The ACUTE initiative

Universities need to establish formal acute care training programmes in their curriculums, as Gavin Perkins and Julian Bion discuss

Each year, an estimated 23 000 preventable in-hospital cardiac arrests occur in the UK.^w1 It is well recognised that, in many of these cases, signs of clinical deterioration remain undetected or ignored by ward staff in the minutes to hours preceding a cardiac arrest.^w2 A recent report by the National Confidential Enquiry into Patient Outcome and Death, An Acute Problem, evaluated the care of more than 1500 medical admissions to intensive care and found evidence of suboptimal management in nearly 50% of cases.^w3 Suboptimal care is often related to poor management of simple aspects of acute care—those involving the patient's airway, breathing, and circulation; oxygen administration; and fluid balance.^w4 w5 Other contributory factors include organisational failures, a lack of knowledge, failure to appreciate the clinical urgency of a situation, a lack of supervision, failure to seek advice, and poor communication.^{w6 w7} Effective earlier intervention requires staff trained in the care of acutely ill patients. Ideally, competence (knowledge, skills, and attitudes) in caring for these patients should be a clearly defined component of healthcare curriculums, starting at undergraduate level.

JAMES KING-HOLMES/SPL

The General Medical Council, the licensing body for doctors in the UK, requires medical undergraduates at completion of training to be able to undertake cardiopulmonary resuscitation and advanced life support (ALS); understand the principles of recognising and managing acute illness; and administer oxygen safely.^w8 However, the GMC does not identify the specific competencies nor a common core curriculum that should be acquired in these aspects of acute care. A survey of UK medical schools in 2001 found that all taught basic life support (using variable methods) and 79% taught some aspects of ALS. However, only 13% provided formal certified ALS training.^w9 The following year, a questionnaire survey assessing preregistration doctors' knowledge and skills in managing acutely ill patients found poor levels of understanding—few were able correctly to identify common features of critical illness such as airway obstruction or recognise abnormal from normal physiology.^w7 An international survey of English speaking medical schools found strong support (84%) from respondents for undergraduate teaching in aspects of intensive care medicine, but in only 31% was this teaching a formal part of the curriculum.^w10 The Society of Critical Care Medicine's undergraduate medical education committee found that only 45% of medical schools in the USA provided formal didactic teaching in critical care medicine, though 60% offered it as an elective option.^w11 A report from Australia, describing medical students attitudes to critical care education, concluded that the undergraduate curriculum had not kept pace with the rapid evolution of critical care practice.^w12 These surveys show that in many countries undergraduate training in acute care is uncoordinated and lacking in strategic focus.

With this background, the ACUTE project, a joint initiative between the Resuscitation Council (UK) and Intercollegiate Board for Training in Intensive Care Medicine, sought to develop a framework of core competencies for medical undergraduates in the care of acutely ill patients. The study obtained the views of over 350 doctors, nurses, medical students, resuscitation officers, and university teachers as to which competencies (described in terms of attitudes, knowledge, and skills) they deemed essential for medical students to have at the point of graduation. The original 2629 suggestions from respondents were condensed into 95 representative competency statements linked under the heading of airway and oxygenation, breathing and ventilation, circulation, confusion and coma, drugs therapeutics and protocols, clinical examination and monitoring, team working and organisation, patient and societal needs, trauma, equipment, infection, and inflammation.

These were then individually rated for importance by a nominal group composed of experts in resuscitation, education, and intensive care. Seventy one competencies were rated as important or very important by the nominal group and are included as essential competencies. Sixteen competencies were rated with moderate importance and are included as optional competencies. Full details of the competencies can be found in the original paper^w13 or at the Resuscitation Council (UK) website (www.resus.org.uk/acute/projrept.pdf).

These competencies provide a focus for curriculum planning for students and undergraduate tutors. The advantage of a competency based curriculum is that it defines the desired outcomes of the training programme rather than the process of education. This promotes standardisation of the end product while at the same time encouraging locally appropriate approaches to content delivery and the integration of training throughout the curriculum, rather than confining it to one particular approach or time point in the curriculum. An additional strength of standardising outcomes of undergraduate education is that, for doctors, this facilitates integration with the postgraduate foundation programmes.^w14

Postgraduate education has benefited from the development of specific training courses targeted at the resuscitation and caring of the acutely ill patient^w15 by harmonising resuscitation training at a national (and European) level. The recently developed immediate life support course addresses the initial resuscitation of a patient in cardiac arrest, and the acute life threatening emergencies recognition and treatment (ALERT) course deals with the recognition and treatment of the acutely ill patient; these courses are well suited to meet the needs of the medical undergraduate.

It is time for medical schools to recognise the importance of training undergraduates in the care of the acutely ill patient, and to use a common outcomes-based curriculum. We hope that the publication of this report will act as a stimulus to review undergraduate curriculums in this important area.

Competing interests: GDP is a member of the Resuscitation Council (UK) Immediate Life Support Working Group.

Gavin D Perkins, lecturer in respiratory and critical care medicine, University of Birmingham
Email: gavin.perkins@virgin.net
Julian F Bion, reader in critical care medicine


studentBMJ 2006;14:133 - 176 April ISSN 0966-6494

1. Hodgetts TJ, Kenward G, Vlackonikolis I, Payne S, Castle N, Crouch R, et al. Incidence, location and reasons for avoidable in-hospital cardiac arrest in a district general hospital. Resuscitation 2002;54:115-23.
2. Franklin C, Mathew J. Developing strategies to prevent inhospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med 1994;22:244-7.
3. National Confidential Enquiry into Patient Outcome and Death. An Acute Problem. www.ncepod.org.uk/2005report/. 2005.
4. Neale G. Risk management in the care of medical emergencies after referral to hospital. J R Coll Physicians Lond 1998;32:125-9.
5. McGloin H, Adam SK, Singer M. Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable? J R Coll Physicians Lond 1999;33:255-9.
6. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001;322:517-9.
7. Smith GB, Poplett N. Knowledge of aspects of acute care in trainee doctors. Postgrad Med J 2002;78:335-8.
8. General Medical Council. Tomorrows doctors: recommendations for undergraduate education. London: General Medical Council, 2003.
9. Phillips PS, Nolan JP. Training in basic and advanced life support in UK medical schools: questionnaire survey. BMJ 2001;323:22-3.
10. Shen J, Joynt GM, Critchley LA, Tan IK, Lee A. Survey of current status of intensive care teaching in English-speaking medical schools. Crit Care Med 2003;31:293-8.
11. Frankel HL, Rogers PL, Gandhi RR, Freid EB, Kirton OC, Murray MJ. What is taught, what is tested: findings and competency-based recommendations of the Undergraduate Medical Education Committee of the Society of Critical Care Medicine. Crit Care Med 2004;32:1949-56.
12. Harrison GA, Hillman KM, Fulde GW, Jacques TC. The need for undergraduate education in critical care: (results of a questionnaire to year 6 medical undergraduates, University of New South Wales and recommendations on a curriculum in critical care). Anaesth Intensive Care 1999;27:53-8.
13. Perkins GD, Barrett H, Bullock I, Gabbott DA, Nolan JP, Mitchell S, et al. The Acute Care Undergraduate TEaching (ACUTE) Initiative: consensus development of core competencies in acute care for undergraduates in the United Kingdom. Intensive Care Med 2005;31:1627-33.
14. Department of Health. Modernising medical careers; the response of the four UK health ministers to the consultation on unfinished business: proposals for reform of the senior house officer grade. London: DoH. 2003
15. Perkins G, Lockey A. The advanced life support provider course. BMJ 2002;325:S81.

       

           

	EDITORIALS The ACUTE initiative       Gavin D Perkins, Julian F Bion (April 2006)
	Charlotte Davies (April 2nd, 2006)       4th Year, Medicinem, Leeds ugm2cd@leeds.ac.uk
	Leeds University is currently the only medical school in England to have an affiliated St John Ambulance (SJA) Unit, membership of which is only open to Healthcare Professionals HCPs). This weekend, our training scheme was presented, at the National Links Conference, to other HCPs in SJA, and it was very well received. LMSU has a three staged approach to teaching pre-hospital care. Stage One- Basic Life Support and Manual Handling Once stage one is completed, members can go out on duty, as a member of SJA, ready to use their basic first aid knowledge. Stage Two-Major Duty Training This training prepares members for what they might see at a major duty, like the V Festival. Assessing ankle injuries, drugs, alcohol, head injuries and use of medical gases are just a few of the subjects LMSU covers. We refresh rather than repeat information the medical school has given them. Stage Three- Student Doctor Training Members in their third year of LMSU or above, receive training in how to act as a Student Doctor once on duty. Our training complements medical school training, culminating in a first aid specific OSCE. We perfect history taking and examination skills. Stage Four- Teaching

	EDITORIALS The ACUTE initiative       Gavin D Perkins, Julian F Bion (April 2006)
	Alexander Davey (April 9th, 2006)       fourth year medical student,Queen's University Belfast adavey02@qub.ac.uk
	As an undergraduate with a special interest in trauma and acute medicine I was very pleased to read Gavin Perkins article on the ACUTE initiative. The call for a review on this aspect of undergraduate education stimulates some interesting thoughts on the undergraduate curriculum in general. Even though "tomorrow's doctors" was only implemented ten years ago and "modernising medical careers' has just been implemented in 2005, it is likely that no one will ever be totally satisfied with undergraduate and early postgraduate teaching and training. This is understandable as there are many influences and demands on what knowledge and skills institutions ensure their undergraduates acquire before starting work as a junior doctor. From a student's perspective these influences are wide-ranging and complex. They include regulatory bodies such as the GMC, government and members of the public. The pragmatic and logistical limitation in planning and delivering an undergraduate medical course also needs to be considered. Indirect influence on the role of junior doctors and therefore the undergraduate curriculum, arises from government policy and public demands on the NHS. Furthermore, there is considerable variation between medical schools on exactly what is taught and how it is delivered. The overall picture is that medical schools have the very tough job of producing diversely and adequately schooled professionals with the right amount of vocational training to work in a public service bound with bureaucracy and laden with litigation. Although in agreement with the authors on teaching undergraduates acute care, I believe it is also worthwhile encouraging the development of interests and professional attitudes through other means and mediums. These means include extracurricular events run by medical student societies and mediums such as the internet organisations run by students and junior doctors. This year Queen's University Belfast saw the organisation of a national conference on trauma and acute medicine. To my knowledge this is the first ever undergraduate conference in the UK and Ireland to have acute medical care as a main theme. We are also developing an undergraduate scheme for teaching prehsopital care in association with our local BASICs scheme. Undergraduate societies do not offer a definitive or alternative answer to the problem of ensuring medical students graduate with a minimum competence in acute care. However, they do contribute significantly towards an overall solution by promoting desirable attitudes to professional development, education and responsibility at an undergraduate level through peer interaction.

	EDITORIALS The ACUTE initiative       Gavin D Perkins, Julian F Bion (April 2006)
	Abdul Moiz Khan (April 10th, 2006)       MBBS, 4-Mile Gojra Road, PO Baghwala, Jhang-35200, Pakistan. moiz2005@yahoo.com
	A very important issue has been highlighted by the authors in this article. Learning Basic Life saving skills is of tent amount importance for any medical professional. Seeing physicians at a loss of what to do in face of an acute medical emergency is sadly a common sight at places which do not ensure sufficient training in these skills. In resource poor countries training medical professionals in these basic life saving skills can translate into a major difference in outcomes of acute emergencies. This point can not be over-emphasized. In Pakistan hardly any medical school imparts satisfactory BLS knowledge, save Aga Khan University. Medical students at this medical school are required to be ACLS certified in their fourth year of training. It is true that all of us set high goals for ourselves and want to perform mind-shattering tasks but we often tend to ignore these basic skills. Little do we realize that a simple CPR is a difference between life and death or adequate hydration of a child with diarrhoea is lease of life. Medical curricula should be improved to include Basic Life Skills in early stages of medical education.