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Consensus Statement by the Congenital Cardiac Anesthesia Society: Milestones for the Pediatric Cardiac Anesthesia Fellowship

Nasr, Viviane G. MD*; Guzzetta, Nina A. MD, FAAP; Miller-Hance, Wanda C. MD; Twite, Mark MD§; Latham, Gregory J. MD; Zabala, Luis MD; Nicolson, Susan C. MD#; Mossad, Emad B. MD; DiNardo, James A. MD, FAAP*

doi: 10.1213/ANE.0000000000002482
Pediatric Anesthesiology: Special Article

Pediatric cardiac anesthesiology has evolved as a subspecialty of both pediatric and cardiac anesthesiology and is devoted to caring for individuals with congenital heart disease ranging in age from neonates to adults. Training in pediatric cardiac anesthesia is a second-year fellowship with variability in both training duration and content and is not accredited by the Accreditation Council on Graduate Medical Education. Consequently, in this article and based on the Accreditation Council on Graduate Medical Education Milestones Model, an expert panel of the Congenital Cardiac Anesthesia Society, a section of the Society of Pediatric Anesthesiology, defines 18 milestones as competency-based developmental outcomes for training in the pediatric cardiac anesthesia fellowship.

Published ahead of print September 14, 2017.

From the *Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts; Department of Anesthesiology, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia; Division of Cardiovascular Anesthesia, Department of Anesthesiology, Texas Children’s Hospital, Houston, Texas; §Division of Cardiovascular Anesthesia, Department of Anesthesiology, Children’s Hospital Colorado, Aurora, Colorado; Department of Anesthesiology, Seattle Children’s Hospital, University of Washington, Seattle, Washington; Division of Cardiac Anesthesia, Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Dallas, Texas; and #Division of Cardiothoracic Anesthesia, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania.

Published ahead of print September 14, 2017.

Accepted for publication August 14, 2017.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Viviane G. Nasr, MD, 300 Longwood Ave, Boston Children’s Hospital, Boston, MA 02115. Address e-mail to viviane.nasr@childrens.harvard.edu.

Pediatric cardiac anesthesiology has evolved as a subspecialty of both pediatric and cardiac anesthesiology and is devoted to caring for individuals with congenital heart disease (CHD) ranging in age from neonates to adults. Second-year fellowships are offered in pediatric cardiac anesthesia after completion of a pediatric anesthesia fellowship or an adult cardiothoracic anesthesia fellowship.1 Currently, 17 programs offer 24 positions for subspecialty training in the United States. At present, there is no accreditation process by the Accreditation Council on Graduate Medical Education (ACGME) for pediatric cardiac anesthesia fellowships.2 While the structure and educational content of pediatric cardiac anesthesia fellowships have been generally defined, there currently exists substantial variability in both the training duration and the clinical and didactic content of existing programs.3 Consequently, the leadership of the Congenital Cardiac Anesthesia Society, a section of the Society of Pediatric Anesthesiology, felt it necessary to better define competency-based developmental outcomes (eg, knowledge, skills, attitudes, and performance) for training in the subspecialty. An expert panel was convened to utilize the ACGME Milestones Model as is currently applied to anesthesia residency programs, pediatric anesthesia fellowship programs, and adult cardiothoracic anesthesia programs to develop specific milestones for pediatric cardiac anesthesia fellowship training.4–6

The purpose of the fellowship year of training is to train proficient consultants in anesthesia for congenital and pediatric acquired heart disease. The goal is that this training is achieved through clinical competency and education with progress measured through the developmental milestones defined below. During the 12-month fellowship, trainees are also expected to develop consultant-level knowledge of relevant areas such as perioperative cardiac intensive care and the management of children and adults with CHD having noncardiac surgery and other procedures.

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EXPERIENCE/CLINICAL EXPOSURE

The primary purpose of the fellowship year program is to train anesthesiologists to be expert in the perioperative care of patients with both simple and complex forms of congenital and pediatric-acquired cardiac disease. At the completion of the program, fellows are expected to have both sufficient knowledge of congenital cardiac pathophysiology and the applicable surgical and catheter-based interventions and the technical expertise necessary to direct the perioperative management of neonates, infants, children, and adults with congenital and pediatric-acquired heart disease undergoing cardiac and noncardiac surgery. The fellowship graduate must be able to expertly deliver anesthetic care for cardiopulmonary bypass (CPB), deep hypothermic circulatory arrest and antegrade cerebral perfusion, hemodynamic and interventional cardiac catheterization procedures, intrathoracic procedures, other cardiac procedures such as electrophysiologic studies, radiofrequency ablation, transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), magnetic resonance imaging, and computerized tomography and noncardiac procedures for patients with CHD.

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DIDACTIC COMPONENT

A suggested comprehensive formal didactic program would include weekly lectures on pertinent topics in pediatric cardiology, cardiac surgery, and anesthesia (eg, CPB, coagulation, myocardial preservation, cerebral protection, specific congenital cardiac lesions in children and adults), a cardiac anesthesia journal club, and a mortality and morbidity conference where interesting and complicated cases are discussed. In addition, exposure to and participation in research projects should be encouraged. Trainees should be encouraged to attend multidisciplinary, combined cardiac surgery/cardiology/cardiac anesthesia/cardiac critical care conferences and meetings where complex cases are discussed. Daily informal 1-on-1 teaching is also an important component of the educational program. Fellows are expected to fully evaluate and discuss their cases preoperatively with the responsible staff member. Intraoperative teaching (case-based and on more general didactic topics) is also emphasized and is a daily part of the fellow’s education.

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SUGGESTED MILESTONES FOR THE PEDIATRIC CARDIAC ANESTHESIA FELLOWSHIP

The intent is that the presented milestones will define the educational goals of the trainees and will be used to facilitate delivery of feedback with the goal of improving performance over time. Programs will utilize these milestones to formulate a structured curriculum framework that facilitates growth of well-defined, competency-based skills for individual fellows over 12 months of training.

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Suggested Milestones

Currently, the pediatric anesthesia fellowship includes 14 milestones and the adult cardiothoracic anesthesia fellowship includes 15 milestones. These are summarized in Table 1. The suggested milestones for the pediatric cardiac anesthesia fellowship would include 18 milestones based on the ACGME six core competencies as listed in Table 2.

Table 1

Table 1

Each of the milestones for the pediatric cardiac anesthesia fellowship listed in Table 2 is assessed based on the ACGME definition of levels 1 (basic) through 5 (independent). The ACGME defines the levels as: “Level 1, the fellow demonstrates milestones expected of an incoming fellow; Level 2, the fellow is advancing and demonstrates additional milestones but is not yet performing at a mid-fellowship level; Level 3, the fellow continues to advance and demonstrate additional milestones, consistently including the majority of milestones targeted for fellowship; Level 4, the fellow has advanced such that he or she now demonstrates mastery of the milestones targeted for fellowship; this level is designed as the graduation target. Level 5, the fellow has advanced beyond performance targets set for fellowship and is demonstrating ‘aspirational’ goals which might describe the performance of someone who has been in practice for several years.”

Table 2

Table 2

Patient Care—Perioperative Assessment, Planning, and Management

Patient Care—Perioperative Assessment, Planning, and Management

Patient Care—Technical/Procedural Skills

Patient Care—Technical/Procedural Skills

Patient Care—Understanding Cardiovascular Surgical Procedures

Patient Care—Understanding Cardiovascular Surgical Procedures

Patient Care—Understanding Catheter-Based Cardiac Therapeutic Procedures and Electrophysiologic Studies

Patient Care—Understanding Catheter-Based Cardiac Therapeutic Procedures and Electrophysiologic Studies

Medical Knowledge—Congenital and Acquired Cardiovascular Anatomy, Physiology, and Pathophysiology

Medical Knowledge—Congenital and Acquired Cardiovascular Anatomy, Physiology, and Pathophysiology

Medical Knowledge—Pharmacology

Medical Knowledge—Pharmacology

Medical Knowledge—CPB, Extracorporeal Circulation, and Circulatory Assist Device Principles

Medical Knowledge—CPB, Extracorporeal Circulation, and Circulatory Assist Device Principles

Medical Knowledge—Understanding Cardiac Diagnostic Procedures (eg, Echocardiography, Magnetic Resonance, Catheterization, Computerized Tomography)

Medical Knowledge—Understanding Cardiac Diagnostic Procedures (eg, Echocardiography, Magnetic Resonance, Catheterization, Computerized Tomography)

System-Based Practice—Coordination of Care

System-Based Practice—Coordination of Care

System-Based Practice—Incorporation of Patient Safety and Quality Improvement Into Clinical Practice

System-Based Practice—Incorporation of Patient Safety and Quality Improvement Into Clinical Practice

System-Based Practice—Understanding of Health Care Economics: Cost Awareness and Cost-Benefit Analysis

System-Based Practice—Understanding of Health Care Economics: Cost Awareness and Cost-Benefit Analysis

Practice-Based Learning and Improvement: Self-Directed Learning and Scholarly Activity

Practice-Based Learning and Improvement: Self-Directed Learning and Scholarly Activity

Practice-Based Learning and Improvement: Education of Team Members and Other Health Care Providers

Practice-Based Learning and Improvement: Education of Team Members and Other Health Care Providers

Professionalism—Commitment to Institution, Department, and Colleagues

Professionalism—Commitment to Institution, Department, and Colleagues

Professionalism—Receiving and Giving Feedback

Professionalism—Receiving and Giving Feedback

Professionalism—Responsibility to Maintain Personal, Emotional, Physical, and Mental Health

Professionalism—Responsibility to Maintain Personal, Emotional, Physical, and Mental Health

Interpersonal and Communication Skills: Communication With Patients and Families

Interpersonal and Communication Skills: Communication With Patients and Families

Interpersonal and Communication Skills—Interprofessional Communication and Transitions of Care

Interpersonal and Communication Skills—Interprofessional Communication and Transitions of Care

Milestones for the pediatric cardiac anesthesia fellowship with examples illustrating level 4 competency are described.

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CONCLUSIONS

This article written by an expert panel of the Congenital Cardiac Anesthesia Society/Society of Pediatric Anesthesiology presents a template for pediatric cardiac anesthesia training programs in the United States with the intent of defining educational and performance-based criteria for graduation. It will provide programs the opportunity to develop a curriculum with competency-based milestones. International programs may also consider this template and modify it to fit their own requirements.

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DISCLOSURES

Name: Viviane G. Nasr, MD.

Contribution: This author designed the milestones, wrote and revised the manuscript, and approved the final version.

Name: Nina A. Guzzetta, MD, FAAP.

Contribution: This author helped design the milestones, review the manuscript, and approve the final version.

Name: Wanda C. Miller-Hance, MD.

Contribution: This author helped design the milestones, review the manuscript, and approve the final version.

Name: Mark Twite, MD.

Contribution: This author helped design the milestones, review the manuscript, and approve the final version.

Name: Gregory J. Latham, MD.

Contribution: This author helped design the milestones, review the manuscript, and approve the final version.

Name: Luis Zabala, MD.

Contribution: This author helped design the milestones, review the manuscript, and approve the final version.

Name: Susan C. Nicolson, MD.

Contribution: This author helped design the milestones, review the manuscript, and approve the final version.

Name: Emad B. Mossad, MD.

Contribution: This author helped design the milestones, review the manuscript, and approve the final version.

Name: James A. DiNardo, MD, FAAP.

Contribution: This author designed the milestones, wrote and revised the manuscript, and approved the final version.

This manuscript was handled by: Edward C. Nemergut, MD.

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REFERENCES

1. Andropoulos DB, Walker SG, Kurth CD, Clark RM, Henry DB. Advanced second year fellowship training in pediatric anesthesiology in the United States. Anesth Analg. 2014;118:800–808.
2. Andropoulos DB. Training residents and fellows in paediatric cardiac anaesthesia. Cardiol Young. 2016;26:1525–1530.
3. DiNardo JA, Andropoulos DB, Baum VC. Special article: a proposal for training in pediatric cardiac anesthesia. Anesth Analg. 2010;110:1121–1125.
4. Culley D, Cohen N, Hall S, et al. The Anesthesiology Milestone Project. July 2015. Available at: http://www.acgme.org/Portals/0/PDFs/Milestones/AnesthesiologyMilestones.pdf?ver=2015-11-06-120534-217. Accessed on July 6, 2017.
5. Mason L, Cohen IT, Davis P, et al. The Pediatric Anesthesiology Milestone Project. July 2015. Available at: http://www.acgme.org/Portals/0/PDFs/Milestones/PediatricAnesthesiology.pdf?ver=2015-11-06-120524-183. Accessed on July 6, 2017.
6. Ramsay J, Edgar L, Sullivan AG, et al. The Adult Cardiothoracic Anesthesiology Milestone Project. July 2015. Available at: http://www.acgme.org/Portals/0/PDFs/Milestones/AdultCardiothoracicAnesthesiologyMilestones.pdf?ver=2015-11-06-120534-430. Accessed on July 6, 2017.
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