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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 6  |  Page : 327-330

Spectrum of invasive critical procedures performed by clinical fellows in the pediatric intensive care unit of a developing country


Department of Pediatrics, The Indus Hospital, Karachi, Pakistan

Date of Submission27-Jul-2020
Date of Decision26-Aug-2020
Date of Acceptance06-Sep-2020
Date of Web Publication11-Nov-2020

Correspondence Address:
Dr. Sadiq Mirza
The Indus Hospital, Plot C-76, Sector 31/5, Sector 39, Korangi Crossing, Karachi
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JPCC.JPCC_118_20

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  Abstract 


Objective: The objective of this study is to describe the frequency of invasive critical procedures (ICPs) performed by pediatric critical care medicine (PCCM) fellows during their training period.
Design: This was a retrospective study.
Setting: This was a multidisciplinary, closed 6-bed pediatric intensive care unit (PICU) staffed by four pediatric critical care physicians.
Methods: We reviewed the electronic medical record and logbook of each fellow from January 2018 to December 2019. Two most commonly performed ICPs included in this study were endotracheal intubation and ultrasound-guided central venous catheter (USG-CVC) insertion. Demographic data and details of ICPs performed were collected on a structured data collection sheet. The primary outcome was the frequency of ICPs performed by clinical fellows during the training period and their success rate.
Results: Of the total 1080, 352 ICPs were performed on 560 (51.8%) patients by four PCCM fellows during the 2-year period. Only two most commonly performed procedures, i.e., ET-intubation and UG-CVC insertion were included in this study. These ICPs comprised of endotracheal tube placement (52.85%, n = 186) and USG central venous line insertion (47.15%, n = 166). About 64.4% of patients were under 5 years, 56% were male, and 72% were admitted with cardiorespiratory failure. The frequency of endotracheal intubation was 23/fellow/year and USG-CVC insertion was 21/fellow/year and the success rate was >90%.
Conclusion: Our clinical fellows performed adequate numbers of endotracheal intubation and USG-CVC insertion to achieve competency of procedural skills during their training period.

Keywords: Endotracheal intubation, invasive critical procedure, pediatric critical care fellow, pediatric intensive care unit, ultrasound-guided central venous catheter insertion


How to cite this article:
Qurat-ul-Ain B, Mirza S, Haque A, Gova M, Shahani M, Munir S, Rehman F, Ahmad AR. Spectrum of invasive critical procedures performed by clinical fellows in the pediatric intensive care unit of a developing country. J Pediatr Crit Care 2020;7:327-30

How to cite this URL:
Qurat-ul-Ain B, Mirza S, Haque A, Gova M, Shahani M, Munir S, Rehman F, Ahmad AR. Spectrum of invasive critical procedures performed by clinical fellows in the pediatric intensive care unit of a developing country. J Pediatr Crit Care [serial online] 2020 [cited 2020 Nov 30];7:327-30. Available from: http://www.jpcc.org.in/text.asp?2020/7/6/327/300577




  Introduction Top


Pediatric critical care medicine (PCCM) is a well-established discipline of pediatrics in developed countries and is in a very early stage in developing countries such as Pakistan. Respiratory failure and shock of various etiologies are the most common reasons for admission in the pediatric intensive care unit (PICU) of developing countries.[1] Lack of prompt recognition and delay in the implementation of appropriate interventions increase the morbidity and mortality in these critically ill or injured children in the first 24 h of admission.[2],[3] PCCM Fellowship is recently recognized as a second fellowship in pediatrics by the College of Physicians and Surgeons Pakistan, the national governing body of postgraduate education. The acquisition of medical knowledge and technical skills are necessary to achieve competency in PCCM.[4] The medical knowledge can be acquired by bedside teaching rounds, dedicated lectures, and studying textbooks and journals and free online access like “OPEN Pediatrics.” The trainees learned procedural skills gradually over a period with personal interest. The gaining competencies in procedural skills for trainees are essential such as airway management, vascular access, and point of care ultrasonography.[5] The importance of safe and secure endotracheal intubation and central venous catheter (CVC) insertion has become life-saving procedures in the management of children with respiratory failure and shock. Acquiring skills and competency to perform invasive critical procedures (ICPs) is essential to deliver the highest level of care and ensuring patient safety.[6] There is no minimum number of ICPs required for competency in procedural skills for PCCM fellows defined in the PCCM fellowship. However, a recent study demonstrated that PCCM fellows are getting a limited opportunity for critical care procedures in PICU during their fellowship training.[6] The objective of this study is to assess the frequency of performing ICPs (ET-intubation and UG-CVC insertion) by pediatric critical care fellows during their training period.


  Methods Top


We reviewed electronic record from the PICU database of all children (1 month–14 years) admitted in the PICU of the Indus Hospital (TIH) Karachi who received ICPs by clinical fellows from January 2018 to December 2019. These data were reaffirmed from the logbook of pediatric critical care fellows. TIH is a large, nongovernment organization, tertiary-care, postgraduate training center with a large pediatric oncology unit. The pediatric critical care unit (PICU) of TIH is 6-bedded, Level-III, and closed multidisciplinary unit. The team comprised of PICU consultant, clinical fellows, and pediatric residents. Nurse–patient ratio is 1:1. The PICU is equipped with advanced technology such as blood gas machine, point-of-care ultrasound machine, high-frequency oscillation ventilation, as well as continuous renal replacement therapy machine. The pediatric critical care team provides clinical service to the PICU and performs pediatric procedural sedation and analgesia to a large volume of pediatric oncology patients. The PCCM team is supported by many other subspecialties such as pediatric surgery, pediatric nephrology, pediatric cardiology, pediatric infectious disease, and pediatric oncology team. Inclusion criteria for study consist of all children who required ICPs in their management during their stay in the PICU. The clinical fellowship in PCCM was initiated in 2018 with the induction of two fellows per year. Currently, we have four clinical fellows (Two first year fellows and two second year fellows) in our PICU. We defined the ICPs as “all invasive procedures performed on critically ill or injured children in their management in PICU.” These ICPs included endotracheal intubation, ultrasound-guided CVC insertion, arterial line insertion, and pigtail catheter insertion. However, we considered the two most commonly performed procedures in this study, i.e., endotracheal intubation and UG-CVC insertion. We still using the apprenticeship model for the clinical procedure such as observer, assistant, performed under supervision, performed independently under indirect supervision, and performed independently. Afterward, they started teaching to the junior colleagues in our fellowship program. In our curriculum, four to six procedures as an assistant, followed by 15 procedures under supervision, and 20 procedures performed with distant supervision independently by each fellow. In our fellowship program, we required that each fellow performed forty US-guided CVC insertions as well as forty endotracheal intubations during their training period to become competent to perform independently.

All ICPs were performed with all aseptic precautions according to the standard guidelines. We have a checklist for each ICP in our PICU. After each ICP, the documentation (including type, success, and immediate complications) was noted on physician procedure note as well as nurse documentation. Each PCCM fellow was also provided with a logbook to make entries after each clinical procedure and academic activities such as topic presentation, journal club, and mortality presentation. The primary outcome was the frequency of ICPs performed by clinical fellows during the study period. The demographic variables (age and gender), admitting diagnosis, and procedural details including type, indication, and procedure-related complications were collected on a structured data collection sheet. Descriptive statistics were applied on SPSS v.22 Statistical Package For The Social Sciences. The ethical approval was obtained from the institutional ethical committee (IRD_IRB_2019_10_010).


  Results Top


Of the total 1080 patients, 352 ICPs were performed on 560 children (51.85%) by four clinical fellows during the study period. We included only two most commonly performed procedures in our study, i.e., endotracheal tube placement (52.84%, n = 186) and ultrasound-guided CVC insertion (47.15%, n = 166). Approximately two-third (64.44%, n = 696) of the study population were under the age of 5 years and 51.38% were male. Almost three-fourth of the study population (72%, n = 782) were admitted with cardiopulmonary failure and shock states. The frequency of endotracheal intubation and US-guided CVC insertion were 52.85% (n = 186) and 47.15% (n = 166), respectively [Table 1]. The frequency of arterial line insertion and pigtail catheter insertion by fellows was very low and not included in the study. The overall success rate was more than 90%. On an average, each fellow performed approximately 23 endotracheal intubations and 21 UG-CVC insertions per year. The frequency of each procedure per fellows is shown in [Figure 1].
Table 1: Invasive critical procedures performed by pediatric critical care medicine fellows during 2 years

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Figure 1: Graphic appearance of procedures by pediatric critical care medicine fellows

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  Discussion Top


Our PCCM fellows performed 352 ICPs in 560 critically ill children during the study period. Sixty-seven percent of program directors of PCCM fellowship in the United States agreed that ten (n = 10) successful CVC insertion should be required to make them competent during training in a survey of program directors suggested an agreement.[7] Ishizuka et al. reported that 90% success rate was achieved after a mean of 26 (n = 26) endotracheal intubations from a large training center of PCCM fellowship of a tertiary care pediatric academic institution.[8] All of our fellows meet these numbers during their training period. However, Engorn et al. evaluated the frequency of ICPs performed by PCCM fellows during the training period and found declining in the rate of CVC and arterial catheter insertion trends over the last 10-year period.[6] The rate of endotracheal intubation was not changed for PCCM fellows in this cohort. Our fellows had adequate opportunity for endotracheal intubation and CVC insertion. Like Engorn et al., our PCCM fellows had less opportunity for arterial catheter insertion.[6] Few pediatric emergency medicine reports also showed the low rate of critical procedures in large pediatric academic hospitals.[9],[10] Nevertheless, there is a shift of paradigm in the care of critically ill patients from an approach of very aggressive, invasive, expensive, and high rates of complications to a more cautious, vigilant, noninvasive, and careful for associated risks. Advances in modern medicine have introduced sophisticated and reliable noninvasive monitoring techniques in acute care settings such as emergency rooms and intensive care units.[11] The various forms of noninvasive ventilation decrease the need of tracheal intubation, whereas on the other hand, oxygenation assessment by the new technology of pulse oximetry as well as end-tidal CO2(EtCO2) monitoring significantly decreases the rate of arterial line insertion for blood gas measurement, and use of vasoactive agents through a good peripheral line in the early phase decreases the need of CVC insertion.[12],[13]

There is an increasing evidence of simulation-based medical education in the last two decades in the literature.[14] Several reports are available with a significant positive impact on clinical outcome from different disciplines of medicine, including high-risk specialties like training in PCCM.[15],[16],[17],[18] Due to the reason that the developed world has now moved from numbers to a competency-based model, we are also planning to move from the apprenticeship model to the competency-based model like simulation-based learning education (Boot Camp).

It is not known that what minimum numbers are required for ICPs for PCCM fellows to achieve competency and provide safe and effective patient care. However, our PCCM fellows are very frequently engaged in conducting a large number of pediatric critical care workshops on manikins for pediatric residents in different institutions. In our curriculum, four to six procedures as an assistant, followed by 15 procedures under supervision and 20 procedures performed with distant supervision independently by each fellow. We required that each fellow performed forty US-guided CVC insertions as well as forty endotracheal intubations during their training to become competent in our institutional fellowship program. We used work-based assessment tool in our institution. We use Direct Observation of Procedural Skills (DOPS) as a formative assessment tool for assessing competencies in ICPs as published in the literature.[19] This DOPS will help Entrustable Professional Activity which is the modern way to assess the competency-based education.[20]

There were several limitations in our study. The major one was retrospective, single-center, and small sample size. We were unable to record the number of attempts and complications related to the procedure. We did not calculate the ICPs per 1000 admissions. However, it was only very few in numbers, we did not include the procedure done by residents or consultants. Recently, the taskforce of PCCM, a subboard of the American Board of Pediatric trying to create a comprehensive document to establish necessary knowledge and skills in PCCM to serve as a vital tool in guiding education and practice assessment.[21] This document may serve as a guideline for them in creating education and training programs of PCCM.


  Conclusion Top


We found that our PCCM fellows performed adequate numbers of endotracheal intubation and US-guided CVC insertion to achieve competency in procedural skills during their training period. Simulation-based education can fill this gap and improve the education and skills of the trainees.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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Adeboye MA, Ojuawo A, Ernest SK, Fadeyi A, Salisu OT. Mortality pattern within twenty-four hours of emergency paediatric admission in a resource-poor nation health facility. West Afr J Med 2010;29:249-52.  Back to cited text no. 2
    
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Murthy S, Chugh K, Musa N, Ouellette Y, Phan PH. Editorial: Pediatric critical care in resource-limited settings. Front Pediatr 2019;7:80.  Back to cited text no. 3
    
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Bhalala U, Khilnani P. Pediatric critical care medicine training in India: Past, present, and future. Front Pediatr 2018;6:34.  Back to cited text no. 4
    
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Joyce MF, Berg S, Bittner EA. Practical strategies for increasing efficiency and effectiveness in critical care education. World J Crit Care Med 2017;6:1-2.  Back to cited text no. 5
    
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Engorn BM, Newth CJ, Klein MJ, Bragg EA, Margolis RD, Ross PA. Declining procedures by pediatric critical care medicine fellowship trainees. Front Pediatr 2018;6:365.  Back to cited text no. 6
    
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Boyer DL, Zurca AD, Mason K, Mink R, Petrillo T, Schuette J, et al. Assessing competence in central venous catheter placement by pediatric critical care fellows: A national survey study. Crit Care Med 2019;47:e654-e661.  Back to cited text no. 7
    
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Ishizuka M, Rangarajan V, Sawyer TL, Napolitano N, Boyer DL, Morrison WE, et al. The development of tracheal intubation proficiency outside the operating suite during pediatric critical care medicine fellowship training: A retrospective cohort study using cumulative sum analysis. Pediatr Crit Care Med 2016;17:e309-16.  Back to cited text no. 8
    
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Guilfoyle FJ, Milner R, Kissoon N. Resuscitation interventions in a tertiary level pediatric emergency department: Implications for maintenance of skills. CJEM 2011;13:90-5.  Back to cited text no. 9
    
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Mittiga MR, Geis GL, Kerrey BT, Rinderknecht AS. The spectrum and frequency of critical procedures performed in a pediatric emergency department: implications of a provider-level view. Ann Emerg Med 2013;61:263-70.  Back to cited text no. 10
    
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Vincent JL, Creteur J. Paradigm shifts in critical care medicine: The progress we have made. Crit Care 2015;19 (suppl 3):S10.  Back to cited text no. 11
    
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Davis AL, Carcillo JA, Aneja RK, Deymann AJ, Lin JC, Nguyen TC, et al. American college of critical care medicine clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. Crit Care Med 2017;45:1061-93.  Back to cited text no. 12
    
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Buche VB, Bhutada A. Respiratory monitoring in PICU. J Pediatr Crit Care 2014 5;1:254-66.  Back to cited text no. 13
    
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Zendejas B, Brydges R, Wang AT, Cook DA. Patient outcomes in simulation-based medical education: A systematic review. J Gen Intern Med 2013;28:1078-89.  Back to cited text no. 14
    
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McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med 2011;86:706-11.  Back to cited text no. 15
    
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Thomas SM, Burch W, Kuehnle SE, Flood RG, Scalzo AJ, Gerard JM. Simulation training for pediatric residents on central venous catheter placement: a pilot study. Pediatr Crit Care Med 2013;14:e416-23.  Back to cited text no. 16
    
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Barsuk JH, McGaghie WC, Cohen ER, O'Leary KJ, Wayne DB. Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med 2009;37:2697-701.  Back to cited text no. 17
    
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Tofil NM, Benner KW, Zinkan L, Alten J, Varisco BM, White ML. Pediatric intensive care simulation course: A new paradigm in teaching. J Grad Med Educ 2011;3:81-7.  Back to cited text no. 18
    
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Fleming GM, Mink RB, Hornik C, Emke AR, Green ML, Mason K, et al. Developing a tool to assess placement of central venous catheters in pediatrics patients. J Grad Med Educ 2016;8:346-52.  Back to cited text no. 19
    
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Ten Cate O. Nuts and bolts of entrustable professional activities. J Grad Med Educ 2013;5:157-8.  Back to cited text no. 20
    
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Turner DA, Boyer DL, Dwyer A, Czaja AS, Odetola FO, Schuette J, et al. Establishing the knowledge and skills necessary in pediatric critical care medicine: A systematic approach to practice analysis. Pediatr Crit Care Med 2020;21:667-71.  Back to cited text no. 21
    


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