GEORGE WASHINGTON UNIVERSITY MEDICAL CENTER

CRITICAL CARE MEDICINE

The GW critical care unit is a 48-bed mixed Med-Surg ICU which includes the care of patients following trauma, cardiothoracic surgery, neurosurgery and of all the medical and surgical subspecialties managed by two ICU teams.

The critical care fellow, regardless of the program pathway, is involved in the care of all of these patients, and through their training will develop expertise in the management of critically ill patients across these disciplines. The diversified faculty composed of faculty based in Internal Medicine, Surgery, Anesthesiology, Nephrology and Pulmonology as well as strong relationships among subspecialties at GW further creates an environment of collegiality and scholarship.

This fellowship is not for everyone and exposure to a such a large and varied patient population requires fellows strong organizational and prioritization skills along with considerable learning capacity, . However , this effort is rewarded with a comprehensive training afforded by a breadth of clinical experience that is nearly unparalleled compared to other critical care programs in the United States.

 

APPLICATION FORMS:

Anesthesia Critical Care Fellowship we participate in the SF Match Program www.sfmatch.org

After Match Application Form Link

Surgical Critical Care Fellowship: Application Form

-For Internal Medicine Critical Care Fellowship: Applications are submitted via the ERAS system- http://www.aamc.org/audienceeras.htm.

                       

Medicine Critical Care Fellowship
Danielle Davison,MD
900 23rd St NW
Dept Anesthesiology, Room G2092
Washington, DC 20037

202-715-4089
ddavison@mfa.gwu.edu

Anesthesiology Critical Care Fellowship
Christopher D. Junker, MD
900 23rd St NW
Dept Anesthesiology, Room G2092
Washington, DC 20037

202-715-4710
cjunker@gmail.com

Fellowship Coordinator
Inga Ricks
Residency Coordinator
Office of Graduate Medical Education
900 23rd Street, NW, Suite 6120
Washington, DC 20037

202-994-7903
ILR1@gwu.edu

 


CRITICAL CARE CURRICULUM TABLE OF CONTENTS:

 

   I. OVERALL SCOPE and EDUCATIONAL GOALS

  II. FACULTY

 III. DURATION OF TRAINING

 IV. RESOURCES:

 A. SUPPORT SERVICES

 B. LIBRARY

 C. SPACE

 D. MEDICAL RECORDS

   V. COMPETANCY BASED GOALS AND OBJECTIVES

  VI. TEACHING METHODS/EDUCATIONAL ACTIVITIES

 VII. ASSESSMENT METHODS

VIII. LINES OF RESPONSIBILITY AND SUPERVISION

  IX. READING LIST

 

 

 

I. OVERALL SCOPE and EDUCATIONAL GOALS:  The goals of the George Washington University Critical Care fellowship program are to provide fellows with the knowledge base and clinical experience to successfully evaluate and treat medical and surgical conditions that require admission to the critical care unit. Commonly encountered conditions include sepsis, acute and chronic respiratory failure, acute renal failure, hemodynamic instability, overdoses and poisonings, acute neurologic insults, electrolyte and endocrine emergencies, coagulation disorders, and post-operative complications. As a mixed medical/surgical unit, the ICU fellow will also develop expertise in the management of patients with trauma, neurosurgical emergencies, cardiac, and critical obstetric and gynecologic disorders. Both the faculty and the sponsoring institution are fully committed to provide the educational program, resources, and facilities to meet these goals.

      THE GWUMC ICU: Subspecialty training in critical care medicine (CCM) occurs principally in the ICU. The ICU is capable of providing acute and long-term life support of patients with multiple organ system derangements. The ICU at the GWUMC is a multidisciplinary 48-bed mixed medical/surgical unit, with cardiothoracic, neurosurgical and trauma patients.

       PATIENT POPULATION: The CCM fellows receive a large range of exposure to clinical problems and stages of disease. The average daily census is 20. There is one critical care fellow on service during the day; and one critical care fellow on service at night.

     

II. FACULTY

Michael Seneff, M.D.
Associate Professor Anesthesiology and Critical Care Medicine
Medical Director, Intensive Care Unit

Christopher Junker, M.D.
Assistant Professor of Anesthesiology and Neurosurgery
Program Director, Anesthesia Critical Care Medicine Fellowship

Babak Sarani, MD, FACS, FCCM
Director of Trauma and Acute Care Surgery

Lakhmir Chawla, M.D.         Associate Professor of Medicine   
Department of Anesthesiology & Critical Care Medicine and
Division of Renal Diseases and Hypertension
Director, ICU Research

 

 

 

Jacqueline Honig, M.D.                                                               
Assistant Professor of Anesthesiology and Critical Care Medicine 

Director, Cardiothoracic Intensive Care Unit

Danielle Davison, M.D. 
Assistant Professor Anesthesiology and Critical Care Medicine
Program Director, Critical Care Medicine Fellowship, Internal Medicine

Bruce Abell, M.D.                                                                           Assistant Professor of Surgery                                                      

Lynn Abell, M.D.                                                                            Assistant Professor of Anesthesiology Critical Care Medicine and Surgery

Seth Akst, M.D.
Assistant Professor of Anesthesiology and Critical Care Medicine

Guillermo Gutierrez, M.D., PhD
Professor of Medicine
Chairman, Division of Pulmonology
Program Director, Pulmonary and Critical Care Medicine

Vinayak Jha, M.D.                                                                         Assistant Professor of Medicine, Pulmonary and Critical Care Medicine

Jalil Ahari, M.D.                                                                             Assistant Professor of Medicine, Pulmonary and Critical Care Medicine                                            

III. DURATION OF TRAINING: Applicants who completed training in Anesthesiology, Surgical and Internal Medicine Sub-Specialty graduates must complete a 12 month critical care fellowship. For those applicants who completed a core internal medicine program, the fellowship training is 24 months. At least 75% of training in these programs will be spent in the care of critically ill patients in the ICU. The remainder of the training will be in educational activities or performing research relevant to critical care.

IV. RESOURCES:

     A. SUPPORT SERVICES:

1. The ICU is staffed by nurses certified in critical care medicine. Technicians with expertise in biomedical engineering supervise the operation and maintenance of equipment. At least three respiratory therapists are assigned to the ICU at all times. Nutritionists and pharmacologists are also available and participate in daily rounds.

2.  The Department of Pathology, located in the basement of the hospital, provides facilities for laboratory measurements pertinent to the care of critically ill patients with multiple organ system derangements. These include measurement of blood chemistries, blood gases and pH, culture and sensitivity, toxicology, and analysis of plasma drug concentrations. Point of care testing is also available in the ICU for core laboratory studies.

3. The Department of Radiology, located on the first and second floors of the hospital, provides facilities for special radiologic imaging procedures, including magnetic resonance imaging, computed tomography, plain x-rays, ultrasound, interventional and angiography. All radiographic imaging is available on web-based PACS system on all ICU computers. The Department of Cardiology provides facilities and equipment for vascular imaging, echocardiography, and cardiac catheterization. ACGME-accredited subspecialty programs and the trainees from cardiovascular disease, gastroenterology, infectious diseases, nephrology, and pulmonary disease, anesthesia, ob-gyn, radiology, and surgical services (general, cardiothoracic, vascular, plastics, ENT, urology, orthopedics, and neurosurgery) are all available on-site.

4.  The ICU has all appropriate monitoring and life-support equipment readily available and representative of current levels of technology. Each ICU bed has a dedicated monitor that can support pulmonary artery catheterization, invasive and non-invasive blood pressure monitoring, capnography, pulse oximetry, and intracranial pressure monitoring. The equipment necessary to carry out these functions is stored in the ICU.

B. LIBRARY: The Himmelfarb Health Sciences Library, in the George Washington University Medical School is conveniently located next door to the GWUMC. The library contains 96,127 titles and subscribes to 1225 journals (this number increases on a regular basis). The library has many electronic resources and supplies assess to OVID search programs and MD Consult off campus and in the hospital.

The National Library of Medicine, at the NIH, is easily accessible from our campus by Metro.

C. SPACE:

Space for research is available in the Anesthesiology laboratory located in the School of Medicine. Several rooms for teaching conferences in CCM are available, including a dedicated conference room located just outside the ICU. There is a departmental and divisional library with adequate material relevant to critical care. This is supplemented by private faculty book collections in offices located within offices inside the ICU.

D. MEDICAL RECORDS:

GWUH has an electronic medical record system that is password protected. Fellows and residents have access to complete medical records 24 hours a day/ 365 days/year.


 

V. EDUCATIONAL GOALS/OBJECTIVES: The fellows are required to achieve the following goals and objectives based on the six core competencies. Core competencies include Patient Care, Medical Knowledge, Practice Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and Systems Based Practice. Throughout the training, the fellow will be expected to progress through three levels of training (Levels I-III). The levels are found in parenthesis following each objective. The teaching methods/educational activity and assessment methods of the competencies are listed in the columns on the right. The explanation of the educational and assessment methods can be found in sections VI and VII.

Patient Care:

TEACHING & EDUCATIONAL ACTIVITY

EVALUATION METHOD

  1. Demonstrate ability to access accurate sources of information from the patient and/or family. (Level I)

 

Clinical Experience

Direct Observation            Record Chart Review

  1. Formulating a differential diagnosis on patients with critical illness and injury, including multisystem organ failure and life threatening trauma.(Level I-II)

 

Teaching Rounds   Clinical Experience    Case Conference

Direct Observation           Record Chart Review

  1. Evaluate, and prioritize current ICU patient care needs during daily

      care of the patients (Level I)

Clinical Experience     Role Modeling

Direct Observation                    M and M Conference

  1. Demonstrate competency in triaging (including emergent consultation) of patients in the ED, med-surg wards, and PACU (Level II)

Clinical Experience     Role Modeling

Direct Observation                 360 eval                                     M and M Conference

  1. Demonstrate proficiency in the use of monitoring devices including the ability to interpret data derived from the device in relation to other patient data and trends, and then incorporate the results into management of the patient.

Monitoring Devices include:

1.  Invasive Blood Pressure Monitoring (Level I)

2.  Pulse Contour Analyses (Level I)

3.  Central Venous Pressure and Venous Oxygen Saturation (Level I)

4.  ICP monitoring (Level II)

5.  Pulmonary Artery Catheter (Level III)

6.  Transcutaneous and transvenous pacers (Level III)

 

 

 

 

Teaching Rounds   Clinical Experience  Lecture Series          Board Review             Case Conference

 

 

 

 

 

Direct Obs

 In-Training Exam

  1. Utilize subspecialty consultation appropriately during the care of ICU patients
    1. The fellow will directly communicate with subspecialist in a timely fashion. (Level I-II)

Teaching Rounds    Clinical Experience     Role Modeling

Direct Obs                                 M and M Conference

  1. Demonstrate competency in the use of ultrasound during various techniques including central line placement, thoracenteses, and paracentesis. (Level I)

 

Clinical Experience     Anat models/Simulators

Direct Obs                        Procedural Log Review

  1. Provide maximize patient comfort through the use of appropriate anesthetics (local vs. systemic) when performing a procedure. (Level I)

 

Role Modeling         Clinical Experience

Direct Obs                             Procedural Log Review

  1. Demonstrate proficiency in performing the following procedures:
    1. Airway Management

                                          i.    Ventilation by bag and mask (Level I)

                                        ii.    Suction techniques (Level I)

                                       iii.    Use of oral airway (Level I)

                                       iv.    Direct laryngoscopy, endotracheal intubation techniques including rapid sequence (Level I-II)

                                        v.    Use of a laryngeal mask airway (Level III)

    1. Fiberoptic bronchoscopy (Level I-II)
    2. Pneumothorax Management

                                          i.    Needle Thoracostomy (Level I)

                                        ii.    Chest Tube Insertion (Level II)

                                       iii.    Drainage Systems (Level I)

    1. Thoracentesis (Level I)
    2. Insertion of Monitoring Catheters

                                          i.    Central Venous Lines (Femoral, Subclavian, Internal Jugular, Hemodialysis catheters)- (Level I)

                                        ii.    Arterial Lines (Femoral, Radial, Brachial, Axillary) (Level I)

                                       iii.    Pulmonary Artery Catheter placement (Level III)

    1. Pericardiocentesis (Level III)
    2. Transvenous pacemaker insertion (Level III)
    3. Cardioversion, Defibrillation (Level I)
    4. Lumbar Puncture (Level I)

 

Anesthesia/Airway Conf  Anat models/Simulators  Clinical Experience     Role Modeling            Core Lecture Series

 

Procedural Log Review             M and M Conference              Direct Obs

  1. Demonstrate competency with emergent airway management using bag and mask ventilation in non-intubated, conscious and unconscious, paralyzed and non-paralyzed patients (Level I-II)

Anesthesia/Airway Conf Clinical Experience

Procedural Log Review      Direct Obs

  1. Demonstrate the proper immobilization technique for intubating patients potential cervical spine injury (Level II)

Anesthesia/Airway Conf  ClinicalExperience  Lecture Series

Direct Obs

  1. Demonstrate appropriate, evidenced based, direct care to post-operative patients including cardiothoracic, vascular, gastrointestinal, genitourinary, endocrine, orthopedic, neurosurgical, plastic, and ENT (Level I-II)

Clinical Experience; Lecture Series            Case Conferences

Direct Obs                                 M and M Conferences

  1. Demonstrate proficiency in the evaluation, diagnosis, and management of patients with …

      CARDIOVASCULAR

a.  Recognize and manage the care of a patient in shock

1. Adrenal Insufficiency (Level I-II)

2. Septic Shock (Level I- II)

3. Anaphylaxis (Level I- II)

4. Cardiogenic shock (Level II)

5. Hypovolemic/Hemorrhagic shock (Level I-II)

6. Neurologenic shock (Level  II)

7. Obstructive shock (Level I-II)

b. Manage the care of a patient during cardiopulmonary    

     resuscitation

     1. Delivery of advanced cardiopulmonary resuscitation (Level I)

     2. Cardioversion (Level I)

     3. Appropriate use of anti-arrhythmic beyond standard ACLS(Level II)

c.  Institute the appropriate monitors and institute appropriate intervention in the patient with cardiovascular disorders

      1. Acute coronary syndrome (Level I)

      2. Acute valvular disorders (Level II)

      3. Congestive heart failure (Level I)

      4. Aortic dissection (Level II)

      5. Arrhythmias (Level I)

      6. Hypertensive emergency (Level I)

      7. Veno thromboembolism (Level I)

       8.pericarditis and tamponade (Level II)

d. Provide appropriate fluid resuscitation based on hemodynamic information and signs of end organ damage. (Level II-III)

e. Integrate information based on hemodynamic monitoring to determine type and amount of vasoactive and inotropic therapy (Level II-III)

     PULMONARY

a.   Manage the acute care of a patient with respiratory failure

Secondary to

Hypercapnia

1.    Obstructive lung disease (Level I-II)

2.    Drug induced (Level I-II)

3.    Neuromuscular (Level I-II)

            Hypoxemia

1.       ARDS/ALI  (Level I-II)

2.       Pneumonia (Level I-II)

3.       Pulmonary Edema (Level I-II)

4.       Pneumonitis (aspiration, inhalation) (Level I-II)

5.       Pulmonary embolism (Level I-II)

b.   Initiation and adjust mechanical ventilation settings in patients with respiratory failure secondary to

1.     ARDS (Level II)

2.     Obstructive lung disease (Level II)

3.     Status Asthmaticus (Level II)

4.    Neuromuscular Disease (Level II)

c.    Interpret ventilator wave forms and adjust ventilator appropriately (Level II-III)

d.   Recognize and manage the complications of ventilation

1.  Auto-PEEP (Level II)

2.  Barotrauma (Level II)

3.  Hypotension Level II)

e.   Evaluate and determine the appropriate timing to liberate a patient from the ventilator (Level I-II)

f.Demonstrate proficiency in the following respiratory care techniques-use of reservoir masks, CPAP, humidifiers, nebulizers, incentive spirometry (Level I)

g.   Manage the care of a patient with massive hemoptysis (Level II)

    CNS

a.   Employ the appropriate imaging studies and institute the therapeutic management of choice for the following conditions

1.  Acute stroke syndromes (Level I-II)

2.  Status epilepticus (Level I-II)

3.  CNS infections (Level I-II)

4.  Muscular paralysis (Level I-II)

5.  Delirium (Level I-II)

6.  Traumatic Brain Injury (Level I-II)

7.  Cerebral edema (Level I-II)

8.  Intoxication(Level I-II)

9.  Acute withdrawal syndrome (Level I-II)

b.   Select and titrate sedatives, analgesics, antipsychotics, anxiolytics, and paralytics (Level I-II)

     GI/GU/ENDOCRINE

a.   Evaluate and Manage the care of a patient with

1.   Massive GI Bleed (Level II)

2.   Acute liver failure (Level II-III)

3.   After Abdominal surgery (Level I-II)

4.   Stress ulcer prophylaxis (Level I)

5.   DKA and HONK (Level I)

6.   Severe hypothyroidism and thyrotoxicosis

    INFECTIOUS DISEASES

a.   Initiate the appropriate antimicrobial therapy (Level I)

b.   Manage the febrile immunocompromised patient (Level II)

c.    Implement early goal directed therapy (Level II)

  HEMATOLOGY 

a.    Manage the care of a patient with

1.    Anemia (Level I)

2.    Platelet disorders (Level I)

3.    Coagulopathy and thrombophilia (Level I)

4.    Neutropenia (Level II)

5.    Leukocytosis, polycthythemia, hyperviscosity (Level II)

6.    Acute chest Syndrome (Level II)

7.    SVC Syndrome (Level II)

8.    Tumor Lysis Syndrome (Level II)

9.    Massive transfusion (Level II)

      MISCELLANEOUS

a.   Manage the care of the Trauma Patients with

1.   Pulmonary contusion (Level I)

2.   Spinal cord injury (Level II)

3.   Compartment syndromes (Level II)

b.   Evaluate and resuscitate the post-operative patient (Level I-II)

c.    Apply principles of palliative care and end-of-life care (Level I-III)

d.   Perform brain death certification (Level II-III)

e.   Identify if a patient is safe for transport, and demonstrate appropriate management during transport (Level II-III)

f.     Manage the critically ill Obstetric patient with HELLP,    Preclampsia/Eclampsia, and Uterine bleeding (Level II-III)

 

 

 

 

 

 

 

 

Teaching Rounds        Clinical Experience Lecture Series             Role Modeling

 

 

 

Direct Obs                                M and M Conference               Chart Review                           In-Training exam

Medical Knowledge:

TEACHING & EDUCATIONAL ACTIVITY

EVALUATION METHOD

1.    Seeks and locates resources useful to secure medical knowledge (asks questions on rounds, seeks faculty advice, looks up evidence in literature) (Level I-III)

Teaching Rounds        Fellow Lecture Series     Lit Review for M and M Self study Research Seminar

Direct Obs                                M and M Conference

2.    Identifies areas of improvement of self-knowledge (Level I-III)

M and M conference Board Review

Self-Assessment (done during 360 eval)

3.    List the risks, benefits, indications and potential complications for the critical care procedures as listed in patient care. (Level I-II)

Lecture Series     Teaching Rounds     Board Review

In-Training Exam              Procedural Log Review

4.    Demonstrate medical knowledge of the following topics…

     CARDIOVASCULAR

a.    Describe 4 types of shock and its complications (Level I)

b.    Differentiate between the different kinds of myocardial infarctions and define the complications (Level I)

c.    Recognize cardiac arrhythmias and conduction disturbances (Level I-II)

d.    Discuss vasoactive and inotropic therapy (Level I-II)

e.    Derive the equations of oxygen transport and utilization (Level II-III)

f.     Distinguish between thrombus, air, fat, and amniotic pulmonary emboli (Level II)

g.    Define pulmonary hypertension and cor pulmonale (Level I)

h.    Define hypertensive urgency and emergency and describe the management (Level I)

i.      Distinguish between cardiogenic and non-cardiogenic pulmonary edema (Level I)

      PULMONARY

a.    List the five causes of hypoxia (Level I)

b.    Define ALI and ARDS (Level I)

c.    Summarize the path physiology of ARDS (Level I)

d.    Explain the purpose and mechanism behind lung protected ventilator strategies (Level I-II)

e.    Summarize the patho-physiology and therapy for status asthmaticus (Level I)

f.     Recognize smoke inhalation and airway burns. Recite the management (Level II-III)

g.    Define flail chest and pulmonary contusion (Level I-II)

h.    Summarize tests used to measure pulmonary mechanics and gas exchange

i.      Describe the following terms used with mechanical ventilation

1.    Pressure vs. volume controlled ventilation (Level I)

2.    CPAP, SIMV, AC, PC, PRVC, APRV (Level II)

3.    NIPPV (Level I)

4.    Barotrauma (Level I)

5.    Volutrauma (Level I)

6.    Inverse ration ventilation (Level II-III)

7.    Permissive hypercapnea (Level I)

8.    Auto-peep (Level II)

j.      Summarize methods to improve oxygenation on the ventilator (Level II)

k.    Describe the flow-volume loop of a patient with auto-peep (Level II)

l.      Discuss the criteria for weaning mechanical ventilation (Level I)

m.  List the different weaning techniques and recite the evidence (Level II-III)

n.    Recite the causes of ventilator muscle failure (Level III)

CNS

a.    Describe brain death evaluation and certification (Level II-III)

b.    Describe the definition and management of status epilepticus (Level II)

c.    Describe and give examples of the following CNS pathologies- metabolic, anoxic, and infectious encephalopathy. (Level I-II)

d.    Summarize the pathophysiology and management of traumatic brain injury. (Level II)

e.    List a differential diagnosis for altered mental status (Level I)

f.     Define Intracranial hypertension (Level I)

g.    List the different modes of management for elevated intracranial pressure and discuss their mechanism of action (Level II-III)

h.    Explain the principles of management of vasospasm in SAH (Level II)

GI/ GU/ ENDOCRINE

a.    Provide a differential diagnosis for GI bleeding. (Level I)

b.    Describe the pathophysiology and presentation of acute and  chronic liver failure, pancreatitis, cholecystistis, gastritis, and peptic ulcer disease (Level II)

c.    Summarize the major causes of acute renal failure and define the ways to distinguish them (Level I-II)

d.    Recognize derangements in osmolarity and electrolytes (Level I-II)

e.    Explain the principles of renal replacement therapy including hemodialysis, ultrafiltration, CVVH, CVVHD (Level II-III)

f.     Describe the presentation and treatment of rhabdomyolysis (Level I)

g.    Contrast HONK vs. DKA and explain the management of each (Level I)

INFECTIOUS DISEASE:

   a.  Define and describe the pathophysiology of systemic inflammatory response syndrome and sepsis (Level I)

b. List the most common nosocomial infections and describe the algorithm for antimicrobial agents. (Level I-II)

c. Delineate the time line for infectious complications after transplant. (Level III)

d. Formulate an algorithm for the evaluation of fever in the ICU (Level I-II)

e. List the diagnostic criteria for Ventilator Pneumonia (Level I)

f.  Describe the algorithm for the management of catheter related blood stream infections (Level I)

HEMATOLOGY:

a.    Describe the following acute defects in hemostasis (Level I-II)

1.    Thrombocytopenia

2.    Disseminated intravascular coagulation

3.    Anticoagulaton

4.    Fibrinolytic therapy

b.    Explain the difference between the following blood therapy components: (Level I)

1.    Platelets

2.    Red Blood Cells

3.    Fresh Frozen plasma

4.    Coagulation factor concentrates

5.    Cryoprecipitate

6.    Albumin

c.    Summarize acute syndromes associated with neoplastic disease and antineoplastic therapy (Level II-III)

d.    Acute allergic reactions and/or anaphylaxis (Level I)

    MISCELLANEOUS

a.    Define the following obstetric terms and list the tx for: (Level II)

1.    HELLP

2.    Pre-Eclampsia/Eclampsia

b.    Summarize the initial approach to the management of multisystem trauma (Level II)

c.    Diagram the organization and staffing of critical care units. (Level II-III)

d.    List the antidote for toxins commonly seen in the ICU (Level I- II)

e.    Define abdominal compartment syndrome and its management (Level I-II)

f.     List the advantages of enteral vs. parental feeding. (Level I)

Lecture Series          Board Review      Teaching Rounds

In-Training Exam

5.    Define the mechanism of action, indications, contraindications, and side effects of paralytics, analgesics, and sedatives used on ICU patients. (Level II)

Lecture Series

In-Training Exam

6.    Describe the psychosocial and emotional effects of critical illness on patients and their families. (Level I-III)

Role Modeling         Computer Modules              Clinical Experience

360 Eval                                        Palliative Care Assessment                  Direct Obs

7.    Describe the strategies to manage ethical and legal dilemmas between families, patients, and staff in the ICU. (Level I-III)

GME Conference               Computer Modules   Clinical Experience

360 Eval                                             In-Training Exam

8.     Discuss ways to detect and prevent iatrogenic and nosocomial problems in the ICU. (Level II)

M and M Conf         Quality Performance Project

M and M Conf.                          In-Training Exam

  1.  Demonstrate knowledge of the indications, contra-indications, and complications of placement of a percutaneous tracheostomy (Level II)

 

Lecture Series        Teaching Rounds      Board Review

In-Training Exam

11. List the indications, risks, and contraindications for insertion of an     esophagogastric balloon tamponade device. (Level III)

Lecture Series     Teaching Rounds      Board Review

In-Training Exam

12. List the indications, risks, and contraindications of performing a pericardiocentesis (Level III)

Lecture Series     Teaching Rounds

In-Training Exam

13. List the indications, risks, and contraindications for insertion of

a. Extra-corporeal membrane oxygenation (Level III)

b. Ventricular assist device (Level III)

Lecture Series     Teaching Rounds     Board Review

In-Training Exam

14. Describe the indications, risks, and contraindications for insertion of an intra-aortic balloon device. (Level III)

Lecture Series       Teaching Rounds     Board Review

In-Training Exam

15. Describe the indications, risks, and contraindications and limitations for ICP monitor or extra-ventricular drain placement  (Level II)

 

Lecture Series     Teaching Rounds     Board Review

 

 

In-Training Exam

Interpersonal/Communication skills

TEACHING & EDUCATIONAL ACTIVITY

EVALUATION METHOD

1.    Appropriately identify themselves to the patient and/or family members (Level I)

Clinical Experience      Role Modeling

360 Eval                                Direct Obs

2.    Communicate effectively to maximize the patient/family’s understanding

a.    Demonstrate skill in conducting family conferences concerning prognosis, end of life care, code status, and withdrawal of support with the assistance of an attending. (Level I-II)

b.    Independently conduct family conferences concerning prognosis, end of life care, code status, and withdrawal of support. (Level III)

Clinical Experience      Role Modeling

Palliative Care Assessment   360 Eval                             Direct Obs

3.    Demonstrate sensitivity to different educational levels and socio- cultural backgrounds (Level I-II)

GME Conferences Computer Modules      Role Modeling

360 Eval                             Direct Obs

4.    Provide education and counseling to patients and families, using nontechnical and clear language. (Level I-II)

Clinical Experience     Role Modeling

360 Eval                             Direct Obs

5.    Exhibit a leadership role of the critical care team

a.    Organize and communicate effectively with housestaff including running sign-out rounds and coordinating follow up on plans developed on rounds. (Level I-II)

b.    Supervise and teach residents on rounds, during procedures, and during the management of patients (Level II-III)

c.    Provide constructive verbal feedback to residents (Level II-III)

d.    Demonstrate leadership skills in running a code, appropriately delegate tasks (Level II)

 

Clinical Experience    GME Lecture Series   Anat Models/Simulators

Direct Obs

6.    Establish collaborative and effective working relationships with other members of the healthcare team

a.    Coordinate discussions with the consulting physicians and together decide on appropriate diagnostic and therapeutic strategies (Level II-III)

b.    Foster effective and respectful discussion with nurses, respiratory therapists, and case managers concerning specifics of patient care plans and problems they may encounter

                                          i.    Communicate with the charge nurse regarding allocation of resources, transfers and admissions (Level I-II)

                                        ii.    Collaborate with case management and the patient/family to accomplish appropriate discharge planning (Level I-II)

c.    Contact and Communicate effectively with a patient’s primary care physician upon a patient’s admission and discharge (Level I)

 

Clinical Experience

 

 

 

I

360 Evals                           Direct Observation                    M and M Conference

7.    Present cases to the ICU attending in a clear, concise and thorough manner

a.    Communicate effectively regarding new admissions to the ICU (Level I)

b.    Communicate effectively the status of patients and the progress of care plans. (Level I)

Clinical Experience

 

360 Evals                                 Direct Obs

8.    Provide and complete timely and comprehensive notes on patients who have had significant changes in status and after family discussions. (Level I)

Clinical Experience    GME Lecture Series

Chart Review

Professionalism:

TEACHING & EDUCATIONAL ACTIVITY

EVALUATION METHOD

1.    Demonstrate punctuality and appropriate attendance of all lectures (Level I)

Role Modeling

Direct Obs

2.    Maintain timely and accurate medical records (Level I)

 

Clinical Experience    GME Lecture Series

Chart Review

3.    Demonstrate the following professional  attributes (Level I)

a.    Act with honesty and integrity

b.    Maintain patient confidentiality

c.    Demonstrate accountability and admit to error

d.    Provide compassion and empathy by listening attentively and responding to concerns of patients and families

e.    Interact with patients and staff in a respectful manner including appropriate dress, verbal and non-verbal behavior

f.     Indicate knowledge of one’s own limitations by seeking guidance/ supervision from attending and completing self-evaluation form

g.    Respond positively to constructive criticism by improving behavior and/or skill

Computer Modules      Role Modeling            GME Lecture Series

Direct Obs                                M and M Conference              360 Evals

4.    Demonstrate commitment to on-going professional development through (Level II)

a.    Regular attendance and participation at conferences (list of conferences, see below)

b.    Attendance to a national meeting

c.    Demonstrate reading of the medical literature as demonstrated by discussion on rounds and inclusion of material in fellow’s lectures.

d.    Seeking feedback from attending after week on clinical service

e.    Adhere to deadlines regarding research projects

f.     Maintain a complete procedural log

g.    Actively participate in teaching rounds and ICU conferences

Teaching Rounds   Lecture Series     Research Seminar   Journal Club         Research Project

Direct Obs                           Chart Review Procedure       Log Review

5.    Obtain proper informed consent from patient or family member/legal guardian. (Level I)

GME Lecture Series Computer Modules

Direct Obs                           Chart Review

6.    Recognize the situational need to determine competence. (Level I-II)

GME Lecture Series Computer Modules

Direct Obs                           Chart Review

System-Based Practice:

TEACHING & EDUCATIONAL ACTIVITY

EVALUATION METHOD

1.    Exhibit resource allocation and demonstrate commitment to the practice of cost-effective medical care.

 

a.    Work closely with the charge nurse to decide the priority of admissions from the emergency room, out-of-hospital transfers, PACU, and floor. (Level I-II)

 

b.    Consider cost/benefit analysis of diagnostic or therapeutic interventions prior to initiation. (Level III)

Clinical Experience    GME Conference Series

360 Eval                                   M and M Conference

2.    Effectively collaborate with health care manager providers to assess, coordinate, and improve health care discharge planning and transition from critical care to outpatient or to the floor. (Level II-III)

 

Clinical Experience

 

360 Eval

3.    Demonstrate awareness of how to manage patients in different treatment settings  (Level II)

 

a.    Recognize the available resources available and communicate with the support staff in the ED, PACU, medical floor or surgical floor.

 

Clinical Experience

 

360 Eval                              Direct Observation                     M and M Conference

4.    Demonstrate knowledge regarding the business aspects of medical practice including coding, billing, reimbursement, and insurance (Level III)

 

GME Lecture Series  Computer Modules

 

Direct Observation

5.    Appreciate the necessity and rationale for program policies, protocols and procedures. (Level III)

Quality Performance Project

Direct Observation

Practice-Based Learning:

TEACHING & EDUCATIONAL ACTIVITY

EVALUATION METHOD

1.      Demonstrate a willingness to learn from errors. Identify strengths, deficiencies and limits to knowledge and expertise.  (Level I-II)

Role Modeling                 M and M Conference       

M and M Conference               Direct Obs

2.      Implement strategies to enhance knowledge, skills, attitude, and processes of change. (Level II-III)

Conference Series        Board Review                    Quality Improvement Project

M and M Conference               Direct Obs

  1. Analyze the fellowship program at large and implement strategies to continually improve the quality of patient practice (Level III)

ICU retreat               Quality performance project

Direct Obs

4.      Demonstrate an understanding of the principles of evidence-based medicine and statistics by performing a critical appraisal of the literature (Level III)

 

Journal Club          Research project Research seminar

Direct Obs

5.      Effectively utilize technology to promote life-long learning

 

a.    Use on-line technology to manage information, generate fellow lectures, and teach medical students/residents on rounds (Level II-III)

Lecture Series                 GME Lecture Series

Direct Obs

 

 

 


VI. TEACHING METHODS/EDUCATIONAL ACTIVITIES:

  1. Clinical Teaching:
    1. Teaching Rounds:  Teaching rounds consist of one critical attending, one fellow, 4 residents, 4 interns and 1 to 4 medical students. The residents and interns are from different specialties including surgery, internal medicine, anesthesia, ob-gyn, and emergency medicine. The housestaff present the history and physical findings to the fellow and the attending for each patient on morning rounds. The fellow is responsible for obtaining additional detailed history/physical findings that are relevant to the case and present the data in summary format. Discussion of the case then ensues, focusing on the physical and hemodynamic findings, differential diagnoses and management plan. In addition to clinical bedside review, the team reviews the radiologic images for each patient.  Cases provide a stimulus for discussion on topics including hemodynamic devices, ventilator modes and management, and review of evidenced based data.
    2. Clinical Experience:  After teaching rounds are completed, the critical care fellow (day or night fellow) will supervise residents and medical students in the management of the current ICU patients, performing ICU consults, and admitting patients from the ED, floor, and PACU. The fellow will present all admissions and consults to the attending physician. The attending will provide one-on-one feedback and provide teaching tools at the bedside. The fellow will have increasing responsibility in patient care, leading, teaching, and administration over the course of their fellowship. Activities include

                                          i.    Obtaining thorough and complete history and physical examination of all new admissions and help to formulate and prioritize a differential diagnosis and treatment plan. The fellow will ensure appropriate documentation.

                                        ii.    Triaging- Decide the priority of admissions from the emergency room, out-of-hospital transfers, PACU, and floor. Communicate with the charge nurse regarding allocation of resources, transfers and admissions.

                                       iii.    Performing or supervising bedside procedures.

                                       iv.    Respond to changes in patient status-incorporating results from labs, radiographic studies, and monitoring devices in order to provide appropriate treatment. Skills include endotracheal tube/airway management, ventilator management, changing sedative/analgesic or initiating paralysis, resuscitation and titration pharmacologic infusions, renal replacement therapy, nutrition, antibiotic administration, control of electrolytes… etc.

                                        v.    Conducting family and patient discussions

                                       vi.    Initiating and discussing plans with consultants. Keep other services (i.e. surgical services) informed of changes in status or changes in interventions

                                      vii.    Leading the code team- delegate responsibilities and order appropriate ACLS interventions.

                                    viii.    Conducting sign-out with residents, mid-level practitioners, and with the other fellow at the end of each shift.

                                       ix.    Collaborating with case management and the patient/family to accomplish appropriate discharge planning.

 

                                        x.    Evaluating and performing tests to confirm brain death.

 

                                       xi.    The critical care fellow spends one week in the operating room with an anesthesia attending to practice intubating in a controlled environment.

                    

 As a multi-disciplinary unit, the fellow also develops clinical experience in the management of patients with trauma, neurosurgical emergencies, and critical obstetric and gynecologic disorders. The fellows also complete a 4-week elective in the cardio-thoracic ICU each year. ( See CT ICU Goals and Objectives). The fellows also have the opportunity to pursue elective rotations in burns and in the neonatal ICU. The topics of burns and neonatal critical care are reviewed in our lecture series.

 

 

2.    Departmental Conferences and Lectures

 

a.    Core Lecture Series: Weekly one hour lecture given by a critical care attending on a topic from the curriculum. Fellows, residents, and medical students attend.

b.    Fellow Core Lecture Series: Twice weekly, a fellow gives a lecture to housestaff and attendings covering a basic topic from the critical care curriculum. A list of the lecture topics can be found at http://gwicu.com/Pages/shedulepage.htm. The fellows play an active role in planning of these conferences.

c.    Case Conference: Occurs weekly. Attending reviews a case. Fund of knowledge and patient care skills are tested as the fellows are asked questions about how he/she would diagnose and manage the particular case. A review of the literature is provided.

d.    Morbidity and Mortality Conference: Each fellow will present a case at the monthly conference. The fellow will complete a self-analysis form for each case, in attempts to improve patient safety, patient care, and education. The fellow will perform a targeted literature review and present the data with respect to each case. The Morbidity and Mortality Conference will serve as stimulus for a quality improvement project.

e.    Journal Club: Occurs monthly. Two articles from topics in current journals are presented by the fellow and discussed. Specifically, whether practice patterns should change based on the data review. A review of all abstracts from Critical Care Medicine is also reviewed.

f.     Research Seminar: Conducted monthly by Dr. Chawla, Director of ICU research. The aim of the seminar is to discuss scientific methods and analysis of results.

g.    Department Grand Rounds: Anesthesia, Surgery, and Medicine departments each have weekly grand rounds.  Fellows and faculty attend to one of the GRs when critical care topics are discussed.

h.    GME Conference: Monthly lectures for fellows and residents on the following topics (subject to change yearly):

                                          i.    Financial Planning for Physicians

                                        ii.    Communications and Interviewing Success

                                       iii.    Primer on Business and contract Issues for New Physicians

                                       iv.    Alternative Medicine: What Every Resident Should Know

                                        v.    The Epidemiologic Cycle and Clinical Practice

                                       vi.    Rapid Response

                                     vii.    Resident Impairment

                                    viii.    Health Policy

                                       ix.    Business of Medicine

                                        x.    Spirituality in Medicine

                                       xi.    Navigating the IRB

                                     xii.    Emergency Preparedness

                                    xiii.    Case Topics TBA

                                    xiv.    The Peer Review Process

                                     xv.    Town Hall Meeting

                                    xvi.    Infection Control and Patient Safety

i.      Board Review: Multiple choice questions from board review courses and book (i.e. seek questions) are reviewed.

j.     Anesthesia/Airway Management Conference: Occurs yearly. Fellows are exposed to various intubating devices and techniques for the difficult airway. Anatomic models are provided for practice.

k.    GW ICU Retreat/Program Review: Each year, the ICU attendings, mid-level practitioner, director of nursing, and chief ICU fellow review all aspects of the ICU program including current and previous board scores, on-going and future research projects, faculty development, allocation of resources, and quality improvement projects etc.

 

3.    Individual or Group Project: 

a.    Individual Research Project: Each fellow will complete one research project during their fellowship

b.    Group Project: The critical care fellows individually or as a group complete a quality performance project or help to develop a critical care protocol.

 

4.    Computer Modules: computer-based instructional unit on risk management, conducting appropriate informed consent, patient confidentiality, demonstrating social-cultural sensitivity, medical ethics, billing and coding procedures.

5.    Anatomical Models/Simulators: Prior to starting fellowship, each fellow completes a central line course and a-line course using ultra-sound guidance on anatomical models. (beginning Sept 2011) The fellows also have 24 hour access to our sim-center which has the fellow can practice or rehearse skills including- difficult airway management, running an ACLS code, treating various arrythmias, and placing central and arterial lines.

6.    Role Model: At GWU ICU, the attending physicians are in house for at least 18 hours per day and provide constant supervision. The attending physician is present for family discussions, bedside management…etc.  Throughout their training, the fellow will try to emulate the professional behaviors, communication skills, and clinical skills of the attending physicians.

7.    Self Study/Reading: Fellows are expected to read and familiarize themselves with each of the general principles of critical care medicine. A list of topics from the curriculum is reviewed during the core lectures (for topics – www.gwicu.com/schedules- lecture topics. Library resources- see resources.

 

VII. EVALUATION & ASSESSMENT METHODS:

  1. Global Assessment:  Assessment of overall functioning of the fellow across all six competencies (patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practice). This is completed by the program director and reviewed with the fellow annually. The program director will provide a written summative evaluation at the midpoint and at completion of the program. This will be reviewed with the fellow.
  2. Procedure Log: Each fellow will keep either a written or electronic log of all procedures performed during their fellowship. An attending must sign off of each procedure performed. Batches of the log will be reviewed by the program director to ensure the fellow documents the indications, technique, and complications of the procedure. The log will also ensure that the fellow is completing the expected number and type of procedures.
  3. Review of Patient Outcomes/Morbidity and Mortality Conference: Each fellow will present a case at the monthly conference. The fellow will complete a self-analysis form for each case in attempts to improve patient care. The fellow will perform a targeted literature review and present the data with respect to each case. The Morbidity and Mortality Conference will serve as stimulus for a quality improvement project. Fellow performance at the monthly conference will, in part, form the basis of the faculty’s assessment of performance in critical care and will be reported on the global assessment form.
  4. “On the Fly” Direct Observation and Evaluation: An attending physician will directly observe an individual fellow in direct, hands-on patient care activities including a patient or family encounter, performing a procedure, teaching residents,  giving fellow lecture, interacting with consultants, interacting with hospital administration etc.  This also includes the fellow’s proficiency in chart recall. The attending will give direct feedback (that day) in written and oral form. One of the six core competencies will be addressed in this evaluation.
  5. Quarterly Observation and Evaluation: The attending physicians will provide an evaluation of the fellow based on the six core competencies quarterly. The fellow’s strengths, weaknesses and areas in need of improvement are discussed based on the six general competencies and the curricular expectations.  The attending physicians complete the form through an electronic system (E-value).
  6. 360° Assessments:  The fellow will be evaluated by non-MDs (Nurses, Respiratory Therapists, Pharm D’s, and case workers and patients). Self-Assessment will also be required, focusing on the six competencies.
  7. Palliative Care Assessment: The palliative care specialists are present during an end-of-life discussion with a patient/family and the ICU fellow. The palliative care clinician provides direct feedback to the fellow and provides a written evaluation.
  8. In-Training Exam:  The multiple-choice exam (the Society of Critical Care Medicine’s annual written exam process; MCCKAP) will be given annually. Scores will be reviewed with each individual fellow. Results are used for self assessment and program review.
  9. Record/Chart Review:  An abstraction of information from 1 or 2 patient records for which the fellow was primarily responsible will be reviewed. Specifically, the P.D. will review specific aspects of patient care, communication, and professionalism- whether orders are legible, diagnostic tests ordered are appropriate, and whether family discussions are documented in a clear and concise fashion.

 

VIII. LINES OF RESPONSIBILITY and SUPERVISION: The ICU fellow will progress through three levels of training. The fellow will be expected to meet each detailed level of competency as described above. In general, during level I of training, the ICU attending will conduct morning teaching rounds. The ICU fellow will be present and actively participate in rounds. During the afternoon and evening, the level I ICU fellow will present all cases to the ICU attending in a concise and thorough manner that includes all important factors contributing to the patient’s critical illness. The ICU attending will be present during family meetings in situations where poor outcome is expected.

     The level II ICU fellow will continue to meet prior objectives while taking a greater leadership role on rounds, teaching, and in the care of patients. The level II ICU fellow will independently communicate with patients and families in situations where a poor outcome is expected with occasional help from the attending. The Level II fellow will expand his/her ability to formulate and initiate diagnostic and care plans without first consulting the attending, while keeping attending informed of all decisions made.

     The level III critical care fellow will continue to meet prior objectives. The level III critical care fellow will occasionally conduct rounds without the attending present and communicate a summary of the care plans developed to the attending. The level III fellow will independently conduct family conferences concerning prognosis, end of life care, DNR, withdrawal of support. At this level, the fellow will assist the resident in performing the initial evaluation on most admissions and formulate a treatment plan, including appropriate consultations without assistance. The Level III fellow will also coordinate lectures, fellow schedules, and complete a research project.

 

   Moonlighting Policies and Procedures:  Moonlighting is permitted during the critical care fellowship. All policies and procedures are in accordance with those of the GME rules. Prior to moonlighting, the fellow must obtain written consent from the program director.  Moonlighting hours will count towards total resident-work hours and must be reported. Moonlighting privileges will be revoked if difficulties with learning, performance, patient care, fatigue or other issues arise.  Please visit the GME website for further information regarding moonlighting: http://smhs.gwumc.edu/graduatemedicaleducation/currentresidentresources/moonlightingaddendum.

  

VI. READING LIST:

1.  The ICU Book/ Paul L. Marino

2.  ACLS/ ATLS

3.  Irwin and Rippe’s Intensive Care medicine/ editors, Richard Irwin, Frank B. Cerra, James M. Rippe.

4.  Principles and practice of intensive care monitoring/ editor, Martin J. Tobin

5.  Critical Care Medicine: Principles of Diagnosis and Management in the Adult / Joseph E. Parillo and R. Phillip Dellinger

6.  Critical Care Medicine: The Essentials/ John J. Marini and Arthur P. Wheeler

7.  Commonly Cited Articles in Critical Care – See www.gwicu.com under section “articles”