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A national survey of UK Intensive Care Medicine (ICM) trainee experience of critically ill obstetric patients.

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A national survey of UK Intensive Care Medicine (ICM) trainee experience of critically ill obstetric patients.
L Vincent1, H Vollmer1, A Quinn2, C Waldmann3
1Oxford University Hospitals NHS Foundation Trust, 2James Cook University Hospital, 3Royal Berkshire Hospital


•The complexity of medical and obstetric complications affecting pregnant or ‘recently pregnant’ women is increasing1.
•Only 2.4:1000 peri-partum women go to ICU, but up to 1:20 require an enhanced level of care for morbidity2.
•Many ICM trainees lack exposure to these patients, due to an increasingly junior ICM workforce, greater numbers of trainees from non-anaesthetic backgrounds and the relatively low incidence of obstetric admissions to ICU3.
•With rota constraints and competing service commitments, creating opportunities to fulfill the knowledge and competencies in this field, according to the FICM syllabus, is challenging.  


•With FICM approval, a once-only national electronic survey was submitted via the FICM email list to ‘snapshot’ all currently registered ICM trainees (600) in June 2016.
•Questions explored training background and programme structures of ICM trainees, their exposure to critically ill obstetric patients and the training opportunities available in this field, at a local and regional level.


•98 trainees responded (response rate 16.3%), representing all regions of Health Education England and all grades ST3 to ST7.
•16 (16.3%) respondents were single-stem ICM trainees and 82 (83.7%) were on combined training programmes, of which 63 (76.8%) were training with anaesthetics, 5 (6.1%) with Emergency Medicine (EM) and 14 (17.1%) with Acute/General Medicine (AGM). 


•79.6% trainees had cared for ≤ 10 obstetric patients on ICU and 51% trainees had cared for ≤ 5.
•Experience managing obstetric complications varied considerably according to background specialty and was reflected in trainees’ self-perceived confidence. Fewer trainees from non-anaesthetic backgrounds ‘feel confident’ managing obstetric patients with respiratory failure, sepsis, major haemorrhage or difficult airways.
•40% medicine and single-stem trainees have never managed Pre-eclampsia. 66.7% single-stem ICM trainees, 50% EM trainees and 66.7% AGM trainees had never intubated a patient ≥ 20 weeks gestation.
•Only 1/3 of  trainees had awareness of local (33.3%) or national (38.6%) guidelines for Maternal Critical Care.
•Most single-stem ICM trainees and those undertaking combined training with Emergency Medicine or Acute Medicine, do not feel that their MCC training needs can be met through their current programme. 
•86% trainees would be interested in attending a Maternal Critical Care simulation-based training day.


•There is marked variability in the experience in maternal critical care of trainees from different backgrounds, with many feeling their training needs are not being fulfilled.  The inconsistency in teaching and simulation provision seen, provides a strong argument for interventions to enhance education in this field.
•A poor response rate limits this survey. However, with the representative spread of training backgrounds and grades, the results may reflect the wider trainee body.
•There may be positive bias with trainees who have concerns about their training opportunities being more likely to engage with the survey. Alternatively, negative bias may result from the greater proportion of senior trainees with anaesthetic backgrounds (hence more obstetric experience) due to expansion in non-anaesthetic and single-stem ICM training posts.
•In our region there are maternal critical care teaching days (including simulation) during Stage 1/2, our recent regional ICM meeting was correspondingly themed and there are 20 non-clinical days available during Stage 3, which could be used to gain obstetric experience.  
•National multi-disciplinary simulation-based maternal critical care training days are emerging, offering unique opportunities for cross-specialty professional interaction, managing complex cases in a safe environment4. This survey endorses increased availability of such courses. 


1.Knight M et al. (MBRRACE- UK). Saving Lives, Improving Mothers’ Care. Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–12 NPEU, Oxford 2014. https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports                                                      
2.Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman.2011 https://www.rcoa.ac.uk/system/files/CSQ-ProvEqMatCritCare.pdf
4.Maternal Critical Care: A Practical Training Day for the Team (Babylifeline) http://babylifelinetraining.org.uk/home/courses/maternal-critical-care
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