Models for Intensive Care Training. A European Perspective

Sustainability of the Subspecialty of Anesthesiology Critical Care: An Expert Consensus and Review of the Literature

While considerable literature exists with respect to clinical aspects of critical care anesthesiology (CCA) practice, few publications have focused on how anesthesiology-based critical care practices are organized and the challenges associated with the administration and management of anesthesiology critical care units. Currently, numerous challenges are affecting the sustainability of CCA practice, including decreased applications to fellowship positions and decreased reimbursement for critical care work. This review describes what is known about the subspecialty of CCA and leverages the experience of administrative leaders in adult critical care anesthesiologists in the United States to describe potential solutions.

Brief Comparative Analysis of Trauma Care Specialties in Europe and the United States

Understanding the variation in training and nuances of trauma provider practice between the countries in Europe and the United States is a daunting task. This article briefly reviews the key specialties of trauma care in Europe including emergency medical services (EMS), emergency medicine, anesthesia, trauma surgery, and critical care. The authors hope to inform U.S. military clinicians and medical planners of the major differences in emergency and trauma care that exist across Europe. Emergency medicine exists as both a primary specialty and a subspecialty across Europe, with varying stages of development as a specialty in each country. There is heavy physician involvement in EMS in much of Europe, with anesthesiologists having additional EMS training typically providing prehospital critical care. Because of the historical predominance of blunt trauma in Europe, in many countries, trauma surgery is a subspecialty with initial orthopedic surgery training versus general surgery. Intensive care medicine has various training pathways across Europe, but there have been great advances in standardizing competency requirements across the European Union. Finally, the authors suggest some strategies to mitigate the potential negative consequences of joint medical teams and how to leverage some key differences to advance life-saving medical interoperability across the North Atlantic Treaty Organization alliance.

Competency assessment of residents of Intensive Care Medicine through a simulation-based objective structured clinical evaluation (OSCE). A multicenter observational study

OBJECTIVES

The current official model of training in Intensive Care Medicine (ICM) in Spain is based on exposure to experiences through clinical rotations. The main objective was to determine the level of competency (I novice to V independent practitioner) achieved by the residents at the end of the 3rd year of training (R3) in ICM through a simulation-based OSCE. Secondary objectives were: (1) To identify gaps in performance, and (2) To investigate the reliability and feasibility of conducting simulation-based assessment at multiple sites.

DESIGN

Observational multicenter study.

SETTING

Thirteen Spanish ICU Departments.

PARTICIPANTS

Thirty six R3.

INTERVENTION

The participants performed on five, 15-min, high-fidelity crisis scenarios in four simulation centers. The performances were video recorded for later scoring by trained raters.

MAIN VARIABLES OF INTEREST

Via a Delphi technique, an independent panel of expert intensivists identified critical essential performance elements (CEPE) for each scenario to define the levels of competency.

RESULTS

A total of 176 performances were analyzed. The internal consistency of the check-lists were adequate (KR-20 range 0.64-0.79). Inter-rater reliability was strong [median Intraclass Correlation Coefficient across scenarios: 0.89 (0.65-0.97)]. Competency levels achieved by R3 were: Level I (18.8%), II (35.2%), III (42.6%), IV/V (3.4%). Overall, a great heterogeneity in performance was observed.

CONCLUSION

The expected level of competency after one year in the ICU was achieved only in half of the performances. A more evidence-based educational approach is needed. Multiple center simulation-based assessment showed feasibility and reliability as an evaluation method of competency.

TRIAL REGISTRATION

COBALIDATION. NCT04278976. (https://register.

CLINICALTRIALS

gov).

Motivations for and Challenges in the Development of Global Medical Curricula: A Scoping Review

PURPOSE

The aim of this scoping review is to understand the motivations for the creation of global medical curricula, summarize methods that have been used to create these curricula, and understand the perceived premises for the creation of these curricula.

METHOD

In 2018, the authors used a comprehensive search strategy to identify papers on existing efforts to create global medical curricula published from 1998 to March 29, 2018, in the following databases: MEDLINE; MEDLINE Epub Ahead of Print, In-Process, and Other Non-Indexed Citations; Embase; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; PsycINFO; CINAHL; ERIC; Scopus; African Index Medicus; and LILACS. There were no language restrictions. Two independent researchers applied the inclusion and exclusion criteria. Demographic data were abstracted from publications and summarized. The stated purposes, methods used for the development, stated motivations, and reported challenges of curricula were coded.

RESULTS

Of the 18,684 publications initially identified, 137 met inclusion criteria. The most common stated purposes for creating curricula were to define speciality-specific standards (50, 30%), to harmonize training standards (38, 23%), and to improve the quality or safety of training (31, 19%). The most common challenges were intercountry variation (including differences in health care systems, the operationalization of medical training, and sociocultural differences; 27, 20%), curricular implementation (20, 15%), and the need for a multistakeholder approach (6, 4%). Most curricula were developed by a social group (e.g., committee; 30, 45%) or Delphi or modified Delphi process (22, 33%).

CONCLUSIONS

The challenges of intercountry variation, the need for a multistakeholder approach, and curricular implementation need to be considered if concerns about curricular relevance are to be addressed. These challenges undoubtedly impact the uptake of global medical curricula and can only be addressed by explicit efforts to make curricula applicable to the realities of diverse health care settings.

Contemporary Academic Contributions From Anesthesiologists in Adult Critical Care Medicine

BACKGROUND

Anesthesiology has a long relationship with critical care medicine (CCM). However, US anesthesiologists are less likely to practice CCM than non-US anesthesiologists. To date, no studies have compared academic contributions in CCM between US anesthesiologists and non-US anesthesiologists. The objective of our study was to use recent trends in critical care publications as a surrogate for academic contribution among US and non-US anesthesiologists.

METHODS

Research articles published between 2010 and 2015 in 3 anesthesiology journals (Anesthesiology, Anesthesia & Analgesia, and British Journal of Anaesthesia) and 3 multidisciplinary CCM journals (Critical Care Medicine, Intensive Care Medicine, and Journal of Critical Care) were reviewed. Author information, including the primary department appointment and geographic location for the first and senior author(s), and article details, including topic and publication type, were collected. Odds ratios for having a first or senior author from the United States were calculated. Anesthesiologists' contributions in individual journals were summarized, as were trends in anesthesiology CCM publications during the 6-year study period.

RESULTS

A total of 3831 articles were reviewed, with 1050 (27.4%) having US authors. Eighty-two and one-half percent of CCM articles in anesthesiology journals had a US anesthesiologist as first author, and 81% had a US anesthesiologist as senior author, while fewer CCM articles in multidisciplinary journals had a US anesthesiologist as first (12.1%) or senior (12.3%) author. When considering all publications, 16.3% and 16.4% of articles had a US anesthesiologist as the first or senior author compared with articles for which non-US anesthesiologists were first (23.8%) or senior (20.9%) authors. The odds of having a US anesthesiologist as first or senior author compared to a non-US anesthesiologist for all publications were 0.6 (0.5-0.7) and 0.7 (0.6-0.9). The number of publications trended downward for both US anesthesiologists and non-US anesthesiologists during the study period.

CONCLUSIONS

When compared to non-US anesthesiologists, US anesthesiologists had more CCM publications in anesthesiology journals and fewer publications in multidisciplinary CCM journals. The number of anesthesiology CCM publications decreased for both US and non-US anesthesiologists throughout the study period.

Entrustable professional activities (EPAs) for postgraduate competency based intensive care medicine training in the Netherlands: The next step towards excellence in intensive care medicine training

INTRODUCTION

The Competency Based Training in Intensive Care Education (CoBaTrICE) programme developed common standards of ICM training by describing competencies of an intensivist. Entrustable Professional Activities (EPAs) of Intensive Care Medicine (ICM) (EPAsICM) are presented as a new workplace-based assessment tool in competency-based training of intensivists. EPAs are activities to be entrusted to a trainee once he (or she) has attained competence. EPAs emphasise the role of trust between trainees and supervisors. EPAs bridge the gap between competencies and competence.

METHODS

An expert panel of ICM (vice)programme directors and intensivists in The Netherlands integrated the CoBaTrICE and CanMEDS competencies into EPAsICM. Comment and feedback was sought from other ICM programme directors and educational experts and processed in the final version of EPAsICM before implementation in the Dutch ICM training programme.

RESULTS

A list of 15 EPAsICM are considered to reflect the spectrum of clinical practice while incorporating the competencies of CoBaTrICE and CanMEDS. The grading system is designed as a 5-point entrustment scale based on the amount of supervision a trainee needs, aligning with daily judgement of trainees by intensivists.

CONCLUSION

EPAsICM is an assessment tool that formalises entrustment decisions and can be a valuable addition in international ICM training.

Clinically relevant pharmacokinetic knowledge on antibiotic dosing among intensive care professionals is insufficient: a cross-sectional study

BACKGROUND

Antibiotic exposure in intensive care patients with sepsis is frequently inadequate and is associated with poorer outcomes. Antibiotic dosing is challenging in the intensive care, as critically ill patients have altered and fluctuating antibiotic pharmacokinetics that make current one-size-fits-all regimens unsatisfactory. Real-time bedside dosing software is not available yet, and therapeutic drug monitoring is typically used for few antibiotic classes and only allows for delayed dosing adaptation. Thus, adequate and timely antibiotic dosing continues to rely largely on the level of pharmacokinetic expertise in the ICU. Therefore, we set out to assess the level of knowledge on antibiotic pharmacokinetics among these intensive care professionals.

METHODS

In May 2018, we carried out a cross-sectional study by sending out an online survey on antibiotic dosing to more than 20,000 intensive care professionals. Questions were designed to cover relevant topics in pharmacokinetics related to intensive care antibiotic dosing. The preliminary pass mark was set by members of the examination committee for the European Diploma of Intensive Care using a modified Angoff approach. The final pass mark was corrected for clinical relevance as assessed for each question by international experts on pharmacokinetics.

RESULTS

A total of 1448 respondents completed the survey. Most of the respondents were intensivists (927 respondents, 64%) from 97 countries. Nearly all questions were considered clinically relevant by pharmacokinetic experts. The pass mark corrected for clinical relevance was 52.8 out of 93.7 points. Pass rates were 42.5% for intensivists, 36.1% for fellows, 24.8% for residents, and 5.8% for nurses. Scores without correction for clinical relevance were worse, indicating that respondents perform better on more relevant topics. Correct answers and concise clinical background are provided.

CONCLUSIONS

Clinically relevant pharmacokinetic knowledge on antibiotic dosing among intensive care professionals is insufficient. This should be addressed given the importance of adequate antibiotic exposure in critically ill patients with sepsis. Solutions include improved education, intensified pharmacy support, therapeutic drug monitoring, or the use of real-time bedside dosing software. Questions may provide useful for teaching purposes.

The National Competency Framework for Registered Nurses in Adult Critical Care: An overview

In the years following the abolition of the English National Board for Nursing, Midwifery and Health Visiting in 2002, concerns were raised within the Critical Care nursing community about a lack of consistency in post-registration education programmes. In response to this, the Critical Care Network National Nurse Leads (CC3N) formed a sub-group, the Critical Care Nurse Education Review Forum (CCNERF) to address these concerns. A review of UK course provision confirmed marked inconsistency in the length, content and associated academic award. The CCNERF commenced a two-phase project, first developing national standards for critical care nurse education such as length of course and academic credit level, followed by the development of a national competency framework. Following significant review and revision, version two of the National Competency Framework for Registered Nurses in Adult Critical Care was published by CC3N in 2015. This paper introduces the National Competency Framework and provides an overview of its background, development and implementation. It then considers the future direction of UK post-registration Critical Care nurse education.

The Intensive care unit specialist: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine

The role of the critical care specialist has been unequivocally established in the management of severely ill patients throughout the world. Data show that the presence of a critical care specialist in the intensive care unit (ICU) environment has reduced morbidity and mortality, improved patient safety, and reduced length of stay and costs. However, many ICUs across the world function as "open ICUs," in which patients may be admitted under a primary physician who has not been trained in critical care medicine. Although the concept of the ICU has gained widespread acceptance amongst medical professionals, hospital administrators and the general public; recognition and the need for doctors specializing in intensive care medicine has lagged behind. The curriculum to ensure appropriate training around the world is diverse but should ideally meet some minimum standards. The World Federation of Societies of Intensive and Critical Care Medicine has set up a task force to address issues concerning the training, functions, roles, and responsibilities of an ICU specialist.

Palliative and end-of-life educational practices in US pulmonary and critical care training programs

PURPOSE

To describe educational features in palliative and end-of-life care (PEOLC) in pulmonary/critical care fellowships and identify the features associated with perceptions of trainee competence in PEOLC.

METHODS

A survey of educational features in 102 training programs and the perceived skill and comfort level of trainees in 6 PEOLC domains: communication, symptom control, ethical/legal, community/institutional resources, specific syndromes, and ventilator withdrawal. We evaluated associations between perceived trainee competence/comfort in PEOLC and training program features, using regression analyses.

RESULTS

Fifty-five percent of program directors (PDs) reported faculty with training in PEOLC; 30% had a written PEOLC curriculum. Neither feature was associated with trainee competence/comfort. Program directors and trainees rated bedside PEOLC teaching highly. Only 20% offered PEOLC rotations; most trainees judged these valuable. Most PDs and trainees reported that didactic teaching was insufficient in communication, although sufficient teaching of this was associated with perceived trainee competence in communication. Perceived trainee competence in managing institutional resources was rated poorly. Program directors reporting significant barriers to PEOLC education also judged trainees less competent in PEOLC. Time constraint was the greatest barrier.

CONCLUSION

This survey of PEOLC education in US pulmonary/critical care fellowships identified associations between certain program features and perceived trainee skill in PEOLC. These results generate hypotheses for further study.