Task Force 5: Pediatric Cardiology Fellowship Training in Critical Care Cardiology

HomeCirculationVol. 132, No. 6Task Force 5: Pediatric Cardiology Fellowship Training in Critical Care Cardiology Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBTask Force 5: Pediatric Cardiology Fellowship Training in Critical Care Cardiology Timothy F. Feltes, MD, FAAP, FACC, FAHA, Stephen J. Roth, MD, MPH, FAAP, Melvin C. Almodovar, MD, Dean B. Andropoulos, MD, FAAP, Desmond J. Bohn, MB, BCh, FFARCS, MRCP, FRCPC, John M. Costello, MD, MPH, FAAP, Robert J. Gajarski, MD, MHSA, FAAP, FACC, Antonio R. Mott, MD and Peter Koenig, MD, FACC, FASE Timothy F. FeltesTimothy F. Feltes Search for more papers by this author , Stephen J. RothStephen J. Roth Search for more papers by this author , Melvin C. AlmodovarMelvin C. Almodovar Search for more papers by this author , Dean B. AndropoulosDean B. Andropoulos Search for more papers by this author , Desmond J. BohnDesmond J. Bohn Search for more papers by this author , John M. CostelloJohn M. Costello Search for more papers by this author , Robert J. GajarskiRobert J. Gajarski Search for more papers by this author , Antonio R. MottAntonio R. Mott Search for more papers by this author and Peter KoenigPeter Koenig Search for more papers by this author Originally published13 Mar 2015https://doi.org/10.1161/CIR.0000000000000196Circulation. 2015;132:e81–e90Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2015: Previous Version 1 1. Introduction1.1. Document Development ProcessThe Society of Pediatric Cardiology Training Program Directors (SPCTPD) board assembled a Steering Committee that nominated 2 chairs, 1 SPCTPD Steering Committee member, and 6 additional members from a wide range of program sizes, geographic regions, and subspecialty focuses. Membership of this writing group reflected the diverse backgrounds of the physicians who currently direct pediatric cardiac critical care management, including pediatric cardiology, critical care medicine, and anesthesiology. Representatives from the American College of Cardiology (ACC), American Academy of Pediatrics (AAP), and American Heart Association (AHA) participated. The Steering Committee member was added to provide perspective to each Task Force as a “nonexpert” in that field. Relationships with industry and other entities were not deemed relevant to the creation of a general cardiology training statement; however, employment and affiliation information for authors and peer reviewers are provided in Appendixes 1 and 2, respectively, along with disclosure reporting categories. Comprehensive disclosure information for all authors, including relationships with industry and other entities, is available as an online supplement to this document.The writing committee developed the document, approved it for review by individuals selected by the participating organizations (Appendix 2), and addressed their comments. The final document was approved by the SPCTPD, AAP, and AHA in February 2015 and approved by the ACC, as well as endorsed by the Pediatric Cardiac Intensive Care Society, in March 2015. This document is considered current until the SPCTPD revises or withdraws it.1.2. Background and ScopeTo achieve the best clinical outcomes and provide a safe care environment, every pediatric cardiologist should have basic patient assessment and stabilization skills, command a clear understanding of complex cardiovascular anatomy and physiology, know the effects of pharmacological agents on cardiac physiology, and function as an effective communicator within a multidisciplinary team (MDT). The experience garnered by a pediatric cardiology trainee in the pediatric cardiac intensive care unit (CICU) concentrates the educational opportunity to refine these skill sets and is an important part of cardiology fellowship training.The mission of this writing group was to build upon the pediatric cardiac critical care training guidelines published in 2005.1 We retained and added to the General Training Goals identified by the 2005 task force (Sections 3.2.1 to 3.2.6) and have added to some of the Specific Training Goals (Sections 3.3.1 to 3.3.7) as well. We have added expected proficiencies to the 2005 guidelines, and where appropriate, included descriptive text to address these competencies. Our revised training recommendations describe the program resources and environment that are required for training pediatric cardiology fellows, together with a competency-based system promulgated by the American College of Graduate Medical Education (ACGME), to implement specific goals and objectives for training pediatric cardiology fellows. This system categorizes competencies into 6 core competency domains: Medical Knowledge, Patient Care and Procedural Skills, Systems-Based Practice, Practice-Based Learning and Improvement, Professionalism, and Interpersonal and Communication Skills, along with identification of suggested evaluation tools for each domain. Competencies unique to pediatric cardiac critical care are listed in Sections 3 and 4 (see the “2015 SPCTPD/ACC/AAP/AHA Training Guidelines for Pediatric Cardiology Fellowship Programs [Revision of the 2005 Training Guidelines for Pediatric Cardiology Fellowship Programs]: Introduction” for additional competencies that apply to all Task Force reports). Advanced competencies unique to pediatric cardiac critical care are listed in Section 4. Other publications address more comprehensive aspects of critical care knowledge that the pediatric cardiology trainee should attain.21.3. Levels of Training—Core and AdvancedIn this statement, we discuss core training for all fellows enrolled in a traditional 3-year pediatric cardiology fellowship and advanced training for fellows who wish to embark on a career in critical cardiac care. Core training is required for all trainees and is intended to ensure that fellows acquire the knowledge base and skills necessary to become a pediatric cardiologist referring his/her patient to the intensive care unit (ICU) and serve as a consultant or co-manager (not independent) of the patient. Advanced training guidelines are recommended for practitioners who are board-eligible/board-certified in pediatric cardiology and intend to manage patients as the primary cardiac intensivist in a pediatric ICU. These guidelines do not address training for practitioners with primary fellowship training other than pediatric cardiology.2. Program Resources and EnvironmentPhysical and/or administrative standalone pediatric CICUs are currently not a requirement in pediatric cardiology fellowship programs, although the trend is certainly toward that model. The cardiology trainee should attain the specified requirements outlined in these guidelines through interaction with pediatric cardiologists, pediatric intensivists, neonatologists, pediatric cardiac surgeons, and other practitioners. Cardiology program directors should have significant input related to the cardiac critical care experience of trainees to ensure the following proficiencies are obtainable. Pediatric cardiology fellows should receive the appropriate supervision by faculty well-versed in cardiac critical care.3. Core Training: Goals and Methods3.1. Length of TrainingThe committee’s recommendations on length of training are based on 2 primary goals: 1) those supervising trainees in the ICU environment require adequate exposure over time to evaluate trainee progress; and 2) every trainee needs to develop the competencies required to consult on patients in the ICU setting by the completion of fellowship training. In training programs where pediatric cardiology fellows act as the first-line (primary) medical provider for cardiac patients in the ICU (generally programs that have a separate CICU), a minimum of 2 months of full-time supervised experience in the ICU is recommended over the course of the 3-year fellowship. For programs where pediatric cardiology fellows function more as a consultant for cardiac patients in the ICU setting, at least 4 months of supervised experience providing such consultation is recommended over the course of the 3-year fellowship. Although the above represents the minimal training, the committee advocates strongly that cardiology fellows gain experience as a primary care provider for 3 to 6 months in a CICU setting over the course of the general cardiology fellowship. It is also important to note that these defined experiences require evaluation and management of neonates and pediatric patients with and/or being evaluated for cardiac disease. Therefore, fellowship directors must be cognizant that trainees gain experience in a neonatal and pediatric intensive care setting during fellowship training as part of their routine night/weekend inpatient call responsibilities. Trainees should be evaluated by the appropriate supervising faculty. The pediatric cardiology fellowship director should work closely with those supervisory physicians to create clear goals and measures of cognitive and technical competence and to provide a mechanism for timely evaluation of trainees.3.2. General CompetenciesThrough training and upon completion of a fellowship, the pediatric cardiology trainee is expected to demonstrate incremental proficiency in the skill sets delineated in Table 1. First is a proficiency in diagnostic skills. The pediatric cardiologist in the pediatric CICU should be able to diagnose congenital and acquired heart disease accurately and assess severity and acuity using physical examination and conventional, noninvasive methods. This includes the ability to perform an accurate and comprehensive cardiovascular examination, interpret the physical examination findings, assess the patient’s history and laboratory data, and determine whether there are any inconsistencies in the patient’s presentation and ongoing disease process. The trainee should demonstrate a proficiency in identifying physical and diagnostic indicators of patient deterioration (eg, recognition of a low cardiac output state) and be capable of intervening appropriately. Second, the trainee would be expected to demonstrate the ability to create a patient care plan. The pediatric cardiologist should be able to determine the appropriate use (or make recommendations to do so) of diagnostic testing, medical treatments, and interventional procedures for the care of the patient with congenital or acquired heart disease in the ICU setting. Such a care plan should be efficient, cost effective, and as safe as possible for the patient. The cardiology trainee should be able to construct an effective care plan and execute (or recommend) that plan, including appropriate communication with multiple teams (eg, echocardiography, interventional catheterization, and surgical teams). He/she should provide ongoing input regarding physical examination, laboratory, and diagnostic study interpretation at the request of the managing clinical service(s).Table 1. Core Curricular Competencies and Evaluation Tools for Pediatric Cardiac Critical CareMedical Knowledge• Know what medical and surgical treatments are appropriate for the underlying cardiac condition and the outcomes of these therapies.• Know indications for, and limitations and risks of, invasive tests and procedures in critically ill patients.• Know the interaction between the cardiac disease and other organ systems (see Section 3.3.1).• Know the age-related differences in morbidity.• Know the complex physiology of heart disease (see Section 3.3.2).• Know the principles of pharmacology and relationship with cardiovascular physiology (see Section 3.3.3).• Know the relationship between cardiac structure, function, and hemodynamic state.• Know the means of, and indications for, mechanical circulatory support.Evaluation Tools: direct observation, conference participation and presentation, procedure logs, and in-training examinationPatient Care and Procedural Skills• Have the skills to evaluate and treat pediatric patients with congenital and acquired heart disease and assess acuity of illness (see Sections 3.2.1 and 3.2.2).• Have the skills to triage patients through the levels of critical care from highest intensity to step-down care.• Have the skills to create a patient care plan.• Have the skills to provide resuscitative and stabilizing medical care (see Section 3.3.4).• Have the skills to provide care or consultation to those managing patients with cardiac disease who have illnesses of noncardiac origin (see Section 3.2.3).• Have the skills to provide consultation to those caring for postoperative cardiac patients (see Section 3.2.4).• Have the skills to recognize complications of surgical procedures and plan investigation and recommend interventions when appropriate.• Have the skills to diagnose and treat arrhythmias encountered in the ICU setting (see Section 3.3.5).• Have the skills in airway management to assess airway adequacy and treat airway insufficiency, including mechanical ventilation, or consult experts to do so (see Section 3.3.6).• Have the skills to provide cardiopulmonary support and resuscitation.Evaluation Tools: direct observation, multidisciplinary rounds participation, and procedure logsSystems-Based Practice• Carry out high-quality, cost-effective, and safe patient care (see Section 3.2.6).• Function as a member of a multidisciplinary team (see Section 3.2.5).Evaluation Tools: conference participation and presentation, direct observation, faculty evaluations, and 360 evaluationsPractice-Based Learning and Improvement• Identify knowledge and performance gaps and engage in opportunities to achieve focused education and performance improvement.• Appropriately integrate new or emerging medical evidence.Evaluation Tools: multisource evaluation and reflection and self-assessmentProfessionalism• Conduct oneself in a respectful and collegial manner.Evaluation Tools: conference participation and presentation, direct observation, faculty evaluation, 360 evaluation, and reflection and self-assessmentInterpersonal and Communication Skills• Effectively communicate with multiple teams involved in complex patient care.• Provide nonbiased information to the patient/family.• Communicate with the primary care and/or referring physicians.• Practice effective handover of care between services.Evaluation Tools: direct observation, faculty evaluations, and 360 evaluationsICU indicates intensive care unit.Additional information on general competencies is included in the following text.3.2.1. Evaluate and Treat Neonates, Infants, and Older Pediatric Patients With Critical Structural Cardiac DiseaseThe cardiology trainee is expected to be proficient in the following:Skill to establish an accurate anatomic diagnosis and ascertain the relevant cardiopulmonary physiology compared to normal physiology across all pediatric ages.Knowing how to triage patients and which patients require ICU observation for potential risk of decompensation or to meet immediate medical needs.Providing appropriate medical therapy to stabilize the patient (provide for adequate oxygen delivery and organ perfusion).Knowing the indications for and limitations and risks of invasive testing and procedures, including issues related to sedation, anesthesia, and intrahospital transport of the critically ill patient with cardiac disease.Knowing what medical and surgical treatments are appropriate for the cardiac condition, and the short- and long-term outcomes of these therapies.Recognizing patients who are deviating from the usual postoperative course after commonly performed cardiac operations. Specifically, the trainee should be able to recognize patients who have a residual cardiac lesion, either due to an imperfect operation or incomplete preoperative diagnosis, and plan appropriate anatomic investigation and determine the need to recommend surgical or transcatheter intervention when clinically indicated.3In particular, the trainee should have sufficient training and experience to be effective in managing these types of patients:Neonates and young infants with ductal-dependent right heart obstructive lesions (eg, tetralogy of Fallot with severe pulmonary stenosis, pulmonary valve atresia)Neonates with complex physiology such as obstructive left heart lesions (eg, hypoplastic left heart syndrome, critical aortic stenosis), severe Ebstein’s anomaly, and pulmonary atresia with ventricular septal defect and major aortopulmonary collateral vesselsNeonates with d-transposition of the great arteriesNeonates with total anomalous pulmonary venous connection with obstructionInfants with anomalous origin of a coronary artery from the pulmonary arterySingle-ventricle patients with staged palliation (including cavopulmonary connection and Fontan physiology)3.2.2. Evaluate and Treat Neonates, Infants, and Older Pediatric Patients With Other Forms of Critical Cardiac DiseaseIn particular, the trainee should have sufficient training and experience to be effective in evaluating and treating the following:Patients with primary myocardial dysfunctionPatients with acutely compromised cardiopulmonary status due to viral myocarditis or decompensated, end-stage cardiomyopathyPatients with acutely symptomatic arrhythmiasPatients with acutely compromised cardiopulmonary status that is due to infectious endocarditis/sepsis and inflammatory (noninfectious) endocarditisPatients with pericardial effusion and tamponadePatients having a hypercyanotic episodePediatric patients of any age with elevated pulmonary vascular resistance, with or without a structural abnormality of the heart3.2.3. Provide Care Assistance or Consultation to Those Providing Primary Care for Cardiac Patients With Illnesses of Noncardiac OriginAn example of this is an infant with single-ventricle physiology who develops bowel obstruction requiring a treatment approach that is different than a patient with a normal heart. Similarly, a fellow should understand what risks are posed to the cardiac patient undergoing noncardiac surgery. The fellow should be capable of accurately relaying the cardiovascular physiological concerns for this patient to care providers such as neonatologists, anesthesiologists, and noncardiac surgeons. The cardiology trainee is expected to be proficient in addressing the cardiovascular concerns of cardiac patients with pediatricians and noncardiac consultants.3.2.4. Provide Consultation to Those Caring for Postoperative Cardiac PatientsIn particular, the pediatric cardiologist should be able to do the following:Provide interpretation of diagnostic studies such as echocardiograms and heart catheterizations, including a clear delineation of the limitations of such studies.Diagnose and treat acutely symptomatic arrhythmias.Provide consultation regarding therapies to maximize oxygen delivery and cardiac output.Provide consultation regarding pharmacological and other therapies for patients with single-ventricle physiology.Provide consultation regarding therapies for patients with high pulmonary vascular resistance and pulmonary hypertension.3.2.5. Function as a Member of a MDT Demonstrating Professionalism and Excellent Communication SkillsIn the current era, the pediatric cardiologist is an important member of a MDT. Cardiology trainees should demonstrate competency in the following MDT skill sets:Provide nonbiased information to the patient/family regarding known causes of congenital heart disease, the genetic and developmental implications, and treatment options.Conduct himself/herself in a respectful and collegial manner in the CICU.Be able to put the entire clinical picture together for the family and the care team. He/She should be familiar with the short-, mid-, and long-term consequences of congenital heart disease, and be able to provide patients, their families, and other clinical team members with realistic expectations.Provide ongoing updates to the patient and/or family while a patient remains in the pediatric CICU (eg, in group case management discussions) and serve as an advocate for patients and their families.Communicate with primary care and referring physicians in a manner that keeps these physicians engaged and part of the MDT.Understand the general principles for providing effective and compassionate end-of-life and palliative care.Interact effectively with subspecialty teams (eg, heart failure, transplant, electrophysiology).3.2.6. Quality Improvement and Patient SafetyIn the past 10 years, there has been increasing focus on quality improvement and patient safety initiatives in intensive care medicine. Cardiology trainees should demonstrate competency in the following quality improvement and patient safety skill sets:Understand the principles behind a quality improvement process and recognize and abide by the principles of safe care delivery in the hospital.Understand the elements of an effective handover of care between services.Be familiar with institutional quality goals such as compliance with hand hygiene practices, elimination of iatrogenic infections, and reduction of medication errors. Fellows should be aware of their influence on the accomplishment of these measures and be active participants in the institution’s safe care delivery efforts.Know the common complications that occur in cardiac patients in the ICU and how they may be prevented and treated.3.3. Specific CompetenciesCardiology trainees should demonstrate an incremental proficiency in each of the following specific areas.3.3.1. Multiorgan System ManagementThe pediatric cardiologist consulting in the pediatric CICU should have an appreciation and understanding of the integration of cardiac function with other organ systems. This appreciation goes beyond simple oxygen delivery and cardiac output physiology. The cardiologist is expected to understand the effects of cardiac performance on the function of the respiratory, renal, neurological, and hepatic/gastrointestinal systems. Cardiology fellows rotating in the CICU should achieve a moderate level of knowledge and proficiency in the management of noncardiac conditions, including acute and chronic respiratory failure, acute and chronic renal failure, hepatic dysfunction, neurological dysfunction (as a result of hemorrhage, stroke, or anoxia), endocrinopathies, nutritional insufficiency, sepsis, hematologic abnormalities, and dependence on sedative/analgesic medications. Fellows should have an understanding of the neurocognitive outcome of patients as it relates to surgical as well as preoperative and postoperative factors. They should also become familiar with comorbidities, some congenital and others developmental in nature, that are frequently seen in older adolescents and young adults. The cardiology trainee should show proficiency in:Understanding interactions between the major noncardiac organ systems (eg, lungs, kidney, liver, brain) and the heart.Understanding age-specific vulnerability of organ system function (eg, renal function in the adult congenital heart disease patient postangiography).Understanding the major medical concerns related to older adolescents and young adults.Understanding the implications of genetic conditions and syndromes and implication for care.3.3.2. Cardiopulmonary PhysiologyThe cardiology trainee should show competency in understanding complex physiology that relates to the determinants of, and means of influencing, systemic arterial oxygen saturation, oxygen delivery, cardiac output, myocardial work, and vascular resistance for patients with all forms of congenital lesions, cardiomyopathies, and heart transplantation but with particular emphasis on those with the following:Single-ventricle and mixing lesionsDuctal-dependent left-sided obstructive lesionFixed restriction of pulmonary blood flow and/or ductal-dependent pulmonary blood flow lesionsd-Transposition of the great arteriesPulmonary and systemic ventricles stressed by abnormal preload or afterloadCavopulmonary connection physiology3.3.3. Pharmacology and Relationship to Cardiovascular PhysiologyThe trainee should show competency in understanding the actions, mechanisms of action, side effects, and clinical use of these pharmacological agents:Inotropic agents (eg, digoxin, adrenergic agonists, phosphodiesterase inhibitors)Vasodilators/antihypertensive agents (eg, alpha-adrenergic antagonists, angiotensin-converting enzyme inhibitors, calcium channel antagonists, beta-adrenergic antagonists, nitric oxide donors)Commonly used antiarrhythmic agents (eg, digoxin, adenosine, esmolol/propranolol, procainamide, lidocaine, amiodarone)Pulmonary vasodilators (eg, inhaled nitric oxide, prostacyclin, PDE5 inhibitors)Prostaglandin E1Neuromuscular blocking agents (eg, pancuronium, vecuronium, rocuronium, succinylcholine)Analgesics and sedatives (eg, opiates, ketamine, benzodiazepines, dexmedetomidine)The cardiovascular effects, risks, and benefits of commonly-used general anestheticsAnticoagulants (unfractionated and low-molecular-weight heparin, warfarin) and antiplatelet agents (aspirin, clopidogrel)Diuretics (eg, furosemide, chlorothiazide, bumetanide, metolazone)Gastroesophageal reflux prophylaxisAntibioticsImmunosuppressant medications3.3.4. The Relationship Between Cardiac Structure, Function, and Hemodynamic StateThe graduating cardiology fellow should know and be proficient in delivering stabilization management of the patient with congenital heart disease in the following circumstances:Recognize the appropriate circumstances for intravascular volume resuscitation in the hypotensive patient.Understand indications for fluid restriction and removal.Determine the need for initiation of prostaglandin E1 infusion for ductal-dependent lesions in the neonate.Deliver pediatric advanced life-support measures per established guidelines.Recognize the indications for and know how to perform a supervised pericardiocentesis in patients with pericardial tamponade.Be familiar with factors that predispose to common postoperative complications and the appropriate diagnostic techniques and therapies for these complications.Know the indications for vasoactive and inotropic support.Know indications for antiarrhythmic management.Know indications and technique for cardioversion, defibrillation, and temporary pacing.3.3.5. Diagnosis of and Therapy for ArrhythmiasAlthough a minority of patients admitted to the pediatric CICU develop hemodynamically significant arrhythmias, these can be associated with cardiovascular compromise, and if incessant under specific conditions, even death. Fellows should be able to recognize the more common rhythm abnormalities in the ICU setting, especially those occurring in postoperative patients, such as the types of atrioventricular block, accessory pathway-mediated supraventricular tachycardia, atrial flutter, ectopic atrial tachycardia, junctional ectopic tachycardia, and ventricular tachycardia, and identify when they are causing hemodynamic compromise. Fellows should also learn the circumstances in which it is appropriate for them to consult a pediatric electrophysiologist for assistance with either diagnosis or management of more complex or refractory arrhythmias. For a more detailed discussion of the competencies required in electrophysiology, the reader is referred to Task Force 4: Pediatric Cardiology Fellowship Training in Electrophysiology.3.3.6. Airway ManagementPediatric cardiology fellows have widely varying experiences with airway management depending upon the role they have in caring for critically ill cardiac patients. Fellows training in programs that lack a pediatric CICU are typically in a consultant role, and they often obtain limited hands-on experience with both airway and mechanical ventilator management. By contrast, those who train in institutions that have a pediatric CICU and work in a primary provider role on the team usually gain more practical experience. In either training setting, fellows should acquire a basic understanding of airway and respiratory management and appreciate cardiopulmonary interactions.4 Cardiology trainees should demonstrate competency in or an understanding of the following:How to perform a thorough patient examination and interpret laboratory tests to assess the pulmonary system, including chest radiographs and blood gases.How to distinguish between respiratory insufficiency and cardiac decompensation.In patients with evolving respiratory insufficiency or failure, understand the indications for both noninvasive and invasive (tracheal intubation) airway support.How to bag-mask ventilate patients (adequate gas exchange can be maintained in many decompensating patients with this technique until tracheal intubation is performed).Commonly used modes of respiratory support and mechanical ventilation and their applications in patients with heart disease.Commonly-used agents for sedation, analgesia, and muscle relaxation for controlled tracheal intubation and positive pressure ventilation, including their cardiovascular effects.The effects of airway support on cardiac function and pulmonary vascular resistance.3.3.7. Cardiopulmonary Support, Including Cardiopulmonary Resuscitation and Mechanical Circulatory SupportCardiology trainees should have basic skills in the ability to conduct cardiopulmonary resuscitation per established guidelines. Pediatric cardiology fellows should acquire the following:Pediatric Advanced Life Support (PALS) certification (or accepted alternative training, eg, Fundamental Critical Care Support sponsored by the Society of Critical Care Medicine).Understanding of the specific clinical situations in which modifications of the PALS guidel