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Scaling Up Global Critical Care -

Educational Approaches

Neill Adhikari

Critical Care Medicine, Sunnybrook Health Sciences Centre and

University of Toronto

11 November 2019

Disclosures

• none

Objective

• discuss selected methods for clinical and research

education in resource-constrained settings

– short courses

– long-term partnerships

Same educational needs?

short courses

Critical care training

Learning sequence 9

Invasive mechanical ventilation for

acute respiratory distress syndrome (ARDS)Deliver Lung Protective Ventilation

Influenza Other Respir Viruses 2018;12:649-655

Influenza Other Respir Viruses 2018;12:649-655

BASIC collaborationDepartment of Anaesthesia and Intensive Care, Chinese University of Hong Kong

• Suite of short critical care training

courses intended for non-specialists

• not-for-profit and essentially open

access

BASIC collaboration

• 14 different courses in >50 countries in the past ~12 years

• 3 day course

• International RNs and trained

local trainers

• Broad range of topics

• Deployed nationally

J Crit Care 2015;30:438.e7–438.e11

• Six 2-3 week bedside teaching modules over 20 months

• MD and RN teachers

PLoS ONE 12(3):

e0173483

Short courses

• Advantages

– easy to scale up

– alternate delivery methods possible

– can reach many healthcare workers

• Disadvantages

– integration of knowledge into daily practice often not measured

– long-term retention?

– Clinical impact?

longer-term partnerships

Federal Democratic Republic of Ethiopia

የኢትዮጵያ ፌዴራላዊ ዴሞክራሲያዊ ሪፐብሊክ

Capital: Addis AbabaOfficial language: AmharicArea: 1 104 300 km2 (28th)

Population: 108 386 391 (12th) Median age: 18 y

GDP per capita: USD 2200 (204th)Health expenditure: 4.9% GDP (CAN 10.4)

Physicians 0.03/1000 (CAN 2.61)Hospital beds 0.3/1000 (CAN 2.7)

CIA World Factbook

Critical illness in Ethiopia: the need

• Trauma

• NCDs

• Obstetric problems

• Sepsis

• [HIV infection 0.9%]

• Adult critical care resources

• National capacity not published

• ICU beds have become more available

• Lack of trained personnel

• CCM training viewed as important by MoH

• No certification or national professional society

Critical care in Ethiopia: the resources

Tikur Anbessa Specialized Hospital (“Black Lion”)

• Public national referral

hospital

• 600 beds

• ED, OR, ICUs

• X-ray/Echo/US

• CT scan (generally)

• MRI (sometimes)

• Some labs

Der biaber anbessa yaser

(Together a spider’s web will tie a lion)

• Objective: build postgraduate program capacity in

medicine, engineering, social sciences

• Started with psychiatry in 2008

• New graduates faculty at AAU and elsewhere

• Long-term: continue independent of external

assistance

Acad Med 2018;93:1795–1801

• Three annual trips to Addis

• UofT faculty and a trainee

• bedside and formal teaching

• Weekly webinars

• Observerships

• Academic support

• mentorship

• research collaboration

• curriculum development

TAAAC CCM fellowship: what does UofT do?

• Results (as of 2017)

– 15 programmes delivered in Addis

– 222 graduates; 143 enrolled trainees

• 90% retention rate in Ethiopia

Acad Med 2018;93:1795–1801

TAAAC CCM fellowship: what do the fellows do?

• Two year fellowship

• Rotations

– ICUs (medical, surgical, cardiac)

– Non-ICU (trauma, burns, cardiology, nephrology)

– Planned Vellore, India (MSICU, 3-6 months)

– UofT observership

• Differences

– Private work to supplement salary

– Residents primarily responsible for night call

The positives

UofT

• Motivated learners

• Different pathologies

• Learning to adapt

AAU

• External faculty time,

expertise, commitment

• Longitudinal follow-up

• Expertise in US and

echocardiography

The challenges

UofT

• Lack of resources, money,

infrastructure

• Aspects of daily practice

take a long time

• No impact on nursing and

allied health

• End of life care

AAU

• Lack of resources, money,

infrastructure

• Different ICUs, hierarchal

organisational structure

• Need for additional

experience outside of

Ethiopia

• 2-year pulmonary and critical care fellowship

– critical care exposure is in MICU

• World Lung Foundation funding

• US faculty present most months

• 12 fellows graduated as of February 2019

Ann Am Thorac Soc 2016; 13:451–455

Reflections

• TAAAC is an academic partnership model

• Complements other global health activities

– short-term medical missions

– short courses

– research

• Investment of time and resources into a small

number of trainees

– aim to train core national CCM faculty

health research education

There are not enough health researchers

https://www.who.int/research-observatory/en/

Toronto faculty:

Gordon Rubenfeld

Andre Amaral

Niall Ferguson

Damon Scales

Neill Adhikari

Federico Angriman

Bruno Ferreyro

ATS MECOR: building research capacity

• L1: study designs

–Assignment: design a study; be ready to go by L2

• L2: advanced design; manual of procedures

–Assignment: write a manual of procedures

–Do the study by L3

• L3: analysis and drafting of manuscript

11/22/2019 35BASIC Clinical Research

Authors:

Anthony Delaney

Rob Fowler

Charles Gomersall

Czarina Leung

Shay McGuinness

Rachael Parke

Neill Adhikari

Education: part of an ICU improvement ecosystem

Slide courtesy of @rhaniffa

Summary

• High burden of critical illness worldwide

• Education is a key strategy to improve care

–Short courses

–Long-term partnerships

–Enabler of research and QI

38

Thank you

neill.adhikari@sunnybrook.ca

• Engage trainees from all disciplines

• Basic management and ICU organisation

– Rounds and handovers

– Empowering nurses

– Documentation of vital signs

– Admission and discharge policies

– Goals of care

• …in addition to ICU specific content

JAMA 2016;315:753-754

• Multipronged effort

– Local trainings

– Bidirectional exchanges

– Checklists

– Equipment

– Research

– Regional and national activities to promote the

specialty

Globalization and Health (2016) 12:7

• Steps to starting a new programme

– Initiation and partnership development

– Curriculum development

– Curriculum delivery in Addis

– UofT observerships

– Local programme delivery

Acad Med 2018;93:1795–1801

Surgical ICU: resources

• 6-8 beds

• Most beds have

– ventilator

– continuous SpO2

– ECG monitoring

– NIBP

– invasive arterial monitoring

• Some infusion pumps

• One consultant, many residents

• 4-8 patients : 1 nurse

Surgical ICU: patients

• Surgical

– abdominal, vascular, thoracic surgery

• Neurosurgical

– meningioma resection, pituitary resection, intracranial hemorrhage

• Obstetrical

• Trauma

– TBI

– blunt chest and abdominal trauma

Critical care resources at AAU

• Adult ICUs: total ∼18 beds

– Medical: int med + respirology

– Cardiac: int med + cardiology

– Surgical: anaesthesia

– ED: not formally an ICU

• Pediatric: ∼6 beds

Typical day

• 0800-0900: Handover

– Discuss new admissions and issues with admitted patients

• 0900-1030: Morning rounds

• 1030-1230: Procedures, scanning

• 1230-1400: Lunch

• 1400-1600: Teaching

Feb 2018: TAAAC-supported CCM fellowship launches at AAU

Admission

graduates of EM, internal medicine, anaesthesia

General objectives

Train intensivists to provide comprehensive management for all types of

patients with organ and system failure, regardless of primary pathology

Competencies

patient care and education at tertiary hospitals;

quality assurance and research;

ICU leadership

TripsFEBRUARY-APRIL 2018

Alberto Goffi, Mika Hamilton,Sameer Vakani, Neill Adhikari

• ENLS course

• Critical Care Ultrasound

• Journal Clubs

OCTOBER 2018

Alexander White, Alexandra Cheung,Matteo Parotto, Sameer Vakani, Neill Adhikari

• Airway Curriculum

• Clinical Pharmacology

• Critical Care Ultrasound

TripsFEBRUARY 2019

Alberto Goffi, Alya Kamani

• Bedside mechanical ventilation

• Toxicology

• Mock examination scenarios

MAY 2019

Sameer Kumar, Niall Filewod

• Simulation teaching

• Physiology

• Critical Care Ultrasound

• Mock examination scenarios

Bedside teaching

Webinars

• weekly online sessions

• ZOOM platform

• lectures

• case-based discussion

• image interpretation

• mechanical ventilation course

Faculty Monday Tuesday Wednesday Thursday Friday

We

ek

1

WhiteAdhikari

October 1MORNING

Morning reportM/SICU rounds

October 2MORNING

Morning reportM/SICU rounds

October 3MORNING

Morning reportM/SICU rounds

October 4MORNING

Morning reportM/SICU rounds

October 5MORNING

Morning reportM/SICU rounds

AFTERNOON

Endocrine emergencies

AFTERNOON AFTERNOON

ArrhythmiasHemodynmonitoring

AFTERNOON AFTERNOON

Journal Club (steroid guideline)

Wee

k 2

WhiteParottoCheung

October 8MORNING

Morning reportM/SICU rounds

October 9MORNING

Morning reportM/SICU rounds

October 10MORNING

Morning reportM/SICU rounds

October 11MORNING

Morning reportM/SICU rounds

October 12MORNING

Morning ReportM/SICU rounds

AFTERNOON AFTERNOON

Airway quiz Preparation for airway managementAirway management –Hands-on 1

AFTERNOON

Execution of airway managementAirway management –Hands-on 2

AFTERNOON

Pharmacology in ICU (part 1)

AFTERNOON

Advanced concepts in airway managementAirway management –Hands-on 3

Outside the hospital…

ATS MECOR: building research capacity

• Methods in Epidemiologic, Clinical, and Operations

Research

• Prepares clinicians to design and conduct research

relevant to their context

• Founded in 1994; 1st course in Mexico

• Now 6 courses per annum

• >1800 graduates

Objectives

• Provide new and established clinicians who work in

Intensive Care or other acute care areas with the basic

skills to develop clinical research within their own hospital

• Understand the principles of ethical research and how to

apply these in your research

BASIC

– CUHK

– 2 day course

– multiple countries

– CC physician trainees, non-CC

physicians, nurses

– Manual, lectures, skill stations

– MCQ

– No charge

FCCS

– SCCM

– Focus on 1st 24h

– Similar topics

– USD 220-1320

J Crit Care 2011;26:533.e1–533.e10

• high burden of respiratory disease in LMICs

• traditional ‘vertical’ focus on selected high-priority

conditions, e.g. TB

• specialists needed

– implement programmes that start with patient symptoms

– define / direct local priorities for training and research

Ann Am Thorac Soc 2015;12:486–490