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SHANDS MEDICAL INTENSIVE CARE UNIT (MICU)

Rotation: SHANDS MEDICAL INTENSIVE CARE UNIT (MICU)

 

Updated: November 2012

Approved by Fellowship Program Education Committee

Fellow Level: F1                Duration: 1 month blocks

Location:          Shands MICU

Evaluation:      Done by supervising faculty in both written and verbal form

General Description:

The Shands MICU rotation includes the workup, evaluation, and management of critically ill patients with predominantly medical conditions. Patients seen during this rotation have a wide variety of common and uncommon medical critical care disorders involving one or more organ systems. Patients may have acute critical illness or more chronic critical illness.  Patients may be admitted from the surrounding community or transferred from another institution for tertiary level care.  Due to the nature of the institution, significant exposure to more severely ill and more medically complex patients including solid and hematopoietic cell transplant patients and patients with underlying malignancy occurs during this rotation.  The fellow on this service is responsible for initiating and coordinating the evaluation and management of patients on the service.  The fellow is responsible for performing intubations, bronchoscopies, and chest tube thoracostomies and to assist the residents with central venous access procedures and arterial line placements.  The fellow is responsible for coordinating consultations in the MICU and interacting with consulting services in implementation of evaluation and treatment recommendations.  Professionalism and helpfulness to the requested providers are expected at all times. The fellow is expected to be available to families to discuss treatment plans, response to therapy, and prognosis.  The fellow is expected to participate in end-of-life discussions with families and assist with provision of palliative treatments at the end-of-life.  An attending pulmonary and critical care medicine faculty member rounds with the fellow and MICU team to provide guidance and education as well as supervise procedures.

Multidisciplinary management of the critically ill patient is required as part of good clinical care and is an embedded component of this rotation. The fellow will interact with and coordinate care with nursing, respiratory therapy, pharmacy, social work, nutrition, and physical therapy.  The fellow will also supervise and teach residents and medical students on the rotation.

Learning takes place during bedside rounds, didactic conferences, sit down teaching rounds related to the care of patients, and through self study.

Core Competencies:

1. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

 To recognize the following:

The appropriate diagnostic studies including selection, implementation, and application in the critically ill medical patient

  • The synthesis of complex clinical information
  • The development of patient care plans in the critically ill medical patient
  • The ability to manage single and multiorgan failure
  • The technical expertise in performing procedures necessary to practice critical care medicine
  • The ability to initiate and interpret physiologic data monitoring in the critically ill medical patient
  • The appropriate and sensitive counseling of patient and family
  • The appropriate end-of-life decision making and ability to discuss these issues with patients and families

2. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care

To understand the following:

  • Healthcare team-Functioning as a member of a multidisciplinary team         
  • Ethics-Understand the principles of advance directives, terminal care, withdrawal of life support and conflict resolution
  • Severity of Illness
    • Understand the rationale, applications, and limitations of severity of illness evaluation
    • Know the basic components of the common severity of illness scoring systems, such as the APACHE system
  • Hemodynamic monitoring
    • Know the indications, contraindications, techniques, and potential complications of central venous catheterization
    • Know the indications, contraindications, techniques, and potential complications for arterial catheterization
    • Know the indications, contraindications, techniques, and potential complications for pulmonary artery catheterization
    • Interpret hemodynamic data including waveform analysis
    • Know how to calculate cardiac output, SVR, PVR
    • Know the pitfalls of hemodynamic monitoring
  • Pharmacology in the ICU
    • Understand the basic principles of pharmacokinetics and how organ dysfunction and critical illness can affect drug levels
    • Understand the indications and use of sedatives, hypnotics and paralytic drugs
  • Advanced cardiac life support
  • Endotracheal intubation, artificial airways, and airway management
    • Know the indications, contraindications, techniques, and potential complications of oral and nasotracheal intubation
    • Be familiar with the indications, contraindications, care, and potential complications of tracheostomy
    • Know the principles of airway management and emergency alternatives to endotracheal intubation
  • Mechanical Ventilation
    • Understand the principles of positive pressure ventilation
    • Know the common ventilator modes, settings, alarms, and monitors
    • Know the principles and rationale for modes of mechanical ventilation for ARDS/ALI
    • Know the mechanisms, risk factors, recognition, and management of pneumothorax and barotrauma
    • Understand the principles of weaning from mechanical ventilation
    • Appreciate the indications, contraindications, techniques, and potential complications of noninvasive mechanical ventilation
  • Arterial blood gas and pulse oximetry interpretation and acid / base disturbances
    • Understand how blood gases are measured
    • Understand pulse oximetry and its limitations
    • Know the principles of acid-base physiology and acid base disturbances
    • Interpret arterial blood gases and other laboratory measurements for acid base disturbances
  • Respiratory failure
    • Understand the causes, pathophysiology, and management of various forms of respiratory failure, including hypercapnic and hypoxemic respiratory failure
  • Acute respiratory distress syndrome
    • Understand the defining characteristics, causes, and pathophysiology of ARDS
    • Know the management principles for ARDS
  • Pneumonia in the ICU
    • Understand the pathophysiology, manifestations, prevention, diagnosis and management of ventilator-associated pneumonia
    • Know the causative agents and antibiotics for severe community acquired pneumonia
  • Life-threatening asthma
    • Know the pharmacologic management options for severe asthma
    • Understand the principles of mechanical ventilation for life-threatening asthma
  • Shock
    • Understand the various mechanisms of shock including hypovolemic, septic, cardiogenic, anaphylactic and obstructive
    • Know the principles of resuscitation from shock and understand how to monitor the effectiveness of resuscitation    
    • Know the characteristics and indications for common inotropic and vasopressor agents
  • Myocardial infarction                                                                                                                               
    • Know the diagnostic studies and basic management of cardiac ischemia and acute coronary syndrome
  • Cardiac arrhythmias
    • Identify atrial and ventricular tachyarrhythmias, heart blocks, and ECG abnormalities associated with electrolyte disturbances          
    • Know the anti-arrhythmic agents, including indications, contraindications, potential adverse effects
  • Hypertensive crisis
    • Know the criteria for hypertensive urgency and emergency
    • Know the medications to treat hypertensive crisis, including indications, contraindications, potential adverse effects
  • Acute renal failure
    • Know the differential diagnosis for acute renal failure
    • Know the management principles for acute renal failure, including indications for hemodialysis and CVVHD
  • Fluid and electrolyte disorders
    • Understand the pathophysiology, manifestations, and management of the electrolyte disorders
    • Understand the advantages and disadvantages of various forms of fluid administration (crystalloids / colloids)
  • Endocrine disorders in the ICU
    • Diabetic ketoacidosis-understand the pathophysiology, management and complications
    • Know the manifestations, diagnostic tests, and management of adrenal insufficiency
    • Know the manifestations, diagnosis and management of thyroid storm     
    • Know the manifestations, diagnosis and management of hypothyroidism
  • Nutrition
    • Know the principles of enteral nutrition
    • Know the principles of parenteral nutrition
    • Calculation of caloric need
  • Gastrointestinal disorders
    • Differential diagnosis, evaluation and management of upper GI bleeding
    • Differential diagnosis, evaluation and management of lower GI bleeding
    • Evaluation and management of acute pancreatitis
    • Evaluation and management of fulminate hepatic failure
    • Know the complications of cirrhosis and management
  • Hematology / Oncology disorders
    • Know the causes and management of bleeding disorders, including use of blood products
    • Management of the neutropenic and immunocompromised patient
    • Complications, and management of hematopoietic transplant patients
  • Nervous system disorders
    • Causes, evaluation, and management of coma
    • Causes, evaluation, and management of cerebrovascular accidents
    • Causes and management of seizures and status epilepticus
    • Criteria and testing for brain death
    • Causes and management of delirium and psychiatric disorders
    • Principles of sedative and paralytic drug administration
    • Know the causes, evaluation, and management of weakness and neuromuscular disorders including critical illness polyneuropathy, Guillain Barre syndrome, ALS myasthenia gravis
    • Principles, indications, methods for monitoring intracranial pressure
    • Management of elevated intracranial pressure
  • Infectious diseases issues in the ICU
    • Principles of infection control and prevention of nosocomial infection
    • Appreciate the spectrum of activity and potential adverse effects of antimicrobial agents
    • Causes and evaluation of fever in the ICU patient
    • Criteria, causes, evaluation, and management of septic shock
  • Miscellaneous critical care topics
    • Principles for evaluation of poisoning and drug overdose
    • Primary manifestations, evaluation, and management of common drug overdoses including acetaminophen, salicylate, tricyclic antidepressants, benzodiazepines
    • Disorders of temperature control including hypothermia, hyperthermia and neuroleptic malignant syndrome and their evaluation and management
    • Appreciate issues surrounding ICU management, billing and documentation, admission / discharge

3. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

To recognize the following:

  • The effective utilization of educational and evidence-based resources to seek answers to scientific and clinical questions
  • Identification of perceived deficiencies in knowledge or experience and actively seek opportunities for correction
  • Appropriate response to faculty direction and criticism and demonstrate learning from faculty/fellow interactions
  • Proficiency at using the electronic medical record and the use of electronic resources to look up medical information
  • Commitment to self-education by attending Divisional educational activities including conferences and journal clubs
  • Facilitate the learning of students, residents, and other healthcare professionals as well as colleagues

4. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals

To recognize the following:

  • Skills needed to interact with patients and their families in a manner that demonstrates compassion, competence and professionalism
  • Education to the residents and students working with their patients
  • The importance of peer-peer relationships and methods of handing off patient care responsibilities for safety and continuity of care
  • Appropriate relationships and communication skills with the ICU staff including nurses, pharmacists, respiratory therapists, social workers, and all other support personnel
  • Effective communication with colleagues, medical consultants, and consultants from other specialties

5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

To recognize the following:

  • The skills needed to interact with patients and their families in a manner that demonstrates compassion, competence and professionalism
  • Keeping the patient’s best interest as the primary goal and performing these duties in a professional and courteous manner when interacting with consulting services
  • Communication skills with patients and their families with attention not just to the medical aspects of care, but also to the psychological, social and spiritual dimensions as well
  • High standards of ethical / moral behavior
  • Honesty / integrity
  • Reliability / Responsibility
  • Reaction to stressful / emotional situations in an appropriate manner
  • Commitment to on-going professional development and lifelong learning
  • Attention to documentation in the medical record and communication with other treating physicians

6. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

To recognize the following:

  • Importance of leadership within a healthcare team
    • Provides appropriate documentation of effort for reimbursement
    • Demonstrates knowledge of and behavior consistent with strict Medicare and insurance compliance
  • Cost-effective health care that does not compromise patient care
  • Appropriate utilization of consultants and diagnostic testing information to provide effective patient care
  • Awareness of hospice and end-of-life resources available for patients and families
  • Adequate recordkeeping skills

 

Rotation: SHANDS MEDICAL INTENSIVE CARE UNIT (MICU)

Updated: November 2012

Approved by Fellowship Program Education Committee

Fellow Level: F2                Duration: 1 month blocks

Location:          Shands MICU

Evaluation:      Done by supervising faculty in both written and verbal form

General Description:

The Shands MICU rotation includes the workup, evaluation, and management of critically ill patients with predominantly medical conditions. Patients seen during this rotation have a wide variety of common and uncommon medical critical care disorders involving one or more organ systems. Patients may have acute critical illness or more chronic critical illness.  Patients may be admitted from the surrounding community or transferred from another institution for tertiary level care.  Due to the nature of the institution, significant exposure to more severely ill and more medically complex patients including solid and hematopoietic cell transplant patients and patients with underlying malignancy occurs during this rotation.  The fellow on this service is responsible for initiating and coordinating the evaluation and management of patients on the service.  The fellow is responsible for performing intubations, bronchoscopies, and chest tube thoracostomies and to assist the residents with central venous access procedures and arterial line placements.  The fellow is responsible for coordinating consultations in the MICU and interacting with consulting services in implementation of evaluation and treatment recommendations.  Professionalism and helpfulness to the requested providers are expected at all times. The fellow is expected to be available to families to discuss treatment plans, response to therapy, and prognosis.  The fellow is expected to participate in end-of-life discussions with families and assist with provision of palliative treatments at the end-of-life.  An attending pulmonary and critical care medicine faculty member rounds with the fellow and MICU team to provide guidance and education as well as supervise procedures.

Multidisciplinary management of the critically ill patient is required as part of good clinical care and is an embedded component of this rotation. The fellow will interact with and coordinate care with nursing, respiratory therapy, pharmacy, social work, nutrition, and physical therapy.  The fellow will also supervise and teach residents and medical students on the rotation.

Learning takes place during bedside rounds, didactic conferences, sit down teaching rounds related to the care of patients, and through self study.

Core Competencies:

1. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

To recognize the following:

  • The appropriate diagnostic studies including selection, implementation, and application in the critically ill medical patient
  • The synthesis of complex clinical information
  • The development of patient care plans in the critically ill medical patient
  • The ability to manage single and multiorgan failure
  • The technical expertise in performing procedures necessary to practice critical care medicine
  • The ability to initiate and interpret physiologic data monitoring in the critically ill medical patient
  • The appropriate and sensitive counseling of patient and family
  • The appropriate end-of-life decision making and ability to discuss these issues with patients and families

2. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care

To understand the following:

  • Healthcare team-Functioning as a member of a multidisciplinary team         
  • Ethics-Understand the principles of advance directives, terminal care, withdrawal of life support and conflict resolution
  • Severity of Illness
    • Understand the rationale, applications, and limitations of severity of illness evaluation
    • Know the basic components of the common severity of illness scoring systems, such as the APACHE system
  • Hemodynamic monitoring
    • Know the indications, contraindications, techniques, and potential complications of central venous catheterization
    • Know the indications, contraindications, techniques, and potential complications for arterial catheterization
    • Know the indications, contraindications, techniques, and potential complications for pulmonary artery catheterization
    • Interpret hemodynamic data including waveform analysis
    • Know how to calculate cardiac output, SVR, PVR
    • Know the pitfalls of hemodynamic monitoring
  • Pharmacology in the ICU
    • Understand the basic principles of pharmacokinetics and how organ dysfunction and critical illness can affect drug levels
    • Understand the indications and use of sedatives, hypnotics and paralytic drugs
  • Advanced cardiac life support
  • Endotracheal intubation, artificial airways, and airway management
    • Know the indications, contraindications, techniques, and potential complications of oral and nasotracheal intubation
    • Be familiar with the indications, contraindications, care, and potential complications of tracheostomy
    • Know the principles of airway management and emergency alternatives to endotracheal intubation
  • Mechanical Ventilation
    • Understand the principles of positive pressure ventilation
    • Know the common ventilator modes, settings, alarms, and monitors
    • Know the principles and rationale for modes of mechanical ventilation for ARDS/ALI
    • Know the mechanisms, risk factors, recognition, and management of pneumothorax and barotrauma
    • Understand the principles of weaning from mechanical ventilation
    • Appreciate the indications, contraindications, techniques, and potential complications of noninvasive mechanical ventilation
  • Arterial blood gas and pulse oximetry interpretation and acid / base disturbances
    • Understand how blood gases are measured
    • Understand pulse oximetry and its limitations
    • Know the principles of acid-base physiology and acid base disturbances
    • Interpret arterial blood gases and other laboratory measurements for acid base disturbances
  • Respiratory failure
    • Understand the causes, pathophysiology, and management of various forms of respiratory failure, including hypercapnic and hypoxemic respiratory failure
  • Acute respiratory distress syndrome
    • Understand the defining characteristics, causes, and pathophysiology of ARDS
    • Know the management principles for ARDS
  • Pneumonia in the ICU
    • Understand the pathophysiology, manifestations, prevention, diagnosis and management of ventilator-associated pneumonia
    • Know the causative agents and antibiotics for severe community acquired pneumonia
  • Life-threatening asthma
    • Know the pharmacologic management options for severe asthma
    • Understand the principles of mechanical ventilation for life-threatening asthma
  • Shock
    • Understand the various mechanisms of shock including hypovolemic, septic, cardiogenic, anaphylactic and obstructive
    • Know the principles of resuscitation from shock and understand how to monitor the effectiveness of resuscitation    
    • Know the characteristics and indications for common inotropic and vasopressor agents
  • Myocardial infarction                                                                                                                              
    • Know the diagnostic studies and basic management of cardiac ischemia and acute coronary syndrome
  • Cardiac arrhythmias
    • Identify atrial and ventricular tachyarrhythmias, heart blocks, and ECG abnormalities associated with electrolyte disturbances          
    • Know the anti-arrhythmic agents, including indications, contraindications, potential adverse effects
  • Hypertensive crisis
    • Know the criteria for hypertensive urgency and emergency
    • Know the medications to treat hypertensive crisis, including indications, contraindications, potential adverse effects
  • Acute renal failure
    • Know the differential diagnosis for acute renal failure
    • Know the management principles for acute renal failure, including indications for hemodialysis and CVVHD
  • Fluid and electrolyte disorders
    • Understand the pathophysiology, manifestations, and management of the electrolyte disorders
    • Understand the advantages and disadvantages of various forms of fluid administration (crystalloids / colloids)
  • Endocrine disorders in the ICU
    • Diabetic ketoacidosis-understand the pathophysiology, management and complications
    • Know the manifestations, diagnostic tests, and management of adrenal insufficiency
    • Know the manifestations, diagnosis and management of thyroid storm     
    • Know the manifestations, diagnosis and management of hypothyroidism
  • Nutrition
    • Know the principles of enteral nutrition
    • Know the principles of parenteral nutrition
    • Calculation of caloric need
  • Gastrointestinal disorders
    • Differential diagnosis, evaluation and management of upper GI bleeding
    • Differential diagnosis, evaluation and management of lower GI bleeding
    • Evaluation and management of acute pancreatitis
    • Evaluation and management of fulminate hepatic failure
    • Know the complications of cirrhosis and management
  • Hematology / Oncology disorders
    • Know the causes and management of bleeding disorders, including use of blood products
    • Management of the neutropenic and immunocompromised patient
    • Complications, and management of hematopoietic transplant patients
  • Nervous system disorders
    • Causes, evaluation, and management of coma
    • Causes, evaluation, and management of cerebrovascular accidents
    • Causes and management of seizures and status epilepticus
    • Criteria and testing for brain death
    • Causes and management of delirium and psychiatric disorders
    • Principles of sedative and paralytic drug administration
    • Know the causes, evaluation, and management of weakness and neuromuscular disorders including critical illness polyneuropathy, Guillain Barre syndrome, ALS myasthenia gravis
    • Principles, indications, methods for monitoring intracranial pressure
    • Management of elevated intracranial pressure
  • Infectious diseases issues in the ICU
    • Principles of infection control and prevention of nosocomial infection
    • Appreciate the spectrum of activity and potential adverse effects of antimicrobial agents
    • Causes and evaluation of fever in the ICU patient
    • Criteria, causes, evaluation, and management of septic shock
  • Miscellaneous critical care topics
    • Principles for evaluation of poisoning and drug overdose
    • Primary manifestations, evaluation, and management of common drug overdoses including acetaminophen, salicylate, tricyclic antidepressants, benzodiazepines
    • Disorders of temperature control including hypothermia, hyperthermia and neuroleptic malignant syndrome and their evaluation and management
    • Appreciate issues surrounding ICU management, billing and documentation, admission / discharge

3. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

To recognize the following:

  • The effective utilization of educational and evidence-based resources to seek answers to scientific and clinical questions
  • Identification of perceived deficiencies in knowledge or experience and actively seek opportunities for correction
  • Appropriate response to faculty direction and criticism and demonstrate learning from faculty/fellow interactions
  • Proficiency at using the electronic medical record and the use of electronic resources to look up medical information
  • Commitment to self-education by attending Divisional educational activities including conferences and journal clubs
  • Facilitate the learning of students, residents, and other healthcare professionals as well as colleagues

4. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals

To recognize the following:

  • Skills needed to interact with patients and their families in a manner that demonstrates compassion, competence and professionalism
  • Education to the residents and students working with their patients
  • The importance of peer-peer relationships and methods of handing off patient care responsibilities for safety and continuity of care
  • Appropriate relationships and communication skills with the ICU staff including nurses, pharmacists, respiratory therapists, social workers, and all other support personnel
  • Effective communication with colleagues, medical consultants, and consultants from other specialties

5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

To recognize the following:

  • The skills needed to interact with patients and their families in a manner that demonstrates compassion, competence and professionalism
  • Keeping the patient’s best interest as the primary goal and performing these duties in a professional and courteous manner when interacting with consulting services
  • Communication skills with patients and their families with attention not just to the medical aspects of care, but also to the psychological, social and spiritual dimensions as well
  • High standards of ethical / moral behavior
  • Honesty / integrity
  • Reliability / Responsibility
  • Reaction to stressful / emotional situations in an appropriate manner
  • Commitment to on-going professional development and lifelong learning
  • Attention to documentation in the medical record and communication with other treating physicians

6. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

 To recognize the following:

  • Importance of leadership within a healthcare team
    • Provides appropriate documentation of effort for reimbursement
    • Demonstrates knowledge of and behavior consistent with strict Medicare and insurance compliance
  • Cost-effective health care that does not compromise patient care
  • Appropriate utilization of consultants and diagnostic testing information to provide effective patient care
  • Awareness of hospice and end-of-life resources available for patients and families
  • Adequate recordkeeping skills

The second year fellow will demonstrate the following:

  • Competency in medical interviewing
  • Competency in physical examination
  • Begins to develop proficiency in selection, implementation, and application of diagnostic testing pertinent to pulmonary and critical care medicine
  • Further develops proficiency in the synthesis of clinical information
  • Further develops proficiency in the ability to develop a patient care plan
  • Competency in performing the following procedures necessary to practice Pulmonary and Critical Care Medicine
    • Arterial cannulation
    • Central line placement
    • Chest tube placement and management
    • Continues to develop proficiency in performing the following procedures necessary to practice Pulmonary and Critical Care Medicine and demonstrates greater independence in performing these procedures
      • Flexible bronchoscopy in the ventilated patient
      • Endotracheal intubation
      • Management of the difficult airway
      • Initiation, maintenance, and discontinuation of mechanical ventilation
      • Pulmonary artery catheter data interpretation
      • Proficiency in counseling of patient and family
      • Proficiency in end-of-life decision making and ability to discuss these issues with patients and families
      • Continues to develop basic science knowledge (physiology, pharmacology, anatomy) and understanding of pathophysiology as related to the patient’s disease process requiring ICU care
      • Continues to develop understanding of laboratory, imaging techniques, and invasive procedures required to make correct diagnoses in patients with disease processes requiring ICU care
      • Continues to develop knowledge of pharmacologic and other management options for diseases requiring ICU care
      • Develops greater understanding of surgical procedures relevant to care of the ICU patient
      • Continues to learn how to use evidence-based medicine to improve patient care
      • Proficiency in using medical databases and the use of Internet resources to improve their knowledge base, improve patient care, and conduct research
      • Ability to teach students, residents, and other healthcare professionals as well as colleagues
      • Proficiency in communicating and working effectively with patients, their families and members of the health care team in relevant health care delivery settings and systems
      • Effective communication with colleagues, medical consultants, and consultants from other specialties
      • Commitment to on-going professional development and lifelong learning
      • Attention to documentation in the medical record and communication with other treating physicians
      • Continues to develop the ability to deliver cost-effective health care that does not compromise patient care
      • Continues to develop the ability to appropriately utilize consultants and diagnostic testing information to provide effective patient care
      • Continues to develop an awareness of hospice and end-of-life resources available for patients and families
      • Continues to develop adequate recordkeeping skills that:
        • Provides appropriate documentation of effort for reimbursement
        • Demonstrates knowledge of and behavior consistent with strict Medicare compliance

 

Rotation: SHANDS MEDICAL INTENSIVE CARE UNIT (MICU)

 Updated: February 2012

Approved by Fellowship Program Education Committee

Fellow Level: F3                Duration: 1 month blocks

Location:          Shands MICU

Evaluation:      Done by supervising faculty in both written and verbal form

General Description:

The Shands MICU rotation includes the workup, evaluation, and management of critically ill patients with predominantly medical conditions. Patients seen during this rotation have a wide variety of common and uncommon medical critical care disorders involving one or more organ systems. Patients may have acute critical illness or more chronic critical illness.  Patients may be admitted from the surrounding community or transferred from another institution for tertiary level care.  Due to the nature of the institution, significant exposure to more severely ill and more medically complex patients including solid and hematopoietic cell transplant patients and patients with underlying malignancy occurs during this rotation.  The fellow on this service is responsible for initiating and coordinating the evaluation and management of patients on the service.  The fellow is responsible for performing intubations, bronchoscopies, and chest tube thoracostomies and to assist the residents with central venous access procedures and arterial line placements.  The fellow is responsible for coordinating consultations in the MICU and interacting with consulting services in implementation of evaluation and treatment recommendations.  Professionalism and helpfulness to the requested providers are expected at all times. The fellow is expected to be available to families to discuss treatment plans, response to therapy, and prognosis.  The fellow is expected to participate in end-of-life discussions with families and assist with provision of palliative treatments at the end-of-life.  An attending pulmonary and critical care medicine faculty member rounds with the fellow and MICU team to provide guidance and education as well as supervise procedures.

Multidisciplinary management of the critically ill patient is required as part of good clinical care and is an embedded component of this rotation. The fellow will interact with and coordinate care with nursing, respiratory therapy, pharmacy, social work, nutrition, and physical therapy.  The fellow will also supervise and teach residents and medical students on the rotation.

Learning takes place during bedside rounds, didactic conferences, sit down teaching rounds related to the care of patients, and through self study.

Core Competencies:

1. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

To recognize the following:

  • The appropriate diagnostic studies including selection, implementation, and application in the critically ill medical patient
  • The synthesis of complex clinical information
  • The development of patient care plans in the critically ill medical patient
  • The ability to manage single and multiorgan failure
  • The technical expertise in performing procedures necessary to practice critical care medicine
  • The ability to initiate and interpret physiologic data monitoring in the critically ill medical patient
  • The appropriate and sensitive counseling of patient and family
  • The appropriate end-of-life decision making and ability to discuss these issues with patients and families

2. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care

To understand the following:

  • Healthcare team-Functioning as a member of a multidisciplinary team         
  • Ethics-Understand the principles of advance directives, terminal care, withdrawal of life support and conflict resolution
  • Severity of Illness
    • Understand the rationale, applications, and limitations of severity of illness evaluation
    • Know the basic components of the common severity of illness scoring systems, such as the APACHE system
  • Hemodynamic monitoring
    • Know the indications, contraindications, techniques, and potential complications of central venous catheterization
    • Know the indications, contraindications, techniques, and potential complications for arterial catheterization
    • Know the indications, contraindications, techniques, and potential complications for pulmonary artery catheterization
    • Interpret hemodynamic data including waveform analysis
    • Know how to calculate cardiac output, SVR, PVR
    • Know the pitfalls of hemodynamic monitoring
  • Pharmacology in the ICU
    • Understand the basic principles of pharmacokinetics and how organ dysfunction and critical illness can affect drug levels
    • Understand the indications and use of sedatives, hypnotics and paralytic drugs
  • Advanced cardiac life support
  • Endotracheal intubation, artificial airways, and airway management
    • Know the indications, contraindications, techniques, and potential complications of oral and nasotracheal intubation
    • Be familiar with the indications, contraindications, care, and potential complications of tracheostomy
    • Know the principles of airway management and emergency alternatives to endotracheal intubation
  • Mechanical Ventilation
    • Understand the principles of positive pressure ventilation
    • Know the common ventilator modes, settings, alarms, and monitors
    • Know the principles and rationale for modes of mechanical ventilation for ARDS/ALI
    • Know the mechanisms, risk factors, recognition, and management of pneumothorax and barotrauma
    • Understand the principles of weaning from mechanical ventilation
    • Appreciate the indications, contraindications, techniques, and potential complications of noninvasive mechanical ventilation
  • Arterial blood gas and pulse oximetry interpretation and acid / base disturbances
    • Understand how blood gases are measured
    • Understand pulse oximetry and its limitations
    • Know the principles of acid-base physiology and acid base disturbances
    • Interpret arterial blood gases and other laboratory measurements for acid base disturbances
  • Respiratory failure
    • Understand the causes, pathophysiology, and management of various forms of respiratory failure, including hypercapnic and hypoxemic respiratory failure
  • Acute respiratory distress syndrome
    • Understand the defining characteristics, causes, and pathophysiology of ARDS
    • Know the management principles for ARDS
  • Pneumonia in the ICU
    • Understand the pathophysiology, manifestations, prevention, diagnosis and management of ventilator-associated pneumonia
    • Know the causative agents and antibiotics for severe community acquired pneumonia
  • Life-threatening asthma
    • Know the pharmacologic management options for severe asthma
    • Understand the principles of mechanical ventilation for life-threatening asthma
  • Shock
    • Understand the various mechanisms of shock including hypovolemic, septic, cardiogenic, anaphylactic and obstructive
    • Know the principles of resuscitation from shock and understand how to monitor the effectiveness of resuscitation    
    • Know the characteristics and indications for common inotropic and vasopressor agents
  • Myocardial infarction                                                                                                                               
    • Know the diagnostic studies and basic management of cardiac ischemia and acute coronary syndrome
  • Cardiac arrhythmias
    • Identify atrial and ventricular tachyarrhythmias, heart blocks, and ECG abnormalities associated with electrolyte disturbances          
    • Know the anti-arrhythmic agents, including indications, contraindications, potential adverse effects
  • Hypertensive crisis
    • Know the criteria for hypertensive urgency and emergency
    • Know the medications to treat hypertensive crisis, including indications, contraindications, potential adverse effects
  • Acute renal failure
    • Know the differential diagnosis for acute renal failure
    • Know the management principles for acute renal failure, including indications for hemodialysis and CVVHD
  • Fluid and electrolyte disorders
    • Understand the pathophysiology, manifestations, and management of the electrolyte disorders
    • Understand the advantages and disadvantages of various forms of fluid administration (crystalloids / colloids)
  • Endocrine disorders in the ICU
    • Diabetic ketoacidosis-understand the pathophysiology, management and complications
    • Know the manifestations, diagnostic tests, and management of adrenal insufficiency
    • Know the manifestations, diagnosis and management of thyroid storm     
    • Know the manifestations, diagnosis and management of hypothyroidism
  • Nutrition
    • Know the principles of enteral nutrition
    • Know the principles of parenteral nutrition
    • Calculation of caloric need
  • Gastrointestinal disorders
    • Differential diagnosis, evaluation and management of upper GI bleeding
    • Differential diagnosis, evaluation and management of lower GI bleeding
    • Evaluation and management of acute pancreatitis
    • Evaluation and management of fulminate hepatic failure
    • Know the complications of cirrhosis and management
  • Hematology / Oncology disorders
    • Know the causes and management of bleeding disorders, including use of blood products
    • Management of the neutropenic and immunocompromised patient
    • Complications, and management of hematopoietic transplant patients
  • Nervous system disorders
    • Causes, evaluation, and management of coma
    • Causes, evaluation, and management of cerebrovascular accidents
    • Causes and management of seizures and status epilepticus
    • Criteria and testing for brain death
    • Causes and management of delirium and psychiatric disorders
    • Principles of sedative and paralytic drug administration
    • Know the causes, evaluation, and management of weakness and neuromuscular disorders including critical illness polyneuropathy, Guillain Barre syndrome, ALS myasthenia gravis
    • Principles, indications, methods for monitoring intracranial pressure
    • Management of elevated intracranial pressure
  • Infectious diseases issues in the ICU
    • Principles of infection control and prevention of nosocomial infection
    • Appreciate the spectrum of activity and potential adverse effects of antimicrobial agents
    • Causes and evaluation of fever in the ICU patient
    • Criteria, causes, evaluation, and management of septic shock
  • Miscellaneous critical care topics
    • Principles for evaluation of poisoning and drug overdose
    • Primary manifestations, evaluation, and management of common drug overdoses including acetaminophen, salicylate, tricyclic antidepressants, benzodiazepines
    • Disorders of temperature control including hypothermia, hyperthermia and neuroleptic malignant syndrome and their evaluation and management
    • Appreciate issues surrounding ICU management, billing and documentation, admission / discharge

3. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

To recognize the following:

  • The effective utilization of educational and evidence-based resources to seek answers to scientific and clinical questions
  • Identification of perceived deficiencies in knowledge or experience and actively seek opportunities for correction
  • Appropriate response to faculty direction and criticism and demonstrate learning from faculty/fellow interactions
  • Proficiency at using the electronic medical record and the use of electronic resources to look up medical information
  • Commitment to self-education by attending Divisional educational activities including conferences and journal clubs
  • Facilitate the learning of students, residents, and other healthcare professionals as well as colleagues

4. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals

To recognize the following:

  • Skills needed to interact with patients and their families in a manner that demonstrates compassion, competence and professionalism
  • Education to the residents and students working with their patients
  • The importance of peer-peer relationships and methods of handing off patient care responsibilities for safety and continuity of care
  • Appropriate relationships and communication skills with the ICU staff including nurses, pharmacists, respiratory therapists, social workers, and all other support personnel
  • Effective communication with colleagues, medical consultants, and consultants from other specialties

5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

To recognize the following:

  • The skills needed to interact with patients and their families in a manner that demonstrates compassion, competence and professionalism
  • Keeping the patient’s best interest as the primary goal and performing these duties in a professional and courteous manner when interacting with consulting services
  • Communication skills with patients and their families with attention not just to the medical aspects of care, but also to the psychological, social and spiritual dimensions as well
  • High standards of ethical / moral behavior
  • Honesty / integrity
  • Reliability / Responsibility
  • Reaction to stressful / emotional situations in an appropriate manner
  • Commitment to on-going professional development and lifelong learning
  • Attention to documentation in the medical record and communication with other treating physicians

6. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

To recognize the following:

  • Importance of leadership within a healthcare team
    • Provides appropriate documentation of effort for reimbursement
    • Demonstrates knowledge of and behavior consistent with strict Medicare and insurance compliance
  • Cost-effective health care that does not compromise patient care
  • Appropriate utilization of consultants and diagnostic testing information to provide effective patient care
  • Awareness of hospice and end-of-life resources available for patients and families
  • Adequate recordkeeping skills

The third year fellow will demonstrate the following:

  • Competency in medical interviewing
  • Competency in physical examination
  • Competency in the selection, implementation, and application of diagnostic testing pertinent to pulmonary and critical care medicine
  • Competency in the synthesis of clinical information
  • Competency in the ability to develop a patient care plan
  • Competency in performing the following procedures necessary to practice Pulmonary and Critical Care Medicine
    • Arterial cannulation
    • Central line placement
    • Pulmonary artery catheter data interpretation
    • Chest tube placement and management
    • Flexible bronchoscopy in the ventilated patient
    • Endotracheal intubation
    • Management of the difficult airway
    • Initiation, maintenance, and discontinuation of mechanical ventilation
    • Competency in counseling of patient and family
    • Competency in end-of-life decision making and ability to discuss these issues with patients and families
    • Continues to develop basic science knowledge (physiology, pharmacology, anatomy) and understanding of pathophysiology as related to the patient’s disease process requiring ICU care
    • Understanding of laboratory, imaging techniques, and invasive procedures required to make correct diagnoses in patients with disease processes requiring ICU care
    • Continues to develop knowledge of pharmacologic and other management options for diseases requiring ICU care
    • Develops greater understanding of surgical procedures relevant to care of the ICU patient
    • Proficiency in the use evidence-based medicine to improve patient care
    • Proficiency in using medical databases and the use of Internet resources to improve their knowledge base, improve patient care, and conduct research
    • Ability to teach students, residents, and other healthcare professionals as well as colleagues
    • Competency in communicating and working effectively with patients, their families and members of the health care team in relevant health care delivery settings and systems
    • Competency in effective communication with colleagues, medical consultants, and consultants from other specialties
    • Commitment to on-going professional development and lifelong learning
    • Attention to documentation in the medical record and communication with other treating physicians
    • Competency in delivering cost-effective health care that does not compromise patient care
    • Competency in the ability to appropriately utilize consultants and diagnostic testing information to provide effective patient care
    • Awareness of hospice and end-of-life resources available for patients and families
    • Competency in adequate recordkeeping skills that:
      • Provides appropriate documentation of effort for reimbursement
      • Demonstrates knowledge of and behavior consistent with strict Medicare compliance