Establishing Entrustable Professional Activities in Pediatric Cardiac Critical Care

Validation of entrustable professional activities for use in neonatal care residency programs

OBJECTIVE

Define and develop a set of entrustable professional activities (EPAs) to link clinical training and assessment of the hospital components of neonatal care in neonatology medical residency programs.

METHODS

An exploratory study was conducted in two phases using a modified Delphi approach. In the first phase, a committee of five neonatology residency program coordinators drafted an initial set of EPAs based on the national matrix of competencies and on EPAs defined by international organizations. In the second phase, a group of neonatal care physicians and medical residents rated the indispensability and clarity of the EPAs and provided comments and suggestions.

RESULTS

Seven EPAs were drafted by the coordinators´ committee (n = 5) and used in the content validation process with a group (n = 37) of neonatal care physicians and medical residents. In the first Delphi round, all EPAs reached a content validity index (CVI) above 0.8. The coordinators´ committee analyzed comments and suggestions and revised the EPAs. A second Delphi round with the revised EPAs was conducted to validate and all items maintained a CVI above 0.8 for indispensability and clarity.

CONCLUSION

Seven entrustable professional activities were developed to assess residents in the hospital components of neonatal care medicine. These EPAs might contribute to implementing competency-based neonatology medical residency programs grounded in core professional activities.

Roadmap for the Development and Implementation of Entrustable Professional Activities to Enable Effective Clinical Training

In the field of clinical training, entrustable professional activities (EPAs) generally deal with those activities that health-care professionals will be encountering in their routine practice, and thus exposure to these activities prepares them for their future clinical practice. Workplace-based assessment tools have been used to assess the progress of medical students across these defined EPAs. The act of development of EPAs essentially requires the adoption of a systematic process to identify and define the core tasks and responsibilities that medical students must be able to perform independently in a specific specialty. The process of integration of EPAs into the medical school curriculum essentially requires systematic planning and implementation to ensure that students get an adequate number of opportunities to develop and demonstrate the desired competencies. In conclusion, EPAs provide an excellent framework for transforming medical education by preparing medical students to be ready for the complexities of health-care delivery.

Cardiac Critical Care Fellowship Training in the United States and Canada: Pediatric Cardiac Intensive Care Society-Endorsed Subcompetencies to the 2022 Entrustable Professional Activities

OBJECTIVES

We aimed to define and map subcompetencies required for pediatric cardiac critical care (PCCC) fellowship education and training under the auspices of the Pediatric Cardiac Intensive Care Society (PCICS). We used the 2022 frameworks for PCCC fellowship learning objectives by Tabbutt et al and for entrustable professional activities (EPAs) by Werho et al and integrated new subcompetencies to the EPAs. This complementary update serves to provide a foundation for standardized trainee assessment tools for PCCC.

DESIGN

A volunteer panel of ten PCICS members who are fellowship education program directors in cardiac critical care used a modified Delphi method to develop the update and additions to the EPA-based curriculum. In this process, the experts rated information independently, and repetitively after feedback, before reaching consensus. The agreed new EPAs were later reviewed and unanimously accepted by all PCICS program directors in PCCC in the United States and Canada and were endorsed by the PCICS in 2023.

PROCEDURE AND MAIN RESULTS

The procedure for defining new subcompetencies to the established EPAs comprised six consecutive steps: 1) literature search; 2) selection of key subcompetencies and curricular components; 3) written questionnaire; 4) consensus meeting and critical evaluation; 5) approval by curriculum developers; and 6) PCICS presentation and endorsement. Overall, 110 subcompetencies from six core-competency domains were mapped to nine EPAs with defined levels of entrustment and examples of simple and complex cases. To facilitate clarity and develop a future assessment tool, three EPAs were subcategorized with subcompetencies mapped to the appropriate subcategory. The latter covering common procedures in the cardiac ICU.

CONCLUSIONS

This represents the 2023 update to the PCCC fellowship education and training EPAs with the defining and mapping of 110 subcompetencies to the nine established 2022 EPAs. This goal of this update is to serve as the next step in the integration of EPAs into a standardized competency-based assessment framework for trainees in PCCC.

Fit for Service: Preparing Residents for Neurointensive Care with Entrustable Professional Activities: A Delphi Study

BACKGROUND

Although the relevance of neurointensive medicine and high-quality training of corresponding physicians is increasingly recognized, there is high heterogeneity in the nature, duration, and quality of neurointensive care curricula around the world. Thus, we aimed to identify, define, and establish validity evidence for entrustable professional activities (EPAs) for postgraduate training in neurointensive care to determine trainees' readiness for being on-call.

METHODS

After defining EPAs through an iterative process by an expert group, we used a modified Delphi approach with a single-center development process followed by a national consensus and a single-center validation step. EPAs were evaluated by using the EQual rubric (Queen's EPA Quality Rubric). Interrater reliability was measured with Krippendorff's α.

RESULTS

The expert group defined seven preliminary EPAs for neurointensive care. In two consecutive Delphi rounds, EPAs were adapted, and consensus was reached for level of entrustment and time of expiration. Ultimately, EPAs reached a high EQual score of 4.5 of 5 and above. Interrater reliability for the EQual scoring was 0.8.

CONCLUSIONS

Using a multistep Delphi process, we defined and established validity evidence for seven EPAs for neurointensive medicine with a high degree of consensus to objectively describe readiness for on-call duty in neurointensive care. This operationalization of pivotal clinical tasks may help to better train clinical residents in neurointensive care across sites and health care systems and has the potential to serve as a blueprint for training in general intensive care medicine. It also represents a starting point for further research and development of medical curricula.

Ventricular Assist Device Training and Emergency Management Among Pediatric Cardiac Intensive Care Physicians - Multicenter Cross-Sectional Survey

Background/Aim: Pediatric cardiac intensive care physicians practicing at centers that implant ventricular assist devices (VAD's) are exposed to increasing numbers of VAD patients, with a significant number of VAD-days. We aimed to delineate pediatric cardiac critical care practices surrounding routine and emergency management of VADs. Methodology: We administered a multicenter cross-sectional survey of pediatric cardiac intensive care unit (CICU) physicians in the United States and Canada. Survey distribution occurred between August 31st and October 26th 2021. Results: A total of 254 CICU physicians received a formal invitation to participate, with 108 returning completed surveys (42.5% response rate). Responses came from CICU attending physicians at 26 separate institutions. Respondents' level of experience was well distributed across junior, mid-level, and senior staff: less than 5 years (38%), 5-9 years (25%), and >/= 10 years (37%). Most respondents had received formal training in the management of VAD patients (n = 93, 86.1%), with training format including fellowship (61%), simulation (36%), and national/international conferences (26.5%). Dedicated advanced cardiac therapies teams were available at the institutions of 97.2% of respondents. A total of 78/108 (72.2%) described themselves as "comfortable" or "very comfortable" in pediatric VAD management. While 63% (68/108) of respondents reported that they had never performed (or overseen the performance of) chest compressions in a pediatric patient with a VAD, 37% (40/108) reported performing CPR at least once in a VAD patient. Conclusion: With no existing international guidelines for emergency cardiovascular care in the pediatric VAD population, our survey identifies an important gap in resuscitation recommendations.

Development, implementation, and evaluation of entrustable professional activities (EPAs) for medical radiation technologists in Taiwan: a nationwide experience

BACKGROUND

Competency-based medical education (CBME) is an outcomes-oriented approach focused on developing competencies that translate into clinical practice. Entrustable professional activities (EPAs) bridge competency assessment and clinical performance by delineating essential day-to-day activities that can be entrusted to trainees. EPAs have been widely adopted internationally, but not yet implemented for medical radiation professionals in Taiwan.

MATERIALS AND METHODS

A nationwide consensus process engaged 97 experts in radiation technology education representing diagnostic radiography, radiation therapy, and nuclear medicine. Preliminary EPAs were developed through the focus group discussion and the modified Delphi method. The validity of these EPAs was evaluated using the QUEPA and EQual tools.

RESULTS

Through iterative consensus building, six core EPAs with 18 component observable practice activities (OPAs) in total were developed, encompassing routines specific to each radiation technology specialty. QUEPA and EQual questionnaire data verified these EPAs were valid, and of high quality for clinical teaching and evaluation.

CONCLUSION

The consensus development of tailored EPAs enables rigorous competency assessment during medical radiation technology education in Taiwan. Further expansion of EPAs and training of clinical staff could potentially enhance care quality by producing competent professionals.

Development and implementation of a paediatric cardiac intensive care advanced practice provider curriculum

BACKGROUND

Education of paediatric advanced practice providers takes a generalist approach which lacks in-depth exposure to subspecialties like paediatric cardiac intensive care. This translates into a knowledge gap related to congenital cardiac physiology and management for APPs transitioning to the paediatric cardiac ICU.

METHODS

A specialised interprofessional peer-reviewed curriculum was created and distributed through the Pediatric Cardiac Intensive Care Society. This curriculum includes a textbook which is complemented by a didactic and simulation review course. Course evaluations were collected following each course, and feedback from participants was incorporated into subsequent courses. Pediatric Cardiac Intensive Care Society partnered with the Pediatric Nursing Certification Board to develop a 200-question post-assessment (exam) bank.

RESULTS

From December 2017 to January 2022, 12 review courses were taught at various host sites (n = 314 participants). Feedback revealed that courses improved preparedness for practice, contributed to advanced practice provider empowerment, and emphasised the importance of professional networking. 97% of attendees agreed/strongly agreed that the course improved clinical knowledge, 97% agreed/strongly agreed that the course improved ability to care for patients, and 88% agreed/strongly agreed that the course improved confidence to practice. 49% of participants rated the course as extremely effective, 42% very effective, 6% moderately effective, and 3% as only slightly effective.

CONCLUSIONS

A standardised subspecialty curriculum dedicated to advanced practice provider practice in cardiac intensive care was needed to improve knowledge, advance practice, and empower APPs managing critically ill patients in the cardiac ICU. The developed curriculum provides standardised learning, increasing advanced practice provider knowledge acquisition, and confidence to practice.

High variability in cardiac education and experiences during United States paediatric critical care fellowships

BACKGROUND

Paediatric cardiac critical care continues to become more sub-specialised, and many institutions have transitioned to dedicated cardiac ICUs. Literature regarding the effects of these changes on paediatric critical care medicine fellowship training is limited.

OBJECTIVE

To describe the current landscape of cardiac critical care education during paediatric critical care medicine fellowship in the United States and demonstrate its variability.

METHODS

A review of publicly available information in 2021 was completed. A supplemental REDCap survey focusing on cardiac ICU experiences during paediatric critical care medicine fellowships was e-mailed to all United States Accreditation Council of Graduate Medical Education-accredited paediatric critical care medicine fellowship programme coordinators/directors. Results are reported using inferential statistics.

RESULTS

Data from 71 paediatric critical care medicine fellowship programme websites and 41 leadership responses were included. Median fellow complement was 8 (interquartile range: 6, 12). The majority (76%, 31/41) of programmes had a designated cardiac ICU. Median percentage of paediatric critical care medicine attending physicians with cardiac training was 25% (interquartile range: 0%, 69%). Mandatory cardiac ICU time was 16 weeks (interquartile range: 13, 20) with variability in night coverage and number of other learners present. A minority of programmes (29%, 12/41) mandated other cardiac experiences. Median CHD surgical cases per year were 215 (interquartile range: 132, 338). When considering the number of annual cases per fellow, programmes with higher case volume were not always associated with the highest case number per fellow.

CONCLUSIONS

There is a continued trend toward dedicated cardiac ICUs in the United States, with significant variability in cardiac training during paediatric critical care medicine fellowship. As the trend toward dedicated cardiac ICUs continues and practices become more standardised, so should the education.

Entrustable Professional Activities and Their Relevance to Pediatric Cardiology Training

Entrustable professional activities (EPAs) have become a popular framework for medical trainee assessment and a supplemental component for milestone and competency assessment. EPAs were developed to facilitate assessment of competencies and furthermore to facilitate translation into clinical practice. In this review, we explore the rationale for the introduction of EPAs, examine whether they fulfill the promise expected of them, and contemplate further developments in their application with specific reference to training in pediatric cardiology.

Applying Practice Analysis to Develop a New Test Content Outline for the Pediatric Cardiology Certification Examination

The evolving breadth and complexity of the contemporary pediatric cardiology specialty requires regular, systematic analysis of the practice to ensure that training and certification requirements address the demands of real-world clinical experience. We report the process of the American Board of Pediatrics (ABP) for conducting such a practice analysis and revising the test content outline (TCO) for the pediatric cardiology subspecialty certification exam. A panel of 15 pediatric cardiologists conducted seven 2-h virtual meetings, during which they identified 37 unique tasks that represent the work a pediatric cardiologist may reasonably expect to perform within the first 5 years after training. These tasks were grouped into nine performance domains, similar to the entrustable professional activities (EPA), previously endorsed by the ABP in collaboration with the pediatric cardiology education community, and which represent the critical activities of the profession. The panel then enumerated the knowledge, skills, and abilities necessary to perform each task. These deliberations resulted in two work products: a practice analysis document (PAD) and subspecialty board TCO based on testable knowledge, skills, and abilities. Survey assessments of the panel's work were then distributed to pediatric cardiology fellowship program directors and to practicing pediatric cardiologists for their input, which largely aligned with the panel's recommendations. Survey responses were considered in the final revisions of the PAD and TCO. This approach to practice analysis proved to be an efficient process for describing the work performed by today's pediatric cardiologists and the knowledge, skills, and abilities needed to competently perform that work.

Entrustable Professional Activities for Chinese Standardized Residency Training in Pediatric Intensive Care Medicine

BACKGROUND

Entrustable professional activities (EPAs) were first introduced by Olle ten Cate in 2005. Since then, hundreds of applications in medical research have been reported worldwide. However, few studies discuss the use of EPAs for residency training in pediatric intensive care medicine. We conducted a pilot study of EPA for pediatric intensive care medicine to evaluate the use of EPAs in this subspecialty.

MATERIALS AND METHODS

A cross-sectional study was implemented in pediatric intensive care medicine standardized residency training at the Qilu Hospital of Shandong University. An electronic survey assessing EPA performance using eight scales composed of 15 categories were distributed among residents and directors.

RESULTS

A total of 217 director-assessment and 44 residents' self-assessment questionnaires were collected, both demonstrating a rising trend in scores across postgraduate years. There were significant differences in PGY1-vs.-PGY2 and PGY1-vs.-PGY3 director-assessment scores, while there were no differences in PGY2-vs.-PGY3 scores. PGY had a significant effect on the score of each EPA, while position significantly affected the scores of all EPAs except for EPA1 (Admit a patient) and EPA2 (Select and interpret auxiliary examinations). Gender only significantly affected the scores of EPA6 (Report a case), EPA12 (Perform health education), and EPA13 (Inform bad news).

CONCLUSION

This study indicates that EPA assessments have a certain discriminating capability among different PGYs in Chinese standardized residency training in pediatric intensive care medicine. Postgraduate year, gender, and resident position affected EPA scores to a certain extent. Given the inconsistency between resident-assessed and director-assessed scores, an improved feedback program is needed in the future.