August 2001
Volume 65 |
Number 8
|
| |
|
Pulmonary Artery
Catheter Education Program:
A New Collaborative Educational Tool |
(Note: Please contact the authors below for further information
on the PACEP Web Site.)
William
H. Montgomery, M.D.
C.
William Hanson III, M.D.
In a 1996 Journal of the American Medical Association article,
Conners et al. reported increased morbidity and mortality when
patients had pulmonary artery catheters (PACs) used to guide therapy.1
The accompanying editorial by Dalen called for a discontinuation
of the use of PACs until further data could be obtained with regard
to their safety and efficacy. 2 Multiple professional
societies, including ASA, responded in support of the PAC but
also indicated that interested parties should come together to
study the PAC and its use. This process was facilitated and promoted
by the Food and Drug Administration and the National Institutes
of Health.
The initial Pulmonary Artery Catheter Clinical Outcomes (PACCO)
conference attendees were of the opinion that the PAC was poorly
understood and that users were for the most part uninformed regarding
indications for insertion, technique of insertion and management
of catheter-derived data. The participants could not find good
data to support the use of a PAC in patients with acute respiratory
distress syndrome (ARDS), sepsis or in congestive heart failure.
They recommended that clinical trials be conducted to determine
PAC efficacy and safety in these disease states.
The conference acknowledged that approximately 50 percent of
PACs were placed by anesthesiologists and that there were articles
regarding the pros and cons of PAC use in cardiac and noncardiac
surgical cases. The PAC was introduced in 1970, and at the time
of the initial PACCO conference, industry representatives estimated
that 2 million catheters were sold around the world at an annual
cost of approximately $2 billion in the United States alone. The
landmark PAC guidelines published in 1993 by ASA was cited.3
Other societies subsequently published similar guidelines regarding
the appropriateness of utilization and competency requirements
for the PAC.
The ASA House of Delegates charged the Committee on Critical
Care Medicine and Trauma Medicine in 1997 with actively participating
in the evolving activities surrounding the PACCO process. Representatives
of professional societies, government and industry have all been
part of this ongoing PACCO project. The PACCO conference attendees
adopted as a goal the development of a program for “transfer
of basic hemodynamic monitoring knowledge.”
The Pulmonary Artery Catheter Education Project (PACEP) thus
evolved; it has been developed and designed to provide a state-of-the-art
Web-based educational tool on how to use and interpret information
obtained from the PAC in the clinical environment and measure
learning outcomes. Topic content has been divided into modules
to facilitate participant progression from novice to expert as
well as to provide the ability to include information on any new
technologies that in the future could be added as devices or therapies
are introduced into practice and as results of studies become
available.
Primary Purpose of PACEP
It was a consensus of the participating societies that a permanent
structure was necessary to continue to do the work of PACCO and
to complete the PACEP. A Board of Directors is being created,
and any professional society that wants to become more involved
is encouraged to join. The goal is to be one of inclusiveness,
with some basic criteria for membership.
The overall goal of PACEP is to provide efficient transformation
of useful hemodynamic information with Web-based technology to
allow clinicians to practice in a safe and competent fashion.
Participating organizations include the following: ASA; the American
College of Chest Physicians; the Society of Critical Care Medicine;
the American Association of Critical Care Nurses; the American
Association of Nurse Anesthetists; the American Thoracic Society;
and the National Heart, Lung and Blood Institute. For the purpose
of simplicity, all participating organizations with PACEP will
be referred to as the “PACEP Collaborative.”
This educational resource is intended for physicians-in-training,
physicians practicing critical care medicine and anesthesiology,
critical care nurses, nurse anesthetists and others who routinely
care for patients requiring advanced hemodynamic monitoring of
fluid levels and cardiac function. The benefits of using Web-based
technology include the following:
• Users can access the information at their leisure.
• Users can proceed to each lesson at their own pace and
repeat lessons as necessary.
• Information can be updated more economically, and information
can be provided that is considered the most current to medical
practice.
• Users can evaluate their own level of understanding with
the use of pretests, post-tests and case studies.
• A collective database can determine how effective the use
of Web-based technology is in educating those targeted for using
the information.
PACEP Collaborative Structure
The PACEP Collaborative consists of a Board of Directors that
has representation from each society participating with PACEP.
This group is intended to help in facilitating the development
of the project and in monitoring its implementation. All educational
content related to the PACEP project will be copyrighted solely
by the PACEP Collaborative and not be owned by one specific organization
or society. In addition, this copyright will be applicable to
any new formats or platforms that are decided upon by the PACEP
Collaborative as determined by educational need and available
financial resources. All decisions will be made by a majority
consensus of the PACEP Collaborative.
In return for a society’s participation, recognition of
its participation will be included on the PACEP Web site, and
participating societies will receive all information collected
from the PACEP that users have provided as they access and participate
on the PACEP Web site. There will be a two-way hyperlink from
the ASA Web site to the PACEP Web site and from the PACEP Web
site to the ASA Web site.
Development of the PACEP and Timeline
Module I is currently under development with an implementation
date on the PACEP Web site of July 2001. Module I has been designed
with a pretest, followed by a PowerPoint™ presentation that
is moderated by an expert in the field, and then a post-test.
Certain lessons within the module have three to five mini-case
studies that are utilized in preparing the user for the more complicated
case studies presented in Modules II and III. The development
of Level I and II educational content in Module I has been subdivided
for the beginner versus the more advanced practitioner.
Module I: Level I — Fundamental Hemodynamic Information
• Lesson A: Physiologic concepts of hemodynamic monitoring
(Part I of II)
• Lesson B: Interpretation of hemodynamic information (Part
I of II)
• Lesson C: Therapeutic interventions (Part I of II)
• Lesson D: Hemodynamic waveform analysis and interpretation
(Part I of II)
• Lesson E: Technical aspects of hemodynamic monitoring (Part
I of II)
• Lesson F: Complications of hemodynamic monitoring
• Lesson G: Assembly of pressure monitoring system
Module I: Level II — Advanced Hemodynamic Information
• Lesson A: Physiologic concepts of hemodynamic monitoring
(Part II of II)
• Lesson B: Interpretation of hemodynamic information (Part
II of II)
• Lesson C: Therapeutic interventions (Part II of II)
• Lesson D: Hemodynamic waveform analysis and interpretation
(Part II of II)
• Lesson E: Technical aspects of hemodynamic monitoring (Part
II of II)
• Lesson F: Insertion of the PAC
Module II — Currently under development with an implementation
date on the PACEP Web site of October 2001. The format includes
a pretest, followed by a PowerPoint presentation that is moderated
by an expert in the field, and then a post-test. Certain lessons
in Module II also have three to five mini-case studies.
Module III — “Case Studies for Interpretation
of the PAC Usage.” Module III will include all case-based
questions that build upon the content learned from Modules I and
II. It is scheduled for implementation on the PACEP Web site in
February 2002.
Module IV — “Interactive Pulmonary Artery Waveform
Troubleshooting Program.” This program is scheduled for implementation
on the PACEP Web site in July 2002.
• Lesson A: Right arterial waveforms
• Lesson B: Pulmonary arterial waveforms
• Lesson C: Pulmonary capillary wedge waveforms
• Lesson D: Tutorials
Module V — “Other Forms of Hemodynamic/Technology.”
This module is reserved to educate and/or test knowledge of new
therapies or new technologies that could be additive to PACEP.
Some technological advances could be items such as the HemoSonic™
100 echo-doppler probe for determining key hemodynamic parameters,
the PiCCO continuous pulse contour cardiac output device as well
as many others. An actual implementation date for this module
has not yet been determined.
CME and Other Continuing Education Units
Continuing medical education (CME) credit will be offered on
a lesson-by-lesson basis for each module. Other continuing educational
units for critical care nurses and nurse anesthetists will be
offered through AACN and AANA, respectfully.
The permanent PACEP structure represents an opportunity to participate
with other professional societies in the development of a strong
educational product for the practice of perioperative medicine.
ASA members have been involved from the beginning with this educational
product. PACEP represents an opportunity for our specialty to
be involved with and influence other societies as this and potentially
other educational instruments and methodologies evolve.
References:
1. Connors AF Jr, Speroff T, Dawson NV, et al.
The effectiveness of right heart catheterization in the initial
care of critically ill patients. JAMA. 1996; 276:889-897.
2. Dalen JE, Bone RC. Is it time to pull the pulmonary
artery catheter? JAMA. 1996; 276:916-918.
3. Practice Guidelines for Pulmonary Artery Catheterization.
Anesthesiology. 1993; 78:380-394.
|
William
H. Montgomery, M.D., is Assistant Professor of Anesthesiology,
University of Hawaii School of Medicine, Straub Clinic and
Hospital, Honolulu, Hawaii. |
|
|
C.
William Hanson III, M.D., is Professor of Anesthesia, Surgery
and Internal Medicine, University of Pennsylvania Medical
Center, Philadelphia, Pennsylvania. |
|
return to top
|