An international survey of training in adult intensive care medicine

Impact of number of critical care procedural skill repetitions on supervision level and teaching style

BACKGROUND

During critical care procedural skills training (e.g., in intubation and pericardiocentesis) the appropriate supervision level is important to ensure correct use of techniques and guarantee patient safety. The appropriate teaching style should be selected to address residents' learning behavior and foster their competence. The aim of this study was to explore the number of repetitions for given skills needed to achieve a specified supervision level and a specific teaching style.

METHODS

This cross-sectional multicenter survey obtained data from residents and faculty of three multidisciplinary intensive care units (ICU) in Switzerland. Using a 4-point Likert scale, participants were asked to indicate the number of repetitions required to achieve the specified supervision level and teaching style.

RESULTS

Among 91 physicians, the response rate was 64% (n = 59). Their median estimations of the numbers of skill repetitions needed to achieve the final fourth level of supervision and final fourth stage of teaching style were as follows: arterial catheter insertion: supervision level 32, teaching style 17.5; peritoneal paracentesis: supervision level 27, teaching style 17; central venous catheter insertion: supervision level 38, teaching style 28; lumbar puncture: supervision level 38, teaching style 21; endotracheal intubation: supervision level 100, teaching style 45; chest drain insertion: supervision level 27, teaching style 21.5; temporary pacemaker placement: supervision level 50, teaching style 19.5; percutaneous tracheostomy: supervision level 50, teaching style 29; pericardiocentesis: supervision level 50, teaching style 35. Comparison of repetitions between supervision level and teaching style revealed no difference at the first and second levels, except for endotracheal intubation at level 2 (p = 0.03). Differences were observed at the third and fourth levels of supervision level and teaching style (p≤0.04).

CONCLUSIONS

It appears that the supervision level and teaching style applied by faculty should change according to both the number of repetitions and the difficulty of critical care procedural skills.

Learner-centered education: ICU residents' expectations of teaching style and supervision level

BACKGROUND

If the education of intensive care unit (ICU) residents focuses on individual learning behavior, the faculty's style of teaching and level of supervision need to be adapted accordingly. The aim of this study was to delineate the associations between residents' perceived learning behavior, experience, and demographics and their expectations with regard to teaching style and supervision levels.

METHODS

This multicenter survey obtained data on ICU residents' base specialty, duration of ICU training, individual postgraduate year, gender, and number of repetitions of ICU skills. Using 4-point Likert scales, residents assessed perceived learning behavior, expected teaching style, and supervision level for respective skills. Multivariate regression analysis was used to evaluate associations between assessed variables.

RESULTS

Among 109 residents of four interdisciplinary ICUs, 63 (58%) participated in the survey and 95% (60/63) questionnaires were completed. The residents' perceived learning behavior was associated with number of skill repetitions (p < 0.0001), internal medicine as base specialty (p = 0.02), and skill type (p < 0.0001). Their expected teaching style was associated with learning behavior (p < 0.0001) and skill type (p < 0.0001). Their expected supervision level was associated with skill repetitions (p < 0.0001) and skill type (p < 0.0001).

CONCLUSION

For effective learner-centered education, it appears useful to recognize how the residents' learning behavior is affected by the number of skill repetitions and the skill type. Hence, faculty may wish to take into account the residents' learning behavior, driven mainly by skill complexity and the number of skill repetitions, to deliver the appropriate teaching style and supervision level.

Comparative analysis of environmental noise levels in two paediatric intensive care units

AIMS

1) To determine noise levels in two paediatric intensive care units (PICU) of a tertiary hospital and 2) to analyse whether these values comply with the current standards.

METHOD

Observational, descriptive and cross-sectional study carried out in two PICU with different infrastructure: bays separated by curtains and individual bedrooms. A PCE-999 sound level meter was used to determine noise levels, which were registered in decibels (dB). At the same time, an ad hoc data recording document was designed in which we differentiated between each unit (open concept or closed), time of recording.

RESULTS

A total of 330 tests, 72 from open PICUs and 258 from closed PICUs were collected. The noise in the open PICU was 56.74 ± 3.61 decibels versus 50.36 ± 4.71 in the closed PICU, obtaining the highest levels during the morning.

DISCUSSION

As it occurs in other studies, noise levels exceed the allowed limits. At the same time, the main sources of noise in the PICU came from alarms, medical equipment, such as monitors or respirators, and conversations between health professional.

CONCLUSIONS

This investigation has shown high levels of environmental noise in the two PICUs analysed. The data obtained indicate that the architectural concept of individual bedrooms may have an impact in decreasing this environmental input.

The practice of intensive care in Latin America: a survey of academic intensivists

Background

Intensive care medicine is a relatively young discipline that has rapidly grown into a full-fledged medical subspecialty. Intensivists are responsible for managing an ever-increasing number of patients with complex, life-threatening diseases. Several factors may influence their performance, including age, training, experience, workload, and socioeconomic context. The aim of this study was to examine individual- and work-related aspects of the Latin American intensivist workforce, mainly with academic appointments, which might influence the quality of care provided. In consequence, we conducted a cross-sectional study of intensivists at public and private academic and nonacademic Latin American intensive care units (ICUs) through a web-based electronic survey submitted by email. Questions about personal aspects, work-related topics, and general clinical workflow were incorporated.

Results

Our study comprised 735 survey respondents (53% return rate) with the following country-specific breakdown: Brazil (29%); Argentina (19%); Chile (17%); Uruguay (12%); Ecuador (9%); Mexico (7%); Colombia (5%); and Bolivia, Peru, Guatemala, and Paraguay combined (2%). Latin American intensivists were predominantly male (68%) young adults (median age, 40 [IQR, 35–48] years) with a median clinical ICU experience of 10 (IQR, 5–20) years. The median weekly workload was 60 (IQR, 47–70) h. ICU formal training was between 2 and 4 years. Only 63% of academic ICUs performed multidisciplinary rounds. Most intensivists (85%) reported adequate conditions to manage patients with septic shock in their units. Unsatisfactory conditions were attributed to insufficient technology (11%), laboratory support (5%), imaging resources (5%), and drug shortages (5%). Seventy percent of intensivists participated in research, and 54% read scientific studies regularly, whereas 32% read no more than one scientific study per month. Research grants and pharmaceutical sponsorship are unusual funding sources in Latin America. Although Latin American intensivists are mostly unsatisfied with their income (81%), only a minority (27%) considered changing to another specialty before retirement.

Conclusions

Latin American intensivists constitute a predominantly young adult workforce, mostly formally trained, have a high workload, and most are interested in research. They are under important limitations owing to resource constraints and overt dissatisfaction. Latin America may be representative of other world areas with similar challenges for intensivists. Specific initiatives aimed at addressing these situations need to be devised to improve the quality of critical care delivery in Latin America.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-1956-6) contains supplementary material, which is available to authorized users.

Physician staffing needs in critical care departments

Departments of Critical Care Medicine are characterized by high medical assistance costs and great complexity. Published recommendations on determining the needs of medical staff in the DCCM are based on low levels of evidence and attribute excessive significance to the structural/welfare approach (physician-to-beds ratio), thus generating incomplete and minimalistic information. The Spanish Society of Intensive Care Medicine and Coronary Units established a Technical Committee of experts, the purpose of which was to draft recommendations regarding requirements for medical professionals in the ICU. The Technical Committee defined the following categories: 1) Patient care-related aspects; 2) Activities outside the ICU; 3) Patient safety and clinical management aspects; 4) Teaching; and 5) Research. A subcommittee was established with experts pertaining to each activity category, defining criteria for quantifying the percentage time of the intensivists dedicated to each task, and taking into account occupational category. A quantitative method was applied, the parameters of which were the number of procedures or tasks and the respective estimated indicative times for patient care-related activities within or outside the context of the DCCM, as well as for teaching and research activities. Regarding non-instrumental activities, which are more difficult to evaluate in real time, a matrix of range versus productivity was applied, defining approximate percentages according to occupational category. All activities and indicative times were tabulated, and a spreadsheet was created that modified a previously designed model in order to perform calculations according to the total sum of hours worked and the hours stipulated in the respective work contract. The competencies needed and the tasks which a Department of Critical Care Medicine professional must perform far exceed those of a purely patient care-related character, and cannot be quantified using structural criteria. The method for describing the 5 types of activity, the quantification of specific tasks, the respective times needed for each task, and the generation of a spreadsheet led to the creation of a management instrument.

Neurocritical Care Education During Residency: Opinions (NEURON) Study

BACKGROUND

The American Academy of Neurology (AAN) has established a core curriculum of topics for residency training in neurocritical care. At present there is limited data evaluating neurology residency education within the neurological intensive care unit. This study evaluates learner concerns with the neurological intensive care unit.

METHODS

The Communication Committee and Resident & Fellow Taskforce within the Neurocritical Care Society (NCS) developed an online survey that consisted of 20 selection and free-text based questions. The survey was distributed to NCS members and then to neurology residency program directors. Statistical analysis of neurocritical care exposure were completed with t or Fisher exact test with p-value <0.05 considered significant.

RESULTS

A total of 95 individuals from 32 different residency programs (36.5 % response rate) responded to the questionnaire. Most individuals train with neurocritical care attendings, fellows and advanced practitioners and have neurocritical care exposure during multiple years of residency training. 54 % of responders cite improvement in education as a means to improve neurocritical care training. Those that raised concern had no difference in time in the neurocritical care unit (9.4 weeks vs 8.8 weeks), exposure to trained neurointensivists, neurocritical care fellows or advanced providers (p value 0.53, 0.19, 0.83, respectively).

CONCLUSIONS

There is significant learner concern regarding education within the neurointensive care unit. Although there are educational guidelines and focused neurocritical care educational materials, these alone do not satisfy residents' educational needs. This study demonstrates the need for educational changes, but it does not assess best strategies nor curricular content.

An international survey and modified Delphi process revealed editors' perceptions, training needs, and ratings of competency-related statements for the development of core competencies for scientific editors of biomedical journals

Background: Scientific editors (i.e., those who make decisions on the content and policies of a journal) have a central role in the editorial process at biomedical journals. However, very little is known about the training needs of these editors or what competencies are required to perform effectively in this role. Methods: We conducted a survey of perceptions and training needs among scientific editors from major editorial organizations around the world, followed by a modified Delphi process in which we invited the same scientific editors to rate the importance of competency-related statements obtained from a previous scoping review. Results: A total of 148 participants completed the survey of perceptions and training needs. At least 80% of participants agreed on six of the 38 skill and expertise-related statements presented to them as being important or very important to their role as scientific editors. At least 80% agreed on three of the 38 statements as necessary skills they perceived themselves as possessing (well or very well).  The top five items on participants' list of top training needs were training in statistics, research methods, publication ethics, recruiting and dealing with peer reviewers, and indexing of journals. The three rounds of the Delphi were completed by 83, 83, and 73 participants, respectively, which ultimately produced a list of 23 "highly rated" competency-related statements and another 86 "included" items. Conclusion: Both the survey and the modified Delphi process will be critical for understanding knowledge and training gaps among scientific editors when designing curriculum around core competencies in the future.

Practical strategies for increasing efficiency and effectiveness in critical care education

Technological advances and evolving demands in medical care have led to challenges in ensuring adequate training for providers of critical care. Reliance on the traditional experience-based training model alone is insufficient for ensuring quality and safety in patient care. This article provides a brief overview of the existing educational practice within the critical care environment. Challenges to education within common daily activities of critical care practice are reviewed. Some practical evidence-based educational approaches are then described which can be incorporated into the daily practice of critical care without disrupting workflow or compromising the quality of patient care. It is hoped that such approaches for improving the efficiency and efficacy of critical care education will be integrated into training programs.

Rheumatology training experience across Europe: analysis of core competences

Background

The aim of this project was to analyze and compare the educational experience in rheumatology specialty training programs across European countries, with a focus on self-reported ability.

Method

An electronic survey was designed to assess the training experience in terms of self-reported ability, existence of formal education, number of patients managed and assessments performed during rheumatology training in 21 core competences including managing specific diseases, generic competences and procedures. The target population consisted of rheumatology trainees and recently certified rheumatologists across Europe. The relationship between the country of training and the self-reported ability or training methods for each competence was analyzed through linear or logistic regression, as appropriate.

Results

In total 1079 questionnaires from 41 countries were gathered. Self-reported ability was high for most competences, range 7.5–9.4 (0–10 scale) for clinical competences, 5.8–9.0 for technical procedures and 7.8–8.9 for generic competences. Competences with lower self-reported ability included managing patients with vasculitis, identifying crystals and performing an ultrasound. Between 53 and 91 % of the trainees received formal education and between 7 and 61 % of the trainees reported limited practical experience (managing ≤10 patients) in each competence. Evaluation of each competence was reported by 29–60 % of the respondents. In adjusted multivariable analysis, the country of training was associated with significant differences in self-reported ability for all individual competences.

Conclusion

Even though self-reported ability is generally high, there are significant differences amongst European countries, including differences in the learning structure and assessment of competences. This suggests that educational outcomes may also differ. Efforts to promote European harmonization in rheumatology training should be encouraged and supported.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-016-1114-y) contains supplementary material, which is available to authorized users.

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.

Is a Single Entry Training Scheme for Intensive Care Medicine Both Inevitable and Desirable?

The development of Intensive Care Medicine as a recognizable branch of medicine has been underway for more than half a century, with delivery by a number of different service models. This delivery may be entirely by related medical specialties, such as anesthesiology or pulmonology; alternatively, it may be as a standalone-recognized specialty and frequently by a hybrid of these two extremes. A country may have a completely different delivery model from neighboring countries, and different models may exist within a single country. Debate about the most appropriate method of providing critical care services frequently centers around the training. However, an alternative perspective is that training regimes only follow on from another objective, namely to have Intensive Care Medicine represented in important forums by dedicated critical care physicians. A historical perspective of the development of critical care in two countries over a 40-year period is discussed, whereby a transition from a multiple specialty provision of critical care medicine to that of a single binational pathway occurred. The perceived advantages and disadvantages are outlined, offering insights into how possible future challenges in a highly complex medical specialty can be anticipated and strategies formulated.

Resource-poor settings: infrastructure and capacity building: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

Planning for mass critical care (MCC) in resource-poor or constrained settings has been largely ignored, despite their large populations that are prone to suffer disproportionately from natural disasters. Addressing MCC in these settings has the potential to help vast numbers of people and also to inform planning for better-resourced areas.

METHODS

The Resource-Poor Settings panel developed five key question domains; defining the term resource poor and using the traditional phases of disaster (mitigation/preparedness/response/recovery), literature searches were conducted to identify evidence on which to answer the key questions in these areas. Given a lack of data upon which to develop evidence-based recommendations, expert-opinion suggestions were developed, and consensus was achieved using a modified Delphi process.

RESULTS

The five key questions were then separated as follows: definition, infrastructure and capacity building, resources, response, and reconstitution/recovery of host nation critical care capabilities and research. Addressing these questions led the panel to offer 33 suggestions. Because of the large number of suggestions, the results have been separated into two sections: part 1, Infrastructure/Capacity in this article, and part 2, Response/Recovery/Research in the accompanying article.

CONCLUSIONS

Lack of, or presence of, rudimentary ICU resources and limited capacity to enhance services further challenge resource-poor and constrained settings. Hence, capacity building entails preventative strategies and strengthening of primary health services. Assistance from other countries and organizations is needed to mount a surge response. Moreover, planning should include when to disengage and how the host nation can provide capacity beyond the mass casualty care event.

Training in intensive care medicine. A challenge within reach

The medical training model is currently immersed in a process of change. The new paradigm is intended to be more effective, more integrated within the healthcare system, and strongly oriented towards the direct application of knowledge to clinical practice. Compared with the established training system based on certification of the completion of a series or rotations and stays in certain healthcare units, the new model proposes a more structured training process based on the gradual acquisition of specific competences, in which residents must play an active role in designing their own training program. Training based on competences guarantees more transparent, updated and homogeneous learning of objective quality, and which can be homologated internationally. The tutors play a key role as the main directors of the process, and institutional commitment to their work is crucial. In this context, tutors should receive time and specific formation to allow the evaluation of training as the cornerstone of the new model. New forms of objective summative and training evaluation should be introduced to guarantee that the predefined competences and skills are effectively acquired. The free movement of specialists within Europe is very desirable and implies that training quality must be high and amenable to homologation among the different countries. The Competency Based training in Intensive Care Medicine in Europe program is our main reference for achieving this goal. Scientific societies in turn must impulse and facilitate all those initiatives destined to improve healthcare quality and therefore specialist training. They have the mission of designing strategies and processes that favor training, accreditation and advisory activities with the government authorities.

The future of intensive care medicine

Intensive care medical training, whether as a primary specialty or as secondary add-on training, should include key competences to ensure a uniform standard of care, and the number of intensive care physicians needs to increase to keep pace with the growing and anticipated need. The organisation of intensive care in multiple specialty or central units is heterogeneous and evolving, but appropriate early treatment and access to a trained intensivist should be assured at all times, and intensivists should play a pivotal role in ensuring communication and high-quality care across hospital departments. Structures now exist to support clinical research in intensive care medicine, which should become part of routine patient management. However, more translational research is urgently needed to identify areas that show clinical promise and to apply research principles to the real-life clinical setting. Likewise, electronic networks can be used to share expertise and support research. Individuals, physicians and policy makers need to allow for individual choices and priorities in the management of critically ill patients while remaining within the limits of economic reality. Professional scientific societies play a pivotal role in supporting the establishment of a defined minimum level of intensive health care and in ensuring standardised levels of training and patient care by promoting interaction between physicians and policy makers. The perception of intensive care medicine among the general public could be improved by concerted efforts to increase awareness of the services provided and of the successes achieved.

Survey of the current status of teaching intensive care medicine in Australia and New Zealand medical schools

INTRODUCTION

The place of Intensive Care Medicine education within Medical Schools in Australia and New Zealand was investigated by survey in 2009.

MATERIALS AND METHODS

All intensive care units in Australia and New Zealand were invited to take part in the survey. The survey included commitment to intensive care medicine training, teaching methods, curriculum content, assessment, and hours of student contact. All university teaching hospitals were identified and results analyzed.

INTERVENTIONS

None.

RESULTS

From recognized tertiary referral teaching hospitals, the response was 60%. A mandatory teaching program was offered by 56%, with a further 22% offering an optional program. The medical school curricula were primarily a mix of problem-based learning and traditional, lecture-based courses. Intensive care experience was usually undertaken in the latter years of the course. Contact hours allocated under the curriculum was less than 1 wk in the great majority. Assessment of students, where it existed, was undemanding. Intensive care medicine, although growing in stature within medical schools, still appears to occupy only a small place in the overall curriculum.

CONCLUSION

A survey was undertaken to determine the extent of intensive care medicine training undertaken in medical student courses in Australia and New Zealand. A small majority of university hospitals had mandatory programs, with nearly a quarter having neither a mandatory or optional program. This is a higher proportion than identified in previous international surveys, but the results indicate considerable deficits requiring ongoing development within the undergraduate program.

The Knowledge of Medical Students and Newly Qualified Doctors concerning the Specialty of Intensive Care Medicine

Current evidence suggests that around the transition from undergraduate to postgraduate training, deficiencies exist in doctors' knowledge of acute care. This study assessed Foundation Year 1 (FY1) doctors and medical students in intensive care/acute medicine with respect to their understanding of ICU practice and identifying critically ill patients. A qualitative questionnaire was formulated focusing on several targeted areas including training experience, broader ICU knowledge, formal assessment of ICU medicine and critically ill patients encountered outside the ICU. After successfully piloting the study, ethics approval was granted. In February 2010, the questionnaires were distributed to 50 final-year medical students at Brighton and Sussex Medical School and 50 FY1 doctors working at Worthing Hospital or the Royal Sussex County Hospital. One hundred percent of participants completed the questionnaires; 12.5% of medical students knew about the Surviving Sepsis Campaign compared to 62% FY1s (p<0.05). Non-significant trends were evident when choosing three most useful observations for identifying sick patients. The study concluded medical students lack knowledge regarding assessment and monitoring of critically ill patients. Undergraduate training and ICU exposure did not differ between groups, however differences existed in understanding of ICU practice. There was a relative paucity in understanding from final year students regarding the Surviving Sepsis Campaign compared to FY1 doctors, which highlights the need for further improvement.

Surgical intensive care unit - essential for good outcome in major abdominal surgery?

PURPOSE

Surgical intensive care units (ICU) play a pivotal role in perioperative care of patients undergoing major abdominal surgery. Differences in quality of care provided by medical staff in ICUs may be linked to improved outcome. This review aims to elucidate the relationship between quality of care at various ICUs and patient outcome, with the ultimate aim of identifying key measures for achieving optimal outcome.

METHODS

We reviewed the literature in PubMed to identify current ICU structural and process concepts and variations before evaluating their respective impact on quality of care and outcome in major abdominal surgery.

RESULTS

ICU leadership, nurse and physician staffing, and provision of an intermediate care unit are important structural components that impact on patients' outcome. A "mixed ICU" model, with intensivists primarily caring for the patients in close cooperation with the primary physician, seems to be the most effective ICU model. Surgeons' involvement in intensive care is essential, and a close cooperation between surgeons and anesthesiologists is vital for good outcome. Current general process concepts include early mobilization, enteral feeding, and optimal perioperative fluid management. To decrease failure-to-rescue rates, procedure-specific intensive care processes are particularly focused on the early detection, assessment, and timely and consistent treatment of complications.

CONCLUSIONS

Several structures and processes in the ICU have an impact on outcome in major abdominal surgery. ICU structures and care processes connected with optimal outcome could be transmitted to other centers to improve outcome, independent of procedure volume.

[Intensive medicine in Spain]

Intensive care medicine is a medical specialty that was officially established in our country in 1978, with a 5-year training program including two years of common core training followed by three years of specific training in an intensive care unit accredited for training. During this 32-year period, intensive care medicine has carried out an intense and varied activity, which has allowed its positioning as an attractive and with future specialty in the hospital setting. This document summarizes the history of the specialty, its current situation, the key role played in the programs of organ donation and transplantation of the National Transplant Organization (after more than 20 years of mutual collaboration), its training activities with the development of the National Plan of Cardiopulmonary Resuscitation, with a trajectory of more than 25 years, its interest in providing care based on quality and safety programs for the severely ill patient. It also describes the development of reference registries due to the need for reliable data on the care process for the most prevalent diseases, such as ischemic heart disease or ICU-acquired infections, based on long-term experience (more than 15 years), which results in the availability of epidemiological information and characteristics of care that may affect the practical patient's care. Moreover, features of its scientific society (SEMICYUC) are reported, an organization that agglutinates the interests of more than 280 ICUs and more than 2700 intensivists, with reference to the journal Medicina Intensiva, the official journal of the society and the Panamerican and Iberian Federation of Critical Medicine and Intensive Care Societies. Medicina Intensiva is indexed in the Thompson Reuters products of Science Citation Index Expanded (Scisearch(®)) and Journal Citation Reports, Science Edition. The important contribution of the Spanish intensive care medicine to the scientific community is also analyzed, and in relation to the future of intensive care medicine in Spain and in Europe, recommendations are made towards specialization in intensive care medicine incorporating in the training program those competences (knowledge, skills and attitudes) that should be present an intensivist in Europe and that are extensively fulfilled by the current Spanish training program. The trajectory followed by intensive care medicine in Europe and recently in China, shows the increasing need of intensive care and the progressive recognition of the specialty in economically growing countries, and emphasizes the need of homogenization in the training of future specialists in intensive care medicine globally.

[The future of intensive medicine]

Although Intensive Care Medicine is a young specialty compared with other medical disciplines, it currently plays a key role in the process of care for many patients. Experience has shown that professionals with specific training in Intensive Care Medicine are needed to provide high quality care to critically ill patients. In Europe, important steps have been taken towards the standardization of training programs of the different member states. However, it is now necessary to take one more step forward, that is, the creation of a primary specialty in Intensive Care Medicine. Care of the critically ill needs to be led by specialists who have received specific and complete training and who have the necessary professional competences to provide maximum quality care to their patients. The future of the specialty presents challenges that must be faced with determination, with the main objective of meeting the needs of the population.

The future of intensive medicine

Although Intensive Care Medicine is a young specialty compared with other medical disciplines, it currently plays a key role in the process of care for many patients. Experience has shown that professionals with specific training in Intensive Care Medicine are needed to provide high quality care to critically ill patients. In Europe, important steps have been taken towards the standardization of training programs of the different member states. However, it is now necessary to take one more step forward, that is, the creation of a primary specialty in Intensive Care Medicine. Care of the critically ill needs to be led by specialists who have received specific and complete training and who have the necessary professional competences to provide maximum quality care to their patients. The future of the specialty presents challenges that must be faced with determination, with the main objective of meeting the needs of the population.

Critical care education during internal medicine residency: a national survey

BACKGROUND

Current training practices and teaching methods for critical care medicine education during internal medicine residency have not been well described. This study explored critical care medicine education practices and environments for internal medicine residents in the United States.

METHODS

A web-based survey recruited Pulmonary and Critical Care Medicine fellowship program directors involved with internal medicine residency programs at academic institutions in the United States.

RESULTS

Of 127 accredited Pulmonary and Critical Care Medicine programs in 2007, 63 (50%) responded. Demographics of the intensive care units varied widely in size (7-52 beds), monthly admissions (25-300 patients), and presence of a "night float" (22%) or an admissions "cap" (34%). All programs used bedside teaching, and the majority used informal sessions (91%) or didactic lectures (75%). More time was spent on resident teaching in larger (≥20 bed) medical intensive care units, on weekdays, in programs with a night-float system, and in programs that suspended residents' primary care clinic duties during their intensive care unit rotation.

CONCLUSIONS

Although similar teaching methods were used within a wide range of training environments, there is no standardized approach to critical care medicine education for internal medicine residents. Some survey responses indicated a correlation with additional teaching time.

Critical care and the global burden of critical illness in adults

Critical care has evolved from treatment of poliomyelitis victims with respiratory failure in an intensive care unit to treatment of severely ill patients irrespective of location or specific technology. Population-based studies in the developed world suggest that the burden of critical illness is higher than generally appreciated and will increase as the population ages. Critical care capacity has long been needed in the developing world, and efforts to improve the care of the critically ill in these settings are starting to occur. Expansion of critical care to handle the consequences of an ageing population, natural disasters, conflict, inadequate primary care, and higher-risk medical therapies will be challenged by high costs at a time of economic constraint. To meet this challenge, investigators in this discipline will need to measure the global burden of critical illness and available critical-care resources, and develop both preventive and therapeutic interventions that are generalisable across countries.

So much to teach, so little time: a prospective cohort study evaluating a tool to select content for a critical care curriculum

Introduction

Curricular content is often based on the personal opinions of a small number of individuals. Although convenient, such curricula may not meet the needs of the target learner, the program or the institution. Using an objective method to ensure content validity of a curriculum can alleviate this issue.

Methods

A form was created that listed clinical presentations relevant to residents completing intensive care unit (ICU) rotations. Twenty residents and 20 intensivists in tertiary academic multisystem ICUs ranked each presentation on three separate scales: how life-threatening each is, how commonly each is seen in critical care, and how reversible each is. Mean scores for the individual scales were calculated, and these three values were subsequently multiplied together to achieve a composite score for each presentation. The correlation between the two groups' scores for the presentations was calculated to assess reliability of the process.

Results

There was excellent agreement between the two groups for rating each presentation (correlation coefficient r = 0.94). The 10 clinical presentations with the highest composite scores formed the basis of our new curriculum.

Conclusions

We describe a method that can be used to select the content of a curriculum for learners in an ICU. Although the content that we selected to include in our curriculum may not be applicable to other ICUs, we believe that the process we used is easily applied elsewhere, and that it provides an efficient method to improve content validity of a curriculum.

Critical care workforce

OBJECTIVE

The recent Health Resources and Services Administration report on critical care manpower details the impending crisis in the critical care workforce in the United States.

DESIGN

A review of the Health Resources and Services Administration statistics indicate the present structure for training critical care physicians through combined pulmonary/critical care fellowships is, and will remain, woefully inadequate to meet demand.

INTERVENTION

Training for intensive care unit physicians will require new paradigms for training, including consideration of free-standing critical care residencies and multidisciplinary critical care fellowships.

CONCLUSION

Unless the training structure changes, the worsening shortage of intensivists will precipitate a crisis, resulting in the disintegration of critical care delivery in the United States.

The views of patients and relatives of what makes a good intensivist: a European survey

OBJECTIVE

This study examined the views of adult patients and relatives about desirable characteristics of specialists in intensive care medicine (ICM) to incorporate these into an international competency-based training programme, CoBaTrICE.

DESIGN

Convenience sample of patients and relatives administered after discharge from 70 participating ICUs in eight European countries (1,398 evaluable responses). The structured questionnaire included 21 characteristics of medical competence categorised as 'medical knowledge and skills', 'communication with patients', and 'communication with relatives'. It was available in the national languages of the countries involved. Questions were rated by respondents for importance using a four-point Likert scale. Responses to open questions were also invited.

RESULTS

Most characteristics were highly rated, with priority given to medical knowledge and skills. Women were more likely to emphasise communication skills. There were no consistent regional differences. Free-text responses welcomed the opportunity to participate.

CONCLUSIONS

Patients and relatives with experience of intensive care in different European countries share similar views on the importance of knowledge, skills, decision making and communication in the training of intensive care specialists. These generic patient-centred components of training have been incorporated into the international competency-based ICM training programme, CoBaTrICE.

Variability in outcome and resource use in intensive care units

OBJECTIVE

To examine variability in outcome and resource use between ICUs. Secondary aims: to assess whether outcome and resource use are related to ICU structure and process, to explore factors associated with efficient resource use.

DESIGN AND SETTING

Cohort study, based on the SAPS 3 database in 275 ICUs worldwide.

PATIENTS

16,560 adults.

MEASUREMENTS AND RESULTS

Outcome was defined by standardized mortality rate (SMR). Standardized resource use (SRU) was calculated based on length of stay in the ICU, adjusted for severity of acute illness. Each unit was assigned to one of four groups: "most efficient" (SMR and SRU < median); "least efficient" (SMR, SRU > median); "overachieving" (low SMR, high SRU), "underachieving" (high SMR, low SRU). Univariate analysis and stepwise logistic regression were used to test for factors separating "most" from "least efficient" units. Overall median SMR was 1.00 (IQR 0.77-1.28) and SRU 1.07 (0.76-1.58). There were 91 "most efficient", 91 "least efficient", 47 "overachieving", and 46 "underachieving" ICUs. Number of physicians, of full-time specialists, and of nurses per bed, clinical rounds, availability of physicians, presence of emergency department, and geographical region were significant in univariate analysis. In multivariate analysis only interprofessional rounds, emergency department, and geographical region entered the model as significant.

CONCLUSIONS

Despite considerable variability in outcome and resource use only few factors of ICU structure and process were associated with efficient use of ICU. This suggests that other confounding factors play an important role.

Undergraduate training in the care of the acutely ill patient: a literature review

OBJECTIVE

To characterise the problem of teaching acute care skills to undergraduates and to look for potential solutions.

DESIGN

Systematic literature review including Medline, EMBASE, CINAHL. Eligible studies described education and training issues focusing on caring for acutely ill patients. Articles were excluded if they did not address either educational or clinical aspects of acute care and resuscitation.

MEASUREMENT AND RESULTS

We identified and reviewed 374 articles focusing on training or clinical aspects of caring for the acutely ill patient. Undergraduates and junior physicians lack knowledge, confidence and competence in all aspects of acute care, including the basic task of recognition and management of the acutely ill patient. There is wide variability both between and within countries regarding the amount of teaching in critical care offered to undergraduate medical students. Many centres are starting to use an integrated approach to acute care teaching, with early exposure to basic life support and clinical skills, coupled with later exposure to more complex acute care topics. Clinical attachments remain a popular method for training in acute care. Acute care courses are increasingly being used to standardise delivery of practical skills and patient management training.

CONCLUSION

The training of healthcare staff in the care of acutely ill patients is suboptimal, adding to patient risk. Improvements in training should start at undergraduate level for maximal effect, should be integrated with postgraduate education, and are likely to enhance current efforts to improve patient safety in acute care.

A global view of education and training in critical care medicine

The Educational Committee of the World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM) performed a survey in various countries and reviewed data from the Cobatrice study and from surveys of the Pan-American and Iberic Federation of Societies of Intensive and Critical Care Medicine to characterize current structures and processes in education in intensive care medicine to determine the potential for convergence to a common competency-based training program, and to a common competency certification in most countries around the world, guided by the local scientific societies and the WFSICCM. Training in critical care medicine sponsored by the WFSICCM should provide a competency approach that permits diversity of training methods while creating a common outcome: doctors with a universal set of knowledge, skills, and attitudes essential for a specialist in intensive care medicine.

Intensive care medicine in Europe

Health care systems stem from specific political, historical, cultural,and socioeconomic traditions. As a result, the organizational arrangements for health care differ considerably between Member States of the European Union. Health care in the European Union is at a crossroads between challenges and opportunities. The Member States are facing common challenges in delivering equal, efficient, and high-quality health services at affordable cost in times when the amount of care to be delivered is starting to exceed the resource base.