Download Fellowship in Pediatric Critical Care Medicine University of

Fellowship in Pediatric Critical Care Medicine
University of California, San Francisco (UCSF) Benioff Children’s Hospitals
Educational Goals and Objectives
I. OVERVIEW:
The Pediatric Critical Care Medicine subspecialty fellowship training program is a threeyear ACGME approved program with as overall goal to train pediatric intensive care
physicians who will become leaders in their field with expertise in clinical care, research
and teaching. The program aims to provide clinical and research experiences as well as
formal curricular activities and mentorship to ensure trainees develop such expertise.
The program follows the guidelines as outlined in the “ACGME Program Requirements
for Graduate Medical Education in the Subspecialties of Pediatrics” and the “ACGME
Program Requirements for Fellowship Education in Pediatric Critical Care Medicine”,
effective July 1, 2016 (available from http://https://www.acgme.org/).
The fellowship offers a balanced training program, with approximately half of the
training period dedicated to developing clinical expertise and half to the completion of a
“scholarly work product” as outlined by the American Board of Pediatrics (ABP), while
developing necessary research skills. For select applicants with a particular interest in
academic pediatrics, opportunities exist for a 4-year fellowship program, with the 4th year
dedicated almost entirely to non-clinical scholarly activities such as basic, translational,
clinical and medical education research. This program is funded by the Divisional NIH
T32 Training Grant. Opportunities to pursue an advanced degree, including a Master’s in
clinical research, public health or medical education exist within this program. See
http://cvri.ucsf.edu/CVRIDocuments/TrainingOpportunities/fineman.shtml. Similarly, for
fellows who secure funding through the Physician Scientist Development Program
(PSDP), opportunities for a 4 or 5 year extended fellowship training program exist.
The clinical training takes place at 2 main training sites, UCSF Benioff Children’s
Hospital (BCH) San Francisco and BCH Oakland. Across the two sites, fellows are
exposed to a broad spectrum of Pediatric Critical Care Medicine, including, amongst
others, pediatric trauma, solid organ transplantation, and congenital heart surgery. A
total of 17 full-time pediatric intensive care faculty members provide supervision at the 2
sites, and are committed to foster an environment for adequate training of fellows in
clinical, technical, communication and professional skills. The fellowship encourages
fellows to take on gradually increasing responsibility for patient care, teaching, and
supervision, as well as progressive independence.
Fellows have a wide range of opportunities for the pursuit of research or equivalent
scholarly activities, either at UCSF, Children’s Hospital Oakland Research Institute
(CHORI) or affiliated institutions. The fellowship’s track record in this regard is excellent,
both in terms of diversity of projects as well as in terms of successful completion of
projects leading to peer-reviewed publications and further pursuit of academic careers.
Fellows develop research skills, grant writing skills and other skills needed for academic
success through direct mentorship and through courses and workshops organized by
the Cardiovascular Research Institute (CVRI, http://cvri.ucsf.edu/), CHORI
(http://www.chori.org/) and Fellows’ College, a professional development program for
pediatric subspecialty fellows at UCSF (http://pediatrics.ucsf.edu/fellows-college).
II. PROGRAM OUTLINE
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The 3-year program is divided into block rotations; blocks are typically 4 weeks in length
at BCH-O and occur in increments of 3 weeks at BCH-SF. Four weeks per year are set
aside for vacation. Approximately half of the training time is dedicated to clinical training:
60 PICU weeks (either at BCH-SF or BCH-O), 4 weeks for pediatric anesthesia (2 at
BCH-O and 2 at BCH-SF), 4 weeks for an adult ICU rotation (at UCSF Medical Center)
and two 2-week elective rotations. In addition, fellows do one 12-hr transport shift in their
first year and 2 weeks of “pre-attending time” (1 week at each training site) in the 3rd
year, during which the fellow acts as an attending (see below). Fellows spend the
remainder of the training time focusing on research/scholarly activities and educational
activities. When not on scheduled clinical rotations, second, third year and more senior
fellows participate in the weekend call schedule at BCH-SF. The weekend schedule
consists of two 12-hr Saturday-Sunday day-time shifts in the PICU (assigned to one
senior fellow) and a 28-hr Saturday shift (daytime coverage of the CICU and night time
coverage of both units -assigned to a different senior fellow). The fellow who starts a
week of nights in the CICU starts at 11 AM on Sunday, the fellow who starts a week of
nights in the PICU will start at 5 PM on Sunday. Of note, the fellowship program
complies with both ACGME and UCSF GME regulations regarding duty hour limitations,
as outlined in the PICU Fellowship Duty Hours Policy.
The program is committed to helping fellows succeed in their academic goals and
achieve a meaningful accomplishment in research as dictated by the ABP. To this end,
the program maintains flexibility in scheduling of clinical rotations. For most fellows,
however, a relatively large proportion of clinical rotations will be scheduled in the first
year, with pediatric anesthesia as one of the first rotations. The Adult ICU rotation will be
scheduled in the 2nd year, and elective rotations are scheduled in the 3rd year of training.
For goals and objectives of specific rotations, see section III below. A 5-day orientation
(one day at BCH-O, three days at BCH-SF and one day in the simulation center at the
UCSF Kanbar Center) is organized for 1st year fellows in July of each year, during which
fellows are oriented to the program and to the respective units. In addition, code
procedures and resuscitation equipment are reviewed during the orientation, and
procedural skills are reviewed and practiced using partial skill simulation trainers.
III. CLINICAL ROTATIONS: SPECIFIC GOALS AND OBJECTIVES.
A.
Pediatric Anesthesiology Rotation (1st year)
All fellows complete a 4 week rotation in Pediatric Anesthesiology in the first year,
typically scheduled early in the academic year. Optional additional week(s) with adult
and/or cardiac anesthesiology at UCSF Medical Center can be arranged on a asneeded/desired basis. The main goals of the anesthesiology experiences are to become
skilled in airway management and vascular access, and understand the basic principles
of anesthesiology as it pertains to pediatric patients. Fellows work with pediatric
anesthesiologists at both hospitals, in order to reach the following objectives:
1. Demonstrate skills in airway management; including bag-valve-mask ventilation,
endotracheal intubation, and placement of laryngeal mask airways and use of
oral and nasopharyngeal airways.
2. Demonstrate vascular access skills, with particular emphasis on peripheral IV
placement. In addition, fellows should become comfortable with techniques used
for arterial puncture, arterial line placement and central venous catheter
placement in various locations (femoral, intrajugular, and subclavian) and be able
to demonstrate sterile technique for any of these procedures.
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3. Know the basic principles of sedation and anesthesia and acquire knowledge
regarding levels of sedation, ASA classification, medications (including
indications, pharmacokinetics, side effects and interactions) and monitoring
required.
In addition, fellows have the opportunity to participate in a 1-week experience in the
pediatric cardiac OR at BCH-SF. The additional learning objectives for this experience
are:
1. Anticipate complications of induction anesthesia in patients with various
congenital heart lesions, in particular single ventricle physiology
2. Describe principles of cardiopulmonary bypass
3. Anticipate, troubleshoot and understand management of problems encountered
when separating from cardiopulmonary bypass
4. List strategies for anticoagulation during bypass surgery and approaches towards
hemostasis
B.
Pediatric Transport (1st year)
Fellows participate in one 12-hr transport shift during their first year of training, and
function as the Transport Physician for transports coming to BCH-SF. Almost all of our
fellows have acquired experience in transport of pediatric patients during residency.
Fellows function as medical control officers for transports while on ICU rotations (see
below). It is important that they 1) gain understanding of the operational issues
surrounding transports, including limitations in capabilities for management at referring
facilities and during transport and 2) develop appreciation for the importance of
adequate communication with the transport team and the referring health care
professionals. Additional transport experience can be arranged on an as needed/as
desired basis.
C.
Pediatric Intensive Care Rotations
Overview and summary of overall objectives
Fellows complete a total of 60 weeks in PICU rotations spread out over 3 years of
training, and the goals and objectives of these rotations should be seen as a continuum
with progressive acquisition of knowledge and skills expected over the course of the
years. As mentioned above, some flexibility exists regarding the scheduling of clinical
rotations; therefore the expected level of functioning at the end of each training year may
differ from fellow to fellow. In general, however, the main emphasis of fellowship training
during the 1st year is on acquisition of knowledge and insight in general principles and
common diseases and development of technical skills as well as decision-making and
management skills. During the 2nd year emphasis is on further deepening of
understanding and knowledge, becoming proficient in technical skills and on acquisition
of teaching and supervision skills, whereas the main focus of the 3rd year is on
solidifying knowledge base with an emphasis on finding and understanding the scientific
evidence, becoming proficient in the supervisory role and on gaining independence.
During the last clinical rotation of the 3rd year, fellows spend 2 weeks (1 week at each
institution) doing “pre-attending”, performing all the tasks attendings normally perform
with the attending available at all times for discussion and guidance. Year by year
competency-based objectives are outlined in more detail in the second half of this
section. To accomplish the objectives below, fellows participate in direct patient care in
the PICU, perform consultations outside the ICU, respond to code white calls and
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function as the medical control officer for pediatric transports, with instruction and
supervision by Pediatric Critical Care faculty. In both institutions, at least one Pediatric
Critical Care faculty member is available in-house 24 hours a day, 7 days a week. BCHO has a 23-bed PICU, a busy pediatric emergency room and transport program and is
the only dedicated pediatric trauma center in the San Francisco/Oakland Bay area.
BCH-SF has a 20-bed PICU, a 12-bed CICU, an 18-bed Pediatric Emergency Room and
also an active transport program. The clinical experience is augmented by didactic
conferences as outlined in section V below.
What follows is a summary of competency-based goals and objectives for all 3 years.
Specific goals and objectives per training year and location are outlined in the second
half of this section.
At the end of 3 years of fellowship, fellows are expected to have reached the following
objectives:
1. Medical Knowledge: Demonstrate knowledge and understanding regarding
physiology, pathophysiology, diagnosis, and therapy of critical illness in pediatric
patients involving the following systems: 1) cardiovascular; (2) respiratory; 3) renal;
4) gastrointestinal; 5) genitourinary; 6) neurologic; 7) endocrine; 8) hematologic; 9)
musculoskeletal; and 10) immunologic and infectious diseases. In addition, fellows
will gain knowledge regarding metabolic, nutritional, and endocrine effects of critical
illness, hematologic and coagulation disorders secondary to critical illness,
management of anaphylaxis and acute allergic reactions, monitoring and medical
instrumentation, pharmacokinetics and drug metabolism in critical illness, and
iatrogenic and nosocomial problems in Critical Care Medicine. At CHRCO, fellows
gain knowledge regarding management of acute pediatric trauma.
2. Patient Care: a) Apply knowledge regarding acute life-threatening illnesses in the
management of pediatric patients as well as pre- and post-surgical management of
patients with congenital heart disease and other critically ill surgical patients, and
evaluate the effectiveness of management. b) Demonstrate proficient skills in airway
management and vascular access, both when performed on an elective basis as well
as in emergency situations. In addition, fellows will become competent in
thoracocentesis and thoracostomy tube placement in management of patients on
extracorporeal life support and patients requiring renal replacement therapy. c) Apply
and interpret invasive and non-invasive monitoring of respiratory, hemodynamic and
intracranial pressure parameters. d) Demonstrate competency in cardiopulmonary
resuscitation, and ability to assume a leadership role in a resuscitation team. Fellows
respond to code white calls at both institutions and are a member of the Rapid
Response Team at both institutions.
3. Interpersonal and Communication Skills: a) Demonstrate effective communication
skills, including communication with patients and parents regarding end-of-life and
dying, communication with nursing staff, ancillary staff, and consultants, and written
communication regarding patient care. b) Demonstrate team leadership skills
including effective coordination of care with consultants, and adequate supervision of
housestaff, nursing staff and ancillary staff. c) Coordinate transport of critically ill
patients from outside facilities and effectively communicate with referring physicians
and transport team members regarding stabilization and medical management prior
to and during transport. d) Demonstrate effective teaching skills during bedside
rounds, formal lectures and procedural skills training, develop educational core
curriculum for PICU topics and perform educational outcome assessment.
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4. Professionalism: Comply with guidelines regarding professional behavior and
ethical conduct as outlined in institutional policies, demonstrate ethical conduct and
respect towards patients, colleagues and other individuals encountered in the work
environment, complete assigned tasks adequately in a timely manner, demonstrate
commitment to self-improvement and life-long learning.
5. Practice-based Learning: Be able to reflect on medical practice and incorporate
components of self-reflection as well as feedback from others in practice
improvement. Fellows complete bi-annual, competency-based Individual Learning
Plans in the UCSF ePortfolio system to practice reflection and self-direction.
Mentorship and regular feedback will be provided throughout fellowship training as
outlined in the PICU Fellowship Evaluation Policy. In addition, fellows are required to
actively participate in morbidity and mortality conferences as well as journal club.
6. Systems-based Learning: a) Understand the financial and administrative aspects of
Pediatric Critical Care Medicine. b) List initiatives for improvement of health care
quality and patient safety. Fellows are required to participate in at least one quality
improvement project and demonstrate documentation of their role in this. c)
Appreciate the impact of cultural norms and health beliefs of families on health care
and practice health care in a manner that takes these factors into account.
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Objectives per year and per location
Note: this list is meant as a general guideline and does not pretend to be complete.
Since there is variation between fellows in distribution of clinical rotations over the 3
years of training and the patient load and variety is unpredictable, there will also be
variation between fellows in regards to the objectives that they are able to meet at the
end of each training year.
YEAR 1
1. Medical Knowledge. At the end of 1st year Pediatric Intensive Care rotations at both
BCH-SF and BCH-O, fellows are expected to be able to:
•
Describe the anatomy of the lungs and airways with their blood supply. Describe
key concepts of respiratory physiology including relationships between flow,
volume, pressure, resistance and compliance. Describe the pulmonary circulation
and the factors that affect pulmonary vascular tone. Define respiratory failure
and describe different causes. Define acute lung injury and ARDS and describe
its pathophysiology. Summarize tests used to measure pulmonary mechanics
and gas exchange. Explain the role of ventilation in the acid buffering system and
describe the concept of ventilation-perfusion matching and ways to assess this.
Describe basic modes of mechanical ventilation including NIPPV, CPAP, IMV,
AC, dual modes and HFOV. Define barotrauma, volutrauma and describe the
principle of permissive hypercapnia and lung-protective ventilation strategies.
•
Describe the anatomy of the heart. List the determinants of cardiac function and
describe the assessment of cardiac function and derived hemodynamic
parameters. Describe the principles of arterial, central venous, and pulmonary
artery pressure monitoring. Define shock and describe the different types of
shock and their complications. Describe the pathophysiology of shock and
derive equations of oxygen transport and utilization. List commonly used
vasoactive and inotropic medications, their mechanism of action, indications and
adverse effects.
•
Describe the structural components of the brain and identify the major arterial
and venous blood vessels and the regions of their supply and drainage. Relate
specific regions of the CNS to their function and describe the consequences of
injury. Describe regulation of cerebral blood flow and its modulators. Describe the
physiology of CSF production, absorption and circulation and the consequences
of disturbances in these. List causes of abnormal cell, protein or glucose content
of CSF. Explain the function of the (para) sympathetic nervous system. Define
coma and describe methods for assessment of mental status. List different
causes of coma. List causes of increased intracranial pressure and describe the
principles of ICP monitoring. List different modes of management of increased
ICP and describe their mechanism of action. Define different levels of sedation,
the drugs used to induce sedation with their mechanisms of action,
pharmacokinetics and side effects. Describe methods to assess and manage
pain, including medications commonly used in the ICU with their mechanisms of
action, pharmacokinetics and side effects. List the classes of neuromuscular
blocking agents with their specific indications, mechanisms of action,
pharmacokinetics and side effects.
•
Describe the structure and function of the renal tubule and glomerulus and the
anatomy and physiology of the renal circulation. Explain renal regulation of fluid
balance and electrolytes. Interpret laboratory values for acid-base disturbances,
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differentiate such disturbances and list their causes and describe the
pathophysiology. Describe the renal handling of drugs and other agents
frequently used in critical care and list medications with renal toxicity. Define
renal failure; describe the causes and pathophysiology and list indications for
renal replacement therapy. Describe the principles of renal replacement therapy
and list the different modes with their indications, mechanism of action and
complications.
•
Define acute and chronic liver failure and describe the typical clinical and
laboratory abnormalities. List the causes and the pathophysiology of liver failure
and treatment modalities. Describe the stages of hepatic encephalopathy.
Describe the hepatic metabolism of drugs and other agents frequently used in
critical care and list medications with hepatic toxicity.
•
Describe defects in hemostasis including thrombocytopenia and disseminated
intravascular coagulation and list common causes and the pathophysiology.
Describe management options for both anticoagulation and fibrinolytic therapy
with their specific indications, mechanisms of action and adverse effects.
Summarize acute syndromes associated with neoplastic disease and
antineoplastic therapy.
•
List common microbial pathogens for both community acquired infections and
hospital acquired infections common among pediatric intensive care patients,
differentiating between immunocompetent and immunocompromised hosts. List
resistance patterns of common microbial agents. Summarize mechanism of
action, indication and side effects of antimicrobial agents used in the ICU.
Demonstrate knowledge and understanding regarding physiology,
pathophysiology, diagnosis, and therapy of common conditions in pediatric
intensive care patients including status asthmaticus, pulmonary infections,
bronchiolitis, pneumothorax, pulmonary hypertension, cardiac arrhythmias and
conduction disturbances, cardiomyopathy, congenital heart defects,
hypertension, pulmonary edema, renal failure, liver failure, status epilepticus,
hydrocephalus, meningitis, encephalitis, toxidromes, diabetic ketoacidosis,
SIADH, sepsis, nosocomial infections, anaphylaxis and acute allergic reactions,
gastrointestinal bleeding.
In addition, at the end of 1st year Pediatric Intensive Care rotations at BCH-SF
fellows are expected to be able to:
•
Demonstrate an understanding of solid organ transplantation, including the
principles of organ procurement and preservation, and of allocation and
transportation. Describe indications and complications of kidney, liver and small
bowel transplantation.
At the end of 1st year Pediatric Intensive Care rotations at BCH-O fellows are
expected to be able to:
•
Summarize the initial approach to the management of multi-organ trauma, list the
management algorithm for traumatic brain injury and describe diagnostic
procedures to differentiate accidental from non-accidental trauma.
Fellows are expected to take the Pediatric Critical Care Medicine in-training exam
from the American Board of Pediatrics in the spring of their first year, and are
expected to score at or above the national average (around 65%).
2. Patient Care: At the end of 1st year Pediatric Intensive Care rotations at both BCHSF and BCH-O, fellows are expected to be able to:
•
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•
Recognize respiratory failure. Demonstrate proficient skills in airway
management including bag-valve-mask ventilation, oral endotracheal intubation
both on an elective basis as well as in emergency situations in patients with
otherwise uncomplicated airways. Select and insert adjuvant airways as
indicated in patients with upper airway obstruction. Demonstrate proficient skill in
thoracocentesis. Manage patients on both non-invasive and invasive mechanical
ventilatory support and apply the principles of lung-protective strategies.
•
Recognize shock. Demonstrate proficient skills in vascular access techniques,
including peripheral IV placement, peripherally inserted central catheter
placement, femoral venous catheterization, femoral arterial catheterization and
radial artery catheterization. Demonstrate competency in cardiopulmonary
resuscitation. Manage patients in shock and apply appropriate management
strategies for reversal of shock based on categorization of shock and correct
interpretation of hemodynamic monitoring parameters. Interpret EKG findings,
recognize arrhythmias and implement appropriate intervention based on the
nature of the arrhythmia and the patient’s clinical status.
•
Perform a mental status assessment using the Glasgow Coma Scale and
recognize and differentiate between abnormalities in pupillary responses. Assess
cranial nerve function and interpret findings. Recognize the signs of increased
intracranial pressure including (near) herniation and apply appropriate
management strategies to lower ICP. Perform mild and moderate sedation and
anticipate and treat adverse events. Manage pain effectively and anticipate and
treat adverse effects of therapy.
•
Perform calculations to assess renal function and serum osmolarity, interpret
results of urinalysis and blood gas analysis. Perform appropriate diagnostic tests
to work-up electrolyte abnormalities, anticipate the consequences of electrolyte
abnormalities and apply appropriate management strategies. Adjust drug therapy
as indicated in patients with renal failure to avoid drug toxicity.
•
Recognize the clinical and laboratory abnormalities of liver failure and perform
appropriate diagnostic tests to work-up etiology of liver failure. Recognize hepatic
encephalopathy. Provide supportive care for patients in liver failure. Adjust drug
therapy as needed in patients with liver failure to avoid drug toxicity.
•
Perform an appropriate diagnostic work-up for patients with anemia and patients
with abnormalities in hemostasis and select the appropriate treatment modalities
to achieve hemostasis or anticoagulation as indicated. Anticipate and manage
complications of transfusion of blood products. Recognize tumor lysis syndrome
and apply management strategies to prevent and treat tumor lysis syndrome.
•
Perform diagnostic work-up of new-onset fever in pediatric ICU patients. Select
appropriate empiric antibiotic therapy for clinical infectious syndromes including
sepsis, pneumonia, meningitis, encephalitis, cellulitis, and osteomyelitis.
•
Apply the appropriate diagnostic and management strategies for common
conditions in pediatric intensive care patients, including status asthmaticus,
pulmonary infections, bronchiolitis, pneumothorax, pulmonary hypertension,
cardiac arrhythmias and conduction disturbances, cardiomyopathy, congenital
heart defects, pulmonary edema, hypertension, renal failure, liver failure, status
epilepticus, hydrocephalus, meningitis, encephalitis, toxidromes, diabetic
ketoacidosis, SIADH, sepsis, nosocomial infections, anaphylaxis and acute
allergic reactions, gastrointestinal bleeding.
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In addition, at the end of 1st year Pediatric Intensive Care rotations at BCH-SF
fellows are expected to be able to:
Anticipate common complications after solid organ transplantation and apply
appropriate management strategies.
At the end of 1st year Pediatric Intensive Care rotations at BCH-O fellows are
expected to be able to:
•
Apply appropriate management strategies for patients with multi-organ trauma
and traumatic brain injury and recognize potential cases of non-accidental
trauma.
3. Interpersonal and Communication Skills: At the end of 1st year Pediatric Intensive
Care rotations at both BCH-SF and BCH-O, fellows are expected to be able to:
•
•
Demonstrate effective communication skills, including communication with
housestaff, medical students, nursing staff, ancillary staff, and consultants, and
written communication regarding patient care.
•
Coordinate transport of critically ill patients from outside facilities and effectively
communicate with referring physicians and transport team members regarding
stabilization and medical management prior to and during transport.
Understand principles of adult learning theory and perform effective bedside
teaching about basic PICU cases for medical students and residents. Create an
organized formal lecture.
4. Professionalism: At the end of 1st year Pediatric Intensive Care rotations at both
BCH-SF and BCH-O, fellows are expected to be able to:
•
•
Comply with guidelines regarding professional behavior and ethical conduct as
outlined in institutional policies.
•
Demonstrate ethical conduct and respect towards patients, colleagues and other
individuals encountered in the work environment.
•
Complete assigned tasks adequately in a timely manner.
Demonstrate commitment to self-improvement and life-long learning, as
evidenced by completion of a semi-annual self-assessment in the form of an
annual Individual Learning Plan (ILP) for competency-based learning of clinical
skills and an Individual Development Plan (IDP) for scholarly work and career
development.
5. Practice-based Learning: At the end of 1st year Pediatric Intensive Care rotations at
both BCH-SF and BCH-O, fellows are expected to be able to:
•
•
Summarize a clinical case in a concise and comprehensive manner; outline the
issues in diagnostic process and clinical management that contributed to the
outcome of the case and offer suggestions for improvement of care.
•
Apply knowledge of study designs and statistical methods in a critical review of
the literature regarding diagnostic and therapeutic interventions pertinent to
critical care, and translate findings obtained from review towards patient care.
•
Demonstrate awareness of complications of health care interventions and follow
guidelines to prevent such complications.
•
Perform a self-assessment, identify areas requiring improvement and formulate a
plan to accomplish learning goals. To facilitate this, fellows complete a
competency-based Individual Learning Plan using the UCSF ePortfolio system,
which they discuss with their faculty advisor and the program director.
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6. Systems-based Learning: At the end of 1st year Pediatric Intensive Care rotations
at both BCH-SF and BCH-O fellows are expected to be able to:
•
Demonstrate an awareness of the larger context and system of health care.
•
Demonstrate awareness of quality of care and patient safety initiatives and
implement related guidelines into practice.
•
Advocate for quality of patient care and assist patients and their families in
dealing with critical illness.
YEAR 2
Year 2 objectives build on year 1 objectives; emphasis is on further deepening of
understanding and knowledge, becoming proficient in technical skills and on acquisition
of supervision skills.
1. Medical Knowledge. At the end of 2nd year Pediatric Intensive Care rotations at both
BCH-SF and BCH-O, fellows are expected to be able to:
•
Describe the maturational changes in anatomy and function of the respiratory
system, describe mechanisms for fluid clearance in the lungs, demonstrate
understanding of the biology and function of surfactant and the immunological
responses of the lungs and airways. List the factors that affect breathing control
in the central nervous system and know the causes of disordered control of
breathing. Describe advanced modes of mechanical ventilation including APRV,
HFJV, VS and the principles of negative pressure ventilation. List available
exogenous gases and other adjuncts, including NO, heliox, surfactant and
aerosol therapy with their indications, limitations and complications.
•
Describe the major embryologic developments important for the understanding of
congenital heart disease. List the developmental changes in myocardial function.
List factors that influence cardiac function, including neural control, electrolyte
abnormalities and hormonal influences. Explain cardiopulmonary interactions.
Describe myocardial energy metabolism and list factors and medications that
influence myocardial oxygen demand. Describe regulation and modulation of
vascular tone and regional blood flow. List biomarkers for cardiac dysfunction
and myocardial cell injury. Describe common complications after
cardiopulmonary bypass and their management. List different forms of
extracorporeal life support and describe the principles.
•
Describe the maturational changes of the central nervous system. Describe the
blood-brain barrier and the causes of disruption. List major neurotransmitters and
their function. Define the metabolic requirements of the brain and factors that
influence this. Distinguish between the different forms of cerebral edema and list
the implications for therapy. Describe mechanisms of neuronal injury. List causes
of metabolic encephalopathy. Describe the neuromuscular junction and the role
of electromyography and nerve conduction studies in diagnosis of neuromuscular
diseases. Differentiate between different neuroimaging studies and list their
indications. Describe brain death and list the criteria for diagnosis.
•
Describe the autonomic influences on renal circulation as well as the effects of
hormones and drugs. Describe the pathophysiologic response to alterations in
renal blood flow that occur during renal vascular disease. Describe the clinical
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manifestations of hepatorenal syndrome and discuss the pathophysiology. List
the principles of treatment of renal failure in the setting of circulatory shock.
•
Explain the pathophysiology of coma in hepatic failure. Define and describe
hepatorenal syndrome. Differentiate the different causes of hepatitis and
describe the clinical course of the various toxic and infectious causes of hepatitis.
•
Describe principles of energy metabolism in critically ill patients and list methods
to assess nutritional status and caloric needs. Discuss the benefits and risks
associated with enteral and parenteral feeding in critical care patients. Explain
the pathophysiology of hyperglycemia in critical illness.
•
Differentiate between the innate and the acquired immune system and list the
different components of each and their function. List common congenital and
acquired causes of the immune system and their presentation. List indications for
IVIG and other immunotherapies and their complications. List the potential lifethreatening complications of anti-retroviral therapy.
Demonstrate knowledge and understanding regarding physiology,
pathophysiology, diagnosis, and therapy of conditions in pediatric intensive care
patients including but not limited to congenital and acquired abnormalities of the
upper airway, chemical pneumonitis, pulmonary hemorrhage, restrictive lung
disease, pulmonary embolism, diaphragmatic dysfunction, chylothorax, cystic
fibrosis, myocarditis, endocarditis, pericarditis, myocardial ischemia and
infarction, Tamponade, neuromuscular diseases, rhabdomyolysis, Kawasaki
syndrome, rheumatic fever, toxic shock syndrome, peritonitis, hemophagocytic
syndrome, SLE, vasculitis, rheumatoid arthritis, dermatomyositis, AIDS,
opportunistic infections in immunocompromised hosts, orbital cellulitis,
necrotizing fasciitis, lemierre syndrome, nephritic syndrome, HUS, ATN, renal
vein thrombosis, adrenal insufficiency, Cushing disease, pheochromocytoma,
thyrotoxicosis, inborn errors of metabolism, gastric ulcer disease, inflammatory
bowel disease, pancreatitis, cholecystitis, necrotizing enterocolitis, cerebral
vasculitis, diabetes insipidus, cerebral salt wasting, burns, near-drowning,
starvation, inhalation injury, environmental heat injury, lightning/electrocution
injuries.
In addition, at the end of 2nd year Pediatric Intensive Care rotations at BCH-SF
fellows are expected to be able to:
•
•
Demonstrate knowledge and understanding regarding physiology,
pathophysiology, diagnosis, and therapy of stroke and intracranial hemorrhage
due to vascular abnormalities.
Describe the rapid deployment extracorporeal life support (ECLS) system and list
the steps involved in deployment.
At the end of 2nd year Pediatric Intensive Care rotations at BCH-O fellows are
expected to be able to:
•
•
Describe the proper evaluation of specific injuries, including neck injury, facial
fractures, blunt abdominal trauma and penetrating injuries, their specific
symptomatology, complications and management strategies.
Demonstrate knowledge and understanding regarding pathophysiology,
diagnosis, and therapy of acute complications of sickle cell disease.
Fellows are expected to take the Pediatric Critical Care Medicine in-training exam
from the American Board of Pediatrics in the spring of their second year, and are
expected to score at or above the national average (around 70%).
•
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2. Patient Care: At the end of 2nd year Pediatric Intensive Care rotations at both BCHSF and BCH-O, fellows are expected to be able to:
•
Demonstrate proficient skills in advanced airway skills including nasal
endotracheal intubation and oral endotracheal intubation in patients with
abnormal airway anatomy. Choose between different ventilator modes depending
on disease process, interpret ventilator waveforms and make changes in
ventilatory strategy accordingly if appropriate. Appropriately select exogenous
gases and other adjunct therapies for respiratory diseases.
•
Demonstrate proficient skills in advanced vascular access techniques including
catheterization of the internal jugular vein, the subclavian vein, and the axillary,
posterior tibial and dorsalis pedis arteries. Appropriately select between different
types and sizes of catheters according to patient size, indication and site of
insertion. Execute supportive management of patients with complex congenital
heart disease both pre- and post-operatively taking into account cardiopulmonary
interactions and factors that influence cardiac function.
•
Interpret bedside EEG monitoring for the presence of seizure activity and burstsuppression. Recognize cerebral edema and hypoxic ischemic injury on
neuroimaging and differentiate epidural, subdural and intraparenchymal and
intraventricular hemorrhages. Perform a brain death examination and obtain
confirmatory testing according to guidelines. Perform deep procedural sedation
and anticipate and manage adverse events.
•
Choose between different modalities of renal replacement therapy and manage
patients on CVVH or hemodialysis.
•
Assess a patient’s nutritional status and caloric needs, choose between
nutritional strategies and anticipate possible complications.
•
Select appropriate tests to work-up a patient with suspected immunodeficiency.
Apply the appropriate diagnostic and management strategies for conditions in
pediatric intensive care patients including but not limited to congenital and
acquired abnormalities of the upper airway, chemical pneumonitis, pulmonary
hemorrhage, restrictive lung disease, pulmonary embolism, diaphragmatic
dysfunction, chylothorax, cystic fibrosis, myocarditis, endocarditis, pericarditis,
myocardial ischemia and infarction, Tamponade, neuromuscular diseases,
rhabdomyolysis, Kawasaki syndrome, rheumatic fever, toxic shock syndrome,
peritonitis, hemophagocytic syndrome, SLE, vasculitis, rheumatoid arthritis,
dermatomyositis, AIDS, opportunistic infections in immunocompromised hosts,
orbital cellulitis, necrotizing fasciitis, lemierre syndrome, nephritic syndrome,
HUS, ATN, renal vein thrombosis, adrenal insufficiency, Cushing disease,
pheochromocytoma, thyrotoxicosis, inborn errors of metabolism, gastric ulcer
disease, inflammatory bowel disease, pancreatitis, cholecystitis, necrotizing
enterocolitis, cerebral vasculitis, diabetes insipidus, cerebral salt wasting, burns,
near-drowning, starvation, inhalation injury, environmental heat injury,
lightning/electrocution injuries.
In addition, at the end of 2nd year Pediatric Intensive Care rotations at BCH-SF
fellows are expected to be able to:
•
•
Recognize the symptoms of stroke and apply the appropriate management
strategies.
•
Triage patients with respiratory failure that benefit from VV-ECMO and work with
the multidisciplinary team to manage a patient on VV-ECMO
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Implement rapid deployment VA-ECMO after cannulation by the surgeons and
manage patients on VA-ECMO.
At the end of 2nd year Pediatric Intensive Care rotations at BCH-O fellows are
expected to be able to:
•
•
Evaluate patients with specific injuries, including neck injury, facial fractures,
blunt abdominal trauma and penetrating injuries, anticipate complications and
implement appropriate management.
Recognize acute complications of sickle cell disease and apply the appropriate
management strategies.
3. Interpersonal and Communication Skills: At the end of 2nd year Pediatric Intensive
Care rotations at both BCH-SF and BCH-O, fellows are expected to be able to:
•
•
Demonstrate effective communication skills, including communication with
patients and families regarding dying and end-of-life decisions.
•
Effectively teach residents, medical students and nursing staff both in an informal
(bedside teaching) and formal setting (case conferences, lectures, etc).
•
Effectively teach procedural skills to residents and medical students.
•
Give effective feedback to residents, medical students and nurses.
Effectively supervise housestaff and medical students in the management of
patients.
4. Professionalism: At the end of 2nd year Pediatric Intensive Care rotations at both
BCH-SF and BCH-O, fellows are expected to be able to:
•
•
Comply with guidelines regarding professional behavior and ethical conduct as
outlined in institutional policies.
•
Demonstrate ethical conduct and respect towards patients, colleagues and other
individuals encountered in the work environment.
•
Complete assigned tasks adequately in a timely manner.
Demonstrate commitment to self-improvement and life-long learning, as
evidenced by completion of a semi-annual self-assessment in the form of an
annual Individual Learning Plan (ILP) for competency-based learning of clinical
skills and an Individual Development Plan (IDP) for scholarly work and career
development.
5. Practice-based Learning: At the end of 2nd year Pediatric Intensive Care rotations
at both BCH-SF and BCH-O, fellows are expected to be able to:
•
•
Organize a morbidity and mortality conference, selecting cases with issues that
are relevant from a practice-based learning perspective.
•
Apply knowledge of study designs and statistical methods in a critical review of
the literature regarding diagnostic and therapeutic interventions pertinent to
critical care, and translate findings obtained from review towards patient care.
Perform a self-assessment, identify areas requiring improvement and formulate a
plan to accomplish learning goals. To facilitate this, fellows complete a
competency-based Individual Learning Plan (ILP) using the UCSF ePortfolio
system, which they discuss with their faculty advisor and the program director.
6. Systems-based Learning: At the end of 2nd year Pediatric Intensive Care rotations
at both BCH-SF and BCH-O, fellows are expected to be able to:
•
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•
Demonstrate awareness of the influence of cultural and religious factors on
decisions regarding end-of-life and dying in discussions with patients and
families.
•
Identify factors that affect quality of care and patient safety and design measures
to influence these. Fellows are expected to have identified a quality improvement
project during their second year of training which can be completed either during
their 2nd or 3rd year of training. Fellows summarize the project in a written report
that contains a section reflecting on the learning experience.
• Understand principles of triage and resource allocation.
YEAR 3
Year 3 objectives build on year 1 and 2 objectives, but emphasis is on solidifying
knowledge base with an emphasis on finding and understanding the scientific evidence,
becoming proficient in the supervisory role and on gaining independence.
1. Medical Knowledge. At the end of 3rd year Pediatric Intensive Care rotations at both
BCH-SF and BCH-O, fellows are expected to be able to:
Discuss the evidence from the medical literature for diagnostic and therapeutic
strategies commonly applied in pediatric critical care, including, amongst others:
use of steroids in ARDS, use of steroids in sepsis, goal-directed therapy for
sepsis, transfusion thresholds in critically ill patients, glucose control, nutritional
strategies, lung-protective ventilation strategies, diagnosis and prevention of
VAP, diagnosis and prevention of catheter-related infections, liver replacement
therapies, osmotherapy for traumatic brain injury, hypothermia in prevention of
secondary brain injury, optimal vasoactive medications for various forms of
shock, fluid management strategies including use of renal replacement therapy,
optimal medications for sedation and pain control, ventilator weaning strategies.
Fellows are expected to take the Pediatric Critical Care Medicine in-training exam
from the American Board of Pediatrics in the spring of their third year, and are
expected to score at or above the national average (around 75%).
2. Patient Care: At the end of 3rd year Pediatric Intensive Care rotations at both BCHSF and BCH-O, fellows are expected to be able to:
•
•
Formulate and implement management plans for complex patients, taking into
account evidence-based literature if available, and including both short and longterm plans and stating goals of care.
•
Manage multiple patients simultaneously and prioritize tasks.
• Perform a leadership role in pediatric resuscitation.
3. Interpersonal and Communication Skills: At the end of 3rd year Pediatric Intensive
Care rotations at both BCH-SF and BCH-O, fellows are expected to be able to:
•
Supervise a team of housestaff, medical students, nursing staff and ancillary
staff.
•
Coordinate care of patients with physicians from different subspecialties and
health care providers from different disciplines.
Design and implement a basic curriculum to teach core PICU topics to medical
students, residents and nursing staff.
4. Professionalism: At the end of 3rd year Pediatric Intensive Care rotations at both
BCH-SF and BCH-O, fellows are expected to be able to:
•
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•
Comply with guidelines regarding professional behavior and ethical conduct as
outlined in institutional policies.
•
Demonstrate ethical conduct and respect towards patients, colleagues and other
individuals encountered in the work environment.
•
Complete assigned tasks adequately in a timely manner.
• Demonstrate commitment to self-improvement and life-long learning.
5. Practice-based Learning: At the end of 3rd year Pediatric Intensive Care rotations at
both BCH-SF and BCH-O, fellows are expected to be able to:
•
Identify issues amendable for improvement of patient care on a daily and
ongoing basis and implement changes as needed.
•
Stay up-to-date with current medical literature and apply changes to patient care
as indicated.
•
Publish a critical review of a published paper relevant to pediatric critical care in
the PedsCCM on-line peer-reviewed journal club.
Formulate a plan for life-long learning, including plans to attend courses,
workshops and other CME activities after completion of fellowship.
6. Systems-based Learning: At the end of 3rd year Pediatric Intensive Care rotations
at both BCH-SF and BCH-O, fellows are expected to be able to:
•
D.
•
Triage patients and prioritize for resource allocation.
•
Diagram the organization and staffing of intensive care units and list different
models.
•
Demonstrate awareness of financial aspects of critical care, including costs of
different types of care and reimbursement patterns.
Adult ICU Rotation
Fellows complete a 4-week rotation in the Adult ICU at UCSF Medical Center during
their 2nd or 3rd year of training. The goal of this rotation is to acquire insight into
similarities and differences between pediatric and adult intensive care, and learn from
the adult ICU management approach. Fellows have an observing role during this
rotation and do not have any responsibilities towards patient care, nor do they participate
in the call schedule. Fellows are expected to attend all daily and weekly conferences
organized for Adult ICU housestaff during their rotation, in addition to morning rounds.
Fellows are encouraged to participate in patient care together with the Adult ICU
housestaff and to seize opportunities to watch and perform ICU procedures in adult
patients, under supervision by the adult ICU attendings.
Specific objectives of the Adult ICU rotation are:
1. Recognize common presentations of common adult acute-life threatening
illnesses, including myocardial infarction, stroke, pulmonary embolism and septic
shock.
2. Describe the major evidence-based management principles for critically ill adult
patients, in particular in regards to management of septic shock, ARDS, cardiac
arrest, pulmonary embolism and stroke.
3. Identify pros and cons of different approaches to management of critically ill
patients in regards to the role of consultants versus primary team (“open” vs.
“closed” unit).
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E.
Pre-attending rotation:
Fellows complete 2 one-week pre-attending rotations in their 3rd year of fellowship, one
week at each institution, during which they “pretend” to be the attending. At BCH-SF,
pre-attending takes place in the PICU, whereas at BCH-O the fellow supervises one of
the 2 teams at the discretion of the site director and the attendings on clinical service.
Scheduling of pre-attending weeks will be done together with the site director and will
take into account a “best match” between pre-attending and attending to ensure
maximum benefit for the fellow.
Specific objectives for the pre-attending rotations are:
1. Supervise the entire health care team in the care of multiple patients ensuring
adequate prioritization and sufficient attention to detail.
2. Establish both short and long term care plans for patients, in collaboration with
consultants and other health care providers.
3. Effectively communicate with patients and their families.
4. Document patient care activities and plans in an accurate and comprehensive
fashion.
F.
Elective Rotations
Fellows are encouraged to participate in two 2-week electives during their 3rd (or last)
year of training. Possibilities for elective rotations will be investigated on a yearly basis
based on fellows’ specific interests, and goals and objectives will be established based
on mutual expectations.
Examples are:
Cardiology Elective
1. Interpret pressure monitoring and measurement of saturations in the
catheterization lab.
2. Interpret echocardiogram findings as applicable to pediatric intensive care
patients (assess function, recognize PDA, diagnose effusions).
3. Interpret an EKG as applicable to pediatric intensive care patients.
4. Be able to set an external pacemaker, understand the indications for different
pacemaker settings and be able to troubleshoot a pacemaker.
Anesthesiology Elective
1. Acquire additional experience with central line placement, in particular subclavian
catheters in small children.
2. Understand basic principles of difficult airway management, in particular fiber
optic laryngocopy.
3. Perform deep procedural sedation, especially with agents less frequently used in
the PICU.
4. Get exposure to cardiac anesthesia and management of patients on
cardiopulmonary bypass.
Vascular Access Elective
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1. Use non-invasive ultrasound imaging to locate peripheral sites for venous
access.
2. Successfully place peripherally inserted central catheters (PICC) in pediatric
patients of various ages and sizes.
3. Anticipate and address potential problems encountered during PICC insertion,
including difficulties with identifying insertion sites, PICC malfunction
(breaks/cracks) and malposition of catheters.
IV. RESEARCH/SCHOLARLY ACTIVITIES
In addition to training outstanding clinicians, the fellowship program aims to train
physician-scientists in clinical, translational and basic research as well as physicianeducators. All fellows, including fellows who are not planning on an academic career, are
expected to gain solid understanding regarding the conduct of research. Fellows are
expected to complete a scholarly project as defined by the American Board of Pediatrics
in the general eligibility criteria for subspecialty board certification
(https://www.abp.org/ABPWebSite/). As outlined above, a wide range of opportunities
for research/scholarly work are available at UCSF, CHORI and affiliated institutions.
Prior to the start of fellowship training, fellows are assigned an advisor who assists in the
process of defining a scholarly project and finding an appropriate mentor for the project.
A Scholarship Oversight Committee (SOC) provides additional mentoring, evaluation
and feedback based on annual review of an Individual Development Plan. The SOC also
determines whether the scholarly product satisfies board eligibility criteria at the end of
fellowship. For further information on the SOC process, please go to
http://www.pediatrics.medschool.ucsf.edu/fellowscollege/overview/oversite.aspx
Fellows have at least 70 weeks to dedicate to research/scholarly activities, which are
spread out over the 3 training years.
Specific objectives for research electives include:
1. Understand the basic principles of conduct of research, including research
design and analysis of results.
2. Critically analyze published data and apply to patient care as appropriate.
3. Design and conduct research or equivalent scholarly project under guidance of
an appropriate mentor and complete a publication or report that meets SOC
criteria for board eligibility.
4. Gain skills and experience in scientific writing and grant applications.
V. DIDACTIC CONFERENCES.
To support learning goals outlined in the various sections above, the program organizes
formal didactic sessions on a weekly basis, during which a wide variety of topics are
addressed. The content outline for the pediatric critical care subspecialty board
examination (available at https://www.abp.org/ABPWebSite/) serves as a guide in
selection of relevant topics. Didactics, which are delivered in the form of lectures,
interactive (case) discussions, demonstrations and workshops, take place on a weekly
basis and are delivered by experts in the field. All sessions are evaluated by participating
fellows and faculty, and evaluation results are used to make improvements in the
curriculum. Journal club (prepared and presented by fellows under guidance of a faculty
member) and morbidity and mortality conferences are part of the weekly conference
schedule. In addition to weekly fellows’ conference, a variety of other educational
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sessions are available to our fellows. See the educational conference attendance policy
for more details.
VI. MENTORSHIP, EVALUATION AND FEEDBACK
The fellowship program is committed to provide adequate mentorship, and monitors the
progress of fellows closely. In addition to a research mentor, every fellow has an
assigned advisor who is a member of the Pediatric Critical Care faculty at either BCH-SF
and BCH-O. A process for evaluation and feedback is in place, as outlined in the PICU
Fellowship Evaluation Policy. The program director meets with each fellow individually
on a semi-annual basis and reviews all evaluations, in-training exam results, Individual
Learning Plans, Individual Development Plans and SOC reports as well as overall career
plans with the fellows. The fellowship program documents progressive improvement as
well as any interventions undertaken to address obstacles encountered in the pursuit of
the program goals and objectives as outlined here. In addition to the fellows, the critical
care faculty and the program as a whole are evaluated on a regular basis, with
documentation of encountered problems and proposed interventions. For further
information see the PICU Fellowship Evaluation Policy.
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