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Website: www.eba-uems.eu Email: [email protected] ETR Anaesthesiology 2018 1 European Training Requirement ETR in ANAESTHESIOLOGY FROM THE STANDING COMMITTEE ON EDUCATION AND PROFESSIONAL DEVELOPMENT (EPD) OF THE SECTION AND BOARD OF ANAESTHESIOLOGY

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Website: www.eba-uems.eu Email: [email protected]

ETR Anaesthesiology 2018 1

EuropeanTrainingRequirementETRin

ANAESTHESIOLOGY

FROMTHESTANDINGCOMMITTEEONEDUCATIONANDPROFESSIONALDEVELOPMENT(EPD)OFTHESECTIONANDBOARDOFANAESTHESIOLOGY

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ETR Anaesthesiology 2018 2

TableofContentsPart1.GeneralinformationabouttheETR................................................................................5ETRupdatepreparation.............................................................................................................5TimelinesincurrentETRupdatepreparation............................................................................5ScopeoftheETRupdate............................................................................................................5Durationandtypeoftraining.....................................................................................................6Genericcompetenciesandroles................................................................................................6Part2.DomainsandcompetenciesintheETR...........................................................................9Definitionofdomains.................................................................................................................9Learningobjectives.....................................................................................................................9NewaspectsintheETRupdate2018.......................................................................................10Domain1.1:Perioperativemedicine,patientassessmentandriskreduction.........................12a.Knowledge............................................................................................................................12b.Clinicalskills..........................................................................................................................12c.Specificattitudes..................................................................................................................13Domain1.2:Generalanaesthesiaandsedation.......................................................................14a.Knowledge............................................................................................................................14b.Clinicalskills..........................................................................................................................14c.Specificattitudes..................................................................................................................15Domain1.3.Airwaymanagement............................................................................................16a. Knowledge......................................................................................................................16b. Clinicalskills....................................................................................................................16Domain1.4:Regionalanaesthesia...........................................................................................17a.Knowledge............................................................................................................................17b.Clinicalskills..........................................................................................................................17Domain1.5:Postoperativecareandacutepainmanagement................................................18a.Knowledge............................................................................................................................18b.Clinicalskills..........................................................................................................................18c.Specificattitudes..................................................................................................................18Domain1.6:Intensivecaremedicine.......................................................................................19a.Knowledge............................................................................................................................19b.Clinicalskills..........................................................................................................................21c.Specificattitudes..................................................................................................................23Domain1.7:Criticalemergencymedicine(CREM)...................................................................24

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a.Knowledge............................................................................................................................24b.Clinicalskills..........................................................................................................................24c.Specificattitudes..................................................................................................................24Domain1.8:AnaesthesiaNon-TechnicalSkills(ANTS).............................................................25a.Knowledge............................................................................................................................25b.Clinicalskills..........................................................................................................................25Domain1.9:Professionalismandethics...................................................................................26a.Knowledge............................................................................................................................26b.Clinicalskills..........................................................................................................................26c. Specificattitudes............................................................................................................27Domain1.10:Patientsafetyandhealtheconomics.................................................................28a.Knowledge............................................................................................................................28b.Clinicalskills..........................................................................................................................28c.Specificattitudes..................................................................................................................29Domain1.11:Education,Self-directedLearning,Research.....................................................29a.Knowledge............................................................................................................................29b.Clinicalskills..........................................................................................................................29c.Specificattitudes..................................................................................................................29Domain2.1:Obstetricanaesthesiology....................................................................................30a.Knowledge............................................................................................................................30b.Clinicalskills..........................................................................................................................31c.Specificattitudes..................................................................................................................31Domain2.2:Cardiothoracicanaesthesiology...........................................................................32a.Knowledge............................................................................................................................32b.Clinicalskills..........................................................................................................................32c.Specificattitudes..................................................................................................................32Domain2.3:Neuroanaesthesiology.........................................................................................33a.Knowledge............................................................................................................................33b.Clinicalskills..........................................................................................................................33Domain2.4:Paediatricanaesthesiology..................................................................................34a.Knowledge............................................................................................................................34b.Clinicalskills..........................................................................................................................34Domain2.5:Multidisciplinarychronicpainmanagement.......................................................35a.Knowledge............................................................................................................................35

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b.Clinicalskills..........................................................................................................................36c.Specificattitudes..................................................................................................................37Part3.RequirementsforETRimplementation........................................................................38Traininginstitutions..................................................................................................................38Requirementonclinicalactivities.............................................................................................38Requirementoninfrastructureandprocess............................................................................38Qualitymanagement:accreditationbyHVTAP........................................................................39Trainers.....................................................................................................................................39Assessmentoftrainees’competencegain...............................................................................41Listofabbreviations.................................................................................................................42

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Part1.GeneralinformationabouttheETR

ETRupdatepreparationTheconstantdevelopmentofspecialisttrainingandpracticedictatestheneedforaperiodicalreviewoftheETRstoensurethattheyareconsistentwithcurrentpracticeandfitforpurpose.According to the Guidelines for the Development of UEMS European Training Requirements(publishedon3.4.2017)theoriginaltrainingcurriculuminAnaesthesiologypublishedin2013bythe European Board and Section of Anaesthesiology (EBA) under the auspices of the UnionEuropéenne des Médecins Spécialistes (UEMS) has been revised. This document is the firstupdateoftheETRinAnaesthesiologysince2013.NextreviewoftheETRinAnaesthesiologyisplannedin3years.

TimelinesincurrentETRupdatepreparationTheprocessof theETRupdatedevelopment started in-depth inAugust2016and includedanextensive review of the current status in care delivery and experiences regarding trainingrequirements across European countries. Extensive internal consultation within the StandingCommitteeonEPDandtheSectionandEuropeanBoardofAnaesthesiology(EBA)wasfollowedbyareviewofoverlappingareasofpractice,specificallyinintensivecaremedicine,emergencymedicineandpainmedicine.InJuly2017consensuswasobtainedwithintheEBAregardingtheETR update. Consultation of the European Society of Anaesthesiology (ESA) resulted inminorrevisionswhichhavebeenapprovedbytheEBAinNovember2017.Finally,theETRupdatehasbeensubmittedtotheUEMSETRsCommitteeforcommentsandapprovalinFebruary2018.

ScopeoftheETRupdateThe UEMS ETR update does not aim to be imposed over established national curricula (ifprepared under consideration of theUnitedNations declaration onHuman Rights andWorldMedicalAssemblyInternationalCodeofMedicalEthics)butmaycomplementthembyofferingacomprehensiveandrobustoveralltrainingframeworkcreatedbymedicalspecialistsandbasedonassembledEU-wideeducationalandtrainingexperience.Theadvantageofspecialiststrainedaccording to the competency based UEMS ETR is professional mobility across Europe;qualificationswill automatically be recognised in other EU countries as establishedby EU law(Directive2005/36/EC).TheETRupdate represents current trainingpractice inmostEuropeancountriesand supportshighlevelofamedicaltrainingstandardwhichwillpavethewaytofirstclasspatientsafetyandquality of care for thebenefit of all European citizens. The ETR competencies in general coredomainsshouldbeachievablebymostnational trainingprogrammes,even in thepresenceofconsiderablenationalvariationsdueto,e.g.infrastructure,resources,manpower,workinglaws,financing,traditions.Basiccompetencelevelsproposedinspecificcoredomainsmaystimulateimplementationofeducationandtrainingplansinclinicalbottleneckareas.Europeanhospitalsnotofferingtrainingpossibilitiesinspecificcoredomaincompetenciesmaysearchforupgradingtrainingquality, e.g. by forming trainingunitswith traininghospital. Thereby, the ETRupdate

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may foster future clinical exchangeprogrammesbetweenhospitals (e.g. European fellowship)andmayencouragetheutilizationofnovellearningmodalities,e.g.medicalsimulationcentres.NotallcompetencieslistedinthisdocumentreachlevelD(fordefinitionseepage8).Attainingfull competencies in all domains of the broad discipline of Anaesthesiology in the minimumtrainingtimeframewouldbean idealbututterly impossibledemandinanyEuropeancountry.In-servicetrainingaftercompletionofmedicaltrainingwillenrichboththenumberandlevelofcompetencies.Descriptionofprofessionaldevelopmentinknowledge,skillsandattitudesisbeyondthescopeofthecurrentUEMSETRupdate.Implications of the UEMS ETR update are aimed at the content of the European Diploma inAnaesthesiology and Intensive Care (EDAIC) as well as the Hospital Visiting and TrainingAccreditationProgramme(HVTAP).

DurationandtypeoftrainingAnaesthesiologyasa specialtyhasgrown froma service specialty strictlywithin theoperatingroom tohaving responsibilities in various areasofmedicine. The traditional role as amedicalspecialty, included assessment and evaluation, maintenance of organ function as well asanalgesiaandamnesiaforallpatientsundergoingdiagnostic,therapeuticorsurgicalprocedures.ThepracticeofAnaesthesiologyhassignificantlychangedtowardsmoreholisticcompetenciesinthe perioperative period, in intensive caremedicine, emergencymedicine and painmedicinewhichinmanycountriesareintegratedpartsoftheclinicalspecialty.Thus,trainingrequiresnewgenericcompetenciesandcommonprinciplestobedefinedfortheEuropeanspecialist.Theprocessoftraining,attainingdefinedcompetenciesandapplyingthemsafelyandefficientlyin clinical practice require time so that trainees can mature and develop. Minimum trainingdurationis5years,ofwhichatleast1yearistobespentatanintensivecareunit.According to the UEMS basic principles, specialist training is competence-based and notnumber- or count-based. Scientific anaesthesia societies of EU member states may defineminimum average numbers required for imparting and internalizing clinical skill at arecommendedcompetencelevelinthespecificlocal/nationaltrainingsetting.ETR-based trainingmay include a variety of training activities including operative procedures,interventional procedures, ward rounds, multidisciplinary meetings, clinical research,attendance of training courses, and medical simulation training. Training activities are notuniformthroughoutEuropeanddependonthenationalstructuresandprocesses.However,thecommon goal of specialist training should always be the development of professionalcompetencyinthefieldsofgenericcompetenciesandrolesasdescribedbelow.

GenericcompetenciesandrolesTheETRreflectstheholisticqualificationsoftheEuropeanspecialist.ThefollowingfourgenericcompetencesandroleshavebeenidentifiedasthemostimportantforanyEuropeanspecialistinAnaesthesiology.

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ExpertclinicianAsacentral role, theoneofmedicalexpert states thatall anaesthesiologistsmustbe familiarwith anaesthetic and medical technology, general medicine, including diagnostic andtherapeuticmethodsbasedonthoroughknowledgeofappliedrespiratory,circulatoryandCNS-associatedphysiologyandpharmacology.An expert in anaesthesiology should acquire all necessary competences enabling him/her tofulfilthisexpertroleandfunctioninthemultidisciplinarysettingsinanaesthesia,intensivecare,criticalemergencymedicine,andpainmedicine.a) The domain of perioperativemedicine comprises the continuum in patient care, startingbefore theoperative procedure and lastingwell into thepostoperative period; it concerns allpatientcategories(includingchildren,pregnantwomenandthoselackingmentalcapacity)andcomprisesthefollowingtasks,whichpracticeshouldbeevidence-based:• Preoperative evaluation and preparation of the patient, appropriate choice and relevantuseofpreoperativelaboratorytestsandallothercomplementaryexaminations/investigations,aswelluseofandreferraltointerdisciplinaryconsultationswhenrequire;• Preoperativediscussionandinformationofpatients,obtaininginformedconsent;• Individualizedselectionandconductofthesafestanaesthetictechnique,bestsuitedtothemedicalconditionsofthepatientandtotheoperativeprocedureplanned;• Knowledgeandappropriateuseofclinicallyrelevantinvasiveandnon-invasivemonitoringdevices;• Safe conduct of anaesthesia as well as safe and appropriate perioperative clinicalmanagementofproblems,incidentsandcomplications;• Appropriate selectionofpostoperativemanagementandcare, including transfer tootherspecializedsurveillancestructuressuchasICUs;• Postoperativepainmanagementb) Othermajordomainsofcompetencesare:• Intensivecaremedicine• Pre- and in-hospital resuscitation and emergency management of critical conditions,includingtraumaandburn• Acuteandchronicpainmanagement

ProfessionalleaderThe specialist in anaesthesiology should have competences in communication that enableshim/her to dealwith different aspects of human interactions and relationships. Furthermore,he/sheshouldhavecompetencesthatpermiteffectiveorganizationandmanagementtaskstotakeplaceduringprofessionalactivities.Themainaspectsare:• Effective,openempathicandrespectfulcommunicationwithpatientsandfamily/relatives

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• Effective and professional communication with colleagues and other collaborators toensureoptimalpatientcare• Multidisciplinary and inter-professional team working in acute care (operating theatre,intensivecareunit,emergencyandrecovery room, labourwards),aswellas in thecontextofresuscitation• Effective communication in the setting of multidisciplinary teams in the resolution ofconflicts,decision-makingskills,givingfeed-back,takingandassumingleadership• Implementation and use of quality assurance programs according to recognized nationalandinternationalstandards• Implementation and use of local, national and international practice guidelines andstandardswhilecomplyingwithnationalhealthcarepolicies• Promotionofandparticipationinbetterandsaferpatientcare• Knowledge of administrative, medico-legal, ethical, and economical aspects ofanaesthesiologypractice;Operatingroommanagementprinciples• Cost-effective and relevant use of diagnostic, prophylactic and therapeutic means andmeasures(healtheconomics)AcademicscholarIt is the specialist’s responsibility to develop and maintain a high degree of professionalcompetence,tofacilitatedevelopmentofcolleaguesandothergroupsofprofessionals,andtopromotedevelopmentofthespecialtyitself.Differentaspectscomprise:• Life-long learning and reflective thinking; critical reading and appraisal of up-datedinformationrelevanttoclinicalanaesthesiologyandintensivecaremedicine;• Acquisition of basic tools for teaching (including supervision), skills for research andeducation presentations, teaching of young colleagues, residents and allied healthcareprofessionals;• Contributiontoresearch,development,and implementation/transmissionofnewmedicalknowledgeaswellasauditing;• Contributiontoeducationofpatients,studentsandhealthcareprofessionals

InspiredhumanitarianThe specialist in anaesthesiologywill exhibit irreproachablebehaviourandbeawareofdutiesandresponsibilitiesinherenttohis/herroleasaprofessional:• Provisionofhighqualitycarewithempathy,integrity,honestyandcompassion;• Recognition of one’s personal limits and abilities, and appropriate consultation with/ ordelegationtootherswhencaringforthepatient;• Medical decision-making based on thorough consideration of ethical aspects in patientcare,managementofethicalconflicts;• Knowledge ofmedico-legal aspects of anaesthesiology practice,with particular emphasisonthemanagementandpreventionofconflictsofinterest;• Appropriatemanagementofanaestheticincidentsandaccidents,includingnearmisses.

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Part2.DomainsandcompetenciesintheETR

DefinitionofdomainsInordertofulfilthefourprofessionalrolesofaspecialistinAnaesthesiology,thefollowinglistofdomainsofexpertiseandrelatedcompetencieswithinthesedomainsaretobeobtainedduringmedicaltraining:1.Domainsofgeneralcorecompetencies1.1Perioperativemedicine,patientassessmentandriskreduction1.2Generalanaesthesiaandsedation1.3Airwaymanagement1.4Regionalanaesthesia1.5Postoperativecareandacutepainmanagement1.6Intensivecaremedicine1.7Criticalemergencymedicine(CREM)1.8AnaesthesiaNon-TechnicalSkills(ANTS)1.9Professionalismandethics1.10Patientsafetyandhealtheconomics1.11Education,Self-directedLearning,Research2.Domainsofspecificcorecompetencies2.1Obstetricanaesthesiology2.2Cardiothoracicanaesthesiology2.3Neuroanaesthesiology2.4Paediatricanaesthesiology2.5Multidisciplinarychronicpainmanagement

LearningobjectivesTraining includes acquisition of knowledge and expertise in all patient groups undergoing allcontemporary elective and urgent surgical interventions aswell as in all patients groupswithcriticalillnessandtrauma.Foreachdomain,learningobjectivesaredividedinto“knowledge,skillsandattitudes”thataredeemednecessarytoachievetherequiredlevelofcompetencies,asdefinedbytheUEMS:• A:observerlevel(hasknowledgeof,describes)• B:performs,manages,demonstratesunderdirectsupervision• C:performs,manages,demonstratesunderdistantsupervision• D:performs,manages,demonstratesindependentlya.KnowledgecompetenciesareperdefinitionrequiredatalevelofcompetenceA.b.Clinicalskills:Skillsuniforminallclinicalsettingsarereportedonlyhereandapplythroughout.

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− Basicandadvancedlifesupport,includingresuscitationofthenewborn− AccuraterecordkeepingSkills required at various locations (intraoperatively in the OR, postoperative in the recoveryroom, in the emergency room, prehospital) are listed only once upon first appearance, e.g.defibrillation, cardioversion. (Exceptions: In domain 1.6 several skills are listed in order tovisualizecompetenciesasacompletetraininginintensivecaremedicine.Indomain2.1severalskills are listed in order to visualize competencies as a complete training in a specific coredomain.)Levelsofskillcompetencearereportedinthedescriptionofthedomains.c.Specificattitudes:Attitudescommontoallclinicalsettingsarereportedonlyhereandapplythroughout(Exception:Indomain1.5severalskillsarelistedinordertovisualizecompetencesasacompletetraininginintensivecaremedicine):− Effectively communicate and interactwith patients and their relatives, including patientswith impaired capacity of discernment and consent, and language barriers, treat them withrespectandcourtesyinansweringallquestionsandconcernstheymayhave− Effectivelycommunicatewithotherhealthcareproviders− Teamwork togetherwith other health care professionals to ensure smooth patient careandsafety− Vigilanceandsituationalawareness− Respectingbasicethicalandlegalprinciples− Promotingsafetyandwell-beingofstaffTheseattitudesareperdefinitionrequiredatalevelofcompetenceD.

NewaspectsintheETRupdate2018By eliminating redundancy and self-evident content, resorting the domains of general andspecificcorecompetencies,theETRupdatehasbeenshortenedsubstantially,therebyincreasingitsapplicability.Formalrevisionsinclude:- Compared to the original work from 2013, former guidelines and syllabus have beencondensedintoonesingleETRupdate.- Domainsofgeneralandspecificcorecompetenceshavebeenre-assignedcomparedtotheoriginalETR2013accordingtotheclinicalrequirement.- Knowledge already gained during undergraduatemedical studies are not explicitly listed(e.g. anatomy, physiology, pathophysiology, pharmacology, toxicology, hygiene, physics,chemistry, biochemistry, psychology, statistics) but are understood as a prerequisite andrequirementforanaesthesiology-specificknowledge.Duringresidency,basicmedicalknowledgehastoberefreshedandenlargedbyanaesthesiology-specificcontent.- General skills already gained during undergraduate trainings are not explicitly listed (e.g.ECGmonitoringandinterpretation).- Redundancyhasbeenavoidedinlistinguniformskillsandspecificattitudesonlyonceinthedocument.Byaddingdomainsandcompetenciesinclinicalfields,revisingcompetencelevelsandincludingscientificguidelinesandnewtrainingactivities,thequalityoftheETRupdateisenhanced.

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Contentrevisioninclude:- International clinical guidelines and standards of high quality and prepared according tohighmethodologicalstandards,e.g.bytheESAandEBA,havebeenreferenced.- Medicalsimulationtraininghasbeenreferencedasaneffectivetrainingactivity.- The ETR update proposed competence levels have been defined throughout and newcompetencieshavebeenincluded,e.g.2.4organtransplantationanddonormanagement.

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Domain1.1:Perioperativemedicine,patientassessmentandriskreductiona.Knowledge− Preoperativeriskassessment− Airway assessment including bedside tests to assess difficult intubation, ventilation,oxygenation− Understanding disease processes, natural evolution and knowing its influence on themanagementoftheperioperativeperiod− Knowledgeoftheeffectsofanaestheticagentsonthephysiologyofmajorsystemssuchascardiac,respiratoryandneurologic− Treatmentof pre-existingdiseases, in order tooptimizepatients and reduce risks beforeanaesthesiaandsurgeryincooperationwithotherphysicians− Pharmacologyandinteractionsofperioperativedrugs− Othermedical history (personal and family history of previous anaesthesia, allergy, drugabuse,habits)− Understandingtheneedandvalueofpreoperativetesting− Scores,e.g.ASA,riskfornauseaandvomiting,physicalcapacity,OSAS

− Understandingspecificperioperativerisks,e.g.inthetransplantpatientundergoinggeneralsurgery,theelderlycomorbidpatient− PreoperativeevaluationguidelinesfromESA− PreoperativefastingguidelinesfromESA− Patientbloodmanagementinpre-existinganaemiaandcoagulopathy− Medico-legal aspects of patient information and informed consent, appraisal of thecapacityofdiscernmentandconsentb.Clinicalskills− Patient assessment based on history and physical examination, use of appropriateexaminations and laboratory tests in patients of all age groups with and without reducedfunctional cardiorespiratory capacity undergoing major and minor surgical routine andemergencyinterventionsD− Evaluationofthescores,includingrisksandASAphysicalstatusD− EvaluationoftheairwayD− Interpretation, considering the value and limitation of preoperative tests andmonitoringincluding:o Electrocardiogram,andothermethodsassessingcardiovascularfunction(echocardiography,ergometrymyocardialscintigraphy,coronaryangiography)o Pulmonaryfunctiontest(spirometry)andarterialbloodgasanalysiso CommonradiologicaltestingwithspecialemphasisonchestX-rayo Coagulationtestso Liverandrenalfunctiontestso Endocrinefunctiontestso DrugmonitoringD− Interdisciplinary patient optimization and risk reduction, including preoperative anaemiacorrection,cardiopulmonarytreatmentD

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− Selection and planning of the individual anaesthesia technique, including rational use ofmonitoring, difficult airway management, allogeneic blood products ordering, and providingotherequipmentrequiredfortheprocedureD− PatientselectionforanaesthesiaindaysurgeryD− Decision-makingrelatingtopostponementorcancellationofsurgeryD− PreparingpatientswithimplanteddefibrillatorsforsurgeryD− Applyingrecognizedprinciplesofpreoperativefasting,therapyandpremedicationDc.Specificattitudes− Delivering patient information including alternatives, disclosure of risks, and obtaininginformedconsent

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Domain1.2:Generalanaesthesiaandsedationa.Knowledge− Physicsandclinicalmeasuremento Behaviour of fluids; flow of fluids; measurement of volumes, flows, and pressures;measurementoftemperature;o Behaviour of gases (humidification, oximetry, analysis of gases, capnography, electricalsafety,firesandexplosions;gasesinclosedbodycavities)− Stressresponsetosurgery− Pharmacology of muscle relaxants, analgesic drugs, inhaled and intravenous anaestheticagentsincludingshortactingagentssuitablefordaysurgery− Work-relateddiseasesandtheirprevention− Equipment and apparatus (equipment design, physics, and standards; gas supply;anaesthesia delivery system, including pressure valves and regulator; vaporizer; breathingsystem; devices to maintain the airway such as video- and conventional laryngoscopes,endotracheal tubes, tracheotomy tubes, face masks, supraglottic airway devices; informationsystems)− Minimum monitoring standards, and additional monitoring when appropriate (includingcentral venous pressure, invasive arterial pressure, cardiac output monitoring, preloadmonitoring,echocardiography,neuromuscularmonitoring,cerebralfunction,coagulation,bloodgasanalyses,urinaryoutput,anaesthesiadepth,neuromuscularmonitoring)− Planning and physical layout of operating rooms and post-anaesthesia recovery room;lighting;safety;infectionandpollutioncontrolinoperatingrooms;sharpspolicies − Principlesofsafetysuchasliftingandpositioningpatients− Indication,contraindications,andcomplicationsofgeneralanaesthesiaandsedation− Managementofanaesthesia-relatedcomplications− PerioperativebleedingmanagementguidelinesfromESA(PatientBloodManagement)− PreventionofvenousthromboembolismguidelinesfromESA− PreventionofpostoperativedeliriumandcognitivedeficitsguidelinesfromESA− EmergencychecklistfromESA− ProceduralSedationguidelinesfromEBA/ESA− SafetyRecommendationsfromEBAforminimummonitoringanduseofcapnography− Ethicalandmedico-legalaspects− Understandingthebasicconceptofevidence-basedmedicine(includinglevelsofevidence)b.Clinicalskills− Providingsafeinhalationandintravenousinduction,maintenanceof,andemergencefromgeneral anaesthesia, including the choiceofdrugs, airwaymanagement, ventilation techniqueandintraoperativeadverseeventmanagementD− Defibrillation,cardioversionD− Aseptic techniques for invasive procedures including peripheral and central (ultrasound-guided) venous access, intraosseous access, arterial catheterization, arterial blood gascollection,urinarycatheterization,chestdraininsertionD− GastrointestinaltubeinsertionD− BloodsalvageD− BloodtransfusionD

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− Preparation of the workplace according relevant checklists and environmental safetymeasuresD− Useofmedicalandtechnicalequipmentappropriately, includingneuromuscularblockademonitoring,volumemonitoring,echocardiographyD− Trouble-shootingbasictechnicalmalfunctionsofmonitorsandmachinesD− UseofrelevantchecklistsandguidelinesD− MonitoringnervefunctionduringbrainandspinesurgeryD− PerioperativepatientpositioningavoidingtissuedamageD− Maintenanceofhomeostasisoforgansystemsthroughoutdifferentsurgicalproceduresinpatientswithandwithoutpre-existingdiseasesD− Diagnosisandmanagementofintraoperativecriticalincidentsincludingo allergicreactions,anaphylaxiso laryngospasm,bronchospasm,inadequateairwayo gasembolism,pulmonaryaspirationandpneumothoraxo hypoxia, hypercarbia, hypocarbia, hypoventilation, hyperventilation, high ventilator peakinspiratorypressureso hypertension, hypotension, arrhythmias, myocardial ischemia, bradycardia, tachycardia,cardio-pulmonaryresuscitationo oliguria,anuriao hypothermia,hyperthermia,malignanthyperthermiao intraoperativebloodgasandelectrolytedisturbanceso intraoperativeawarenesso seizureo adversetransfusionreactiono severebleedingo stressandinflammatoryresponseD− PerforminganaesthesiaforlaserairwaysurgeryandinterventionswithasharedairwayD− PerforminganaesthesiaforfasttracksurgeryandenhancedrecoveryaftersurgeryD− PerforminganaesthesiainICUpatientsD− PerformingsedationforinvasiveproceduresD− Performing anaesthesia and sedationoutside theOR, taking into accountorganizationofthesite,typeofproceduresandpatientsD− ManagementofpatienttransporttoandfromremotelocationsD− ApplicationofprinciplesofsafetyduringX-ray,MRID− ApplicationofdischargecriteriaforambulatoryanaesthesiaD− Considerationofethicalandmedico-legalaspectsD− InitialsurgicalinterventioninburntraumaandtraumaticinjuryoftheupperairwayD− ManagementofbraindeathsyndromeanddonormanagementincludingexplanationDc.Specificattitudes− Training in the management of rare adverse events and rare clinical situations in themedicalsimulationcentre

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Domain1.3.Airwaymanagementa. Knowledge− Basicairwaymanagement− Difficultairwayalgorithms− Criteriaforpostoperativeextubation− Maintenanceofpatentoralandnasalairway− Airwaycomplications:stridor/laryngospasm,airwayobstructionb. Clinicalskills− RapidsequenceinductionD− EstablishmentandmaintenanceofanadequateairwayinpatientswithanticipatedandunanticipateddifficultairwayincludingpatientswithairwaytraumaandincludingtheuseofdifferentdevicesandtechniquesaccordingtoexistingalgorithmsD− CricothyroidectomyC(e.g.inmedicalsimulationtraining)− ManagementofdifficultanddelayedextubationafterairwayinterventionsD

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Domain1.4:Regionalanaesthesia

a.Knowledge− Pharmacologyoflocalanaestheticsandadjuvants− Indicationsandcontraindicationsofperipheralandcentralblocks,choiceoftechniques− Risksandcomplications− Recognitionofsystemiclocalanaesthetictoxicity,treatmentandresuscitationmeasures− Techniquesofperipheralandneuraxialblocks− Equipment and apparatus (equipment design, physics, standards, limitations;ultrasonography;nervestimulator)− EmergencychecklistfromESA− EBAsafetyRecommendationonInvasiveProceduresinPainMedicineb.Clinicalskills− Performing neuraxial blocks such as spinal (single shot), thoracic epidural and lumbarepidural(singleshotandcathetertechnique)combinedspinal-epidural,caudalblockD− Performing peripheral nerve blocks of the upper extremity (single shot and cathetertechnique)suchasinterscalene,axillaryblocksD− Performing peripheral nerve blocks of the lower extremity (single shot and cathetertechnique)suchasfemoral,obturator,sciaticblocksC− Performingnerveblocksofthetorsosuchasparavertebral,intercostalblocksC− Providingsaferegionalanaesthesia, includingchoiceofdrugs,techniques,andmonitoringD− PositioningofpatientswithspecificpathologicalconditionsD− ManagementofnerveblocksinpaintherapyB− Diagnosisandmanagementofintraoperativecriticalincidentsincludingo residualnerveblocko inadequatenerveblockadeo localanaesthetictoxicityD

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Domain1.5:Postoperativecareandacutepainmanagementa.Knowledge− Scoringsystemsforpostoperativestatus,transferanddischargecriteria(e.g.AldreteScore)− Pathophysiologyandtreatmentofpostoperativecomplications− Equipment and apparatus (equipment design, physics, standards, limitations; Patient-controlledanalgesiapumps,non-invasiveandinvasivepostoperativeventilation)− Weaningfromnon-invasiveandinvasiveventilatorsupport− Multimodalandpre-emptiveanalgesiaconcepts− Logisticsandpatientpathwaysb.Clinicalskills− ProvidinghandoverofapatientinPACU(appropriatesummaryofrelevantclinicalfeaturesofthepatient’scare)D− Providing postoperative standard monitoring, indicating and interpreting individualizedtesting(e.g.ischemiamonitoring,X-ray)D− PainassessmentinallpatientgroupsD− UseofrelevantchecklistsandguidelinesD− Maintenance of homeostasis of organ systems after the impact of different surgicalproceduresandanaesthesiainpatientswithandwithoutpre-existingdiseasesD− Diagnosis and management of postoperative critical incidents (beyond those listed indomain1.1)andpostoperativeadverseeventsincluding:o residualneuromuscularblockadeo anaesthesiaoverhango atelectasiso nauseaandvomitingo shiveringo paino discomforto nervedamageo post-duralpunctureheadacheo bleedingo delirium,cognitivedysfunctiono postoperativefacialandairwayswellingo centralanticholinergicsyndromeD− Detectionof,indicationfor,andinterprofessionalorganizationofre-operationD− PerformingweaningfromsupportivetherapyofvitalfunctionsD− ApplicationofdischargecriteriaandtransfercriteriatoICUD− Applicationofmultimodalandpre-emptiveanalgesiaconceptsDc.Specificattitudes− Supporting interdisciplinary efforts to further improve clinical outcome and preventpostoperativeadverseevents− Considering post-anaesthesia visit for assessment of intermediate-term clinical outcomesandpatients’qualityoflife

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Domain1.6:Intensivecaremedicinea.Knowledge− Anatomy,physiology,pharmacology,toxicology,hygiene,physics,chemistry,biochemistry− Aetiology, pathophysiology, diagnosis and treatment plans / bundles according tointernational standardsof specific critical conditions in all patient cohorts includingpaediatricpatients,geriatricpatients,perioperativepatientsafterelectiveandemergencysurgery,(burn)traumapatients:o Circulatoryfailure§ Shock§ Cardio-respiratoryarrest§ Cardiacarrhythmias§ Ischemicheartdisease§ Cardiomyopathy§ Valvularheartdiseaseincludingendocarditis§ Pulmonaryembolism§ Anaphylaxiso Respiratoryfailure§ ARDS§ Pulmonaryoedema§ Airwayobstructionandstenosis§ Pneumothorax§ Aspiration§ Pneumonia§ COPDandasthma

o Renalfailure

§ Chronicandacute(RIFLE)

o Gastrointestinalfailure§ Ileus§ Peritonitisofvariousaetiologies(includingcolitisandintestinalischemicdisease)§ Pancreatitis§ Liverfailure§ Digestivefistulas

o Neurologicalfailure

§ DeliriumandComa§ Cerebrovascularandbleedingdiseases§ Cerebraloedema§ Increasedintracranialpressureincludingmonitoring§ Brainstemdeath§ Seizures§ GuillainBarrésyndromeandMyastheniagravis

o Trauma

§ Head/faceandspineinjury§ Airwayandchestinjuries

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§ Aorticinjuries§ Abdominaltrauma§ Pelvicandlongboneinjuries§ Massivetransfusion§ Burnsandelectrocution§ Near-drowning§ Hyper-andhypothermia

o Infectiousdiseases§ SIRSandsepsisincludingsepsisbundlestrategy§ Severecommunityacquiredinfections(e.g.meningitis)§ Severenosocomialinfections(e.g.MRSA)§ Fungalinfectionso Endocrineandmetabolicdisorders§ Diabetesmellitusandinsipidus§ Addison’sdisease,CushingandConnsyndrome§ Thyroiddisorders§ Phaeochromocytoma§ Malnutrition§ Carcinoid§ Acid-baseandelectrolytedisturbanceo Coagulationdisorders§ DIC§ Heparinresistance,heparin-inducedthrombocytopenia§ Severebleeding§ Transfusionreaction

o Obstetriccomplications

§ HELLPsyndrome,Pre-eclampsia,Eclampsia§ Septicabortion§ amnioticfluidembolism

o Intoxications

o Organdonation

− Equipment and apparatus (equipment design, physics, standards, limitations; e.g. non-invasiveandinvasivepostoperativeventilation,continuousrenalreplacementtherapydevices,non-invasiveandinvasivehaemodynamicmonitoringincludingTTEandTEE,intracranialdopplermonitoring,intracranialpressuremonitoring)− Scoringsystems(e.g.sedationdepth,painseverity,APACHE,TISS,SAPS,SOFA)− Indication, contraindication, drug selection, complications: sedation, anaesthesia,analgesia,neuromuscularrelaxation,nutritionintheICU− Multimodalandpre-emptiveanalgesiaconcepts− Weaningandextubationcriteria− Transferanddischargecriteria

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− Ethicalandmedico-legalaspectsincludingendoflifedecisions,organdonation− UnderstandingtheprinciplesofdeterminationofBrainStemdeath− Familiarity with the legal aspects of brain stem death and organ donation within theirjurisdiction− Knowledgeofthepathophysiologicalchangesthatoccurafterbraindeath− Maintenanceofthebraindeadorgandonor− Principlesofnon-heartbeatingorgandonation− DemographicsoforgandonationandtransplantationinEurope− Principlesoflivingkidneydonation− Familiarity with the EU directives and Council of Europe Recommendations on organdonationandtransplantation− OrganizationofIntensiveCareUnitsandICUstandardsincluding:

o Evaluating and taking into consideration the difficulty and complexity of the tasks inrelationtoresources,qualifications,aswellaslocalorganization.o Identifying patients with need for treatment beyond local competencies according tonationalorganizationandtakeinitiativetoorganizetransportforthesepatients.o Coordinatingthemultidisciplinaryapproachofpatientsandprovidingcooperationwithallrelevant partners, with proper respect for their medical competences and roles in specificsituations.o Contributetotheholisticvisionofahomogeneousteaminteractionbothwithpatientsandpeers,andprovidingconsensualinformation.o Medicalauditinginintensivecareb.Clinicalskills− Performingpatientassessmentandphysicalexaminationincludingrepetitivetestinge.g.ofperistalticsounds,respiratorysounds,capillaryrefill,temperaturegradient)D− IdentificationofsignsofinstabilityofthecervicalspineD− Performingsedation,generalanaesthesia,multimodalanalgesiaD− PerformingneuraxialandperipheralnerveblocksforanalgesiaD− PerformingairwaymanagementincludingintubationunderemergencysituationsD− Performingaseptic insertionof venous, central venous, arterial, intra-osseus cannulation,pleuraldrainageD− Gastrointestinaltubeinsertion,urinarycatheterizationD− Diseaseassessmentanddiseasemanagementincluding:o Respiratory support including endotracheal suction, bronchoscopy (lavage, sampling),percutaneous tracheotomy, invasive and non-invasive ventilation techniques, ventilation inproneposition,weaningo Haemodynamic management and stabilization including advanced cardiovascularmonitoring, inotropic and vasoactive therapy, basic and advanced life support, defibrillation,cardioversion,pacing,pericardiocentesiso Fluidsubstitution,volumemanagemento Correctionofcoagulopathy,patientbloodmanagement,bloodproducttransfusiono Acutekidneyinjuryandrenalreplacementtherapyo Nutritionalsupport(enteral,parenteral)includingmanagementofelectrolyte,glucoseandacid-basedisturbances

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o Neurological management including intracranial pressure control and maintenance ofintracranialperfusionpressureo Infectiousdiseasesandantibiotictherapy;antiviraltherapy;rulesforhospitalhygieneo Identificationandimplicationofrelevantpreexistingco-morbiditieso Prevention,recognition,andtreatmentofcomplicationssuchas:§ thromboembolism§ ventilatorassociatedinjuries,aspiration,pneumonia§ stressulceration§ renalfailure§ nosocomialinfection§ gastrointestinalparalysis§ criticallyillpolyneuropathy§ sepsis-inducedadrenalinsufficiency§ druginteractionso RespondingtotrendsinphysiologicalvariablesD− Applying EBM-based therapeutic interventions, care bundles, guidelines protocols, andorgansupportinsingleormultipleorganfailure(MODS)D− Patienttransportationinter-andintra-hospitalD− Applyingdamagecontrolandsystematicpriority-basedapproachinseveretraumapatientsD− Applyingtransfercriteriatospecializedcentrese.g.thecriticallyillchildD− ApplyingneuroprotectioninheadtraumaandspinalcordtraumapatientsD− PerforminggeneralanaesthesiaforrepeatedsurgicalinterventionsinburntraumapatientsB− ApplyingtriageandprioritizationofpatientsD− Applyingscoringsystems(e.g.sedationdepth,painseverity,APACHE,SAPS,TISS)D− Performingbasicultrasoundtechniquesfor:o Ultrasound-guidedcentralvenouslineplacement;o Recognition of severely abnormal ventricular function (right or left ventricle; hypo- orhyperkinesia,hypovolaemia);o Measurementofinferiorvenacavadiameter;o Recognitionoflargepericardial,pleural,orabdominaleffusion;o Recognitionofurinaryretention(distendedbladder)D− Indicating,interpretation,consideringthevalueandlimitationof:o Electrocardiogram,andothermethodsassessingcardiovascularfunctiono Pulmonaryfunctiontest(spirometry)andarterialbloodgasanalysiso CommonradiologicaltestingwithspecialemphasisonchestX-rayo Coagulationtestso Liverandrenalfunctiontestso Endocrinefunctiontestso DrugmonitoringD− Differentialdiagnosis,liasingwithinterdisciplinaryspecialiststointerpretcomplexdataD− Indicatingphysio-andergotherapyD− Considerationofethicalandmedico-legalaspectsD− Performingregularvisitrounds,ensuringcontinuityofcareD

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− ApplyingdischargecriteriaD− ApplyingcriteriaformanagementchangefromcurativetopalliativecareD− Providing handover of a patient to the ward (appropriate summary of relevant clinicalfeaturesofthepatient’scare)D− AccuraterecordkeepingD− PerformingbrainstemtestingB− ManagementoforgandonorsinIntensivecareandduringorganretrievalB− PerforminganaesthesiaforkidneytransplantationC− PerformingimmediatepostoperativecareofakidneytransplantpatientC− hasbeenexposed to the skills required todiscusswith relatives aboutendof life issues,braindeathandorgandonationBc.Specificattitudes− Effectivelycommunicatewithpatients,treatpatientswithrespectofbasicethicalprinciplessuchasautonomy,privacy,dignity,confidentiality,includingdiscussingendoflifedecisionsD− Establishingeffectiveinteractionwithpatients,includingpatientswithimpairedcapacityofdiscernmentandconsentandtheirrelativesD− EffectivelycommunicatewithpatientswithlanguagebarriersD− EffectivelycommunicatewithotherhealthcareprovidersD− Teamwork togetherwith other health care professionals to ensure smooth patient careandsafetyD− VigilanceandsituationalawarenessD− RespectinglegalconstraintsD− Promotingsafetyandwell-beingofstaffD− PromotinginfectioncontrolmeasuresD

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Domain1.7:Criticalemergencymedicine(CREM)a.Knowledge− Combiningtheknowledgefromdomains1.1to1.5− Scoringsystems(e.g.GCS)− Rapidresponsesystems,principlesandrules− Transfercriteriaforpre-andinter-hospitaltransport− Helicopterrescue,evacuationusinganairplane− Massaccidentsanddisasters,includingterroristrelatedmassdisasterswithbiologicalandchemicalagents− Basicsinhyperbarictreatment− Organization and coordination of an emergency department, a burn centre, an anti-poisoningcentre,aprehospitalemergencysystemincludingahelicopterbase− Medicalauditinginemergencymedicine− EuropeantraumaguidelinesendorsedbyESA− Ethicalandmedico-legalaspectsincludingwithdrawal,withholdingoftherapy− Prehospitalhygiene,patientsafety,riskmanagementb.Clinicalskills− Applyingskillsfromdomains1.1to1.5inpre-hospitalcriticalemergencyscenariosC− Managementoflife-threateningmedicalandsurgicalemergencyconditionsD− ApplyingresuscitationalgorithmsandtraumaguidelinesD− AssistinginrescueworkC− PerformingemergencymedicineintheinterdisciplinaryteamofanemergencyroomD− Performingintra-hospitalresuscitationintheinterdisciplinarycardiacarrestteamD− Performingechocardiographyforfastdifferentialdiagnosis(FASTapproach)D− SupportingthecomplexorganizationofhealthcareincasesofmassaccidentsanddisastersB− DeclarationofdeathatthesceneofemergencyDc.Specificattitudes− Effectivelycommunicatewithpatientsandrelativesinexceptionalcircumstances− Effectivelycommunicatewith firefighters,membersofactionforces,publicandexecutiveauthorities,publichealthofficer− Performingteamtrainingfocusingoncrisisresourcemanagement− Repeatedtraining(1-2peryear)inthemedicalsimulationcentre

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Domain1.8:AnaesthesiaNon-TechnicalSkills(ANTS)

a.Knowledge− Psychologicalaspectsofteamperformanceforsuccessfultaskperformance− Crisisresourcemanagement− Humanerrorresearch,relevantfortheperioperativesetting− Behaviouralmarkersystems,relevantforsuccessfultrainingb.Clinicalskills− Taskmanagemento Planningandpreparingo Prioritizingo Providingandmaintainingstandardso Identifyingandutilizingresourceso Ensuringeffectivejointtaskcompletion− Teamworkingo Coordinatingactivitieswithteammemberso Exchanginginformationo Effectivecommunicationo Usingauthorityandassertivenesso Assessingcapabilitieso Supportingotherso Assessingteamsatisfaction− SituationAwarenesso Gatheringinformationo Recognizingandunderstandingo Anticipating− Decisionmakingo Identifyingoptions:individualcaseplans,long-termschedulingplansundernormalconditionsandtime-pressurecrisissituationso Balancingrisksandselectingoptionso Re-evaluating− Leadership

o OrganizingtasksD

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Domain1.9:Professionalismandethics

a.Knowledge− Principlesofmedicalethics:autonomy,beneficence,non-maleficence,andjustice− TheGenevaDeclarationandHelsinkiprotocol− Legal principles and medico-legal obligations defining medical practice and the use ofpatientdata− Governmentalregulationsrelevantforanaesthesiapractice− Principlesofcommunicationwithpatientsandphysician-patient“contract”including:o Rightsandresponsibilitiesofpatient,doctorsandothermedicalstaffo Informedconsento Patientconfidentialityandprivacyo Errorandincidentsdisclosure− Principlesofcommunicationwithcolleaguesincluding:o Methods(verbal,written,consultationorreferral)o Manner(courtesy,integrity,respect)o Adequaterecordkeeping(includingmedico-legalimplications)− Personalissuesincluding:o Balancingfamilyandwork,andtheimportanceofnon-professionalactivitieso Depression;recognitionandcareplanso Substanceabuse;recognitionandaccesstoappropriatereferralo Mentoringandteaching− Leadershipresponsibilitiesandstyles;teambehaviours− Stressandcrisismanagement− Principlesunderpinningconflictresolution− Principlesofrolemodel− Principlesofteachingandpatientempowermentb.Clinicalskills− Applyingprinciplesofmedicalethicstoproblemsolving;forexampleinthefollowingareas:o end-of-lifeandpalliativecare;o withholdingandwithdrawingtreatment;o Jehovah’switnesses;o patientunabletodisplayjudgmentD− Attainingattributesinthe4rolesofaspecialistinanaesthesiology:medicalexpert,leader;scholar;professionalD− Applyingtheprinciplesofevidence-basedmedicinetoclinicalpracticeD− Use of information technology in order to optimize clinical care, conducting literaturesearchesD− Basic appraising journal articles including the interpretation of study design, statistics,results,andconclusionsD− Awareness and management according to medico-legal obligations related to medicalpracticeD− Commitment to the main ethical principles and professional values, such as altruism,fidelity,socialjustice,honour,integrity,andaccountabilityD

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− Commitment to the rights of patients to autonomy, confidentiality, informed consent,comprehensionoftherisksofmedicaltechniques(patient-centeredness)irrespectivelyofrace,culture,gender,sexualorientation,andsocio-economicstatusDc. Specificattitudes− Commitment to lifelong continuing professional education, perpetual refreshment ofcompetenciesinreflectivelearning,andmaintaininganinquisitiveattitude− Commitmenttoresponsibilityinlocalethicscommittee

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Domain1.10:Patientsafetyandhealtheconomicsa.Knowledge− PatientsafetyguidelinesfromEBA− Recommendations of quality of care and patient safety from national, European andinternationalauthorities− Fundamentalsinpatientsafetyincluding:§ Error-model,systemfailure§ ThesocalledSwisscheesemodelbyJamesReasonornowadaysthethreatanderrormodel§ Humanlimitations§ Stress,fatigue,decisionmaking,fixationerrors,prospectivememory§ Theroleoftheteams,hierarchy§ Safety culture, principles of High Reliability Organizations (HROs), the five commonprinciplesofHROs:• Preoccupationwithfailure• Reluctancetosimplifyinterpretation• Sensitivitytooperations• Commitmenttoresilience• Deferencetoexpertise− Toolsforqualityassuranceanderrormanagement:o Analyzingtheproblem:§ Reportingsystems,§ Criticalincidentmonitoring,§ Differentmethodsofevent-analysis,§ Root-causeanalysis,§ London-protocolo Tacklingtheproblem:§ Maintopicsinsafetyproblems,§ Medicationerror(prescribing:wrongdrug,wrongdose),§ Wrongside/siteprocedures, § Hospitalacquiredinfections,§ Patient-handover§ Opendisclosurecommunication− Economicaspects:o Demographicdataandresourceutilizationdatarelevantforanaesthesiapracticeo Basicknowledgeonfinancialaspectsofanaesthesiapracticeo Basic knowledge on organizational and budgeting aspects of anaesthesia practice(Principlesofbusinessmanagement)b.Clinicalskills− Application of standards of quality of care and patient safety in daily practice includinganaesthesiainremotelocationsD− UseofchecklistsandguidelinesD− ProvidingdataforbothlocalandnationaldatasystemsD− Consideringcost-effectivenessC

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c.Specificattitudes− Commitmenttocriticalincidentsreporting

Domain1.11:Education,Self-directedLearning,Research

a.Knowledge− Traineeswillunderstandthescientificapproachtoanalysisandsolvingquestionsworthyofscientificinvestigation.− Informationsearchandliteraturereview− Proposingahypothesis;researchdesign,biasandappropriatemethodsofmeasurement;datacollectionandstorage;goodrecordkeeping− Commonstatisticaltestsandapplicationofstatisticsrelevanttotheproject;Interpretationofresults− Monitoringofstudiesandpoststudysurveillance− Copyrightandintellectualproperty− ResponsibilitiesofInstitutionalReviewBoard/independentethicscommittee,andofinvestigatortotheethicscommittee;ethicalprinciples− Principlesofwritingascientificpaper,andoforalorposterpresentationofapaper− Principlesofevidence-basedmedicine(includinglevelsofevidence)− Theprocessofobtainingfundingandwritingabasicgrantapplication

b.Clinicalskills− ConductingandappraisingliteraturesearchesD− AppraisingjournalarticlesincludingtheapplicationofstatisticsC− Applyingtheprinciplesofevidence-basedmedicinetoclinicalpracticeD− CarryingoutoralpresentationsandprofessionalcommunicationD− PresentingqualityassuranceexercisesorprojectsD− Developingfacilitationskills,suchastutoringinsmall-grouplearningandconductingsmall-groupmeetingsC

c.Specificattitudes− Valuingrigorouseducationalandscientificprocesses− Distinguishingbetweenpracticewithasoundscientificbasisandthatwhichrequiresfurtherobjectiveassessment− Committingtoinformedconsent,confidentialityandallotherethicalprinciplesofresearch− Criticalappraisal:tohaveinsightintoone’sownlimitations,abilitiesandareasofexpertise− Committingtolifelongcontinuingprofessionaldevelopment

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Domain2.1:Obstetricanaesthesiologya.Knowledge− Knowledgecompetenciesfromdomains1.1to1.4inparturient− Physiologicalandanatomicalchangesassociatedwithnormalpregnancy− Physiologyoflabouranddelivery− Fetalandplacentalphysiologyandpathophysiologyo Placentaltransfero Materno-fetalcirculationo Theeffectsofpharmacologicagentsandanaesthetictechniquesonuterinebloodflowandfoetaldevelopment− Embryologyandteratogenicity− Neonatalphysiologyandneonatalresuscitationo Foetalheartratemonitoringo Dopplerumbilicalbloodflowo Apgarscoreandneuro-adaptivescoresandtheirprognosticsignificance− Obstetricmanagementoflabour(normalandabnormal)− Painoflabourandpainpathways− Tocolytictherapy,indicationsandcontra-indications− Localanaestheticuseinobstetrics− Medicaldiseaseandpregnancy:o Pre-eclampsia/eclampsiao HELLPo Fattyliverofpregnancyandliverdiseaseso Gestationaldiabeteso Heartdiseaseo Neurologicaldiseaseso Obesityo Bleedingdisorderso Thyroiddiseaseso Substanceabuseo Immunologicaldiseaseso Renaldiseases− Regionalanaesthetictechniquesinobstetrics:o Neuraxialuseofopioidsinobstetrics− Methods of analgesia during labour: indications and contraindications (psychologicalmethods, complementary methods, systemic analgesia, epidural, combined spinal-epidural,paracervicalandpudendalblocks,continuousspinal)− Complicationsofregionalanaesthesiainobstetrics− Generalanaesthesiainobstetrics− Airwaymanagementintheparturient− Anaestheticcareofthehighriskobstetricalpatient,includingtrauma− Anaestheticmanagementofcomplications:o Obstetrichaemorrhage:Antepartum,peripartumandpostpartum

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o Pulmonaryembolismo Amnioticfluidembolismo Fetaldeath− Cardiopulmonaryresuscitationandadvancedcardiaclifesupportoftheparturient− Post-operativepainmanagementinobstetrics− Maternalmedicationsandbreastfeeding− Anaesthesiafornon-obstetricsurgeryduringpregnancy− Anaesthesiaforassistedreproductivetechnologiesandintrauterinesurgery− Maternalmortalityb.Clinicalskills− Applyingskillsfromdomains1.1to1.4inparturientsincludingo Airwayassessmento Rapidsequenceinductiono Diagnosis and management of critical incidents such as post-dural puncture headache,pulmonaryaspirationD− PositioningofparturientsD− PerforminganaesthesiafordeliveryD− Performing spinal anaesthesia (single shot), combined spinal-epidural anaesthesia andlumbarepiduralanaesthesia(singleshotandcathetertechnique)forcaesareansectionD− ManagementofpaininpregnancyandlabourD− PerforminglumbarepiduralcatheterplacementforlabouranalgesiaD− Managementofsevereperi-partumhaemorrhageD− Initialmanagement of high-risk parturients and application of transfer criteria to higher-levelhospitalsC− PerforminganaesthesiainpregnantandbreastfeedingwomenD− Performing anaesthesia and analgesia in assisted reproductive technologies andintrauterinesurgeryB− Applyingskillsfromdomains1.7to1.9inparturientsD− Applyinguniformskillsfrompart1oftheETRupdate:o Basicandadvancedlifesupport,includingresuscitationofthenewborno AccuraterecordkeepingDc.Specificattitudes− Recognizingethicalissuesincludingfoetalandmaternalrights− Recognizingpsychologicalissuesrelevanttopregnancyanddelivery− Effectivelycommunicatewithpatientsandrelativesinexceptionalcircumstancesrelatedtochildbirth− Effectively communicate with interdisciplinary team including obstetrician, midwife,neonatologist,labour/deliverynurseduringcriticalphases(e.g.peri-partumhaemorrhage)

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Domain2.2:Cardiothoracicanaesthesiologya.Knowledge− Knowledgecompetenciesfromdomains1.1to1.3− Generalprinciplesofaetiology,pathophysiologyandclinicalpresentationofcardiovasculardiseasesrequiringcardiacsurgeryandofthoracicdiseasesrequiringthoracicsurgery− Understandingtheprinciples,appliedbasicsciences,andmanagementofanaesthesiaandperioperativecareforo Thoracotomyand:§ Lungresection,includingpneumonectomyandlungreductionsurgery§ Mediastinalmassresection§ Oesophagealsurgery§ Surgeryonthethoracicaortao Trachealandbronchialsurgery(includinguseoflasersandstents)o Thoracoscopicprocedureso Mediastinoscopy− Generalprinciplesofmechanicalassistdevices forcirculation (intra-aorticballoonpump),cardio-pulmonarybypassorextracorporealmembraneoxygenation− Generalprinciplesofone-lungventilation− Specificintra-andpostoperativecomplicationsincludinghypoxiaandhypoventilationb.Clinicalskills− Specificrespiratoryevaluationwithregardstoplannedsurgery(assessmentofoperability)B− Performanceoflungseparationtechniqueso DoublelumentrachealintubationCo ClinicalandfiberopticcontroloftubepositioningDo Lungseparationindifficultairwaypatients(includingtubeexchangedevices)B− Patientpositioning,particularlyinthelateraldecubituspositionD− UsingchesttubedrainagesystemsandsuctionD− Basicskillsinthemanagementofanaesthesiaandperioperativecareforcardiacoperationsperformedon-pumpandoff-pumpB− UseofadvancedhaemodynamicmonitoringC− UseofTEEforevaluationofsizeandfunctionofleftandrightventricle,allvalves(stenosis,insufficiency,severity),diagnosisofpericardialfluidortamponade,dilationordissectionoftheaortaBc.Specificattitudes− Recognizingpsychologicalissuesrelevanttopatientsscheduledforcardiacsurgery− Effectivelycommunicatewithpatientsandrelativesinexceptionalcircumstancesrelatedtocardiacdisease− Effectively communicate with surgical team during critical phases (e.g. lung separation,weaningfromcardiopulmonarybypass)

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Domain2.3:Neuroanaesthesiologya.Knowledge− Knowledgecompetenciesfromdomains1.1to1.3− General principles of aetiology, pathophysiology and clinical presentation of centralnervousdiseasesrequiringneurosurgery− Neurologicalexamination− Basicneuroimaging− Understandingtheprinciples,appliedbasicsciences,andmanagementofanaesthesiaandperioperativecareforo Supra-tentorialsurgeryo Posteriorfossasurgeryo Pituitaryfossaandskullbasesurgeryo Epilepsysurgeryo Awakecraniotomyo Craniofacialandcraniobasalsurgeryo Spinalsurgery,includingemergencycorddecompressiono Paediatricneurosurgeryo Ventriculo-peritonealshunts,neuro-endoscopyo Imagingandinterventionalradiologicalprocedureso Functionalsurgeryanddeepbrainstimulationo Vascularneurosurgeryo Diagnosticandinterventionalneuroradiologyo Electroconvulsivetherapyo Routinediagnosticprocedures(e.g.MRI,CT)− General principles, indications, limitations and complications of advancedneurophysiologicalmonitoring

b.Clinicalskills− Specificevaluationwithregardstoplannedsurgery(assessmentofoperability)B− Patientpositioning,particularlyinthesittingpositionD− Managementofspecificcomplicationsincludingairembolism,intracranialhypertensionD− Basic skills in the management of anaesthesia and perioperative care for intracranialoperations,includinginducedhypotension,inducedhypothermiaB− ApplyprinciplesofneuroprotectionD− Use and interpretation of advanced neuromonitoring (e.g. evoked potentials, cerebraloxygenation,bloodflow,metabolism)B

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Domain2.4:Paediatricanaesthesiology

a.Knowledge− Knowledgecompetenciesfromdomains1.1to1.3− Generalprinciplesofcommoncomorbiditiesincludingcongenitaldiseases,syndromesrelated to difficult airway, cerebral palsy and seizures, respiratory susceptibility, and typicaldifferences in children < 1 year compared to adults in terms of anatomy, physiology, andpharmacology− General principles of aetiology, pathophysiology and clinical presentation of diseases inearlychildhoodrequiringsurgery− Understandingtheprinciples,appliedbasicsciences,andmanagementofanaesthesiaandperioperativecareinsurgeryforo Congenitalcardiacdisease(e.g.tetralogyofFallot,septumdefects)o Prematurityanditscomplicationso Neonatalemergencies(e.g.trachea-oesophagealfistula,abdominalwalldefects)

b.Clinicalskills− Applyingskillsfromdomains1.1to1.4inpaediatricpatients>1yearofageC− Performingvascularaccessinyoungchildren<1yearB− Performingairwaymanagementinyoungchildren<1yearB− Performinggeneralanaesthesiainyoungchildren<1yearB− Performingperipheralandneuraxialregionalblocksincludingcaudalanaesthesiainyoungchildren<1yearB− Performingpostoperativecare,painmanagement,generalintensivecareinyoungchildren<1yearB− PerformingcardiorespiratoryresuscitationinchildrenandneonatesD− RecognizingpatientsthatshouldbetransferredtoahighercompetencefacilityandsafelytransferthemD

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Domain2.5:Multidisciplinarychronicpainmanagementa.KnowledgeAnatomyandPhysiology− Paintransmissionandmodulation,developmentofthepainsystems− Painsensitization:Progressionfromacutetochronicpain(painchronification)− Typesofpain:classification− Mechanismstoblockorimpedepaintransmissionandinduceanalgesia− TheplaceboeffectAssessment− Painhistory,physicalexamination.Requestandinterpretadditionaltests− Socioeconomicfactors:work/compensation,family,personal− Painevaluation,includingscales,questionnaires,andquantitativesensorytesting− Clinicalnervefunctionalstudiesandimaging− Follow-up:Patient’spaindiaryEpidemiology,PsychologyandResearch− Painmanagementasafundamentalhumanright− Epidemiologyofpain,includinggeneticdifferences,psychosocialandculturalaspects− Designing,performing,andreportingclinicaltrialsonpainandanalgesia− Comprehendthepreclinicalmodelsofpainasessentialtoolstoimprovepainmanagementinhumans− EthicalstandardsinpainmanagementandresearchPainManagement:DrugsComprehensiveknowledgeonthemechanisms,therapeuticandsideeffects,clinicaluse,routes(non-invasiveandinvasive),doses,anddruginteractions,ofthefollowingdrugsandadjuvants:− Opioids− Non-steroidalanti-inflammatorydrugsandantipyreticanalgesics− Antidepressantsandanticonvulsants− Localanaesthetics,adjuvants,andglucocorticoids− Miscellaneousagents− Multimodalorbalancedanalgesia− Patientcontrolledanalgesia− Implantableintrathecaldevicesfordrugadministration− Substanceabuse,addictionanddetoxificationofanalgesicdrugsPainManagement:Non-PharmacologicalmethodsUnderstanding the mechanisms, limitations and the risk/benefit of the methods in order torecommendandenforcetheirusewheneverappropriate:− Interventionalproceduresincludingnerveblocks,neurolysis,andradiofrequency− Neuromodulationandneurostimulation(TENS,peripheral,central)− Radiofrequency− Surgicalprocedures− Physicalmedicineandrehabilitation.Workrehabilitation− Psychological:Cognitiveandbehaviouralinterventionsandpsychiatrictreatment− Complementarytherapiesincludingacupuncture− Basicknowledgeofpatientmanagementinpalliativecare

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Clinicalstates− Somaticpaino Acutepain:procedural,postoperative,emergency/transporto Chronicpost-surgicalpaino Musculoskeletalpains:Cervical,lumbaro Muscle,tendonandmyofascialpains− Visceralpaino Urogenitalpaino Pelvicpaino Chronicgastrointestinalpaino Pancreaticpaino Thoracicpain(cardiacandnon-cardiac).Post-thoracotomypain.o Referredpainandvisceralhyperalgesia− Neuropathicandmixedpainso Radicularpain:lumbar,cervicalo Post-laminectomypaino Peripheralneuropathieso Centralpaino Post-amputationpaino Complexregionalpainsyndromes− Cancerpain− Headache,oralandfacialpains− Paininspecialsituations:o Painininfants,childrenandadolescentso Paininolderadultso Painreliefinpatientswithcognitiveimpairmento Painreliefinsubstanceabuserso PainreliefinareasofdeprivationandconflictMultidisciplinaryPainClinicsOrganizationofapainclinic,referrals,circuitandfluxofpatientsRoleofthedifferentmedicalspecialtiesandhealthcareprofessionalsinpainclinicsb.Clinicalskills− Evaluationofpatientswithchronicpain:history,physicalexaminationandrequestingandinterpretationofadditionaltestsconsideringthebio-psycho-socialmodelB− ApplyingpainscalesandvalidatedquestionnairesD− ExplainingtreatmentoptionsandclinicalgoalsB− Initialmultimodaltreatmentofpatientswithchroniccancerandnon-cancerpainB− DiagnosisandmanagementofadverseeffectsofpaintherapyB− Accurate record keeping (logbook), including treatments andprocedures.DocumentationofpainevolutionB

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c.Specificattitudes− Establish effective interactions with the multidisciplinary team of health professionalsworkinginthepainclinic− Considerthatpatientshavetherighttobeheard,believed,andinformed,regardingtheirpainanditsmanagement− Recognizetheprincipleofminimumintervention,usingthesimplestandsafesttechniqueslikelytobeeffectivetoachievetheclinicalgoal− Develop skills to communicate professionally with patients giving information about thebesttreatmentoptionsbasedontheavailablemedicalevidence.Explaintherisk/benefitofthetreatments, andobtain verbalorwrittenagreement for theuseofopioids.Kindly answersallquestionsandconcernspatientsmayhave− Becomeskilledatdiscerningpainfromsimulation,oftenrelatedtodrugabuseorworker’scompensation

− Effectivelycommunicateswiththeprimarycarephysiciandiscussingtreatmentoptionsandthefollow-upofthepatient

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Part3.RequirementsforETRimplementationHighqualitytrainingcanonlybeprovidedinhighqualitytrainingcentresbyhighqualitytrainersandhastobeassessedinameaningfulandrobustway.

TraininginstitutionsTraining requirements and standards for training institutions vary in the different Europeancountries. The conditions for accreditation of training centres depend on national regulatorybodies.AttheEuropeanlevel,basedontheEUDirectiveonProfessionalQualificationsandtheUEMSCharta1997onvisitingprogrammesandappraisal,whichincludesrecommendationsonthe quality criteria of training centres, the Hospital Visiting and Training AccreditationProgramme (HVTAP) Committee has been established. HVTAP is a Joint Committee of theEuropeanSocietyofAnaesthesiology (ESA)and theEuropeanBoardofAnaesthesiology (EBA).TogetherwiththeEuropeanDiplomainAnaesthesiologyandIntensiveCare(EDAIC)Committee,theHVTAP aims to improve andharmonise training in anaesthesiology throughout EuropebyensuringthattheaccreditedcentresmeettheprerequisitesoftrainingassetoutinthisUEMSETR.

RequirementonclinicalactivitiesThe training hospital as the training centre or the training unit consisting of more than onetraining hospital (with rotation of the trainees) must offer all relevant specialties andsubspecialtiessuchasgeneral,orthopaedic,headandneck(earnosethroat,eye,maxillofacial),paediatric,neonatal,ambulatorysurgery,urology,gynaecology,obstetrics,trauma,painclinics,general intensive care as well as subspecialties (neurosurgery, cardiothoracic and transplantsurgery). The training centre must offer training in the pre-hospital environment and criticalemergencymedicine.

RequirementoninfrastructureandprocessAllrelevantclinicalactivitiesmustbeavailableinthedepartmentofanaesthesiologyinordertoacquire clinical skills and attitudes listed in the UEMS ETR, including expertise in regionalanaesthesia, invasive techniques, monitoring technologies, diagnostic methods such asultrasound.Faculty, teachers, trainers, consultant, and tutorsmust be available for efficient training at aminimumnumberandtrainee-trainer-ratio.Adequacy of departmental accommodation and facilities for trainees is expected for bothregularhoursandwhenon-duty.Accreditedtrainingcentres/unitsmustprovidemedical-technicalequipmentasneededtofulfilskill-trainingaccordingtotheUEMSETR.Accesstoalibrary(books,online,journals)andotherlearningaidfacilitiesareaprerequisite.

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Trainingcentres/unitsmayofferaccesstoresearchfacilities,supportinITandstatistics.Anaccrediteddepartmentofanaesthesiologyisalsoexpectedtoorganiseandrunprogrammesofeducationalactivities,includinglectures,meetings,seminarsonmatterssuchasmortalityandmorbidity, critical incident reporting and clinical audit. It is expected that the department ofanaesthesiologysupportsopportunitiesfortraineestoattendeducationalcoursesandscientificmeetings, offer access to e-learning. Repetitive participation in training inmedical simulationscenariosshouldbeencouragedbythedepartmentespeciallyinordertoimprovenon-technicalskillsaswellastechnicalskillsinemergencysituationsandmanagementofraredisorders.EPDrecommendsthepreparationofawrittendocumentdescribingtheteachingprogrammeinthe specific training centre/unit including departmental guidelines / standard procedures foranaestheticpractice,consideringtheUEMSETR.

Qualitymanagement:accreditationbyHVTAPHVTAPaccreditationoftrainingscentresishighlyencouragedbyUEMSEBA.

AccreditationbyHVTAPincludesinspectionofthetrainingcentre/unit,interviewswithtrainersand trainees, reviews of anaesthesia records, logbooks, audit reports, written guidelines andlocalprotocols.TheinspectionbyHVTAPforaccreditationofthetrainingcentre/unitfocusesoninfrastructureaswellasprocesses.Good training conditions require standards:Assessmentof infrastructurebyHVTAPaddressesresourcessuchasmedicalstaff,directorofstudies,facilities,trainee-trainer-ratio,qualificationof trainers, library, technical equipment, existence and transparency of written trainingprogrammes and guidelines, access to medical service and opportunities for research anddevelopment,facultypublicationrecord,facultylecturingandacademicactivities.Processreferstothe“educationalclimate”andtohowexistingeducationalresourcesareused,howprofessionalguidanceisorganizedincludingtrainee’assessmentbythetrainers,appraisaland guidance. EPD recommends a continuous assessment of trainees’ progress (formativeassessment)andacompetency-basedevaluationsystem(e.g.trainingportfolio)inplace.DuringHVTAP accreditation the structure and coordination of training, standard of clinical care andpatientsafety,medico-legalaspects,workenvironmentincludingcompliancywiththeEuropeanWorkingTimeDirectiveareassessed.Onceaccreditedandcertifiedthesetrainingcentres/unitswill,ascentresofexcellence,serveasreferences for national visiting programmes, and hopefully also take on amentoring role forotherEuropeandepartments seekingaccreditation.Thiswill alsopromote rotationof trainersandtraineeswhichwill furthercontributeto futurequalityofcareandpatientsafety inacuteandperioperativehealthcare in linewiththe intentionsoftheHelsinkiDeclarationonpatientsafety.EPDrecommendsthatmedicalsimulationcentresandtheirmethodologicaltrainingtechniquesbe assessed and accredited by professional simulation societies. On a national level,accreditationofsuchtraininginstitutionshasalreadybeenimplemented.

TrainersClinicalteachingoptionsappliedbytrainersincludebed-sideteaching,in-theatre/atthescene

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training at day time and during on-duty, individualized supervision and information, help,advice,assistanceappropriateforthecompetencelevelofthetrainee.EPD encourages educational innovations such as for the promotion of skill development;medicalsimulationisanoveltrainingsupportoptionappliedbytrainerswithspecifictraining.RequirementonteachingqualificationTrainingstaffmusthavecompetencelevelDintheassignedareaoftraining.Trainingstaffmusthavesufficienttimeallocatedforthetrainingassignment.TrainingstaffmusthaveknowledgeabouttheUEMSETR.Training staffmust have a positive attitude towards clinical training and expertise in didacticteaching,aclearcommitmenttotheoreticalteachingandpracticalinstructionoftraineeswithinthefullrangeofclinicalpractice.

According to the System for Evaluation of Teaching Qualities (SETQ), core competencies fortutors and trainers include 1) creating a positive learning climate, 2) professional attitudetowardsresidents,3)communicationoflearninggoals,4)evaluationofresidents,5)feedbacktoresidents.

Commitmentandcompetenceoftrainingstaffinscienceandresearchissupportiveforeffectivetrainingbutnotaprerequisite;training,however,willstimulateclinicalquestionswithanimpactonfutureresearch.

CurrentpracticeinmostEuropeancountriesiscount-basedassessmentoftraineesbytrainers.Expertise in competence-based teaching and assessment are limited. EPD recommendspreparationanddisseminationofguidelinesonhowtoteachcompetence-based(handbookoncompetence-basedteachingandassessment).Qualitymanagement:trainercompetenciesThe UEMS Council of European Specialist Medical Assessments (CESMA) definedrecommendationsonthedevelopmentandorganisationofassessment,selectionandtrainingoftrainers.The System for Evaluation of TeachingQualities (SETQ) recommends validatedquestionnairescompleted by residents and faculty as tools for assessing teaching performance. Bothquestionnairesevaluatethe5teachingqualitieslistedaboveascorecompetenciesfortutor.

Teaching isnotpartofunder-graduateandpost-graduate training inAnaesthesiology.Currentpractice in most European countries is “learning teaching by doing”. The EPD recommends“teach the tutors”programsthroughoutEuropeancountrieswhichshould implement learningtechnology and learning models focused on conceptual learning and behavioural practice.Faculty shouldbeprepared to takeon the academic challengesof instruction, alongwith thechallenges of information delivery and active learning across all curricular phases. The EPDfurther proposes scientific research comparing the effectiveness of teachingmethods and ofprofessional development courses on the topic of lecturing, enhanced learning and effectivecommunication.

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Assessmentoftrainees’competencegainTransparency of training programmesmeans that all training activities are recorded. The EBArecommends1)logbookand2)portfolio(e-portfolio)fordocumentation.Logbooksdocumentallclinicalproceduresandcases.Portfoliocontinuouslymonitorsprogressandacquisitionofcompetencies, interventionsatthespecific competence level, instruction from the trainer, self-reflection on themanagement ofthecaseandthevalueforthetrainingprogress.Regularmeetingsofthetrainer/tutorwiththetraineepermitprovidingguidanceandplanningfurtherprogress.Assessmentoflogbooksandportfoliosallowqualitycontrolofthetraininginstitution.A combination of 1) formative and 2) summative assessment modalities should be used forassessingthestatusofthecompetencesacquired.Formativein-trainingassessmentshouldtakeplacethroughoutthetrainingperiodandshouldincludeevaluationtoolsbasedonmini-clinicalevaluationexercise,directobservationofclinicalencounters,skillsandprocedures,SWOT(Strengths,Weaknesses,Opportunities,Threats)analysisofanaesthesiaproceduresperformedandsimulation-basedtrainingevaluation.Knowledgeshouldbeassessedwithmultiplechoicequestionsorvivavoce(ifapplicable)duringthetrainingperiod.Summative(final)assessmentisperformedatpredefinedtimepointsofthetrainingperiod.- Early during training (e.g. after the first year) compulsory appraisal of the trainee isrecommended inorder to identify residentsunfit for training inAnaesthesiology,whomaybeencouragedtochangetoanotherspecialty.- After3yearsof training,part Iof theexamfortheEuropeanDiploma inAnaesthesiologyandIntensiveCare(EDAIC)maybecompleted.- After3yearsperformingaresearchprojectmaybeconsideredbutisnotarequirementforaccreditation as Anaesthesiologist; however, active research will stimulate effective in-depthknowledgeandskillgainevenduringthisearlystageinprofessionallife.- Towardstheendoftraining,nationaldiplomaorpartIIofEDAICmaybecompleted.The EPD endorses the EDAIC exams as a label of excellence for specialist practice inAnaesthesiology. EDAIC examination covers relevant basic sciences and clinical topicsappropriateforaspecialistanaesthesiologist.AnincreasingnumberofEuropeancountrieshaveofficially adopted the EDAIC as their national examination. The existence of a supra-nationalexaminationinanaesthesiologyprovidesanincentiveforthedevelopmentandimprovementofdepartmental,university,nationalandEuropeantrainingprograms.EDAICexaminationachieveauniformlyhighstandardofknowledgethroughoutEuropeasjudgedbyanindependentBoardof Examiners. The UEMS Council of European Specialist Medical Assessments (CESMA) havedefined recommendationson thedevelopmentandorganisationof assessment, selectionandtrainingofassessors.

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ListofabbreviationsAPACHE acutephysiologyandchronichealthevaluationARDS adultrespiratorydistresssyndromeASA AmericanSocietyofAnesthesiologistsCESMA UEMSCouncilofEuropeanSpecialistMedicalAssessmentsCNS centralnervoussystemCOPD chronicobstructivepulmonarydiseaseCT computertomographyEBM evidence-basedmedicineEPD StandingcommitteeoneducationandprofessionaldevelopmentofEBAEBA EuropeanSectionandBoardofAnaesthesiologyEDAIC EuropeanDiplomainAnaesthesiologyandIntensiveCareETR EuropeantrainingrequirementGCS GlasgowcomascaleHVTAP HospitalVisitingandTrainingAccreditationProgrammeHRO highreliabilityorganizationICU intensivecareunitMODS multipleorgandysfunctionsyndromeMRI magneticresonanceimagingOSAS obstructivesleepapneasyndromeRIFLE risk,injury,failure,loss,end-stagekidneydiseaseSAPS simplified acute physiology scoreSOFA sequential organ failure assessmentTEE transesophagealechocardiographyTENS transcutaneouselectricalnervestimulationTISS therapeutic intervention scoring systemTTE transthoracicechocardiographyUEMS UnionEuropéennedesMédecinsSpécialistes