Department of Internal Medicine
Texas Tech University Health Sciences Center
Critical Care Curriculum
Revision Date: July 10, 2006
Approved by the Curriculum Meeting June 30, 2006
I. Educational Background and Purpose
Graduate training exposure to critically ill patients is required of all Internal Medicine
residents. Given the expected growth in the aging population, the demand for critical care is
likely to increase in the future. Most of the critically ill patients admitted to the ICU in the U.S.
are managed by their primary physicians. Although critical care consultants are readily
available in many hospitals, it is unlikely that in the near future involvement in patient care
will exceed present figures, due to both increased demands and limited specialist supply. It
is thus crucial that trainees in all specialties assuming primary responsibility for the care of
the critically ill patient are well equipped to provide appropriate, high quality care.
The nature of critical illness is often complex enough to benefit from a multidisciplinary team
approach. Tremendous explosion of knowledge and technology in critical care has occurred,
commonly involving several specialty lines. However, major variations in resident training
continue to occur and are in part due to the fact that most training programs limit the resident
physician's intensive care unit experience to managing patients within that program's
This document outlines the skills, knowledge and professional attitudes expected at each
level of resident training and upon completion of the residency program, in order to be able
to formulate and initiate a treatment plan for the critically ill patient.
II. Educational Goals
Upon completion of residency training, the resident will have developed a measurable
quantity of knowledge, learned a set of observable skills, demonstrated adequate decision
making, and possess a caring and compassionate attitude for patients who are critically ill.
Attainment of these skills is not to be necessarily misconstrued as conveying the ability to be
an independent subspecialty-level practitioner for critically ill and injured patients.
Specifically, on completion of residency training, each resident physician will be able to
perform the following:
III. General Goals
• Diagnose and stabilize and properly triage patients with impending organ failure
(respiratory, cardiac, neurologic, hepatic, gastrointestinal, hematologic, renal,
• Identify the need for and initiate cardiopulmonary resuscitation.
• Diagnose and prevent hemodynamic instability and/or initiate treatment for
cardiogenic, traumatic hypovolemic, and distributive shock.
• Identify and initiate treatment for life-threatening electrolyte and acid-base
• Suspect and initiate treatment for common poisonings.
• Use date from appropriate invasive and noninvasive monitoring devices to titrate
therapy in an ICU.
• Understand basic infection control techniques.
• Understand basic nutrition support principles.
• Understand basic sedation and analgesia principles.
• Understand basic concepts of therapeutic decision making and medication
• Recognize, use and help integrate the unique skills of ICU nurses and ancillary
personnel in caring for critically ill patients into the multiple-professional team
• Consider ethical issues and patients’ wishes in making treatment decisions.
• Identify when a patient treatment best delivered in an ICU, and the need for
consultation and/or primary care by a Critical Care specialist.
• Seek consultation, when appropriate with specialty physicians in managing
complex ICU problems.
• Communicate effectively with families and all members of the healthcare team
about ICU capabilities and patient-specific issues.
• Communicate with and support patients, their families, and all members of the
healthcare team through the physical and psychological complexities of critical
• Understand the need for and help in the process of assessing patient and family
• Maintain good relationships with other healthcare providers.
• Support initiatives to improve care of critically ill patients.
• Understand the need for patient safety monitoring and error reduction strategies
• Understand and ensure compliance with institutional and unit policies and
procedures as well as regulatory policies from accreditors, regulators, and
IV. Specific Educational Categories
All housestaff should achieve and maintain Advanced Cardiac Life Support (ACLS) provider
status throughout training.
Specific Cognitive Skills, Knowledge and Professional Attitudes
1. Recognition and Acute Management of:
Shock (all forms)
Cardiogenic Pulmonary Edema
Acute valvular insufficiency
Acute coronary syndromes
2. Principles and application of:
Vasoactive and inotropic therapy
Arterial, central venous, and pulmonary artery catheterization monitoring
Cardiovascular physiology in the critically ill patient
1. Recognition and Acute Management of:
Acute and chronic respiratory failure
Acute respiratory distress syndrome (noncardiogenic/capillary leak pulmonary
Upper airway obstruction, including foreign bodies and infection
2. Principles and application of:
Mechanical ventilation (invasive and noninvasive) including indications, modes,
complications, and weaning.
3. Use of:
Pulmonary function tests, including bedside spirometry
Arterial blood gas analysis
1. Recognition and Acute Management of:
Fluid and electrolyte disturbances
2. Principles and application of:
Drug dosing in renal failure
Fluid and electrolyte therapy in the critically ill patient
D. Central and peripheral Nervous System
1. Recognition and Acute Management of:
Coma and altered mental status conditions
Drug overdose & Poisoning (carbon mono-oxide, ethylene glycol etc)
Brain death evaluation
Intracranial vascular accidents
Emergent disorders of spinal cord, peripheral nerves, and neuromuscular
Spinal cord injury
E. Metabolic and Endocrine
1. Recognition and Acute Management of:
Thyroid storm and myxedema coma
2. Principles of Alimentation
F. Infectious Diseases
1. Recognition and Acute Management of:
Sepsis, severe sepsis, and septic shock
Hospital-acquired, healthcare-associated, and opportunistic infections,
including those related to HIV
Antibiotic selection and dosage schedules for the critically ill patient
Infection risks to healthcare workers
G. Hematologic Disorders
1. Recognition and Acute Management of:
Defects in hemostasis
Hematologic dysplasias and their complications
Sickle cell crisis
H. Gastrointestinal Disorders
1. Recognition and Acute Management of:
Mesenteric ischemia and infarction
2. Principles and application of prophylaxis against stress-related mucosal
I. Critical Illness in the Pregnant Patient
J. Principles of Sedation, Analgesia, and Neuromuscular Blockade in the Critically
K. Preventive care in the critically ill patient
Prevention of complications related to underlying critical illness
Preventive measures related to procedures and invasive devices
Preventive measures related to altered consciousness and immobilization
L. Transport of the Critically ill Patient
M. Ethical and Legal Aspects of Critical Care
Rights of patients
Principles of informed consent
Living wills, Advance directives, durable powers of attorney
Withholding and withdrawing life support
N. Psychosocial Issues
Understanding the effect of life-threatening illness on patients and their families
Death and dying
O. Monitoring, prognostication, and biostatistics
Prognostic indices such as the Acute Physiology and Chronic Health Evaluation
(APACHE), as indicated
Respiratory monitoring (pulse oximetry, capnography)
Electronic pressure transduction
Specific Core Procedural Skills and Knowledge
In addition to practical training in the following procedural skills, the resident must have
an understanding of the indications, contraindications, complications, and pitfalls of these
A. Airway Management
Maintenance of an open airway in the nonintubated patient
Ventilation by bag-mask
Emergent Management of pneumothorax
Arterial puncture and cannulation
Insertion of central venous catheters
Dynamic electrocardiogram interpretation
V. Principle Teaching Methods
1. Supervised direct patient care activities. Resident teams participate in daily
management rounds with their supervising Critical Care faculty (See also Rotation
Structure). Residents assume primary care responsibility for the patient evaluation,
management and coordination of care for all patients admitted to the Texas Tech
Critical Care service, including performance of any necessary procedures. Similarly,
residents will assume responsibility for critical care of patients on whom Texas Tech
Critical Care service was consulted. Proper care coordination is maintained with the
primary physicians of consultation patients.
2. Small group discussions. Residents participate in a morning report 5 days a week
(Monday-Friday), during which patient evaluation and management are discussed,
moderated by faculty and senior residents. Presentations and subsequent
interactive exchange, moderated by faculty and senior residents. In addition,
residents make brief presentations of results of literature search on clinical
questions raised in relation to discussed patient cases. Teaching rounds are
conducted daily with attending Critical Care faculty, as a separate part of attending
rounds. During both morning report and teaching rounds, emphasis is placed on
learning accurate, focused data communication, formulation of problem lists and
pertinent differential diagnosis, and selected, derived aspects of diagnosis,
management, prognostication, triage, as well as relevant bioethical and resource
utilization issues. Skills for proper validation, follow-up and communication of
patient’s data are emphasized in context of general management, continuity of care,
and patient safety. Regular sessions on ethics are included within the teaching
3. Didactic sessions. Residents participate in the Medical Emergencies lecture series
at the beginning of each academic year and the subsequent core lecture series on
Monday, Tuesday and Friday, as well as attend the monthly interdepartmental and
geriatrics lecture series. Residents continue to participate in the weekly Internal
Medicine Grand Rounds, conducted on Thursday.
4. Morbidity and Mortality Conferences: Residents participate in these monthly
conferences to review cases, which are often drawn from the critical care units.
Presentations are made by residents, with faculty commentary.
5. Assigned reading: Residents are expected to complete reading of pre-rotation core
Critical Care article and guideline packets, as well additional directed reading,
based upon their patient census. Directed self-study also involves the on-line
presentations on the RICU web site. In addition, there is guided readings from
standard texts and key reference article, related to specific patients under residents’
care and the didactic sessions (See also Ancillary Educational Materials).
VI. Educational Content
1. Patient Characteristics: Medical Center Hospital (MCH) serves as the primary
critical care facility for residents of Ector County and a major referral center for
patients requiring critical in surrounding west Texas counties and part of New
Mexico, commonly utilizing the airlift capability of the CareStar program. In addition,
MCH is a local referral trauma center, serving 17 surrounding counties. Texas Tech
Critical care service provides daily on-call coverage for primary and consultative
critical care support. Midland Memorial Hospital (MMH) is the primary acute care
facility for residents of Midland county requiring critical care, and occasionally
serves patients referred for critical care from adjacent counting. In addition,
residents on the critical care service at MMH admit and manage patients requiring
cardiac telemetry. Patients in both hospitals include Texas Tech patients, as well as
unassigned or consultation critically ill patients.
2. Disease Mix: Patients requiring management by the Critical Care Service may have
a wide spectrum of critical illnesses. These include among other, respiratory
system pathology, most commonly respiratory failure; severe sepsis and septic
shock; acute and chronic metabolic and endocrine aberrations, including toxin and
drug overdose and diabetic ketoacidosis; acute coronary syndromes and
decompensated heart failure; neurological emergencies; and trauma-related organ
dysfunction and failure (managed by the critical care team as a consulting service).
3. Educational Venues:
I. Facilities: The critical care rotation occurs at Medical Center Hospital and
Midland Memorial Hospital. Residents take of care for patients admitted to the
Texas Tech Critical Care Service or requiring its consultative support in the
Intensive Care Unit and the Coronary Care Unit at both hospitals, and patients
admitted to Texas Tech service, requiring cardiac telemetry at MMH. Both
hospitals have computer facilities with Internet access for resident use. Critical
Care units (and the telemetry unit at MMH) have on-line access to digitized
imaging data of surface films, nuclear medicine studies, CT scans, MRI, MRA,
and invasive angiography. MCH also has provides on-line access to the full
content of medical records from patients’ previous hospitalizations, as well as
electronic access to results of laboratory investigations.
II. Procedures: Residents have the opportunity to perform a variety of procedures
on patients under their care, including tracheal intubation, central venous and
arterial catheterization, pulmonary artery catheterization, lumbar puncture,
paracentesis, thoracentesis, and gastric tube placement. Residents also apply
standard ACLS protocols in the care of patients, as needed. Opportunity is
provided for the residents to interpret all laboratory tests and imaging studies
obtained on their patients. Radiology images and diagnostic test results are
readily accessible from the desktop computer terminals in units and throughout
both hospitals, as described above.
III. Ancillary Services: Throughout the Critical Care rotation residents interact with
subspecialty clinician from various disciplines; residents from other disciplines
who serve either as consultants (i.e., OB-Gyn) or from other primary patient
services (i.e, family practice); nursing personnel; respiratory therapists; clinical
pharmacists; social service staff; and case managers.
IV. Rotation Structure:
a. Teams: [need to finalize future number of residents on rotation]
b. Duty Hours: All resident schedules are structured to limit duty hours
to no greater than 80 hours per week when averaged over four weeks.
Morning report commences resident duties at [may need to change]
…. am; therefore, on post call days, residents are expected to sign off
patient responsibilities no later than [need to discuss changes] pm.
Sign out on non-call days occurs at [need to discuss changes] pm.
c. Call: [need to discuss and finalize call structure to comply with work
d. Rounds: Residents perform daily management rounds with Critical
Care faculty. Start times are between faculty and residents. Patients’
case discussion and care is provided at the bedside. Imaging studies
may also be reviewed electronically during management rounds.
e. Clinics: Residents continue to participate in their continuity clinics in
Odessa and Midland, 2 half days per week, unless such participation
would conflict with post call duty hour restrictions.
f. Didactic activities: ICU residents continue to participate in residency-
wide didactic activities as noted in Principle Teaching methods. ICU
teaching rounds with Critical Care faculty occur daily, complementing
the management rounds component.
VII. Ancillary Educational Materials
A variety of educational materials are available at the TTUHSC library of the Odessa
campus, including all the textbooks and handbooks cited below, as well as the full text hard
copy and electronic versions of the remainder references.
In addition, residents have access to educational material on-line at both MCH and MMH.
Those include also program-sponsored subscription to UpToDate.
A. Principle Ancillary Educational Materials
At the beginning of the rotation, each resident receives a copy of the Critical Care
curriculum’s Goals and Learning Objectives.
Textbooks in Adult Critical Care Medicine (each of these texts provides adequate
coverage for Critical Care Medicine)
1. Hall JB, Schmidt GA, Wood LH, eds. Principles of critical care, 3rd edition.
New York, NY: McGraw-Hill, 2005.
2. Irwin RS, Rippe JM, eds. Intensive care medicine, 5th edition. Philadelphia,
PA: Lippincott Raven, 2003.
3. Grenvik A, Ayers SM, Holbrook PR, Shoemaker WC, eds. Textbook of
critical care, 4th edition. Philadelphia, PA: W.B. Saunders, 2000.
Handbooks in Critical Care
1. Marino PL. The ICU book, 2nd edition. Baltimore, MD: Williams & Wilkins,
2. Marini JJ, Wheeler AP. Critical care medicine, the essentials, 2nd edition.
Baltimore, MD: Williams & Wilkins, 1997
Useful web sites for Critical Care Medicine
1. Society of Critical Care Medicine: http://www.sccm.org (provides good
overview of critical care related practice guidelines by the American College
of Critical Care Medicine, as well as useful web links)
2. http://www.ricu.org (an on-line web site developed and maintained by the
Society of Critical Care Medicine targeted specifically residents of Internal
Medicine and other specialties. Provides Power Point presentations on core
critical care topics. Pre- test and post-test evaluations are available on-
3. American College of Chest Physicians: http://www.chestnet.org (provides
useful data on critical care and pulmonary medicine. Includes an online
care and pulmonary medicine. Includes an online consensus statements,
4. http://www.lcuroom.net (provides numerous critical care-related calculators,
guidelines, near daily updated and referenced critical care “pearls”,
practical aspects of bioethics and specific system and specialty related
5. The Cochrane Collaboration and Cochrane Library – evidence-based
6. http://www.intensivecare.com (a detailed resource of evidence-based
practice in critical care and in general; include core full-text references)
7. UpToDate http://www.uptodate.com (general, periodically updated resource
that includes several relevant systematic review-type discussions)
B. System/Disease/Problem-Specific Reference (updated periodically)
1. Ventilation with lower tidal volumes as compared with traditional tidal
volumes for acute lung injury and the acute respiratory distress syndrome.
The Acute Respiratory Distress Syndrome Network. N Engl J Med
2. Fan E, et al. Ventilatory management of acute lung injury and acute
respiratory distress syndrome. JAMA 2005; 294: 2889-2896.
3. Ram FS, et al. Non-invasive positive pressure ventilation for treatment of
respiratory failure due to exacerbations of chronic obstructive pulmonary
disease. Cochrane Database Syst Rev 2004; 3: CD004104.
4. Esteban A, et al. Effect of spontaneous breathing trial duration on outcome
of attempts to discontinue mechanical ventilation. Spanish Lung Failure
Collaborative Group. Am J Respir Crit Care Med 1999;159(2):512-8.
5. Coplin WM, Pierson DJ, Cooley KD, Newell DW, Rubenfeld GD.
Implications of extubation delay in brain-injured patients meeting standard
weaning criteria. Am J Respir Crit Care Med 2000; 161(5): 1530-6.
1. Dellinger RP, et al. Surviving Sepsis campaign guidelines for management
of severe sepsis and septic shock. Crit Care Med 2004; 32: 858-873.
2. Levy MM, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis
Definitions Conference. Crit Care Med 2004; 32: 858-873.
3. Calandra T, et al. The International Sepsis Forum Consensus Conference
on Definitions of Infection in the Intensive Care Unit. Crit Care Med 2005;
4. Martin C, Viviand X, Leone M, Thirion X. Effect of norepinephrine on the
outcome of septic shock. Crit Care Med 2000; 28(8): 2758-65.
5. Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of
recombinant human activated protein C for severe sepsis. N Engl J Med.
6. Annane D, Sebille V, Charpenter C, et al. Effect of treatment with low doses
of hydrocortisone and fludrocortisone on mortality in patients with septic
shock. JAMA. 2002; 288:862-71.
7. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson
E, Tomlanovich M; Early Goal-Directed Therapy Collaborative Group. Early
goal-directed therapy in the treatment of severe sepsis and septic shock. N
Engl J Med. 2001 Nov 8;345(19): 1368-77.
8. Hollenberg S, et al. Practice parameters for hemodynamic support of
sepsis in adult patients: 2004 update. Crit Care Med 2004; 27: 1928-1948.
1. Varon J, Marik PE. The diagnosis and management of hypertensive crises.
Chest 2000; 118: 214-27
Intravenous Fluid Resuscitation
Finfer S, et al. A comparison of albumin and saline for fluid resuscitation in the
intensive care unit. N Engl J Med 2004; 350: 2247-2256.
Dorman T, Breslow MJ, Lipsett PA, Rosenberg JM, Balser JR, Almog Y, Rosenfeld
BA. Radial artery pressure monitoring underestimates central arterial pressure
during vasopressor therapy in critically ill surgical patients. Crit Care Med 1998;
Multiple Organ Dysfunction Syndrome
1. Zimmerman JE, Knaus WA, Wagner DP, Sun X, Hakim RB, Nystrom PO. A
comparison of risks and outcomes for patients with organ system failure:
1982-1990. Crit Care Med 1996; 24(10): 1633-41.
2. Marshall JC, Cook DJ, Christou NV, Bernard GR, Sprung CL, Sibbald WJ.
Multiple organ dysfunction score: a reliable descriptor of a complex clinical
outcome. Crit Care Med 1995; 23: 1638-52.
Neurological Complications of Critical Illness
1. Provenicio JJ, et al. Critical illness neurology. Am J Respir Crit Care Med
2001; 164: 341-345
2. Bleck TP, et al. Neurologic complications of critical medical illnesses. Crit
Care Med 1993; 21: 98-103.
3. Latronico N, et al. Critical illness myopathy and neuropathy. Curr Opin Crit
care 2005; 11: 126-132
4. Bolton CF. Sepsis and the systemic inflammatory response syndrome:
neuromuscular manifestations. Crit Care Med 1996; 24(8): 1408-16.
1. American Thoracic Society: Infectious Diseases Society of America.
Guidelines for the management of adults with hospital-acquired, ventilator-
associated, and healthcare-associated pneumonia. Am J Respir Crit Care
Med 2005; 171:338-416
2. Dodek P, et al. Evidence-based clinical practice guideline for the prevention
of ventilator-associated pneumonia. Ann Intern Med 2004; 141: 305-313.
3. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M. Supine
body position as a risk factor for nosocomial pneumonia in mechanically
ventilated patients: a randomized trial. Lancet 1999; 354: 1851-8.
4. Cook DJ, Walter SD, Cook RJ, Griffith LE, Guyatt GH, Leasa D, Jaeschke
RZ, Brun-Buisson C. Incidence of and risk factors for ventilator-associated
pneumonia in critically ill patients. Ann Intern Med 1998; 129: 433-40.
Other Infectious complications of Critical Illness
1. Ibrahim EH, Sherman G, Ward S, Fraser VJ, Kollef MH. The influence of
inadequate antimicrobial treatment of bloodstream infections on patient
outcomes in the ICU setting. Chest 2000; 118(1): 146-55
2. Kollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial
treatment of infections: a risk factor for hospital mortality among critically ill
patients. Chest 1999; 115(2): 462-74.
3. O'Grady NP, Barie PS, Bartlett JG, Bleck T, Garvey G, Jacobi J, Linden P,
Maki DG, Nam M, Pasculle W, Pasquale MD, Tribett DL, Masur H. Practice
guidelines for evaluating new fever in critically ill adult patients. Task Force of
the Society of Critical Care Medicine and the Infectious Diseases Society of
America. Clin Infect Dis 1998; 26: 1042-59.
4. Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern
Med 2000; 132: 391-402.
1. Kollef MH, O'Brien JD, Zuckerman GR, Shannon W. BLEED: a classification
tool to predict outcomes in patients with acute upper and lower
gastrointestinal hemorrhage. Crit Care Med 1997; 25: 1125-32.
2. Cook DJ, Fuller HD, Guyatt GH, Marshall JC, Leasa D, Hall R, Winton TL,
Rutledge F, Todd TJ, Roy P, et al. Risk factors for gastrointestinal bleeding in
critically ill patients. Canadian Critical Care Trials Group. N Engl J Med 1994;
3. Cook D, Guyatt G, Marshall J, Leasa D, Fuller H, Hall R, Peters S, Rutledge
F, Griffith L, McLellan A, Wood G, Kirby A. A comparison of sucralfate and
ranitidine for the prevention of upper gastrointestinal bleeding in patients
requiring mechanical ventilation. Canadian Critical Care Trials Group. N Engl
J Med 1998;338: 791-7.
4. Ivatury RR, Sugerman HJ. Abdominal compartment syndrome: a century
later, isn't it time to pay attention? Crit Care Med 2000; 28: 2137-8.
1. Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G,
Tweeddale M, Schweitzer I, Yetisir E. A multicenter, randomized, controlled
clinical trial of transfusion requirements in critical care. Transfusion
Requirements in Critical Care Investigators, Canadian Critical Care Trials
Group. N Engl J Med 1999; 340: 409-17.
2. Vichinsky EP, Neumayr LD, Earles AN, Williams R, Lennette ET, Dean D,
Nickerson B, Orringer E, McKie V, Bellevue R, Daeschner C, Manci EA.
Causes and outcomes of the acute chest syndrome in sickle cell disease.
National Acute Chest Syndrome Study Group. N Engl J Med 2000; 342:
Metabolic and Endocrine disease
1. Mange K, Matsuura D, Cizman B, Soto H, Ziyadeh FN, Goldfarb S, Neilson
EG. Language guiding therapy: the case of dehydration versus volume
depletion. Ann Intern Med 1997; 127: 848-53.
2. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in
the critically ill patients. N Engl J Med. 2001;345:1359-67.
3. Van den Berghe G, et al. Intensive insulin therapy in the medical ICU. N Engl
J Med. 2006;354: 449-461.
4. Adrogue HJ, Madias NE. Hyponatremia. N Engl J Med 2000; 342: 1581-9
5. Adrogue HJ, Madias NE. Hypernatremia. N Engl J Med 2000; 342: 1493-9
6. Hillier TA, Abbott RD, Barrett EJ. Hyponatremia: evaluating the correction
factor for hyperglycemia. Am J Med 1999; 106: 399-403.
7. Forsythe SM, Schmidt GA. Sodium bicarbonate for the treatment of lactic
acidosis. Chest 2000;117: 260-7.
8. Kannan CR. Bicarbonate therapy in the management of severe diabetic
ketoacidosis. Crit Care Med 1999; 27: 2833-4.
9. Viallon A, Zeni F, Lafond P, Venet C, Tardy B, Page Y, Bertrand JC. Does
bicarbonate therapy improve the management of severe diabetic
ketoacidosis? Crit Care Med 1999; 27: 2690-3.
1. Gramlich L, et al. Does enteral nutrition compared to parenteral nutrition
result in better outcomes in critically ill adult patients? A systematic review of
the literature. Nutrition 2004; 20: 843-848.
2. Cerra FB, Benitez MR, Blackburn GL, Irwin RS, Jeejeebhoy K, Katz DP,
Pingleton SK, Pomposelli J, Rombeau JL, Shronts E, Wolfe RR, Zaloga GP.
Applied nutrition in ICU patients. A consensus statement of the American
College of Chest Physicians. Chest 1997; 111: 769-78
3. McClave SA, Sexton LK, Spain DA, Adams JL, Owens NA, Sullins MB,
Blandford BS, Snider HL. Enteral tube feeding in the intensive care unit:
factors impeding adequate delivery. Crit Care Med 1999; 27: 1252-6.
Ethics, End of Life Issues
1. Brody H, Campbell ML, Faber-Langendoen K, Ogle KS. Withdrawing
intensive life-sustaining treatment -- recommendations for compassionate
clinical management. N Engl J Med 1997; 336: 652-7
2. A controlled trial to improve care for seriously ill hospitalized patients. The
study to understand prognoses and preferences for outcomes and risks of
treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA 1995;
3. Faber-Langendoen K, Lanken PN. Dying Patients in the Intensive Care Unit:
Forgoing Treatment, Maintaining Care. Ann Intern Med 2000; 133: 886-893.
4. Azoulay E, Chevret S, Leleu G, Pochard F, Barboteu M, Adrie C, Canoui P,
Le Gall JR, Schlemmer B. Half the families of intensive care unit patients
experience inadequate communication with physicians. Crit Care Med 2000;
5. Gianakos D. Conversations with Stella. Ann Intern Med 1999; 130: 698-9
Drug and Toxin Exposure
1. Trujillo MH, Guerrero J, Fragachan C, Fernandez MA. Pharmacologic
antidotes in critical care medicine: a practical guide for drug administration.
Crit Care Med 1998; 26: 377-91.
2. Mokhlesi B, Leiken JB, Murray P, et al. Adult Toxicology in Critical Care: Part
I: General Approach to the Intoxicated Patient. Chest 2003 123: 577-592.
3. Mokhlesi B, Leiken JB, Murray P, et al. Adult Toxicology in Critical Care: Part
II: Specific Poisonings. Chest 2003 123: 897-922.
Prognosis Critical Illness
1. Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, Bastos PG,
Sirio CA, Murphy DJ, Lotring T, Damiano A, et al. The APACHE III prognostic
system. Risk prediction of hospital mortality for critically ill hospitalized adults.
Chest 1991; 100: 1619-36.
2. Eddleston JM, White P, Guthrie E. Survival, morbidity, and quality of life after
discharge from intensive care. Crit Care Med 2000; 28: 2293-9.
3. Pettila V, Kaarlola A, Makelainen A. Health-related quality of life of multiple
organ dysfunction patients one year after intensive care. Intensive Care Med
2000; 26: 1473-9.
4. Afessa B, Green B. Clinical course, prognostic factors, and outcome
prediction for HIV patients in the ICU. The PIP (Pulmonary complications,
ICU support, and prognostic factors in hospitalized patients with HIV) study.
Chest 2000; 118: 138-45.
VIII. Methods of Evaluation
1. Resident Performance: Critical Care Service faculty complete written resident
evaluation forms provided by the Internal Medicine Residency coordinators. The
evaluation is competency-based, and uses a detailed assessment of resident’s
effort, progress and achievement on each core competency component. Faculty
review the written evaluation in person with each resident and provide detailed
feedback on resident’s performance. In addition, the following sources and methods
of evaluation are included in assessing residents performance: a) written
evaluations completed by end of each rotation by the other member of the resident
team. b) written evaluations by ICU nursing staff. c) resident’s performance on the
pre-test and post-test on the RICU web site. d) mini-CEX and CEX. e) all other
(verbal, written) evaluation comments provided to the Program Director/Associate
Program Director by faculty and community physicians interacting with the resident
during ICU rotation are documented in writing. f) performance on the periodic
Critical Care exam administered as part of the monthly subspecialty exams. All
evaluations are available for resident review (excluding direct review of evaluations
completed by resident colleagues). All evaluations are part of the resident file and
are incorporated into the semiannual performance review for directed resident
2. Procedures: Residents submit documentation of any procedures performed during
the rotation, on a hard-copy form, completed by supervising faculty. Procedure
forms include supervisors’ evaluation of resident’s performance.
3. Program and Faculty Performance: [Need to finalize our version] End of the Critical
Care rotation, the residents are asked to complete a service evaluation form
commenting on the faculty, facilities, and service experience. These evaluations
are returned by the residents to the residency office and are reviewed by Program
Director and department chair.
Institutional Resources: Strengths and Limitations:
1. Strengths: [need to finalize our version]
2. Limitations: [need to finalize our version]
IX. Rotation-Specific Competency Objectives
1. Patient Care:
I. Data Gathering
a. History. Residents at all levels of training will collect a thorough history
from patients, as allowed by their clinical condition, and consult other
sources or primary data (including but not limited to direct contact with
family members, friends, EMS teams, healthcare providers in
referring/other institutions; current and prior hard-copy and electronic
medical records). History taking will be hypothesis-driven. History
gathering from all sources will be performed in a timely, logical and
organized fashion. Interviewing will adapt to the time available and
instability of the patient, use appropriate nonverbal techniques, and
demonstrate sensitivity and consideration for the patient and family.
Residents will recognize verbal and nonverbal cues from the patient.
Cues will be followed in an organized directed logical fashion with a
complete exploration of symptoms. Data gathering should not conflict
with need for simultaneous specific and non-specific life-support and
stabilization interventions. The resident will inquire about the emotional
aspects of the patient’s or family’s experience while demonstrating
flexibility based on patient need.
b. Physical Exam. Residents at all levels of training will use correct
technique and perform a comprehensive physical examination
describing the physiological and anatomical basis for normal and
abnormal findings. PGY-2 and PGY-3 residents will demonstrate
knowledge and skills of maneuvers that can elicit findings not otherwise
present, and routinely adapt the physical exam for patients with
diminished levels of consciousness or cooperativeness.
Medical Decision-Making and Clinical Judgment. All residents will demonstrate
improving skills in systematically applying information that they have gathered
from the history, physical exam and other available data.
1. PGY-1 residents will be able to identify and prioritize all patients’
problems and develop a prioritized differential diagnosis. Abnormal
findings will be interrelated with altered physiology. They will start
integrating up-to-date scientific evidence to support their hypotheses.
Residents will demonstrate understanding of their limitation of skills and
knowledge and seek the advice of more advanced clinicians. Residents
will establish an orderly sequence of diagnostic testing based on
patients’ history, physical exam and other available data. They will be
able to describe goals of diagnostic studies for individual patients (i.e.,
confirmatory test, assessment of secondary organ system dysfunction,
etc.) and the impact of “negative”, “positive”, and “inconclusive” test
results on decision-making. Residents will progressively improve ability
to revise assessments in the face of new data.
2. PGY-2 residents will demonstrate the above and in addition will also
regularly integrate medical facts and clinical data while weighing
alternatives and keeping in mind patient preferences. They will regularly
incorporate consideration of risks and benefits when considering
diagnostic testing. Residents routinely will present up-to-date scientific
evidence to support their hypotheses.
3. PGY-3 residents will demonstrate the above and in addition will
demonstrate appropriate reasoning in ambiguous situations, while
continuing to seek clarity. Residents at this level of training will not
overly rely on tests and procedures. PGY-3 residents will continuously
revise assessments in the face of new data.
1. PGY-1 residents will begin to develop specific and detailed (translatable
into actual practice) therapeutic plans that are evidence or consensus
based. Specific organ dysfunction will be anticipated based on known
side effects of therapy. Additionally, residents will understand the
correct administration of drugs, describe drug-drug interactions, and be
familiar with expected outcomes.
2. PGY-2 and PGY-3 residents will demonstrate the above and in addition
will also regularly incorporate consideration of risks and benefits when
considering therapies and regularly incorporate patients’ preferences
into their decision-making. They will develop plans to avoid or delay
known treatment complications and be able to identify when illness has
reached a point where treatment no longer contributes to improved
quality of life.
1. PGY-1 and PGY-2 residents will demonstrate knowledge of procedural
indications, contraindications, necessary equipment, specimen
handling, trouble-shooting, patient after-care, and risk and discomfort
minimization. They will participate in informed consent and assist
patients with decision making. PGY-1 residents will initially observe and
then perform procedures under proper supervision.
2. PGY-3 residents will demonstrate the above and in addition will also
demonstrate extensive knowledge and facility in the performance of
procedures while minimizing risk and discomfort to patients. They will
assist their junior peers in skill acquisition.
V.Implementation of Care:
a. General. Residents at all levels of training will consistently oversee
implementation of care and assure the accurate and timely delivery of care
plan. Orders for care for will be consistently complete in all components,
clear, legible, and follow commonly used guidelines for avoiding errors in
interpretation and maximizing patient safety. They will consistently monitor
and follow-up patients appropriately. All residents will assure effective and
accurate continuity of care through proper hand-over procedures to cross-
b. Patient counseling.
1. PGY-1 residents will be able to describe the rationale for a chosen
therapy and will be able to describe medication side effects in lay
terms. They will assess patient/family understanding and provide
more information when necessary. Residents will demonstrate the
ability to be a patient advocate.
2. PGY-2 residents, in addition to the above, will be able to explain
the pros and cons of competing therapeutic interventions. PGY-2
residents will be expected to counsel patients regarding adverse
habits, and educate patients and families for enhanced
compliance. They will be able to effectively communicate with
critically ill patients and engage patients and families in issues
related to advance directives and end-of-life discussions.
3. PGY-3 residents, in addition to the above, will effectively
communicate with patients making life-style modifications.
VI.Documentation: Residents at all levels of training will record data in a legible,
thorough and systematic manner.
2. Medical Knowledge:
1. PGY-1 Residents will demonstrate progressive expansion of medical
knowledge related to Critical Care Medicine, acquired through the
didactic program, prior rotations and expected self-study, and show
initiative and ability to clarify uncertainties through available resources.
Residents will consistently apply current concepts in the basic and
clinical sciences to clinical problem solving. They will use information
from the literature and other sources including electronic databases.
PGY-1 residents will demonstrate satisfactory knowledge of common
medical conditions, sufficient to manage urgent complaints with
supervision. Residents must exhibit sufficient content knowledge of
common conditions to provide care with minimal supervision by
completion of the PGY-1 year.
2. PGY-2 residents will demonstrate the above and in addition will also
demonstrate a progression in knowledge and analytical thinking in order
to develop well-formulated differential diagnoses for multi-problem
patients. They will also demonstrate socio-behavioral knowledge.
3. PGY-3 residents in addition to the above will demonstrate appropriate
habits to stay current with new medical knowledge, and will exhibit
knowledge of effective teaching methods.
3. Practice Based Learning and Improvement.
Residents at all levels of training will readily acknowledge gaps in skills and
knowledge, and incorporate feedback into improving clinical practice and self-
1. PGY-1 residents will use University library and personal educational
resources to start developing and improving skills to critically appraise
medical literature and apply evidence to patient care. They will use
hand- held computers, desktop PC’s and Internet electronic references
to support patient care and self-education.
2. PGY-2 residents will in addition consistently seek out and analyze data
on practice experience, identify areas for improvement in knowledge or
patient care performance and make appropriate adjustments. Residents
will consistently demonstrate ability to critically appraise medical
literature, and will regularly demonstrate knowledge of the impact of
study design on validity or applicability to individual practice.
3. PGY-3 residents will additionally model independent learning and
4. Interpersonal and Communication Skills.
1. PGY-1 residents will develop and refine their individual style when
communicating with patients. They will strive to create ethically sounds
relationships with patients and family members, the physician team and
supporting hospital personnel. They will create effective written
communications through accurate, complete, and legible notes.
Residents will communicate effectively will all members of the
healthcare team, with focus delivery of patient-centered care. They will
exhibit listening skills appropriate to patient-centered interviewing and
communication. Residents will recognize verbal and nonverbal cues
from patients and family members. Residents will respond to feedback
in an appropriate manner and make necessary behavioral changes.
2. PGY-2 and PGY-3 residents will also exhibit team leadership skills
through effective communication as manager of a team. PGY2 residents
are expected to assist junior peers, medical students, and other hospital
personnel to form professional relationships with support staff.
All residents will demonstrate integrity, accountability, respect, compassion, patient
advocacy, and dedication to patient care that supersedes self-interest. Residents
will demonstrate a commitment to excellence and continuous professional
development. They will be punctual and prepared for teaching sessions and
management rounds. Residents will demonstrate a commitment to ethical
principles pertaining to provision or withholding of clinical care, confidentiality of
patient information, and informed consent. Residents are expected to show
sensitivity and responsiveness to patients’ culture, age, gender and disabilities.
6. Systems Based Practice.
1. PGY-1 residents will be sensitive to health care costs while striving to
provide quality care. They will begin to effectively coordinate care with
other health care professionals, as required for patient needs.
2. PGY-2 residents, in addition to the above, will consistently understand
and adopt available clinical practice guidelines and recognize the
limitations of these guidelines. They will work with all members of the
healthcare team, including patient care managers, discharge
coordinators and social workers to coordinate and improve patient care
3. PGY3 residents, in addition, will enlist social and other out-of-hospital
resources to assist patients with therapeutic plans. PGY-3 residents are
expected to model cost-effective therapy.