Jean-Daniel Chiche, MD PhD

La Réanimation en Europe - la même chose partout ?-

MICU & Dept of Host-Pathogen Interaction

Hôpial Cochin & Institut Cochin, Paris-F

How could this be ?

How could this be ?

Always a good reason to differ…

Is Intensive Care the Same Over Europe ?

Organisation of intensive care services

Delivery of intensive care

Patterns of care

Outcome

Processes of care

Intensive care training

Intensive care research

How many ICU beds in EU? (/100,000 inhab)

9.7

11.1

12.5

15.1

17.5

29.2

0 10 20 30

Spain

Switzerland

Italy

Austria

Belgium

Germany

4.0

5.9

5.9

6.4

7.4

8.1

0 10 20 30

Portugal

Sweden

UK

Netherlands

France

Norway

60,000 ICU beds

3% of acute care beds

Numbers of ITU beds / 100,000 Population

0

5

10

15

20

25

30

Percentage of ITU beds / acute care beds

0.0

1.0

2.0

3.0

4.0

5.0

Europe: requirement for MV ?

Vincent et al., Intensive Care Med 1997

Is there an intensivist in the ICU?

55

20

14

Medium

2

9

10

36

34

Largest

19

2

7

50

12

Small

1

30

40 37

4

Large

14

5

Full-time Intensivist

Consultant Intensivist

Consultant Specialist

Single Physician

Other

Angus et al. JAMA 2000

13

46

19

General ICU

17

4

18

45

21

SICU

14

4

14

21

52

Specialty

13

17

33

47

MICU

3

Unit Type Hospital size

Europe: intensivist present 24/7 ?

Vincent et al., Intensive Care Med 1997

Intensivist model (closed ICUs) reduce

mortality & ICU

length of stay

Worldwide differences in ICU settings

ICU beds

Open vs. Closed ICUs

Full-time presence of ICU physician

Shifts vs « on-call » care patterns

Staffing

MDs

Nurses ++, aid-nurses

Physotherapists, respiratory therapists

Pharmarcists, hospitalists, psychologists,…

Working-time directives

Intensive Care Medicine as a Specialty

Intensive care medicine is about the

combination of high-intensity hands-on care

with the rational use of modern technology.

“It’s the human resources of the ICU team, their organization and distribution, and how we apply

technology consistently, NOT the genius of

individuals or the treatment “magic bullet” that

leads to efficient and effective ICU”1

1. Knaus et al. Ann Intern Med 1986

Anaesthesia 52%

Intensive Care

Medicine 25%

Cardiology 7%

Cardiac Surgery

1%

Internal

medicine 9%

Neurology 1%

Pulmonology 3% Neurosurgery 1%

General surgery

1%

Types of Specialists practicing ICM …

N ≈ 20,000

Most Positive Factors Most Negative factors

Intellectual stimulation Lack of leisure time

Treating acutely ill patients Stress among faculty

Application of complex

physiology

Treating chronically ill

patients

Procedure orientated Inconsistent with my personality

Dealing with end-of-life

issues

Dealing with complex

ethical issues

The Perfect Storm

Increasing demand with static supply

The solution:

train more intensive care specialists

Fewer, but bigger units

What is a specialty ?

• The Group Government engages with

• A College governing training and entry to the specialty

• An accreditation / revalidation process

• An examination / diploma

• A quality control framework

• A fee structure

• Research

The Road Map to Recognition of ICM

Competency Based Training in Intensive

Care Medicine in Europe (& Elsewhere)

Covers 42 countries across Europe and also Chile, Costa Rica, Indonesia, India, Hong Kong, USA…

41 countries: n = 38

Formal adult ICM training

in 36 (95%)

54 different training

programmes

Variations in structure,

duration & format

CBT in UK, Canada

Ownership 55% supraspeciality (multidisciplinary access with common

programme)

30% anaesthesia only

15% multiple subspeciality

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Minimum duration of training (months)

= COMPETENCE

Knowledge

+ skills

+ attitude

Competence-Based Education & Training

Competence ? Competency-based training ?

Defines what a practitioner can do, in terms of

knowledge, skills, attitudes & behaviours

Workplace-based assessment of training

outcomes

Curriculum determined by competencies, not by

examination or duration of training

Competency-based training focuses attention on

the physician solely as craftsman / technician –

What distinguishes the ‘craftsman’ from the

‘professional’?

Attitudes, behaviours & ethics

Self-regulation & life-long learning

COMPETENCY-BASED TRAINING IN INTENSIVE CARE MEDICINE IN EUROPE

CURRICULUM

Syllabus

Knowledge, skills & attitudes for each

competence

Assessment

Descriptors of how competencies are

assessed in workplace

Educational Resources

Learning & teaching

Competencies

Final set of 102

Phase 1: 2003-2006

169 competencies presented online for comment

Expertise simplified to knwoledge, supervised & independent practice

102 competence statements grouped into 12 domains

CURRICULUM

Syllabus

Knowledge, skills & attitudes for each

competence

Assessment

Descriptors of how competencies are

assessed in workplace

Educational Resources

Learning & teaching

Competencies

Final set of 102

Phase 2: 2008-2010

Propose programme standards

grouped within 4 domains

• Programmes

• Training centres (ICUs)

• Selection of trainees

• Trainers’ profiles & support

Guidance on methods of assessment

• www.cobatrice.org

e-portfolio

• http://prototype.cobafolio.cobatrice.org

COMPETENCY-BASED TRAINING IN INTENSIVE CARE MEDICINE IN EUROPE

Phase 1: 2003-2006

Training • Formal

• Lectures / Seminars

• Practical

• Informal • Clinical practice

• Reading

• Disussing

Assessment • Workplace based (WBA)

• DOPS

• miniCEX

• Multi-source feedback (MSF)

• …

• Summative – formative

Examination • Oral

• Case discussion

• Simulation

• ..

• Written

Certificate • EDIC

• National diploma

E-portfolio (logbook)

Lectures, seminars & courses • ACLS, ATLS, PALS, …

• Basic assessment & support in intensive care (BASIC)

• Advanced trainings courses in intensive care (ATCIC)

• Postgraduate courses

• MSc course

• Websites, podcasts, flash-conferences

• …

Educational material • PACT • …

The ICM

specialist

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Countries that Recognize ICM as Particular Competence

…and as a Primary Specialty

1992 Formation of Joint Advisory Committee

for ICM by Royal Colleges (JACIT).

1996 Formation of Intercollegiate Board for

Training of ICM (ICBTICM).

1999 ICM included in specialist register as

joint CCT with base specialty.

2001 Competency based training program

launched.

2010 Creation of Faculty of ICM.

2011 Agreement of Primary CCT in ICM

Development of ICM as Primary Specialty in the UK

Year 1 - 2 Core training

Medicine / anaesthesia/ ICM/ EM

Year 3 ICM

Year 4 Complementary specialty

Year 5 Specialist ICM

Paeds/ Neuro / Cardiac

Year 6 ICM

Year 7 ICM

Primary CCT in the UK ICM Program

Models of Governance

• Boards after primary boards

• 20% director control

• Open units

• Medical & surgical units

• Primary critical care training

• Specialist diploma

• 100% directors

• Closed or semiclosed units

• Combined units

Criticisms:

‘ICM is considered to be too complex to be covered by one medical speciality alone.’

‘as ICM is extremely demanding physically and mentally ……..physicians who will have to leave ICM after some years due to ‘burnout’’

What is essential today…

Attract young physicians to intensive care

medicine !

Improve the ICU environment Bigger units…

Better working conditions

Dedicated time for life-long learning, research,…

Convey the right message ICM is a great specialty

You can be an intensivist your whole life

There are (and will be) reasonnably well-paid job

opportunities

Quality of patient care is compatible with quality of life

for care givers

Raise awareness on ICM as a specialty and improve the profile of intensivists

the ICU specialist