Critical Care Medicine Training Research Articles

Survey of Clinical Knowledge and Procedural Readiness of Pulmonary Fellows to Start Interventional Pulmonary Fellowship: A Survey of Interventional Pulmonary Fellowship Directors.

Entry into the interventional pulmonary (IP) fellowship requires prerequisite training in pulmonary and critical care medicine (PCCM) fellowship in the United States. IP fellowship has become standardized, but the prerequisite training may be quite variable depending on the learner's exposure to IP during their PCCM fellowship. A survey study was conducted to identify potential foundational knowledge and/or skills gaps of new fellows entering IP fellowships. This may help both PCCM and IP fellowship directors to identify common knowledge gaps within PCCM training specific to IP. Based on components of the ACGME's common program requirements for PCCM fellowships, a survey was developed and categorized into 5 domains: nonprocedural skills, didactic knowledge, diagnostic bronchoscopy, pleural procedures, and airway/percutaneous procedures. The survey was then sent to 42 IP fellowship directors after the content validity review and approval by the Association of Interventional Pulmonary Program Directors. The survey response rate was 88.1% (37/42). The overall mean scores in all 5 domains were perceived as below competent (<3). The highest mean domain was nonprocedural skills, and the lowest was airway/percutaneous procedures. Within the domains, there were 4/ 30 topics that were considered competent with a score of ≥3 as competent or higher; bronchoscopy lavage (mean: 3.5/5, SD: 0.87), interpersonal skills (mean: 3.03/5, SD: 0.76), thoracentesis (mean: 3.14/5, SD: 0.89), and ultrasound for pleural effusion (mean: 3.19/5, SD: 0.84). There are perceived gaps in PCCM training pertaining to IP fellowship readiness.

Development of a Prioritized Anesthesiology Residency Critical Care Content Outline.

Critical care education is an important, mandatory component of residency training in anesthesiology. Currently, there is no accepted national standardized curriculum, and a prioritized critical care content outline would be beneficial to the creation of a pragmatic standardized residency curriculum. The modified Delphi method is a recognized method for establishing consensus in medical education. We developed a prioritized critical care content outline using the modified Delphi method. Topics were selected from critical care topics included in the Program Requirements for Graduate Medical Education in Anesthesiology and the American Board of Anesthesiology Content Outline. Panel members rated critical care topics on a 9-point Likert scale (1 = not important, 9 = mandatory). Consensus was defined as ≥75% rating the topic as very important to mandatory for inclusion (Likert scale 7-9). Topics with >80% consensus were removed from subsequent surveys and included in the final list, and topics with <50% were removed. Members were asked to select the ideal timing of topic delivery during residency (Foundational-Early Residency, Intermediate-Mid Residency, Advanced-Late Residency). A total of 158 panel members who were contacted using national anesthesiology organization email lists completed the initial round, 119 (75%) completed the second iteration, and 116 (73%) completed the third. Response rate on the first survey was (22/55) 40% for anesthesiology critical care program directors, (18/132) 14% for core anesthesiology residency program directors, and (77/1150) 7% for the remaining respondents. Trainees (n = 41) were not included in response rate calculations. Most participants (103/158, 65%) had completed both core anesthesiology and subspecialty critical care medicine training and most (87/158, 55%) had formal roles in medical education. Forty-one (26%) responders were currently in training. All panelists worked in institutions with graduate medical education (GME) learners. Fifty-eight of 136 (43%) topics met consensus for inclusion. Most consensus topics (50/58, 86%) were recommended to be delivered early during residency with the other 8 topics to be delivered in the middle of residency. We developed a prioritized critical care content outline for anesthesiology residents that includes highly recommended critical care topics with ideal timing for inclusion in residency. This outline provides the first step in developing a pragmatic standardized curriculum to guide faculty and programs in critical care education.

Reimagining Undergraduate Critical Care Medical Education: A Path for the Next Decade.

Foundational training in critical care medicine is an integral part of both undergraduate and graduate medical education. Yet, many medical school graduates enter residency underprepared to care for critically ill patients because of a lack of ubiquity of undergraduate critical care education and the heterogeneity of existing didactic and clinical experiences. This Perspective explores the importance of undergraduate critical care education, the current national and international landscape, innovative educational strategies and exemplar curricula, and recent advances in assessment that may better reflect learner-centered educational outcomes. As broad curricular reforms push medical education toward a more innovative, interactive, and collaborative future, now is the time to rethink and reimagine undergraduate critical care education.

Enhancing the Central Venous Catheterization Competency of Medical Students through a Specialized Team and an Interactive Response System: A pre-post study.

Central venous catheterization (CVC) is a critical clinical procedure. To avoid complications, possessing good knowledge regarding the CVC care bundle and skills for the proper insertion and maintenance of CVC are important. To evaluate the effectiveness of an educational intervention and the use of an interactive response system in enhancing the CVC bundle care and insertion skills of medical students undergoing critical care medicine training. Sixth-year medical students (equivalent to fourth-year students in the United States) engaged in didactic lessons, interactive demonstrations, and simulator training facilitated by a CVC team comprising three thoracic and two vascular surgeons (all with a minimum 5 years of experience in central venous access) during their intensive care unit (ICU) rotation. Self-reported knowledge and confidence levels were assessed using pre-and posttests administered through the Zuvio App, an interactive response system. A total of 60 students underwent the educational intervention, of which 54 completed the pretest and 40 completed the posttest. In the posttest, significant improvement was found in the CVC bundle care competency and understanding (P = 0.002), preprocedural preparation (P = 0.002), insertion procedures (P = 0.004), complications (P = 0.003), and insertion depth decisions (P = 0.001). Staff and students reported that assessment and interaction via the Zuvio App were valuable, practical, and feasible in a clinical setting, providing trainees with an individual competency portfolio of receiving precise medical education. Integrating the training provided by a specialized team with an interactive response system enhanced the knowledge and competency level in CVC insertion among medical students in this study.

Pediatric Critical Care Fellow Perception of Learning through Virtual Reality Bronchoscopy.

Virtual reality (VR) simulators have revolutionized training in bronchoscopy, offering unrestricted availability in a low-stakes learning environment and frequent assessments represented by automatic scoring. The VR assessments can be used to monitor and support learners' progression. How trainees perceive these assessments needs to be clarified. The objective of this study was to examine what assessments learners select to document and receive feedback on and what influences their decisions. We used a sequential explanatory mixed methods strategy. All participants were pediatric critical care medicine trainees requiring competency in bronchoscopy skills. During independent simulation practice, we collected the number of learning-focused practice attempts (scores not recorded), assessment-focused practice (scores recorded and reviewed by the instructor for feedback), and the amount of time each attempt lasted. After simulation training, we conducted interviews to explore learners' perceptions of assessment. There was no significant difference in the number of attempts for each practice type. The average time per learning-focused attempt was almost three times longer than the assessment-focused attempt (mean [standard deviation] 16 ± 1 min vs. 6 ± 3 min, respectively; P < 0.05). Learners perceived documentation of their scores as high stakes and only recorded their better scores. Learners felt safer experimenting if their assessments were not recorded. During independent practice, learners took advantage of automatic assessments generated by the VR simulator to monitor their progression. However, the recording of scores from the simulation program to document learners' trajectory to a set goal was perceived as high stakes, discouraging learners from seeking supervisor feedback.

Critical care medicine training in the age of COVID-19.

The COVID-19 pandemic caused the largest disruption to graduate medical education in modern history. The danger associated with SARS-CoV-2 necessitated a paradigm shift regarding the fundamental approach to the education of medical residents and fellows. Whereas prior work has examined the effect of the pandemic on residents' experiences during training, the effect of the pandemic on academic performance of critical care medicine (CCM) fellows is not well understood. This study examined the relationship between CCM fellow's lived experiences during the COVID-19 pandemic and performance on in-training examinations. This mixed-methods study consisted of a quantitative retrospective analysis of critical care fellows' in-training examination scores and a qualitative, interview-based phenomenological examination of fellows' experiences during the pandemic while training in a single large academic hospital in the American Midwest. Quantitative: Prepandemic (2019 and 2020) and intrapandemic (2021 and 2022) in-training examination scores were analyzed utilizing an independent samples t test to determine whether a significant change occurred during the pandemic. Qualitative: Individual semi-structured interviews were conducted with CCM fellows exploring their lived experiences during the pandemic and their perception of the effect on their academic performance. Transcribed interviews were analyzed for thematic patterns. These themes were coded and categorized, and subcategories were developed as indicated during the analysis. The identified codes were then analyzed for thematic connections and apparent patterns. Relationships between themes and categories were analyzed. This process was continued until a coherent picture could be assembled from the data to answer the research questions. Analysis was performed from a phenomenological perspective with an emphasis on interpretation of the data from the participants' perspectives. Quantitative: Fifty-one in-training examination scores from 2019 to 2022 were obtained for analysis. Scores from 2019 to 2020 were grouped as prepandemic scores, while scores from 2021 to 2022 were grouped as intrapandemic scores. Twenty-four prepandemic and 27 intrapandemic scores were included in the final analysis. A significant difference was found between mean total prepandemic and intrapandemic in-service examination scores (t 49=2.64, p=0.01), with mean intrapandemic scores being 4.5 points lower than prepandemic scores (95 % CI, 1.08-7.92). Qualitative: Interviews were conducted with eight CCM fellows. Thematic analysis of the qualitative interviews revealed three main themes: psychosocial/emotional effects, effects on training, and effects on health. The factors that most effected participants' perceptions of their training were burnout, isolation, increased workload, decreased bedside teaching, decreased formal academic training opportunities, decreased procedural experience, a lack of an external reference point for normal training in CCM, fear of spreading COVID-19, and neglect of personal health during the pandemic. In-training examination scores decreased significantly during the COVID-19 pandemic for CCM fellows in this study. The fellows in this study reported perceived effects of the pandemic on their psychosocial/emotional well-being, medical training, and health.

Can High-volume Centers in India Serve as Anesthesiology, Critical Care and Emergency Medicine Training Locations for African Physicians?

Can High-volume Centers in India Serve as Anesthesiology, Critical Care and Emergency Medicine Training Locations for African Physicians?

The Time is Now: Addressing the Need for Training in Maternal Critical Care Medicine

(Int J Obstet Anesth. 2022;50:103544) Indirect medical conditions, such as cardiovascular disease and sepsis, now cause the majority of deaths during the peripartum period within the United States, United Kingdom, and Australia. In addition average maternal age, and the number of co-morbidities and rates of severe maternal morbidity have all increased alongside pregnancy-related deaths from indirect medical conditions. Despite efforts from the National Partnership for Maternal Safety, the Royal College of Midwives, and the Obstetric Anaesthetists’ Association, delays in diagnosis and treatment and disparities in care continue. Current tools may not be able to prevent important adverse events. This article addresses dual fellowship training for critical care medicine (CCM) and obstetric anesthesiology as way to address these issues in maternal care.

A point-of-care ultrasound education curriculum for pediatric critical care medicine

BackgroundDiagnostic and procedural point-of-care ultrasound (POCUS) change patient management with the potential to improve outcomes. Pediatric critical care medicine trainees have limited access to education and training opportunities in diagnostic POCUS in the pediatric ICU. A dearth of published pediatric ICU curricular resources restricts these educational opportunities.MethodsA 7-week longitudinal curriculum including lectures, practical skills sessions, and knowledge assessment covering core modules including (1) machine operation, (2) vascular access, (3) non-vascular procedures, (4) cardiac imaging, (5) hemodynamic assessment, (6) pulmonary imaging, and (7) abdominal imaging, was disseminated to pediatric critical care trainees and faculty at a single tertiary care pediatric hospital.ResultsThe knowledge of trainees and participating faculty in procedural and diagnostic POCUS improved after implementing the curriculum. Pre-test scores mean and standard deviation (59.30% ± 14.15%) improved significantly (75.60% ± 9.43%) for all learners (p < 0.001). The overall self-reported comfort in diagnostic and procedural ultrasound improved for all learners. 100% of the learners reported utilizing diagnostic POCUS in their clinical practice four months after disseminating the curriculum.DiscussionWe describe a single center’s approach to POCUS education with improvement in knowledge, self-reported comfort, and attitudes towards procedural and diagnostic POCUS. The curricular resources for adaptation in a similar educational context are provided.

A brief of critical care education in Cambodia

Cambodia's population is 16,7 million people (2020). From 1975 to 1979, Cambodia experienced a horrendous genocide; therefore, the country started to reconstruct from beginning. Health is a significant topic and priority in development. The healthcare system in Cambodia is undergoing reform. Currently, only one large public university provides postgraduate training in critical care medicine as part of a residency in anesthesiology, critical care, and emergency medicine. The combination of three skills would enable the nation to achieve its requirements despite limited resources. National and international educational collaboration in Cambodia encourages greater treatment for the critically ill, often as part of emergency medicine or anesthetic programs. In order to handle the magnitude of critical care medical difficulties, Cambodia's critical care medicine requires undergo significant improvement. Education should be the primary emphasis of this area's growth.

The time is now: addressing the need for training in maternal critical care medicine

Amongst many high-income countries, indirect medical conditions (e.g. cardiovascular disease, sepsis) now account for the majority of maternal deaths. In response to this concerning rise in indirect causes of maternal deaths, professional societies have developed guidelines that regionalize high-risk obstetric care and prioritize critical care expertise as a requirement for designated ‘top’ maternity hospitals. Critical care proficiency is mandated by the Accreditation Council for Graduate Medical Education for graduating obstetric anesthesiology fellows. Despite these requirements, no formal obstetric critical care educational curricula or fellowship pathways, combining critical care medicine and obstetric anesthesiology, currently exist. Dual subspecialty training in both obstetric anesthesiology and critical care medicine represents one strategy to improve the care of critically-ill obstetric patients and reduce maternal mortality and morbidity, which is one of the pressing healthcare issues of our time.

The first step is recognizing there is a problem: a methodology for adjusting for variability in disease severity when estimating clinician performance

BackgroundAdoption of innovations in the field of medicine is frequently hindered by a failure to recognize the condition targeted by the innovation. This is particularly true in cases where recognition requires integration of patient information from different sources, or where disease presentation can be heterogeneous and the recognition step may be easier for some patients than for others.MethodsWe propose a general data-driven metric for clinician recognition that accounts for the variability in patient disease severity and for institutional standards. As a case study, we evaluate the ventilatory management of 362 patients with acute respiratory distress syndrome (ARDS) at a large academic hospital, because clinician recognition of ARDS has been identified as a major barrier to adoption to evidence-based ventilatory management. We calculate our metric for the 48 critical care physicians caring for these patients and examine the relationships between differences in ARDS recognition performance from overall institutional levels and provider characteristics such as demographics, social network position, and self-reported barriers and opinions.ResultsOur metric was found to be robust to patient characteristics previously demonstrated to affect ARDS recognition, such as disease severity and patient height. Training background was the only factor in this study that showed an association with physician recognition. Pulmonary and critical care medicine (PCCM) training was associated with higher recognition (β = 0.63, 95% confidence interval 0.46–0.80, p < 7 × 10− 5). Non-PCCM physicians recognized ARDS cases less frequently and expressed greater satisfaction with the ability to get the information needed for making an ARDS diagnosis (p < 5 × 10− 4), suggesting that lower performing clinicians may be less aware of institutional barriers.ConclusionsWe present a data-driven metric of clinician disease recognition that accounts for variability in patient disease severity and for institutional standards. Using this metric, we identify two unique physician populations with different intervention needs. One population consistently recognizes ARDS and reports barriers vs one does not and reports fewer barriers.

Commentary on "Development of postgraduate training in critical care medicine for nurse practitioners and physician assistants" JAANP, 33(12):1116-1119, December 2021.

Commentary on "Development of postgraduate training in critical care medicine for nurse practitioners and physician assistants" JAANP, 33(12):1116-1119, December 2021.

SARS-CoV-2, Lung Protective Ventilation, Low Middle Income Countries, and Pediatric Intensivists as Cross Disciplinary Knowledge Translation and Implementation Science Specialists

PurposeWe hypothesized that despite the low incidence of severe SARS-CoV-2 infections in children in Guyana, due to their specific skillset in lung protective ventilation, our Pediatric Intensivists were uniquely positioned to address significant training and readiness gaps in our colleagues attending a surging critically ill Adult COVID-19 patient population.Methods & MaterialsIn Guyana, there are few clinicians trained in Critical-Care Medicine (CCM). The high incidence of ventilator dependence in seriously ill SARS-CoV2 patients, combined with a dearth of CCM practitioners competent in complex mechanical ventilation management left Guyana ill prepared to manage these patients. This knowledge deficit was further exacerbated in that many clinicians at our National Infectious Diseases Hospital were co-opted into CCM roles from other specialties with little to no CCM training. We have a very small core of Pediatric Surgical Critical Care Medicine staff that was formally trained in PCCM outside of Guyana. This core was instrumental in establishing a unique and formal Pediatric Critical-Care Medicine Micro-Modular Fellowship (PCCM-MMF) program that allowed the creation of Guyana's only Pediatric ICU. A significant number of that core are also involved in Guyana‘s National COVID Task Force. Given that all graduates of our PCCM-MMF program are extensively trained in Lung Protective Ventilation, it was very appropriate to utilize them to augment Adult critical care capacity. Thirty physicians with primarily adult practices and little to no previous knowledge of ventilator management were enrolled in a multi-modal triphasic mechanical ventilation short course facilitated by PCCM staff.ResultsWe were able to rapidly enable two cohorts of 15 Adult clinicians to competently address critical knowledge deficits and staffing shortfalls. We improved morbidity and mortality amongst our mechanically ventilated adult COVID-19 patients, as well as relieved significant multifactorial caregiver strain.ConclusionOur successful utilization of PCCM staff as Mechanical Ventilation didactic and clinical educators for an Adult patient population carries implications for cross disciplinary Knowledge Translation and Implementation Science in a wide variety of practice milieus. We are actively pursuing research opportunities to further experiment with other skill sets incorporated in our PCCM Micro-Modular Fellowship and welcome potential collaborators.

Assessing agreement on Canadian pediatric critical care training objectives in Japan.

Japan has no accredited learning objectives for pediatric critical care medicine trainees. This study examined the extent of agreement among a panel of Japanese Pediatric Intensive Care (PICU) directors regarding the necessity of the Canadian learning objectives in pediatric critical care knowledge and technical skills training. Using a two-round Delphi survey, we developed consensus among directors of PICUs in Japan on the Canadian training objectives in pediatric critical care medicine. To assess the agreement, we applied a 4-point Likert scale (1=unnecessary, 2=relatively unnecessary, 3=relatively necessary, 4=necessary). We conducted a web-based survey and an Excel-based survey over four-week periods for the first and second rounds, respectively. Consensus was set at ≥80% agreement; therefore, items rated 3 or 4 by ≥80% participants in either rounds were included in the final list. Of the 36 PICU directors invited, 32 (88.9%) completed all survey rounds. In the first round, 164 items were agreed as necessary, 1 item was deemed unnecessary, and 15 items did not reach agreement and were included in the second round. In the second round, 5 items were agreed as necessary and 10 items did not reach agreement. Finally, 169 (94.9%) of the Canadian learning objectives reached the agreement after the two-round Delphi survey. Sixteen participants commented that non-technical skills, such as communication, collaboration, management, and education, were important additional objectives. High consensus was observed among Japanese pediatric critical care experts concerning the Canadian learning objectives for pediatric critical care knowledge and technical skills training.

Assessment of physician training and prediction of workforce needs in paediatric cardiac intensive care in the United States.

To assess the training and the future workforce needs of paediatric cardiac critical care faculty. REDCap surveys were sent May-August 2019 to medical directors and faculty at the 120 US centres participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database. Faculty and directors were asked about personal training pathway and planned employment changes. Directors were additionally asked for current faculty numbers, expected job openings, presence of training programmes, and numbers of trainees. Predictive modelling of the workforce was performed using respondents' data. Patient volume was projected from US Census data and compared to projected provider availability. Sixty-six per cent (79/120) of directors and 62% (294/477) of contacted faculty responded. Most respondents had training that incorporated critical care medicine with the majority completing training beyond categorical fellowship. Younger respondents and those in dedicated cardiac ICUs were more significantly likely to have advanced training or dual fellowships in cardiology and critical care medicine. An estimated 49-63 faculty enter the workforce annually from various training pathways. Based on modelling, these faculty will likely fill current and projected open positions over the next 5 years. Paediatric cardiac critical care training has evolved, such that the majority of faculty now have dual fellowship or advanced training. The projected number of incoming faculty will likely fill open positions within the next 5 years. Institutions with existing or anticipated training programmes should be cognisant of these data and prepare graduates for an increasingly competitive market.

Editorial introductions.

Editorial introductions.

Impact of the COVID-19 Pandemic on U.S. Pulmonary and Critical Care Medicine Fellowship Training.

BackgroundAlthough it is well known that the coronavirus disease (COVID-19) pandemic has had a profound effect on health care, its impact on fellowship training in Pulmonary and Critical Care Medicine (PCCM) has not been well described.ObjectiveWe conducted an anonymous survey of PCCM program directors (PDs) to assess the impact of the COVID-19 pandemic on PCCM fellowship training across the United States.MethodsWe developed a 30-question web-based survey that was distributed to U.S. PCCM PDs through the Association of Pulmonary and Critical Care Medicine Program Directors.ResultsThe survey was sent to 242 PDs, of whom 28.5% responded. Most of the responses (76.8%) came from university-based programs. Almost universally, PDs reported a decrease in the number of pulmonary function tests (100%), outpatient visits (94.1%), and elective bronchoscopies (96%). Three-quarters (77.6%) of the PDs reported that their PCCM fellows spent more time in the intensive care unit than originally scheduled.ConclusionThe COVID-19 pandemic has had a variable impact on different aspects of fellowship training. PDs reported a significant decrease in the core components of pulmonary training, whereas certain aspects of critical care training increased. It is likely that targeted mitigation strategies will be needed to ensure no gaps in PCCM training while optimizing well-being.

Training strategies for point of care ultrasound in the ICU.

Ultrasound in critical care medicine (CCUS) is a relatively young tool that has been evolving rapidly as skillsets, applications and technology continue to progress. Although ultrasound is identified as a core competency in intensive care unit (ICU) training, there remains significant variability and inconsistencies in the delivery of ultrasound training. The goal of this narrative review is to explore areas of consensus and highlight areas where consensus is lacking to bring attention to future directions of ultrasound training in critical care medicine. There exists considerable variation in competencies identified as basic for CCUS. Recent efforts by the European Society of Intensive Care Medicine serve as the most up to date iteration however implementation is still limited by regional expertise and practice patterns. Major barriers to ultrasound training in the ICU include a lack of available experts for bedside teaching and a lack of familiarity with new technology. Though international uptake of CCUS has made many gains in the past 20 years, further adoption of technology will be required to overcome the traditional barriers of CCUS training. Although the availability and time constraints of experts will remain a limitation even with wireless capabilities, the ability to expand beyond the physical constraints of an ultrasound machine will vastly benefit efforts to standardize training and improve access to knowledge.

Standardization of critical care management of non-critically ill patients with COVID-19.

The large global outbreak of coronavirus disease 2019 (COVID-19) has seriously endangered the health care system in China and globally. The sudden surge of patients with severe acute respiratory syndrome coronavirus 2 infection has revealed the shortage of critical care medicine resources and intensivists. Currently, the management of non-critically ill patients with COVID-19 is performed mostly by non-intensive care unit (ICU) physicians, who lack the required professional knowledge, training, and practice in critical care medicine, especially in terms of continuous monitoring of the respiratory function, intervention, and feedback on treatment effects. This clinical problem needs an urgent solution. Therefore, here, we propose a series of clinical strategies for non-ICU physicians aimed at the standardization of the management of non-critically ill patients with COVID-19 from the perspective of critical care medicine. Isolation management is performed to facilitate the implementation of hierarchical monitoring and intervention to ensure the reasonable distribution of scarce critical care medical resources and intensivists, highlight the key patients, timely detection of disease progression, and early and appropriate intervention and organ function support, and thus improve the prognosis. Different management objectives are also set based on the high-risk factors and the severity of patients with COVID-19. The approaches suggested herein will facilitate the timely detection of disease progression, and thus ensure the provision of early and appropriate intervention and organ function support, which will eventually improve the prognosis.