Medical ICU Curriculum for all Fellows rotating through Critical Care

Curriculum

Updated July 2018 

Please note: this is a great reading list for the ICU put out and updated by ATS

 

General Description and Purpose

This rotation offers each fellow the direct opportunity to gain the knowledge and skills necessary to care for patients in a medical intensive care unit in our large tertiary care center.  During this rotation, fellows actively care for critically ill patients and work closely with midlevel providers (on the Green service) and residents (on the teaching services) under the direct supervision of faculty members certified by the ABIM in Critical Care Medicine.   Fellows assigned to this clinical service are responsible for providing supervised comprehensive care of critically ill patients with a wide variety of medical disorders in an 18-bed closed medical/surgical ICU service.  Fellows will also be responsible for triaging patients to all 68 beds (20 beds midlevel, 48 beds teaching) and overseeing care on the 48 beds on the resident teaching services on call and overnight.  A nighttime intensivist attending will provide direct or indirect supervision of procedures and admissions as appropriate Sun – Thur nights.

Each rotation is 1 month in length.  Attendings rotate in 2 week blocks, so 2 attendings during the rotation is typical. Additional rounders may be on service on the weekends.

Fellows are expected to start their work day at 7am in the ICU (unless program-wide schedule changes are made) and pre-round on the patients in their ICU.  The most acutely ill and/or unstable patients should be the priority, along with patients that need urgent procedures.  The rounding attending should be made aware of the need for direct supervision of procedures (intubation, bronchoscopy, etc) and is available in the afternoons to provide direct or indirect supervision.

Fellows should discuss their personal learning goals for the month (independent rounding, level-specific discussion of ICU topics, etc) with their rounding attending at the beginning of each 2-week rotation with the attending.  Fellows are also expected to solicit feedback from their attending at the end of their rounding block (i.e. at the middle and end of the rotation).

General Objectives

The overall procedural objectives for the rotation are applying the diagnostic and therapeutic technology used in critical care, including hemodynamic and non-invasive monitoring, mechanical ventilation, airway management, ultrasound, and bronchoscopy. Fellows will also learn ICU quality improvement, multidisciplinary care, and ethics and end-of-life care.  Particular emphasis will be had in the areas of systems based practice as fellows learn how to organize and work effectively as a member of a multidisciplinary team,  supervise mid-level providers and/or residents in the delivery of care, and coordinate consultations with the physician specialty services and other hospital ancillary services (PT, OT, RT, Nutrition Service, etc).

 

Educational Goals

The MICU provides an educational forum to support the following general learning goals:

• The diagnosis of severe, life-threatening derangements spanning multiple physiologic systems.
• The ability to triage, organize, and prioritize between multiple problems and patients.
• The ability to recognize and rapidly correct urgent, life-threatening disorders.
• Expertise with the technology and procedures that are some of the tools of modern critical care.
• 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.

 

 

Objectives

Patient Care

All fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.  They will achieve this by:

• Providing consultation as requested on inpatient or emergency room patients in a timely and appropriate fashion,
• Providing daily management to established patients on the service,
• Effectively guiding residents or mid-level providers with the management plan of patients,
• Coordinating diagnostic and therapeutic procedures (fiberoptic bronchoscopy, thoracentesis, chest tube thoracostomy, venous, arterial, pulmonary arterial line placement, etc).

Fellows will gain competence in the practice of health promotion, disease prevention, diagnosis, care, and treatment of patients of each gender, from adolescence to old age, during health and all stages of illness; and, will gain competence in the prevention, evaluation, and management of patients with:

 

• acute lung injury, including radiation, inhalation, and trauma;
• acute metabolic disturbances, including overdosages and intoxication syndromes;
• anaphylaxis and acute allergic reactions in the critical care unit;
• cardiovascular diseases in the critical care unit;
• circulatory failure;
• end-of-life issues and palliative care;
• hypertensive emergencies;
• immunosuppressed conditions in the critical care unit;
• metabolic, nutritional, and endocrine effects of critical illness, hematologic and coagulation disorders associated with critical illness;
• multi-organ system failure;
• perioperative critically-ill patients,

including hemodynamic and ventilatory support;

• renal disorders in the critical care unit,

including electrolyte and acid-base disturbance and acute renal failure;

• respiratory failure,

including acute respiratory distress syndrome, acute and chronic respiratory failure in obstructive lung diseases, and neuromuscular respiratory drive disorders;

• sepsis and sepsis syndrome;
• severe organ dysfunction resulting in critical illness,

including disorders of the gastrointestinal, neurologic,

endocrine, hematologic, musculoskeletal, and immune

systems, as well as infections and malignancies; and, shock syndromes.

Additionally fellows will:

• Develop expertise in the history and physical examination of the critically ill

patient.

• Develop expertise in the utilization and interpretation of physiologic data, laboratory testing and radiological studies in the critically ill.
• Integrate clinical data in the formation of a comprehensive care plan

Procedural Skills

Fellows will gain exposure in interpreting data derived from various bedside devices commonly employed to monitor patients; and exposure in procedural and technical skills, including:

 

• airway management;
• the use of a variety of positive pressure ventilatory modes, including:

initiation and maintenance of, and weaning off of,ventilatory support;

respiratory care techniques; and

withdrawal of mechanical ventilatory support.

• the use of reservoir masks and continuous positive airway pressure masks for delivery of supplemental oxygen, humidifiers, nebulizers, and incentive spirometry;
• therapeutic flexible fiber-optic bronchoscopy procedures limited to indications for therapeutic removal of airway secretions, diagnostic aspiration of airway secretions or lavaged fluid,or airway management
• diagnostic and therapeutic procedures, including paracentesis, lumbar puncture, thoracentesis, endotracheal intubation, and related procedures;
• use of chest tubes and drainage systems;
• insertion of arterial, central venous, and pulmonary artery balloon flotation catheters;
• operation of bedside hemodynamic monitoring systems;
• emergency cardioversion;
• nutritional support;
• use of ultrasound techniques to perform thoracentesis and place intravascular and intracavitary tubes and catheters; and
• use of transcutaneous pacemakers

Fellowship Year-Specific Objectives:

FY1: Fellows are expected to demonstrate the ability to obtain and document an accurate and complete history from patient and/or care taker, and coordinate the clinical efforts of the multidisciplinary team. Second-year fellows are expected to perform (with attending supervision and assistance) fiberoptic bronchoscopies, thoracenteses, chest tube placements, and other procedures that may arise on the service. They shall provide updates to patients and their families and participate in family discussions about prognosis and end of life issues. They will also communicate with residents or mid-level providers, consultants, therapists, and other professionals regarding patients on the service.

 

FY2 and FY3: Senior fellows are additionally expected to demonstrate the ability to

anticipate and proactively address potential problems with regards to patient care. Senior fellows are expected to perform (with attending supervision and assistance) all

required medical critical care procedures that may arise on the service. They will lead family meetings and end-of-life discussions, as appropriate. They will demonstrate understanding of the role of policy and care protocols as an instrument of patient safety, as well as role model safe care through maintenance of isolation procedures, time-outs, etc.

 

Medical Knowledge

Fellows will develop knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.

 

Fellows:

Will demonstrate knowledge of the scientific method of problem solving, and evidence-based decision making.

 

Will demonstrate knowledge of indications, contraindications, limitations, complications, techniques, and interpretation of results of those diagnostic and therapeutic procedures integral to the discipline, including the appropriate indication for and use of screening tests/procedures:

• pericardiocentesis
• placement of percutaneous tracheostomies
• imaging techniques commonly employed in the evaluation of patients with critical illness, including the use of ultrasound;
• screening tests and procedures; and
• renal replacement therapy

Will gain knowledge of:

• the basic sciences, with particular emphasis on biochemistry and physiology, including cell and molecular biology and immunology, as they relate to critical care medicine;

• the ethical, economic and legal aspects of critical illness;
• the psychosocial and emotional effects of critical illness on patients and their families;
• the recognition and management of the critically ill from disasters including,

those caused by chemical and biological agents inhalation, and trauma;

• the use of paralytic agents and sedative and analgesic drugs in the critical care unit;
• detection and prevention of iatrogenic and of nosocomial problems in critical care medicine
• monitoring and supervising special services, including:

respiratory care units,

respiratory care techniques and services;

pharmacokinetics, pharmacodynamics, and drug metabolism and excretion in critical illness;

• Quality improvement and patient safety in the ICU, including recognition and prevention of nosocomial and iatrogenic injury.

Fellowship Year-Specific Objectives:

FY1: Fellows are expected work in conjunction with the attending physician who leads daily rounds and provides bedside teaching. They should suggest the diagnostic and therapeutic approaches to MICU patients with input from the attending as needed. They will also demonstrate skills in radiographic interpretation.

 

FY2: Fellows will be able to formulate comprehensive diagnostic and therapeutic approaches to MICU patients with minimal attending input.

 

FY3: Senior fellows must demonstrate the ability to reliably generate an extensive differential diagnosis, and generate a patient care plan, and round independently on patients mutually agreed upon with the attending. The attending will provide support and input as appropriate for the fellows’ level of progressive responsibility.

 

Practice-Based Learning and Improvement

Fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care

based on constant self-evaluation and life-long learning.

 

Fellows are expected to develop skills and habits to be able to meet the following goals:

• Identify strengths, deficiencies, and limits in one’s knowledge and expertise;
• set learning and improvement goals;
• identify and perform appropriate learning activities;
• systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement;
• incorporate formative evaluation feedback into daily practice;

• locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems;
• use information technology to optimize learning;
• participate in the education of patients, families, students, fellows and other health professionals;
• obtain procedure-specific informed consent by competently educating patients about rationale, technique, and complications of procedures

Fellowship Year-Specific Objectives:

FY1: Fellows will pursue independent reading on each patient encounter. They should self-reflect on performance and develop learning plans with assistance from supervising faculty. Fellows should incorporate formative feedback into daily practice improvement and seek feedback from faculty members on performance.

 

FY2: Fellows are expected to be able to perform efficient literature searches and evaluate manuscripts based on EBM principles. Fellows should demonstrate effective self-directed learning to faculty members.

 

FY3: Fellows are expected to consider how their personal values, ethics, and culture influence their approach to patient care and communications.  They are expected to use their knowledge of physiology and basic science to guide care decisions, use medical literature and professional society guidelines to critique and improve the standards of care in the MICU, and evaluate the risks, expense, and benefits of equipment and interventions used in the MICU and on the patients under their care.

 

Systems Based Practice

Fellows are expected to:

• Work as an effective member of the MICU team in all interdisciplinary activities (rounds, intensivist care, consultations, and procedures).

• coordinate patient care within the health care system relevant to their clinical specialty;
• incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate;
• advocate for quality patient care and optimal patient care systems;
• work in interprofessional teams to enhance patient safety and improve patient care quality;
• participate in identifying system errors and implementing potential systems solutions
• participate in quality improvement and patient safety activities in the intensive care unit(ICU
• acquire skills required to organize, administer, and direct a critical care unit.

• 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
• When possible, contribute to ongoing research and quality initiatives in the MICU
• Organize and work effectively as a member of a multidisciplinary team, coordinating the consultations with the nursing services and other hospital ancillary services (PT, OT, RT, Nutrition Service, etc)
• Efficiently and effectively request consultation from subspecialty services

Fellowship Year-Specific Objectives:

FY1: Fellows are expected to be able to coordinate care for MICU patients. They should demonstrate their ability to obtain relevant current and old medical records, and suggest cost-efficient and effective diagnostic and therapeutic plans. They should recognize the need for consultation from ancillary services or other fields of medicine when needs exceed the expertise of the MICU team.

FY2 and FY3: Senior fellows should avail themselves of opportunities to be involved in the administration of the MICU. They will demonstrate leadership and management skills, including

quality improvement. Senior fellows should demonstrate and incorporate thorough understanding of documentation guidelines and billing processes. Care plans should demonstrate consideration of the place of the MICU within the larger context of the health system.

 

Professionalism

Fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

 

Fellows are expected to demonstrate:

• compassion, integrity, and respect for others;
• responsiveness to patient needs that supersedes self-interest;
• respect for patient privacy and autonomy;
• accountability to patients, society and the profession;
• sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation;
• high standards of ethical behavior, including maintaining appropriate professional boundaries and relationships with other physicians and other health care team members, and avoiding conflicts of interest

• Model professional behavior for the ICU team including punctuality andpreparation for rounds.

Fellowship Year-Specific Objectives:

FY 1,2,3: All fellows are to respond promptly and politely to pages, phonecalls, and email. They must respect patient privacy and autonomy at all times. They must show respect for patients and other health care personnel. In clinical care, fellows must uphold principles of truth and integrity, and reliably put patients’ interests ahead of own. They are expected to recognize that off-campus or on-line behavior reflects not only on them, but also on the community of professionals of which they are a part.

FY 2&3: Senior fellows will be a role model for more junior fellows.

 

Interpersonal and Communication Skills

Fellows are expected to:

• communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds;

• communicate effectively with physicians, other health professionals, and health related agencies;
• work effectively as a member or leader of a health care team or other professional group;
• act in a consultative role to other physicians and health professionals;
• maintain comprehensive, timely, and legible medical records as applicable

 

Fellowship Year-Specific Objectives:

FY1, 2 & 3: All fellows should demonstrate an understanding of a patient’s perspective and share relevant information to patients, medical decision makers, and other key health care providers. Fellows should participate in family meetings and discussions regarding end-of-life

care, palliation, and patient prognosis or preferences. All fellows should function as an effective team leader and coordinate team communication to optimize patient care. They

should be able to integrate bedside teaching into work rounds effectively.

 

Educational methods

The attending physician on service will be responsible for the teaching of the fellow. Fellows should discuss their personal learning goals for the month (independent rounding, level-specific discussion of ICU topics, etc) with their rounding attending at the beginning of each 2-week rotation with the attending. Fellows will meet with their supervising faculty member to arrange one-on-one teaching interactions.  Practical experience in all aspects of care is provided as case based learning experiences.  Teaching will be performed using a variety of methods including daily bedside rounding with discussion of pertinent patient findings, daily review of imaging with discussion of pertinent radiologic findings, and daily teaching rounds on which discussion of current or past patients will be augmented with recent reviews of similar cases/findings from the medical literature.  All fellows participate in teaching rounds on a daily basis along with weekly conferences dedicated to Critical Care Medicine, and regular Morbidity and Mortality conferences.

 

Work hours

Fellows are expected to adhere to ACGME guidelines for work hours which require fewer than 80 hours per week in the hospital.  Fellows receive one day off each week during the rotation. Fellows will not take in-house night call. 

Reading Lists and Educational Resources

Faculty members regularly direct trainees to specific textbooks and leading articles related to specific and relevant topics.  The ATS reading list is an invaluable resource and can be accessed here:

http://www.thoracic.org/professionals/career-development/residents-medical-students/ats-reading-list/adult/index.php

 

Evaluation

Fellows are evaluated on each of the six core competencies, in the relevant milestones domains. Fellows are also expected to solicit feedback from their attending at the end of their rounding block (i.e. at the middle and end of the rotation). Evaluation of each fellow is provided in a formative fashion during the rotation along with a written summative fashion at the end of the rotation.  The faculty will evaluate fellow performance in a timely manner during each rotation or and document this evaluation at completion of the assignment.  The faculty will discuss this evaluation with each fellow at the completion of the rotation.