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Duke Pulmonary and Critical Care Medicine

Guidelines and Curriculum

http://pulmonary.medicine.duke.edu/

Rotation: Medical ICU, Durham Veterans Affairs Medical Center (DVAMC, 5A wing)

Contact names and phone number: Dr. Tim McMahon, or Sharon Waddell, 286-6946.

The educational goal and objectives of this rotation are to:

Learn the diagnosis and management of critical illness, including respiratory, general medical, and neurological

critical care. 1. Develop proficiency in obtaining a comprehensive history and performing a thorough physical exam.

2. Provide safe and effective health care with compassion, consideration, professionalism, and courtesy.

3. Formulate in conjunction with the fellow/attending a thoughtful assessment and plan for your patients.

4. Gain proficiency in the basic procedures of internal medicine and critical care medicine, including but not limited to

phlebotomy, arterial blood gas, arterial line placement, nasogastric tube placement, central venous line placement,

intubation, thoracentesis, arthrocentesis, paracentesis, and lumbar puncture.

5. Record daily notes on patient’s condition.

6. Follow-up on studies and tests performed on patients.

7. Gain basic understanding of critical care management in sepsis, cardiac and respiratory failure, sedation practices,

hemodynamic monitoring, and acute neurovascular disease such as strokes, intracerebral hemorrhages and hypertensive

emergencies.

Teaching methods used to attain these goals include:

Review by the faculty and fellow of the resident’s history and physical examination, plan of therapy and

evaluation of laboratory and other diagnostic data,

Role modeling by faculty practicing in clinical practice,

Didactic clinical conferences held four times per month,

Recommended reading lists

Hands-on performance and interpretation of the following procedures:

arterial lines

central lines

pulmonary artery catheters

thoracentesis

paracentesis

lumbar puncture

blood gases

scheduled review of radiological material

opportunities for interacting with other trainees within this discipline.

opportunities for interacting with other trainees from other disciplines.

Self-study and testing materials, including online procedural educational modules.

Department of Medicine

Internal Medicine Residency

Program

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CONSULTS:

1. Please accommodate all consult requests as promptly as possible.

2. All consultations need to be documented in CPRS (MICU Consult Note) if you do not accept the patient to the ICU.

The notes do not have to be lengthy but should include the pertinent story and assessment, why the patient did not meet

criteria for admission to the ICU, and the measures you recommended to stabilize or improve the patient's clinical

condition. Please identify your MICU Attending and the MICU fellow for cosignature on the Consult Note.

3. The ER MOD has the final say in decisions on ICU or floor admission from the ER, technically speaking. In cases of

disagreement, involving the MICU fellow and/or attending and ER attending early on may be helpful, and nearly always a

consensus can be attained. At a minimum, please let the on-service attending know about admissions with which you

disagreed.

4. The consult should be discussed with the MICU Pulmonary/Critical Care Fellow. The fellow should always be

included in the decision process.

5. If possible, eyeball the patient again within 15 mins upon his/her arrival to MICU.

6. If the patient is admitted to the Intensive Care Unit, give the attending physician a brief call. This is imperative if the

patient is unstable and has a high probability of dying within the next 24 hours.

7. Complicated (comatose, resp. failure) stroke and TIA patients must be admitted to the MICU service for at least the

first 24 hours. Uncomplicated TIA and stroke cases are admitted to CCU.

8. A cardiology consult must be called for newly positive troponins or other evidence of ACS.

9. The VA has a Rapid Response Team. The MICU resident sees the RRT patients only in cases where there is no

satisfactory improvement or resolution of the concern after being seen by the core team (MICU RN and respiratory

therapist). In that case the patient is handled just like a MICU Consult.

TRANSFERS FROM OUTSIDE HOSPITALS:

1. You will be contacted, via the MICU pager 904, by outside facilities thru the DVAMC transfer coordinator (TC)

regarding the transfer of service connected (SC) and NSC veterans to the Durham VA Medical Intensive Care Unit.

Generally we try to be as accommodating as possible but beds are often very tight. Communication is key and a decision

on transfer is needed within 24 hours and typically faster depending on the particular medical problem. The paperwork

must go through the TC / AOD (admitting officer of the day) and they should be notified of the decision as well. She/he

will check on eligibility and the priority for transfer. Generally service-connected Veterans have priority over non-SC

veterans during times of limited bed availability. Use CPRS’s “Transfer Communication Note.”

2. Please u the outside physician and, when a case is “accepted and pending” for transfer then update her/him daily on

the status of bed availability. Patients in outside ICUs, regardless of clinical status, need to be transferred to the ICU and

not the regular service. If in the meantime the patient is transferred to the regular floor at the outside institution, the

transfer should be turned over to the Assistant Chief Medical Resident. Under no circumstances should a patient be

accepted/transferred for “evaluation in the emergency department.”

3. The physician making the arrangements for the transport has to assure safety and stability of the patient. It is good

practice to get an update on the patient’s status from the nursing staff at the outside ICU. Referring physicians are not

always up-to-date on the current status of the patient prior to transfer. Life-flight arrangements are more difficult to make

and require the involvement of Duke since the VA has no helicopter pad.

TRANSFERS FROM THE ER, and TRANSPORT TO DIAGNOSTIC/THERAPEUTIC STUDIES:

1. All patient transfers from the regular inpatient service and the emergency room to the Critical Care Units must be

accompanied by an ACLS-certified physician, typically the assigned ICU resident. The transfer requires the presence of

resuscitation equipment (i.e. defibrillator and mask ventilation equipment) deemed appropriate to deal with potential

emergencies during the transfer process.

2. All transfers from the Critical Care Units to diagnostic/therapeutic procedure areas require as a minimum the

presence of an ACLS certified nurse and, for medically unstable patients, the presence of the responsible ICU physician.

The transfer requires the presence of appropriate resuscitation equipment as outlined above.

3. An unstable patient in need of immediate ICU care will be transferred and stabilized in the Surgical Intensive Care

Unit (SICU) in those situations where no medical critical care beds are available in any of our medical ICUs (CCU,

MICU). It is the responsibility of the house officer (CCU, MICU or SICU resident) assuming care for the patient to

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stabilize and stay with the patient. Nursing support may be limited in those situations depending on patient acuity and

workload in the SICU. In the meantime the nursing coordinator together with the physician staff in all ICUs will define a

more stable ICU patient to transfer to an outside Intensive Care Unit in order to open a critical care bed for the patient in

the SICU. The permission for transfer will be obtained through the Chief of Staff.

CODES: The MICU resident is the "procedure MD" during a code. Her/his position is at the right of the patient, at the

level of the groin. His/her responsibilities are to obtain central venous access and draw lab samples. It is also very

important to be familiar with the other team members' roles and responsibilities. The key information is summarized in

the chart on page one of the CRT document posted in the workroom and available on the Shared drive accessible from

VA computers.

DIAGNOSTIC PROCEDURES:

1. Always make sure that you have obtained written informed consent for the procedure. Please use iMed for

consent forms whenever possible. Consent is good only for 1 procedure per form completed, but renewals up to 30 days

may be written into the consent.

2. Phone consent must go through the MAS (three-way phone call). Complications of procedures need to be

adequately documented in the patient’s digital record (i.e. pneumothorax post line placement). Each Procedure Note in

CPRS must indicate the attending of record, even if the attending was not physically present.

3. Please avoid the use of femoral lines unless absolutely necessary, and in that case please justify in the procedure

note the reason an internal jugular or subclavian site could not be accessed or attempted. Reevaluate on a daily basis the

need to keep any femoral line, either replacing it with a CVC elsewhere or justifying its need in daily notes.

4. Pulmonary artery catheter placement requires the presence of the pulmonary fellow. If in doubt please

contact your fellow for help/assistance of any procedure.

5. Vascular radiology procedures: Our ability to provide vascular procedures such as bronchial arterial embolization

and TIPS can be limited by equipment and personnel in vascular radiology. If a patient is to be transferred specifically for

one of these procedures, check with vascular first to see if we can provide it. If not, it is in the patient’s best interest to be

transferred elsewhere. Our own patients who need to go to Duke for a procedure must be transferred first to a Duke

inpatient service, after approval by the Chief of Staff’s office. This is the only way to maintain adequate critical care for

an ICU patient between the VA and Duke.

INTUBATIONS:

1. Uncredentialed medical residents do not have privileges to intubate patients primarily except in emergent situations

where no RT, anesthesiologist, or pulmonary fellow is immediately available. It is possible to meet the VA requirements

for gaining ET intubation privileges by training in the OR under the supervision of anesthesia attendings. This can be

done efficiently in a few short mornings before MICU rounds and is highly recommended but not required. To arrange

this, please contact Dr. Dana Wiener, Anesthesia, via Duke email.

2. Once approved, use every opportunity to intubate the patients yourself. Make sure they are adequately volume-

loaded. Excessive benzodiazepines or propofol may provoke hypotension. The fellow and attending may use etomidate

but not the residents.

3. As is the case for other events, the VA MICU fellow should be involved, and provides backup and typically can

ensure an airway when your RT cannot. Please contact them early when the need for this is possible. If emergent, it is

understood that the Pulmonary/CC fellow covering the Duke MICU can “cross the street” also be present temporarily in

some cases, until the “VA” MICU fellow arrives.

4. Upper-level anesthesia (“difficult airway”) coverage is available during the day and variable at night. An

experienced attending anesthesiologist can be called in from at home in more difficult situations. See the posted schedule

at the residents’ desk in MICU; also posted on the S: drive server that is accessible to you on VA computers (folder S:

MED/ PULM/ Anesthesiology/ Faculty Schedules). Look there if and when Anesthesia Dept. has not posted a paper copy

yet, like on the first day of a month. Or call the hospital operator for the covering pager number; the pager number is also

available through the RT. Call the anesthesiologist in if you anticipate problems rather than waiting for a problem to

develop (it is understood that these can’t always be predicted). The anesthesia attendings expect and want to be called for

difficult airway cases.

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VENTILATOR MANAGEMENT:

1. Housestaff are responsible for all setting changes on ventilators. When physically making changes yourself, please

also notify/ discuss with the respiratory therapist and place the relevant order. All changes need to be clearly documented

as orders in CPRS order section to avoid misunderstandings. If in doubt call your fellow and discuss the appropriate

ventilator mode. If you have difficulties, call your fellow or attending for help.

2. A ventilator management protocol is in place and can be executed by RT under MD orders. However, you should

still be aware of your patient’s current settings, the rationale, and objectives. Patients requiring extreme mech. vent.

settings (e.g., inverse ratio I:E, PEEP >12) should not be managed primarily on this protocol but rather with each change

discussed by MD team and RT together and entered as individual orders.

3. We do not provide non-invasive positive-pressure mask ventilation (NPPV) for respiratory failure (i.e. hypercapnia

or refractory hypoxemia) on the regular floor. NPPV should be provided in the ICU because it is time- and personnel-

intensive and ~one in four patients will ultimately require mechanical ventilation. The respiratory therapists are

instructed to only provide NPPV on the floor for patients with stable, documented disease requiring either BiPAP or

CPAP (such as OSA).

MISCELLANEOUS:

Progress notes. Where possible, strive to articulate diagnoses or working diagnoses in the A/P section, rather than

simply naming signs and symptoms. Not only is this good form in medicine; it also helps the Medical Center accurately

capture both the severity of illness (providing the most accurate and thus most constructive QA/QI feedback on patient

outcomes), and the physician/housestaff and ICU workload.

Census cap. The MICU resident caps at 10 patients. Once you get to census = 9, please notify the attending, Chief

Medical Resident, and CCU service in order to prepare diversion of any subsequent Medical ICU candidate patients, who

will go typically to VA CCU Service.

Medication reconciliation upon transfer into and out of (or DC to home or SNF) must be thorough and fully

documented.

Type and screen. When clinical staff (RNs or MDs) are the ones obtaining the specimen then ONE SF -518 needs to

have patient information on the bottom and the upper right area needs to have name of individual who obtained the

specimen printed and then signed with date and time of lab draw.

Massive bleeding (GI or other) protocol for transfusion: the restriction to “one unit at a time” can be quickly

circumvented for emergencies by paging either the pathology resident on call or the blood bank director,

Dr. Maureane Hoffman (cell 810-3868). Dr. Hoffman also encourages contact for ANY scenario in which timely

availability of blood products appears to be or might become a problem.

Transfers to floor. Whenever possible, please try to avoid or minimize number of transfers on Saturday to the PRIME

service, especially if the patient is complicated.

Code status. Establishing DNR status requires completion of a DNR Progress note in CPRS and a DNR order in CPRS.

An identical order must be electronically entered and signed by the attending within 24 hours. There is no special form or

paperwork need for the withdrawal of life support, other than good documentation within CPRS of relevant conversations

with patient/ family. Any single attending has authority to withdraw such care at the VA.

Insulin / blood glucose management orders can now be entered in a coordinated fashion via a new Orders tab in CPRS.

“58: Inpatient insulin order set”.

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Fri. AM Conference. A weekly pulmonary/critical care led by the pulmonary fellow takes place at 9am Friday mornings.

Your attendance is expected and encouraged unless you are on call.

Rescission of DNR status requires that all DNR orders in CPRS be cancelled, and that a “DNR-Revoke” note be written

in CPRS and co-signed by attending. Please note that the template “Advance Directive – Rescind” is not what you want

here and will not unflag the DNR in CPRS. Withdrawal of care does not require a second attending signature, provided

that the patient and/or family are in agreement.

Potential organ donors. Please do contact CDS for any potential organ donors. CPRS indicates (upper right corner of

cover sheet) in some cases those patients who have elected in advance to be organ donors.

Educational resources: 1. http://criticalcare.duhs.duke.edu/ Website with relevant didactic material and links to relevant articles.

2. Reading list by topic:

ARDS

Brower, R.G. et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute

lung injury and the acute respiratory distress syndrome. N Engl J Med (NEJM) 242: 1301-1308, 2000. (“ARMA

study”).

Steinberg, K. P., L. D. Hudson, R. B. Goodman, C. L. Hough, P. N. Lanken, R. Hyzy, B. T. Thompson,

and M. Ancukiewicz. 2006. Efficacy and safety of corticosteroids for persistent acute respiratory distress

syndrome. NEJM 354:1671-84.

Wiedemann, H. P., A. P. Wheeler, G. R. Bernard, B. T. Thompson, D. Hayden, B. deBoisblanc, A. F.

Connors, Jr., R. D. Hite, and A. L. Harabin. 2006. Comparison of two fluid-management strategies in

acute lung injury. NEJM 354:2564-75.

Non-invasive ventilation

Brochard, L. et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease.

NEJM 333(13) 817-822, 1995 (CPAP and COPD).

Central venous catheter use and placement

Wheeler, A. P., G. R. Bernard, B. T. Thompson, D. Schoenfeld, H. P. Wiedemann, B. deBoisblanc, A. F.

Connors, Jr., R. D. Hite, and A. L. Harabin. 2006. Pulmonary-artery versus central venous catheter to guide

treatment of acute lung injury. N Engl J Med 354(21):2213-24.

McGee D. C., Gould M. K. Current Concepts: Preventing complications of central venous catheterization.

NEJM 2003; 348:1123-1133, 2003. (Central line overview).

Merrer, J. Complications of femoral and subclavian venous catheterization in critically ill patients. JAMA

286(6) 701-707, 2001.

Connors, A.F. et al. The effectiveness of right-heart catheterization in the initial care of critically ill patients.

JAMA 276(11) 889-97, 1996.

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Sandham J.D. et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical

patients. NEJM 348:5-14, 2003.

Insulin therapy in the ICU

van den Berghe, G., P. Wouters, F. Weekers, C. Verwaest, F. Bruyninckx, M. Schetz, D. Vlasselaers, P.

Ferdinande, P. Lauwers, and R. Bouillon. 2001. Intensive insulin therapy in the critically ill patients. N Engl J

Med 345(19):1359-67.

Sepsis

Rivers, E., B. Nguyen, S. Havstad, J. Ressler, A. Muzzin, B. Knoblich, E. Peterson, and M. Tomlanovich. 2001.

Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345(19):1368-77.

Hotchkiss R, Karl I. The pathophysiology and treatment of sepsis. NEJM. 348:138-150, 2003.

(Pathophysiology of sepsis).

Bernard, GR et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. NEJM

344(10) 699-709, 2001. (Xigris)

Holmes, CL et al. Physiology of vasopressin relavent to management of septic shock. Chest 120(3) 989-1002,

Sept. 2001.

Annane, D et. al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in

patients with septic shock. JAMA 288(7) 862-871, August 2001. (Sepsis and steroids)

Cooper, M. S., and P. M. Stewart. 2003. Corticosteroid insufficiency in acutely ill patients. N Engl J

Med 348(8):727-34.

Schrier, R. W., and W. Wang. 2004. Acute renal failure and sepsis. N Engl J Med 351(2):159-69.

RBC transfusion or erythropoietin in the ICU

Hebert, P. C., G. Wells, M. A. Blajchman, J. Marshall, C. Martin, G. Pagliarello, M. Tweeddale, I.

Schweitzer, and E. Yetisir. 1999. A multicenter, randomized, controlled clinical trial of transfusion

requirements in critical care. Transfusion Requirements in Critical Care Investigators,

Canadian Critical Care Trials Group. N Engl J Med 340(6):409-17.

Tinmouth, A., D. Fergusson, I. C. Yee, and P. C. Hebert. 2006. Clinical consequences of red cell storage

in the critically ill. Transfusion 46(11):2014-27.

Corwin, H. L., A. Gettinger, T. C. Fabian, A. May, R. G. Pearl, S. Heard, R. An, P. J. Bowers, P.

Burton, M. A. Klausner, and M. J. Corwin. 2007. Efficacy and safety of epoetin alfa in critically ill

patients. N Engl J Med 357(10):965-76.

Corwin, H. L., A. Gettinger, R. G. Pearl, M. P. Fink, M. M. Levy, E. Abraham, N. R. MacIntyre, M. M.

Shabot, M. S. Duh, and M. J. Shapiro. 2004. The CRIT Study: Anemia and blood transfusion in the

critically ill--current clinical practice in the United States. Crit Care Med 32(1):39-52.

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Ventilator weaning

Henneman, E., K. Dracup, T. Ganz, O. Molayeme, and C. Cooper. 2001. Effect of a collaborative weaning plan

on patient outcome in the critical care setting. Crit Care Med 29(2):297-303.

Ely, EW et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing

spontaneously. NEJM 335(25)1862-1869, Dec. 1996. (Ventilator weaning: SBT)

Esteban, Frutos, Tobin et al. A comparison of four methods of weaning patients from mechanical ventilation.

N Engl J Med 334:555-61, Feb. 1995. (Comparison of ventilator weaning methods)

DVT prophylaxis

Samama, MM et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism

in acutely ill medical patients. NEJM 341:793-800, 1999. (Enoxaparin in the ICU).

Sedation and neuromuscular blockade in the ICU

Kress J. P. et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical

ventilation. N Engl J Med 2000; 342:1471-1477, 2000. (Daily “sedation vacation”).

Bernard De Jonghe, et al Paresis acquired in the intensive care unit: a prospective, multicenter study. JAMA

2002; 288: 2859-2867.

Nosocomial ICU infections

Kollef MH. The prevention of ventilator-associated pneumonia. NEJM 1999;340:627-634.

Klompas, M. 2007. Does this patient have ventilator-associated pneumonia? JAMA 297(14):1583-93.

Drakulovic MB, Torres A, Bauer TT, et al. Semirecumbency to prevent VAP. Lancet 1999;354:1851-8.

Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med 2000;132:391-402.

Neurological critical care

Critical Care Neurology, a review. AJRCCM 2001;164:341-5.

Lowenstein et al. Status epilepticus. NEJM 1998;338:970-6.

De Jonghe B., Cook D., Sharshar T., et al. Acquired neuromuscular disorders in critically ill patients: a

systematic review. Intensive Care Med 1998;24:1242-50.

Zanbergen E.G.J., de Haan R.J., Stoutenbeek C.P., Koelman J.H.T.M., Hijdra A. Systematic review of

early predictors of poor outcome in anoxic-ischemic coma. Lancet 1998;352:1808-12.

Coplin W.M., Pierson D.J., Cooley K.D., et al. Implications of extubation delay in brain-injured patients

meeting standard weaning criteria. Am. J. Resp. Crit. Care Med. 2000;161:1530-1536.

Prognostication and management of patients who are comatose after cardiac arrest.

Neurology 2006; 67(4): 556-7.

ICU outcomes

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Herridge M. S., et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med

2003; 348:683-693, Feb 20, 2003.

Acute renal failure

Murray P., Hall J. Renal replacement therapy for acute renal failure. Am. J. Resp. Crit. Care Med. 2000;

162:777-81.

Schiffl, H., S. M. Lang, and R. Fischer. 2002. Daily hemodialysis and the outcome of acute renal failure.

N Engl J Med 346(5):305-10.

Ronco, C., R. Bellomo, P. Homel, A. Brendolan, M. Dan, P. Piccinni, and G. La Greca. 2000. Effects of

different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a

prospective randomised trial. Lancet 356(9223):26-30.

The disease entities likely to be encountered on this rotation include:

shock (cardiogenic, septic, hypovolemic)

encephalopathy, delirium

hypoxemic and hypercarbic respiratory failure

acute stroke syndromes

acute coronary syndromes

status epilepticus

acute renal failure

acute liver failure

acute gastrintestinal bleed

disseminated intravascular coagulopathy

The characteristics of the patients seen on this rotation include: Critically ill adults, average age 63. All

patients are veterans, the majority male. Most patients have multiple medical comorbidities in addition to

critical illness. Neurologically critical patients are also admitted to the VA MICU routinely.

The types of clinical encounters with these patients include:

acute inpatient admissions

critical care inpatient

consultations requested by other teams

The procedures performed:

arterial lines

central venous lines

pulmonary artery catheters

thoracentesis

paracentesis

lumbar puncture

arterial blood gas

endotracheal intubation

The services provided include:

Diagnostic testing for acute and chronic complaints

Therapeutic Interventions and Advice

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Psychosocial Support and Counseling

Nutritional Support

Physical and Occupational Therapy

Spiritual Services

Pain Management and Palliative Care

Patient Education and Counseling

The trainees will be evaluated by: Written evaluation

Supervision of the trainees by faculty is accomplished by:

Review by the faculty of the resident’s history and physical examination, plan of therapy and evaluation

of laboratory and other diagnostic data

Direct Observation of Resident’s History and Physical Examination

Direct Observation of Procedures and Skills

Case Review and Discussion at Conferences and Morning Report

Assumption of graduated responsibility for the care of patients is monitored by:

Review by the faculty of the resident’s history and physical examination, plan of therapy and evaluation

of laboratory and other diagnostic data

Direct Observation of Resident’s History and Physical Examination

Direct Observation of Procedures and Skills

Case Review and Discussion at Conferences and Morning Report

Concerns for and training to respond to the patients cultural, socioeconomic, ethical, occupational,

environmental, and behavioral problems are addressed by:

Consultative support by spiritual leaders, ethics counsels

Consultative support by psychology and psychiatry colleagues

Consultative support by social workers, occupational counselors and colleagues with expertise in

environmental hazards

Leadership skills are developed by:

Role Modeling by Faculty

Delegation of Teaching Roles to Trainees

Opportunities for mentor-relationships between trainees of different levels of training

Training in basic science underpinning of disease is addressed by:

Case Discussion with Expert Faculty Comment

Training in the critical appraisal of the literature is addressed by:

Case-based conferences

Morning rounds review of evidence

Evaluation of the trainees’ documentation of their observations in the medical record is monitored

by:

Direct Review with comment and co-signature by attending faculty

Feedback on individual write-ups (either verbal or in writing)

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Evaluation of the trainees professional interpersonal relations and humanistic care of patients is

assessed by: Direct Observation of provider-patient interactions with feedback on performance (either

verbal or in writing)

Trainees are provided the opportunities to interact with support health care professionals by:

Multidisciplinary Team Structure in the clinical environment (providers of different specialties caring for

patients together in the context of a single environment or multidisciplinary team)

Multidisciplinary Team Conference (cases discussed in a multidisciplinary setting)

Multidisciplinary Team Rounds

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Core Competencies on the VAMC MICU Rotation

Patient care – Your main goal while on the MICU rotation is to provide care that is

compassionate, appropriate, and effective for the treatment of the health problems of the

critically ill patients.

The residents on the team should work together as advocates for each patient cared for by the

MICU team. MICU patients frequently have complex histories and medical problems. Take

ownership for the care of your patients and strive to provide them the best possible care. This

will often involve coordinating consultations, diagnostic tests and therapy.

You will see a broad variety of problems while on the service some of which are listed above.

Important diagnostic tests and urgent therapy (IV fluids, antibiotics etc.) should be ordered

promptly and carried out expeditiously.

Care should involve prompt history and physical as soon as a patient arrives from the

emergency department or from the floor. You will need to assess acutely how ill the patient is

and begin upon a course of diagnosis and therapy. Do not rely upon the history or diagnosis

given by the ED! Your admission and daily notes should reflect your own assessment and

exam.

The MICU team will assess each patient at least twice daily and whenever needed for a

change in status with daily examination and documentation with medical chart notes.

Housestaff should spend as much time as possible at the patient’s bedside. Exams should be

careful and accurate. A sick patient deserves a doctor close at hand.

Care should be delivered with sensitivity and caring. Treat all patients and their families with

the utmost respect.

Resident are expected to communicate information about patient’s progress (or lack thereof)

with patients’ family or decision making surrogate.

Medical knowledge - Housestaff are to use the MICU experience to review pertinent parts of the

established and evolving biomedical, clinical, and sciences as pertinent in the care of patients on

MICU.

MICU is a time for patient-focused learning. Reading should be primarily based around the

problems your patients have (although housestaff should read broadly on topics as their

schedule allows). Textbooks of medicine (Harrison’s), systematic reviews from key journals

(NEJM), ACP journal club reviews, guidelines from national organizations are all reasonable

sources of information. A key reading list is provided above.

There is a Duke University Critical Care Website that contains a file of commonly used

critical care articles as well as a core lecture series. See link above.

Medicine Department noon conferences, and the Friday VA Pulmonary/CC conference

should be attended if possible during the MICU month as these provide a source of core-

curriculum. Patient care is the priority.

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Practice-based learning and improvement – While on MICU, housestaff should remain

mindful of the quality of the care they provide. This involves investigation and evaluation of their

own patient care, appraisal and assimilation of scientific evidence, and improvements in patient

care.

When errors are noted, these should be reported through the error-reporting systems in place.

When in doubt, the attending or MICU Director should be notified.

If there are systems improvements that the housestaff discover, particularly in the realm of

safety, these should be shared with the chief resident or MICU director.

Application of medical knowledge should be an active pursuit while on MICU. Critical

appraisal behind the medical evidence (or lack-thereof) should be an important part of the

rotation.

Interpersonal and communication skills – Housestaff on the MICU service should always

practice the most respectful and clear communication with colleagues, staff, patients and

families. The goal is effective information exchange for the betterment of patient care.

There may be times on MICU when one’s patience will be tried by a consultant who is

yelling into the phone, by another floor or ED consult or by a family who is scared and frantic

about a loved one. Always take the upper-hand when communicating with others.

Do your best to remain empathetic. Listening is often the best tool you can use. Echo the

emotion of the person with whom you are communicating. Take a deep breath and try to learn

why the other person is so worried, frustrated, scared etc.

If communicating with others is a skill where you need to improve, talk with the chief

resident (sooner rather than later) or your attending. These skills can be learned. There are

many helpful books that teach communication skills (Getting to Yes, Difficult Conversations:

How to Discuss What Matters Most, Crucial Conversations are three resources that may be

helpful).

Effective communication and hand-offs with other housestaff are critical for patient care and

safety. On the MICU rotation, interns and residents should be able to provide a concise, clear

presentation of each patient. This is a skill that should be practiced over the course of the

rotation. Residents should help their students learn to give excellent oral presentations of

their patients.

Questions to consultants should be clearly articulated with pertinent history provided. Think

in advance about why you are calling (for a second opinion, for a procedure, to help make the

diagnosis, for expert opinion, for a therapy that needs approval…).

The written medical record is an important part of the MICU experience. Each new patient

needs an admission note on the chart to be available for the attending and any consultants to

review.

Daily notes must be written by a team member and should clearly reflect any new events that

have occurred. The physical exam and pertinent labs should always be included in the note.

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Whenever possible, communicate directly with the PCP to review events of the MICU

hospitalization and plans for transfer from the MICU.

Professionalism – The VAMC MICU rotation, as with all of your Internal Medicine rotations,

demands a high level of professionalism as manifested through a commitment to carrying out

professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient

population.

Professional attire and demeanor are expected. Scrubs may be worn while in MICU.

Refer to patients respectfully by their last names (Mrs. Smith).

Treat all confidential medical information in accordance with HIPAA. Patient records and

outside documents should be maintained in the chart outside the patient room. Documents

should not be left in workrooms, call rooms, or any conference rooms used for rounds.

Learn the names of the nurses with whom you work and always treat them as colleagues and

members of the care team– it goes a long way.

Be respectful of your colleagues. If one of your peers is overwhelmed, ask what you can do to

help.

Systems-based practice 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

Resident teams will partner with Patient Resource Managers, Social Workers, nurses,

physical and occupational therapists, pharmacists, respiratory therapists and other health

professionals to provide comprehensive and effective care for patients on DVAMC MICU.

MICU teams are expected to communicate and partner with referring physicians within and

outside of the Durham VA to ensure safe and effective transitions of care for our patients.

Date this curriculum was revised: 10 MAY, 2012