Training and certification in surgical critical care: a position paper by the Surgical Critical Care Program Directors Society

Trauma ICU Prevalence Project: the diversity of surgical critical care

Background

Surgical critical care is crucial to the care of trauma and surgical patients. This study was designed to provide a contemporary assessment of patient types, injuries, and conditions in intensive care units (ICU) caring for trauma patients.

Methods

This was a multicenter prevalence study of the American Association for the Surgery of Trauma; data were collected on all patients present in participating centers’ trauma ICU (TICU) on November 2, 2017 and April 10, 2018.

Results

Forty-nine centers submitted data on 1416 patients. Median age was 58 years (IQR 41–70). Patient types included trauma (n=665, 46.9%), non-trauma surgical (n=536, 37.8%), medical (n=204, 14.4% overall), or unspecified (n=11). Surgical intensivists managed 73.1% of patients. Of ICU-specific diagnoses, 57% were pulmonary related. Multiple high-intensity diagnoses were represented (septic shock, 10.2%; multiple organ failure, 5.58%; adult respiratory distress syndrome, 4.38%). Hemorrhagic shock was seen in 11.6% of trauma patients and 6.55% of all patients. The most common traumatic injuries were rib fractures (41.6%), brain (38.8%), hemothorax/pneumothorax (30.8%), and facial fractures (23.7%). Forty-four percent were on mechanical ventilation, and 17.6% had a tracheostomy. One-third (33%) had an infection, and over half (54.3%) were on antibiotics. Operations were performed in 70.2%, with 23.7% having abdominal surgery. At 30 days, 5.4% were still in the ICU. Median ICU length of stay was 9 days (IQR 4–20). 30-day mortality was 11.2%.

Conclusions

Patient acuity in TICUs in the USA is very high, as is the breadth of pathology and the interventions provided. Non-trauma patients constitute a significant proportion of TICU care. Further assessment of the global predictors of outcome is needed to inform the education, research, clinical practice, and staffing of surgical critical care providers.

Level of evidence

IV, prospective observational study.

Ultrasound Training in Surgical Critical Care Fellowship: A Survey of Program Directors

OBJECTIVE

Surgical critical care (SCC) fellows are expected to receive training in critical care ultrasound (CCUS) but training is sporadic and there is no standardized curriculum to guide educators. Previous studies show wide variation in CCUS training during fellowship across specialties but SCC has been underrepresented. This study was performed to assess SCC program directors' views regarding CCUS during fellowship training.

DESIGN

Adult SCC program directors were surveyed regarding the role of CCUS in fellowship training. This survey assessed how CCUS training was performed, perceived barriers to education, and importance of specific studies. Survey responses were measured using a Likert scale ranging from 5 (strongly agree) to 1 (strongly disagree).

SETTING

Web-based survey.

PARTICIPANTS

Adult Surgical Critical Care Fellowship Program Directors.

RESULTS

A total 67 of 108 (62%) SCC program directors responded to the survey. Over 75% felt that CCUS during training should be a priority. Fifteen (24.6%) programs required a specific number of ultrasounds to be performed. Five programs (7.5%) provided no CCUS training at all. Over 75% felt that training in FAST, transthoracic echocardiography, inferior vena cava assessment, and US for procedures (line placement, thoracentesis, and paracentesis) were either important or very important but experience in transesophageal echocardiography, assessment for deep vein thrombosis, and pulmonary US were not important. Lack of time (63.8%) and trained faculty (51.2%) were the most cited barriers to training.

CONCLUSIONS

There is a wide variation in how CCUS training is performed during SCC fellowship. SCC programs will need trained faculty, appropriate time allocation, and implementation of a standardized curriculum to provide consistent and high-quality CCUS education during fellowship.

Fellowship training in extracorporeal life support: Characterization and educational needs assessment

PURPOSE

Adult Extracorporeal Life Support (ECLS) use is rapidly increasing. The structure of fellowship ECLS education is unknown. We sought to define current ECLS education and identify curricular needs.

MATERIALS AND METHODS

An anonymous survey with Likert, binary and free response questions was sent to Critical Care Program Directors (CCPDs).

RESULTS

A total of 103 CCPDs responded, a response rate of 31. ECLS training was provided by 64% (66/103) of fellowships. Importantly, 50% (52/103) of CCPDs agreed or strongly agreed that fellows should be competent in ECLS and 70% (72/103) agreed or strongly agreed that ECLS will be an important part of critical care in the next 10years. Only 28% (29/103) and 37% (38/103) of CCPDs agreed or strongly agreed their fellows could independently manage veno-arterial or veno-venous ECLS, respectively. Formal ECLS education was 5h or less in 85% (88/103) of programs. Desired curricular improvements were: simulation 50% (51/103), patient volume 47% (48/103), and didactics 44% (45/103).

CONCLUSIONS

CCPDs identified ECLS as a critical care skill, but believe that a minority of fellows are prepared for independent practice. Simulation, formal didactics and clinical volume are key needs. These data will guide the development of ECLS curriculum.