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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
• 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
