SCCM Pod-542: Strengthening Confidence and Collaboration Through Fundamentals Training
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So hello and welcome to the 2024 Congress edition of the Society of Critical Care Medicine podcast. I'm your host, Maureen Madden. Today I'm joined by Mark Edward Hamill, MD, to discuss fundamentals training and its importance in critical care. Dr. Hamill recently published a paper on the values of fundamentals training titled, Impact of Standardized Multidisciplinary Critical Care Training on Confidence with Critical Illness and Attitudes Towards Interprofessional Education and Multidisciplinary Care.

Findings in that paper were that they increased confidence in students. So we're going to discuss this paper over our time together. But Dr. Hamill is a trauma surgeon, surgical intensivist, and an acute care surgeon, as well as an associate professor at the University of Nebraska Medical Center in Omaha, Nebraska.

He supports a robust program in surgical trauma and critical care education and is a co-editor for the current edition of the SCCM Fundamental Critical Care Support Program. Additionally, he has been heavily involved in the society with the Fundamentals Program and is currently going to be exiting off as the Fundamentals Chair as well as the Fundamentals Leadership Chair. So welcome, Dr. Hamel. And before we start, do you have any disclosures to report? I have no disclosures.

It's wonderful to have you here today and we have some time to sit and discuss something that is really near and dear to my heart, having participated in the Pediatric Fundamentals Program. So first off, tell me how you got involved in the Fundamentals Programs. So it's interesting. At the prior institution I was at, when I first started there, there was a surprising lack of

basic critical care education for a lot of our GME trainees. And the way I initially brought the program to the institution was as a kind of primer for the residents that would be rotating through our surgical intensive care unit. And I basically was wanting to make sure everyone was on the same page in terms of the basics of critical care.

And, you know, that went on for a year. Then the next year, our internal medicine program got wind we were doing it. And they're like, hey, can we put all of our residents into it? Sure. Not a problem.

And then the next year, some of the nursing programs in the hospital got wind of it. And, you know, some of the people who were new ICU nurses coming off of some of their orientation. Yeah. You know, when they're like, well, this would be great for them. And then suddenly the program grew over about a 10 year period to where we were doing one a year to one a month. And it was it was pretty amazing to watch the growth of the program as it came in.

You know, we were lucky to have a mentor who was familiar with the program had been involved in some prior prior revisions in the area. You know, to help us get the program started and he remained a you know he remained an integral part of helping us teach the course over that period.

But I think what I found is I'm passionate about this, about the topic of education in general, but specifically critical care education, is I think it's something where there is a great need. And a lot of people, you know, medical students from various specialties, early trainees from various specialties really don't understand what goes on in the ICU.

And, you know, I think the whole point is to try to make sure people can identify patients who are probably going to be getting sick or are in the process of getting sick and start to intervene early to hopefully prevent some of the decompensation that happens. So, I mean,

Before you even brought it into your institution, how did you become aware that such a program existed? Was it something that you participated in or anybody else? You said you had a local person. I had heard about the program. I had never formally participated in it. Probably about a year before we brought the program there, I actually went down to Charlotte and took the course with the idea of probably becoming an instructor and thinking this might be a good thing to bring to our institution.

And, you know, from the first time I took the course, I was convinced this would be a very useful product to have. And then, you know, over the years, I got involved in the Adult Fundamentals Program Committee and then became the editor of the contributed to one of the chapter revisions in the sixth edition and then was invited to be the editor of the seventh edition, one of the co-editors of the seventh edition edition.

And then kind of went through the committees. And, you know, from there, I mean, it's overall it's been a long run. It's been probably about a 13, 12, 13 year run now. But it's it's been very satisfying both personally and professionally over that period. What I found as my own participation in the fundamentals family is you somehow do get so engaged in this that then becomes something.

a professional passion and you put a lot of time and energy behind it. But also I found too, that I've always made this statement that oftentimes I taking it, whether it's domestically or internationally, I feel at times that I'm gaining more from the people who come to participate versus what I'm possibly providing to them. But there's also sometimes some incredibly memorable moments,

items that happen, whether they make you laugh or they resonate. And there's a realization that you truly have touched somebody and

they have managed to then go on and really touch the lives of others. Do you have any examples of that? We do. I've actually, not with the adult FCCS course, but with the newer FCCS surgical course, I've actually had a number of opportunities to go internationally with it. I've been to Rwanda. I've been to Jerusalem and Palestine. And most recently, I was involved in the mission, in the educational outreach mission we did to the Ukraine. Wow.

We spent nine days in Lviv, Ukraine, teaching both the FCCS surgical course and the ICU liberation course to physicians and nurses from Ukraine. That was, I mean, an unbelievably satisfying and emotional experience. It was truly remarkable, almost a once-in-a-lifetime experience that we hope to get back to. Is there one moment in...

any one of those environments that you'd like to share a story or from the Ukraine trip, just having some of the people come up to you and they're like, we don't believe you're here.

that you would come to a country that's, you know, at war. I mean, we weren't near the front line, anywhere near the front lines or where most of the things were going on. And just they were so grateful that we would come and do this for them. I mean, it was truly a remarkable experience. I mean, any of the people who are on the trip can tell you it was something that was truly, you know, one of the highlights of my career so far going and doing that.

Well, I actually know several people that participated in that trip. And I actually had the privilege to host one of the other podcasts with Susanna Rudy the other day. And I'm not sure if you were there at the same time, but she was also talking about the experience of the Ukraine with this fundamentals courses and just how truly life changing a lot of this is. And clearly here, the society is demonstrating their gratitude about the

participation in that. As you say, going to a war zone, and you've just talked about two other places now that are sitting in the middle of a war zone as well for those pieces. It's something I've wanted to get involved with in my career for the last several years. And unfortunately, once I moved to the University of Nebraska, some time opened up and things like that, and a little more support from the institution to help make these trips become a reality, which I'm very grateful for.

So when individuals are talking about either contemplating enrollment in the course or contemplating actually that they want to conduct a course, is there any advice that you would talk about who this is appropriate to or how to conduct the course? Because now we have several different

possible methods of delivering the course. Yeah, I am somewhat biased in this. I am very biased towards live courses. I think the hybrid model courses and the virtual courses probably have a place, but preferentially, I am very biased towards putting on a live course. I think

Just the some of the most useful parts of that parts of the course are the interaction you get with the students and the questions and answers back and forth. Absolutely. Which really, I mean, that, you know, it might might not all be on specific content from the course, but it's something that it can be very helpful. And I would also say just, you know, talk to someone who has some experience with the course. I mean, talk to any of the course consultants we have.

You know, you'll find someone, you know, you'll find someone probably close to your area that can help you out. And, you know, it does take a little bit of effort to get the, get a course going at a new institution, but it's doable. It's very doable. And, and,

Again, the feedback you get from your staff after you start doing this core, doing these types of courses will be almost certainly very, very positive. A lot of staff really appreciate the chance to participate in things like that. And it can also serve as a, you know, as growth as professionally for the people who you recruit to help teach the class.

It can be, you know, it can be a major point. I see you at bedside. I see you say, oh, I can't teach. I can't do that. I'm like, well, yeah, you can. As a matter of fact, the impact of you doing some of this, it's going to be more impactful than me doing it because you're the one at the bedside doing a lot of these things, you know, minute to minute during the day.

And I think that's one of the nice things about the whole fundamentals program is it's a very, you know, multidisciplinary program. It's one of the few courses that from the ground up has been designed to be, you know, to hit practitioners of all professions, all levels of training. And everyone's going to get something different out of it. But everyone's going to get something out of it.

So I love hearing your perspective on it because it just echoes my own feelings about it. And I'm coming from the pediatric realm and people have asked me different things about, would you change the program for a different discipline? And I'm like, no, my perspective is everybody has an expectation of being exposed and to get a greater understanding of the

knowledge level and the skills level and apply it to the population that's in there. So, and I think that's what's amazing about also the growth of the FCCM family of courses. But more importantly, I want to touch on the fact that you have now put a step out there and made a mark with your publication. So you have something out there that

that was just published in 2023, talking about the FCCS program and looking at people in training and their confidence and attitudes towards, first of all, interprofessional multidisciplinary care. So I want to ask you to talk a little bit about where did the impetus for this manuscript

come from? What did you hope to find? Were you surprised by things you found? So this came from, you know, the adult fundamentals program has been around for almost 30 years now. I just said it was in, when this study started, it was in the sixth edition. It's moved on to the seventh edition now.

But one of the things is there is not a lot of published data suggesting that the course does what we those are involved with the course all know it does, but a lot of published data.

And, you know, talking several years ago at one of the fundamentals program committee meetings, it came up that, you know, some places are having problems getting the course certified locally for continuing medical education credit because there's just not a lot of publications they can show that, you know, that it does what we know it does.

There are some that have been, some smaller studies that have been presented in abstract form. There are a couple of international studies, smaller international studies that looked at it, but no one has really looked at it on a large, no one that I know of has looked at it on a large scale in the U.S.,

So the idea was, how could we do this? And I was lucky to be selected to participate in a health education research program at my former institution where we were given a little bit of protected time to kind of work on these topics and go through the medical education research fellowship from the AAMC and

It was a nice, it kind of, the stars aligned and gave me some time to do this. And the idea was, you know, how can we easily assess the people we have going through this program to see, you know, what is it doing? And it

It was nice because, I mean, we got to the point where we were doing basically one of these courses a month and they were almost all full courses. And it just gave us the opportunity to really kind of look at this somewhat structured format.

Now, I'll talk a little bit later, but are there other questions I would have liked to have asked? Yes. But I think... That's the next paper. Yeah, but that's exactly it. And I think I'm going to use this particular study as a basis for looking at some other aspects of this and to hopefully support a grant proposal, look at it a little more formally and structured, maybe using simulation and things like that. So are you willing to...

We'll talk about that a little bit because I want to know if you're willing to share maybe what you're angling towards. And maybe somebody listening to the podcast can also then come on and say, hey, I want to join you and maybe have a more robust data set in that regards. So I want to know a little bit more about...

how you came to develop the specific study that you did and the concepts that you wanted to look at. You know, again, not having a lot of published data out there about the adult fundamentals course, the idea was what can we do to show the course is doing what we all knew that it was doing.

And again, we had just with the robust number of courses and students that we had taking the course, it was kind of the perfect opportunity to go in and look at this. So just to pause, on average, when you're running it monthly and you said you were typically at capacity, how large did you have in terms of enrollment per course?

At least 20 typically, sometimes more than that. I mean, over the study, the 18 month study period we had here, we had 328 students, which you figure that averages out to about 22, 23 a course. Well, that's pretty remarkable, though, because when you look at it, you only had seven people say they didn't want to participate. Yeah.

That's quite a return on your surveys. Yeah, it was the way the way we did it again. We 328 people participated at the you know, right before we took the pretest when it was a live pretest. What I did is I gave them a survey instrument and said, you know, we would like you to participate in this. We offered a little monetary, you know, drawing into it for a small monetary prize to help encourage people do both stages of the study.

And, you know, he said, hey, you know, if you'd like to participate, give me your email, give me your profession and just, you know, fill out this paper survey, which, you know, someone had someone being me had to hand enter all those paper surveys, which is kind of interesting. But then once we got their information, we set it up into an electronic survey system.

And basically had them do the, you know, put in all the pre-course answers. We put in the post-course survey was done electronically. We got a little more demographic information, things like that during the post-course period. And then we did a three month follow up period.

You know, as I said, almost 98% of the people agreed to participate initially. About 75% ended up, 75%, 76% filled out the post-course survey, gave us the full demographics. And then, you know, we had some drop off at the follow-up period. About almost 60% of the people, though, did agree to continue at the follow-up period.

Which, I mean, for participations for an educational evaluation survey, that's actually pretty good numbers. Not just pretty good. There are people right now going, really? How did you manage that? Amazon gift cards. As you said, you were enrolled, though, and not everybody was given one, correct? Yeah. No, we enrolled everyone in a drawing we offered online.

four for the people who completed the four smaller ones who completed both the pre and the post course survey. And then we offered one larger one for the people who completed all three stages of it. And it worked. And that's, you know, it's a valid way of helping to enhance participation. And it didn't really skew your results with having, you know, potentially offered every single person the incentive. In that regard, so then how I'm understanding the structure of it

you were making an assessment of from their pre-test knowledge to their post-test knowledge. So the difference in the knowledge acquisition and then the three months was then to see about retention or something? Yeah, we looked at knowledge based on the test scores. OK, but what we were looking at was self-assessed confidence in critical care assessment.

And, you know, we did it in a structured form. We did the pre-test. We did the post-test. We also did what's called a retrospective pre-test analysis. Essentially, what we did is we went back and said, now that you've taken the course, how do you re-rate your ability, your confidence in these areas before the course? So essentially what you're

trying to kind of tease out is what didn't they know that they didn't know at the initial assessment. And then the follow-up period was just to kind of look at if they maintained their confidence or if it was enhanced further over the follow-up period.

So when I'm looking at the participants in this and the majority who had the response were your nurses and your physicians, but you also had physicians assistants and paramedics also represented. Were there any other disciplines that you had in there that? Yeah.

We had a handful of pharmacists who took it. They were typically pharmacy residents doing critical care pharmacy residency. We had a couple of respiratory therapists, a couple of nurse practitioners. A lot of them were students in a nurse practitioner program, though we did have one or two practicing nurse practitioners take it also.

So it was pretty much we had a pretty wide base of professions that we were looking at. Some were students, some were new GME trainees just right before their intern year. So that was going to be one of my questions to try and tease out a little bit about what level of exposure or experience each of these disciplines may have had to see how it

was impacting. Yeah. And the average length in practice was about 8.2 years. And I think that was skewed heavily because of the nurse participants and the paramedic participants, honestly. And were the nurses, when you ask about years of experience, all in critical care or did that get parsed out? It was truly a mixed practice setting. Probably about 18% thereabouts were primary outpatient. That includes the emergency department.

There was some mixed inpatient outpatient, some, you know, there are some community, some people at community hospitals who were taking the course. There was some people who were community at tertiary care centers. The largest group was inpatient at a tertiary care center was their primary practice location. But again, it was kind of we got people literally from all over. And it wasn't just a course that enrolled internal participants to our health system.

We actually, once we put it out there and we're doing so commonly, we were very commonly getting people from all over the region to come in and take these courses, which is one of the nice things is that, you know, if you build it, they will come. And the, you know, offering this course regularly meant that you had a pretty big draw. I mean, from, you know, two or three states away sometimes. So also a pretty big incentive then, as you talked about,

you know, it's a traditional two-day course face-to-face, people are making a time commitment as well as the faculty. And oftentimes with that time commitment, they're hoping for a return that they can, if they have obligations for continuing education. So I can see that as a, not just to validate for the CME piece, but a push on the participants part going,

Why don't you have this or can we have this? Did you do it just for medical education or did you expand out to some of the other disciplines in terms of their CME? We were offering traditional CME, which would cover advanced practice providers and physicians. We offered nursing CME. We offered paramedic.

continuing education credits. The pharmacist was a little bit more challenging just because of some of the restrictions on their CME credits, but we did manage to get them involved. And the respiratory therapists, there are a couple of pathways they can use apparently to get CME. They can use the tradition, you know, if you have something that's certified for traditional CME, you can use it

you can use it or they have their own pathway they can go through. But yeah, we offered the continuing education credits to just every, just about every participant. All right. So I really want to ask you, um, as the author, you're clearly going to know, um,

and have the significant results. If you could highlight those for us and explain the importance. So in general, what we did is we looked at every critical care domain that was addressed by the course at the time, including just diagnosing critical illness,

Pediatric critical illness was a part of the course at that point. Respiratory failure, sepsis, shock, neurologic illness, traumatic injuries, electrolyte abnormalities, pregnancy-related complications, infection, and ethical dilemmas were the major kind of domains. And what we saw is there was a significantly increased confidence between the pre- and the post-course period in every domain that we assessed.

I mean, it was across the board. It was thought to be a useful course. Interestingly, when we did put the retrospective pre-course analysis in, we found four domains which participants probably overestimated their confidence and their ability in.

before they were taking the course. That included respiratory failure, sepsis, shock, and ethical dilemmas, which was just kind of interesting, which might suggest that some of those areas needed a little more formal education to people just coming out into practice. The increases were sustained in the post-course period, the increases in confidence,

And I think basically what that says to me is that in general, the course is at least at one level doing what we want it to do, which is to say, hey, I'm going to feel more comfortable being able to assess people for the presence of critical illness and being able to start intervening on critical illness. So not necessarily just being more comfortable, but actually being more accurate in

Well, that is the one of the flaws or limitations of the study as we did it. What we were assessing was self-assessed confidence. Okay. I think when you look at Kirkpatrick, who has a basically a format for assessing programs, there are a couple of levels that he described in terms of how he was assessing programs. There was a, you know, there's basically how do they react to the course? Are they happy with the course? That's the basic level.

The second level is, did they learn something from the course? And that's probably between the pre and post the self-assessed ability or self-assessed confidence. We probably hit that where they did learn something from the course. The next step is, did the course change practice? And unfortunately, with the model we had just using surveys, we were unable to assess that. And then ultimately, what you want to do at the highest level is say, did it change outcomes?

And that's kind of the gold standard is can you show that you did this and it changed your outcomes either for patients or globally within the health system? Did it improve your outcomes? Well, I think that there's some work maybe out there for you to do. So you've achieved a wonderful piece having this paper published and starting on a place for CME to be published.

for all of these learners, which is fantastic. But as you said, the FCCS adult course really doesn't have a lot of published literature. And for the length of time that it's been out and being conducted, that surprises me. But now you've got a niche. I don't know if this is where you want your research piece to be. As you said, you focus on education.

But would you be thinking about how to continue some more work on this? Yeah, absolutely. I'm actually in the formative stages right now to look at a simulation model to be able to test this and see if it actually did change people's

practice or did change the way they practice, you know, when given standardized patients and kind of looking at the same thing, a pre-post model. To do it rigorously, I'm probably going to require some grant funding. And ideally, I would love to do it as a multidisciplinary or, excuse me, multi-institutional model.

You know, if you can get a number of facilities that have simulation centers that can follow the model that we're going to develop and, you know, give us some results for that. I mean, I think that would be, you know, that would be great. I mean, again, looking at are you going to change system outcomes from this? That's great.

Exceedingly difficult. Not impossible, but exceedingly difficult. It's a big endeavor. Yeah. Absolutely. Unfortunately, we're about out of time. So before we conclude, I just wanted to ask if there was anything else that you wanted to have an opportunity to talk about or mention? No. I mean, overall, again, for the people who are on the fence about this program or haven't been involved with this program, I would highly, highly recommend it.

I mean, one of the things that happened that we saw in the program where at the institution I was, was that

Over the course of time, two-thirds of our participants in this program were nurses from throughout the institution. And, I mean, people would come up to me regularly. You know, we took that course a month or two ago, and it was fantastic. I mean, it helped us take care of this patient. It helped us identify that this patient was getting sick, and this patient probably didn't get as sick because we identified it early. That's truly amazing.

I mean, it's just from a professional standpoint, that's what I want to do. I mean, yes, I want to treat my patients and I want to do the best I can for my patients. But also if I can improve the care that other people are giving for their patients and quite frankly, see less severe patients, I'll take it. And I mean, I think anyone would be happy with that. I think...

everybody would agree with that statement. So hopefully all the listeners here, I just want to mention again, as this is Dr. Mark Hamill from Nebraska, Omaha, Nebraska. And if anybody who's listening feels that they would like to try and participate in that multicenter study with the simulation, I'm sure you can find him on the SECM

membership. But at this time, I want to say thank you. This concludes another episode of the Society of Critical Care Medicine podcast. If you're listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine podcast, I'm Maureen Madden.

Maureen A. Madden, DNP, RN, CPNC, AC, CCRN, FCCM, is a professor of pediatrics at Rutgers Robert Wood Johnson Medical School and a pediatric critical care nurse practitioner in the Pediatric Intensive Care Unit at Bristol-Myers Squibb Children's Hospital in New Brunswick, New Jersey. The SCCM Podcast is the copyrighted material of the Society of Critical Care Medicine and all rights are reserved.

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