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CICU Rotation Goals & Learning Objectives

2016 CICU Rotation

Goals and Learning Objectives

I. Medical Knowledge

Goal:  Demonstrate knowledge of established and evolving biomedical, clinical and social sciences and the application of knowledge to patient care and education of others. Fellows are expected to develop this knowledge through reading major textbooks in pediatric critical care and pediatric cardiac critical care; attending monthly lectures including core lecture series, cardiac surgery morbidity and mortality conference, cardiology catheterization conference, ethics conference, cardiac surgery conference, journal club, professor rounds; and observing and discussing senior fellow and faculty management.

Objectives:

  1. Year One
    1. Recognize need for, state proper indications for, discuss potential complications of, and demonstrate appropriate initial stabilization of patients with critical cardiac disease requiring
      1. Airway management
      2. Cardiopulmonary resuscitation
      3. Transport (intra- and inter-facility)
      4. Invasive procedures
      5. Recognition and initial management of shock
  1. Demonstrate appropriate titration of basic life support including
    1. Conventional mechanical ventilation
    2. Hemodynamic support
  1. Explain indications for, and manage, advanced life support technologies (under close senior fellow and attending supervision) including:
    1. Extracorporeal life support
    2. Renal replacement therapies
    3. Plasmapheresis/plasma exchange
    4. Ventricular assist devices
    5. Whole blood exchange
    6. Temporary pacemaker
  1. Explain methods of, indications for, and limitations of, and demonstrate interpretations of resulting data from common ICU monitoring modalities, including
    1. Respiratory
      1. Pulse oximetry
      2. End-tidal CO2 monitoring
      3. Flow-volume loops
      4. Pressure volume curves
      5. Pacemakers
  1. Hemodynamic
    1. Invasive hemodynamic monitoring, including arterial, central venous, and pulmonary arterial, left atrial
    2. ECG
    3. Non-invasive cardiac output determination
    4. Central/mixed venous oxygen saturation
    5. Basics of echocardiography
  1. Neurologic
    1. Glasgow Coma Scale
    2. Train-of-four monitoring
  1. Write orders reflecting understanding of
    1. Pre operative care of critically ill children and neonates with congenital or acquired cardiac defects
    2. Post operative care of  critically ill children and neonates with congenital or acquired cardiac defects
    3. Principles of antimicrobial therapy
    4. Nutritional requirements of critically ill children
    5. Alterations in drug metabolism during critical illness and organ dysfunction
    6. Alterations in antimicrobials for patients with immunosuppression
  1. Explain basic pathophysiologic and pharmacologic principles underlying management of, provide care for patients with, and relate management decisions to classic literature about patients with cardiac disease accompanied by
    1. Respiratory disease, including
      1. Respiratory physiology and monitoring
      2. Post operative respiratory failure
      3. Acute Lung Injury and Acute Respiratory Distress Syndrome
      4. Chronic respiratory failure
  1. Cardiac disease, including
    1. Cardiogenic shock secondary to cardiomyopathy or myocarditis
    2. Shock of multiple etiologies
    3. Deranged cardiorespiratory interactions
    4. Pulmonary hypertension
    5. Heart failure in infants and children
    6. Pre and post operative care of children and infants with congenital or acquired cardiac defects
    7. Medical and pharmacologic management of dysrhythmias
  1. Neurological/neuromuscular disease
    1. Coma
    2. Neurologic monitoring
    3. Neurologic imaging
    4. Cerebrovascular disease, including stroke in cardiopulmonary bypass patients
    5.  Brain death
    6. Post cardiopulmonary bypass seizures
  1. Immunologic/inflammatory diseases
    1. Multiple organ dysfunction syndrome
    2.  Complications of cardiac transplantation
    3.  White blood cell function in critical illness
    4.  Immune system and viral Illness
    5. Immune modulation and immunotherapy
  1. Infectious diseases
    1. Bacterial sepsis
    2. Critical viral infections
    3. Nosocomial Infections in the CICU
    4. Opportunistic infections
  1. Nutritional and gastrointestinal disorders
    1. Liver failure s/p cardiac arrest
    2. Pancreatitis in the post operative patient
    3. Gastrointestinal bleeding in the CICU patient
    4. Malabsorption syndromes
    5. Necrotizing enterocolitis related to unbalanced circulation
  1. Renal, endocrine, and metabolic disorders
    1. Adrenal dysfunction
    2. Disorders of glucose homeostasis
    3. Disorders of water, sodium, and potassium homeostasis
    4. Disorders of calcium, magnesium, and phosphate
    5. Acute renal failure and end-stage renal disease
  1. Hematologic disorders
    1. Post operative hemorrhage
    2. Hematologic emergencies  
    3. Coagulation issues in the CICU
    4. Coagulation issues in the post cardiopulmonary bypass patient
  1. Environmental crises
    1. Electrical injuries resulting in dysrhythmia
  1. Year Two
    1. Explain principles of advanced pediatric critical care support in the following areas including demonstrating familiarity with current literature:
      1. Life support technologies
        1. Advanced modes of mechanical ventilation (HFO, APRV, Inverse Ratio)
        2. Management, complications and outcomes of extracorporeal life support
        3. Management, complications and outcomes of renal replacement therapies
  1. Respiratory disease
    1. Principles of chronic and home ventilator needs of cardiac patients
  1. Cardiac disease
    1. Cardiovascular physiology
    2. Mechanisms of and treatment for dysrhythmias
    3. ECG interpretation
    4. Cardiorespiratory interactions
  1. Neurological disease
    1. Postoperative neurologic injury
  1. Hematology
    1. Anticoagulation of the cardiac patient
  1. Infectious diseases
    1. Immunosuppressive regimens for the cardiac transplant patient
  1. Nutritional and gastrointestinal disorders
    1. Nutritional needs in the post operative cardiac patient
  1. Renal, endocrine, and metabolic disorders
  1. Year 3
    1. Read and be able to explain principles relevant to pediatric cardiac critical care medicine of the following:
      1. Advanced concepts of pediatric critical care
        1. Principles and ethics of cardiac transplantation
        2. Cellular adaptations to stress
        3. Rehabilitation of children with cardiac critical illness
        4. Organ donation concepts and protocols

II. Patient Care

Goal:  Provide patient care that is compassionate, appropriate, and effective for the promotion of health, prevention or treatment of disease especially associated with cardiac disease or failure, and at the end-of-life

Objectives:

  1. Year One
    1. Provide direct titrated bedside care for patients at with cardiac disease consistent with evidence from the medical literature
    2. Interpret laboratory and physiologic data, synthesize it to recognize patient deterioration or improvement, and make fundamentally sound decisions regarding patient support
    3. Demonstrate appropriate recognition of major congenital cardiac lesions according to patient history, physical exam, and radiologic or laboratory findings
    4. Demonstrate appropriate management for CICU patients, pre and post operatively as necessary according to the patient’s congenital cardiac lesion
    5. Plan an approach for sedation and analgesia in the CICU and titrate the medications as needed
    6. Develop basic proficiency performing CICU procedures
    7. Perform patient consultations to emergency room and pediatric cardiac floor and make triage decisions based on patient condition, hospital policies, and needs of the institution as a whole
    8. Initiate appropriate invasive monitoring; evaluate data, and implement appropriate treatment plans
    9. Initiate appropriate pharmacologic support for hypertension, hypotension, and arrhythmias, and evaluate the effectiveness of the intervention
    10. Identify indications for extra-corporeal membrane oxygenation (ECMO) and provide basic management for ECMO patients
    11. Order appropriate and timely laboratory tests for CICU patients
    12. Recognize and provide treatment under close supervision by senior fellows and faculty of acute, life-threatening illnesses in children ranging from newborn to adolescents. Specifically, this includes understanding the management of pediatric CICU patients with:
      1. Cardiovascular instability including arrhythmias, congestive heart failure, pacemaker utility and function and cardiomyopathy
      2. Congenital or cardiac defects
      3. Post operative respiratory failure and recognition and management of the difficult pediatric airway
      4. Renal insufficiency; acute or chronic
      5. Metabolic, endocrine and electrolyte abnormalities including hypo- or hypokalemia, hypcalcemia and their effect on cardiac function
      6. Infectious diseases including management of the immunocompromised cardiac transplant patients
      7. Shock including, cardiogenic, septic, and hypovolemic shock
      8. Hematologic disorders including anemia, neutropenia, thrombocytopenia, and coagulation disorders
      9. Gastrointestinal diseases including upper and lower GI hemorrhage, chronic malabsorptive syndromes
      10. Heart and/or lung transplantation patients
  1. Year Two
    1. Demonstrate and titrate bedside care for patients in the CICU with greater autonomy
    2. Supervise first year PCCM, cardiology, and anesthesiology fellows in the care of patients in the CICU
    3. Interpret laboratory and physiologic data with increased recognition of exceptions to usual presentations, synthesize it to recognize patient deterioration or improvement, and make fundamentally sound decisions regarding patient support
    4. Demonstrate appropriate management of a child following major cardiac surgery, including repair of congenital defects and cardiac transplantation and recognize complications.
    5. Demonstrate appropriate management for CICU patients, pre and post operatively as necessary according to the patient’s congenital cardiac lesion
    6. Plan an approach for sedation and analgesia in the CICU and titrate the medications as needed
    7. Demonstrate proficiency performing CICU procedures and begin to supervise first year fellows performing procedures
    8. Perform patient consultations to emergency room and pediatric floors and supervise first year fellows as they learn to consult outside of the CICU
    9. Initiate appropriate invasive monitoring; evaluate data and implement appropriate treatment plans
    10. Initiate and titrate appropriate pharmacologic support for hypertension, hypotension, and arrhythmias, and evaluate the effectiveness of the intervention
    11. Demonstrate competence in the management of patients on ECMO and ability to troubleshoot common circuit problems
    12. Order appropriate laboratory tests for CICU patients
    13. Demonstrate ability to initiate advanced levels of support for acute, life-threatening illnesses in children ranging from newborn to adolescents who do not respond adequately to basic support. Specifically, this includes understanding the etiology and pathophysiology as well as the management of pediatric cardiac patients with:
      1. Cardiovascular instability including arrhythmias, pacemaker function,congestive heart failure, cardiomyopathy, and vascular abnormalities
      2. Respiratory failure including acute respiratory distress syndrome, upper airway obstruction, pneumonia, and bronchiolitis
      3. Airway management issues including the difficult airway
      4. Renal insufficiency; acute or chronic
      5. Metabolic, endocrine and electrolyte abnormalities including hypo- or hyperkalemia, hypocalcemia and its affect on cardiac function
      6. Infectious diseases including appropriate antimicrobial therapy for immunosuppressed transplant patients
      7.  Shock including cardiogenic, septic, and hypovolemic shock
      8. Hematologic disorders including anemia, neutropenia, thrombocytopenia, and coagulation disorders
      9. Gastrointestinal diseases including upper and lower GI hemorrhage, chronic malabsorptive syndromes
      10. Heart and/or lung transplantation patients 
    14. Recognize broad needs of patients and families during critical illness and discuss application of palliative care
  1. Year Three
    1. Provide advanced titrated bedside care for patients in the CICU with decreased need for faculty modification of plans
    2. Supervise residents and first and second year cardiology, PCCM, neonatology, and anesthesiology fellows providing care in the CICU
    3. Demonstrate mature ability to Interpret complex laboratory and physiologic data, synthesize it to recognize patient deterioration or improvement, and make fundamentally sound decisions regarding patient support
    4. Demonstrate appropriate management of a child following major cardiac surgery, including repair of congenital defects and cardiac transplantation and recognize complications
    5. Refine approach and titration for patient sedation and analgesia in the CICU
    6. Demonstrate advanced proficiency and efficiency performing CICU procedures and supervise junior fellows performing procedures
    7. Perform consultations to emergency room and pediatric floors and supervise junior fellows as they learn to consult outside of the CICU
    8. Initiate appropriate invasive monitoring; evaluate data, and develop and implement appropriate treatment plans. Anticipate and manage potential complications
    9. Initiate and titrate appropriate advanced pharmacologic support for hypertension, hypotension, and arrhythmias, and evaluate the effectiveness of the intervention
    10. Competently and proactively manage patients before, during, and after ECMO to minimize complications and demonstrating appropriate judgment in initiating and discontinuing ECMO
    11. Order appropriate and timely laboratory tests for CICU patients
    12. Demonstrate mature ability to initiate advanced levels of support for acute, life-threatening illnesses in children ranging from newborn to adolescents who do not respond adequately to basic support. Specifically, this includes generating a complete differential diagnosis addressing the problem, understanding the pathophysiology, and implementing cutting edge approach to management of pediatric patients with:
      1. Cardiovascular instability including arrhythmias, congestive heart failure, cardiomyopathy, and vascular abnormalities
      2. Respiratory failure including acute respiratory distress syndrome, upper airway obstruction, pneumonia, and bronchiolitis
      3. Airway management issues including the difficult airway
      4. Renal insufficiency; acute or chronic
      5. Metabolic, endocrine and electrolyte abnormalities including hypo- or hyperkalemia, hypocalcemia and its affect on cardiac function
      6. Infectious diseases including appropriate antimicrobial therapy for immunosuppressed transplant patients
      7.  Shock including cardiogenic, septic, and hypovolemic shock
      8. Hematologic disorders including anemia, neutropenia, thrombocytopenia, and coagulation disorders
      9. Gastrointestinal diseases including upper and lower GI hemorrhage, chronic malabsorptive syndromes
      10. Heart and/or lung transplantation patients 
  1. Recognize broad needs of patients and families during critical illness and initiate appropriate application of palliative care

III. Interpersonal and Communication Skills

Goal:  Demonstrate interpersonal and communication skills that enable you to establish and maintain professional relationships with patients, families and other members of health care teams; demonstrate effective and compassionate communication skills with parents and patients

Objectives:

  1. Year One
    1. Demonstrate ability to obtain a comprehensive history from patient or family member
    2. Perform professional and effective CICU consultations to other physicians and health care professionals under close supervision]
    3. Interact with cardiac surgery team on daily basis to develop plans of care for surgical CICU patients
    4. Provide concise, respectful, and  appropriate advice to physicians requesting patient transport
    5. Develop therapeutic and ethically sound professional relationships with patients, their families, colleagues and students
    6. Describe and attend to cultural preferences of patients and families derived from conversations with them
    7. Employ effective listening, nonverbal, questioning, and narrative skills while communicating with patients and their families
    8. Attend monthly ethics conferences and work with multidisciplinary CICU team to understand family communication needs
    9. Maintain comprehensive, timely, and legible medical records
  1. Year Two
    1. Perform professional and effective consultations to other physicians and health care professionals with increased independence
    2. Develop therapeutic and ethically sound professional relationships with patients, their families, colleagues and students
    3. Interact with cardiac surgery team on daily basis to develop plans of care for surgical CICU patients
    4. Demonstrate maturing ability to interact with challenging colleagues and families
    5. Employ effective listening, nonverbal, questioning, and narrative skills while communicating with patients and their families
    6. Attend monthly ethics conferences and work with multidisciplinary CICU team to understand family communication needs
    7. Maintain comprehensive, timely, and legible medical records.
    8. Demonstrate ability to synthesize complex information and provide a concise summary of a patient’s course
  1. Year Three
    1. Perform mature professional and effective consultations to other physicians and health care professionals under decreased supervision
    2. Develop therapeutic and ethically sound professional relationships with patients, their families, colleagues and students
    3. Interact with cardiac surgery team on daily basis to develop plans of care for surgical CICU patients
    4. Employ  effective listening, nonverbal, questioning, and narrative skills while communicating with patients and their families
    5. Demonstrate ability to manage complex family interactions
    6. Attend monthly ethics conferences and work with multidisciplinary CICU team to understand family communication needs
    7. Initiate and participate in family care conferences
    8. Maintain comprehensive, timely, and legible medical records
    9. Demonstrate mature ability to synthesize complex information and provide a concise summary of a patient’s course

IV. Professionalism

Goal: Demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession and society

Objectives:

  1. Year One
    1. Demonstrate respect, compassion, integrity and altruism in relationships with patients, families and colleagues
    2. Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues
    3. Apply principles of confidentiality, scientific/academic integrity, and informed consent to patient care
    4. Recognize and support family communication needs as an individual and within a team framework
    5. Discuss ethical issues of particular relevance to patient care in the CICU including surrogate decision making, limiting support, and withdrawal of support
    6. Adhere to institutional policies
  1. Year Two
    1. Demonstrate respect, compassion, integrity and altruism in relationships with patients, families and colleagues
    2. Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues
    3. Apply principles of confidentiality, scientific/academic integrity, and informed consent to patient care
    4. Recognize and support family communication needs as an individual and within a team framework
    5. Adhere to institutional policies
  1. Year Three
    1. Demonstrate respect, compassion, integrity and altruism in relationships with patients, families and colleagues
    2. Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues
    3. Apply  principles of confidentiality, scientific/academic integrity, and informed consent
    4. Recognize and support family communication needs as an individual and within a team framework
    5. Adhere to institutional policies

V. Practice-Based Learning and Improvement

Goal: Use scientific evidence and methods to investigate, evaluate and improve patient care practices

Objectives:

  1. Year One
    1. Develop and maintain a willingness to learn from successes/errors in the workplace
    2. Read classic literature related to patients admitted to support management decisions
    3. Participate in cardiac surgery M&M, cardiac catheterization conference, and other case conferences
    4. Apply information gathered from successes/errors to improve the system or processes of care,
    5. Share errors and near-miss experiences with team members to help correct system weaknesses
    6. Examine feedback and incorporate into improvement activities
    7. Apply information technology and other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education
    8. Establish individualized learning plan and formalize patient care learning goals for the first year of fellowship
    9. Demonstrate basic teaching skills with respect to residents and students
  1. Year Two
    1. Develop and maintain a willingness to learn from successes/errors in the workplace
    2. Read classic and current literature related to patients admitted to support management decisions
    3.  Participate in cardiac surgery M&M, cardiac catheterization conference, and other case conferences
    4. Apply information gathered from successes/errors to improve the system or processes of care,
    5. Share errors and near-miss experiences with team members to help correct system weaknesses
    6. Examine feedback and incorporate into improvement activities
    7. Apply information technology and other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education
    8. Examine individualized learning plan, identify achievement of patient care learning goals for year one of fellowship and develop goals for year two of fellowship
    9. Provide effective teaching for residents and junior fellows based on one’s growing clinical experience and command of the literature
  1. Year Three
    1. Develop and maintain a willingness to learn from successes/errors in the workplace
    2. Seek literature to address particularly complex and/or perplexing patient care issues
    3. Participate in cardiac surgery M&M, cardiac catheterization conference, and other case conferences
    4. Share errors and near-miss experiences with team members to help correct system weaknesses
    5. Apply information gathered from successes/errors to improve the system or processes of care,
    6. Examine feedback and incorporate into improvement activities
    7. Apply information technology and other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education
    8. Examine individualized learning plan, identify  achievement of patient care learning goals for year two of fellowship and develop goals for year three of fellowship
    9. Provide teaching for residents and junior fellows based on one’s growing clinical experience and command of the literature on rounds and at the bedside as well as formal lectures for junior learners as well as faculty

VI. Systems-Based Practice

Goal: Demonstrate both an understanding of the contexts and systems in which health care, in particular critical care, is provided, and the ability to apply this knowledge to improve and optimize health care

Objectives

  1. Year One
    1. Utilize the resources, providers and systems necessary to provide optimal care (social services, PharmDs, nutrition service, case managers, physical therapists, etc.)
    2. Apply evidence-based strategies to prevention, diagnosis and disease management
    3. Collaborate with other members of the health care team at CICU arrest events and triage patients to appropriate level of care
    4. Participate in bed allocation decisions with senior fellows and nurse leaders at times of high census
    5. Operate as a member of  CHP Transport team, providing advice on the evaluation and management of referred patients with cardiac disease and triaging patients to appropriate CICU care at CHP, providing medical leadership to the team during transport, communicating with appropriate receiving personnel at CHP, and accompanying team on transport when requested
    6. Recognize requisites necessary for administering a pediatric cardiac critical care program
  1. Year Two
    1. Utilize the resources, providers and systems necessary to provide optimal care (social services, PharmDs, nutrition service, case managers, physical therapists, etc.)
    2. Apply evidence-based strategies to prevention, diagnosis and disease management with increased application of current literature
    3. Collaborate with other members of the health care team at CICU arrest events and triage patients to appropriate level of care
    4. Recognize of requisites necessary for administering a pediatric cardiac critical care program via professionalism lecture series and experience in CICU
    5. Participate in bed allocation decisions with nurse leaders at times of high census
    6. Operate as member of  CHP Transport team, providing advice on the evaluation and management of referred patients with cardiac disease, triaging patients to appropriate  cardiac care at CHP, providing medical leadership to the team during transport, communicating with appropriate receiving personnel at CHP, and accompanying team on transport when requested
    7. Participate in quality improvement efforts, particularly those related to patient flow and handoffs from one portion of the system to another, e.g transport, ED, OR
    8. Demonstrate ability to understand problems from the perspective of other services
    9. Recognize and discuss cost-benefit considerations in patient-care decisions
  1. Year Three
    1. Utilize the resources, providers and systems necessary to provide optimal care (social services, PharmDs, nutrition service, case managers, physical therapists, etc.)
    2. Apply evidence-based strategies to prevention, diagnosis and disease management with progressively greater application of contemporary literature
    3. Collaborate with other members of the health care team at CICU arrest events and triage patients to appropriate level of care
    4. Recognize requisites necessary for administering a pediatric cardiac critical care program via professionalism lecture series and experience in CICU
    5. Participate in bed allocation decision with nurse leaders in times of high census
    6. Operate as a member of CHP Transport team, providing advice on the evaluation and management of referred patients with cardiac disease, triaging patients to appropriate cardiac care at CHP, providing medical leadership to the team during transport, communicating with appropriate receiving personnel at CHP, and accompanying team on transport when requested
    7. Participate in quality improvement efforts, particularly those related to patient flow and handoffs from one portion of the system to another, e.g transport, ED, OR
    8. Demonstrate ability to understand problems from the perspective of other services
    9. Demonstrate understanding of cost-benefit considerations in patient-care decisions and apply as appropriate