Curriculum Guide (2005-2006).doc

2,083 views

Published on

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,083
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
10
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Curriculum Guide (2005-2006).doc

  1. 1. Internal Medicine Residency Program CURRICULA 2005 / 2006 John H. Stroger, Jr. Hospital of Cook County Department of Medicine
  2. 2. CURRICULA for Internal Medicine Residency Program TABLE OF CONTENTS CORE PATIENT CARE EXPERIENCES HIV Inpatient Service …...................….....................………….................................3 Ambulatory Medicine……………………..…………………………………………...………..6 Coronary Care Unit (CCU) ……………….........................................................................9 Critical Care (MICU) ……………………………………..….…………………………13 Emergency Medicine ……………………..………………………….…………………16 General Medicine Clinic…………………………………………….…………………………18 Medicine Short Stay Unit (SSU) …………………………….……………………….…….21 Geriatrics/Rehabilitative Medicine …………………………………..……………………….34 Inpatient Medicine ……………………….………………………………………….……….37 Women’s Health ………………….………………………………………………...……..41 SUBSPECIALTY ROTATIONS Cardiology ……………………………………………………...……………………………43 Endocrinology & Metabolism ……………………………...……………………………47 Gastroenterology ………………………………………………………..………………….56 General Medicine Consultation …………………………………….……………………..60 Hematology ……………………………………………………………………...……………65 Infectious Disease ………………………………………………………………….………..68 Nephrology/Hypertension ………………………………………………..………………….73 Oncology …………………………………………………………………….……………..77 Pulmonary ……………………………………………………………………...……………80 Rheumatology ……………………………………………….…………………………..84 ELECTIVES Adolescent Medicine …………………………………………….……………………..87 Dermatology ……………………………………………………...……………………………89 Neurology ……………………………………………….………………….……………….92 Occupational Medicine ……………………………………………...……………………95 Toxicology …………………………………………………….……………………………..98 ADDITIONAL INSTRUCTIONS Hospice/Palliative Medicine and End-Of-Life Care …...………………………..…..……100 Otolaryngology………………………………………………………………………………..102 Ophthalmology………………………………………………………………………………..104 Orthopedics…………………………………………………………………………………...106 Psychiatry……………………………………………………………………………………..108 Evidence Based Medicine …………………………….…………………………………...110 Laboratory Medicine & I Skills …..…………………………………………..……………..111 Medical Ethics ……………………………………..…………………………………..113 Medical Procedures …………………………………………………………………………114 Physician Impairment ………………………………………………………………....117 Principles of Legal & Governmental Regulations ………………………………….119 Socioeconomic & Cost Effectiveness Issues ………………………………………….120
  3. 3. CURRICULUM OUTLINE Curriculum Topic: HIV Inpatient Service 1. Educational Purpose and Rationale for the Curriculum The HIV Inpatient Service is a four-week intensive training of housestaff on the inpatient management of HIV infected patients. The attending physician is an Infectious Disease Specialist. This ward promotes a multidisciplinary approach to the health care of the HIV infected patient. The goal of this rotation is to provide the housestaff with the skills to be the primary physician in the inpatient care of patients with advanced HIV disease. Instruction is given by a specialist trained in this area with assistance from a clinical pharmacist and Physician Assistant (PA). The care of HIV infected patients with advanced disease is a complicated issue. Management of multiple medications with their high incidence of adverse events and diagnosis and therapy of multiple opportunistic and nosocomial infections can be an overwhelming challenge. Additional problems such as nutritional depletion, psychological manifestations of HIV disease, social service issues, and rapid FDA release of agents used in the care of HIV infected patients makes the inpatient care of the HIV infected patient a daunting challenge. The HIV Inpatient Service provides an environment where the house staff can concentrate on the issues affecting HIV infected patients under the direct supervision of specialists trained in this area. 2. Principal teaching methods a. Didactics/lectures: Lectures, by the Infectious Disease Division, are given 3 days a week. Additional lectures may be given regarding specific patients. Infectious Disease fellows assigned to the HIV ward assess points of interest regarding cases on the unit and do a literature search and give a more formal presentation to the housestaff the following day. The clinical pharmacist gives formal lectures to the housestaff regarding antiretroviral agents and use of these medications in HIV infected patients. Additional formal conferences are held regarding the care of Infectious Diseases and HIV+ patients' 2x per week. Case presentations and formal lectures are rotated in these conferences. b. Self study: Housestaff are encouraged to self study. Attendings, PA’s, and Clinical Pharmacists provide housestaff with literature and try to stimulate reading by providing questions (e.g., MKSAP format) for housestaff. The house staff's' medical background and improvement in the rotation is evaluated in an end of the rotation evaluation form completed by the attending physician. Attending physicians also communicate periodically with housestaff about housestaff progress, areas of weakness, and ways to improve their clinical skills. c. Other: Patient care rounds are teaching rounds involving informal instruction on the care of the patients on the ward. These rounds are geared to management issues and discussion of the differential diagnosis and diagnostic workup of HIV infected patients. d. Microbiology Rounds are held once a week. Topics reviewed during these sessions include: HIV diagnostics, Blood cultures, Mycobacterial testing, Susceptibility testing. Patient specific results may also be reviewed during that session. 3. Educational content a. Major objectives --10-15 most important subjects covered: 1. Use of common antimicrobial agents in the management of HIV infected patients (i.e., antiretrovirals and OI prophylaxis). 2. Differential diagnosis of fever in the HIV infected patient. 3. Use of common diagnostic procedures in the inpatient management of HIV infected patient (CXR, standard blood tests, PPD). 4. Use of advanced diagnostic procedures in the diagnostic management of HIV infected patients (viral cultures, MRI, CT scans). 5. Use of empiric antibacterial agents in the treatment of suspected bacterial infection. 6. Use of antimicrobial agents specific to AIDS patients.
  4. 4. 7. The pathogenesis of HIV and its effect on the immune system. 8. Adverse drug effects commonly seen in HIV infected patients (e.g., Bactrim, Pentamidine toxicity). 9. Use of cytokines in the management of AIDS related anemias and neutropenias. 10. Principles of timely and meaningful diagnostic workup of HIV infected patients and relation of OI’s to level of immune suppression. 11. Psychological problems in HIV infected patients. 12. Nutritional problems in management of HIV infected patients. 13. Use of viral load and CD4 counts to assess HIV disease progression.. 14. HIV salvage therapy. 16. Knowledge of mechanisms for failure of HAART therapy. 17. Orientation for specific history and physical findings in the HIV infected patient. 18. Understanding of issues around confidentiality of medical information for the HIV infected patient. b. Patient characteristics: All patients seen by housestaff will be HIV infected. The overwhelming majority will have advanced HIV disease (<200 CD4 cells/mm3). Demographics of the patients seen will reflect the general demographics of HIV infected patients seen at Stroger Hospital of Cook County (age 30-40; sex 80% male, 20% female; 60% African American, 30% Latino, 10% Caucasian; 40% IDUs; 40% bi/homosexual men, 20% heterosexual). c. Patient care experiences in teaching areas: # sessions/wk avg # patients/session Outpatient clinic(s) N/A N/A Inpatient ward 6 days/wk avg. 7 pts on each intern's team d. Procedures 1. Producing a meaningful and concise differential diagnosis and treatment plan in the inpatient care of the HIV infected patient. 2. Interpreting CD4 cell counts. 3. Interpreting laboratory and radiographic results in the management of HIV infected patients. 4. Aspiration of skin and soft tissue infections. 5. Culturing of suspicious skin lesions for herpes viruses. 6. Lumbar punctures. e. Educational Resources Required/recommended readings: 1) Principles and Practices of Infectious Diseases. Eds. Mandell, Bennett, Dolan; 2) The AIDS Knowledge Base. Eds. Cohen, Sande, Volberding; 3) AIDS. Eds. DeVita, Hellman, Rosenberg. Handbooks or distributed materials: 1) Sanford's pocket Infectious Disease manual; 2) Numerous articles on topics germaine to the management of specific problems in the care of patients during the rotation; 3) Slide sets, CD ROM, other materials, available in the Division of Infectious Diseases. 4. Evaluation The resident’s performance evaluation comes in the form of the electronic evaluation. Performance in this rotation is included in summative evaluation across ward evaluations.
  5. 5. Other Methods Patient Care Interpersonal and None Communication Skills Electronic Medical Knowledge Resident Practice Based Learning and Evaluation Improvement Form Professionalism Systems-Based Practices Resident rotators evaluate attending physician supervisors using the electronic evaluation form for subspecialty attendings. 5. Strengths and Limitations of Educational Experience a. Strengths: • Comprehensive and intensive exposure under the guidance of attending, pharmacist, and PA specialized in the care of HIV infected patients. • Multidisciplinary approach to the care of HIV infected patients with daily rounds with clinical pharmacist, PA, and medical team. • Exposure to medications approved recently by FDA in the management of HIV infected patients. • Exposure to research protocols being performed in the management of HIV infected patients. • Laboratory demonstrations of specific tests. b. Limitations • Difficulties in ensuring timely administration of patient medications on the ward based on pharmacy and nursing problems. However, this problem has been partially resolved by QA and intensive follow-up by clinical pharmacist and nursing staff on the ward. • Limited required outpatient experience for strictly HIV patients; however, HIV patients are seen randomly across other outpatient experiences.
  6. 6. CURRICULUM OUTLINE Curriculum Topic: Ambulatory Medicine 1. Educational purpose and rationale for the curriculum The Division of General Medicine sponsors a four week rotation in acute ambulatory medicine based on clinical experience in the Ambulatory Screening Clinic (ASC). The rotation is provided to all medicine house staff, during their second or third year of residency, and complements ambulatory experience and curriculum supported by the Division of General Medicine in the General Medical Clinics (GMC). Goals 1. Given a patient presenting for acute ambulatory medical care, residents will efficiently elicit the patient's chief complaint and relevant medical history including relevant psychological, behavioral, socioeconomic, and cultural information. 2. Given a patient with a chief complaint or potential diagnosis listed below under CORE CONTENT AREAS, residents will: a) perform a focused physical examination, b) request appropriate diagnostic tests, c) formulate a set of working diagnoses, d) formulate appropriate treatment plans including referrals. 3. Having arrived at a working diagnosis, residents will present the diagnosis to the patient, elicit patient feedback and negotiate a treatment plan with the patient. 4. Given a patient without previous access to primary care, residents will identify the patient's need for primary care, deliver appropriate preventive health interventions for the acute care visit, and make appropriate referrals. Justification of Goals At the Fantus outpatient facility of Cook County Hospital, twice as many individuals receive ambulatory episodic general medical care at the walk-in Ambulatory Screening Clinic as receive ambulatory continuity care at the General Medical Clinics. The patient populations served by the two sites overlap but are not identical, with younger, less chronically ill people being served through the ASC. The types of patient problems encountered in the two areas also overlap but are not identical, with more sexually transmitted diseases and acute dermatological, orthopedic and respiratory conditions encountered in the ASC. This rotation allows residents to encounter the range of patients and presenting complaints represented in the ASC and to practice focused health assessments and medical interventions appropriate to acute ambulatory care. 2. Principal teaching methods a. Didactics lectures: All residents attend ten 90 to 120 minute teaching sessions facilitated by an Attending in General Medicine. The sessions cover CORE CONTENT AREAS listed below, using didactic, case based and/or interactive teaching styles. b. Group discussions: See section above, which incorporates approximately one-third of the allotted time to interactive/group discussion. c. Self-study: All residents receive a packet of required readings supporting the CORE CONTENT AREAS. d. Other: 3. Educational content a. Major objectives -- 10-15 most important subjects to be covered (key concepts the residents are expected to know by the end of the experience/rotation) CORE CONTENT AREAS - Lecture/Discussion Topics 1. Ear, Nose and Throat Otitis 6
  7. 7. Rhinitis/Sinusitis Pharyngitis 2. Common skin lesions 3. Ophthalmology Red eye Eye pain Eye emergencies 4. Genitourinary BPH Prostatitis Sexual Dysfunction 5. Orthopedics I Back pain Neck pain Shoulder pain 6. Orthopedics II Knee pain Ankle/Foot pain 7. Psychosocial issues in health care Brief psychiatric assessment and referral Domestic violence Substance abuse 8. Ambulatory medicine outreach Health care for homeless individuals Tuberculosis screening CORE CONTENT AREAS - Specialized Clinic Settings 1. Geriatric screening 2. Dietary behavior change 3. Outreach health care to homeless b. Patient characteristics  Ambulatory Screening Clinic: 54% female; 40% age 16-35 years, 30% ages 36-55 years, 30% age 56 years or older; 70% African American, 14% Hispanic.  Computer Assisted Dietary Advice Clinic: representative of ASC general population. c. Patient care experience in teaching areas All clinic encounters are supervised by an attending in general medicine. # sessions/rot avg # pts seen/session Outpatient clinic(s) Ambulatory Screening Clinic 15 5 Dietary Advice Clinic. 1-2 2-4 Eye clinic 1-2 4 Musculoskeletal Clinic 1-2 4 Dermatology 1-2 4 d. Procedures Pelvic Exam Skills Joint Exam Skills Interviewing Skills 7
  8. 8. e. Educational resources Required/recommended readings: Syllabus of readings (attached) Handbooks or distributed materials: Reference texts and patient care protocols on site. Slide sets, computer based, other materials: Videotaping 4. Evaluation The resident’s performance evaluation comes in the form of the electronic evaluation. Performance in this rotation is included in summative evaluation across outpatient evaluations. Other Methods Patient Care None Interpersonal and Communication Skills Electronic Medical Knowledge Resident Practice Based Learning and Evaluation Improvement Form Professionalism Systems-Based Practices Resident rotators evaluate attending physician supervisors using the electronic evaluation form for subspecialty attendings. 8
  9. 9. CURRICULUM OUTLINE Curriculum Topic: Coronary Care Unit (CCU) 1. EDUCATIONAL PURPOSE To provide internal medicine residency trainees with knowledge, experience and skills in the evaluation and management of various serious and life-threatening cardiac disorders especially acute myocardial infarction, unstable angina, congestive hear failure, pulmonary edema, tachy- and bradyarrhythmias. These skills are essential to perform at high level of competence as a general internist. 2. TEACHING METHODS a. Didactic lectures/conferences: 13 hours/month i. Non-invasive evaluation of patients with ischemic heart disease; 2 lectures (1 hour each) to cover the following subjects: • Various stress testing techniques, applications and interpretation. • Value of non-invasive methods in risk assessment of patients with coronary artery disease. • Concept of hibernating/stunned myocardium and assessment of viability. ii. Echocardiography and its applications in the evaluation and management of patients with cardiac disease (1 hour lecture). iii. Right and Left Cardiac catheterization for general internists: indications, principles and applications in patients with various cardiac conditions (1 hour lecture). iv. Electrophysiologic studies, tilt table testing, holter and event monitoring for general internists; indications, principles and applications in patients with various cardiac conditions (1 hour lecture). v. Cardiology clinical case conference: 4 hours/month. Combined conference between CCU and cardiology rotation residents, moderated by cardiology faculty. vi. Rush/Stroger Hospital of Cook County Cardiology Grand rounds: 4 hours/month. b. Patient-care directed group discussions: 20 hours/month c. Other: i. Electrocardiography: 4 hours/months • Review of 30-40 ECGs done on various patients in the institution (inpatients, outpatients, ED). This is done under the supervision of cardiology faculty. • ECG review on CCU patients during bedside rounds. ii. Cardiac catheterization laboratory (2 hours/month): • Residents to observe and understand the principles of right and left cardiac catheterization, angiography and percutaneous interventions on 2-4 of their own patients. iii. Cardiac physical examination: • Bedside rounds. d. Self-study: i. Internal Medicine Textbooks; Harrison’s principles of Internal Medicine is “the” recommended textbook for core education of cardiovascular medicine. All residents are expected to read cardiology section in Harrison’s during their CCU rotation. ii. Additional reading: a. Cardiovascular Medicine Textbooks for expanded reading (Braunwald is recommended). b. Assigned articles: • Major landmark studies and state-of-the-art review articles relevant to content. • Literature addressing specific issues in patients cared for. c. American College of Cardiology/American Heart association (ACC/AHA) guidelines in the evaluation and management of various cardiac conditions. 9
  10. 10. d. Medical Knowledge self assessment program (MKSAP) learning material, cardiovascular medicine section. 3. MIX OF DISEASES a. Coronary Artery Diseases: i. ST-elevation myocardial infarction and its complications. ii. Non-ST elevation myocardial infarction and unstable angina. iii. Care of post-CABG and post-PTCA patients. iv. Care of post myocardial infarction patients and risk factor modification. b. Congestive heart failure: i. Chronic heart failure. • Systolic heart failure from various etiologies (ischemic and non-ischemic). • Diastolic heart failure. ii. Pulmonary edema and cardiogenic shock. iii. Interpretation and management of balloon-tipped pulmonary artery catheter. iv. Understanding the indication and basic management of intra-aortic Balloon pump (IABP). c. Valvular heart disease. d. Infective endocarditis. e. Arrhythmias i. Ventricular arrhythmias and sudden cardiac death, and indications for AICD implantation. ii. Supraventricular arrhythmias. iii. Bradyarrhythmias and indications of temporary and permanent pacing. iv. Basic understanding of pacemaker function. v. Management of temporary transvenous and transcutaneous pacing. f. Adult congenital heart disease. g. Hypertensive crisis. h. Cardiomyopathies and myocarditis. i. Aortic disease; aortic dissection and aortic aneurysm. j. Pericardial disease (acute pericarditis and pericardial tamponade). k. Venous thrombembolic disease/Pulmonary embolism and pulmonary vascular disease. l. Dyslipidemia. 4. PATIENT CHARACTERISTICS Age 16 and up, all races, equal sex distribution. 5. TYPES OF CLINICAL ENCOUNTERS, SERVICES AND PROCEDURES a. Patients admitted to the coronary care unit (12-bed unit) with occasional overflow to medical intensive care unit. b. Residents are on call every fourth day. Resident on call admits all new patients from the emergency department and other units in the hospital. Number of admission per call varies, with an average of 4 admissions per call. Each resident follows-up an average of 4 patients at any given time. c. Procedures: i. Arterial line placement (radial and femoral). A minimum of five supervised procedure are required. ii. Central Line placement (subclavian, internal jugular, and femoral). A minimum of five supervised procedure are required. iii. Residents who did not achieve adequate competency in above mentioned procedures must be supervised by an experienced cardiology fellow, a competent senior internal medicine resident, and/or an attending physician. iv. Internal medicine residents are expected to observe and understand the principles of insertion, function and the interpretation of balloon-tipped pulmonary artery catheter (Swan-Ganz catheter) and transvenous temporary pacemaker. 10
  11. 11. v. Insertion of balloon-tipped pulmonary artery catheter (Swan-Ganz catheter) and temporary transvenous pacemaker wire are optional procedures for internal medicine residents. 6. READING LIST, PATHOLOGICAL MATERIAL AND OTHER EDUCATIONAL RESOURCES USED a. Internal Medicine Textbooks; Harrison’s principles of Internal Medicine is “the” recommended textbook to cover the core education of cardiovascular medicine. All residents are expected to read cardiology section in Harrison’s during their CCU rotation. b. Additional reading: i. Cardiovascular Medicine Textbooks for expanded reading (Braunwald is recommended). ii. Assigned articles: • Major landmark studies and state-of-the-art review articles relevant to content. • Literature addressing specific issues in patients cared for. iii. ACC/AHA guidelines. iv. MKSAP. 7. EVALUATIONS a. Attending physician on CCU service is responsible for submitting an overall comprehensive evaluation at the end of each rotation. b. A mini-evaluation is submitted by the attending physician supervising ECG reading sessions to the attending physician on the service. o A grade of unsatisfactory, satisfactory, and superior is assigned to each resident based on his/her performance. o ECG sessions performance is based on attendance, ECG interpretation skills, and progress that reflects the residents’ effort to improve their skills. o The attending physician on service incorporates the mini-evaluation into the overall evaluation. c. The overall evaluation is based on: 1) Patient care. 2) Medical knowledge. 3) Practice-based learning. 4) Interpersonal communication skills. 5) Professionalism. 6) System-based practice. 8. SUPERVISION Positive supervision is maintained in all aspects of CCU rotation: a. Patients are assigned to residents on their call days. b. Patients are interviewed and examined by admitting resident who formulates an assessment and care plan. c. Plan formulated by the resident is discussed with the cardiovascular fellow and/or the attending physician on the service for additional guidance. d. Admitting resident presents the patient history and physical exam and his/her own assessment and plan in a problem list format, in presence of the whole CCU team (when feasible). e. Patient is reassessed by the attending physician. f. The attending physician moderates an interactive discussion on the case and the resident’s assessment and plan involving the admitting resident and other CCU team members. Feed- back and corrective guidance are provided by the attending physician. g. Final decisions and plans are formulated after the above explained comprehensive discussion. h. The attending physician is ultimately responsible for all decisions. 11
  12. 12. i. Residents are responsible for writing all orders. j. Residents who did not achieve adequate competency in above defined procedures must be supervised by an experienced cardiology fellow, a competent senior internal medicine resident, and/or cardiology attending physician. k. A cardiology attending physician on call is available for advice and back-up at all time on pager, and in house during regular working hours. l. A cardiology fellow on call is available for advice and back-up in house at all time. 9. CURRICULUM REVIEW AND REVESIONS a. Feedback from residents; formally (rotation evaluation) and informally is constantly obtained. b. Feedback is also obtained from division of cardiology faculty and internal medicine residency program director regarding residents’ training strengths and deficiencies. c. Feedbacks are evaluated by the cardiology training coordinator in the division of cardiology and by the division chairman. In collaboration with the program director of internal medicine residency, feedback is considered into continuous course adjustment. d. The curriculum will be fully reevaluated and rewritten in 3 years. 12
  13. 13. CURRICULUM OUTLINE Curriculum Topic: Critical Care (MICU) 1. Educational purpose and rationale for the curriculum. Training in critical care medicine is crucial for the general internist. Important aspects of this training include: identifying patients who are candidates for intensive care, the bedside approach to the critically-ill patient, knowledge of algorithms for diagnosis and management of common problems in the ICU, death and resuscitation issues, interaction with families (*see addition at end). 2. Principal teaching methods. a. Didactics lectures: A core lecture series is repeated each rotation (see attached addendum). This series consists of 14 hour-long lectures on a variety of critical care topics. The lectures are delivered by faculty members from CCH as well as Rush. b. Group discussions: Group discussion usually occurs in the MICU charting area or at the patient’s bedside. These discussions are very management oriented; the relevant pathophysiology is also reviewed. Journal articles are often supplied by the attending or fellow. This is perhaps the most productive teaching format. c. Self study: Residents are expected to read on their own. A 218-page core curriculum manual is distributed at the beginning of the rotation. This manual covers a wide variety of topics in critical care medicine. It is updated regularly. d. Other: Relevant journal articles are gleaned from Medline searches are distributed to the housestaff during the course of the rotation. 3. Educational content. a. Major objectives 1. Mechanical ventilation: indications, initial set-up, trouble shooting, weaning 2. Critical care nutrition: indications, disease-specific nutrition, writing TPN orders 3. Oxygen transport: physiology, alterations in the critically-ill 4. Arterial blood gases: approach to analysis, common alterations 5. Hemodynamics: physiology, PA catheter, hemodynamic waveforms, trouble-shooting 6. Critical care pharmacology: pressors/inotropes, antibiotic dosing, drug dosing in ARF 7. Shock: pathophysiology, approach to resuscitation 8. Fluid and electrolyte disturbances: sodium, potassium, magnesium, calcium 9. Acute renal failure: approach differential diagnosis, management 10. Coma: pathophysiology, neurological exam, differential diagnosis 11. Multiple organ dysfunction syndrome 12. Airway management, tracheotomy 13. Acute CHF 14. Ethical issues in the ICU b. Patient characteristics: The MICU admits a wide variety of adult patients of all races. The age of the typical patient in the MICU at CCH tends to be younger than what is seen in many MICUs in private hospitals. The patients have acute medical (non-surgical) problems; respiratory failure requiring mechanical ventilation is common. 13
  14. 14. c. Patient care experiences in teaching areas: # sessions/wk avg # pts seen/session Outpatient clinics 0 0 Inpatient consults 0 0 Inpatient ward 12 18 d. Procedures 1. Arterial line insertion 2. Central venous catheterization 3. Pulmonary artery catheterization 4. Assistance in endotracheal intubation e. Educational resources Critical are course curriculum Med-line searches Required/recommended readings: Critical care course curriculum. Critical care textbook is recommended but optional. Handbooks or distributed materials: Critical care course curriculum, relevant journal articles Slide sets, computer based, other materials: Med-line searches 4. Evaluation. The resident’s performance evaluation comes in the form of the electronic evaluation. Performance in this rotation is included in summative evaluation across ward/ICU evaluations. Other Methods Patient Care None Interpersonal and Communication Skills Electronic Medical Knowledge Resident Practice Based Learning and Evaluation Improvement Form Professionalism Systems-Based Practices Resident rotators evaluate attending physician supervisors using the electronic evaluation form for subspecialty attendings. 5. Strengths and limitations of the educational experience. Strengths: The MICU rotation gives the resident a solid grounding in the approach to the critically ill patient. The types of illnesses seen are diverse, the severity of illness is substantial, the degree of supervision is excellent, and the support from nursing, pharmacy and dietary is of great value. The MICU at CCH is a “closed” system (i.e., the MICU attending assumes primary patient care responsibility for patients admitted to the unit). This system places the house officer in the 14
  15. 15. position of the primary provider. This is a more rewarding experience than the “open” system in which the internist functions as a consultant. Limitations: Lecture time is not consistently protected due to constraints of admitting new patients, clinics, etc. Addendum: MICU Lecture Series Day/week of rotation Topic Week 1 Wed orientation Thurs mechanical ventilation 1 Fri nutrition in the ICU Week 2 Mon mechanical ventilation 2 Tues sepsis Wed prevention in the MICU Thurs OPEN Fri GI bleeding Week 3 Mon mechanical ventilation 3 Tues pharmacology in the MICU Wed acute CHF Thurs OPEN Fri multiple organ dysfunction Week 4 Mon MICU ethics Tues airway management/tracheostomy Wed OPEN Thurs acute renal failure Fri TEAM LUNCH Week 5 Mon barotrauma Tue SIGNOFF DAY * During the three years of training each resident will rotate twice - once during the first year, and once during the subsequent two years. This document describes the experience for both the first year and the senior residents. 15
  16. 16. CURRICULUM OUTLINE Curriculum Topic: Emergency Medicine 1. Educational purpose and rationale for the curriculum. General introduction to the practice of Emergency Medicine. The resident will gain exposure to areas of medicine which he/she would not encounter in their training as well as a different perspective on common presenting complaints. 2. Principal teaching methods. a. Didactics lectures: Twelve hours: General orientation to emergency department. Emergency Medicine approach to common presenting complaints. Splint/suture laboratory, toxicology, environmental emergencies. b. Group discussions: Asthma Forum. c. Self-study: Splint/suture laboratory. d. Other: Eye lecture/slit lamp lab. 3. Educational content. a. Major objectives --10-15 most important subjects to be covered: 1. Recognition/prioritization medical emergencies 2. Laceration repair 3. Wound care 4. Asthma management 5. Splinting techniques 6. Ophthalmologic emergency management 7. Evaluation of chest pain 8. Management of OB/gyne emergencies 9. Evaluation of shortness of breath 10. Management of environmental emergencies 11. Basic toxicology principles b. Patient characteristics: The resident will work in the Adult Emergency Department. The patient range is from 16 years and up. The population is predominantly African American. c. Patient care experiences in teaching areas: # sessions/wk avg # pts seen/sessions Outpatient clinic(s) N/A Inpatient clinic(s) N/A Inpatient ward(s) N/A d. Procedures 1. Splint placement 2. Slit lamp operation 3. Wound repair 4. Arterial blood gas 16
  17. 17. e. Educational resources Required/recommended readings: Lecture handout packet Handbooks or distributed materials: Orientation handbook Slide sets, computer based, other materials: 4. Evaluation a. Evaluation of the resident - which components are used? Yes No Attending evaluation X Fellow/Sr. Resident evaluation X Objective written test X Evaluation of prepared presentation X Other (describe) b. Evaluation of the educational experience - how is it evaluated? Yes No Resident’s written evaluation of rotation X Informal feedback from residents X Attending feedback X Residents meeting educational objectives Other (describe) 5. Strengths and limitations of the educational experience. a. Strengths: Laboratories (splint/suture) Broad-based lecture series Dedication to rotating resident education in Emergency Department b. Limitations: (e.g., objectives difficult to achieve, plans to address these limitations) 1. Objective evaluation (Would like to develop pre/post test). 2. Assure that residents are giving equal time in various areas of the Emergency Department (Review schedule, resident evaluation concerning shift). 17
  18. 18. CURRICULUM OUTLINE Curriculum Topic: General Medicine Clinic 1. Educational purpose and rationale for the curriculum. The general internist will spend the vast majority of his/her practice in the outpatient continuity setting. As economic forces drive ever more complex care into the outpatient arena, residency-training programs bear the responsibility of ensuring first rate training in this area. The curriculum document summarizes the program provided for the weekly, longitudinal three-year experience in outpatient continuity general medicine care. 2. Principal teaching methods. a. Didactics lectures: The intern lecture series includes several topics central to the discipline of continuity medical care during the early months of intern training: cholesterol lowering, cancer screening, diabetes-glycemic control and screening/management of complications, and hypertension. One to two times per year the entire GMC session is closed to clinical activity and the residents attend a series of educational sessions surrounding general ambulatory care. b. Group discussions: Each lecture is followed up later in the week with a firm based small group discussion of issues presented in lecture. c. Self-study: Residents are asked to read the literature provided surrounding a topic of the month. Residents research “educational prescription 2-4 per month as assigned by the supervising attending. Written answers are stored in the GMC files. Residents make one presentation per year to their firm, generally about a topic arising from the educational prescriptions. d. Other: Direct attending supervision of clinical care is certainly the most important arena for teaching in the clinic. 3. Educational content. a. Major objectives --10-15 most important subjects to be covered: The following is not intended to be an inclusive list of all disease processes or clinical encounters experienced in such a setting. Rather, this is a summary of the most important basic skills to acquire in the three-year experience. After graduating the training program the resident should be able to: 1. Care for the hypertensive patient, including initial medical/nonpharmacologic therapy, appropriate follow up, identification of secondary hypertension, and care of resistant cases. 2. Provide comprehensive care for the diabetic patient; glycemic control as well as screening/identification and care for complications. 3. Diagnose and treat degenerative joint disease in an efficient, cost effective manner: diagnosis, drug therapy, use of lab/x-ray, and referral for orthopedic/rheumatologic consultation. 4. Care for patients with asthma and obstructive lung disease in the outpatient setting: drug therapy, especially corticosteroids and antibiotics, use of PFT’s/x-rays, indications for admission and follow up intervals. 5. Give appropriate advice concerning cancer screening: breast, cervical, colon, and prostate. 6. Appropriately screen for and care for hypercholesterolemia with diet & medication. 7. Care for patients with coronary artery disease, chest pain evaluation, indications for and interpretation of diagnostic testing, long-term medical management, and indications for cardiology referral. 8. Care for the patient with chronic congestive heart failure: diagnosis with history and physical exam, ancillary tests, medication management, indication for readmission/referral. 18
  19. 19. 9. Diagnose and manage diverse causes of subacute/chronic abdominal pain in a competent, cost effective manner: ulcer, dyspepsia, pancreatitis, biliary tract, irritable bowel, reflux, and occult malignancy. 10. Manage geriatric patients with age-related issues amenable to remediation and understand how age may or may not affect approach to clinical care. 11. Identify and work with patients with reactive depression and anxiety disorders: appreciate the interplay of these with other medical disorders, negotiate medication use and make psychiatric referral where indicated. 12. Manage medications competently and monitor their use especially antihypertensives, antidiabetics, nonsteroidals, coumadin, corticosteroids and nonprescription drugs, incorporating and understanding of efficacy, cost effectiveness, risks/side effects, compliance, and drug interactions. 13. Identify patients with substance use problems, especially tobacco and alcohol, and provide brief interventions to facilitate behavior change. 14. Develop professional, productive, mutually satisfying primary caregiver-type working relationships with a panel of patients. 15. Provide comprehensive continuity primary care: interval care for continuity problems, acute care for new problems, preventive care, efficient charting, appropriate follow-up intervals, and maintaining availability for ongoing problems in an efficient, capable manner. b. Patient characteristics: The clinic cares for a large variety of patients of both sexes. Most patients are over 50 years of age. The most common diagnoses are hypertension, diabetes, and asthma/COPD although the patients may have a multiplicity of other clinical and social problems. c. Patient care experiences in teaching areas: # sessions/wk avg # pts seen/session Outpatient clinic(s) 1/week 3-4 (PG1)/5-6 (PG2, 3) Inpatient consults N/A Inpatient ward Residents are expected to see patients on their panel who are admitted to the hospital at the time of admission and periodically thereafter. However, the primary responsibility for care still resides with the ward team. d. Procedures 1. General physical exam skills: e.g., ophthalmoscopy, cardiac auscultation. 2. Substance abuse counseling 4. Geriatric assessment 5. Smoking cessation counseling. e. Educational resources Required/recommended readings: Articles concerning “topic of the month” Handbooks or distributed materials: General medicine texts: Harrison’s, Cecil’s, Reilly, Goroll, Kelly and Barker as well as the USP Drug Manual are available on site. Slide sets, computer based, other materials: Every computer has internet access, Up to Date, and institutional antibiotic guidelines. 19
  20. 20. 4. Evaluation The resident’s performance evaluation comes in the form of the electronic evaluation. Performance in this rotation is included in summative evaluation across outpatient evaluations. Other Methods Patient Care Mini-CEX Interpersonal and “ Communication Skills Electronic “ Medical Knowledge Resident “ Practice Based Learning and Evaluation “ Improvement Form “ Professionalism Systems-Based Practices Resident rotators evaluate attending physician supervisors using the electronic evaluation form for subspecialty attendings. 5. Strengths and limitations of the educational experience. a. Strengths: The establishment of the “GMC+” system has improved the continuity aspect of care, allowing patients to more readily access help if they develop problems between visits. Over three years, residents follow a large number of patients with multi-system disease. As a result, they become quite capable of managing older adults with multiple medical problems. There have been improvements in the ratio of attending supervisors to housestaff, intensifying the supervisory/teaching role. b. Limitations: Experience with more acute ambulatory problems is limited: orthopedic injuries, vaginal discharge and bleeding, ophthalmologic events, and outpatient infections. Also, there is minimal exposure to younger/adolescent patients. All residents must rotate through the ambulatory medicine and women’s health rotations, which complement the GMC and address these deficits. c. Other observations: The Fantus General Medicine Clinic is one of the largest general medicine clinics in the country. It is staffed by highly motivated, full time general internists with interest in teaching and primary care health related issues. 20
  21. 21. Medicine Shor t Stay Unit Last updated 25 August 2004 Brian Lucas MD, Director Handbook brian_lucas@rush.edu · 7 4 0- 8 4 5 7 The MSSU is located in two noncontiguous areas: the MSSU without an endorsement, notify the ED charge attending.) 1) Observation East, adjacent to the ED Blue Team; 2. The MSSU resident on-call then: a) 2) Observation West, adjacent to the Pediatric ED. accepts the patient, b) asks the triaging ED physician to hold the triage until she The Department of Medicine’s Short Stay Unit and can discuss the case with the MSSU the Emergency Department’s Observation Unit attending physician on-call (see Holding a share the 25 beds in these two areas. Bed Triage from the ED below), or c) if the assignments are flexible—changing from one unit MSSU team has reached capacity (14 to the other (MSSU or Obs Unit) depending on the patients), accepts the endorsement but need for cardiac monitoring or isolation. asks the ED physician not to send the patient until a patient is discharged. (Such The Observation Unit is not synonymous with patients should be entered on the either Observation East or West. It is a team of Quickbase list, see below, in “bed 99”.) Emergency Medicine physicians and their After the MSSU resident accepts the patient, the patients, who are interspersed with the MSSU’s ED charge attending assigns a bed location. patients in the same two geographic areas. (Neither the MSSU resident nor the MSSU attending is responsible for bed assignments.) The basic criterion for triage to the MSSU is that a patient can receive exemplary care and be discharged within 48 hours. It can be difficult to HOLDING A TRIAGE FROM THE ED predict length of stay, but the following usually When an ED physician triages a patient to the indicate a stay longer than 48 hours: MSSU, only an MSSU attending physician can • need for complex social services make the final decision that the patient would be better served by a medicine ward service. The • need for placement in long-term care MSSU resident on-call cannot single-handedly facility “block” a patient triaged from the ED. • need for interventional procedures Procedure All patients residing in Observation East and West will remain under the care of the MSSU team (or 1. MSSU resident on-call asks the endorsing Observation Unit) until they physically leave the ED physician to hold the transfer until she area (i.e., “boarding” patients is not allowed). Until discusses the case with an MSSU transfer, all orders will be written by the MSSU (or attending physician. Observation Unit) physicians. 2. MSSU resident on-call examines the patient and reviews the medical chart. I. TRIAGE FROM THE ED 3. MSSU resident on-call pages an MSSU attending physician and explains the case. The MSSU is designed for patients who can be 4. MSSU attending physician examines the discharged within 48 hours. About half of these patient (still in the ED). patients have one of the MSSU Major Diagnoses: 5. If an MSSU attending agrees that the asthma, chest pain, heart failure, or diabetes-out- patient should be admitted to a ward of-control (see Appendix, Triage Guidelines). service, then the attending explains her However, patients who are triaged from the ED do reasoning directly with the ED attending not have to have one of these diagnoses. physician. Procedure 1. ED physician pages the MSSU resident on-call (400-9445) to “endorse” the patient. (If a patient is sent from the ED to 21 MSSU Handbook ║ Updated 25 August 2004 ║ 1
  22. 22. The MSSU is located in two noncontiguous areas: 1) Observation East, adjacent to the ED Blue Team; 2) Observation West, adjacent to the Pediatric ED. The Department of Medicine’s Short Stay Unit and the Emergency Department’s Observation Unit share the 25 beds in these two areas. Bed assignments are flexible—changing from one unit to the other (MSSU or Obs Unit) depending on the need for cardiac monitoring or isolation. The Observation Unit is not synonymous with either Observation East or West. It is a team of Emergency Medicine physicians and their patients, who are interspersed with the MSSU’s patients in the same two geographic areas. The basic criterion for triage to the MSSU is that a patient can receive exemplary care and be discharged within 48 hours. It can be difficult to predict length of stay, but the following usually indicate a stay longer than 48 hours: • need for complex social services • need for placement in long-term care facility • need for interventional procedures All patients residing in Observation East and West will remain under the care of the MSSU team (or Observation Unit) until they physically leave the area (i.e., “boarding” patients is not allowed). Until transfer, all orders will be written by the MSSU (or Observation Unit) physicians. I. TRIAGE FROM THE ED The MSSU is designed for patients who can be discharged within 48 hours. About half of these patients have one of the MSSU Major Diagnoses: asthma, chest pain, heart failure, or diabetes-out-of-control (see Appendix, Triage Guidelines). However, patients who are triaged from the ED do not have to have one of these diagnoses. Procedure 1. ED physician pages the MSSU resident on-call (400-9445) to “endorse” the patient. (If a patient is sent from the ED to the MSSU without an endorsement, notify the ED charge attending.) 2. The MSSU resident on-call then: a) accepts the patient, b) asks the triaging ED physician to hold the triage until she can discuss the case with the MSSU attending physician on-call (see Holding a Triage from the ED below), or c) if the MSSU team has reached capacity (14 patients), accepts the endorsement but asks the ED physician not to send the patient until a patient is discharged. (Such patients should be entered on the Quickbase list, see below, in “bed 99”.) After the MSSU resident accepts the patient, the ED charge attending assigns a bed location. (Neither the MSSU resident nor the MSSU attending is responsible for bed assignments.) HOLDING A TRIAGE FROM THE ED When an ED physician triages a patient to the MSSU, only an MSSU attending physician can make the final decision that the patient would be better served by a medicine ward service. The MSSU resident on- call cannot single-handedly “block” a patient triaged from the ED. Procedure 1. MSSU resident on-call asks the endorsing ED physician to hold the transfer until she discusses the case with an MSSU attending physician. 22
  23. 23. 2. MSSU resident on-call examines the patient and reviews the medical chart. 3. MSSU resident on-call pages an MSSU attending physician and explains the case. 4. MSSU attending physician examines the patient (still in the ED). 5. If an MSSU attending agrees that the patient should be admitted to a ward service, then the attending explains her reasoning directly with the ED attending physician. II. TRIAGE FROM A MEDICINE CLINIC Patients can be admitted directly from a medicine clinic—including the ASC, GMC, and subspecialty clinics—if they meet both criteria: 1) one of the MSSU Major Diagnoses, and 2) expected length of stay is under 48 hours. Procedure 1. Clinic physician confirms patient meets both criteria 2. Clinic physician pages the MSSU attending physician to discuss triage: 689-2743 3. If the MSSU attending physician agrees that this patient should be triaged into the MSSU, she will then arrange a bed assignment through the ED Blue Team attending. (The MSSU attending physician does not have control over bed assignments. Each case must be approved by the ED charge attending.) 4. Once a bed assignment has been secured, the MSSU attending physician notifies the clinic physician. 5. The clinic physician fills out a consultation form that requests that the patient be registered and includes both a brief description of the need for MSSU admission and the approving MSSU attending physician’s name. 6. The clinic physician will send the patient to the Triage Treatment Area in the ED with the consultation form. 7. The patient will be registered in the Triage Treatment Area and sent back to the MSSU. II. EXPECTATIONS AND SCHEDULES ATTENDING PHYSICIAN PRESENCE One attending physician should remain present in the MSSU and, if necessary, leave for only brief periods, e.g., meals, library, morning report, noon conferences. Reasons for this include: 1. Demonstrates commitment to the MSSU—assures excellent patient care with efficient patient flow. 2. Allows full advantage of teaching opportunities—primarily one-on-one interactions with the residents. ATTENDING PHYSICIANS’ TEACHING SESSIONS A member from the Section of Inpatient Medicine will give a 2-hour “Advanced Topics in Medicine” lecture to all four residents on Wednesday mornings. 23
  24. 24. ATTENDING PHYSICIANS’ SCHEDULES Attending physicians should arrive early enough to evaluate overnight admissions before morning rounds. ATTENDING PHYSICIANS’ EVALUATION OF RESIDENTS 1. Near the end of the rotation, an administrative assistant from the department of medicine (P McGowan) will email each attending physician a request to evaluate one randomly selected MSSU resident. In addition, she will arrange a meeting for all attending physicians who worked in the MSSU during the rotation. 2. The attending physicians meet to discuss each resident. Specific comments are written down. (This meeting can occur electronically or over the phone.) 3. Each MSSU attending fills out the evaluation that they were sent. RESIDENT PHYSICIANS’ SCHEDULES Prior to the start of their rotation, the four resident physicians who are assigned to the MSSU will be given a schedule template with instructions. Working together, the residents will arrange their call schedule and bring it to the orientation on the first day of the rotation. During the rotation, when an unanticipated absence arises, the resident must contact the MSSU attending physician on-call, the chief medical resident, and the Department of Medicine. Jeopardy coverage does not exist for residents in the MSSU. Another resident in the group will have to cover for the absent resident. IDENTIFY THE PCP Identifying a patient’s PCP requires a comprehensive and, at times, relentless inquisition. In the patient’s own language, question both the patient and their family or friends. (You can find contact information for patients in the Cerner PowerChart application. Once you have opened the patient’s virtual chart, click on the Patient Information tab. The Patient Demographics folder is automatically opened.) In addition, consider questions like: “Who prescribes your medicines?” and “Did you bring any medicines with you?” and “Do you have an orange card?” If the patient has been seen previously in the Cook County Bureau of Health Services, the PCP may be identifiable through one of two methods in the Cerner software applications. 1. Which doctors have defined Lifetime Relationships? In the PowerChart application, open the patient’s virtual chart. Click the Patient Information tab. (The Patient Demographics folder will automatically open.) Then click on the PPR Summary tab. A folder will open that displays Lifetime Relationships on the top half of the screen and Visit Relationships on the bottom half of the screen. If a physician has identified herself as the PCP, her name will be listed as a Lifetime Relationship. (Unfortunately, the Lifetime Relationships are often inaccurate.) 2. Which doctors have seen the patient in the past? In the Scheduling Appointment Book application, click on the Appointment Inquiry button. (This button is along the toolbar at the top of the screen. The schematic on the button is a close-up frontal view of a person’s eye.) After clicking this button, a dialogue box entitled “Resource Schedule Inquiry-Standard” will appear. Click on the Person tab below the yellow stripe. Notice that the title of the dialogue box changes to “Person Schedule Inquiry-Standard.” Click on the button immediately to the right of the Person field. (There are three dots, or an ellipse, on this button.) A dialogue box entitled “Person Search” appears. Enter your patient’s medial record number into the MRN field and click on the Search button. Click on your patient’s name in the window to the right, and then click the OK button. You will be redirected 24
  25. 25. to the “Person Schedule Inquiry-Standard” dialogue box. Using the arrow buttons to the right of the Start date field, change the start date to several years earlier. Click on the Find button. In the window to the right, you will see several appointments listed with location. The providers listed next to confirmed appointments have seen the patient. COMMUNICATE WITH THE PCP After you have identified the PCP, you must then communicate with the PCP. Page the PCP directly. If the PCP does not return the page, you have several options: 1. Voice mail message. Leave a voice mail message with the patient’s name, medical record number, and reason for admission. Ask the PCP to call the MSSU resident on-call (400-9445) when available. Remember that although you have made contact with the PCP and informed her of the patient’s admission, a member of the MSSU team still needs to communicate with the the PCP. 2. Job for the Oncoming Resident. Sign-out to the oncoming resident that communication with the PCP has not yet been made. Don’t forget to establish a follow-up appointment by asking for a specific time, date, and location. RECORD PCP, COMMUNICATION ATTEMPTS, AND FOLLOW-UP PLANS ON MSSU PATIENT LIST Personal experience confirms that communicating with the PCP is an iterative process. Because patient care in the MSSU is quickly passed on from one resident to the next, at each step in this process, residents must record the information on the MSSU Patient List. Examples of how to record the 3 steps toward communication with PCP: 1. Identify. “Dr. S. Gawrieh, Medicine Resident. Need to Contact.” 2. Contact. “Paged Dr. Gawrieh, no answer. Left voice mail message with Dr. Lucas, Star Attending.” 3. Communicate. “To see Dr. Lucas, Monday, 2:30 PM, Fantus GMC” III. ORDERS AND CHARTING ENTERING ORDERS MSSU admission orders are similar to those on the inpatient medicine services. However, several important differences should be noted: 1. If possible, order medications stocked in one of the ED Pyxis machines (see MSSU Infrastructure, Pyxis Machines above); 2. Place two orders for each phlebotomy order: one entered in the Cerner PowerChart application (so that a label for the blood tube will be printed) and one written in the patient’s chart for the nurse (so the blood will be drawn); 3. Ultrasounds. Place order in Order USG in Cerner PowerChart application. Call ultrasound 4-3780 and clearly state that your patient is “coming from the ED.” Then, arrange transportation with nursing. 25
  26. 26. INTRAVENOUS “DRIP” AND “PUSH” MEDICATIONS Based on hospital-wide policies about nursing-to-patient ratios, patients that require continuous intravenous drip medications (except for insulin and unfractionated heparin) are not allowed in the MSSU. Though other drips can be started in the MSSU on an emergent basis, physicians must have a request in place for a transfer to an ICU. Most intravenous “push” medications are allowed. CHARTING Though MSSU patients’ length-of-stay is much shorter than ward patients’, documentation of their presentation and hospital course is similar. As a minimum requirement, the resident and attending physicians should each write an admission note on every patient. In addition, every 24 hours either the resident or the attending should write a progress note on every patient. (Notably, a Discharge Summary counts as a progress note.) IV. ROUNDING PROTOCOL The MSSU Resident who is finishing her shift should print out updated copies of the MSSU Patient List for each resident and attending. Morning rounds start at 8:30 AM on weekdays (10 AM if ground rounds) and 12 N on weekends and holidays. Sign-out rounds start at 5 PM. Residents should arrive early enough to pre-round on all of the “old” patients (patients not newly admitted overnight). Rounds should be at the bedside. Be mindful of the inability of curtains to insulate sounds, particularly confidential statements about patient health. After morning rounds, one attending should contact the ED Blue Team attending with a list of the patients that are planned for discharge. The other attending should ensure that the MSSU nursing staff (usually four separate nurses) know the basic plan for each patient. Rounds start time weekdays weekends & holidays Morning 8:30 AM 12 N (10 AM if grand rounds) Sign-out 5 PM no formal sign-out V. INFRASTRUCTURE MSSU DEDICATED PAGERS resident pager 400-9445 attending pager 689-2743 Dedicated pagers for both the on-call MSSU attending and resident are handed over (along with a key to the conference room) at each shift change. (Instructions for the attending pager are on the bulletin board in the MSSU work room.) 26
  27. 27. MSSU WORK ROOM The conference room adjacent to the nursing station in Observation East (room 1982) is a secure place to hang coats and store bags. PYXIS MACHINES The two Pyxis machines located in Observation East and West are identically stocked with medications used most often in the MSSU. In addition to these two machines, there are six more in the ED. Your familiarity with medications stocked in these eight Pyxis machines will lead to greater efficiency. A list of all of the medications stocked in the ED Pyxis machines in both Observation East and Observation West is kept in three-ringed binders labeled “Pyxis Machines.” These lists are updated bi- monthly by the pharmacy. Stocked medications are listed alphabetically by generic name. Next to each medication is the code for the Pyxis machine where the medication is stocked. Use the table labeled “Pyxis Station Codes” to identify the location of the Pyxis machine. SOCIAL WORKER There is a social worker dedicated to the ED who is available 24 hours a day. To contact the social worker, look on the first page of the Adult Emergency Services Plan of the Day which is updated daily and conveniently located on the counters of both Observation East and West. INTERPRETER SERVICES Spanish Interpreter from 10 AM to 6 PM 864-1571 Other Languages or after hours 864-5225 INTERCOM 1. Decide exactly what you want to say 2. From one of the gray phones (not the yellow “house phones”), press the “Page” button (the last speed dial button to the right of the speed-dial menu). The number “1-9-0-0-0” will be automatically dialed. 3. After four short beeps, dial “1-3-#” 4. You will hear another short beep. Speak in your message. 5. Hang up. 6. In a few seconds, you will hear your message overhead. TRANSPORTATION A team of transporters is assigned to the transportation of patients either within the ED (e.g., from the MSSU to the ED radiology department) or from the ED to another part of the hospital (e.g., to the echocardiography laboratory). To “order” transportation, use the ED intercom system (see Intercom above). Speak the following into the intercom: “Transportation to Observation West with a wheelchair. Transportation to Observation West with a wheelchair.” 27
  28. 28. “MUSE” ECG RETRIEVAL SYSTEM A dedicated “MUSE” computer sits on the Observation East counter top. From this computer, you can access all of the studies conducted by the cardiology department since the move to the new hospital. This includes ECG’s, echocardiograms, and coronary catheterizations. FIRSTNET Both attending and resident physicians rotating through the MSSU need to access the Cerner FirstNet application. All patients in the ED are registered and discharged (see Discharge Process, Prepare Discharge Forms) through FirstNet. Prior to starting your rotation in the MSSU, you will be contacted by an administrative assistant from the ED. She will ask you to sign the CCBHS System Sign-on Request Form. For the 30-day period you are rotating through the MSSU, you will have access to the FirstNet system. VI. NON-INVASIVE TESTING Several dedicated slots are established for the MSSU and Observation Unit to share. Monday to Friday the two units share 6 ETT’s, 4 transthoracic echocardiograms, and 2 dobutamine echos. On Saturdays the units share 4 transthoracic echocardiograms (done by a portable echo machine in Obs East or West). Monday to Friday the units share 7 adenosine thallium tests. MSSU Observation Unit Studies Monday to Friday Exercise Treadmill Test (ETT) 3 3 Transthoracic Echocardiogram 2 2 Dobutamine Stress Echocardiograms 1 1 Adenosine Thallium Test Monday 1 1 Tuesday 1 0 Wednesday 0 1 Thursday 1 0 Friday 1 1 Saturday Transthoracic Echocardiogram 2 2 EXECG, RESTING AND DOBUTATINE ECHOS 1. Complete the cardiology request form (include details!) and place it in the patient’s chart; 2. Write the patient’s name in the appropriate slot on the “OBS-MSSU STUDIES” signup sheet in the nursing station in Observation East; 3. If the MSSU’s slots are filled, ask the Observation Unit attending—at or before 7:30AM on the day of the study—whether you can use one of their “extra” slots. (Since they, too, will be using this board, you will be know if they have any “extra” slots.) 4. On the morning of the study, inform the nurses which patients should be transported (by ED patient transporters) to the Cardiology Department. Include the patient chart (with the needed cardiology requisition form). 5. If problems arise, call Echo lab—864-3404. 28
  29. 29. STRESS THALLIUMS 1. No caffeine-containing beverages for the last 24 hours; no aminophyline for the last 72 hours 2. NPO after midnight. 3. Asthma is a relative contraindication. 4. Complete cardiology request form, a radiology request form, and order the test in PowerChart. VII. PATIENT LISTS We use a password-protected site on the web called Quickbase.com to transfer comprehensive patient information from one MSSU physician to the next. The following instructions describe how to log-on: 1. Go to https://www.quickbase.com; 2. Click the "sign in/register" tab in the upper right corner; 3. You are now at the "Sign in to QuickBase" web page (https://www.quickbase.com/db/main? act=signin); 4. In the field "Your email address or screen name:" type “shortstay”; 5. Type in our QuickBase password, "cookcounty," and click the “sign in” tab. 6. You are now in "My QuickBase". Hover the pointer over "SHORT STAY UNIT PATIENT LIST" (you will see the hyperlink change colors) and click; 7. You are now at the "Short Stay Unit Patient List". Click on the "Views" tab at the top and center of the screen. Several views are listed, including "ARCHIVED," "CURRENT," “download from this one,” "List All, by BED,” and "List Changes"; 8. To see our current patient list, click "CURRENT." 9. To edit individual records, click on the "edit" tab in the far left column. 10. To add a new record, click on "Add a new record" near the top of the screen (underneath the "Customize"). 11. To print, click on the "I want to . . . " tab (near the “?” tab). A pull down menu entitled “Related actions” appears. Click on “Display a print-friendly version of this view.” When ED physicians endorse patients after the MSSU is “full” (14 patients), the MSSU resident or attending who accepts the endorsement should enter their information into “bed 99.” If these patients never arrive in the MSSU, delete their record (do not simply change their “current” field to “N.”) XIII. THE “CRASHING” PATIENT You should not wait to transfer a patient to an ICU who is, for example, in shock or in urgent need of endotracheal intubation. Instead, you should speak to the ED Red Team Attending and ask that your patient be brought immediately in the resuscitation (“recess”) area. 29
  30. 30. IX. DISCHARGE PROCESS ADMISSIONS TO MEDICINE FROM THE MSSU Despite efforts to appropriately triage patients into the MSSU, some patients require admission to a ward or ICU service (usually because their expected length of stay is more than 48 hours). This decision should be made by the MSSU attending as soon as such a need is identified. (In some cases, this decision may occur after the initial evaluation.) Procedure 1. From a Compaq computer with ViewSonic flat screen monitor (a “slim client”) click on the “Med Team Asgn” Icon. 2. In the dialogue box entitled "Medicine Assignments", click on the button next to "Obtain Medicine Assignment Patient." 3. On the next screen, entitled "Team Assignments for Patients Admitted to Medicine and Family Practice," fill in the 9 required fields which are colored yellow. Then click "Auto Medicine Assignment." 4. The next screen, entitled "Medicine Assignment," displays the team assignment. Click on the "Finish and Print" button. 5. Place the printed assignment in the chart. 6. Endorse the team to the appropriate resident. 7. Enter a “ED to Full Admit” order through FirstNet (required for Bed Control to reserve a bed for the patient). 8. While the patient is in Observation East or West, the MSSU will continue writing orders on the patient. IDENTIFY AND COMMUNICATE WITH THE PCP (IF NOT YET ALREADY DONE) Because the Identification of and communication with a patient’s PCP are so important, these steps should be completed on admission and documented on the MSSU Patient List (see Admission Process, Identify and Communicate with Primary Care Provider above). If by the time of discharge, however, the PCP has not been reached, an additional attempt is needed. WHEN A PATIENT DOES NOT HAVE A PCP: WHO SHOULD BE THE NEW PCP? 1. The MSSU resident most familiar with the patient’s presentation and MSSU course. Usually, this is the admitting resident. (see Procedure to Check Availability in Residents’ Clinic below). 2. A consulting subspecialist PCP. For some patients (e.g., new-onset severe cardiomyopathy), a subspecialist PCP may be better equipped to provide the most urgent and relevant care. In such cases, the discharging MSSU staff must ensure that the subspecialist’s follow-up is clearly established and bona fide. 3. New provider (discuss with attending). 30
  31. 31. REQUIRED DISCHARGE FORMS (3) 1. Discharge Diagnosis Form for patient’s signature (accessed through FirstNet) 2. Pink Outpatient Prescription Form. a. In the "clinic" field write "Observation Unit." Separate the duplicate copy (white) and give to patient on discharge. b. Tube the pink copy to inpatient pharmacy (tube station 300). c. If the request arrives before 11AM, the prescription should be filled in 2 to 3 hours. If the request arrives after 11AM, the prescription should be filled in 3 to 4 hours. d. Once filled, the medications will not be sent back to Obs East or West. Instead, patients, after discharge, should go to the Stroger Hospital Pharmacy Window 8 (“the outpatient pharmacy window”) with their "discharge papers" (including the white duplicate copy) to pick up their medications. 3. Appointment Slip If a patient is not returning to the CCBHS system, give them a copy of the Discharge Summary. IX. READING LIST Numbers correspond to files on The MSSU CD. The first-week reading list (**) must be completed by the second Wednesday of the rotation. CHF MANAGEMENT **Heart Failure Management. Recommendations and annotated 1916 references. Cook County Hospital Heart Improvement Study. Nohria A, Lewis E, Stevenson LW. Medical management of advanced heart failure. 093 JAMA 2002;287:628. **Farrell MH, Foody JM, Krumholz HM. β– Blockers in Heart Failure. JAMA 021 2002;287:890. Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure. Part 1: Diagnosis, prognosis, and measurements of diastolic function 1925 (Circulation 2002;105:1387) and Part 2: Causal mechanisms and treatment (Circulation 2002;105:1503). 31
  32. 32. Alderman ED, Fisher LD, Litwin P, Daiser GC, et al. Results of coronary artery surgery 1464 in patients with poor left ventricular function (CASS). Circulation 1983;68:785. ASTHMA MANAGEMENT **Asthma Management. Recommendations from the Cook County Hospital Asthma 1926 Study. CHEST PAIN: CLASSIFICATION AND NON- CARDIAC CAUSES Reilly BM. Chest Pain. In: Reilly BM, ed. Practical strategies in outpatient medicine. 2nd ed. Philadelphia: WB Saunders; 854 1991:440-544. [Focus on pages 440 to 465 and 484 to 537.] **Constant J. The clinical diagnosis of nonanginal chest pain: the differentiation of 1595 angina form nonanginal chest pain by history. Clin Cardiol 1983;6:11. Panju AA, Hemmelgarn BR, et al. Is this patient having a myocardial infarction? JAMA 105 1998;280:1256. Goldman L, Kirtane AJ. Triage of patients with acute chest pain and possible cardiac 1417 ischemia: the elusive search for diagnostic perfection. Ann Intern Med 2003;139:987. Goldman L, Cook F, Johnson PA, Brand DA, Rouan GW, et al. Prediction of the need for intensive care in patients who come to 1553 emergency departments with acute chest pain. NEJM 1996;334:1498. Reilly BM, Evans AT, Schaider JJ, Das K, Calvin JE, Moran LA, et al. Impact of a clinical decision rule on hospital triage of 429 patients with suspected acute cardiac ischemia in the emergency department. JAMA 2002;288:342. CHRONIC STABLE ANGINA Snow V, Barry P, Fihn SD, Gibbons RJ, et al. 1908 Evaluation of primary care patients with chronic stable angina: guidelines from the American College of Physicians. Ann Intern 32
  33. 33. Med 2004;141:57. Fihn SD, Williams SV, Daley J, Gibbons, RJ. Guidelines for the Management of Patients with Chronic Stable Angina: Treatment. Ann 165 Intern Med 2001;135:616. [Update to be published soon.] UNSTABLE ANGINA PECTORIS **Yeghiazarians Y, Braunstein JB, Askari A, Stone PH. Unstable angina pectoris. NEJM 1923 2000;342:101. Antman EM, Cohen M, Bernink P, McCabe CH, et al. The TIMI Risk Score for Unstable Angina/Non-ST elevation MI: a method for 726 prognostication and therapeutic decision making. JAMA 2000;284:835. “DIZZINESS” AND SYNCOPE Reilly BM. Dizziness. In: Reilly BM, ed. Practical strategies in outpatient medicine. 807 2nd ed. Philadelphia: WB Saunders; 1991:162-236. Linzer M, Yang EH, Estes M, Wang P, et al. Diagnosing syncope. Part 1: Value of history, 001, physical examination, and electrocardiography. (Ann Intern Med 002 1997;126:989) and Part 2: Unexplained syncope (Ann Intern Med 1997;127:76) Sarasin FP, Junod A-F, Carballo D, Slama S, et al. Role of echocardiography in the 1352 evaluation of syncope: a prospective study. Heart 2002:88:363. Soteriades ES, Evans JC, Larson MG, Chen MH, et al. Incidence and prognosis of 410 syncope. NEJM 2002;347:878. MISCELLANEOUS Wang K, Asinger R, Marriott, H. ST-segment elevation in conditions other than acute 1423 myocardial infarction. NEJM 349;22:2128. **Brater DC. Diuretic therapy. NEJM 1062 1998;339:387. Salpeter SR, Ormiston TM, Salpeter EE. 709 33
  34. 34. Cardioselective –Blockers in patients with reactive airway disease: a meta-analysis. Ann Intern Med 2002;137:715. CURRICULUM OUTLINE Curriculum Topic: Geriatrics/Rehabilitative Medicine 1. Educational purpose and rationale for the curriculum. Given an increasingly aging population and the focus on primary care practitioners as the major care providers, a solid working knowledge and understanding of the principles of geriatric medicine and long term care is essential for a well-trained general internist. 2. Principal teaching methods. a. Didactics lectures: 18-20-sessions per 4-week (20 contact days) rotation b. Group discussions: 2-3 hrs/week or 10-12 hrs/4-week rotation c. Self-study: 5-10 hours/week or 20-40 hours/4 week rotation d. Other: Bedside teaching by primary supervising attending during daily clinical work: at least 5-10 hours/week or 20-40 hours/4 week rotation 3. Educational content. a. Major objectives --10-15 most important subjects to be covered: 1. Demonstrate ability to perform assessment of needs and determine most appropriate level of care for each individual. 2. Demonstrate understanding of basic principles of: interdisciplinary teamwork; skin care and pressure ulcer prevention; health maintenance and preventive medicine; nutrition; ethics; clinical pharmacology; discharge planning and appropriate utilization of resources. 3. Understand principles of diagnosis and management of: common infections in LTC; incontinence; delirium, dementia, cognitive impairment; behavior problems; disorders of vision, hearing, communication; falls; pressure ulcers. 4. Develop ability to assess ADL function and rehabilitation potential. 5. Understand indications for and risks of chemical and mechanical restraints and recognize need for use of least restrictive means of management. 6. Understand indications for and risks of psychotropic medication in this population and demonstrate ability to assess for unwanted effects. 7. Demonstrate basic understanding of the most common problems, by organ system, experienced by the elderly and disabled. b. Patient characteristics: Inpatients in Long Term Care range in age from 16 to 100+ and are evenly divided by gender and represent all ethnic and racial groups. c. Patient care experiences in teaching areas: # sessions/wk avg # pts seen/session 34
  35. 35. Outpatient clinic(s) 0 0 Inpatient consults Inpatient ward 5 six-hr sessions 10-15 d. Procedures (See item 3a above) e. Educational resources Pertinent textbooks, including but not limited to the following, are available in the Department of Long Term Care Services and in the OFH Professional Library.  Ouslander, Osterwell, Morley: MEDICAL CARE IN THE NURSING HOME, McGraw Hill, 1991.  Kane, Ouslander, Abrass: ESSENTIALS OF CLINICAL GERIATRICS, 2nd Ed, McGraw Hill, 1989.  Kemp, Brummel-Smith, Lamsdell: GERIATRIC REHABILITATION, College Hill, 1990.  DeLaFuent, Stewart: THERAPEUTICS IN THE ELDERLY, Williams & Wilkins, 1988.  Cassel, Riesenberg, Sorensen, Walsh: GERIATRIC MEDICINE, 2nd ed., Springer-Verlag, 1990.  Hazzard, Andres, Bierman, Blass: PRINCIPLES OF GERIATRIC MEDICINE AND GERONTOLOGY. 3rd ed., 1995.  American Geriatrics Society: GERIATRICS REVIEW SYLLABUS II.  Morris, Hawes, Murphy, Nonemaker, et al., RESIDENT ASSESSMENT INSTRUMENT TRAINING MANUAL AND RESOURCE GUIDE, Eliot Press, 1991. PERIODICALS: JOURNAL OF THE AMERICAN GERIATRIC SOCIETY; GERIATRIC CARE. Required/recommended readings: Residents are advised to use one or both of the first two textbooks listed above as their source of basic study during this rotation, with supplementation from other sources pertinent to clinical problems experienced by the patients under their care. Handbooks or distributed materials: Handouts are provided with every didactic presentation. Residents are also encouraged to utilize articles from the extensive LTC files. They receive copies of any issues of GERIATRIC CARE, which are received during the rotation and have access to a file of past issues in LTC. A complete bibliography of articles is not included with this document because of large volume of materials and need for continuous updating. Slide sets, computer based, other materials: A large selection of videotapes, including the NETWORK FOR CONTINUING MEDICAL EDUCATION videotapes from 1985 to the most current are available through the LTC department office and the OFH Professional Library. (A list of tapes available in LTC is attached; a listing of titles available through the library is not included due to the extensive volume of available material.) 4. Evaluation a. Evaluation of the resident - which components are used? Yes No Attending evaluation X Fellow/Sr. Resident evaluation X Objective written test X Evaluation of prepared presentation X Other (describe) 35
  36. 36. b. Evaluation of the educational experience - how is it evaluated? Yes No Resident’s written evaluation of rotation X Informal feedback from residents X Attending feedback X Residents meeting educational objectives X Other (describe) 5. Strengths and limitations of the educational experience. a. Strengths: Residents are exposed to “state-of-the-art” geriatrics and long term care as it is currently practiced at Oak Forest Hospital. Additionally, they will be introduced to such issues as managed care, achieving highest quality in the most cost effective manner, and learning to cope with constant change; Large volume of patients with a wide variety of conditions receiving several levels of care; Experienced and dedicated primary care attending faculty who serve as teachers as well as role models; Enthusiastic OFH administrative support and a cooperative and cohesive Medical Staff; Focus on attending physicians rather than trainees as primary caregivers and physician of record. Opportunity for residents to experience partnership-teamwork model of providing primary patient care (as contrasted with traditional hierarchical model) in a 1:1 relationship with experienced attending physicians; Superb hospital support staff in an efficient, modern physical plant; Clinical Ethics Fellowship program with University of Chicago (positions for a fellowship coordinator and two Ethics fellows are funded through OFH; fellows are supervised by University of Chicago Ethics faculty and provide ethics consultation services and teaching). Funding for speakers from Illinois Geriatric Education Center and other nationally known experts in the field of Geriatrics. b. Limitations: Outpatient/ambulatory experience in geriatrics and long-term care is not yet available. Long-term plans include providing each attending physician in LTC with his/her own outpatient clinic sessions for follow up and continuity of care for patients who are discharged from their services. Residents would be expected to accompany the attending to whom they are assigned for clinic sessions and participate in the ambulatory experience. Due to the physical distance between institutions, communication and program coordination is difficult and occasionally not timely. Current efforts by the Cook County Bureau of Health to better integrate the three institutions should improve this. c. Other observations: This rotation offers a unique experience to trainees in internal medicine and includes training not only in the basic principles of geriatric medicine and long term care but also demonstrates how primary are is provided for a group of people with some special needs. Residents participate in 36
  37. 37. formal and informal discussions of medical ethics, follow patients as they move along the continuum of levels of care, observe a highly motivated and integrated medical staff at work, gain experience in managing difficult problem behaviors, and have exposure to socioeconomic concepts in health care. 37
  38. 38. CURRICULUM OUTLINE Curriculum Topic: Inpatient Medicine 1. Educational purpose and rationale for the curriculum. The purpose of rotations on the inpatient medicine service is that residents will acquire the knowledge, skills, and attitudes essential to the practice of general internal medicine for unselected, acutely ill, hospitalized patients. The ability to provide comprehensive, coordinated inpatient care to unselected patients in the hospital, and to establish inpatient-outpatient continuity, is a key requirement for the practicing internist. House officers rotate on the inpatient medicine service an average of 7 times during their first year and 10 times during their second and third year combined. Each rotation lasts four weeks. Thus, the educational goals of this training experience are accomplished through a total of 17 months on service, distributed over the course of three years. 2. Principal teaching methods. a. Didactics lectures: Scheduled teaching conferences for the inpatient medicine service include the following: 1. Resident morning report occurs each weekday for one hour. Typically, two overnight admissions are discussed in detail. Focus is on critical thinking, clinical reasoning skills, and evidence based medicine. 2. A weekly firm conference is held for one hour. Format includes inpatient case conference, morbidity & mortality, critical appraisal of the medical literature, and resident run case presentations. 3. The majority of the topics in the weekly intern lecture series are basic inpatient medicine topics. The sessions are paired with one-hour small group firm based discussion sections to reinforce educational points. b. Group discussions: Ward Teams: Scheduled attending teaching rounds, separate from attending management rounds, take place two to three days per week for 1.5 to 2 hours. The ward team is protected from new admissions on these designated days in the call cycle, to ensure availability of team members. Sessions are scheduled to begin at either 10:00 a.m. or at 2:00 p.m., depending on the clinic obligations of the attending physician. These sessions are always based on the spectrum of pathology present on the ward team but format is variable: bedside teaching, small group conference room sessions, interpretative sessions spent looking at X-rays or blood smears, sessions devoted to ethical issues are some examples. Ward Service: Separate morning reports are held for residents and interns : Residents’ Morning Report -- daily (9:00 - 10:00) Interns’ Report -- weekly (Tuesday, 12:00 - 1:00) c. Self-study: Housestaff are expected to read about each patient in a standard textbook of medicine. In addition, to promote development of problem-solving skills, residents are asked to answer specific questions arising on service in an evidence-based manner through reference to the literature. d. Other: 38

×