Fellowship Training Program


Published on

Published in: Health & Medicine, Education
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Fellowship Training Program

  1. 1. Program Description and Supervision Policy Critical Care Medicine Fellowship Page 1 of 7 Version February 4, 2008 Program Goal: The overall goal of our Fellowship program in Critical Care Medicine is to train and educate physicians in the care of critically ill patients. The Fellowship is a one or two year program designed to foster both the clinical and the leadership skills necessary to develop and promote a multi-disciplinary approach to Critical Care Medicine. The specific goals of the program are: I. To understand the physiology and pathophysiology of critical illness. II. To evaluate and manage the critically ill patient. III. To develop the procedural skills necessary for the care of the critically ill. IV. To understand the administrative aspects of Intensive Care Unit management. V. To understand ethical and legal aspects of Critical Care. VI. To understand research design and data interpretation. To accomplish these goals, the following guidelines have been accepted and enacted. 1. Interdepartmental Relationships A. Relationship with the Department of Anesthesiology: a. Administration: The section of Critical Care Medicine is a division of the Department of Anesthesiology at Dartmouth-Hitchcock Medical Center (DHMC) and Dartmouth Medical School. The training hospital is the Mary Hitchcock Memorial Hospital (MHMH). Administrative aspects of the section are the responsibility of the director of the section, who reports directly to the chairman of the department of anesthesiology. b. Fellowship: The anesthesiology-based fellowship program interacts with the director of the anesthesiology residency program. Residency reviews are accomplished in coordination with the review of the residency program. B. Relationship with the Department of Internal Medicine: The director of the internal medicine residency program interacts with the internal medicine-based fellowship program. General reviews and oversight reviews are accomplished in coordination with the internal medicine residency program. C. Relationship with the Pulmonary Medicine Section: The combined pulmonary medicine and critical care medicine fellowship is conducted in coordination with the program director for this training program. While on the Critical Care Service, all fellows are expected to meet the same performance criteria.
  2. 2. CCM Fellowship Page 2 of 7 Version February 4, 2008 2. SUPERVISION AND CLINICAL RESPONSIBILITIES A. Critical Care Service Structure: The Critical Care Service (CCS) functions on two models. a. One model is a collaborative care co-attending model. The primary service and the CCS both maintain responsibility for the patient. b. The second model is a primary attending model. With this designation, the only physician service with primary responsibility for the patient is the CCS. B. Critical Care Service Responsibilities: On the CCS, an attending physician rounds with the trainees seven days a week and is available on call twenty-four hours a day, seven days a week to supervise the trainees. The trainees notify the attending of all admissions and consults. Each patient seen by a trainee is seen by the attending. This oversight includes the presentation of the patient by the trainee including past medical records, history, physical and laboratory data, and review of all pertinent roentgenograms. The data are then corroborated at the bedside with the trainee including key historical and physical exam items. The differential diagnosis and approach to diagnostic testing and treatment are reviewed. All active patients are reviewed in detail regarding clinical course, new problems, results of diagnostic testing, and response to therapy on daily rounds. a. On Call Responsibilities i. First call: 1. AVAILABILITY: The intent is to provide immediate supervision of the residents on-call for CCS patients and to provide immediate consultative services for in-hospital patients as well as emergency room patients. This responsibility is best met by remaining in the hospital. Hence, the expectation is that the person on first call will remain immediately available. a. Brief, nonrepeating absences from the immediate campus may be permitted on a per incident basis. This must be discussed with the supervising attending, the residents on-call, and the charge nurse for the intensive care unit (ICU). 2. RESPONSIBILITIES: The fellow will cover the admission and triage beeper (see responsibilities, below), supervise residents, provide administrative support for the ICU, and report to the attending intensivist on call. ii. Second call: Second call occurs when an in-house attending covers the first call responsibilities. The fellow
  3. 3. CCM Fellowship Page 3 of 7 Version February 4, 2008 will remain available on beeper while out of the hospital. Interesting admissions, unusual clinical circumstances, high volume or acuity will constitute the most common reasons for a fellow to be called in. b. Rounds: i. Morning Rounds: Rounds are multi-disciplinary including not only physicians but also the Nursing Staff, Respiratory Therapists, Clinical Pharmacists, Nutritionists. During the morning bedside rounds, a patient’s clinical course is reviewed, and the care plan for the day is formulated. This is done in conjunction with the CCS attending and other members of the health care team. 1. Note that the post-call fellow on weekend days when he/she has no assigned responsibilities on the posted schedule is expected to transfer appropriate information. Once this is accomplished, he/she is not expected to round with the on-call teams. ii. Afternoon Rounds (Hand-off rounds): From 1:30 PM to 2 PM all members of the CCS who are on service are expected to attend afternoon rounds. C. 2419 Responsibilities: The attending or fellow carrying the virtual pager 2419 is responsible for admission and triage administrative responsibilities. The responsibilities for the fellow include: a. Each AM the fellow will check for ICU reservations and assess ICU patients for potential discharges. Following this, the fellow should meet with the ICU charge nurse of the day to review bed availability and staffing. The responsible CCS Attending must approve all discharges. b. If an ICU admission is requested, whenever possible, the patient should be evaluated by the fellow prior to transfer. A decision to refuse ICU admission must be discussed with the responsible CCS Attending. c. If ICU admission is deemed appropriate, the ICU charge nurse should be contacted to arrange transfer to the ICU. If no critical care bed is available in the ICU, the Administrative Coordinator on Site (ACOS) should be contacted. d. If the CCS and DHMC is on triage status, then no transfers from another hospital may be accepted unless the admission is of the pre-approved type. Bed availability must be discussed with the ACOS and the access center staff. e. The responsible CCS Attending must be notified in a timely fashion about all admissions to the ICU. f. The notification of the primary attending and the patient's family is generally the responsibility of the service transferring the
  4. 4. CCM Fellowship Page 4 of 7 Version February 4, 2008 patient to the ICU. However, the CCS team should ensure that this has taken place. g. If contacted directly by an outside physician regarding transfer of a patient, the fellow should facilitate transfer. If necessary, a patient may be evaluated in the Emergency Department (ED) by the primary service and CCS fellow prior to ICU admission. h. CCS consultations that are requested should be performed as soon as possible. These must be reviewed with the CCS Attending prior to making final recommendations. i. Patients can be admitted to the ICU as APC patients. These patients remain the responsibility of the primary service. D. Consult Service Rotation: The Critical Care Consult Service has multiple responsibilities and clinical duties. The intent of this service is to provide longitudinal critical care coverage for long-term, less acutely ill patients, and to provide a readily available source for critical care consultations throughout the hospital. The consult service will generally consist of an attending intensivist, a critical care fellow, and a nurse practitioner. a. Adult Progressive Care (APC) Patients: APC patients become assigned as such through many different mechanisms. For example, the patient may be a former CCS patient transferred to less acute care, or the patient may have been directly admitted to this rubric to benefit from the close nursing ratio and/or require therapy not available on the regular wards (such as an acute transfer to receive non-invasive positive pressure ventilation.) i. APC Patient Responsibility: APC patients are the direct responsibility of the primary service. The Critical Care Consult service will provide consultative services. ii. Critical Care Consult Service Role: The Critical Care Consult Service will round daily on APC patients, and progress notes will be entered into the record. Triage into and out of APC status will be the responsibility of the consult service. The consult service will be available for direct emergency care on an as-needed basis. b. Cardiac surgical patients – Consult service responsibility: A consultation will be performed on all cardiac surgical patients who have persisting critical care issues at 24 hours after admission to the CTICU. Consultations may be requested at any time by the primary service on an as-needed basis. c. Triage responsibilities (2419 beeper): The consult service fellow, attending or nurse practitioner will assume 2419 beeper responsibilities (see above) from 8 AM to 2 PM. He/she will evaluate patients and provide initial comprehensive care if admission to CCS is appropriate. Care will be transferred to the CCS service at either hand-off afternoon rounds, or earlier as
  5. 5. CCM Fellowship Page 5 of 7 Version February 4, 2008 appropriate for the level of care required. E. Non-Clinical Rotations: The fellows report directly to the fellowship director while on research rotations, as well as to their research mentor. During elective rotations on other services, the fellow reports directly to the attending physician covering the service. F. DUTY HOURS: The duty hours will strictly follow the requirements of the ACGME. These describe the frequency of in-house call, the hours worked, the length of time between required shifts, and the number of days off. The specific requirements may be found on the website for the ACGME: http://www.acgme.org. It should be noted that the anesthesiology and internal medicine subsections have slightly different requirements. The program will generally follow the more strict requirements for all fellows, regardless of their primary specialty. a. DUTY HOUR TRACKING: Duty hours will be tracked with the E*Value program. Reliable and timely reporting of hours is an expectation of the program. Training in using this simple web- based system will be provided. G. Away time: Time away, such as for vacation and meetings, must be approved by the program director. In general, such time away should be scheduled during elective time. No more than 3 fellows may be away at a given time. H. Promotion, Dismissal and Probation: 1. Promotion: The results of evaluations are used to determine whether to promote a fellow from one PGY level to the next. If the program director feels promotion should not be granted, a special faculty meeting is convened before the final decision is rendered. 2. Probation: Any fellow who is not performing well based on faculty evaluations and/or examination performance may be placed on probation. The program director will notify a fellow of such a situation in writing. In addition, the program director will specify the reason for probation, assign a faculty advisor during this probation period and will counsel the fellow accordingly. A probationary period should, ideally, precede a dismissal action unless the dismissal is the result of actions other than clinical and/or academic underachievement. For a more detailed accounting of probation procedures and the fair hearing process please see the “Fair Hearing Policy” and “Grievance Policy” in the DHMC Graduate Medical Education Manual. 3. Dismissal: Recommendations for dismissal due to an academic or non- academic deficiency will generally be preceded by a defined period of remedial training in order to allow the fellow to improve and remain in the program. Fellows may be dismissed without an intervening probationary period for behavior incompatible with the role of the physician. For a more detailed accounting of dismissal procedures and the fair hearing process
  6. 6. CCM Fellowship Page 6 of 7 Version February 4, 2008 please see the “Fair Hearing Policy” and “Grievance Policy” in the DHMC Graduate Medical Education Manual. 3. Educational Program A. Conference Schedule: Attendance at conferences is an expectation of the program. a. Advanced Lecture: Lectures will be presented by Critical Care faculty and other invited guest lecturers. This conference will follow a didactic format and is led by faculty. b. Professor's Rounds: D. David Glass, MD conducts bedside teaching rounds on a semi-monthly basis. Fellows are expected to participate actively in these rounds c. Case Conferences: A fellow on the CCS presents interesting cases from the intensive care unit. Review of the clinical course and a literature review will be accomplished. The intent of this conference is to create a dialogue on care of the critically ill patient. Faculty and fellows will select special cases of current or unusual interest. d. Journal Club: Current, published topics on research and subject matter of special interest, the journal club is presented in an interactive forum. The fellow and faculty presenting at the conference will choose topics. The fellow leads the discussion. e. Quality Assurance Conference: On a monthly basis cases that have met QA criteria will be reviewed. Cases will be presented from section-gathered data. f. Palliative Care/Ethics Conference: Cases and issues in palliative care and ethics will be presented to an attending from the palliative care service on a monthly basis. The fellow will present cases/issues. g. CURRICULUM: The full curriculum for critical care fellows is available on the website at: www.dhmcicu.org, and is based on the core competencies. C. RESEARCH: Research by the fellow in training is supported by the section of critical care medicine. 4. Procedure Training and Documentation In Critical Care Medicine A. ACGME Requirements: The Accreditation Council for Graduate Medical Education (ACGME) requires that trainees develop a comprehensive understanding of the technical procedures integral to his/her training. This includes cognitive as well as technical competence as determined by the faculty. Documentation of your experience in procedural training and competence is required. The following guidelines outlined below have been established to achieve those goals. B. Procedure log: Procedures should be documented and logged. The E*Value system has been employed to perform this task, and timely
  7. 7. CCM Fellowship Page 7 of 7 Version February 4, 2008 completion of the log is an expectation of the program. C. Supervision: Documentation of supervising attending physician should be indicated. D. Evaluation: A minimum number of procedures (varies according to procedure) should have a completed evaluation signed by the supervising attending physician. This criterion is accomplished with the E*Value system. a. Minimum Number of Procedures: i. Radial arterial catheter: 20 ii. Femoral arterial catheter: 10 iii. Internal jugular central venous access: 25 iv. Subclavian central venous access: 25 v. Femoral central venous access: 25 vi. Endotracheal intubation: 50 vii. Tube thoracostomy: 10 viii. Pulmonary artery catheter: 35 ix. Flexible bronchoscopy (pre-existing endotracheal tube): 25 5. Training Program Evaluation Process A. Fellow evaluations: At the end of each rotation, the attending faculty will evaluate the performance of the fellows. The evaluation will follow the core clinical competencies as required by the ACGME (see enclosed form.) B. To assess their educational progress, once each year Critical Care Fellows are required to take the Critical Care Fellowship Assessment Exam (MCCKAP) which is administered by the Society of Critical Care Medicine. C. Evaluations by the fellows: Fellows will be provided the opportunity to evaluate the attending faculty and comment on the training program. D. Evaluation Reviews: The program director will meet with the fellows on a quarterly basis. This meeting will review the evaluations of the fellows by the attending, and provide a forum for the fellow to give feedback on the training program.