ACCA Business Plan FY12-13

Acute Cardiovascular Care AssociationCore Curriculumand advanced training in cardiology to the level required for certification as acardiologist at a National level. The acute cardiac care cardiologist will be able torecognise and treat a wide variety of acute, as well as chronic cardiovascularconditions leading to acute cardiological deterioration, and be well acquaintedwith the range of diagnostic and therapeutic tools available to the moderncardiologist. In addition, such a physician should be able to investigate andmanage resulting organ system dysfunction, and be competent the operation ofavailable equipment including monitoring (invasive and non-invasive), cardiacpacemakers, defibrillators, ventilators (invasive and non-invasive), renalreplacement therapy and mechanical circulatory support. A comprehensiveknowledge of interventions to treat cardiac pathology and also associated noncardiac conditions such as liver, gastrointestinal, neurological and renaldysfunction is mandatory, in addition to knowledge regarding the management ofinfection, nutrition, sedation, and analgesia.Although the natural evolution of the specialty of cardiology has increasinglyrequired team-working between cardiologists with different profiles and betweenrelated specialties, the nature of acute cardiac care has always demandedeffective multi-professional and multidisciplinary team-working. ofessionalteam-workingisimperative in order to optimise the delivery of patient-centred care to thecritically ill, including end-of-life decision making, potentially in high-stress andtime-pressured environments and frequently involving relatives and surrogatedecision-makers. The acute cardiac care cardiologist must know the strengthsand limitations of every investigation and intervention, including the addedcomplexity of the acutely unwell/critically ill patient, where frequently theevidence-base is less solid than in other areas of cardiology, the risks of patienttransportation potentially significant, and the costs of patient care substantiallyhigher. In the acute/critical setting, involvement of patients and their relatives indecision-making is challenging, and skilful communication (respecting theirethical, cultural and religious background) is vital to communicate effectively andallow informed decision-making about treatment options.Good clinical governance is central to the practice of modern medicine. The acutecardiac care cardiologist must treat patient data with confidentiality, inaccordance with personal eta protection legislation in the European Union. Theprocess of continuing medical education with lifelong learning, demonstratingacquisition of knowledge and performance of current best clinical practice isimperative, demonstrating compliance with national and local appraisal andrevalidation processes where present. Further, implementation of strategies andstructures proposed to minimise risk and maximise patent safety must be7

Acute Cardiovascular Care AssociationCore Curriculumintegral, encompassing the ethical principles of autonomy, beneficence, nonmaleficence and distributive justice.Assessment of competence is not included in this document. As in generalcardiology, this does not obviate the need for regular structured and formallydocumented assessment throughout the training programme. This should includeassessments of knowledge (formative and summative), formally observedprocedures and practices, completion of logbooks, acquisition of multi-sourcefeedback and where available and appropriate, the use of simulators (applicableto both training and assessment).The training should continue with the ethos of lifelong learning, enabling theacute cardiac care cardiologist to improve their knowledge of and experience inthe practice of the subspecialty, to adapt to technological innovations, to providethe educational and experiential preparation necessary to underpin ongoingprogression, and to respond to changing societal expectations. Depending uponthe centre in which the acute cardiac care cardiologist eventually practices,trainees may wish/need to undertake additional training in the supra-specialistareas of acute cardiac care, including extracorporeal support, congenital heartdisease in the critically ill, intensive care echocardiography, either as anadditional fellowship or as CME in their subsequent consultant career. Throughoutthe training programme and throughout their career, the acute cardiac carecardiologist should apply the best available evidence to deliver optimal patientcentred care.1.2 General aspects of training in the sub-specialtyThis curriculum is relevant to board-certified or country-recognised cardiologistswho wish to be certified in acute cardiac care. A comprehensive cardiologicalbackground is necessary not only to master the technical aspects of thecardiological techniques, but also to recognise the indications, and thecontraindications of different cardiological interventions for patients in need ofintensive acute cardiac care and/or general intensive care who havecardiovascular complications/co-morbidities. The cardiologist will additionallyneed to have had training and experience in the field of general internal andintensive care medicine. They must have the necessary linguistic ability tocommunicate with patients and colleagues in the country of training and later inthe country of practice. Training should be undertaken in recognisednational/international training centres and under the supervision of appropriatelyqualified supervisors (see below).8

Acute Cardiovascular Care AssociationCore CurriculumLearning outcomes should be clearly defined, and are preferred torecommendations based solely on the amount of time spent in a particulardepartment and/or on the number of procedures performed. However, in order toprovide guidance for training in this relatively new subspecialty,recommendations for minimal duration of training is outlined. Learning outcomesshould include knowledge, and specific and generic skills includingcommunication and appropriate behaviours and attitudes that will be furtherreinforced during ongoing training.Many of the skills outlined in this Curriculum are supplementary to thoseexpected from general cardiologists and general intensivists not workingregularly in a CCU/ICCU. In order to gain sufficient experience, followingcompleting cardiology training and certifying as a cardiologist, the potential acutecardiac care cardiologist will be required to work full time in a Cardiac IntensiveCare Unit for a total of at least 12 months (1), with additional on-call/nighttime/weekend duties for the equivalent of at least 1 night per week for at leastthree years. To achieve these goals, the cardiologist must additionally undertakethe following periods of full-time training (minimum): anaesthesia (2)1 month,pulmonology/respiratory medicine 1 month, nephrology 1 month, and generalintensive care 3 months. A minimum of a total of 6 months ICCU during generalcardiology training, 6 months training as junior attending physician (postresidency) and 6 months in the other listed specialties should have beenundertaken. This gives a total of at least 21 months of intensive care trainingover their whole training period (at least 3 months general intensive care, 6months cardiac intensive care as part of general cardiology training plus 12months as part of sub specialist training).The duration of anaesthesia training will be similarly supplemented by havingundertaken anaesthesia as part of general cardiology training/more juniortraining, with a recommended minimum total of 6 months dedicatedanaesthesia/airway training in total.The trainee will assume appropriate responsibility in obtaining the theoreticalknowledge outlined in the curriculum. To do this, they are advised to use the ESCTextbook of Intensive and Acute Cardiac Care, current ESC guidelines, the ESCeLprogramme, and other teaching materials from the different and relevantAssociations and Working Groups of the ESC. Reference to training materialsfrom the ESICM and/or national intensive care and cardiological societies will alsobe useful.Footnotes:(1) Or part time equivalent(2) Should be more than a month in particular if none has previously been undertaken9

Acute Cardiovascular Care AssociationCore CurriculumThe acute cardiac care cardiologist will be required to engage in continuous,independent self-directed learning and self-assessment.They should also be involved in the management of an appropriate case mix andnumber of patients. The following considerations apply: Participation in the clinical management of inpatients including the CICU andICU including supervised ward rounds and consultation regarding acutecardiac referrals should constitute a substantial part of the trainingprogramme Supervised involvement in the management of new admissions/referralsshould be undertaken at least weekly throughout the programme At least 2h/day in structured learning under direct supervision of a clinicalsupervisor which may include:- explicit learning: journal clubs, methodology of research and statistics,postgraduate teaching, training in communication skills, exercises inevidence-based medicine, discussion of guidelines for clinical practice,lectures/tutorials/seminars, simulation-based learning, web-based learning,courses, annual meetings of scientific societies- implicit learning: ward rounds, case-based discussions, supervisedacquisition of diagnostic, investigational and therapeutic skills Basic, clinical and/or translational research in cardiovascular medicine is aninherent part of training in acute cardiac care. Trainees should be stimulatedto participate in basic or clinical research and develop a critical and researchorientated approach to clinical practice. If research is performed on a full-timebasis such that impacts to prevent sufficient progression of clinical training,adaption of the training time should be considered The training programme should be clearly defined for each individual,incorporate a periodic review of their progress and a formalreview/assessment at least annually.In order to ascertain that the trainee has fulfilled the above requirements theywill be assessed by an examination, and presentation of a log-book.Candidates may wish to undertake an additional year of training, with the aim ofextending their skills in more specialised techniques, and/or obtaining advancedtraining in intensive care medicine. This may be undertaken through the relevantnational or international training bodies. Further, acute cardiac care cardiologistsmay wish to proceed to work in centres with GUCH and/or complex cardiacsurgery including extracorporeal support and transplantation, in which caseadditional specific training will be required.10

Acute Cardiovascular Care AssociationCore Curriculum1.3 Requirements for training institutions and trainers1.3.1 Requirements for training institutions Training institutions should be recognised by a National Training Authority asbeing complement to provide a complete training programme, either in thesame centre or in collaboration with others. The ideal solution is for a training programme to be situated within acomprehensive cardiothoracic centre, where all aspects of cardiovasculardisease are managed, and covering the full curriculum. However, it isrecognised that not every aspect of training is likely to be widely available atsingle sites; here, rotation through different institutions or sessional attendancein centres providing sub-specialties or technologies that are not widely availablemay need to be incorporated into the programme. In each centre, the traineewill be required to have a nominated supervisor (cardiologist), in addition totrainers/supervisors in the non-cardiological subspecialties where relevant. Training institutions should have a library and internet facilities, offering accessto the current scientific literature, specifically major international journalsrelating to cardiology and intensive care medicine, and should provide thenecessary infrastructure for education, including conference rooms andallocated office space for trainees. The training institution alone (or as part of a structured and organisedcollaboration) should have the necessary facilities to ensure that trainees canfulfil all aspects of the Acute Cardiac Care Curriculum with a sufficient numberof patients and procedures for developing the required skills. The trainee should be provided with the opportunity to participate in basicscientific or clinical research.1.3.2 Requirements for trainersTrainers should be recognised by the National Training Authorities andsupervision of training should be available at all times. There should be anadequate number of expert cardiologists and intensivists in the traininginstitution to ensure training in all areas included in the Acute Cardiac CareCurriculum. Delivery of the curriculum may be facilitated by a structure thatincludes a Director of Training (National/Regional/Local), an educationalsupervisor (or training mentor) and multiple clinical supervisors (or clinicaltrainers). The educational supervisor (or equivalent) should be responsible fororganising the training programme in acute cardiac care, co-ordinating external11

Acute Cardiovascular Care AssociationCore Curriculumrotations to other centres, attendance at courses and congresses, an organisingstructured learning. It is necessary that both trainee and educational supervisorsare subject to periodic assessment.1.4 Learning outcomesThese are specific statements of intent which express what the learner will beable to do at the end of the educational intervention. They are framed in terms ofthe trainees’ capabilities in specific tasks. Objectives are classified under theheadings of knowledge, skills and behaviours and attitudes. Each objectivedefines what is to be achieved. Knowledge: The knowledge-base trainees require. The subject matter isdefined by the ESC Acute Cardiac Care Curriculum chapters. This knowledgeincludes mechanisms of diseases as the rational basis for long-term learning. Skills: The effective application of knowledge to problem-solving, clinicaldecision-making and performing procedures, acquired from experience andtraining. Behaviours and attitudes: The attitudes that underlie best behaviour inclinical practice that trainees need to develop and demonstrateCategories and levels of competenceThis section of the curriculum describes the different levels of competenceexpected for skills related to investigations and procedures. These are defined asfollows: Level I: experience of selecting the appropriate diagnostic or therapeuticmodality and interpreting results or choosing an appropriate treatment. Thislevel of competency does not include performing a technique, but participationin procedures during training may be valuable; Level II: goes beyond Level I. In addition to Level I requirements, the traineeshould acquire practical experience but not as an independent operator. Theyshould have assisted in or performed a particular technique or procedure underthe guidance of a trainer. This level also applies to circumstances in which thetrainee needs to acquire the skills to perform the technique independently, butonly for routine indications in uncomplicated cases; Level III: goes beyond the requirements for Level I and II. The trainee mustbe able independently to recognise the indication, perform the technique orprocedure, interpret the data and manage the complications.12

Acute Cardiovascular Care AssociationCore CurriculumLevel of competence of cardiological skillsThe table below summarises the level of competence that the ESC considersdesirable for a trainee in acute cardiac care to achieve. Additional critical carecompetencies are outlined in the ESICM CoBaTrICE collaboration. It isappreciated that the organisation of cardiac services and the resources fortraining are not uniform throughout Europe and ESC member states, but thecurriculum aspires to an optimal rather than a minimal standard. In countries (orcentres) that are currently unable to deliver training in all its aspects, thecurriculum should be used as a benchmark to promote policies for improvement.Rotation of trainees between different centres can, in most situations, provide anadequate solution.13

Acute Cardiovascular Care AssociationCore CurriculumPart 2: The Core Curriculum for the Acute Cardiac CareCardiologist per TopicCardiologists training for certification in Acute Cardiac Care must be fully trainedin general cardiology. Therefore, the following topics focus on the additional,specific aspects of patient care in the ICCU. Thus, possession of generalcardiology knowledge, skills and behaviours and attitudes is considered a given.2.1. History taking and clinical examinationObjectivesHistory takingTo establish a relationship with a patient and/or relatives based on empathy andtrust, and to obtain a clinical history relevant to acute cardiac care including: the patient’s/relative’s spontaneous account of the symptoms questions focused on the presence/absence of cardiovascular symptoms, andindicators of critical illness the past history cardiovascular risk factors and reversible causes for cardiovascular diseases symptoms of any co-morbidities family history (cardiovascular and other diseases) curren

of Europe and the ESC member states. In this curriculum, the ACCA is setting a standard that cardiologists and national societies can use in further defining the subspecialty. In line with the 2013 Core Curriculum in Cardiology, the acute cardiac care curric