How Do I Get The Skills? Competency-Based Training in Critical Care Cardiology
This article was authored by Jessica Fleitman, MD, Fellow in Training (FIT) at the University of Pennsylvania in Philadelphia, PA.
In recent years, discussion regarding the need for training in cardiac critical care has advanced significantly. There are multiple training programs developing tracks in critical care, often involving a dedicated critical care training year in the medical critical care department, which culminates in critical care board eligibility. In accordance with critical care training requirements, there is significant time allocated to non-cardiac intensive care unit (ICU) training such as time on procedural services and anesthesia, as well as in trauma, surgical (SICU), neurologic (NICU) and medical (MICU) ICUs. As medical training moves away from a time dwelt on rotations to a competency model, it is useful to think about the particular areas of expertise specific to cardiac critical care and how rotations ectopic to the cardiac ICU can develop competency within these arenas. With critical skills enumerated prior to starting a rotation, educational efforts can focus more to ensure not only general critical care knowledge but also greater depth of knowledge in areas specific to our subspecialty.
In guiding my own thinking about the particular cardiac critical care areas of expertise and skills needed, I used the seminal paper by David A. Morrow, MD, MPH, FACC, et al., describing new training and staffing models in critical care cardiology. This paper developed a list of competencies, as well as the Accreditation Council for Graduate Medical Education critical care fellowship list of competencies. The abbreviated list of expertise that seemed to encapsulate the specialty knowledge specific to cardiac critical care included:
- Temporary mechanical circulatory support
- Management of acute complications of long term left ventricular assist devices (LVADs)
- Arrhythmia/post arrest management
- Management of respiratory support and sedation in cardiac patients (particularly right heart failure and pulmonary hypertension)
- Management of massive/high-intermediate risk pulmonary embolism
- Advanced hemodynamic monitoring
This list could expand significantly if it included skills easily developed across any general cardiology or critical care fellowship.
In order to develop an expertise in temporary mechanical circulatory support, rotations in the cardiothoracic surgical ICU (CTSICU) could be helpful to spend time managing intraaortic balloon pumps (IABP), temporary ventricular assist devices (impella and centrimag, for example), and extracorporeal membrane oxygenation. Extra time could be spent in the cardiac cath lab working on vascular access and IABP placement. Finally, trips to the operating room to see placement of the more invasive devices may be helpful in better understanding early management.
Acute complication of LVADs include hemodynamically significant gastrointestinal bleeds, ischemic stroke and intracerebral hemorrhages (ICH). Skills in managing massive transfusion protocol should be focused on in the MICU, SICU and CTSICU. Although the NICU is specifically developed to monitor intracranial pressures in ICH, they may not be staffed to care for LVAD patients and in such cases, those trainees should develop comfort with ICH monitoring devices while on a NICU rotation.
To develop specialized skills in arrhythmia and post arrest management, time in the NICU and MICU could be focused on the intricacies of targeted temperature management. The NICU should be used to develop skills in brain death exams. Extra focus during CICU, CTSICU, electrophysiology or cardiac cath rotations could be placed on ensuring proficiency in placing transvenous pacemaker placement.
Management of respiratory failure in cardiac patients requires an extra degree of skill, especially in patients with right heart failure, pulmonary hypertension, constriction or tamponade. There should be a focus on learning mechanics and adjustments to positive pressure ventilation while rotating with pulmonary colleagues on MICU rotations. Specific attention to positive pressure ventilation in right heart failure could be discussed on a pulmonary hypertension rotation or with cardiac anesthesia in the CTSICU. Management of sedation in right heart failure should also be focused on when rotating in the CTSICU. I suggest an initial base knowledge by reading the Journal of the American College of Cardiology review on positive pressure ventilation in the cardiac ICU. Airway management, bronchoscopy, chest tube placement and thoracentesis are all skills necessary for management of respiratory failure, which can be learned on anesthesia, MICU, SICU and CTSICU rotations.
Finally, there are skills that fall squarely within the field of cardiology but may require extra focus to develop expertise, which include management of massive and high-intermediate risk pulmonary embolism and advanced hemodynamic monitoring. Additional expertise in pulmonary embolism management can be obtained by involvement in your center’s pulmonary embolism response team, if available. Advanced hemodynamic monitoring skills can be obtained by extra time on heart failure rotations and extra practice within the cath lab placing right heart catheters.