faculty neurointensivist. The database was also designed to capture
admitting diagnoses and procedures that were logged. However, all
secondary diagnoses and complications a patient may have were
not captured. This is a major limitation the database, as it does
not capture a vital portion of critical care training: the severity
of illness and multi-organ dysfunction. The database could be
modified in the future to capture higher levels of severity of illness,
but in a busy fellowship, compliance would be difficult.
The questions we hoped to address with this fellowship database
were as follows: to assess the variety of cases and volume of each
diagnosis at our institution; to assess the volume and types of
procedures; and to assess how interval progression audits could
assist when considering the type of rotations in the second year of
fellowship. Our neurocritical care unit had undergone a physical
move during the database collection period to a building separate
from the surgical intensive care where they had previously been
adjacent. This created a decrease in the number of neurotrauma
cases seen, since the ease of communication and care from being
adjacent to the SICU changed, especially as it pertained to the
multisystem trauma patients. As such, after the first year of the
fellowship, the fellowship director and fellow sought an outside
rotation in the UPMC neurotrauma unit. This experience not
only bridged the gap but offered the experience of a different
institution and an NCCU built on a different dogma that proved
to be invaluable. Being able to pick the brain of a different group
of neurointensivists while you are doing your fellowship was an
extremely formative experience.
Neurocritical care remains a relatively new subspecialty, and the
fellowships vary tremendously depending on size of the unit,
unit structure (open versus closed; consultative versus primary
service), relationship with neurological surgery, and neurology
and procedural arrangements. Many things can affect a two-year
fellowship that are out of the fellow’s control, such as an ICU
move that affects protocols (in our case), but others that are
common include change in faculty, changes in community referral
patterns for certain diseases and ICU triage arrangements. As such,
it may be of benefit for programs to not only start a database
but to monitor it regularly to not only ensure case variety and
numbers, but also to monitor the impact on the numbers if there
are changes in an institution, department, division or unit. We
have also shown that if the fellow and fellowship director are open
to establishing additional rotations or outside hospital rotations,
it can be an important educational solution. Maybe a fellow
who is at a major trauma center does not see a lot of tumors or
vascular disease and may want to go to Ohio State University to
experience a high volume of vascular and neuro-oncology and
their complications of rare immunocompromised infections and
complex resuscitation.
This data also raises the question of what is the minimum
standard of cases that a neurocritical care fellow should see.
While we considered our neurotrauma numbers temporarily low,
were they low comparatively to other neurocritical care fellows
experience on average? Such comparative data is not available.
We feel it would be important to establish such standards in
neurocritical care training.
Outside of educational goals, another benefit of a fellowship
database is easing the vetting process by prospective employers
when applying for a job. Even though neurointensive care
is an internationally recognized field, we are still oftentimes
met with misplaced skepticism and criticism by employers
because colleagues and employers do not know our full range
of practice and expertise. By providing cases and procedure logs
to prospective hospitals, employers and colleagues, it may help
establish the important role of neurointensivists and specialized
health care for neurocritically ill patients. The database made the
credentialing of procedural privileges process extremely easy.
In our experience, the importance of an ongoing database in
neurocritical care training served as a tool to supplement a fellow’s
education and understand the impact of unit changes that can
affect diagnosis numbers and
eased the process of applying for
procedural and critical care privileges
as a new attending physician. We
hope to start a conversation among
fellowship directors about the ideal
number of cases and procedures
each fellow should have upon
completion of training. We also
hope to encourage more fellows to
collect data and share their numbers
to further understand neurocritical
care education across different
institutions and consider doing
outside rotations to gain a different
perspective while in training from
other neurointensivists.
References
1. https://www.ucns.org/globals/axon/assets/3675.pdf
2. ACGME Neurological Surgery Critical Care Milestones.
http://www.acgme.org/Specialties/Milestones/pfcatid/10/
Neurological%20Surgery
3. ACGME General Surgery Critical Care Milestones.
https://www.acgme.org/Portals/0/UPDATED_DEFINED_
CATEGORY_MINIMUM_NUMBERS_EFFECTIVE_
ACADEMIC_YEAR_2017-2018_GENERAL_SURGERY.pdf
4. https://www.acgme.org/Portals/0/PDFs/Milestones/
CriticalCareAnesthesiologyMilestones.pdf
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/CriticalCareAnesthesiologyMilestones.pdf
