Competencies Required by Anesthesiologists Managing Critically Ill Patients
Condition: Training; Education; Competence
MeSH terms: Critical Illness
Study type: Observational

Summary: 
      Critical Care Medicine (CCM) has emerged as an independent specialty over the last few
      decades. Anesthesiologists being perioperative physicians, often practice CCM full time or
      part-time. 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 Intensive care unit (ICU). This is often compounded by considerable variation in the
      training curriculum of the Anesthesiologists based on the geographical region and base
      specialty. The Intensive & Critical Care Medicine Committee of the World Federation of
      Societies of Anesthesiologists (WFSA), has developed a preliminary survey of recently
      qualified Anesthesiologists, to review the existing competencies for CCM in the
      Anesthesiology curriculum across the globe. The results of this survey will be used to
      identify the gaps and additional competencies required for Anesthesiologists to practice
      Critical Care in ICU through expert consensus, using a Delphi process.
    

Detailed description: 
      BACKGROUND:

      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. The coronavirus disease 2019 (COVID-19) pandemic has
      brought unprecedented challenges to the health care system. Anesthesiologists working in the
      operating room (OR) and those working in the 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 a formal
      curriculum for training in CCM. 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. 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, experts have noted
      deficiencies in the Anesthesiology training in certain competencies required for the
      management of critically ill medical and surgical patients in the ICU. 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 their ability to manage critically ill
      patients in ICU in different World Health Organization defined healthcare facilities levels.
      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. The investigators plan to review the existing competencies for CCM in the
      Anesthesiology curriculum across the globe through a preliminary survey. Thereafter, the
      investigators 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. The investigators aim to review/identify the existing competencies for CCM in the
           Anesthesiology curriculum across the globe.

        2. The investigators aim to generate expert consensus on the additional competencies
           (mandatory desirable and optional) required for Anesthesiologists to practice Critical
           Care in the 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).

      Preliminary survey:

      The Steering Committee will develop a preliminary survey to assess the knowledge and skills
      of Anesthesiologists across the globe following Anesthesiology training, which 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. The preliminary survey will be sent to
      approximately 500 Anesthesiologists across the globe by the Experts. The competencies of
      participants 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 training characteristics. The results of
      the survey will be used to draft competencies for inclusion in Round one of the Delphi.

      Delphi process:

      The Delphi process is a well-established methodology to generate consensus on a particular
      topic using the "collective intelligence" of panel members. 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 participating 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 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 more than 20% of participating experts considered them
      "mandatory". 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.
    

Intervention name(s): Global Experts Consensus opinion using Delphi Methodology
Intervention type(s): Behavioral
Intervention description(s): The Investigators will conduct iterative Delphi Rounds with Global experts to achieve consensus on Competencies required for Anesthesiologists to manage critically ill medical and surgical patients in ICU
Observational model: Cohort
Time perspective: Cross-Sectional
Sampling method: Non-Probability Sample
Study population: 
        Preliminary survey: A cross-sectional will be circulated through snowball sampling
        technique among Anesthesiologists worldwide.

        Delphi Process:

        Global Experts in Anesthesiology and Critical Care Medicine.
      
Keywords: Training of Anesthesiologists; Training in Intensive care medicine; Anesthesiologists intensivist; Curriculum of training for Anesthesiologists