CRITICAL CARE UNIT COMPETENCY BASED CURRICULUM
OVERVIEW
Critical care medicine involves caring for the most acutely ill patients
with a broad range of clinical problems and is often best achieved by
adopting a team approach consisting of the general internist and critical
care specialist or cardiologist as well as other subspecialists as indicated.
Residents must learn to recognize critical illness and facilitate timely
transfer of patients to the Intensive Care Units, but must also learn
to allocate these limited resources appropriately to those patients most
likely to benefit from this level of care. Residents will need to gain
experience and a level of comfort in dealing with numerous difficult ethical
and social issues including the initiation and withdrawal of life-support
measures, advance directives, determination of brain death, and organ
transplantation.
PRINCIPAL TEACHING/LEARNING ACTIVITIES
-ICU Conferences (ICU)--Conferences will be held 2-3 times a week to discuuss
didaictic topic related specifially to the care of the critically ill
patient. (see scheule at end of curriculum)
-Sign-out Rounds (SR) -- Every evening, Monday through Friday, the the
senior residents (Chief Resident, or his/her designate will be present
during the first few months of the academic year), supervise sign-out
rounds, which are attended by the out-going day team and incoming ADMITTING
team. These may include topical discussions.
-Attending/Management Rounds (AR) -- Each day the Attending physician responsible
for care of patients on this service will meet with the residents to evalute
all patients and review plans for patient management. It will be on these
occasions that residents are supervised in prsentation skills, knowledge
of patient, details of recordkeeping, interaction with other healthcare
team members, communication with consultants and family members, and all
other aspects of patient management.
-Grand Rounds (GR) -- Medical Grand Rounds are held each Wednesday from
8:00 -9:00 a.m. in the Medical Center Auditorium. Formats vary and include
invited guests/visiting professor presentations, clinical-pathological
conferences, morbidity and mortality conference, resident presentations,
or other didactic, topical, or patient related topics.
- Turnover Rounds (TR)-- Turnover rounds occur at the end/beginning of
each rotation and from 6:30- 7:30 a.m. daily. These facilitate transfers
of patient care from one resident to another. (Sign in Rounds are a daily
version of turnover rounds.)
-Autopsy Rounds (AuR) When a death occurs on any of the teaching teams
the family is offered the option of performing an autopsy. If an autopsy
is performed, we hold a multidisciplinary presentation of the findings
that includes medicine, pathology, radiology, surgery, and/or ob/gyn residents
and faculty that were involved.
-MKSAP study pan (MKSAP)-This self directed study plan helps residents
stay on track with their didactic reading and helps them evaluate their
medical knowledge (strengths and areas of deficit). Residents can help
develop individualized study plans to fill in any knowledge gaps and reinforce
what they already know. This also helps residents develop skills and habits
needed for lifelong learning.
-In-Training Examination (ITE) -- All of our residents must take this examination
annually for their own assessment of progress and for edification. When
examination results become available, the program director discusses these
individually with residents and counsels residents about individualized
study programs to facilitate their acquisition of knowledge.
DESCRIPTION OF ROTATION/ASSIGNMENT
Senior residents and interns are assigned to the ICU each month are. They
may be assigned to work either day time or night time shifts. Patient
care responsibilities are exclusively to patients in the medicial ICU.
These are supervised by patients' individual attending physicians.
It is anticipated that increasingly patient care will become the primary
responsibility of full-time intensivists. Daily multidisciplinary teaching
rounds are made under the direction of a member of the attending staff
usually with specialty training in pulmonary medicine or intensive care;
these are distinct from management rounds.
Interns should arrive each morning sufficiently early to be intimately
familiar with their patients for work rounds at c. 7:00 a.m. This will
include reviewing graphic sheets, events of the preceding evening, and
being familiar with all new admissions, diagnostic information, and therapeutic
interventions; interns must be prepared to comprehensively present their
patients on work and attending rounds. Senior residents have a responsibility
to provide didactic information appropriate to individual patients'
problems to their interns. They are expected to have relevant medical
literature each morning to use to supplement discussion of patient management.
Work rounds will commence not later than 7:00 each morning. The senior
residents serve as the team leaders. Whenever possible these rounds will
be multidisciplinary in nature, incorporating all health personnel participating
in the care of individual patients. This will include but need not be
limited to nurses, respiratory therapists, social workers, nutritionists,
case managers, discharge planners, and certainly attending physicians
and consultants. Rounds will be made together, with the intensivist, as
a team, assuring that all patients are seen and that all members of the
team have familiarity with the problems of all patients in the unit. Work
rounds must be made efficiently-- and it is for that reason that interns
must be familiar with their patients prior to the beginning of work rounds.
This is a time when it is essential that the residents, as a team, communicate
with patients' attending physicians, and consultants as well as all
of the ancillary medical staff involved in their care.
Teaching rounds, under the supervision an attending physicianwill occure
daily. These rounds will be both patient care related and didactic in
nature. They must include presentation and discussion of each patient,
at the bedside.
Formal "sign-out" rounds are scheduled at 4:30 each afternoon;
these should be supervised. All residents attend this session. During
this time individual patients are reviewed, daily events assessed, and
pertinent information passed on to the resident covering that evening.
In addition, time will be set aside during this session for brief didactic
discussion of topics according to the schedule enclosed.
A core ICU lecture series is held during the month. Resident attendance
is expected.
Students, at 3rd and 4th year levels, will be incorporated into all of
these activities. Their progress notes cannot be the official progress
notes of record. This means that residents should countersign student
notes but must record their own assessments. Students, by New Jersey Statute,
are not permitted to write orders. They are encouraged to use a duplicate
but unofficial order sheet to do so, for educational purposes, but these
cannot be part of the permanent record.
It is required that residents acquire competence in certain procedures.
Therefore the senior residents, together with interns, must aggressively
and assertively insist on learning and doing all procedures on all patients
under their care. Fellows, when present, can surely facilitate this. Similarly
it is expected that residents will write all orders for all patients under
their care. A reading and reference list will be appended.
GOALS AND OBJECTIVES
1. The resident will need to understand the approach to and establish competence in the
management of the following clinical presentations in the intensive care unit:
• Acute abdominal pain
• Acute chest pain
• Acute intoxication
• Acute liver failure
• Acute renal failure
• Altered mental status, coma
• Hypotension, shock
• Life-threatening arrhythmia
• Massive gastrointestinal bleeding
• Massive hemoptysis
• Respiratory distress or failure
• Severe hypertension
• Status epilepticus
• Multi organ failure
2. The resident should understand and be capable of interpreting the following:
• Hemodynamic monitoring
• Telemetry monitoring
• Arterial blood gases
• Pulse oximetry
3. PROCEDURES
Residents will learn, as appropriate to individual patients, the indications
and contraindications and performance of those medical procedures required
by the American Board of Internal Medicine and Residency Review Committee.
The resident will have opportunity to develop competence in some or all
the following procedures under direct suprervision of a faculty member,
fellow, or reident who is competent to teach the procedure:
• Advanced cardiac life support
• Arterial puncture for arterial blood gas
• Bedside pulmonary function
• Mechanical ventilation (basic)
• Placement of arterial and central venous lines
• Placement of nasogastric tube
• Placement of pulmonary artery catheter
• Insertion of temporary pacemaker
• Placement of endotracheal tube
EVALUATIONS
Assessment Methods (of Resident)
The evaluation methods that apply to these rotations include some or all
of the following:
- Evaluation of resident competence by faculty attendings (AE)- Formal formative
evaluations should occur at the completion of the specific rotation. It
is to be based on direct observation on rounds, at conferences, and at
the bedside. All faculty members are encouraged to complete the form prior
to the completion of the rotation and review their impressions directly
with the resident. All completed evaluation forms are returned to the
Program Director for review and placed in the resident's permanent file.
- Mini CEXs may be used when warranted, particularly in the beginning of
the academic year (CEX).
- Self-evaluation by In-service training examination scores (ITE).
- MKSAP study plan (MKSAP)
- Participation and presentations at didactic conferences (DC)
- Multi Source evaluations by patients and staff (MS)
Assessment Method (of Program)
Residents have the ability to evaluate teaching faculty and experience
at the end of each rotation. They are encouraged to use this opportunity
to give constructive feedback.
Residents are encouraged to maintain a high level of communication with
the Program Director and faculty. These informal meetings can be used
to disseminate information, receive timely feedback, and for other purposes.
Annually, all residents are required to complete and return an evaluation
form of the faculty and the program. Evaluations are collected in a fashion
to assure the anonymity of the resident. The feedback received during
informal meetings, formal meetings, and the semi-annual evaluation form
will be used to make programmatic change.
PRINCIPLE EDUCATIONAL GOALS BY RELEVENT COMPETENCY
In the tables below, the principle educational goals for the Faculty Inpatient
Service rotation are indicated for each of the six ACGME competencies.
The second column of the table indicates the most relevant principle teaching/learning
activity for each goal, using the legend below.
* Legend for Learning Activities/Evauation tools
AE-Attending Evaluations
AR- Attending Rounds
AuR- Autopsy Rounds
CEX-mini CEX
DC-residenct participation/performance in didactic conferences
DPC-Direct Patient Care
GR- Grand Rounds
ICU-ICU conferences
ITE-In-Training Exam
MKSAP-Knowledge Self Study Plan
MS-Multisource evals
SR- Signout Rounds
TR-Turnover Rounds
1.) Patient Care
| Goals and Objectives: PGY-1 |
Learning Activities* |
Assessment |
| Master basic patient interviewing skills |
DPC, AR, ICU |
AE, MS, CEX |
| Master basic patient exam skills |
DPC, AR, ICU |
AE, MS, CEX |
| Master basic psycho-social evaluation skills |
DPC, AR, ICU |
AE, MS, CEX |
| Define and prioritize patients' medical problems |
DPC, AR, ICU |
AE, MS, CEX |
| Generate and prioritize differential diagnoses |
DPC, AR, ICU |
AE, MS, CEX |
| Develop rational, evidence-based management strategies |
DPC, AR, ICU |
AE, MS, CEX |
|
Goals and Objectives: : PGY-3 (in addition to above)
|
Learning Activities* |
Assessment |
| Efficiently and effectively direct the initial evaluation and continued
management of patients requiring hospitalization including appropriate
discharge planning. |
DPC, AR, ICU |
AE, MS, CEX |
| Complete obtainment of certification in required Internal Medicine procedures.
Supervises junior trainees in these procedures once certified to teach |
DPC, AR, ICU |
AE, MS, CEX |
| Systematically obtains and reviews all prior/obtainable medical records
pertinent to patient care. |
DPC, AR, ICU |
AE, MS, CEX |
| Understands significance of all diagnostic test results affecting patient care. |
DPC, AR, ICU |
AE, MS, CEX |
| Clinical judgment – makes informed decisions using risk/benefit analysis
based on sound scientific evidence, patient performance after informed
consent and consultation with consultants and more senior physicians (attending). |
DPC, AR, ICU |
AE, MS, CEX |
| Begin to function as independent primary care givers |
DPC, AR, ICU |
AE, MS, CEX |
2.) Medical Knowledge
| Goals and Objectives: : PGY-1 |
Learning Activities* |
Assessment |
| Read and expand clinically applicable knowledge base of the basic and clinical sciences |
DPC, AR, ICU, MKSAP, GR |
AE, MS, MKSAP, DC |
| Access and critically evaluate medical information and scientific evidence
relevant to patient care |
DPC, AR, ICU, MKSAP, GR |
AE, MS, MKSAP, DC |
|
Goals and Objectives: : PGY-3 (in addition to above)
|
Learning Activities* |
Assessment |
| Develop medical knowledge about each patient illness so as to be able to
make independent decisions based on scientific evidence and patient preference. |
DPC, AR, ICU, MKSAP, GR |
AE, MS, MKSAP, DC |
| Demonstrates knowledge by leading discussions on areas of pathophysiology
concerning patient care including ongoing management of hospitalized patients. |
DPC, AR, ICU, MKSAP, GR |
AE, MS, MKSAP, DC |
| Demonstrates ability to access information from 3 different sources and
to synthesize sources into an indepth understanding. |
DPC, AR, ICU, MKSAP, GR |
AE, MS, MKSAP, DC |
| Develop medical knowledge adequate to practice independently |
DPC, AR, ICU, MKSAP, GR |
AE, MS, MKSAP, DC |
3.) Practice- Based Learning and Improvement
| Goals and Objectives: : PGY-1 |
Learning Activities* |
Assessment |
| Identify and acknowledge gaps in personal knowledge and skills |
DPC, AR, ICU, ITE, MKSAP |
AE, MS, MKSAP, DC |
| Develop and implement strategies for filling gaps in knowledge and skills |
DPC, AR, ICU, ITE, MKSAP |
AE, MS, MKSAP, DC |
| Accepts guidance from more experienced physicians and uses scientific evidence
and practice outcomes for practice improvement. |
DPC, AR, ICU, GR |
AE, MS, DC |
| Readily acknowledges practice omissions (errors) determined by self or
supervisors and takes corrective measures. |
DPC, AR, ICU |
AE, MS |
|
Goals and Objectives: : PGY-3 (in addition to above)
|
Learning Activities* |
Assessment |
| Continues to progressively reduce practice omissions/commissions from R-1,
R-2 levels. |
DPC, AR, ICU |
AE, MS |
| From medical knowledge and patient care experiences is able to question
patient care practices not supported by scientific evidence/evidenced
based care. |
DPC, AR, ICU, GR, MKSAP |
AE, MS, MKSAP |
| Develop PI skills to use in independent practice |
DPC, AR, ICU |
AE, MS |
4) Interpersonal Skills and Communication
| Goals and Objectives: : PGY-1 |
Learning Activities* |
Assessment |
| Communicate effectively with patients and families |
DPC, AR, ICU |
AE, MS, CEX |
| Communicate effectively with physician colleagues at all levels |
DPC, AR, ICU |
AE, MS, CEX |
| Communicate effectively with all non-physician members of the health care
team to assure comprehensive and timely care of patients |
DPC, AR, ICU |
AE, MS, CEX |
| Present patient information clearly, in notes and during presentations |
DPC, AR, ICU |
AE, MS, CEX |
|
Goals and Objectives: : PGY-3 (in addition to above)
|
Learning Activities* |
Assessment |
| Successfully communicate with patients and families that may be considered
difficult (angry, anxious, etc) advanced level |
DPC, AR, ICU |
AE, MS, CEX |
| Become fascicle at discussing difficult issues such as end of life care
and delivering bad news |
DPC, AR, ICU |
AE, MS, CEX |
| Effectively teach students and junior trainees to improve their communication skills |
DPC, AR, ICU |
AE, MS, CEX |
5) Professionalism
| Goals and Objectives: : PGY-1 |
Learning Activities* |
Assessment |
| Demonstrate respect, compassion, integrity, and altruism in relationships
with patients, families, and colleagues while maintaining confidentially. |
DPC, AR, ICU |
AE, MS, CEX |
| Always act in a moral, honest professional manner, and maintain appropriate
relations with patients. |
DPC, AR, ICU |
AE, MS, CEX |
| Respect and defend each patient's autonomy and privacy and always act
in the patients' best interest |
DPC, AR, ICU |
AE, MS, CEX |
|
Goals and Objectives: : PGY-3 (in addition to above)
|
Learning Activities* |
Assessment |
| Understand the principles of moral and ethical behavior required of an
independent practitioner |
DPC, AR, ICU |
AE, MS, CEX |
| Become familiar with actual or potential conflicts of interest; particularly
those involving personal financial gain. |
DPC, AR, ICU |
AE, MS, CEX |
6) Systems-Based Practice
| Goals and Objectives: : PGY-1 |
Learning Activities* |
Assessment |
| Understand and utilize the multidisciplinary resources necessary to care
optimally for patients |
DPC, AR, ICU |
AE, MS |
| Collaborate with other members of the health care team to assure comprehensive
patient care |
DPC, AR, ICU |
AE, MS |
| Use evidence-based, cost-conscious strategies in the care of patients |
DPC, AR, ICU |
AE, MS |
|
Goals and Objectives: : PGY-3 (in addition to above)
|
Learning Activities* |
Assessment |
| Develop lifelong strategies to optimize care for individual patients as
an independent practitioner |
DPC, AR, ICU |
AE, MS |
REFERENCE LIST
*All residents are expected to read about their patients in an appropriate
general medicine text. In addition, a vast variety of print and on-line
reference material is available though the library (24-hour access for
all residents) and the on-line portal. Specific reading material will
be recommended and/or distributed during rounds. Because it is frequently
updated, extensively referenced, and includes abstracts of reference articles,
the program highly recommends UpToDate as an adjunctive information source.
MDConsult is also a valuable resource and residents should become familiar
with use as a rapid search engine for clinical information
1. The ICU Book by Paul Marino
2. MKSAP- Pulmonary and Critical Care.
3. Useful Websites
http://www.learnicu.org/Quick_Links/Pages/default.aspx
http://www.uptodateinc.com/online/content/topic.do?topicKey=cc_medi/2523&selectedTitle=19&source=search_results
http://www.chestnet.org/education/guidelines/currentGuidelines.php#ebg
http://www.thoracic.org
http://www.chestnet.org/education/cs/index.php
http://www.thoracic.org/sections/careerdevelopment/fellowandfellowships/atsreading-list-intro.html
http://www.survivingsepsis.org/Pages/default.aspx
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