Impact of Novel Multiinstitutional Curriculum on Critical Care Fellow Ventilator Knowledge

Abstract

Background: Management of mechanical ventilation (MV) is a curricular milestone for trainees in pulmonary critical care medicine (PCCM) and critical care medicine (CCM) fellowships. Though recognition of ventilator waveform abnormalities that could result in patient complications is an important part of management, it is unclear how well fellows recognize these abnormalities.

Objective: To study proficiency of ventilator waveform analysis among first-year fellows enrolled in a MV course compared with that of traditionally trained fellows.

Methods: The study took place from July 2016 to January 2019, with 93 fellows from 10 fellowship programs completing the waveform examination. Seventy-three fellows participated in a course during their first year of fellowship, with part I occurring at the beginning of fellowship in July and part II occurring after 6 months of clinical work. These fellows were given a five-question ventilator waveform examination at multiple time points throughout the two-part course. Twenty fellows from three other fellowship programs who were in their first, second, or third year of fellowship and who did not participate in this course served as the control group. These fellows took the waveform examination a single time, at a median of 23 months into their training.

Results: Before the course, scores were low but improved after 3 days of education at the beginning of the fellowship (18.0 ± 1.6 vs. 45.6 ± 3.0; P < 0.0001). Scores decreased after 6 months of clinical rotations but increased to their highest levels after part II of the course (33.7 ± 3.1 for part II pretest vs. 77.4 ± 2.4 for part II posttest; P < 0.0001). After completing part I at the beginning of fellowship, fellows participating in the course outperformed control fellows, who received a median of 23 months of traditional fellowship training at the time of testing (45.6 ± 3.0 vs. 25.3 ± 2.7; P < 0.0001). There was no difference in scores between PCCM and CCM fellows. In anonymous surveys, the fellows also rated the mechanical ventilator lectures highly.

Conclusion: PCCM and CCM fellows do not recognize common waveform abnormalities at the beginning of fellowship but can be trained to do so. Traditional fellowship training may be insufficient to master ventilator waveform analysis, and a more intentional, structured course for MV may help fellowship programs meet the curricular milestones for MV.

Keywords: critical care; fellowship education; mechanical ventilation; waveform analysis.

Figure 1.

Comparison of timing of waveform testing for ventilator course participants and traditionally trained fellows. The top part of the figure shows timing of testing of fellows who took the ventilator course. These fellows took the waveform examination in the first month of fellowship, before and after completing the 3 days of education in part I of the course and then during their seventh month of fellowship, before and after completing the 2 days of education in part II. The bottom of the figure shows testing for the traditionally trained control group, who were either first-, second-, or third-year fellows who took the waveform examination a single time. ^aOne fellow who took the waveform test in the traditionally trained group did not report their year of training in fellowship, so 19 of 20 are included in the breakdown of scores by fellowship year.

Figure 2.

Control group of 20 fellows from one critical care medicine and two pulmonary critical care medicine fellowships took the waveform examination a single time after a median of 21 months of fellowship training, with a mean score of 25.3 ± 2.7. At the beginning of fellowship, in July, part I of the ventilator course took place. Mean ± standard error waveform examination score was 18.0 ± 1.6 before training in part I and increased significantly to mean 45.6 ± 3.0 after the 3 days of training was completed for 73 fellows (P < 0.0001). Between the July training and part II of the course in January, waveform examination scores decreased to mean 33.7 ± 3.1 (P = 0.0004). By the end of the January course, scores increased to highest level to date (mean 77.4 ± 2.4; P < 0.0001). FY = Fellow Year; Vent = Ventilator.

Figure 3.

Comparison of waveform examination scores for fellows in standalone critical care versus pulmonary critical care fellowships at each of the four time points when the examination was administered. There was no significant difference in examination scores for either pretests or posttests based on type of fellowship during testing for part I in July or part II in January. Jan = January.