By Shaheryar Hafeez, MD1 (left); Michel T. Torbey, MD, MPH, FNCS, FAHA, FCCM, FANA2,3 (center); and Diana Greene-Chandos, MD2,3 (right)
- Department of Neurosurgery, UT Health Science Center San Antonio
- Department of Neurology, The Ohio State University College of Medicine
- Department of Neurosurgery, The Ohio State University College of Medicine
The aim of neurocritical care fellowship training, as outlined by the UCNS, is to “prepare the physician for the independent practice of Neurocritical Care1
.” The way to achieve this objective is different in the eyes of every program director, institution and trainee. However, the UCNS has identified six core competencies for the fellowship: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice. The method of assessment suggested by the UCNS to determine if the fellow has achieved the competencies for individual rotations is a global assessment in chart review, self-assessment and 360-degree evaluations. While these are crucial to the program, they are all subjective measurement tools. Therefore, we sought to determine if a neurocritical care fellowship database would be helpful in providing a well-rounded fellowship experience.
Neurocritical care training programs across the country are extraordinarily heterogeneous. There are training programs with different call structures, types of hospitals — large urban tertiary care trauma center, community hospitals, private hospitals — resident-based teams, mid-level provider teams, vascular-heavy programs, trauma-heavy programs, procedure heavy, procedure light, etc. From a procedural experience standpoint, the fellowship can consist of being part of a rotating procedure team, versus a program where all procedures are done by the fellow, versus other programs where barely any procedures are done. Certain programs allow fellows to do all the bedside neurosurgical procedures — EVD or ICP monitor placement — while others will never have the experience to attempt any type of bedside neurosurgical procedure because of the political climate.
The programs are all very different. Each have positives and negatives, and individuals must decide which fits their career path best. The ACGME has implemented milestones for anesthesia critical care, pulmonary critical care and surgical critical care that requires mastery of the subjects and skills specific to that subspecialty. The procedural milestones vary from program to program but are based on the collective faculty opinion that the trainee is able to competently perform all medical, diagnostic and surgical procedures considered essential for the area of practice3, 4
. Some surgical critical care training requires fellows to keep two written records of their experience: a summary record documenting the numbers and types of critical care patients, and an operative log of numbers and types of operative experiences, including bedside procedures, the results of which are unpublished3. The UCNS requires demonstration of the six ACGME core competencies to the expected level of a new practitioner of neurocritical care: patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism and systems-based practice1
. However, the UCNS does not require any type of written log of cases or procedures.
We constructed a database based on a “minimal hassle” assumption for logging cases. It took an average of one minute and 15 seconds (+/- 45 seconds) to input each patient on a simple Microsoft access database that kept track of patients’ admitting diagnosis, procedures performed and encounter location at two different training centers: Ohio State University Wexner Medical Center and a two week away rotation at University of Pittsburgh Medical Center (UPMC). The database variables included patient name, medical record number, date of birth, admitting diagnosis, procedures performed and a free text box for notes. Only the admitting diagnosis were logged without secondary diagnoses or complications during the hospital course. The procedures logged were ones only performed primarily by the fellow and non-supervised procedures that residents or mid-level providers performed. Additionally, most vascular access procedures were only performed after failure by others at the procedure (or when on call by himself). This data set is the experience of one fellow from the period of July 2014 to June 2016.
In total, approximately 1,224 patients were collected over the two-year fellowship. During the period of time measured, and when the fellow was present in the unit, the highest number of diagnoses were within the neurovascular and neuro-oncology categories. The lowest number were within the traumatic brain injury category, specifically with diagnoses of cerebral contusions and diffuse axonal injury but excluding subdural hematoma.
The fellow performed a total of 305 procedures. The types of procedures were placement of EVD, ICP monitor, Licox monitor, central venous catheter, arterial line catheter, bronchoscopy, chest tube, intubations and percutaneous tracheostomy. The highest number of procedures were central venous catheter placements. The lowest number of procedures were ICP bolt and Swan-Ganz catheter placements.
The results of the database show the fellowship case mix was well-rounded and provided enough procedural opportunity, in the opinion of the faculty, to the expected level of a qualified junior faculty neurointensivist. The database was also designed to capture admitting diagnoses and procedures that were logged. However, all secondary diagnoses and complications a patient may have were not captured. This is a major limitation the database, as it does not capture a vital portion of critical care training: the severity of illness and multi-organ dysfunction. The database could be modified in the future to capture higher levels of severity of illness, but in a busy fellowship, compliance would be difficult.
The questions we hoped to address with this fellowship database were as follows: to assess the variety of cases and volume of each diagnosis at our institution; to assess the volume and types of procedures; and to assess how interval progression audits could assist when considering the type of rotations in the second year of fellowship. Our neurocritical care unit had undergone a physical move during the database collection period to a building separate from the surgical intensive care where they had previously been adjacent. This created a decrease in the number of neurotrauma cases seen, since the ease of communication and care from being adjacent to the SICU changed, especially as it pertained to the multisystem trauma patients. As such, after the first year of the fellowship, the fellowship director and fellow sought an outside rotation in the UPMC neurotrauma unit. This experience not only bridged the gap but offered the experience of a different institution and an NCCU built on a different dogma that proved to be invaluable. Being able to pick the brain of a different group of neurointensivists while you are doing your fellowship was an extremely formative experience.
Neurocritical care remains a relatively new subspecialty, and the fellowships vary tremendously depending on size of the unit, unit structure (open versus closed; consultative versus primary service), relationship with neurological surgery, and neurology and procedural arrangements. Many things can affect a two-year fellowship that are out of the fellow’s control, such as an ICU move that affects protocols (in our case), but others that are common include change in faculty, changes in community referral patterns for certain diseases and ICU triage arrangements. As such, it may be of benefit for programs to not only start a database but to monitor it regularly to not only ensure case variety and numbers, but also to monitor the impact on the numbers if there are changes in an institution, department, division or unit. We have also shown that if the fellow and fellowship director are open to establishing additional rotations or outside hospital rotations, it can be an important educational solution. Maybe a fellow who is at a major trauma center does not see a lot of tumors or vascular disease and may want to go to Ohio State University to experience a high volume of vascular and neuro-oncology and their complications of rare immunocompromised infections and complex resuscitation.
This data also raises the question of what is the minimum standard of cases that a neurocritical care fellow should see. While we considered our neurotrauma numbers temporarily low, were they low comparatively to other neurocritical care fellows experience on average? Such comparative data is not available. We feel it would be important to establish such standards in neurocritical care training.
Outside of educational goals, another benefit of a fellowship database is easing the vetting process by prospective employers when applying for a job. Even though neurointensive care is an internationally recognized field, we are still oftentimes met with misplaced skepticism and criticism by employers because colleagues and employers do not know our full range of practice and expertise. By providing cases and procedure logs to prospective hospitals, employers and colleagues, it may help establish the important role of neurointensivists and specialized health care for neurocritically ill patients. The database made the credentialing of procedural privileges process extremely easy.
In our experience, the importance of an ongoing database in neurocritical care training served as a tool to supplement a fellow’s education and understand the impact of unit changes that can affect diagnosis numbers and eased the process of applying for procedural and critical care privileges as a new attending physician. We hope to start a conversation among fellowship directors about the ideal number of cases and procedures each fellow should have upon completion of training. We also hope to encourage more fellows to collect data and share their numbers to further understand neurocritical care education across different institutions and consider doing outside rotations to gain a different perspective while in training from other neurointensivists.
#NCSRoundup #ShaheryarHafeez #MichelTorbey #DianaGreene-Chandos #September2018
- ACGME Neurological Surgery Critical Care Milestones. http://www.acgme.org/Specialties/Milestones/pfcatid/10/ Neurological%20Surgery
- ACGME General Surgery Critical Care Milestones. https://www.acgme.org/Portals/0/UPDATED_DEFINED_ CATEGORY_MINIMUM_NUMBERS_EFFECTIVE_ ACADEMIC_YEAR_2017-2018_GENERAL_SURGERY.pdf
- https://www.acgme.org/Portals/0/PDFs/Milestones/ CriticalCareAnesthesiologyMilestones.pdf