Our Critical Care Residency Program spans two years and comprises 18 mandatory and eight elective rotations. Each rotation/block is 4-weeks in duration.

Mandatory Rotations

· Medical Surgical ICU (MSICU) at University Hospital: 7 blocks

· Critical Care Trauma Center (CCTC) at Victoria Hospital: 7 blocks

· Cardiac Surgery Recovery Unit (CSRU): 2 blocks

· Neurocritical Care (NCC): 1 block

· External ICU: 1 block

2) What are the stages of training?

As per the Royal College of Physicians & Surgeons Competence by Design (CBD) model, all training programs can be divided into four stages:

· Transition to Discipline (D)

· Foundations of Discipline (F)

· Core of Discipline (C)

· Transition to Practice (P)

The timing of the Royal College Examination differs according to program duration. For two-year programs like Critical Care, the exam is currently after completion of the entire two-year program (i.e. not after the Core stage, as shown in the diagram). Related image

3) How do these stages of training align with my rotations?

Senior residents/fellows are expected to progress in their training per the following approximate timeline.

Transition to Discipline (D): 2 to 3 blocks

Foundations (F): 3 to 6 blocks

Core (C): 7 to 12 blocks

Transition to Practice (P): 2 to 5 blocks

Trainees are deemed fit to graduate from one stage of training to the next based on a detailed assessment of compiled trainee evaluations. This detailed assessment of trainee performance is undertaken by Critical Care Western’s Competence Committee (CC).

4) What is the Competence Committee (CC)?

Critical Care Western's Competence Committee (CC) is a subcommittee of the Residency Program Committee (RPC) responsible for curation, collation and review of resident performance. The CC is also responsible for deciding whether trainees are progressing as expected and can graduate from one stage of training to the next. CC decisions are made by group consensus and are based on an in-depth examination of multiple sources of written feedback.

5) What are the sources of feedback that the Competence Committee reviews?

The Competence Committee reviews feedback from multiple sources, including:

· Entrustable Professional Activity (EPA) assessments

· In-training evaluation reports (ITERs)

· Procedure Logbook

· Academic half-day attendance (days attended / days available to attend)

· Charge nurse evaluations for MSICU, CCTC, & CSRU

· Junior resident evaluations

· Academic advisor reports

· Witnessed communication forms

· MCCKAP & Metrics exam results

· Internal SAQ test performance

· Scholarly project reports & feedback

· Presentation evaluations

· Other multisource evaluations submitted by the trainee, allied health care workers, or consultants (e.g. letters from families, emails from nurses, etc.)

6) How often does the Competence Committee meet?

The Competence Committee meets every two months for resident review. Review findings are then communicated in confidence with each resident and their academic advisor/coach.

7) What is an “EPA”?

EPA stands for Entrustable Professional Activity. These EPAs form the building blocks of trainee learning. EPAs may be clinical or non-clinical but usually pertain to discrete observable or entrustable tasks. Trainees are expected to seek feedback on EPAs from their supervising consultants and, in the process, reflect on their performance, trigger discussion, and document their learning.

EPA evaluations are work-based low-stakes assessments that are meant to guide trainee learning. They are not pass-fail assessments. However, it is the responsibility of trainees to trigger EPA assessments and verbally communicate this with their consultants. Trainees are encouraged to pre-fill EPA assessments with their own self-evaluation and reflections then submit to their attending staff for signing off.

Senior residents will find that they can collect most required EPAs during their mandatory rotations. Some EPAs, however, are non-clinical.

8) Is there a quick and easy way to find a list of the Critical Care EPAs?

Yes. Go to our critical care website:

http://criticalcarelondon.ca/

Click on tab “CBME” > “Entrustable Professional Activities (EPAs)” > scroll down to “EPAs for Adult Critical Care Medicine 2019 (Web Browser Version)” and click on this hyperlink.

Alternatively, click on this link to get you straight to the EPAs page:

http://criticalcarelondon.ca/wp-content/uploads/2019/06/Final-EPAs.htm

9) How many EPAs do I need to collect per working day to stay on track?

Approximately 1 or 2 per working day while on your mandatory blocks. Verbally informing your staff that you will be sending them an EPA for completion is imperative. We also encourage trainees to pre-fill these EPAs in Elentra with their own self-assessment and narrative comments. Pre-filled EPAs make it easier for staff to remember the encounter being assessed and aids in providing meaningful feedback.

It is good practice to send 1 or 2 EPAs to your staff during or immediately after the working day and not delay sending accumulated EPAs to the very end of your service week. EPAs are meant to encourage documentation of instantaneous feedback. We strongly encourage “in-the-moment” feedback and live completion of EPAs with a face-to-face discussion.

10) Can I trigger a Core or Transition to Practice EPA while still in my first rotation of training?

Absolutely!

There are some EPAs that you may only experience once or twice in your training (e.g. Core EPA #10: Identifying and addressing patient safety incidents and contributing to a culture of safety, see question 23). We would encourage you to capture those whenever you encounter them. That is why we would encourage you to orient yourself to all EPAs expected of you throughout your training. That way, you do not miss out on capturing the infrequent EPAs when you experience them.

We would, however, recommend prioritizing the EPAs for your current stage of training. The Competence Committee will assess these stage-specific EPAs when determining whether you could be promoted to the next stage of training. While it is good to capture rare EPA opportunities as they present themselves, it is still important that you focus on the EPAs of your current stage of training.

11) What are the "procedural EPAs" in critical care?

The procedural EPAs include:

· Transition to Discipline # 3: Basic CCM Procedures

· Foundations # 3: Common CCM Procedures

· Core # 4: Advanced CCM Procedures

There are no procedural EPAs in the Transition to Practice Stage.

12) Do I need to capture all procedural EPAs in Elentra, or does the Procedure Logbook suffice?

Try to collect procedural EPAs in Elentra with direct staff observation (preferable) or indirect observation during your first two blocks in any of the main units (MSICU or CCTC). Also, log all your procedures in your Procedure Logbook, whether they are captured in Elentra or not.

Beyond your second block in a main unit, log your procedures in your Procedure Logbook only. It is expected that you will have achieved procedural independence beyond block 2. Hence procedural EPA collection in Elentra will not be necessary. The Competence Committee will, however, be checking your Procedure Logbook regularly to determine procedural EPA achievement. Be vigilant in logging your procedures throughout your residency and in all rotations (mandatory and elective).

13) Some of the required procedures are relatively infrequent to come by. Are there any procedural EPAs that can be achieved in simulation?

Yes. You are encouraged to collect the following EPAs in simulation:

· TTD # 3: Intra-osseous insertion, chest compression and defibrillation

· Core # 4 A: Cricothyrodotomy

Remind your instructor of these EPAs in your next Simulation Session.

14) How can I achieve Foundations EPA # 2: Evaluating and managing uncomplicated and/or routine patients requiring mechanical ventilation?

A total of 9 observations of achievement are required for Foundations EPA # 2 completion.

These nine observations must be in the context of:

a. initiation of invasive ventilation (at least one required)

b. initiation of non-invasive ventilation (at least one required)

c. discontinuation of invasive ventilation (at least one required)

The above three settings are called the "contextual variables" for this EPA. Note that the RCPSC EPA guideline document suggests the following additional contextual variables: maintenance of invasive ventilation, maintenance of non-invasive ventilation, weaning of invasive ventilation, weaning of non-invasive ventilation, and discontinuation of non-invasive ventilation. However, our CC at Western only requires the presence of at least one of each of the above three contextual variables and a total of 9 observations of achievement.

15) How can I achieve Foundations EPA # 3: Thoracentesis (2 required)?

Our practice at CCW is such that thoracenteses are commonly part of a Seldinger chest tube placement. We do not commonly perform thoracentesis only, without placing a drain, in ICU patients.

The CCW Competence Committee therefore requires:

· At least 1 open chest tube

· At least 3 Seldinger chest tubes

The CCW Competence Committee, therefore, does not mandate performing two isolated thoracenteses for EPA achievement. However, 3 Seldinger chest tubes are required instead of 1.

16) How can I achieve Foundations EPA # 5: Developing and implementing learning plans?

The motivation behind this EPA is to encourage self-reflection and the building of plans to achieve broad goals. Learners are expected to identify a deficit of skills, knowledge or professional development and design a strategy to develop these skills. Developing your personal learning plan is meant to be more meaningful than checking UpToDate or reading a guideline. It should include activities like developing a new skill set, becoming self-sufficient in an area, building a skillset tailored to future career plans/goals, etc. Learning plans are expected to include experiences spanning a broad time horizon, such as (1) electives, (2) courses and/or (3) longitudinal mentorship.

In terms of evaluation, there are many options. Some may choose to accomplish this EPA through an elective rotation. In this case, the senior resident needs to document their learning objectives at the start of the elective rotation then document their self-reflection at its conclusion. A second option would be through a structured course. The learner will also need to document goals and objectives motivating course registration then self-reflections post-completion. A third option would be through longitudinal mentorship. This would involve meetings with a mentor where a learner discusses their career goals, reflects on barriers and pursues a targeted strategy to accomplish these goals. Other avenues for evaluation would be pre-existing scheduled meetings with the program director, a narrative reflection submitted to the PD/competency committee or any alternative mechanism capable of communicating these goals.

Documentation of the deficit and learning plan goals, justification of the relevance of the goal and explanation of the process by which the deficit was/will be addressed is required. You and/or a faculty need to submit a written explanation of the learning goal/plan. Once deemed complete, achievement of the learning plan will be approved and signed off on by the mentor or PD using the Foundations EPA # 5 form in Elentra. Ultimately this EPA is broad in its scope, reflects what you do intuitively and simply ensures our program fosters reflection. If you have an alternative mechanism for demonstrating this personal learning, feel free to discuss it with your mentor or PD (Dr. Butler).

17) How can I achieve the Core EPA # 4 A: Testing of epicardial pacer wires?

This EPA is to be collected in your CSRU rotation. Only one is required. Remind your CSRU day staff of this required EPA while on this rotation.

18) How can I achieve Core EPA # 4 A: Dialysis line insertions?

This EPA is to be collected in your CCTC rotation. Two are required. Dialysis line insertions recorded in your Procedure Logbook beyond block 2 in a main unit would also suffice (see question 12).

19) How can I achieve Core EPA # 4 A: Cricothyrotomy?

This EPA can be collected in a Simulation Session, or you could perform a percutaneous tracheostomy instead. The CCW Competence Committee accepts the performance of percutaneous tracheostomies instead of cricothyrotomies. Only one is required. A percutaneous tracheostomy EPA submission in Elentra (during your first two blocks in a main unit) or one that is recorded in your Procedure Logbook (beyond your second block in a main unit) would suffice (see question 12).

20) How can I achieve the Core EPA # 4 B: PoCUS?

To complete this EPA, you need five lung and five cardiac/volume status assessments fulfilling achievement scores. The Competence Committee considers a submitted and QA'd ultrasound rated as (1) or (2) to count towards EPA achievement. This rating can be found in the QA section under "Summary of Quality Score."

Summary of Quality Score

(1)"No concerns."

(2) "Standards met with improvement suggestions."

Both of the scores above (1) & (2), reflect image acquisition, interpretation, and clinical integration within the acceptable range of practice.

The Competence Committee (CC) will not be using Elentra to assess Core EPA # 4B. Instead, residents are to submit their selected Q-Path reports as pdf’s to our Program Administrator (Corey Hilliard) by email. The CC is only interested in reports that count towards achieving competence, so please do not submit all your reports to Corey. Submit only five cardiac/volume status assessments and five thoracic scans of your choosing, where the scan report indicates that the Summary of Quality score is a (1) or (2).

These scans can be performed and submitted at any time during your critical care training. However, please submit all ten pdf reports before completing your Core stage, i.e. before the start of block 9 of your second year. The Block 9 start usually corresponds to the second Tuesday in February. This is considered a deadline for this EPAs submission. Please set up a calendar reminder for yourself.

Generating a pdf for your ultrasound reports can be done as follows:

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Questions regarding this EPA can be directed to Dr. Cameron or Dr. Butler. Questions regarding Q-path and pdf generation can be directed to Dr. Arntfield.

21) How can I achieve Core EPA # 6: Identifying, assessing, and managing potential organ donors?

This EPA is divided into two parts.

· Core 6A: Organ Donation:

This EPA (Core 6A) includes identifying a potential organ donor with the health care team, referral to the organ procurement organization Trillium Gift of Life Network (TGLN), and participating in the organ assessment and preparation process (e.g. bronchoscopy, hormone replacement, etc.) Two observations of this EPA are required.
Note that you are not required to discuss and offer the option of organ donation to families. In fact, at London Health Sciences Centre, you are discouraged from initiating this discussion yourself. TGLN representatives usually initiate this discussion. TGLN reps have the training to do this and have been demonstrated to have higher success rates in obtaining consent from families for organ donation.

· Core 6B: Neurologic Determination of Death (NDD):

This EPA can be achieved by asking your consultant to observe you as you perform the NDD testing. In Ontario, two licensed physicians (consultants) are required to complete an NDD exam. Therefore, you will be acting on behalf of one of the consultants. This observing consultant will be watching as you go through the steps. The observing consultant can subsequently be asked to complete this EPA for you. The other consultant helping with the NDD exam will be doing the exam with you in a more hands-on fashion.

22) How can I achieve Core EPA # 8: Managing the transport of patients who are critically ill? Does this EPA require that I participate in a Criticall?

Two observations of achievement are required for Core EPA # 8 achievement. One of these observations should be in the setting of an inter-hospital transfer and the other in an in-hospital transfer.

Managing a Criticall (actual or simulated) would fulfill this EPA for inter-hospital transfer. Next time you cover CCOT, remind your consultant to involve you in a Criticall. That way, you will be able to trigger this Core EPA # 8: inter-hospital transfer.

Safely managing the transfer of a patient down to the ICU from the ward allows you to trigger this EPA for in-hospital transfer. Further, an elective in Transport Medicine gives you plenty of opportunities to complete this EPA as well (interhospital transfer).

There will be opportunities throughout your training where you will be facilitating patient transfer (in-hospital and inter-hospital). We would, however, recommend that you request being involved with Criticalls for this EPA’s completion.

23) How can I achieve Core EPA # 10: Identifying and addressing patient safety incidents and contributing to a culture of safety?

This EPA can be achieved by managing an adverse event either in a clinical or simulated setting.

An adverse event could be:

(1) an unintended error resulting in an adverse patient outcome or

(2) a “near-miss” where patient outcome was not affected due to either early detection or by luck

Do not forget this second type whereby the resident identifies and prevents an adverse event from happening. These near misses can count as an observation for this EPA. Two observations are needed for this EPA, one of which should involve disclosing the error to the patient or family. Also, do not forget to inform your assessor whether you have documented or helped document this adverse event in our LHSC Adverse Events Management System (i.e. completed an AEMS report).

24) How can I achieve Core EPA # 12: Participating in and/or contributing to scholarly activity?

This EPA can be achieved by meeting with your scholarly project supervisor. Your meeting with your supervisor could focus on generating the research question, discussing the results of your literature evaluation, summarizing your literature review, securing your supervisor's commitment for the project, selecting an appropriate method of addressing the given question, discussing ethical principles in your scholarly work, or presenting data you have collected for your project. Only one observation for this EPA is required. Remember to inform your project supervisor that you will be submitting this EPA to him/her for completion.

25) How can I achieve Transition to Practice EPA # 3: Contributing to continuous quality improvement initiatives that address system-level safety or quality concerns?

This EPA can be achieved when you present M & M Rounds or Continuous Quality Improvement (CQI) Rounds.

When you are assigned a presentation of M&M or CQI rounds, please remember to trigger this EPA. Speak with one of the consultants in attendance right after you finish your presentation and ask them to complete this EPA for you. There is never a better time for you to do this than right after presenting rounds!

26) How can I achieve Transition to Practice EPA # 4: Demonstrating self-directed personal and professional development?

This EPA consists of two parts. Part A: Learning Plan and Part B: Mentorship Discussions.

Part A: Learning Plan:

Submission of this EPA to the PD or CC Chair, indicating attendance of at least 4 hours of transition to practice seminars on managing finances, insurance, medical-legal responsibilities, and other issues related to the clinical practice environment, will be considered sufficient. A series of such sessions are offered by the Ontario Medical Association (OMA) titled "Resident Transition Program" (link below). Submission of proof of attendance of 4 hours of sessions would fulfil this EPA. The OMA series includes lectures titled Getting Ready to Practise in Ontario, Medical Billing Principles in Ontario, Starting a Practice on the Right Foot, Legal Considerations When Starting a Practice AND Taking Care of Your Health & Well-Being, Medical Record Keeping, Medical-Legal Considerations for Early-Career Physicians, Medical Record Keeping, Insurance Coverage: Resident to Physician Financial Risk 101 AND Financial Planning & Management, Using Digital Health and Virtual Care Tools in Your Practice, Privacy & Security in a Digital and Virtual World: What You Need to Know, and Soft Skills Training.

Link for OMA sessions.

https://events.eply.com/ResidentTransitionWednesdays

Residents who will not be practicing in Ontario (e.g. Internationally Sponsored Residents) may submit a brief personal learning plan for future practice and ongoing professional development towards the end of their training instead of attending these sessions. The questions below provide guideline questions that would need to be addressed by the resident in this EPA submission.

a. Outline your career plan for maintaining clinical competence, including your plans for professional development.

b. Describe your approach to the incorporation of innovations in the field of Critical Care Medicine over your career.

c. Provide your strategy for managing personal finances, taxes, insurance and investing.

d. Outline your approach to considerations relevant to practice management, such as human resources, equipment, and space.

Part B: Mentorship Discussions:

Having at least one documented meeting with your coach per year or a total of 2 meetings during the two-year program will be considered sufficient to fulfil this EPA. Please submit this EPA to your coach after convening and pre-populating the EPA form with your narrative comments.

27) How can I achieve Transition to Practice EPA # 5: Conducting scholarly work?

This EPA can be achieved by presenting your project at the McMaster-Western Research Day. After completing your presentation, submit this EPA to your scholarly project supervisor for completion.

FAQ Document Manager: Ahmed Hegazy

On behalf of the CCW Competence Committee:

· Paul Cameron (Competence Committee Chair)

· Ron Butler (Program Director)

· Rob Leeper

· Tina Mele

· John Basmaji

· John Landau

· Jeff Granton

· Anna Gunz (PCCM CC Chair)

· Corey Hilliard (Program Administrator).

Resources and References:

· Royal College of Physicians and Surgeons Resources on Competence By Design (CBD):

https://www.royalcollege.ca/rcsite/cbd/competence-by-design-cbd-e

· Resident Transition Wednesday Program offered by the Ontario Medical Association:

https://events.eply.com/ResidentTransitionWednesdays