Critical Care Medicine - acgme

Frequently Asked Questions: Critical Care Medicine Review Committee for Internal Medicine ACGME Question Sponsoring Institutions What other accredited fellowships must exist at an institution that is looking to start a critical care medicine program?

Answer Because of the unique multidisciplinary nature of critical care medicine education, there should be peer interaction from at least three of the following internal medicine fellowships at the sponsoring institution: cardiovascular disease, gastroenterology, infectious disease, nephrology, and pulmonary disease.

[Program Requirement: I.A.2] Program Personnel and Resources Does the required average daily census of at The required average daily census of at least five patients per fellow on duty applies to all critical least five patients per fellow apply to all critical care units. care units, or just the medical intensive care unit (MICU)? [Program Requirement: II.D.6.e)] Educational Program If a fellow completes a pulmonary disease fellowship and then enters a critical care medicine fellowship, would he or she be required to complete an additional 50 bronchoscopies in the critical care fellowship given that he or she would already have completed 100 bronchoscopies during the pulmonary fellowship? [Program Requirement: IV.A.5.a).(4).(d)] If an emergency medicine graduate enters a critical care medicine program and has completed only four months of the prerequisite clinical education, does his or her educational experience get extended by two months in order fulfill the prerequisite requirement for six months of patient care experience in internal medicine (i.e., instead of needing to complete the fellowship in 24 months, will he or she require 26 months to finish the educational program in critical care medicine)?

If a fellow has already completed a pulmonary fellowship and has done 100 bronchoscopies and achieved this competency, he or she is not required to complete any of these procedures upon entering a critical care medicine fellowship. The fellow may want to maintain his or her competency in this area and therefore do a small number of these procedures during the critical care medicine fellowship (at his or her discretion, and with the program director’s approval), but he or she is not required to do the minimum number of bronchoscopies noted in the critical care medicine requirements in addition to those already completed during his or her prior fellowship.

If an emergency medicine graduate enters a critical care medicine program and has completed only four months of prerequisite clinical education, he or she will need to complete the remaining two months at the beginning of fellowship. These two months will not count towards meeting the 12 months of clinical experiences in critical care medicine (Program Requirement IV.A.6.a)), but will count towards meeting the 24 months of total education (Program Requirement Int. C). All critical care medicine fellows need to have 24 months of educational experiences: 12 months of clinical experiences (Program Requirement IV.A.6.a)) and 12 months of appropriate elective experiences or scholarly activity (Program Requirement IV.A.6.c)). So, in this particular scenario, the fellow will have two months less time to devote to electives and scholarly work.

©2012 Accreditation Council for Graduate Medical Education (ACGME)

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Question [Program Requirements: IV.A.6.a)-b)] Does time in the coronary care unit (CCU) or in observation units count toward the three months of required experiences in a MICU? [Program Requirement: IV.A.6.a).(1).(a)] If a resident rotated for one month in a combined MICU/CCU, would that count towards the prerequisite three-month MICU orthree-month non-MICU experience?

Answer Only time in the MICU itself can be used meet this requirement. Experiences in the CCU can be used toward the three months of non-MICU medicine, but not toward the three months required in the MICU. Experience in observation units cannot be used to fulfill any part of the required six months of prerequisite clinical experiences. As noted above, only time in the MICU can be used to meet the minimum three-month MICU prerequisite. If a resident rotates for a month to a combined MICU/CCU, the time that can be applied to meeting the MICU requirements will need to be prorated depending on the amount of time the fellow spent in the MICU seeing MICU patients.

[Program Requirement: IV.A.6.a).(1).(a)] Must the three-month non-MICU prerequisite Yes, all three months of the non-MICU prerequisite experience must be spent on floor medicine. experience have to be three months of floor Neither consults nor experiences in observation units count towards meeting this requirement. medicine, or do consult months or experience in an observation unit count as well? [Program Requirement: IV.A.6.a).(1).(a)] Are emergency medicine graduates who need to Since the Program Requirement states that "at least” three months must have been in a medical complete the prerequisite clinical experience intensive care unit, it allows for the possibility of all six months of prerequisite experience to be required to have three months of non-ICU time, completed in the MICU. or can all of the prerequisite time be completed in a MICU? [Program Requirement: IV.A.6.a).(1).(a)] Can an emergency medicine graduate in a An emergency medicine graduate in a critical care medicine fellowship can supervise internal critical care medicine program supervise internal medicine residents in the MICU only if he or she has completed the prerequisite six months of medicine residents in the MICU when acting as clinical experience. the MICU fellow? [Program Requirement: IV.A.6.a).(1).(a)] Is a rotation in an electronic (virtual) ICU (eICU) Yes. However, rotations in an eICU are expected to conform to the same educational permitted as an experience in a critical care requirements as other clinical experiences (i.e., written competency-based and level-specific medicine fellowship? goals and objectives, defined curriculum, adequate attending supervision, and competencybased evaluations). In addition, these rotations must be structured to offer an educational [Program Requirement: IV.A.6.a).(1)] experience, and not merely provide clinical service to the institution. Specifically, there must be in-person attending rounds with the fellow(s) on a daily basis. Entirely off-site (remote) supervision is not permitted for eICU rotations. The amount of time spent in an eICU would be included in the 15-month ICU limitation.


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Question What is expected in terms of fellows’ clinical experience in the evaluation and management of patients with trauma?

Answer A program letter of agreement (PLA) will need to be in place for all eICU experiences. The Review Committee expects that fellows will have the equivalent of at least one month of experience in the care of trauma patients – either in a block rotation or in aggregate over the duration of the fellowship. Consultative care alone (e.g., ventilatory management only) is considered insufficient to acquire the expertise needed to care for critically-ill trauma patients.

[Program Requirement: IV.A.6.e).(1)] Some hospitals do not have major trauma centers, but do have all of the other requisite faculty members, patients, and facilities needed for education in critical care. Therefore, the Review Committee would accept a trauma rotation to a participating site (i.e., a trauma unit experience) of at least one month’s duration in order to fulfill this requirement. 07/2012


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Appendix I Review Committee for Internal Medicine Calculation of Minimum Key Clinical Faculty (KCF) and KCF Scholarship Participation/Productivity Critical Care Medicine Minimum 3 KCF or 1:1.5 faculty-fellow ratio for programs with 6 or more fellows PRODUCTIVITY PARTICIPATION Pubs All KCF & KCF with at Least non-KCF in Minimum Certified Majority of 1 SA in Past 3 Years Approved Fellow KCF Minimum KCF Past 3 Years (1/yr x 3 yrs) Complement (incl PD) (50%) [259] [259] 2 3 2 2 6 3 3 2 2 6 4 3 2 2 6 5 3 2 2 6 6 4 2 2 6 7 5 3 3 9 8 6 3 3 9 9 6 3 3 9 10 7 4 4 12 11 8 4 4 12 12 8 4 4 12 13 9 5 5 15 14 10 5 5 15 15 10 5 5 15 16 11 6 6 18 17 12 6 6 18 18 12 6 6 18 19 13 7 7 21 20 14 7 7 21 21 14 7 7 21 22 15 8 8 24 23 16 8 8 24 24 16 8 8 24 25 17 9 9 27 26 18 9 9 27 27 18 9 9 27 28 19 10 10 30 29 20 10 10 30 30 20 10 10 30 The Review Committee requires that fellowship education occurs in an environment of inquiry, scholarship, and research productivity. The Review Committee requires that KCF demonstrate both participation and productivity in scholarship of discovery and dissemination as evidenced by: • Participation Expectation: 50% of the certified, minimum-required-number of KCF must demonstrate at least one acceptable product of scholarship in the past three years. (See definition of acceptable products of scholarship below) • Productivity Expectation: Total acceptable scholarly products for KCF and non-KCF (There must be at least one product per year x three years x the 50% of the minimum required KCF. The non-


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KCF are counted as long as they contribute to fellow education and devote at least 10 hours a week to the program. Acceptable Products of Scholarship The Review Committee defines acceptable products of scholarship as follows: • Publication of original research manuscripts in a peer-review journal • Publication of a review article in a peer-review journal • Publication of an editorial in a peer-review journal • Publication of a book chapter published in medical textbooks (full citation required including publisher and date) o This includes chapters published in specialty society review texts, such as MKSAP, NephSAP, ACCSAP, the Geriatrics Review Syllabus, etc. • Publication of a case report indexed in PubMed o A copy of the case report must be included o Case reports published as an abstract, letter, correspondence, or illustration do not count • Peer-review funding of research such as NIH, NCI, or other external funding organizations • In press or accepted for publication in a peer-review journal The following will not fulfill requirements for scholarship: • Submitted or in preparation • Abstracts, letters-to-editor, correspondence, or illustrations • Case reports published as an abstract, letter, correspondence, or illustration • Non-peer-review publications • Non-peer review funding, such as industry funding, or internal institutional funding, or multicenter industry funding, or other non-peer-review grant o Exception: Pharmaceutical studies in which the KCF is the overall PI (lead investigator) for all sites will be accepted as counting as one product of scholarship The Review Committee expanded its expectation for participation in scholarship to include the “Acceptable Products of Scholarship” as listed above as well as the following: o Presentations at national, international or regional meetings o Leadership roles in national medical organizations or serving as a reviewers or editorial board members for peer-reviewed journals This broadened expectation does not extend to scholarly productivity. Scholarly products are limited to what appears above under the title “Acceptable Products of Scholarship.” Summary/Example: • For an application for a new six-fellow endocrinology program there must be four KCF (which includes the program director). • In order to meet the Participation Expectation, two of the four KCF must have evidence of a scholarly project or activity from the last three calendar years. • In order to meet the Productivity Expectation, there must be at least six scholarly products across the KCF and non-KCF. Note: • •

Publications with several KCF as authors can only be counted once “Last three calendar years” means that the Review Committee will count the scholarly products (as defined above) from 2011, 2012, 2013, and 2014 for an application that is submitted in 2014. 

See summary of KCF minimum numbers and research productivity in Appendix I


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