Research Fundamentals: Answering Causal Questions Using Clinical Data
Summary
Many research questions are causal, but the causal goal of a research endeavour is seldom explicitly stated. Because observational studies can never definitely ‘prove’ causation, many editors, reviewers and thesis supervisors believe that all causal language should be banned from non-randomized research manuscripts. This has led to the ubiquitous use of cloaked causal statements such as “X was independently associated with Y after adjusting for potential confounders.”
While the injunction on causal language is rooted in justifiable caution about the overinterpretation of observational studies, it is ultimately unhelpful in the evaluation of methods and results. The problem with cloaked causal statements is that causal vs. non-causal questions require different analytical choices, even if the same pair of variables is being analysed.
Suppose we are interested in the relationship between pulmonary embolism thrombus load (as quantified using CT angiography) and the risk of death. We have collected data on these two variables and on the cardiac biomarker troponin. If our research question is prognostic (i.e.: variable A predicts outcome Β), we could build a model that includes thrombus load and troponin as predictors of death. The results would show us the added predictive risk per unit of thrombus load. “Thrombus load was not associated with mortality after adjustment for troponin” could be a meaningful result in this context. But if our research question is about the causal relationship (i.e.: variable A causes outcome Β) between thrombus load and risk of death, including troponin as covariable in the model would be wrong.
Because more troponin release (through right ventricular strain) is a consequence of higher thrombus load, it is on the causal path between thrombus load and death. Adjusting for the mediating variable troponin in a model would ‘capture’ part of the causal effect of thrombus load on risk of death. This leads to a biased estimate (toward null) of the full effect of thrombus load. Therefore, “thrombus load was not associated with mortality after adjustment for troponin” would be a meaningless and misleading statement if our aim is to quantify the total effect of thrombus load on the risk of death. Readers of a study report can only judge whether the choice to include troponin or not in the model was correct if the authors state explicitly whether their question was causal or predictive.
This so-called overadjustment bias is one of the pitfalls that will be further explored below. It shows that answering causal questions requires a clear causal hypothesis. This module provides an introduction to formal causal thinking using Directed Acyclic Graphs (DAGs), a standard method to communicate hypothesized causal pathways.
General Information
Enrolled trainees 89
Open 18.05.2023
Available for ESICM members
Student effort 2
Last Updated May 18, 2023
Intended Learning Outcomes
- To understand why causal research questions using observational data require explicit causal hypotheses.
- To explain the two components of total estimation error.
- To explain the components of a Directed Acyclic Graph (DAG).
- To understand the meanings of confounders, mediators and colliders.
- To explain the difference between exposure modelling and outcome adjustment.
- To recognize time varying confounding and immortal time bias.
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All authors of ACE courses sign a document declaring absence or any actual or potential conflicts of interest. In addition, they sign a copyright document confirming the work is their own and that they have obtained the necessary permission for any copyrighted material. The latter document also transfers the intellectual copyright to the ESICM. Both the conflict of interest and copyright forms are filed and stored in compliance with GDPR and are available for inspection upon request.
Research Fundamentals: Fundamental and translational biology in critical care
Summary
Most critical care research is underpinned by a knowledge base of biology, drawn from various scientific disciples including anatomy, physiology, immunology, biochemistry, genetics and microbiology. Scientific work in this area often cuts across a range of disciples and may involve collaborative teams of scientists with complementary skills. Not all critical care researchers will undertake this type of research, however an understanding of this area is important as solid underpinning biological knowledge base is key to identifying likely therapies.
This self-study course is a key component of phase 2 of the ESICM research education pathway and needs to be completed before attending the “nuts and bolts of critical care research design” masterclass. Understanding the concepts contained in this module are key to getting the most out of the masterclass, as the masterclass will extend your knowledge and skills in this area. This is intended as an introduction. For those seeking more detail, hyperlinks to more in-depth resources have been embedded, however these are not essential for the completion of the module.
General Information
Enrolled trainees 61
Open 18.05.2023
Available for ESICM members
Student effort 2
Last Updated May 18, 2023
Intended Learning Outcomes
- To understand the terms ‘fundamental’ and ‘translational’ biological research
- To describe different experimental models and their strengths and weaknesses
- To understand, in general terms, core biological research techniques including assays for protein detection, gene expression, genotyping and cell functional assays
- To describe the basic design of a fundamental and translational biology experiment
- To understand how biological data can be represented and analysed
Relevant competencies in CoBaTrICE
- 12.15 Participates in research or audit under supervision
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All authors of ACE courses sign a document declaring absence or any actual or potential conflicts of interest. In addition, they sign a copyright document confirming the work is their own and that they have obtained the necessary permission for any copyrighted material. The latter document also transfers the intellectual copyright to the ESICM. Both the conflict of interest and copyright forms are filed and stored in compliance with GDPR and are available for inspection upon request.
Patient Transportation Part III: Prehospital Transport and Critical Care
Summary
Providing emergency and critical care outside the hospital has unique challenges. Part I and Part II primarily focused on transporting patients either between facilities or within a facility. Under both circumstances, the patient has already been evaluated by a physician, has undergone diagnostic testing, and care has been initiated. Part III will discuss civilian and military care outside the walls of the hospital and the transportation of patients to definitive care.
General Information
Enrolled trainees 159
Open 09.05.2023
Available for ESICM members
Student effort 2
Last Updated May 9, 2023
Intended Learning Outcomes
After studying this module on Patient Transportation Part III: Prehospital Transport and Critical Care, you should be able to:
- Understand specific safety considerations in prehospital care
- Explain environmental and situational impact on providing clinical interventions in the prehospital environment
- List effective elements of prehospital patient report and hand-off
- Review key elements of effective communication before, during, and after transportation
- Understand important aspects of prehospital triage
- Discuss appropriate prehospital care based on an assessment of the patient’s condition
- List important changes and controversies in modern prehospital care
- Identify principal elements of training hospital physicians to perform effectively in the prehospital realm
- Review different forms of military medical transport
- Explain the role of military transport in support of civilian operations
Relevant competencies in CoBaTrICE
- 10.1 Undertakes transport of the critically ill patient outside the ICU (prehospital)
- 12.2 Communicates effectively with members of the health care team
- 12.3 Maintains accurate and legible records/documentation
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Disclaimer
All authors of ACE courses sign a document declaring absence or any actual or potential conflicts of interest. In addition, they sign a copyright document confirming the work is their own and that they have obtained the necessary permission for any copyrighted material. The latter document also transfers the intellectual copyright to the ESICM. Both the conflict of interest and copyright forms are filed and stored in compliance with GDPR and are available for inspection upon request.
Patient Transportation Part II: Conducting Interfacility and Intrahospital Patient Transportation
Summary
Patient Transportation Part I provided an introduction and overview to the world of patient transportation. Part II will review how to effectively prepare for and execute patient transfer. It will cover clinical and logistic aspects of interfacility (IFT) and intrahospital (IHT) transport.
General Information
Enrolled trainees 174
Open 09.02.2023
Available for ESICM members
Student effort 2
Last Updated February 9, 2023
Intended Learning Outcomes
After studying this module on Patient Transportation Part II: Conducting Interfacility and Intrahospital Patient Transportation, you should be able to:
- Understand specific safety considerations during interfacility (IFT) and intrahospital (IHT) transport
- Compare the different advantages and limitations of different modes of patient transportation (fixed wing, rotor wing, and ground)
- Explain physiologic changes expected during air transportation
- List effective elements of patient hand-off
- Review key elements of effective communication before, during, and after transportation
- Effectively plan the transfer of a critically ill patient using a team approach
- Conduct patient transfer and deliver needed interventions
- Identifying problems during patient and troubleshooting
- Discuss appropriate pre-hospital care based on an assessment of the patient’s condition
Relevant competencies in CoBaTrICE
- 10.1 Undertakes transport of the critically ill patient outside the ICU (intra-hospital as well as inter-hospital)
- 12.2 Communicates effectively with members of the health care team
- 12.3 Maintains accurate and legible records/documentation
Enrollment Options
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Disclaimer
All authors of ACE courses sign a document declaring absence or any actual or potential conflicts of interest. In addition, they sign a copyright document confirming the work is their own and that they have obtained the necessary permission for any copyrighted material. The latter document also transfers the intellectual copyright to the ESICM. Both the conflict of interest and copyright forms are filed and stored in compliance with GDPR and are available for inspection upon request.
Patient Transportation Part I: Introduction to Transportation of the Critically Ill or Injured Patient
Summary
Transportation of the critically ill patient is inevitable in most health systems. Prehospital transportation (PHT) may be necessary after major injury or as a result of life-threatening illness – for example, myocardial infarction, intracranial hemorrhage, or metabolic coma. This mode of response and transport specifically refers to patients that are outside of a medical facility and are being mobilized to an emergency department for initial triage, resuscitation, and stabilization. There are some exceptions to this as patients are occasionally brought from outside the hospital directly to other destination areas of the hospital such as the cardiac catheterization lab or operating theater for definitive management.
General Information
Enrolled trainees 225
Open 09.02.2023
Available for ESICM members
Student effort 2
Last Updated February 9, 2023
Intended Learning Outcomes
After studying this module on Patient Transportation Part I: Introduction to Transportation of the Critically Ill or Injured Patient, you should be able to:
- List indications for inter-hospital and intra-hospital transport
- Weigh the risks and benefits of patient transport in the context of individual pathologies and patient condition
- Describe ethical considerations for patient transport
- Understand potential complications that can occur during transport and how to mitigate them
- Explain important pre-transport interventions to stabilize patients for transfer
- Outline the different transport team models and their capabilities
- Identify important clinical parameters to be monitored during transport
- Recognize the capabilities and limitations of equipment used in the transport environment
Relevant competencies in CoBaTrICE
- 1.4 Triages and prioritises patients appropriately, including timely admission to ICU
- 10.1 Undertakes transport of the critically ill patient outside the ICU (intra-hospital as well as inter-hospital)
- 11.4 Identifies and minimizes risks of critical incidents, adverse events and complications
Enrollment Options
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Disclaimer
All authors of ACE courses sign a document declaring absence or any actual or potential conflicts of interest. In addition, they sign a copyright document confirming the work is their own and that they have obtained the necessary permission for any copyrighted material. The latter document also transfers the intellectual copyright to the ESICM. Both the conflict of interest and copyright forms are filed and stored in compliance with GDPR and are available for inspection upon request.
Core Concepts in Clinical Research — Data and Basic Statistics
Summary
An understanding of data and how to analyse it is crucial to research in the intensive care unit. As clinicians we are all familiar with individual patient data, such as a patient’s age, or ventilator-delivered tidal volume, and handle such information on a daily basis. However, to undertake research we need to be able to compare values between patients and most specifically between populations of patients.
This self-study course is a key component of Module 1 of the ESICM Research Education Pathway and needs to be completed before attending the masterclass. Understanding the concepts contained in this module is key to getting the most out of the masterclass, as the masterclass will extend your knowledge and skills in this area.
General Information
Enrolled trainees 322
Open 21.06.2022
Available for ESICM members
Student effort 1
Last Updated June 21, 2022
Intended Learning Outcomes
- To understand how summary data allow us to describe and compare populations
- To understand categories of data, specifically nominal, ordinal, and discrete and continuous
- To understand the concepts of central tendency, spread and distribution/skewness of ordinal and continuous data and explain why these are important
- To understand how data can be compared between two populations, and recognise the appropriate statistical tests for each data type
- Be introduced to types of error in statistical analysis.
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Disclaimer
All authors of ACE courses sign a document declaring absence or any actual or potential conflicts of interest. In addition, they sign a copyright document confirming the work is their own and that they have obtained the necessary permission for any copyrighted material. The latter document also transfers the intellectual copyright to the ESICM. Both the conflict of interest and copyright forms are filed and stored in compliance with GDPR and are available for inspection upon request.
Core Concepts in Clinical Research — Populations and Outcomes
Summary
In this second self-study course of the ‘Introduction to research in the ICU’ module, we move beyond basic statistics to provide a first introduction to key concepts in clinical studies. The reader may note that this course is about study populations and outcomes, while everything ‘in between’, such as inferential statistical methods, is missing. This is no accident. A good research hypothesis is the foundation of high-quality clinical research, and formulating a good hypothesis requires clear thinking about the intended patients (the target population) and about the way in which the hypothesis can be quantified and tested (the study endpoints). These concepts apply to practically all clinical study designs, from descriptive, predictive or observational comparative effectiveness studies to randomized controlled trials. Later modules in the Research Education Pathway will focus on specific study designs and inferential methods, such as diagnostic accuracy studies, predictive studies, or randomized trials.
This self-study course is a key component of Module 1 of the ESICM research education pathway and needs to be completed before attending the masterclass. Understanding the concepts contained in this module is key to getting the most out of the masterclass, as the masterclass will extend your knowledge and skills in this area.
General Information
Enrolled trainees 238
Open 21.06.2022
Available for ESICM members
Student effort 1
Last Updated June 21, 2022
Intended Learning Outcomes
- To understand how summary data allow us to describe and compare populations
- To evaluate the justification of exclusion criteria
- To understand the goals of baseline characteristics descriptions in different study designs
- To understand the concepts of internal and external validity and their components.
- To understand sources of bias in population/sub-population sampling.
- To describe study endpoints in terms of disease-oriented versus patient-oriented endpoints and primary versus secondary endpoints.
Enrollment Options
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Disclaimer
All authors of ACE courses sign a document declaring absence or any actual or potential conflicts of interest. In addition, they sign a copyright document confirming the work is their own and that they have obtained the necessary permission for any copyrighted material. The latter document also transfers the intellectual copyright to the ESICM. Both the conflict of interest and copyright forms are filed and stored in compliance with GDPR and are available for inspection upon request.
Disseminated Intravascular Coagulation
Summary
Disseminated intravascular coagulation (DIC) is a syndrome characterised by systemic intravascular activation of coagulation, leading to the widespread deposition of fibrin, with formation of widespread microvascular thrombosis. These microthrombi impair organ perfusion and thus contribute to organ failure. During the coagulation process, consumption of coagulation factors and aggregation of platelets occur resulting in reduced levels of both procoagulant and anticoagulant clotting proteins. Therefore patients with DIC may have both thromboembolic events and hemorrhage.
General Information
Enrolled trainees 1945
Open 06.04.2020
Available for ESICM members
Student effort 3
Last Updated March 15, 2022
Intended Learning Outcomes
At the end of the Unit the student should able to:
- Describe the clinical syndrome of disseminated intravascular coagulation (DIC)
- Understand clinical consequences of DIC including the risk for bleeding and thrombosis
- Describe the pathophysiology of DIC
- Recognize the patient at risk for DIC
- Interprete laboratory findings in DIC
- Determine the likelihood of DIC with the use of scoring systems
- List differential diagnoses of DIC
- Describe supportive care for DIC
- Describe transfusion strategies for DIC
- Describe current and future anticoagulant strategies for DIC
- Understand the prognosis and clinical outcomes of DIC
Relevant competencies in CoBaTrICE
- 2.1 Obtains a history and performs an accurate clinical examination
- 2.2 Undertakes timely and appropriate investigations
- 2.10 Integrates clinical findings with laboratory investigations to form a differential diagnosis
- 3.1 Manages the care of the critically ill patient with specific acute medical conditions
- 4.1 Prescribes drugs and therapies safely
- 5.10 Performs arterial catheterisation
- 6.1 Manages the pre- and post-operative care of the high risk surgical patient
Enrollment Options
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Disclaimer
All authors of ACE courses sign a document declaring absence or any actual or potential conflicts of interest. In addition, they sign a copyright document confirming the work is their own and that they have obtained the necessary permission for any copyrighted material. The latter document also transfers the intellectual copyright to the ESICM. Both the conflict of interest and copyright forms are filed and stored in compliance with GDPR and are available for inspection upon request.
Wellbeing at work for professionals in the intensive care unit
Summary
Working in the intensive care unit (ICU) confronts every healthcare professional with patients suffering from disease and their relatives suffering from uncertainty, being torn between hope and loss. The professionals’ own role in the patients’ journey might also have challenges as professionals are human. Additionally, working within a team of different personalities, different competencies, and different specialties with constraints and demands, all contribute to a working environment that is prone to conflicts and disagreements. Evidently, this underscores the ICU as a stressful place threatening the wellbeing of the ICU professionals, e.g., nurse, doctor, supervisors and allied health professionals alike.
If one wants to improve working conditions in ICU, it is not sufficient to only help those professionals perceived to be under too much stress. The majority of ‘healthy’ employees also need examples and advice to keep their energy balance healthy and to nourish their wellbeing. Stress reactions are the first indicators of an imbalance in physical or emotional (work) load and the individual’s ability to adapt to challenging situations. In the past, an abundance of research focused on the negative emotions related to work-related stress and burnout in ICU. However, an emphasis on positive emotions, takes an innovative approach to wellbeing that focuses on promoting people’s positive health assets. In relation to the proposed definition of health, represented as the ability to adapt and self-manage, focus has shifted towards employees adapting to their work environment. Positive occupational health psychology aims to understand and foster the factors that allow individuals and communities to flourish. It seems of utmost importance to focus research on the motivational process affecting personal health and successful working. In the end, to protect against occupational risks getting out of hand.
Flourishing (or engaged) employees to believe in themselves, generate positive feedback, set higher goals, have values that match that of the organisation, and can maintain long-lasting personal health are all of vital importance. Individual positive and flourishing conditions are not only related to personal wellbeing but are also helpful to improve performance at work and team spirit. In addition, a healthy working environment helps individual employees to flourish; it’s a reciprocal relationship. Changing the wellbeing of ICU professionals also requires addressing organisational wellbeing. Taking time to refresh is a vital part of building personal resilience to cope with a challenging role and strive towards wellbeing at work. This means, being aware for small adaptations in daily practice and encompass self-care in personal life. Organisational strategies such as addressing leadership, intra-team conflicts and ethical issues in the ICU might have a positive influence on wellbeing at work as well.
This e-course helps you identify and explain stressors in the ICU environment, covers the theoretical background on work-related stress and wellbeing at work, provides insights into strategies to cope with personal stressors, and describes how to react with resilience. This e-course also supports you in understanding and addressing the challenges of your working environment in a proactive way by focusing on strengths, not on complaints. Just start your personal movement.
General Information
Enrolled trainees 949
Open 01.08.2018
Available for ESICM members
Student effort 3
Last Updated August 29, 2022
Intended Learning Outcomes
After studying this module on Wellbeing at work for professionals in the intensive care unit, you should be able to:
- Describe the relevance of (Personal, professional & organizational) wellbeing for your health and performance at work
- Assess stressors in your environment in the ICU
- List your own specific stressors of working in the ICU
- Explain associated factors influencing work-related stress and wellbeing at work
- Recognise ways to cope with personal stressors and learn how to react with resilience
- Describe how positivity can stimulate creative thinking and vitality at work (evidence-based good practice)
Relevant competencies in CoBaTrICE
- 11.3 Identifies environmental hazards and promotes safety for patients & staff
Enrollment Options
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Disclaimer
All authors of ACE courses sign a document declaring absence or any actual or potential conflicts of interest. In addition, they sign a copyright document confirming the work is their own and that they have obtained the necessary permission for any copyrighted material. The latter document also transfers the intellectual copyright to the ESICM. Both the conflict of interest and copyright forms are filed and stored in compliance with GDPR and are available for inspection upon request.
Bleeding & thrombosis
Summary
Critically ill patientsare inherently at risk of thrombotic events due to severity of illness, immobilization and altered coagulation. Less frequently, patients are admitted to the emergency room with haemorrhagic shock or from the operating room with
a coagulopathy. Knowledge of normal haemostasis and disorders of coagulation are paramount to achieving optimal outcomes. The incidence of drug-induced and circuit-induced coagulopathies is increasing with the advent of new pharmacological agents
and novel modes of organ support aimed at prolonging life. We discuss aetiology and management of thrombotic and bleeding events in critical care patients.
General Information
Enrolled trainees 2799
Open 10.10.2018
Available for ESICM members
Student effort 3
Last Updated April 4, 2022
Intended Learning Outcomes
After studying this module on Bleeding and Thrombosis, you should be able to:
- Describe the physiology of normal coagulation
- Describe common bleeding disorders in the critically ill and discuss the appropriate treatment with surgery, haemostatic interventions, blood components and pharmacological agents
- Interpret traditional laboratory tests of coagulation and point of care assessment of coagulation
- Diagnose and manage thrombotic disorders that occur in the critically ill
- Discuss traditional antithrombotic drugs and new oral anticoagulants
- Discuss management of anticoagulation and bleeding associated with novel technologies in organ support
Relevant competencies in CoBaTrICE
- 3.1 Manages the care of the critically ill patient with specific acute medical conditions
Enrollment Options
You are currently NOT enrolled in this course.
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Disclaimer
All authors of ACE courses sign a document declaring absence or any actual or potential conflicts of interest. In addition, they sign a copyright document confirming the work is their own and that they have obtained the necessary permission for any copyrighted material. The latter document also transfers the intellectual copyright to the ESICM. Both the conflict of interest and copyright forms are filed and stored in compliance with GDPR and are available for inspection upon request.
Acute Liver Failure
Summary
Acute liver failure is an uncommon condition, and most patients should be treated in a liver unit where management of complications and assessment for and management of liver transplantation can be undertaken by teams experienced in the management of liver disease. Apart from primary ALF, secondary or acquired acute liver failure (i.e. liver failure following extrahepatic – mainly cardiovascular - organ failure like in hypoxic liver injury or cholestasis) is observed in 10-20 percent of critically ill patients. However, optimum management involves early identification of these patients and consequently it is vital that all intensivists can recognise the condition, assess severity, liaise with a liver unit if necessary and provide appropriate supportive and specific medical treatment through the period of assessment and transfer.
Chronic liver disease is relatively common, particularly in the context of alcohol and viral infection. Decompensation and new onset of acute on chronic liver failure is often due to sepsis or bleeding, and admission to ICU should be sought. Again, centres offering expertise in the management of these episodes can add to patient management and advice should be sought at an early stage.
General Information
Enrolled trainees 3544
Open 10.09.2018
Available for ESICM members
Student effort 3
Last Updated December 12, 2023
Intended Learning Outcomes
After studying this module on Liver failure, you should be able to:
- Describe the clinical, laboratory and radiological features used to diagnose acute liver failure (ALF) and determine its aetiology.
- Assess the severity and prognosis of the patient with ALF and institute appropriate monitoring and immediate management.
- Understand the differences between ALF and Acute on Chronic Liver Failure (ACLF).
- Choose therapies to optimise support of the liver and other organ systems.
- Determine which patients with ALF should be considered for transplantation or other advanced treatment options.
Relevant competencies in CoBaTrICE
- 2.1 Obtains a history and performs an accurate clinical examination
- 2.8 Liaises with radiologists to organise and interpret clinical imaging
- 2.10 Integrates clinical findings with laboratory investigations to form a differential diagnosis
- 3.1 Manages the care of the critically ill patient with specific acute medical conditions
- 3.2 Identifies the implications of chronic and co-morbid disease in the acutely ill patient
- 3.5 Recognises and manages the patient with, or at risk of, acute liver failure
- 5.22 Performs Sengstaken tube (or equivalent) placement
- 6.4 Manages the care of the patient following solid organ transplantation
Enrollment Options
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Disclaimer
All authors of ACE courses sign a document declaring absence or any actual or potential conflicts of interest. In addition, they sign a copyright document confirming the work is their own and that they have obtained the necessary permission for any copyrighted material. The latter document also transfers the intellectual copyright to the ESICM. Both the conflict of interest and copyright forms are filed and stored in compliance with GDPR and are available for inspection upon request.