IM MICU Curriculum


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IM MICU Curriculum

  1. 1. Medical Intensive Care Unit (MICU) Service University of Kansas Medical Center Director: Amy O’Brien-Ladner, MD Revised 12/2006 The Residency Review Committee requires that the resident and attending have a face-to-face meeting at the beginning of the rotation to review the learning objectives. Educational Purpose for Rotation: Residents are required to rotate in the Medical Intensive Care Unit in order to acquire the skills, knowledge, and experience to evaluate and provide care for critically ill patients and to recognize patients who are critically ill. The rotation also provides opportunities to acquire procedural skills for the resuscitation of critically ill patients, as well as experience with the multidisciplinary approach to the care of critically ill patients. Teaching Methods: Pulmonary Diseases Clinical Conference • Thursdays, 4:00 to 5:00 PM, Eaton Conference Room, 4th floor. • Residents and fellows give brief presentations of patients with challenging diagnostic or therapeutic problems for discussion by faculty. • Attendance is required. Journal Club • One Tuesday per month, 8:00 – 9:00 AM, Pulmonary Conference Room, 4th Floor, Delp Pavilion. • Topical journal articles are presented by fellows, and residents for critical review, led by Pulmonary and Critical Care Faculty. • Attendance is encouraged. Pulmonary Diseases Core Curriculum • Three Tuesdays per month, 8:00 – 9:00 AM, Pulmonary Conference Room, 4th Floor, Delp Pavilion. • Faculty and fellows present lectures on topics in the Pulmonary and Critical Care Medicine curriculum for fellows. • Residents are strongly encouraged to come. Pulmonary Pathology Conference • Alternating Tuesdays at 5:00 – 6:00 PM, Pathology Conference Room, 1st Floor, KU Hospital. • Pulmonary/critical care fellows and residents present cases, including radiographs, to Pathology and Pulmonary staff.
  2. 2. • Pathological specimens from these cases are reviewed at the multiheaded microscope. • Attendance is required. Procedures Endotracheal intubation – Residents will perform endotracheal intubations under the supervision of the attending staff and/or critical care fellow in patients with acute respiratory failure. Techniques of sedation, pre-oxygenation, neuromuscular blockade, laryngoscopy will be discussed and/or demonstrated for the resident. Indications for endotracheal intubation will be discussed. Central venous catheters – Residents will place central vein catheters in internal jugular, subclavian, and femoral veins under the supervision of the attending staff and/or critical care fellow. The relative advantages and disadvantages of the techniques will be discussed. Careful attention to sterile technique will be emphasized. Pulmonary artery catheters – Residents will place flow directed pulmonary artery (Swan – Ganz) catheters under the supervision of the attending staff and/or critical care fellow. Indications and complications of the procedure will be discussed, as will appropriate wave form analysis. Arterial catheters – Residents will place indwelling arterial catheters under the supervision of the attending staff and/or the critical care fellow. Relative merits of invasive vs. non-invasive blood pressure monitoring will be discussed. Principles of transducer placement will be discussed. Mechanical ventilation – Residents will participate in the initiation and management of mechanical ventilation under the supervision of the attending staff and/or critical care fellow. Principles of ventilation and weaning will be discussed. The relative merits of invasive vs. non-invasive mechanical ventilation will be discussed. Bronchoscopy – Residents are expected to attend bronchoscopies, both diagnostic and therapeutic, when they occur in the intensive care unit. Indications and contraindications of the procedure are discussed. Interested residents may use the bronchoscope under the careful supervision of the attending staff during portions of the procedure. Tube thoracostomy – Residents will assist with the insertion of thoracostomy tubes for pneumothorax and pleural effusion. Indications and risks of the procedure will be discussed. Residents may be allowed to insert thoracostomy tubes under the careful supervision of the attending staff. Thoracentesis – Residents will perform thoracenteses under the supervision of the attending staff and/or pulmonary fellow in cases where the procedure is appropriate.
  3. 3. Indications for diagnostic and therapeutic thoracentesis, as well as risks and complications, and interpretation of results will be discussed. Abdominal paracentesis – Residents will perform diagnostic and therapeutic paracentesis under the supervision of the attending staff and/or the critical care fellow. Indications for and risks of the procedure will be discussed, as will interpretation of results. Lumbar puncture – Residents will perform diagnostic lumbar puncture under the supervision of the attending staff and/or the critical care fellow. Indications for and risks of the procedure will be discussed, as will interpretation of results. Clinical Care MICU Rounds Daily multidisciplinary rounds in which the resident presents patients s/he has evaluated and listens to the presentations of the other members of the team. All cases are discussed in detail by the staff physician, with an eye toward teaching. Equal participants in these rounds are nursing staff, pharmacists, respiratory therapists, social workers, and at times physical therapists. Members of all disciplines are encouraged and expected to provide input on each patient. Review of radiographs and teaching in that technique will be included in these rounds. Didactic Lectures These lectures will be given as time permits over such topics as ventilator management, diagnosis of acid/base disorders, resuscitation of shock, severe sepsis, hemodynamic monitoring, etc. Clinical Experience and Level of Resident Supervision: Residents are responsible for the initial workup of patients for whom the MICU service has been consulted. The resident will be supervised by the critical care fellow; when the fellow is in hospital, the fellow and resident will evaluate patients together. Both the ICU attending and fellow are available in-house or by pager at all times for questions or concerns, and residents are encouraged to contact the attending or fellow with any changes in a patient’s clinical condition, as well as to discuss new admissions to the MICU. Residents round on a daily basis with the critical care attending and fellow. Residents are responsible for presenting patient data in rounds in a cogent, well- organized fashion and for formulating an initial plan of care for the day. Residents are responsible for writing daily progress notes on all patients under their care. The notes should reflect the decision making that occurs during rounds with the attending physician. Residents take overnight call in blocks of “night float” for 5 consecutive nights during the rotation. During their call nights residents will be responsible for supervising
  4. 4. and for teaching junior residents and/or medical students, and will attend a morning teaching session with the attending to review overnight events in the format of chart- stimulated recall and bedside teaching. Prior to leaving the hospital the night call resident should provide sufficient updates on overnight events to his/her colleagues, so that the team can understand the patient’s circumstances and make critical decisions regarding their care. Residents are not expected to answer pages, nor to take phone calls after leaving the hospital. Residents are expected to attend their outpatient continuity clinics, as required. Residents are expected to participate in learning activities as described above. Competency-Based Educational Goals and Objectives by Level of Training and Evaluation Methods: Medical Knowledge: PGY-1: • Become familiar with the following topics in critical care medicine: o Basic ventilator management o Resuscitation of shock o Volume administration o Vasopressor and inotrope administration o Hemodynamic monitoring o Fluid and electrolyte management o Diagnosis and management of sepsis o Antibiotic administration o Procedural skills o Arterial Blood Gas Analysis o Diagnosis and management of acute renal dysfunction o Acute Pleural Disease o Pleural effusion o Tension pneumothorax o Endocrine emergencies o Diabetic ketoacidosis o Adrenal insufficiency o Thyroid emergencies o Hypertensive Emergencies o Chest X-Ray Interpretation o Diagnosis and management of sepsis o Management of GI Bleeding o Administration of Blood Products o Neurological Emergencies o Thrombotic and hemorrhagic CVA o Status epilepticus o Meningitis
  5. 5. o Cardiac Emergencies • Acute myocardial infarction • Life threatening arrhythmias • Pericardial tamponade o Acute and Chronic Hepatic Insufficiency and Failure o Diagnosis and Management of Thromboembolic Disease o Hypertensive Emergencies o Prophylaxis of common ICU complications • Stress ulcer • DVT • Ventilator-associated pneumonia • Sedation/analgesia o Nutritional issues • Diagnosis of Malnutrition • Enteral nutrition • Total parenteral nutrition o Poisoning and Overdose o End of life decision making and ethics • Use written and electronic reference and literature sources to learn about patients' conditions. • Demonstrate growth in knowledge of critical care over the course of the rotation. • Be able to apply knowledge to patient care to begin to formulate a care plan. PGY-2: All of the above, and: • Demonstrate more thorough knowledge of the subjects listed above • Be aware of indications, contraindications and risks of commonly used medications and procedures in critical care. • Demonstrate knowledge of epidemiologic and social-behavioral sciences. • Apply the basic, clinical, epidemiologic and social behavioral science knowledge to the care of the patient • Successfully complete the required Internet-based training module for the rotation. PGY-3: All of the above, and: • Demonstrate an investigatory and analytic approach to clinical situations. • Demonstrate near-mastery of the subjects listed above, indicative of success on the critical care portion of the ABIM certification examination Evaluation Methods: Attending evaluation, chart-stimulated recall sessions following night call, performance on Internet-based training module
  6. 6. Patient Care: PGY-1: • Recognize limits in clinical experience and know when to ask for help. • Understand and weigh alternatives for diagnosis and treatment of common conditions in critical care. • Obtain a complete history. • Elicit common findings on physical examination. • Contribute to development and completion of management plans. • Recognize deterioration in clinical condition in a critically-ill patient and take appropriate initial diagnostic and therapeutic steps. PGY-2: All of the above, and: • Understand and weigh alternatives for diagnosis and treatment of less common conditions in critical care. • Use diagnostic procedures and therapies appropriately. • Elicit subtle findings on physical examination. • Obtain a precise, logical and efficient history. • Interpret results of procedures properly. • Be able to manage multiple problems at once. • Develop and carry out management plans. • Triage patients to appropriate level of care. PGY-3: All of the above, and: • Reason well in ambiguous situations. • Spend time appropriate to the complexity of the problem. • Anticipate potential deterioration in clinical condition and take appropriate diagnostic and therapeutic steps. Evaluation Methods: Attending evaluation, mini-CEX, chart-stimulated recall sessions following night call Professionalism: PGY-1: • Establish trust with patients and staff. • Be honest, reliable, and cooperative. • Accept responsibility appropriate to level of training. • Demonstrate respect, compassion and integrity. • Demonstrate sensitivity to patient culture, gender, age, preferences and disabilities. • Acknowledge errors and work to minimize them. PGY-2: All of the above, and: • Display initiative and leadership.
  7. 7. • Be able to delegate responsibility to others. • Demonstrate commitment to ethical principles pertaining to the provision or withholding of care, patient confidentiality, informed consent and business practices. PGY-3: All of the above, and: • Demonstrate commitment to on-going professional development. Evaluation Methods: Attending evaluation, MICU nurse evaluation, mini-CEX Systems-Based Practice: PGY-1: • Understand the multidisciplinary approach to ICU management • Be a patient advocate. • Advocate for high quality patient care and assist vulnerable, critically-ill patients and families in dealing with system complexity. • Demonstrate ability to adapt to change. PGY-2: All of the above, and: • Apply knowledge of how to partner with nurses, pharmacists, MICU team members, and consultants to assess, coordinate and improve patient care. • Use systematic approaches to reduce errors. • Participate in developing ways to improve systems of practice and health management. PGY-3: All of the above, and: • Provide cost effective care. • Understand how individual practices affect other health care professionals, organizations and society. • Demonstrate knowledge of types of medical practice and delivery systems. • Practice effective allocation of health care resources that does not compromise the quality of care. Evaluation Methods: Attending evaluation Practice-Based Learning and Improvement: PGY-1: • Understand personal limitations of knowledge. • Show willingness to learn from mistakes. • Be self motivated to acquire knowledge. • Accept feedback and develop self-improvement plans. PGY-2: All of the above, and: • Undertake self-evaluation with insight and initiative.
  8. 8. • Facilitate the learning of students and other health care professionals. • Be able to access and apply multiple sources of information to practice evidence-based patient care. PGY-3: All of the above, and: • Analyze personal practice patterns systematically, and look for ways to improve. Evaluation Methods: Attending evaluation, chart-stimulated recall sessions, performance on journal club presentation Interpersonal and Communication Skills: PGY-1: • Write pertinent and organized systems-based progress notes. • Dictate timely, concise, and cohesive discharge summaries. • Use effective listening, narrative and non-verbal skills to elicit and provide information. • Work effectively as a member of the multidisciplinary MICU care team. • Create and sustain therapeutic and ethically sound relationships with patients and families. PGY-2: All of the above, and: • Provide education and counseling to patients, families and colleagues. • Be able to discuss end of life care with patient/families with skill and compassion. • Work effectively as a leader of the health care team. PGY-3: All of the above, and: • Be able to communicate with consultants and referring physicians with confidence and clarity. Evaluation Methods: Attending evaluation, MICU nurse evaluation, mini-CEX Resources Up to Date (available on hospital and clinic computers) Textbook of Critical Care, Shoemaker, Ayres, Grenvik, Holbrook, 3rd edition Harrison’s Principles of Internal Medicine, current edition Critical Care Medicine, Parrillo, Dellinger, 2nd edition The ICU Book, Marino, 2nd edition**
  9. 9. Pulmonary and Critical Care Update Online; Chest, American Journal of Respiratory and Critical Care Medicine, Thorax – all available online through Dykes Library **Highly recommended and affordable.
  10. 10. Review of Goals and Objectives with Resident Block ______ Rotation_________________________________ Resident statement: The above goals and objectives were reviewed with me at the beginning of my rotation, and I understand the expectations for the rotation and how I will be evaluated. Resident Signature: ______________________________________________________ Printed Name: ______________________________________________________ Date: ______________________________________________________ Staff Signature: ______________________________________________________ I have discussed with my staff my need for a Mini-CEX during this block. 