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Critical Care Medicine Curriculum

Description of ICU Rotation at the Cambridge Hospital campus

The rotation is designed around a multidisciplinary team approach to patient care.  As such, there are two main teams of providers, a day team and a night team, that will overlap and provide continuous care to our critically ill patient panel.  Interns will admit and manage patients, calling upon the resident and attending staff for guidance as needed.

Resident service patients are exclusively located on the 4th floor ICU.  All resident care of patients is supervised by an attending physician.  Residents receive a broad introduction to the evaluation and management of a wide variety of critical care problems common in general medical intensive care units as well as conducting pulmonary consultation to the inpatient services.  In addition to the routine case mix for community hospital intensive care unit, the rotation provides a unique opportunity for residents to consider the complex relationships between health status and poverty including in-depth clinical experiences with substance abuse, co-morbid medical and psychiatric disease, geriatrics, HIV/ AIDS, homelessness, international and immigrant health.


Goals and Objectives

Broad goals and objectives for the inpatient rotation are listed below and organized within the six core competencies identified by the ACGME.

Medical knowledge

During the rotation residents should:

  • Expand understanding of the basic, clinical, and social sciences underlying the care of medical inpatients
  • Access and critically evaluate current medical information and scientific evidence relevant to patient care
  • Build basic fund of knowledge related to clinical diagnosis and management of common and “cannot miss” diagnoses, see ICU Curriculum.

 

PGY 1 Learning Objectives

PGY 2 Learning Objectives

PGY 3 Learning Objectives

o   Build cognitive schemas to facilitate approaches to common symptoms and syndromes

o   Demonstrate independent critical thinking in patient evaluation and management

o   Consolidate basic fund of knowledge related to evaluation and management of common and cannot miss diagnoses

o   Apply clinical guidelines and principles of evidence-based medicine to patient evaluation and management

o   Review core knowledge base related to common and cannot miss diagnoses

o   Develop more detailed knowledge of selected topics within inpatient internal medicine

o   Critically appraise data from recent literature and evidence behind clinical guidelines

Patient care

During the rotation, residents should improve their ability to:

  • Interview and examine patients
  • Define and prioritize patients’ medical problems
  • Generate and prioritize differential diagnoses
  • Develop rational, evidence-based management strategies
  • Understand the role of the hospital and the acute phase in the overall illness episode and develop effective patient care plans for post-hospital care
  • Perform basic clinical procedures and interpret common radiology studies
  • Manage common inpatient medical emergencies

 

PGY 1 Learning Objectives

PGY 2 Learning Objectives

PGY 3 Learning Objectives

o   Gather essential and accurate information about patients through history, physical exam, and review of secondary data

o   Identify and prioritize patient’s medical problems and develop rational plans for evaluation and management

o   Work effectively with nurses and allied health professionals in daily activities of patient care

o   Attend to patient needs and provide patient-centered care

o   Supervise interns in their work of gathering, interpreting, and managing information for patient care

o   Apply scientific evidence to the work of patient evaluation and management and assist interns in formulating plans of care

o   Triage patients to appropriate levels of care and ensure appropriate communication with colleagues and attending physicians

o   Manage inpatient medical emergencies

o   Work effectively with multidisciplinary team in planning patient discharge

o   Assist interns as necessary in completing daily tasks of patient care to facilitate the primary care-giving relationship between the patient and intern

o   Supervise interns in their work of gathering, interpreting, and managing information for patient care

o   Apply scientific evidence to the work of patient evaluation and management and assist interns in formulating plans of care

o   Triage patients to appropriate levels of care and ensure appropriate communication with colleagues and attending physicians

o   Manage inpatient medical emergencies

o   Work effectively with multidisciplinary team in planning patient discharge

o   Assist interns as necessary in completing daily tasks of patient care to facilitate the primary care-giving relationship between the patient and intern

Interpersonal skills and communication

During the rotation, residents should:

  • Communicate effectively with patients and families
  • Communicate effectively with physician colleagues at all levels
  • Communicate effectively with all members of the health care team
  • Present patient information concisely and clearly, verbally and in writing
  • Teach colleagues effectively
  • Participate and conduct in palliative care, end of life and goals of care discussions with patients and families

 

PGY 1 Learning Objectives

PGY 2 Learning Objectives

PGY 3 Learning Objectives

o   Complete comprehensive and concise written documentation for patient care including admission H&Ps, daily progress notes, and discharge summaries and other discharge paperwork.

o   Orally present patients effectively in a variety of patient care settings including work rounds, signout rounds, and in requesting consultation.

o   Build effective therapeutic alliances with patients

o   Teach medical students effectively and provide peer teaching on discrete clinical topics

o   Cultivate respectful relationships with coworkers

o   Review and provide feedback to interns on written documentation; complete a resident addendum note on all new admissions.

o   Teach effectively in informal settings in the context of shared work and in formal settings such as morning report and visit rounds.

o   Provide effective team leadership including setting expectations, reinforcing productive behaviors, providing feedback

o   Facilitate interdisciplinary team meetings with patients and families

o   Assist interns in negotiating conflictual relationships and managing difficult patients

o   Review and provide feedback to interns on written documentation; complete a resident addendum note on all new admissions.

o   Teach effectively in informal settings in the context of shared work and in formal settings such as morning report and visit rounds.

o   Provide effective team leadership including setting expectations, reinforcing productive behaviors, providing feedback

o   Facilitate interdisciplinary team meetings with patients and families

o   Assist interns in negotiating conflictual relationships and managing difficult patients

 

Professionalism

During the rotation, residents should:

  • Behave respectfully with colleagues including effective conflict resolution, reliability, honesty, punctuality
  • Demonstrate a commitment to standards for lifelong excellence and patient centered care
  • Cultivate compassionate relationships with patients and family
  • Reflect on physician responsibilities to society

 

PGY 1 Learning Objectives

PGY 2 Learning Objectives

PGY 3 Learning Objectives

o   Work within duty hours restrictions

o   Identify personal limitations and seek help as needed to facilitate optimal patient care and optimal self care

o   Demonstrate commitment to excellence including careful follow through and attention to detail

o   Demonstrate principles of ethical practice including altruism and honesty

o   Demonstrate compassion in relationships with patients and families

o   Supervise work of interns and ensure compliance with duty hours restrictions

o   Facilitate the personal and professional development of the interns

o   Model self reflection and self care

o   Demonstrate commitment to excellence of the overall work of the team

o   Demonstrate principles of ethical practice including altruism and honesty

o   Demonstrate compassion in relationships with patients and families

o   Supervise work of interns and ensure compliance with duty hours restrictions

o   Facilitate the personal and professional development of the interns

o   Model self reflection and self care

o   Demonstrate commitment to excellence of the overall work of the team

o   Demonstrate principles of ethical practice including altruism and honesty

o   Demonstrate compassion in relationships with patients and families

 

Practice-based learning and improvement

During the rotation, residents should:

  • Demonstrate curiosity and demonstrate capacity to ask relevant clinical questions
  • Identify knowledge gaps in personal knowledge and/or skills in the care of hospitalized patients and assess personal learning objectives for the rotation
  • Develop and implement strategies for filling gaps in knowledge and skills

PGY 1 Learning Objectives

PGY 2 Learning Objectives

PGY 3 Learning Objectives

o   Set personal learning goals in each of the six core competencies for the rotation

o   Learn something from the care of each patient

o   Develop familiarity with a range of information resources

o   Set personal learning goals in each of the six core competencies for the rotation

o   Generate effective clinical questions for personal learning

o   Use resources effectively to answer clinical questions

o   Set personal learning goals in each of the six core competencies for the rotation

o   Generate clinical questions for personal learning and meaningful teaching with attention to learner needs

o   Expand repertoire of information technology resources for teaching and learning

 


Systems-based practice

During the rotation, residents should:

  • Understand and utilize the multidisciplinary resources necessary for the care of critically ill patients
  • Manage transitions of care effectively
  • Use evidence-based, cost-conscious strategies
  • Participate in improving systems of care
  • Participate in improving the rotation as a resident clinical learning experience

 

PGY 1 Learning Objectives

PGY 2 Learning Objectives

PGY 3 Learning Objectives

o   Understand challenges imposed by dysfunctions in the health care system and their impact to patients

o   Develop basic knowledge of costs of care in the inpatient environment

o   Identify opportunities for improvement in systems of patient care

o   Offer constructive suggestions for improvement

o   Develop familiarity with the multidisciplinary resources necessary for effective in-hospital and post-discharge patient care

o   Review available data on quality of care and patient satisfaction in the inpatient environment

o   Consider costs of care intentionally in making patient care plans

o   Propose strategies for improvement in systems of patient care

o   Reflect on the rotation and offer constructive suggestions for improving the rotation

o   Advocate effectively for patients within the complex multidisciplinary environment of the health care system

o   Review available data on quality of care and patient satisfaction in the inpatient environment

o   Provide cost-conscious guidance to interns in making patient care plans

o   Participate in patient care quality improvement initiatives

o   Reflect on the rotation and offer constructive suggestions for improving the rotation


Clinical encounters and learning venues


During the rotation, residents will perform:

  • Initial evaluation of all new admissions and transfers from other services
  • Daily evaluation and management
  • Participate in multidisciplinary rounds
  • Procedures including intubations, central line access, intra-osseous needle placement and removal, thoracentesis, arterial cannulation, abdominal paracentesis, ABG, lumbar puncture, gastric tube placement,   
  • Daily review of radiologic studies
  • Formal teaching sessions including daily weekday educational sessions based on the ICU Curriculum, palliative care didactic sessions, and Grand Rounds
  • Morning and afternoon patient management rounds with the attending physician

 

Principal resources

  • On-line databases including Critical Care Team Site and provided links therein
  • UptoDate
  • Primary and secondary medical literature accessible through full-text searching using PubMed
  • Textbooks including The ICU Book, Harrison’s, Washington Manual

 

Daily Schedule

Pre-Rounding

  1. The night intern is responsible for reviewing all relevant data (labs, vitals, overnight events etc) and formulating a progress note. (Please see sample progress note in the orientation folder and discuss with your resident).
  2. The night intern should discuss with the night resident at the bedside the plan for the day prior to the start of rounds from 7:30 until 8:00 am.
  3. The day team will get a brief report from the night team from 8:00 am until 8:30 am.

Rounding

  1. Board Huddle:

    Starting at 8:30 am, the residents, attending and the charge nurse will huddle at the patient board and identify the order of
    rounds and possible transfers. 

  1.  Ventilator Rounds:

     Following the board huddle, the residents, respiratory therapist, nurse and attending will quickly see all vented patients
     and formulate a ventilator plan for the day. 

  1. Work Rounds:

    The intern will present each patient with focused attention on 12 hour events, ongoing reassessment of patient’s current
    status and plan for the day.  The day interns will enter all orders and will complete a task list on the ICU Signout Report
    and summarize the task list at the end of the presentation. During the presentation, nurses will provide an updated
    medication list and will contribute formally to the assessment and plan for each patient.  Prior to the next patient, the
    presenting intern will ask if there are any “patient safety or skin concerns” to the larger group.

    The night resident will lead am rounds and direct the flow of rounds.

    The attending will direct education.

Afternoon

1. The day interns will alternate responsibility for the completion of all necessary work and critical care evaluations (under the guidance of the resident and attending) and the completion of all procedures and the daily task list.

2. The nature of ICU medicine requires constant patient reassessment and reevaluation.  It is the responsibility of the residents to perform these critical tasks throughout their time.  At no later than 4:00 pm the residents and nurses will reevaluate all patients with the attending, ascertain that all tasks are being completed, and document an updated plan for the day.  The resident should review and update the ICU Signout Report during these rounds. 

Education

1. At a mutually agreed upon time daily in the afternoon, the day team will gather in the back room for an educational lecture based on the ICU curriculum.

2. Every week, the resident will direct journal club.  Journal articles should be relevant to ICU medicine, not review articles, and of recent publication.  They will be picked by the resident and approved by the attending no later than Tuesday of that week.

3. Time permitting there will be resident level directed teaching in the afternoon that will be evidenced based and relevant to actual ICU patients.

Team transfer

In an effort to clarify the flow process around ICU transfers, the following process needs to be observed.

1.  Prior to morning rounds, the resident, attending and charge nurse will identify potential transfers.

2.  The ICU resident will notify the Charge Nurse/NM/OSM/Bed flow coordinator of any transfers.

3.  The Charge Nurse/NM/OSM/Bed flow coordinator will then notify the ICU Team of bed availability as soon as possible.

4.  Only after a bed has been assigned will the ICU Team initiate the multi-tiered team transfer process that includes transfer orders, face to face sign out etc…

Overnight

1. There will always be a member of the team in the ICU at all times.

2. At midnight, the residents and nurses will round on all patients in the ICU to assure that the goals of care are being met.

3. Any significant changes in status will be communicated with the attending on call.

4. The night intern will be responsible for completing the Critical Care Case Series as time permits.

5. The night intern will be responsible for updating any information in the hospital course and transfer summary.

Critical Care Consultation

1. The resident will evaluate all critical care consultation at Cambridge Hospital and will discuss their evaluation with the ICU attending. The resident will communicate with the requesting physician the results of our evaluation within 15 minutes. If the patient is to be transferred to the ICU service, the resident will communicate with the Charge Nurse in the ICU and the Bed Flow Coordinator/Off Shift Manager of the impending transfer (Pager 0590). 

2. A formal consult will be entered in the chart to document our findings in situations where the patient is not accepted to the ICU.

Critical Care Consultation Guidelines

1. Inpatient ward teams (resident service or hospitalist) can request a critical care consultation on a patient that they think is medically unstable.

2. Seeking critical care consultation should be a provider-provider conversation and the reason for consultation should be clear.

3. ICU team will assess the patient and discuss with ICU attending within 15 minutes and provide recommendations to the referring doctor. Again, this communication should be a provider-provider conversation in addition to usual chart documentation.

4. If the ICU team thinks that the patient can be managed safely on the floor, the consulting team will be explicit in regards to the following:

(a) If ICU team going to check-in on patient's status by following along until the worrisome scenario abates.

(b) Inform the team requesting the consult when the ICU team is signing off on the patient's case.

(b) Inform the team requesting the consult what worrisome features to watch out for to re-consult ICU team.

5. Attending to attending clarification is welcomed if the primary team is dissatisfied with the recommendation to manage the patient on the floor.

Managing a seriously ill patient can be stressful for any physician and clear expectations as well as healthy communication will strengthen working relationships necessary for effective patient care.

Orders

All patients admitted to the ICU require the following order sets irrespective of admitting diagnosis:  
  1. Medication Reconciliation
  2. ICU Admissions Order Set
  3. ICU Prophylaxis Order Set
No other admitting order sets will be accepted.

Rapid Response and Code

1. The ICU team is primarily responsible for all rapid responses and codes.

2. The resident will always attend and based on personnel availability, an intern may attend if the unit is left with
    physician staffing.

3. Upon completion of the Rapid Response, the resident responder will document the findings and interventions in a
    note in the medical record.

ICU Culture

  1. The entire team is responsible for all patients in the ICU.  Tasks may be divided but all members of the team are expected to have full knowledge and have responsibility for the management of each case.
  2. Never enter an order without communicating with the nurse.
  3. No charts, ECG’s and other patient paperwork should be left in the back room.
  4. The intensive care unit can be a stressful environment given the nature of critical illness.  It is imperative to remain calm and respectful at all times.
  5. At 6:00 am, 2 pm, 6:00 pm, and 10:00 pm the respiratory department changes shifts. At 7:00 am and 7:15 pm, the nurses change shifts.  These are busy times for them and we should avoid interruptions to them during change of shifts.  No elective procedures will be conducted at change of shifts. 
  6. Family meetings are vital to ongoing patient care.  They will be coordinated and directed by the resident with the attending physician and the patient’s nurse in attendance.  The discussion will be summarized in a note by the resident in a Family Note.
  7. Upon admission to the ICU, the primary care provider for that patient will be notified of their patient’s condition within 6 hours of ICU arrival.  The team will ask the PCP how further communication should occur.  The template for the PCP communication is available on the House Staff Document Folder in the Critical Care Team Site.  Communication can also be made via an EPIC In-basket Message.
  8. All significant changes in a patient clinical condition will be communicated to the attending in a timely manner.
  9. Hand disinfection will be performed before and after entering a patient’s room.  Prior to entering a patient’s room all applicable personal protective equipment will be worn.  Before exiting the room, all personal protective equipment will be discarded. 
  10. At least one member of the team is to remain physically in the ICU at all times.

Procedures

  1. Consent will be obtained by the team and placed in the chart prior to the initiation of the procedure from either the patient or the Health Care Proxy/Next of Kin. 
  2. All supplies will be gathered by the intern from the Procedure Cart or from the Clean Utility Room (Code 512) or from the ICU Office (Code 315).  Additional supplies should not be brought into the patient’s room so they can be restocked if unused.
  3. A time out sheet will be stamped and handed to the nurse prior to entry into the patient’s room.  The STOP sign will be hung in the doorway prior to the initiation of the procedure.

4.   If the ultrasound is needed for a procedure, the intern will pick up ultrasound machine from the ICU office.  Once the procedure is completed the ultrasound machine is to be disinfected and returned to ICU office.

 

Evaluation

Resident Evaluation

The ICU attending will assume responsibility for orienting his or her team to the rotation and facilitating a conversation with each house officer about his or her learning goals for the rotation.  At the end of each week, the ICU attending will meet with the team and provide ongoing feedback.  The resident will be formally evaluated in keeping with the standard evaluation tools of the Internal Medicine Residency Program at the end of their rotation.

Residents are encouraged to take initiative in seeking targeted feedback if not initiated by the ICU attending.

Attending Evaluation

Interns and residents are expected to complete an online evaluation form on both of the attending hospitalist physicians with whom they work during the rotation.


Program Evaluation

Interns and residents are expected to complete an online evaluation form of the rotation.  Additional comments, questions, concerns, and suggestions for improvement are always welcome.