Undergraduate training in the care of the acutely ill patient: a literature review
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- Smith, C.M., Perkins, G.D., Bullock, I. et al. Intensive Care Med (2007) 33: 901. doi:10.1007/s00134-007-0564-8
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To characterise the problem of teaching acute care skills to undergraduates and to look for potential solutions.
Systematic literature review including Medline, EMBASE, CINAHL. Eligible studies described education and training issues focusing on caring for acutely ill patients. Articles were excluded if they did not address either educational or clinical aspects of acute care and resuscitation.
Measurement and results
We identified and reviewed 374 articles focusing on training or clinical aspects of caring for the acutely ill patient. Undergraduates and junior physicians lack knowledge, confidence and competence in all aspects of acute care, including the basic task of recognition and management of the acutely ill patient. There is wide variability both between and within countries regarding the amount of teaching in critical care offered to undergraduate medical students. Many centres are starting to use an integrated approach to acute care teaching, with early exposure to basic life support and clinical skills, coupled with later exposure to more complex acute care topics. Clinical attachments remain a popular method for training in acute care. Acute care courses are increasingly being used to standardise delivery of practical skills and patient management training.
The training of healthcare staff in the care of acutely ill patients is suboptimal, adding to patient risk. Improvements in training should start at undergraduate level for maximal effect, should be integrated with postgraduate education, and are likely to enhance current efforts to improve patient safety in acute care.
KeywordsCritical careCardiopulmonary resuscitationUndergraduate medical educationTraining
Safe care of the acutely ill patient: a challenge for healthcare systems
Hospitals are becoming increasingly complex environments because of developments in medical technology, more potent treatments, an aging and dependent population of patients, increasing emergency admissions (World Health Organisation Report, ‘Emergency Medical Services’, 2005: http://www.who.dk/emergservices; accessed 23 October 2005], fewer acute beds, and consequently higher throughput of sick patients (OECD Health Data, ‘A Comparative Analysis of 29 OECD Countries’, 2000: http://www.oecd.org; accessed 23 October 2005]. These acutely ill patients are more at risk of error and adverse outcomes ; around 3–16% of hospitalised patients suffer an adverse event, with a mortality rate of 5–8% and costs ranging from $4.7 to $29 billion [1, 2]. As many as one-half  of these events are attributed specifically to the clinician. This is likely to be an even greater problem in systems where acute and emergency care out-of-hours is provided by less experienced physicians or inadequately supervised trainees .
Education in acute care safety
This makes training in acute care and patient safety a priority for medical education. This training needs to start at undergraduate level for maximum effect, and should be continued within postgraduate education. However, there is no common curriculum in acute and emergency care for undergraduates [4, 5]. Deficiencies in knowledge of acute and emergency care are common amongst junior physicians around the time of transition from undergraduate to postgraduate training , which is a matter of concern given that they may be responsible for the early assessment and treatment of the acutely ill patient.
In order to address this we convened a group to develop recommendations for undergraduate curricula in the care of acutely ill patients. As implementing a new curriculum can be problematic , we used consensus techniques to develop the competencies ; these competencies can be integrated within existing undergraduate curricula and with postgraduate acute care training. To underpin this development we have conducted a review of the literature related to training in the care of the acutely ill patient, with a predominant focus on undergraduate education.
The aims of our literature review were to characterise the problem of teaching acute care skills to undergraduates and to look for potential solutions. A selective review of the literature examining those aspects of clinical care of acutely ill patients with implications for education and training augments this approach.
A systematic review of the literature relating to undergraduate training in the care of acutely ill patients was undertaken to determine current approaches and opportunities for improvement. Searches were performed using key words derived from MeSH subject headings (and the ‘explode’ function where available to identify relevant subheadings) via Ovid Online using Medline (from 1966), EMBASE (from 1980), and CinAHL (from 1982) until 2005. Full original text articles that could not be viewed online were obtained from local libraries.
Step 1: The following key words were used to identify publications relating to the care of acutely ill patients: acute disease; advanced cardiac life support; basic life support; cardiopulmonary resuscitation; critical care; critical illness; emergency medicine; emergency treatment; heart arrest; intensive care; life support care; resuscitation; subacute care.
Step 2: We then used the following key words to identify publications relating to education and training: competency-based education; graduate education; medical education; medical students; nursing education; nursing students; postgraduate medical education; problem-based learning; undergraduate medical education.
Step 3: Step 1 with step 2 datasets were linked (using Boolean ‘and’) to identify original articles linking care of the acutely ill patient to education and training that were potentially suitable for inclusion in the review. These articles were examined by a single reviewer (C.M.S.) and additional potentially suitable publications were identified by using links to related articles and by reviewing the bibliographies of all articles obtained. Information was also collected from letters to journals, editorials or commentaries, and review articles. Publications were selected for review if they described aspects of undergraduate or immediate post-graduate training in the care of the acutely ill patient, including resuscitation. Articles were also included if they described clinical problems and solutions in caring for acutely ill patients. We did not attempt an exhaustive review of this clinical literature, but focussed on those aspects which were relevant to training and education. Articles were excluded if they did not address either educational or clinical aspects of acute care and resuscitation, including caring for the acutely ill patient. Only English language papers were included in the final dataset. The articles were reviewed and categorised into five ‘levels of evidence’ using the Centre for Evidence-Based Medicine's 2002 grading (http://www.eboncall.org/content/levels.html; accessed 23 October 2005; see Table E1, see Electronic Supplementary Material, ESM). Finally, we identified practical courses in areas of medicine relevant to acute care. Courses were identified by online searches of web pages of organisations known to arrange acute care courses, by entering search terms into an online search engine (www.google.co.uk) or by personal communication. The list of courses compiled was not exhaustive, but was a good representation of the breadth of courses that are available.
We identified 42,077 articles relating to the care of acutely ill patients and 32,961 relating to the science of education and teaching. Combination of these two datasets yielded 482 articles. From these 482 original articles, and other potentially suitable articles that were reviewed, 374 focussed on training or clinical aspects of caring for the acutely ill patient and were included in the final dataset for review (Table E1, ESM). There were 95 articles addressing aspects of education and training in acute care, and 135 which reported educational interventions. Of these 230 articles 165 (71.7%) were cohort studies, audits or questionnaires. We also reviewed 104 clinical articles examining the impact of suboptimal acute care and 40 reporting clinical interventions targetted at the acutely ill patient, all of which had implications for training and education. Again, the great majority were cohort studies or audits (Table E1, ESM). Taught courses in areas of medicine relevant to acute care and with materials of interest to, or targetted at, undergraduates, are summarised in Table E2 (ESM).
The scale of the problem
A consistent theme is that both undergraduates and junior physicians lack knowledge , confidence  and competence  in all aspects of acute care, including the basic task of recognition and management of the acutely ill patient . These deficits have been demonstrated in the United Kingdom [6, 9], Europe  and the United States .
Teaching of acute care at undergraduate level is often dispersed within the curriculum, lacking focussed core teaching [4, 5]. Few textbooks provide detailed guidance on basic aspects of the assessment of acutely ill patients . A worldwide study of English-speaking medical schools conducted in the United States revealed that few institutions have dedicated teaching time set aside for acute care teaching to undergraduate students . In Europe there is wide variability both between and within countries regarding the amount of teaching in critical care offered to undergraduate medical students . Formal assessment of undergraduates in critical care is also only required by a minority of institutions .
Most medical students in the UK receive basic life support (BLS) training and some receive immediate or advanced training . In the UK , Europe  and worldwide  the actual delivery and feedback of resuscitation skills is highly variable. Inadequate practical skills training at undergraduate level translating into poor performance after qualification  is an international problem [18, 19, 20, 21]. Many practical skills are obtained in the first year after qualification , but junior physicians are still not confident in their ability to competently perform some acute care skills up to 3 years post-qualification .
Potential educational interventions
Student learners often have clear and consistent ideas about what they want from their learning experience, highlighting the importance of self-directed learning . Rotations through specialities dealing with acutely ill patients are an effective part of the undergraduate learning experience [24, 25], and are received well by students themselves . Many centres are starting to use an integrated approach to acute care teaching, with early exposure to BLS and clinical skills, coupled with later exposure to more complex acute care topics [26, 27]. An example from the University of Birmingham Medical School (UK) is given below:
1styear:multi-professional(medicine,nursing,physiotherapy) peer-led BLS and AED course using senior student instructors who themselves undergo a 2-day European Resuscitation Council BLS/AED instructor course. The provider course is delivered to 700 students each year and has been shown in a randomised controlled trial to be as effective as consultant-led teaching .
3rd year: 350 medical students take a half-day locally developed introductory course on the management of the acutely ill patient.
4th year: 6-week clinical placement in anaesthesia, critical care and respiratory medicine with supporting lectures and tutorials, and a 3-day pre-hospital trauma course endorsed by the Royal College of Surgeons (Edinburgh) 
5th (final) year: Resuscitation Council (UK) immediate life support course and a locally developed management of life-threatening illness course; each 1 full day. Compulsory structured practical skills teaching is also provided in the following areas: infection control, venous access and cannulation, arterial blood sampling, therapeutic injections, catheterisation and suturing.
Alternative approaches include reflective, case-based learning using portfolios, as developed in Liverpool, UK (R. Griffiths, personal communication). In a recent international survey of intensive care training programmes 50% of national coordinators reported formal involvement of intensive care medicine in the undergraduate curriculum . Clinical attachments in acute care and emergency medicine are popular with students because they provide practical and relevant ‘hands-on’ experience [24, 31] resulting in improvements in practical skills and patient management . Induction courses and ‘shadowing’ more senior colleagues around the time of transition from undergraduate to postgraduate training are also of benefit .
Courses that have traditionally been targetted at postgraduates can also be successfully delivered to undergraduate medical students. The European Resuscitation Council runs BLS/AED courses that are taught to undergraduate health care students . Its advanced life support and European paediatric life support courses are targetted at healthcare professionals and may also be appropriate for senior undergraduate students (Table E2, ESM). Indeed, in parts of the UK the advanced life support course is taught to new medical graduates before they commence their first-year jobs. Similarly, the European Society for Intensive Care Medicine runs a multi-professional distance learning course called “Patient-Centred Acute Care Training” and a “Fundamentals of Critical Care Support” course for physicians not specialising in intensive care that may also be appropriately targetted to more senior students (Table E2, ESM).
Advanced trauma life support courses and other courses similar to them employing simulation and small group teaching have resulted in improved performance in the practical management of acute illness amongst senior medical students [34, 35]. Advanced cardiac life support  and procedural skills courses  offered to medical students have also resulted in increased scores in formal evaluations of skills. Medical students' participation in the 1-day multi-professional ALERT course resulted in increased knowledge  in many aspects of caring for an acutely ill patient. Before and after cohort studies suggest that such acute care courses may improve patient outcome although, due to other confounding factors, this is difficult to demonstrate conclusively .
Many novel and effective methods for providing acute care teaching have been described, including the method of peer-led tuition in BLS . Self-directed learning using video or computer reference material in BLS teaching has resulted in comparable levels of theoretical and practical knowledge in medical students , but distance learning is less effective for practical skills . An advanced procedures course incorporating teaching via online reference materials and practice on models and unembalmed cadavers resulted in subjective increases in understanding and confidence amongst medical students in more advanced practical skills .
The use of medical simulation is growing, and it has proved a reliable and popular method of both assessing and improving skills in managing the acutely ill patient . Patients will usually allow inexperienced medical students to perform simple procedures upon them but would prefer if the student had been taught and assessed using simulation first . Candidate feedback on simulation in assessment is also invariably positive . Repeat training on medical simulators would be required for maintenance of optimal clinical skills , but this presents some practical difficulties .
Written examination performance is not correlated with practical knowledge in acute care subjects , and learning for written examinations results in students spending less time acquiring practical skills . The Objective Structured Clinical Evaluation (OSCE) is used in an attempt to standardise clinical examinations for students, using either real or simulated patients. It can be used in the acute care setting, for example, to test examination or procedural skills without risk to patient safety. Many students feel that the OSCE is a fair method of assessment, particularly in acute care subjects , but only a fewareas of clinical experience are correlated with future OSCE performance ; continuous assessment may be better for assessing clinical skills . An example from BLS teaching demonstrates that simplicity in instruction of practical skills is correlated well with future examination performance and subsequent retention of these skills .
The use of simulation for formal skills assessment is not widespread  but evidence suggests that it would be a reliable method of assessment across a wide range of abilities, including medical students . Although simulation is not correlated well with performance in written or other clinical examinations , it has been demonstrated to have good predictive value in simulated resuscitation scenarios .
This review has identified many opportunities for improvement in undergraduate and postgraduate training in caring for the acutely ill patient, and several effective methods for delivery and assessment of training. However, teaching in acute care is rarely provided as a coherent entity, but is contained within speciality-specific teaching programmes which do not necessarily prioritise the care of the acutely ill patient. Aspects of patient safety in acute care which could be addressed by educational interventions include recognition and management of the acutely ill patient, appreciation of clinical urgency, communication skills, team-working and organisation, knowledge, end-of-life care, and knowing when to seek advice.
In the UK the National Confidential Enquiry into Patient Outcomes and Deaths report (‘Medical Admissions to Intensive Care: An Acute Problem’, 2005: http://www.ncepod.org.uk/2005report/NCEPOD_Report_2005.pdf; accessed 23 October 2005) found suboptimal processes of care in the management of the acutely ill patient which are associated with adverse patient outcomes . Informal contacts suggest that these problems are not unique to the UK; indeed, even in the intensive care unit safety issues do not appear to respect European national borders . A consistent problem in ward care is failure to detect clinical deterioration , which worsens morbidity and mortality . Predictors of impending cardiac arrest should prompt medical staff to take action or to summon experienced help , but the response is frequently inadequate or delayed .
Training is a key issue in the early detection and management of the acutely ill patient. Early warning systems may facilitate earlier referral but this does not necessarily improve outcome . A central issue is the training of staff in the interpretation of these warning signs, and the content of the intervention which follows. Some hospital systems are now establishing multidisciplinary rapid response teams (medical emergency teams, nurse-led outreach care, and ‘hospitalists’) to identify and manage acutely ill patients in ordinary wards, to improve outcome of those requiring referral to intensive care and to reduce cardiac arrest rates . It seems likely that improved clinical outcomes are a consequence of better training in the initial recognition and early management of the acutely ill or deteriorating patient . In the Australian randomised controlled study of medical emergency teams , despite there being no difference in the primary outcome (survival), there were improvements overall in both hospital clusters, suggesting a beneficial effect from the 2-month educational intervention which preceded the randomised introduction of medical emergency teams.
Education clearly underpins the need for better process control in the safe care of acutely ill patients. The curriculum and competencies required have been defined for undergraduates in the Acute Care Undergraduate Teaching (ACUTE) project  and at postgraduate level for critical care by the Competency-Based Training in Intensive Care in Europe project . Many centres are starting to use an integrated approach to teach increasingly complex aspects of acute care to students throughout the entire undergraduate medical course [26, 27], and activities coordinated by students themselves can prove highly successful . Introduction of dedicated acute care curricula into medical school rotations has met with positive feedback from students , as well as leading to marked improvements in knowledge and skills . Palliative care is also increasingly of importance to acute care, but is similarly neglected at undergraduate level .
This review aimed to provide a comprehensive review of the literature relating to training in the care of the acutely ill patient. However, there are some inherent weaknesses with the search strategies used for this review. The review of abstracts was restricted to abstracts published in English. Although non-English language articles accounted for only 3 of 482 articles (0.6%) initially identified, this may have missed important material. The search databases used (Medline, Embase and CinAHL) provide broad coverage of the literature but they do not include potentially important details published in non-peer reviewed material such as theses, textbooks or journals that are not listed in these search engines. MeSH headings were used to identify key search words, but not all of these terms were available throughout the entire period covered by these search engines (e.g. 1966–present for Medline), and some terms had replaced different MeSH headings used in the past. Thus some potentially important earlier studies may have been overlooked.
The review and selection of abstracts for inclusion in this review was undertaken by a single author (C.M.S.) using pre-defined criteria, which could have introduced bias. Whether the results would differ if two or more reviewers participated in this process is unknown. The review of available training courses was not exhaustive and the examples provided may not fully illustrate the spectrum of courses available to facilitate learning critical care skills.
The finding of only 15 level 1 evidence studies (randomised controlled trials or cross-over trials, if randomised) out of a total of 374 studies (4%) highlights the paucity of high quality evidence in this area. Moreover, the level of evaluation for many studies are at the lower end of the Kirkpatrick's  pyramid for evaluation, focusing on reaction, learning and to a lesser extent behaviour. Few studies evaluated the impact of interventions on patient outcomes (level 4). Further high quality studies are urgently required to help identify the optimal strategy for training physicians in the future.
Both individual and team-working skills are important for effective clinical management, and never more so than in the setting of acute care. Teaching of these different skills may vary enormously dependent on whether learning occurs on formal courses, in the clinical setting according to a locally agreed curriculum, or on an ‘ad hoc’ basis. The varying motivation of individual learners and teachers may also be a barrier to implementation of widespread improvements in acute care education.
Nevertheless, our review demonstrates that the training of undergraduate healthcare students and staff in the care of acutely ill patients is suboptimal, adding to patient risk. Improvements in training should start at undergraduate level for maximal effect, should be integrated with postgraduate education, and are likely to enhance current efforts to improve patient safety in acute care.
This review was funded by a research grant from The Resuscitation Council UK. GDP is supported by a DH (NIHR) Clinician Scientist Award.