Guest Editorial: Caring for Tiny Hearts! Training Physicians in Paediatric Cardiac Intensive Care

Perspective from Mirjana Cvetkovic, MD, 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