Canadian Journal of Cardiology 32 (2016) 1204e1213

Special Article
From Coronary Care Units to Cardiac Intensive Care
Units: Recommendations for Organizational, Staffing,
and Educational Transformation
Michel Le May, MD,a Sean van Diepen, MD,b Mark Liszkowski, MD,c Gregory Schnell, MD,d
Jean-François Tanguay, MD,c Christopher B. Granger, MD,e Craig Ainsworth, MD,f
Jean G. Diodati, MD,g Neil Fam, MD,h Richard Haichin, MD,i Davinder Jassal, MD,j
Christopher Overgaard, MD,k Wayne Tymchak, MD,b Benjamin Tyrrell, MD,l
Christina Osborne, BSc,a and Graham Wong, MDm
a
Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
b
Mazankowski Heart Institute, University of Alberta, Alberta, Canada
c
Montreal Heart Institute, University of Montreal, Montreal, Que bec, Canada
d
Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
e
Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
f
Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada
g
Hôpital du Sacre -Coeur de Montre al, University of Montreal, Montreal, Que bec, Canada
h
St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
i
McGill University Health Centre, McGill University, Montreal, Que bec, Canada
j
St Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
k
University Health Network, University of Toronto, Toronto, Ontario, Canada
l
Royal Alexandra Hospital, University of Alberta, Edmonton, Alberta, Canada
m
Vancouver General Hospital, University of British Columbia, British Columbia, Canada

See editorial by Bourke, pages 1197-1199 of this issue.

ABSTRACT 
RESUM 
E
Medical care in Canadian cardiac units has changed considerably over pondre aux besoins de plus en plus complexes et diversifie
Afin de re s
the past 3 decades in response to an increasingly complex and diverse des patients souffrant d’un problème cardiaque aigu, les soins
patient population admitted with acute cardiac pathology. To maintain medicaux prodigue
s dans les unite
s de cardiologie canadiennes ont
the highest level of care for these patients, there is a pressing need to rablement e
conside volue
 au cours des trois dernières de cennies.
evolve traditional coronary care units into contemporary cardiac Cependant, si nous voulons continuer d’offrir les meilleurs soins

In 2013, a cardiac intensive care unit (CICU) workshop
conducted by Canadian coronary care unit (CCU) directors at
the Canadian Cardiovascular Society meeting highlighted the
change in the landscape of the traditional CCU, and
Received for publication August 10, 2015. Accepted November 26, 2015.
Corresponding author: Dr Michel Le May, Ottawa Heart Institute, 40
Ruskin St, Ottawa, Ontario K1Y 4W7, Canada. Tel.: þ1-613-761-4223;
fax: þ1-613-761-4690.
E-mail: mlemay@ottawaheart.ca
See page 1211 for disclosure information.
emphasized the increasingly important role of critical care
medicine in CCUs. It became evident that a “position paper”
(or a scientific statement) was necessary to guide our Canadian
institutions. Hence, a national Working Group was formed
that included cardiologists with an interest in critical care
medicine, 3 physicians with dual certification in cardiology
and critical care medicine, and a coauthor on the scientific
statement from the American Heart Association (AHA).1
Finally, as part of the internal review process, the Working
Group solicited the input of various Canadian leaders, the

http://dx.doi.org/10.1016/j.cjca.2015.11.021
0828-282X/Ó 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
Le May et al.
Canadian Cardiac Intensive Care Units
intensive care units. In this article we aim to highlight the current
variations in Canadian units, develop approaches to overcome logis-
tical and infrastructural obstacles, and propose staffing and training
recommendations that would allow for the establishment of contem-
porary cardiac intensive care units.
Canadian Association of Interventional Cardiology, the CA-
Nadian CARdiovascular Critical CarE Society, and fellows in
the process of training in critical care cardiology.
Overview
Acute cardiac care has evolved since the advent of CCUs in
the early 1960s. Although the original CCU was specifically
designed to admit patients with acute myocardial infarction
who might need timely defibrillation, the modern CICU is
now admits a variety of increasingly complex cardiac patients
commonly complicated by multisystem organ failure.2 A
detailed historical perspective of the evolution of the CCU is
provided (see the Historical Perspective: Evolution of Cardiac
Monitoring section of the Supplementary Material).
In addition to acute coronary syndromes, reasons for
admission now include: (1) management of cardiogenic shock;
(2) hemodynamic support for decompensated heart failure
and transplant evaluation; (3) target temperature management
after cardiac arrest; (4) diagnosis and management of complex
arrhythmias including implanted cardiac defibrillator mal-
function; (5) hemodynamic evaluation and initiation of novel
medical therapy for severe pulmonary hypertension; (6)
monitoring after percutaneous intervention for structural
heart disease; (7) management of decompensated complex
adult congenital heart disease; and (8) complicated
endocarditis.
This shift in CCU admissions of various critical cardiac
problems also has been accompanied by a host of critical
noncardiac problems, which has increased the need for critical
care expertise among attending physicians. This situation now
requires a balanced approach to patient care including advanced
modes of respiratory care, renal replacement support, neuro-
protection and neuro-optimization, concomitant treatment of
multisource infections, and enhanced nutritional support.
This evolution of critical care cardiology and the need to
transform the CCU has been acknowledged by the AHA.1
Accordingly, within the concept of a critical care-enabled
CCU, it is increasingly evident that attending cardiologists
will require further training and expertise in critical care
medicine. Recently the American College of Cardiology Core
Cardiovascular Training Statement-4 Task Force reported on
the standards needed for competency in critical care cardiol-
ogy.3 With that said, many logistical and infrastructural ob-
stacles must be addressed before the evolution of CCUs to
CICUs can be fully implemented across Canada.
In the context of an evolving CICU, the Working Group
believes that it will be important to integrate the best practices
of critical care and cardiovascular medicine. As such,
1205
possible aux patients, les unite s de soins coronariens traditionnelles
devront se muer en unite s de soins intensifs cardiaques plus con-
temporaines. Dans cet article, nous voulions faire ressortir les diffe-
rences actuelles caracte risant les unites de soins canadiennes,
developper des approches visant à surmonter les obstacles lie s à la
logistique et à l’infrastructure et recommander des modifications en
matière de dotation en personnel et de formation ne cessaires à
tablissement d’unite
l’e s de soins intensifs cardiaques à la fine pointe
de la modernite.
physicians will need to formally embrace the guidelines
adhered to by established critical care organizations such as the
Canadian Critical Care Society and the Society of Critical
Care Medicine into the planned structure of the evolving
CICU.4-6
The primary objective of this article was to establish how
contemporary Canadian CCUs can optimally serve an
increasingly heterogeneous and complex population of cardiac
patients, identify strategies needed to transform current Ca-
nadian CCUs into units capable of critical care management
(ie, CICUs), and propose initial suggestions and recommen-
dations to achieve this end. A more comprehensive evaluation
of issues related to other critical care units such as medical
intensive care units (MICUs) and cardiac surgical intensive
care units was beyond the scope of this article.
Similarities and Differences Between CICUs and
MICUs
The level of acuity in most Canadian tertiary care units has
risen to a level at which similarities now exist between our
modern CICU and a traditional MICU. However, clinically
important differences exist between patients admitted to the
MICU and the CICU. The primary reason for admission to
the CICU is almost always an acute cardiac illness. In general,
in the MICU a more diverse population of patients admitted
for conditions such as septic shock, respiratory failure, trauma,
or postoperative complications are monitored. Many of these
conditions are now more typically present in current CICU
patients.
Current variability in the resources and infrastructure of
some centres commonly requires that patients admitted in the
CCU with an acute cardiac illness require transfer to the
MICU (ie, need for mechanical ventilation). These patients
then usually fall under the care of an intensivist. Care of many
of these patients could alternatively be directed within the
confines of an evolved CICU by a cardiologist trained in
critical care medicine. However, although the Royal College
of Physicians and Surgeons of Canada (RCPSC) provides
training objectives in adult critical care medicine and certifi-
cation to physicians who have successfully completed the
program, it does not currently provide subspecialty training
and certification for critical care cardiology.
Importantly, the training and experience of several health
care disciplines is often required to manage critically ill pa-
tients. The Writing Group believes that collaboration between
CICUs and MICUs would be mutually beneficial to ensure
that optimal patient care is maintained and that clinical re-
sources are optimally distributed and allocated. Management
1206
protocols should be shared and standardized, and the directors
of the CICU and MICU should have regular interactions (ie,
critical care monthly meetings). A potential collaborative care
model for patients admitted to CICUs or intensive care units
(ICUs) is outlined in Figure 1.
Proposed CICU Classification
Because of the diversity in CICU clinical practices, acute
care volumes, and resource availability across Canada, it is
unrealistic to expect that all CICUs adopt the same level of
staffing, training, and organizational structures. However, we
do recommend that each city or region develop a hub and
spoke referral system(s) for acute cardiac care, in which the
care of the most critically ill cardiac patients is centralized in
high-volume centres capable of providing high intensity and
comprehensive care for critically ill cardiac patients (Fig. 2).
We propose a 3-tiered CICU classification system (Table 1)
similar to the American College of Surgeons trauma centre
classification system and to the model described in the AHA
scientific statement on critical care cardiology.1,7
This classification system could: (1) help provinces, re-
gions, and/or cities set up regional hub and spoke care net-
works; (2) guide individual CICUs in the development of
optimal staffing, training, and educational care plans to meet
the clinical needs of their population; (3) guide the develop-
ment of a future framework for CICU accreditation; and (4)
assist in the rationalization of costly critical care resources to
the best possible sites.
Level 1 CICU
A level 1 CICU should have the staffing, training, on-site
medical resources, and the medical technologies to centralize
comprehensive care for all cardiac conditions including the
most acutely ill cardiovascular patients. The standards and
technologies in these units should mirror those in a general
intensive care unit or a large tertiary cardiovascular centre.
Moreover, these select centres ought to serve as tertiary referral
centres within regional systems of care. Reasons to support
this model come from data that indicate that institutional and
Cardiologist
or Intensivist
Cardiologist-
Intensivist
IInternist
nterni
ern st
Medical and Surgical Consultants, Nurses,
Pharmacists, Physical/OccupaƟonal/Respiratory
Therapists, DieƟcians, and Social Workers
Figure 1. Collaborative care model for cardiac patients admitted to
cardiac intensive care units and intensive care units.
Canadian Journal of Cardiology
Volume 32 2016
Level 3
Level 3
CICU
CICU
Level 2
CICU
Level 3 Level 3
CICU CICU
Level 2 Level Level 2
CICU
CICU 1 CICU
Level 3
CICU
Level 3
CICU
Level 2
CICU
Level 3
CICU
Level 3
CICU
Figure 2. Hub and spoke cardiac intensive care unit (CICU) regional
care networks.
individual physician volumes affect patient outcomes.8-15 The
primary goal in centralizing the care of critically ill cardiac
patients is to concentrate expertise and resources to ensure
adequate volumes to promote superior clinical outcomes
across a broad range of complex acute cardiac pathologies.
Medical staffing of level 1 CICUs will play an important
role in the unit transformation and patient care. The physician
who leads the unit should be a cardiologist who has the
necessary education and training in cardiovascular disease to
optimally meet CICU patient care needs. We propose that
future level 1 CICU cardiology recruits have either dual cer-
tification in cardiology and intensive care or a minimum of 1
year of dedicated critical care training (see the section on
Pathways to Critical Care Cardiology Training) after their
cardiology residency (CICU intensivist).
An in-house physician, medical resident, or advanced nurse
practitioner with acute cardiac life support training should be
available at all times, as should consultation with an attending
CICU physician.
Nonphysician staffing should also reflect standards in
critical care units (see the Nursing Intensity and Allied Health
Professional Staffing section of the Supplementary Material).
Optimal nurse to patient ratios should be 1:1-1:2, dependent
on patient acuity.16-18 The unit should have a clinical
pharmacist,19-21 a respiratory therapist,22,23 and access to
physical therapy,24 occupational therapy,24 nutritional sup-
port,25 and social work services.26,27
Each unit should also develop standardized protocols, with
a particular focus on critical care evidence-based care strategies
(see the Standardized Treatment Protocols and Prevention sec-
tion of the Supplementary Material). Although specific evi-
dence from CICUs is largely lacking, we encourage the
adoption of existing best evidence from critical care medicine.
Units should be leaders in resident and cardiology trainee
education, and academic centres might choose to develop
Le May et al.
Canadian Cardiac Intensive Care Units
1-year cardiology critical care fellowships in conjunction with
the RCPSC.
Level 2 CICU
These units should have the staffing, medical resources,
and therapeutic technologies to diagnose and initiate appro-
priate management of most cardiovascular conditions. These
centres should manage a high volume of cardiac emergencies
and have 24/7 on-site percutaneous coronary intervention
(PCI), echocardiography, and access to critical care. These
centres might not necessarily have on-site cardiac surgery,
cardiac transplant, or electrophysiology services. Level 2 units
should be equipped to provide all forms of cardiac moni-
toring, and to manage patients who require intravenous
vasoactive agents, mechanical ventilation, transvenous pacing,
and therapeutic hypothermia. These units could transfer
complex or critically ill patients to level 1 centres, but could
also serve as a referral centre for moderate-acuity patients from
level 3 CICUs.28
Future physician recruitment to level 2 CICUs would
ideally comprise either cardiologists with 1 year of dedicated
critical care training (see the section on Pathways to Critical
Care Cardiology Training), or cardiologists with additional
dedicated critical care training that does not meet the 1-year
fellowship criteria; in the latter case, electives in critical care
medicine during cardiology training could potentially count
toward additional CICU training. Cardiologists with dual
cardiology-critical care certification would be eligible to work
in level 2 CICUs, but we believe that this career path would
best serve level 1 units. With a more modest patient acuity,
nurse to patient ratios could vary from 1:1 to 1:3. Allied
health staffing, in-house coverage, and unit protocol devel-
opment standards should otherwise remain similar to the level
1 CICU recommendations.
Level 3 CICU
Level 3 CICUs, more likely located in smaller community
hospitals, should be staffed and equipped to primarily manage
common cardiovascular diagnoses that require noninvasive
cardiac monitoring. A level 3 unit should focus on the initial
stabilization of the patient, which might include pharmaco-
logical and emergent mechanical therapies followed by timely
transfer to a level 1 or 2 CICU.28 These units should have the
capacity to administer intravenous vasoactive agents, manage
temporary transvenous pacemakers, and perform echocardi-
ography, but might not have access to in-hospital cardiac
surgery, primary PCI, or other cardiac subspecialty services.
The primary attending physicians in a level 3 CICU should
be certified cardiologists or certified general internists.
Attending physicians should maintain basic critical care
competencies although the degree of acuity in these units is
usually expected to be lower. A minimum 1:2 or 1:3 nurse to
patient ratio should be the standard.
We acknowledge that many centres that currently serve as
tertiary referral centres or regional hub might not currently
meet the proposed level 1 or 2 standards. As such, we would
like to reiterate that the purpose of this proposal is not to
validate all existing practice models, but rather to set reason-
able evidence-informed practice standards that each centre
could aim to meet in the coming years.
1207
Organizational Models
Regional referral networks and CICU institutional
volume
Regionalizing the care of critically ill patients is a strategy
that helps ensure consistent and timely access to high-volume
specialized centres. Surgical, trauma, and critical care studies
show that institutional volumes are linked to lower mortality
rates.8,10-14,29 The implementation of regional systems of care
for ST-elevation myocardial infarction and out-of-hospital
cardiac arrest is also associated with better patient
outcomes.28,30-32 However, recommendations for regional
systems of acute cardiac care are currently limited to the initial
triage of specific time-sensitive conditions. There might be
additional benefits to extending these systems beyond the
point of first medical contact to patients who deteriorate after
admission. Our recommendation to broadly regionalize the
management of all emergent and nonemergent cardiac critical
care might be justified on the basis of the consistency and
weight of published nonrandomized evidence.11-15,29-31
Development of specialized regional centres also represents
an opportunity to improve our knowledge in cardiovascular
disease (see the Prioritizing Critical Care Cardiology Research
section of the Supplementary Material).
Physician service volumes
Individual physician volumes have been associated with
improved clinical outcomes.9,12,33 The Leapfrog group, a
coalition advocacy group for hospital quality and safety, rec-
ommends a minimum of 6 weeks of annual intensive care
service for intensivists.34 In line with: (1) the Leapfrog
recommendation; (2) the AHA scientific statement; and (3)
the results of our national survey (see the Pan-Canadian
CICU Survey on Acute Cardiac Care section of the
Supplementary Material and Supplemental Table S4), we
propose that all physicians who practice in level 1 or level 2
CICUs maintain a minimum of 6 weeks of CICU clinical
service annually. We do, however, acknowledge that each insti-
tution must satisfy their needs within the available staffing and
infrastructural parameters that define their institution. As such,
we encourage the chief of cardiology of each institution to define
within reason what constitutes a “week.” Moreover, because of
the intensity and complexity of patient care within level 1 and
level 2 CICUs, the attending physician should limit practice to
the patients in the unit and be readily available at all times.
Interventional cardiologists are often actively responsible
for the initial management of critically ill patients in the
catheterization laboratory and during the transition of this
care to the CICU. We believe that interventional cardiologists
who wish to attend in the CICU might maintain a minimum
of 5 weeks of CICU clinical service annually, provided that
they also undertake at least 6 weeks of PCI call. Similarly, for
physicians with dual cardiology and critical care certification
who practice in multiple critical care settings, we propose that
a minimum of 4 weeks of service annually in the CICU is
reasonable if they also partake in a minimum of 6 weeks of
service in other critical care units, (ie, a total of 10 weeks). We
believe that the centralization of care coupled with standard-
ization of physician practice volumes will increase expertise
and experience with complex cardiac conditions in the CICU.
 1208
Table 1. Classification of Canadian CICUs
Future physician Medical and
staffing and Role of the On-site medical technological Nurse staffing and Unit protocols and
Level Patient population recruitment intensivist resources capabilities allied health support standards Education
1 “Regional Hub” All cardiovascular Cardiologist- Cardiac-intensivist 24/7 Primary Noninvasive cardiac RN:patient ratio: Infection control Resident and
diagnoses: intensivist or percutaneous coronary and hemodynamic 1:1-1:2 Sedation protocols cardiology fellow
All acute coronary or intensivist intervention monitoring Pharmacist Mechanical ventilation education
syndromes CICU intensivist consultation with Cardiac surgery Invasive cardiac and Respiratory therapist protocols Might include cardiac
Advanced heart failure collaborative Echocardiography hemodynamic Physical and VAP, CLI, VTE intensivist training
Arrhythmia and device management Electrophysiology monitoring occupational therapy prevention and Critical care
management Adult congenital Cardiac arrest team Dietician reporting continuous medical
Aorta and peripheral Intensive care Intravenous vasoactive Social worker Standardized order sets education for
vascular disease Neurology agents for common attending
emergencies 24/7 In-house physician, Transvenous conditions cardiologists
Cardiac arrest care resident, or advanced temporary pacing Delirium screening
Transplant nurse practitioner Mechanical ventilation Early mobilization
Adult congenital heart coverage Therapeutic Morbidity and
disease hypothermia mortality review
Cardiogenic shock Intra-aortic balloon
Cardiac patients with pump and/or
multisystem organ percutaneous left
failure ventricular assist
device
Hemodialysis
Continuous renal
replacement
Bronchoscopy
Electronic medical
records
2 “Secondary Most cardiovascular CICU intensivist Intensivist 24/7 Primary Noninvasive cardiac RN:patient ratio: Infection control Resident and
Referral Centre” diagnoses: or consultation with percutaneous coronary and hemodynamic 1:1-1:3 Sedation protocols cardiology fellow
All acute coronary cardiologist collaborative intervention monitoring Pharmacist Mechanical ventilation education
syndromes management Echocardiography Invasive cardiac and Respiratory therapist protocols Critical care
Advanced heart failure Intensive care hemodynamic Physical and VAP, CLI, VTE continuous medical
Arrhythmia and device Neurology monitoring occupational therapy prevention and education for
management Other resources available Cardiac arrest team Dietician reporting attending
Aorta and peripheral by telephone Intravenous vasoactive Social worker Standardized order sets cardiologists
vascular disease consultation agents for common
emergencies 24/7 In-house physician, Transvenous conditions
Cardiac arrest care (initial resident, or advanced temporary pacing Delirium screening
management) nurse practitioner Mechanical ventilation Early mobilization
Transplant coverage Initiation of Morbidity and
Adult congenital heart therapeutic mortality review

Canadian Journal of Cardiology

disease hypothermia
Cardiogenic shock Hemodialysis
Cardiac patients with Electronic medical
multisystem organ records
failure

Volume 32 2016
Transfer complex and
critically ill patient to
level 1 centre
Le May et al. 1209
Canadian Cardiac Intensive Care Units

Open vs closed units

Resident education

Critical care and CICU units are traditionally organized

into an open vs closed structure. In an open unit, multiple
physicians can admit patients to the unit and maintain the
primary responsibility for daily care. In a closed unit, a single
physician maintains primary responsibility for all patients.
Observational studies and meta-analyses show lower ICU
Standardized order sets
CLI, VTE prevention

mortality rates and shorter lengths of stay in closed units with

mortality review

intensivist-directed care or with mandatory consultation with

Infection control

and reporting

for common

an intensivist.35-37 A closed unit might also better provide an

Morbidity and
conditions

administrative framework that enables timely development of

new protocols and progress. Although it is impossible to
clearly delineate the contribution of unit organization and
staffing in critical care cardiology, the weight of existing evi-
occupational therapy
RN:patient ratio: 1:2-

dence is sufficient to recommend the adoption of closed

Respiratory therapist

CICU, cardiac intensive care unit; CLI, central line infection; RN, registered nurse; VAP, ventilator acquired pneumonia; VTE, venous thromboembolism.

staffing models for CICUs.

Social worker
Physical and
Pharmacist

Physician staffing, training, and expertise

Dietician
1:3

The overwhelming majority of CICU patients have a pri-

mary cardiac diagnosis at the time of admission that requires
daily management by a physician with expertise in cardiology.
Mechanical ventilation
Intravenous vasoactive
and hemodynamic

(before transfer to
temporary pacing
Noninvasive cardiac

Cardiac arrest team

Therefore, it is the opinion of this Writing Group that a

Electronic medical
level 1 centre)

cardiologist with critical care training is ideally the most

monitoring

Transvenous

appropriate physician to lead the care of patients admitted to a

records
agents

level 1 or 2 CICU.
In light of the growing medical complexity among CICU
patients, it is anticipated that the future CICU physician will
24/7 In-house physician,
Other resources available

require advanced critical care knowledge in addition to

resident, or advanced

expertise in acute cardiac care. Currently, critical care certifi-

nurse practitioner
Echocardiography

cation in Canada does not necessarily require dedicated car-

by telephone
consultation

diovascular training.38 We believe that the RCPSC will need

Intensive Care

coverage

to define the competencies and training requirements for

other types of physicians to assume the position of the most
responsible physician in a level 1 or 2 CICU, potentially
resulting in an area of focused competency. Medical inten-
sivists, cardiac anaesthesiologists, cardiac surgeons, and other
physicians who work with critically ill patients could, in this
consultation

manner, gain the necessary qualifications to assume the role of

Intensivist

the most responsible physician in a level 1 or 2 CICU.

However, until these changes are implemented, the Working
Group recommends that noncardiologists who seek this op-
tion should complete additional formal cardiology training
and certification. In units staffed by a noncritical care trained
Common cardiovascular Cardiologist or

cardiologist, we suggest that each CICU develop guidelines for

internist

critical care consultation and develop a collaborative patient

care strategy.
In level 3 CICUs, we recognize the need and ongoing role
Arrhythmia and device

and critically ill patient

for experienced and knowledgeable community physicians

Advanced heart failure

transfer of complex
management of all

from a variety of training backgrounds, who already provide

Initial diagnosis and

emergencies with

to level 1 centre
All acute coronary

care to this patient population, to remain as the most

cardiovascular
management

responsible physician.
syndromes
diagnoses:

Multiple nonrandomized studies consistently showed

improved clinical outcomes, such as mortality, length of stay,
and length of mechanical ventilation, in ICUs managed by an
intensivist.35,36,39,40 However, the RCPSC does not currently
require critical care training for cardiology certification.38
3 “Community

Nevertheless, we believe that the consistency of the data

CICU”

suggests that dedicated critical care training has the potential

to improve outcomes in complex CICU patients through
improved prevention, recognition, and management of
1210
noncardiac complications. Hence, we concur with the Euro-
pean Society of Cardiology and AHA recommendations that
CICU cardiologists receive formal extended training in critical
care.1,41
Continuing Medical Education and
Competencies
We endorse the development and adoption of a formal
continuing medical education (CME) curriculum as an
essential aspect in the evolution of modern Canadian CICUs.
CME will help bring current CICU physicians in line with
modern critical care medicine but also ensure that all CICU
physicians maintain competencies in critical care cardiology. It
is hoped that CICUs gain certification in the future through
the RCPSC Areas of Focused Competency Program. An
RCPSC Areas of Focused Competency status could then
promote the development and application of national
accreditation standards to all CICU physicians. Finally, to
maintain “best practice care,” the ongoing competency
assessment of CICUs will require gathering and acting on
clinical practice data (see the Quality Improvement Initiatives
section of the Supplementary Material). These data will assist
in:
1. Clarification of guidelines for admission to level 1, level 2,
and level 3 CICUs;
2. Improvement of resource and personnel allocation;
3. Assessment of clinical outcomes and length of stay;
4. Assessment of patient and family satisfaction;
5. Assessment and implementation of novel techniques and
technology; and
6. To foster and optimize relationships with other health care
units (MICU, Emergency Department, medical ward) and
relevant consultants.
Current CICU Attending Physicians
The process of training new cardiologists with the addi-
tional expertise in critical care medicine will take time. Many
current CICU physicians are experienced, committed, and
competent cardiologists who have recognized expertise that
has evolved with changing CICU needs. Although they might
not be formally trained in critical care, they will continue to
be an integral part of care for these patients while upcoming
attending physicians are trained. These physicians should
actively maintain and further develop the knowledge and
skills necessary to deliver ongoing CICU care. The following
suggestions are made in an attempt to ensure adequate
exposure for these physicians in the area of critical care
cardiology:
1. Institutions should establish collaborative care or consul-
tation standards for the most critically ill patients;
2. Individuals should maintain basic critical care skills (ie,
acute cardiac life support certification, basic airway man-
agement skills, basic echocardiography, and procedural
skills including central line placement and temporary
pacemaker insertion); and
3. Individuals should maintain a minimum of 15 hours of
critical care CME a year; this might also be in the form of a
critical care track at a national cardiology meeting.
Canadian Journal of Cardiology
Volume 32 2016
Pathways to Critical Care Cardiology Training
Cardiovascular organizations worldwide have advocated for
changes in CICU physician training.1,41 In Canada, there are
currently no recognized pathways or training standards toward
critical care cardiology certification. Herein, we propose 2
possible pathways (Table 2) toward specialized critical care
training in Canada: either dual certification in cardiology and
critical care or a minimum of 1 year of dedicated critical care
training after cardiology residency (CICU intensivist). The
foundation of both pathways will necessarily involve the
RCPSC and would follow formal cardiology subspecialty
certification.
First, dual certification as a cardiologist-intensivist is
possible. Currently, this is the only formal RCPSC-recognized
pathway to prepare trainees to work in CICUs and ICUs, and
requires the completion of a 2-year RCPSC-accredited critical
care fellowship after a 3-year RCPSC cardiology fellowship.
Dual certification in this way would ultimately provide all of
the technical skills and practice knowledge expected of a
general cardiologist/intensivist. If successful, this pathway
would provide trainees with RCPSC certification in critical
care and cardiology, and allow for clinical practice in cardiac
and general intensive care units.
However, the Writing Group recognizes that a focused
year of critical care training might be sufficient to meet the
patient care needs in contemporary level 1 and 2 CICUs. At
present, the University of Alberta has the only established
CICU critical care program in Canada.42 However, because of
the lack of national standards to underpin this program, we
advocate for the development of a formal standardized CICU
critical care fellowship. Ideally this would include 1 clinical
year after RCPSC certification in cardiology with broad crit-
ical care exposure (Table 2) administered by a joint critical
care and cardiology program. Trainees would acquire many of
the same technical skills as physicians with dual certification
and would be certified to work in CICUs but not in general
critical care units. Ultimately the development and imple-
mentation of such national standards, as done with other
traditional cardiology fellowships, would provide the best
avenue to train most of the future CICU cardiac intensivists
in Canada. To meet these goals, discussions and collaboration
between the RCPSC and critical care training programs (ie,
‘joint programs’) will likely be needed to accommodate
additional trainees.
Conclusions and Future Directions
Over the past half century, the CCU has evolved from a
unit highly focused on acute myocardial infarction arrhythmia
monitoring into a medically complex unit that provides
increasingly complex critical care to patients who present with
a primary cardiac illness. This shift in care was driven in part
by the increasing number of acutely ill cardiac patients who
populate modern CICUs, and also in part by the development
and use of highly specialized medical and therapeutic critical
care technologies. This new clinical paradigm requires an
organizational, staffing, and training transformation of our
CICUs.
We endorse the concept of development of regional cardiac
care systems and the centralization of critical and complex
cardiac patients into level 1 and level 2 centres staffed with
Le May et al. 1211
Canadian Cardiac Intensive Care Units

Table 2. Proposed Canadian critical care cardiology training pathways

RCPSC cardiology certification
RCPSC critical care certification
Training after cardiology, years
Clinical practice certification
General intensive care units
Cardiac intensive care units
Program leadership
Program accreditation
Clinical training content, (4-week
blocks)
Technical skills
Additional potential areas of
knowledge
CICU, cardiac intensive care unit; N, no; RCPSC, Royal College of Physicians and Surgeons of Canada; Y, yes.
Training pathway
Dual certification of cardiology-intensivists CICU intensivist
Y Y
Y N
2 1
Y N
Y Y
RCPSC accredited critical care residency program Nonaccredited collaborative critical care and cardiology
program
RCPSC None
RCPSC critical care training standards General intensive care (6)
Cardiac surgical intensive care (2)
Anaesthesia (1)
CICU (1)
Medical or surgical (s)electives (1)
Research or quality improvement initiatives (1)
Advanced airways management Endotracheal intubation
Advanced invasive and noninvasive mechanical ventilator Basic invasive and noninvasive mechanical ventilator
management management
Fibre optic bronchoscopy Fibreoptic bronchoscopy
Central venous and arterial placement Central venous and arterial placement
Pulmonary arterial catheter placement Pulmonary arterial catheter placement
Transvenous pacemaker placement Transvenous pacemaker placement
Intra-aortic balloon pump placement Intra-aortic balloon pump placement
Acute cardiac life support certification Acute cardiac life support certification
Cardioversion Cardioversion
Vasopressor and inotropic management Vasopressor and inotropic management
Echocardiography Echocardiography
Pericardiocentesis Pericardiocentesis
Thoracentesis and chest tube insertion Thoracentesis and chest tube insertion
Paracentesis Paracentesis
Procedural sedation Procedural sedation
Intracranial pressure monitoring and management
Continuous renal replacement therapy
Hemodialysis
Extracorporeal membrane oxygenation management Advanced airways management
Percutaneous and surgical left ventricular assist device Advanced mechanical ventilator management
management Intracranial pressure monitoring and management
Transesophageal echocardiography Continuous renal replacement therapy
Hemodialysis
Transesophageal echocardiography

cardiologists with appropriate critical care training. Hence, we References

advocate for the development, implementation, and recogni-
tion of formal critical care training pathways for cardiologists.
The recommendations outlined in this document will
undoubtedly require further engagement of regional, provin-
cial, and national organizations involved in the care of acutely
ill cardiac patients. Future engagement of all levels of gov-
ernment will likely be required to evaluate and reorganize the
health care delivery that aligns health care resources with pa-
tient care needs in contemporary CICUs. The proposals
outlined in this document can potentially serve as a frame-
work to meet the needs of our evolving cardiac population.
1. Morrow DA, Fang JC, Fintel DJ, et al. Evolution of critical care cardi-
ology: transformation of the cardiovascular intensive care unit and the
emerging need for new medical staffing and training models: a scientific
statement from the American Heart Association. Circulation 2012;126:
1408-28.
2. Katz JN, Turer AT, Becker RC. Cardiology and the critical care crisis: a
perspective. J Am Coll Cardiol 2007;49:1279-82.
3. O’Gara PT, Adams JE III, Drazner MH, et al. COCATS 4 Task Force
13: Training in Critical Care Cardiology. J Am Coll Cardiol 2015;65:
1877-86.

4. Canadian Critical Care Society. Guidelines. Available at: http://www.

canadiancriticalcare.org/guidelines#. Accessed November 3, 2015.
Acknowledgements
See the Acknowledgements section of the Supplementary 5. Society of Critical Care Medicine. Guidelines. Available at: http://www.
Material. sccm.org/Research/Guidelines/Pages/default.aspx. Accessed November 3,
2015.

6. Society of Critical Care Medicine. Guidelines. http://www.learnicu.org/

Disclosures Pages/Guidelines.aspx Critical Care Medicine. Accessed November 3,
The authors have no conflicts of interest to disclose. 2015.
1212
7. DiRusso S, Holly C, Kamath R, et al. Preparation and achievement
of American College of Surgeons level I trauma verification raises
hospital performance and improves patient outcome. J Trauma
2001;51:294-9.
8. Walkey AJ, Wiener RS. Hospital case volume and outcomes among
patients hospitalized with severe sepsis. Am J Respir Crit Care Med
2014;189:548-55.
9. Tu JV, Austin PC, Chan BT. Relationship between annual volume of
patients treated by admitting physician and mortality after acute
myocardial infarction. JAMA 2001;285:3116-22.
10. Ross JS, Normand SL, Wang Y, et al. Hospital volume and 30-day
mortality for three common medical conditions. N Engl J Med
2010;362:1110-8.
11. Kahn JM, Goss CH, Heagerty PJ, et al. Hospital volume and the out-
comes of mechanical ventilation. N Engl J Med 2006;355:41-50.
12. Hannan EL, Wu C, Walford G, et al. Volume-outcome relationships for
percutaneous coronary interventions in the stent era. Circulation
2005;112:1171-9.
13. Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and
operative mortality for high-risk surgery. N Engl J Med 2011;364:
2128-37.
14. Dimick JB, Upchurch GR Jr. Endovascular technology, hospital volume,
and mortality with abdominal aortic aneurysm surgery. J Vasc Surg
2008;47:1150-4.
15. Lin HC, Xirasagar S, Chen CH, Hwang YT. Physician’s case volume of
intensive care unit pneumonia admissions and in-hospital mortality. Am
J Respir Crit Care Med 2008;177:989-94.
16. Pronovost PJ, Dang D, Dorman T, et al. Intensive care unit nurse
staffing and the risk for complications after abdominal aortic surgery. Eff
Clin Pract 2001;4:199-206.
17. Penoyer DA. Nurse staffing and patient outcomes in critical care: a
concise review. Crit Care Med 2010;38:1521-8.
18. Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association
of registered nurse staffing levels and patient outcomes: systematic review
and meta-analysis. Med Care 2007;45:1195-204.
19. MacLaren R, Bond CA, Martin SJ, Fike D. Clinical and economic
outcomes of involving pharmacists in the direct care of critically ill pa-
tients with infections. Crit Care Med 2008;36:3184-9.
20. Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists
and inpatient medical care: a systematic review. Arch Intern Med
2006;166:955-64.
21. Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on
physician rounds and adverse drug events in the intensive care unit.
JAMA 1999;282:267-70.
22. Kollef MH, Shapiro SD, Silver P, et al. A randomized, controlled trial of
protocol-directed versus physician-directed weaning from mechanical
ventilation. Crit Care Med 1997;25:567-74.
23. Ely EW, Bennett PA, Bowton DL, et al. Large scale implementation of a
respiratory therapist-driven protocol for ventilator weaning. Am J Respir
Crit Care Med 1999;159:439-46.
24. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early phys-
ical and occupational therapy in mechanically ventilated, critically
ill patients: a randomised controlled trial. Lancet 2009;373:
1874-82.
25. Soguel L, Revelly JP, Schaller MD, Longchamp C, Berger MM. Energy
deficit and length of hospital stay can be reduced by a two-step quality
Canadian Journal of Cardiology
Volume 32 2016
improvement of nutrition therapy: the intensive care unit dietitian can
make the difference. Crit Care Med 2012;40:412-9.
26. Davidson JE, Powers K, Hedayat KM, et al. Clinical practice guidelines
for support of the family in the patient-centered intensive care unit:
American College of Critical Care Medicine Task Force 2004-2005. Crit
Care Med 2007;35:605-22.
27. Brilli RJ, Spevetz A, Branson RD, et al. Critical care delivery in the
intensive care unit: defining clinical roles and the best practice model.
Crit Care Med 2001;29:2007-19.
28. Kahn JM, Linde-Zwirble WT, Wunsch H, et al. Potential value of
regionalized intensive care for mechanically ventilated medical patients.
Am J Respir Crit Care Med 2008;177:285-91.
29. Nathens AB, Jurkovich GJ, Maier RV, et al. Relationship between
trauma center volume and outcomes. JAMA 2001;285:1164-71.
30. Nichol G, Aufderheide TP, Eigel B, et al. Regional systems of care for
out-of-hospital cardiac arrest: a policy statement from the American
Heart Association. Circulation 2010;121:709-29.
31. Henry TD, Gibson CM, Pinto DS. Moving toward improved care
for the patient with ST-elevation myocardial infarction: a mandate
for systems of care. Circ Cardiovasc Qual Outcomes 2010;3:
441-3.
32. Kushner FG, Hand M, Smith SC Jr, et al. 2009 Focused Updates: ACC/
AHA Guidelines for the Management of Patients With ST-Elevation
Myocardial Infarction (updating the 2004 Guideline and 2007
Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous
Coronary Intervention (updating the 2005 Guideline and 2007 Focused
Update): a report of the American College of Cardiology Foundation/
American Heart Association Task Force on Practice Guidelines. Circu-
lation 2009;120:2271-306.
33. Shahian DM, O’Brien SM, Normand SL, Peterson ED,
Edwards FH. Association of hospital coronary artery bypass volume
with processes of care, mortality, morbidity, and the Society of
Thoracic Surgeons composite quality score. J Thorac Cardiovasc
Surg 2010;139:273-82.
34. The Leapfrog group. ICU Physician Staffing. Available at: http://www.
leapfroggroup.org/56440/SurveyInfo/leapfrog_safety_practices/icu_physician_
staffing. Accessed May 7, 2014.
35. Pronovost PJ, Angus DC, Dorman T, et al. Physician staffing patterns
and clinical outcomes in critically ill patients: a systematic review. JAMA
2002;288:2151-62.
36. Multz AS, Chalfin DB, Samson IM, et al. A “closed” medical
intensive care unit (MICU) improves resource utilization when
compared with an “open” MICU. Am J Respir Crit Care Med
1998;157:1468-73.
37. Carson SS, Stocking C, Podsadecki T, et al. Effects of organiza-
tional change in the medical intensive care unit of a teaching
hospital: a comparison of ‘open’ and ‘closed’ formats. JAMA
1996;276:322-8.
38. Royal College of Physicians and Surgeons of Canada. Information by
Discipline. Available at: http://www.royalcollege.ca/rc/faces/oracle/
webcenter/portalapp/pages/ibd.jspx;jsessionid¼lo7akGFJob-1n5NH8iPB
qDvhXjlBookKQjep8CYslLdu1nnCJqQC!-398589652?lang¼en&_afrLoop¼
15145067894894674&_afrWindowMode¼0&_afrWindowId¼null#%40%3F_
afrWindowId%3Dnull%26_afrLoop%3D15145067894894674%26lang%3Den
%26_afrWindowMode%3D0%26_adf.ctrl-state%3Dxfsijyqeb_4. Accessed May
7, 2014.
39. Reynolds HN, Haupt MT, Thill-Baharozian MC, Carlson RW.
Impact of critical care physician staffing on patients with septic shock
Le May et al.
Canadian Cardiac Intensive Care Units
in a university hospital medical intensive care unit. JAMA 1988;260:
3446-50.
40. Dimick JB, Pronovost PJ, Heitmiller RF, Lipsett PA. Intensive care unit
physician staffing is associated with decreased length of stay, hospital cost,
and complications after esophageal resection. Crit Care Med 2001;29:
753-8.
41. Hasin Y, Danchin N, Filippatos GS, et al. Recommendations for the
structure, organization, and operation of intensive cardiac care units. Eur
Heart J 2005;26:1676-82.
1213
42. University of Alberta. Faculty of Medicine & Dentistry. Division of Critical
Care Medicine. Fellowship Training. Available at: http://www.critical.
med.ualberta.ca/en/Education/FellowshipTraining.aspx. Accessed May
8, 2014.
Supplementary Material
To access the supplementary material accompanying this
article, visit the online version of the Canadian Journal of
Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10.
1016/j.cjca.2015.11.021.