Draft – 26 October 2008 - ACC Curriculum page 1 of 49
CURRICULUM FOR TRAINING IN INTENSIVE, ACUTE CARDIAC CARE IN
EUROPE
7
Draft – 26 October 2008 - ACC Curriculum page 2 of 49
TABLE OF CONTENTS:
PREAMBLE
PART 1
1. INTRODUCTION
2. RATIONALE
2. A...
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PREAMBLE:
Medical knowledge has expanded rapidly in recent decades, ...
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number of patients with acute cardiovascular disorders or severe car...
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need to be accepted by all the National Societies in Europe. This wi...
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 ACUTE CORONARY SYNDROME (ACS)
To understand the pathophysiology, c...
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 ACUTE VALVULAR DISEASE (endocarditis, degenerative valve, artifici...
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2.- Application of this theoretical knowledge in the treatment of a ...
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invasive haemodynamic
monitoring
 Intraaortic balloon
pump
 10  I...
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medicine 1 month, nephrology 1 month, and general ICU 3 months. A t...
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that they have undergone the appropriate training (listed above) in...
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6.1 ASSESSMENT ORGANIZATION
The Accreditation System structure comp...
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 Submit ratification of accreditation of those candidates who are ...
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Designation for committee members will be held every three years, b...
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 Assist in preparing and carrying out the theoretical and practica...
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This training should be done in certified training centres for acut...
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ii. Exceptional method. Formal heads of CCU‘s accredited for traini...
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 REQUIREMENTS FOR TRAINING CENTRES AND
TRAINING SUPERVISORS
Traini...
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means). Accreditation candidates must submit the following document...
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established. The costs will include: Travelling fees for Accreditat...
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 NSTEACS
 Unstable
angina
laboratory results that
are diagnostic ...
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arrhythmias and
supraventricular
arrhythmias).
- Outline risk
strat...
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biochemistry and full
blood count,
natriuretic peptides
imaging (ec...
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outcomes - Select the best
ventricular support,
when needed
-Insert...
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tests: chest X-ray,
ECG, natriuretic
peptides, general
biochemistry...
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5.- CARDIAC TAMPONADE
OBJECTIVES KNOWLEDGE SKILLS ATTITUDES
- To di...
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treat patients with
endocarditis
fungi and other
microorganisms as
...
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OBJECTIVES KNOWLEDGE SKILLS ATTITUDES
- To diagnose and
treat patie...
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treat patients with
 Trauma to
the aorta
 Trauma to
the heart
and...
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- To diagnose and treat
patients with
 Bradyarrhythmia
 Atrial fi...
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- Outline predictors
of survival and
outcomes in the
different cate...
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and resuscitation
- Explain associated
cardiac conditions
leading t...
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other medical
measures
- Outline secondary
prevention
- Select the ...
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13.- Sepsis
OBJECTIVES KNOWLEDGE SKILLS ATTITUDES
- To diagnose and...
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ANNEX : ESC Report
Recommendations for the structure, organization,...
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their relations to the other facilities in the hospital. Specific r...
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Two changes occurred over the past two decades that demand distinct...
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intervention procedures. These patients represent a special group o...
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Equipment
The standard monitoring equipment, including invasive and...
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(vii) patients with acute pulmonary oedema unresolved by initial th...
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(i) intermediate risk unstable coronary syndrome patients;
(ii) pat...
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Patients beds for the ICCU
Beds in the ICCU have to allow vertical ...
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. Department head: a certified cardiologist.
. First six beds: one ...
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Furthermore, allocating nursing manpower should take into account t...
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(vi) The separate intensive care procedure room should be spacious ...
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Nevertheless, there are objective difficulties and obstacles on the...
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will play a key role in the treatment of patients with ACS. The con...
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13. Mielck F, Buhre W, Hanekop G, Tirilomis T, Hilgers R, Sonntag H...
Draft – 26 October 2008 - ACC Curriculum page 49 of 49
27. Flynn MR, Barrett C, Cosio FG, Gitt AK, Wallentin L, Keamey P, ...
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  1. 1. Draft – 26 October 2008 - ACC Curriculum page 1 of 49 CURRICULUM FOR TRAINING IN INTENSIVE, ACUTE CARDIAC CARE IN EUROPE 7
  2. 2. Draft – 26 October 2008 - ACC Curriculum page 2 of 49 TABLE OF CONTENTS: PREAMBLE PART 1 1. INTRODUCTION 2. RATIONALE 2. AIMS/LEARNING OUTCOMES 3. LEARNING OBJECTIVES 4. TEACHING AND LEARNING METHODS 5. ASSESSMENT METHODS PART 2 1. THE TRAINING PROGRAMME 2. ENTRY REQUIREMENTS FOR CARDIOLOGISTS 3. REQUIREMENTS FOR TRAINING CENTRES AND TRAINING SUPERVISORS 4. ADVANCED TRAINING PART 3  SYLLABUS ANNEX: “ Recommendations for the structure, organization and operation of intensive cardiac care units” Eur Heart J 2005; 26: 1676-82 ________________________________________________________________________ DETAILED DESCRIPTION
  3. 3. Draft – 26 October 2008 - ACC Curriculum page 3 of 49 PREAMBLE: Medical knowledge has expanded rapidly in recent decades, as have advances in cardiology. Not only new drugs have become available, but also different diagnostic, interventional and therapeutic procedures have been developed. Many have resulted in better patient treatment and improved outcomes. Increasingly, patients and society in general are aware of medical progress and demand state of the art therapies. Because, much of cardiology has become very technical and sub-specialised, specific training is needed to assure that the process of investigation and management is of the high standards required by both the medical profession and their patients. One of the fields in which these complexities are apparent is acute cardiac care (ACC). Since the early 1970s, ACC has been delivered in coronary care units that were initially developed to treat lethal arrhythmias in patients with acute myocardial infarction (AMI). Subsequently, the scope of therapies offered in these units has greatly expanded. In the last decade there has been an increase in the number of patients with severe cardiological conditions requiring ACC, many of whom are elderly, presenting with acute coronary syndromes, severe heart failure, rhythm disturbances or severe valvular dysfunction. Thus, coronary care units are required to treat not only patients with acute coronary syndromes, but a wide range of severe cardiac conditions. Currently, these areas are generally known as called intensive cardiac care units (ICCUs) to reflect this change in patient demographics. Appropriately trained cardiologists should remain involved in the management of complex cardiac problems that may be associated with multi-system organ dysfunction, as they will be able to address not only the investigation and management of the underlying cardiological disease, but also the effects of other organ system (dys)function on the cardiovascular system. To disregard this responsibility is not in the best interests of our patients. PART 1 1. INTRODUCTION Patients with acute cardiac conditions (i.e. acute myocardial infarction, severe unstable coronary syndrome, acute myocarditis, decompensated heart failure, complex cardiac arrhythmias, etc.) require continuous monitoring with special medical and nursing care. Therefore they should be admitted to ICCUs, designed, equipped and staffed by specially trained nurses. Although the
  4. 4. Draft – 26 October 2008 - ACC Curriculum page 4 of 49 number of patients with acute cardiovascular disorders or severe cardiac co-morbidities requiring special treatment is increasing, there is to date no pan-European standardized and accepted training program for physicians in charge of the ICCU. This document proposes a program for training and credentialing needed to become an accredited ICCU physician. 2. RATIONALE A physician in charge of the ICCU should be able to recognize and treat a wide variety of acute, as well as chronic cardiac conditions leading to cardiac decompensation. In addition, such a physician should be able to investigate and manage resulting organ system failure, in addition to determining more long-term management following stabilization. ICCU physicians should be well acquainted with the diagnostic and therapeutic means available to the modern cardiologist including electrocardiography, echocardiography, nuclear cardiology, hemodynamic measurements and their interpretation, cardiac and coronary angiography, cardiac pharmacotherapy, and interventional cardiology. They should be familiar and fluent in the operation of the available equipment including monitoring (invasive and non-invasive), cardiac pacemakers, defibrillators, artificial respirators (invasive and non-invasive), renal replacement therapy and mechanical cardiac support. A comprehensive knowledge of interventions to treat cardiac pathology and also associated conditions such as liver and renal dysfunction is mandatory, in addition to knowledge regarding the management of infection, nutrition, sedation, and analgesia. To meet these requirements demands training in cardiology (all applicants must be fully certified cardiologists) with additional training in intensive care medicine. 3. AIMS/LEARNING OUTCOMES The aims of the learning process detailed in this document are: 1.To provide guidance on the training requirements for cardiologist in charge or working in the ICCU 2.To delineate the core competencies and curriculum for such physicians (see Part 3) 3.To define the techniques in which the ICCU cardiologist should be proficient 4.To describe the minimum numbers of procedures that trainees must have done before applying for accreditation 5To determine the need for recertification The main expected outcome is to have appropriately trained cardiologists in the subspecialty of acute cardiac care, to support state of the art treatment for patients with severe cardiac dysfunction. In order to have credibility, the proposed programme contained in this document will
  5. 5. Draft – 26 October 2008 - ACC Curriculum page 5 of 49 need to be accepted by all the National Societies in Europe. This will result in a more uniform treatment of critically ill cardiac patients all over Europe, reducing inequalities among countries and improving outcomes. 4. LEARNING OBJECTIVES Cardiologists wishing to be trained appropriately to manage an ICCU applying for accreditation in ACC must achieve the following objectives in the following items during their learning process: Many of the skills outlined in this Curriculum are supplementary to those expected from general cardiologists not working regularly in an ICCU, or general intensivists not working regularly in an ICCU. Definition of Levels of Competence The levels of competence required below follow the recommendations of the Core Curriculum for the General Cardiologist (ref) and are defined as follows: Level I: Experience of selecting the appropriate diagnostic modality and interpreting the results or choosing and appropriate treatment. Does not include the performance of a technique Level II: Practical experience, but not as an independent operator (the technique is performed under the guidance of a superior) Level III: Able to independently perform a technique unaided.  GENERAL, CORE INTENSIVE CARE MEDICINE The basis of optimal patient management in the ICCU includes many of the principles required in the management of acutely and/or critically ill patients with non-cardiac disease. In order to achieve this, the ICCU cardiologist will be required to understand the pathophysiology, clinical presentation, investigation, treatment options, complications and secondary prevention measures which underpin the general management of the acute cardiac care patient who is critically ill. These objectives will be achieved by: 1.- A complete theoretical knowledge of the principles underlying general care of the ICCU patient 2.- Application of this theoretical knowledge in the management patients admitted to an intensive care unit to level III competence.
  6. 6. Draft – 26 October 2008 - ACC Curriculum page 6 of 49  ACUTE CORONARY SYNDROME (ACS) To understand the pathophysiology, clinical presentation, investigation, differential diagnosis, treatment options, complications and secondary prevention measures. These objectives will be achieved by: 1.- A complete theoretical knowledge of the principles underlying this syndrome 2.- Application of this theoretical knowledge in the treatment of a minimum of 300 patients or all patients with ACS admitted to an ICCU during 1-year residency/fellowship, (level III competence).  ACUTE HEART FAILURE (AHF) AND CARDIOGENIC SHOCK To understand the pathophysiology, clinical presentation, investigation, differential diagnosis, treatment options, complications and secondary prevention measures. These objectives will be achieved by: 1.- A complete theoretical knowledge of the principles underlying these syndromes 2.- Application of this theoretical knowledge in the treatment of a minimum of 100 patients with AHF and cardiogenic shock admitted to an ICCU (level III competence).  MYOCARDITIS To understand the pathophysiology, clinical presentation, investigation, differential diagnosis, treatment options, complications and secondary prevention measures. These objectives will be achieved by: 1.- A complete theoretical knowledge of the principles underlying this syndrome 2.- Application of this theoretical knowledge in the treatment of a minimum of 10 patients with myocarditis admitted to an ICCU (level III competence).  CARDIAC TAMPONADE To understand the pathophysiology, clinical presentation, investigation, differential diagnosis, treatment options, complications and secondary prevention measures. These objectives will be achieved by: 1.- A complete theoretical knowledge of the principles underlying this syndrome 2.- Application of this theoretical knowledge in the treatment of a minimum of 20 patients with cardiac tamponade admitted to an ICCU (level III competence).
  7. 7. Draft – 26 October 2008 - ACC Curriculum page 7 of 49  ACUTE VALVULAR DISEASE (endocarditis, degenerative valve, artificial valves, chest trauma and AMI) To understand the pathophysiology, clinical presentation, investigation, differential diagnosis, treatment options, complications and secondary prevention measures. These objectives will be achieved by: 1 - A complete theoretical knowledge of the principles underlying these pathological processes 2 - Application of this theoretical knowledge in the treatment of a minimum of 10 patients with severe acute valve disease admitted to an ICCU (level III competence).  TRAUMA AND DISEASES OF THE AORTA To understand the pathophysiology, clinical presentation, investigation, differential diagnosis, treatment options, complications and secondary prevention measures. These objectives will be achieved by: 1 – A complete theoretical knowledge of the principles underlying these pathological processes 2 - Application of this theoretical knowledge in the treatment of a minimum of 10 patient with aneurysm or dissection of the aorta admitted to an ICCU (level III competence).  RESPIRATORY INSUFFICIENCY To understand the pathophysiology, clinical presentation, investigation, differential diagnosis, treatment options, complications and secondary prevention measures. These objectives will be achieved by: 1.- A complete theoretical knowledge of the principles underlying respiratory insufficiency and its treatment 2 - Application of this theoretical knowledge in the treatment of 100 patients in need of respiratory support, invasive or non-invasive and to perform a minimum of 30 endotracheal intubations (level III competence)..  ARRHYTHMIAS To understand the pathophysiology, clinical presentation, investigation, differential diagnosis, treatment options, complications and secondary prevention measures. These objectives will be achieved by: 1.- A complete theoretical knowledge of the principles underlying these syndromes
  8. 8. Draft – 26 October 2008 - ACC Curriculum page 8 of 49 2.- Application of this theoretical knowledge in the treatment of a minimum of 20 patients with ventricular tachycardia, 50 with supraventricular tachycardia, 20 patients with atrio- ventricular block admitted to an ICCU (level III competence).  PULMONARY EMBOLISM (PE) AND PRIMARY PULMONARY HYPERTENSION (PPH) To understand the pathophysiology, clinical presentation, investigation, differential diagnosis, treatment options, complications and secondary prevention measures. These objectives will be achieved by: 1.- A complete theoretical knowledge of the principles underlying these syndromes 2.- Application of this theoretical knowledge in the treatment of a minimum of 10 patients with PE and 10 patients with significant pulmonary hypertension (level III competence).  SEPSIS AND INFLAMMATORY SYNDROMES To understand the pathophysiology, clinical presentation, investigation, differential diagnosis, treatment options, complications and secondary prevention measures. These objectives will be achieved by: 1 – A complete theoretical knowledge of the principles underlying these syndromes 2 – Application of this theoretical knowledge in the treatment of a minimum of 50 patients (level III competence). SPECIAL SKILLS It is expected that during the learning process, the trainee will undertake the following techniques to the level of competence requested, with additional supporting evidence in provision of the logbook:  TECHNIQUE  MINIMUM NUMBER OF CASES IN THE LOGBOOK  LEVEL OF COMPETENCE (Accreditation)  LEVEL OF COMPETENCE (Revalidation)  Primary angioplasty  50  I  II  Right heart catheterization  20  III  III  Invasive and non-  100  III  III
  9. 9. Draft – 26 October 2008 - ACC Curriculum page 9 of 49 invasive haemodynamic monitoring  Intraaortic balloon pump  10  III  III  Advanced renal support  30  III  II  Non-invasive ventilation  50  III  III  Endotracheal intubation  30  III  III  Mechanical ventilation  50  III  III  Pericardiocentesis  10  III  III  Temporary pacemaker implantation  50  III  III  Current ACLS (advanced cardiac life support certificate)  N/A  N/A  N/A  Care of the Post resuscitation patient *  20  Level III  III  Extra corporeal cardio pulmonary support  10  I  I  Transthoracic & Transoesophageal Echocardiography  125 (TTE)  50 (TOE)  Level III (TTE)  Level III (TOE)  II * including the process of arranging organ donorship. To achieve the above outlined goals, the trainee must be a fully trained cardiologist, who has worked full time in an ICCU of a Department of Cardiology for a total of at least 12 months and has been on call for the equivalent of at least 1 night per week for at least three years. In addition, the following time training will be required: anaesthesiology 1 month, pulmonology/respiratory
  10. 10. Draft – 26 October 2008 - ACC Curriculum page 10 of 49 medicine 1 month, nephrology 1 month, and general ICU 3 months. A total of 6 months ICCU during general cardiology training, 6 months training as junior attending physician (post- residency) and 6 months in the other listed specialties should be undertaken. In order to ascertain that the trainee has fulfilled the above requirements they will be assessed by an examination, and presentation of a log-book. In addition, the base hospital will be a certified training centre (see below). 5. TEACHING AND LEARNING METHODS The trainee will assume appropriate responsibility in obtaining the theoretical knowledge outlined in the syllabus (see below). To do this, it is advisable to use the Core Curriculum book of Cardiology from the ESC (CD, tutorials in the web page of the ESC), recent ESC guidelines and other teaching materials from the different and relevant Working Groups of the ESC, especially those from the WG on ACC, and also from other textbooks. Reference to training materials from the ESICM and/or national intensive care societies may also be useful. The trainee will therefore be required to engage in continuous, independent self-directed learning and self-assessment. It is also recommended that other learning resources be used, such as:  Ward rounds and supervised consultation in outpatient clinics  Case presentations  Bedside teaching  Lectures, tutorials  Seminars  Simulation-based teaching  Web-based teaching  Courses  Journal clubs  Annual meetings of Scientific Societies 6. ASSESSMENT METHODS The Accreditation Committee (see below) is responsible for ensuring that the theoretical examination is based on the Curriculum and that the questions asked are relevant. Thus, to assess the proficiency in Acute Cardiac Care, several methods will be used to ensure that both the theoretical and practical skills have been mastered by the applicant. The trainees must prove
  11. 11. Draft – 26 October 2008 - ACC Curriculum page 11 of 49 that they have undergone the appropriate training (listed above) in a accredited Unit under the guidance of accredited staff. They will be required to provide a log-book in which all procedures and patients have been listed, and signed by the trainee‘s tutor. They will also provide a list of other educational activities in which they have actively participated This documentation must be provided before applying for the examination. Only trainees with an adequate CV will be allowed to sit the written examination. The examination will be in English. Theoretical assessment The theory examination will consist of 100 multiple-choice questions which will be based on the Syllabus (see part 3). The examination will be compiled by the Accreditation Committee and designed to be completed in a 3 hours session. The examination will be marked by the examination team, and the pass mark set at 60%. Candidates will be notified of the results by mail. The names of candidates will remain confidential. However, the WG on ACC reserves the right to publish lists of successful candidates. A period for appeals will be opened after the candidates have been notified of their results. There is no limit on the number of times a candidate may sit the examination. Upon re- examination, it will not be necessary for documentation to be re-presented with the exception of the receipt for payment of the applicable fees. Frequency Examinations will be held annually during the ESC annual meeting and biannually during the WG on ACC meeting; this may subsequently be modified depending demand. In the event there are insufficient candidates, the Accreditation Committee will be authorised to cancel an examination round. Future developments The web-based platform will be available for both trainees and established cardiologists in Spring 2009. This will be too late to affect the assessment methods used in Autumn 2009, which will remain as outlined above. In Autumn 2010, the methods for accreditation in Intensive and Acute Cardiac Care will be entirely based on the EBSC / ACC web-based platform.
  12. 12. Draft – 26 October 2008 - ACC Curriculum page 12 of 49 6.1 ASSESSMENT ORGANIZATION The Accreditation System structure comprises:  An Accreditation Committee  The WG Nucleus  Evaluation teams Accreditation Committee Composition The committee will be composed of 7 previously accredited WG members, one of these necessarily being a member of the WG Nucleus. One member will be nominated by the UEMS cardiology section. Other members will be appointed by the WG chairman. 1. The first Accreditation Committee will be formed by 5 WG members with recognised prestige and merit in the field of acute cardiac care The members of this first committee will also be appointed by the WG chairman. Initially, an automatic accreditation to founding fathers (ICCU directors at the date of October 2006) may be given. They will need to supply formal documents from hospital administration indicating that they hold a permanent formal position as head of ICCU. Those who do not apply within the first three years will be required to sit the examination and present a log-book. Functions The functions of the Accreditation Committee are:  To announce and open the period for the presentation of applications for examination from both professionals and training centres, as well as the management of the same.  Co-ordination of degree and diploma verification, and audit to evaluate the merits of those professionals and centres applying for accreditation, as well as participation in carrying out the same when deemed necessary.  Preparation and composition of theoretical examination exercises.  Maintenance of a question database and practical cases for the composition of future examinations.  Co-ordination and management of examination results.  Offer and attend appeals from candidates regarding the evaluation of the merits they present or the results of the examination.
  13. 13. Draft – 26 October 2008 - ACC Curriculum page 13 of 49  Submit ratification of accreditation of those candidates who are considered suitable by virtue of the results obtained in examination to the WG Nucleus.  Maintain a register of those who are accredited together with their merits and requisites accomplished.  Maintain a register of activities of the current and previous Accreditation Committees.  Promote, plan and organise training courses in co-ordination with the WG Nucleus.  Notify the WG Nucleus of any changes in the accreditation system which is deemed necessary to adapt to changes and evolution in Acute Cardiac Care.  Implement any changes which are deemed necessary to adapt the accreditation system to changes and evolution in Acute Cardiac Care.  Co-ordinate with the relevant bodies of other national or European accrediting entities, and if considered proper, those of non-European, international standing.  Take steps to publicise the accreditation system so it can serve as a reference for third parties.  Keep the WG Nucleus informed about the activities, status and changes in the accreditation system. Meetings  Frequency The Accreditation Committee will hold ordinary meetings at least twice a year. The Secretary to the Committee may call extraordinary meetings at the request of the Chairman of the WG when there are matters of sufficient urgency or importance to warrant the same.  Attendance Accreditation Committee meetings will always be held with a quorum equal to half the members plus one. Dependence The Accreditation Committee will be appointed by and organically dependent on the WG Nucleus. Elections
  14. 14. Draft – 26 October 2008 - ACC Curriculum page 14 of 49 Designation for committee members will be held every three years, but not coinciding with elections for the WG Nucleus members. With the objective of guaranteeing a degree of continuity, no more than 4 members may be re-elected to the committee. The WG Nucleus The WG nucleus is formed by a Chairman, past-chairman, secretary, treasurer and other 8 members from different National Societies. Duties The fundamental duties of the WG Nucleus will be to ratify and legitimise the decisions taken by the Accreditation Committee, and at all times to supervise and rectify any deviation which endangers the integrity of the system. These functions will be as follows:  Settle appeals where there is disagreement with decisions taken by the Accreditation Committee.  Ratify and approve Accreditation of those candidates presented to this end by the Accreditation Committee.  Ratify and approve any proposals for adaptation presented by the Accreditation Committee.  Perform an annual review of the Accreditation System procedures and results, and present the report to the WG members and the ESC‘s Board of Directors.  Ensure the integrity, impartiality and independence of the Accreditation Committee and System. Teams and Evaluators The Accreditation Committee will assign teams of evaluators to assist in the preparation of the examination and to audit merits presented by accreditation candidates. Composition These will comprise WG members who have previously been accredited (initially by members with recognised prestige and merit in the field of acute cardiac care). Duties Evaluators will have the following duties:
  15. 15. Draft – 26 October 2008 - ACC Curriculum page 15 of 49  Assist in preparing and carrying out the theoretical and practical examination.  Assist in auditing the merits presented by accreditation candidates.  Maintain the confidentiality of all data obtained.  Maintain impartiality. Dependence Evaluation teams will be selected directly by the Accreditation Committee and will also be dependent on the same. Note: This composition is proposed as a minimum at the beginning of the activity. Subsequent circumstances will determine the necessities for change of duties and/or the incorporation of additional personnel. PART 2  THE TRAINING PROGRAMME This training is available to board certified or country recognised cardiologists. A comprehensive cardiological background is necessary not only to master the technical aspects of the invasive techniques, but also to recognise the indications, and the contraindications of different treatments for patients in need of intensive acute cardiac care. In addition, the trainee will need to obtain experience in the field of intensive care medicine. In order to achieve these objectives:  The trainee will be a fully trained cardiologist who will have been working for a minimum of over a1 year period in one centre authorized to give this training, and participate fully and regularly in formal and informal training provided by the centre.  the trainee will have been an on-call junior cardiologist responsible for the ICCU for the equivalent of at least 1 night per week for at least three years.  The trainee will undertake a 1-year period to at least 6 months as an ICCU attending physician, 3 months in a general intensive care unit, 1 month in intensive pulmonology/respiratory unit, 1 month in nephrology and 1 month in anesthesia.The trainee should keep a log book to register the patients he/she has taken care of, and invasive and non invasive diagnostic and therapeutic procedures used in each patient. The logbook will be verified by the supervisor.
  16. 16. Draft – 26 October 2008 - ACC Curriculum page 16 of 49 This training should be done in certified training centres for acute cardiac care and under the supervision of certified supervisors (see below). The requirements of the procedures that the trainee needs to perform are listed above (see Part 1, paragraph 4 LEARNING OBJECTIVES). In addition to clinical activities and training, the trainee will be directly involved in the research activities of the training institution. Further, the trainee should attend relevant national and international meetings during their training.  ENTRY REQUIREMENTS FOR CARDIOLOGISTS Applicants for accreditation must meet each and every one of the following requisites: 1. Theoretical and practical training in the diagnosis and treatment of all types of cardiac pathologies and, especially, in cardiac catheterisation techniques, mechanical ventilation, renal replacement therapy and mechanical cardiopulmonary support, insertion of pacemakers , and echocardiographic techniques. (transthoracic and transesophageal) 2. Hold a Cardiology Specialist Qualification issued by a National Authority of Health (or equivalent) or the European Union or, in the future, by the UEMS. Similarly, accreditation will be contemplated for those professionals who hold a Cardiology Specialist qualification issued by a foreign country, always provided that the same is homologated by an equivalent in Europe. Other non cardiologist physicians will be allowed to sit the theoretical examination and will be issued a certification of this examination but will not be accredited as an intensive acute cardiac care cardiologist. 3. Theoretical and practical training in Acute Cardiac Care. Until the system is implemented and available to future professionals, it must be possible to recognise the training of those trained prior to the same. Thus training may be proven by the following two methods: i. Standard method. Full time training of at least one year (in addition to ICCU for Cardiology specialization training) in a centre which is recognised and accredited. Subspeciality training may take place at any time during training in cardiology as well as after its completion.
  17. 17. Draft – 26 October 2008 - ACC Curriculum page 17 of 49 ii. Exceptional method. Formal heads of CCU‘s accredited for training (valid for three years following the implementation of the system) may be awarded accreditation. All staff cardiologists working full time in an ICCU will be immediately recognized as fully trained in ACC 3. Theoretical and practical examinations in Intensive and Acute Cardiac Care: Examination of clinical cases and theoretical questions prepared and co-ordinated by the Accreditation Committee. Accreditation procedure Professionals Applications The Accreditation Committee will announce the period for the submission of accreditation applications through diverse media (letter to all WG on ACC members, WG Web page and other means). Accreditation candidates must submit the following documentation within the aforementioned period:  MD degree (or equivalent)  License to practice medicine  Standard form completed with records and a recent photograph.  Receipt showing payment of Accreditation fees  Curriculum vitae.  Certified photocopy of the Cardiology Specialist qualification issued by the National Authority of Health or the European Union (or equivalent).  Original letter signed and stamped by the Director of the ICCU Accredited for Training, as well as the Head of the Cardiology Department/Service of the corresponding centre, certifying that the applicant has completed a full-time stay of at least one year in the unit detailing the activities undertaken, and the degree of competence attained.  The log-book After evaluation, the Accreditation Committee will send candidates a letter indicating the result of their application and setting a date and place for the examination. The Accreditation Committee retains the right to investigate any applications.
  18. 18. Draft – 26 October 2008 - ACC Curriculum page 18 of 49  REQUIREMENTS FOR TRAINING CENTRES AND TRAINING SUPERVISORS Training centres will be located in hospitals certified by the local/national authorities to train general cardiologists. The ICCU must be part of the Cardiology Department and directed by a cardiologist who has been accredited by the WG on ACC. The hospital may also have other intensive care units where the trainee may complete his/her training. Training centres must be able to offer minimum capacity for training which will be evaluated by the Accreditation Committee in accordance with the following recommendations:  Patient care capacity: Have a staff level which includes at least 2 cardiologists that hold ACC accreditation and a minimum of 4 beds  Research capacity: Maintain a minimum level of scientific activity and interest in Acute Cardiac Care which is endorsed by the presentation of at least 3 Acute Cardiac Care related scientific communications to recognised speciality congresses during the previous three 3 years ( ESC, American Heart Association, American College of Cardiology and European National annual congresses) and the publication of at least one scientific article related to ACC in a journal with an objective ‗impact factor‘ during the previous 3 years. It is expected that the training supervisor is an accredited cardiologist in ACC and the director of the hospital‘s ICCU. Those centres that comply with all the above-mentioned requisites, with the exception of accreditation of their professionals may apply for accreditation for training imparted during the 3 years prior to the implementation of the Accreditation System provided that these obtain accreditation as professionals during the first three years following implementation of the Accreditation System. The training supervisor will supervise training during the whole period and ensure that the trainee becomes fully competent in the subjects and techniques specified in this document. The supervisor should certify the learning skills of the trainee at the end of the training period Application of Training Centres The Accreditation Committee will announce the period for the submission of accreditation applications through diverse media (letter to all WG on ACC members, WG Web page and other
  19. 19. Draft – 26 October 2008 - ACC Curriculum page 19 of 49 means). Accreditation candidates must submit the following documentation within the aforementioned period:  Standard form.  Receipt showing payment of Accreditation fees (audit and evaluation).  Report on the ICCU detailing all the merits for patient care, research and training performed the previous two years.  If there are any doubts on the merits of the centre an audit must be done, the Accreditation Committee may delegate it to the National Working Groups on ACC which would act as team of evaluators under the support and expertise of the Accreditation Committee. For this purpose, candidates for accreditation by this method must attach a standard signed letter of authorisation agreeing to facilitate and cooperate with the eventual audit. After evaluating the applications, checking the documentation and performing appropriate investigations where indicated, the Accreditation Committee will notify candidates about the result of their application by letter. Frequency Accreditation rounds for Training Centres will coincide with those for accrediting professionals.  ADVANCED TRAINING Candidates may wish to undertake a second year of training, with the aim of extending their skills in more specialised techniques. Recertification Professionals and centres must recertify their accreditation at least every 5 years or whenever there is any substantial change in their structure or operation, the latter case may result in the centre requiring recertification by the Accreditation Committee  FUNDING The Accreditation System requires a solid organisational base and this implies structural and personnel costs. Therefore, accreditation fees that cover procedural costs will be
  20. 20. Draft – 26 October 2008 - ACC Curriculum page 20 of 49 established. The costs will include: Travelling fees for Accreditation Committee members and examination teamsand other, miscellaneous expenses. Fees for individuals and training centres must also be defined. PART 3 2. SYLLABUS Cardiologists applying for accreditation on Acute Cardiac Care must be fully trained in general cardiology. Therefore, the following syllabus provided below focuses on the additional, specific aspects of patient care in the ICCU. Thus, other basic cardiologic knowledge is considered a given. 1 – General Core Intensive Care Medicine OBJECTIVES KNOWLEDGE SKILLS ATTITUDES - To obtain the knowledge, skills and behaviours underlying the management of the critically ill, in order to effectively care for patients with cardiac pathology in an intensive care unit setting ref Cobatrice* ref Cobatrice* ref Cobatrice* *CoBaTrICE is the Competency Based Training programme in Intensive Care Medicine for Europe and other world regions, and was developed as an international partnership of professional organisations and critical care clinicians (www.cobatrice.org). 2.- MYOCARDIAL INFARCTION AND ACS OBJECTIVES KNOWLEDGE SKILLS ATTITUDES - To diagnose and treat patients with:  STEACS - Identify clinical characteristics, ECG changes and - Analyse clinical, ECG and laboratory data to diagnose AMI - Choose properly the best treatment strategies for each
  21. 21. Draft – 26 October 2008 - ACC Curriculum page 21 of 49  NSTEACS  Unstable angina laboratory results that are diagnostic of acute myocardial infarction (AMI). - Explain initial risk stratification for STEACS and NSTEACS and the utilization of the different risk scores - Describe the importance of time to treatment and the choices of reperfusion - Outline antithrombin and antiplatelet therapies and other pharmacological treatments: Indications and contraindications - Explain hemodynamic problems related to AMI (left ventricular failure and cardiogenic shock, right ventricular infarction, mechanical problems) - Describe associated arrhythmias (bradyarrhythmias, ventricular - Apply risk scores to stratify patients with ACS - Evaluate time delays and hospital setting to determine the best reperfusion option - Participate in primary angioplasty - Select the optimal pharmacological treatment - Discuss hemodynamic measurements and imaging findings patient - Recognise complications as soon as they appear - Participate in the treatment decision from the emergency room until discharge - Consult with other colleagues on specific matters (image, cardiac catheterization, surgery, electrophysiologists, etc…) - Inform the patient and family members of the prognosis and treatment decisions - Educates patient and family members on secondary prevention measures - Refers to ESC guidelines to choose the best evidence- based therapies
  22. 22. Draft – 26 October 2008 - ACC Curriculum page 22 of 49 arrhythmias and supraventricular arrhythmias). - Outline risk stratification after AMI - Explain secondary prevention measures -Interpret rhythm disturbances - Evaluate short and long-term risk - Select the best secondary prevention strategies 3.- ACUTE HEART FAILURE (AHF) AND CARDIOGENIC SHOCK OBJECTIVES KNOWLEDGE SKILLS ATTITUDES - To diagnose and treat patients with AHF secondary to:  Myocardial disease  Hypertension  Valve disease  Pericardial disease  High output syndromes - Identify the maladaptative responses to heart failure. - Explain symptoms due to heart failure and physical examination findings - Describe diagnostic procedures to: confirm diagnosis, identify causes, prognosis and response to treatment - Outline diagnostic tests: chest X-ray, ECG, oxygen saturation, , general - Interpret clinical findings, chest X-ray, ECG and laboratory data to diagnose AHF - Analyse the causes of AHF in relationship with patients medical history -Interpret results of diagnostic tests to - Choose properly the best treatment strategies for each patient - Recognise complications as soon as they appear - Participate in the treatment decision from the emergency room until discharge - Consult with other colleagues on specific matters (imaging, cardiac catheterization, surgical options, arrhythmia ablation, etc)
  23. 23. Draft – 26 October 2008 - ACC Curriculum page 23 of 49 biochemistry and full blood count, natriuretic peptides imaging (echo, MRI), endomyocardial biopsy. - Identify the need for invasive hemodynamic monitoring - Describe the use of diuretic, vasodilators, and inotropes: Indications and contraindications - Explain when and how to use mechanical ventilation (invasive and non-invasive) - Describe associated arrhythmias - Outline ventricular support (IABP, ventricular assist devices), surgical treatment (CABG, valve replacement, heart transplantation) - Explain predictors of survival and determine the best treatment options - Select the optimal noninvasive and invasive tests to obtain the appropriate diagnosis -Insert PAC or other haemodynamic monitoring devices as necessary - Interpret hemodynamic (invasive and non- invasive) measurements and imaging findings Select the best drug treatment according to changes in patient condition - Apply invasive or non-invasive mechanical ventilation, when needed - Interpret and treat acute rhythm disturbances - Inform the patient and family members of the prognosis and treatment decisions - Educate patient and family members on secondary prevention measures - Refer to ESC guidelines to choose the best evidence- based therapies
  24. 24. Draft – 26 October 2008 - ACC Curriculum page 24 of 49 outcomes - Select the best ventricular support, when needed -Insert IABP, if needed (level III); cooperate with surgeons with ventricular assistance devices - Evaluate short and long-term risk - Select the best secondary prevention strategies 4.- MYOCARDITIS OBJECTIVES KNOWLEDGE SKILLS ATTITUDES - To diagnose and treat patients with myocarditis - Describe the aetiology of acute myocarditis - Explain the pathology of viral, non-viral and non- infective myocarditis - Outline clinical features (fever, chest pain, acute heart failure, arrhythmias,…) - Identify diagnostic - Analyse the causes of myocarditis - Interpret clinical findings, chest X-ray, ECG and laboratory data to diagnose myocarditis - Choose properly the best treatment strategies for each patient - Recognise complications as soon as they appear - Participate in the treatment decision from the emergency room until discharge - Consult with other colleagues on specific
  25. 25. Draft – 26 October 2008 - ACC Curriculum page 25 of 49 tests: chest X-ray, ECG, natriuretic peptides, general biochemistry and full blood count, imaging (echo, MRI), endomyocardial biopsy. - Describe the use of diuretic, vasodilators, inotropes and anthyarrhytmics drugs: Indications and contraindications - Outline the need for ventricular support (IABP, ventricular assist devices) heart transplantation) - Explain predictors of survival and outcomes -Select the best drug treatment according to changes in patient condition - Interpret rhythm disturbances - Select the best ventricular support, when needed -Insert IABP, if needed (level III); cooperate with surgeons with ventricular assistance devices - Evaluate short and long-term risk - Select the best secondary prevention strategies matters (imaging, cardiac catheterization, surgical options, control of arrhythmia, etc) - Inform the patient and family members of the prognosis and treatment decisions - Educate patient and family members on secondary prevention measures - Refer to ESC guidelines to choose the best evidence- based therapies
  26. 26. Draft – 26 October 2008 - ACC Curriculum page 26 of 49 5.- CARDIAC TAMPONADE OBJECTIVES KNOWLEDGE SKILLS ATTITUDES - To diagnose and treat patients with cardiac tamponade - Describe the aetiology of cardiac tamponade - Explain the pathology of cardiac tamponade - Outline signs and symptoms of cardiac tamponade - Describe diagnostic tests: chest X-ray, ECG, general biochemistry and full blood count, and echocardiography - Indicate the need for pericadiocentesis (percutaneous or surgical) - Explain outcomes according to diagnosis - Analyse the causes of cardiac tamponade - Interpret clinical findings, chest X-ray, ECG, echocardiographic findings and laboratory data to diagnose cardiac tamponade -Perform pericardiocentesis (level III) or refer patient to surgical drainage - Evaluate short and long-term risk - Choose properly the best treatment strategies for each patient - Recognise complications as soon as they appear - Participate in the treatment decision - Consult with other colleagues on specific matters (echocardiography, surgical option, oncologist) - Inform the patient and family members of the prognosis and treatment decisions - Refer to ESC guidelines to choose the best evidence- based therapies 6.- ENDOCARDITIS OBJECTIVES KNOWLEDGE SKILLS ATTITUDES - To diagnose and - Identify bacteria, - Discuss the - Choose properly the
  27. 27. Draft – 26 October 2008 - ACC Curriculum page 27 of 49 treat patients with endocarditis fungi and other microorganisms as the cause of endocarditis - Explain the pathophysiology of endocarditis (predisposing lesions, cardiac tissue destruction, anatomic location, immunologic process, embolisation) - Outline clinical findings (cardiac, systemic) - Describe diagnostic tests: general biochemistry, full blood count and inflammatory markers, chest X-ray, ECG, microbiology, echocardiography - Identify the use of antibiotics, medical and surgical treatment: Indications and contraindications - Explain predictors of survival and outcomes relationship between infection and cardiac disease - Analyse the cause of endocarditis in relationship with patient‘s medical history - Interpret clinical findings. -Analyse chest X-ray, ECG, laboratory data and echocardiographic findings to diagnose endocarditis -Select the adequate antibiotic regimen and other medical treatment or surgical procedure - Evaluate short and long-term risk - Select the best secondary prevention strategies best treatment strategies for each patient - Recognise complications as soon as they appear - Participate in the treatment decision from admission until discharge - Consult with other colleagues on specific matters (imaging, surgical options, infectious disease specialist, microbiologist) - Inform the patient and family members of the prognosis and treatment decisions - Educate patient and family members on secondary prevention measures - Refer to ESC guidelines to choose the best evidence- based therapies 7.- DISEASES OF THE AORTA
  28. 28. Draft – 26 October 2008 - ACC Curriculum page 28 of 49 OBJECTIVES KNOWLEDGE SKILLS ATTITUDES - To diagnose and treat patients with  Aortic dissection/ hematoma - Describe and classify aortic dissections /hematoma - Explain the aetiology of dissection /hematoma (intimal tear, hematoma, ulcer, involvement of the media, false lumen) - Outline clinical signs and symptoms (pain, syncope, emboli, pulses, murmurs) - Describe diagnostic tests: chest X-ray, transesophageal echocardiography, CT, MRI, angiography - Identify the use of medical and surgical treatment: Indications and contraindications - Explain predictors of survival and outcomes - Outline long-term treatment - Discuss the relationship between dissection and previous medical history - Interpret clinical findings. - Analyse chest X-ray, and findings from imaging techniques - Select the adequate hypotensive regimen and surgical treatment - Evaluate short and long-term risk - Select the best secondary prevention strategies - Choose properly the best treatment strategies for each patient according to presentation - Recognise complications as soon as they appear - Participate in the treatment decision from admission until discharge - Consult with other colleagues on specific matters (imaging, surgical options) - Inform the patient and family members of the prognosis and treatment decisions - Educate patient and family members on secondary prevention measures - Refer to ESC guidelines to choose the best evidence- based therapies 8.- TRAUMA TO THE HEART AND AORTA OBJECTIVES KNOWLEDGE SKILLS ATTITUDES - To diagnose and - Describe incidence - Discuss the - Choose properly the
  29. 29. Draft – 26 October 2008 - ACC Curriculum page 29 of 49 treat patients with  Trauma to the aorta  Trauma to the heart and causes of trauma to the aorta / heart - Explain the pathophysiology of different trauma (deceleration, penetrating, blunt and electrical trauma. -Identify injured structures and location of rupture - Outline clinical signs and symptoms (pain, hypovolemia, tamponade…) - Describe diagnostic tests: chest X-ray, aortography, CT, echocardiography, myocardial enzymes - Explain the urgency of surgical repair and medical management of pain and other complications - Outline predictors of survival and outcomes relationship between the type of accident and lesions - Interpret clinical findings according to injury and clinical findings. - Analyse chest X-ray, and findings from imaging techniques - Select the adequate surgical treatment and other therapies to treat complications (heart failure, arrhythmias, pain..) - Evaluate short and long-term outcomes best treatment strategies for each patient according to presentation - Recognise complications as soon as they appear - Participate in the treatment decision from admission until discharge - Consult with other colleagues on specific matters (imaging, surgical options) - Inform the patient and family members of the prognosis and treatment decisions - Refer to ESC guidelines to choose the best evidence- based therapies 9.- ARRHYTHMIAS OBJECTIVES KNOWLEDGE SKILLS ATTITUDES
  30. 30. Draft – 26 October 2008 - ACC Curriculum page 30 of 49 - To diagnose and treat patients with  Bradyarrhythmia  Atrial fibrillation  Supraventricular tachychardia  Ventricular tachycardia  VT storm - Identify different rhythm disturbances on surface ECG - Explain symptoms due to bradycardia or tachycardia and physical examination findings - Describe diagnostic procedures: ECG, Holter, carotid sinus massage, tilt-test, invasive electrophysiology, exercise test, echo, MRI - Outline the use of drugs to treat rhythm disturbances and prevention of emboli - Explain indications for: cardiac pacing, external and internal defibrillation, cardioversion, catheter ablation, - Classify tachyarrhythmia by QRS width - Explain the use of imaging techniques to study size and function of cardiac chambers - Interpret surface ECG and clinical findings - Analyse the causes of rhythm disturbances in relationship with patient medical history -Interpret results of diagnostic tests to determine the best treatment options - Select the optimal treatment to end an arrhythmic episode (provisional pacemaker, cardioversion, defibrillation, level III) - Interrogate devices (pacemakers and ICDs) and make measurements and parameter changes - Implant a temporary pacemaker (level - Choose properly the best treatment strategies for each patient - Recognise complications as soon as they appear - Participate in the treatment decision from the emergency room until discharge - Consult with other colleagues on specific matters (arrhythmia ablation, permanent pacemaker, ICD.. - Inform the patient and family members of the prognosis and treatment decisions - Educate patient and family members on secondary prevention measures - Refer to ESC guidelines to choose the best
  31. 31. Draft – 26 October 2008 - ACC Curriculum page 31 of 49 - Outline predictors of survival and outcomes in the different categories III) - Evaluate short and long-term risk - Select the best secondary prevention strategies evidence-based therapies 10.- SUDDEN CARDIAC DEATH AND RESUSCITATION OBJECTIVES KNOWLEDGE SKILLS ATTITUDES - To diagnose and treat patients with  Sudden cardiac death (SCD) - Identify causes of sudden cardiac death - Explain the pathology underlying SCD - Describe the pathophysiology (tachyarrhythmias, bradyarrhythmias, cardiac arrest) - Identify clinical characteristics (onset, survivors..) - Outline techniques of CPR - Identify legal and ethical issues of CPR - Describe use of cardioversion, pacemaker, drugs in advanced life support - Analyse SCD in relationship with patients medical history -Interpret rhythm recordings and circumstances previous to SCD - Select the best treatment to resuscitate the patient: perform CPR, endotracheal intubation, insert a temporary pacemaker, cardioversion, defibrillation (all at level III) - Choose properly the best strategies for each patient - Recognise the need for termination of CPR or ―do not resuscitate‖ orders - Participate actively in the CPR - Consult with other colleagues on specific matters (arrhythmia ablation, permanent pacemaker, ICD.. - Inform the family members of the prognosis and treatment decisions - Educate patient and family members on secondary prevention
  32. 32. Draft – 26 October 2008 - ACC Curriculum page 32 of 49 and resuscitation - Explain associated cardiac conditions leading to SCD - Outline therapies to prevent cardiac arrest (ICD, catheter or surgical ablation, CABG) - Analyse the best drug treatment according to patients response - Interpret associated medical conditions that may have triggered cardiac arrest - Evaluate short and long-term risk - Select the best secondary prevention strategies measures - Refer to ESC guidelines to choose the best evidence- based therapies 11.- PULMONARY EMBOLISM OBJECTIVES KNOWLEDGE SKILLS ATTITUDES - To diagnose and treat patients with  Pulmonary embolism (PE) - Identify incidence and risk factors of PE - Describe clinical characteristics (dyspnea, syncope, tachycardia, hypotension…) - Outline findings on ECG, blood markers (troponins, D-Dimer, BNP), chest X-ray, echo, CT angio - Explain differential diagnosis of acute PE - Describe use of Thrombolytics, embolectomy and - Analyse PE in relation to patients medical history -Interpret clinical signs and symptoms in patients with PE - Evaluate the results of laboratory and imaging in relation to PE - Select the best treatment for PE (need for thrombolysis, support ventilation; level III) - Evaluate short and long-term risk - Choose properly the best strategies for each patient - Participate actively in the diagnosis and treatment - Consult with other colleagues on specific matters (radiologists, surgeons) - Inform the patient and family members of the prognosis and treatment decisions - Educate patient and family members on secondary prevention
  33. 33. Draft – 26 October 2008 - ACC Curriculum page 33 of 49 other medical measures - Outline secondary prevention - Select the best secondary prevention strategies measures - Refer to ESC guidelines to choose the best evidence- based therapies 12.- PULMONARY HYPERTENSION OBJECTIVES KNOWLEDGE SKILLS ATTITUDES - To diagnose and treat patients with  Primary pulmonary hypertension (PPH)  Secondary pulmonary hypertension - Describe definition, classification and epidemiology of PPH and secondary PH - Identify the pathology of PPH and secondary PH - Outline clinical findings - Explain the value of blood tests, blood gases, chest X-ray, CT, MRI, cardiac catheterization, lung scan,… - Outline management: medical and surgical treatments. - Define prognosis -Interpret clinical signs and symptoms in patients with PH - Evaluate the results of laboratory and imaging in relation to PH - Select the best treatment for PH - Evaluate prognosis in relation to the response of management - Choose properly the best strategies for each patient - Participate actively in the diagnosis and treatment - Consult with other colleagues on specific matters (radiologists, surgeons, pneumologists) - Inform the patient and family members of the prognosis and treatment decisions - Educate patient and family members disease management - Refer to ESC guidelines to choose the best evidence- based therapies
  34. 34. Draft – 26 October 2008 - ACC Curriculum page 34 of 49 13.- Sepsis OBJECTIVES KNOWLEDGE SKILLS ATTITUDES - To diagnose and treat patients with  Sepsis  Related inflammatory syndromes - Describe definition, classification and epidemiology of sepsis - Characterize the pathology of sepsis - Summarize clinical findings - Explain the value of blood tests, blood gases, chest X-ray, abdomen X-ray, CT, ultrasonography, echocardiography, etc. - Review management: medical and surgical treatments. - Define prognosis -Interpret clinical signs and symptoms in patients with sepsis - Evaluate the results of laboratory and imaging in relation to sepsis - Select the best treatment for sepsis (e.g. early goal directed therapy, early antibiotic therapy etc.) - Select the best treatment for sepsis:. early goal directed therapy, early antibiotic therapy etc. - Describe monitoring techniques - Adequate hemodynamic monitoring and interpretation of hemodynamic findings - Choose properly the best strategies for each patient - Participate actively in the diagnosis and treatment - Consult with other colleagues on specific matters (microbiologists, infectious disease specialists,…) - Inform the patient and family members of the prognosis and treatment decisions - Educate patient and family members disease management - Refer to ESC guidelines to choose the best evidence- based therapies
  35. 35. Draft – 26 October 2008 - ACC Curriculum page 35 of 49 ANNEX : ESC Report Recommendations for the structure, organization, and operation of intensive cardiac care units Yonathan Hasin1*, Nicolas Danchin2, Gerasimos S. Filippatos3, Magda Heras4, Uwe Janssens5, Jonathan Leor6, Menachem Nahir1, Alexander Parkhomenko7, Kristian Thygesen8, Marco Tubaro9, Lars C. Wallentin10, and Ilia Zakke11 on behalf of the Working Group on Acute Cardiac Care of theEuropean Society of Cardiology 1 Poria Medical Center, M.P. Lower Galilee, Tiberias, Israel; 2 Hopital Europeen Georges Pompidou, Paris, France; 3Evangelismos General Hospital, Athens, Greece; 4 Cardiovascular Institute, University of Barcelona, Spain; 5 Universitat Klinikum, Aachen, Germany; 6Sheba Medical Center, Ramat Gan, Israel; 7 Ukrainian Institute of Cardiology, Kiev, Ukraine; 8Aarhus University Hospital, Aarhus, Denmark; 9San Fillippo Neri Hospital, Rome, Italy; 10 Uppsala Cardiothoracic Center, Uppsala, Sweden; and 11P. Stradins Clinical University Hospital, Riga, Latvia Received 15 September 2004; revised 1 February 2005; accepted 10 February 2005; online publish-ahead-of-print 21 March 2005. Eur Heart J 2005 Aug; 26(16):1676-82 Keywords Intensive care unit; Acute cardiac care; Functional recommendations; Medical equipment Abstract Two major changes in patient characteristics and management occurred recently that demand distinctive alterations in the function of the intensive cardiac care unit (ICCU). These changes include the introduction of an early invasive strategy for the treatment of acute coronary syndromes, enabling early recuperation and shorter need for intensive care on the one hand, while the number of older and sicker patients requiring prolonged and more complex intensive care is steadily increasing. A task force of the European Society of Cardiology Working Group on Acute Cardiac Care was set to give a modern updated comprehensive recommendation concerning the structure, organization, and function of the modern ICCUs and intermediate cardiac units. These include the statement that specially trained cardiologists and cardiac nurses who can manage patients with acute cardiac conditions should staff the ICCUs. The optimum number of physicians, nurses, and other personal working in the unit is included. The document indicates the desired architecture and structure of the units and the intermediate cardiac unit and
  36. 36. Draft – 26 October 2008 - ACC Curriculum page 36 of 49 their relations to the other facilities in the hospital. Specific recommendations are also included for the minimal number of beds, monitoring system, respirators, pacemaker/defibrillators, and necessary additional equipment. The desired function is discussed, namely, the patients to be admitted, the length of stay, and the relocation policy. A uniformed electronic chart for ICCUs is advised, anticipating a common European database. Introduction The following represents an expert consensus document written by the nucleus members of the European Society of Cardiology (ESC) Working Group for Acute Cardiac Care (ACC). The first description of the intensive cardiac care units (ICCUs) was presented by Julian (1) to the British Thoracic Society in 1961 and was based on monitoring patients with acute myocardial infarction (AMI) for the early diagnosis and treatment of ventricular fibrillation. Nevertheless, significant benefit of the units was not obtained until some decisive policy changes were made, including treatment protocols and structural organizations (2). The current objectives of the ICCUs are the monitoring and support of failing vital functions in acute and/or critically ill cardiac patients, in order to perform adequate diagnostic measures followed by medical and invasive therapies to improve outcome. The current published literature regarding the structure, operation, and function of ICCUs is insufficient because of the following reasons: it focuses on non-cardiac care (3), it is limited to part of the needs(4), it describes only local standards (5) it is published in non-English literature (6) or it is very old (7). In a continental survey among hospitals from different parts of Europe, a great deal of divergence was found concerning the whole spectrum of organization and function of ICCUs (ESC WG on Acute Cardiac Care; unpublished results). The ESC Working Group on ACC was established in 2001. One of its declared tasks is to improve and unify the function of ICCUs across Europe. A task force composed of the nucleus members of the Working Group set out to write the following document in order to provide an updated guide indicating the minimal optimal requirements for the modern functioning ICCU. The manuscript is based on the current available literature; it reflects the existing working states in different European countries and the personal opinion of the task force members. The manuscript has undergone extensive revision by the Guideline Committee of the ESC and by the editorial board of the European Heart Journal. Local modifications should be implemented according to the local special needs derived from specific patient case-mix, available resources, and different laws and regulations.
  37. 37. Draft – 26 October 2008 - ACC Curriculum page 37 of 49 Two changes occurred over the past two decades that demand distinctive alterations in the function of the ICCUs in the next decade. Changes will take place both in the patient population admitted to the ICCU and in the medical care supplied. (i) Emergency reperfusion treatment policies (non-invasive or invasive) were adopted as an accepted standard of care in patients with AMI (8). These policies dictate the necessity for special attention and immediate treatment of the patients early on, but after the success of the initial treatment, the patients show immediate drastic improvement in many cases. Follow-up and management are simpler and easier than in the past, recovery is faster, and the average length of stay is shorter. (ii) The medical profession has reached a level of specialization in which the cardiologists and the intensive care physician are impelled to establish a long-term treatment policy for their patients rather than take care of only the patient‘s immediate and urgent problems. Patient population Acute coronary syndrome (ACS) will probably remain the most frequently primary admission diagnosis in ICCU in the next decade. Today these patients are treated effectively and quickly in different ways, thus the length of stay both in the unit and in the hospital is expected to decrease. On the other hand, the aging population in Europe, with increasing co- morbidities will probably change the ICCU population. Dramatic improvement in therapeutic measures will lead to a better outcome, with a prolonged survival for patients with coronary artery disease, with either a normal or a depressed left ventricular function. Therefore, the case-mix of our patients in the ICCU will change dramatically in the next decades. As the population is aging, the unit will have to treat elderly patients who tend to suffer from multisystem diseases; the number of patients treated by multiple percutaneous or surgical revascularization procedures will increase; moreover, the ICCU is becoming the treatment centre for patients suffering from severe cardiac arrhythmias and decompensate heart failure or different combinations of diseased heart and other organs. As a result, it may likely be that the ICCU will be utilized for more complex patients who require a relatively longer length of stay in the Unit and will provide the treating staff with a special challenge. For these reasons, the requirements of the ICCU will increase, not decrease. A special group of patients are those suffering from complications following invasive treatments in the catheterization lab. The still growing number of severe cases with multivessel disease, complex lesions, reduced left ventricular function, and a multitude of co-morbidities treated in the catheterization lab may increase the number of complications during and after coronary
  38. 38. Draft – 26 October 2008 - ACC Curriculum page 38 of 49 intervention procedures. These patients represent a special group of patients admitted to the Unit and need specific cardiological nursing and medical expertise. Treatment policies Reperfusion in acute ST-elevation myocardial infarction patients is undoubtedly an emergency (9). Direct mechanical revascularization is becoming more and more popular, even though its availability is still restricted owing to lack of trained staff and budget constraints. In the near future, the catheterization laboratory and the ICCU will become more and more inseparable. In the coming decade, the cardiologists will continue to observe constant efforts of the pharmaceutical industry to improve reperfusion at the patient‘s bedside, with new, more efficient thrombolytics, anticoagulants, and antiplatelets agents, and more effective interventional therapy, which, in combination with newly developed drugs aimed at the salvage of the microvasculature and of the myocardium from ischaemia/reperfusion injury, will hopefully improve outcome in these patients. This pre-vision has clear implications for the necessity of constantly updating the Units about novel resources for diagnosis and treatment, as well as preparing them to participate in multicentre research in order to determine the efficacy of the new therapeutic developments. Professionalization of medicine is becoming more intense, with the need for cardiac patients be treated preferentially by properly trained cardiologists. In those hospitals in which the patients are transferred directly to the internal medicine ward, the physician in the Unit is compelled to determine a long-term treatment policy, in addition to being obliged to provide acute treatment. Thus, the different Units will develop methods for prognostic stratification (index-risk stratification), which will most probably include a combination of clinical data (age, sex, heart rate, blood pressure); ECG (ST-segment depression or elevation, T-wave inversion); cardiac markers of elevation, especially troponin; evaluation of the left ventricular function; residual ischaemia; and electrical instability. Staff The change in patient population and treating policies necessitate appropriate staff training. An increase in the number of complex and/or elderly patients (who may need respiratory treatment, intra-aortic balloon counter pulsation, haemodynamic complex monitoring, or dialysis) and participation in multicentre research projects require suitable training of the physicians and the nursing staff. It is reasonable that for specific specialization, there will be suitable training and accreditation both for physicians and for nurses, especially for the research nurses who will be an integral part of the ICCUs nursing staff.
  39. 39. Draft – 26 October 2008 - ACC Curriculum page 39 of 49 Equipment The standard monitoring equipment, including invasive and non-invasive electrocardiographic, haemodynamic, and respiratory assessment, will continue to be the basis of the ICCU (10) Monitoring for the evaluation of autonomous function and electrical instability (heart rate variability, baroreceptor sensitivity, signal average electrocardiogram, and built-in continuous ECG Holter monitoring (11) is likely to be added to standard equipment. Non-invasive assessment of cardiac function such as cardiac output (12,13) as well as continuous CO2 and O2 saturation monitoring, is becoming available and is routinely used in the modern ICCU. Computers are a part of the everyday monitoring of the patients; it is used for collecting and analysing patient‘s data. A uniform electronic database management system of all the European ICCUs is an important task for the Working Group on ACC, including at least basic demographic and clinical data, modes of interventions, and in-hospital outcome. This will make communication among the different ICCUs simpler and could serve as database with an enormous source of information both for research and for quality control purposes. Functional recommendations ICCU patients The decision to admit a patient will be made by the ICCU physician on duty; in case of physician disagreement, the decision will be made at the senior physician level. It is advisable for the following patients to be routinely admitted to the ICCU (14,15) (i) any patient with suspected acute ST-elevation myocardial infarction, up to 24 h from the onset of symptoms, especially if suitable for thrombolytic or primary angioplasty treatment; (ii) patients with AMI, presenting .24 h after onset of symptoms with complications, or unstable high-risk patients (heart failure that requires intravenous therapy or haemodynamic monitoring or support of an intra-aortic balloon, serious cardiac dysrrhythmias, conduction disturbances, temporary pacemakers); (iii) patients in cardiogenic shock; (iv) patients with high-risk unstable coronary syndromes (e.g. ongoing or repeated anginal pain, heart failure, significant diffuse ST-depression, dynamic ST-shift, elevated troponins); (v) unstable patients after a complicated percutaneous coronary intervention (PCI), who need special attention (at the discretion of the PCI operator); (vi) patients with life-threatening cardiac arrhythmias, as a result of ischaemic heart disease, cardiomyopathy, rheumatic heart disease, electrolyte disturbances, drug effects, or poisoning;
  40. 40. Draft – 26 October 2008 - ACC Curriculum page 40 of 49 (vii) patients with acute pulmonary oedema unresolved by initial therapy and depending on the underlying conditions; (viii) patients in need of haemodynamic monitoring for evaluation of therapy; (ix) patients after a heart transplant with acute problem, i.e. infection, haemodynamic deterioration, electrolyte imbalance, suspected acute rejection, and so on; (x) massive pulmonary embolism. This list is conclusive and should be adapted according to each individual case. Length of stay in the ICCU . The length of stay in the ICCU should be primarily planned to be at least 2–4 days, dictated by the individual clinical presentation. . Patients with ST-elevation myocardial infarction without complications should continue the treatment in the ICCU for 48 h. . Patients with unstable coronary syndromes with dynamic ST-shift and elevated cardiac troponins should stay in the ICCU until 24 h after the latest episode of ischaemia (non-invasive or planned invasive treatment, as dictated by ESC guidelines). . High-risk ACS patients after acute PCI (with GP IIb/IIIa antagonists) should stay in the ICCU until the stable phase. Relocation policy . Once stabilized, patients are transferred from the ICCU to a cardiac intermediate care unit (with a simple electrocardiographic monitoring and run by cardiology oriented staff) or to the general ward, according to the local policy. After a short stay, an out-of-hospital specialized recreation facility is recommended prior to going back home. An alternative route is outpatient rehabilitation clinic. . It is advisable to discuss the following with the patient in the presence of one of their dominant family members: medications, return to activities, risk factors and life-style modifications, a healthy diet, and recommendations for future tests (invasive and non-invasive) including an appointment for the outpatient follow-up clinic; this should be done shortly before their discharge from the ICCU. Intermediate cardiac care unit patients Decision to admit a patient to the intermediate ward is at the discretion of the treating physician, and according to the local policy at the particular institution (16). It is recommended to consider the following conditions:
  41. 41. Draft – 26 October 2008 - ACC Curriculum page 41 of 49 (i) intermediate risk unstable coronary syndrome patients; (ii) patients in first stages of recovery from myocardial infarction; (iii) patients with uncontrollable cardiac insufficiency not responsive to regular oral therapy, especially those with co-morbidities; (iv) patients with heart disease in need of medical therapy adjustment, special cardiac investigations (e.g. electrophysiological study, cardiac catheterization, etc.), or some of the patients after special cardiac procedure (e.g. implantation of permanent pacemaker or internal cardiac defibrillators). Number of beds in the ICCU The number of beds in the ICCU must suit the size of the reference population and the relative specific workload of the hospital. The hospital‘s specific workload can be evaluated in a number of ways: the simplest measure of the relative workload is the number of visits to the hospital‘s internal emergency room. Recommended formula for calculation: (i) for each 100 000 inhabitants, four to five ICCU beds; (ii) for every 100 000 visits per year in the internal emergency room, 10 ICCU beds. The number of beds will be determined according to the highest of the two. Number of beds in the intermediate cardiac care unit The desired ratio of beds between ICCU and the intermediate CCU is 1:3. ICCU equipment (i) Patient monitoring unit: the basic patient monitoring unit must include at least two ECG channels, invasive pressure channel, non-invasive blood pressure monitor, and an SaO2 metre. It is desirable that 50% of the beds include the following additional basic parameters: five ECG channels, two additional haemodynamic channels, end tidal CO2, non-invasive cardiac output, and thermometer. (ii) Nurse station: to be used for central monitoring and analysing. At least one ECG lead from each patient as well as relevant haemodynamic and respiratory data should continuously be present on a central screen. Slave monitors should be installed to enable monitoring of patients from different sites of the unit, as well as working stations for retrospective analysis of index events, i.e. changes in heart rate, rhythm disturbances, ST-events (ST-segment changes algorithm), heart rate variability, blood pressure, O2 saturation, and so on.
  42. 42. Draft – 26 October 2008 - ACC Curriculum page 42 of 49 Patients beds for the ICCU Beds in the ICCU have to allow vertical movement, with the possibility of up and down head and leg positioning. Every bed must be equipped with oxygen, vacuum, and compressed- air intakes. It is desirable that one of the beds be suitable for patients with active contagious infectious diseases (e.g. methicillin resistant Staphylococcus aureus, HIV, tuberculosis, etc.) and filtered accordingly. It is important to make sure that the patient can be X-rayed on the bed. Additional equipment (17) . Volumetric pump/automatic syringe: four to six per bed; . mechanical respirators (including CPAP delivery system to use with face mask): one machine per two beds; . intra-aortic balloon pump: one consol every three beds, up to the first six patients; . haemodyalisis/haemofiltration machine: should be available (probably more cost effective if supplied by the nephrology department); . pacemaker defibrillator (possibly biphasic): one apparatus every three beds; . external pacemaker: one to two every six to eight beds; . temporary pacemakers: three to four VVI and one DDD every six to eight beds; . mobile echocardiography machine: one (consider a portable one, according to future technology development), including a TEE probe; . blood clot metre (ACT): one; . biochemical markers kits, for myocardial infarction, optional (to be omitted provided that the biochemistry tests are in the central laboratory in ,30 min; . glucose level measurement kit: one; . blood gasses and electrolyte analyser: optional (to be omitted provided that the results of the blood gas and electrolyte tests come back from the central lab within 10 min); . X-ray system for fluoroscopy: digital cardiac mobile C-arm enabling coronary angiography is recommended; * Ideally, a fully equipped catheterization and PCI laboratory should be in close association with the Unit and ready to perform invasive procedure on a 24 h basis. * An alternative route would be an available mobile unit to transfer a patient in need to a near by catheterization laboratory. . mechanical compression devices used for groin and radial homeostasis: optional. ICCU and intermediate CCU staff . (physicians: cardiologists/residents in cardiology/cardiology fellows) . Physicians (day time shift):
  43. 43. Draft – 26 October 2008 - ACC Curriculum page 43 of 49 . Department head: a certified cardiologist. . First six beds: one physician every three beds. . If more than six beds: one physician every four beds. The ICCU should be staffed by at least one physician for every three to four patients, including the Unit director. The director of the Unit should be a board certified cardiologist, specially trained and accreditated as an acute cardiac care specialist, as cardiologists are the physicians better trained to assist patients with ACS and lifethreatening cardiac diseases. The cardiologist in charge of the ICCU should be skilled in treating urgent cardiac situations, including rhythm and haemodynamic disturbances and acute ischaemia. The cardiologist must be skilled at inserting an endotracheal tube, a temporary pacemaker, a catheter in the pulmonary artery, and a balloon in aorta for counter-pulsation. The cardiologist should be able to perform a transthoracic echo study on a basic level (i.e. evaluate the left ventricle systolic function, identify severe valvular disease, and find pericardial fluid) and should have further training in the general intensive care unit. On-duty and on-call physicians A skilled physician on duty should be present in the Unit at all times. This physician should be able to handle acute cardiac emergencies after short local training and approval for night duties by the director of the unit. An attending cardiologist on call should always be available for consultation and assistance. Nurses Nurses are as important as physicians. Proper nursing staff is the strength of the ICCU. A head nurse for the ICCU is appointed with authority and responsibility for the appropriateness of nursing care; they must have extensive experience in intensive care nursing and proper medical managerial skills, must be able to conduct routine nursing activity of the unit, must be involved in the on-going training of the unit staff, and must take an active part in research activities. The ICCU will employ only registered nurses. At least 75% of them should have completed formal intensive care training (which includes formal cardiology training)(18). A unified recommendation for the size of the nursing staff is an intricate issue hampered by the divergence of nursing working habits and skills, case-mix of patients, and different Therapeutic Interventions Scoring System levels (19). The following recommendation is based on the estimated workload of an average ICCU, the calculated Whole Time Equivalents (20), and the personal experience of the authors.
  44. 44. Draft – 26 October 2008 - ACC Curriculum page 44 of 49 Furthermore, allocating nursing manpower should take into account the need for the number of shifts per day, the number of beds in the units, the desired occupancy rate, extra manpower for holidays, and the ability to transfer the nurses from one facility to the other (intensive to intermediate to cardiology and vice versa). The nursing staff should be constructed of at least 2.8 nurses per bed, to cover three shifts per day, so that the minimal number of nurses in a given time will be at least one nurse per two beds during day time and one per three beds during night shift (21,22). The intensive care nurse should have further training once in at least 5 years in the general intensive care unit. It is also advisable that further training courses be reciprocal so that the nurses working in the general intensive care unit could work in the cardiac intensive care unit as well. Intermediate cardiac care unit staff . Department head: a certified cardiologist. . First 12 beds: one physician every six beds. . If more than 12 beds: one physician every eight beds. . Nurses: 1.8 nurses per bed. Additional staff . Secretary and nurse assistant- full time. . Dietician, computer expert (hardware and software), ventilation technician, social worker, physiotherapist, porters, and cleaners—part time. ICCU and intermediate CCU: construction (23–25) (i) The cardiac intensive care unit/intermediate unit/ cardiac ward should be constructed as an independent ward in the hospital (26) (ii) The desired intensive care unit standard is a separate room for each patient and up to two to three patients per one room in the intermediate unit. (iii) There should be at least one single bedroom with thepossibility to isolate patients with contagious infection. (iv) The architecture of the unit should be designed to make it possible to observe the patients from the nurses‘ monitoring station and to have easy and fast access. (v) The station should be in a central position and well equipped, and the surrounding area will be spacious so as to afford optimal working conditions.
  45. 45. Draft – 26 October 2008 - ACC Curriculum page 45 of 49 (vi) The separate intensive care procedure room should be spacious enough so that it can contain all the physicians (cardiologists, anaesthesiologists, nurses, technicians) and multitude of bulky equipment (X-ray machine, heavy monitoring, intra-aortic balloon pump) necessary to initiate treatment for a complicated acute case. The minimal area should be 25 m2. The room must have washable walls for 2 m in height. Construction should fit requirement for the use of X- ray fluoroscopy. (vii) The electrical equipment should have an emergency feeding and a continuity apparatus. (viii) Windows in the intensive care ward are desirable, but not a pre-requisite. (ix) The lighting should be good, but not dazzling; lightning should be indirect. (x) A dialysis facility (source of water and sewage) should be established in a few rooms as necessary. (xi) In larger intensive care units, one should consider dividing the nurses station into two or three according to the number of beds. It is advised that one nurses station should serve not more than six to eight beds. (xii) The cardiac intensive care unit should be situated as close as possible to the emergency room, the catheterization lab, general intensive care unit, and operating theatres (if available in the institution). (xiii) It is also desirable that the intensive care ambulance may have a direct access to the unit, so that in appropriate cases, a patient may be directly admitted, bypassing the emergency department. Other areas to be included (i) staff rooms (meeting the demands of the secretary, medical staff, nursing staff, patient relatives‘ interview, physician on-call dormitory, head nurse, and director of the unit); (ii) meeting room; (iii) family waiting room; (iv) office; (v) store room (a lot of electronic equipment that requires constant electricity recharge); (vi) computer communications—inter-departmental. Departments and laboratories—an external system. Database The computer system is regarded as a positive means of collecting information, at local, national, and international levels. It facilitates everyday activities in patient management and data archiving. It can be used as database and enables analysis of information and quality control.
  46. 46. Draft – 26 October 2008 - ACC Curriculum page 46 of 49 Nevertheless, there are objective difficulties and obstacles on the way to adopt a uniform programme to be used as a continental database. (i) Currently, there is no accepted optimal software for cardiac intensive care patients. (ii) Many of the cardiology departments in Europe have a computer system with or without connections to similar systems within or out of the hospital. (iii) Development of computerized systems depends on strategic decisions made by different Health System Authorities, both at national and at hospitals levels. Therefore, it will be impossible to introduce a uniform programme across Europe. (iv) The existing programmes, and those to be developed in the near future, are based on different software systems. Effort and resources should be invested for the connection of those systems into a common database. It is recommended that the ICCU will use an electronic chart routinely. This could facilitate patient admission, discharge, and follow-up as well as research and quality control. As several hardware and software facilities are available, and obviously many Units in Europe have already implemented their own electronic chart, a common European electronic chart would be an impractical dream. Yet, some key items common to all electronic charts could be chosen, transmitted through the internet, and will be used as a common European database for patient admitted to the different ICCUs. Recently, the European Society of Cardiology launched the Cardiology Audit and Registration Data Sets (CARDS) initiative, under the auspices of the European Union (27). One of the three main issues in CARDS is ACS, and the related Expert Committee on ACS published a report on the data standards for a ICCUs DB on ACS. This data set can constitute the common basis for all the different databases in European ICCUs, allowing interoperability and data sharing. Quality assurance should be an integral part of the organization and standards of a ICCU: processes currently considered effective for patients outcome, such as adequately timed reperfusion and evidence-based care at discharge, should be monitored and quality control performed reviewed at least on an annual basis, together with personnel and administrators. Conclusion The current recommendations have been written as a guide and a rule for the function of a modern ICCU. The exponential speed of changes in technology, procedures, and treatment policies will undoubtedly provide a repeated need for updating these guidelines. For instance, what will be the effect of chest pain units (which are emerging throughout Europe) on the ICCU? In the near future, reference centres for primary or facilitated PCI for ST-elevation myocardial infarction, as well as for early intervention in patients with non-ST-elevation myocardial infarction,
  47. 47. Draft – 26 October 2008 - ACC Curriculum page 47 of 49 will play a key role in the treatment of patients with ACS. The concept of networking for the coordination among tertiary centres, community hospitals, emergency rooms, and transportation, might also result in a need for updating. The lack of evidence-based recommendation on the structure and function of ICCUs call upon properly designed studies looking at unresolved issues such as numbers of ICCU beds required for a given populations size, specific equipment, required personnel, and alike. References 1. Julian DG. The history of coronary care units. Br Heart J 1987; 57:497–502. 2. Killip T, Kimball JT. Treatment of myocardial infarction in a coronary care unit: a two year experience with 250 patients. Am J Cardiol 1967;20:457–464. 3. Ferdinande P. Members of the Task Force of the European Society of Intensive Care Medicine. Recommendations on minimal requirements of Intensive Care Departments. Intensive Care Med 1997;23:226–232. 4. Merkouris A, Papathanassoglou ED, Pstolas D, Papagiannaki V, Floros J, Lemonidou C. Staffing and organizations of nursing care in cardiac intensive care units in Greece. Eur J Cardiovasc Nurs 2003;2:123–129. 5. Valle Tudela V, Alonso Garcia A, Aros Borau F, Gutierrez Morlote J, Sanz Romero G, Spanish Society of Cardiology. Guidelines of the Spanish Society of Cardiolgy on requirements and equipment of the coronary care unit. Rev Esp Cardiol 2001;54:617–623. 6. Ruda Mla. Intensive care units for patients with acute coronary insufficiency. Kardiologiia 1976;16:148–158. 7. Shachtman J, Fields J, Craig S. Basic design and equipment needed for a coronary care units. Isr J Med Sci 1967;3:287–294. 8. Fuster V. 50th anniversary historical article. Myocardial infarction and coronary care units. J Am Coll Cardiol 1999;34:1851–1853. 9. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomized trials. Lancet 2003;361:13–20. 10. Mangan B. Structuring cardiology services for the 21st century. Am J Crit Care 1996;5:406– 411. 11. Leeper B. Continuous ST-segment monitoring. AACN Clin Issues 2003;14:145–154. 12. Cotter G, Moshkovitz, Y. Kaluski E, Cohen AJ, Miller H, Goor D, Vered Z. Accurate, noninvasive continuous monitoring of cardiac output by whole-body electrical bioimpedance. Chest 2004;125:1431–1440.
  48. 48. Draft – 26 October 2008 - ACC Curriculum page 48 of 49 13. Mielck F, Buhre W, Hanekop G, Tirilomis T, Hilgers R, Sonntag H. Comparison of continuous cardiac output measurements in patients after cardiac surgery. J Cardiothorac Vasc Anesth 2003;17:211–216. 14. Nasraway SA, Cohen IL, Dennis RC, Howenstein MA, Nikas DK, Warren J, Wedel SK. Guidelines on admission and discharge for adult intermediate care units. American College of Critical Care Medicine of the Society of Critical Care Medicine. Crit Care Med 1998;26:607–610. 15. Bone RC, McElwee NE, Eubanks DH, Gluck EH. Analysis of indications for intensive care unit admission. Clinical efficacy assessment project: American College of Physicians. Chest 1993;104:1806–1811. 16. Task Force of the American Society of Critical Care Medicine. Guidelines on Admission and Discharge for Adult Intermediate Care Units. Crit Care Med 1998;26:607–610. 17. Quinio P, Baczynski S, Dy L, Ferrec G, Catineau J, de Tinteniac A. Evaluation of a medical equipment checklist before intensive care room opening. Ann Fr Anesth Reanim 2003;22:284– 290. 18. Depasse B, Pauwels D, Somers Y, Vincent JL. A profile of European ICU nursing. Intensive Care Med 1998;24:939–945. 19. Miranda DR, Nap R, de Rijk A, Schanufeli W, Lapichino G, TISS Working Group. Therapeutic intervention scoring system. Nursing activities score. Crit Care Med 2003;31:374–382. 20. Galley J, O‘riordan B, Royal College of Nursing. Guidance for nurse staffing in critical care. Intensive Crit Care Nurs 2003;19:257–266. 21. Williams G, Clarke T. A consensus driven method to measure the required number of intensive care nurses in Australia. Aust Crit Care 2001;14: 106–115. 22. Pronovost PJ, Jenckes MW, Dorman T, Garrett E, Breslow MJ, Rosenfeld BA, Lipsett PA, Bass E. Organization characteristics of intensive care units related to outcomes of abdominal aortc sugery. JAMA 1999;281: 1330–1331. 23. Wedel S, Warren J, Harvey M, Hitchens Biel M, Dennis R. Guidelines for Intensive Care Unit Design. Crit Care Med 1995;23:582–588. 24. Ferdinande P. Recommendations on minimal requirements for Intensive Care Departments. Members of the Task Force of the European Society of Intensive Care Medicine. Intensive Care Med 1997;23:226–232. 25. Valle Tudela V, Alonso Garcia A, Aros Borau F, Gutierrez Morlote J, Sanz Romero G; Spanish Society of Cardiology. Guidelines of the Spanish society of cardiology on requirements and equipment of the coronary care unit. Rev Esp Cardiol 2001;54:617–623. 26. Fracchia C, Ambrosino N. Location and architectural structure of ICCU. Monaldi Arch Chest Dis 1994;49:496–498.
  49. 49. Draft – 26 October 2008 - ACC Curriculum page 49 of 49 27. Flynn MR, Barrett C, Cosio FG, Gitt AK, Wallentin L, Keamey P, Lonergan M, Shelley E, Simmons ML. The Cardiology Audit and Registration Data Standards (CARDS), European data standards for clinical cardiology practice. Eur Heart J 2005;26,208–313.

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