August 2002
Volume 66 |
Number 8
|
| |
|
| Pulmonary Artery
Catheter Education Program: A Progress Report on This New
Collaborative Educational Tool |
William H. Montgomery, M.D.
C. William Hanson III, M.D.
Committee on Critical Care Medicine and Trauma Medicine
In the August 2001 NEWSLETTER, we reported on the collaborative
development of the Pulmonary Artery Catheter Education program.
This update is intended to provide a brief review of the stimulus
for the program, the mechanism for participating on the Web in
this educational endeavor and the content of the program currently
on the Web or soon to be there.
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 anesthesiologists placed approximately
50 percent of PACs 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 were cited.3
Other societies subsequently published similar guidelines regarding
the appropriateness of utilization and competency requirements
for the PAC. The debate as to the usefulness of the pulmonary
catheter continues with no conclusive data available as of this
printing.4,5
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.
Primary Purpose of PACEP
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.
The overall goal of PACEP is to provide efficient transformation
of useful hemodynamic information with Web-based technology that
will allow clinicians to practice in a safe and competent fashion.
Collaborating organizations include: ASA; the American College
of Chest Physicians (ACCP); the Society of Critical Care Medicine
(SCCM); the American Association of Critical Care Nurses; the
American Association of Nurse Anesthetists; the American Thoracic
Society (ATS); and the National Heart, Lung and Blood Institute.
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.
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. Users can access the information
at their leisure on the Web site and can proceed
to each lesson at their own pace and repeat lessons as necessary.
The lesson begins with a pretest to gauge the participant's baseline
knowledge of the subject matter. When the answers are submitted,
immediate feedback is received in the form of a percentage of
questions answered correctly. At the core of each lesson is a
slide presentation by expert faculty. The slides are viewed as
the speaker presents the information. A convenient slide summary
also is available in text format. Each slide may be expanded for
better viewing. Once the presentation is begun, it will automatically
advance, or the participant may choose to jump to individual slides.
The slide gallery allows one to see a thumbnail view of all slides
contained within a lesson. This special feature allows a quick
and efficient review of individual slides. Selected lessons contain
mini-case studies that challenge one to answer a series of multiple-choice
questions. As the student proceeds through a diagnostic pathway,
he or she will be advised in detail on whether or not his or her
answer was the most appropriate response. Each lesson ends with
a post-test that can be compared to the pretest score to determine
the level of improvement. When the answers are submitted, the
student receives the test score as well as the correct answers
to any questions answered incorrectly.
Continuing Medical Education Credit Instructions
ACCP designates each lesson of Level 1 of this continuing medical
education (CME) activity for two credit hours in category 1 of
the Physician's Recognition Award of the American Medical Association.
Participants should claim only those hours actually spent in the
educational activity.
This activity has been planned and implemented in accordance
with the Essential Areas and Policies of the Accreditation Council
for Continuing Medical Education (ACCME) by the ACCP, SCCM, ATS,
ASA and the Society of Cardiovascular Anesthesiologists. ACCP
takes responsibility for the content, quality and scientific integrity
of this CME activity. Other professionals participating in this
activity should check with their respective organizations to determine
the appropriate number of continuing education (CE) credit hours.
In order to obtain CME credit for each lesson, one simply completes
the learning activity, takes the post-test and upon submission
receives the test results. In addition, a link will be provided
that will take the participant directly to the online CME application
form for that particular lesson. The CME application fee for physicians
(each lesson awarded two credit hours in category 1 of the Physician's
Recognition Award of AMA) is $26 (U.S.). Upon submitting the completed
CME application form and test fee, a CME certificate will immediately
be e-mailed to each participant. If, however, a participant only
needs to obtain a certificate of completion without CME credit,
this is available for free at the end of each lesson once completed.
After completing an entire level, one may elect to answer an evaluation
form to obtain CME or CE credit hours. The amount of credit hours
for each level is shown in the CME and CE credit information and
instructions pages, which may be accessed from the PACEP home
page.
Development of the PACEP and Timeline
Module I has been developed. 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 have 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 Module III Case Studies for Interpretation of the
PAC Usage.
Module III – 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 2003.
Module IV – "Interactive Pulmonary Artery Waveform
Troubleshooting Program" is scheduled for implementation
on the PACEP Web site in late 2002.
Lesson A: Right arterial waveforms
Lesson B: Pulmonary arterial waveforms
Lesson C: Pulmonary capillary wedge waveforms
Lesson D: Tutorials
Module V – The "Other Forms of Hemodynamic/
Technology" module is reserved to educate and/or test knowledge
of new therapies or new technologies that could be additive to
PACEP.
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. The site averages approximately 105 visitors/users per
day with the most frequent users being intensivists followed by
pulmonologists, registered nurses, anesthesiologists, residents
and fellows, followed by a variety of "others." PACEP
offers 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. ASA Practice Guidelines for Pulmonary Artery
Catheterization. Anesthesiology. 1993; 78:380-394.
4. Hall JB. Use of the pulmonary artery catheter
in critically ill patients: Was invention the mother of necessity?
JAMA. 2000; 283:2577-2578.
5. Shah MR, O'Connor CM, Sopko G, et al. Evaluation
study of congestive heart failure and pulmonary artery catheterization
effectiveness (ESCAPE): Design and rationale. Am Heart J. 2001;
141:528-535.
| |
|
William
H. Montgomery, M.D., is Associate 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
|