Harmonising paediatric anaesthesia training in Europe

Abstract

Children have the right to receive the highest attainable standard of care under the United Nations Convention on the Rights of the Child (www.ohchr.org/en/professionalinterest/pages/crc.aspx). This declaration has been signed by almost 200 countries worldwide. However, we are still far away from fulfilling this commitment in anaesthesia1,2 with ongoing efforts hampered by the lack of physical resources, organisation and training of clinicians. We feel confident that the training and education of clinicians in paediatric anaesthesia can and must be improved and harmonised across Europe. Additionally, the provision of safe anaesthesia for children means performing a minimum number of cases per year as well as life-long continuous education. Children are ten times more likely than adults to suffer complications related to anaesthesia. Children who are harmed by anaesthesia often suffer devastating consequences.3–14 Even healthy infants with a long life expectancy are at risk, as are those children who are disadvantaged and/or critically ill. Serious complications in paediatric anaesthesia are associated with higher mortality when compared with adult anaesthesia.8 Children are different from adults from an anatomical, physiological, pharmacological, psychological and social standpoint.15,16 When a clinician is not adequately trained and/or does not operate within a secure clinical environment, these differences can significantly impact morbidity and mortality17,18 The APRICOT and NECTARINE studies and subsequent sub-analyses have revealed that there is wide variation in the performance of practices across Europe.1,2 Therefore, there is an urgent need to coordinate and harmonise education and training in paediatric anaesthesia in Europe.19 Over the past 2 decades, several training programmes in paediatric anaesthesia and intensive care have been introduced and tailored to regional needs. Among these programmes, the Scandinavian training programme in paediatric anaesthesia (www.ssai.info/education/paediatric-anaesthesia) is the most developed.20 However, a unified European approach to education and training remains elusive. In 2016, the Safetots initiative was established to improve quality and safety in paediatric anaesthesia worldwide in (www.safetots.org).16 Specifically, it emphasises that the quality of anaesthesia management and the well-known risk factors associated with perioperative care affect surgical outcomes and can be modified. Importantly, it describes the 5 Ws (www.safetots.org/professionals/competence-5w/): the ’who’, the ’where’, the ’what’, the ’when’, and the ’how’. A definition of the paediatric anaesthetist is the subject of this proposal, as the last 4 Ws are pivotal in defining the organisation of paediatric anaesthesia care. We propose that specially trained paediatric anaesthetists should treat children younger than 3 years with underlying congenital and metabolic diseases as well as children irrespective of age who undergo major or complex surgery as they are most susceptible to perioperative complications and poor outcomes. Otherwise healthy children who are 3 years or older undergoing simple and routine procedures may be attended to by anaesthetists who have enough experience in paediatric anaesthesia, and are competent in all aspects of their practice. Anaesthesia care for neonates and small infants is clinically challenging and is characterised by high risk and low error tolerance. As a ‘hands-on’ (craft) speciality, anaesthesia demands theoretical knowledge, manual dexterity and experience, which can only be gained through regular direct contact with patients and bedside teaching. Several studies have shown an inverse relationship between paediatric anaesthesia specialisation and perioperative morbidity and mortality.1,2,4–10,21 However, clinical circumstances and the relatively small number of paediatric cases admitted to most hospitals impede the establishment of an optimal training environment. The lack of experience in rare congenital abnormalities may further compromise the standard of care for these infants. Patients and parents are now better informed and have higher expectations of their doctors. Besides evaluating the qualifications of doctors, they can ask probing questions about their training and experience as well as the risks and outcomes of various treatments. Soon, both institutions and individual doctors will be expected to demonstrate adequate training, maintenance of standards and outcomes. The European paediatric anaesthesia services must be organised in a way that also meets reasonable parental expectations. The proposal Training in paediatric anaesthesia has been significantly hampered by a decline in working hours caused by mandatory time off in lieu of on-call shifts. This has implications, not only for sufficient education and training but also for staff to adequately retain their clinical and theoretical skills and competencies. The current document proposes a roadmap for the creation of a paediatric anaesthesia curriculum under the umbrella of the European Society of Anaesthesiology and Intensive Care (ESAIC) and the European Society for Paediatric Anaesthesiology (ESPA) specifying the minimum amount of education and training required for paediatric anaesthesia across Europe and suggesting harmonisation of programs and certification requirements. Training in paediatric anaesthesia should be competency-based with ongoing assessment and supervision. In recommending the actual caseload, this should be viewed as a guide, not as an absolute requirement. Across Europe, we need to define the following: (1) Who is a ‘paediatric anaesthetist’, what is the role, and what are the required qualifications for this position? (2) What is the minimum duration of paediatric anaesthesia training and what is required to maintain expertise? (3) What are the learning objectives (theoretical and practical) necessary to achieve and maintain expertise in paediatric anaesthesia. (4) What overarching strategies are necessary to achieve and sustain training requirements (theoretical courses, practical skills, integrated learning pathways, e-learning, simulations, CME)? We propose two levels of the process. First, the basic training of all anaesthetists who practice in district general hospitals, office-based centres and private clinics should have received adequate education and training in the anaesthetic care of healthy children 3 years or older who undergo routine and simple procedures. Second, the more specialised training of anaesthetists interested in working in specialised paediatric centres. Having a clear distinction between paediatric anaesthesia and ‘general’ anaesthesia will also benefit low-income countries by directing their anaesthesia training and enhancing patient safety. Minimum paediatric anaesthesia competence To better define paediatric anaesthesia knowledge and skills as it pertains to trainees studying anaesthesia and anaesthetists in district hospitals with exposure to paediatric practice, the following points must be addressed: (1) Understanding neonatal and paediatric anaesthesia issues, including airway management, anatomy, physiology and pharmacology. (2) Ensuring a safe induction and maintenance of and emergence from general anaesthesia, providing perioperative care (pain prevention, postoperative nausea and vomiting prevention, emergence agitation) to otherwise healthy children >3 years of age, and being able to safely care for a healthy child undergoing routine procedures. (3) Master monitoring and equipment for paediatric patients, including peripheral vascular access (including intraosseous access). (4) Master critical situations in paediatric anaesthesia (www.safetots.org/professionals/crisis-10c/). Anaesthetists who have completed their general specialist anaesthesia training should have completed basic paediatric anaesthesia training and thus should be capable of providing anaesthesia and postanaesthetic care for elective and emergency surgery for most older children with American Society of Anesthesiologists physical status score (ASA-PS) <III. Yet, the definition of a cut-off age remains a subject of controversy, with different ages proposed across Europe. We propose 3 years (APRICOT) while recognising that different cut-offs have also been considered (Denmark, 2 years; the United Kingdom, 5 years). The European Training Requirement in Anaesthesiology already defines the minimum recommended level of paediatric competence for all anaesthetists completing their training (Table 1). In addition, every anaesthetist should be able to recognise a neonate, infant and child in a critical clinical condition and to support vital function until a specialised Neonatal and Paediatric Emergency Transport Services (NETS and PETS) team from a paediatric centre takes over the patient to further stabilise and transfer to an appropriate paediatric centre. Scientific societies should make educational modules for achieving theoretical knowledge available for free and academic tertiary paediatric hospitals should accommodate doctors for specialist training and continuing education. It is also desirable that smaller hospitals affiliated with larger tertiary centres have the facilities for direct exchange of expertise as well as programmes for distance learning such as video conferences. Table 1 - The European Training Requirements in Anaesthesiology regulates the minimum requirement for trainees and residents in anaesthesia (https://www.uems.eu/__data/assets/pdf_file/0003/64398/UEMS-2018.17-European-Training-Requirements-in-Anaesthesiology.pdf). A paediatric anaesthesia fellowship should consider the achievement of a level C or D (performs, manages, demonstrates independently) in most of the ‘knowledge, skills and attitudes’ competencies. Based on the Union Européenne des Médecins Spécialistes (UEMS) document, we propose the following areas for minimum exposition and skill and grades of competencies Minimum recommended exposure Clinical skills and grade of competence for the paediatric anaesthetist Preoperative assessment Neonates and children < 1 year General anaesthesia in children > 1 year Regional anaesthesia central blocks Paediatric surgery Regional anaesthesia peripheral blocks ENT and airway surgery Airway management Ophthalmology Advanced and invasive airway management Orthopaedic surgery Advanced resuscitation Neurosurgery Fluid management and nutrition Neonatal surgery Transfusion strategies Dental surgery Vascular access included ultrasound-guided Nonoperating room anaesthesia Advanced acute pain management Acute pain management Chronic pain management Stabilisation and transport Neonatal and paediatric intensive care Organ transplant Cardiac and thoracic anaesthesia Each institution is responsible for appointing anaesthetists with the skills required to meet local clinical practice, structure and needs. This may necessitate secondment to specialist hospitals until the required expertise in paediatric anaesthesia has been achieved and/or the appointment of a local ‘paediatric anaesthesia expert’ within the anaesthetic teams of any hospitals/clinics. In addition to improving the knowledge of any anaesthetist, the curriculum should equip them with the skills necessary to recognise a critically ill child, resuscitate and ultimately stabilise neonates and children for retrieval. Advanced paediatric anaesthesia training In addition to the above, specialised paediatric anaesthesia management is required for children with ASA physical status scores of III and more, congenital and metabolic diseases and/or those undergoing major or complex surgery. Most full-time paediatric anaesthetists employed in children's hospitals or tertiary paediatric centres have completed a minimum of 12 months of advanced training in a tertiary centre following their specialist training in anaesthesia. Having additional training or completing a fellowship in paediatric anaesthesia enables a specialist anaesthetist to become proficient in providing anaesthesia care for neonates, infants and children undergoing a variety of surgical, diagnostic and therapeutic procedures, as well as resuscitation, pain management and routine and critical perioperative care. As of yet, there is no consensus regarding the length of such a training programme, its curriculum or number and types of cases or the size of the faculty or location and academic credentials. It is also necessary to formalise the commitments to paediatric and neonatal intensive care that are included in these programs. A paediatric anaesthetist's training would be extended by 2 years if critical care training is included. Attendance at theoretical courses and formal evaluation at the end of the training period is also required to achieve a ‘diploma’ in paediatric anaesthesia. The next steps Compiling a comprehensive training program in paediatric anaesthesia and intensive care is a complex task. There have been several successful initiatives that have resulted in the creation of specific curricula and fellowships. The European Association of Cardio-Thoracic Anaesthesia (EACTA) has already established a fellowship program for anaesthetists exposed to cardiothoracic anaesthesia.22 Similarly, ESAIC is building a curriculum for obstetric anaesthesia that should follow a similar path as the EACTA curriculum and fellowship described above. Paediatric anaesthesia, which may include paediatric cardiothoracic anaesthesia and critical care, could follow the two examples above to develop a specific pathway aimed at developing high-quality and well recognised competencies. These initiatives are aimed at improving the quality of perioperative care and reducing paediatric morbidity and mortality in Europe. Different European paediatric anaesthetic societies and associations need to collaborate to succeed. This ambitious undertaking of developing a harmonised European core curriculum should, ideally, be led and coordinated by ESAIC and ESPA using the established Scandinavian program in paediatric anaesthesia and intensive care as a blueprint. However, the specific competencies required for paediatric anaesthesia must follow the European training requirements. A harmonised ESAIC and ESPA paediatric curriculum can provide countries and institutions with a necessary framework adapted by individual national and scientific societies. Collaboration and the development of partnerships for Paediatric and Neonatal Emergency Transfer Services are critical to the success of this European Paediatric Anaesthesia Training curriculum. To achieve a harmonised European paediatric anaesthesia training program, we challenge national and European paediatric anaesthesia societies to collaborate following this roadmap.

Topics & Concepts