The overall improving results in the management of congenital and acquired cardiac diseases are the result of an intense multidisciplinary effort, and of the search for consistency, quality, improvement, and safety that should be promoted from the training period.
This important interaction between paediatric and adult cardiologists, cardiac surgeons, intensivists, anaesthetists, nurses, research staff, perfusion technicians, psychologists, nutritionists, physiotherapists, and other specialised caregivers, optimises conditions to provide an outstanding quality of care to our patients and their families. The advantages of such interdisciplinary collaboration widely justify our bid to include a rotation through the arena of cardiac intensive care for trainees in paediatric cardiology, who may even fully develop comprehensive dual skills in both cardiology and intensive care. The latter is a crucial matter, because clinical paediatric cardiologists may be primarily in charge of the management of critically ill cardiac patients, from neonates to adults, or else will often be asked to advice on such patients.
Europe is a complex forum to develop homogeneous guidelines for training in paediatric cardiac intensive care, since hosting varied patterns of training and practitioner backgrounds. Thus, the format for training of future paediatric cardiologists ought to ally tradition with innovation. Nevertheless, consistency will be an important key to success.
The following document provides a summary of the guidelines and recommendations for paediatric cardiac intensive care training as a requirement for recognition as a European paediatric cardiologist. It is therefore primarily targeting paediatric cardiology trainees in Europe, including those doctors who might wish to become experts in cardiac intensive care. These recommendations represent a frame for consistency, will evolve, and may be adapted to specific institutional requirements. They will be complemented by a learning module to be provided by our Association in the near future.
Training in the field of paediatric cardiac intensive care concerns many entities, and therefore a strong collaboration within an interdisciplinary faculty is required. The future will hopefully bring further developments in training requirements in compliance with other Societies involved with paediatric critical patients, like the European Society of Paediatric and Neonatal Intensive Care, the European Association for Cardiothoracic Surgery, the European Association of Cardiothoracic Anesthesiologists, and other analogue entities, as well as with the future European Board of Intensive Care and the European Union of Medical Specialists. Future initiatives will also promote the inclusion, whenever possible, of simulation techniques for training in paediatric cardiac intensive care.
Institutional requirements for delivery of training
Specialised centres wishing to provide training in paediatric cardiac intensive care should ideally perform at least 100 open-heart surgeries a year for levels 1 and 2 and 150 open-heart procedures for level 3,Reference Jacobs, Lacour-Gayet and Jacobs1–Reference Jacobs, Mavroudis and Jacobs4 in order to provide a significant volume and variety of patients in a solid academic and clinical structure. Such centres should be able to provide clinical and academic discussions, teaching sessions, journal clubs, and revision of related subjects that must be held on a regular basis.Reference Abdulla5 An oversight tutor or committee should be set to supervise, review training goals, and review a logbook with the trainee on a regular basis. Accredited institutions should also participate in the EACTS-STS database and use the Aristotle score.
It is strongly recommended that a detailed curriculum be followed, as defined by the tutor and compliant with a learning module provided by the Association for European Paediatric Cardiology.
For specific modalities, such as circulatory mechanical assistance, complex neonatal surgery, or cardiac transplant, the trainee may rotate if desired in a recognised specialised institution.
Requirements for trainees
It is impossible and futile to pretend that all paediatric cardiologists become experts in the field of paediatric cardiac intensive care. Nevertheless, it is crucial that all paediatric cardiologists become familiar with the common issues related to critical care.Reference Jacobs, Mavroudis and Jacobs6 Prior to training in paediatric cardiac intensive care, paediatric cardiology trainees should have a general background on normal and abnormal physiology of the cardiovascular system, aetiology, diagnosis and differential diagnosis of congenital and acquired diseases, electrocardiography, echocardiography, cardiovascular radiology, rhythmology, and cardiovascular pharmacology. Candidates should therefore have completed at least 1 year of paediatric cardiology and 3–6 months of neonatal intensive care, as required in the guidelines and recommendations for general paediatric cardiology training.
Trainees should keep a comprehensive logbook specifying demographic data of patients, technical procedures performed while in training, attendance to teaching sessions and speciality meetings, published papers and research projects they have been involved with. This requirement will have the purpose of documentingReference Kulik, Giglia and Kocis7–Reference Van Mook, de Grave and Gorter13 a breadth of exposure to the training resources and must be monitored on a regular basis by the tutor or committee in charge.
There will be three levels of training available to trainees, the first one – basic – being the minimal required to become a European paediatric cardiologist, the second level – intermediate – being available to those wishing to become more independent in the management of paediatric cardiac critical care patients, and the third level – advanced – offered to candidates, who wish to further develop their expertise in order to become specialists in paediatric cardiac intensive care.
Levels of training
Level 1
The basic level 1 of training is required for all paediatric cardiology trainees, for a period of 6 months. It provides an understanding of the clinical and pathophysiological assessment of critical medical and surgical paediatric cardiac patients, the use of cardiovascular monitoring, and facilitates the acquisition of knowledge allowing the use of cardiovascular drugs and pacemakers, and the anticipation of potential complications (Table 1).
Table 1 Level 1 (basic) of training in paediatric cardiac intensive care for paediatric cardiology trainees.
NIBP = non-invasive blood pressure; EKG = electrocardiogram; ICU = intensive care unit; PALS = paediatric advanced life support; ACLS = advanced cardiac life support
Level 2
Level 2 or intermediate level of training will enable paediatric cardiologists to become more independent and knowledgeable in the assessment and management of critical complex cardiac diseases from the neonatal period to adulthood. This includes management of medical conditions, post-operative care, and, whenever possible, cardiac transplant. It will also allow the development of skills with regard to the insertion of pericardial and thoracic drains and indwelling catheters, basic oral and nasal tracheal intubation, management of multi-organ dysfunction, peritoneal dialysis and basic management of mechanical assist devices, with emphasis on extracorporeal membrane oxygenation. A training period of 9 months would be required to achieve this level. Trainees will have to be certified by their trainers as competent, based on the clinical performance and acquisition of skills, rather than on the number of patients (Table 2).
Table 2 Level 2 (intermediate) of training in paediatric cardiac intensive care for paediatric cardiology trainees.
EKG = electrocardiogram
*The tutor(s) in charge of the trainees may wish to liaise with their sections of Anaesthesia and Cardiac Surgery to organise this rotation
**In some institutions, this procedure might be exclusive to surgical caregivers; it is therefore recommended, although not mandatory, to get acquainted with the technique
***The tutor(s) in charge of the trainee may wish to liaise with their Anaesthesia section to organise specific rotations in the operating rooms for this purpose
Note: some of these requirements may need to be fulfilled with rotations in specific high-volume centres
Level 3
Level 3 or advanced level of training will require a minimum of 12 months rotation, as a complementary year after the full training in paediatric cardiology including level 2 competencies, in a programme offering exposure to neonatal and grown-up congenital heart patients. Training in cardiac transplant, Extracorporeal Membrane Oxygenation, and other types of mechanical assistance is suggested. It will enable paediatric cardiologists to become paediatric cardiac intensivists, proficient, and autonomic in the comprehensive management of critically ill cardiac patients, from the neonatal period to adulthood. This includes the development of capacities to anticipate, prevent, and manage potential cardiac or non-cardiac complications. This level will provide expertise in the management of multi-organ failure, mechanical assistance – extracorporeal membrane oxygenation and ventricular assist devices – and, if possible, Continuous Renal Replacement Therapy. It will also promote the development of higher-level skills with invasive procedures such as insertion of indwelling venous and arterial lines, pericardial and thoracic drains,and eventually difficult airway intubation. At the end of the training period, trainees should be able to independently manage complex cardiac patients (Table 3).
Table 3 Level 3 (advanced) of training in paediatric cardiac intensive care for paediatric cardiology trainees.
ARDS = acute respiratory distress syndrome; BPD = broncho-pulmonary dysplasia; NEC = necrotizing enterocolitis; CVVH = continuous veno-venous hemofiltration; CVVHD = continuous veno-venous hemodiafiltration; CVAHD = continuous veno-arterial hemodiafiltration
*The tutor(s) in charge of the trainee may wish to liaise with their Anaesthesia section to organise specific rotations in the operating rooms for this purpose
**In some institutions, this procedure might be exclusive to surgical caregivers; it is therefore recommended, although not mandatory, to get acquainted with the technique
Assessment of training
The trainee's proficiency will be assessed upon the logbook and the tutor's appraisal. The oversight tutor(s) or committee is required to meet with the trainees every 3 months to review the achievement of goals, and provide orientation in order to optimise training. Tutors are also required to supervise and validate the development of skills with regard to invasive procedures. At the end of the training period, the assigned tutor(s) will be required to certify the trainees’ competencies in their respective level of training. It is also suggested that trainees evaluate their trainers following premises established by the Association for European Paediatric Cardiology Council.
Acknowledgements
The authors are grateful to Dr Eero Jokinen, Dr Joerg Stein, Dr Andras Szatmari, and Dr Joseph De Giovanni for their editorial assistance.
