Critical Care Critical Care _____________________________________________________________________________________________________
I. GOALS
Develop the attitudes, knowledge, and skills for competent care of critically ill patients. Welcome to CFH Critical Care is required reading for the rotation.
A. PATIENT CARE:
Objective 1: Demonstrate clinical skills of medical history and physical examination in the critically ill patient, including comprehensive functional assessment and mental status, interpretation of chest films, and hemodynamic data.
Objective 2: Order and interpret renal function studies to promote optimal fluid and electrolyte managment, and prevent acute renal failure.
Objective 3: Demonstrate ability to prioritize medical problems in critically ill patient with multisystem disease.
Objective 4: Perform and record procedures
a. Procedure Skills : The resident is expected to perform and become adept at the following procedural skills:
Objective 5: Obtain and maintain current certification in Basic Life Support and Advanced Cardiac Life Support
B. MEDICAL KNOWLEDGE:
Objective 1: Describe common presentation of illnesses, and responses to therapy, including pharmacokinetics and pharmacodynamics.
Objective 2: Demonstrate knowledge of presentation, care, and management of the following:
a. Hemodynamic problems, e.g. shock states, hypertensive emergencies, cardiac arrhythmias, principles of invasive respiratory, and hemodynamic monitoring.
b. Respiratory failure and principles of mechanical ventilation
c. Gastrointestinal bleeding and intra-abdominal catastrophes.
d. Fluid and electrolyte management, acid-base disorders, and renal failure.
e. Endocrine disorders, e.g., diabetes insipidis, thyrotoxicosis and adrenal crisis.
f. Sepsis, pneumonia, central nervous system infections, and nosocomial infections, and those related to invasive procedures.
g. Intracranial hemorrhage, seizure disorders, coma, encephalopathies, acute stroke, and polyneuropathies.
h. Enteral and parenteral routes for nutrition support.
i. Drug toxicity, overdoses, and withdrawal syndromes.
j. Acute delirium, depression, and dementia
C. PRACTICE-BASED LEARNING AND IMPROVEMENT
Objective 1: Order and organize appropriate consultations and work with consultants to optimize care of the critically ill patient.
Objective 2: Demonstrate ability in medical decision making for allocation of resources, do not resuscitate orders, and withdrawal of care.
Objective 3: Demonstrate ability to incorporate medical assessment, and patient and family values and preferences.
E. PROFESSIONALISM
Objective 1: Demonstrate respect and compassionate use of medical skills for the critically ill. This includes the utility of high-quality care and technology and, in the event of terminal illness, an awareness of the limits of medical intervention and the obligation to provide humane care.
Objective 2: Demonstrate sensitivity and responsiveness to patients’ culture, age, religion, gender, sexual orientation and disabilities.
Objective 3: Recognize the legal requirements of advanced directives and describe the process of assessing a patient's advance directives, including the patient's perspective.
Objective 4: Demonstrates commitment to assigned reading and illustrates independent initiative in case-related reading.
F. SYSTEM-BASED PRACTICE
Objective 1: Recognize financial issues of heath care, with emphasis on understanding critical, acute and chronic care, and medication coverage; and the role of the Centers for Medicare and Medicaid Services (CMS), and other third party payers.
Objective 2: Actively participate in the multidisciplinary approach to caring for critically ill patients, including appropriate recognition of other health professional and paraprofessionals roles and demonstrate competence in team interactions, i.e. pharmacist, physician’s assistant, advanced practice nurse, occupational and physical therapist, social worker, case manager.
Residents receive critical care training for 2 four-week blocks. Residents are expected to be present for attending rounds which begin at 7 am. Residents are required to rounds on at least one weekend day, and assure coverage for days off on weekends.
The resident's primary responsibility is to Critical Care assuming responsibility for the management of assigned patients. S/he develops a professional relationship with critical care personnel to create an effective team. On-call responsibilities for admission are determined by the chief resident. The resident signs out to the senior on-call after hours with a thorough discussion of patient and responsibilities.
1. Patients are admitted to teaching service in Critical Care in conjunction with a member of the Critical Care Service, i.e. Michael Freeland, MD; John Hill, MD; Shalini Manchanda, MD; Karen White, MD; Uretz Oliphant, MD.
2. Transfer of teaching service patient to the Critical Care Service requires the consent of the patient's attending physician. If the attending physician is unavailable, the on-call Critical Care Service physician should be notified regarding the transfer. The patient must arrive in the Critical Care Service with initial management orders or accompanied by the resident directly managing care.
3. On admission to Critical Care Service the resident assigned to Critical Care assumes primary responsibility.
4. Because of their unstable nature, Critical Care patients should be seen at least twice daily by the resident. Daily progress notes are required, as well as appropriate notes documenting significant changes in the patient's condition. The resident must be readily available (within 10 minutes) for patient care problems.
5. On nights when the Critical Care resident is not on-call, patients are signed out to the attending physician on-call.
6. The resident is required to document off-service and on-service notes to transfer to or from the Critical Care Service. In addition, upon transfer out of the Critical Care, direct contact with the resident who will assume care from the primary resident is required. All patients transferred out of the unit must have a complete set of transfer orders. All patients on the teaching service, in the Critical Care Unit, continue to be on teaching service after transfer out of the Critical Care.
7. Residents must abide by the policy on procedures privileging.
8. Interns must clear all orders first with either the senior resident or attending intensivist.
9. Residents must observe the "Rules of Conduct", and behave professionally in accordance with the Carle Critical Care values.
10. Residents must be familiar with and abide by OSHA regulations.
1. Cardiology Intensive Care Unit patients are admitted by the cardiology senior resident, or if available, the cardiology intern. Cardiology patients in the ICU are under the direct supervision of the cardiology staff.
2. Because of their unstable nature, ICU patients should be seen at least twice daily by the resident. Daily progress notes are required. Changes in the patients' condition must be documented in a timely fashion. The resident must be readily available (within 10 minutes) for patient care problems.
3. On nights when the ICU resident is not on-call, patients are signed out to the senior resident covering ICU call that evening. Sign out rounds are conducted at 1700.
4. Residents must abide by the policy on procedures privileging.
5. Junior residents must clear all orders first with either the senior resident or attending internist.
6. Residents must observe the "Rules of Conduct", and behave professionally in accordance with the Carle ICU values.
7. Residents must be familiar with and abide by OSHA regulations.
Core Conference Curriculum :
The core conference curriculum is an 18 month curriculum including a core conferences in Critical Care. There are 2 grand rounds lectures offered annually on Critical Care topics.
According to Accreditation Council of Graduate Medical Education (ACGME), training and evaluation must include the following competencies: Patient Care, Medical Knowledge, Practice – Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and System-Based Practice.
Patient Care will be evaluated by global assessment of the attending physician and additional information from nursing staff. Procedures performed will be documented.
Medical Knowledge will be evaluated by global assessment of the attending physician, and peer-reviewed chart audit.
Practice-Based Learning and Improvement will be evaluated by peer-reviewed chart audit.
Interpersonal and Communication Skills will be evaluated by global assessment of attending physician and additional information from nursing staff, patients and families.
Professionalism will be evaluated by global assessment of attending physician and additional information from nursing staff, patients and families; and peer-reviewed chart audit.
System-Based Practice will be evaluated by global assessment of attending physician, and peer-reviewed chart audit.
The evaluation method is primarily accomplished electronically. Residents' performance in Critical Care is evaluated by the attending physician. Evaluations are reviewed with the residents for formal feedback. Face to face interaction between the attending physician and the resident is the required method. At the midway point of the rotation, the resident is encouraged to approach the attending to assess and discuss performance. In addition, ongoing feedback is provided related to residents’ patient care responsibilities and activities.
Residents will document the Critical Care rotation in portfolios, e.g. procedures performed, peer-reviewed chart audit. This tool will provide individual learning, reflection and assessment. Additionally, residents will evaluate the critical care rotation.
Residents provide input on the core lecture series, which is used in scheduling future topics and speakers. Periodically, residents are surveyed to evaluate the curriculum and teaching faculty.
Welcome to CFH Critical Care. Required reading for Critical Care rotation.
Critical Care Literature. Required reading for Critical Care rotation. (Rev 2/15/2008)
www.thoracic.org/go/atsreadinglist. "Reading List for Pulmonary and Critical Care Medicine," American Thoracic Society
Rev 9/15/05, Rev 3/13/06, Rev 8/15/07, Rev 2/15/2008 S. Manchanda, MD and K. Buttitta, RN, MS Ed