Download UK Catheterization and Inpatient Service Rotation for Third

UT Inpatient Cardiology Rotation
Brief description and target group: A four-week rotation for Internal Medicine residents
caring for patients under the care of a cardiologist in a tertiary medical center.
Overall Educational Goals and Objectives:
This rotation involves all aspects of caring for hospitalized patients under the care of a
cardiologist. The rotation centers around the management of patients admitted or consulted on
by an academic “teaching” service. The service is comprised of an attending cardiologist, a
general cardiology fellow, 2 internal medicine residents, and a cardiovascular pharmacist. The
larger multidisciplinary team includes members from nursing, pharmacy, physical therapy and
nutrition. There will be an emphasis on patients that are critically ill, but will include those
admitted to a telemetry floor or other areas of the hospital.
The responsibilities of the resident on this rotation includes performing histories and physicals
on admissions or new consults, daily notes and orders, communication with patients’ families,
coordination of consultations, procedures, discharge summaries, identifying the academic team
patients with a sticker and face-to-face hand-over to the night medicine service.
The fellow will lead the team and provide oversight to patients admitted to the cardiac intensive
care unit, be the first point of contact for the family members of patients who are critically ill and
coordinate the transfer of patients out of the intensive care setting and into an acute care or
telemetry environment, ensuring excellent handover. The fellow will serve as the immediate
contact for the residents and will guide daily rounds and management of the patients.
It is the responsibility of the team (fellow or resident) to communicate with the attending of
record whenever there is a decline in the clinical condition of a patient that necessitates a transfer
to the ICU, intubation, or cardiopulmonary resuscitation. In the event of a patient death, this
must also be communicated to the attending of record.
Rotation Specific Educational Goals by Competency
Overall Goals for each resident
1. Medical Knowledge. Exhibit an understanding of the basic and clinical science
associated with common conditions that affect the cardiovascular system. Develop and
execute a care plan for patients that are seriously or critically ill.
2. Patient Care. Implement a treatment plan in the setting of a multidisciplinary team.
Provide patients and families a detailed understanding of the plan and the associated
potential risks and benefits.
3. Interpersonal Skills and communication. Provide care for the patient that leaves the
patient and family well informed. Communicate effectively with other members of the
multidisciplinary team. Participate in bedside and class room didactic teaching.
4. System Based Practice. During the rotation, there will be opportunities to participate in
ongoing quality improvement initiatives focused on improving care of the cardiovascular
patient. A multidisciplinary team that includes Cardiothoracic Surgeons, Cardiovascular
Intensivists and representatives from nursing, pharmacy, respiratory therapy and nutrition
are working to improve care delivery, quality and outcomes. The goals of this team are
to address issues relating to the delivery of healthcare services to patients with a
cardiovascular diagnosis. Issues will include meeting core-measures, and patient safety
goals, early ambulation and extubation, ensuring a smooth transfer out of the intensive
care environment, optimizing patient education, and creating more efficient systems of
care.
5. Problem Based Learning. The team will identify areas for further study on rounds. The
fellow will coordinate a mini-journal club around the topics and organize a time to review
the evidence.
6. Professionalism. Adhere to the dress and behavioral standards set forth by the University
of Tennessee at Chattanooga. All members of the team will be expected to interact with
patients honestly and provide an atmosphere that is patient and family centered; to fully
participate in quality of care and safety initiatives to insure patient safety; and to
participate in the education of the team and to develop a pattern of lifelong learning.
Additionally, all members of the team will be expected to accurately report duty hours,
identify situations in which fatigue or other issues impair their ability to provide excellent
clinical care.
Teaching methods:
The principal teaching method is practical hands-on experience in a mentored environment for
the trainee in all aspects of the care process on the inpatient service, encompassing patients
admitted to the service. The Cardiovascular Disease attending has ultimate responsibility for all
patients so will constantly supervise and guide the trainee as needed in the evaluation, diagnosis
and treatment of patients.
Teaching is centered around discussion of the individual patient with emphasis on decisionmaking, evidence-based therapies, ethical and socio-economic issues. More formally, the
service has a 13-block lecture schedule and the residents will be invited to attend all lectures.
They will be required to attend the Friday afternoon core lectures and case management series
that occurs from 1:30-3:30 PM.
Mix of diseases, patient characteristics, types of clinical encounters, procedures, and
services:
The patients seen during this rotation include the typical mix of the acute adult cardiac care with
~60% male and 40% female. The clinical pathology to which the resident will be exposed is
wide-ranging and includes acute and chronic ischemic disease manifestations, all types of
valvular heart disease, pulmonary hypertension, heart failure in all its etiologies, hypertension,
and conduction system disease, and patients with renal and other peripheral arterial disease. Most
learning on this rotation will be triggered by a first-hand encounter with a patient with either an
acute or non-acute indication for hospitalization. Specific aspects of care include, but are not
limited to, the management of ST segment elevation and non-ST segment elevation myocardial
infarction, management of heart failure in all its etiologies, secondary prevention of ischemic
heart disease, managing acute disturbances of cardiac rhythm, the management of antiarrhythmic drug therapy, management of acid-base and electrolyte disturbances in the cardiac
patient, and the management of cardiogenic shock. Experience will also be gained in the postoperative management of patients undergoing cardiac surgery.
Service Coverage:
DAY
MONDAY
R1
R2
TUESDAY
R1
R2
WEDNESDAY R1
R2
THURSDAY
R1
R2
FRIDAY
R1
R2
SATURDAY
R1
R2
SUNDAY
R1
R2



TIME
7:45 AM – 8:15 PM
6 AM – 6 PM
7:45 AM – 8:15 PM
6 AM – 6 PM
7:45 AM – 8:15 PM
6 AM – 6 PM
7:45 AM – 8:15 PM
OFF
7:45 AM – 8:15 PM
6 AM – 6 PM
7:45 AM – 8:15 PM
6 AM – 6 PM
OFF
7:45 AM – 8:15 PM
HOURS
12.5
12
12.5
12
12.5
12
12.5
0
12.5
12
12.5
12
0
12.5
TOTAL
12.5
12
25
24
37.5
36
50
36
62.5
48
75
60
75
72.25
The service coverage will be daily with one resident covering 6 AM – 6 PM and the
second resident covering 7:45 AM – 8:15 PM.
Each resident will take one day off per week. This must be coordinated with the fellow at
the beginning of the rotation. The fellow is off on Saturday so this day cannot be taken
off.
Transition of care to the night float team must be face-to-face each morning and night.
Reading lists and other educational resources to be used:
The core of information underlying diagnosis and clinical decision making in inpatient
cardiology is to be found either on-line in practice guidelines or in core clinical journals. A
significant number of relevant publications can be found referenced in the American College of
Cardiology-American Heart Association guidelines. Thus, while the trainee will receive a virtual
continuous infusion of references from the inpatient service attending physician, and will be
responsible for gaining a grasp of this literature.
The general internal medicine review series MKSAP and Medstudy provide a good general
overview on cardiovascular disease.
Method of evaluation of resident performance:
The resident will be continuously evaluated each day as the rotation proceeds, with feedback
from attending cardiologists and fellows throughout the rotation. A written evaluation using the
competency based, global evaluation form in New Innovations will be prepared for each resident
after completion of the rotation by both the attendings and fellows that were on the team during
that time. Medical knowledge is assessed daily during rounds and patient admissions. In order
to achieve a PASSING GRADE for the rotation, the attending physician must verify that the
resident performed at an average or better level in each of the 6 medical competencies.
Assessment Tool
Faculty end of rotation
assessment
Fellow end of rotation
assessment
Staff assessment
Procedure supervision
Type
Global Assessment
Competency
All
PGY Level
All
Multisource feedback
All
All
Multisource feedback
Direct observation
All
PC
All
All
UT Cardiovascular Disease Inpatient Service Rotation for Residents
Upon completion of this rotation, residents will be able to:
Objective
Core
Competency
Learning Activity
Teaching Method
Evaluation
Method
MEDICAL KNOWLEDGE
Understand the pathophysiology, clinical manifestations, natural history, and principles of management of
aortic dissection, atrial arrhythmias (fibrillation, flutter, AVNRT), ventricular arrhythmias (tachycardia and
fibrillation), AND simple congenital heart lesions.
Understand the pathophysiology, clinical manifestations, natural history, prevention and principles of
management and of coronary artery disease and myocardial infarction including follow-up care and postoperative care.
Understand the pathophysiology, clinical manifestations, natural history, and principles of management of
endocarditis.
Understand the pathophysiology, clinical manifestations, natural history, and principles of management of
hypertension including evaluation for primary and secondary hypertension and hypertensive emergency.
Understand the pathophysiology, clinical manifestations, natural history, and principles of management of
myocarditis and pericarditis.
Understand the pathophysiology, clinical manifestations, natural history, and principles of management of
cardiogenic shock.
Understand the pathophysiology, clinical manifestations, natural history, and principles of management of
valvular heart disease including aortic stenosis and mitral regurgitation.
Demonstrates basic understanding of the pathophysiology, clinical manifestations, natural history,
prevention, and principles of management of the common iatrogenic complications including adverse drug
reactions, cardiac catheterization complications, central venous access complications, deep venous
thrombosis, bleeding complications associated with antiplatelet and anticoagulant therapy, hypotension, and
acute renal failure.
Recognize major findings on routine imaging, including CXR, CT/MRI of chest, left ventricular
catheterization, coronary angiography, right ventricular catheterization, echocardiogram, EKG, and
ambulatory EKG monitoring.
Demonstrates basic knowledge of the predictive power and test characteristics of laboratory and radiological
testing.
PATIENT CARE
MK
1, 2, 3, 6, 7
A,C,E
MK
1, 2, 3, 6, 7
A,C,E
MK
1, 2, 3, 6, 7
A,C,E
MK
1, 2, 3, 6, 7
A,C,E
MK
1, 2, 3, 6, 7
A,C,E
MK
1, 2, 3, 6, 7
A,C,E
MK
1, 2, 3, 6, 7
A,C,E
MK
1, 2, 3, 6, 7
A,C,E
MK
1, 2, 3, 6, 7
A,B,C,E
MK
1, 2, 3, 6, 7
A,C,E
Acquire accurate and relevant history from the patient in an efficiently customized, prioritized, and
hypothesis driven fashion.
Seeks and obtains appropriate, verified, and prioritized data from secondary sources.
Perform an accurate physical examination that is appropriately targeted to the patient's complaints and
medical conditions. Identify pertinent abnormalities using common maneuvers.
Identify some subtle or unusual physical findings that may influence clinical decision making, using
PC
1,2,7
A,C
PC
PC
1,2,7
1,2,7
A,C
A,C
PC
1,2,7
A,C
advanced maneuvers where applicable.
Accurately track important changes in the physical examination over time.
Synthesize all available data, including interview physical examination, and preliminary laboratory data, to
define each patient’s central clinical problem.
Develop prioritized differential diagnoses and evidence based diagnostic / therapeutic plans for common
inpatient conditions.
Modify differential diagnosis and care plan based upon clinical course and data as appropriate.
With supervision, demonstrates competence, technical proficiency, and post procedure management in
advanced cardiac life support.
Make appropriate clinical decisions based upon the results of common diagnostic testing, including routine
blood chemistries, hematologic studies, coagulation tests, arterial blood gases, ECG, chest radiographs,
urinalysis and other body fluids.
Demonstrate basic management of patients whose diagnosis is unclear.
Recognize situations with a need for urgent or emergent medical care including life threatening conditions.
Initiate management and obtain urgent assistance for patients with emergent medical conditions.
Recognize when to seek additional guidance.
Provide appropriate preventive care and teach patient regarding self-care.
Effectively manage patients with common clinical disorders seen in the practice of inpatient cardiovascular
medicine with appropriate supervision.
Customize care in the context of the patient’s preferences, overall health, and wishes.
PRACTICE-BASED LEARNING AND IMPROVEMENT
PC
PC
1,2,7
1,2,7
A,C
A,C
PC
1,2,7
A,C
PC
PC
1,2,7
1,2,7
A,C,
A,C,D
PC
1,2,7
A,C
PC
PC
PC
PC
PC
PC
1,2,7
1,2,7
1,2,7
1,2,7
1,2,7
1,2,7
A,C
A,C,D
A,C,D
A,C,D
A,C,D
A,C,D
PC
1,2,7
A,C,D
Communicate risks and benefits of alternatives to patients.
Customize clinical evidence for an individual patient.
Appreciate the responsibility to assess and improve care collectively for patients on the inpatient service.
Identify clinical questions through self study as they emerge in patient care activities.
Access medical information resources to answer clinical questions and library resources to support decision
making.
Respond welcomingly and productively to feedback from all members of the health care team including
faculty, peer residents, students, nurses, allied health workers, patients and their advocate.
Actively seek feedback from all members of the health care team.
Integrate teaching, feedback, and evaluation with supervision of interns’ and students’ delivery of patient
care.
Identify areas in the inpatient hospital environment that can be changed to improve effect of the processes
and outcomes of care.
Actively participate in the department’s required teaching conferences.
Develop time management skills to perform required tasks in a reasonable amount of time with satisfactory
quality.
Reflect on feedback in developing plans for improvement.
INTERPERSONAL AND COMMUNICATION SKILLS
PBLI
PBLI
PBLI
PBLI
PBLI
1,2
1,2
1,2
1,2
1,2
A,C
A,C,D
A,C,D
A,C
A,C
PBLI
1,2
A,C,D
PBLI
PBLI
1,2
1,2
A,C,D
A,C
PBLI
1,2
A,C,D
PBLI
PBLI
1,2,3,4,5,6
1,2
A,C
A,C
PBLI
1,2
A,C
Demonstrate patient-centered interviewing techniques: a compassionate approach to history taking; the
ability to modify interview techniques in response to the patient’s demeanor, cultural and/or religious
background, and level of competency. Communicate sensitively and effectively with patients and with their
families, including sensitivity to differences in race, culture, gender, sexual orientation, socioeconomic
ICS
1,2
A,B,C,D
status, literacy, and religious beliefs.
Write complete, timely, and concise admission notes for all patients admitted.
Write complete, timely, and concise progress notes documenting daily care of patients admitted.
Request consultative services in an effective manner.
Clearly communicate the role of consultant to the patient, in support of the primary care relationship.
Explain the general process of any ordered procedure (Cardiac catheterization, Echo, etc) with the emphasis
on alleviating the patient’s fears and apprehensions.
Assist patients in decision-making regarding treatment options, end-of-life care, and discharge planning.
Utilize the electronic medical record to compose a complete, concise discharge summary. Ensure that the
patient’s primary care physician and referring physician (when applicable) receives a copy of the discharge
summary in a timely manner.
Communicate effectively with colleagues when signing out patients or turning over care to another service.
Engage in collaborative communication with all members of the health care team.
Deliver appropriate, succinct, hypothesis-driven oral presentations.
PROFESSIONALISM
ICS
ICS
ICS
ICS
ICS
1,2
1,2
1,2
1,2
1,2
A,C,D
A,C,D
A,C,D
A,C,D
A,C,D
ICS
ICS
1,2
1,2
A,C,D
A,C
ICS
ICS
ICS
1,2
1,2,3,5,6
1,2,3,5,6
A,C,D
A,B,D
A,B,D
Adhere to the UT COM Chattanooga Code of Professional Conduct.
Demonstrate honesty and integrity at all times.
Behave with high regard and respect for patients, colleagues, consultants, and all members of the health care
team.
Appreciate the effects of cultural and religious background on the patient’s approach and attitudes toward
decision making, their disease, and treatment.
Recognize the common ethical issues that face patients, their families, and caregivers related to chronic
illnesses.
Provide meaningful feedback to colleagues regarding their performance.
Demonstrate a commitment to relieve pain and suffering.
Respond promptly and appropriately to clinical responsibilities including but not limited to calls and pages.
Carry out timely interactions with colleagues, patients and their designated caregivers.
Ensure prompt completion of clinical, administrative, and curricular tasks.
Recognize the scope of his/her abilities and ask for supervision and assistance appropriately.
Maintain patient confidentiality.
Recognize that disparities exist in health care among populations and that they may impact care of the
patient.
Provide physical, psychological, social and spiritual support for dying patients and their families.
Recognize, respond to and report impairment in colleagues or substandard care via peer review process.
Recognize the need to assist colleagues in the provision of duties.
Serve as a professional role model for more junior colleagues .
Effectively advocate for individual patient needs.
Recognize, respond to and report impairment in colleagues or substandard care via peer review process.
Recognize and manage conflict when patient values differ from their own.
SYSTEMS-BASED PRACTICE
P
P
P
1,2,3,4,5,6
1,2,3,4,5,6
1,2,3,4,5,6
A,C,D
A,C,D
A,C,D
P
1,2,3,4,5,6
A,C,D
P
1,2,3,4,5,6
A,C,D
P
P
P
P
P
P
P
P
1,2,3,4,5,6
1,2
1,2
1,2,3,4,5,6
1,2,3,4,5,6,7
1,2,3,4,5,6
1,2,3,4,5,6
1,2,3,4,5,6
A,C,D
A,C,D
A,C,D
A,C,D
A,C,D
A,C,D
A,C,D
A,C,D
P
P
P
P
P
P
P
1,2
1,2,3,4,5,6
1,2,3,4,5,6
1,2,3,4,5,6
1,2
1,2,3,4,5,6
1,2,3,4,5,6
A,C,D
A,C,D
A,C,D
A,C,D
A,C,D
A,C,D
A,C,D
Understand the role of multidisciplinary resources to prepare patients and their families for hospital
discharge, home management of disease, nursing home placement, and end-of-life care.
Consider alternative solutions provided by other teammates.
SBP
1,2
A,C,D
SBP
1,2
A,C,D
Identify, reflect upon, and learn from critical incidents such as near misses and preventable medical errors.
Reflect awareness of common socio-economic barriers that impact patient care.
Collaborate with other members of the health care team to assure comprehensive patient care.
Manage and coordinate care and care transitions for patients discharged from the in-patient service,
including home, rehabilitation, inter-hospital transfer, and hospice.
Understand mechanisms for analysis and correction of systems errors.
Demonstrate the incorporation of cost-awareness principles into standard clinical judgments and decisionmaking..
Use evidence-based, cost-conscious strategies in the care of hospitalized patients with complex illness.
Negotiate patient-centered care among multiple care providers.
SBP
SBP
SBP
SBP
1,2
1,2
1,2
1,2
A,C,D
A,C,D
A,C,D
A,C,D
SBP
SBP
1,2,3,6
1,2
A,C
A,C,D
SBP
SBP
1,2
1,2
A,C
A,C,D
Core Competencies
Learning Activities / Teaching Methods
Evaluation Methods
PC
Patient Care
MK Medical Knowledge
PBLI Practice-Based Learning & Improvement
ICS
Interpersonal & Communication Skills
P
Professionalism
SBP
Systems-Based Practice
1.
2.
3.
4.
5.
6.
7.
A.
B.
C.
D.
E.
Direct Patient Care
Teaching Rounds
Noon Conference
Medical Grand Rounds
Journal Club
Cardiovascular Conferences
Assigned Readings
Attending Evaluation
Attending Observation of Procedures
Fellow Evaluation
Multisource Evaluation
In-Training Examination