Critical Care Medicine Fellowship
UF Emergency Medicine

Overview of Program

The Department of Emergency Medicine and Division of Critical Care supports a critical care fellowship for interested Emergency Medicine trained physicians. The primary teaching facility is at UF Health Shands Hospital in Gainesville, Florida. The fellowship is multi-disciplinary with curriculum consisting of surgical, medical, neurosurgical, burn, and cardiovascular ICUs.

Mission and Vision

Our program’s mission is to expose fellows to a variety of critical care medicine cases through multiple, highly specialized Intensive Care Units, and thereby provide the impetus for basic science and research along with experiential learning that leads to the growth and development of fellows who become board certified intensivists and leaders of ICUs throughout the world.

Goals and Objectives

This program exists to develop well-rounded Emergency Medicine Intensivists capable of treating critically ill patients with any variety of pathophysiology. Our program’s aims are encompassed in the following goals and objectives.

1. Expand and apply medical knowledge through scholarship, as measured by the number of publications, presentations, and other documented contributions.
   • Objectives to meet this goal are:
     • Facilitate each fellow’s participation in basic, applied, or clinical outcomes research.
     • Ensure that each fellow contributes to the specialty in a documentable way, including, but not limited to presentations at local, regional, national, or international conferences, peer-reviewed journal publications, peer-reviewed online educational or research platforms such as the Anesthesia Toolbox, and participation in educational activities for the community, medical professionals and patients.
2. Ensure that fellows are well-prepared to treat our community’s patient population with the latest advances in management of care for critically ill patients, as measured by Board certification rates at or above the national average.
   • Objectives to meet this goal are:
     • Provide a comprehensive clinical and didactic training program caring for patients with an extensive selection of comorbidities across a variety of intensive care settings.
     • Provide didactic and experiential training in pain management in the critical care setting, including recognition of the signs of addiction.
3. Establish in our fellows a culture of patient safety and quality improvement as measured by documented fellow contributions to departmental and/or institutional patient safety and quality improvement efforts.
   • Objectives to meet this goal are:
     • Facilitate each fellow’s involvement in specific, measurable patient safety/quality improvement initiatives.
     • Provide each fellow with training on root cause analysis.

These goals have allowed our fellows to maintain a pass rate that exceeds the national average on the Anesthesiology Critical Care In-Training Exam and the Critical Care Board Exam.

Why Us?

This program provides the opportunity to learn in various ICU environments which enables the fellow to feel comfortable in any future job prospect.  Our graduates have accepted positions in many different environments and mixes (ICU/EM), academic and community, with the confidence to be medical directors after fellowship.

We also have an excellent opportunity for fellows who are interested in Neurocritical care.  After completing this program, fellows can extend fellowship for one year and obtain Neurocritical care training and examination for boards through a pathway created with Neurocritical care faculty here at UF.

Eligibility

Residency training in Emergency Medicine must be from an ACGME accredited program and completed by the time of matriculation. Applicants must be board-eligible or board certified. This program does not accept J-1 Visa applicants at this time. Once a letter of offer is extended, employment will be contingent on a positive result from a criminal background screening, procurement/maintenance of a Florida Medical License and ability to meet requirements for appointment as a Faculty member.

Key Curriculum Themes

The UF Department of Emergency Medicine co-sponsors this critical care fellowship with the Anesthesiology Department and is pleased to announce a critical care certification pathway. The University of Florida Anesthesiology Critical Care Medicine program has received American Board of Anesthesiology approval for a two year training program in critical care for Emergency Physicians. This approval permits the emergency physicians that enter and complete this program entry into subspecialty critical care certification.

The first year of the program will consist of a typical ACGME Anesthesia CCM program that includes a multi-disciplinary model with a focus towards surgical intensive care (trauma, burn, transplant, orthopedic, vascular, ENT, urology, cardiothoracic). A significant time is also spent in a 30 bed neurosurgical intensive care unit (status epilepticus, stroke, neurosurgical diseases). The second year gives the fellows a multi-disciplinary opportunity to expand the intensive care experience with added time in a medical intensive care unit, electives, and research. During the second year the fellows are also given time in the ED to ease the transition into a well rounded ED-Critical Care physician. During this time, the fellows are ideally suited to improve coordination between the ED and ICU, as well as enhance ED care, system/protocol implementation, and education in critical care. We also work closely with our trauma/surgical colleagues who have Surgical Critical Care and Acute Care Surgery Fellowships.

Rotations with brief description

Neurosurgical ICU / Burn ICU – 30 bed Neurosurgical ICU with management of both neurological and neurosurgical critically ill patients. Clinical conditions managed in this unit includes medicine based (stroke, status epilepticus, myasthenia gravis, meningitis, etc.) and surgical based (intracranial bleeds, increased intracranial pressure, subarachnoid hemorrhages, aneurysms, spinal disorders, etc.). The burn unit is cross covered on nights and weekends by the ICU fellow and there is also an opportunity for a Burn elective. This is an ICU rotation providing direct care to the critically ill patient.

Surgical ICU / ES / SP – “4EAST” 24 bed Surgical ICU; includes surgical population of patients with clinical conditions related to transplant (liver, pancreas, kidney), urological, ear-nose-throat, minimally invasive surgery, pancreas-biliary, colo-rectal, and obstetric-gynecological surgeries. Both elective surgery patients and emergency surgery patients are admitted to this unit related to the above conditions. This is an ICU rotation providing direct care to the critically ill patient.

Surgical ICU / TS / ACS – “4WEST” 24 bed surgical ICU; includes surgical population of patients with clinical conditions related to trauma, acute care & emergency surgery, vascular, and orthopedic surgeries. Both elective surgery patients and emergency surgery patients are admitted to this unit related to the above conditions. This is an ICU rotation providing direct care to the critically ill patient.

Medical ICU – 24 bed medical ICU; includes medical population of patients with clinical conditions related to heart failure, cardiac arrest, pneumonia, sepsis, obstructive lung disease (COPD/Asthma); interstitial lung disease, chronic lung conditions, chronic kidney disease, hepatic failure, and toxicological syndromes. This is an ICU rotation providing direct care to the critically ill patient.

Cardiac ICU – 24 bed med/surgical ICU; includes medical and surgical population of patients. Medical conditions include cardiac arrest, myocardial infarction, arrythmias, heart failure. Surgical conditions include cardiac transplant, valvular disorders, etc. Both elective patients and emergency surgery patients are admitted to this unit related to the above conditions. This is an ICU rotation providing direct care to the critically ill patient.

Research – All fellows are assigned mentors to work with throughout the two years of fellowship. The research month will be used to facilitate planning and execution of research at the institution. It is expected the fellow begin the process prior to the month and use the time to continue working on a project already in approval through the IRB. All fellows are also required at the start of the year to choose a quality improvement topic and develop a system/protocol for evaluation or improvement. Time can be spent during this month to finalize this and present at the weekly protocol meetings held by the ICU.

Elective – Fellows have options such as burn ICU, nutrition, pediatric ICU, trauma, echocardiography, infectious disease, Anesthesia/airway, as well as many others.

Clinical Responsibility

The fellows in this program are appointed as post doctorate clinical associates in the Department of Emergency Medicine for their second year. They have a core clinical commitment of 480 hours working as Attending Physicians in one of the four UF Health Gainesville Emergency Departments over the course of their second fellowship year. Options for additional hours with extra pay available.

Salary and Benefits

2025 – 2026 Housestaff Annual Stipends

Benefits

Generous stipend for academic enhancement and conference attendance/presentations.

GatorBites meal program.

15 days of paid vacation per year. 10 days of paid sick leave per year.

Fellows are employed by the University of Florida College of Medicine and are considered to be PGY4-7+ housestaff for salary and benefit purposes. Please see the Housestaff Benefits webpage for more information on insurance, retirement plan, leave policy, malpractice insurance, and additional services included.

Ample moonlighting opportunities within the UF Health system at the Main ED, Pediatric ED and two freestanding EDs (Springhill and Kanapaha) for additional income, all covered by malpractice insurance and sovereign immunity.

Application Process

This fellowship program participates in the SF Match. Applications should be submitted using the Anesthesia Application process. Applications should include three letters of recommendation (one from the resident program director if currently a resident), the applicant’s CV and a personal statement (not to exceed one page). After the Match, please follow instructions on the Anesthesia website and submit documents as instructed. We do not routinely offer fellowship spots in surgery or medicine pathways, but are working to incorporate these into the models described below from the individual organizations (ABS, ABIM, ABEM). Any questions regarding applying can be directed to our fellowship program coordinator below.

Applications may only be submitted until April 2024. Results are announced through the SF Match system in early June 2024 (for a July 2025 start date).

Program Faculty and Staff

Program Director

Rohit P Patel M.D.

Clinical Associate Professor; Associate Chief, Division of Critical Care Medicine; Co-Director, Emergency Medicine Critical Care Fellowship; Co-Director, Surgical Intensive Care Unit

Other Program Faculty

Beulah D Augustin M.D.

Clinical Assistant Professor

Torben K Becker MD, PhD, MBA, RDMS, E-AEC, FAWM, FAEMS, FCCM

Associate Professor & Vice-Chair – Emergency Medicine, Executive Director – Critical Care Organization

John Bruno M.D.

Clinical Assistant Professor; Director of Critical Care Education – EM residency

Cameron Kyle-Sidell MD

Clinical Assistant Professor

Oswald Perkins MD

Clinical Assistant Professor

Adjunct Program Faculty

Marie-Carmelle Elie M.D., RDMS, FACEP, FCCM

Adjunct Professor

OPS Program Faculty

Kruti Shah M.D.

Clinical Assistant Professor

Graduated, Current, and Incoming Fellows

• 2010-2012
  Rohit Patel, MD (now: University of Florida CCM Program Director)
• 2011-2013
  David McConoughey, DO (now: University Hospitals St. John Medical Center)
• 2012-2013
  Nathan Gilmore, MD (now: Hoag Hospital)
• 2012-2014
  Ali Dabaja, DO (now: Beaumont Hospital)
  Brian Shippert, DO (now: Mount Nittany Medical Center)
• 2013-2014
  Ahsan Janoo, MD (now: Chino Valley Medical Center)
• 2014-2016
  Irina Brennan, MD, PhD (now: Inova Alexandria Hospital)
  Sean Lee, MD (now: Wellstar Hospitals)
• 2015-2017
  Kenechukwu Chukwuanu, MD (now: SSM Health Saint Louis University Hospital)
• 2017-2019
  Karina Bartlett, MD (now: CHRISTUS Trinity Mother Frances Health System)
• 2018-2020
  Caleb Harrell, MD (now: Summa Health)
  Kruti Shah, MD (now: University of Florida OPS CCM Faculty)
• 2018-2021
  Bárbara Flores González, MD (now: University of Florida Jacksonville)
• 2019-2021
  Abdulaziz Alburaih, MD (now: University of Florida Jacksonville)
  Casey Carr, MD (now: University of Florida CCM Faculty)
  Adnan Javed, MD (now: University of Florida Jacksonville)
• 2020-2021
  Travis Murphy, MD – Surgery CCM (now: University of Miami Health System)
• 2020-2022
  John Bruno, MD (now: University of Florida Neurocritical Care Supra-Fellow/Faculty)
  Nicolas Segal, MD, PhD (now: AdventHealth Medical Group Cardiovascular Surgery)
• 2021-2023
  Beulah Augustin, MD (now: University of Florida CCM Faculty)
  Terrance Creighton, MD (now: Cardiothoracic ICU at Cleveland Clinic)

• 2022-2024
  Manuel Borobia, MD
  Hady Khalifa, MD
  Pooja Mysore, MD
• 2023-2025
  Nhi Luu, DO
  Jacob Milling, MD
  Nishil Patel, DO, MBS

2024-2026

Justin Sauter D.O.

Critical Care Medicine Fellow

2025-2027

Osvaldo E Duran MD

Critical Care Medicine Fellow

Michael B Oliver MD

Critical Care Medicine Fellow

Rylee Pence MD

Critical Care Medicine Fellow

Additional Information

Critical Care Medicine Curriculum

ACGME Program Requirements for Graduate Medical Education in Surgical Critical Care

Effective: July 1, 2012

Introduction:

Int.A. Residency and fellowship programs are essential dimensions of the transformation of the medical student to the independent practitioner along the continuum of medical education. They are physically, emotionally, and intellectually demanding, and require longitudinally-concentrated effort on the part of the resident or fellow. The specialty education of physicians to practice independently is experiential, and necessarily occurs within the context of the health care delivery system. Developing the skills, knowledge, and attitudes leading to proficiency in all the domains of clinical competency requires the resident and fellow physician to assume personal responsibility for the care of individual patients. For the resident and fellow, the essential learning activity is interaction with patients under the guidance and supervision of faculty members who give value, context, and meaning to those interactions. As residents and fellows gain experience and demonstrate growth in their ability to care for patients, they assume roles that permit them to exercise those skills with greater independence. This concept—graded and progressive responsibility—is one of the core tenets of American graduate medical education. Supervision in the setting of graduate medical education has the goals of assuring the provision of safe and effective care to the individual patient; assuring each resident’s and fellow’s development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishing a foundation for continued professional growth.

Int.B.  Definition and Scope of the Subspecialty

Int.B.1. Surgical critical care is a subspecialty of surgery that manages complex surgical and medical problems in critically-ill surgical patients.Graduate educational programs in surgical critical care provide the educational, clinical, and administrative resources to allow fellows to develop advanced proficiency in the management of critically-ill surgical patients, to develop the qualifications necessary to supervise surgical critical care units, and to conduct scholarly activities in surgical critical care. The educational programs enhance and are an integral part of an Accreditation Council for Graduate Medical Education (ACGME)-accredited core program in surgery.

Int.B.2. The goal of a surgical critical care fellowship program is to prepare the fellow to function as a qualified practitioner at the advanced level of performance expected of a Board-certified subspecialist. The education of surgeons in the practice of surgical critical care encompasses didactic instruction in the basic and clinical sciences of surgical diseases and conditions, as well as education in procedural skills and techniquesused in the intensive care settings. This educational process leads to the acquisition of an appropriate fund of knowledge and technical skills, the ability to integrate the acquired knowledge into the clinical situation, and the development of judgment.

Int.C. The educational program in surgical critical care must be 12 months in length.

I. Institutions

I.A. Sponsoring Institution

One sponsoring institution must assume ultimate responsibility for the program, as described in the InstitutionalRequirements, and this responsibility extends to fellow assignments at all participating sites.

The sponsoring institution and the program must ensure that the program director has sufficient protected timeand financial support for his or her educational and administrative responsibilities to the program.

I.A.1. The sponsoring institution must provide the program director with a minimum of 10% protected time or direct salarysupport or indirect salary support, such as release from clinical activities.

I.A.2. The sponsoring institution must also sponsor an ACGME-accredited residency program in pediatric surgery,surgery, thoracic surgery, or vascular surgery.

I.A.2.a) There must be interaction between the core residency program in pediatric surgery, surgery, thoracic surgery, orvascular surgery and the fellowship program which results in coordination of educational, clinical, and investigativeactivities.

I.A.3. Any institution that sponsors more than one critical care program must coordinate interdisciplinary requirements toensure that fellows meet the specific criteria of their primary specialties.

I.A.4. It is strongly suggested that the sponsoring institution also sponsor ACGME-accredited residency programs in thosespecialties that relate particularly to surgery, such as anesthesiology, diagnostic radiology, internal medicine, andpathology.

I.B. Participating Sites

I.B.1. There must be a program letter of agreement (PLA) between the program and each participating siteproviding a required assignment. The PLA must be renewed at least every five years.

The PLA should:

I.B.1.a) identify the faculty who will assume both educational and supervisory responsibilities for fellows;

I.B.1.b) specify their responsibilities for teaching, supervision, and formal evaluation of fellows, as specified later inthis document;

I.B.1.c) specify the duration and content of the educational experience; and,

I.B.1.d) state the policies and procedures that will govern fellow education during the assignment.

I.B.2. The program director must submit any additions or deletions of participating sites routinely providing an educational experience, required for all fellows, of one month full time equivalent (FTE) or more through the Accreditation Council for Graduate Medical Education (ACGME) Accreditation Data System (ADS).

I.B.2.a) Clinical assignments to participating sites must be approved prior to fellows’ rotating to the sites, and must not be more than three months in length.

II. Program Personnel and Resources

II.A. Program Director

II.A.1. There must be a single program director with authority and accountability for the operation of the program. The sponsoring institution’s GMEC must approve a change in program director. After approval, the program director must submit this change to the ACGME via the ADS.

II.A.1.a) The length of the program director’s appointment must be at least two years.

II.A.2. Qualifications of the program director must include:

II.A.2.a requisite specialty expertise and documented educational and administrative experience acceptable to the Review Committee;

II.A.2.b) current certification in the subspecialty by the American Board of Surgery or subspecialty qualifications that are acceptable to the Review Committee; and,

II.A.2.c) current medical licensure and appropriate medical staff appointment.

II.A.2.c).(1) This must include unrestricted credentials at the primary clinical site, and

II.A.2.c).(2) The program director should possess licensure to practice medicine in the state where the primary clinical site is located.
 
II.A.2.d) faculty appointment in good standing at the primary clinical site.

II.A.3. The program director must administer and maintain an educational environment conducive to educating the fellows in each of the ACGME competency areas. The program director must:

II.A.3.a) prepare and submit all information required and requested by the ACGME;

II.A.3.b) be familiar with and oversee compliance with ACGME and Review Committee policies and procedures as outlined in the ACGME Manual of Policies and Procedures;

II.A.3.c) obtain review and approval of the sponsoring institution’s GMEC/DIO before submitting to the ACGME information or requests for the following:

II.A.3.c).(1) all applications for ACGME accreditation of new programs;

II.A.3.c).(2) changes in fellow complement;

II.A.3.c).(3) major changes in program structure or length of training;

II.A.3.c).(4) progress reports requested by the Review Committee;

II.A.3.c).(5) responses to all proposed adverse actions;

II.A.3.c).(6) requests for increases or any change to fellow duty hours;

II.A.3.c).(7) voluntary withdrawals of ACGME-accredited programs;

II.A.3.c).(8) requests for appeal of an adverse action; and,

II.A.3.c).(9 appeal presentations to a Board of Appeal or the ACGME.

II.A.3.d) obtain DIO review and co-signature on all program information forms, as well as any correspondenceor document submitted to the ACGME that addresses:

II.A.3.d).(1) program citations, and/or

II.A.3.d).(2) request for changes in the program that would have significant impact, including financial, on the program or institution.

II.A.3.e) maintain a collegial relationship with faculty members to enhance the educational opportunities for all fellows; and,

II.A.3.f) direct or co-direct one or more of the critical care units in which the clinical aspects of the educational program take place, and personally supervise and teach surgery and surgical critical care fellows in that unit.

II.B. Faculty

II.B.1. There must be a sufficient number of faculty with documented qualifications to instruct and supervise all fellows.

II.B.1.a) In addition to the program director, at least one surgeon certified in surgical critical care must be appointed to the faculty for every critical care fellow enrolled in the program.

II.B.2. The faculty must devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities and demonstrate a strong interest in the education of fellows.

II.B.3. The physician faculty must have current certification in the subspecialty by the American Board of Surgery, or possess qualifications acceptable to the Review Committee.

II.B.4. The physician faculty must possess current medical licensure and appropriate medical staff appointment.

II.B.5. Non-surgical physician faculty members must be certified in critical care in their specialty area or possess alternative qualifications judged to be acceptable by the Review Committee.

II.B.6. Faculty members must regularly participate in organized clinical discussions, rounds, journal clubs, and conferences.

II.B.7. Faculty members must establish and maintain an environment of inquiry and scholarship with an active research component.

II.B.7.a) The program director and some members of the faculty should also demonstrate scholarship by one or more of the following:

II.B.7.a).(1) peer-reviewed funding;

II.B.7.a).(2) publication of original research or review articles in peer-reviewed journals, or chapters in textbooks;

II.B.7.a).(3) publication or presentation of case reports or clinical series at local, regional, or national professional and scientific society meetings; or,

II.B.7.a).(4) participation in national committees or educational organizations.

II.C. Other Program Personnel

The institution and the program must jointly ensure the availability of all necessary professional, technical, and clerical personnel for the effective administration of the program.

II.C.1. Staff members must include specially-trained nurses and technicians skilled in critical care instrumentation, respiratory function, and laboratory medicine.

II.D. Resources

The institution and the program must jointly ensure the availability of adequate resources for fellow education, as defined in the specialty program requirements.

II.D.1. Resources should include a simulation and skills laboratory.

II.D.2. Resources must include:

II.D.2.a) a critical care unit located in a designated area within the institution, constructed and designed specifically for the care of critically-ill patients;

II.D.2.b) a common office space for fellows that includes a sufficient number of computers and adequate workspace at the primary clinical site;

II.D.2.c) online radiographic and laboratory systems at the primary clinical site and participating sites;

II.D.2.d) software resources for production of presentations, manuscripts, and portfolios;

II.D.2.e) an average daily census of at least 10 patients in each intensive care unit to which a fellow is assigned; and,

II.D.2.f) an average daily census for each critical care unit to which fellows are assigned that ensures a fellow-to-patient ratio of1:10.

II.D.3. The education must take place in care settings for critically-ill adult and/or pediatric surgical patients.

II.E. Medical Information Access

Fellows must have ready access to specialty-specific and other appropriate
reference material in print or electronic format. Electronic medical literature
databases with search capabilities should be available.

II.E.1. Fellows must have Internet access to full-text journals and electronic medical reference resources for education and patient care at all participating sites.

III.  Fellow Appointments

III.A. Eligibility Criteria

Each fellow must successfully complete an ACGME-accredited specialty program and/or meet other eligibility criteria as specified by the Review Committee. The program must document that each fellow has met the eligibility criteria.

III.A.1. Prior to appointment in the program, fellows must have completed at least three clinical years in an ACGME-accredited graduate educational program in one of the following specialties: anesthesiology,emergency medicine, neurological surgery, obstetrics and gynecology, orthopaedic surgery, otolaryngology, surgery, thoracic surgery, vascular surgery, or urology.

III.A.1.a) Fellows, who have completed an emergency medicine residency, must also complete one preliminary year of education in the surgery program at the institution where they will enrollin the surgical critical care fellowship. At a minimum theprelimary year of education must include supervised clinical experience in:

III.A.1.a).(1) pre-operative evaluation, including respiratory, cardiovascular, and nutritional evaluation;

III.A.1.a).(2) pre-operative and post-operative care of surgical patients, including outpatient follow-up care;

III.A.1.a).(3) care of injured patients;

III.A.1.a).(4) care of patients requiring abdominal, breast, head and neck, endocrine, thoracic, and vascular operations;

III.A.1.a).(5) management of complex wounds; and,

III.A.1.a).(6) minor operative procedures related to critical care, such as venous access, tube thoracostomy, and tracheostomy.

III.B. Number of Fellows
 
The program director may not appoint more fellows than approved by the
 
Review Committee, unless otherwise stated in the specialty-specific requirements. The program’s educational resources must be adequate to support the number of fellows appointed to the program.

III.C. The presence of other learners, including residents from other specialties, subspecialty fellows, PhD students, and nurse practitioners, in the program must not interfere with the appointed fellows’ education. The program director must report the presence of other learners to the DIO and GMEC in accordance with sponsoring institution guidelines.

IV.  Educational Program

IV.A. The curriculum must contain the following educational components:

IV.A.1. Skills and competencies the fellow will be able to demonstrate at the conclusion of the program. The program must distribute these skills and competencies to fellows and faculty annually, in either written or electronic form. These skills and competencies should be reviewed by the fellow at the start of each rotation;

IV.A.2. ACGME Competencies

The program must integrate the following ACGME competencies into the curriculum:

IV.A.2.a) Patient Care

Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows:
 
IV.A.2.a).(1) must have supervised training that will enable them to demonstrate competence in the following critical care skills:

IV.A.2.a).(1).(a) circulatory: performance of invasive and noninvasive monitoring techniques, and the use of vasoactive agents and management of hypotension and shock; application of trans-esophageal and transthoracic cardiac ultrasound and transvenous pacemakers, dysrhythmia diagnosis and treatment, and the management of cardiac assist devices;

IV.A.2.a).(1).(b) endocrine: performance of the diagnosis and management of acute endocrine disorders, including those of the pancreas, thyroid, adrenals, and pituitary;

IV.A.2.a).(1).(c) gastrointestinal: performance of utilization of gastrointestinal intubation and endoscopic techniques in the management of the critically-ill patient; and management of stomas, fistulas, and percutaneous catheter devices;

IV.A.2.a).(1).(d) hematologic: performance of assessment of coagulation status, and appropriate use of component therapy;

IV.A.2.a).(1).(e) infectious disease: performance of classification of infections and application of isolation techniques, pharmacokinetics, drug interactions, and management of antibiotic therapy during organ failure; nosocomial infections; and management of sepsis and septic shock;

IV.A.2.a).(1).(f) monitoring/bioengineering: performance of the use and calibration of transducers and other medical devices;

IV.A.2.a).(1).(g) neurological: performance of management of intracranial pressure and acute neurologic emergencies, including application of the use of intracranial pressure monitoring techniques and electroencephalography to evaluate cerebral function;

IV.A.2.a).(1).(h) nutritional: performance of the use of parenteral and enteral nutrition, and monitoring and assessing metabolism and nutrition;

IV.A.2.a).(1).(i) renal: performance of the evaluation of renal function; use of renal replacement therapies; management of hemodialysis, and management of electrolyte disorders and acid-base disturbances; and application of knowledge of the indications for and complications of hemodialysis; and,

IV.A.2.a).(1).(j) respiratory: performance of airway management, including techniques of intubation, endoscopy, and tracheostomy, as well as ventilator management.

IV.A.2.a).(2) must demonstrate competence in the application of the following critical care skills:

IV.A.2.a).(2).(a) circulatory: transvenous pacemakers; dysrhythmia diagnosis and treatment, and the management of cardiac assist devices; and use of vasoactive agents and the management of hypotension and shock;

IV.A.2.a).(2).(b) neurological: the use of intracranial pressure monitoring techniques and electroencephalography to evaluate cerebral function;

IV.A.2.a).(2).(c) renal: knowledge of the indications for and complications of hemodialysis, and management of electrolyte disorders and acid-base disturbances; and,

IV.A.2.a).(2).(d) miscellaneous: performance of the use of special beds for specific injuries, and employment of skeletal traction and fixation devices.
 
IV.A.2.b) Medical Knowledge

Fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care. Fellows:
 
IV.A.2.b).(1) must demonstrate advanced knowledge of the following aspects of critical care, particularly as they relate to the management of patients with homodynamic instability, multiple system organ failure, and complex coexisting medical problems:

IV.A.2.b).(1).(a) biostatistics and experimental design;

IV.A.2.b).(1).(b) cardiorespiratory resuscitation;
 
IV.A.2.b).(1).(c) critical obstetric and gynecologic disorders;
 
IV.A.2.b).(1).(d) critical pediatric surgical conditions;

IV.A.2.b).(1).(e) ethical and legal aspects of surgical critical care;

IV.A.2.b).(1).(f) hematologic and coagulation disorders;

IV.A.2.b).(1).(g) inhalation and immersion injuries;

IV.A.2.b).(1).(h) metabolic, nutritional, and endocrine effects of critical illness;

IV.A.2.b).(1).(i) monitoring and medical instrumentation;

IV.A.2.b).(1).(j) pharmacokinetics and dynamics of drug metabolism and excretion in critical illness;

IV.A.2.b).(1).(k) physiology, pathophysiology, diagnosis, and therapy of disorders of the cardiovascular, respiratory, gastrointestinal, genitourinary, neurological, endocrine, musculoskeletal, and immune systems, as well as of infectious diseases;

IV.A.2.b).(1).(l) principles and techniques of administration and management; and,

IV.A.2.b).(1).(m) trauma, thermal, electrical, and radiation injuries.
 
IV.A.2.c) Practice-based Learning and Improvement

Fellows are expected to develop skills and habits to be able to meet the following goals:

IV.A.2.c).(1) systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement; 

IV.A.2.c).(2) locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems.
 
 IV.A.2.d)  Interpersonal and Communication Skills

Fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.

IV.A.2.d).(1)  Fellows must demonstrate effective skills in teaching the specialty of surgical critical care.

IV.A.2.e)  Professionalism

Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

IV.A.2.f) Systems-based Practice

Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

IV.A.2.f).(1) Fellows must be able to administer a surgical critical care unit and appoint, educate, and supervise specialized personnel; establish policy and procedures for the unit; and coordinate the activities of the unit with other administrative units within the hospital.

IV.A.3. Curriculum Organization and Fellow Experiences

IV.A.3.a) All 12 months must be devoted to advanced educational and clinical activities related to the care of critically-ill patients and to the administration of critical care units.

IV.A.3.a).(1) At least eight months must be in a surgical intensive care unit.

IV.A.3.a).(1).(a) At least five of the eight months should be in a unit in which a surgeon is director or co-director.

IV.A.3.a).(1).(b) The surgical intensive care unit must be largely dedicated to the care of oneor more of the following surgical patients: adult surgical, burn, cardiothoracic, neurosurgical, pediatric surgical, transplant, and trauma.

IV.A.3.a).(2) No more than two months should be in non-surgical intensive care units, such as medical, cardiac, or pediatric units.

IV.A.3.a).(3) No more than two months should be in elective rotations in areas relevant to critical care, such as trauma or acute care surgery.

IV.A.3.a).(3).(a) Elective clinical rotations done outside of the critical care unit should involve the care of patients with acute surgical diseases such as those related to injury or emergent surgical conditions.

IV.A.3.b) The core curriculum must include a regularly-scheduled didactic program based on the core knowledge content and areas defined as a fellow’s outcomes in the specialty.

IV.A.3.c) Participation in direct operative care of critically-ill patients in the operating room during critical care rotations should not be so great as to interfere with the primary educational purpose of the critical care rotation.

IV.A.3.d) Fellows must keep two written records of their experience: a summary record documenting the numbers and types of critical care patients; and an operative log of numbers and types of operative experiences, including bedside procedures.

IV.A.3.e) A chief resident in surgery and a fellow in surgical critical care must not have primary responsibility for the same patient.

IV.B. Fellows’ Scholarly Activities

V.  Evaluation

V.A.  Fellow Evaluation

V.A.1.  Formative Evaluation

V.A.1.a) The faculty must evaluate fellow performance in a timely manner.

V.A.1.b) The program must:

V.A.1.b).(1) provide objective assessments of competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice;

V.A.1.b).(2) use multiple evaluators (e.g., faculty, peers, patients, self, and other professional staff); and,

V.A.1.b).(3) provide each fellow with documented semiannual evaluation of performance with feedback.

V.A.1.c) The evaluations of fellow performance must be accessible for review by the fellow, in accordance with institutional policy.

V.A.1.d) Semiannual assessment must include a review of case volume, breadth, and complexity, and must ensure that fellows are maintaining the required written records.

V.A.2. Summative Evaluation

The program director must provide a summative evaluation for each fellow upon completion of the program. This evaluation must become part of the fellow’s permanent record maintained by the institution, and must be accessible for review by the fellow in  accordance with institutional policy. This evaluation must:

V.A.2.a)  document the fellow’s performance during their education, and

V.A.2.b) verify that the fellow has demonstrated sufficient competence to enter practice without direct supervision.

V.B. Faculty Evaluation

V.B.1. At least annually, the program must evaluate faculty performance as it relates to the educational program.

V.B.2. These evaluations should include a review of the faculty’s clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism, and scholarly activities.

V.C. Program Evaluation and Improvement

V.C.1. The program must document formal, systematic evaluation of the curriculum at least annually. The program must monitor and track each of the following areas:

V.C.1.a) fellow performance, and

V.C.1.b) faculty development.

V.C.2. If deficiencies are found, the program should prepare a written plan of action to document initiatives to improve performance in the areas listed in section V.C.1. The action plan should be reviewed and approved by the teaching faculty and documented in meeting minutes.

V.C.3. 65% of a program’s graduates from the preceding five years taking the American Board of Surgery certifying examination for surgical critical care for the first time must pass.

VI. Fellow Duty Hours in the Learning and Working Environment

VI.A. Professionalism, Personal Responsibility, and Patient Safety

VI.A.1. Programs and sponsoring institutions must educate fellows and faculty members concerning the professional responsibilities of physicians to appear for duty appropriately rested and fit to provide the services required by their patients.

VI.A.2. The program must be committed to and responsible for promoting patient safety and fellow well-being in a supportive educational environment.

VI.A.3. The program director must ensure that fellows are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs.

VI.A.4. The learning objectives of the program must:

VI.A.4.a) be accomplished through an appropriate blend of supervised patient care responsibilities, clinical teaching, and didactic educational events; and,

VI.A.4.b) not be compromised by excessive reliance on fellows to fulfill non-physician service obligations.

VI.A.5. The program director and sponsoring institution must ensure a culture of professionalism that supports patient safety and personal responsibility. Fellows and faculty members must demonstrate an understanding and acceptance of their personal role in the following:

VI.A.5.a) assurance of the safety and welfare of patients entrusted to their care;

VI.A.5.b) provision of patient- and family-centered care;

VI.A.5.c) assurance of their fitness for duty;

VI.A.5.d) management of their time before, during, and after clinical assignments;

VI.A.5.e) recognition of impairment, including illness and fatigue, in themselves and in their peers;

VI.A.5.f)  attention to lifelong learning;

VI.A.5.g) the monitoring of their patient care performance improvement indicators; and,

VI.A.5.h) honest and accurate reporting of duty hours, patient outcomes, and clinical experience data.

VI.A.6. All fellows and faculty members must demonstrate responsiveness to patient needs that supersedes self-interest. Physicians must recognize that under certain circumstances, the best interests of the patient may be served by transitioning that patient’s care to another qualified and rested provider.

VI.B. Transitions of Care

VI.B.1. Programs must design clinical assignments to minimize the number of transitions in patient care.

VI.B.2. Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety.

VI.B.3. Programs must ensure that fellows are competent in communicating with team members in the hand-over process.

VI.B.4. The sponsoring institution must ensure the availability of schedules that inform all members of the health care team of attending physicians and fellows currently responsible for each patient’s care.

VI.C. Alertness Management/Fatigue Mitigation

VI.C.1. The program must:

VI.C.1.a) educate all faculty members and fellows to recognize the signs of fatigue and sleep deprivation;

VI.C.1.b) educate all faculty members and fellows in alertness management and fatigue mitigation processes; and,

VI.C.1.c) adopt fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning, such as naps or back-up call schedules.

VI.C.2. Each program must have a process to ensure continuity of patient care in the event that a fellow may be unable to perform his/her patient care duties.

VI.C.3. The sponsoring institution must provide adequate sleep facilities and/or safe transportation options for fellows who may be too fatigued to safely return home.

VI.D. Supervision of Fellows

VI.D.1. In the clinical learning environment, each patient must have an identifiable, appropriately-credentialed and privileged attending physician (or licensed independent practitioner as approved by each Review Committee) who is ultimately responsible for that patient’s care.

VI.D.1.a) This information should be available to fellows, faculty members, and patients.

VI.D.1.b) Fellows and faculty members should inform patients of their respective roles in each patient’s care.

VI.D.2. The program must demonstrate that the appropriate level of supervision is in place for all fellows who care for patients.

Supervision may be exercised through a variety of methods. Some activities require the physical presence of the supervising faculty member. For many aspects of patient care, the supervising physician may be a more advanced fellow. Other portions of care provided by the fellow can be adequately supervised by the immediate availability of the supervising faculty member or fellow physician, either in the institution, or by means of telephonic and/or electronic modalities. In some circumstances, supervision may include post-hoc review of fellow-delivered care with feedback as to the appropriateness of that care.

VI.D.3. Levels of Supervision

To ensure oversight of fellow supervision and graded authority and responsibility, the program must use the following classification of supervision:

VI.D.3.a) Direct Supervision – the supervising physician is physically present with the fellow and patient.

VI.D.3.b) Indirect Supervision:

VI.D.3.b).(1) with direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide Direct Supervision.
 
VI.D.3.b).(2) with direct supervision available – the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide Direct Supervision.
 
 VI.D.3.c) Oversight – the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

VI.D.4. The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each fellow must be assigned by the program director and faculty members.

VI.D.4.a) The program director must evaluate each fellow’s abilities based on specific criteria. When available, evaluation should be guided by specific national standards-based criteria.

VI.D.4.b) Faculty members functioning as supervising physicians should delegate portions of care to fellows, based on the needs of the patient and the skills of the fellows.

VI.D.4.c) Fellows should serve in a supervisory role of residents or junior fellows in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual fellow.

VI.D.5. Programs must set guidelines for circumstances and events in which fellows must communicate with appropriate supervising faculty members, such as the transfer of a patient to an intensive care unit, or end-of-life decisions.

VI.D.5.a) Each fellow must know the limits of his/her scope of authority, and the circumstances under which he/she is permitted to act with conditional independence.

VI.D.6. Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each fellow and delegate to him/her the appropriate level of patient care authority and responsibility.

VI.E. Clinical Responsibilities

The clinical responsibilities for each fellow must be based on PGY-level, patient safety, fellow education, severity and complexity of patient illness/condition and available support services.

VI.E.1. The workload associated with optimal clinical care of surgical patients is a continuum from the moment of admission to the point of discharge.

VI.E.2. During the residency education process, surgical teams should be made up of attending surgeons, residents at various PG levels, medical students (when appropriate), and other health care providers.

VI.E.3. The work of the caregiver team should be assigned to team members based on each member’s level of education, experience, and competence.

VI.E.4. As fellows progress through levels of increasing competence and responsibility, it is expected that work assignments will keep pace with their advancement.

VI.F. Teamwork

Fellows must care for patients in an environment that maximizes effective communication. This must include the opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty.

VI.F.1. Effective surgical practices entail the involvement of members with a mix of complementary skills and attributes (physicians, nurses, and other staff). Success requires both an unwavering mutual respect for those skills and contributions, and a shared commitment to the process of patient care.

VI.F.2. Fellows must collaborate with fellow surgical residents, and especially with faculty, other physicians outside of their specialty, and non-traditional health care providers, to best formulate treatment plans for an increasingly diverse patient population.

VI.F.3. Fellows must assume personal responsibility to complete all tasks to which they are assigned (or which they voluntarily assume) in a timely fashion. These tasks must be completed in the hours assigned, or, if that is not possible, fellows must learn and utilize the established methods for handing off remaining tasks to another member of the fellow team so that patient care is not compromised.

VI.F.4. Lines of authority should be defined by programs, and all fellows must have a working knowledge of these expected reporting relationships to maximize quality care and patient safety.

VI.G. Fellow Duty Hours

VI.G.1. Maximum Hours of Work per Week

Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities and all moonlighting.

VI.G.1.a) Duty Hour Exceptions

A Review Committee may grant exceptions for up to 10% or a maximum of 88 hours to individual programs based on a sound educational rationale.

The Review Committee for General Surgery will not consider requests for exceptions to the 80-hour limit to the fellows’ work week.

VI.G.1.a).(1) In preparing a request for an exception the program director must follow the duty hour exception policy from the ACGME Manual on Policies and Procedures.

VI.G.1.a).(2) Prior to submitting the request to the Review Committee, the program director must obtain approval of the institution’s GMEC and DIO.

VI.G.2. Moonlighting

VI.G.2.a) Moonlighting must not interfere with the ability of the fellow to achieve the goals and objectives of the educational program.

VI.G.2.b) Time spent by fellows in Internal and External Moonlighting (as defined in the ACGME Glossary of Terms) must be counted towards the 80-hour Maximum Weekly Hour Limit.

VI.G.3. Mandatory Time Free of Duty

Fellows must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks). At-home call cannot be assigned on these free days.

VI.G.4. Maximum Duty Period Length

Duty periods of fellows may be scheduled to a maximum of 24 hours of continuous duty in the hospital. Programs must encourage fellows to use alertness management strategies in the context of patient care responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00 a.m., is strongly suggested.

VI.G.4.a) It is essential for patient safety and fellow education that effective transitions in care occur. Fellows may be allowed to remain on-site in order to accomplish these tasks; however, this period of time must be no longer than an additional four hours.

VI.G.4.b) Fellows must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.

VI.G.4.c)  In unusual circumstances, fellows, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient.Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family.

VI.G.4.c).(1) Under those circumstances, the fellow must:

VI.G.4.c).(1).(a) appropriately hand over the care of all other patients to the team responsible for their continuing care; and,

VI.G.4.c).(1).(b) document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the program director.

VI.G.4.c).(2) The program director must review each submission of additional service, and track both individual fellow and program-wide episodes of additional duty.

VI.G.5. Minimum Time Off between Scheduled Duty Periods
 
VI.G.5.a) Fellows must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods.
 
Surgical critical care fellows are considered to be in the final years of education.

VI.G.5.a).(1) This preparation must occur within the context of the 80-hour, maximum duty period length, and one-day-off-in-seven standards. While it is desirable that fellows have eight hours free of duty between scheduled duty periods, there may be circumstances when these fellows must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty.

VI.G.5.a).(1).(a) Circumstances of return-to-hospital activities with fewer than eight hours away from the hospital by fellows must be monitored by the program director.

VI.G.5.a).(1).(b) The Review Committee defines such circumstances as: required continuity of care for a severely ill or unstable patient, or a complex patient with whom the fellow has been involved; events of exceptional educational value; or, humanistic attention to the needs of a patient or family.

VI.G.6. Maximum Frequency of In-House Night Float
 
Fellows must not be scheduled for more than six consecutive nights of night float.

VI.G.6.a) Any rotation that requires fellows to work nights in succession is considered a night float rotation, and the total time on nights is counted toward the maximum allowable time for each fellow.

VI.G.6.b) Night float rotations must not exceed two months in succession, or three months in succession for rotations with night shifts alternating with day shifts.

VI.G.6.c) There can be no more than four months of night float per year.

VI.G.6.d) There must be at least two months between each night float rotation.

VI.G.7. Maximum In-House On-Call Frequency
 
Fellows must be scheduled for in-house call no more frequently than every-third-night (when averaged over a four-week period).

VI.G.8. At-Home Call

VI.G.8.a) Time spent in the hospital by fellows on at-home call must count towards the 80-hour maximum weekly hour limit. The frequency of at-home call is not subject to the every-third-night limitation, but must satisfy the requirement for one-day-in-seven free of duty, when averaged over four weeks.

VI.G.8.a).(1) At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each fellow.

VI.G.8.b) Fellows are permitted to return to the hospital while on at-home call to care for new or established patients. Each episode of this type of care, while it must be included in the 80-hour weekly maximum, will not initiate a new “off-duty period”.
 
ACGME-approved: October 1, 2011; Effective: July 1, 2012

Summary of Critical Care Pathways

1. Surgical Critical Care (effective July, 2012)

Prior to appointment in the program, fellows must have completed at least three clinical years in an ACGME-accredited graduate educational program in emergency medicine and must also complete one preliminary year of education in the surgery program at the institution where they will enroll in the surgical critical care fellowship.

ABEM announcement.

ABS announcement.

Requirements:

At a minimum the preliminary year of education must include supervised clinical experience in:

• pre-operative evaluation, including respiratory, cardiovascular, and nutritional evaluation;
• pre-operative and post-operative care of surgical patients, including outpatient follow-up care;
• care of injured patients;
• care of patients requiring abdominal, breast, head and neck, endocrine, thoracic, and vascular operations;
• management of complex wounds; and;
• minor operative procedures related to critical care, such as venous access, tube thoracotomy, and tracheostomy.

2. Anesthesia Critical Care (effective July 2013)

Certification in the subspecialty of Anesthesiology Critical Care Medicine (ACCM) is available to American Board of Emergency Medicine (ABEM)–certified physicians (diplomates) who fulfill the eligibility criteria and pass the ACCM subspecialty examination. ABEM co-sponsors this subspecialty with the American Board of Anesthesiology (ABA).

ABEM-ABA overview.

ABEM diplomates starting ACCM fellowship training on or after July 1, 2014, for the purpose of seeking subspecialty certification in ACCM, must enter an ACCM fellowship program that includes the ACGME-accredited ACCM fellowship program and an additional 12 months of ACCM training. The program and its training design must have the prospective approval of the ABA prior to the entry of the emergency physician into that program.

Requirements:

• The physician must have successfully completed an Accreditation Council for Graduate Medical Education (ACGME)–accredited EM residency program (36 or 48 months in length)
• The physician must be an ABEM diplomate
• The physician must be meeting the requirements of the ABEM MOC program at the time of application and throughout the certification process
• Prior to entering an ACCM fellowship program, and during the ACGME-accredited EM residency, emergency physicians must have completed four months (or 16 weeks) of critical care training
• Emergency physicians must successfully complete an ACGME-accredited ACCM fellowship program; and Complete an additional 12 months of ACCM training that have been prospectively approved by the ABA. This additional 12 months of training must occur at the same site as the ACCM fellowship program

3. Internal Medicine (Effective February 2012)

Certification in the subspecialty of Internal Medicine-Critical Care Medicine (IM-CCM) is available to diplomates of the American Board of Emergency Medicine (ABEM) who fulfill the eligibility criteria and pass the IM-CCM certification examination. ABEM co-sponsors this subspecialty with the American Board of Internal Medicine (ABIM).

IM-CCM announcement.

IM-EM-CCM FAQS.

Requirements:

• The diplomate must be meeting the requirements of the ABEM Maintenance of Certification program.
• Medical licensure must be in compliance with the ABEM Policy on Medical Licensure.
• ABEM must be able to obtain independent verification of clinical competence in Critical Care Medicine; successful completion of IM-CCM fellowship training; and, if the physician applies via the practice pathway, the physician’s practice of CCM. ABEM will independently verify, with the fellowship program director, the applicant’s successful completion of that training and the applicant’s clinical competence in CCM.
• The applicant must have successfully completed an ACGME-accredited IM-CCM fellowship on or after September 21, 2011, that is a minimum of 24 months duration.

4. European Diploma of Intensive Care (EDIC) from European Society of Intensive Care Medicine

Requirements (written component):

• Fully registered Medical Doctor (i.e. internship completed). Candidates must be in good standing with their national medical registration authorities.
• Entry into a national training program in a primary specialty. This may include Anesthesiology, General/Internal Medicine (and other medical specialities), General Surgery (and other surgical specialities), Accident & Emergency Medicine, Pediatrics, or Intensive Care Medicine if a primary speciality.
• Entry into a national training program in intensive care medicine or satisfactory completion of12 months training/experience in ICM**, of which not more than six months may includecomplementary training. Complementary training entails training in the acute and emergencymedical care of patients other than in the trainee’s primary speciality. ** Intensive Care Medicine training/experience should be undertaken in modules of dedicated, full-time, supervised training / experience in Intensive CareMedicine
• Specialists (Consultants/Attending) may take the EDIC if they have a regular, substantive day- time and emergency call commitment to intensive/critical care medicine.

Requirements (oral/clinical component):

• Successful completion of EDIC Part I
• 24 months of training/experience in ICM**, of which not more than 6 months may include ‘complementary training’ (see above). ** Intensive Care Medicine training/experience should be undertaken in modules of dedicated, full-time, supervised training / experience in Intensive Care Medicine
• To minimize the failure rate and to accommodate requests for candidates from outside Europe, it is recommended that candidates should acquire a thorough understanding of European ICM practice. It is recommended that this is best facilitated by working in an academic European ICU for a period of at least six months. If your application form does not specify training within a European ICU, you may be requested to provide documentation confirming such training / experience.

FAQs

1) Is there a need Nationally / Locally for these physicians? Do they go into academics or private practice?

Critical care can be defined as medical care to any patient who is physiologically unstable and requiring constant titration of therapy according to the evolution of the disease process. This definition extends to any location such that critical care is defined physiologically rather than geographically. The American College of Chest Physicians (ACCP), American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM) predicted that the proportion of care provided by critical care physicians in the United States will fall below standards because of the growing disease burden created by the aging population. In 2004, along with the American Association of Critical Care Nurses, they published a white paper asking federal healthcare policy makers to address the compelling evidence that current trends predict that the demand for critical care services will exceed the supply of critical care physicians into the year 2030 (1). Angus et al also concluded that adoption of an intensivist model would require a large expansion of the critical care workforce, as only about one in three ICU patients is currently cared for by intensivists (2).

The Leapfrog Group, a consortium of major private and public organizations that studies ways to improve health care, has advocated the use of an “intensivist model” of critical care delivery, where all ICU patients are managed or co- managed by an intensivist. In its ICU physician staffing model, the Leapfrog Group defines “intensivist” as one of the following: 1) Critical Care Board- certified physician; 2) Board-certified emergency medicine (EM) physician who completed an Accreditation Council for Graduate Medical Education (ACGME) accredited Critical Care Fellowship; or 3) Board-certified physicians in medicine, anesthesiology, pediatrics, or surgery who completed training before the availability of Critical Care Fellowships (3-5). This model is also supported by the National Quality Forum, a nonprofit organization created to develop and implement a national strategy for health care quality measurement and reporting (6).

In 2005, a consensus paper endorsed by SCCM and multiple emergency medicine societies called for establishing access to formal critical care medicine (CCM) training and certification for emergency physicians (EPs) and noted that EM-CCM physicians would not only help address the intensivist shortage, but also strengthen critical care delivery in the emergency department (ED) and facilitate coordination between EDs and intensive care units (7). In a survey performed by Mayglothling et al (8), 49% of EPs who completed ICU fellowships practice both EM and CCM, and 62% practice in academic institutions. The number of EPs completing CCM fellowships has risen: 12 from 1974 to 1989; 15 from 1990 to 1999; and 43 from 2000 to 2007. This number may be underrepresented since there is no easy way to track EPs who choose to do critical care fellowships and there has been no certification process in the United States.

2) Is there sufficient patient volume and faculty expertise at University of Florida Health Shands to create a competitive program?

Yes, UF-Shands is a very busy tertiary care center that accepts many of the sickest and most complex patients in the region. With multiple sub-specialties such as vascular surgery, neurosurgery, urology, transplant, orthopedics, cardiovascular, and medical, many difficult cases in the region are transferred here. Currently there are three departments with adult critical care fellowship training (anesthesia, surgery, and medicine), with a total of 17 fellows. See below for statistics of individual units.

Units Available for rotation and number of faculty in each:

Medical ICU (24 ICU beds) – 20 faculty in the Pulmonary/Critical Care Division Surgical ICU (48 ICU beds) – 7 trauma/CCM faculty; 7 anesthesia/CCM faculty Neurosurgical ICU (30 ICU beds) – 7 anesthesia/CCM faculty
Burn ICU (12 ICU beds) – 7 anesthesia/CCM faculty, 2 Burn/trauma faculty Emergency Department – 6 bed critical care area, 3 ED-ICU trained faculty; currently 3 Emergency Medicine trained fellows in the anesthesiology CCM training program (3 recent graduates)

Number of fellows in other programs:

• Internal Medicine Pulm/CC fellowship: 9 Fellows
• Surgical CC fellowship: 2 Fellows
• Anesthesia CC fellowship: 6 Fellows
• Emergency Medicine CC fellowship (with Anesthesia): 3 Fellows

Trauma Quality Management Committee Data at Shands:

# Trauma Alerts + #Acute Care Surgery 2010: 1040 + 836 = 1876 total patients 2011: 1143 + 915 = 2058 total patients 2012: 1131 + 1069 = 2200 total patients

Most of the surgical patients in the trauma unit come from ‘trauma alerts’ and acute care surgery consult patients who may be very sick and need optimization of hemodynamic status prior to surgical intervention. Complex multi-trauma and head injured patients present to this unit.

Emergency Department “Alerts”: The emergency department volume is around 65,000 per year (adult only) and sees a wide variety of emergencies. Strokes, sepsis, trauma, and STEMI are specific conditions that have an ‘alert’ system in place and help identify and streamline care of the patient to the appropriate unit. Fellows have an opportunity to learn systems based approaches to complex and critical patient.

3) How does the program function in conjunction with the core program and other subspecialty training programs.

This program will function as part of a multi-disciplinary environment of critical care training. The Emergency Medicine critical care fellows will rotate through the individual ICU’s with goals and objectives similar to other fellows in each particular program. The fellows will also be involved with the Emergency Medicine residency critical care teaching initiatives, which includes a lecture series as well as ‘hands on’ courses in areas such as airway, venous access, and ultrasound. See below for individual units the fellows will rotate and estimates of block time.

ED Critical Care lecture series for ED residents: fellows would be involved in the lecture series and involved in joint CCM conferences between ED and MICU/ SICU/NeuroICU. Topics covered include hypertensive emergencies, intracranial hypertension, trauma, toxic overdoses, palliative care, ethics, vasopressor therapies, massive pulmonary embolism, massive gi bleeding, etc.

Critical Care Ultrasound: Ultrasound is a core requirement for ED resident graduates. This would be beneficial in certain applications for cross-training in ICU ultrasound curriculum.

Medical ICU: estimate of 4 total MICU rotation blocks (2 per year), with opportunity to do extra MICU time during elective

Surgical ICU: 4west (trauma ICU) and 4east (surgical ICU) would do according to anesthesiology ACGME requirements in first and second year (estimate 12 total blocks)

Neurosurgical ICU: would do according to anesthesiology ACGME requirements in first and second year (estimate 6 total blocks)

4) How does a critical care fellowship program enhance the institution?

This EM program allows a more multi-disciplinary training program in critical care for all programs involved. Some specific knowledge or skills that an EM applicant may bring to the fellowship include use of point of care ultrasound, toxicological patterns, acute arrhythmia interventions and ECG interpretation, procedural sedation, minor orthopedic procedures (reductions), and wide breath of patient types and disease processes (obstetric, pediatric, opthalmic, psychiatric)

Emergency physicians with additional critical care training would provide critical care expertise in the ED, facilitating earlier delivery of critical care and potentially reducing morbidity and mortality rates and cost (9). These fellows would also be ideally suited to improve coordination between the ED and ICU. As demonstrated with other fellowships available to EM physicians such as toxicology and pediatric emergency medicine, fellowship trained emergency physicians enhance ED care, system implementation, and education in their specific areas (9).

Also, the Department of Emergency Medicine would benefit with a better understanding and collaboration of intensive care unit best practices in the Emergency Department. For example, certain protocols in the units (traumatic brain injury, diabetic ketoacidosis, status epilepticus, sedation/analgesia, central venous line placement, etc) could be introduced in a transitional form to provide better care of our patients. Fromm et al have reported that during a one year study period in a teaching hospital, 154 patient days of ED critical care were provided in the ED with a length of stay up to 11 hours. Other studies have also confirmed that patients frequently stay for extended amounts of time in the ED and in one study found that 15% of all critical care was performed in the ED (10-11). We currently have an ED resident rotation in our 6 bed critical care/ resuscitation area and may benefit from increased training of critical care through our fellowship program.

5) What are the goals and objectives of the program?

Goal: To offer a training program to the graduating emergency medicine resident that provides training in a multi-disciplinary intensive care unit practices. Topics would include complex medical ICU patients (such as obstructive lung disease, renal failure, septic shock, cardiogenic shock, pneumonia, etc.), complex surgical ICU patients (s/p transplant, complex vascular surgery patients, trauma, etc.), and neurological ICU patients (status epilepticus, stroke, intracranial bleeds, etc.).

It is difficult for an EM resident to find a true multi-disciplinary training/fellowship setting. Most EM residents have rotated through medicine, surgical, and pediatric type settings and search for programs that are able to provide all of these. It is also sometimes difficult for EM residents to find programs that will accept based on their emergency medicine training. CCM fellowship directors cite the lack of specific EM pathways to formal critical care certification and resultant concerns of criticism from their Residency Review Committee as major barriers to accepting EM physicians into their programs (12-13).

Objective: It would be expected for EM fellows to be able to have and pass board certification through the ABA-ABEM pathway recently approved (July 2013). Other institutions that have accepted EM residents over the past 10-15 years have provided information on ability of EM residents to successfully complete fellowship and tested knowledge base compared to other specialties. For instance, Chiu et al recently published a comparison between surgery trained residents and emergency medicine at Shock-Trauma (University of Maryland). Surgeons and EPs performance scores on the MCCKAP (testing guide by SCCM) were not different. The mean National Board Equivalent score was 419 +/- 61 for surgeons and 489 +/- for EP’s. Since scores do not always equate to competency in management of a unit, all of the fellows at the same center also receive a formative interval based (9 point scale with 1 as most unsatisfactory and 9 as most superior) and narrative evaluations. The range of mean clinical evaluations was 7.2 for surgeons and 6.8 for EPs (14).

Other good FAQS:

• ACEP
• EMCrit
• University of Pittsburgh
• EMCCM Fellowship

References:

1. Ewart GW, Marcus L, Gaba MM, Bradner RH, Medina JL, Chandler EB. The critical care medicine crisis: a call for federal action: a white paper from the critical care professional societies. Chest. 2004;125: 1518 –1521
2. Angus DC, Kelley MA, Schmitz RJ, et al: Current and projected workforce require- ments for care of the critically ill and pa- tients with pulmonary disease: Can we meet the requirements of an aging population? JAMA 2000; 284:2762–2770
3. Milstein A, Galvin RS, Delbanco SF, et al. Intensive care unit physician staffing: the Leapfroginitiative. Eff Clin Prac. 2003; 3:313–6
4. Gutsche JT, Kohl BA. Who should care for intensive care unit patients? Crit Care Med.2007;35:S18–S23
5. National Quality Forum. Available at: http:// www.qualityforum.org/. Accessed August 5, 2013:
6. Huang DT, Osborn TM, Gunnerson KJ, et al. Critical care medicine training and certification foremer- gency physicians. Ann Emerg Med. 2005; 46:217–23
7. Mayglothling et al. ACADAEMIC EMERGENCY MEDICINE 2010; 17:325–329
8. Huang D: Impact of emergency department care on intensive care unit costs. Crit Care 2004;8:498 –502
9. Fromm RE Jr, Gibbs LR, McCallum WG, et al: Critical care in the emergency department: A time-based study. Crit Care Med 1993; 21:970 –976
10. Nelson M, Waldrop RD, Jones J, et al: Critical care provided in an urban emergency department. Am J Emerg Med 1998; 16:56–59
11. Huang DT, Gunnerson KJ, Kimball EJ, et al: Emergency medicine residents’ access to critical care fellowships. Crit Care Med 2003; 31(12 Suppl):A27
12. Milzman DP, Rubin S, Moskowitz L: Consid- eration of adult critical care training for emergency physicians. Acad Emerg Med 1999; 6:345–348
13. Chiu et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 71, Number 1, July 2011

Anesthesia Pathways

Program Requirements

Curricula, Duration, and Program Standards for Training Programs

ACGME-accredited ACCM training programs are one year in length. Some programs are two-year programs, but the additional year is not ACGME accredited. Institutions that have an ACGME-accredited ACCM training program must also have ACGME-accredited core residencies in anesthesiology, general surgery, and internal medicine. The program guidelines require that nine months of a 12-month ACCM fellowship be in an ICU providing direct care to critically ill patients. The remainder of the fellowship may be in clinical activities or research relevant to critical care medicine.

The educational goals for emergency physicians entering ACCM fellowships are to assure competency in all realms of critical care medicine including the care of trauma and surgically-related conditions. The length of training for emergency physicians in ACCM is a minimum of two years. This is different than that of an anesthesiologist (one year).

Given the frequency of trauma and surgical conditions that are encountered in the ACCM fellowship, an early and substantial knowledge regarding surgical disease is required. There is a desire for this to occur in a manner similar to (but not necessarily identical to) the approach by the ABS and RRC-Surgery. Prior to entry into an SCC fellowship, the Emergency Medicine physician must complete a modified advanced preliminary year of training. The intention is for the physician to be in an intermediate-to-advanced role as a trainee (e.g., a non-operating 3rd, 4th- or 5th-year surgery resident). This is expressed in the following ACGME requirement:

III.A.1.a) Fellows who have completed an emergency medicine residency must also complete one preparatory year as an advanced preliminary resident in surgery at the institution where they will enroll in the surgical critical care medicine fellowship. The content of this year should be defined jointly by the program directors of the surgery program and the surgical critical care medicine program. It must include clinical experience in the foundations of surgery and the management of complex surgical conditions.

The content of this year should include the following areas:

III.A.1.a).(1) pre-operative evaluation, including respiratory, cardiovascular, and nutritional evaluation;

III.A.1.a).(2) pre-operative and post-operative care of surgical patients, including outpatient follow-up care;

III.A.1.a).(3) advanced care of injured patients;

III.A.1.a).(4) care of patients requiring abdominal, breast, head and neck, endocrine, transplant, cardiac, thoracic, vascular, and neurosurgical operations;

III.A.1.a).(5) management of complex wounds; and,

III.A.1.a).(6) minor operative procedures related to critical care medicine, such as venous access, tube thoracostomy, and tracheostomy.

Though both SCC training and ACCM training for emergency physicians are 24 months, the structure is slightly different. This does not prohibit an early surgical emphasis that covers the afore-listed content. In fact, it is assumed that this content will be emphasized early (the first 6 months) in the ACCM experience.

One requirement that would readily accomplish the acquisition of knowledge and skills required for the evaluation and care of the surgical patient would be to “front-end load” core training in surgically-based rotations. To that end, in the first six months of an ACCM fellowship there should be three months of rotations that have a surgical emphasis such as any combination of the following: trauma surgery; acute care surgery; emergency surgery; or an equivalent experience.

An additional consideration to assure the sufficient acquisition of knowledge, skills, and experience in the care of surgical disease is to have a robust aggregate educational exposure to surgical conditions. To accomplish this, ACCM fellowships should have at least 12 months (or rotations) that involve surgical patients. The three additional months of surgical emphasis would count towards this as would any months in the surgical or combined medical- surgical critical care unit. Other rotations could also count, such as a pediatric intensive care rotation, because pre- and post-operative children would be treated. Finally, rotations such as infectious disease (ID) might be included or excluded depending on the nature of the ID population. If a rotation included a sufficient number of surgical patients, it would be included. Despite this emphasis on surgical disease, the emergency physician would still have ample opportunity to garner additional CCM experience in pulmonary medicine and bronchoscopy, coronary care and echocardiography, infectious disease, nephrology, and neurologic disorders. In addition, Anesthesiology rotations with pre-operative and peri-operative activities could be considered.

Research electives should be limited to a total of no more than two rotations (two months) during the 24 months fellowship.

Finally, most ACGME-accredited ACCM fellowships are 12 months in duration. Programs must receive prospective approval from the ABA before any trainees accepted into the two year anesthesiology critical care medicine fellowship can qualify for certification under the training pathway. The grandfathering provision will be available for four years beginning July 1, 2013. A physician seeking certification under the grandfathering pathway must complete both training and a practice component to be considered for certification.

The pathway to qualify for the ACCM certification examination for physicians trained in Emergency Medicine is a minimum of five years in duration. This requires that graduating Emergency Medicine residents who have successfully completed a three-year or four-year residency to:

(1) complete a 12 month ACGME-accredited ACCM fellowship as well as an additional 12 months in the same fellowship setting, but the 2nd year must be approved by the ABA; or

(2) prospectively complete a two-year ABA-approved fellowship which incorporates the above requirements.

Eligibility

Effective July 2013

Certification in the subspecialty of Anesthesiology Critical Care Medicine (ACCM) is available to American Board of Emergency Medicine (ABEM)–certified physicians (diplomates) who fulfill the eligibility criteria and pass the ACCM subspecialty examination. ABEM co-sponsors this subspecialty with the American Board of Anesthesiology (ABA).

The ABA is the administrative board for the ACCM subspecialty. The ABA develops and oversees the administration of the subspecialty examination. ABEM diplomates submit applications for certification in ACCM to ABEM. ABEM reviews the applicant’s credentials to determine eligibility, reports the results of the examination, and issues certificates to its candidates. All applicants are encouraged to review the FAQs for more details about the application process and eligibility criteria.

General Eligibility Criteria

The general criteria for emergency physicians seeking certification in ACCM are as follows:

• The physician must have successfully completed an Accreditation Council for Graduate Medical Education (ACGME)–accredited EM residency program (36 or 48 months in length).
• The physician must be an ABEM diplomate.
• The physician must be meeting the requirements of the ABEM MOC program at the timeof application and throughout the certification process.

Additionally, the physician must fulfill the eligibility criteria of either the Fellowship Training Pathway or the Fellowship Training-plus-Practice Pathway.

Application Pathways

Fellowship Training Pathway:

These criteria pertain to ABEM diplomates who enter ACGME-accredited, ABA-approved, ACCM fellowship programs on or after July 1, 2014.

ABEM diplomates must meet all of the following requirements:

• Prior to entering an ACCM fellowship program, and during the ACGME-accredited EM residency, emergency physicians must have completed four months (or 16 weeks) of critical care training.
• Emergency physicians must successfully complete an ACGME-accredited ACCM fellowship program; and
• Complete an additional 12 months of ACCM training that have been prospectively approved by the ABA. This additional 12 months of training must occur at the same site as the ACCM fellowship program.

The fellowship program and additional ACCM training requirements for emergency physicians are available from the ABA.

Fellowship Training-Plus-Practice Pathway (Grandfathering Pathway):

There is an eligibility opportunity for some ABEM diplomates who have previously completed an ACGME-accredited ACCM fellowship program and have practiced critical care medicine.

This pathway of application is time limited. Physicians seeking certification through the Fellowship Training-Plus-Practice Pathway must have completed both an ACGME-accredited ACCM fellowship program and the CCM practice component by the time they submit their certification application and no later than June 30, 2018. In addition, the physician must submit an application to ABEM no later than the final day of the application period that ends in calendar year 2018.

Fellowship Training Requirement:

• The physician must have successfully completed an ACGME-accredited ACCM fellowship program.

Practice Requirement

• ABEM must be able to obtain independent verification of the physician’s clinical competence in CCM.
• During the two years immediately preceding the submission of an application for certification in ACCM, the applicant must have completed one of the following: 40% of their post-training clinical practice time in the practice of CCM (≥16 hours per week),* or 25% of their total post-training professional time in the practice of CCM (≥10 hours per week).**

* This calculation is based on an average work week of 40 hours. Physicians whose total practice exceeds 40 hours per week may still use the 40 hours number as the denominator of their 40% or 25% calculation.

** This approach specifically applies to academic program directors, administrators, or researchers, and provides them a pathway to qualification

The “practice of CCM,” is strictly defined for the purpose of meeting this requirement. An acceptable practice of CCM must occur in a designated critical care unit such as a surgical critical care unit, medical intensive care unit, or combined med-surg ICU. For purposes of ACCM eligibility, practices that occur in critical care areas in the emergency department do not count. The CCM practice must involve scheduled time in the critical care unit when the physician has no other clinical responsibility (e.g., seeing patients in the emergency department or elsewhere). Likewise, any other venue that is not specifically designated as a critical care or intensive care venue that is also not under the purview of a department of critical care medicine or similar authority does not count as a critical care unit for the purpose of meeting this practice requirement. In addition, providing medical care to critically ill and injured patients in the emergency department does not, by itself, constitute practicing CCM. Although emergency physicians care for critical patients daily, this does not constitute the practice of CCM.

Timing Considerations

For Physicians Completing ACGME-accredited ACCM Fellowship Training on or Before June 30, 2014

ABEM diplomates who successfully complete an ACGME-accredited ACCM fellowship program on or before June 30, 2014, will have completed the training requirement of the Fellowship Training-Plus-Practice Pathway of application. They must also complete two years of clinical practice in CCM as described above. This practice must have occurred in a designated CCM unit as defined above.

After July 1, 2014, completing only 12 months of training in ACCM will be insufficient to qualify for ACCM certification eligibility.

For Physicians Starting ACCM Fellowship Training on or after July 1, 2014

ABEM diplomates starting ACCM fellowship training on or after July 1, 2014, for the purpose of seeking subspecialty certification in ACCM, must enter an ACCM fellowship program that includes the ACGME-accredited ACCM fellowship program and an additional 12 months of ACCM training. The program and its training design must have the prospective approval of the ABA prior to the entry of the emergency physician into that program. The program director must seek this approval from the ABA. Training completed in any program that does not have the prior approval of the ABA will not fulfill the training requirement.

Verification of ACCM Training, CCM Practices, and Clinical Competence

For physicians who apply through the Fellowship Training Pathway, ABEM will seek independent verification of the physician’s successful completion of the ACCM fellowship program from the ACCM fellowship program director.

For physicians who apply through the Fellowship Training-Plus-Practice Pathway, ABEM will seek independent verification of the physician’s successful completion of the ACCM fellowship program from the ACCM fellowship program director.

ABEM will also seek independent verification of the ACCM practice a physician submits to fulfill the CCM practice requirement and the physician’s clinical competence in CCM. ABEM will accept this verification from the program director of the ACGME-accredited CCM fellowship program affiliated with the hospital where the physician spends the majority of CCM clinical time. If an ACGME-accredited CCM fellowship is not present at this hospital, ABEM will seek verification by the Chief of Critical Care Medicine in the hospital where the physician spends the majority of CCM clinical time. Should the physician who is applying be the Chief of Critical Care, verification will be accepted from the Chief of Staff, Vice-President of Medical Affairs, or someone in a similar position.

Certification

ABEM diplomates who have met the ACCM eligibility criteria and who pass the ACCM subspecialty examination are recognized as being certified in the subspecialty of Anesthesiology Critical Care Medicine. Certification is for a period of ten years.

Certificates are dated from the date of the examination results letter and expire December 31, ten years thereafter. The diplomate’s Emergency Medicine certification must be valid in order for the subspecialty certification to remain valid.

FAQs

1. What are the eligibility criteria that ABEM diplomates must meet to apply for ACCM subspecialty certification?GENERAL ELIGIBILITY CRITERIAThe general criteria for emergency physicians seeking certification in ACCM are as follows:
   • The physician must have successfully completed an ACGME-accredited EM residency program (36 or 48 months in length).
   • The physician must be an ABEM diplomate.
   • The physician must be meeting the requirements of the ABEM MOC program at thetime of application and throughout the certification process.Additionally, the physician must fulfill the eligibility criteria of either the Fellowship Training Pathway or the Fellowship Training-plus-Practice Pathway. The specific requirements of these pathways of application are described in the ACCM Eligibility Criteria for ABEM Diplomates.
2. Is there a “grandfathering” pathway for ABEM-certified physicians and what are the eligibility criteria for that pathway? Yes, there is a pathway for some ABEM-certified physicians who have previously completed an ACGME-accredited ACCM fellowship program. This pathway is the Fellowship Training-Plus Practice Pathway. In addition to completing an ACGME-accredited ACCM fellowship training program, physicians must also have practiced critical care medicine for a specific period of time and intensity in a critical care unit. The specific eligibility criteria of this pathway are described in the ACCM Eligibility Criteria for ABEM Diplomates.
3. Regarding the practice requirement of the “grandfathering” pathway, what constitutes the “practice of critical care medicine”? The “practice of CCM,” is strictly defined for the purpose of meeting this requirement. An acceptable practice of CCM must occur in a designated critical care unit such as a surgical critical care unit, medical intensive care unit or combined med-surg unit. For purposes of ACCM eligibility, practices that occur in critical care areas in the emergency department do not count. The CCM practice must involve scheduled time in the critical care unit when the physician has no other clinical responsibility (e.g., seeing patients in the emergency department or elsewhere). Any other venue that is not specifically designated as a critical care or intensive care venue that is also not under the purview of a department of critical care medicine or similar authority, does not count as a critical care unit for the purpose of meeting this practice requirement. In addition, providing medical care to critically ill and injured patients in the emergency department does not, by itself, constitute practicing CCM. Emergency physicians care for critical patients daily, but this does not constitute the practice of CCM.
4. How long will the “grandfathering” pathway be available? This pathway of application is time limited. The training and practice requirements must be completed by June 30, 2018, and the physician must submit an application to ABEM no later than the final day of the application period that ends in calendar year 2018. Physicians seeking certification through the “grandfathering” pathway must have completed both the training and the CCM practice requirement before they submit their application to be considered for certification.
5. Will ABEM verify the information I provide on my application for ACCM certification? Yes, ABEM will seek independent verification of ACCM training, CCM practices, and clinical competence. ABEM will obtain verification of ACCM training from the ACCM fellowship program director.If you apply through the Fellowship Training-Plus-Practice Pathway, ABEM will also obtain verification of practice and clinical competence from the program director of the ACGME-accredited CCM fellowship program affiliated with the hospital where you spend the majority of your CCM clinical time. If an ACGME-accredited CCM fellowship is not present at this hospital, ABEM will seek verification by the Chief of Critical Care Medicine in the hospital where you spend the majority of CCM clinical time. If you are the Chief of Critical Care, verification will be accepted from the Chief of Staff, Vice-President of Medical Affairs, or someone in a similar position.
6. Will ACCM Fellowship Program Requirements allow EM residency graduates to enter ACGME-accredited ACCM fellowship training programs? Yes. However, the entry of emergency physicians into an ACGME-accredited ACCM fellowship program is ultimately the decision of the fellowship program director. The Residency Review Committee for Anesthesiology has proposed changes to the ACCM Program Requirements to allow ACGME-accredited ACCM programs to accept EM residency graduates.
7. I completed fellowship training in another CCM subspecialty program (Internal Medicine or Surgery). Am I able to submit this training to fulfill the training requirement of the ACCM eligibility criteria and then take the ACCM certification examination to achieve ACCM subspecialty certification? No. Only emergency physicians who are graduates of ACGME-accredited ACCM fellowship programs may apply for certification in ACCM through this ABEM co- sponsorship arrangement.
8. I completed an ACCM fellowship program that became ACGME-accredited after I completed the program. Does this training meet the eligibility criteria? No. The ACCM fellowship must have been ACGME-accredited at the time you completed the program.
9. If I am an ABEM-certified physician, how will I apply for ACCM certification? ABEM diplomates will submit applications to ABEM during the annual application period. The first application period will be for the 2014 examination. The application period dates have not yet been determined, but will be announced on the ABEM website when they are available. ABEM will determine if an ABEM applicant fulfills the eligibility criteria.
10. When will the first ACCM subspecialty certification examination be available to ABEM diplomates? The earliest opportunity for ABEM diplomates who meet eligibility criteria to take the ACCM subspecialty certification examination will be in August 9, 2014. The ABA administers the ACCM subspecialty certification examination on an annual basis.
11. What is the format and content of the examination? The ACCM certification examination is a one-day examination consisting of approximately 200 multiple choice questions. It is administered using a secure, computerized examination platform. The ABA administers this examination in Pearson VUE testing centers. An examination content outline is available at theaba.org.
12. Who will issue the certificate to ABEM diplomates who pass the ACCM subspecialty certification examination? ABEM will issue ACCM certificates to its diplomates.
13. What are the requirements to maintain certification in ACCM? Physicians certified in ACCM must meet the requirements of the ABEM MOC program or the ABA MOCA program.
14. I completed a one-year ACGME-accredited ACCM fellowship on June 30, 2013. Does this training fulfill the eligibility criteria? Do I also have a practice requirement? Completion of this fellowship training fulfills the training requirement of the Fellowship Training-Plus-Practice Pathway. This pathway also requires completion of two years of critical care medicine practice as described in FAQ #3. When both the training and practice requirements are completed, you can apply to ABEM for certification in ACCM.
15. I completed a two-year ACCM fellowship on June 30, 2013. Does this training fulfill the eligibility criteria? Do I also have a practice requirement? Yes, completion of this fellowship training fulfills the training requirement of the Fellowship Training-Plus-Practice Pathway. This pathway also requires completion of two years of critical care medicine as described in an earlier FAQ. When both the training and practice requirements are completed, you can apply to ABEM for certification in ACCM.
16. I started a one-year ACGME-accredited ACCM fellowship on July 1, 2013. Will this satisfy the training criteria? Do I also have a practice requirement? Completion of this training will satisfy the training criteria of the FellowshipTraining-plus- Practice Pathway of application but you must also complete the two-year practice requirement as outlined in FAQ #3 to fulfill the eligibility criteria. This is the last year that an emergency physician can enter a one-year ACCM fellowship without the additional 12 months of ABA-approved ACCM training. After July 1, 2014, completing only 12 months of training in ACCM will be insufficient to qualify for ACCM certification eligibility.
17. I started a two-year ACCM fellowship on July 1, 2013. Will this satisfy the training criteria? Do I also have a practice requirement? Completion of this training will satisfy the training criteria of the Fellowship Training-plus-Practice Pathway of application but you must also complete the two-year practice requirement as outlined in FAQ #3 to fulfill the eligibility criteria. After July 1, 2013, the 24-month ACCM fellowship training curriculum for emergency physicians must be prospectively approved by the ABA prior to the emergency physician entering the fellowship training program for that training to fulfill the Fellowship Training Pathway eligibility criteria.
18. When does the fellowship training-only pathway go into effect? The fellowship training-only pathway goes into effect July 1, 2014. ABEM diplomates starting ACCM fellowship training on or after July 1, 2014, for the purpose of seeking subspecialty certification in ACCM, must enter an ACCM fellowship program that includes the ACGME-accredited ACCM fellowship program and an additional 12 months of ACCM training. The program and its training design must have the prospective approval of the ABA prior to the entry of the emergency physician into that program. No emergency physician entering a fellowship after July 1, 2014, is eligible to take the examination under the grandfathering provisions. There are no exceptions to this requirement.
19. What is the process for obtaining ABA approval for the 24 months of ACCM fellowship training that an emergency physician must complete to fulfill the eligibility criteria? It is the ACCM fellowship program director’s responsibility to submit the program curriculum to the ABA for review and approval. Training completed in any program that does not have the prior approval of the ABA will not fulfill the training requirement. (ACCM Two-Year Critical Care Medicine Fellowship Program Application Form)
20. When an ABEM diplomate has fulfilled the ACCM eligibility criteria and has taken and passed the ACCM certification examination, how is that accomplishment recognized? The ABEM diplomate who has met the ACCM eligibility criteria and who passes the ACCM subspecialty examination is recognized as being certified in the subspecialty of Anesthesiology Critical Care Medicine. Certification is for a period of ten years.ABEM issues the certificates to its diplomates. The certificates are dated from the date of the examination results letter and expire December 31 ten years thereafter. The diplomate’s Emergency Medicine certification must be valid in order for the subspecialty certification to remain valid.

Sample Curriculum

Year 1 Block – Anesthesia ACGME Year – 10 blocks of Surgical ICU (1 MICU, 1 Elective)

1: Anesthesiology OR Difficult Airway (ANES, EE, SP)

2: Surgical ICU: 4WEST (Trauma, Ortho, Vascular) (SP, SICU, TS, ICU-CIP)

3: Surgical ICU: 4EAST (Transplant, ENT, Panc/Bili, Gen Surg, Minimally Invasive) (SP, SICU, ICU-CIP)

4: Surgical ICU: 4WEST (Trauma, Ortho, Vascular) (SP, SICU, TS, ICU-CIP)

5: Surgical ICU: 4EAST (Transplant, ENT, Panc/Bili, Gen Surg, Minimally Invasive) (SP, SICU, ICU-CIP)

6: Cardiothoracic ICU (CT ICU, SP, ICU-CIP)

7: MICU (MICU, ICU-CIP)

8: Neuro ICU (Neurological, Neurosurgical, Burn) (Neurosurgical ICU, SP, ICU-CIP, BU)

9: Neuro ICU (Neurological, Neurosurgical, Burn) (Neurosurgical ICU, SP, ICU-CIP, BU)

10: Neuro ICU (Neurological, Neurosurgical, Burn) (Neurosurgical ICU, SP, ICU-CIP, BU)

11: Surgical ICU: 4EAST (Transplant, ENT, Panc/Bili, Gen Surg, Minimally Invasive) (SP, SICU, ICU-CIP)

12: Surgical ICU: 4WEST (Trauma, Ortho, Vascular) (SP, SICU, TS, ICU-CIP)

13: Elective

Year 2 Block – Anesthesia ABA Pre-Approved Year – (5 Surgical ICU, 2 Medical ICU, 4 Electives, 2 Research)

Total ED time 472 hours

1: Research: Three 12 hour shifts (SpringHill) + Four 8 hour shifts (Adult ED) = 68 hours

2: Surgical ICU: 4EAST (Transplant, ENT, Panc/Bili, Gen Surg, Minimally Invasive) (SP, SICU, ICU-CIP)

3: Elective: Three 12 hour shifts (SpringHill) + Four 8 hour shifts (Adult ED) = 68 hours

4: Burn ICU (BU, SP, ICU-CIP)

5: Neuro ICU (Neurological, Neurosurgical, Burn) (Neurosurgical ICU, SP, ICU-CIP, BU)

6: Elective: Three 12 hour shifts (SpringHill) + Four 8 hour shifts (Adult ED) = 68 hours

7: *MICU (MICU, ICU-CIP): Four 8 hour shifts (Adult ED) = 32 hours

8: *MICU (MICU, ICU-CIP): Four 8 hour shifts (Adult ED) = 32 hours

9: Neuro ICU (Neurological, Neurosurgical, Burn) (Neurosurgical ICU, SP, ICU-CIP, BU)

10: Elective: Three 12 hour shifts (SpringHill) + Four 8 hour shifts (Adult ED) = 68 hours

11: Surgical ICU: 4WEST (Trauma, Ortho, Vascular) (SP, SICU, TS, ICU-CIP)

12: Research: Three 12 hour shifts (SpringHill) + Four 8 hour shifts (Adult ED) = 68 hours

13: Elective: Three 12 hour shifts (SpringHill) + Four 8 hour shifts (Adult ED) = 68 hours

MICU: Mon-Thu 7am to 7pm + ED time as stated above

Vacation time during both years during Elective Months.

Surgery Pathway

Program Requirements

Impact Statement

Requirement #: III.A.1 through III.A.1.a)(6)

Requirement Revision (major revisions only):

III.A.1 Prior to appointment in the program, fellows must have completed at least three clinical years in an ACGME-accredited graduate educational program in one of the following specialties: anesthesiology, emergency medicine, neurological surgery, obstetrics and gynecology, orthopaedic surgery, otolaryngology, surgery, thoracic surgery, vascular surgery, or urology.

III.A.1.a). Fellows who have completed emergency medicine residency, must also complete one preliminary year of education in the surgery program at the institution where they will in the surgical critical care fellowship. The preliminary year of education must include, and does not need to be limited to, supervised clinical experience in:

III.A.1.a).(1). Pre-operative evaluation, including respiratory, cardiovascular, and nutritional evaluation.

III.A.1.a).(2) Pre-operative and postoperative care of surgical patients, including outpatient follow up care.

III.A.1.a).(3) Care of injured patients.

III.A.1.a).(4) Care of patients requiring abdominal, breast, head and neck, endocrine, thoracic, and vascular operations

III.A.1.a).(5) Minor operative procedures related to critical care, such as venous access, tube thoracotomy, and tracheostomy

III.A.1.a).(6). Management of complex wounds.

Describe, as appropriate, how the revision:

• Impacts the quality and safety of patient care; Currently approved preliminary positions are expected to be allocated to support the Emergency Medicine program graduate wishing to enroll in a Surgical Critical Care fellowship. The quality and safety of patient care is expected to remain consistent with current standards of quality and patient care.
• Improves the quality of resident education; The Emergency Medicine program graduate will have the opportunity to participate in those aspects of graduate medical education in surgery in order to be prepared for a Surgical Critical Care fellowship program.
• Affects the way the resident, the service, and the staff provide patients with continuing care; It is expected that a program would use one of their existing approved preliminary positions to support a graduate of an emergency medicine program causing no change in the way the resident, service, and staff provide patients with continuing care.
• Requires a change in institutional resources (e.g., facilities; organization of other services; addition of faculty; financial impact); No additional resources would be required as programs would use one of their existing approved preliminary positions to support a graduate of an emergency medicine program preparing to enter a Surgical Critical Care fellowship program.
• May change the volume and variety of patients required to provide proper educational resources in the institution(s); None. It is expected that a program would use one of their existing approved preliminary positions to support a graduate of an emergency medicine program.
• Impacts residency education in other specialties. The Emergency Medicine program graduate will have the opportunity to participate in those aspects of graduate medical education in surgery in order to be prepared for a Surgical Critical Care fellowship program.

Medicine Pathway

Eligibility

American Board of Emergency Medicine.

Internal Medicine-Critical Care Medicine (IM-CCM) Eligibility Criteria for ABEM Diplomates Seeking Certification in IM-CCM.

Effective February 2012.

Certification in the subspecialty of Internal Medicine-Critical Care Medicine (IM-CCM) is available to diplomates of the American Board of Emergency Medicine (ABEM) who fulfill the eligibility criteria and pass the IM-CCM certification examination. ABEM co-sponsors this subspecialty with the American Board of Internal Medicine (ABIM).

General Criteria

The general criteria for ABEM diplomates to be eligible for certification in IM-CCM include the following:

1) The diplomate must be meeting the requirements of the ABEM Maintenance of Certification program.

2) Medical licensure must be in compliance with the ABEM Policy on Medical Licensure.

3)  The diplomate must fulfill the eligibility criteria of the pathway through which they apply, as defined below.

4)  ABEM must be able to obtain independent verification of clinical competence in Critical Care Medicine; successful completion of IM-CCM fellowship training; and, if the physician applies via the practice pathway, the physician’s practice of CCM.

Application Pathways

There are two application pathways for certification in IM-CCM: an ACGME-accredited fellowship pathway (training pathway) and a practice pathway.

Training Pathway

The applicant must have successfully completed an ACGME-accredited IM-CCM fellowship on or after September 21, 2011, that is a minimum of 24 months duration.

ABEM will independently verify, with the fellowship program director, the applicant’s successful completion of that training and the applicant’s clinical competence in CCM.

Physicians seeking certification in more than one subspecialty or specialty may not apply the same subspecialty fellowship training period toward fulfillment of requirements of more than one specialty or subspecialty.

Practice Pathway

The practice application pathway requires both completion of a 24-month CCM fellowship and practice of CCM as defined below. This pathway will be available to ABEM diplomates for the first five years and will close on the last day of the fifth application period, anticipated to be June 30, 2016.

Training component

The applicant must have successfully completed a CCM fellowship of at least 24 months duration. The fellowship must be one of the following:

• An ACGME-accredited IM-CCM fellowship completed before September 21, 2011.
• An unaccredited IM-CCM fellowship that subsequently became ACGME accredited on or before December 31, 1992.
• An ACGME-accredited fellowship in another critical care specialty (e.g. Surgery-CCM, Anesthesiology-CCM)

Practice component

The applicant must have completed the following practice as of the date on which the application is submitted to ABEM.

For at least three, not necessarily contiguous, years of the five years prior to submitting an application for certification in IM-CCM, including the twelve months immediately prior to submitting an application, the applicant must have completed one of the following*:

• 40% of their post-training clinical practice time in the practice of CCM
• 25% of their total post-training professional time in the practice of CCM.

Practice component exception for physicians who completed accredited IM-CCM fellowship training between September 21, 2008, through September 20, 2011
Applicants who successfully completed an ACGME-accredited IM-CCM fellowship in the three years prior to September 21, 2011 (i.e. September 21, 2008, through September 20, 2011), may apply for certification if, during 60% of the time between completing fellowship training and applying for certification, they completed one of the following*:

• 40% of their post-training clinical practice time in the practice of CCM
• 25% of their total post-training professional time in the practice of CCM.

*Physicians whose total practice exceeds 40 hours per week may use 40 hours as the denominator of their 40% or 25% calculation.Attestation and verification for all practice applicants

Attention and verification for all practice applicants

All practice pathway applicants must attest that they have satisfactory clinical competence in the following specific areas:

• Care of patients presenting with critical care illness traditionally cared for in an MICU
• Multi-disciplinary care involving ABIM- or other ABMS member board-certified specialists and subspecialists. Satisfactory clinical competence is defined as

Satisfactory clinical competence is defined as:

• clinical experience that meets these criteria
• clinical privileges that have never been suspended or revoked by a hospital, nor has the physician ever knowingly taken steps to avoid suspension or revocation of clinical privileges.

ABEM will seek independent verification of the applicant’s practice in CCM and clinical competence in CCM from the Program Director of an ACGME-accredited CCM fellowship affiliated with the hospital where the candidate spends the majority of clinical time. If an accredited CCM fellowship is not present at this hospital, ABEM will seek verification by the Chief of Critical Care Medicine in the hospital where the applicant spends the majority of clinical time. Should the applicant actually be the Chief of Critical Care, verification can be made by the Chief of Staff, Vice-President of Medical Affairs, or someone in a similar position.

Certification

A candidate who has met the eligibility criteria and who passes the subspecialty examination is recognized as being certified in the subspecialty of Internal Medicine – Critical Care Medicine. Certification is for a period of ten years.

An ABEM diplomate’s primary certification in Emergency Medicine must be current for certification in IM-CCM to be valid.

FAQs

1. What are the requirements for certification in IM-CCM? The generalrequirements for ABEM diplomates seeking certification in IM-CCM are as follows:1) The physician must be an ABEM diplomate meeting the requirements of the ABEM Maintenance of Certification program.
   2) Medical licensure must be in compliance with the ABEM Policy on Medical Licensure. 3) The diplomate must fulfill the eligibility criteria of the pathway through which they apply, as described in FAQ 2.4) ABEM must obtain independent verification of successful completion of IM-CCM fellowship training; clinical competence in Critical Care Medicine; and, if the physician applies via the practice pathway, the physician’s practice of CCM.The complete eligibility criteria can be viewed on the ABEM website under Subspecialty Certification – IM-CCM.
2. What are the application pathways available to ABEM diplomates? There are two pathways for certification: a training pathway and a practice pathway. The practice pathway includes both a training and a practice component. The complete eligibility criteria can be viewed on the ABEM website under Subspecialty Certification – IM-CCM.
3. For how long will the practice pathway be available? The practice pathway of application will be available through the end of the application period in 2016, anticipated to be June 30, 2016. Applicants must have fulfilled all requirements of this pathway as of the date on which they submit their application to ABEM.
4. How do I apply for IM-CCM certification? ABEM diplomates submit applications to ABEM during the application period. ABEM determines if the applicant fulfills the eligibility criteria. Physicians must have an approved, active IM-CCM application on file with ABEM if they wish to take the IM-CCM certification exam. If you wish to receive an application packet contact ABEM at subspecialties@abem.org. The application packet can be sent to you via email or regular mail.Diplomates of the American Board of Internal Medicine (ABIM) seeking IM-CCM certification should contact ABIM for specific information about their application process.
5. What if an ABEM diplomate is also a diplomate of the ABIM? How do they apply for the examination? Physicians who are diplomates of ABEM and ABIM may choose the board through which they wish to apply. Their IM-CCM certificate will be issued by the board through which they apply for certification in IM-CCM.
6. What is the deadline for ABEM diplomates to apply for certification in IM- CCM? ABEM sets the dates for its application cycle annually.
7. What are the fees related to IM-CCM certification? Both the application and the examination fee must be submitted with the application. The application fee is an administrative fee and is not refundable. If ABEM determines that a diplomate does not fulfill the eligibility criteria, the examination fee is refunded in full. If the physician withdraws from the examination, 90% of the examination fee is refunded.
8. When is the IM-CCM certification examination offered? The IM-CCM certification examination is offered by ABIM each fall in Pearson VUE testing centers.
9. How do I schedule an appointment to take the examination? ABEM will register you for the IM-CCM examination by submitting your name to ABIM. This will happen after your application has been approved as meeting the eligibility criteria, or approved contingent on ABEM receiving verification of your practice and/or your training. After ABIM receives your name from ABEM and obtains authorization from Pearson VUE for you to schedule your examination appointment, you will receive a letter from ABIM stating that you can schedule your examination appointment directly with Pearson VUE. You must schedule your appointment at least 48 hours before the examination day.
10. HowdoesanABEMdiplomaterequestspecialaccommodationsunderthe Americans with Disabilities Act (ADA)? Information regarding how to submit a request for special testing accommodations is included in the IM-CCM application packet. Requests must be submitted to ABEM at the same time the application is sent to ABEM.ABEM offers a limited range of exam accommodations. If you submit a request for accommodations, with appropriate documentation, ABEM will review your request and determine if it will be granted. If the decision is favorable, your examination appointment will occur on a different day (or days) than the regular examination day.
11. What does the examination cover? The detailed IM Critical Care Medicine Certification examination blueprint. This information includes the content areas the examination covers, their relative percentages, and the approximate number of questions in each area to expect in a typical examination.
12. When and how will I receive my examination scores? You will receive your examination scores from ABEM via regular mail no more than 90 days after the examination. At this time, you will receive your scores only by U.S. mail.
13. How long is the certification effective? TheIM-CCMcertificationisfortenyears.
14. What are the ongoing requirements to maintain this certification? To maintain IM-CCM certification, ABEM diplomates must maintain their primary certification in Emergency Medicine. ABEM diplomates must continue to meet the requirements of the ABEM Maintenance of Certification program.
15. I have heard that EM residency graduates cannot enroll in IM-CCM fellowships. How is it possible to meet the eligibility criteria in that case? As part of the agreement by which ABEM now co-sponsors certification in IM-CCM, ACGME-accredited IM-CCM fellowship programs may now accept EM residency graduates if they so choose. However, an IM-CCM fellowship must have 75% of its positions filled by IM residency graduates.
16. Are there unique requirements for Emergency Medicine residency graduates to enter an ACGME-accredited IM-CCM fellowship training program? The ACGME Program Requirements for Graduate Medical Education in Critical Care Medicine specify that graduates of ACGME-accredited Emergency Medicine programs should have completed at least six months of direct patient care experience in internal medicine, of which at least three months must have been in a medical intensive care unit during their EM residency training. These revised IM-CCM program requirements go into effect July 1, 2012.A fellow may complete the rotations needed to fulfill this requirement while they are enrolled in the IM-CCM fellowship program. However, they cannot supervise IM residents until these rotations are completed. These rotations can replace other rotations in the fellowship program so that the fellow’s training need not be extended beyond the standard two years.
17. I completed fellowship training in another type of CCM (Surgeryor Anesthesiology). Is there a way for me to become certified in IM-CCM? If your ACGME-accredited Surgery or Anesthesiology CCM fellowship training was at least 24 months duration, and if you meet the practice requirements, you may apply for certification through the practice pathway while that pathway is in place (through the end of the application period in 2016). If the fellowship training was less than 24 months duration or was not ACGME-accredited, you are not eligible to apply for certification in IM-CCM. ABEM continues to explore avenues for EM residency graduates to become certified in Surgery CCM and Anesthesiology CCM.