Critical Care

International Fellowship

Education: International Fellowship in Critical Care

If you are a physician with a medical specialty (fully validated in your own country) in anesthesiology, cardiology, critical care, emergency medicine, internal medicine, or respirology surgery, and you want to broaden your field of expertise in a Canadian academic hospital, this program is for you.

The program provides a clear view and understanding of how care, education and research are led in critical care in one of the University of Toronto hospitals.

If you are interested in this experience, you will find all the information you need here.

Download the fellowship application form (pdf file) and send it to criticalcare@smh.ca.

Critical Care Department

Critical care provides acute care for those patients who are generally unstable, critically ill and in urgent need of the treatments of an intensive care unit.

We have embarked on a new strategic direction in critical care. Under the direction and leadership of the chief of critical care, Dr. Andrew Baker, we aim to develop academic growth, interdisciplinary research and collaborative care practices across the diverse but interrelated critical care units.

Our mission is to provide the highest level of patient care, optimize the use of intensive care resources and fulfill patient needs. We serve the critical care needs of all patient populations served in the Hospital. All units accept patients and are strongly linked to the regional emergency and critical health care system named "Criticall".

We also promote critical care academic activities in relation with the University of Toronto. The directors of education, research, quality and communication are working collaboratively to achieve this goal.

There are four units in the department.

The medical surgical intensive care unit (24 beds) is a large tertiary and quaternary unit serving a full range of patients served by academic medical and surgical programs of the hospital as well as receiving patients surgical programs of the hospital and receiving patients through Criticall within and outside the city. Specialized services and expertise include complex ventilation, dialysis and continuous dialysis, specialized hematology and sepsis services (60%) and those surgical services without program specific critical care units (40%). Those services are predominately vascular, general surgery/MIS and orthopaedics. Of the 1,031 cases in 2001/2 weighted cases were 6,599, 34.65 of patients are elective and 51.1% of total patients are admitted through the ER with an ALOS of 7.7 days (total).
The cardiovascular intensive care unit (13 beds) determines its population in close cooperation with the Cardiac Care Network of Ontario. Typically, there are approximately 1200 admissions per year with a relatively high proportion of higher risk and complex surgical patients. Weighted cases in 2001/2 were 6,183 with 60% elective cases and an average LOS of 3.5 days. This fellowship is only available for International Fellows who have an anesthesiology speciality.
The coronary care unit (2 ventilated, 8 CC beds) serves a variety of patients but most commonly those with acute coronary syndromes arriving both from our local catchment area and the emergency department. It also serves as a tertiary and quaternary referral from regional hospitals and facilitates advanced interventional cardiological procedures. Of the 815 cases for 2001/2, weighted cases were 3144, with 44% of total patients admitted through the ER.
The trauma & neurosurgery unit (13 ICU +4 stepdown beds) serves two sets of patients. The Hospital is a designated regional trauma centre for patients with multi-system trauma (typically an ISS >15). The unit serves the area of Metro Toronto with a geographic division (with Sunnybrook) and patients transported from outside the city on alternating days through Criticall. There are approximately 400/yr with ISS >15. The neurosurgical ICU beds serve a large tertiary neurosurgical patient population as well as certain quaternary neurosurgical programs (pituitary, skull base, brain tumor PDT). The unit serves a large proportion of the Critical neurosurgery referrals. Of the 1,153 cases or 2001/2 weighted cases were 4,945 and an average length of stay (ALOS) 4.4 days. 30% of patients are elective and 65.3% are admitted through the ER.

The four units see approximately 4,000 patients each year with an average RIW of 4.818. The average age of the patients is 59.8 yrs with 67 % of patients between the ages of 18-69 and 32 % over 70 yrs. The catchment area for these patients is 16 % St. Michael's Hospital, 48.6 % from the Greater Toronto Area, and 32 % from Ontario.

Each unit receives quarterly data from the decision support of the Hospital that collates the patient CMF and diagnoses. The CCU and CVICU use data from provincial sources and receive provincial targets and quotas in order to define their scope. The MSICU uses decision support data and Hospital program priorities to define its scope. The TNICU has a mandate to serve a trauma population as defined by negotiations with the ministry. Data from decision support and from Criticall is monitored and demonstrates the high contribution the unit too provides neurosurgical services in the city and province.

Each unit actively uses the above data to forecast staffing and resource needs, and to align referral patterns with priorities. The critical care committee (CCC), a sub committee of the medical advisory committee makes this a regular item of business.

The department of critical care medicine is eminently aware that it operates in a system that is critically dependent on its linkages and partnerships. The department as a whole and each unit has actively fostered these linkages. For example, as a whole through the CCC, the department links with critical care services and with local hospitals to coordinate services provision.

Every year, the Hospital articulates goals that are adopted and pursed by critical care. These include quality of service indicators and cost indicators. As well, a wide variety of process-focused outcomes are monitored (response time to cardiac arrest, use of drugs, achieving quotas, open time to Criticall, refusal of trauma patients). Strategies are developed to meet the yearly goals based on feedback from various indicators and their outcomes. For instance:

Department-wide sedation protocol is evaluated by the change in use and costs of expensive agents.
Staffing models are assessed by their impact on cost per weighted case.
End of life care improvements are evaluated by families in the filling out of a deceased patients survey.
Overall performance is evaluated by a satisfaction survey.
There is regular debriefing at the CCC after all events that impact the department.

The department's centerpiece is its patient care model. This model was put in place in 2001 and every unit has begun measuring its progress against the standard:

All critical care areas employ a common model of shared decision making.
All critical care staff recognize the illness experience is culturally shaped, and will ensure the availability of resources in order to acknowledge and explore the meaning of the illness to patients and families.
End of life care is handled with a focus on respect for dignity.
Patient problems and goals are documented and kept current. They are used to communicate with both team members and healthcare providers outside the critical care units at phases prior to, during and at transfer out of this phase.
Multidisciplinary bedside rounds are established, with full participation from the various team members, respecting their individual expertise.
The patient and family are considered to be partners with the multidisciplinary team.
The interdisciplinary team is committed to ongoing learning and development to ensure they are current and competent in their area of practice.
A standardized framework is used to develop clinical and patient care processes that focus on quality improvement and consistency across all critical care units.
An evidence-based multidisciplinary practice model is adopted to evaluate the effectiveness of an intervention or management of disease or condition.
The team develops evidence based clinical protocols, clinical pathways and clinical practice guidelines to promote consistency in care and best practice.
Critical care units are academic units dedicated to the generation of new knowledge aimed at improving patient care.

The Fellowship Program

This program has been designed to offer foreign young physicians the opportunity of learning critical care and anesthesia in a Canadian academic institution. It aims to provide first class teaching of clinical practice, education and research.

Clinical practice in critical care is developed around the concept of evidence-based medicine, using standardization of care and quality of care policies. Evidence-based medicine joins experience-based practice in a multidisciplinary approach. This approach is common in the four intensive care units and in the operating rooms. The same concept of critical care is shared by all ICUs which are also specialized in their own field of specialty.

The trauma & neurosurgery ICU has developed a field of excellence in brain trauma injury and neurosurgery allowing the fellows to learn the best clinical approach of brain protection and management in one of the most advanced centers in Canada.

Similarly the coronary care and cardiovascular ICUs provide acute cardiac care including the management of coronary artery disease, valvular disease, severe heart failure and dysrhythmia. Access to cath lab investigations and perioperative transesophageal echocardiography is available to fellows having a special interest in these fields.

The medical surgical ICU offers a broad field of expertise in medical and surgical critical care. A specific approach of advanced ventilatory support, airway management and inflammatory response of sepsis has been developed by this unit.

Besides the clinical experience that can be acquired in the different units, the critical dare and anesthesia department has recently introduced a new concept of continuum of care centered on the patient needs. This approach has been the origin of a transversal critical care team, the critical care transitional team (CCTT), which is called by other departments to provide consultation, assessment of patient conditions and appropriate care. This multidisciplinary team provides the fellow the opportunity to deal with critically ill patients outside the ICUs.

Education

The education program results from a combination of specific training they can have in the different ICUs and ORs and the teaching program organized by the two departments.

Education is provided by academic physicians acting as staff physicians at the bedside and providing formal teaching sessions.

The education system is coordinated by the education committee and the director, who is in charge of its practical realization. The training program uses theoretical, simulation, and bedside teaching. A progression in teaching is used to adapt the program to the learning curve of the fellows. A tailored approach of education has been recently designed and developed. It allows the fellows to better define their needs with the director of education and to have a specific training in defined areas.

Evaluation of this program is by the educational committee and follows University of Toronto standards. A certificate will be given at the end of the program.