ICU GORs

Moses Cone Family Medicine Residency

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ICU Goals, Objectives & Resources

Faculty Supervisor: Dr. McDiarmid

Introduction: The Family Medicine physician's ability to provide continuous and comprehensive care requires a full understanding of the care of their patients requiring ICU care. The resident physicians' clinical experiences on the ICU Rotation will provide the experiences necessary to this full understanding.

Medical Knowledge:

Goal - To acquire and apply the conceptual medical knowledge necessary to meet the needs of patients with illnesses requiring ICU care. The list of diagnoses and conditions below are among the most common ICU patient care experiences recommended to all family medicine residents by graduation.

Objectives - the resident will be able to:

To acquire and apply the concepts and schema necessary to the diagnostic evaluation of the common illness presentations of the undifferentiated or unstable patient requiring ICU care.
To acquire and apply the concepts and schema necessary to the therapeutic management of patients with common diagnoses or common illness presentations in patients requiring ICU care.
To acquire and apply the concepts of patient-centered care and behavioral medicine to understand the psychosocial impact of common diseases or illness presentations on ICU patients and their support systems.

Topic	Photo	Evidence Based Review	Classic Review	Case*
1. Acute Respiratory Failure	Pulmonary Edema CXR with Bat wing pattern	British Thoracic Society 2002 Guidelines Non-Ventilatory Management of Acute Respiratory Failure American College of Chest Physicians 2001: Guidelines for Weaning & Discontinuing Mechanical Ventilation	BMJ 1998 Oxygen Transport Physiology and Treatment Pleural effusion (NEJM 2002;346:1971) BiPap & CPAP for Acute Respiratory Failure 2007 Review in Critical care Medicine	Clinical Cases and Images: Atelectasis due to Hypoventilation and Mucus Plug Clinical Cases and Images: Weaning & Extubation Criteria in a Patient with Septic Shock and Respiratory Failure Respiratory Depression in COPD Patient COPD vs. CHF Exacerbation Respiratory Arrest

2. Shock and Sepsis		Surviving Sepsis Campaign Guidelines 2008 JAMA Rational Clinical Exam 1999; Is this Patient Hypovolemic	Med Clinic N Am 2007 Review Cardiogenic Shock Early Goal-directed therapy in treatment of (NEJM Nov 2001) Intensive insulin therapy in critically ill patients (NEJM Nov 2001) BMJ 1999; Circulatory Support Review Lancet 2005 Review Septic Shock Critical Care 2004 Review of hemorrhagic Shock Practice parameters for hemodynamic support of sepsis in adult (Crit Care Med 2004;32)	Twelve Clinical Cases of Shock Tutorial on Sepsis and Shock University of Kentucky Video Tutorial on SIRS and Sepsis

3. Mechanical Ventilation & Weaning		ACCP 2001 Guidelines for Weaning and Discontinuing Mechanical Ventilation ATS 2004 Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia	BTS 2002 Guidelines Non-Ventilatory Management of Acute Respiratory Failure Up to Date Topic: Methods of weaning from mechanical ventilation Kee, V. Hemodynamic Pharmacology of IV Vasopressors. Crit Care Nurse 2003 Aug; 23(4): 79-82 Inotropes and Vasopressors Noninvasive positive-pressure ventilation for respiratory failure after extubation (NEJM June 2004) Crit Care Med 2007 Review NIPPV in Critical and Palliative care NEJM 2001 Mechanical Ventilation review	Interactive Tutorial on Intubation & Commencing Mechanical Ventilation Interactive Clinical Cases in Intubation and Ventilation

4. Coma & Persistent Vegetative State		American Academy of Neurology 2006 Clinical Prediction of Outcomes in Comatose Survivors after CPR- Short Version Rational Clinical Exam 2004; Is this Patient Dead, Vegetative, or Severely Neurologically Impaired?	Recognition and Treatment of Patients in the Persistent Vegetative State Review Mayo Clinics 2005 Clinical Diagnosis of Prolonged States of Impaired Consciousness in Adults Determining brain death in adults (AAN glines - Brain Injury and brain death - Curr Guidelines - reaffirmed 1/13/07 & 10/13/03)	Clinical Case: Coma Video lecture Acute Mental Status Changes and Coma American Academy of Neurology 2006 Clinical Prediction of Outcomes in Comatose Survivor after CPR-- Patient Education Material

5. Malignant Dysrhythmias & Heart Blocks		AHA & ACC 2006 Pocket Guideline Management of Patients with Ventricular Arrhythmias and Prevention of Sudden Cardiac Death AHA & ACC 2006 Executive Summary Guidelines Management of Patients with Ventricular Arrhythmias and Prevention of Sudden Cardiac Death AHA & ACC 2002 Summary Guidelines: Indications for Implantation of Cardiac Pacemakers	BMJ 2002 ABD of ECG; Broad Complex Tachycardias; Part 1 BMJ 2002 ABC of ECG; Broad Complex Tachycardias; Part 2 Heart 2005 Wide-Complex Tachycardia Review Atrioventricular block and problems with atrioventricular conduction AFP 2003 Diagnosis and Treatment of Sick Sinus Syndrome Management of common arrhythmias: Ventricular arrhythmias & arrhythmias in special populations (AFP)	36 yr old with cocaine use and abnormal ECG 75 year old with arrhythmia and abnormal ECG 69 yr old with Chest Pain, SOB and Abnormal ECG McGill University ECG Case Studies Rhythm Strip Quizzes

6. Hemodynamic Monitoring		Functional Hemodynamic Monitoring Textbook 2005	2007 Chest Review Hemodynamic Monitoring Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism (NEJM Oct 2002) Clinical Medicine 2002 The Pulmonary Artery Catheter Quick Review Anaesthesia 2008 Review: Basic Science Cardiac Output Monitoring Comparison of cardiac output measured with echocardiographic volumes & aortic doppler methods (Int Care Med 2003;29:208)

7. ARDS	Chest X-ray of pt with ARDS (Wikimedia)		BMJ 2007 Review ARDS Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury & ARDS (NEJM May 2000) Lancet 2007 Review ARDS Chest 2007 State-of-the-Art Review Mechanical Ventilation in ARDS ARDS brochure (By itself, insufficient for more than a novice’s understanding of etiology, pathophysiology, diagnosis and treatments. Daily hemodialysis & the outcome of acute renal failure (NEJM 2002 346:305)	Critical Care Medicine Tutorials eMedicine Test: Acute Respiratory Distress Syndrome*

8. Acute Renal Failure & Oliguria		Up to Date: Acute Renal Failure Interventions to Prevent Acute Renal Failure in patients receiving IV contrast Clinical Evidence (BMJ 2007)	AFP 2005 Management of Acute Renal Failure Review Chest 2005 Review Acute Tubular Necrosis NEJM 1998; Review of Acute Oliguria Clinical Medicine 2005 Management of Acute Renal Failure in the ICU	8 Clinical Scenarios In Renal Problems and Fluid Balance in Critical Care 45 yr old with Chronic Back Pain Presents to ER for Same 65 yr old Nursing Home Patient with Weakness and Poor PO intake 65 yr old with Weakness and Potassium 6.5 Interactive Tutorial on Renal Problems in Intensive Care

9. End-of-Life Decision making			JAMA 2003 End of Life Withdrawal of Care Review and Discussion Recommendations for end-of-life care in the intensive care unit: A consensus statement by the ACCCM (Crit Care Med 2008 Vol. 36) - Abstract JAMA Communication in End of Life Review and Discussion AFP 2001 Evaluating Patient Decision Making Capacity AFP 2004 Making Decisions with Families at End of Life Recommendations for end-of-life care in the ICU: A consensus statement by the ACCCM (Crit Care Med 2008 Mar) - link is to abstract	Interactive Case: Woman Desiring No Aggressive Interventions for Breast Cancer

10. End-of-Life Care		ACP 2008 Guidelines for Palliative Care of Pain, Dyspnea, and Depression at the End of Life	AFP 2001 Treatment of Common Symptoms in Terminally Ill Patients; Part 1 AFP 2001 Treatment of Common Symptoms of Terminally Ill Patients; Part 2 AFP 2004 Challenges in Pain Management in Terminally Ill Patients

11. Acid-Base Physiology			BMJ 1998 Review ABG Interpretation Critical Care Lectures on Acid-Base Management Critical Care Medicine 2007 Review of Acid-Base Balance Sodium Bicarbonate for the Treatment of Lactic Acidosis (Chest 2000; 117:260)	Canadian Family Physician 2005 Case Based Approach to Common Acid Base Problems: Keep It Simple Disease a Month; Case Based Primer on Clinical Acid Base Problem Solutions

12. DIC / Hematologic Disorders			D-dimer levels correlate with mortality in pts with acute pulmonary embolism: Findings from the RIETE registry (login to resources) Chest 2005 DIC Academic Review Clinical aspects of DIC Pol J Pharmacol Jan-Feb; 48(1) 73-5; 1996 (link is to abstract) Heparin-induced thrombocytopenia in the critical care setting: diagnosis and management Heparin-induced thrombocytopenia in the critical care setting: Diagnosis and management. Crit Care Med 2006; 34(12), 2898-2911. (available on site through AHEC library A-Z online journals) DIC review (BMJ 2003;327:974) Critical Care Medicine 2007 Concise Review of DIC Corticosteroid insufficiency in acutely ill patients (NEJM 2003 348;8:727) Adrenal insufficiency in critically ill patients with HIV (login to resources)

13. Hospital-Acquired and Ventilator-associated Pneumonia		American Thoracic Society 2004 Guidelines for Management Hospital-Acquired Pneumonia And Ventilator-Associated Pneumonias Ventilator-Associated Pneumonia or Not? Contemporary Diagnosis (CDC 2001) Infectious Disease Society of America 2005 Guidelines for Healthcare-Acquired Pneumonias and Ventilator-Associated Pneumonias	Surgical Clinics of N. America 2006 Review Ventilator-Associated Pneumonias	Tutorial Management of MRSA Infections in the Intensive Care Unit: Focus on Pneumonia

Patient Care:

Goal- to develop the skills to manage common disorders seen in patients requiring hospitalization.

Objectives - the resident will be able to:

Obtain accurate histories regarding acute disease conditions requiring hospitalization and co-morbid conditions.
Perform appropriate physical examinations on patients with acute disease conditions requiring hospitalization.
Competently Perform procedures necessary for the diagnosis and management of acute disease conditions requiring hospitalization.

Procedures	Texts/Articles	Videos/Cases*
Lumbar Puncture	Procedures for Primary Care, Pfenniger, Mosby Publishing, 2003	Lumbar Puncture Procedure and Cases
	AFP 2003 CSF Analysis	Video of Lumbar Puncture, courtesy WFU School of Medicine
	DVD of Primary Care Procedures

Thoracentesis	Procedures for Primary Care, Pfenniger, Mosby Publishing, 2003	Thoracentesis Procedure Instructions
	DVD of Primary Care Procedures†	Thoracentesis Procedure Video

EKG Interpretation	ECG Interpretation Learning Module	Electrocardiogram (ECG, EKG) library

Paracentesis	Procedures for Primary Care, Pfenniger, Mosby Publishing, 2003
	DVD of Primary Care Procedures
	Description of Paracentesis Procedure
	Rational Clinical Exam: Does this Pt Have Ascites?

† Available in FPC Computer Lab.

Interpersonal & Communications Skills:

Goal - to communicate effectively with patients and healthcare team concerning the evaluation and management of conditions requiring ICU care.

Objectives - the resident will be able to:

Describe diagnosis and treatment plans for acute conditions to ICU patients and their families.
Counsel patients regarding their concerns and incorporate prevention.
Accurately convey medical information regarding diseases to colleagues, verbally and written.
Accurately document patient encounters.

Practice-Based Learning & Improvement:

Goal - to appraise and utilize the best evidence in caring for patients with or at risk for various acute conditions requiring ICU care.

Objectives - the resident will be able to:

Organize and manage ICU patients' clinical information.
Formulate clinical questions based on clinical experiences.
Access medical information in a timely fashion for use in caring for patients with acute conditions requiring ICU care.
Assess validity and applicability of medical evidence answering the clinical question.
Apply answers appropriate to ICU patients, and monitor outcomes.

Systems Based Practice:

Goal - to work within the health care system to provide optimum care for patients with acute conditions requiring ICU care.

Objectives - the resident will be able to:

Appropriately utilize consultation with specialty services in the management and co-management of acute conditions requiring ICU patient care.
Care for patients with an acute condition requiring ICU care in a cost effective manner.
Utilize local resources available for patients with acute conditions requiring ICU care.
Understand basics of Medicare and Medicaid reimbursement for acute conditions requiring ICU care.

Professionalism:

Goal - to demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diversity when dealing with acute patient conditions requiring ICU care.

Objectives - the resident will be able to:

Demonstrate respect and sensitivity in dealing with patients with acute conditions requiring hospitalization, regardless of race or cultural background or sexual orientation.
Demonstrate good work habits including timeliness, efficiency, and punctuality.
Behave in a professional manner in dealing in all departments of the healthcare system.

Moses Cone Family Medicine Residency Program

Last updated: December 04, 2008