Minutes of cardiothoracic Intensivists in ACTA 14 th Jan
University Hospital of South Manchester
Attendance : representatives from the following units :
Alistair Macfie
Tim Strang
Glasgow (ACTA committee)
Manchester ( Local Organiser)
Andy Ronald
Aberdeen
Chris McConkey
Belfast
Robert Kong
Brighton
James Hillier
Bristol
Mike Higgins
Glasgow
Tim Palfreman
Leeds
Nigel Scawn
Liverpool
Chris Allsager
Leicester
Ruth Hurley
London
Jeremy Cordingley London
Nick Fletcher
London
Lee Winslow
Manchester
Nick Startford
Middlesborough
Kevin Brennan
Newcastle
Henry Skinner
Nottingham
Kamen Valchanov
Cambridge
Nick Fernandes
Sheffield
Peter Robbins
Plymouth
Mike Herbertson
Southampton
David Morrice Wolverhampton
Alison Parnell
Sheffield
Apologies: Jamie Macdonald, P Saravanan, Colin Moore, Niall O’Keeffe,
Opening introduction and terms of reference for the group
Alistair Macfie (Glasgow)
Aims of the group:
1. To improve clinical standards in cardiac intensive care including developing policies
and guidelines.
2. To enhance recognition of cardiac intensive care as a subspeciality in the UK through
the development of links with the Royal College of Anaesthetists and the
Intercollegiate Board for Intensive Care Medicine and the SCTS.
3. To standardise training in cardiac intensive care including the development of a
syllabus.
4. To develop a standard for training and revalidation in ICM for cardiac anaesthetists.
5. To promote education in the field of cardiac intensive care including running
educational meetings.
6. To collect data for clinical governance and business management such as quality
indicators and benchmarking.
7. The development of research in the intensive care setting
The above were discussed and the following expanded:
The group will develop under the wing of ACTA in a similar way to the development of
TOE which was lead by anaesthetists within ACTA. Hence the name Cardiothoracic
Intensivists in ACTA (CIA) would be used for now.
The main body of the group would consist of CT anaesthetists who would be keen to
retain their CT anaesthetic as well as ICU skills. However it was appreciated that some
pure intensivists including ones from other parent specialities would appreciate
representation with this body.
Leadership of the group would initially be from Alistair Macfie (as existing ACTA
committee member). ACTA will consider CT ICU being the main platform for the next
elected representative. (Alistair Macfie given option to continue/compete in election).
In view of the large remit of the CIA group it was suggested that ACTA should consider
the responsibilities of the committee members and consider either the appointment of an
additional elected member who would have no other heavy responsibilities within ACTA
(eg thoracic interest) or a redistribution of roles. Allocation of roles and responsibilities
within CIA would be important to allow CIA to drive forward developments in the fields
of education, training, syllabus, governance development, research and data collection.
It was felt that links to other specialist bodies (eg RCOA, SCTS, ICS) were important but
too affiliate preferentially with one at present would be premature.
Meetings would be six monthly. One would coincide with a major ACTA meeting, the
other would be standalone so as to allow attendance of interested parties.
The educational meetings such as those currently organised by Dr Strang or Dr
Valchenov at the Association would come under the CIA label. Suggestions to have CT
ICU topics at the SCTS and ICS meetings were well received
A major concern of the group was that at present only 20% of cardiothoracic ICU’s
have posts to train advanced trainees in ICM . Even accredited CT ICUs experience a
reluctance of ICM STC’s to release trainees who wish to be exposed to CT ICU. It was
suggested that reciprocal relationships with local general ICU’s may result in more
trainees coming to CT ICU. It was agreed that improving trainees exposure to CT ICU
should be one of the main priorities of the group.
The formation of the group would represent an opportunity to shape and develop training
together with raising standards of governance, research and data collection in CT ICU- an
as yet relatively under-represented sub speciality. However the main opinion was that
separation of CT ICU from CT anaesthesia was undesirable
ACTION Alistair Macfie to take the above views to ACTA committee
Development of CT Anaesthetic and CT ICU training syllabus
Dr Chris Rigg (Hull)
(See accompanying document)
Chris Rigg presented a comprehensive review of training and the development of a
syllabus for training in cardiothoracic ICU.
The adoption of this comprehensive syllabus covering essential topics and skills required
for cardiothoracic anaesthesia and intensive care was proposed .
It was agreed that such training should cover both disciplines together.
Measurable assessment of completion and competency using the tools of DOPS mini Cex
and Multi source feedback should underpin the training as outlined by PMETB . A log
book of CT ICU 10 case studies would also be required .
TOE accreditation would be expected.
It was suggested that resuscitation elements include ALS and CALS methodology and
certification
There may also be elements of skills of dealing with complications in vascular surgery
and interventional cardiology as many CT ICU’s are developing this work
It is our understanding that there has is a draft guidance issued by the RCOA on this
which at the meeting we were unable to accurately substantiate.
Subsequent review shows that the link to this recommendation is
http://www.rcoa.ac.uk/index.asp?PageID=1419 within the Annex E Advanced
Level Training (draft).It states:
“For consultant posts with a commitment to both cardiothoracic anaesthesia and critical care,
minimum clinical learning outcomes are:
All identified above and, in addition, provide clinical leadership to a wide variety of patients
requiring cardiothoracic critical care; management and leadership in using the facilities available
to best effect. [It is recommended that this requires three months of cardiac critical care training
and should form part of twelve months Step 2 training in intensive care medicine leading to a
joint CCT in anaesthesia/intensive care medicine]. In such situations, trainees must discuss their
specific training requirements with their TPD [including the TPD for ICM if necessary] early, to
ensure that they can fit the recommended training into their CCT programme in the requisite
time, whilst also ensuring that a balanced programme of training is completed, as required for
RCoA recommendation to the PMETB for a CCT. Such programmes will need early discussions
with the Medical Secretary [or Deputy], contacted via the RCoA Training Department; this is also
a ready source of advice to both trainees and trainers.”
At present typical timing of training would be as follows:
3/12 exposure to general ICU as CT1,2
6/12 general ICU and 3 months cardiothoracic anesthesia as ST3,4
An optional year dedicated to CT anaesthesia and intensive care in ST 4,5,6 (competitive
interview).
The recent draft curriculum for Anaesthetics 2010 draft has defined an additional four
higher essential units ( ICM, Cardiothoracic, Paediatrics and neurosurgery) which must
be completed in six months . The cardiothoracic block would be between 4 and 12 weeks
duration.
It was appreciated that many trainees will have also gained an additional year in general
ITU prior to expressing an interest in CT ITU or anaesthesia – this would allow them to
retreat to general ICU consultancy if faced with a paucity of CT posts.
The above would be feasible within the current RCOA training arrangements.
It was appreciated that excessive training time would put off potential trainees but too
short a training would lack credibility .
ACTION ACTA CIA representatives to further develop syllabus in consultation with
RCOA
Attracting trainees to CT ICU
Dr Tim Strang (UHSM)
Tim Strang presented a coherent strategy for attracting ICM trainees to CTICUs and why
this is important.
All representatives are to push locally for ICM accreditation of their CT ICU .
Approaching the local STC to release trainees can be a daunting task.
We must demonstrate the unique skill mix we can offer eg treatment of acute MI’s
including primary PCI and IABP , RHF therapy , TOE skills
If we are to attract the advanced level ICM trainees we must make it clear that their
service provision will be minimal and not involve theatre work. They will be effectively
need to be treated as supernumerary so as to gain experience ‘acting up’ for consultant
roles eg. taking ward rounds etc.
ICM STC’s will see delivery of PMETB style work based assessments as essential.
ACTION: Local CT ICU departments should become PMETB compliant and approach
local ICM bodies to gain trainees. Potential trainee numbers for recognized units should
be tabulated
Clinical Governance
Dr Tim Palfreman (Leeds)
(see accompanying document )
Tim presented an agenda of quality markers and standards by which to run our units .
Such stringent benchmarks covered standards for the working environment, safe staffing
levels, work patterns , equipment, formal links to audit surgical, microbiology and
radiology departments . The suggestions were well received with a view to incorporation
into an ACTA ICU Standards Toolkit / handbook.
Data Collection
Dr Valchenov (Papworth) then started a discussion regarding data collection on our units
.
CT units such as Papworth, Newcastle and ?Nottingham have been in discussion with
ICNARC in developing a modified data collection of clinical parameters suitable for the
CT arena.
It was suggested that if all units press their local management to pay for such data
collection .This would prove useful for comparison between CT units and general ICUs.
Most physiological monitoring charting systems are compatible with the ICNARC
system. If many CT units could subscribe then possibly the implementation costs would
be reduced.
It was noted that the NCBC have also been collecting mainly work force and efficiency
data from most UK units. Both these systems may have to feed into future PBR tariff
generation.
ACTION CIA representatives should liase further with ICNARC to develop national
data and press management to fund local modified ICNARC data collection
DOTNM.
This will be at the EACTA meeting in Edinburgh. Time and place to be confirmed.