Essential reading for "Structure and Process"

The "Structure and Process" section represents annotations and footnotes to Section 2.1.1 ("Structure and Process") from the CICM Second Part General Exam Syllabus (First Edition). For each of the syllabus topics, the expected knowledge domains are supposed to be "principles and practice / implementation", "relevant guidelines and evidence" and "controversies and risks". Where possible, these expectations were addressed throughout these chapters, though it was sometimes baffling or ridiculous to apply them (what are the risks of team-based health care? What is so controversial about fatigue mitigation or burnout prevention?). Of course the returning reader will agree that baffling and ridiculous is what we do here at Deranged Physiology, which means this mess has no new horrors for them. But this does mean that the chapters are probably not a good surrogate for published works, and the past paper SAQs are not a great syllabus because under new leadership the exam has become both fairer and more formidable.

What follows is a selected reading list of hand-picked review articles, important trials, influential papers and professional guidelines for Section 2.1.1 ("Structure and Process") from the CICM Second Part General Exam Syllabus (First Edition).  The articles and guidelines here are provided with the caveat that they appear here only because they must have, at some stage, appealed to one person, who may have minimal insight into the expectations of CICM examiners, and who may not have had all the time in the world to do a thorough literature review. That also may have been some time ago, and they may have since become obsolete. The readers with better options are humbly asked to submit them via the contact form below.

L1 topics for Structure and Process

Important (L1) topics for Structure and Progress include Transport of the critically ill patient, Rapid Response systems and principles of infection control. "Detailed knowledge and comprehension of the principles and facts" is expected, which presumably means "read the official CICM policy documents, they are right there". 

Transport of the critically ill patient

• Overview: Milligan et al (2011) or Le Cong & Ramin (2014) 
• CICM IC-10 Guidelines for Transport of Critically Ill Patients
• ANZCA "PG52(G) Guideline for transport of critically ill patients 2015
• Standards for Aeromedical Services (2020) by the Aeromedical Society of Australasia (ASA) 
• Royal Flying Doctors Service guideline manuals:
  • RFDS clinical manual - Part 1 - clinical guidelines
  • RFDS clinical manual - Part 2 - drug infusion guidelines
  • RFDS clinical manual - Part 3 - procedures
  • RFDS clinical manual - Part 4 - standard drug list

Rapid Response Systems / Critical Care Outreach

• Overviews: Jones et al (2006) and Subramaniam et al (2016)
• IC-25 Joint Position Statement on Rapid Response Systems in Australia and New Zealand and the Roles of Intensive Care
• IC-26 Minimum Standards for Intensive Care Unit Based Rapid Response Systems
• NSQHS Standard 3 - Guide to the Implementation of Rapid Response Systems (it's now Standard 8)
• MERIT trial - 2005 - RRTs in 23 Australian hospitals; n=23 hospitals. No difference in mortality or unplanned ICU admission.

Principles of infection control including SDD

• Overview: Lepape, 2003 
• CDC guidelines:
  • CDC Infection Control Guidelines Library
  • CDC document on Transmission-Based Precautions
  • CDC isolation precaution guideliness, especially which bug needs which level of precautions (airborne, droplet, contact, etc) and especially this table
  • HIV occupational exposure management
  • Infection control for MROs
• NSW Health  Infectious Diseases page, for notifiable diseases data
• NSW Health Infection Control Policy Directive
• As for SDD:
  • Overview: Tejerina-Álvarez et al (2023)
  • Pros (De Waele et al, 2023) and cons (Hurley, 2023)
  • SuDDICU trial - 2022 -  colistin, tobramycin and nystatin, 19 ICUs in Australia. n=5982. No difference in mortality, but marked difference in MRO colonisation rate (20.9% vs 32.5%)
  • A BMJ meta-analysis by the SuDDICU collaborators

L2 topics for Structure and Process

Less important L2 topics contain such administrative nightmares as design and staffing of intensive care units, role of clinical information systems,  workplace culture, workforce design and disaster management. The lower expectations for these topics presumably stem from the tacit understanding by the examiners that none of their senior registrars are at risk of being asked to design an ICU or to develop a mass casualty disaster management plan. On the other hand, it's a part of their future job, and so it would be irresponsible of CICM to produce graduates who have absolutely no idea about these matters. 

ICU design and organization

• Overview: Thompson et al (2012) or Rashid (2006)
• IC-1 Minimum Standards for Intensive Care Units
• IC-13 Guidelines on Standards for High Dependency Units in Intensive Care Medicine

Role of clinical information systems, other expert systems

• Overview: Fraenkel (2003) or Mason & Leong (2016)
• Functional standards: Tello et al (2011)
• What are "other expert systems"? The system is the expert? Are we talking about AI decisionmaking support?

Workplace culture e.g., burnout, fatigue (management and prevention)

• Workplace culture
  • Overview: Alameddine et al (2009) or Guidet et al (2011)
  • IC-20 Prevention of Bullying, Discrimination and Harassment in the Workplace 
• Burnout prevention
  • Critical Care Societies Collaborative Statement on burnout syndrome (Moss et al, 2016)
  • IC-5 Statement on the Health and Wellbeing of Fellows and Trainees
  • IC-31 Guidelines on the Welfare Advocate Role in Intensive Care Units
• Fatigue mitigation
  • ANZCA guideline PG43(A), "Guideline on fatigue risk management in anaesthesia practice" (2020) is by far the best resource on this
  • 2020 review by Bywood et al is far too verbose
  • AMA "minimum standard" statement on work hours and rostering for hospital doctors

Role of team-based health care in ICU

• What even is that: Mitchell (2012)
• Practically speaking, how do we: Ervin et al, 2019

Pandemic and major incident planning and response

• Overview: Horvath (2006), Briggs (2016) or Thomson et al (2023)
• Ethics framework: Dawson et al, 2020
• Australian Health Management Plan for Pandemic Influenza (2019)

There was nowhere else to put the FASTHUG

But it seemed like an important process that forms a part of the ICU ward round structure, and  therefore ended up being shoved into this syllabus section, sideways and on its edge.

Protocolised bundles of supportive care in general

• CHECKLIST-ICU - 2016 - daily checklist and goal setting bundle; n=6877 in Brazil. No difference in mortality ((32.9% vs 34.8%) but a few secondary outcomes were better (use of low tidal volumes, avoidance of heavy sedation, use of central venous catheters, use of urinary catheters, perception of team work, and perception of patient safety climate)
• 2018 SCCM guidelines on, basically, FASTHUG

Nutrition trials and guidelines

• Covered in the nutrition trials and guidelines chapter

Analgesia and sedation

• Covered in the sedation trial and guidelines chapter

Thromboprophylaxis trials and guidelines

• 2020 Australian (ACQSHC) guidelines for VTE prevention
• 2018 European (ESA) guidelines on VTE prophylaxis in perioperative ICU patients
• 2018 American (ASH) guidelines on VTE prophylaxis

Patient mobility and positioning 

• As fas as relevant to VAP prevention:
  • 2008 Candian VAP prevention guidelines
  • 2014 Spanish "Zero-VAP" guidelines
• General position and mobility:
  • 2019 Brazilian guidelines for early mobility in the ICU
  • 2017 Australian (ACI) guideline for the mobilisation of critically ill patients
  • 2015 German guidelines for positioning and mobility
  • One good systematic review of them all: Lang et al, 2020

Physiotherapy for the critically ill

• 2015 Belgian guidelines on physiotherapy in the ICU
• 2008 ERS/ESICM guidelines on physiotherapy in the ICU

Pressure area prevention

• 2020 intenational consensus guidelines on pressure area prevention in ICU
• 2014 ACI guidelines for pressure area prevention in the critically ill

Ulcer prophylaxis

• The evidence for this is discussed in the chapter on ulcer prophylaxis
• Those SUP guidelines that have been published after SUP-ICU (2019) include:
  • 2020 international consensus guidelines
  • 2019 Portuguese (SPCI) guidelines

Glycaemic control in the ICU

• The evidence for this is discussed in the chapter on glycaemic control
• 2016 American (ADA) guidelines for glucose targets in the critically ill
• 2012 Australia (ADS) guidelines for glucose control in hospital patients
• 2010 international recommendations (by the French, SFAR/SRLF)