Competencies Required by Anesthesiologists Managing Critically Ill Medical and Surgical Patients in an Intensive Care Unit
Conditions: Training, Education, Competence
Sponsor: Prashant Nasa

 
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RESEARCH PROTOCOL 
 
STUDY TITLE   
 
COMPETENCIES 
REQUIRED 
BY 
ANESTHESIOLOGISTS 
MANAGING 
CRITICALLY ILL MEDICAL AND SURGICAL PATIENTS IN AN INTENSIVE 
CARE UNIT: EXPERT CONSENSUS USING A DELPHI METHOD 
 
INVESTIGATORS  
 
Dr. Sheila Nainan Myatra (Principal Investigator) 
Dr. Prashant Nasa 
Dr. Ravi Jain  
Dr. Carolina Haylock- Loor  
Dr. Michael Lipnick 
Dr. Adrian Gelb 
 
DOCUMENT DATED 09 August 2021 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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BACKGROUND 
 
Critical Care Medicine (CCM) has emerged as an independent specialty over the last few 
decades. Anesthesiologists being perioperative physicians are an integral part of this 
progress, with many of them opting for CCM as a full-time career. [1] The coronavirus 
disease 2019 (COVID-19) pandemic has brought unprecedented challenges in the health 
care system. Anesthesiologists working in the operating room (OR) and those working in 
the Intensive Care Unit (ICU) have been the frontline workers along with other Critical 
Care professionals in the management of critically ill patients with COVID-19.  
 
Though a few countries have recognized CCM as a separate specialty of medicine, in 
most countries, it is considered as a sub-specialty of broad specialties like 
Anesthesiology, Pulmonary Medicine or Internal Medicine. Some professional bodies 
have developed formal curriculum for training in CCM. [2, 3] The Competency-Based 
Training programme in Intensive Care Medicine (CoBaTrICE) from the European 
Society of Intensive Care Medicine (ESICM) is a widely accepted formal structured 
training curriculum in CCM. [3] Most curricula are designed only for high-income, well-
resourced training and practice environments and do not account for additional skills and 
competencies that may be required to practice in resource variable settings, something the 
COVID-19 pandemic has demonstrated needs to be universal. 
. 
The transition of Anesthesiologists working in OR, or managing critically ill surgical/ 
polytrauma patients, into working in ICU has largely been smooth. Nevertheless, 
deficiencies have been noted by experts in the Anesthesiology training in certain 
competencies required for the management of critically ill medical and surgical patients 
in the ICU. [4, 5] This is often compounded by considerable variation in the training 
curriculum of the Anesthesiologists based on the geographical region and type of 
institution. 
 
There is a need to identify these competencies, so that Anesthesiologists who wish to 
practice full time or part time Critical Care, can acquire these competencies to improve 

 
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their ability to manage critically ill patients in ICU, in different WHO defined healthcare 
facilities levels. [6] This may also help provide guidance to educators worldwide 
regarding the competencies to be included in Anesthesiology training that may help 
Anesthesiologists work better with critically ill patients in ICU. These competencies have 
never been formally identified or published. We plan to review the existing competencies 
for CCM in the Anesthesiology curriculum across the globe through a preliminary 
survey. Thereafter, we plan to identify the additional competencies required through 
consensus among Experts, using a Delphi method. These additional competencies, 
classified as mandatory, desirable, and optional may serve as a guide for 
Anesthesiologists to practice Critical Care in ICU in different levels of health care 
facilities worldwide.  
 
 
 
OBJECTIVES 
 
1. To review / identify the existing competencies for CCM in the Anesthesiology 
curriculum across the globe. 
2. To generate expert consensus on the additional competencies (mandatory desirable 
and optional) required for Anesthesiologists to practice Critical Care in ICU. 
3. Provide guidance to educators worldwide regarding the competencies to be  included 
in the Anesthesiology curriculum that may help Anesthesiologists work better with 
critically ill patients in ICU. 
 
METHODOLOGY  
 
Steering Committee 
 
A Steering Committee comprising of Anesthesiologists with experience in CCM will be 
formed under the auspices of the Intensive and Critical Care Medicine Committee 
(ICCCM) of the World Federation of Societies of Anaesthesiologists (WFSA). 

 
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Selection of Experts  
 
The Steering Committee will select global experts to participate in a Delphi process.  
The selection criteria will include 1. Anesthesiologist (a medical graduate who has 
completed a nationally recognized Anesthesiology training programme) 2. Involved in 
the management of critically ill patients in ICU 3. More than ten years of experience in 
teaching and training in Critical Care. We aim for a total sample size of 30 experts for the 
Delphi rounds. Invitations to various global experts will be sent by email along with the 
study details and objectives of the Delphi process. 
 
 
 
 
Preliminary survey 
The Steering Committee will develop a preliminary survey to assess the knowledge and 
skills acquired by Anesthesiologists across the globe following Anesthesiology training, 
that is required to achieve the various Critical Care competencies. A literature review on 
the existing Critical Care competencies from various professional bodies will be 
conducted to develop a list of Critical Care competencies, using CoBaTrICE as a base.  
Anesthesiologists who have completed their training within the last three years will be 
surveyed. The preliminary survey will be sent to approximately 500 Anesthesiologists 
across the globe by the Experts. Their competencies in CCM will be assessed under six 
domains in the survey. (Disease diagnosis and management, Procedures, Monitoring and 
therapeutic interventions, Resuscitation, Communication and End-of-life care, Patient 
safety and Crisis Resource Management) using a 5-point Likert scale (never seen, have 
observed, can manage under supervision, can manage with minimal assistance, and can 
manage independently). The first section of this survey will include the participant 
demographics, country of origin and training, year of completing training, and a few 

 
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training characteristics. The results of the survey will be used to draft competencies for 
inclusion in Round one of the Delphi. 
The Delphi process 
The Delphi process is a well-established methodology to generate consensus on a 
particular topic using the “collective intelligence” of panel members. [7-9] The steering 
committee members will perform a literature search on the available evidence, draft the 
initial statements and conduct iterative Delphi rounds to generate consensus among the 
experts. The Steering Committee members will not participate in the Delphi surveys 
themselves. 
 
 
Steps of the Delphi process 
Step 1: Establishing a preliminary list of competencies 
A literature review on the existing Critical Care competencies from various professional 
bodies will be conducted to develop a list of Critical Care competencies, using 
CoBaTrICE as a base and categorized under the six core domains (disease diagnosis and 
management, procedures, monitoring and therapeutic interventions, resuscitation, 
communication and end-of-life care, patient safety and crisis resource management). The 
results of the preliminary survey will be used to draft statements for Round one of 
Delphi. 
Step 2: Preparation of the Delphi Round one survey 
The list of the competencies will be sent to the Experts as a Delphi questionnaire. The 
anonymity of the experts will be maintained during the Delphi rounds. The participant 
will be asked to score each of the competencies listed on a 5-point Likert scale (non-
essential, optional, optional but desirable, desirable, and mandatory). The participating 

 
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expert will be invited to provide feedback regarding omission, addition, or modification 
of the items on the questionnaire. The response and feedback of experts will be collated 
during the analysis of results and shared in the following survey as controlled feedback.  
 
Step 3: Subsequent Delphi Rounds 
The steering committee will review the results of round one. The competencies listed will 
be modified, deleted, or added if found ambiguous based on the feedback and comments 
of the results. Competencies deemed “non-essential” by more than 50% of the 
respondents will be eliminated. The remaining competencies will be continued in the 
subsequent rounds until consensus is achieved (>80% of respondents). Lower-rated items 
identified for removal may be retained in the second round if they are considered 
“mandatory” by more than 20% respondents. The summary results of Round two will be 
presented to Experts, and the survey process will be repeated with the modified 
questionnaire. The Delphi rounds will be continued till desired consensus and stability is 
achieved for competencies.  
Step 4: Final Consensus on Competencies to be included 
The summary results of the last stable round will be used to issue the consensus on the 
additional competencies to be included. These competencies will also be classified as 
those mandatory, desirable, and optional, which may serve as a guide to decide which 
competencies are required for working in different levels of health care facilities 
worldwide. The results of the final survey, consensus competencies, and the manuscript 
will be circulated among the experts for approval before submission for publication. 
 
 
Statistical analysis  
 
A descriptive analysis of the preliminary survey will be performed. For the Delphi 
process, stability will be checked by non-parametric chi-square (χ2) tests from round two 
onwards. 
A 
p-value 
<0.05 
is 
considered 
as 
a 
significant 
variation 
or 

 
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unstable. Consensus will be considered as the competency that achieved >80% votes. A 
competency will be continued in the questionnaire round until the stability of the 
responses is achieved. Consensus competencies will be considered as those that generate 
both consensus and stability. 
 
 
 
PROPOSED TIMELINE 
 
Preliminary survey  
30th September 2021 
Preliminary survey development, dissemination, and analysis  
 
Development and dissemination of the Round one Delphi survey 
31st October 2021 
 
Subsequent Delphi rounds 
November-December 2021  
 
Analysis of Delphi survey results and preparation of the list of competencies  
31st January 2022 
 
Manuscript writing and submission for publication  
30th April 2022 
 
 
 
 
 
 
 

 
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