Dr. Mirjana Cvetkovic Consultant in Paediatric Cardiac Intensive Care Training Director in Paediatric Intensive Care, Great Ormond Street Hospital, UK Honorary Lecturer, University College London, UK
	Dr. Katherine Brown Consultant in Children’s Intensive Care, Great Ormond Street Hospital, UK Associate Professor, University College London, UK

Perspective from Dr Mirjana Cvetkovic, Training Director, Paediatric Intensive Care, Great Ormond Street Hospital, London, United Kingdom.

“What do you do?”

“I am a Paediatric Cardiac Intensivist.”

The question opens a longer conversation: “How do you become one?”

“How did I actually become one?!”

In United Kingdom (UK) as in the rest of the Europe, there are multiple training pathways for the subspeciality of Paediatric Cardiac Intensive Care (PCIC), and our main stakeholders include general paediatrics, anaesthesia, paediatric cardiology and paediatric cardiac surgery. The majority of PCIC physicians, have a background in either paediatrics or anaesthesia, followed by an advanced, two-year subspecialty training programme in paediatric intensive care medicine (PICM). The curriculum for PICM training in the UK is standardised and accredited by Royal College of Paediatricians and Child Health (RCPCH) https://www.rcpch.ac.uk/resources/paediatric-intensive-care-medicine-sub-specialty and supported by Paediatric Critical Care Society (PCCS) https://pccsociety.uk/picm-medical-trainees/. PICM training incorporates a minimum of six months placement in PCIC. Then, following PICM training, PCIC specialists are expected to gain at least a further year (and sometimes they do more) of additional specific experience, in one of the specialised units around the world that hosts a specialised programme for mechanical circulatory support including Extracorporeal Membrane Oxygenation (ECMO) and Ventricular Assisted Devices (VAD). The PCIC training pathway in the UK is similar in the rest of Europe, and many physicians rotate internationally. I gained my advanced paediatric cardiac anaesthetic and intensive care skills in several European countries including UK before I settled at Great Ormond Street Hospital (GOSH) in London, UK.

“It is not enough to be busy… The question is: What are we busy about?!-Henry David Thoreau.”

Of 26 PICM units in UK, 8 are mixed, (caring for general PIC and cardiac patients) and 3 are dedicated ‘PCIC only’ units. The PCIC at GOSH comprises a purpose-built unit that admits nearly 800 sick children with heart disease annually. In addition to cardiac conditions, GOSH hosts a national pulmonary hypertension programme, a large thoracic practice and is the only dedicated tracheal service in the UK for children. GOSH currently has one of the largest paediatric heart/lung transplant programmes in the world and provides regional services for ECMO and VAD as a bridge to recovery or transplant. Our educational programme is focused on advanced multidisciplinary training. We host 16 junior and 9 senior PCIC training posts, and training includes didactic sessions, skills training, simulation, and virtual training sessions. It is expected that the fellows will participate in and organise teaching sessions, undertake a quality improvement project and develop a relevant guideline. Fellows are introduced to the methodology of advanced study and research, and tailored support is available for research projects. Training and research time is protected and incorporated in the rota. Of note, formal PCIC training in UK and Europe is continuously evolving and developing.

“It always seems impossible until its done. Nelson Mandela”

In the UK and Europe, we are striving for standardised, accredited training with well-defined curriculum and syllabus, that draws on the most evidence available. The evolution and advancement of care for children with critical cardiac disease over the past 50 years has been remarkable. (1) Then more recently, we have learned that collaborative learning in PCIC, with reductions in variability, is linked to better outcomes. (2) High-quality PCIC training is crucial component of efforts to optimise outcomes for PCIC patients. Thus, innovative educational programs that attend to the needs of such a highly specialised group of providers are of practical importance. (3) These have the potential to contribute to patient outcomes and to promote further growth and maturation in the field. (4) A modern approach to adult learning, given the increasing complexity of medical care, emphasises educational requirements in areas fundamental to critical care including medical knowledge, procedural skills, communication, handovers, conflict resolution, cultural competency, team leadership and followership. (5) Medical simulation is highlighted as a training modality which provides a safe environment to meld medical knowledge assessment with teamwork training while mitigating the variability of time and risks to patient safety. (5) PCIC simulation programs are strengthened by utilising traditional education, with consideration of complex physiologies, interprofessional personnel, and centre-specific resources creating relevant learning objectives contributing to patient safety, team performance, and patient outcomes. (6) In addition, virtual platforms, matured during COVID-19 pandemic, will continue to evolve, providing convenient venues for individual learners and teams. (6) As PCIC education and training continue to emerge, international collaboration and globalisation of curricula could help us to deliver cost-effective and state-of-the-art treatment world-wide. (5)

“Where we’re going, we don’t need roads…- Back to the Future”

Lately, since I became more occupied with medical education, I noticed that there is a clear relationship between knowledge and action for patient benefit. The exploration of how we apply knowledge, became not just fascinating, but a key driver in planning how we work strategically and on the ground. The field of PCIC is developing and it is exciting to consider how our centre is a part of not only the UK, but also European and even world-wide collaborations that aim to develop the comprehensive PCIC curriculum and syllabus including didactic, simulation and virtual training sessions. Hopefully, soon we will have a well-established training programme in the UK, Europe and wider.

References:

1. Paul A Checchia, Katherine L Brown, Gil Wernovsky, et al. The Evolution of Pediatric Cardiac Critical Care. Crit Care Med. 2021;49(4):545-557; doi:10.1097/CCM.0000000000004832
2. Michael Gaies, David S. Cooper, Sarah Tabbutt et al. Collaborative quality improvement in the cardiac intensive care unit: development of the Paediatric Cardiac Critical Care Consortium (PC⁴). Cardiol Young. 2015: 25(5): 951–957; doi:1017/S1047951114001450
3. Mary E. McBride, Dorothy M. Beke, James D. Fortenberry et al. Education and Training in Pediatric Cardiac Critical Care. PCCM journal 2018 19(6); doi:10.1177/2150135117727258
4. Sarah Tabbutt, Catherine Krawczeski, Mary McBride et al. Standardized Training for Physicians Practicing Pediatric Cardiac Critical Care. PCCM journal 2022 23(1)
5. Sinai C. Zyblewski, Louise Callow, Dorothy M. Beke et al. Education and Training in Pediatric Cardiac Critical Care: International Perspectives. World J Pediatr Congenit Heart Surg. 2019: 10(6):769-777; doi:10.1177/2150135119881369
6. Tarif A. Choudhury, Jonathan N. Flyer, Mary E. McBride. Simulation as an Educational Tool in the Pediatric Cardiac Intensive Care Unit. Curr Pediatr Rep.2021; 9(3): 52–59; doi:1007/s40124-021-00241-0

Peter P. Roeleveld, MD, PhD Pediatric Intensivist PICU Medical Director ECMO Director Leiden University Medical Center The Netherlands

The Netherlands, also known as ‘Holland’ with its famous capital Amsterdam, is a small country in Western Europe which fits 231 times in the United States. It is however 12 times more densely populated compared to the USA (424 versus 34 inhabitants/km²) with 17.5 million inhabitants of whom 3.5 million are children. Nationwide, approximately 4 children are born with congenital heart disease every day. Within this small country there are 7 medical universities with associated pediatric hospitals and at the moment four of these provide congenital and pediatric cardiac surgery (Leiden, Rotterdam, Utrecht, and Groningen).

There are dedicated congenital heart surgeons in the Netherlands, but no dedicated pediatric cardiac intensive care units or cardiac intensivists. And postoperatively these children are therefore cared for in combined pediatric intensive care units (medical, surgical). This means that the professionals taking care of these children are all trained as general pediatric intensive care nurses and pediatric intensive care physicians. We do not have dedicated cardiac intensivists, but some have a more ‘cardiac-focus’ than others (for instance in Leiden where more than 60% of our patients are post-cardiac surgery). In the Netherlands it is not possible to be ‘double-boarded’, so one cannot be a pediatric cardiologist and a pediatric intensivist at the same time. We as intensivists therefore work very closely together with our cardiology colleagues when taking care of children with congenital heart disease. To become a pediatric intensivist in the Netherlands one first has to fully qualify as either a general pediatrician or as an anesthesiologist (5-6 year training following medical university). And then one can further subspecialize during an intensive care fellowship which lasts another 2.5-3 years. All intensive care fellows will do a rotation of 3-6 months in one of the four centers that provide cardiac surgery so that all pediatric intensivists receive some exposure during their training.

But, things may very well change. There currently are plans to further centralize congenital heart surgery to three or even only two centers (instead of the current four). Certainly, centralizing care and increasing exposure can be a good development for our patients, but choosing the right centers and organizing this transition well is proving to be challenging and requires careful planning and preparation. If not done carefully, there is a significant chance that the quality of care could actually temporarily decrease and not increase as would be the ultimate goal. Further centralization of congenital heart surgery will certainly have a significant impact on the organization of pediatric intensive care in the Netherlands and maybe we should start to consider establishing dedicated cardiac intensive care units which could eventually lead the way to a new official specialty for the Netherlands: the pediatric cardiac intensivist?

Peter P. Roeleveld, MD, PhD
Pediatric Intensivist, PICU Director
Leiden University Medical Center

David K. Werho, MD Assistant Clinical Professor, Cardiac Intensivist Associate Fellowship Program Director, Pediatric Cardiology UC San Diego – Rady Children’s Hospital

In the United States, the delivery of critical care to cardiac patients is quite heterogeneous and the units in which these patients receive their care can vary from dedicated cardiac intensive care units (CICUs) to mixed pediatric intensive care units (PICUs) to specialized neonatal intensive care units (NICUs), and no two units are exactly the same.  Similarly, the providers leading the care teams in each of these units are also quite variable in training taxonomy, ranging from surgeons and anesthesiologists with specialized training, cardiology-, critical care-, and neonatology-trained intensivists with additional training, intensivists with no additional training but extensive experience, to dual-boarded cardiac intensivists.  The training of these providers is not standardized and until recently, there were not even common guidelines or expectations for what one was expected to do/know coming out of training.

Earlier this year, Dr. Sarah Tabbutt and a large team of experts from PCICS published a set of standardized consensus guidelines for training programs including rotation requirements for the different pathways, institutional requirements for training programs, and an extensive list of learning objectives (https://journals.lww.com/pccmjournal/Abstract/2022/01000/Standardized_Training_for_Physicians_Practicing.8.aspx). These objectives are the foundation of the knowledge-base that pediatric cardiac intensivists should be expected to acquire during their training in order to care for critically ill children with heart disease, regardless of which path they take. In the same issue of Pediatric Critical Care Medicine, my collaborators and I published a set of nine entrustable professional activities (EPAs) for pediatric cardiac intensivists, which were generated through mixed methods with a broad and diverse group of respondents. (https://journals.lww.com/pccmjournal/Abstract/2022/01000/Establishing_Entrustable_Professional_Activities.7.aspx).  These EPAs were created with input from stakeholders in all training pathways with the intent that they could be implemented into any training program where a future cardiac intensivist is trained.

EPAs are the current wave of competency-based assessment in medical education, which are meant to be easier to implement in training programs and translate to clinical practice.  An EPA is an activity that a trainee would be expected to perform at various levels of mastery/independence as they enter clinical practice.  For example, one of the CICU EPAs is: “Management of patients with decompensated heart failure, including management of those requiring mechanical circulatory support”, which is an activity that integrates multiple learning objectives and competencies including medical heart failure therapy, referral for advanced cardiac therapies, and management of multiple organ systems like anticoagulation, ventilation, and extracorporeal support.  A faculty member assessing a trainee already subconsciously decides on a frequent basis how much they entrust that trainee to perform this activity.  For instance, one trainee might be entrusted to initiate and escalate medical heart failure therapy with minimal oversight, but requires very close supervision and support to manage a patient on extracorporeal life support (ECMO), while another trainee might be entrusted to manage ECMO support with less intensive hands-on oversight.  Each faculty should be able to translate this to a level of entrustment for assessment of this EPA.  Each trainee is expected to attain entrustment over the course of their development, but not necessarily mastery of every EPA during their training.  The further development of mastery naturally should occur during the early career with appropriate mentorship.

We are currently in the process of mapping competencies and learning objectives to each EPA and developing anchored levels of entrustment, so that these can be used in a common validated assessment tool for all trainees in our field.  We hope to find ways to integrate these tools into our various training programs and I believe that this is the next step of evolution of our field into one that has more consistency and standardization in training.  I also think these EPAs could apply to training and assessment in other countries and care models, though the training pathways may be quite variable.  All of this, however, will be foundational to establishing pediatric cardiac critical care as a distinct subspecialty with recognition by accrediting bodies and policymakers.