CORRESPONDENCE: LETTER TO THE EDITOR
Pediatric Cardiac Critical Care Patients Should Be Cared for by Intensivists
Harris P. Baden, MD*,
John Berger, MD,
Richard I. Brilli, MD,
Jeffrey P. Burns, MD,
Paul A. Checchia, MD,
Heidi J. Dalton, MD,
Vinay Nadkarni, MD,
Murray Pollack, MD,
Randall C. Wetzel, MD and
Jerry J. Zimmerman, MD, PhD
* Children’s Hospital and Regional Medical Center, Pediatric Cardiac Intensive Care, 4800 Sand Point Way NE, Seattle, Washington 98105 (Email: harris.baden{at}seattlechildrens.org).
We read with great interest the "Recommendations for Training in Pediatric Cardiology" by Beekman et al. (1). As critical care physicians from high-volume pediatric teaching hospitals with large cardiac intensive care unit (ICU) patient populations, we would like to comment specifically on the section describing advanced training in Pediatric Cardiac Critical Care.
The practice of high-quality pediatric cardiac intensive care requires a multidisciplinary collaboration between physicians (surgeon, cardiologist, intensivist, anesthesiologist, neonatologist) and other clinical disciplines, such as nursing, respiratory therapy, pharmacology, and nutrition support. Our comments are predicated upon the well-established concept that critically ill patients, including children, are best cared for by a multidisciplinary team of clinicians with the intensivist as the team leader or co-leader (2–5). Based upon data demonstrating better outcomes and decreased costs of such a model, market forces like Leapfrog and the National Quality Forum have mandated intensivist management of ICU patients, including pediatric patients. Published guidelines for general pediatric ICUs, endorsed by the American College of Critical Care Medicine, offer similar recommendations (6). In addition, the specialty boards in medicine, surgery, anesthesia, and pediatrics have each established pathways for certification in critical care medicine. We submit that critically ill children in a cardiac ICU deserve the same collaborative multidisciplinary model of clinical care.
We acknowledge that cardiologists who complete the abbreviated critical care rotations outlined in the American College of Cardiology Foundation/American Heart Association/American Academy of Pediatrics (ACCF/AHA/AAP) document will have added critical care skills, but this additional clinical experience does not transform a cardiologist into an "intensivist" any more than a few clinical months of cardiology training could convert an "intensivist" into a "cardiologist." The training for any physician who wishes to practice pediatric critical care medicine should not be fast-tracked. The specific areas of proposed knowledge and competence outlined by Beekman et al. (1) are similar to the curriculum document of a full critical care medicine fellowship, including but not limited to knowledge regarding management of increased intracranial pressure, coagulation disorders, advanced ventilator management techniques, renal failure management, and nutrition support. It takes a full three years of a critical care medicine fellowship to begin to master these concepts; therefore, we believe nine months of additional clinical training beyond a standard cardiology fellowship is insufficient to produce clinicians to fulfill the "intensivist" role in the cardiac ICU.
In sum, all critically ill children should be cared for by a team of clinicians, including but not limited to board-certified critical care medicine specialists. Critically ill children in the cardiac ICU deserve the same level of expertise. The physician who wishes to fulfill both the "cardiologist" and the "intensivist" role in the cardiac ICU should follow the five-year path outlined by the American Board of Pediatrics for dual certification in both cardiology and critical care medicine. There can be no shortcuts on this very important issue in the care of critically ill children. We advocate a model of care that incorporates all relevant clinical experts. We believe that such a model is most consistent with the highest quality critical care practice.
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1. Graham Jr TP, Beekman III RH. ACCF/AHA/AAP recommendations for training in pediatric cardiologya report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence (ACC/AHA/AAP Committee on Pediatric Cardiology). J Am Coll Cardiol 2005;46:1380-1403.[Free Full Text]2. Brilli R, Spevetz A, Branson R, et al. Critical care delivery in the intensive care unitdefining clinical roles and the best practice model. Crit Care Med 2001;29:2007-2019.[CrossRef][Web of Science][Medline] 3. Pollack M, Cuerdon T, Patel K, et al. Impact of quality of care factors on pediatric intensive care unit mortality JAMA 1994;272:941-946.[Abstract/Free Full Text] 4. Pronovost P, Angus D, Dorman T, et al. Physician staffing patterns and clinical outcomes in critically ill patients JAMA 2002;288:2151-2162.[Abstract/Free Full Text] 5. Dimick J, Pronovost P, Heitmiller R, et al. Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection Crit Care Med 2001;29:753-758.[CrossRef][Web of Science][Medline] 6. Rosenberg D, Moss M. Guidelines and levels of care for pediatric intensive care units Crit Care Med 2004;32:2117-2127.[CrossRef][Web of Science][Medline]
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