Fig. 1). The number of clinical episodes and procedures dropped significantly, in many cases by more than 50%, during the COVID-19 period in virtually all clinical scenarios, with an increase seen only for device implantation and Holter monitoring (Figs 2, 3). Figs 4 and 5 demonstrate the total number of cases/procedures performed by fellows during each specific rotation. In line with the reduced number of clinical episodes, we observed a reduction in the number of hands-on trainee procedures during COVID19. Four cardiology fellows fulfilled the inclusion criteria for both time periods and responded to the survey questionnaire. Their responses on the question regarding their training targets and expectations being met by the end of training are summarised in Table 2. With regard to the didactic instruction, all respondents noted a significant increase in the number of didactic classes during the time of COVID-19. They reported an average of three to four didactic sessions per week during the time of COVID-19, while teaching sessions occurred once to twice weekly in 2019. The official training schedule confirms an average of 3.5 weekly classes in 2020 compared with 1.8 in 2019. Many didactic sessions that had been scheduled for later in the year were brought forward in order to utilise the availability of the faculty and students. Moreover, respondents noted an increase in the provision of virtual local and international meetings and conferences, which supported their training positively. Table 1. Comparison of data volume for cardiac procedures and number of patients between March and May 2019 and March and May 2020 Procedures Pre-COVID COVID-19 In-patient visits 956 537 Out-patient visits 1696 668 Transthoracic echo 761 501 Holter monitoring 53 87 Ambulatory blood pressure monitoring 35 16 Treadmill ECG testing 164 62 Dobutamine stress echo 14 9 Tilt-table testing 7 5 Coronary angiography 181 95 PCI 57 42 Right (and left) heart catheterisation 4 3 Device implantations (pacemaker, ICD, CRT) 18 20 Transoesophageal echo 11 10 Dobutamine stress echo 14 9 PCI: percutaneous coronary intervention; ICD: implantable cardioverter defibrillation; CRT: cardiac resynchronisation therapy. March–May 2019 March–May 2020 Out-patient visits In-patient visits 1 800 1 600 1 400 1 200 1 000 800 600 400 200 0 Episodes Fig. 1. Comparison of in- and out-patient episodes between March and May 2019 and March and May 2020.
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