I Can See Your HALO: Consensus-based List of High Acuity, Low Occurrence Procedures for Critical Care Medicine...

The Accreditation Council of Graduate Medical Education (ACGME) requires proficiency in procedures such as endotracheal intubation, central line insertion, and bronchoscopy for certification in critical care medicine (CCM). These are common in the intensive care unit and gaining sufficient exposure to attain competence during fellowship training is generally not challenging. However, intensivists are also expected to perform several high-risk procedures that are less frequent. Such high-acuity, low-occurrence (HALO) procedures lack a clear designation, possibly due to a lack of consensus on training standards, and exposure to them during fellowships can be inconsistent.

We aimed to identify HALO procedures specific to CCM fellowship training.

A modified Delphi methodology was employed to gather iterative data from and reach consensus among a diverse panel of CCM-trained fellowship faculty with expertise in fellowship curricula. Three rounds of quantitative data were completed, with a final round of qualitative data collected to better define why experts chose certain procedures over others. Experts were blinded to the responses of each other, and investigators were blinded to the responses of individual experts.

Six procedures (namely, awake bronchoscopic intubation, bronchoscopic intubation under sedation, cricothyrotomy, esophageal balloon tamponade, pericardiocentesis, and surgical chest tube placement requiring blunt dissection) qualified as HALO procedures relevant to CCM fellowship training. According to feedback from experts, procedures were selected based on their relevance to high-risk situations in the ICU, their frequency of occurrence, and the typical scope of practice of ICU providers.

This study provides a consensus-based list of qualifying HALO procedures in CCM training. This list can inform curriculum development and support the integration of targeted training strategies to better prepare CCM fellows for rare, high-risk procedures.

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