Intensive Care Fellows Research Articles

Exploring Interprofessional Development of Entrustable Professional Activities For Pediatric Intensive Care Fellows: A Proof-of-Concept Study

Phenomenon : Entrustable professional activities (EPAs) delineate major professional activities that an individual in a given specialty must be “entrusted” to perform, ultimately without supervision, to provide quality patient care. Until now, most EPA frameworks have been developed by professionals within the same specialty. As safe, effective, and sustainable health care ultimately depends on interprofessional collaboration, we hypothesized that members of interprofessional teams might have clear and possibly additional insight into which activities are essential to the professional work of a medical specialist. Approach : We recently employed a national modified Delphi study to develop and validate a set of EPAs for Dutch pediatric intensive care fellows. In this proof-of-concept study, we explored what pediatric intensive care physicians’ non-physician team members (physician assistants, nurse practitioners, and nurses) constitute as essential professional activities for PICU physicians and how they regarded the newly developed set of nine EPAs. We compared their judgments with the PICU physicians’ opinions. Findings : This study shows that non-physician team members share a mental model with physicians about which EPAs are indispensable for pediatric intensive care physicians. Despite this agreement however, descriptions of EPAs are not always clear for non-physician team members who have to work with them on a daily basis. Insights : Ambiguity as to what an EPA entails when qualifying a trainee can have implications for patient safety and trainees themselves. Input from non-physician team members may add to the clarity of EPA descriptions. This finding supports the involvement of non-physician team members in the developmental process of EPAs for (sub)specialty training programs.

Development of entrustable professional activities for paediatric intensive care fellows: A national modified Delphi study.

Entrustable professional activities (EPAs), as a focus of learner assessment, are supported by validity evidence. An EPA is a unit of professional practice requiring proficiency in multiple competencies simultaneously, that can be entrusted to a sufficiently competent learner. Taken collectively, a set of EPAs define and inform the curriculum of a specialty training. The goal of this study was to develop a set of EPAs for Dutch PICU fellows. A multistage methodology was employed incorporating sequential input from task force members, a medical education expert, PICU fellowship program directors, and PICU physicians and fellows via a modified three-round Delphi study. In the first modified Delphi round, experts rated indispensability and clarity of preliminary EPAs. In the subsequent rounds, aggregated scores for each EPA and group comments were provided. In round two, respondents rated indispensability and clarity of revised EPAs. Round three was used to gain explicit confirmation of suitability to implement these EPAs. Based on median ratings and content validity index (CVI) analysis for indispensability in the first two rounds, all nine preliminary EPAs covered activities that were deemed essential to the clinical practice of PICU physicians. Based on median ratings and CVI analysis for clarity however, four EPAs needed revision. With an agreement percentage of 93–100% for all individual EPAs as well as the set as a whole, a high degree of consensus among experts was reached in the third round. The resulting nine PICU EPAs provide a succinct overview of the core tasks of Dutch PICU physicians. These EPAs were created as an essential first step towards developing an assessment system for PICU fellows, grounded in core professional activities. The robust methodology used, may have broad applicability for other (sub)specialty training programs aiming to develop specialty specific EPAs.

The Interrater Reliability of Inferior Vena Cava Ultrasonography Performed by Intensive Care Fellows

The Interrater Reliability of Inferior Vena Cava Ultrasonography Performed by Intensive Care Fellows

Current situation of pediatric intensive care specialty and pediatric intensive care units in Turkey: Results of a national survey.

In this study, we have planned to present the results of a national survey performed to evaluate the last situation of pediatric intensive care specialty and pediatric intensive care units in Turkey. We have sent an electronic survey which includes 47 questions about the characteristics of pediatric intensive care units, staff, and equipment to members of the Turkish Society of Pediatric Emergency and Intensive Care via email. A total of 58 participant units responded to our survey. 93.2% of the centers have tertiary level pediatric intensive care units. There were 841 tertiary level pediatric intensive care beds. There were 35 pediatric intensive care faculty members, 44 pediatric intensive care specialists, and 53 pediatric intensive care fellows. In the participant units, the total number of invasive mechanical ventilators in the units was 806, the number of specific non-invasive mechanical ventilators was 126. It was learned that 79.3% of the centers could apply continuous renal replacement therapy, 84.4% of therapeutic plasma exchange, 46.5% of extracorporeal membrane oxygenation. We see that the way we have traveled in the 20 years since the establishment of the first units is very important and proud. The number of educated new generation pediatric intensive care specialists and the well-equipped pediatric intensive care units established by these specialists in every region of our country together with the fellowship education applied in many centers make a great contribution to the treatment of the critically ill pediatric patient population in our country.

Implementation of a Formal Debriefing Program After Pediatric Rapid Response Team Activations.

Debriefing after pediatric rapid response team activations (RRT-As) in a tertiary care children's hospital was identified to occur only sporadically. The lack of routine debriefing after RRT-As was identified as a missed learning opportunity. We implemented a formal debriefing program and assessed staff attitudes toward and experiences with debriefing after pediatric RRT-As. Real-time feedback for pediatrics residents captured clinical and debriefing data for each RRT-A from July 2014 to June 2016. The debriefing on physiology, team communication, and anticipation of clinical deterioration was introduced in July 2015. To assess debriefing perceptions, residents, intensive care fellows, nurses, and respiratory therapists participated in anonymous preintervention and postintervention surveys. We also developed a workshop to teach residents how to lead debriefing. Debriefing after RRT-As increased from 26% preintervention to 46% postintervention (P < .0001). A total of 43 of 76 pediatrics residents (57%) attended at least 1 of 4 debriefing workshops. Both preintervention and postintervention, more than 80% (70 of 78 preintervention and 54 of 65 postintervention) of health professionals surveyed strongly agreed or agreed that there was a benefit to debriefing after RRT-As. Postintervention, 65% (26 of 40) of respondents strongly agreed or agreed that debriefing improved their understanding of the RRT-A process. The rate of debriefing was sustained at 46% (6 months after the end of the study period). Debriefing frequency after pediatric RRT-As significantly increased with the introduction of a formal debriefing program. A majority of health professionals and trainees reported this practice was a valuable experience.

Should ongoing airway education be a mandatory component of continuing professional development for College of Intensive Care Medicine Fellows?

This study aimed to determine whether airway education should be introduced to the continuing professional development (CPD) program for College of Intensive Care Medicine (CICM) Fellows. A random representative sample of 11 tertiary intensive care units (ICUs) was chosen from the list of 56 units accredited for 12 or 24 months of CICM training. All specialist intensive care Fellows (n=140) currently practising at the eleven ICUs were sent the questionnaire via email. Questionnaire data collection and post-collection data analysis was used to determine basic respondent demographics, frequency of certain airway procedures in the past 12 months, confidence with advanced airway practices in ICU, participation in airway education in the past three years, knowledge of can't intubate, can't oxygenate (CICO) algorithms, preference for certain airway equipment/techniques, and support for required airway education as a component of the CICM CPD program. All responses were tabled for comparison. Data was analysed to establish any significant effect of another specialty qualification and current co-practice in anaesthesia on volume of practice, confidence with multiple airway procedures, use of airway equipment, and support for airway education. In total, 112 responses (response rate 80%) to the questionnaire were received within four weeks; 107 were completed in full (compliance 96%). All results were tabled. There is currently widespread support amongst CICM Fellows for airway skills education as a CPD requirement for CICM Fellows. Volumes of practice and confidence levels with different airway procedures vary amongst Fellows and further support the need for education.

Transfusion-associated circulatory overload: A survey among Dutch intensive care fellows

ObjectivesTransfusion-associated circulatory overload (TACO) is a severe pulmonary transfusion reaction and leading cause of transfusion-related morbidity and mortality in Europe. TACO is of particular importance in critically ill patients, since they often receive blood transfusions and have multiple risk factors for TACO. This study investigates transfusion practices in patients at risk of developing TACO, and furthermore knowledge concerning risk factors, diagnoses and treatment strategies among Dutch intensive care unit (ICU) fellows. Material and methodsAn unannounced paper-based survey was conducted among Dutch ICU fellows during an educational conference. The survey consisted of 16 multiple and open choice questions. ResultsOf all 65 Dutch ICU fellows 56.8% completed the survey; of respondents 88.9% identified the correct constellation of symptoms for TACO. In total, 29.7% of the respondents are aware they are obligated to report TACO cases to the blood bank. Major risk factors for TACO that respondents identified were reduced left ventricular function, infusion volume and infusion rate. In a non-emergency setting, 45.9% of fellows start red blood cell transfusion with 2 units or more. Transfusion rates exceeded national guidelines in 15.4% of fictitious cases. TACO is treated with furosemide by 94.5% of the fellows, however goals of the therapy varied greatly. ConclusionDutch ICU fellows are knowledgeable of TACO symptoms, risk factors and treatment, however knowledge on reporting and transfusion practice in the setting of at risk patients for TACO should be improved.

Communication at pediatric rapid response events: a survey of health care providers.

The objective of this study was to explore perceptions of communication quality at pediatric rapid response events and to determine whether these perceptions differed between rapid response team (RRT) members (RRTm) and floor providers (FP). This survey study was conducted of clinical providers involved in RRT events at a tertiary care children's hospital. Perceptions of RRT communication were assessed by using a 5-point Likert scale, and qualitative comments were collected. Responses were compared between RRTm (responder nurses and intensive care fellows) and FP (floor nurses and resident physicians). Survey response was 64% (18 of 28) for RRTm and 70% (194 of 278) for FP. RRTm gave lower ratings than FP for communication of: (1) the purpose of the call; (2) airway and breathing; (3) circulation; (4) background information; and (5) possible diagnosis and treatment. RRTm were more likely than FP to indicate that description of background information delayed communication of critical management problems ("often": RRTm, 7 of 17 [41%]; FP, 23 of 175 [13%]; "always": RRTm, 2 of 18 [12%]; FP, 19 of 175 [11%]; P=.001 for overall comparison). A structured approach for communication was generally supported, although less strongly among floor nurses. Themes from qualitative responses included role confusion, fractured room entry, and a dismissive attitude by RRTm. A disconnect in perceived quality of communication was observed between RRTm and FP at pediatric rapid response events. A structured approach with well-defined roles may improve communication quality.

Quality improvement of interdisciplinary rounds by leadership training based on essential quality indicators of the Interdisciplinary Rounds Assessment Scale

The implementation of interdisciplinary teams in the intensive care unit (ICU) has focused attention on leadership behavior. Daily interdisciplinary rounds (IDRs) in ICUs integrate leadership behavior and interdisciplinary teamwork. The purpose of this intervention study was to measure the effect of leadership training on the quality of IDRs in the ICU. A nonrandomized intervention study was conducted in four ICUs for adults. The intervention was a 1-day training session in a simulation environment and workplace-based feedback sessions. Measurement included 28 videotaped IDRs (total, 297 patient presentations) that were assessed with 10 essential quality indicators of the validated IDR Assessment Scale. Participants were 19 intensivists who previously had no formal training in leading IDRs. They were subdivided by cluster sampling into a control group (ten experienced intensivists) and intervention group (nine intensive care fellows). Mann-Whitney U test was used to compare results between control and intervention groups. Baseline measurements of control and intervention groups revealed two indicators that differed significantly. The frequency of yes ratings for the intervention group significantly increased for seven of the ten indicators from before to after intervention. The frequency of yes ratings after training was significantly greater in the intervention than control groups for eight of the ten essential quality indicators. The leadership training improved the quality of the IDRs performed in the ICUs. This may improve quality and safety of patient care.

Transthoracic echocardiography performed by intensive care fellows: is minimal focused training enough?

Transthoracic echocardiography (TTE) has an important role in the diagnosis of shock in the ICU. There is evidence that noncardiologist residents can address simple clinical questions in the ICU with TTE [1]. We conducted this study to evaluate whether ICU fellows, with minimal focused training in TTE, could reliably acquire good-quality images in critically ill patients.

Evaluating end of life practices in ten Brazilian paediatric and adult intensive care units

ObjectiveTo evaluate the modes of death and treatment offered in the last 24 h of life to patients dying in 10 Brazilian intensive care units (ICUs) over a period of...

Assessment of Communication Skills and Self-Appraisal in the Simulated Environment: Feasibility of Multirater Feedback with Gap Analysis

Multirater assessment is a powerful means of measuring communication skills. The use of gap analysis to assess self-appraisal is a strength of this technique. On the basis of Kalamazoo Consensus Statement framework and 360-degree assessment models, we developed a multirater instrument with gap analysis, with the goals of examining both communication skills and situational self-appraisal, and assessing the feasibility of the combined approach. The multirater communication skills instrument was used to assess Pediatric and Neonatal Intensive Care fellows after participation in seven simulated family meetings. Instrument reliability was determined using Cronbach's Alpha and Factorial Analysis. Correlations between rater groups were examined with Spearman's Rank Coefficient. Gap analyses and rater perceptions of the instruments were analyzed using descriptive statistics. Seven pediatric intensive care unit and neonatal intensive care fellows were each assessed by 11 to 18 raters (108 total assessments). Correlations were identified between disciplinary groups within each encounter. Among the 7 fellows, 30 communication strengths or areas needing improvement and 24 significant gaps were identified, indicating self under-appraisals, 9 (38%) of which overlapped. The instrument was logistically feasible and well received. Our multirater communication skills instrument with gap analysis proved useful in identifying areas of strength and areas needing improvement, and in highlighting areas of self over- and under-appraisal that require focused feedback. The use of multirater assessment with gap analysis, in a simulated and "safe" environment, may assist in the delivery of feedback to trainees.

Engagement and listening skills: identifying learning needs

Context and setting Communication during difficult medical interactions is often taught and assessed as a series of discrete tasks, the sum of which comprise the interaction. Just as important, however, are less tangible aspects of communication such as engagement and emotional presence. In particular, good listening skills have been identified as predictive of family satisfaction during the delivery of bad news. We sought to gain a sense of the relative communication strengths and deficiencies present in paediatric and neonatal critical care doctor trainees using a 360-degree tool. Why the idea was necessary The Accreditation Council for Graduate Medical Education (ACGME) has identified communication skills as an area requiring more focused teaching and assessment. Recent literature has identified listening skills and engagement as crucial to an effective interaction, yet these aspects can be more difficult to teach. Determining the relative strengths and weaknesses of trainees in different aspects of communication will allow the development of appropriate educational interventions. What was done We developed a 360-degree evaluation instrument based on ‘Essential Elements: the Communication Checklist’, created by the Kalamazoo Consensus Statement group. The survey consists of nine items on dimensions of communication (Builds a Relationship, Opens the Discussion, Gathers Information, Understands the Patient’s and Family’s Perspective, Shares Information, Reaches Agreement, Provides Closure, Demonstrates Empathy, Communicates Accurate Information) assessed by 5-point Likert scales, followed by two forced-choice questions assessing relative areas of strength and need for improvement. Seven paediatric and neonatal intensive care fellows were each evaluated by 11–18 multidisciplinary raters (108 assessments) after delivering difficult information during the simulation-based Programme to Enhance Relational and Communication Skills at the Children’s Hospital, Boston. Scores are given as percentage of subjects showing strength or a need for improvement in a given dimension. Evaluation of results and impact The dimensions most frequently identified as strengths were Shares Information (in 86% of subjects), followed by Communicates Accurate Information (71%), Demonstrates Empathy (57%), and Opens the Discussion (43%). The dimensions identified as needing improvement were Understands the Patient’s and Family’s Perspective (in 71% of subjects) and Gathers Information (43%). The remaining dimensions of communication were not identified as either strengths or areas needing improvement in more than 14% of subjects. The above distribution is significant in that it suggests a predisposition towards delivering information and away from listening, gathering information and sufficient engagement to understand the patient’s and family’s perspective. In two cases, subjects were ranked poorly in understanding the family’s perspective but highly in demonstrating empathy. This finding may reflect the presence of empathic attitudes and statements in the subject’s delivery that nevertheless were concurrent with deficiencies in their listening skills. Based on this sample, it appears that some paediatric and neonatal critical care fellows may lack well-developed listening and engagement skills. Further research is necessary to determine if this pattern holds over larger groups of trainees. Such data could be used to drive specific educational interventions targeting the development of listening and engagement capacities.

Infectious diseases in the paediatric intensive care unit

Infectious Diseases in the Pediatric Intensive Care Unit is a comprehensive collection of infectious disease topics in the paediatric intensive care unit (PICU) and in the neonatal intensive care unit (NICU) written by different experts. The chapters cover a broad range of interest, from the development of the immune system to diagnosis, treatment and prophylaxis of various infectious diseases including sepsis. The chapters on immunology, including the immunosuppressed host – with abundant information about congenital immunodeficiencies and HIV – are more comprehensive than other topics covered. There is further emphasis on potentially life-threatening tropical infections such as malaria, dengue, tetanus and Japanese encephalitis. The purpose of the book is to provide a comprehensive overview of infectious diseases in critically ill neonates and infants. The scope of the book is broad, and it aims to provide information on pathophysiology as well as to serve as a practical manual on diagnosis, therapy and prevention of infectious diseases in the PICU and the NICU. Infectious Diseases in the Pediatric Intensive Care Unit is primarily directed at physicians working with children in intensive care facilities who are not infectious diseases specialists. Most chapters of the book could also reach out to a larger audience, including medical students and infectious disease fellows who are not paediatricians. The short chapter on infection control might be of interest for nonspecialists; however, several of its paragraphs and references (for example, hand hygiene, epidemiology, antibiotic control) are outdated. Most chapters of the book are quite basic and therefore cannot replace currently available standard textbooks or state-of-the-art reviews. Overall, this book does a good job of summarising and presenting the essentials of infectious diseases in the PICU and in the NICU in 580 pages. Moreover, it gives useful and practical information about diagnostic and therapeutic challenges. While some chapters are excellent, however, others are less so and – as the one about fungal infections – are partially outdated and somewhat inaccurate due to recent publications in this field. Furthermore, the merged discussion of issues related to the NICU and the PICU makes some chapters difficult to read because there is considerable variation among differential diagnoses, therapies and prevention strategies among neonates versus older children. Finally, several chapters could have benefited from more illustrations and summary tables to facilitate quick reading. This first edition of the Infectious Diseases in the Pediatric Intensive Care Unit provides comprehensive information about infectious diseases in paediatric and neonatal intensive care facilities. It is a useful guide for paediatric intensive care fellows and physicians in order to gain an overview of specific infectious disease topics in their daily practice.

Teaching physicians how to break bad news: a 1-day workshop using standardized parents.

To evaluate the effectiveness of a training program using standardized parents (SPs) to improve the performance of pediatric intensive care fellows in communicating bad news to parents. Self-controlled crossover design. Tertiary pediatric intensive care unit in a university-affiliated children's hospital. Seven pediatric intensive care fellows and 4 trained volunteers (2 sets of SPs) participated in the study. Two case scenarios of children admitted to the intensive care unit with a near-fatal diagnosis were used for the fellow's interactions with the SPs. The SPs had received 15 hours of training in role playing, performance evaluation, and giving feedback to the physicians. At the end of the first session, SPs provided feedback to the physicians under each of the 5 following categories: communication skills, content issues, support systems, interventions, and parent perceptions. During the second session, the parent meeting was repeated with a new but similar case scenario and a different set of SPs. Both sessions were videotaped, and a rater blinded to the order of the sessions used a weighted scale based on a checklist to score changes in physician performance. The performance by the fellows showed a significant mean (+/-SEM) improvement in scores of 18.1 (+/-5.2) points (P = .007) between the first and the second sessions. Ranking of session scores revealed that physician performance improved significantly during the second session (Wilcoxon signed rank test, P = .002). To our knowledge this is the first study that demonstrates short-term improvement in physician performance in conveying bad news in a pediatric intensive care setting using SPs in a 1-day workshop.