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Canadian Journal of Cardiology 32 (2016) 1204e1213 Special Article From Coronary Care Units to Cardiac Intensive Care Units: Recommendations for Organizational, Staffing, and Educational Transformation Michel Le May, MD,a Sean van Diepen, MD,b Mark Liszkowski, MD,c Gregory Schnell, MD,d Jean-François Tanguay, MD,c Christopher B. Granger, MD,e Craig Ainsworth, MD,f Jean G. Diodati, MD,g Neil Fam, MD,h Richard Haichin, MD,i Davinder Jassal, MD,j Christopher Overgaard, MD,k Wayne Tymchak, MD,b Benjamin Tyrrell, MD,l Christina Osborne, BSc,a and Graham Wong, MDm a Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada b c d e Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA f g Mazankowski Heart Institute, University of Alberta, Alberta, Canada Montreal Heart Institute, University of Montreal, Montreal, Que bec, Canada Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada Hôpital du Sacre -Coeur de Montre al, University of Montreal, Montreal, Que bec, Canada h i j m St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada McGill University Health Centre, McGill University, Montreal, Que bec, Canada St Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada k University Health Network, University of Toronto, Toronto, Ontario, Canada l Royal Alexandra Hospital, University of Alberta, Edmonton, Alberta, Canada Vancouver General Hospital, University of British Columbia, British Columbia, Canada See editorial by Bourke, pages 1197-1199 of this issue. ABSTRACT RESUM E Medical care in Canadian cardiac units has changed considerably over the past 3 decades in response to an increasingly complex and diverse patient population admitted with acute cardiac pathology. To maintain the highest level of care for these patients, there is a pressing need to evolve traditional coronary care units into contemporary cardiac pondre aux besoins de plus en plus complexes et diversifie s Afin de re des patients souffrant d’un problème cardiaque aigu, les soins dicaux prodigue s dans les unite s de cardiologie canadiennes ont me rablement e volue au cours des trois dernières de cennies. conside Cependant, si nous voulons continuer d’offrir les meilleurs soins In 2013, a cardiac intensive care unit (CICU) workshop conducted by Canadian coronary care unit (CCU) directors at the Canadian Cardiovascular Society meeting highlighted the change in the landscape of the traditional CCU, and emphasized the increasingly important role of critical care medicine in CCUs. It became evident that a “position paper” (or a scientific statement) was necessary to guide our Canadian institutions. Hence, a national Working Group was formed that included cardiologists with an interest in critical care medicine, 3 physicians with dual certification in cardiology and critical care medicine, and a coauthor on the scientific statement from the American Heart Association (AHA).1 Finally, as part of the internal review process, the Working Group solicited the input of various Canadian leaders, the Received for publication August 10, 2015. Accepted November 26, 2015. Corresponding author: Dr Michel Le May, Ottawa Heart Institute, 40 Ruskin St, Ottawa, Ontario K1Y 4W7, Canada. Tel.: þ1-613-761-4223; fax: þ1-613-761-4690. E-mail: [email protected] See page 1211 for disclosure information. http://dx.doi.org/10.1016/j.cjca.2015.11.021 0828-282X/Ó 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. Le May et al. Canadian Cardiac Intensive Care Units 1205 intensive care units. In this article we aim to highlight the current variations in Canadian units, develop approaches to overcome logistical and infrastructural obstacles, and propose staffing and training recommendations that would allow for the establishment of contemporary cardiac intensive care units. s de soins coronariens traditionnelles possible aux patients, les unite s de soins intensifs cardiaques plus condevront se muer en unite temporaines. Dans cet article, nous voulions faire ressortir les diffe risant les unite s de soins canadiennes, rences actuelles caracte velopper des approches visant à surmonter les obstacles lie s à la de logistique et à l’infrastructure et recommander des modifications en cessaires à matière de dotation en personnel et de formation ne tablissement d’unite s de soins intensifs cardiaques à la fine pointe l’e . de la modernite Canadian Association of Interventional Cardiology, the CANadian CARdiovascular Critical CarE Society, and fellows in the process of training in critical care cardiology. physicians will need to formally embrace the guidelines adhered to by established critical care organizations such as the Canadian Critical Care Society and the Society of Critical Care Medicine into the planned structure of the evolving CICU.4-6 The primary objective of this article was to establish how contemporary Canadian CCUs can optimally serve an increasingly heterogeneous and complex population of cardiac patients, identify strategies needed to transform current Canadian CCUs into units capable of critical care management (ie, CICUs), and propose initial suggestions and recommendations to achieve this end. A more comprehensive evaluation of issues related to other critical care units such as medical intensive care units (MICUs) and cardiac surgical intensive care units was beyond the scope of this article. Overview Acute cardiac care has evolved since the advent of CCUs in the early 1960s. Although the original CCU was specifically designed to admit patients with acute myocardial infarction who might need timely defibrillation, the modern CICU is now admits a variety of increasingly complex cardiac patients commonly complicated by multisystem organ failure.2 A detailed historical perspective of the evolution of the CCU is provided (see the Historical Perspective: Evolution of Cardiac Monitoring section of the Supplementary Material). In addition to acute coronary syndromes, reasons for admission now include: (1) management of cardiogenic shock; (2) hemodynamic support for decompensated heart failure and transplant evaluation; (3) target temperature management after cardiac arrest; (4) diagnosis and management of complex arrhythmias including implanted cardiac defibrillator malfunction; (5) hemodynamic evaluation and initiation of novel medical therapy for severe pulmonary hypertension; (6) monitoring after percutaneous intervention for structural heart disease; (7) management of decompensated complex adult congenital heart disease; and (8) complicated endocarditis. This shift in CCU admissions of various critical cardiac problems also has been accompanied by a host of critical noncardiac problems, which has increased the need for critical care expertise among attending physicians. This situation now requires a balanced approach to patient care including advanced modes of respiratory care, renal replacement support, neuroprotection and neuro-optimization, concomitant treatment of multisource infections, and enhanced nutritional support. This evolution of critical care cardiology and the need to transform the CCU has been acknowledged by the AHA.1 Accordingly, within the concept of a critical care-enabled CCU, it is increasingly evident that attending cardiologists will require further training and expertise in critical care medicine. Recently the American College of Cardiology Core Cardiovascular Training Statement-4 Task Force reported on the standards needed for competency in critical care cardiology.3 With that said, many logistical and infrastructural obstacles must be addressed before the evolution of CCUs to CICUs can be fully implemented across Canada. In the context of an evolving CICU, the Working Group believes that it will be important to integrate the best practices of critical care and cardiovascular medicine. As such, Similarities and Differences Between CICUs and MICUs The level of acuity in most Canadian tertiary care units has risen to a level at which similarities now exist between our modern CICU and a traditional MICU. However, clinically important differences exist between patients admitted to the MICU and the CICU. The primary reason for admission to the CICU is almost always an acute cardiac illness. In general, in the MICU a more diverse population of patients admitted for conditions such as septic shock, respiratory failure, trauma, or postoperative complications are monitored. Many of these conditions are now more typically present in current CICU patients. Current variability in the resources and infrastructure of some centres commonly requires that patients admitted in the CCU with an acute cardiac illness require transfer to the MICU (ie, need for mechanical ventilation). These patients then usually fall under the care of an intensivist. Care of many of these patients could alternatively be directed within the confines of an evolved CICU by a cardiologist trained in critical care medicine. However, although the Royal College of Physicians and Surgeons of Canada (RCPSC) provides training objectives in adult critical care medicine and certification to physicians who have successfully completed the program, it does not currently provide subspecialty training and certification for critical care cardiology. Importantly, the training and experience of several health care disciplines is often required to manage critically ill patients. The Writing Group believes that collaboration between CICUs and MICUs would be mutually beneficial to ensure that optimal patient care is maintained and that clinical resources are optimally distributed and allocated. Management 1206 Canadian Journal of Cardiology Volume 32 2016 protocols should be shared and standardized, and the directors of the CICU and MICU should have regular interactions (ie, critical care monthly meetings). A potential collaborative care model for patients admitted to CICUs or intensive care units (ICUs) is outlined in Figure 1. Proposed CICU Classification Because of the diversity in CICU clinical practices, acute care volumes, and resource availability across Canada, it is unrealistic to expect that all CICUs adopt the same level of staffing, training, and organizational structures. However, we do recommend that each city or region develop a hub and spoke referral system(s) for acute cardiac care, in which the care of the most critically ill cardiac patients is centralized in high-volume centres capable of providing high intensity and comprehensive care for critically ill cardiac patients (Fig. 2). We propose a 3-tiered CICU classification system (Table 1) similar to the American College of Surgeons trauma centre classification system and to the model described in the AHA scientific statement on critical care cardiology.1,7 This classification system could: (1) help provinces, regions, and/or cities set up regional hub and spoke care networks; (2) guide individual CICUs in the development of optimal staffing, training, and educational care plans to meet the clinical needs of their population; (3) guide the development of a future framework for CICU accreditation; and (4) assist in the rationalization of costly critical care resources to the best possible sites. Level 1 CICU A level 1 CICU should have the staffing, training, on-site medical resources, and the medical technologies to centralize comprehensive care for all cardiac conditions including the most acutely ill cardiovascular patients. The standards and technologies in these units should mirror those in a general intensive care unit or a large tertiary cardiovascular centre. Moreover, these select centres ought to serve as tertiary referral centres within regional systems of care. Reasons to support this model come from data that indicate that institutional and Cardiologist or CardiologistIntensivist Intensivist IInternist nterni ern st Medical and Surgical Consultants, Nurses, Pharmacists, Physical/OccupaƟonal/Respiratory Therapists, DieƟcians, and Social Workers Figure 1. Collaborative care model for cardiac patients admitted to cardiac intensive care units and intensive care units. Level 3 CICU Level 3 CICU Level 2 CICU Level 3 CICU Level 3 CICU Level 1 CICU Level 2 CICU Level 2 CICU Level 3 CICU Level 3 CICU Level 2 CICU Level 3 CICU Level 3 CICU Figure 2. Hub and spoke cardiac intensive care unit (CICU) regional care networks. individual physician volumes affect patient outcomes.8-15 The primary goal in centralizing the care of critically ill cardiac patients is to concentrate expertise and resources to ensure adequate volumes to promote superior clinical outcomes across a broad range of complex acute cardiac pathologies. Medical staffing of level 1 CICUs will play an important role in the unit transformation and patient care. The physician who leads the unit should be a cardiologist who has the necessary education and training in cardiovascular disease to optimally meet CICU patient care needs. We propose that future level 1 CICU cardiology recruits have either dual certification in cardiology and intensive care or a minimum of 1 year of dedicated critical care training (see the section on Pathways to Critical Care Cardiology Training) after their cardiology residency (CICU intensivist). An in-house physician, medical resident, or advanced nurse practitioner with acute cardiac life support training should be available at all times, as should consultation with an attending CICU physician. Nonphysician staffing should also reflect standards in critical care units (see the Nursing Intensity and Allied Health Professional Staffing section of the Supplementary Material). Optimal nurse to patient ratios should be 1:1-1:2, dependent on patient acuity.16-18 The unit should have a clinical pharmacist,19-21 a respiratory therapist,22,23 and access to physical therapy,24 occupational therapy,24 nutritional support,25 and social work services.26,27 Each unit should also develop standardized protocols, with a particular focus on critical care evidence-based care strategies (see the Standardized Treatment Protocols and Prevention section of the Supplementary Material). Although specific evidence from CICUs is largely lacking, we encourage the adoption of existing best evidence from critical care medicine. Units should be leaders in resident and cardiology trainee education, and academic centres might choose to develop Le May et al. Canadian Cardiac Intensive Care Units 1-year cardiology critical care fellowships in conjunction with the RCPSC. Level 2 CICU These units should have the staffing, medical resources, and therapeutic technologies to diagnose and initiate appropriate management of most cardiovascular conditions. These centres should manage a high volume of cardiac emergencies and have 24/7 on-site percutaneous coronary intervention (PCI), echocardiography, and access to critical care. These centres might not necessarily have on-site cardiac surgery, cardiac transplant, or electrophysiology services. Level 2 units should be equipped to provide all forms of cardiac monitoring, and to manage patients who require intravenous vasoactive agents, mechanical ventilation, transvenous pacing, and therapeutic hypothermia. These units could transfer complex or critically ill patients to level 1 centres, but could also serve as a referral centre for moderate-acuity patients from level 3 CICUs.28 Future physician recruitment to level 2 CICUs would ideally comprise either cardiologists with 1 year of dedicated critical care training (see the section on Pathways to Critical Care Cardiology Training), or cardiologists with additional dedicated critical care training that does not meet the 1-year fellowship criteria; in the latter case, electives in critical care medicine during cardiology training could potentially count toward additional CICU training. Cardiologists with dual cardiology-critical care certification would be eligible to work in level 2 CICUs, but we believe that this career path would best serve level 1 units. With a more modest patient acuity, nurse to patient ratios could vary from 1:1 to 1:3. Allied health staffing, in-house coverage, and unit protocol development standards should otherwise remain similar to the level 1 CICU recommendations. Level 3 CICU Level 3 CICUs, more likely located in smaller community hospitals, should be staffed and equipped to primarily manage common cardiovascular diagnoses that require noninvasive cardiac monitoring. A level 3 unit should focus on the initial stabilization of the patient, which might include pharmacological and emergent mechanical therapies followed by timely transfer to a level 1 or 2 CICU.28 These units should have the capacity to administer intravenous vasoactive agents, manage temporary transvenous pacemakers, and perform echocardiography, but might not have access to in-hospital cardiac surgery, primary PCI, or other cardiac subspecialty services. The primary attending physicians in a level 3 CICU should be certified cardiologists or certified general internists. Attending physicians should maintain basic critical care competencies although the degree of acuity in these units is usually expected to be lower. A minimum 1:2 or 1:3 nurse to patient ratio should be the standard. We acknowledge that many centres that currently serve as tertiary referral centres or regional hub might not currently meet the proposed level 1 or 2 standards. As such, we would like to reiterate that the purpose of this proposal is not to validate all existing practice models, but rather to set reasonable evidence-informed practice standards that each centre could aim to meet in the coming years. 1207 Organizational Models Regional referral networks and CICU institutional volume Regionalizing the care of critically ill patients is a strategy that helps ensure consistent and timely access to high-volume specialized centres. Surgical, trauma, and critical care studies show that institutional volumes are linked to lower mortality rates.8,10-14,29 The implementation of regional systems of care for ST-elevation myocardial infarction and out-of-hospital cardiac arrest is also associated with better patient outcomes.28,30-32 However, recommendations for regional systems of acute cardiac care are currently limited to the initial triage of specific time-sensitive conditions. There might be additional benefits to extending these systems beyond the point of first medical contact to patients who deteriorate after admission. Our recommendation to broadly regionalize the management of all emergent and nonemergent cardiac critical care might be justified on the basis of the consistency and weight of published nonrandomized evidence.11-15,29-31 Development of specialized regional centres also represents an opportunity to improve our knowledge in cardiovascular disease (see the Prioritizing Critical Care Cardiology Research section of the Supplementary Material). Physician service volumes Individual physician volumes have been associated with improved clinical outcomes.9,12,33 The Leapfrog group, a coalition advocacy group for hospital quality and safety, recommends a minimum of 6 weeks of annual intensive care service for intensivists.34 In line with: (1) the Leapfrog recommendation; (2) the AHA scientific statement; and (3) the results of our national survey (see the Pan-Canadian CICU Survey on Acute Cardiac Care section of the Supplementary Material and Supplemental Table S4), we propose that all physicians who practice in level 1 or level 2 CICUs maintain a minimum of 6 weeks of CICU clinical service annually. We do, however, acknowledge that each institution must satisfy their needs within the available staffing and infrastructural parameters that define their institution. As such, we encourage the chief of cardiology of each institution to define within reason what constitutes a “week.” Moreover, because of the intensity and complexity of patient care within level 1 and level 2 CICUs, the attending physician should limit practice to the patients in the unit and be readily available at all times. Interventional cardiologists are often actively responsible for the initial management of critically ill patients in the catheterization laboratory and during the transition of this care to the CICU. We believe that interventional cardiologists who wish to attend in the CICU might maintain a minimum of 5 weeks of CICU clinical service annually, provided that they also undertake at least 6 weeks of PCI call. Similarly, for physicians with dual cardiology and critical care certification who practice in multiple critical care settings, we propose that a minimum of 4 weeks of service annually in the CICU is reasonable if they also partake in a minimum of 6 weeks of service in other critical care units, (ie, a total of 10 weeks). We believe that the centralization of care coupled with standardization of physician practice volumes will increase expertise and experience with complex cardiac conditions in the CICU. 1208 Table 1. Classification of Canadian CICUs Future physician staffing and recruitment On-site medical resources Cardiologistintensivist or CICU intensivist Cardiac-intensivist or intensivist consultation with collaborative management 24/7 Primary percutaneous coronary intervention Cardiac surgery Echocardiography Electrophysiology Adult congenital Intensive care Neurology 24/7 In-house physician, resident, or advanced nurse practitioner coverage CICU intensivist 2 “Secondary Most cardiovascular or Referral Centre” diagnoses: cardiologist All acute coronary syndromes Advanced heart failure Arrhythmia and device management Aorta and peripheral vascular disease emergencies Cardiac arrest care (initial management) Transplant Adult congenital heart disease Cardiogenic shock Cardiac patients with multisystem organ failure Transfer complex and critically ill patient to level 1 centre Intensivist consultation with collaborative management Level Patient population 1 “Regional Hub” All cardiovascular diagnoses: All acute coronary syndromes Advanced heart failure Arrhythmia and device management Aorta and peripheral vascular disease emergencies Cardiac arrest care Transplant Adult congenital heart disease Cardiogenic shock Cardiac patients with multisystem organ failure Medical and technological capabilities Noninvasive cardiac and hemodynamic monitoring Invasive cardiac and hemodynamic monitoring Cardiac arrest team Intravenous vasoactive agents Transvenous temporary pacing Mechanical ventilation Therapeutic hypothermia Intra-aortic balloon pump and/or percutaneous left ventricular assist device Hemodialysis Continuous renal replacement Bronchoscopy Electronic medical records 24/7 Primary Noninvasive cardiac percutaneous coronary and hemodynamic intervention monitoring Echocardiography Invasive cardiac and Intensive care hemodynamic Neurology monitoring Other resources available Cardiac arrest team by telephone Intravenous vasoactive consultation agents 24/7 In-house physician, Transvenous resident, or advanced temporary pacing nurse practitioner Mechanical ventilation coverage Initiation of therapeutic hypothermia Hemodialysis Electronic medical records Nurse staffing and allied health support Unit protocols and standards Education RN:patient ratio: 1:1-1:2 Pharmacist Respiratory therapist Physical and occupational therapy Dietician Social worker Infection control Resident and Sedation protocols cardiology fellow Mechanical ventilation education protocols Might include cardiac VAP, CLI, VTE intensivist training prevention and Critical care reporting continuous medical Standardized order sets education for for common attending conditions cardiologists Delirium screening Early mobilization Morbidity and mortality review RN:patient ratio: 1:1-1:3 Pharmacist Respiratory therapist Physical and occupational therapy Dietician Social worker Infection control Resident and Sedation protocols cardiology fellow Mechanical ventilation education protocols Critical care VAP, CLI, VTE continuous medical prevention and education for reporting attending Standardized order sets cardiologists for common conditions Delirium screening Early mobilization Morbidity and mortality review Canadian Journal of Cardiology Volume 32 2016 Role of the intensivist Le May et al. Canadian Cardiac Intensive Care Units 1209 CICU, cardiac intensive care unit; CLI, central line infection; RN, registered nurse; VAP, ventilator acquired pneumonia; VTE, venous thromboembolism. 3 “Community CICU” Common cardiovascular Cardiologist or diagnoses: internist All acute coronary syndromes Advanced heart failure Arrhythmia and device management Initial diagnosis and management of all cardiovascular emergencies with transfer of complex and critically ill patient to level 1 centre Intensivist consultation Echocardiography Intensive Care Other resources available by telephone consultation 24/7 In-house physician, resident, or advanced nurse practitioner coverage Noninvasive cardiac and hemodynamic monitoring Intravenous vasoactive agents Cardiac arrest team Transvenous temporary pacing Mechanical ventilation (before transfer to level 1 centre) Electronic medical records RN:patient ratio: 1:21:3 Pharmacist Respiratory therapist Physical and occupational therapy Dietician Social worker Infection control Resident education CLI, VTE prevention and reporting Standardized order sets for common conditions Morbidity and mortality review Open vs closed units Critical care and CICU units are traditionally organized into an open vs closed structure. In an open unit, multiple physicians can admit patients to the unit and maintain the primary responsibility for daily care. In a closed unit, a single physician maintains primary responsibility for all patients. Observational studies and meta-analyses show lower ICU mortality rates and shorter lengths of stay in closed units with intensivist-directed care or with mandatory consultation with an intensivist.35-37 A closed unit might also better provide an administrative framework that enables timely development of new protocols and progress. Although it is impossible to clearly delineate the contribution of unit organization and staffing in critical care cardiology, the weight of existing evidence is sufficient to recommend the adoption of closed staffing models for CICUs. Physician staffing, training, and expertise The overwhelming majority of CICU patients have a primary cardiac diagnosis at the time of admission that requires daily management by a physician with expertise in cardiology. Therefore, it is the opinion of this Writing Group that a cardiologist with critical care training is ideally the most appropriate physician to lead the care of patients admitted to a level 1 or 2 CICU. In light of the growing medical complexity among CICU patients, it is anticipated that the future CICU physician will require advanced critical care knowledge in addition to expertise in acute cardiac care. Currently, critical care certification in Canada does not necessarily require dedicated cardiovascular training.38 We believe that the RCPSC will need to define the competencies and training requirements for other types of physicians to assume the position of the most responsible physician in a level 1 or 2 CICU, potentially resulting in an area of focused competency. Medical intensivists, cardiac anaesthesiologists, cardiac surgeons, and other physicians who work with critically ill patients could, in this manner, gain the necessary qualifications to assume the role of the most responsible physician in a level 1 or 2 CICU. However, until these changes are implemented, the Working Group recommends that noncardiologists who seek this option should complete additional formal cardiology training and certification. In units staffed by a noncritical care trained cardiologist, we suggest that each CICU develop guidelines for critical care consultation and develop a collaborative patient care strategy. In level 3 CICUs, we recognize the need and ongoing role for experienced and knowledgeable community physicians from a variety of training backgrounds, who already provide care to this patient population, to remain as the most responsible physician. Multiple nonrandomized studies consistently showed improved clinical outcomes, such as mortality, length of stay, and length of mechanical ventilation, in ICUs managed by an intensivist.35,36,39,40 However, the RCPSC does not currently require critical care training for cardiology certification.38 Nevertheless, we believe that the consistency of the data suggests that dedicated critical care training has the potential to improve outcomes in complex CICU patients through improved prevention, recognition, and management of 1210 noncardiac complications. Hence, we concur with the European Society of Cardiology and AHA recommendations that CICU cardiologists receive formal extended training in critical care.1,41 Continuing Medical Education and Competencies We endorse the development and adoption of a formal continuing medical education (CME) curriculum as an essential aspect in the evolution of modern Canadian CICUs. CME will help bring current CICU physicians in line with modern critical care medicine but also ensure that all CICU physicians maintain competencies in critical care cardiology. It is hoped that CICUs gain certification in the future through the RCPSC Areas of Focused Competency Program. An RCPSC Areas of Focused Competency status could then promote the development and application of national accreditation standards to all CICU physicians. Finally, to maintain “best practice care,” the ongoing competency assessment of CICUs will require gathering and acting on clinical practice data (see the Quality Improvement Initiatives section of the Supplementary Material). These data will assist in: 1. Clarification of guidelines for admission to level 1, level 2, and level 3 CICUs; 2. Improvement of resource and personnel allocation; 3. Assessment of clinical outcomes and length of stay; 4. Assessment of patient and family satisfaction; 5. Assessment and implementation of novel techniques and technology; and 6. To foster and optimize relationships with other health care units (MICU, Emergency Department, medical ward) and relevant consultants. Current CICU Attending Physicians The process of training new cardiologists with the additional expertise in critical care medicine will take time. Many current CICU physicians are experienced, committed, and competent cardiologists who have recognized expertise that has evolved with changing CICU needs. Although they might not be formally trained in critical care, they will continue to be an integral part of care for these patients while upcoming attending physicians are trained. These physicians should actively maintain and further develop the knowledge and skills necessary to deliver ongoing CICU care. The following suggestions are made in an attempt to ensure adequate exposure for these physicians in the area of critical care cardiology: 1. Institutions should establish collaborative care or consultation standards for the most critically ill patients; 2. Individuals should maintain basic critical care skills (ie, acute cardiac life support certification, basic airway management skills, basic echocardiography, and procedural skills including central line placement and temporary pacemaker insertion); and 3. Individuals should maintain a minimum of 15 hours of critical care CME a year; this might also be in the form of a critical care track at a national cardiology meeting. Canadian Journal of Cardiology Volume 32 2016 Pathways to Critical Care Cardiology Training Cardiovascular organizations worldwide have advocated for changes in CICU physician training.1,41 In Canada, there are currently no recognized pathways or training standards toward critical care cardiology certification. Herein, we propose 2 possible pathways (Table 2) toward specialized critical care training in Canada: either dual certification in cardiology and critical care or a minimum of 1 year of dedicated critical care training after cardiology residency (CICU intensivist). The foundation of both pathways will necessarily involve the RCPSC and would follow formal cardiology subspecialty certification. First, dual certification as a cardiologist-intensivist is possible. Currently, this is the only formal RCPSC-recognized pathway to prepare trainees to work in CICUs and ICUs, and requires the completion of a 2-year RCPSC-accredited critical care fellowship after a 3-year RCPSC cardiology fellowship. Dual certification in this way would ultimately provide all of the technical skills and practice knowledge expected of a general cardiologist/intensivist. If successful, this pathway would provide trainees with RCPSC certification in critical care and cardiology, and allow for clinical practice in cardiac and general intensive care units. However, the Writing Group recognizes that a focused year of critical care training might be sufficient to meet the patient care needs in contemporary level 1 and 2 CICUs. At present, the University of Alberta has the only established CICU critical care program in Canada.42 However, because of the lack of national standards to underpin this program, we advocate for the development of a formal standardized CICU critical care fellowship. Ideally this would include 1 clinical year after RCPSC certification in cardiology with broad critical care exposure (Table 2) administered by a joint critical care and cardiology program. Trainees would acquire many of the same technical skills as physicians with dual certification and would be certified to work in CICUs but not in general critical care units. Ultimately the development and implementation of such national standards, as done with other traditional cardiology fellowships, would provide the best avenue to train most of the future CICU cardiac intensivists in Canada. To meet these goals, discussions and collaboration between the RCPSC and critical care training programs (ie, ‘joint programs’) will likely be needed to accommodate additional trainees. Conclusions and Future Directions Over the past half century, the CCU has evolved from a unit highly focused on acute myocardial infarction arrhythmia monitoring into a medically complex unit that provides increasingly complex critical care to patients who present with a primary cardiac illness. This shift in care was driven in part by the increasing number of acutely ill cardiac patients who populate modern CICUs, and also in part by the development and use of highly specialized medical and therapeutic critical care technologies. This new clinical paradigm requires an organizational, staffing, and training transformation of our CICUs. We endorse the concept of development of regional cardiac care systems and the centralization of critical and complex cardiac patients into level 1 and level 2 centres staffed with Le May et al. Canadian Cardiac Intensive Care Units 1211 Table 2. Proposed Canadian critical care cardiology training pathways Training pathway Dual certification of cardiology-intensivists RCPSC cardiology certification RCPSC critical care certification Training after cardiology, years Clinical practice certification General intensive care units Cardiac intensive care units Program leadership Y N 1 Y Y RCPSC accredited critical care residency program N Y Nonaccredited collaborative critical care and cardiology program None General intensive care (6) Cardiac surgical intensive care (2) Anaesthesia (1) CICU (1) Medical or surgical (s)electives (1) Research or quality improvement initiatives (1) Endotracheal intubation Basic invasive and noninvasive mechanical ventilator management Fibreoptic bronchoscopy Central venous and arterial placement Pulmonary arterial catheter placement Transvenous pacemaker placement Intra-aortic balloon pump placement Acute cardiac life support certification Cardioversion Vasopressor and inotropic management Echocardiography Pericardiocentesis Thoracentesis and chest tube insertion Paracentesis Procedural sedation Program accreditation Clinical training content, (4-week blocks) RCPSC RCPSC critical care training standards Technical skills Advanced airways management Advanced invasive and noninvasive mechanical ventilator management Fibre optic bronchoscopy Central venous and arterial placement Pulmonary arterial catheter placement Transvenous pacemaker placement Intra-aortic balloon pump placement Acute cardiac life support certification Cardioversion Vasopressor and inotropic management Echocardiography Pericardiocentesis Thoracentesis and chest tube insertion Paracentesis Procedural sedation Intracranial pressure monitoring and management Continuous renal replacement therapy Hemodialysis Extracorporeal membrane oxygenation management Percutaneous and surgical left ventricular assist device management Transesophageal echocardiography Additional potential areas of knowledge CICU intensivist Y Y 2 Advanced airways management Advanced mechanical ventilator management Intracranial pressure monitoring and management Continuous renal replacement therapy Hemodialysis Transesophageal echocardiography CICU, cardiac intensive care unit; N, no; RCPSC, Royal College of Physicians and Surgeons of Canada; Y, yes. cardiologists with appropriate critical care training. Hence, we advocate for the development, implementation, and recognition of formal critical care training pathways for cardiologists. The recommendations outlined in this document will undoubtedly require further engagement of regional, provincial, and national organizations involved in the care of acutely ill cardiac patients. Future engagement of all levels of government will likely be required to evaluate and reorganize the health care delivery that aligns health care resources with patient care needs in contemporary CICUs. The proposals outlined in this document can potentially serve as a framework to meet the needs of our evolving cardiac population. Acknowledgements See the Acknowledgements section of the Supplementary Material. Disclosures The authors have no conflicts of interest to disclose. References 1. Morrow DA, Fang JC, Fintel DJ, et al. Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association. Circulation 2012;126: 1408-28. 2. Katz JN, Turer AT, Becker RC. Cardiology and the critical care crisis: a perspective. J Am Coll Cardiol 2007;49:1279-82. 3. O’Gara PT, Adams JE III, Drazner MH, et al. COCATS 4 Task Force 13: Training in Critical Care Cardiology. J Am Coll Cardiol 2015;65: 1877-86. 4. Canadian Critical Care Society. Guidelines. Available at: http://www. canadiancriticalcare.org/guidelines#. Accessed November 3, 2015. 5. Society of Critical Care Medicine. Guidelines. Available at: http://www. sccm.org/Research/Guidelines/Pages/default.aspx. Accessed November 3, 2015. 6. Society of Critical Care Medicine. Guidelines. http://www.learnicu.org/ Pages/Guidelines.aspx Critical Care Medicine. Accessed November 3, 2015. 1212 7. DiRusso S, Holly C, Kamath R, et al. Preparation and achievement of American College of Surgeons level I trauma verification raises hospital performance and improves patient outcome. J Trauma 2001;51:294-9. 8. Walkey AJ, Wiener RS. Hospital case volume and outcomes among patients hospitalized with severe sepsis. Am J Respir Crit Care Med 2014;189:548-55. 9. Tu JV, Austin PC, Chan BT. Relationship between annual volume of patients treated by admitting physician and mortality after acute myocardial infarction. JAMA 2001;285:3116-22. 10. Ross JS, Normand SL, Wang Y, et al. Hospital volume and 30-day mortality for three common medical conditions. N Engl J Med 2010;362:1110-8. 11. Kahn JM, Goss CH, Heagerty PJ, et al. Hospital volume and the outcomes of mechanical ventilation. N Engl J Med 2006;355:41-50. 12. Hannan EL, Wu C, Walford G, et al. Volume-outcome relationships for percutaneous coronary interventions in the stent era. Circulation 2005;112:1171-9. 13. Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 2011;364: 2128-37. 14. Dimick JB, Upchurch GR Jr. Endovascular technology, hospital volume, and mortality with abdominal aortic aneurysm surgery. J Vasc Surg 2008;47:1150-4. 15. Lin HC, Xirasagar S, Chen CH, Hwang YT. Physician’s case volume of intensive care unit pneumonia admissions and in-hospital mortality. Am J Respir Crit Care Med 2008;177:989-94. 16. Pronovost PJ, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Eff Clin Pract 2001;4:199-206. 17. Penoyer DA. Nurse staffing and patient outcomes in critical care: a concise review. Crit Care Med 2010;38:1521-8. 18. Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care 2007;45:1195-204. 19. MacLaren R, Bond CA, Martin SJ, Fike D. Clinical and economic outcomes of involving pharmacists in the direct care of critically ill patients with infections. Crit Care Med 2008;36:3184-9. 20. Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med 2006;166:955-64. 21. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999;282:267-70. 22. Kollef MH, Shapiro SD, Silver P, et al. A randomized, controlled trial of protocol-directed versus physician-directed weaning from mechanical ventilation. Crit Care Med 1997;25:567-74. Canadian Journal of Cardiology Volume 32 2016 improvement of nutrition therapy: the intensive care unit dietitian can make the difference. Crit Care Med 2012;40:412-9. 26. Davidson JE, Powers K, Hedayat KM, et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005. Crit Care Med 2007;35:605-22. 27. Brilli RJ, Spevetz A, Branson RD, et al. Critical care delivery in the intensive care unit: defining clinical roles and the best practice model. Crit Care Med 2001;29:2007-19. 28. Kahn JM, Linde-Zwirble WT, Wunsch H, et al. Potential value of regionalized intensive care for mechanically ventilated medical patients. Am J Respir Crit Care Med 2008;177:285-91. 29. Nathens AB, Jurkovich GJ, Maier RV, et al. Relationship between trauma center volume and outcomes. JAMA 2001;285:1164-71. 30. Nichol G, Aufderheide TP, Eigel B, et al. Regional systems of care for out-of-hospital cardiac arrest: a policy statement from the American Heart Association. Circulation 2010;121:709-29. 31. Henry TD, Gibson CM, Pinto DS. Moving toward improved care for the patient with ST-elevation myocardial infarction: a mandate for systems of care. Circ Cardiovasc Qual Outcomes 2010;3: 441-3. 32. Kushner FG, Hand M, Smith SC Jr, et al. 2009 Focused Updates: ACC/ AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update): a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. Circulation 2009;120:2271-306. 33. Shahian DM, O’Brien SM, Normand SL, Peterson ED, Edwards FH. Association of hospital coronary artery bypass volume with processes of care, mortality, morbidity, and the Society of Thoracic Surgeons composite quality score. J Thorac Cardiovasc Surg 2010;139:273-82. 34. The Leapfrog group. ICU Physician Staffing. Available at: http://www. leapfroggroup.org/56440/SurveyInfo/leapfrog_safety_practices/icu_physician_ staffing. Accessed May 7, 2014. 35. Pronovost PJ, Angus DC, Dorman T, et al. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 2002;288:2151-62. 36. Multz AS, Chalfin DB, Samson IM, et al. A “closed” medical intensive care unit (MICU) improves resource utilization when compared with an “open” MICU. Am J Respir Crit Care Med 1998;157:1468-73. 37. Carson SS, Stocking C, Podsadecki T, et al. Effects of organizational change in the medical intensive care unit of a teaching hospital: a comparison of ‘open’ and ‘closed’ formats. JAMA 1996;276:322-8. 24. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009;373: 1874-82. 38. Royal College of Physicians and Surgeons of Canada. Information by Discipline. Available at: http://www.royalcollege.ca/rc/faces/oracle/ webcenter/portalapp/pages/ibd.jspx;jsessionid¼lo7akGFJob-1n5NH8iPB qDvhXjlBookKQjep8CYslLdu1nnCJqQC!-398589652?lang¼en&_afrLoop¼ 15145067894894674&_afrWindowMode¼0&_afrWindowId¼null#%40%3F_ afrWindowId%3Dnull%26_afrLoop%3D15145067894894674%26lang%3Den %26_afrWindowMode%3D0%26_adf.ctrl-state%3Dxfsijyqeb_4. Accessed May 7, 2014. 25. Soguel L, Revelly JP, Schaller MD, Longchamp C, Berger MM. Energy deficit and length of hospital stay can be reduced by a two-step quality 39. Reynolds HN, Haupt MT, Thill-Baharozian MC, Carlson RW. Impact of critical care physician staffing on patients with septic shock 23. Ely EW, Bennett PA, Bowton DL, et al. Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Am J Respir Crit Care Med 1999;159:439-46. Le May et al. Canadian Cardiac Intensive Care Units in a university hospital medical intensive care unit. JAMA 1988;260: 3446-50. 40. Dimick JB, Pronovost PJ, Heitmiller RF, Lipsett PA. Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection. Crit Care Med 2001;29: 753-8. 41. Hasin Y, Danchin N, Filippatos GS, et al. Recommendations for the structure, organization, and operation of intensive cardiac care units. Eur Heart J 2005;26:1676-82. 1213 42. University of Alberta. Faculty of Medicine & Dentistry. Division of Critical Care Medicine. Fellowship Training. Available at: http://www.critical. med.ualberta.ca/en/Education/FellowshipTraining.aspx. Accessed May 8, 2014. Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2015.11.021.