To the Editor In the subgroup analysis of the recently published Stroke-Related Early Tracheostomy vs Prolonged Orotracheal Intubation in Neurocritical Care Trial 2 (SETPOINT2), 1 the enrolled patients were divided into 3 subgroups according to their pathology diagnosis: acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. However, the type of stroke is not necessarily related to the need for tracheostomy. We believe it would be helpful to classify these patients based on the location of brain infarction, including distinct categories for brainstem or cerebellar stroke. The purpose of tracheostomy in patients with severe stroke is not only to provide mechanical ventilation but also to protect the airway. Airway protection is particularly important in patients with stroke who have impaired swallow and cough reflexes. Because these reflexes are primarily controlled by the brainstem, patients with stroke affecting this area of the brain are more likely to have impaired cough and swallow reflexes. Prior studies have shown that patients with brainstem diseases and space-occupying cerebellar diseases are more likely to undergo tracheostomy. 2

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Background A training program for intensive care unit (ICU) physicians entitled “Chinese Critical Care Certified Course” (5 C) started in China in 2009, intending to improve the quality of intensive care provision. This study aimed to explore the associations between the 5 C certification of physicians and the quality of intensive care provision in China. Methods This nationwide analysis collected data regarding 5 C-certified physicians between 2009 and 2019. Fifteen ICU quality control indicators (three structural, four procedural, and eight outcome-based) were collected from the Chinese National Report on the Services, Quality, and Safety in Medical Care System. Provinces were stratified into three groups based on the cumulative number of 5 C certified physicians per million population. Results A total of 20,985 (80.41%) physicians from 3,425 public hospitals in 30 Chinese provinces were 5 C certified. The deep vein thrombosis (DVT) prophylaxis rate in the high 5 C physician-number provinces was significantly higher than in the intermediate 5 C physician-number provinces (67.6% vs. 55.1%, p = 0.043), while ventilator-associated pneumonia (VAP) rate in the low 5 C physician-number provinces was significantly higher than in the high 5 C physician-number provinces (14.9% vs. 8.9%, p = 0.031). Conclusions The higher number of 5 C-certified physicians per million population seemed to be associated with higher DVT prophylaxis rates and lower VAP rates in China, suggesting that the 5 C program might have a beneficial impact on the quality of intensive care provision.