Accepted Manuscript Redefining Our Cardiothoracic Surgical Intensive Care Units: Change is Good Ernest G. Chan, MD, MPH, Jonathan D’Cunha, MD, PhD PII:
S0022-5223(16)30319-1
DOI:
10.1016/j.jtcvs.2016.05.011
Reference:
YMTC 10605
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 1 May 2016 Accepted Date: 2 May 2016
Please cite this article as: Chan EG, D’Cunha J, Redefining Our Cardiothoracic Surgical Intensive Care Units: Change is Good, The Journal of Thoracic and Cardiovascular Surgery (2016), doi: 10.1016/ j.jtcvs.2016.05.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Redefining Our Cardiothoracic Surgical Intensive Care Units: Change
Ernest G. Chan, MD, MPH, and Jonathan D’Cunha, MD, PhD
RI PT
is Good
Department of Cardiothoracic Surgery; University of Pittsburgh Medical Center;
M AN U
SC
Pittsburgh, PA
Corresponding Author:
TE D
The authors have no conflicts of interest to disclose.
Jonathan D'Cunha, MD, PhD
EP
Department of Cardiothoracic Surgery
University of Pittsburgh Medical Center UPMC Presbyterian
AC C
Suite C-900
200 Lothrop St.
Pittsburgh, PA 15213 Tel: (412) 648-6315
FAX: (412) 802-8020 email: [email protected]
ACCEPTED MANUSCRIPT
"The secret of change is to focus all of your energy, not on fighting the old, but on
RI PT
building the new." - Socrates
In order to fully evaluate the evolving nature of critical care in cardiothoracic surgery, it is helpful to take a step back and evaluate how we define our specialty. According to
SC
the American Board of Thoracic Surgery (ABTS), thoracic surgery “encompasses the operative, perioperative, and surgical critical care of patients with acquired and
M AN U
congenital pathologic conditions within the chest”[1]. As many areas of medicine and surgery, this traditional definition is challenged in the modern era by the increased pressures of subspecialty focus. The cardiothoracic intensive care unit (CTICU) is no exception to this given the importance of critical care education [2]. As thoracic surgeons, we need to lead this conversation and guide our colleagues through these
TE D
unchartered territories both to provide the best care possible for thoracic patients as
EP
well as avoid the potential marginalization of our roles in the CTICU by outside forces.
Throughout the decades, thoracic surgeons have learned the valued of championing
AC C
their subspecialty areas. The field of critical care as a subspecialty area is one that is growing rapidly and certainly matured already in other surgical subspecialty areas. Traditionally, thoracic surgeons have provided care to patients alongside non-thoracic surgical physicians and medical professionals. Thus far, this model has been adequate, but in the area of increasing specialization of procedural care and outcomes pressures, the current system may require restructuring with thoracic surgeons being the ones
ACCEPTED MANUSCRIPT
leading the charge. In fact, Whitman and colleagues reported the potential impact of a thoracic-boarded intensivist whereby demonstrating a 1.5 day decrease in postoperative length of stay and a 2.2 day decrease in post-operative stay [3]. They also
RI PT
did it less expensively with less drug costs. Several individuals sharing the same sentiment include Dr. Nevin Katz, the President and Executive Director of the
Foundation for Advancement of Cardiothoracic Surgical Care, and Dr. Hisham M.F.
M AN U
surgery critical care subspecialty certificate [4-7].
SC
Sherif, who have been longtime advocates for the ABTS to develop a cardiothoracic
The evolution of cardiothoracic surgical critical care (CTSCC) indicates the need to create credentialing and recertification procedures that are modeled after those used for other medical and surgical specialties. Currently, Dr. Katz has reviewed the certification
TE D
process with the ABTS and the American Board of Surgery (ABS) and active discussions have been underway to define requirements for certifying thoracic surgery
EP
trainees [4]. Curriculums for CTSCC have also been proposed [6]. We believe now is the time to act and use what has already been proposed to being the next step in this
AC C
process. In reviewing guidelines set forth by the Accreditation Council for Graduate Medical Education (ACGME), new specialties are required to maintain a minimum number of active programs and residents nationally [8]. It is imperative for thoracic surgeons across the country to all play an active role in this endeavor. Therefore, we have to continue to increase awareness within the thoracic community of this ongoing process and define our roles locally. As our specialty evolves, it will be important to be respectful of how we will navigate the challenges of what this means to those of us who
ACCEPTED MANUSCRIPT
are well trained in critical care as part of the core training, but do not pursue the advanced certification. That is, would some hospitals only grant CTICU privileges to CTSCC-certified surgeons? It would make sense to have our CTICUs remain open to
RI PT
those surgeons such that the subspecialty certification is not viewed as being a burden and unwelcomed. What would then be the potential value of certification? Those
pursuing certification would be the leaders of our CTICUs and drive protocols, practices,
SC
and research initiatives to define them as centers of excellence. They would not
obstruct those of us who still love to manage our critically ill patients and be expertly
M AN U
involved by brining our subspecialty-specific knowledge to daily care. In fact, they would only protect our long-term interests of maintaining quality and reducing morbidity for an increasingly complex population. Additionally, the CTSCC-certified surgeon would lead the collaborative design of our units locally with other critical care specialists
TE D
as needed. The time to come together on this process is now so that we can develop a viable plan to ensure this is done correctly and putting aside the concern about being marginalized by certification. The thoughtful design of this new future in our
EP
subspecialty may move with clarity once this is embraced fully. We believe this movement is what we would want for our critically ill loved one and centering decisions
AC C
on this theme universally guides us down the correct pathway for the future.
ACCEPTED MANUSCRIPT
REFERENCES Definition of Thoracic Surgery. American Board of Thoracic Surgery, 2016.
2.
Whitson, B.A. and J. D'Cunha. The thoracic surgical intensivist: the best critical
RI PT
1.
care doctor for our thoracic surgical patients. in Seminars in thoracic and cardiovascular surgery. 2011. Elsevier. 3.
Whitman, G.J., et al., Cardiothoracic surgeon management of postoperative
Katz, N.M., The evolution of cardiothoracic critical care. The Journal of thoracic
M AN U
4.
SC
cardiac critical care. Arch Surg, 2011. 146(11): p. 1253-60.
and cardiovascular surgery, 2011. 141(1): p. 3-6. 5.
Katz, N.M., It is time for certification in cardiothoracic critical care. The Journal of thoracic and cardiovascular surgery, 2013. 145(6): p. 1446-1447.
6.
Sherif, H.M., Developing a curriculum for cardiothoracic surgical critical care:
TE D
Impetus and goals. The Journal of thoracic and cardiovascular surgery, 2012. 143(4): p. 804-808. 7.
Sherif, H.M., Cardiothoracic Surgical Critical Care Certification: A Future of
Accredidation Council for Graduate Medical Education: Policies and Procedures.
AC C
8.
EP
Distinction. The Journal of Thoracic and Cardiovascular Surgery, 2016.
Accredidation Council for Graduate Medical Education, 2016.
S0022-5223(16)30319-1
DOI:
10.1016/j.jtcvs.2016.05.011
Reference:
YMTC 10605
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 1 May 2016 Accepted Date: 2 May 2016
Please cite this article as: Chan EG, D’Cunha J, Redefining Our Cardiothoracic Surgical Intensive Care Units: Change is Good, The Journal of Thoracic and Cardiovascular Surgery (2016), doi: 10.1016/ j.jtcvs.2016.05.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Redefining Our Cardiothoracic Surgical Intensive Care Units: Change
Ernest G. Chan, MD, MPH, and Jonathan D’Cunha, MD, PhD
RI PT
is Good
Department of Cardiothoracic Surgery; University of Pittsburgh Medical Center;
M AN U
SC
Pittsburgh, PA
Corresponding Author:
TE D
The authors have no conflicts of interest to disclose.
Jonathan D'Cunha, MD, PhD
EP
Department of Cardiothoracic Surgery
University of Pittsburgh Medical Center UPMC Presbyterian
AC C
Suite C-900
200 Lothrop St.
Pittsburgh, PA 15213 Tel: (412) 648-6315
FAX: (412) 802-8020 email: [email protected]
ACCEPTED MANUSCRIPT
"The secret of change is to focus all of your energy, not on fighting the old, but on
RI PT
building the new." - Socrates
In order to fully evaluate the evolving nature of critical care in cardiothoracic surgery, it is helpful to take a step back and evaluate how we define our specialty. According to
SC
the American Board of Thoracic Surgery (ABTS), thoracic surgery “encompasses the operative, perioperative, and surgical critical care of patients with acquired and
M AN U
congenital pathologic conditions within the chest”[1]. As many areas of medicine and surgery, this traditional definition is challenged in the modern era by the increased pressures of subspecialty focus. The cardiothoracic intensive care unit (CTICU) is no exception to this given the importance of critical care education [2]. As thoracic surgeons, we need to lead this conversation and guide our colleagues through these
TE D
unchartered territories both to provide the best care possible for thoracic patients as
EP
well as avoid the potential marginalization of our roles in the CTICU by outside forces.
Throughout the decades, thoracic surgeons have learned the valued of championing
AC C
their subspecialty areas. The field of critical care as a subspecialty area is one that is growing rapidly and certainly matured already in other surgical subspecialty areas. Traditionally, thoracic surgeons have provided care to patients alongside non-thoracic surgical physicians and medical professionals. Thus far, this model has been adequate, but in the area of increasing specialization of procedural care and outcomes pressures, the current system may require restructuring with thoracic surgeons being the ones
ACCEPTED MANUSCRIPT
leading the charge. In fact, Whitman and colleagues reported the potential impact of a thoracic-boarded intensivist whereby demonstrating a 1.5 day decrease in postoperative length of stay and a 2.2 day decrease in post-operative stay [3]. They also
RI PT
did it less expensively with less drug costs. Several individuals sharing the same sentiment include Dr. Nevin Katz, the President and Executive Director of the
Foundation for Advancement of Cardiothoracic Surgical Care, and Dr. Hisham M.F.
M AN U
surgery critical care subspecialty certificate [4-7].
SC
Sherif, who have been longtime advocates for the ABTS to develop a cardiothoracic
The evolution of cardiothoracic surgical critical care (CTSCC) indicates the need to create credentialing and recertification procedures that are modeled after those used for other medical and surgical specialties. Currently, Dr. Katz has reviewed the certification
TE D
process with the ABTS and the American Board of Surgery (ABS) and active discussions have been underway to define requirements for certifying thoracic surgery
EP
trainees [4]. Curriculums for CTSCC have also been proposed [6]. We believe now is the time to act and use what has already been proposed to being the next step in this
AC C
process. In reviewing guidelines set forth by the Accreditation Council for Graduate Medical Education (ACGME), new specialties are required to maintain a minimum number of active programs and residents nationally [8]. It is imperative for thoracic surgeons across the country to all play an active role in this endeavor. Therefore, we have to continue to increase awareness within the thoracic community of this ongoing process and define our roles locally. As our specialty evolves, it will be important to be respectful of how we will navigate the challenges of what this means to those of us who
ACCEPTED MANUSCRIPT
are well trained in critical care as part of the core training, but do not pursue the advanced certification. That is, would some hospitals only grant CTICU privileges to CTSCC-certified surgeons? It would make sense to have our CTICUs remain open to
RI PT
those surgeons such that the subspecialty certification is not viewed as being a burden and unwelcomed. What would then be the potential value of certification? Those
pursuing certification would be the leaders of our CTICUs and drive protocols, practices,
SC
and research initiatives to define them as centers of excellence. They would not
obstruct those of us who still love to manage our critically ill patients and be expertly
M AN U
involved by brining our subspecialty-specific knowledge to daily care. In fact, they would only protect our long-term interests of maintaining quality and reducing morbidity for an increasingly complex population. Additionally, the CTSCC-certified surgeon would lead the collaborative design of our units locally with other critical care specialists
TE D
as needed. The time to come together on this process is now so that we can develop a viable plan to ensure this is done correctly and putting aside the concern about being marginalized by certification. The thoughtful design of this new future in our
EP
subspecialty may move with clarity once this is embraced fully. We believe this movement is what we would want for our critically ill loved one and centering decisions
AC C
on this theme universally guides us down the correct pathway for the future.
ACCEPTED MANUSCRIPT
REFERENCES Definition of Thoracic Surgery. American Board of Thoracic Surgery, 2016.
2.
Whitson, B.A. and J. D'Cunha. The thoracic surgical intensivist: the best critical
RI PT
1.
care doctor for our thoracic surgical patients. in Seminars in thoracic and cardiovascular surgery. 2011. Elsevier. 3.
Whitman, G.J., et al., Cardiothoracic surgeon management of postoperative
Katz, N.M., The evolution of cardiothoracic critical care. The Journal of thoracic
M AN U
4.
SC
cardiac critical care. Arch Surg, 2011. 146(11): p. 1253-60.
and cardiovascular surgery, 2011. 141(1): p. 3-6. 5.
Katz, N.M., It is time for certification in cardiothoracic critical care. The Journal of thoracic and cardiovascular surgery, 2013. 145(6): p. 1446-1447.
6.
Sherif, H.M., Developing a curriculum for cardiothoracic surgical critical care:
TE D
Impetus and goals. The Journal of thoracic and cardiovascular surgery, 2012. 143(4): p. 804-808. 7.
Sherif, H.M., Cardiothoracic Surgical Critical Care Certification: A Future of
Accredidation Council for Graduate Medical Education: Policies and Procedures.
AC C
8.
EP
Distinction. The Journal of Thoracic and Cardiovascular Surgery, 2016.
Accredidation Council for Graduate Medical Education, 2016.
