Core Curriculum and Competencies for Advanced Training in Neurological Intensive Care United Council for Neurologic Subspecialties Guidelines Stephan A

Neurocritical Care Copyright © 2006 Humana Press Inc. All rights of any nature whatsoever are reserved. ISSN 1541-6933/06/5:159–165 ISSN 1556-0961 (Online) DOI: 10.1385/Neurocrit. Care 2006;05:159–165 Special Article

Core Curriculum and Competencies for Advanced Training in Neurological Intensive Care United Council for Neurologic Subspecialties Guidelines Stephan A. Mayer , William M. Coplin , Cherylee Chang , Jose Suarez , Daryl Gress , Michael N. Diringer , Jeffery Frank , J. Claude Hemphill , Gene Sung , Wade Smith , Edward M.Manno , Andrew Kofke , Arthur Lam and , Thorsten Steiner, on behalf of the Neurocritical Care Society , the American Academy of Neurology Section on Critical Care and Emergency Neurology, and the Society of Neurosurgical Anesthesia and Critical Care

Introduction dates of cognitive and procedural skills nec- These guidelines regarding the program essary for a training program. Each director content of advanced training in neurological determines the specific content of his or her intensive care were preliminarily endorsed program. on October 20, 2005 by the United Council of Neurological Subspecialties (UCNS), and are A. Cognitive Skill Set based on existing criteria developed by the Acquisition of the following cognitive Society of Critical Care Medicine (SCCM) and skills by trainees can be accomplished through by the Accreditation Council for Gradute the use of any number of techniques, includ- Medical Education (ACGME). These guide- ing supervised direct patient care, didactic lines have been reviewed and adapted by the sessions, journal clubs, or literature reviews. authors to ensure that they combine basic aspects of general critical care medicine that are relevant to neurocritical care, as well as I. Neurological Disease States: specialized skills that are specific to neuro- Pathology, Pathophysiology, and critical care. The following is a listing of Therapy cognitive and procedural skills that are The following are specific diseases, con- fundamental to the training of specialists ditions, and clinical syndromes commonly in neurocritical care, regardless of whether managed by a neurointensivist: a training program is based in neurology, neuro surgery, internal medicine, anesthesi- ology, pediatrics, or another specialty. This A. Cerebrovascular Diseases *Correspondence to: list also includes pertinent aspects on general 1 . Infarction and ischemia Mari E. Mellick critical care, such a cardiac, pulmonary, and a. Massive hemispheric infarction United Council for infectious disease management. b. Basilar artery occlusion and stenosis Neurologic Subspecialties, Fellowship program directors may choose c. Carotid artery occlusion and stenosis 1080 Montreal Avenue, to include additional cognitive or procedural d. Crescendo transient ischemic attacks St. Paul, MN 55116. skills to augment this listing in order to suit e. Occlusive vasculopathies (Moya- E-mail: [email protected] their goals for advanced training for physi- Moya, sickle cell) cians in neurocritical care. These guidelines f. Spinal cord infarction should be used as recommendations for 2 . Intracerebral hemorrhage training directors to use in the development a. Supratentorial of each program. They are not intended to b. Cerebellar constrain any training program. They pro- c. Brainstem vide the basic framework for future man- d. Intraventricular

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3 . Subarachnoid hemorrhage (SAH) — aneurysmal and other 3. Drug overdose and withdrawal (e.g., barbiturates, 4. Vascular malformations narcotics, alcohol, cocaine, acetaminophen). a. Arteriovenous (AV) malformations 4. Temperature-related injuries (hyperthermia, hypothermia) b. AV fistulas c. Cavernous angiomas H. Inflammatory and Demyelinating Diseases d. Venous angiomas 5. Dural sinus thrombosis 1. Multiple sclerosis (Marburg variant, transverse myelitis) 6. Carotid-cavernous ﬁ stulae 2. Neurosarcoidosis 7. Cervical and cerebral arterial dissections 3. Acute disseminated encephalomyelitis (ADEM) 4. Central nervous system vasculitis 5. Chemical or sterile meningitis (i.e., posterior fossa B. Neurotrauma syndrome, nonsteroidal anti-inﬂ ammatory drug-induced) 1. Traumatic brain injury 6 . Central pontine myelinolysis a. Axonal shearing injury 7 . Others b. Epidural hematoma c. Subdural hematoma I. Encephalopathies d. Skull fracture 1. Eclampsia, including hemolysis, elevated liver enzymes, e. Contusions and lacerations low platelet count (HELLP) Syndrome f. Penetrating craniocerebral injuries 2 . Hypertensive encephalopathy and posterior reversible g. Traumatic SAH encephalopathy syndrome (PRES) 2. Spinal cord injury 3. Hepatic encephalopathy a. Traumatic injury (transection, contusion, concussion) 4. Uremic encephalopathy b. Vertebral fracture and ligamentous instability 5. Hypoxic-ischemic encephalopathy 3. Electrical injury (e.g., lightning) 6. Mitochondrial encephalopathy, lactic acidosis, and strokelike (episodes) (MELAS) and related disorders

C. Seizures and Epilepsy J. Neuroendocrine Disorders 1. Status epilepticus (SE) 1. Pituitary apoplexy a. Convulsive 2. Diabetes insipidus (including triple phase response) b. Nonconvulsive (partial-compex and “ subtle ” second- 3 . Panhypopituitarism arily generalized SE) c. Myoclonic K. Movement Disorders 1. Severe dystonia and opisthotonus D. Neuromuscular Diseases 2 . Hemiballismus 3 . Acute dystonic reactions 1 . Myasthenia gravis 2 . Guillain-Barré syndrome L. Clinical Syndromes 3 . Amyotrophic lateral sclerosis 4 . Rhabdomyolysis and toxic myopathies 1. Coma 5 . Critical illness myopathy and neuropathy 2. Herniation syndromes 3. Elevated intracranial pressure (ICP) 4. Intracranial hypotension/hypovolemia E. Infections 5. Hydrocephalus 1. Encephalitis (viral, bacterial, parasitic) 6. Cord compression 2 . Meningitis (viral, bacterial, parasitic) 7. Brain death 3 . Brain and spinal epidural abscess 8. Vegetative state 4 . Tetanus 9. Delirium 5 . Botulism 10. Abulia 11. Dysautonomia (central fever, hyperventilation, et cetera) 12. Reversible posterior leukoencephalopathy syndrome F. Neuro-Oncology 13. Psychiatric emergencies 1. Brain tumors and metastases 2. Spinal cord tumors and metastases M. Perioperative Neurosurgical Care 3. Carcinomatous meningitis 1. Postcraniotomy hypertension 4. Paraneoplastic syndromes 2 . Postcraniotomy pain 3 . Wound cerebrospinal ﬂ uid (CSF) leaks 4 . Postcraniotomy CSF hypovolemia G. Toxic-Metabolic Disorders 5 . Wound infections 1. Neuroleptic malignant syndrome/malignant hyperthermia 6 . Postoperative brain edema 2 . Serotonin syndrome 7. Postcraniotomy intracranial hemorrhage Neurocritical Care ♦ Volume 5, 2006 Core Curriculum for Neurological Intensive Care 161

8 . Postcarotid endarterectomy/stenting hyperperfusion d. Barotrauma, airway pressures (including permissive syndrome hypercapnia) 9 . Postcervical spine surgery airway management e . Criteria for weaning and weaning techniques 8. Pleural diseases N. Neurorehabilitation a. Empyema b. Massive effusion O. Pharmacotherapeutics c. Pneumothorax 9. Pulmonary hemorrhage and massive hemoptysis II. General Medical Disease States: Pathology, 10. Chest X-ray interpretation Pathophysiology, and Therapy 11. End tidal CO 2 monitoring 12 . Sleep apnea The following are medical conditions and skill require- 13 . Control of breathing ments often encountered by neurointensivists: C. Renal Physiology, Pathology, Pathophysiology, A. Cardiovascular Physiology, Pathology, and Therapy Pathophysiology, and Therapy 1. Renal regulation of ﬂ uid and water balance and electrolytes 1. Shock (hypotension) and its complications (vasodilatory 2 . Renal failure: prerenal, renal, and postrenal and cardiogenic) 3. Derangements secondary to alterations in osmolality 2. Myocardial infarction and unstable coronary syndromes and electrolytes 3. Neurogenic cardiac disturbances (electrocardiographic 4. Acid-base disorders and their management [ECG] changes, stunned myocardium) 5 . Principles of hemodialysis 4 . Cardiac rhythm and conduction disturbances; use of 6 . Evaluation of oliguria and polyuria antiarrhythmic medications; indications for and types of 7. Drug dosing in renal failure pacemakers 8 . Management of rhabdomyolysis 5. Pulmonary embolism 9 . Neurogenic disorders of sodium and water regulation 6 . Pulmonary edema: cardiogenic versus noncardiogenic (cerebral salt wasting and secretion of antidiuretic hormone (including neurogenic) [SIADH]) 7. Acute aortic and peripheral vascular disorders (i.e., dis- section, pseudoaneurysm) 8. Recognition, evaluation, and management of hyperten- D. Metabolic and Endocrine Effects of sive emergencies and urgencies Critical Illness 9 . Calculation of derived cardiovascular parameters, 1 . Enteral and parenteral nutrition including systemic and pulmonary vascular resistance, 2 . Endocrinology alveolar-arterial gradients, oxygen transport, and a. Disorders of thyroid function (thyroid storm, myx- consumption edema coma, sick euthyroid syndrome) b. Adrenal crisis B. Respiratory Physiology, Pathology, c. Diabetes mellitus Pathophysiology, and Therapy i. Ketotic and hyperglycemic hyperosmolar coma ii. Hypoglycemia 1 . Acute respiratory failure d. Pheochromocytoma a. Hypoxemic respiratory failure (including acquired e. Disorders of calcium and magnesium balance respiratory distress syndrome [ARDS]) 3. Systemic inﬂ ammatory response syndrome (SIRS) b. Hypercapnic respiratory failure 4 . Fever, thermoregulation, and cooling techniques 2 . Aspiration 3. Bronchopulmonary infections 4. Upper airway obstruction E. Infectious Disease Physiology, Pathology, 5. Chronic obstructive pulmonary disease (COPD) and Pathophysiology, and Therapy status asthmaticus, including bronchodilator therapy 1. Antibiotics 6. Neurogenic breathing patterns (central hyperventila- a. Antibacterial agents tion, Cheyne-Stokes respirations, et cetera) b. Antifungal agents 7. Mechanical ventilation c. Antituberculosis agents a. Positive pressure ventilation (including endotracheal d. Antiviral agents intubation and noninvasive positive pressure venti- e. Antiparasitic agents lation [NPPV]) 2. Infection control for special care units b. Currently available ventilator modes: synchronized a. Development of antibiotic resistance intermittent mechanical ventilation (SIMV), controlled b. Universal precautions mechanical ventilation (CMV), continuous positive air- c. Isolation and reverse isolation way pressure (CPAP), inverse ratio ventilation, pres- 3. Hospital acquired and opportunistic infections in the sure support ventilation, pressure control ventilation. critically ill c. Negative pressure ventilation 4 . HIV/AIDS Neurocritical Care ♦ Volume 5, 2006 162 Mayer et al.

5 . Evaluation of fever in the intensive care unit patient 5 . Noninvasive hemodynamic monitoring 6 . Central fever 6 . Respiratory monitoring (airway pressure, intrathoracic 7 . Interpretation of antibiotic concentrations and pressure, tidal volume, pulse oximetry, dead space, sensitivities compliance, resistance, capnography) 7. Metabolic monitoring (oxygen consumption, carbon F. Physiology, Pathology, Pathophysiology, and dioxide production, respiratory quotient) Therapy of Acute Hematologic Disorders 8. Use of computers in critical care units for multimodality monitoring 1. Acute defects in hemostasis a. Thrombocytopenia, thrombocytopathy b. Disseminated intravascular coagulation B. Administrative and Management Principles and c. Acute hemorrhage (e.g., gastrointestinal [GI] hemor- Techniques rhage, retroperitoneal hematoma) 1. Organization and stafﬁ ng of critical care units 2. Anticoagulation and ﬁ brinolytic therapy 2 . Standards for special care units, Joint Commission on 3. Principles of blood component therapy (blood, platelets, Accreditation of Healthcare Organizations fresh frozen plasma [FFP]) 3 . Collaborative practice principles, including multidisci- 4. Hemostatic therapy (e.g., vitamin K, aminocaproic acid, plinary rounds and management protamine, factor VIIa) 4. Emergency medical systems in prehospital care 5. Acute hemolytic disorders including thrombotic 5 . Performance improvement, principles and practices, microangiopathies quality assurance 6. Prophylaxis against thromboembolic disease 6 . Principles of triage and resource allocation, bed 7. Hypercoagulable states management 7 . Posthospital care and discharge planning G. Physiology, Pathology, Pathophysiology, and 8 . Medical economics: health care reimbursement, budget Therapy of Acute GI and Genitourinary Disorders development 1. Upper and lower gastrointestinal bleeding 2. Acute and fulminant hepatic failure (including drug C. Ethical and Legal Aspects of Critical dosing) Care Medicine 3. Ileus and toxic megacolon 1 . Death and dying 4 . Acute perforations of the gastrointestinal tract 2 . Forgoing life-sustaining treatment and orders not to 5 . Acute vascular disorders of the intestine, including resuscitate mesenteric infarction 3 . Rights of patients, the right to refuse treatment 6. Acute intestinal obstruction, volvulus 4 . Living wills, advance directives; durable power of at- 7 . Pancreatitis torney 8 . Obstructive uropathy, acute urinary retention 5 . Terminal extubation and palliative care 9. Urinary tract bleeding 6 . Rationing and cost containment 7 . Emotional management of patients, families, and care- H. Immunology and Transplantation givers. 1. Principles of transplantation (brain death, organ donation, procurement, maintenance of organ donors, D. Principles of Research in Critical Care implantation) 1. Study design 2. Immunosuppression, especially the neurotoxicity of 2 . Biostatistics these agents 3 . Grant funding and protocol writing 4 . Manuscript preparation I. General Trauma and Burns 5 . Presentation preparation and skills 1. Initial approach to the management of multisystem 6 . Institutional Review Boards and Health Insurance Por- trauma tability and Accountability Act (HIPAA) 2 . Skeletal trauma including the spine and pelvis 3 . Chest and abdominal trauma — blunt and penetrating B. Procedural Competencies 4. Burns and electrical injury All are not required, but all are reasonable to include in a III. General Aspects of Critical Care neurocritical care advanced training program. Asterisk indi- cates procedures to be performed under direct visual supervi- A. Monitoring sion by qualified personnel until competency is established. 1 . Neuromonitoring The definition of competency to perform the listed procedures 2 . Prognostic, disease severity, and therapeutic interven- must include knowledge of the indications, contraindications, tion scores (i.e., Acute Physiology and Chronic Health complications and their treatment, and technical performance Evaluation [APACHE]) of each of these interventions. Advanced procedures are rea- 3. Principles of ECG monitoring sonable to offer in selected cases if qualified personnel provide 4 . Invasive hemodynamic monitoring instruction. Neurocritical Care ♦ Volume 5, 2006 Core Curriculum for Neurological Intensive Care 163

1. General Critical Care (Essential for k. Administration of intravenous and intraventricular Neurointensive Care Trainees) thrombolysis l. Interpretation of computed tomography (CT) and mag- a . Peripheral venous line placement netic resonance standard neuroimaging and perfusion b . Arterial puncture studies, and biplane contrast neuraxial angiography c . Arterial catheter placement m. Perioperative and postoperative clinical evaluation of d . Naso-/oro- gastric/duodenal tube insertion patients undergoing neurosurgery and interventional e . Central venous catheter placement neuroradiology f . Pulmonary artery catheterization n. Application of systemic moderate hypothermia g. Management of mechanical ventilation, including CPAP/Bi-Level Positive Airway Pressure (BiPAP) ventilation 4. Advanced Neurocritical Care (May Be h. Administration of vasoactive medications Considered Optional for Neurointensivists) i . Cardiopulmonary Resuscitation (CPR) and Advanced Cardiac Life Support (ACLS) (with a. Performance and interpretation of cerebral multimodal- certifi cation) ity monitoring (pH, partial pressure of carbon dioxide j . Maintenance airway and ventilation in nonintubated, [pCO 2 ], laser Doppler, microdialysis) unconscious patients b. Intrathecal administration of chemotherapy, and radio- k . Interpretation and performance of bedside pulmonary graphic agents function tests c. Endovascular neurosurgical training (e.g., Guglielmi de- l . Endotracheal intubation tachable coil placement, arterial stenting, cerebral angio- plasty, intraarterial thrombolysis) 2. Advanced General Critical Care (Generally d. Two-dimensional duplex ultrasonography e. Interpretation of single photon emission-CT and positron Considered Optional for Neurointensivists) emission tomography a. Administration of nitric oxide or prostacyclin f. Insertion of ventricular drainage and parenchymal ICP b . Hemodialysis, including peritoneal dialysis (PD), contin- monitoring devices and cerebral oximetric or perfusion uous venovenous hemofiltration (CVVH), and continu- monitor placement ous venovenous hemodialysis (CVVHD) g. Lumbar drain insertion c. Fiberoptic bronchoscopy d. Echocardiography e. Tracheostomy C. Goals f. Percutaneous gastrostomy The overall goals of the educational program are: g. Diagnostic pleurocentesis, chest tube insertion, drainage a. To provide supervised training in patient care in the neu- systems rological intensive care setting. This includes the diagno- h . Vascath/dialysis catheter placement sis and management of life-threatening neurological dis- i. Abdominal paracentesis eases, as well as the medical conditions that frequently j. Extracorporeal membrane oxygenation (ECMO) and occur as complications. other circulatory support systems (intraarterial balloon b. To provide supervised training in technical aspects and pump [IABP], left ventricular assist device [LVAD], and procedures related to the practice of neurological inten- so on) sive care. c. To provide training and mentoring in fundamental as- 3. Neurocritical Care (Essential for pects of clinical and/or basic science research related to Neurointensivists) neurological intensive care. d. To provide training in administrative, management, and a. Lumbar puncture economic aspects of neurological intensive care, with a b. Shunt and ventricular drain tap for CSF sampling focus on collaborative practice and multidisciplinary care c. Performance and interpretation of transcranial delivery. Doppler e. To allow the trainee to develop a sense of purpose with d. Administration of analgosedative medications, includ- regard to ethical and humanistic aspects of care, with an ing conscious sedation and barbiturate anesthesia emphasis on compassion and respect for patient-centered e. Interpretation of continuous electroencephalogram values. monitoring f. To foster the trainee’s transition into a career as an f. Interpretation and management of ICP and cerebral independent, responsible, highly competent, and self- perfusion pressure data sufficient neurointensivist. g. Jugular venous bulb catheterization h . Interpretation of saturation and jugular venous oxygen- D. Objectives ation and Brain tissue oxygen data i. Management of external ventricular drains A. Patient Care j. Management of plasmapheresis and intravenous Neurointensive care trainees are expected to provide immunoglobulin patient care that is compassionate, appropriate, and effective Neurocritical Care ♦ Volume 5, 2006 164 Mayer et al. for the promotion of health, prevention of illness, treatment of and sustain therapeutic and ethically sound profes- disease, and at the end of life. sional relationships with patients, their families, and colleagues. 1. Gather accurate, essential information from all sources, 2. Use effective listening, nonverbal, questioning, and nar- including medical interviews, physical examinations, rative skills to communicate with patients and families. medical records, and diagnostic/therapeutic proce- 3. Interact with consultants in a respectful, appropriate dures. manner. 2 . Make informed recommendations about preventive, di- 4. Maintain comprehensive, timely, and legible medical agnostic, and therapeutic options and interventions that records. are based upon clinical judgment, scientifi c evidence, and patient preference. E. Professionalism 3. Develop, negotiate, and implement effective patient management plans and integration of patient care. Neurointensive care fellows are expected to demonstrate 4 . Perform competently the diagnostic and therapeutic behaviors that reflect a commitment to continuous profes- procedures considered essential to the practice of neuro- sional development, ethical practice methods, an under- logical intensive care. standing and sensitivity to diversity, and a responsible attitude toward their patients, their professional colleagues, and society. B. Medical Knowledge Neurointensive care fellows are expected to demonstrate 1. Demonstrate respect, compassion, integrity, and altru- knowledge of established and evolving biomedical and clini- ism in relationships with patients, families, and col- cal sciences, and the application of their knowledge to patient leagues. care and the education of others. 2. Demonstrate sensitivity and responsiveness to gender, age, culture, religion, sexual preference, socioeconomic 1. Apply an open-minded, analytical approach to acquir- status, beliefs, behaviors, and disabilities of patients and ing new knowledge. professional colleagues. 2 . Access and critically evaluate current medical informa- 3. Adhere to principles of confi dentiality, scientifi c/aca- tion and scientifi c evidence. demic integrity, and informed consent. 3 . Develop a clinically applicable knowledge of the basic 4. Recognize and identify defi ciencies in peer perfor- and clinical sciences that underlie the practice of neuro- mance. intensive care. 4 . Apply this knowledge to clinical problem solving, clini- F. Systems-Based Practice cal decision making, and critical thinking. Neurointensive care fellows are expected to demonstrate both an understanding of the contexts and systems in C. Practice-Based Learning and Improvement which neurointensive care is provided, and the ability to Neurointensive care fellows are expected to be able to use apply this knowledge to improve and optimize patient scientific evidence and methods to investigate, evaluate, and care. improve patient care practices. 1. Understand, access, and utilize the resources, providers, 1. Identify areas for improvement and implement strate- and systems necessary to provide optimal care. gies to enhance knowledge, skills, attitudes, and pro- 2. Understand the limitations and opportunities inherent cesses of care. in various practice types and delivery systems, and 2 . Analyze and evaluate practice experiences and imple- develop strategies to optimize care for the individual ment strategies to continually improve the quality of patient. patient practice. 3. Apply evidence-based, cost-conscious strategies for 3 . Develop and maintain a willingness to learn from errors prevention, diagnosis, and disease management. and use errors to improve the system or processes of 4. Collaborate with other members of the health care team care. to assist patients in dealing effectively with complex 4. Use information technology or other available meth- systems and to improve systematic processes of care. odologies to access and manage information, support E. Methods of Training to be Used patient care decisions, and enhance both patient and physician education. a. The educational experience will be provided in the form of a postresidency fellowship, to be conducted at a par- D. Interpersonal and Communication Skills ticipating member institution, qualified and in compliance with the program requirements. It is anticipated Neurointensive care fellows are expected to demonstrate that in most instances, the duration of the fellowship will interpersonal and communication skills that enable them be 2 years. to establish and maintain professional relationships with b. The educational experience will be outlined in the form patients, families, and other members of the health care team. of a curriculum meeting the standards and requirements 1. Provide effective and professional consultation to specified in the training program curriculum content and other physicians and health care professionals, training program requirements. Neurocritical Care ♦ Volume 5, 2006 Core Curriculum for Neurological Intensive Care 165

c. Ongoing feedback in the form of progress reports and G. Methods of Feedback evaluations will be performed by the program director and designated faculty and provided to the trainee, and a. Evaluation of program strengths and weaknesses, based assessments of program success and faculty performance on evaluations and perceptions of the trainees, faculty, will be provided by trainees to the faculty. and directors should be performed by the Program Director at least yearly and on an as-needed basis. F. Methods of Evaluation b. A summary of these issues should be made yearly by the The overall success of the program must be documented in program director. The directors should discuss potential written record and may include: improvements with the faculty and minutes should be recorded regarding the recommendations. a. Yearly tabulation of total applicants and number of ac- c. Reasonable efforts to incorporate helpful or constructive cepted applicants. improvements should be made when logistically possi- b. Total trainees completing the programs. ble by the directors in the subsequent years of the train- c. Record of trainee presentations, abstracts, and peer- ing program. reviewed and other publications during the trainee program. d. Documentation of the first professional employment po- Special Note Regarding Updates to This sition or activity of the trainee immediately following Document completion of the training program. In 2006, the UCNS will conduct an in-depth review e. Productivity can also be supplemented by summarizing of these core curriculum requirements, and in consultation subsequent employment positions, honors, or other per- with the subspecialty may make changes to these documents tinent indicators of recognition received by trainees at prior to final approval and implementation. Final approval any time following the training program experience. will be announced on the UCNS website ( http://www , f. The number of patients who take a certification examina- ucns,org), and updated versions of this document can be tion in neurological intensive care, and their performance accessed at http://www.ucns.org/certification/pdfs/core_ on the exam. curr_nic.pdf.

Neurocritical Care ♦ Volume 5, 2006