What do we know about this issue?

The COVlD-i9/SARS-CoV-2 pandemic has had a significant impact on the professional and personal lives of all healthcare, practitioners, affecting their mental and physical health, and their overall wellbeing.

What does this study contribute with?

This study provides and objective represent of the claims that the pandemic has affected healthcare workers, and is an initial approach to the situation arising in Colombia and affecting anesthesiology practitioners as a result of the pandemic.

INTRODUCTION

The COVID-19 pandemic has affected over 200 countries around the world and it is characterized by being highly contagious. Among the population groups with the highest risk of exposure is the medical staff. ¹ In Colombia, as of June 10, 2021, the number of COVID-19 cases among healthcare personnel was 59,750 confirmed cases and 286 deaths. Comparing against the general population which represented 3,665,137 confirmed cases, the percentage of infected people among the healthcare personnel is 1.6 % in terms of the Colombian population. ² Among physicians, those who perform procedures manipulating the airway are at higher risk of contagion mostly due to their exposure to drops and aerosols, which are the primary source of transmission ^1,3-5; anesthesiologists are part of this group of doctors. The practice of anesthesiology during the COVID-19 pandemic does not only present a higher biological risk, but also involves a strong psychological and emotional impact on workload and wellbeing. ^6-8 Hence, it is befitting to describe the impact of this event on aspects such as safety and work-related burden of anesthesiologists, as well as the ethical dilemmas they have dealt with in their practice during the COVID-19 pandemic in Colombia. The purpose of this study was to identify the various situations involving the anesthesiologists certified by the Ministry of Education and members of the Colombian Society of Anesthesiology and Resuscitation (S.C.A.R.E.) during the pandemic.

METHODS

Observational, descriptive, cross-sectional study based on a survey designed by the authors. The survey questions enquire about work days, occupational safety, standards and prevention strategies, and ethical aspects involved in decision-making throughout the COVID-19 pandemic.

The study population included medical doctors specialized in anesthesiology, members of the Colombian Society of Anesthesiology and Resuscitation (S.C.A.R.E) who practice or had clinical activity during the COVID-19 pandemic (all the anesthesiologists who are members of S.C.A.R.E. are licensed to practice in the Colombian territory). All members who expressed their willingness to participate gave their authorization by submitting their informed consent attached to the survey questionnaire. The anesthesiologists who said they were not in clinical practice during the SARS-CoV-2/COVID-19 pandemic were excluded.

The survey (supplement material) was e-mailed to 2,896 members using the QuestionPro platform on March 26, 2021; there was a second e-mail reminder on April 5, 2021. The e-mail was an invitation to participate and included the link to access the survey. When opening the link, there was an introduction describing the purpose of the study and the informed consent form. If a participant agreed to complete the survey, at the end of the introduction, his/her acceptance allowed access to the questions and enabled the answers; otherwise, the page would close.

Based on an estimated response rate of at least 50 %, with a 95% confidence level, the sample size was estimated at 341, which adjusted by potential losses, represented 409 participants. The information was analyzed using the STATA version 13 software. The information compiled allowed for a descriptive analysis, summary and dispersion measures were used to present the information according to the distribution of the data. Since this was an observational, descriptive study, no a priori statistical hypothesis was considered.

To ensure anonymity, the survey did not require any personal information from the participants. Pursuant to Resolution 008430 of 1993 of the Ministry of Health, this research was considered free of risk to the participants and the associated information was privately managed so the data of the participants was not shared with the public, and there was no intervention or transformation of the biological, physiological, psychological or social variables of the subjects participating in the research.

RESULTS

There was a sample of 219 professionals who completed the survey, of which 218 said they had performed clinical activities during the SARS-CoV-2 pandemic. The sample obtained failed to meet the estimated size, hence it is not considered to be representative of the population; the margin of error was estimated at 6 %, and the confidence level was estimated at 95 %.

The mean age of the specialists who completed the survey was 47 years, (IQR: 3857 years). In terms of gender, 93 participants (42.6 %) were females.

Initially the respondents were asked to identify the area in which they practiced, and 213 participants (97 %) said anesthesia/ surgery rooms/perioperative, followed by critical care with 40 participants (18.3 %); outpatient anesthesia 102 participants (46.7 %), palliative care/pain medicine 15 participants (6.8 %), and other options such as sedation outside the OR, administrative and pre-anesthesia consultation in the hospital floors, cath-lab and electrophysiology, emergency department, inter alia. Another question enquired about how long they had been practicing anesthesiology and 78 participants (35.7 %) said between 5-10 years, followed by 21-30 years (30.7 %), 11-20 years (23.3 %) and finally 31 years or more (10 %).

86 (39.45 %) of the participants said they worked at two institutions - this was the most frequent answer -, followed by 75 (34.40 %) at one institution; 45 (20.64 %), at three institutions, and 12 (5.50 %), in more than three institutions.

When asked about whether they had any health disorders, 112 participants (51.37 %) said no; the rest of them have a disease and the most frequent conditions were high blood pressure and obesity with 34 participants (15.59 %) each. Other comorbidities included asthma (9.17 %), hypothyroidism (5.5 %), diabetes (3.2 %), smoking (2.7 %), and arrhythmias (1.8 %), inter alia.

The work hours of the participants during the pandemic ranged between 48 to 60 hours per week in 44.50 % (n = 97), less than 48 hours per week 20.18 % (n = 44), between 61 and 72 hours 20.18 % (n = 44), between 73 and 84 hours per week 9.17 % (n = 20) and more than 84 hours per week 5.96 % (n = 13). In contrast, the number of pre-pandemic work hours is illustrated in Table 1, and shows that although the percentage of practitioners who feel that the workload was not significantly increased, when differentiating these data based on the care area, 42.5 % (n = 17) of the critical care doctors reported an excessive workload and these are the largest percentage.

With regards to the perception about leisure time for rest, recreational activities, etc., 55.96 % (n = 122) of the population feels that leisure time is insufficient; moreover, 78.44 % (n = 171) report tiredness, fatigue, stress, depression or anxiety as a result of their work during the pandemic.

In terms of the perception of lack of safety and contagion risk exposure of both practitioners and their social and family circles, 55.95% (n=122) of the population surveyed feel moderately safe, versus 35.32 % (n = 77) who feel safe and 8,72 % (n = 19) who feel unsafe.

Similarly, the majority feels that they are at a higher risk of contagion as compared to other healthcare professionals and that they represent a higher risk of contagion for their friends and families; hence they have been forced to isolate themselves to avoid such contagion, as shown in Figure 1.

Source: Authors.

Figure 1 Perception versus workload and lack of safety. 

With regards to the perception of safety versus contagion, a large percentage of the population said they received PPE at their job and most of them feel that these PPEs are sufficient and good quality; however, 72.9 % (n = 159) expressed they used their own money to pay for their PPEs (Figure 2).

Source: Authors.

Figure 2 Perception about biosecurity. 

In terms of the perception about the standards and biosecurity protocols in the work areas, most of the population felt these were appropriate. In contrast, in terms of compliance with the protocols in the common areas, a significant percentage feels that it fails to contribute to the prevention of COVID-19 (Table 2).

The results with regards to resource and materials management during the SARS-CoV-2 pandemic and ethical conflicts are illustrated in Table 3. The ethical and personal repercussions on the job of the anesthesiologist during the SAR-CoV-2 pandemic are listed in Table 4.

DISCUSSION

The broad knowledge of anesthesiologists on respiratory anatomy and physiology has strengthened their professional practice during the SARS-CoV-2 pandemic, since they have become more valued first-line practitioners because of their broad experience and skills in the management of the airway and care of the critical patient. However, this involves many risks which in the end result in more stress and a significant impact on personal life. ⁹ This trend has been observed in all healthcare workers, with a 52.8 % of burnout associated with the pandemic, among the population in a case series. ¹⁰

Another trial found that the first line medical personnel had a lower frequency of burnout (13 %), as compared with those usually working in hospitalization (39 %). ínl Similarly, a study by Dimitru et al. reported a 66% prevalence of burnout among first line workers and 86 % among the conventional hospitalization personnel. ¹². Both studies suggested the hypothesis that this unusual trend was because first line workers experienced a stronger sense of belonging and control of the situation. ^11,12 Our study delved into whether the workload has been excessive and/or detrimental, and we found that two thirds of the respondents do not share this view. Associating these percentages with their areas of service, it was possible to conclude that the practitioners working in critical care (since several anesthesiologists were transferred from the OR to the ICUs) are the ones who perceive an excessive and/or detrimental workload increase during the pandemic. Similarly, the respondents feel that the work hours have increased by over one third as compared to the pre-pandemic period. Hence, it may be suggested that although the work hours have increased, in most cases it has not been excessive and/or detrimental.

Anesthesiologists have been negatively affected by the SARS-CoV-2 pandemic due to increase in the flow of patients requiring sedation and invasive mechanical ventilation protocols. This has led to the transfer of these practitioners from their usual activities in the operating room, to critical care units (ICUs). Moreover, many procedures must be conducted in confirmed SARS-CoV-2 infected patients, which represents an even more stressful situation for the anesthesiologist. ¹³ Anesthesiologists have been summoned outside the OR to intubate critical patients, and to take shifts in the ICUs. ¹⁴ The American Society of Anesthesiologists (ASA) conducted a survey similar to ours, finding that many anesthesiologists were transferred from the OR to the ICU, to assist with intubation, ventilation strategies, and all aspects involved in multiple organ failure. ¹⁵ Furthermore, the anesthesiologists that were recruited to work as first line, reported that they worked longer hours, in an unpredictable and irregular fashion. Also, some of them experienced a shortage of PPEs, even during endotracheal intubation procedures or while manipulating the ventilators. ¹⁶

In our population, with regards to the perception of the level of on-the-job safety, the findings showed that a large percentage of the practitioners surveyed feel moderately safe (55.9 %, n = 122). Such perception may be influenced by variables associated with biosecurity aspects implemented in their institutions; one of them is the supply of PPE. Around 94.1 % (n = 205) feel that the PPE are adequate for a safe performance of the anesthesiologist; likewise, a high percentage said that the PPE were sufficient in terms of quantity and quality. However, when asked about the need to use their own resources, 72.9 % (n = 159) said they had to use their own money to pay for their PPE. This situation could be the result of the Occupational Hazard Administrators (OHA) early in the pandemic, which proved to be insufficient for delivering PPE to the professional personnel. This situation led to the need to use their own resources to buy those equipment, particularly among the practitioners working in anesthesiology who were in a more direct contact with aerosols.

Two main components were analyzed in this category: the lack of safety in the hospital setting and the risk of such hospital exposure for the social environment of the anesthesiologist. In terms of the in-hospital environment, 87.6 % (n = 191) of the practitioners feel they have a higher risk of contagion by SARS-COV-2, versus other healthcare professionals; likewise, 94 % (n = 205) considers this a risk for their social environment (family, friends, etc.). This may be partially explained by the procedures that the anesthesiologist is required to conduct, which involve higher aerosol exposure than healthcare professionals working in other areas. Consequently, 66 % (n = 144) said they had to isolate themselves from their families to prevent contagion and this is a situation that may impact their mental health in the short, medium and long term.

This is evidence of the lack of logistics in terms of adequate institutional protocols to provide an optimal work environment for their professionals. Similarly, 68.3 % (n = 149) of the respondents said the OHA performance was untimely. This shows a lack of strategies to ensure the safety of healthcare practitioners who work or have worked during the pandemic.

Similarly, from the extra-institutional perspective, anesthesiologists have also perceived lack of safety. The study identified that 13.7 % (n = 30) have been victims of some sort of discrimination or threat due to their work during the pandemic. According to a report from the Ministry of Health, as of October 2020, 242 attacks had been reported against healthcare professionals in Colombia - the highest rate in 20 years -which represents a 63% increase versus the same period in the previous year. ¹⁷ These findings are alarming, notwithstanding the low proportion, and directly impact personnel safety, with an additional psychological burden and higher risks as a result of such events. Finally, despite the obvious bio-psycho-social impact of the pandemic on anesthesiologists, 66 % (n = 144) of them feel that they have not been timely and adequately remunerated.

In terms of the results obtained with regards to ethical dilemmas, the findings showed that more than fifty percent of the respondents had sufficient resources and medical equipment to deliver proper patient care. Moreover, they agreed with the health resources prioritization strategies. Though half of them said that the shortage of resources during the pandemic involved difficult decision-making, apparently none of the participants were involved in ethical dilemmas difficult to deal with.

With regards to clinical decision-making by healthcare practitioners during the pandemic, there is a large percentage of anesthesiologists who had to make decisions contrary to their own set of values; they also said they made wrong medical decisions. Moreover, half of them felt that the decisions made in terms of prioritizing resources to take care of patients during the pandemic did not exceed their professional and personal abilities. Additionally, around one half of the respondents said that they did not have to deny access to patients to the ICU because of lack of medical resources. However, a number of participants (n = 21, 9,63 %) did say that they were forced to prioritize patients for the allocation of ventilators for SARS-CoV-2 patients.

In terms of the emotional burden experienced by the respondents, approximately fifty percent feel that the lack of experience with regards to the pandemic makes decision-making difficult; they also believe that in order to tolerate the work during the months of the pandemic, they had to become less empathetic and experienced difficulties in the interaction with the surgical team, while delivering care to a SARS-CoV-2 infected patient. In particular, one fourth of the respondents had faced some sort of ethical dilemma when deciding whether to resuscitate or not SARS-CoV-2 infected patients. So it was clear that most of the respondents believe that they have been affected in terms of decision-making processes, with regards to resource availability, the quality of care provided and the emotional demand experienced. However, it should be noted that a number of respondents were affected in terms of what they considered the right decision, or decisions that infringed their ethical professional values.

Some of the limitations of the study include the variability in the time window during which the surveys were administered, considering that the saturation of healthcare services has been heterogenous among the various cities and in terms of the epidemiological peaks. Moreover, the estimated sample size was not accomplished and the questionnaire was not subject to a formal validation process. Therefore, it is difficult to generalize the answers obtained and the sample may not be representative of the population of Colombian anesthesiologists. However, the information collected maybe the foundation for further studies focused on a larger population of anesthesiologists, or addressed to other related groups, such as anesthesiology residents or trainees in the area, or for an initial approach to the situation that developed in Colombia as a consequence of the pandemic.

Finally, we believe that it is important to acknowledge the efforts made by many anesthesiologists worldwide, who work together with other medical professionals to assist in the treatment and management of patients affected by the SARS-CoV-2 virus.

ETHICAL RESPONSIBILITIES

ACKNOWLEDGEMENTS