Assessment of critical care education in the context of a Tele-ICU implementation

Abstract

Background

There’s a gap in understanding how healthcare workers perceive professional development activities and goals, specifically within a Tele-ICU environment. Gaining this knowledge is crucial for optimizing educational strategies and fostering professional engagement in this specialized setting.

Objective

This study aimed to describe the implementation of educational activities for a multidisciplinary team directly involved in patient care, as a component of the Tele-ICU project named TeleUTI Conectada.

Method

This is a prospective study conducted within the TeleUTI Conectada project, involving 8 Brazilian ICUs. The educational component was delivered through 3 distinct methodologies: in-person simulation, asynchronous, and synchronous online classes. The Net Promoter Score (NPS) and additional questionnaires to assess professionals’ self-perceived knowledge were applied. The participants’ performance was assessed by comparing the initial and final scores of the asynchronous classes. Variables were summarized using median (IQR) or frequency (%). The Kruskal–Wallis rank sum test was used to compare the differences between the initial and final scores of the asynchronous classes and the differences between professional performance. A P-value <.05 was considered significant for all analyses.

Results

Between December 2023 and October 2024, 285 professionals were recruited to participate in educational activities. The majority of participants were female (202/285, 71%), with a median age of 36 years (31, 43). Nurses comprised the largest group of participants (161/285, 56.5%). Across all learning strategies, the course was highly rated, as indicated by the NPS and corroborated by the additional self-perception questions. The asynchronous course exhibited lower scores on both NPS and additional questionnaires, though without a statistically significant difference observed among professional groups. Participants expressed positive perceptions of the courses having met their expectations, enhanced their knowledge, and the content being applicable to their clinical practice. The median test scores comparing the initial and final scores of the asynchronous classes showed significant improvement within the respiratory therapist and nursing team.

Conclusion

This study described the implementation of a multidisciplinary education program within the TeleUTI Conectada project. It may offer a viable model for essential critical care training in remote areas with limited access to specialized healthcare professionals.

Introduction

In intensive care, knowledge evolves rapidly, requiring professionals to stay up to date while managing heavy clinical and administrative workloads. This makes balancing ongoing education with daily demands a major challenge. Traditional education, once centered on in-person lectures and conferences, has expanded to include virtual formats, especially asynchronous learning, which allows flexible access to materials. This approach has grown in popularity for overcoming barriers like time and cost, and evidence suggests it may also improve health outcomes.¹

Studies also demonstrated that the outcomes of tele-learning are similar to those of in-person classes.² In this context, teleconsultations may represent a valuable opportunity for knowledge transfer among healthcare professionals, being associated with an increase in their learning. The concept of sharing academic expertise is, therefore, suggested as a powerful tool for education. Its main advantage lies in the collaborative sharing of knowledge between distinct organizations, eliminating the need for physical travel.²

However, to truly enhance education, it’s recommended to tailor the learning environment to participants’ specific needs and ensure team alignment. Integrating practical opportunities, high-fidelity simulations, debriefing sessions, and constructive reflection are also crucial for fostering effective learning.³ Despite these identified best practices, determining the optimal educational format presents an ongoing challenge, with its effectiveness significantly influenced by various factors, including organizational culture, financial considerations, professionals’ time availability, and the technological infrastructure supporting learning.

Given the fundamental role of the organizational environment in understanding learning processes, it is essential to contextualize the present study’s findings. The Brazilian public healthcare system currently provides approximately 1.4 ICU beds per 10 000 inhabitants.⁴ The private healthcare sector contributes by increasing total ICU bed availability to 2.2 beds per 10 000 inhabitants, aligning with World Health Organization recommendations.⁴ However, ICU bed distribution remains highly uneven across the country, with fewer than 10% of municipalities having access to ICUs.⁵ Furthermore, many ICUs lack specialized multidisciplinary teams, and those having such teams are predominantly located in wealthier regions.⁵ Geographically, intensive care medicine specialists are predominantly concentrated in the Southeast region (51.9%). The distribution across other regions includes the South (19.1%), Northeast (15.3%), Central-West (10.0%), and North (3.7%).⁶

The COVID-19 pandemic significantly exacerbated the already critical situation in the Brazilian health system, giving Brazil the second-highest COVID-19 mortality rate globally, with over 703 000 deaths reported (total cumulative).⁷ In response, the Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), the largest hospital in Latin America, repurposed numerous beds for COVID-19 patients and significantly expanded its care through Tele-ICU.^8–10 Supported by the Brazilian Ministry of Health, the TeleUTI Conectada project was developed later as a Tele-ICU model to expand and innovate intensive care in Brazil. The project covered 4 out of 5 regions of Brazil, including 8 different States, most with reduced availability of ICU beds and a shortage of critical care specialists. The project encompassed daily tele-rounds between HCFMUSP’s specialized physicians and the multidisciplinary team of each participant hospital, a real-time patient monitoring system, and comprehensive education. The education was implemented using 3 distinct educational methods, led by the multidisciplinary team of HCFMUSP. The aim was to build ICU skills and expand access to specialized knowledge in the Tele-ICU context.

The primary objective of this study was to describe the implementation of education activities for a multidisciplinary team directly involved in patient care, as a component of the Tele-ICU project named TeleUTI Conectada. Secondarily, it sought to compare satisfaction levels across different teaching approaches, to assess healthcare professionals’ self-perceived knowledge gains following participation in the project, and to assess the medical knowledge exam performance after an asynchronous course. This study may offer immediate value for organizations aiming to implement education programs in remote regions facing social and technological disparities.

Method

Study design

This prospective study was conducted from December 2023 to October 2024, across 8 hospital-based Brazilian ICUs, located in different states (Figure 1), which participated in the TeleUTI Conectada project. The study adhered to ethical and legal standards, ensuring the anonymity of participants and their voluntary involvement. The study was approved by the Research Ethics Committee under CAAE number 76488823.7.1001.0068, in accordance with CONEP-CNS Brazil and the Declaration of Helsinki.

Figure 1.

The map demonstrates the location of participating ICUs across various states of Brazil.

The multidisciplinary team at HCFMUSP implemented educational activities for healthcare professionals providing bedside care in hospitals integrated with the TeleUTI Conectada project. These educational activities utilized 3 methodologies: in-person simulation, online synchronous and asynchronous sessions. All educational content is aimed to cover fundamental aspects of critical care and its management, ensuring comprehensive training for the entire hospital team.

For the purpose of this study’s analysis, however, the participant’s recruitment was specifically focused on multidisciplinary professionals who were directly involved in the care of ICU patients within the TeleUTI Conectada project. Each participating ICU’s designated lead was responsible for identifying and listing these eligible individuals. While the educational program was offered to a wider array of hospital professionals, only those meeting these specific recruitment criteria were included in the study’s data analysis.

Education delivery

The asynchronous training began in December 2023 on the HCFMUSP educational platform (HCx) and comprised 4 modules: (1) sedation and analgesia, (2) cardiovascular changes, (3) respiratory failure, and (4) miscellaneous. Topics included sedation, analgesia, neuromuscular blockers, cardiogenic shock, resuscitation, respiratory monitoring, mechanical ventilation, intubation, prone positioning, sepsis, renal failure, electrolyte disorders, nutritional support, and ICU humanization. The 10-h course remained available for access and review for at least 3 months (Supplementary Appendix A: Detailed Asynchronous Course Curriculum).

The synchronous training began in May 2024 with weekly 2-h webinars via Google Meet, totaling 19 sessions focused on content delivery and clinical discussion. Topics included respiratory effort monitoring, ventilator dyssynchrony, hypercapnia, electrical impedance tomography, prolonged weaning, acute respiratory distress syndrome (ARDS) management, neurocritical care, antibiotic use, early mobilization, psychological support, and core nursing principles, including patient evaluation, early warning sign recognition, vital monitoring, and efficient critical care strategies (Supplementary Appendix B: Detailed Synchronous Course Curriculum).

The in-person simulation trained multidisciplinary teams through realistic ICU scenarios conducted on-site at each hospital, with 4-h sessions (1 or 2 per location). Simulations focused on recognizing clinical deterioration, initiating treatment, and team communication, using essential equipment like ventilators and monitors. Sessions were led by a specialist physician and included pre- and debriefings. Core topics covered sepsis management and ventilatory support (eg, mechanical ventilation, lung recruitment, prone positioning) (Supplementary Table S1: Educational program overview).

Additionally, scientific reports related to intensive care were shared during daily tele-rounds and discussed to strengthen knowledge and evidence-based practice. This action resulted in more than 100 different scientific papers shared, covering general topics such as the use of mechanical ventilation, patient-ventilator asynchrony, the use of vasoactive and sedative drugs, and others.

Evaluation methods

Based on Kirkpatrick’s model, the effectiveness of the training programs was assessed at 2 levels: Reaction and Learning. The first level, Reaction, evaluates participants’ satisfaction with the training, considering both the learning environment and its perceived value for their clinical practice. The second level, Learning, assesses the knowledge acquired, typically measured through the application of pre- and post-tests.¹¹

The Net Promoter Score (NPS), a measure of participant satisfaction and loyalty,¹² was applied across all different delivery modes and professional categories. In the context of education, the NPS evaluates group perceptions using a single question: “Would you recommend this course to a friend or colleague?”¹³ Participants respond on a 0 to 10 scale. The final NPS score is then determined by subtracting the percentage of Detractors (those scoring 0-6) from the percentage of Promoters (those scoring 9-10), yielding a value between −100 and +100. The results are categorized into 4 zones: “excellence zone” (score 76 to 100), “quality zone” (score 51 to 75), “improvement zone” (score 1 to 50), and “critical zone” (score −100 to 0),¹⁴ ie, when an organization achieves an NPS in the Excellence Zone, it signifies the customers are enthusiastic advocates for the brand, product, or service.¹⁵

In addition, other questionnaires were administered to assess professionals’ self-perceived knowledge, using 3 key questions: “Did the course meet your expectations?” “Did the course enhance your knowledge?” and “How applicable is the course content in your practice?” Based on the Likert scale, each question utilized a 0 to 10 scale, where participants rated their agreement.¹⁶ A higher score on this scale indicates a greater degree of positive perception. This approach aligns with common practices in educational evaluation, where self-reported measures offer insights into the immediate impact and perceived value of learning interventions from the perspective of the learners themselves.³ All responses provided for the NPS and questionnaire’s calculation were treated anonymously.

Participants in the asynchronous training underwent an unsupervised test, which involved answering 25 multiple-choice questions, with scores proportionally ranging from 0 to 10 points. These questions were developed by the course instructors, covering the topics addressed in the education session. The same set of questions was administered before and after the course period to evaluate enhanced performance on passing thresholds (Supplementary Appendix C: Online asynchronous education questions). The team coordinator, in collaboration with the learning coordinator, was responsible for motivating participants to complete the test provided on an online platform, and those considered concluded for the asynchronous training were defined as the participants who completed the final test.

Data collection and statistics

Demographic data were collected for these participants, including gender, age, education, profession, and total time spent in professional practice. Variables were summarized using median and IQR (Q1, Q3) or absolute and relative frequencies (n, %). The Kruskal–Wallis rank sum test was used to compare differences between the initial and final scores of the asynchronous training and the differences between professional categories’ performance.¹⁷ When appropriate, the Dunn post-hoc test, using Bonferroni correction, was performed. A P-value <.05 was considered significant for all analyses. Statistical analyses were performed using R, version 4.4.0 (R Foundation for Statistical Computing, Vienna, Austria, 2024).

Results

During the study period, 285 healthcare professionals were recruited to the education program, and their baseline characteristics are detailed in Table 1. The overall study population had a median age of 36 years (IQR: 31, 43), and nurses constituted a significant portion of the overall group, accounting for 56.5% (161/285) of participants. Interestingly, a significant reversal in gender balance was observed. While females comprised 71% (202/285) of the overall group, their representation among physicians dropped to 46% (37/80), with a statistically significant difference (P < .001).

Table 1.

Online asynchronous course study population.

	Overall N = 285	Physician N = 80	NT N = 161	RT N = 44a	P-valueb
Age, years	36 (31, 43)	35 (30, 43)	37 (31, 43)	37 (32, 43)	.7
Gender, n (%)					<.001
Female	202 (71)	37 (46)	135 (84)	30 (68)
Male	83 (29)	43 (54)	26 (16)	14 (32)
Years of practice	9 (4, 15)	8 (4, 18)	9 (4, 13)	10 (6, 15)	.4
PhD degree, n (%)	6 (2.1)	4 (5.0)	1 (0.6)	1 (2.3)	.055
Subspecialty, n (%)					.001
ICU	123 (43)	34 (43)	58 (36)	31 (70)
None	79 (28)	22 (28)	53 (33)	4 (9.1)
Other	83 (29)	24 (30)	50 (31)	9 (20)

Data are shown as median and IQR (Q1, Q3) or frequency (%).

^aMedian (Q1, Q3); n (%).

^bKruskal–Wallis rank sum test, Pearson’s chisquared test, Fisher’s exact test. Bold values indicate P < 0.05.

Abbreviations: NT = nursing team; PhD = philosophy doctor; RT = respiratory therapist.

Regarding other characteristics, there were no significant differences in median years of practice (P = .4) or PhD degree attainment (P = .055). Nevertheless, the groups exhibited significant differences in subspecialty (P = .001) as follows: respiratory therapist (RT) had a higher proportion of ICU-specialized professionals (37/44, 70%), while the nursing team (NT) included a greater number of non-ICU-specialized professionals (103/161, 64%).

Participation in education activities varied significantly by modality. The online asynchronous course had a total pool of 652 participants, of whom 285 were eligible for the study recruitment. Of these 285, 94% (268 participants) engaged with both the educational activities and completed the pre-post tests. The synchronous course participation varied by module, with the highest rates of recruited participants observed in “Nursing Approach” (65%) and “Prolonged Weaning” (61%) (Supplementary Table S2: Synchronous course participation report). The in-person simulation participation varied by region, ranging from 3% to 67% of recruited participants (Supplementary Table S3: in-person simulation participation report).

The NPS results for each educational modality are shown in Table 2. For the online asynchronous course, the Physicians reported a median NPS of 96 (IQR: 82, 100), while NT reported a median NPS of 73 (IQR: 66, 82), and RT reported a median NPS of 100 (IQR: 75, 100). Both the online synchronous and in-person simulation modalities showed consistently high NPS, with a median NPS of 100 across all professional groups (IQR varying from 88 to 100). All educational modalities, tests indicated no statistically significant differences in NPS distributions. This resulted in an NPS falling within the quality and excellence categories.

Table 2.

Summary of NPS results per modalities.

	Physician	NT	RT  a	P-value  b
Online asynchronous	96 (82, 100)	73 (66, 82)	100 (75, 100)	.247
Online synchronous	100 (99, 100)	100 (100, 100)	100 (100, 100)	.32
In-person simulation	100 (88, 100)	100 (98, 100)	100 (91, 100)	.717

Comparison of NPS values across Brazilian states.

^aData are shown as median and IQR (Q1, Q3).

^bKruskal–Wallis rank sum test.

Abbreviations: NPS = Net Promoter Score; NT = nursing team; RT = respiratory therapist.

Table 3 presents the median scores from the self-perceived knowledge questionnaire across different educational modalities. For the question “Did the course meet your expectations?”, median scores were high across all modalities and professional groups. In the asynchronous course, Physicians reported a median of 9.5 (IQR: 9, 10), NT 10 (IQR: 8, 10), and RT 9 (IQR: 9, 10) (P = .696). In both the synchronous course and the in-person simulation, all 3 groups reported a median of 10 (IQR: 10, 10). No statistically significant differences were observed among the professional groups regarding course expectations in any of the modalities.

Table 3.

Professionals’ self-perceived knowledge questionnaire.

	Physician	NT	RTa	P-value  b
Did the course meet your expectations?
Asynchronous course	9.5 (9, 10)	10 (8, 10)	9 (9, 10)	.696
Synchronous course	10 (10, 10)	10 (10, 10)	10 (10, 10)	.88
In-person simulation	10 (10, 10)	10 (10, 10)	10 (10, 10)	.134
Did the course enhance your knowledge?
Asynchronous course	9 (8, 10)	10 (8, 10)	10 (9, 10)	.285
Synchronous course	10 (10, 10)	10 (10, 10)	10 (10, 10)	.284
In-person simulation	10 (9, 10)	10 (10, 10)	10 (10, 10)	.016
How applicable is the course content in your practice?
Asynchronous course	10 (10, 10)	10 (8, 10)	10 (9, 10)	.121
Synchronous course	10 (10, 10)	10 (9, 10)	10 (10, 10)	.215
In-person simulation	10 (10, 10)	10 (10, 10)	10 (10, 10)	.312

^aData are shown as median and IQR (Q1, Q3).

^bKruskal–Wallis rank sum test. Bold values indicate P < 0.05.

Abbreviations: NT = nursing team; RT = respiratory therapist.

Regarding the question “Did the course enhance your knowledge?”, median scores were similarly high across all groups and modalities. In the asynchronous course, Physicians reported a median of 9 (IQR: 8, 10), NT 10 (IQR: 8, 10), and RT 10 (IQR: 9, 10) (P = .285). In the synchronous course, all 3 groups reported a median of 10 (IQR: 10, 10) (P = .284). For the in-person simulation, median scores were 10 for Physicians (IQR: 9, 10), NT (IQR: 10, 10), and RT (IQR: 10, 10). A statistically significant difference was found among professional groups for the in-person simulation modality in relation to knowledge enhancement (P = .016). In the post-hoc analysis comparing professional groups, a statistically significant difference was observed involving the Medicine group. The comparison between Medicine and Nursing yielded a P-value of .00031.

For the question “How applicable is the course content in your practice?”, median scores were consistently high across all modalities. In the asynchronous course, Physicians, NT, and RT all reported a median of 10 (IQRs: 10-10, 8-10, and 9-10, respectively; P = .121). In both the synchronous course (P = .215) and the in-person simulation (P = .312), all groups reported a median of 10 (IQR: 10, 10). No statistically significant differences were found among professional groups regarding the perceived applicability of course content in any modality.

Median test scores improved significantly after the asynchronous course. The post-hoc analyses revealed significant differences in the median pre-course scores among the groups, with a P-value of <.001. However, after the course, the post-course scores showed no significant difference across them (P > .09). Furthermore, the post-hoc analyses on the difference (post-course score minus pre-course score) also showed a statistically significant difference among the groups (P = .002). This implies that while all groups improved, the magnitude of score improvement varied. Specifically, RT (median difference of 4.00) and NT (median difference of 3.60) demonstrated a numerically greater increase in scores compared to Physicians (median difference of 2.00) (Table 4).

Table 4.

Online asynchronous course-test scores.

	Physician	NT	RTa	P-valueb
Pre-course	6.40 (5.20, 8.40)	4.80 (3.60, 7.60)	5.20 (4.40, 6.40)	<.001
Post-course	9.20 (8.40, 10.00)	9.20 (8.40, 10.00)	9.20 (8.80, 9.60)	>.9
Difference	2.00 (1.20, 3.20)	3.60 (1.20, 5.60)	4.00 (2.40, 4.80)	.002

^aData are shown as median and IQR (Q1, Q3).

^bKruskal–Wallis rank sum test. Bold values indicate P < 0.05.

Abbreviations: NT = nursing team; RT = respiratory therapist.

Discussion

This study shows that ICU education can be delivered in-person or online, with wide reach, high satisfaction, and strong clinical applicability. This aligns with evidence that ICU team training supports clinical learning^18,19 and that high satisfaction may boost confidence and improve care quality.²⁰

The asynchronous course demonstrated higher participation rates compared to both synchronous online and in-person simulation formats. This difference can be attributed to the flexibility inherent in asynchronous learning, which allows professionals to engage with educational content at their own pace and convenience, without the rigid time commitments demanded by live sessions or on-site attendance. Using a different environment for learning would have some advantages. First, synchronous training offers participants greater interaction with both peers and the instructor, facilitating the exchange of experiences. Second, it provides the opportunity for real-time adjustment of the content to the student’s needs, which enhances the meaning of the learning experience.

On-site training enables immersion of the learning experience into the working environment, which brings another level of reality to the learning experience and may help solidify knowledge transmission. Asynchronous training has the advantage of offering professionals greater scheduling flexibility and time to acquire and process the information. The online asynchronous environment is a useful tool when applied in a scenario where students are presented with new concepts, sparing the precious time when teachers and students can synchronously meet to elaborate on how to critically apply the learned concepts in clinical practice, which is the final goal for these educational processes.²¹ Offering diverse education modules allows participants to adapt their learning to the modality that best serves them and provides equitable access to educational content, an outcome we believe was achieved with the TeleUTI Conectada.

Given the significant challenges in our team engagement, understanding the barriers and facilitators to education is essential for expanding and improving policies for access to healthcare knowledge. After all, engagement is fundamental for the success of any learning initiative. Literature points to several such obstacles, including a lack of incentive from leadership, family obligations, general stress, financial issues, and insufficient personal support. Furthermore, feelings of uncertainty and hostility, particularly among recently graduated professionals, can negatively influence the development of their skills and competencies.²²

Additionally, educational strategies tend not to include disability rights and psychological illness. In this way, attitudes that aim at diversity, equity, and inclusion may facilitate access and learning results.^23,24 Challenges include difficulties in access and dedicated time to studies, especially in low-income regions. Barriers such as work overload and financing impede professional development, and, additionally, the influence of each center’s organizational culture and the availability of supportive and encouraging environments can reflect positively or negatively.²⁵ In our experience, securing the fundamental support of the ICU’s designated leads, alongside active collaboration with the hospitals’ continuing education teams, was crucial for the initiative’s success. However, the most common barriers encountered were time availability, lack of motivation, and difficulty with the content presented in educational activities.

Being delivered for a multidisciplinary team, the education activities had the challenge of balancing the adaptation of its content for all participant professions while achieving team engagement, since less comprehensive content for certain members of certain professions could affect the results of satisfaction and self-perception of applicability in clinical practice. Additionally, only 40% of the healthcare professionals in our study had prior specialization in intensive care. This not only highlights a significant obstacle but also underscores the opportunity for initiatives like ours, particularly in remote regions. Beyond the scarcity of specialized professionals, healthcare services in these areas often cater to populations with more severe clinical conditions, with limited supplies, logistical support, and a greater reliance on in-person services.²⁶

While the optimal teaching method remains undefined, current technological solutions are recognized as facilitators that encourage professionals to enhance and update their practice. Alongside these, traditional approaches like lectures, workshops, and practical seminars continue to be foundational for developing and reinforcing clinical skills.²⁶ Notably, digital learning offers a significant advantage by potentially mitigating accessibility constraints imposed by vast geographical distances, thereby improving healthcare equity.

However, the shift toward virtual training, greatly accelerated by the COVID-19 pandemic, brought its own set of challenges despite good acceptance by healthcare professionals.¹ While online learning offers ease of access, this very accessibility can sometimes reduce the perceived value by participants and their commitment to the learning program. Furthermore, practical limitations such as limited internet bandwidth and a lack of adequate devices can unfortunately exclude professionals in remote areas who may need this training the most.¹

Despite these inherent challenges, the high satisfaction rates among our multidisciplinary teams suggest that applied education effectively strikes this balance, navigating the complexities of remote learning while still delivering valuable training. Our study has several limitations. Primarily, the absence of an objective, validated knowledge assessment across all learning modalities represents a key limitation. Outcomes were instead measured using unsupervised tests applied only to the asynchronous online course, which introduces a potential source of bias. This restricts our ability to fully evaluate the effectiveness of the other learning strategies and their impact on engagement. Despite this, the self-perceived knowledge gains reported by participants, coupled with high program satisfaction, offer valuable insights into the immediate impact and perceived value of the training. Nevertheless, further research incorporating robust objective assessments is needed to deepen our understanding of multidisciplinary education in critical care settings.

Conclusion

This study described the implementation of educational activities for a multidisciplinary team directly involved in patient care, within the TeleUTI Conectada project.

The educational activities were evaluated, with higher satisfaction rates across learning strategies, good healthcare professionals’ self-perceived knowledge gains, and significantly higher medical knowledge assessment scores assessed by the asynchronous pre-post tests, particularly among RT and NT. This initiative offered a viable model for delivering essential training, providing accessible and equitable educational development. This study may offer immediate value for organizations aiming to implement education programs in remote regions facing social and technological disparities.

Author contributions

All authors have participated in the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the drafting of the work or revising it critically for important intellectual content. Furthermore, all authors have given final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Supplementary material

Supplementary material is available at ATS Scholar online.

Conflicts of interest

The authors declare that they have no competing financial or personal interests that could have influenced the work reported in this manuscript. Completed ICMJE disclosure forms have been provided as supplementary material.

Funding

None declared.

Data availability

This article has a data supplement, which is accessible at the Supplements tab.

Artificial intelligence disclaimer

No artificial intelligence tools were used in writing this manuscript.