Small group discussion, early morning, on weekdays excluding Fridays
Learning Outcome: By the 5th week of this rotation, residents will be able to understand major topics in critical care medicine.
Performance Indicators: By the 5th week of this rotation, medical residents will be able to:
Define, classify, stratify severity and manage sepsis.
Define, classify, stratify severity and manage shock.
Define, classify, stratify severity and manage Respiratory Failure.
Recognize tools and need of hemodynamic monitoring.
Define, classify, stratify severity and manage Sedation in ventilated patients.
Define, classify and stratify severity of Acute Respiratory Distress Syndrome (ARDS).
Apply lung protective strategies and initial methods of oxygenation and ventilation in severe hypoxemia in ARDS.
Conduct appropriate family discussions about progress and end-of-life care.
Recognize different presentations of endocrine emergencies such as; diabetic ketoacidosis, non-ketotic hyper-osmolar states and manage to target glycemic control in critically-ill patients.
Signify gastrointestinal bleeding patients and risk stratify their illness to determine selection of vascular access and level of care.
Determine stratification and prognostication of acute kidney injury, and recognize forms of renal replacement therapy in intensive care setting.
Choose the right options of nutrition in critical care setting: recognize forms of nutrition in intubated and mechanically-ventilated patients, and consider total parenteral nutrition, in the right clinical indication, and anticipate complications.
Manage pulmonary vascular diseases in intensive care setting. This includes awareness of critical care management indications for these conditions such as; pulmonary embolism and pulmonary arterial hypertension.
To use available methods, their indications and recognition of guidelines and application in Sedation, Analgesia and Delirium.
Anticipate complication of transfusion in critical care setting, mainly by recognition of transfusion associated volume overload, transfusion associated acute lung injury.
Apply of evidence-based medicine literature and application of Center of Disease Control initiatives to apply spontaneous awakening and breathing trials.
Contribute in prevention of critical care related conditions: Applications of measures to avoid ventilator associate events including; pneumonia and tracheobronchitides, and stress gastrointestinal ulcers.
Have skills in time management and avoid physical stress: through application of techniques to avoid burn-out and utilize time during a day of work in the ICU.
Details:
Time: early morning on weekdays, as possible 4 days per weekdays to have days-off applied (as required by ACGME).
Duration: 20-30 minutes
Location: MICU conference room.
After daily rounds on new and existing patients, small group discussions will be conducted in MICU conference room. The discussion will be facilitated by MICU fellow or an expert faculty member, who will be invited. Post call residents after rounds will leave to home and have a nap. They will be assigned to review one of the topics listed above. Next day would be a short call day to him/her. Therefore, the short call resident will lead the discussion. The MICU fellow will send an e-mail with updated review of literature about the topic, helping the resident to focus on major references related. However, residents are encouraged to search in other resources to have more discussion. Each of the topics will be discussed in terms of definition, criteria of diagnoses, available investigations and interpretations, management options in critical care setting and prognosis determination. The discussion should not exceed more than 30 minutes. An e-mail to residents with copying expert faculty members will be sent including answers to questions raised, a summary handout about the topic with references electronically-linked as possible of landmark randomized controlled trials, systematic reviews and meta-analyses in relation.
The session designed to discuss family discussion could have a different format. It will be in a role-play manner. MICU attendings expert in this field and Palliative care medicine faculty will be invited to arrange for this role-play sessions. It will be to mimic a family situation receiving information about their sick relative or disclosing medical errors. This session should take place in the same conference room to have a close proximity to medical care emergencies as necessary.
Last week of rotation sessions will be utilized in assessment of skills acquisition, knowledge improvement and attitude adaptation, in learning domains to their expectations.
Assessment:
These sessions represent discussions on the core topics in CCM. Assessing awareness of details and ability to reflect understanding in daily management is the goal. Through evaluation of daily practice, and formative evaluation with reflection, residents will be assessed for understanding. The following methods will aid in this process:
Reviewing Assignments prepared by short call residents to the group: To ensure relevant and related information are included with latest evidence-based medicine.
E-Mailed quizzes: This technique will reflect understanding through once-weekly emailed group of questions in relation to performance indicators outlined above. Source of these questions can be obtained from standardized references such as; Medical Knowledge Self-Assessment Physicians (MKSAP), or American College of Chest Physicians Self-Evaluation and Enhancement of Knowledge (ACCP-SEEK). These references usually have ideal answers that will help in knowledge enrichment, in addition to understanding of mistakes.
Self-Analysis Surveys: Previous surveys in needs assessment, distributed to medical residents and faculty can be distributed again during or after the rotation. They will reflect areas requiring more focus and self-feedback to the trainee.
Preparing and Caring of newly Admitted critically-ill patients to MICU
Learning Outcomes: By 4th week of MICU rotation, residents will be able to:
Obtain a comprehensive history and performing a thorough physical exam in critically-ill patients.
Provide safe and effective critical medical care with compassion, consideration, professionalism, and courtesy.
Formulate, in conjunction with the critical care team, a thoughtful assessment and plan for patients.
Initiate critical care management for patients with critical illnesses.
Performance Indicators: By 4th week of MICU rotation, residents will be able to:
Use available sources of information to have necessary history elements for critically-ill patients.
Communicate with other medical care teams to have necessary information of patients newly admitted to the MICU.
Apply comprehensive physical examination for critically-ill patients.
Conclude important differential diagnoses of critically-ill patients.
Request necessary investigations feasible to critically-ill patients.
Initiate monitoring methods of critically-ill patients.
Reconcile ongoing and prescribe new medications for patients.
Decide appropriate other medical or surgical teams consultations as needed.
Review latest evidence-based medicine literature for management of patients.
Summarize and present patients’ condition and plan of management next day, including latest evidence-based medicine literature supportive of management decided.
Details:
The MICU resident will evaluate requested admissions to the MICU. Sources of admission are; the emergency department, regular and step-down floor beds of the hospital and outside hospital transfers. The MICU resident will review details of the clinical presentation from history taking. If patients are intubated, accompanying family members or details from other caring teams (emergency department or floor caring teams). Review of outside hospital transfers discharge summaries will represent the history portion for intubated, transferred patients.
Residents will evaluate vital signs on presentation to the hospital. MICU resident will review changes of them and what management was initiated to maintain them if any. MICU residents will perform a thorough physical examination, review available and initiated investigations. A list of differential diagnoses will arise and a quick summary of the case will be presented to the MICU fellow. A medical decision will be determined by the fellow and the resident to decide a needed admission to the intensive care unit, or unnecessary up-escalation of care. This is usually the case of emergency department and floor transfer patients. Outside hospital transfers will be decided, in discussion between the outside medical team and MICU fellow, in advance. During discussions, MICU fellows will facilitate brainstorming thoughts of the resident evaluation to have appropriate consideration of all differential diagnoses. Risk stratification of the illness, decision of admission and needed management, according to the latest evidence-based medicine literature and hospital resources, will be discussed with the resident to reach appropriate medical care.
As the patient arrives, MICU resident will perform a quick reevaluation. This is important to review initial management of other caring teams and changes occurred on the patient’s condition. Meanwhile, MICU resident will formulate a plan of investigations and management, which should be reviewed verbally with the fellow. The MICU fellow will direct attention of the resident to available literature about the patient’s condition. The MICU Resident will perform necessary supervised procedures for monitoring or management. He/She will document the clinical presentation, with formulation of assessment and plan of care that should preferably include evidence-based medicine literature. His preparation of this clinical document should be prepared for the next morning presentation.
Assessment:
Review the clinical documentation of history, physical examination, clinical assessment and plan of management: Careful analysis and review of documentation about relevance of information and included evidence as encouraged. Electronic feedback as possible will help to improve active learning and reflect gaps in knowledge for future improvement.
Discussion during rounds: This will facilitate discovery of misunderstandings and awareness of details. If the attending is facilitating the discussion, the clinical fellow will reserve relevant points for later electronic or personal feedback.
Review included and relevant and latest evidence-based literature in Admission notes.
Session: Summarizing Events and Preparing Daily Progress Notes for patients in the MICU
Learning Outcomes: By the 4th week of MICU rotation, residents will be able to:
Record events of patients’ condition, and summarize them to the following care team.
Track and analyze investigations requested for critically-ill patients.
Carry on management plan for patients.
Performance Indicators: By the 4th week of MICU rotation, residents will
Track changes in clinical conditions of critically-ill patients.
Summarize daily events to the following resident.
Analyze changes in conditions of patients to conclude improvement or worsening.
Follow investigations requested for patients.
Communicate with other medical/surgical teams consulted, for care of patients.
Apply latest evidence-based medicine guidelines for management.
Apply preventive measures of complications that may occur to patients in MICU.
Details:
As rounds on newly, overnight admitted patients to MICU finishes, each resident will go to his rounding team for daily rounds on available patients. A summary of clinical events, review of requested investigation, reporting recommendations and/or interventions by consultants and generation of a coming 24-hour plan of care will be discussed for the coming day. Fellows and attendings will review their summary presentation and facilitate discussion to have residents actively decide plan of care. Highlights of latest reviews and critical care literature will be directed to. Each patient will have on average 10-15 minutes.
Assessment:
Review the clinical documentation of daily progress note: Careful analysis and review of documentation about relevance of information and included evidence as encouraged. Electronic feedback as possible will help to improve active learning and reflect gaps in knowledge for future improvement.
Discussion during rounds: This will facilitate discovery of misunderstandings and awareness of details. If the attending is facilitating the discussion, the clinical fellow will reserve relevant points for later electronic or personal feedback.
Review included and relevant evidence in progress notes.
360 degrees review: this tool will reflect objective opinion of nurses, respiratory therapists and rest of ancillary staff in MICU. Interviewing and survey distribution will aid in an objective documented evaluation.
Procedures in MICU
This is a part of daily practice and care for critically-ill patients. This session can exist as a part of care for new patients admitted to the MICU or during daily care for patients.
Learning Outcome: By the end of MICU rotation, residents will perform basic procedures in internal medicine and critical care medicine.
Performance Indicators: By the end of MICU rotation, residents will be able to:
- Perform procedures limited to intensive care setting including;
Arterial line placement.
Central Venous Catheter Placement.
- Continue performance of procedure necessary for care of internal medicine patients, including but not limited to;
Phlebotomy,
Arterial blood gas sampling,
Naso- or Oro-gastric tube placement,
Thoracentesis,
Arthrocentesis,
Paracentesis,
Lumbar puncture.
- Appreciate the clinical indications of each procedure
- Comprehend the risks (complications) and benefit of each procedure.
- Describe the procedure, the indication and com and obtain consent from patients or their families.
- Master the appropriate skill of performance of each of these procedures.
- Request the appropriate investigation if necessary after procedures performance, to assure patients’ safety and look for complications.
Details:
Procedures are necessary component of MICU rotations. It is considered a part of the core competencies in ACGME guidelines. Procedures maybe carried on during day or night practice in the MICU. Fellows are the supervising physicians for all procedures outlined above in performance indicators. Questionnaires obtained in the beginning of the rotation will be helpful to define the level of confidence of residents. The level of supervision will be determined accordingly. Patients’ safety will be assured with assistance by experienced nursing staff.
Assessment
360 degrees review: this tool will reflect objective opinion of nurses, respiratory therapists and rest of ancillary staff observing procedure performance in MICU. This is in addition to fellows’ opinion from supervision of these procedures.
Portfolio: “MedHub” documentation and co-signature on procedures performed in relation to guidelines and ideal performance
Checklists: Prepared checklists to the resident for review after being signed off on performing specific procedures. This will serve to outline necessary steps and in-order to save time and assure patient safety.
Mechanical Ventilation Rounds
Learning Outcome: By the end of this rotation, residents will be able to compare, apply and trouble-shoot emergencies in mechanically-ventilated patients.
Performance Indicators: By the end of the rotation, medical residents will be able to:
Compare basic modes of mechanical ventilation.
Choose the appropriate mode to the right patient.
Analyze ventilator graphics to recognize the mode of the ventilation, and synchrony with the patient.
Apply spontaneous awakening and breathing trials for ventilated patients.
Manage ventilator dyssynchrony (disconnect between the machine and the patient).
Manage ventilator alarms, emergencies and complications.
Explain to patients’ families’ progress, or regress, of their ill relatives.
Details:
This round occurs after admission and daily rounds in MICU. Respiratory therapists, MICU fellow and the long call resident will review ventilator changes, analyze graphics, review application of spontaneous awakening and breathing trials, apply latest evidence-based literature in mechanical ventilation and consider scenarios with plan of mechanical ventilation care in patients in the case of ventilator emergencies. Through answering questions, generating scenarios and discussions, medical residents will build their knowledge and enhance their skills in mechanical ventilation for intubated patients and patients needing non-invasive positive pressure ventilation.
A high-fidelity simulator will be considered in one of the un-utilized clinical rooms in the MICU. The simulator will be used to apply clinical scenarios to mimic ventilatory emergencies, explain basic modes of mechanical ventilation and assess how solution of errors improves outcomes.
Assessment
E-Mailed quizzes: these quizzes will include ventilator graphics, ventilator emergency management scenarios to assess comprehension
Simulation: Through ventilator rounding, this method will assess understanding and provide immediate feedback. It is possible for conduction last one or two weeks in MICU rotation.
Surveys: to faculty, fellows and residents themselves, for objective analysis and self-reflection.
Updated @July 2015