General Description
During this rotation, Critical Care trainees are members of a team of physicians caring for patients in a dedicated neurosurgical intensive care unit. This team is comprised of a supervising faculty neurointensivist, neurosurgical and neurology residents, a physician’s assistant in neurosurgery, and medical students. The Neurosurgical Intensive Care Unit Team co-manages care with the primary neurosurgical services, focusing on the care of the patient while in the ICU.
Goals and Objectives
Fellows are expected to perform a thorough history and physical exam, be able to synthesize the information they gather into an appropriate differential diagnosis, and present each case accurately. Supervising faculty will discuss each patient daily and assist with formulating a diagnostic and therapeutic plan for each patient. Trainees will use their knowledge of internal medicine for problem solving and to function in part as an internal medicine consultant. Trainees will develop a deeper understanding of neurologic emergencies and sequelae of neurologic surgery, and the unique management issues surrounding care of these patients. Trainees will also discuss ethical issues with faculty, and will counsel patients and their families. Active involvement of ancillary team members will enable trainees to learn how to facilitate discharge planning and other aspects of health care delivery in our large health care system.
Educational Goals
The NICU provides an educational forum to support the following general learning goals:
- The diagnosis of severe, life-threatening derangements involving the neurologic system.
- The ability to recognize and rapidly correct urgent, life-threatening neurologic disorders.
- Expertise with the technology and procedures that support the critically ill patient.
- Use of a multidisciplinary team approach to care, encompassing numerous disciplines and professions.
- Use of protocols and policies as quality assurance and improvement tools.
- Medical ethics and law as it applies to the distribution of costly, limited resources.
- Communication with patients and their families under stress.
- Recognition of the limits of medical care and end-of-life discussions.
Goals and Objectives
Patient Care
All fellows are expected to:
- Develop expertise in the history and physical examination of the critically ill neurology and neurosurgical patient.
- Develop expertise in the utilization and interpretation of physiologic data, laboratory testing and radiological studies in the critically ill neurology and neurosurgical patient.
- Integrate clinical data in the formation of a comprehensive care plan
Fellowship Year-Specific Objectives:
FY-1
First year fellows are expected to:
Perform a thorough history and physical exam
Perform a detailed neurologic exam focused on localizing the source of neurologic deficit and/or injury
Synthesize the information they gather into an appropriate differential diagnosis
Learn the management strategy of common critical illness as it relates to the particular population of patients with neurologic injury (sepsis rescusitation, fluid management, blood pressure goals, etc)
Discuss ethical issues with faculty
Supervising faculty will discuss each patient daily and assist with formulating a diagnostic and therapeutic plan for each patient.
FY-2
Second-year fellows are additionally expected to:
Demonstrate the ability to anticipate and proactively address potential problems with regards to patient care.
Perform (with attending presence) all medical critical care procedures that may arise on the service.
Medical Knowledge
All fellows are expected demonstrate knowledge of current and classic literature, clinical management skills, and the scientific foundations of myriad illnesses as they relate to the critically ill neurology and/or neurosurgical patient:
- Acute stroke management
- Status epilepticus
- Management of traumatic brain hemorrhage
- Intracranial pressure monitoring
- Electrolyte and acid-base disturbances and their effect on the neurologic system
- Neurogenic shock syndromes
- Sepsis and sepsis management
- Hypertensive emergencies
- Acute and chronic respiratory failure
- Multi-organ system failure
- Metabolic, nutritional, and endocrine effects of critical illnesses
- Hematologic and coagulation disorders associated with critical illness
- Management of the immunosuppressed patient
- Use of paralytic agents and sedative and analgesic drugs
- Psychosocial and emotional effects of critical illnesses on patients and their families
- Management of end of life issues and palliative care
- Ethical, economic, and legal aspects of critical illness
Fellowship Year-Specific Objectives:
FY1:
First year fellows are expected to:
Learn the clinical indications for use of various bedside monitors (ICP monitors, transcranial Doppler, EEG monitoring)
Accurately interpret data from monitors, ventilators, arterial lines and other devices
Demonstrate knowledge of the scientific method
Understand the indications, contraindications, limitations, complications of diagnostic and therapeutic procedures integral to the care of the critically ill neurology and/or neurosurgical patient
Demonstrate the ability to accurately interpret radiographs
Teach basic concepts of critical care medicine to residents
FY2:
Second-year fellows are additionally expected to:
Accurately interpret and apply the literature for evidence-based decisionmaking
Discuss complex concepts of critical care medicine with residents and medical students
Practice-Based Learning and Improvement
Fellows are expected to:
- Consider how their personal values, ethics, and culture influence their approach to patient care and communications
- Use current medical literature and databases to improve individual patient care using the best available evidence.
- Use their knowledge of physiology and basic science to guide care decisions
- Evaluate the risks, and benefits of equipment and interventions used in the NeuroICU and on the patients under their care
Fellowship Year-Specific Objectives:
FY1:
First year fellows are expected to:
Evaluate the care of their patients for care improvement
Solicit feedback from faculty regarding their performance mid-month and at the end of the rotation
Demonstrate self-directed learning by reading relevant literature on each patient
FY2:
Self-reflect on performance and develop learning plans with assistance from supervising faculty.
Incorporate formative feedback into daily practice.
Perform efficient literature searches and evaluate manuscripts based on EBM
Use information technology to optimize learning
Interpersonal and Communication Skills
Fellows are expected to:
- Communicate appropriately and professionally with patients and families
- Communicate effectively with primary care physicians, hospitalists and other practitioners to whom they are providing consultative care for their patients
- Communicate (verbally and in writing) appropriately with physicians, mid-level providers, nurses and other members of the health care team including completion of comprehensive, timely and legible medical records
Fellowship Year-Specific Objectives:
FY1, FY2:
All fellows are expected to:
Demonstrate an understanding of a patient’s socioeconomic, educational and cultural background and how it plays a role in family decisions
Participate in family meetings regarding patient prognosis, palliation and end-of-life care
Coordinate team communication to optimize patient care
Professionalism
Fellows are expected to:
- Consistently demonstrate respect, altruism, integrity, honesty, compassion,
and empathy for critically ill patients and their families
- Practice ethical behavior both within and outside of the hospital
- Demonstrate respect for patients by providing the highest quality care despite
differences of culture, gender, race, disability, or age
- Demonstrate a commitment to excellence and continuous professional
development
- Demonstrate a commitment to patients and society that supersedes personal
needs
Fellowship Year-Specific Objectives:
FY1, FY2: All fellows are expected to:
Respect patient privacy and autonomy at all times
Uphold principles of truth and integrity
Respond to patient needs that supersede self-interest.
Systems Based Practice
Fellows are expected to:
- Work as an effective member of the NeuroICU team in all interdisciplinary
activities (rounds, primary care, consultations, and procedures).
- Learn about the natural history of critical illness as patients recover and
transition through the medical center, including the impact of critical illness
on family, employment, and long term physical and mental disability
- Demonstrate awareness of the ethical and legal aspects of critical illness.
- Demonstrate knowledge of the societal and individual economic
consequences of severe illness, consideration of cost as well as benefits
and timely discussions of limitations of medical care
Fellowship Year-Specific Objectives:
FY1:
First year fellows are expected to:
Demonstrate skills in working in a multidisciplinary health care team
Work closely with specialty consultants to manage their patients.
Facilitate the learning for other team members they are supervising.
Accurately document patient treatment plans in the electronic medical record.
Involve ancillary team members to facilitate discharge planning
FY2:
Second-year fellows are additionally expected to:
Coordinate care for critically ill medical patients.
Suggest cost-efficient and effective diagnostic and therapeutic plans.
Use system resources to deliver efficient care in the NeuroICU
Demonstrate leadership and management skills
Demonstrate and incorporate thorough understanding of documentation guidelines and billing processes.
Demonstrate understanding of the role of policy and care protocols as an instrument of patient safety
Role model safe care through maintenance of isolation procedures, time-outs, etc.
Teaching Methods
Trainees participate in daily teaching rounds with faculty and other team members. Management rounds that also include practical experience in the care of these patients accompany these teaching rounds. Didactic teaching sessions are also an integral part of this rotation.
Mix of Diseases and Pathological Material
Trainees are exposed to patients of all age groups, except young children, with a comprehensive spectrum of neurosurgically related conditions, both pre-operatively and post-operatively. Trainees participate in the care of patients with neurosurgical and neurologic emergencies.
Types of Clinical Encounters
All clinical encounters occur in the neurosurgical intensive care units, under the direct supervision of a Board-Certified faculty neurointensivist.
Procedures and Services
Trainees learn the indications, contraindications, limitations, and complications and have opportunities to gain practical experience of the following procedures:
- Intracranial Pressure Monitoring
- Ventilator management in the postoperative period
- Hemodynamic monitoring of the critically ill neuro patient
Reading Lists and Educational Resources
Faculty members regularly direct trainees to specific textbooks and leading articles related to specific and relevant topics.
Method of Evaluation
Evaluation of the trainee is provided in a formative fashion during the rotation along with a written summative fashion at the end of the rotation. Trainees are evaluated on their medical knowledge, technical skills of procedures, communication, interpersonal and time management skills, awareness and practice of necessary safety issues, self-directed learning, and professionalism. The summative evaluation is recorded on a five-point Likert scale, along with individualized comments and reviewed with the trainee.