CRITICAL CARE MEDICINE  

INTRODUCTION:A university wishing to have a program in critical care medicine accredited must also sponsor accredited programs in anesthesia, emergency medicine, general surgery, internal medicine, pediatrics or thoracic surgery.

Critical care medicine is a multidisciplinary field concerned with patients who have sustained, or are at risk of sustaining, life-threatening, single or multiple organ system failure due to disease or injury. Critical care medicine seeks to provide for the needs of these patients through immediate and continuous observation and intervention so as to restore health and prevent complications. A specialist in critical care medicine is a physician or surgeon who is competent in all aspects of recognizing and managing acutely ill patients with single or multiple organ system failure, requiring ongoing monitoring and support. It is recognized that critical care medicine specialists might focus their expertise on a specific aspect of the age spectrum.

The purpose of this document is to provide program directors, surveyors and residents with an interpretation of the general standards of accreditation as they relate to the accreditation of programs in adult critical care medicine.

GOALS AND OBJECTIVES:There must be a clearly worded statement outlining the goals of the residency program and the educational objectives of the residents.

The following terminal objectives have been outlined by the Specialty Committee in Critical Care Medicine. Accredited programs are expected to develop enabling, rotation-specific objectives for the program based on these terminal objectives.

General Objectives:The rapidly expanding body of knowledge regarding the treatment of the critically ill, the continuing introduction of new technology for life support, and more complex societal issues, (legal, moral, ethical), have created a need for specialists trained in the recognition and management of this patient subset. The residency program to develop such specialists will focus on knowledge, (including development, management, and evaluation skills), and desirable personal qualities, with a focus throughout on the unique interactive environment in which the critically ill patient is managed.

On successful completion of the residency program, the successful critical care medicine specialist will have a working knowledge of applied clinical physiology and homeostasis, and be able to recognize and treat single or multiple organ failure. In addition, the individual will be familiar with strategies designed to prevent such failures in the high risk patient. A critical care specialist will also be familiar with the administrative organization required to operate an intensive care facility co-operatively within an acute care hospital, and be knowledgeable regarding staffing requirements, skills, education, and organization, and be able to evaluate and cooperatively determine equipment requirements for such a unit. These individuals should be familiar with the concepts of basic applied research, and epidemiology so that they can intelligently evaluate newer forms of therapy in this continuously evolving field.

Specific Objectives:

1. Knowledge (Basic and Applied)

Preamble

Given a basic understanding of

• Physiology
• Pathophysiology
• Pharmacology

the resident must be able to demonstrate the knowledge areas, both basic and applied, as outlined around the following issues:

d.      Respiratory Issues

Given a critically ill patient, the resident must be able to determine the presence or absence of respiratory failure, provide for its emergency support, and have a plan of action to subsequently investigate and manage the problem.

e.       Cardiovascular Issues

Given a critically ill patient presenting with chest pain, myocardial infarction, arrhythmia, pulmonary edema or hemodynamic instability, the resident must be able to recognize the problem, provide emergency life saving support, and embark upon a diagnostic and management program to correct the instability.

f.        Renal Issues

Given a critically ill patient with oliguria, evidence of advancing renal failure, or established renal failure, the resident must be able to recognize the problem, institute measures to preserve remaining renal function, and provide for precise diagnosis, adequate supportive measures, and primary therapy if available.

g.       Neurological Issues

Given a patient with CNS crisis and/or an altered level of consciousness, the resident must be able to recognize the nature of the situation, institute immediate life-sustaining measures, carry out appropriate neurological examination, derive a differential diagnosis, and continue with appropriate diagnostic and supportive measures until the problem is eventually resolved.

h.       Gastrointestinal Issues

Given the critically ill patient who presents with gastrointestinal crisis, the resident must be able to critically evaluate the nature of the illness, institute immediate life-sustaining support, and embark upon a program of precise diagnosis, continuing support and, where possible, resolution of the pathophysiological entity.

i.         Hematological Issues

Given a critically ill patient with a thrombotic or thrombolytic disorder, bleeding, neutropenia, or anemia, the candidate must be able to recognize the problem, provide for any indicated life-sustaining support, and proceed with an orderly course of investigation, management, continued support and treatment.

j.        Hepatic Issues

Given a patient with multisystem disease and jaundice and/or manifest hepatic failure, the resident must be able to recognize the problem, provide for immediate life-sustaining support, and develop a plan for the diagnosis of the precise disorder and the ongoing support and maintenance of the patient.

k.      Nutritional Issues

Given a critically ill patient, the resident must be able to evaluate the present nutritional status of the patient, identify current deficiencies, ongoing losses and extra needs induced by the illness. The resident must also be able to devise a management strategy for the provision of either enteral and/or parenteral nutrition to sustain the patient throughout the period of critical illness.

l.         Metabolic - Endocrine Issues

Given a critically ill patient with metabolic-endocrine, fluid and/or electrolyte abnormalities, the resident must be able to recognize the nature and severity of the problem, establish a differential diagnosis and, embark on a course of definitive diagnosis, continued monitoring and support.

m.     Neuromuscular Issues

Given a patient with progressive life-threatening neuromuscular disorder, the resident must be able to recognize the seriousness of the problem, institute immediate life-sustaining measures, and compose a precise program of definitive diagnosis, ongoing support and specific therapy applicable.

n.       Trauma Issues

Given a patient who has sustained severe multiple trauma, with or without extensive soft tissue and bony injury, the resident must be able to manage such a patient in accordance with practices advocated by the Advanced Trauma Life Support course.

o.      Septic Illness Issues

Given a patient with catastrophic septic illness, the resident must be able to recognize the probably infective nature of the condition, institute immediate life-sustaining measures, establish a differential diagnosis of probable site of origin and etiological pathogens, and embark upon a course of definitive diagnosis, continued life support and appropriate antimicrobial and/or surgical therapy.

p.      Toxicology Issues

Given a patient potentially suffering from the effects of an acute or chronic intoxicant, the resident must be able to identify this probability, stabilize the life-threatening complication and undertake a sequential plan to support organ function, to prevent further absorption, alter distribution, if possible, and enhance elimination by natural and mechanical means.

q.      Burns and Electrical Injury Issues

Given a patient who has sustained primary, secondary or tertiary burns to greater than 30% of the body surface area, the resident must be able to institute immediate life-supportive measures and develop a plan of ongoing support that includes adequate fluid resuscitation, maintenance of vital organ systems' integrity, early grafting and return to function, prevention and management of burn wound sepsis and the minimization of metabolic complications of burns.

r.        Pediatric Exposure of the Adult Resident

Given a child presenting with acute respiratory failure, shock or trauma, the adult resident will be able to recognize the disorder and institute appropriate resuscitation and stabilization.

s.       Patient Behavior Issues

To acquire a conceptual and informational base for the effective use of psychological and social variables as they relate to the patient and the patient's family when confronted with critical illness, in the short term, as well as the long term.

t.        Epidemiology and Administrative Issues

1. to understand, in general, determinants of health, disease, and illness, and specifically to be able to relate occupational and environmental exposures, socio-economic factors, and life style factors, to critical illness and the critical care milieu;
2. to understand the health care system in general terms, and specifically relate the structure, function, and financing of critical care units to this system;
3. to be fully aware of the administrative organization necessary to establish and maintain an effective Intensive Care Unit, in a rural or urban hospital, and be able to manage the clinical, academic, and administrative affairs of an Intensive Care Unit;
4. to be fully aware of, and understand the importance of medico-legal considerations for the critically ill;
5. to be fully aware of, and understand moral and ethical issues as they impact on patients, their families, and the critical care providers;

u.       Information Acquisition and Management Issues

1. to demonstrate the ability to acquire, interpret, synthesize, record, and communicate (written and verbal) clinical information in managing the health problems in the critical care setting;
2. to understand the practice and theory of the clinical reasoning process.
1. Technical Skills

The critical care resident is expected to have mastered all fundamental aspects of these techniques.

For the list that follows, it is assumed that the resident will have an understanding of 1) indications, techniques, limitations, complications.

 .        Airway Management

1. suctioning techniques and airway toilet
2. oropharyngeal airways

Access to the airway by all routes under any circumstances

3. orotracheal intubation
4. nasotracheal intubation
5. intubation over a fiberoptic bronchoscope
6. surgical establishment of an airway
7. airway pharmacology

a.       Mechanical Ventilation

Basic appreciation of the fundamentals of circuitry, flow characteristics and specific modes of ventilation.

b.      Oxygen and Nebulizer Therapy, i.e. supplementary oxygen equipment, use of special gas mixtures, pharmacological approaches.

c.       Vascular Access

The candidate is expected to have a clear understanding of the risk: benefit ratio for all invasive, as opposed to noninvasive techniques for information gathering, both arterial and venous.

d.      Hemodynamic Monitoring

It is expected that candidates will not only have gained expertise in performing the techniques but will have a complete appreciation of risks, methods, limitations, complications and interpretations.

0. Noninvasive
   • doppler-base blood pressure measurement
   • skin temperature
   • O₂ saturation, transcutaneous gas monitoring
   • pulse monitoring
   • electrocardiogram
1. Invasive
   • right heart and pulmonary arterial flow directed catheterization
   • pressures including cvp, cardiac output (thermodilution and other techniques), mixed venous oxygen saturation and tension

e.       Renal Preservation and Support

f.        Peritoneal Tap

g.       Chest Tube Thoracostomy

h.       Thoracentesis, Pericardiocentesis

i.         Temporary Pacemaker Insertion

j.        Lumbar Puncture

k.      ICP Monitoring

l.         Hemoperfusion Techniques

m.     Intra-aortic Balloon Counterpulsation

n.       Plasmapheresis

o.      Diagnostic and Therapeutic Bronchoscopy

p.      Gastroesophageal Tube Placement for Hemostasis (i.e. Blakemore - Sengstaken)

q.      Placement of Nasogastric or Gastric Tubes for Suction and Nutrition

r.        Urinary Bladder Access

s.       Gram Stain of Body Secretions

t.        Urinalysis

3. Self-Directed Learning Skills

 .        to be able to formulate clear learning objectives around specific patient problems;

a.       be able to mobilize appropriate learning resources (texts, monographs, journal literature indices, computer based literature data banks) to analyze problems;

b.      to be able to carry out accurate self assessment and to be able to formulate and carry out plans for overcoming learning skill deficiencies identified by self assessment.

4. Critical Appraisal Skills

 .        to demonstrate ability to apply rules of evidence to clinical data, para-clinical data, and published evidence;

a.       to be able to determine validity and applicability of data subjected to the aforementioned analysis.

5. Personal Qualities

 .        Toward Patients and Families

0. to recognize the unique stressful environment of the critical care milieu
1. to assess, communicate and support patients and families confronted with critical illness.

a.       Toward Colleagues

0. to contribute to productive communication and cooperation among colleagues in all aspects of education, service, and research, as they impact on the critical care environment, recognizing the multi-disciplinary nature of the specialty.

b.      Toward the Community

0. to communicate to the general population issues surrounding critical care and its impact on maintenance and improvement of health care.

c.       Toward Oneself

0. to recognize and acknowledge personal assets, emotional reactions, and limitations in one's own knowledge, skills and attitudes, and to do something about them.

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM:

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The following are the minimum educational requirements in adult critical care medicine. Additional experience may be required by the program director.

1. Pre-requisite:

Three years of anesthesia, emergency medicine, general surgery, internal medicine, pediatrics or thoracic surgery which must be completed prior to entry into the critical care medicine program.

2. Program requirements:

Two years of adult critical care medicine, one year of which may be undertaken in one of the specialties listed above with the joint approval of the program director in the base specialty and the program director of the critical care medicine program. This period must include:

1. one year of adult critical care medicine, including primary patient care, consultative, and administrative functions, at an appropriate level of seniority;
2. one year which may include one or more of the following:
   1. additional residency in adult critical care medicine;
   2. research relevant to the educational objectives in critical care medicine, and acceptable to the residency program director.

During the two-year program, residents must be provided with a graduated increase in responsibility appropriate to their level of competence for the evaluation and management of critically ill patients under appropriate supervision.

For satisfactory completion of the College requirements in adult critical care medicine a resident must:

1. have successfully completed a two-year program in adult critical care medicine in a Royal College accredited program in which the resident has been enrolled for the full two years;
2. have attained Royal College certification in anesthesia, emergency medicine, general surgery, internal medicine, pediatrics or thoracic surgery.

RESOURCES:

There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents to complete the program and achieve the educational objectives in critical care medicine.

In those cases where a university has sufficient resources to provide most of the training in adult critical care medicine but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training.

1. Teaching Faculty

There must be a sufficient number of qualified critical care medicine specialists involved in the program to ensure the continuous availability of supervision and to provide teaching in the basic and clinical sciences related to the subspecialty. The critical care unit must be under the direction of a qualified, full-time critical care medicine specialist with a major university or "full time" appointment.

2. Number and Variety of Patients

There must be a sufficient number and variety of patients available to the program to meet the following specific objectives:

1. to become competent in the provision of primary clinical expertise in the recognition and management of single or multiple organ failure resulting from trauma, infection, malignancy, surgery or other disorders;
2. to provide resuscitative, transport, and consultative services for the critically ill patients and be knowledgeable in the development and supervision of regional transport programs for the critically ill;
3. to become skilled in the use of technology in critical care, especially in regard to trauma, cardiovascular, respiratory, and renal diagnoses and in the support, investigation and management of neurological disorders;
4. to develop an understanding of the interpersonal relationships necessary in establishing a multidisciplinary ICU, and to be able to develop sufficient administrative skills and knowledge to understand budgets (capital and ongoing), personnel requirements, equipment assessment, and to develop and implement effective treatment protocols in a multidisciplinary ICU.
2. Clinical Services Specific to Critical Care Medicine

ICU design and facilities of units participating in the program should be in accordance with federal government standards for intensive care services and should be in a desirable physical relationship with other hospital areas including the operating room, postanesthesia recovery room, emergency, diagnostic imaging, and readily available STAT labs.

4. Supporting Services - Clinical, Diagnostic, Technical

There must be appropriate liaison with teaching services in specialized areas relevant to the practice of critical care medicine including all of the following related areas: cardiology, endocrinology, hematology, immunology, infectious diseases, neurology, nephrology, pharmacology, general surgery, neurosurgery, anesthesia, cardiovascular surgery, orthopedic surgery, plastic surgery, otolaryngology, urology, and respirology.

Diagnostic services should include an active pathology service, a biochemical service, a microbiology service, a full range of radiological and ultrasound services, and specialized staff and facilities for laboratory assessment of endocrine-metabolic, renal, hematologic, cardiologic, respiratory, and neurologic disorders.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

1. Organized Scholarly Activities

Organized scholarly activities such as journal clubs, research conferences and seminars must be a regular part of the critical care medicine program.

2. Basic and Clinical Sciences Relevant to Adult Critical Care Medicine

This program must include definitive learning in the relevant basic sciences and in the advanced clinical and scientific knowledge essential to the understanding of those areas of the discipline outlined in previous sections.

The program must provide opportunities for residents to gain experience in epidemiology, specifically in tabulation and evaluation of institutional and regional morbidity and mortality, high risk scoring systems, patient evaluation systems (Apache, TISS, etc.). Opportunity should be available to participate in educational programs for personnel of regional and community hospitals.

3. Biomedical Ethics

The academic program must provide opportunities for residents to gain an understanding of the basic principles of biomedical ethics as it relates to critical care medicine.

4. Communication Skills

There must be opportunities for residents to learn effective communication skills for interacting with their patients and their families, colleagues and students. Clearly defined educational objectives for teaching these skills and mechanisms of formal assessment should be in place.

5. Teaching Skills

Residents must be given opportunities to develop effective teaching skills by teaching junior colleagues and students, as well as through conference presentations, clinical and scientific reports, and patient education.

6. Quality Assurance/Improvement

The program must provide residents with opportunities to gain an understanding of the principles and practice of quality assurance/improvement. Opportunities should be provided for residents to participate actively in such programs in their hospital departments.

7. Research Opportunities for Residents

The academic program must provide the opportunity for residents to learn biostatistics and the critical appraisal of research methodology and medical literature.

Research programs in which the resident may spend up to one of the two required years required must be under the direction of a scientist or critical care medicine specialist of university rank. The role of the resident in the research program must be clearly defined. There must be adequate space in the institutions participating in the program for clinical research investigations and this space should be situated close to the patient care facilities. If the research is in basic science, allowance must be made for concurrent maintenance of clinical expertise.

8. Faculty Research

A satisfactory level of research and scholarly activity must be maintained among the faculty identified with the critical care medicine program.

9. Outside Conferences

The program should provide opportunities for residents to attend conferences outside their own university.

PROGRAMS (WITH TRAINING REQUIREMENTS):

Diplomas(Dip):

Six months of approved residency training.

Doctor of Medicine(M.D):

Eighteen months of approved residency training.

Doctor of Philosophy(Ph.D):

Forty eight months(four years)of approved residency training.