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Surgical Critical Care Residency Handbook 2007-2008 Department of Surgical Education Orlando Regional Medical Center 2 "THE TEN COMMANDMENTS" "Honesty first, last, and always." "The smart man admits when he is wrong" "Do it now." If the unit becomes busy, there may not be time later. Sleep always comes last. "Do it right the first time." The patient will likely not give you a second chance. "If you don't know, ask." There is no such thing as a "stupid question”. You are here to learn. The majority of your critical care education will be through one-on-one discussions with the ICU faculty. "Communicate before, not after." You can be faulted only if you don't call. "Do it yourself." Trust no one and assume nothing. Always see test results or x-rays yourself. Delegate with discretion. "Round frequently." Anticipate disasters by knowing your patients and identifying untoward physiologic events before they happen. "Write it down." Keep a list of tasks and constantly revise and update it throughout the day. "Read everyday." Read about the diagnosis and management of each of your patients. "Remember the patient and their family." Keep in mind that it is a privilege to care for each patient AND their family. Communication is essential. 1 This Fellow’s Manual has been continually revised over the past three decades by countless fellows from the University of Miami, Vanderbilt University, and Orlando Regional Medical Center. During your fellowship, you will want to refer to this manual often, mark it up liberally, and take note of changes that you believe are necessary to improve the manual for future fellows. TABLE OF CONTENTS I. Introduction – Mission Statement 2 II. Definitions 3 III. Program Philosophy and Overview 4 IV. Goals and Objectives 5 V. Resident Responsibilities 14 VI. Joining the Surgical Critical Care Team: A Day in the Life 16 VII. Resident Evaluation and the Core Competencies 23 VIII. Didactic Teaching Conferences 34 IX. Supervision & Decision Making Authority: Relation to Faculty, Residents, Medical Students 39 X. Scholarly Environment 41 XI. Quality Assurance 41 XII. Resident Duty Hours and Working Environment 41 XIII. Grievance Procedure 42 XIV. Monitoring Resident Stress and Fatigue 42 2 I. INTRODUCTION - MISSION STATEMENT The Surgical Critical Care residency program at Orlando Regional Medical Center (ORMC) is an American Council for Graduate Medical Education (ACGME) accredited 12-month residency program that is intended to prepare graduates for a career in either academic or private practice surgical critical care. Following completion of the program, the surgeon will be eligible to sit for the American Board of Surgery examination certifying "Added Qualifications in Surgical Critical Care". The educational philosophy of the program is to provide a comprehensive matrix upon which to: 1) Develop a scientifically sound, evidence-based medicine approach to cost-effective management of the critically ill patient using the latest technologies and innovations, 2) Facilitate interpersonal skills in physician-patient and physician-family communication especially with regards to end-of-life and other ethical issues, 3) Promote effective and productive teaching abilities, 4) Encourage and develop intensive care unit leadership and hospital administrative skills, and 5) Foster an interest in and aptitude for scientific research, statistics, and critical thinking. Although the term "SCC fellow" is commonly used in day-to-day practice, it must be remembered that for the purposes of the ACGME and the Residency Review Committee (RRC), the SCC program is actually a postgraduate "residency" and the terms "fellow” and “resident" may be used interchangeably. Each resident is trained according to the guidelines set forth by the Society of Critical Care Medicine to ensure a comprehensive exposure to all aspects of critical care practice (Guidelines for Advanced Training for Physicians in Critical Care, Crit Care Med 1997; 25:16011607). Our ultimate goal is to fully prepare our graduates to be not only superb clinicians, but also excellent academic teachers and thought leaders in their future institutions. The Surgical Critical Care (SCC) Residency is based at ORMC, the 517-bed flagship hospital of a six-hospital not-for-profit comprehensive healthcare system ("Orlando Regional Healthcare") that serves the needs of patients throughout Central Florida as well as millions of tourists each year. ORMC has served as the regional Level I trauma center and burn center for over 20 years and currently provides trauma care for 22 different counties. With the Arnold Palmer Children's Hospital, Winnie Palmer Hospital for Women and Babies, and Charles Lewis / MD Anderson Cancer Center, ORMC serves as a state-of-the-art tertiary referral center providing Central Florida with a full range of medical services. This "Fellow's Manual" is intended to provide you with a comprehensive discussion of the SCC program as well as a brief introduction to the patient care protocols and day-to-day workings of the intensive care units (ICU) at ORMC. This manual is being constantly revised and updated as protocols, therapies, and technologies change. As your SCC residency concludes, your suggestions and additions to the Fellow's Manual will be incorporated. Please read this manual closely prior to beginning your time at ORMC and review it frequently as your residency progresses, taking the time to note changes that you believe are necessary to further improve the manual for future fellows. 3 II. DEFINITIONS For the purpose of this manual, the following definitions and abbreviations apply: Surgical Critical Care (SCC) Service – the clinical patient care team providing 24 hour per day service in the ICU and operating within the SCC residency program. This team generally consists of a SCC attending surgeon, two SCC residents, a general surgery resident from the Department of Surgical Education, and a resident from the Department of Emergency Medicine. During several months of the year, visiting students from various medical schools may also rotate on the service. Surgical Critical Care (SCC) Program – the educational program within the Department of Surgical Education. The program consists of the program director, five full-time surgical faculty, the research manager, the residency coordinator, and other support staff. Surgical Critical Care (SCC) Resident – the resident engaged in advanced training for 12 months who intends to become eligible for examination for the “Certificate of Added Qualifications in Surgical Critical Care” from the American Board of Surgery. Rotating residents – all residents from the primary general surgery program or other programs who spend one to two months on the SCC Service. Chief Resident – the general surgery resident in his/her final year of training. Admitting physician – the medical staff physician who admits the patient to the hospital. Primary surgical attending – the primary surgeon responsible for admitting and/or operating upon a patient admitted to the ICU and consulting the SCC service for assistance with patient management. Critical care attending – the consulting surgeon with added qualifications in Surgical Critical Care who is responsible for the daily operation of the SCC service. Consulting physician – the physician requested by the attending physician or ICU managing physician to recommend treatment or diagnostic alternatives while the patient is in the ICU. Intensivist – a critical care physician who is board certified within his/her specialty in the field of critical care. ICU Managing physician – the physician responsible for management decisions while the patient is in the ICU. The managing physician is the attending physician unless there is a written order in the patient’s medical record designating a managing physician or an order consulting a critical care service for comprehensive patient management. Intensive Care Unit (ICU) – the critical care units in which the SCC service cares for patients. This includes the Trauma ICU (TICU), the Neurosciences ICU (NSICU), Surgical ICU (SICU), the Medical ICU (MICU), and, at times, the Post-Anesthesia Recovery Unit (PACU), the Trauma Step-Down Unit, the Intermediate Critical Care Unit (ICCU), and the Emergency Department (ED). Orlando Regional Healthcare (ORH) – the not-for-profit corporation owning Orlando Regional Medical Center (ORMC), Arnold Palmer Hospital for Children (APH), Winnie Palmer Hospital for Women and Babies (WPH), and other hospitals and care centers which are not part of the educational program. All references in this document are intended to be gender non-specific. 4 III. PROGRAM PHILOSOPHY AND OVERVIEW While the care of the most severely ill or injured patient requires the cooperation of multiple specialties and disciplines, surgeons with advanced knowledge and training are the vital central element. The goal of this residency is to provide an intensive one-year experience in SCC which will train surgeons to assume a leadership role in the care of critically ill patients and be prepared to assume an administrative role in managing a busy surgical or trauma ICU. The specific goals in this regard are to obtain experience in the multidisciplinary care of sick surgical patients and to have exposure to all elements of the domain of critical care knowledge and related procedures. The educational philosophy is to teach not only the individual basics of care of sick surgical patients, but also the integration of care involving multiple practitioners within the interdisciplinary process. Philosophically, the ORMC ICUs are “open” units in which any medical staff physician may admit patients for critical care management. By hospital policy, however, a managing intensivist must be consulted for each patient admitted. Each admitting physician and primary surgeon will determine the degree to which they wish to be involved in the care of their patient while in the ICU. Effective communication and interaction between intensivist and primary physician is a skill that each SCC resident must develop and master if they are to be successful in their future career. The initial year of the residency focuses on gaining advanced skills and knowledge in clinical aspects of patient care and the basics of surgical intensive care administration. Candidates desiring to pursue a career in trauma surgery may participate in an optional second year of training which will offer the opportunity to focus on the development of skills in trauma surgery and trauma administration while continuing to participate in critical care management. The SCC resident will be directly involved in all phases of the care of critically ill surgical patients. The focus of the clinical experience will center around the combined ORMC ICUs. These units admit a variety of patients from different surgical subspecialties including general, trauma, orthopedic, vascular, neurosurgical, urologic, and gynecologic surgery. The SCC residency includes 10 to 12 months in the ICUs at ORMC. The resident may elect to take up to 2 months of elective rotations including the Pediatric ICU at the Arnold Palmer Hospital Children, the Nutritional Support Service, the Burn Service, or dedicated time in clinical research in critical care. Plans to pursue such rotations must be discussed with the program director at the beginning of the year. The resident will receive 3 weeks of vacation during his/her residency. Didactic teaching is accomplished through a number of specific conferences. These include: 1) daily morning bedside rounds; 2) daily afternoon Family Rounds; 3) daily evening checkout telephone rounds; 4) Fellow’s Conference (Tuesday noon); 5) Critical Care Teaching Conference (Wednesday noon); 6) Surgical Grand Rounds (Friday morning); and 7) Surgical Morbidity and Mortality Conference (Friday morning). Residents will be expected to attend and actively participate in all department conferences. Specifically, they will present complex cases at Surgical Morbidity and Mortality Conference and be prepared to contribute to the discussion of cases presented by other surgeons in which they were involved. The SCC residents are responsible for medical student and junior resident education through daily bedside rounds and direct supervision of care. Each SCC resident is responsible for at least one Surgical Grand Rounds presentation each year. The SCC residents will participate as instructors in the Advanced Trauma Life Support (ATLS) and Fundamental Critical Care Support (FCCS) courses taught at ORMC. 5 IV: GOALS AND OBJECTIVES The specific educational goals of the SCC postgraduate residency program are to prepare the resident to apply, evaluate, and teach the fundamentals of surgical critical care and to: 1) Become proficient in critical care knowledge in the following areas: a) Cardiothoracic-respiratory resuscitation b) Physiology, pathophysiology, diagnosis, and therapy of disorders of the cardiovascular, respiratory, gastrointestinal, genitourinary, neurologic, endocrine, musculoskeletal, and immune systems as well as of infectious diseases c) Metabolic, nutritional, and endocrine effects of critical illness d) Hematologic and coagulation disorders e) Critical obstetric and gynecologic disorders f) Trauma, thermal, electrical, radiation, inhalation and immersion injuries g) Monitoring and medical instrumentation h) Pharmacokinetics and dynamics of drug metabolism and excretion in critical illness i) Ethical and legal aspects of surgical critical care j) Principles and techniques of administration and management k) Biostatistics and experimental design 2) Become proficient in critical care skills in the following areas: a) Respiratory: airway management including endoscopy and management of respiratory systems b) Circulatory: invasive and non-invasive monitoring techniques, including pulmonary artery catheterization, pulse contour waveform analysis, mixed venous oximetry, application of transthoracic and transvenous pacemakers, and electrocardiography c) Neurological: the performance of complete neurological examinations; use of intracranial pressure monitoring techniques; application of hypothermia in the management of cerebral trauma; performance of apnea testing for brain death determination d) Renal: the evaluation of renal function, peritoneal dialysis and hemofiltration, knowledge of the indications of complications of hemodialysis e) Gastrointestinal: utilization of gastrointestinal intubation and endoscopic techniques in the management of the critically ill patient; management of stomas, fistulas, and percutaneous catheter devices f) Hematologic: application of autotransfusion, assessment of coagulation status, appropriate use of component therapy g) Infectious Disease: classification of infections and application of isolation techniques, pharmacokinetics, drug interactions, and management of antibiotic therapy during organ failure, nosocomial infections h) Nutritional: application of parenteral and enteral nutrition, monitoring and assessing metabolism and nutrition i) Monitoring/bioengineering: use and calibration of transducers, amplifiers, and recorders j) Miscellaneous: use of special beds for specific injuries; employment of traction and fixation devices The expected time course for achievement of the education goals outlined above is: Orientation to patient care and communication protocols Development of initial critical care knowledgebase and skill set Refinement of critical care knowledgebase and skill set Refinement of teaching skills Development of administrative skills July-September July-January January-March April-June January-June 6 Educational resources to achieve these goals are available through the various department teaching conferences (including the “Fellow’s Conferences” and ”Critical Care Teaching Conferences” as well as the department’s dedicated educational website (www.surgicalcriticalcare.net). Each SCC resident, under the guidance of the SCC faculty, is encouraged to review the medical literature and choose the textbook or combination of textbooks that best suits their educational needs and preferences to augment the above resources. Details of Goals and Objectives - Core Clinical Knowledge Base Cardiothoracic-respiratory resuscitation Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Research Conference, Fundamental Critical Care Support course.. Summary: Residents are exposed to cardiothoracic-respiratory resuscitation on a daily basis through both bedside teaching and didactic lectures. A primary area of research within the department is the testing of new hemodynamic monitoring technologies which will further enhance their understanding. In addition, they will maintain ACLS and BLS skills, and receive training in Fundamental Critical Care Support (FCCS). Physiology, pathophysiology, diagnosis, and therapy of disorders of the cardiovascular, respiratory, gastrointestinal, genitourinary, neurologic, endocrine, musculoskeletal, and immune systems as well as of infectious diseases Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Research Conference, Fundamental Critical Care Support course. Summary: All topics are covered when encountered in the ICU during direct patient care and discussed extensively on daily teaching rounds. The ICU faculty are experienced and well qualified in these areas of knowledge; additional specialty support is obtained through interaction with consultants and attendings from other surgical services, including infectious disease, orthopedics, and neurosurgery. Metabolic, nutritional, and endocrine effects of critical illness Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Research Conference. Summary: This aspect of critical care will be acquired through daily interaction with critical care faculty, supplementary reading, and formal lecture material. The metabolic and nutritional care of surgical patients is both a fundamental component of treatment at ORMC as well as a focus of ongoing research. The discussion of metabolism, appropriate feeding of patients, and the use of enteral feeding to prevent complications is part of routine daily care. The presence of both a doctor of pharmacy and a registered dietician on daily ICU rounds further enhances the teaching in these areas. Hematologic and coagulation disorders Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds. Summary: The majority of hematologic and coagulation disorders will be covered by the critical care faculty with participation from hematology consulting attendings in unusual cases. The format includes daily clinical interactions over patients who have developed specific coagulation disorders as well as didactic material and evidence-based medicine guidelines. Component blood therapy is discussed in a dedicated lecture on fluid resuscitation. 7 Critical obstetric and gynecologic disorders Exposure: Daily ICU rounds; Critical Care Teaching Conference; Critical Care Grand Rounds, Fundamental Critical Care Support course. Summary: The SCC resident will be involved in the care of critically ill patients from the OB/GYN service. These patients are managed primarily by the SCC service with the OB/GYN attending and resident staff providing specialty-specific input as needed. Clinical material will be supplemented with reading and lecture topics. Trauma, thermal, electrical, radiation, inhalation and immersion injuries. Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds; Trauma Grand Rounds, Fundamental Critical Care Support course Summary: The SCC residents participate extensively in the management of patients admitted to ORMC’s Level I trauma center. All of the SCC faculty have a strong dedication to the care of the trauma patient. Trauma care represents a major focus of attention within the department’s research activities. The burn unit is also quite busy serving a large region of Florida. An elective rotation on the ORMC Burn Service is popular among the SCC residents due to both the operative experience and the professional development / employment preparation it provides. Monitoring and medical instrumentation. Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds. Summary: There is a vast clinical experience among the faculty in the use of clinical monitoring devices including all components of hemodynamic, intracranial pressure, intra-abdominal pressure, and respiratory monitoring. The majority of ICU patients are monitored invasively and provide a basis for this experience. Critical pediatric surgical conditions. Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Fundamental Critical Care Support course. Summary: The SCC resident will be involved in the care of pediatric patients who present to the ORMC Emergency Department and who require critical care management, but are too ill to be transferred to the ICU at APH. Such care will be under the direction of the SCC faculty with specialty-specific input from the pediatric surgeons as needed. Pharmacokinetics and dynamics of drug metabolism and excretion in critical illness Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds. Summary: The SCC Service has an active clinical pharmacy presence on daily ICU rounds. Residents will interact on a daily basis with a critical care-trained doctor of pharmacy as well as in lecture settings at various points during the year. Pharmacokinetics are measured and residents are exposed to the techniques and mathematics of drug monitoring and drug calculations. In addition, active discussion of drug metabolism and excretion is discussed on daily rounds as the pharmacist is part of the multidisciplinary daily rounding team. 8 Ethical and legal aspects of surgical critical care Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Professional Development Conference, Fundamental Critical Care Support course. Summary: Attendings on the SCC service are deeply involved in both the ethical and legal issues surrounding the care of critically ill patients. One faculty member currently serves on the Hospital Ethics Committee and interactions with faculty will be supplemented by reading material and teaching conferences. The residents are expected to participate in all case referrals to the Ethics Committee and participate in this important process. Principles and techniques of administration and management Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Professional Development Conference. Summary: Active effort is made to involve the residents in the daily administration of the ICU with an eye toward preparing them for a leadership role during their future career. The residents will work closely with the nursing and various ICU support services and with the program director (the medical director of the ICU) to learn the principles of ICU and hospital administration. The residents participate actively in the ORMC and ORH Critical Care Committee meetings which function to fulfill administrative and quality assurance issues. Residents also participate in the evaluation of outcomes and the process of continuing quality improvement within the ICU and are actively involved in the development of evidence-based medicine guidelines and guideline-derived outcome measures. The residents are actively involved in the ongoing structure and content of the educational program as well, and are actively involved in changing this to suit their individual needs. Biostatistics and experimental design Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Professional Development Conference, Research Conference. Summary: SCC residents are strongly encouraged to become involved in both ongoing clinical research projects as well as research projects of their own design. Core lectures in biostatistics, study design, data interpretation, database analysis, and scientific publication are provided during the Research Conferences. Residents are required to complete the National Institutes of Health online training program for new investigators. Details of Goals and Objectives - Core Basic Science Knowledge Base A thorough understanding of the relevant physiology and pathophysiology of each disease process encountered in the ICU setting is essential in order to provide effective critical care management. As a result, we strive to integrate a thorough discussion of the pertinent basic science issues within each of the clinical didactic conferences as well as during daily bedside teaching rounds. This emphasizes the importance of pathophysiology in daily bedside patient care and promotes a comprehensive approach to evidence-based patient management. At the start of the academic year, the SCC residents attend an intensive introductory lecture series that covers the essential basic science issues pertinent to cardiopulmonary support and shock resuscitation, the foundation of critical care management. As the year progresses, a thorough range of critical care topics are covered, each lecture incorporating both the relevant basic science and clinical care issues. The 12-month long didactic curriculum described below ensures that each SCC resident receives a thorough basic science education. 9 Cardiac Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Research Conference, Fundamental Critical Care Support course. Content: Measured and calculated hemodynamic variables, measured and calculated oxygen transport variables, intravascular pressures, preload assessment and augmentation, contractility, afterload support and reduction, oxygen transport, vasoactive medications and their pharmacokinetics/receptors, cardiac rhythm and conduction disturbances, myocardial ischemia, valvular abnormalities, sepsis-induced myocardial depression and regional malperfusion, various shock states (hypovolemic, hemorrhagic, obstructive, distributive, endocrine). Recommended reading: www.surgicalcriticalcare.net and Irwin and Rippe’s Textbook of Critical Care Pulmonary Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Research Conference, Fundamental Critical Care Support course, Ventilator workshop. Content: Pulmonary volumes (tidal volume, residual volume, inspiratory volume, expiratory volume), lung capacities (total lung capacity, functional residual capacity, inspiratory capacity, expiratory capacity), dead space ventilation, intrapulmonary shunt, alveolar collapse and recruitment, surfactant deficiencies, pulmonary edema, pressure-volume relationships, oxygen delivery and consumption, bronchopulmonary blood flow, acute respiratory failure / acute lung injury, pulmonary mechanics and gas exchange, barotrauma / volutrauma, respiratory monitoring (airway pressure, intrathoracic pressure, tidal volume, pulse oximetry, dead space-tidal volume ratio, compliance, resistance, capnography), metabolic monitoring (oxygen consumption, carbon dioxide production, respiratory quotient) Recommended reading: www.surgicalcriticalcare.net , Irwin and Rippe’s Textbook of Critical Care, J.B. West’s “Pulmonary Physiology” and “Pulmonary Pathophysiology” Gastrointestinal Exposure: Daily ICU rounds (in collaboration with the Nutritional Support Team); Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Research Conference. Content: Gastric and intestinal motility/absorption/malabsorption, stress ulceration and prophylaxis, mucosal integrity and bacterial translocation, intramucosal pH, acute/chronic pancreatitis, nutritional support and assessment, enterocutaneous fistula pathophysiology and management, intra-abdominal hypertension, regional malperfusion, thrombotic/embolic disease. Recommended reading: www.surgicalcriticalcare.net and Irwin and Rippe’s Textbook of Critical Care. Renal Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Research Conference. Content: Fluid and electrolyte balance, prerenal, intrarenal, postrenal acute failure; acid-base disorders, creatinine clearance, electrolyte abnormalities, pharmacokinetics and dynamics of drug metabolism and excretion in critical illness, acute tubular necrosis, renal tubular acidosis, chronic renal insufficiency, medication-induced renal insufficiency, interpretation of urinary electrolytes, rhabdomyolysis. 10 Recommended reading: www.surgicalcriticalcare.net and Irwin and Rippe’s Textbook of Critical Care. Hepatic Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Research Conference. Content: Cirrhosis, cholestasis, hepatitis, albumin, acute hepatobiliary dysfunction, pharmacokinetics and dynamics of drug metabolism and excretion in critical illness. Recommended reading: Irwin and Rippe’s Textbook of Critical Care. Neurologic Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Research Conference, Fundamental Critical Care Support course. Content: Cerebral blood flow/oxygenation/perfusion, encephalopathy and mental status changes (metabolic/drug-induced/traumatic), cerebral herniation, seizure activity, intracranial pressure, cerebral blood flow, cerebral metabolic rate, regional oxygenation, jugular venous bulb oximetry, cerebral cortex oximetry. Recommended reading: www.surgicalcriticalcare.net , Irwin and Rippe’s Textbook of Critical Care, Brain Trauma Foundation Guidelines for Brain Injury Management Endocrine Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Research Conference, Fundamental Critical Care Support course. Content: Hypothalamic-pituitary-adrenal axis, cortisol production and deficiency, ACTH, insulin production and resistance, hypoglycemia, hyperglycemia, pancreatitis (acute, chronic, alcohol/idiopathic/drug-induced), disorders of thyroid function (thyroid storm, myxedema coma, sick euthyroid syndrome), adrenal crisis / insufficiency, diabetes insipidus, diabetes mellitus, disorders of calcium, magnesium, and phosphate balance. Recommended reading: www.surgicalcriticalcare.net and Irwin and Rippe’s Textbook of Critical Care. Immune Response Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Research Conference. Content: Inflammatory cascade, cytokine response (interleukins, leukotrienes, monocyte response, macrophage response), immunomodulation, physiology of drotrecogin alfa activated therapy. Recommended reading: www.surgicalcriticalcare.net and Irwin and Rippe’s Textbook of Critical Care, www.survivingsepsis.org Infectious Disease Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Research Conference. Content: Antimicrobial resistance and sensitivity, bacterial translocation, pharmacokinetics pharmacologic principles and drug administration, metabolism of antimicrobial agents, bacterial/fungal/parasitic disease, systemic inflammatory response syndrome (SIRS),acquired immune deficiency syndrome (AIDS), complications of antibiotic overuse. 11 Recommended reading: www.surgicalcriticalcare.net and Irwin and Rippe’s Textbook of Critical Care, www.survivingsepsis.org Hematologic Exposure: Daily ICU rounds; Critical Care Teaching Conference; Evidence-Based Medicine Conference, Critical Care Grand Rounds, Research Conference. Content: Normal and abnormal coagulation, various coagulopathies, blood components, thrombocytopenia / thrombocytosis, disseminated intravascular coagulation (DIC), thromboembolic disease, pharmacologic manipulation of bone marrow response to critical illness, pharmacologic therapies for coagulopathy. Recommended reading: www.surgicalcriticalcare.net and Irwin and Rippe’s Textbook of Critical Care. Obstetrics / gynecology Exposure: Daily ICU rounds; Critical Care Teaching Conference; Critical Care Grand Rounds, Fundamental Critical Care Support course. Content: Toxemia of pregnancy; amniotic fluid embolism, HELLP Syndrome, physiologic changes of pregnancy. Recommended reading: Irwin and Rippe’s Textbook of Critical Care Details of Goals and Objectives – Critical Care Skills Residents on the SCC service have graded levels of increasing responsibility in the performance of invasive critical care procedures. All of the residents are specifically instructed in the principles, indications, contraindications, complications, and performance of each of the common invasive procedures. There is direct faculty supervision of all invasive procedures performed. The degree of supervision varies with the individual's experience and performance. Residents on the SCC service also provide assistance and supervision for procedures performed by other residents in the ICU. Specific procedures performed by the SCC service are described below. Respiratory airway management including endoscopy and management of respiratory systems Exposure: Daily ICU rounds; Fundamental Critical Care Support course, Airway Workshop. Summary: The SCC service provides all ICU airway management for patients referred to the service. While many patients are initially intubated in the pre-hospital, Emergency Department, or operating room setting, any re-intubation or any elective / urgent airway manipulation is provided by the SCC resident under faculty supervision. The SCC resident with faculty supervision performs all bronchoscopies for diagnosis or therapy. The SCC service does all ventilator management. Specific protocols for airway management are followed and use of bronchoscopy and endoscopy to assess complex airways are practiced on a daily basis. Circulatory: invasive and non-invasive monitoring techniques, including pulmonary artery catheterization, pulse contour waveform analysis, mixed venous oximetry, application of transthoracic and transvenous pacemakers, and electrocardiography Exposure: Daily ICU rounds; Critical Care Teaching Conference, Fundamental Critical Care Support course. Summary: The SCC residents, under faculty supervision, perform all hemodynamic monitoring necessary for patients referred to the SCC service. Modalities used during the average year include arterial lines, central venous catheterization, volumetric continuous cardiac output pulmonary artery catheterization, arterial pulse contour waveform analysis, measurement of 12 mixed venous blood gases, calculation and interpretation of ECGs, treatment of acute arrhythmias, the use of transvenous pacemakers, the use of external pacemakers, and intracranial and intra-abdominal pressure monitoring. Maintenance of these devices and calculation of all hemodynamic variables are performed by the SCC service. Residents are instructed in the indications for echocardiography and the application of the information obtained, but technicians or consulting cardiologists perform the actual procedures. Cardiac assist devices are not used in the Surgical ICU's. Patients requiring such devices are transferred to the Cardiovascular Recovery Room (CVRR) as per ICU policy. Neurological: the performance of complete neurological examinations; use of intracranial pressure monitoring techniques; application of hypothermia in the management of cerebral trauma; performance of apnea testing for brain death determination Exposure: Daily ICU rounds; Critical Care Teaching Conference, Evidence-based Medicine Guidelines, Fundamental Critical Care Support course. Summary: The residents are directly involved in the care of head trauma and postoperative neurosurgical patients. All care of neurosurgical patients is shared with the neurosurgery service and neurosurgical attendings. Treatment modalities include maintenance and calibration of intracranial pressure (ICP) monitors, interpretation and treatment of ICP problems, and the management of cerebral perfusion pressure, barbiturate coma, vasospasm, and optimization of cerebral perfusion pressure. ICP monitors are placed by consulting neurosurgeons or by SCC residents under their direct supervision. Maintenance of the devices, indications, contraindications, complications, and application of information obtained from the devices is a part of daily teaching rounds and regular didactic conferences. Computer assisted continuous EEG monitoring is used in the Neurosciences ICU and the data are reviewed and discussed on a daily basis on ICU teaching rounds. Renal: the evaluation of renal function, peritoneal dialysis and hemofiltration, knowledge of the indications of complications of hemodialysis. Exposure: Daily ICU rounds; Critical Care Teaching Conference. Summary: Avoidance of acute renal failure and application of renal protection protocols is a part of daily ICU teaching rounds. This highly successful program has almost completely eliminated oliguric renal failure and the need for hemodialysis. The various renal replacement techniques including hemodialysis are discussed in didactic conferences and used on occasion in daily patient care. Management of acute renal failure and indications, contraindications, and complications of renal replacement therapies are discussed in regular didactic conferences. The SCC residents work closely with the nephrology consultants to plan the method, timing, and objective of each renal replacement intervention. Goals of each treatment are jointly reviewed to include electrolyte imbalances, acid-base disturbances, and volume status. Gastrointestinal: utilization of gastrointestinal intubation and endoscopic techniques in the management of the critically ill patient; application of enteral feeds, management of stomas, fistulas, and percutaneous catheter devices. Exposure: Daily ICU rounds; Critical Care Teaching Conference. Summary: Gastrointestinal tubes, stomas, and fistulae are a common part of general surgery and are managed jointly by the primary surgical services and the SCC residents. The SCC residents routinely perform intubation of the gastrointestinal tract for feeding, diagnosis, or therapy. The SCC residents, under the direct supervision of the SCC attending surgeon, perform upper gastrointestinal endoscopy for diagnosis and for placement of percutaneous 13 endoscopic gastrostomy (PEG). Indications, contraindications, complications and management are discussed in daily SCC teaching rounds and routinely in didactic conferences. Hematologic: application of autotransfusion, assessment of coagulation status, appropriate use of component therapy. Exposure: Daily ICU rounds; Critical Care Teaching Conference. Summary: Autotransfusion, assessment and treatment of coagulation abnormalities and transfusion of homologous blood components is a part of daily SCC patient care. Indications, contraindications, complications, and management strategies are discussed on daily teaching rounds and routinely in didactic conferences. The assessment of coagulation and use of component therapy is part of the care of virtually every patient in the ICU. Infectious Disease: classification of infections and application of isolation techniques, pharmacokinetics, drug interactions, and management of antibiotic therapy during organ failure, nosocomial infections Exposure: Daily ICU rounds; Critical Care Teaching Conference, Fundamental Critical Care Support course. Summary: Diagnosis, treatment, use of antimicrobials, and adjuvant therapies are discussed in daily teaching rounds and routinely in didactic conferences. A doctor of pharmacy level pharmacist with special interest in antimicrobials and infectious disease is a member of the SCC teaching service and contributes to daily teaching rounds and conferences. When consultation from the Infectious Disease department is requested, the SCC resident interacts directly with the consultant as part of their educational experience. Evaluation of unit microbial flora and antibiotic sensitivity and guidelines using this information for use of antibiotics are developed and used for the care of all patients. The SCC service follows standard protocols for the prevention and management of nosocomial infection. In addition, we have specific procedures and policies for containment and body substance isolation practice to which the residents are exposed. Nutritional: application of parenteral and enteral nutrition; monitoring and assessing metabolism and nutrition. Exposure: Daily ICU rounds; Critical Care Teaching Conference. Summary: Virtually all patients referred to the SCC service receive specialized nutritional support while in the ICUs. Enteral nutrition is utilized preferentially with total parenteral nutrition limited to specific indications. The SCC resident, under supervision of the faculty, directs the selection and administration of the support. Protocols are in place for routine nutritional assessment including nitrogen balance and metabolic expenditure studies. Residents on the SCC service use this information to formulate a comprehensive nutritional support plan. Representatives from the institutional Nutritional Support Team contribute to teaching rounds on a daily basis. Indications, contraindications, complications, and management details are discussed on daily teaching rounds and routinely in didactic conferences. The residents have hands on experience with direct and indirect calorimetry measurements. Monitoring/bioengineering: use and calibration of transducers, amplifiers, and recorders. Exposure: Daily ICU rounds; Critical Care Teaching Conference. Summary: Basic and specialized monitoring devices are used in all patients admitted to the ICU. The SCC residents interpret and apply the information obtained from the devices on a minute-to-minute basis. The principles of the devices, indications, contraindications, complications, and applications are discussed on daily teaching rounds and routinely in didactic conferences. 14 Miscellaneous: use of special beds for specific injuries, traction, and fixation devices. Exposure: Daily ICU rounds; Critical Care Teaching Conference. Summary: Specialized beds, immobilization and mobilization devices, mechanical and chemical techniques for prevention of venous thrombosis and embolization are discussed on daily teaching rounds and routinely in didactic teaching conferences. The use of special beds for pulmonary problems including rotational beds and prone ventilation devices is part of daily experience. The physiology and application intra-abdominal pressure monitoring is emphasized. V. RESIDENT RESPONSIBILITIES SCC residents will take in-hospital call approximately every third to fourth night depending upon the number of general surgery and emergency medicine residents on service. During their times on-call and during their normal daily activities, the SCC residents have the responsibility of carrying out the patient care plan that is mutually agreed upon by the primary surgical team and the SCC service. In general, the primary surgical team retains complete responsibility for development of the patient care plan. While administering the patient care plan, the SCC resident has an appropriate amount of latitude regarding clinical decision making and modification and execution of the care plan. However, should unforeseen circumstances occur, it is the responsibility of the resident to immediately notify the patient care team in order to establish a new patient care plan. Delivery of the patient care plan is under the direct supervision of the ICU attending surgeon. An attending surgeon supervises all technical procedures. General surgical residents and other residents assigned to the ICU make daily morning work rounds with the primary surgical teams in order to exchange information and develop a patient care plan for the current day. Following these early morning rounds, the SCC residents participate in detailed patient care / teaching rounds with the ICU attending, general surgery and emergency medicine residents, and medical students. During these detailed rounds, all aspects of patient management are reviewed with the ICU attending. The patient care plan, as jointly discussed with the primary surgical team and the SCC service, is also reviewed during these rounds. If modifications to the daily care plan are recommended, they are discussed between the two services. FIRST AND FOREMOST, remember that the patient belongs to the attending physician and that the final decision and ultimate responsibility for the patient’s outcome always lies with this surgeon or his/her designee. In the ORMC ICUs, a distinction is made between the patient’s “attending” physician and the patient’s “managing” physician. For some patients, the attending and managing physician will be the same. For others, in which the attending physician may not feel comfortable directing the critical care management of the patient, the designated “managing” physician (usually an intensivist) will direct the patient’s day-to-day ICU care. Both the attending and managing physician may also delegate another physician, the senior resident on the primary service, or a consulting physician to make specific patient care decisions. For every patient on the “teaching” services (“Blue” or “Red”) of the Department of Surgical Education, the SCC Service will be designated as the patient’s managing physician. The SCC Service will make all patient care decisions in conjunction with the patient’s chief surgical resident. The SCC Service will also frequently be designated as the managing physician for “private” general surgical and vascular service patients. In these cases, the SCC Service will manage the day-to-day ICU care, but ultimate decision making responsibility remains with the patient’s private surgical attending. The degree of patient care involvement assigned to the SCC Service on these private patients varies from surgical attending to attending. You will come to know each surgeon’s preferences during your first month or two in the ICU. 15 All plans, procedures, non-routine physician’s orders and diagnostic tests, consultation requests, and therapeutic or management changes will be discussed with the primary surgical team. All adverse occurrences, complications, condition changes, and unexpected test results must be immediately communicated to the primary surgical team as well. Documentation of the discussion and rationale for the actions and therapy instituted should be documented in the Progress Notes section of the patient’s medical record. Communication between the SCC Service and the primary surgical services should be at the senior resident, chief resident, or attending level. Unlike on the regular patient care floors, communication up and down the traditional chain of command with junior level residents can cause confusion and delay therapy. Communicate with the SENIOR resident as much as possible. Both the residents on the primary surgical services and the SCC residents make rounds and document their patient care activities, assessment, and plans in the patient's medical record as frequently as is indicated. Thus, two sets of daily patient care notes are generated each day. The residents rotating on the SCC service for one to two months are members of the general surgery or emergency medicine residency programs. During their rotation, they receive an intense experience in critical care closely supervised by the SCC attendings and SCC residents. The SCC residents enhance the educational experiences of the general surgery and emergency medicine residents by providing close supervision of junior residents and contributing to the teaching conferences attended by these residents. They work as peers to the senior and chief residents in the general surgical program and share in the management of the complex patients admitted to the critical care units. This parallel approach to patient management is intended to improve patient care by making resident and attending physicians available immediately at all times in the critical care units. The program is intended to improve educational efforts in critical care by providing an intense experience for the sponsoring program junior and senior level residents during their rotations on the SCC service. It also provides continuing experience in critical care for senior level and chief residents as they round throughout their entire training program with the ICU attendings and residents. Administrative Resident The Administrative Resident is responsible for the organization of the Surgical Critical Care service and the direction of the residents and medical students rotating upon it. These responsibilities are equally divided, by month, between the SCC residents. This is an opportunity to begin to hone your skills in ICU administration and direction. The duties of the Administrative Resident include: Orientation of new residents (General Surgery, Emergency Medicine) and visiting medical students to the SCC Service including expectations and responsibilities Didactic teaching with residents and medical students Preparation of ICU call schedule (submit to Cynthia 2 weeks before the start of the next month) Monthly resident and medical student evaluations 16 2007 - 2008 ACADEMIC YEAR Month Administrative Fellow July Straus August Straus September Straus October Withers November Withers December Withers January Straus February Straus March Straus April Withers May Withers June Withers VI. JOINING THE SURGICAL CRITICAL CARE TEAM: A DAY IN THE LIFE. THE DAY-TO-DAY WORKINGS OF THE SURGICAL CRITICAL CARE SERVICE The first few months of the residency involve a difficult period of adaptation not only to the microenvironment of the ICU but also to the macro-environment of Orlando Regional Medical Center (ORMC). The new SCC resident will need some time learning to get around a new institution and interact with personnel at different professional levels. The ICUs at ORMC SCC residents rotate on the “Surgical Critical Care Service” for ten months of their 12-month residency. During this time, they care for patients in all of the ICU’s at ORMC. The typical census for the SCC Service is 15-25 patients divided among the various ICUs with the majority of the patients residing in the Trauma ICU. While the ICUs at ORMC are typically considered to be one unit for the purpose of training, the individual units and their specialty include the following: Trauma ICU (14 beds) Surgical ICU (8 beds) Neurosurgical ICU (10 beds) Medical ICU (8 beds) Coronary Care Unit (12 beds) Cardiovascular Recovery Room (8 beds) The Winnie Palmer Women’s and Babies’ Hospital (WPH), which is on the same campus as ORMC, serves the obstetric and gynecologic patient population of Central Florida. They are currently developing a five-bed ICU for the care of women who develop critical care issues during their obstetric / gynecologic care. Historically, these women have been transferred to the ICUs at ORMC for critical care management. Within the next year, it is anticipated that some of the less critically ill women will be kept at WPH and that the SCC service will direct their ICU management in the WPH ICU. This is considered by ORH to be the same site as WPH and ORMC reside on the same campus. The Nursing Staff On an hourly basis, the people that you, as the SCC resident, will spend the most time with will not be the faculty or housestaff, but rather the nursing staff. It cannot be stressed strongly enough that it is vital to be able to work constructively and amicably with the nurses. Good rapport with the staff will lead to better patient care. Most of the nursing staff are highly trained and experienced, and possess sound clinical judgment. You will depend on them for accurate information, early warning of potential problems, execution of the complex orders, and set up and use of the multiple, complex monitoring devices commonly used in the unit today. 17 There is a period of mutual readjustment at the beginning of each academic year for both the new fellows and the nurses. Try to make this a smooth transition for all involved, as a little extra time up front will both save later headaches and provide a good working relationship down the line. Remember that the ICU cannot run smoothly (or at all) without experienced, dedicated nurses, which means that you cannot do your job effectively without the nurses. Also remember that many of the nurses you encounter in the ICU were practicing critical care before you even considered medical school and will continue to be at ORMC long after you leave! Approaching your fellowship with a mind open to learning from the ICU nursing staff will provide you with immeasurable and long lasting benefits. ICU Morning Rounds The main event of a day in the ICU is morning rounds. Rounds starts at 0800 in the TICU and last for 2 - 4 hours. The resident on-call must be physically present at all times during rounds in order for this session to achieve its objectives. All residents and students rotating on the SCC Service should participate actively during rounds. The fellow should be prepared to supplement the general surgery or emergency medicine resident and the medical student presentations with additional relevant information as necessary. Special emphasis is placed on the events of the previous 24 hours. The fellow's contribution is especially important when attendings switch each Monday, especially if the new ICU attending has not been on-call for some time. Since the presentations stress the most recent events, the fellow must be sure to mention all significant events that have occurred since the attending last saw the patient. Representatives from nursing, pharmacy, respiratory care, nutritional support, and the primary service should each add their pertinent comments. Each patient presentation is followed by a discussion of the case by the ICU attending including the pertinent teaching points. After discussion of alternatives and questions, the plan for the next 24 hours is laid out. It is extremely important that communication is clear at this point and that the on-call resident or fellow has a complete understanding of the interventions to be made. The resident/fellow should not try to keep this in his/her memory, but notes should be taken so that specific plans are not forgotten, resulting in significant omissions coming to light during evening rounds. The off-duty resident/fellow may need to handle acute problems during the course of rounds; he/she is encouraged to do so since he/she is abreast of the most recent events. If the continued presence of a physician is required at the bedside, one of the residents/fellows not assigned to patient care that day (i.e., the "in-between team") should leave rounds and manage the problem. Nothing disturbs morning rounds more than waiting for the post-call fellow to return from a bedside with vital information. The last subject of morning rounds is discharges, admissions, elective and emergency consults. The fellow should scrutinize the daily OR schedule prior to rounds and discuss planned or potential admissions with the ICU Charge Nurse. A plan is delineated at this time concerning admissions for the next 12 hours. The charge nurse is a pivotal participant of this discussion since he/she is aware of any staffing problems that might affect bed allocation or the potential acuity of the possible admissions, as well as about the availability of step down beds for transferring patients ready for discharge. It also pays to get to know the nursing coordinators (known as the "PCC") who will know the hospital's bed situation. The ICU nurses and therapists are a vital source of information about the patient. They are in close contact with the patient for 12 hours a day while you, as the fellow, must divide your time between 15-25 patients. The nurse can frequently tell you about the primary team's last visit, the opinions and recommendations of consulting services, and the family's understanding of and questions about the patient's condition. Patients should be assigned to junior residents and students before morning rounds. Otherwise, 3 hours of rounds could go by and, at the end when patients are assigned, residents may only vaguely remember the specific plans laid out. At no time should more than 3 patients be 18 assigned to medical students. This enables each member of the junior staff to concentrate on the remaining patients. Although the junior residents and medical students will generally follow those patients admitted on their nights on call, it may be better (at times) to rotate patients among residents to increase their exposure and, thus, their learning experience. In generally, students should not be assigned chronic, long-term patients. Continuity of care, however, is necessary at the fellow level. Work rounds include a methodical review of the flow sheet including close scrutiny of each system, emphasizing the patient's main problems: Cardiovascular Check vital signs Check hemodynamic parameters and monitoring devices (obtain new values if indicated) Review cardiovascular drips and adjust as necessary Respiratory Check ventilator settings and blood gas results Check pulse oximeters and mixed venous oximeters Calculate Qsp/Qt and Vd/Vt (when necessary) Check adequacy and frequency of respiratory orders (chest physical therapy, aerosol treatments and oxygen therapy); evaluate the need for new orders or need to continue the current ones Only fellows or experienced senior residents should make non-emergent ventilator changes. Students are NOT allowed to make ventilator changes without the fellow or respiratory therapist in attendance. All ventilator changes must be IMMEDIATELY documented on the patient’s flowsheet and in the Physician Orders. Both the nurse and the respiratory therapist should be notified of any ventilator changes. Renal Check urine output and renal function parameters with special attention to trends. Check volume status and the continued need for potentially nephrotoxic medications. Metabolic Evaluate fluid balance and adequacy of fluid orders in volume and composition. Check results of follow up serum and urinary chemistries, arterial blood gases, blood glucose levels and insulin drips. Lactic acid levels should be measured in patients with unexplained metabolic acidosis or until lactate levels return to normal (less than 2.0 mmol/L). Nutrition Assess nutritional status and need for supplementary nutritional support Check recent metabolic cart and UUN studies Check the most recent recommendations by the nutritional support team Reconsider route of current nutritional support and possibility of new routes Check TPN solution type and additives. Hematologic Check hemoglobin and WBC; trend values and evaluate for changes Assess clotting variables, platelets, Evaluate for potential sources of bleeding Check for medications that could be suspected of causing hematologic abnormalities. 19 Gastrointestinal Examine every abdomen and evaluate status of wounds Consider need for continuation of drains and tubes Communicate important findings which seem to have been missed by surgical team (not mentioned in notes or discussions). Infectious Disease Investigate fever spikes, WBC elevations Consider need for new or repeat cultures, need for line changes, need for special cultures Consider continued need for antibiotics, status of antibiotic regimen and need for changes Culture results and antibiotic changes should be recorded Discuss antibiotic levels with the clinical pharmacist. New antibiotic orders and antibiotic level orders should be written. Neurological Recheck the Glasgow Coma Scale reported in morning rounds, address any acute changes Adjust narcotics, sedatives and psychoactive drug Evaluate the need for delirium tremens prophylaxis Check serum sodium (goal = 150-155 mEq/L) and osmolarity (goal = 305-320 mOsm/L) on patients receiving mannitol or hypertonic fluids; adjust as necessary Adjust anticonvulsants according to serum levels Adjust ventilation (if indicated) to maintain a PaCO2 of 30-35 torr Check pupils for reactivity. The nursing medicine administration record (MAR) should also be reviewed online paying special attention to all the medications the patient is receiving. A close watch should be maintained for adverse reactions and dosages should be adjusted according to changes in renal or hepatic function. Reordering medications should be part of morning rounds. IV fluids and rate of administration should be checked. The microbiology data must be checked once it is updated after 9:30 AM each morning. The junior residents should be encouraged to do the order writing during this part of rounds so that they become familiar with the doses and with order writing in general. All medical student orders must be co-signed by a physician. It is important that the reasoning for all the decisions be explained to all involved parties: junior staff, students, nursing staff, respiratory therapists, surgical teams. This constitutes the most important teaching goal of bedside rounds. After the flowsheet and medications have been reviewed and appropriate interventions have been made, specific activities are delegated by the fellow to the junior staff and students. The connotation of the term delegation is very important: ultimately the ICU attending considers the fellow the responsible party; therefore, he/she should assess the capabilities of the junior staff and constantly follow the progression of the task that has been delegated. As previously stated, contacting consultants, scheduling special tests, and obtaining official results of radiological or other clinical tests is an important early priority. Only after those things have been done should the fellow concentrate on other time consuming activities. The next priority is invasive procedures. Elective line placement and changes should be completed before the change of the nursing shift, preferably before 1800 so the ICU attending can be present and before the nurses are busy completing the flowsheets for their evening report. 20 Family Rounds Speaking with families is part of the 4 PM afternoon rounds agenda and usually is a very rewarding activity. The importance of good communication between the physicians and patient families cannot be stressed strongly enough. This cannot be delegated to junior staff. It is best to maintain communication with the family at the attending and fellow level in order to provide consistent information from the coordinator of patient care to the concerned family member. Students and junior residents should direct family's questions to the fellow. Ideally, two people are present when talking to the family including a fellow, attending (especially if there is a problem), nurse, and/or surgical team member. The second person can act to verify information and to assess the family's reaction. Being in the operating room most of the day, the primary services are frequently not available to talk with families. It is not unusual to hear family members say they have not talked with a doctor "in several days". The fellow becomes an important source of information and assurance to many families. Try to be present during visiting hours and accessible to family members. The nurses will frequently ask you to update the family if they have not seen the primary service recently. It takes but a few minutes, fulfills the family's need to talk with a physician, allows you to get to know the family, and can be very rewarding. Obviously any sensitive issues should be discussed between the family and attending surgeon. If you sense any discomfort with the family's relationship with the primary service or any perceived problems in patient care, these items should be immediately brought to the attention of the patient’s primary surgeon. Early Evening Ask the ICU Charge Nurse to inform you of all potential admissions and of all admissions as they actually arrive in the ICU. Make a point of "checking in" with the charge nurse every few hours to find out the latest information on admissions, patients in the Emergency Department (who may become admissions), transfers, and the hospital bed status. More often than not, the ICU is nearly full with only 1 or 2 potential beds or "admissions slots". Triage of stable patients out of the ICU to accommodate critically ill patients should always be in the back of your mind. The hospital in general also stays at a high occupancy rate and floor beds may not always be readily available. Always keep in mind which bed will be used as the admission slot for a cardiac arrest from the floor, an unexpected OR patient, or the trauma patient that needs emergent resuscitation. Close communication with the ICU Charge Nurse is essential and will prevent surprise admissions as well as allow you to budget your time and plan procedures. Reviewing the operating room schedule first thing in the morning and discussing these potential admissions with the charge nurse will allow you to anticipate and plan their care in advance. New admissions introduce variety to the afternoon. Usually, elective admissions of the day arrive from the operating room and require the devoted attention of the fellow and junior resident in charge of the patient at least for the first 30 minutes. Obtain a direct report from the anesthesiologist, CRNA, or surgeon to assess the condition of the patient and to evaluate for potential instability. Remember to inform the ICU attending about the new admissions and to have a plan of action for discussion. The student/resident should write an admission note with details of the history, reason for admission to the ICU, intraoperative course, intraoperative complications, admission physical examination and results of admission blood work and CXR, assessment and plan. Such a note is of use not only for presentation of the patient to the attending, but as a summary for the incoming team. The note should be concise and limited to no more than one page. As long as the plans made during morning rounds and adjusted in afternoon rounds are being followed and no new or significant developments have occurred, there is no need to call the attending. If things are not "going well", problems have developed, or you are not sure how to handle a particular problem, it is best to call the ICU attending and talk it over. It cannot be 21 stressed enough that the ONLY ERROR IS NOT CALLING. As time goes on and you learn and develop competence and confidence, trust between attending and fellow also grows and you will have plenty of time for independent action. This is not true in July! Before calling the attending, all the information pertinent to the problem should be collected and tentative and alternative strategies thought out. Evening Pre-Rounds The on-call resident will update the status of the patients, occurrences of the day and changes made to the plans discussed during morning rounds. New consults will be examined and worked up. Be sure to discuss the bed situation with the ICU Charge Nurse before the evening checkout phone call to the ICU attending. A plan for triage and acceptance of patients must be formulated to optimize bed utilization and expedite admissions. The flowsheets of particularly complex patients should be collected in preparation for the attending phone call and the quietest area of the unit selected to sit down and call the attending. Evening “Checkout” Rounds Evening checkout rounds are at either 9 or 10 PM each evening (check with the ICU attending to determine their preference). This session is a phone conversation between the ICU attending and on-call fellow/resident. This is an opportunity for the fellow/resident to have a one-on-one discussion with the attending. Using the flowsheet as a source of information, the fellow describes the events of the day, the results of the interventions, and conveys the useful information that he/she has collected. He/she is expected to summarize and abstract the crucial facts, avoiding irrelevant trivia. The news story approach is strongly suggested: who, what, where, when, and how in the first paragraph. The events of the evening are discussed including intervention and patient care plans. Clarification of plans, potential triage patients, new admissions, and preoperative evaluations are all discussed. Again, no question should remain at the end of the conversation as to the plan of action for the night. The fellow/resident should ask for any necessary clarification and write down the plans laid out in order to avoid errors and omissions. Rounds are finished with the presentation of new consults as well as any outstanding emergency consults. Advance plans should be made for potential discharges the next morning as well as discussing bed availability for the next day's elective cases. Night Work Rounds Appropriate laboratory studies for the next day should be ordered: there are no "routine" morning labs. Every test should be ordered for a specific reason. Considering the acuity typical to most patients, it is not unusual to have at least a CBC (hemoglobin and white blood cell count) and electrolytes. As a guideline, one CXR should be obtained every 24 hours for intubated patients, but only for specific indications on non-intubated patients. Routine chest X-rays are not needed after guidewire line changes. The overall plan of care should be discussed with the night nursing and respiratory staff and all questions answered so that the teaching objectives of rounds are accomplished for the night crew. All orders should be entered into Sunrise XA; verbal orders are for true emergencies. A physician must co-sign the student's orders at the time the order is written. Many emergency admissions arrive in the ICU after midnight. They also usually constitute the more complex cases (either trauma cases with multiple injuries, cardiovascular and respiratory instability or elective surgical patients with acute cardiorespiratory decompensation and/or sepsis). These cases require immediate attention by on-call resident since the entire database must be created from scratch. Information should be collected rapidly from all sources while, at the same time, therapeutic measures are instituted and monitoring devices are inserted. When the "busy work" is completed, an admission note must be written, containing the list of problems, diagnosis or injuries, work up, an admission physical examination, the results of admission lab results and CXR, and finally, an overall assessment and therapeutic plan. Be sure to check to see that the patient and any procedures are entered into the Surgical Education database. 22 One of the busiest periods in the ICU occurs from 0600 until 0800. During this time, the fellow is expected to review daily progress notes, exchange information with the residents of all the various surgical teams, review all the morning X-rays, review all the new lab data (and institute corrective measures for any abnormal values), find results of important gram stains sent over the previous 24 hours, obtain preliminary readings on radiological studies done overnight, discuss the projected discharges and admissions with the incoming charge nurse, answer questions from the operating room staff, recovery room staff and surgical teams regarding bed availability for elective cases and receive new emergency consults from the trauma and other surgical teams. All these activities are spiced by a multitude of patients' developments brought to the fellow's attention by the incoming nursing shift. It is at this time when the fellow's ability to handle multiple problems at the same time is taxed the most! Daily progress notes should consist of a brief summary of the events of the previous 24 hours. These serve as the most knowledgeable and concise listing of events and decisions. Since the attending dictates a comprehensive note during morning rounds, the fellow/resident/student note should covers the highlights and focus on the plan rather that rewriting of data already written on the flowsheet Close communication should be maintained with the ICU attending throughout the night: when a patient is not responding in the expected fashion, when the fellow has any doubts or even when the attending might want to know about a successful outcome of a therapeutic intervention in a complex case. Admissions There is a general order for prioritizing admissions when a bed becomes available. This is detailed in the ICU Bed Allocation Protocols. In brief, unstable patients in the Emergency Room who will require invasive critical care monitoring or pulmonary support always have first priority for admission. Unstable patients from the floor or step-down units are the second priority. Unstable patients from the operating room are considered next. Pre-operative cardiopulmonary evaluation patients represent a special group of patients who are given a high priority for admission by virtue of their potential for becoming critically ill postoperatively. Only after the above patients are admitted are the more routine admissions assigned beds. It is often useful to make a trip to the recovery room, emergency department, operating room, or floor to evaluate patients before assigning them an ICU bed. Frequently, what constitutes an “ICU admission” in someone else’s mind will just as appropriately be cared for in a step-down unit bed. Standardized, pre-printed orders for admission to the ICU are available on Sunrise XA. Patients admitted to the ICU are strongly encouraged to have these orders filled out. All admission orders should be written or co-signed by a senior resident of the surgical team. The on-call resident must review the orders written by the team to make any necessary changes and additions. Discharges and Transfers A patient is ready to be discharged from the ICU when critical care management is no longer needed or the reason for intensive monitoring either by medical or nursing staff is over. Both the SCC service and the surgical team must agree on this before the actual discharge occurs. Specific transfer criteria and step-down unit admission criteria are available in the ORMC policy and procedure manual. Sometimes disagreements may arise regarding the fitness of the patient for discharge, or the need for a step-down or intermediate care unit. These disagreements are usually ironed out when the teams have an open discussion of the case either at the fellow/resident level or, if necessary, at the attending level. Patients and families should be prepared for the transfer to the floor or step down unit ("cutting the umbilical cord") particularly after prolonged ICU stays. If the patient is transferred in the middle of the night, the family should be prepared and notified in advance. Usually the ICU team 23 is more conservative with respect to placing the patient in an intermediate care unit but, ultimately, the surgical team is responsible for the disposition of the patient after discharge from the unit. All discharges and transfers should be reviewed by the ICU attending (NO EXCEPTIONS). Transfer orders must be in the chart or entered into Sunrise XA before the patient leaves the ICU. It is important to have the senior resident of the surgical team write orders as soon as discharge is agreed upon so there are no delays when the step-down unit or regular ward bed becomes available. Patients with continued critical care problems may be followed by the ICU team until they are transferred from the step down unit (PCU). VII. RESIDENT EVALUATION AND THE CORE COMPETENCIES SCC residents are expected to demonstrate the skills, knowledge, and attitudes necessary to meet the requirements of the core competencies listed below. Residents receive education on the core competencies through exposure during daily ICU rounds and the scheduled department teaching conferences. Fellows are evaluated using a number of methods as outlined below. Evaluations are performed on a quarterly basis and reviewed with the program director in a oneon-one meeting. Copies of the evaluation forms used to evaluate the fellows are included. A. Evaluation of the Resident by Faculty Evaluation of each SCC resident occurs on a contemporaneous ongoing basis through daily feedback and personal interaction between the residents and the faculty. In addition, a formal performance evaluation of the resident by each faculty member is completed every three months using the Core Competencies. The development of appropriate technical skills by each resident is evaluated by the faculty every six months. These evaluations are discussed with each individual resident during quarterly evaluation sessions with the program director. Each resident will be required to maintain a case log of all bedside and operative procedures performed during the residency. This will allow the resident to review and maintain an active understanding of their experience and adjust during the year for any inadequacies. Such a log is also necessary to apply for the American College of Surgeons Added Certificate of Qualification in Critical Care upon completion of the residency. B. Evaluation of the Resident by Peers and Students The resident will be formally evaluated by the general surgery and emergency medicine residents as well as by medical and physician’s assistant students rotating upon the service. These evaluations will be discussed with the SCC resident during the quarterly evaluation sessions. C. Evaluation of the Resident by the Nursing and Respiratory Therapy Staff The resident will be formally evaluated by the ICU nursing and respiratory therapy staff on a quarterly basis using an anonymous online “360 degree” evaluation. The results of these surveys will be discussed with the SCC resident during the quarterly evaluation sessions. D. Evaluation of the Faculty and Program by Resident The residents will be expected to evaluate the faculty using standardized forms on a quarterly basis. Each resident will also participate in an annual program review session in which the core objectives and goals will be re-evaluated and recommendations made as to how to modify and improve the program. Residents are encouraged to discuss any issues or concerns regarding the residency program, their progress in the residency, and the correction of any identified problems with the program director at any time. 24 The Core Competencies 1. Patient Care: a) Effectively lead patient care with clear communication to team, patients, family, and attendings b) Accurately synthesize complex clinical data and propose clear treatment plans c) Actively lead team decision making d) Capably perform procedures suitable to surgical critical care patients with attending supervision 2. Medical Knowledge: a) Demonstrate effective decision making based on adequate knowledge b) Effectively correlate basic science knowledge with clinical scenarios c) Exhibit a desire for additional knowledge d) Appropriately use learning resources e) Be fluent with pharmacology and physiology as it pertains to surgical critical care i) Be familiar with the current literature ii) Demonstrate an investigatory and analytical thinking approach to clinical situations 3. Practice-Based Learning and Improvement: a) Participate in scheduled conferences b) Knowledgeable of evidence-based medicine as applied to critical care c) Adequately use scientific data to help solve clinical problems d) Actively contribute to the team’s education by providing recent and current data as a result of literature searches 4. Interpersonal and Communication Skills: a) Maintain professional, cordial, and compassionate relationships with patients, staff, co-workers and faculty b) Demonstrate the ability to listen and to accept constructive criticism c) Demonstrate the ability to communicate efficiently with team members, attendings, referring and consulting physicians 5. Professionalism: a) Demonstrate compassion, respect and integrity in the work environment b) Flawlessly uphold the professional standards of the surgical critical care / trauma services c) Respect differences in gender, age, culture, disability or educational levels d) Contribute to all educational activities of the surgical critical care / trauma services e) Committed to ethics of confidentiality and informed consent 6. Systems-Based Practice a) Understand one’s position within the team, specialty, profession and society b) Demonstrate sensitivity and awareness at the cost of health care delivery c) Advocate for cost-conscious and effective patient care d) Develop skills as a “team leader” e) Develop administrative skills to organize and lead a busy clinical service 25 ORLANDO REGIONAL MEDICAL CENTER DEPARTMENT OF SURGICAL EDUCATION FACULTY EVALUATION OF SURGICAL CRITICAL CARE RESIDENT 2007 - 2008 Resident Name: Quarter: Instructions: Please evaluate the above SCC resident based upon your recent experiences: SCALE: 5=Outstanding, 4=Very Good, 3=Good, 2=Fair, 1=Poor Please rate the resident on the following core competencies: PATIENT CARE Communicates well with patients, family and colleagues Attentive to detail Participates in team decision making Leads/mentors residents regarding patient care issues MEDICAL KNOWLEDGE Able to integrate basic science concepts into clinical practice Up-to-date with recent scientific discoveries/developments Demonstrates organized thinking Able to effectively teach Provides high quality patient presentations CLINICAL PERFORMANCE Effectively manages critical issues in the ICU Effectively leads a multidisciplinary patient care team Technically proficient in ICU procedures Able to multitask PROFESSIONALISM / INTERPERSONAL SKILLS Demonstrates respect and integrity in work environment Demonstrates compassion to patients and families Able to listen to others and respect people with different opinions and/or backgrounds Relates to others in a cordial, respectful manner Works effectively with others Committed to the ethical principles of the profession Is eminently educable Able to accept criticism SYSTEM-BASED PRACTICE Understands the role of the Surgical Critical Care Service in relation to the patient’s overall care Sensitive to issues related to cost of health care delivery Able to understand one's position in the team Assures safe patient disposition and continuity of care PRACTICE-BASED LEARNING Analyses own clinical practice and improves it Locates and applies scientific evidence to patient care Understands formulation of hypothesis, study design and statistical methods Facile with scientific and medical tools available on the Internet Effectively teaches residents, students, and others 5 4 3 2 1 NA 26 ORLANDO REGIONAL MEDICAL CENTER DEPARTMENT OF SURGICAL EDUCATION COGNITIVE AND CRITICAL CARE SKILLS EVALUATION 2007 - 2008 Fellow Name: First 6 months Second 6 months COGNITIVE KNOWLEDGE (Please check the appropriate box) Knowledge Learning, Absent or Not able & able Knowledge but inadequate Observed to teach able incomplete CARDIOVASCULAR PHYSIOLOGY / PATHOLOGY Principles of electrocardiographic monitoring Cardiac rhythm and conduction disturbances Hemodynamic monitoring: Principles of strain gauge transducers Principles of arterial, central venous and pulmonary artery pressure catheterization and monitoring Assessment of cardiac function and derived hemodynamic parameters Principles of oxygen transport and utilization Shock states (hypovolemic, cardiogenic, distributive, neurogenic, endocrine) Vasoactive and inotropic therapy Myocardial infarction Pulmonary embolism - thrombus, air, fat, amniotic Pulmonary edema - cardiogenic, noncardiogenic Cardiac tamponade & acute pericardial diseases Management of hypertensive emergencies & urgencies RESPIRATORY PHYSIOLOGY / PATHOLOGY Acute respiratory failure / acute lung injury (ALI) Acute Respiratory Distress Syndrome (ARDS) Aspiration Bronchopulmonary infections Upper airway obstruction Pulmonary mechanics and gas exchange Oxygen therapy Indications & hazards of mechanical ventilation Barotrauma / volutrauma Criteria for weaning and weaning techniques Empyema Pneumothorax / hemothorax Respiratory monitoring (airway pressure, intrathoracic pressure, tidal volume, pulse oximetry, dead space-tidal volume ratio, compliance, resistance, capnography) Metabolic monitoring (oxygen consumption, carbon dioxide production, respiratory quotient) 27 Knowledgeable & able to teach Knowledgeable RENAL PHYSIOLOGY / PATHOLOGY Fluid and electrolyte balance Prerenal, renal, and postrenal failure Acid-base disorders and their management Principles of hemodialysis, continuous veno-venous hemofiltration (CVVH) Interpretation of urine electrolytes Evaluation and treatment of oliguria Drug dosing in renal failure Rhabdomyolysis CNS PHYSIOLOGY / PATHOLOGY Coma Metabolic Traumatic Drug induced Perioperative management of neurosurgery patients Brain death evaluation and certification Diagnosis / management of persistent vegetative states Seizure prophylaxis and treatment Nontraumatic intracranial bleed CNS brain monitoring (intracranial pressure, cerebral blood flow, cerebral metabolic rate, EEG, jugular venous bulb oxygenation, transcranial doppler) METABOLIC & ENDOCRINE EFFECTS OF CRITICAL ILLNESS Enteral nutrition Parenteral nutrition Disorders of thyroid function (thyroid storm, myxedema coma, sick euthyroid syndrome) Adrenal crisis / insufficiency Diabetes insipidus Diabetes mellitus Hyperglycemic control Hypoglycemia Disorders of calcium, magnesium, and phosphate balance Learning, Absent or Not but inadequate Observed incomplete 28 Knowledgeable & able to teach Knowledgeable INFECTIOUS DISEASE PHYSIOLOGY Antimicrobial agents Antifungal agents Anaerobic infections Systemic Inflammatory Response Syndrome (SIRS) Severe Sepsis Use of drotrecogin alfa recombinant (Xigris™) Hospital acquired and opportunistic infections Adverse reactions to antimicrobial agents Acquired Immune Deficiency Syndrome (AIDS) Infectious risks to health care workers Evaluation of fever in the ICU patient Development of antibiotic resistance Universal Precautions Isolation and Reverse Isolation ACUTE HEMATOLOGIC & ONCOLOGIC DISORDERS Thrombocytopenia / thrombocytopathy Disseminated intravascular coagulation (DIC) Anticoagulation; fibrinolytic therapy Principles of blood component therapy Platelet transfusion Packed red blood cells Fresh frozen plasma Albumin Cryoprecipitate Prophylaxis against thromboembolic disease Learning, Absent or Not but inadequate Observed incomplete 29 Knowledgeable & able to teach Knowledgeable GASTROINTESTINAL, GENITOURINARY, & OB/GYN Acute pancreatitis Upper GI bleeding including variceal bleeding Lower GI bleeding Acute hepatic failure Toxic megacolon Acute GI perforation Ruptured esophagus Acute inflammatory diseases of the intestine Acute vascular disorders of the intestine, including mesenteric infarction Obstructive uropathy, acute urinary retention Urinary tract bleeding Toxemia of pregnancy; amniotic fluid embolism, HELLP Syndrome Stress ulcer prophylaxis Drug dosing in hepatic failure Acalculous cholecystitis Post-operative complications including fistulas, wound infection, and evisceration ENVIRONMENTAL HAZARDS Drug overdose and withdrawal Hyperthermia Hypothermia Envenomation TRAUMA & BURNS Initial approach to management of multisystem trauma CNS trauma (brain and spinal cord) Skeletal trauma including the spine and pelvis Chest trauma - blunt and penetrating Smoke inhalation, airway burns Flail chest, chest trauma, pulmonary contusion Abdominal trauma - blunt and penetrating Crush injury Burns Electrical injury PHARMACOKINETICS & DYNAMICS Uptake, metabolism, and excretion of common drugs (i.e, aminoglycosides, neuromuscular blockers, sedatives, analgesics) Principles of pain management Learning, Absent or Not but inadequate Observed incomplete 30 Knowledgeable & able to teach Knowledgeable Learning, Absent or Not but inadequate Observed incomplete PRINCIPLES OF RESEARCH IN CRITICAL ILLNESS Study design Biostatistics Abstract preparation Manuscript preparation Prognostic indices, severity and therapeutic intervention scores ADMINISTRATIVE & MANAGEMENT PRINCIPLES Priorities in the care of the critically ill or injured Collaborative practice principles Participation in relevant hospital committees Principles of triage and resource allocation Clinical practice guidelines Electronic data base utilization Use of computers in critical care units ETHICAL & LEGAL ASPECTS OF CRITICAL CARE MEDICINE The ethical decision-making process Do Not Resuscitate orders Futile care Living wills, advance directives, durable power of attorney Comments _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Faculty Signature: ___________________________________ Date: _______________ 31 CRITICAL CARE PROCEDURAL SKILLS The definition of competency to perform the listed procedures must include knowledge of the indications, contraindications and complications of these interventions. (Please check the appropriate box) Knowledgeable & able to teach AIRWAY Maintenance of open airway in non-intubated patients Nasotracheal airways Ambu-bag / mask ventilation Intubation (oral) Intubation (nasotracheal) Cricothyrotomy / tracheostomy Suction techniques BREATHING / MECHANICAL VENTILATION Use of Synchronized Intermittent Mechanical Ventilation (SIMV) Use of Pressure Control Ventilation (PCV) Appropriate use of PEEP Appropriate application of oxygen therapy Monitoring of airway pressures Pressure-volume waveform analysis Application of end tidal CO2 detectors, pulse oximetry Arterial blood gas analysis Management of pneumothorax (needle, chest tube insertion) Fiberoptic laryngotracheobronchoscopy X-ray interpretation CIRCULATION Insertion of monitoring lines Central venous Arterial Pulmonary artery catheter Interpretation of invasive hemodynamic parameters Interpretation of 12-lead ECG Application of vasoactive medications Cardioversion Transcutaneous / transvenous pacing CENTRAL NERVIOUS SYSTEM Management of intracranial and cerebral perfusion pressures GASTROINTESTINAL Insertion of nasoenteric feeding tubes Knowledgeable Learning, but incomplete Absent or inadequate Not Observed 32 Knowledgeable & able to teach Knowledgeable Learning, but incomplete Absent or inadequate Not Observed HEMATOLOGIC Appropriate utilization of blood component therapy Management of massive transfusions including rapid infusers Proper ordering and interpretation of coagulation studies INFECTIOUS DISEASE ICU sterility techniques and precautions Interpretation of blood, sputum, urine, body fluid cultures Appropriate use of antimicrobial agents INTEGUMENT Use of temporary abdominal closures Management of intra-abdominal and abdominal perfusion pressures MONITORING Utilization, zeroing, calibration of transducers Troubleshooting of monitoring equipment NUTRITION Use of total parenteral nutrition Interpretation of metabolic cart and urine urea nitrogen studies Comments _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Faculty Signature: ___________________________________ Date: ________________ 33 ORLANDO REGIONAL MEDICAL CENTER DEPARTMENT OF SURGICAL EDUCATION RESIDENT EVALUATION OF SURGICAL CRITICAL CARE TEACHING FACULTY 2007 - 2008 Faculty Name: Instructions: Please evaluate the above faculty member based upon your recent experiences. SCALE: 5=Outstanding, 4=Very Good, 3=Good, 2=Fair, 1=Poor Please rate the faculty member on the following criteria: 5 4 3 2 1 NA Practices comprehensive patient care addressing all pertinent issues Provides effective leadership during patient care rounds Effectively integrates patient care with bedside teaching Includes the nursing / respiratory therapy staff in decision making Effectively interacts with families during Family Rounds Utilizes Evening Checkout Rounds effectively Serves as a role model for professional / caring interaction with patients and family members Integrates ethical considerations in patient care Provides constructive feedback to residents about their performance Develops and maintains good rapport with residents Utilizes the literature to support patient evaluation and management Actively participates in teaching conferences Helps resident establish personal and professional goals Facilitates resident professional development Encourages resident research and scholarly activities COMMENTS: Name of resident (optional): (continue on back if needed) 34 VIII. DIDACTIC TEACHING CONFERENCES A significant portion of the teaching within the residency program occurs at the bedside during morning ICU Rounds as well as during afternoon Family Rounds. The following represents the didactic teaching conference schedule for the 2007-2008 academic year. All lectures will take place in the Trauma ICU conference room at 12 noon unless otherwise specified. Fellow’s Conferences 1st Tuesday 2nd Tuesday 3rd Tuesday 4th Tuesday 5th Tuesday EBM RES PD RES EBM Critical Care Teaching Conferences 1st Wednesday GR 2nd Wednesday JC 3rd Wednesday JTC 4th Wednesday MM 5th Wednesday GR Evidence-Based Medicine Guidelines Conference Research Conference Professional Development Research Conference Evidence-Based Medicine Guidelines Conference Critical Care Grand Rounds Critical Care Journal Club Joint SCC / MCC Teaching Conference Critical Care Morbidity and Mortality Conference Critical Care Grand Rounds Evidence-Based Medicine Guideline Development (1st and 5th Tuesday) Working in conjunction with the attending staff and PharmD, residents are instructed on and actively participate in the conception, research, formulation, and production of evidence-based medicine (EBM) patient care guidelines for use in the adult ICU's. These guidelines are made available to the physician and nursing staff of the corporation through both SWIFTMD as well as our website, surgicalcriticalcare.net. The intent is to both improve patient care at Orlando Regional Healthcare (ORH) while also creating a repository of guidelines that future, current, and past trainees may access for use in their own ICU's one they leave ORH. Research Conference (2nd and 4th Tuesday) The first of the monthly Research Conferences is a didactic lecture from the faculty covering a particular aspect of scholarly activity such as study design, biostatistics, data analysis, abstract and manuscript preparation and submission, or poster and oral presentation. During the second of the monthly Research Conferences, the status of both current and future research projects within the department is discussed in a “working meeting” format. Although greatest emphasis in placed on trainee-initiated research, education on participation in multi-center, corporate-funded clinical trials is also provided. Professional Development (3rd Tuesday) This conference is intended to provide each resident with the education necessary to apply for employment in critical care and function effectively post-training in the administration of an ICU. Topics include time management, writing a curriculum vitae, the interview process, professional societies and associations, hospital committees, practice management, billing and coding, clinical documentation, core measures, quality assurance programs, and legal depositions. Critical Care Grand Rounds (1st and 5th Wednesday) Scholarly lectures from the SCC faculty, visiting professors, and consultant subspecialty physicians are held monthly to present the breadth of critical care management with an emphasis on evidence-based medicine and the current state-of-the-art. 35 Journal Club (2nd Wednesday) Pertinent recent manuscripts from the various critical care journals are selected by the ICU faculty and discussed jointly by the faculty and residents. The current state-of-theart is discussed with an eye to altering current practices or revising the department’s evidence-based medicine guidelines as needed based upon the latest literature. Joint SCC / MCC Teaching Conference (3rd Wednesday) A combined teaching conference is held, attended by the respective faculty and residents from the Surgical Critical Care (SCC) and Medical Critical Care (MCC) services. Recent interesting cases are presented by each service and discussed. Morbidity and Mortality Conference (4th Wednesday) While all deaths that occur in the intensive care units are discussed in the weekly Department of Surgical Education Morbidity and Mortality conference, specific deaths or complications of particular critical care interest will be presented and discussed in this setting. Potential cases should be submitted to Dr. Cheatham in advance of the conference for review. General Surgery Grand Rounds (Each Friday) Each resident is expected to attend the Department of Surgical Education’s Grand Rounds each Friday morning. The topics rotate between general surgery, trauma / critical care, colorectal surgery, and tumor board. General Surgery Morbidity and Mortality Conference (Each Friday) The SCC residents are expected to actively participate in the Department of Surgical Education’s weekly Morbidity and Mortality conference. The residents play an important role in describing the ICU care provided to patients that are presented in this conference. 36 2007-2008 Critical Care Lecture Series Date Thurs, June 28 1:00 PM 7B Conference Room Fri, June 29 1:00 PM Med Ed Conference Room B Topic Getting Started in Surgical Critical Care: Part I Introduction to the SCC fellowship Hemodynamic Monitoring Principles Hemodynamic Calculations Oxygen Transport Calculations Hemodynamic Monitoring: Today’s Tools in the ICU Getting Started in Surgical Critical Care: Part II Vasoactive Medications Pulmonary Pathophysiology Modes of Mechanical Ventilatory Support Principles of Pharmacology Responsible Faculty Dr. Cheatham Dr. Cheatham Dr. Cheatham Dr. Promes Dr. Gesin Tues, July 3 EBM: “An Introduction to Evidence-Based Medicine” Wed, July 4 Holiday - No Conference Tues, July 10 RES: “The Clinical Research Process” Dr. Cheatham Wed, July 11 GR: “Sepsis, Shock, and SIRS” Dr. Cheatham Tues, July 17 PD: “Your Future Career in Critical Care” Dr. Cheatham Wed, July 18 Joint SCC / MCC Teaching Conference Faculty Tues, July 24 RES: “The Institutional Review Board” Dr. Promes Wed, July 25 Critical Care Morbidity and Mortality Conference Dr. Lube Tues, July 31 EBM: “How to Create an EBM Guideline” Dr. Lube Wed, August 1 GR: “Infectious Disease and Antimicrobial Utilization” Dr. Gesin Tues, August 7 EBM: Guideline review Dr. Lube Wed, August 8 Critical Care Journal Club Dr. Lube Tues, August 14 RES: “Submitting an IRB Proposal” Toby Safcsak Wed, August 15 Joint SCC / MCC Teaching Conference Faculty Tues, August 21 PD: “Time Management” Dr. Cheatham Wed, August 22 Critical Care Morbidity and Mortality Conference Dr. Cheatham Tues, August 28 RES: “Study Design” Dr. Cheatham Wed, August 29 GR: “Fluid Resuscitation: Crystalloid vs. Colloid” Dr. Cheatham Tues, September 4 EBM: Guideline review Dr. Cheatham Wed, September 5 GR: “Surgical Nutrition” Dr. Lube Tues, September 11 RES: “Creating a Research Database” Dr. Cheatham Wed, September 12 Critical Care Journal Club Dr. Lube Tues, September 18 PD: “Quality Assurance” Dr. Block Wed, September 19 Joint SCC / MCC Teaching Conference Faculty Tues, September 25 Research Conference Dr. Cheatham Wed, September 26 Critical Care Morbidity and Mortality Conference Dr. Cheatham Tues, October 2 EBM: Guideline review Dr. Cheatham Wed, October 3 GR: ”The Four Compartment Syndromes” Dr. Cheatham Tues, October 9 RES: “Statistics I” Dr. Cheatham Dr. Cheatham Wed, October 10 Critical Care Journal Club Dr. Lube Tues, October 16 PD: “Writing a Curriculum Vitae” Dr. Cheatham 37 Wed, October 17 Joint SCC / MCC Teaching Conference Faculty Tues, October 23 Research Conference Dr. Cheatham Wed, October 24 Critical Care Morbidity and Mortality Conference Dr. Cheatham Tues, October 30 EBM: Guideline review Dr. Cheatham Wed, October 31 GR: “Acute Renal Failure” Dr. Block Tues, November 6 EBM: Guideline review Dr. Cheatham Wed, November 7 GR: “Endocrine Response to Injury” Dr. Lube Tues, November 13 RES: “Statistics II” Dr. Cheatham Wed, November 14 Critical Care Journal Club Dr. Lube Tues, November 20 PD: “The Interview Process” Faculty Wed, November 21 Joint SCC / MCC Teaching Conference Faculty Tues, November 27 Research Conference Dr. Cheatham Wed, November 28 Critical Care Morbidity and Mortality Conference Dr. Cheatham Tues, December 4 EBM: Guideline review Dr. Cheatham Wed, December 5 GR: “Traumatic Brain Injury” Dr. Lube Tues, December 11 RES: “Publishing Your Research” Dr. Cheatham Wed, December 12 Critical Care Journal Club Dr. Lube Tues, December 18 PD: “Core Measures” Dr. Cheatham Wed, December 19 Joint SCC / MCC Teaching Conference Faculty Tues, December 25 Holiday – No conference Wed. December 26 Holiday – No conference Tues, January 1 Holiday – No conference Wed, January 2 Holiday – No conference Tues, January 8 RES: “Abstract Preparation” Dr. Cheatham Wed, January 9 Critical Care Journal Club Dr. Lube Tues, January 15 PD: “Critical Care Billing and Coding” Dr. Cheatham Wed, January 16 Joint SCC / MCC Teaching Conference Faculty Tues, January 22 Research Conference Dr. Cheatham Wed, January 23 Critical Care Morbidity and Mortality Conference Dr. Cheatham Tues, January 29 EBM: Guideline review Dr. Cheatham Wed, January 30 GR: “Burn Management Update” Dr. Smith Tues, February 5 EBM: Guideline review Dr. Cheatham Wed, February 6 GR: “ICU Sedation and Analgesia” Dr. Gesin Tues, February 12 RES: “Manuscript preparation” Dr. Cheatham Wed, February 13 Critical Care Journal Club Dr. Lube Tues, February 19 PD: “Trauma Billing and Coding” Dr. Cheatham Wed, February 20 Joint SCC / MCC Teaching Conference Faculty Tues, February 26 Research Conference Dr. Cheatham Wed, February 27 Critical Care Morbidity and Mortality Conference Dr. Cheatham Tues, March 4 EBM: Guideline review Dr. Cheatham Wed, March 5 GR: TBA 38 Tues, March 11 RES: “The Manuscript Review Process” Dr. Cheatham Wed, March 12 Critical Care Journal Club Dr. Lube Tues, March 18 PD: “Hospital Committees” Faculty Wed, March 19 Joint SCC / MCC Teaching Conference Faculty Tues, March 25 Research Conference Dr. Cheatham Wed, March 26 Critical Care Morbidity and Mortality Conference Dr. Cheatham Tues, April 1 EBM: Guideline review Dr. Cheatham Wed, April 2 GR: TBA Tues, April 8 RES: “Powerpoint Presentations” Dr. Cheatham Wed, April 9 Critical Care Journal Club Dr. Lube Tues, April 15 PD: “Professional Societies and Associations” Dr. Cheatham Wed, April 16 Joint SCC / MCC Teaching Conference Faculty Tues, April 22 Research Conference Dr. Cheatham Wed, April 23 Critical Care Morbidity and Mortality Conference Dr. Cheatham Tues, April 29 EBM: Guideline review Dr. Cheatham Wed, April 30 GR: TBA Tues, May 6 EBM: Guideline review Wed, May 7 GR: TBA Tues, May 13 RES: “Poster Presentations” Dr. Cheatham Wed, May 14 Critical Care Journal Club Dr. Lube Tues, May 20 PD: “Ethics and End of Life” Dr. Cheatham Wed, May 21 Joint SCC / MCC Teaching Conference Faculty Tues, May 27 Research Conference Dr. Cheatham Wed, May 28 Critical Care Morbidity and Mortality Conference Dr. Cheatham Tues, June 3 EBM: Guideline review Dr. Cheatham Wed, June 4 GR: TBA Tues, June 10 RES: “Oral Presentations” Dr. Cheatham Wed, June 11 Critical Care Journal Club Dr. Lube Tues, June 17 PD: “Depositions and Legal Testimony” Dr. Cheatham Wed, June 18 Joint SCC / MCC Teaching Conference Faculty Tues, June 24 Research Conference Dr. Cheatham Wed, June 25 Critical Care Morbidity and Mortality Conference Dr. Cheatham Dr. Cheatham 39 IX. SUPERVISION AND DECISION MAKING AUTHORITY - RELATION TO FACULTY, RESIDENTS, AND MEDICAL STUDENTS .A good fellow is one who understands how to provide state-of-the-art care to a critically ill patient. An excellent fellow is one who communicates effectively with those around him/her while providing the same excellent level of patient care. First and foremost, remember that the patient belongs to the attending physician and that the final decision and ultimate responsibility for the patient’s outcome always lies with this surgeon or his/her designee. In the ORMC ICU’s, a distinction is made between the patient’s “attending” physician and the patient’s “managing” physician. For some patients, the attending and managing physician will be the same. For others, in which the attending physician may not feel comfortable directing the critical care management of the patient, a “managing” physician (usually an intensivist) will be designated by the attending physician to direct the patient’s day-to-day ICU care. Both the attending and managing physician may also delegate another physician, the chief or senior resident on the primary service, or a consulting physician to make specific patient care decisions. For every patient on the teaching services (Blue or Red) of the Department of Surgical Education, the SCC service will be designated as the patient’s managing physician. The SCC service will then make all patient care decisions in conjunction with the patient’s chief surgical resident. The SCC service will frequently be designated as the managing physician for “private” general surgical and vascular service patients also. In these cases, the SCC service will manage the day-to-day ICU care, but ultimate decision making responsibility remains with the patient’s private surgical attending. The degree of patient care involvement assigned to the SCC service on these private patients varies from surgical attending to attending. You will come to know each surgeon’s preferences during your first month or two in the ICU. All plans, procedures, non-routine physician’s orders and diagnostic tests, consultation requests, and therapeutic or management changes must be discussed with the primary surgical team PRIOR to initiation. All adverse occurrences, complications, condition changes, and unexpected test results must be immediately communicated to the ICU attending and the primary surgical team as well. Evidence of the communication with the primary surgical team must be documented in the medical record. Communication between the SCC service and the primary surgical services should be at the senior resident, chief resident, or attending level. Unlike on the regular patient care floors, communication up and down the traditional chain of command beginning with junior level residents can cause confusion and delay therapy. Communicate with the SENIOR resident as much as possible. The Surgical Critical Care service cannot function without communication and the trust that it fosters. Both the residents on the primary surgical services and the SCC residents make rounds and document their patient care activities, assessment, and plans in the patient's medical record as frequently as is indicated. Thus, two sets of daily patient are notes are generated each day.. The residents rotating on the SCC service for one to two months are members of the general surgery, emergency medicine, and internal medicine residency programs. During their rotation, they receive an intense experience in critical care closely supervised by the SCC attendings and SCC residents. The SCC residents enhance the educational experiences of the general surgery and emergency medicine residents by providing close supervision of junior residents and contributing to the teaching conferences attended by these residents. They work as peers to the senior and chief residents in the general surgical program and share in the management of the complex patients admitted to the critical care units. 40 This parallel approach to patient management is intended to improve patient care by making resident and attending physicians available immediately at all times in the critical care units. The program is intended to improve educational efforts in critical care by providing an intense experience for the sponsoring program junior and senior level residents during their rotations on the SCC service. It also provides continuing experience in critical care for senior level and chief residents as they round throughout their entire training program with the Surgical ICU attendings and residents. You will initially be given responsibility commensurate with your experience and aptitude. As you mature in your abilities and knowledgebase, clinical responsibility will increase. As an SCC fellow, you are responsible for daily rounds in the ICU and overseeing the care of patients and supervision of the residents and medical students on the service. You are responsible for writing orders, assessing patients, and performing procedures. You will make patient management decisions with the aid and supervision of the critical care faculty. You will interact with attending staff from other primary surgical services in reaching clinical strategies and management decisions in a collaborative process. This teaches the elements of working in an “open unit” ICU model. A. Relation to Faculty: The relationship between faculty and the SCC residents is largely one-on-one with direct supervision by an individual faculty member assuming responsibility for each and every patient and each and every patient care decision or procedure. Faculty will be kept informed at all times of any major change and as such assume responsibility for any problems or complications that might occur. It is essential that you work closely and remain in close contact with the ICU attending at all times. This will be one of the most valuable learning opportunities of your fellowship. In addition, you will develop individual relationships with each attending on the surgical staff. This includes general surgery, neurosurgery, vascular, orthopedics, and any other surgical attendings having patients present in the ICU. B. Relation to Residents: SCC residents are to work directly with the general surgery and emergency medicine residents in a supervisory capacity with the expectation that you not only supervise, but also teach and educate residents at the junior levels. You will have a collaborative and complimentary interaction with the chief residents from the primary surgical services, serving as a consultant to them while they maintain primary responsibility for their patient. You and the assigned ICU residents will make rounds with the primary teams and participate in the decision making and provision of care. C. Relation to Medical Students: SCC residents are to work closely with the rotating medical and physician’s assistant students, ensuring that they are supervised in all aspects of the care they provide. You will teach the medical students and provide impromptu continuous teaching opportunities directly related to specific patients. You will also be asked to provide informal evaluation of medical students rotating in the ICU under your supervision, so that a final evaluation done by the ICU attending is consistent with the overall evaluation of the team. 41 X. SCHOLARLY ENVIRONMENT There is an active scientific research program on the Surgical Critical Care service. Current areas of particular interest include the use of continuous cardiopulmonary monitoring systems in the assessment of hemodynamics and oxygen transport in critically ill patients, shock resuscitation, prevention of organ failure, hyperglycemic control, adrenal insufficiency of critical illness, and the pathophysiology surrounding intra-abdominal hypertension and abdominal compartment syndrome. Each resident is expected to complete a one-month elective research rotation during the academic year. These is extensive support available for clinical research including computerized databases, computer support, document processing, information retrieval, and biostatistical support. A full-time research coordinator is available to assist in study design and implementation. During the research elective, the resident will be afforded uninterrupted time to focus on study design and data analysis. Each resident will be expected to complete at least one research study during their fellowship and submit this for both presentation at a national critical care meeting as well as publication in a peer-reviewed journal. Each resident will work under the direction of a faculty supervisor in achieving these goals. XI. QUALITY ASSURANCE The department has a number of programs for quality assurance and performance improvement. Quality assurance and performance improvement will occur through daily rounds, the weekly Department of Surgical Education Morbidity and Mortality conference (in which the SCC residents will be expected to play an active role), the monthly Critical Care Morbidity and Mortality conference, and data collected for the Intensive Care Information System (ICIS) database. Complications and deaths are presented at the Department of Surgical Education Morbidity and Mortality conference with cases presenting complex issues and areas for quality improvement being presented at the monthly Critical Care Morbidity and Mortality conference. Patient group specific complication trending (including ICU and hospitals days, ventilator days, infection rates, and complication rates) is reviewed on a regular basis through the ICIS database. The SCC resident will be exposed to these quality assurance techniques and participate specifically in the presentation of cases, the review of problems as they occur, and the development of performance improvement solutions. XII. RESIDENT DUTY HOURS AND WORKING ENVIRONMENT POLICY A. Duty Hours Duty hours are limited to 80 hours per week averaged over a 4-week period. The duty hours will be in accordance with the ORMC and ACGME Housestaff Duty Hours and Working Environment Policies/Procedures. Through the call scheduling process, residents will be guaranteed at least one weekend per month off and at least one complete day out of seven relieved of all clinical responsibilities. B. Monitoring of Duty Hours Residents and faculty will be provided copies of the rules pertaining to ACGME requirements for limited resident duty hours. These rules will be discussed during the Department of Medical Education orientation meeting at the initiation of the fellowship. Residents will “clock in” and out upon entering and leaving the hospital to document their compliance with the resident duty hours policy. These records will be reviewed by the Program Director on a regular basis assure compliance with ACGME resident duty hour requirements. 42 C. On-Call Activities Call is “in-house” call. Residents will be on call every third to fourth night (seven to eight times per month on average) and will go home on the following day by 1 PM (to allow for attendance at the twice weekly didactic teaching conferences). D. Moonlighting Residents in the Surgical Critical Care training program are not allowed to moonlight. E. Support Services Sleeping quarters and scrubs are provided by the hospital. The on-campus hospital library is available at all times and is supplemented by on line access to a great number of scientific journals. A full function cafeteria is open during hospital hours and available to house staff during this time. F. Pay Salary will be $50,811 per year. In addition, office supplies and equipment needs will be paid for by the department. The department will also sponsor each resident to participate in one educational conference per year to present scholarly research. G. Duty Hours Exception Residents will be allowed to exceed the 80-hour limit only for educational purposes and if they document why they stayed (i.e. special case, conference, or need to provide patient continuity). This will not exceed 10% or 8 hours per week, on average. In the event of being over, they will make it up subsequently to stay in compliance with the average overall. XIII. GRIEVANCE PROCEDURES Should a resident have a specific grievance, you are encouraged to speak with the program director immediately so that the issue may be resolved in an expeditious manner. Alternatively, you may contact the office of Graduate Medical Education to assist with this process and follow the appropriate procedure. XIV. MONITORING RESIDENT STRESS AND FATIGUE Given the stressfulness and complexity of working with critically ill or highly injured patients, the monitoring of stress and fatigue and the attention to its signs and symptoms is an important priority for the Department of Surgical Education. Any indication that residents are physically, psychologically, or personally stressed and/or fatigued will be immediately identified, the resident will be relieved of all clinical duties, and the faculty will assume all responsibilities of the resident until this problem can be dealt with. During the evaluation process, the program director will ask the residents about stress and fatigue. Any resident seeing a colleague or feeling personally fatigued and/or in a stressful situation is asked to identify this immediately to the program director or to other faculty members so that this can be identified.