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A systematic review of short courses for nonspecialist education in intensive care
Journal of Critical Care (2011) 26, 533.e1–533.e10
A systematic review of short courses for nonspecialist education in intensive care☆ Gavin M. Joynt MBBCh a,⁎, Janice Zimmerman MD b , Thomas S.T. Li MBBS a , Charles D. Gomersall MBBS a a
Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Sha Tin, Hong Kong, ROC Department of Medicine, The Methodist Hospital, Houston, Texas, TX 77030, USA
b
Keywords: Education; Mechanical ventilation; Learning; Simulation; Skills; Knowledge
Abstract Purpose: The availability of reliable and accessible educational material for the training of nonspecialist intensive care physicians is potentially advantageous. We assessed the availability, cost, and content of generic short courses designed to teach basic critical care skills to junior physicians or nonspecialist intensive care physicians taking up duties in intensive care units. Materials and Methods: A PubMed and Internet searches were conducted to identify and compare short courses that provide a curriculum similar to that proposed by the Society of Critical Care Medicine and the Australian and New Zealand College of Anaesthetists for resident training purposes. Course material available should allow the short course to be conducted independently by third parties. Results: Two courses, Basic Assessment and Support in Intensive Care and Fundamental Critical Care Support, met most of the Society of Critical Care Medicine and Australian and New Zealand College of Anaesthetists curriculum requirements and can be independently conducted by third parties. Conclusions: Both identified courses use a mixture self-learning, didactic lectures, and experiential learning using manikins and “minisimulations.” Organizing bodies provide administrative support and can readily be located and contacted online. Basic Assessment and Support in Intensive Care charges no license fee, whereas Fundamental Critical Care Support offers fees at a reduced rate for developing countries. Both courses are recognized and conducted internationally. © 2011 Elsevier Inc. All rights reserved.
1. Introduction
☆ Potential conflict of interest: The authors G.M.J. and C.D.G. are involved in the development and administration of the BASIC course, and the author J.L.Z. is involved in the development and administration of the FCCS course. Both are nonprofit operations. ⁎ Corresponding author. Tel.: +852 26322738; fax: +852 26372422. E-mail address: [email protected] (G.M. Joynt).
0883-9441/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jcrc.2011.01.007
Despite the recent introduction of courses in acute care into the undergraduate curriculum [1,2], undergraduate training in acute and intensive care remains limited [3,4]. In addition, many developing countries are unable to staff all intensive care units (ICUs) with trained specialist intensivists. As a result, residents or junior physicians or nonintensive care specialists working in the ICU for the first time are likely to possess little
533.e2 knowledge and few of the skills required to manage critically ill patients. This problem is exacerbated by the acute nature of critical illness that requires a fundamentally different approach to diagnosis and emergency management. In particular, those not familiar with critical illness need to grasp the importance of identification of specific life-threatening conditions and institution of immediate and appropriate resuscitation and lifesupport measures while routine investigations and definitive therapy proceed. The availability of a short intensive course designed to aid nonintensivist specialists, junior physicians, or residents to recognize, assess, and initiate urgent life-support therapy and manage commonly encountered critical illnesses has several potential advantages. For trainees, it provides a time-efficient introduction to basic but essential ICU skills, preparing them to gain maximal benefit from the clinical exposure of the short rotation. In addition, a well-designed course with fully developed standardized teaching material should optimize the use of contact time for teachers because several physicians/residents can be taught at one time. Insufficient time for trainers is a commonly cited impediment to training [4]. Ideally, this type of course should cover essential aspects of critical care practice similar to those proposed by the Society of Critical Care Medicine (SCCM) [5] or the Australian and New Zealand College of Anaesthesia (ANZCA) for resident-training purposes [6]. We have compared available short courses that are openly accessible to potential users, with or without license fees, that substantially meet the requirements for nonspecialist training in critical care proposed by SCCM and ANZCA [5,6].
2. Methods A literature search of articles in the English language published in PubMed databases from January 1970 to February 2010 using the search terms “critical care or intensive care AND program or workshop,” “critical care or intensive care AND training course,” and “critical care or intensive care AND education course” was conducted to identify acute (≤3 days) critical care courses meeting the following criteria: • encompass a comprehensive curriculum (substantially similar to that proposed in the nonspecialist clinical component of the SCCM and ANZCA guidelines) in the basics of critical care diagnosis and management; • designed to educate non–intensive care specialist physicians; and • sufficient course material available to allow the course to be conducted independently by third parties. In addition, courses meeting the criteria were identified by searching the Web sites of known national and international intensive care societies and from the authors' personal knowledge of critical care educational resources.
G.M. Joynt et al. The courses were compared under the following broad categories: administrative requirements, costs, methods and materials, resource requirements, curriculum scope, and assessment methods.
3. Results Initial examination identified 7 courses potentially meeting most of the entry criteria. These included the Acute LifeThreatening Events-Recognition and Treatment [7], Basic Assessment and Support in Intensive Care (BASIC) (www. aic.cuhk.edu.hk/web8), Care of the Critically Ill Surgical Patient [8], DR WHO: a workshop for house officer preparation (DR WHO) [1], Fundamental Critical Care Support (FCCS) (http:// www.sccm.org/FCCS_AND_TRAINING_COURSES/FCCS/ Pages/default.aspx), the Intermediate Life Support course [9], Very BASIC course [2], and the Detecting Deterioration, Evaluation, Treatment, Escalation and Communication and Communicating in Terms (DETECT) course (http://nswhealth. moodle.com.au/DOH/DETECT/content/). These 8 courses were then examined in detail (Fig. 1). The Acute Life-Threatening Events-Recognition and Treatment and DETECT courses were designed to give health care workers greater ability in the recognition and management of adult patients who have impending or established critical illness. However, examination of the course content revealed that course material addresses primarily pre-ICU management of critically ill patients, and therefore, they were excluded from further comparison [7]. Similarly, the 1-day Intermediate Life Support course focuses almost exclusively on resuscitation and emergency airway management and was excluded based on the restricted curriculum [9]. The 1-day DR WHO and 3-day very BASIC courses were not compared further because they are designed for undergraduate medical students and are largely restricted to pre-ICU care [1,2]. The Care of the Critically Ill Surgical Patient course is a 2-and-a-half-day course designed to advance the practical, theoretical, and personal skills necessary for the care of the critically ill surgical patient [8]. Examination of the course content revealed a curriculum focused exclusively on surgical aspects of critical care and failed to meet minimal criteria for a comprehensive basic ICU curriculum as outlined by the clinical component of the SCCM and ANZCA guidelines and thus was excluded from detailed comparison. After detailed examination, 2 courses, BASIC and FCCS, substantially met the inclusion criteria. They both provide a comprehensive clinically based curriculum substantially similar to that suggested by the clinical component of the SCCM and ANZCA guidelines for rotating intensive care residents (Tables 1 and 2). Sufficient course material and administrative support are provided by both course organizers to allow the course to be conducted independently by third parties (Table 3), and both courses primarily enroll nonintensivist physicians such as residents in training, emergency medicine physicians, primary physicians, anesthesiologists, and critical care fellows beginning their training.
Short courses in intensive care
Fig. 1
533.e3
Summary of available short-duration and intensive care courses.
In addition, both courses provide sufficient material to allow some degree of adjustment to meet specific needs. Although the degree of flexibility differs, certain modules in both courses can be changed to accommodate specific groups of physicians or adapted to allow the participation of advanced practice nurses and allied health personnel. The FCCS course allows de-emphasis or omission of the trauma management, cardiopulmonary resuscitation (CPR), airway, and pediatric components depending on the needs and experience of course participants. The BASIC course allows similar flexibility, having both core modules and several modules such as the pediatric module that are considered optional. As for FCCS, de-emphasis or replacement of basic airway management, CPR, trauma, or vascular access with
noncore modules is facilitated if particular groups of participants already have sufficient knowledge in these areas. Both courses, nevertheless, examine basic knowledge on any omitted or de-emphasized core material. The teaching methods of both courses are similar, and both use a mixture of methods. This includes self-learning by preparatory reading of provided course material (manuals and/or CD-ROM), didactic lectures, and experiential learning using manikins and “minisimulations” as well as small group interactive scenario-based teaching. Manuals are delivered to participants before the commencement of courses. The BASIC participants receive an additional CD-ROM that contains electronic interactive tutorials and narrated lectures. The precourse test and preparatory reading are stressed for BASIC
533.e4 Table 1
G.M. Joynt et al. Coverage of requirements for training of residents in critical care medicine as proposed by the Society of Critical Care Medicine BASIC
Identify when a patient requires treatment best delivered in an ICU Diagnose and stabilize patients with impending organ failure Respiratory Cardiac Neurologic Hepatic Gastrointestinal Hematologic Renal Identify the need for and initiate CPR Diagnose and prevent hemodynamic instability and/or initiate treatment of shock Identify and initiate treatment of life-threatening electrolyte disturbances Identify and initiate treatment of life-threatening acid-base disturbances Suspect and initiate treatment of common poisonings Use invasive and noninvasive monitoring devices to titrate therapy in an ICU Understand basic infection-control techniques Understand basic nutrition-support principles Understand basic sedation and analgesia principles Understand basic concepts of therapeutic decision making and medication safety Recognize, use, and help integrate the unique skills of ICU nurses and ancillary personnel in caring for critically ill patients Key pediatric principles Consider ethical issues and patients' wishes in making treatment decisions
FCCS
Manual
Lecture
Skill station
Manual
Lecture
√ √ √
√ √ √ √ √
√ √ √ √
√ √ √ √ √
√ √ √ √ √
p p √ √ √
p √ √ √
√ √
√ √ √ √ p
√ √ √ √
√
√ p
√
√ √
√ √
√ p p √ √ √
√
√ √
√ √
√ √
√ p √ √ p
√
√
√
√ o
p √
√
Skill station
√ √
p o
o
√ indicates covered by a specific chapter/lecture/skill station; p, partially covered; o, optional.
participants because lectures are not a review of material provided in the manual or CD-ROM but a focus on the explanation of difficult concepts as well as integration of material in case-based lectures. To maximize participant learning and optimally use teacher-contact time, primarily factual topics are taught by a self-learning process using the manual and associated electronic material provided on a CDROM. In the FCCS course, interactive case scenario–based lectures are used to reinforce and revise key topics covered in the FCCS course manual. Topics that require motor skill development use manikins to allow the development of manual skills under supervision in participatory skill stations. The essential manual skills required for airway management and vascular access are taught in this way during both courses. The appropriate performance of complex ICU procedures, particularly the use of mechanical ventilators, is taught by skill stations developed as minisimulations where participants are provided with real mechanical ventilators attached to simple lung simulation models that are capable of reproducing common ICU pulmonary pathophysiology. Verbal interactive skill stations require that participants apply their knowledge and make decisions in the initial assessment and management of hypothetical critically ill patients. The FCCS course teaches trauma management concepts using this method, whereas the BASIC course uses
this method to teach trauma management, the assessment of the seriously ill patient, and interpretation of arterial blood gases and serious metabolic abnormalities. All are taught in the form of extended case scenarios. Each skill station involves groups of 4 to 6 participants (BASIC) or up to 8 participants (FCCS) for approximately 35 to 45 minutes. Both the BASIC and FCCS course include formative assessment in the form of an “open book” pretest multiple choice question (MCQ) paper. The online precourse MCQ for BASIC includes immediate automated feedback on those questions that have been have answered incorrectly and includes guidance on which chapters of the book to reread. The FCCS precourse MCQ test is provided as a self-assessment tool and a benchmark for improvement after course completion. The answers are presented to the course director who marks the questions and provides feedback during the course. Both courses also provide formal methods of summative assessment. Immediate postcourse assessment by MCQs is required to successfully complete both the BASIC and FCCS courses. The typical BASIC postcourse MCQ involves a clinical scenario and often requires the interpretation of investigations. Rather than simply testing factual knowledge, the test is designed to test the ability of participants to make clinical decisions based on acute care scenarios. The BASIC postcourse MCQ can be taken online directly if desired. The
Short courses in intensive care
533.e5
Table 2 Coverage of requirements for training of residents in critical care medicine as proposed by the Australian and New Zealand College of Anaesthetists
Knowledge-supportive care of the critically ill patient Organization of intensive care services and standards of ICUs Transport of the critically ill patient Inotropic therapy Effects of critical illness and concomitant therapies on receptor function Effects of inotropic and vasopressor agents Nutrition, fluid, and electrolyte support Metabolic response to critical illness and starvation Adverse consequences of malnutrition, dehydration, and fluid overload Principles of enteral and intravenous nutrition General care Prevention of complications including Nosocomial infection Ventilator-induced lung injury Thromboembolic disease Stress ulceration Knowledge-specific disorders Acute circulatory failure Classification, causes, pathogenesis, and sequelae of shock Principles of management of all forms of shock Monitoring in the management of shock Causes of cardiorespiratory arrest and the effects of body systems Cardiopulmonary resuscitation and external defibrillators Cardiac dysrhythmias and their current therapies Valvular heart disease Endocarditis Pulmonary embolism Congestive cardiac failure Anaphylaxis Ischemic heart disease and myocardial infarction Factors involved in the balance of oxygen supply and demand to the heart Etiology of coronary artery disease and its effects Signs and symptoms of ischemic heart disease Signs of symptoms of myocardial infarction Principles of the management of acute myocardial infarction including thrombolysis, angioplasty, and surgery Indications for a transvenous pacemaker, right side of the heart catheterization, angiography, and echocardiography Long-term effects of acute myocardial infarction and late complications Respiratory failure Causes and pathogenesis of respiratory failure Oxygen therapy and mechanical ventilatory support (invasive and noninvasive) Respiratory disease processes Cardiogenic/noncardiogenic pulmonary edema/ARDS Airway obstruction Airway stenosis and tracheomalacia Bronchopleural fistula Pneumothorax Aspiration syndromes Fat embolism Pneumonia (community and nosocomial) acute airway limitation Asthma
FCCS
BASIC
x √
x √
x √
x √
x p x
p √ √
x √ √ √
x √ √ √
√ √ √ √ √ √ x x √ √ x
√ √ √ √ √ √ x x √ x x
√ √ √ √ √
x x x x p
√
x
x
x
√ √
√ √
√ √ x x √ x x √ √ √
√ √ x p x x x √ √ √
(continued on next page)
533.e6
G.M. Joynt et al.
Table 2 (continued )
Renal failure Definitions of acute and chronic renal failure Causes and pathogenesis of renal failure Acute renal failure Principles of renal replacement therapy and their indications Neurologic failure Definition and causes of coma Causes, pathogenesis, and treatment of cerebral swelling and raised intracranial pressure Principles of cerebral function monitoring, especially intracranial pressure Principles of diagnosing brain stem death Representative conditions to be understood Acute vascular disorders of the central nervous system Acute infective disorders of the central nervous system Cerebral edema Brain stem death Seizures Hemiplegia, paraplegia, and quadriplegia Guillain-Barré syndrome Peripheral nerve and or muscle dysfunction associated with critical illness Myasthenia gravis Hyperthermia, hypothermia Tetanus Delirium Severe trauma Effects of severe trauma on organs and organ systems Principles of EMST for the management of trauma and advantages of an organized team approach Technique of cricothyroidotomy/tracheostomy/minitracheotomy Principles of the management of head injury and Glasgow coma Management of cervical spine injuries Principles of the safe transfer of injured children and adults and portable monitoring systems Sepsis Definition, pathogenesis, and pathophysiology of sepsis and related syndromes Risk factors for nosocomial infection Infection control measures in ICU Endocrine disorders Diabetes mellitus and diabetes insipidus Thyroid disorders Other endocrine disorders Pheochromocytoma Metabolic disorders Electrolyte and acid-base disorders Nutrition and malnutrition Hematology, oncology, immunology, and rheumatology Defects in hemostasis Anemia Transfusion reactions Immunosuppression Gastrointestinal disorders Gastrointestinal bleeding (acute gastric erosions, peptic ulceration, and esophageal varices) Paralytic ileus, gastric dilatation Pseudomembranous colitis Peritonitis and intra-abdominal sepsis Postoperative gastrointestinal problems Malabsorption Pancreatitis
FCCS
BASIC
x x x x
p √ √ p
√ √ √ √
√ √ √ x
√ √ √ √ √ x x x x √ x x
p p √ x √ x x x x x x x
√ √ x √ √ √
√ √ √ √ √ √
√ √ x
√ x x
√ √ p x
√ x x x
√ x
√ √
x x x x
x x x x
p x √ √ x x x
x x x x x x
(continued on next page)
Short courses in intensive care
533.e7
Table 2 (continued )
Infectious disorders Infections: bacterial, viral, fungal, rickettsial, and protozoal Serious community-acquired infections, eg, meningococcal disease Nosocomial infections particularly with multiply resistant microorganisms, eg, MRSA Sepsis, severe sepsis, septic shock, and septicemia Complications of pregnancy and gynecologic disorders Septic abortion Eclampsia, pre-eclampsia Amniotic fluid embolism Obstetric hemorrhage Trauma Maxillofacial and airway injuries Chest injuries and pneumothorax Aortic injuries Abdominal trauma Neurotrauma/acute spinal cord injury Pelvic injuries Long bone trauma Toxic, chemical, and physical agents Drug overdose and poisoning Ingestion of corrosive Burns Envenomation Electrocution Decompression syndromes Altitude sickness Hyperthermia Hypothermia Near-drowning Clinical management Professional practice Comply with the relevant policies, recommendations, and guidelines in professional practice as contained in ANZCA and CICM professional documents Immediate patient assessment and resuscitation Assess life-threatening problems accurately and quickly in a critically ill patient Judge whom to resuscitate (and whom not to) Judge the priorities of immediate resuscitation Undertake emergency management including basic and advanced life support Provide immediate life-supporting therapy Perform primary and secondary surveys Communication Document patient information clearly, presenting problems and progress Generate a list of differential diagnoses and priorities in investigations Confirm or refute some early diagnoses in emergency situations before data collection is complete to start treatment Counsel patients and relatives Consult and collaborate effectively Conduct appropriate hand over to other colleagues, eg, before or after surgery or on discharge to the ward Supportive care of critically ill patients Inotropic therapy Recognize when to use inotropic or vasopressor therapy Choose an appropriate agent, dose, physiologic end point, rate, and route of administration Review the efficacy of inotropic therapy at regular intervals Nutritional support Provide appropriate nutritional support
FCCS
BASIC
p √ √ √
p √ √ √
x √ √ p
x x x x
x √ √ √ √ √ x
x √ √ √ √ √ x
√ x √ x √ x x p p x
x x x x x x x x x
√ √ √ √ √ √
√ √ √ √ √ √
x √ √
x √ √
x x x
x x x
√ √ x
√ √ x
x
√
(continued on next page)
533.e8
G.M. Joynt et al.
Table 2 (continued )
General care Institute an appropriate plan for care of bowels, skin, mouth, and eyes and maintenance of mobility and muscle strength Monitoring of the critically ill patients Principles of monitoring Monitoring of the cardiovascular, respiratory, renal, and central nervous systems Complications of monitoring Electrical safety Specific disorders Acute circulatory failure Recognize and assess severity of shock and manage the condition Manage cardiorespiratory arrest using the Australian Resuscitation Council's and other accepted international protocols Ischemic heart disease and myocardial infarction Recognize the signs and symptoms of ischemic heart disease Recognize the complications of myocardial infarction and the need for medical and surgical intervention Respiratory failure Recognize and manage respiratory failure Distinguish acute from chronic respiratory failure and the implications for management Management of tracheostomy Hemorrhage Control bleeding Use blood components appropriately Manage coagulopathies Renal failure Identify patient at risk for developing renal failure Apply general principles in the management of a patient with renal failure Neurologic failure Recognize coma and assess its severity Manage an unconscious patient Severe trauma Use a systematic, priority-orientated approach in resuscitation, assessment, investigation, and emergency management Recognize differences between management of the injured child from that of the adult Effectively transfer injured adults and children with and between hospitals Continue management including preventing, recognizing, and managing complications Sepsis Apply the definitions of sepsis to diagnosis Resuscitate a patient with septic shock using appropriate monitoring, fluid therapy, and vasoactive agents Collect appropriate specimens for laboratory examination Recognize the need for surgical intervention and consult appropriately Skills—clinical skills Cardiovascular-related Choosing and using inotropic agents, vasodilators, and vasoconstrictors Managing dysrhythmias Choosing and using antimicrobial agents in heart disease Assisting with intra-aortic balloon pumping Cardioversion Advanced life support Right side of the heart catheterization Respiratory-related Oxygen therapy CPAP Noninvasive ventilation Mechanical ventilation, including modes of ventilation
FCCS
BASIC
x
x
√ √ √ x
√ √ √ x
√ √
√ √
√ √
√ √
√ √ x
√ √ x
√ √ x
√ x x
x x
√ √
√ √
√ √
√
√
x √ √
x √ √
√ √ √ √
√ √ √ √
√ √ x x x √ x
√ √ x x √ √ x
√ √ √ √
√ x x √
(continued on next page)
Short courses in intensive care
533.e9
Table 2 (continued )
Pleural drainage Percutaneous tracheostomy Fibreoptic bronchoscopy Renal failure General care of continuous dialysis and hemofiltration techniques Neurologic failure Maintaining cerebral perfusion pressures and intracranial pressures Gastrointestinal Assisting with placing a Sengstaken-Blakemore or other balloon tamponade tube
FCCS
BASIC
√ x x
√ x x
x
x
√
√
x
x
x indicates not covered; p indicates partial coverage; ARDS, acute respiratory distress syndrome; CPAP, continuous positive airway pressure; EMST, emergency management of severe trauma; CICM, College of Intensive Care Medicine of Australia and New Zealand; MRSA, methicillin-resistant staphylococcus aureus.
FCCS course posttest includes both factual and clinical scenario–based interpretive questions. The organizing bodies for both courses provide administrative support for courses, although the extent and cost of the support differ (Table 3).
4. Discussion Our systematic review of the literature identified 2 openly accessible courses with fully developed standardized teaching material that met the criteria of a short course covering a broad range of intensive care topics similar to those recommended by SCCM and ANZCA (Fig. 1). Both the BASIC and FCCS appear to achieve these purposes, although the course content does differ (Tables 1 and 2). Both courses were devised by Table 3
multidisciplinary international groups of acute care specialists with an interest in education and were developed with the aim of providing high-quality teaching in critical care without an excessive demand on the time of busy clinical teachers. As a result, both courses use a similar mixture of complementary teaching methods—including preparatory self-learning from a manual, didactic lectures, as well as experiential learning using manikins, simulations, and small group interactive scenarios. There are several differences between the FCCS and BASIC courses in cost, copyright, and administrative support (Table 3 and electronic supplementary material, Appendix A). There is no license fee for the BASIC course or the course manual. Printed copies of the course manual are available, on request, at the current cost of printing and delivery. Fundamental Critical Care Support charges a license and manual fee that is substantially discounted in developing countries. Administrative
Comparison of BASIC and FCCS courses BASIC
Availability
Host organization: BASIC Collaboration at The Chinese University of Hong Kong. Contact via Internet Web site. Course distribution Australia, Bahrain, Cambodia, Fiji, Peoples Republic of (by country) China, Hong Kong, India, Indonesia, Iraq, Kuwait, Malaysia, New Zealand, Oman, Saudi Arabia, South Africa, Syria, United Arab Emirates, and United Kingdom Cost (licensing) Course fee: no charge. Manual fee: no charge—pdf download
FCCS Host organization: SCCM. Contact via Internet Web site. 33 or more countries in North and South America, Europe, Africa, and Asia
Course fee: US $200-$1200, depending on country's economic status and profit or nonprofit status of course sponsor. Multiple course pricing available. Manual fee US $15-$50 depending on country's economic status and course sponsor's profit/nonprofit status Target participants Critical care fellows and residents beginning training, Critical care nurses, critical care fellows beginning critical care nurses, nonintensivist physicians, house staff, training, nonintensivist physicians and house staff who and allied health care workers who provide coverage in provide coverage in ICU, prehospital emergency care ICU providers, and emergency medical technicians Participants per Maximum, 6 per instructor; recommended Maximum, 24; recommended (may be increased course depending on no. of instructors) Course length 2d 2 d (alternative schedules possible) Course structure Manual and CD-ROM, lectures, and skill stations Manual, lectures, and skill stations Assessment of Pre- and postcourse MCQ paper Pre- and postcourse MCQ paper candidates
533.e10 guidelines for the FCCS course are more detailed, particularly with regard to instructor requirements and accreditation. This provides the advantage of greater uniformity in course quality. General administrative support is similar; however, BASIC provides some additional online support, particularly assistance in the conduct and marking of pre- and posttests. Upon course completion, BASIC certificates are issued by the course organizer, whereas FCCS course certificates are issued by SCCM and bear the SCCM logo. Both FCCS and BASIC use minisimulations and interactive verbal skill stations based on case scenarios. These are designed to challenge the participant with common clinical problems, encourage active participation in providing solutions, and allow expertly guided reflection of the consequences of action taken [10]. Both verbal interactive and integrated skill stations seek to recreate the process of experiential learning to assist knowledge and skill retentions [10,11]. Although the use of skill stations is labor intensive, there is increasing evidence supporting the use of simulation in acute care teaching [12,13]. Although FCCS and BASIC courses cover similar material and use similar teaching techniques, there are some differences. The FCCS manual provides more extensive information than the BASIC manual. The BASIC course provides a greater choice of skill stations. Course content is similar, but there is a greater emphasis on diseases and their treatment in the FCCS course and a greater emphasis on pathophysiology and generic organ support in BASIC. It is important to appreciate that, although the scope of the courses is relatively wide, neither aims to be comprehensive nor is it possible to cover such a wide curriculum comprehensively in 2 days. The data provided in Tables 2 and 3 are presented to indicate the scope of the courses and should not be taken to indicate that the courses provide complete training in these topics. Short courses such as BASIC and FCCS are not a substitute for clinical exposure. However, in the current environment of accountability, the opportunity for physicians to “learn from experience” with real patients is diminishing, particularly in situations of critical illness. Critically ill patients must receive immediate attention, or they may suffer irreparable harm. Therefore, the window for learner contact and involvement is very small. In this setting, preparation for patient contact by undergoing simulation training is likely to become increasingly important as part of acute medical skills teaching [13]. Although both courses were developed in countries with relatively sophisticated intensive care delivery, the nature of the teaching material appears equally suited to delivery of intensive care in countries where intensive care is less well developed, and the high rate of adoption of both courses in such countries supports this view. Positive feedback from an FCCS course held in Kenya was recently published [14]. There are several
G.M. Joynt et al. possible reasons that may explain why each course may have been adopted in different countries. These reasons include the applicability of course content to particular environments, cost differences, convenience of administrative procedures, style of teaching, or simply reflect the distribution of existing critical care networks and personal contacts. The real impact of both BASIC and FCCS in ultimately improving patient care is difficult to assess, and neither course has been rigorously evaluated. However, the rapid adoption and sustained provision of both courses, nationally and internationally, suggest that they are perceived as useful by both providers and participants. Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jcrc.2011.01.007.
References [1] Cave J, Wallace D, Baillie G, et al. DR WHO: a workshop for house officer preparation. Postgrad Med J 2007;83:4-7. [2] Gruber PC, Gomersall CD, Joynt GM, et al. Teaching acute care: a course for undergraduates. Resuscitation 2007;74:142-9. [3] Frankel HL, Rogers PL, Gandhi RR, et al. What is taught, what is tested: findings and competency-based recommendations of the Undergraduate Medical Education Committee of the Society of Critical Care Medicine. Crit Care Med 2004;32:1949-56. [4] Shen J, Joynt GM, Critchley LA, Tan IKS, Lee A. Survey of current status of intensive care teaching in English-speaking medical schools. Crit Care Med 2004;31:293-8. [5] Dorman T, Angood PB, Angus DC, et al. Guidelines for critical care medicine training and continuing medical education. Crit Care Med 2004;32:263-72. [6] Australian and New Zealand College of Anaesthetists (ANZCA). Anaesthesia training program, curriculum modules: intensive care. Available at: http://www.anzca.edu.au/trainees/atp/curriculum/module-9/ overview Accessed August 15 2010. [7] Smith GB, Osgood VM, Crane S, ALERT Course Development Group. ALERT—a multiprofessional training course in the care of the acutely ill adult patient. Resuscitation 2002;52:281-6. [8] Anderson ID. Care of the critically ill surgical patient courses of the Royal College of Surgeons. Br J Hosp Med 1997;57:274-5. [9] Soar J, Perkins GD, Harris S, Nolan J. The immediate life support course. Resuscitation 2003;57:21-6. [10] Kolb DA. Experimental learning: experience as the source of learning and development. Englewood Cliffs: NJ Prentice Hall; 1984. [11] Weller J, Robinson B, Larsen P, Caldwell C. Simulation-based training to improve acute care skills in medical undergraduates. N Z Med J 2004;117:U1119. [12] Wayne DB, Butter J, Siddall VJ, et al. Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice. J Gen Intern Med 2006;21:251-6. [13] Steadman RH, Coates WC, Huang YM, et al. Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills. Crit Care Med 2006;34: 151-7. [14] Macleod JB, Jones T, Aphivantrakul P, Chupp M, Poenaru D. Evaluation of Fundamental Critical Care Course in Kenya: knowledge, attitude, and practice. J Surg Res 2009, doi:10.1016/j.jss.2009.08.030 1-8.
A systematic review of short courses for nonspecialist education in intensive care☆ Gavin M. Joynt MBBCh a,⁎, Janice Zimmerman MD b , Thomas S.T. Li MBBS a , Charles D. Gomersall MBBS a a
Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Sha Tin, Hong Kong, ROC Department of Medicine, The Methodist Hospital, Houston, Texas, TX 77030, USA
b
Keywords: Education; Mechanical ventilation; Learning; Simulation; Skills; Knowledge
Abstract Purpose: The availability of reliable and accessible educational material for the training of nonspecialist intensive care physicians is potentially advantageous. We assessed the availability, cost, and content of generic short courses designed to teach basic critical care skills to junior physicians or nonspecialist intensive care physicians taking up duties in intensive care units. Materials and Methods: A PubMed and Internet searches were conducted to identify and compare short courses that provide a curriculum similar to that proposed by the Society of Critical Care Medicine and the Australian and New Zealand College of Anaesthetists for resident training purposes. Course material available should allow the short course to be conducted independently by third parties. Results: Two courses, Basic Assessment and Support in Intensive Care and Fundamental Critical Care Support, met most of the Society of Critical Care Medicine and Australian and New Zealand College of Anaesthetists curriculum requirements and can be independently conducted by third parties. Conclusions: Both identified courses use a mixture self-learning, didactic lectures, and experiential learning using manikins and “minisimulations.” Organizing bodies provide administrative support and can readily be located and contacted online. Basic Assessment and Support in Intensive Care charges no license fee, whereas Fundamental Critical Care Support offers fees at a reduced rate for developing countries. Both courses are recognized and conducted internationally. © 2011 Elsevier Inc. All rights reserved.
1. Introduction
☆ Potential conflict of interest: The authors G.M.J. and C.D.G. are involved in the development and administration of the BASIC course, and the author J.L.Z. is involved in the development and administration of the FCCS course. Both are nonprofit operations. ⁎ Corresponding author. Tel.: +852 26322738; fax: +852 26372422. E-mail address: [email protected] (G.M. Joynt).
0883-9441/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jcrc.2011.01.007
Despite the recent introduction of courses in acute care into the undergraduate curriculum [1,2], undergraduate training in acute and intensive care remains limited [3,4]. In addition, many developing countries are unable to staff all intensive care units (ICUs) with trained specialist intensivists. As a result, residents or junior physicians or nonintensive care specialists working in the ICU for the first time are likely to possess little
533.e2 knowledge and few of the skills required to manage critically ill patients. This problem is exacerbated by the acute nature of critical illness that requires a fundamentally different approach to diagnosis and emergency management. In particular, those not familiar with critical illness need to grasp the importance of identification of specific life-threatening conditions and institution of immediate and appropriate resuscitation and lifesupport measures while routine investigations and definitive therapy proceed. The availability of a short intensive course designed to aid nonintensivist specialists, junior physicians, or residents to recognize, assess, and initiate urgent life-support therapy and manage commonly encountered critical illnesses has several potential advantages. For trainees, it provides a time-efficient introduction to basic but essential ICU skills, preparing them to gain maximal benefit from the clinical exposure of the short rotation. In addition, a well-designed course with fully developed standardized teaching material should optimize the use of contact time for teachers because several physicians/residents can be taught at one time. Insufficient time for trainers is a commonly cited impediment to training [4]. Ideally, this type of course should cover essential aspects of critical care practice similar to those proposed by the Society of Critical Care Medicine (SCCM) [5] or the Australian and New Zealand College of Anaesthesia (ANZCA) for resident-training purposes [6]. We have compared available short courses that are openly accessible to potential users, with or without license fees, that substantially meet the requirements for nonspecialist training in critical care proposed by SCCM and ANZCA [5,6].
2. Methods A literature search of articles in the English language published in PubMed databases from January 1970 to February 2010 using the search terms “critical care or intensive care AND program or workshop,” “critical care or intensive care AND training course,” and “critical care or intensive care AND education course” was conducted to identify acute (≤3 days) critical care courses meeting the following criteria: • encompass a comprehensive curriculum (substantially similar to that proposed in the nonspecialist clinical component of the SCCM and ANZCA guidelines) in the basics of critical care diagnosis and management; • designed to educate non–intensive care specialist physicians; and • sufficient course material available to allow the course to be conducted independently by third parties. In addition, courses meeting the criteria were identified by searching the Web sites of known national and international intensive care societies and from the authors' personal knowledge of critical care educational resources.
G.M. Joynt et al. The courses were compared under the following broad categories: administrative requirements, costs, methods and materials, resource requirements, curriculum scope, and assessment methods.
3. Results Initial examination identified 7 courses potentially meeting most of the entry criteria. These included the Acute LifeThreatening Events-Recognition and Treatment [7], Basic Assessment and Support in Intensive Care (BASIC) (www. aic.cuhk.edu.hk/web8), Care of the Critically Ill Surgical Patient [8], DR WHO: a workshop for house officer preparation (DR WHO) [1], Fundamental Critical Care Support (FCCS) (http:// www.sccm.org/FCCS_AND_TRAINING_COURSES/FCCS/ Pages/default.aspx), the Intermediate Life Support course [9], Very BASIC course [2], and the Detecting Deterioration, Evaluation, Treatment, Escalation and Communication and Communicating in Terms (DETECT) course (http://nswhealth. moodle.com.au/DOH/DETECT/content/). These 8 courses were then examined in detail (Fig. 1). The Acute Life-Threatening Events-Recognition and Treatment and DETECT courses were designed to give health care workers greater ability in the recognition and management of adult patients who have impending or established critical illness. However, examination of the course content revealed that course material addresses primarily pre-ICU management of critically ill patients, and therefore, they were excluded from further comparison [7]. Similarly, the 1-day Intermediate Life Support course focuses almost exclusively on resuscitation and emergency airway management and was excluded based on the restricted curriculum [9]. The 1-day DR WHO and 3-day very BASIC courses were not compared further because they are designed for undergraduate medical students and are largely restricted to pre-ICU care [1,2]. The Care of the Critically Ill Surgical Patient course is a 2-and-a-half-day course designed to advance the practical, theoretical, and personal skills necessary for the care of the critically ill surgical patient [8]. Examination of the course content revealed a curriculum focused exclusively on surgical aspects of critical care and failed to meet minimal criteria for a comprehensive basic ICU curriculum as outlined by the clinical component of the SCCM and ANZCA guidelines and thus was excluded from detailed comparison. After detailed examination, 2 courses, BASIC and FCCS, substantially met the inclusion criteria. They both provide a comprehensive clinically based curriculum substantially similar to that suggested by the clinical component of the SCCM and ANZCA guidelines for rotating intensive care residents (Tables 1 and 2). Sufficient course material and administrative support are provided by both course organizers to allow the course to be conducted independently by third parties (Table 3), and both courses primarily enroll nonintensivist physicians such as residents in training, emergency medicine physicians, primary physicians, anesthesiologists, and critical care fellows beginning their training.
Short courses in intensive care
Fig. 1
533.e3
Summary of available short-duration and intensive care courses.
In addition, both courses provide sufficient material to allow some degree of adjustment to meet specific needs. Although the degree of flexibility differs, certain modules in both courses can be changed to accommodate specific groups of physicians or adapted to allow the participation of advanced practice nurses and allied health personnel. The FCCS course allows de-emphasis or omission of the trauma management, cardiopulmonary resuscitation (CPR), airway, and pediatric components depending on the needs and experience of course participants. The BASIC course allows similar flexibility, having both core modules and several modules such as the pediatric module that are considered optional. As for FCCS, de-emphasis or replacement of basic airway management, CPR, trauma, or vascular access with
noncore modules is facilitated if particular groups of participants already have sufficient knowledge in these areas. Both courses, nevertheless, examine basic knowledge on any omitted or de-emphasized core material. The teaching methods of both courses are similar, and both use a mixture of methods. This includes self-learning by preparatory reading of provided course material (manuals and/or CD-ROM), didactic lectures, and experiential learning using manikins and “minisimulations” as well as small group interactive scenario-based teaching. Manuals are delivered to participants before the commencement of courses. The BASIC participants receive an additional CD-ROM that contains electronic interactive tutorials and narrated lectures. The precourse test and preparatory reading are stressed for BASIC
533.e4 Table 1
G.M. Joynt et al. Coverage of requirements for training of residents in critical care medicine as proposed by the Society of Critical Care Medicine BASIC
Identify when a patient requires treatment best delivered in an ICU Diagnose and stabilize patients with impending organ failure Respiratory Cardiac Neurologic Hepatic Gastrointestinal Hematologic Renal Identify the need for and initiate CPR Diagnose and prevent hemodynamic instability and/or initiate treatment of shock Identify and initiate treatment of life-threatening electrolyte disturbances Identify and initiate treatment of life-threatening acid-base disturbances Suspect and initiate treatment of common poisonings Use invasive and noninvasive monitoring devices to titrate therapy in an ICU Understand basic infection-control techniques Understand basic nutrition-support principles Understand basic sedation and analgesia principles Understand basic concepts of therapeutic decision making and medication safety Recognize, use, and help integrate the unique skills of ICU nurses and ancillary personnel in caring for critically ill patients Key pediatric principles Consider ethical issues and patients' wishes in making treatment decisions
FCCS
Manual
Lecture
Skill station
Manual
Lecture
√ √ √
√ √ √ √ √
√ √ √ √
√ √ √ √ √
√ √ √ √ √
p p √ √ √
p √ √ √
√ √
√ √ √ √ p
√ √ √ √
√
√ p
√
√ √
√ √
√ p p √ √ √
√
√ √
√ √
√ √
√ p √ √ p
√
√
√
√ o
p √
√
Skill station
√ √
p o
o
√ indicates covered by a specific chapter/lecture/skill station; p, partially covered; o, optional.
participants because lectures are not a review of material provided in the manual or CD-ROM but a focus on the explanation of difficult concepts as well as integration of material in case-based lectures. To maximize participant learning and optimally use teacher-contact time, primarily factual topics are taught by a self-learning process using the manual and associated electronic material provided on a CDROM. In the FCCS course, interactive case scenario–based lectures are used to reinforce and revise key topics covered in the FCCS course manual. Topics that require motor skill development use manikins to allow the development of manual skills under supervision in participatory skill stations. The essential manual skills required for airway management and vascular access are taught in this way during both courses. The appropriate performance of complex ICU procedures, particularly the use of mechanical ventilators, is taught by skill stations developed as minisimulations where participants are provided with real mechanical ventilators attached to simple lung simulation models that are capable of reproducing common ICU pulmonary pathophysiology. Verbal interactive skill stations require that participants apply their knowledge and make decisions in the initial assessment and management of hypothetical critically ill patients. The FCCS course teaches trauma management concepts using this method, whereas the BASIC course uses
this method to teach trauma management, the assessment of the seriously ill patient, and interpretation of arterial blood gases and serious metabolic abnormalities. All are taught in the form of extended case scenarios. Each skill station involves groups of 4 to 6 participants (BASIC) or up to 8 participants (FCCS) for approximately 35 to 45 minutes. Both the BASIC and FCCS course include formative assessment in the form of an “open book” pretest multiple choice question (MCQ) paper. The online precourse MCQ for BASIC includes immediate automated feedback on those questions that have been have answered incorrectly and includes guidance on which chapters of the book to reread. The FCCS precourse MCQ test is provided as a self-assessment tool and a benchmark for improvement after course completion. The answers are presented to the course director who marks the questions and provides feedback during the course. Both courses also provide formal methods of summative assessment. Immediate postcourse assessment by MCQs is required to successfully complete both the BASIC and FCCS courses. The typical BASIC postcourse MCQ involves a clinical scenario and often requires the interpretation of investigations. Rather than simply testing factual knowledge, the test is designed to test the ability of participants to make clinical decisions based on acute care scenarios. The BASIC postcourse MCQ can be taken online directly if desired. The
Short courses in intensive care
533.e5
Table 2 Coverage of requirements for training of residents in critical care medicine as proposed by the Australian and New Zealand College of Anaesthetists
Knowledge-supportive care of the critically ill patient Organization of intensive care services and standards of ICUs Transport of the critically ill patient Inotropic therapy Effects of critical illness and concomitant therapies on receptor function Effects of inotropic and vasopressor agents Nutrition, fluid, and electrolyte support Metabolic response to critical illness and starvation Adverse consequences of malnutrition, dehydration, and fluid overload Principles of enteral and intravenous nutrition General care Prevention of complications including Nosocomial infection Ventilator-induced lung injury Thromboembolic disease Stress ulceration Knowledge-specific disorders Acute circulatory failure Classification, causes, pathogenesis, and sequelae of shock Principles of management of all forms of shock Monitoring in the management of shock Causes of cardiorespiratory arrest and the effects of body systems Cardiopulmonary resuscitation and external defibrillators Cardiac dysrhythmias and their current therapies Valvular heart disease Endocarditis Pulmonary embolism Congestive cardiac failure Anaphylaxis Ischemic heart disease and myocardial infarction Factors involved in the balance of oxygen supply and demand to the heart Etiology of coronary artery disease and its effects Signs and symptoms of ischemic heart disease Signs of symptoms of myocardial infarction Principles of the management of acute myocardial infarction including thrombolysis, angioplasty, and surgery Indications for a transvenous pacemaker, right side of the heart catheterization, angiography, and echocardiography Long-term effects of acute myocardial infarction and late complications Respiratory failure Causes and pathogenesis of respiratory failure Oxygen therapy and mechanical ventilatory support (invasive and noninvasive) Respiratory disease processes Cardiogenic/noncardiogenic pulmonary edema/ARDS Airway obstruction Airway stenosis and tracheomalacia Bronchopleural fistula Pneumothorax Aspiration syndromes Fat embolism Pneumonia (community and nosocomial) acute airway limitation Asthma
FCCS
BASIC
x √
x √
x √
x √
x p x
p √ √
x √ √ √
x √ √ √
√ √ √ √ √ √ x x √ √ x
√ √ √ √ √ √ x x √ x x
√ √ √ √ √
x x x x p
√
x
x
x
√ √
√ √
√ √ x x √ x x √ √ √
√ √ x p x x x √ √ √
(continued on next page)
533.e6
G.M. Joynt et al.
Table 2 (continued )
Renal failure Definitions of acute and chronic renal failure Causes and pathogenesis of renal failure Acute renal failure Principles of renal replacement therapy and their indications Neurologic failure Definition and causes of coma Causes, pathogenesis, and treatment of cerebral swelling and raised intracranial pressure Principles of cerebral function monitoring, especially intracranial pressure Principles of diagnosing brain stem death Representative conditions to be understood Acute vascular disorders of the central nervous system Acute infective disorders of the central nervous system Cerebral edema Brain stem death Seizures Hemiplegia, paraplegia, and quadriplegia Guillain-Barré syndrome Peripheral nerve and or muscle dysfunction associated with critical illness Myasthenia gravis Hyperthermia, hypothermia Tetanus Delirium Severe trauma Effects of severe trauma on organs and organ systems Principles of EMST for the management of trauma and advantages of an organized team approach Technique of cricothyroidotomy/tracheostomy/minitracheotomy Principles of the management of head injury and Glasgow coma Management of cervical spine injuries Principles of the safe transfer of injured children and adults and portable monitoring systems Sepsis Definition, pathogenesis, and pathophysiology of sepsis and related syndromes Risk factors for nosocomial infection Infection control measures in ICU Endocrine disorders Diabetes mellitus and diabetes insipidus Thyroid disorders Other endocrine disorders Pheochromocytoma Metabolic disorders Electrolyte and acid-base disorders Nutrition and malnutrition Hematology, oncology, immunology, and rheumatology Defects in hemostasis Anemia Transfusion reactions Immunosuppression Gastrointestinal disorders Gastrointestinal bleeding (acute gastric erosions, peptic ulceration, and esophageal varices) Paralytic ileus, gastric dilatation Pseudomembranous colitis Peritonitis and intra-abdominal sepsis Postoperative gastrointestinal problems Malabsorption Pancreatitis
FCCS
BASIC
x x x x
p √ √ p
√ √ √ √
√ √ √ x
√ √ √ √ √ x x x x √ x x
p p √ x √ x x x x x x x
√ √ x √ √ √
√ √ √ √ √ √
√ √ x
√ x x
√ √ p x
√ x x x
√ x
√ √
x x x x
x x x x
p x √ √ x x x
x x x x x x
(continued on next page)
Short courses in intensive care
533.e7
Table 2 (continued )
Infectious disorders Infections: bacterial, viral, fungal, rickettsial, and protozoal Serious community-acquired infections, eg, meningococcal disease Nosocomial infections particularly with multiply resistant microorganisms, eg, MRSA Sepsis, severe sepsis, septic shock, and septicemia Complications of pregnancy and gynecologic disorders Septic abortion Eclampsia, pre-eclampsia Amniotic fluid embolism Obstetric hemorrhage Trauma Maxillofacial and airway injuries Chest injuries and pneumothorax Aortic injuries Abdominal trauma Neurotrauma/acute spinal cord injury Pelvic injuries Long bone trauma Toxic, chemical, and physical agents Drug overdose and poisoning Ingestion of corrosive Burns Envenomation Electrocution Decompression syndromes Altitude sickness Hyperthermia Hypothermia Near-drowning Clinical management Professional practice Comply with the relevant policies, recommendations, and guidelines in professional practice as contained in ANZCA and CICM professional documents Immediate patient assessment and resuscitation Assess life-threatening problems accurately and quickly in a critically ill patient Judge whom to resuscitate (and whom not to) Judge the priorities of immediate resuscitation Undertake emergency management including basic and advanced life support Provide immediate life-supporting therapy Perform primary and secondary surveys Communication Document patient information clearly, presenting problems and progress Generate a list of differential diagnoses and priorities in investigations Confirm or refute some early diagnoses in emergency situations before data collection is complete to start treatment Counsel patients and relatives Consult and collaborate effectively Conduct appropriate hand over to other colleagues, eg, before or after surgery or on discharge to the ward Supportive care of critically ill patients Inotropic therapy Recognize when to use inotropic or vasopressor therapy Choose an appropriate agent, dose, physiologic end point, rate, and route of administration Review the efficacy of inotropic therapy at regular intervals Nutritional support Provide appropriate nutritional support
FCCS
BASIC
p √ √ √
p √ √ √
x √ √ p
x x x x
x √ √ √ √ √ x
x √ √ √ √ √ x
√ x √ x √ x x p p x
x x x x x x x x x
√ √ √ √ √ √
√ √ √ √ √ √
x √ √
x √ √
x x x
x x x
√ √ x
√ √ x
x
√
(continued on next page)
533.e8
G.M. Joynt et al.
Table 2 (continued )
General care Institute an appropriate plan for care of bowels, skin, mouth, and eyes and maintenance of mobility and muscle strength Monitoring of the critically ill patients Principles of monitoring Monitoring of the cardiovascular, respiratory, renal, and central nervous systems Complications of monitoring Electrical safety Specific disorders Acute circulatory failure Recognize and assess severity of shock and manage the condition Manage cardiorespiratory arrest using the Australian Resuscitation Council's and other accepted international protocols Ischemic heart disease and myocardial infarction Recognize the signs and symptoms of ischemic heart disease Recognize the complications of myocardial infarction and the need for medical and surgical intervention Respiratory failure Recognize and manage respiratory failure Distinguish acute from chronic respiratory failure and the implications for management Management of tracheostomy Hemorrhage Control bleeding Use blood components appropriately Manage coagulopathies Renal failure Identify patient at risk for developing renal failure Apply general principles in the management of a patient with renal failure Neurologic failure Recognize coma and assess its severity Manage an unconscious patient Severe trauma Use a systematic, priority-orientated approach in resuscitation, assessment, investigation, and emergency management Recognize differences between management of the injured child from that of the adult Effectively transfer injured adults and children with and between hospitals Continue management including preventing, recognizing, and managing complications Sepsis Apply the definitions of sepsis to diagnosis Resuscitate a patient with septic shock using appropriate monitoring, fluid therapy, and vasoactive agents Collect appropriate specimens for laboratory examination Recognize the need for surgical intervention and consult appropriately Skills—clinical skills Cardiovascular-related Choosing and using inotropic agents, vasodilators, and vasoconstrictors Managing dysrhythmias Choosing and using antimicrobial agents in heart disease Assisting with intra-aortic balloon pumping Cardioversion Advanced life support Right side of the heart catheterization Respiratory-related Oxygen therapy CPAP Noninvasive ventilation Mechanical ventilation, including modes of ventilation
FCCS
BASIC
x
x
√ √ √ x
√ √ √ x
√ √
√ √
√ √
√ √
√ √ x
√ √ x
√ √ x
√ x x
x x
√ √
√ √
√ √
√
√
x √ √
x √ √
√ √ √ √
√ √ √ √
√ √ x x x √ x
√ √ x x √ √ x
√ √ √ √
√ x x √
(continued on next page)
Short courses in intensive care
533.e9
Table 2 (continued )
Pleural drainage Percutaneous tracheostomy Fibreoptic bronchoscopy Renal failure General care of continuous dialysis and hemofiltration techniques Neurologic failure Maintaining cerebral perfusion pressures and intracranial pressures Gastrointestinal Assisting with placing a Sengstaken-Blakemore or other balloon tamponade tube
FCCS
BASIC
√ x x
√ x x
x
x
√
√
x
x
x indicates not covered; p indicates partial coverage; ARDS, acute respiratory distress syndrome; CPAP, continuous positive airway pressure; EMST, emergency management of severe trauma; CICM, College of Intensive Care Medicine of Australia and New Zealand; MRSA, methicillin-resistant staphylococcus aureus.
FCCS course posttest includes both factual and clinical scenario–based interpretive questions. The organizing bodies for both courses provide administrative support for courses, although the extent and cost of the support differ (Table 3).
4. Discussion Our systematic review of the literature identified 2 openly accessible courses with fully developed standardized teaching material that met the criteria of a short course covering a broad range of intensive care topics similar to those recommended by SCCM and ANZCA (Fig. 1). Both the BASIC and FCCS appear to achieve these purposes, although the course content does differ (Tables 1 and 2). Both courses were devised by Table 3
multidisciplinary international groups of acute care specialists with an interest in education and were developed with the aim of providing high-quality teaching in critical care without an excessive demand on the time of busy clinical teachers. As a result, both courses use a similar mixture of complementary teaching methods—including preparatory self-learning from a manual, didactic lectures, as well as experiential learning using manikins, simulations, and small group interactive scenarios. There are several differences between the FCCS and BASIC courses in cost, copyright, and administrative support (Table 3 and electronic supplementary material, Appendix A). There is no license fee for the BASIC course or the course manual. Printed copies of the course manual are available, on request, at the current cost of printing and delivery. Fundamental Critical Care Support charges a license and manual fee that is substantially discounted in developing countries. Administrative
Comparison of BASIC and FCCS courses BASIC
Availability
Host organization: BASIC Collaboration at The Chinese University of Hong Kong. Contact via Internet Web site. Course distribution Australia, Bahrain, Cambodia, Fiji, Peoples Republic of (by country) China, Hong Kong, India, Indonesia, Iraq, Kuwait, Malaysia, New Zealand, Oman, Saudi Arabia, South Africa, Syria, United Arab Emirates, and United Kingdom Cost (licensing) Course fee: no charge. Manual fee: no charge—pdf download
FCCS Host organization: SCCM. Contact via Internet Web site. 33 or more countries in North and South America, Europe, Africa, and Asia
Course fee: US $200-$1200, depending on country's economic status and profit or nonprofit status of course sponsor. Multiple course pricing available. Manual fee US $15-$50 depending on country's economic status and course sponsor's profit/nonprofit status Target participants Critical care fellows and residents beginning training, Critical care nurses, critical care fellows beginning critical care nurses, nonintensivist physicians, house staff, training, nonintensivist physicians and house staff who and allied health care workers who provide coverage in provide coverage in ICU, prehospital emergency care ICU providers, and emergency medical technicians Participants per Maximum, 6 per instructor; recommended Maximum, 24; recommended (may be increased course depending on no. of instructors) Course length 2d 2 d (alternative schedules possible) Course structure Manual and CD-ROM, lectures, and skill stations Manual, lectures, and skill stations Assessment of Pre- and postcourse MCQ paper Pre- and postcourse MCQ paper candidates
533.e10 guidelines for the FCCS course are more detailed, particularly with regard to instructor requirements and accreditation. This provides the advantage of greater uniformity in course quality. General administrative support is similar; however, BASIC provides some additional online support, particularly assistance in the conduct and marking of pre- and posttests. Upon course completion, BASIC certificates are issued by the course organizer, whereas FCCS course certificates are issued by SCCM and bear the SCCM logo. Both FCCS and BASIC use minisimulations and interactive verbal skill stations based on case scenarios. These are designed to challenge the participant with common clinical problems, encourage active participation in providing solutions, and allow expertly guided reflection of the consequences of action taken [10]. Both verbal interactive and integrated skill stations seek to recreate the process of experiential learning to assist knowledge and skill retentions [10,11]. Although the use of skill stations is labor intensive, there is increasing evidence supporting the use of simulation in acute care teaching [12,13]. Although FCCS and BASIC courses cover similar material and use similar teaching techniques, there are some differences. The FCCS manual provides more extensive information than the BASIC manual. The BASIC course provides a greater choice of skill stations. Course content is similar, but there is a greater emphasis on diseases and their treatment in the FCCS course and a greater emphasis on pathophysiology and generic organ support in BASIC. It is important to appreciate that, although the scope of the courses is relatively wide, neither aims to be comprehensive nor is it possible to cover such a wide curriculum comprehensively in 2 days. The data provided in Tables 2 and 3 are presented to indicate the scope of the courses and should not be taken to indicate that the courses provide complete training in these topics. Short courses such as BASIC and FCCS are not a substitute for clinical exposure. However, in the current environment of accountability, the opportunity for physicians to “learn from experience” with real patients is diminishing, particularly in situations of critical illness. Critically ill patients must receive immediate attention, or they may suffer irreparable harm. Therefore, the window for learner contact and involvement is very small. In this setting, preparation for patient contact by undergoing simulation training is likely to become increasingly important as part of acute medical skills teaching [13]. Although both courses were developed in countries with relatively sophisticated intensive care delivery, the nature of the teaching material appears equally suited to delivery of intensive care in countries where intensive care is less well developed, and the high rate of adoption of both courses in such countries supports this view. Positive feedback from an FCCS course held in Kenya was recently published [14]. There are several
G.M. Joynt et al. possible reasons that may explain why each course may have been adopted in different countries. These reasons include the applicability of course content to particular environments, cost differences, convenience of administrative procedures, style of teaching, or simply reflect the distribution of existing critical care networks and personal contacts. The real impact of both BASIC and FCCS in ultimately improving patient care is difficult to assess, and neither course has been rigorously evaluated. However, the rapid adoption and sustained provision of both courses, nationally and internationally, suggest that they are perceived as useful by both providers and participants. Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jcrc.2011.01.007.
References [1] Cave J, Wallace D, Baillie G, et al. DR WHO: a workshop for house officer preparation. Postgrad Med J 2007;83:4-7. [2] Gruber PC, Gomersall CD, Joynt GM, et al. Teaching acute care: a course for undergraduates. Resuscitation 2007;74:142-9. [3] Frankel HL, Rogers PL, Gandhi RR, et al. What is taught, what is tested: findings and competency-based recommendations of the Undergraduate Medical Education Committee of the Society of Critical Care Medicine. Crit Care Med 2004;32:1949-56. [4] Shen J, Joynt GM, Critchley LA, Tan IKS, Lee A. Survey of current status of intensive care teaching in English-speaking medical schools. Crit Care Med 2004;31:293-8. [5] Dorman T, Angood PB, Angus DC, et al. Guidelines for critical care medicine training and continuing medical education. Crit Care Med 2004;32:263-72. [6] Australian and New Zealand College of Anaesthetists (ANZCA). Anaesthesia training program, curriculum modules: intensive care. Available at: http://www.anzca.edu.au/trainees/atp/curriculum/module-9/ overview Accessed August 15 2010. [7] Smith GB, Osgood VM, Crane S, ALERT Course Development Group. ALERT—a multiprofessional training course in the care of the acutely ill adult patient. Resuscitation 2002;52:281-6. [8] Anderson ID. Care of the critically ill surgical patient courses of the Royal College of Surgeons. Br J Hosp Med 1997;57:274-5. [9] Soar J, Perkins GD, Harris S, Nolan J. The immediate life support course. Resuscitation 2003;57:21-6. [10] Kolb DA. Experimental learning: experience as the source of learning and development. Englewood Cliffs: NJ Prentice Hall; 1984. [11] Weller J, Robinson B, Larsen P, Caldwell C. Simulation-based training to improve acute care skills in medical undergraduates. N Z Med J 2004;117:U1119. [12] Wayne DB, Butter J, Siddall VJ, et al. Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice. J Gen Intern Med 2006;21:251-6. [13] Steadman RH, Coates WC, Huang YM, et al. Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills. Crit Care Med 2006;34: 151-7. [14] Macleod JB, Jones T, Aphivantrakul P, Chupp M, Poenaru D. Evaluation of Fundamental Critical Care Course in Kenya: knowledge, attitude, and practice. J Surg Res 2009, doi:10.1016/j.jss.2009.08.030 1-8.