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Slide 1: PICU Resident Rotation Alfred I duPont Hospital for Children of the Nemours Foundation July 2007- June 2008 Edward J. Cullen Jr., D.O. Pediatric Critical Care June 2007 Topic Overview Goals for PICU Resident Rotation SCCM goals for PICU residents Page 4 -5 7 - 15 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 1
Slide 2: TJU Pediatric Residency Program Goals PICU Resident Rotation Curriculum July 2007-June 2008 Strengths, Weaknesses, Opportunities, Threats of PICU Resident Rotation 16 - 21 23 - 32 34 - 40 Appendix Background Nemours Vision, Mission, Values Nemours Patient Centered Care and Education Goals Nemours Education Mission Education as part of Nemours Strategic Process The Institute of Medicine of the National Academies ACGME competencies Considerations That Impact the Resident Educational Experience Pediatric residency programs -new challenges ACGME work hour restrictions for residents Leapfrog Inititative PICU Quality goals Education of trainees in the intensive care unit Ideal PICU Resident Rotation Challenges PICU at Alfred I duPont Hospital for Children Personnel / Resources Overview of PICU Resident Rotation Activity Snapshot of Residents’ Evaluations of PICU Rotation Experience Quality Control Pre-Rotation questionnaire / Survey Connecting Patient Care and Resident Education Computer Order Entry Protocol Transferring Patients From PICU Protocol 43 43 43 43 44 45 47 - 48 49 - 50 51 52 53 - 54 55 -57 58 60 - 65 66 - 85 86 - 117 119 - 127 129 - 130 131 - 134 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 2
Slide 3: Overview U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 3
Slide 4: Alfred I. duPont Hospital for Children Pediatric Critical Care Resident Rotation http://www.nemours.org/no/aidhc/picu/index.html (Username: picu Password: resident) Nemours' Pediatric Critical Care physicians supported by the multidisciplinary PICU team provide a pediatric critical care medicine exposure for: • Thomas Jefferson University Pediatric 2nd-year residents • Thomas Jefferson University Emergency Medicine 2nd-year residents • Christiana Care Health System Emergency Medicine 2nd-year residents • Christiana Care Health System 3rd-year Medicine-Pediatric and Internal Medicine-Emergency Medicine residents • 4th year medical students from various programs. • PICU Resident Elective • Pediatric Resident Elective in Transport Medicine / Airway and Intubation Skills (Combined program with Nemours Anesthesiologist) • Pediatric Critical Care Fellows • Pediatric Anesthesia Fellows • Alfred I duPont Hospital for Children Emergency Medicine 1st-year Fellows • Christiana Care Surgical Trauma Critical Care Fellows We aim to introduce individual residents to the art of pediatric critical care in an environment where we need to balance: • Consistent quality and safe bedside care of the critically ill child • Residents' expectations for a productive educational experience • Resident's PICU service obligations • Resident's commitment to outside-of-PICU program expectations • Resident’s restricted duty hours • Pediatric GME and SCCM viewpoints on time committed to resident ICU exposure • Critical care attendings' clinical, administrative, research, and other educational responsibilities • Health care economics. Since 1992, our PICU goals, curriculum, and future plans reflect ongoing development based on recommendations and observations from: • American Medical Association, Graduate Medical Education Guidelines for Intensive Care Experience (NICU and PICU). Graduate Medical Education Directory, American Medical Association, 1996-1997, p 184 • SCCM Guidelines for Resident Physician Training in Critical Care Medicine Crit Care Med 1995; 23:1920-1923 • General Guidelines for Resident Training in Critical Care Medicine New Horizons 1998;6:255-259 • Institute of Medicine “ To Err is Human-Building a Safer Health Care System” Washington, DC: National Academies Press;1999 • Leap Frog Group for Patient Safety http://www.leapfroggroup.org/ • The Future of Pediatric Education II: organizing pediatric education to meet the needs of infants, children, adolescents, and young adults in the 21st century. Pediatrics.2001;105 (suppl):163-212 • Accreditation Council of Graduate Medical Education. Outcomes project 2001.www.acgme.org/Outcome • Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press;2001 o Nemours Education Innovation Program (2001-2005) • Accreditation Council for Graduate Medical Education (ACGME) Work Group on Resident Duty Hours (June 2002) U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 4
Slide 5: • • • • • • • • • • • Gainer AC, Knebel E, eds. Health Professions Education: A Bridge to Quality. Washington, DC: National Academy Press; 2003 Nemours Foundation Drive to Excellence and Commitment to Medical Education (2003) The State of Pediatrics Residency Training: A Period of Transformation of Graduate Medical Education. Pediatrics 2004;114-832-841 Guidelines for critical care medicine training and continuing medical education. CritCare Med 2004; 32 (1):263-272 Integrating the Institute of Medicine’s six quality aims into pediatric critical care: Relevance and applications. Pediatric Critical Care 2005;6(3):264-269 Education of trainees in the intensive care unit. Critical Care Medicine 2007;35 (2)(Suppl):S117S121 SCCM Pediatric ICU Resident Education Committee Alfred I duPont Hospital for Children Graduate Medical Education Office Continuous Quality Improvement via PICU nursing and PICU resident questionnaires Survey of practicing physicians who participated in our PICU rotation as residents Cooperation with the Thomas Jefferson University Pediatric Residency Program, Thomas Jefferson Emergency Medicine Residency Program, Christiana Care Emergency Medicine Residency Program and the Christiana Care Medicine Pediatrics Residency Program. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 5
Slide 6: Goals for PICU Resident Rotation U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 6
Slide 7: The American College of Critical Care Medicine of the Society of Critical Care Medicine The American College of Critical Care Medicine of the Society of Critical Care Medicine recommends that on completion of residency training, the physician should have achieved proficiency in the recognition and initial management of problems commonly encountered in the intensive care unit. This proficiency includes, but is not limited to: • acute respiratory failure • hemodynamic instability • sepsis • acute neurologic insults • acute electrolyte and endocrine disorder • acute renal failure • coagulation disorders • overdoses and poisonings For less common problems, the trainees gain a knowledge base that allows them to formulate a differential diagnosis, initiate a management plan, and request appropriate consultations. Guidelines for resident physician training in critical care medicine. Crit Care Med 1995;23:1920-1923 It is evident, after examination of the comprehensive list of ICU problems outlined in these guidelines that general residents cannot develop proficiency in the complete management of all pathophysiologic states noted. Residents should, however, be able to recognize, stabilize and begin resuscitation of critically ill patients until a critical care specialist is available. General Guidelines for Resident Training in Critical Care Medicine. New Horiz 1998;6:255-259 Recent updated guidelines for critical care medicine training and continuing medical education emphasize that critical care physician education is a continuum from residency through subspecialty training and into continuing practice. Learning in critical care medicine is optimized when the learner is intimately exposed to and participates in the cognitive and technical aspects of care. Training should include a structured process that progressively transfers increasing levels of responsibility for decision making, ensures continued training in the practical aspects of care, and provides training and experience in the administrative and management functions of the ICU In addition to being an environment in which excellence in patient care is the foundation for learning to care for the critically ill and injured patient, the critical care environment should be an intensivist-directed, a collaborative multiple-professional team model of patient-centered care for all ICU patients. The ICU should comply with ACCM guidelines. The training program director must demonstrate a commitment to and competence in all aspects of critical care medicine On completion of an ACGME approved graduate education program in a clinical specialty of medicine (e.g., anesthesiology, internal medicine, pediatrics, or surgery), each resident physician will have developed U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 7
Slide 8: a measurable quantity of knowledge, learned a set of observable skills, demonstrated adequate decision making and possess a caring and compassionate attitude for patients who are critically ill. On completion of an ACGME approved graduate education program, each resident physician will be able to perform the following: Clinical • Identify when a patient requires treatment best delivered in an ICU under the direction of a qualified intensivist. • Diagnose and stabilize patients with impending organ failure (respiratory, cardiac, neurologic, hepatic, gastroinestinal, hemorrhagic, renal, etc.). • Identify the need for and initiate cardiopulmonary resuscitation. • Diagnose and prevent hemodynamic instability, and /or initiate treatment for cardiogenic, traumatic, hypovolemic and distributive shock. • Identify and initiate treatment for life-threatening electrolyte and acid-base disturbances. • Suspect and initiate treatment for common poisonings. • Use data from appropriate invasive and noninvasive monitoring devices to titrate therapy in an ICU. • Understand basic infection control techniques. • Understand basic nutrition support techniques. • Understand basic sedation and analgesia principles. • Understand basic concepts of therapeutic decision making and medication safety. • Recognize, use and help integrate the unique skills of ICU nurses and ancillary personnel in caring for critically ill patients into the multiple-professional team model. • Consider ethical issues and patients’ wishes in making treatment decisions. • • Research Understand the basic methods for searching, reviewing and evaluating the medical and scientific literature. Support ongoing basic and clinical science protocols as well as process improvement protocols within the ICU. Administrative • • • • • • • • • Communicate effectively with families and all members of the healthcare team about ICU capabilities and patient-specific issues. Communicate with and support patients, their families and all members of the healthcare team through the physical and psychological complexities of critical illness. Seek consultation, when appropriate, with specialty physicians in managing complex ICU problems. Maintain good relationships with other healthcare providers. Support initiatives to improve care of critically ill patients. Understand the need for patient safety monitoring and error reduction strategies. Understand the need for and help in the process of assessing patients and family satisfaction. Understand basic compensation methodologies for critical care services. Understand and ensure compliance with institutional and unit policies and procedures as well as regulatory policies from accreditors, regulators and payers. All GME programs must ensure that each resident receives supervised exposure to an adequate number of critically ill patients. These patients should be cared for by appropriately trained individuals in appropriately staffed and equipped ICUs. Since not all trainees will be exposed to the entire length and breadth of clinical problems during their ICU experience, a core critical care curriculum taught by clinical experts should supplement the clinical experience. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 8
Slide 9: Case based education methodology is encouraged. The program director should ensure that each resident achieves the competencies outlined. Credentials and cognitive and procedural skills which are intended to serve as guides for both programs and individuals participating in the educational process are outlined below: I. Specific Credentials Each trainee should achieve provider and /or instructor status in one or more of the following: 1. Advanced Cardiac Life Support 2. Advanced Trauma Life Support 3. Pediatric Advanced Life Support 4. Fundamentals of Critical Care Support II. Cognitive Skills for Residents Acquisition of the following cognitive skills by trainees could be ensured by the training director through the use of any of a number of techniques, including didactic lectures, journal club sessions, and illustrative case reports. A. Cardiovascular Physiology, Pathology, Pathophysiology, and Therapy 1. Shock (hypovolemic, neurogenic, septic, cardiogenic) and its complications 2. Myocardial infarction and its complications 3. Cardiac rhythm and conduction disturbances 4. Indications for and types of pacemakers 5. Pulmonary embolism—thrombus, air, fat, amniotic 6. Pulmonary edema—cardiogenic, noncardiogenic 7. Cardiac tamponade and other acute pericardial diseases 8. Acute and chronic life-threatening valvular disorders 9. Acute aortic and peripheral vascular disorders, including arteriovenous fistulas 10. Acute complications of cardiomyopathies and myocarditis 11. Vasoactive and inotropic therapy 12. Pulmonary hypertension and cor pulmonale 13. Complications of angioplasty 14. Principles of oxygen transport and utilization 15. Hemodynamic effects caused by ventilatory assist devices 16. Thrombolytic and anticoagulant therapy 17. Perioperative management of patient undergoing cardiovascular surgery 18. Recognition, evaluation, and management of hypertensive emergencies and urgencies 19. Congenital heart disease and the physiologic alterations with surgical repair 20. Noninvasive methods of cardiac output assessment (i.e., aortic Doppler, indicator dilution techniques, etc.) B. Respiratory Physiology, Pathology, Pathophysiology, and Therapy 1. Acute respiratory failure a. Hypoxemic respiratory failure including acute respiratory distress syndrome b. Hypercapnic respiratory failure c. Acute on chronic respiratory failure 2. Status asthmaticus 3. Smoke inhalation, airway burns 4. Aspiration 5. Chest trauma (e.g., flail chest, pulmonary contusion, rib fractures) 6. Bronchopulmonary infections including bronchiolitis 7. Upper airway obstruction 8. Near drowning U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 9
Slide 10: 9. Bronchopleural fistulas 10. Pulmonary mechanics and gas exchange 11. Oxygen therapy 12. Hyperbaric oxygenation 13. Mechanical ventilation a. Pressure and volume modes of mechanical ventilators b. Positive end-expiratory pressure, intermittent mandatory ventilation, continuous positive airway pressure, high-frequency ventilation, inverse ratio ventilation, pressure-support ventilation, volume support (airway pressure release ventilation, pressure-regulated volume control ventilation), negative pressure ventilation, differential lung ventilation, pressure control and noninvasive ventilation, spilt lung ventilation, one-lung ventilation c. Indications for and hazards of mechanical ventilation d. Barotrauma and volutrauma e. Criteria for extubation and weaning techniques f. Extracorporeal membrane oxygenation g. Permissive hypercapnia h. Liquid ventilation i. Pulmonary surfactant therapy j. High-frequency oscillatory ventilation 14. Airway maintenance a. Emergency airway management b. Endotracheal intubation c. Tracheostomy, open and percutaneous d. Long-term intubation vs. tracheostomy 15. Ventilatory muscle physiology, pathophysiology, and therapy, including polyneuropathy of the critically ill and prolonged effect of neuromuscular blockers 16. Pleural diseases a. Empyema b. Pleural effusion c. Pneumothorax d. Hemothorax 17. Pulmonary chylothorax, hemorrhage, and hemoptysis 18. Nitric oxide and prostaglandin therapies 19. Noninvasive ventilation 20. Positional therapy (i.e., prone position, rotational therapy) C. Renal Physiology, Pathology, Pathophysiology, and Therapy 1. Renal regulation of fluid balance and electrolytes 2. Renal failure: Prerenal, renal, and postrenal 3. Derangements secondary to alterations in osmolality and electrolytes 4. Acid-base disorders and their management 5. Principles of renal replacement therapy and associated methodologies (hemodialysis, peritoneal dialysis, ultrafiltration, continuous arteriovenous hemofiltration, and continuous veno-venous hemofiltration) 6. Interpretation of urine electrolytes 7. Evaluation of oliguria 8. Drug dosing in renal failure 9. Rhabdomyolysis 10. Systemic diseases that involve the kidney (thrombotic thrombocytopenic purpura, hemolytic uremic syndrome) D. Central Nervous System Physiology, Pathology, Pathophysiology, and Therapy 1. Coma a. Metabolic b. Traumatic U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 10
Slide 11: c. Infectious d. Mass lesions e. Vascular-anoxic or ischemic f. Drug induced g. Assessment and prognosis 2. Hydrocephalus and shunt function and dysfunction 3. Psychiatric emergencies 4. Perioperative management of patient undergoing neurologic surgery 5. Brain death evaluation and certification 6. Diagnosis and management of persistent vegetative states 7. Management of increased intracranial pressure, including intracranial pressure monitors 8. Status epilepticus 9. Neuromuscular disease causing respiratory failure a. Guillain-Barré b. Amyotrophic lateral sclerosis c. Myasthenia gravis d. Myopathies (Duchenne’s, etc.) e. Neuropathy of critical illness 10. Traumatic and nontraumatic intracranial bleed a. Subarachnoid b. Intracerebral c. Epidural d. Others (subdurals) e. Traumatic brain injury f. Axonal shear injury 11. Conscious and deep sedation 12. Pain management: Intravenous, oral, transdermal, and regional and axial 13. Neuromuscular blockade: Use, monitoring, and complications E. Metabolic and Endocrine Effects of Critical Illness 1. Colloid osmotic pressure 2. Nutritional support a. Enteral and parenteral b. Evaluation of nutritional needs including indirect calorimetry c. Immunonutrition and specialty formulas 3. Endocrine a. Disorders of thyroid function (thyroid storm, myxedema coma, sick euthyroid syndrome) b. Adrenal crisis and insufficiency (primary and secondary) c. Disorders of antidiuretic hormone metabolism d. Diabetes mellitus 1. Ketotic and nonketotic hyperosmolar coma 2. Hypoglycemia e. Pheochromocytoma f. Insulinoma g. Disorders of calcium, magnesium, and phosphate balance h. Inborn errors of metabolism 4. Electrolyte disorders including Na, K, Mg, Ca, PO4. 5. Glucose management F. Infectious Disease Physiology, Pathology, Pathophysiology, and Therapy 1. Antibiotics a. Antibacterial agents including aminoglycosides, penicillins, cephalosporins, quinolones, and newer emerging classes of antibiotics b. Antifungal agents c. Antituberculosis agents U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 11
Slide 12: d. Antiviral agents e. Agents for parasitic infections 2. Infection control for special care units a. Development of antibiotic resistance b. Universal precautions c. Isolation and reverse isolation 3. Anaerobic infections 4. Sepsis definitions (sepsis, severe sepsis, septic shock) 5. Systemic inflammatory response syndrome 6. Tetanus 7. Hospital-acquired and opportu- nistic infections in the critically ill 8. Adverse reactions to antimicrobial agents 9. ICU support of the immunosuppressed patient a. Acquired immunodeficiency syndrome b. Transplant c. Oncologic 10. Infectious risks to healthcare workers 11. Evaluation of fever in the ICU patient 12. Biological modifiers (activated protein C, tissue factor, etc.) 13. Mechanisms of antibiotic resistance G. Physiology, Pathology, Pathophysiology, and Therapy of Acute Hematologic and Oncologic Disorders 1. Acute defects in hemostasis a. Thrombocytopenia/thrombocytopathy b. Disseminated intravascular coagulation 2. Anticoagulation; fibrinolytic therapy 3. Principles of blood component therapy a. Packed red blood cell transfusions b. Fresh frozen plasma transfusions c. Platelet transfusions d. Cryoprecipitate transfusions e. Specific coagulation factor concentrates f. Albumin, plasma protein fraction g. Hemoglobin substitutes h. Pharmacologic agents that modify the need for transfusion (i.e., aminocaproic acid, aprotinin) i. Erythropoietin 4. Acute hemolytic disorders including thrombotic microangiopathies 5. Acute syndromes associated with neoplastic disease and antineoplastic therapy 6. Sickle cell crisis and acute chest syndrome 7. Plasmapheresis 8. Prophylaxis against thromboembolic disease 9. ICU-acquired anemia H. Physiology, Pathology, Pathophysiology, and Therapy of Acute Gastrointestinal, Genitourinary, and Obstetrical-Gynecologic Disorders 1. Acute pancreatitis with shock 2. Upper gastrointestinal bleeding, including variceal bleeding 3. Lower gastrointestinal bleeding 4. Acute and fulminant hepatic failure 5. Toxic megacolon and pseudo-obstruction syndromes (i.e., Ogilvie’s) 6. Acute perforations of the gastrointestinal tract 7. Ruptured esophagus 8. Acute inflammatory diseases of the intestine 9. Acute vascular disorders of the intestine, including mesenteric infarction U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 12
Slide 13: 10. Obstructive uropathy, acute urinary retention 11. Urinary tract bleeding 12. Toxemia of pregnancy, amniotic fluid embolism, HELLP (hemolysis, elevated liver function tests, and low platelet count) syndrome, ovarian hyperstimulation 13. Hydatidiform mole 14. Perioperative management of surgical patients 15. Stress ulcer prophylaxis 16. Drug dosing in hepatic failure 17. Acalculous cholecystitis 18. Postoperative complications including fistulas, wound infection, and evisceration 19. Placenta previa and abruption 20. Peripartum cardiomyopathy I. Environmental Hazards 1. Drug overdose and withdrawal a. Barbiturates b. Narcotics c. Salicylates d. Alcohols e. Cocaine f. Tricyclic antidepressants g. Acetaminophen h. Others 2. Temperature-Related Injuries a. Hyperthermia, heat shock b. Hypothermia, frostbite 3. Envenomation 4. Altitude sickness 5. Decompression sickness 6. Skin and wound care 7. Biological and chemical terrorism 8. Radiation exposure J. Immunology and Transplantation 1. Principles of transplantation (organ donation, procurement, preservation, transportation, allocation, implantation, maintenance of organ donors, national organization of transplantation activities) 2. Immunosuppression 3. Organ transplantation: Indications preoperative and postoperative care 4. Transplant-related infectious disease K. Trauma, Burns 1. Initial approach to the management of multiple system trauma 2. Central nervous system trauma (brain and spinal cord) 3. Skeletal trauma, including the spine and pelvis 4. Chest trauma, blunt and penetrating 5. Abdominal trauma, blunt and penetrating 6. Crush injury 7. Burns 8. Electrical injury L. Monitoring, Bioengineering, Biostatistics 1. Prognostic indexes, severity, and therapeutic intervention scores 2. Principles of electrocardiographic monitoring, measurement of skin temperature and resistance, transcutaneous measurements 3. Invasive hemodynamic monitoring U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 13
Slide 14: a. Principles of strain gauge transducers b. Signal conditioners, calibration, gain, adjustment c. Display techniques d. Principles of arterial, central venous, and pulmonary artery pressure catheterization and monitoring e. Assessment of cardiac function and derived hemodynamic variables 4. Noninvasive hemodynamic monitoring 5. Electrical safety 6. Thermoregulation 7. Central nervous system brain monitoring (intracranial pressure, cerebral blood flow, cerebral metabolic rate, electroencephalogram, jugular venous bulb oxygenation, transcranial Doppler) 8. Respiratory monitoring (airway pressure, intrathoracic pressure, tidal volume, pulse oximetry, deadspace/tidal volume ratio, compliance, resistance, capnography, pneumotachography) 9. Metabolic monitoring (oxygen consumption, carbon dioxide production, respiratory quotient, indirect calorimetry) 10. Use of computers in critical care units M. Ethics 1. Consent 2. Study enrollment 3. End-of-life decision making and care 4. Organ procurement 5. Outcome and futility 6. Quality of end of life N. Administration 1. Team building 2. Contracting care 3. Patient triage 4. Physician, nurse, and ancillary staff staffing models 5. Documentation compliance and billing 6. Patient safety O. Genetic 1. Congenital disease (trisomy, etc.) 2. Storage diseases (Hurlers, etc.) 3. Polymorphisms P. Pharmacology 1. Pharmacokinetics 2. Pharmacodynamics 3. Safe medication practice 4. Drug dosing adjustments in hepatic disease 5. Drug dosing adjustments in renal disease Core Procedural Skills for Residents In addition to practical training in the following procedural skills, the resident must have an understanding of the indications, contraindications, complications, and pitfalls of these interventions. Due to the variability of individual training programs, practical experience may be limited for some procedures. A. Airway Management 1. Maintenance of an open airway in the nonintubated patient 2. Ventilation by bag-mask 3. Tracheal intubation U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 14
Slide 15: 4. Management of pneumothorax B. Circulation 1. Arterial puncture and cannulation 2. Insertion of central venous catheters 3. Pericardiocentesis in acute tamponade 4. Dynamic electrocardiogram interpretation 5. Cardioversion and defibrillation 6. Pulmonary artery catheterization 7. Transcutaneous pacing 8. Electrocardiographic monitoring C. Additional Procedures 1. Thoracentesis 2. Paracentesis 3. Endoscopy 4. Bronchoscopy Crit Care Med 2004; 32(1): 267-271 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 15
Slide 16: The Thomas Jefferson Pediatric Residency Program Goals for the Critical Care Rotation, Alfred I duPont Hospital for Children Based on the APA Educational Guidelines for Pediatric Residency (www.ambpeds.org/EGweb/index.cfm) as edited by Keith J. Mann, MD, Assistant Director of the Thomas Jefferson University Pediatric Residency Program (3/31/05): I. Resuscitation and Stabilization (PICU). Recognize the critically ill patient and initiate appropriate stabilization and/or resuscitative measures. A) Explain and perform steps in resuscitation and stabilization, particularly airway management, volume replacement, and resuscitative pharmacology. B) Describe the common causes of acute deterioration in the previously stable patient in the PICU. C) Function appropriately in codes and resuscitations as part of the PICU team. II. Common Signs and Symptoms (PICU). Evaluate and manage, under the supervision of an intensivist, common signs and symptoms seen in critically ill infants, children and adolescents in the intensive care setting. A) Evaluate and manage, under supervision of an intensivist, patients with signs and symptoms that present commonly to the intensive care unit (examples below): 1. Cardiovascular: Acute life-threatening event, bradycardia, cardiopulmonary arrest, congestive heart failure, cyanosis, hypertension, hypotension, poor capillary perfusion, rhythm disturbances, tachycardia 2. Endocrine: Signs and symptoms suggestive of hypo- and hyperglycemia and adrenal insufficiency/crisis 3. GI: Abdominal distension, hematemesis and melena, icterus, peritoneal signs, vomiting 4. Hematologic:, Pallor, petechiae, purpura, uncontrolled bleeding 5. Infectious Diseases: Endotoxic shock, fever 6. Neurologic: Acute weakness, altered mental status, coma, delirium, encephalopathy, seizures, tetany, thermoregulatory abnormalities 7. Renal: Anuria, hematuria, oliguria, polyuria, severe electrolyte disturbance 8. Respiratory: Apnea, cyanosis, dyspnea, hemoptysis, hypercarbia, hyperpnea, hypoxemia, increased or decreased respiratory effort, poor air movement, pulmonary edema, respiratory failure, stridor, tachypnea, wheezing III. Common Conditions (PICU). Recognize and manage, under the supervision of an intensivist, conditions that commonly present to the intensive care unit, using consultation when appropriate. A) Evaluate and manage, under the supervision of an intensivist, patients with conditions that present commonly to the intensive care unit (examples below): 1. General: Burns (thermal, electrical), common intoxications, drug overdose, shock (cardiogenic, hypovolemic, distributive, toxic), inhalation injury, malignant hyperthermia, non-accidental trauma, submersion injury, toxic or caustic ingestion or inhalation injury, toxic shock syndrome 2. Allergy Immunology: Anaphylaxis, life-threatening angioedema, Stevens Johnson Syndrome 3. Cardiovascular: Arrhythmias, cardiac tamponade, congestive heart failure, cyanotic congenital heart U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 16
Slide 17: disease, malignant hypertension, myocarditis/cardiomyopathy 4. Endocrine: Diabetes insipidus and adrenal insufficiency/crisis, diabetic ketoacidosis, hypo- and hyperglycemia, syndrome of inappropriate antidiuretic hormone (SIADH) 5. Fluids, electrolytes, metabolic: Inborn errors of metabolism, severe dehydration (hyper-, normo-, or hyponatremic), severe acid-base disturbances, severe electrolyte disturbance 6. GI/Surgery: Abdominal trauma (blunt/penetrating), acute abdomen, acute GI bleeding, fulminant hepatic dysfunction, hepatic dysfunction, pancreatitis, pre- and post-operative management, stress ulcer 7. Hematologic: Anemia (severe), disseminated intravascular coagulopathy (DIC), Deep venous thrombosis (DVT), neutropenia, sickle crisis, polycythemia, thrombocytopenia, tumor lysis syndrome 8. Infectious disease: Encephalitis, infant botulism, meningitis, nosocomial infections, sepsis 9. Neurologic: Acute increased intracranial pressure, brain death, cerebral edema, cerebrovascular accident (CVA), coma, encephalopathy, Guillain-Barre, head injury, spinal muscle atrophy, status epilepticus 10. Pulmonary: Acute respiratory distress syndrome (ARDS), epiglottitis, pulmonary edema, pneumothorax, respiratory failure/impending respiratory failure, severe croup and bacterial tracheitis, status asthmaticus, upper airway obstruction (infectious, structural, foreign body) 11. Renal: Acute renal failure, hemolytic uremic syndrome IV. GOAL: Diagnostic Testing (PICU). Utilize common diagnostic tests and imaging studies appropriately in the intensive care unit, obtaining consultation as indicated for interpretation of results. A) Demonstrate understanding of common diagnostic tests and imaging studies used in the PICU by being able to: 1. Explain the indications for and limitations of each study. 2. Know or be able to locate readily age-appropriate normal ranges (lab studies). 3. Apply knowledge of diagnostic test properties, including the use of sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios, and receiver operating characteristic curves, to assess the utility of tests in various clinical settings 4. Discuss cost and utilization issues. 5. Interpret the results in the context of the specific patient. 6. Discuss therapeutic options for correction of abnormalities. B) Use appropriately the following laboratory and imaging studies when indicated for patients in the PICU setting: 1. CBC with differential, platelet count, RBC indices 2. Blood chemistries: electrolytes, glucose, calcium, magnesium, phosphate. 3. Renal function tests U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 17
Slide 18: 4. Tests of hepatic function (PT, albumin) and damage (ammonia, bilirubin, liver enzymes) 5. Serologic tests for infection (e.g., hepatitis, HIV). 6. C-reactive protein, erythrocyte sedimentation rate. 7. Therapeutic drug concentrations 8. Coagulation studies: platelets, PT/PTT, fibrinogen, FSP, D-dimers, "DIC screen" 9. Arterial, capillary, and venous blood gases 10. Detection of bacterial, viral, and fungal pathogens 11. Urinalysis 12. CSF analysis 13. Stool studies 14. Toxicologic screens/drug levels 15. Other fluid studies (e.g. pleural fluid, joint fluid) 16. Chest x-ray and Abdominal series 17. Skeletal survey 18. Cervical spine films 19. CT scans of abdomen, chest and head 20. MRI scans V. GOAL: Monitoring and Therapeutic Modalities (PICU). Understand how to use the physiologic monitoring, special technology and therapeutic modalities used commonly in the intensive care setting. A) Demonstrate understanding of the monitoring techniques and special treatments commonly used in the PICU by being able to: 1. Discuss the indications, contraindications and complications. 2. Have a basic understanding of the general techniques (e.g. Seldinger technique for central venous line placement). 3. Interpret the results of monitoring B) Use appropriately the following monitoring techniques in the intensive care unit under supervision of an intensivist: 1. Central venous pressure monitoring 2. Invasive arterial blood pressure monitoring U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 18
Slide 19: 3. Intracranial pressure monitoring 4. Pulse oximetry 5. End-tidal carbon dioxide monitoring C) Utilize appropriately or be familiar with the following treatments and techniques in the intensive care unit, including monitoring effects and anticipating potential complications specific to each therapy: 1. Oxygen administration by cannula, masks, hood 2. Positive pressure ventilation including non-invasive modalities such as nasal/mask BiPAP/CPAP, bag and mask ventilation) 3. Principles of ventilator management, intubation and extubation procedures and criteria 4. Analgesics, sedatives, and paralytics 5. Enteral and parenteral nutrition 6. Blood and blood product transfusions 7. Vasoactive drugs (pressors and inotropes) VI. GOAL: Death, Acute Illness/Injury and Terminal Illness: Provide skillful medical care and empathic support to the acutely ill, injured or terminally ill child and his/her family. A) Discuss principles in the medical management of acutely ill, injured or terminally ill children, and demonstrate an understanding of the goals of treatment, including relevant medical, legal, and psychosocial issues such as: 1. Involving parents in decision-making processes 2. Redirection of the goals of care 3. Symptomatic management of pain, respiratory distress, and nutrition 4. In-hospital "hospice" care 5. Home hospice care 6. "Do Not Resuscitate" orders and termination of life support 7. Use of bioethics committees in difficult decision-making situations 8. Definition of brain death and criteria for organ donation 9. Concepts of futility, withdrawal, and withholding of care, as well as euthanasia B) Discuss the principles of counseling parents regarding treatment options for terminally ill children, including the integration of relevant cultural and religious or spiritual values. C) Describe the stages of the normal grieving process. D) Describe the common reactions of siblings to the impending death of a sibling. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 19
Slide 20: E) Counsel parents with regard to: 1. The diagnosis of life-threatening illness 2. Persistent vegetative states 3. Grief counseling and referral for the child and other children in the family 4. Strategies to help siblings and other children cope with the death of a loved one F) Describe how to formulate management plans for terminally ill patients, including: 1. Pain/comfort management plan 2. Outpatient plan for patients going home or to a hospice 3. In-hospital, hospice-like plan for patients whose parents want them to remain in the hospital G) Demonstrate sensitivity to the balance between involving the family in decision-making and placing inappropriate burdens for these decisions on parents. H) Understand one's personal response and feelings when dealing with death and dying, including: 1. Personal belief and religious/spiritual belief systems related to disease and management of the dying child 2. The need to share feelings with others during times of stress or death Procedures VII. Technical and therapeutic procedures. Describe the following procedures, including how they work and when they should be used; competently perform those commonly used by the pediatrician in practice. 1. Arterial puncture 2. Cardioversion/defibrillation 3. Central line 4. Chest tube placement 5. Endotracheal intubation 6. Lumbar puncture IX. GOAL: Pediatric Competencies in Brief (PICU): Demonstrate high standards of professional competence while working with patients in the Pediatric Intensive Care Unit. [For details see Pediatric Competencies] A) Competency 1: Patient Care. Provide family centered patient care that is developmentally and age appropriate, compassionate, and effective for the treatment of health problems and the promotion of health. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 20
Slide 21: 1. Use a logical and appropriate clinical approach to the care of critically ill patients, applying principles of evidence-based decision-making and problem solving. 2. Provide sensitive support to patients with serious illness and to their families, and arrange for on-going support or preventive services if needed. B) Competency 2: Medical Knowledge. Understand the scope of established and evolving biomedical, clinical, epidemiological and social-behavioral knowledge needed by a pediatrician; demonstrate the ability to acquire, critically interpret and apply this knowledge in patient care. 1. Demonstrate a commitment to acquiring the knowledge base expected of general pediatricians caring for seriously ill children under the guidance of an intensivist. 2. Know and/or access medical information efficiently, evaluate it critically, and apply it appropriately to care of patients in the PICU. C) Competency 3: Interpersonal and Communication Skills. Demonstrate interpersonal and communication skills that result in information exchange and partnering with patients, their families and professional associates. 1. Provide effective and sensitive communication with patients and families in the intensive care setting. 2. Participate effectively as part of an interdisciplinary team in the intensive care unit to create and sustain information exchange, including communication with the primary care physician. 3. Maintain accurate, timely and legally appropriate medical records on complex and critically ill children. D) Competency 4: Practice-based Learning and Improvement. Demonstrate knowledge, skills and attitudes needed for continuous self-assessment, using scientific methods and evidence to investigate, evaluate, and improve one's patient care practice. 1. Use scientific methods and evidence to investigate, evaluate, and improve one's patient care practice in PICU setting. 2. Identify personal learning needs, systematically organize relevant information resources for future reference, and plan for continuing acquisition of knowledge and skills. E) Competency 5: Professionalism. Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diversity. 1. Demonstrate a commitment to carrying out professional responsibilities while providing care in the PICU setting. 2. Adhere to ethical and legal principles, and be sensitive to diversity in the care of critically ill children. F) Competency 6: Systems-Based Practice. Understand how to practice high quality health care and U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 21
Slide 22: advocate for patients within the context of the health care system. 1. Identify key aspects of health care systems, cost control, and mechanisms for payment as they relate to the intensive care setting. 2. Recognize the limits of one's knowledge and expertise and take steps to avoid medical errors. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 22
Slide 23: PICU Resident Rotation Curriculum July 2007 to June 2008 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 23
Slide 24: PICU Rotation Curriculum July 2007 – June 2008 PICU rotation for Pediatric residents is 8 weeks during the PL2 year. The PICU rotation for Thomas Jefferson ER, Christiana ER residents is 4 weeks during the PL2 year; 4 weeks during the PL3 year for Christiana EMIM and Christiana Medicine-Pediatrics residents. Residents and medical students from visiting programs are considered for PICU rotations as long as there are not too many residents so that patient contact is not diluted for the scheduled residents. PICU rotation web site http://www.nemours.org/internet?url=no/aidhc/picu/index.html (Username=picu / Password=resident) The PICU website is updated each June and as necessary. Ilene Sivikoff, critical care secretary, coordinates paperwork between visiting residents and the Alfred I duPont Hospital for Children GME Office. She obtains Cerner and Novell training date / password for visiting residents and medical students. She notifies Stentor radiology site that resident will need access during time frame provided. Ilene obtains Jeffline password for visiting residents and medical students. She obtains meal tickets, beeper for visiting residents and Proxy Cards to enter locked doors and assists the residents in obtaining a Nemours badge. She prepares a folder for new resident(s) that includes: Check-Off sheet, PICU Curriculum, 2-page introduction of essentials for PICU rotation, Primary patient / Procedure flow sheet, Hours reporting form, SCCM Toipic reporting form ,Order Entry Protocol, Transferring Patients Protocol, Infection control that includes RSV and Rotovirus isolation handout. Ilene prepares and distributes a monthly PICU Rotation curriculum. She assists with preparing bi-annual GME data requests, sends out surveys each December to previous residents who are in practice, orders textbooks for the PICU, assists with correspondence. Dr Cullen assigns a resident ID number for the PICU rotation, SCCM post-test password and obtains a temporary Nemours Infolink password for visiting residents and medical students. Ilene Sivikoff and Dr Cullen maintain a PICU resident rotation Access Data Base: Resident ID number and rotation dates, and mentor, pre-rotation questionnaire, Mock Codes, Interactive Teaching Rounds, Journal Clubs, Lectures given, reported patients, procedures, duty hours, SCCM topics reviewed, results of SCCM post rotation test for residents in a PICU, residents’ comfort levels after rotation, residents’ evaluations of PICU rotation, survey for previous PICU residents now in practice. Residents are given access to the Nemours Infolink, an internet resource for medical literature search engines, medical journals, evidence based clinical medicine information, PICU article collection, Lexicomp, Micromedex, Society of Critical Care Medicine powerpoint presentations on PICU topics specifically directed towards residents in the PICU and additional educational activities. Visiting residents and medical students also receive a temporary username/password to Jeffline, Thomas Jefferson University Medical Library. Textbooks available in the PICU Pediatric Critical Care Third Edition Fuhrman/Zimmerman Pediatric Critical Care Medicine Slonim / Pollock U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 24
Slide 25: Pediatric Intensive Care, Third Edition Mark C. Rogers The Difficult Pediatric Airway Anesthesiology Clinics of North America Jalil Riazi, MD, Editor 1999 Principles and Practice of Mechanical Ventilation 2nd Edition Tobin Management of Pediatric Trauma Buntain Critical Heart Disease in Infants and Children Second Edition Nichols, Ungerleider, Spevak, Greeley, Cameron, Lappe, Wetzel Pediatric Cardiac Intensive Care Chang, Hanley, Wernovsky, Wessel Illustrated Textbook of Pediatric Emergency and Critical Care Procedures Dieckmann, Fiser, Selbst Textbook of Pediatric Emergency Medicine Ludwig Fleisher The Pharmacologic Approach to Critically Ill Patients Chernow, Third Edition Principles and Practice of Intensive Care Monitoring Tobin Principles and Practice of Intensive Care Monitoring Tobin Supportive Care of Children with Cancer Current Therapy and Guidelines from the Children's Cancer Group 2nd Edition, 1997 Edited by Arthur R. Ablin MD Smith's Recognizable Patterns of Human Malformation 5th edition, 1997 Residents are given a short introduction to PICU, PICU educational objectives and educational resources during their first day of the rotation. Residents receive handouts which describe the PICU educational format and responsibilities. They receive their Logs for primary patients, procedures, duty hours; check off sheet for completion of SCCM power-point presentations and their password for the SCCM post-test. Visiting residents and medical students receive a 3-hour Cerner order entry computer course, a short Novell computer training and MedRite transcription instructions on day 1 of the rotation. Residents complete an on-line pre-PICU rotation questionnaire during the first week of their rotation. This gathers information about their previous critical care experiences, their goals and their comfort level with critically ill children. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 25
Slide 26: Although all orders ideally should be placed in Cerner by the ordering physician, residents spend too much time at the computer entering orders when they should be interacting with patients. There are no verbal orders in the PICU. Orders can be hand written and then entered into the computer by assigned clerks.. Residents are given our protocol for writing orders in the PICU. Residents are given our protocol for transferring PICU patients to various medical and surgical services in the general hospital areas. Before patient care rounds, the resident is expected to examine their primary patients and begin a combined resident and critical care attending PICU Daily Progress Note. Although residents follow certain primary patients, they are expected to know the diagnosis and care plan for all patients. A critical care attending is available for resident supervision during the day and night. PICU Resident education is mainly through interactive patient care (morning patient rounds and individual patient care) with the critical care attendings. Residents are encouraged to use patient care rounds as check-out rounds such that when rounds are over the off-going resident will have conveyed the important info to the residents who will be staying, especially the person who is on call that night (however, sometimes the night call person has seminars in the morning and doesn't attend rounds). Daily interactive teaching rounds (weekdays 0730 or 0800 on Saturdays, Sundays and holidays) occur as part of patient care rounds. Case based discussions are encouraged during morning multidisciplinary patient-care rounds as time permits. Radiologist reviews PICU radiology studies in the PICU daily Monday-Friday at 1030. Night call residents are expected to be in the PICU no more than 30 hours from the time they arrived the day before. ACGME Duty Hours are monitored and adhered to. Residents are asked to review the Society of Critical Care Medicine powerpoint presentations on PICU topics at their own pace. These power-point presentations are specifically directed towards residents in the PICU. Residents will document what topics they have reviewed. These powerpoints are available on the internet: http://www.sccm.org/specialties/pediatric/picu_course/course_index.asp PICU Mock Code each Friday at 1400. A designated critical care physician who is different from the PICU service physician directs the Mock Code; PICU nurse educators supply equipment and coordinate nursing and respiratory availability. All Mock Codes are documented in our PICU Resident Rotation Data Base. (Simulation Lab is being discussed for future Mock Codes) The Alfred I duPont Hospital for Children medical librarian and Program Director for the Nemours Infolink attends PICU patient care rounds each Friday. Evidence-based literature reviews are emphasized. Evidence-based conference (Journal Club) is held monthly. This is prepared by the critical care attendings and fellows. Evidence-based conferences (Journal Clubs) are documented in the PICU Resident Rotation Data Base. Residents are encouraged to ask focused clinical questions about patient care issues that arise during patient care rounds. They are encouraged to use the available resources to search the most recent medical literature and evaluate the validity, results and applicability to their patients. This information can be shared during U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 26
Slide 27: or after patient care rounds. If a resident does a formal critically appraised topic on a specific focused clinical question, consideration will be given to sending this to the pediatric residency program. The pediatric residency program in collaboration with the Centre for Health Evidence will be starting a collection of pediatric critically appraised topics . Pediatric critical care fellows present a topic to the PICU residents at 1400 on the 3rd Tuesday of each 4 week block. PICU residents present a PICU patient to hospital morning report at 0830 on the second and fourth Tuesday of each 4-week rotation block. It is the responsibility of the PICU residents to designate which resident will present the chosen patient. Pediatric critical care attendings and fellows are encouraged to give any additional formal lectures they wish to the residents. Documentation of this extra educational activity is entered into our PICU Resident Rotation Data Base. PICU residents, fellows , medical students, nurses and attending physicians can suggest the addition of pertinent articles to our PICU Article Collection which is on Nemours Infolink. Request can be made to Dr Cullen who maintains this site at present. Residents participate in on-line Society of Critical Care Medicine national test after the completion of their PICU rotation. This test is designed specifically for residents who have completed a PICU rotation. (Two copies of the second version of the post-test are being prepared by the SCCM PICU resident rotation education committee. A third version is being prepared. The first test will be administered to first time rotators in the ICU. If the resident identifies himself or herself as a second-time rotator in the ICU, s/he will be directed to the second post-test). Their scores are sent to their respective residency programs. Residents are asked to return their procedure logs, patient logs, duty hour logs, SCCM power-point presentations reviewed, and complete a post-rotation comfort level with critically ill children form on the last day of their rotation. This data is entered into the PICU Resident Rotation database. Residents are asked to print out a report of their usage of the Nemours Infolink. (Easily accessable though the Nemours InfoLink resource). Visiting residents are asked to return their beepers, proxy card (and parking permit) to the critical care office. Residents complete an evaluation of their PICU rotation through their respective residency program on-line forms. Respective residency programs send us periodic summaries of resident evaluations of the PICU rotation. Critical care physicians complete individual resident specific residency program evaluations forms on-line. Residents are evaluated on the six ACGME competencies. Respective residency programs employ a 360 degree resident evaluation process. PICU nurses participate. Each December-January, surveys are sent to residents who have completed their PICU rotation here and are in their first year of practice or fellowship. The survey reviews their need to practice critical care in their practice settings and asks how we can better prepare them. PICU Resident Rotation web site is updated annually in June. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 27
Slide 28: PICU Resident Elective For Pediatric Residents who have already completed their scheduled 8 weeks of PICU rotation here at Alfred I duPont Hospital for Children: Suggested Duration: 4 week block Morning • Examine all PICU patient • Know clinical course of all PICU patients • Attend morning patient care rounds Afternoon • Time is used to prepare an evidence-based review of a therapy or therapies suggested for a specific PICU problem that is of interest to the resident. Topics include ARDS, Septic shock, DIC, Closed Head Injury, Renal failure support, multi organ system support, nutrition of critically ill patient. Presentation of evidence-based review to PICU group at end of the elective. No night call associated with PICU Resident Elective. Combined Transport Medicine and Anesthesia Elective Residents must be at least a PGY 3 and have completed their rotations through the PICU. Suggested Duration: 2 week block Approval required from Drs. Arai / Brislin for the Anesthesia component and Dr. Hertzog for the Transport Medicine component of the elective. Only one resident may take the elective at a given time and availability of the elective may be restricted by the number of other individuals present in the operating room for educational experiences. Residents should be available Monday through Friday from 7:30 AM through 4:30 PM. The residents will also be encouraged to arrange to be available for 2-3 evenings during the rotation to participate in additional transports. There is no formal night call response U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 28
Slide 29: Resident Orientation To PICU Rotation Nemours Alfred I duPont Hospital for Children Principle Clinical Responsibility Examine your primary patient before morning and afternoon patient care rounds and frequently throughout the day and night if the child is unstable. Keep critical care physician updated with any changes in your primary patient’s condition. Know the general clinical course and plan of all PICU patients. Expectations for PICU Residents to ensure Safe, Quality Patient Care It is expected that residents will: • Interact professionally with the nurses, respiratory therapists, unit clerks, consultants and families in the ongoing care of the children in the PICU. • Know the history and main clinical issues for each patient in the PICU • Examine assigned patients before formal rounds. • Examine their patients frequently throughout their hours in the PICU and that they will interact with the critical care physician with any changes in the patients’ clinical course. • Learn and use our process for presenting patients on formal rounds • Be prepared for and fully participate in patient care rounds. • Have a basic knowledge of the medical issues affecting the patient they are presenting on rounds • Exchange up-to-date patient information with on-coming day or night resident(s) • Will not give verbal orders. Will learn and utilize the PICU Order Entry Algorithm for written and computer entered orders. (If write orders, need to place your Beeper number under your name) • Complete and document H&Ps on patients admitted to the PICU from the ER, Transport, home or Acceptance Notes for children transferred from OR, PACU or general hospital area. • Complete a daily progress note and if appropriate procedure notes on assigned patients • Review indications, landmarks, procedure details and complication risk for all procedures before procedures are undertaken with the supervision of critical care physicians. Procedures are infrequent. Critical care fellows have priority when the need for procedures presents themselves. Occasionally, the technical or emergent nature of the child’s condition may preclude the resident from participating in the procedure. • Learn and utilize the PICU Transfer Algorithm • Assist with discharge of patients to other facilities or home. A short -stay discharge summary can be done on-line for children discharge from the PICU after 1 or 2 days. Dictated discharge summaries are required for children who are discharged home or to other facilities from the PICU after 2 days. • Assist in communicating patient updates to referring physicians. • Be acquainted with hospital Code Blue responsibilities and review PALS algorithms for pulseless arrest, bradycardia, tachycardia with poor & adequate perfusion. • Be acquainted with the PICU Difficult Airway Cart Housekeeping Issues • • • PICU morning rounds begin at 0730 on week-days and 0800 on Sat/Sun and Holidays. It is expected that you will examine their primary patients & collect necessary data before rounds. Please do not pre-date transfer summaries U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 29
Slide 30: • • • • • • • • • • • • • Residents will put their names next to the critical care attendings’ names on the PICU room board for those primary patients that they are following. In the interest of patient continuity of care, before leaving for clinic, seminar or home, residents must check out in detail the updated clinical course of their primary patients with the resident who is designated on-call and the critical care attending. On Sat/Sun and Holidays, the on-coming resident and the resident from night call are each responsible for examining and collecting data on all PICU patients before rounds and completing the daily patient notes. ER physicians are expected to return to the PICU after their weekly morning seminars PICU on-call resident carries a code beeper. You are the procedure resident for codes. PICU residents are asked to cover for emergencies in the surgical NICU (SNICU) at night and on weekends. The neonatal nurse practitioner has to go on transport runs at times. She will up date you if there are any immediate issues to check. You will be interacting with the Neonatologist when you are in the SNICU. If you are spending a lot of time in the SNICU, please tell the PICU attending that you cannot be in two places at the same time. Communicate any new patient changes or concerns immediately with the PICU physician in order to better attend to the child’s needs. Night call residents must leave the PICU no later than 30 hours after arriving in the PICU. (Night call residents are not to take new patients after 24 hours of continuous call). On the first day of your rotation, introduce yourself to the Unit Clerks and give them your beeper numbers When you page someone please let the PICU clerks know that you are expecting a call. Be sure to date and time all written physician orders and notes. Print your name and beeper number below your signature on notes and written orders. Eating at PICU work stations is discouraged. No email checks during rounds. More details about the PICU Resident Rotation are outlined in these sections of the PICU Resident Rotation Web Site: http://www.nemours.org/internet?url=no/aidhc/picu/index.html (username:picu /password:resident) Administrative Issues General Information Patient Responsibilities Order Entry Transfer Out of PICU Algorithm Surgical NICU Coverage by PICU Rotation Resident Code Blue Difficult Airway Cart Presenting Patients on PICU Rounds Goals Curriculum Principle PICU Educational Objective At the end of your PICU rotation, you should be able to recognize and initially stabilize a critically ill child or adolescent with: Acute Respiratory Failure Hemodynamic Instability Cardiopulmonary arrest Sepsis Acute Neurologic insults Acute electrolyte and endocrine disorders Acute renal failure Coagulation disorders Overdoses & Poisonings U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 30
Slide 31: The primary PICU educational process focuses on interactive case-based teaching during patient care rounds and ongoing bedside discussions with the critical care attending regarding on-going patient care. Additional educational resources include Mock Codes, monthly journal club, internet access to Society of Critical Care Medicine power point presentations geared toward residents in the PICU (http://www.sccm.org/specialties/pediatric/picu_course/course_index.asp) Lynn Joshi, medical librarian and Project Director of Nemours Infolink, attends PICU rounds once a week and is available for assistance via email at other times. (ljoshi@nemours.org ) Residents are encouraged to ask focused clinical questions during PICU rounds, find literature that addresses the question, evaluate the literature for validity, results &applicability to their patient using evidence based clinical practice principles and bring the information back to the PICU team. To facilitate this process, residents have access to the Nemours Infolink Nemours Infolink This is an internet resource that allows access to evidence based clinical practice resources, search engines, medical journals, textbooks, PICU Evidence Based Journal Club, LexiComp hospital formulary, Micromedix and other educational activities. In the PICU, Nemours Infolink can be accessed via desktop computers through the icon Nemours Infolink or via the bedside wireless computers and WYSE terminals through the icon Nemours Infolink Residents can download this internet resource on their office, home or laptop computers by going to the URL http://www.cche.net/nemours and follow directions for Downloading. Pediatric residents who have a Nemours email address can apply for a password through http://www.cche.net/nemours under Registration. Visiting residents and medical students will receive a temporary username/password for their PICU rotation period. Nemours Infolink Resources Browser Tab • Double Click the Bell on the desk for a Tour describing the basic Vividesk technology and an introduction to the on-line Users’ Guides To The Medical Literature Activities Tab • PICU Resident Rotation web site • PICU Article Collection • PICU Lectures • Pediatric lectures Resource Tab • Practice Guidelines Search Engines: PubMed, Ovid, ACP Journal Club, Cochrane Library. • MD Consult (includes access to Nelson’s Pediatrics, Harriett Lane). • Journals (Connection to Journals via Nemours Jeffline). • PedsCCM Pediatric Critical Care educational resources Guides Tab • • • • Users’ Guides To The Medical Literature textbook. Learning Modules: learn evidence based clinical practice at your own pace. Instructions on searching various medical search engines. Calculators for evidence-based clinical practice U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 31
Slide 32: • Personal Evidence Project (Help with doing a Critically Appraised Topic on-line) • Practice Tab • LexiComp (Alfred I duPont Hospital for Children Formulary) • Micromedex. • Stentor acces to radiology studies (in hospital only) • Epic Web connection Textbooks available in PICU Pediatric Critical Care Third Edition Fuhrman/Zimmerman Pediatric Critical Care Medicine Slonim / Pollock Pediatric Intensive Care, Third Edition Mark C. Rogers The Difficult Pediatric Airway Anesthesiology Clinics of North America Jalil Riazi, MD, Editor 1999 Principles and Practice of Mechanical Ventilation 2nd Edition Tobin Management of Pediatric Trauma Buntain Critical Heart Disease in Infants and Children Second Edition Nichols, Ungerleider, Spevak, Greeley, Cameron, Lappe, Wetzel Pediatric Cardiac Intensive Care Chang, Hanley, Wernovsky, Wessel Illustrated Textbook of Pediatric Emergency and Critical Care Procedures Dieckmann, Fiser, Selbst Textbook of Pediatric Emergency Medicine Ludwig Fleisher The Pharmacologic Approach to Critically Ill Patients Chernow, Third Edition Principles and Practice of Intensive Care Monitoring Tobin Principles and Practice of Intensive Care Monitoring Tobin U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 32
Slide 33: Supportive Care of Children with Cancer Current Therapy and Guidelines from the Children's Cancer Group 2nd Edition, 1997 Edited by Arthur R. Ablin MD Smith's Recognizable Patterns of Human Malformation 5th edition, 1997 Monitoring Activities During their first week, residents are asked to complete Pre-PICU Rotation questionnaire located on the PICU Resident Rotation web site. PICU Residents are to document their primary patients’ diagnoses and age, procedures performed with supervision, their hospital work-hours, SCCM power-points reviewed on forms provided and their postrotation comfort level with critically ill children form. Please return to Ilene Sivikoff, Pediatric Critical Care Secretary (extension 5159) at the end of the last week of rotation. During the last week of the rotation, residents complete the Pediatric Section of the Society of Critical Care Medicine (SCCM) Pediatric Resident Education Committee post-PICU test. Their scores will be forwarded to their respective program directors. Residents are asked to print out a report of their usage of the Nemours Infolink. (Easily accessable though the Nemours InfoLink resource) and return to Ilen Sivikoff, Pediatric Critical Care Secretary (extension 5159) at the end of the last week of rotation. Visiting residents are asked to return their beepers, proxy card (and parking permit) to Ilene Sivikoff, Pediatric Critical Care Secretary (extension 5159) at the end of the last week of rotation. Residents complete an evaluation of their PICU rotation through their respective residency program on-line forms. Respective residency programs send us periodic summaries of resident evaluations of the PICU rotation. Critical care physicians complete individual resident specific residency program evaluations forms on-line. Residents are evaluated on the six ACGME competencies. Passwords Nemours Infolink Jeffline Cerner Username: Campus Key: Username Password: Password: Password Novell Username Password Can be used to access the radiology site in the hospital at http://stentor SCCM post-PICU rotation Test Password Questions? Contact Edward J.Cullen Jr., D.O., Pediatric Critical Care Medicine Phone: 302-651-5159 email: ecullen@nemours.org Revised 6/7/07 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 33
Slide 34: PICU Resident Rotation SWOT Strength Weakness Opportunity Threat U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 34
Slide 35: Strengths of the PICU Resident Training Program 22-bed Medical & Surgical, family oriented PICU unit Board certified pediatric critical care physicians Multidisciplinary patient care approach Pediatric critical care physician as role models and as supervisors of residents during the day and most of the night. PICU rotation meets ACGME work hours PICU Resident Rotation Coordinator PICU resident rotation maintenance program for monthly rotations Structured introduction material for new residents on first day of PICU rotation. Monitoring system maintained in an Access Data Base (pre-rotation questionnaire, patient log, procedure log, work hour log, evaluation of and suggestion for improved PICU rotation, survey of residents in practice) Nemours internet web site for PICU Resident Rotation Previous attempt: Critical care attending mentor identified for each individual PICU resident Nemours Desktop internet resources (search engines, medical library journal availability, evidence based medicine resources, PICU article collection). Internet access to SCCM lecture series for PICU residents. Internet access to national SCCM post-PICU rotation test. Critical care textbooks on-site in the PICU Case based learning through interactive teaching during patient care rounds. Evidence-based journal club Mock Codes Nursing staff interested in helping set up Mock Codes Incorporating evidence-based medicine principles into PICU environment Medical librarian and Project Director for Nemours Practice Based Evidence Project attends patient care rounds on Fridays U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 35
Slide 36: Critical care physicians continue to work with Cerner in order to develop order care sets in order to minimize resident time putting in orders into the Cerner computer ordering system. A process has been developed to allow PICU residents to write orders which are then entered into Cerner by PICU clerical staff. PICU resident program secretarial support Nemours Foundation Support Chairman Anesthesiology & Critical Care Support PICU Resident educational activity counts toward academic promotion PICU Publications regarding PICU resident education Cullen EJ, Lawless ST, Nadkarni VM, McCloskey JJ, Corddry DH, Kettrick RG: Evaluation of a pediatric intensive care residency curriculum. Critical Care Medicine 1997; 25:1898-1903 Cullen EJ, Lawless ST, Hertzog JH, Penfil S, Bradford KK, Nadkarni VM, Corddry DH, Costarino AT. A Model of Determining a Fair Market Value for Teaching Residents. Who Profits? Pediatrics 2003;112(1):40-48 PICU Abstracts regarding PICU resident education Lawless S, Kettrick R, Donnar-Reale M, et al: Utilizing a program of continuing quality improvement to evaluate resident’s impact on a pediatric ICU (PICU. Abstr. Pediatric Res 1993; 33:700A Cullen EJ, Lawless ST, Nadkarni VM, McCloskey JJ, Corddry DH, Kettrick RG (sponsored by Alan Spitzer) Department of Anesthesia/Critical Care, Alfred I. duPont Hospital for Children, Wilmington, DE: Assessing resident (RES) desired education delivery styles in pediatric intensive care (PICU). Abstract of Pediatric Research 1996;39:777A Cullen EJ, Lawless ST, Corddry DH (sponsored by John Stefano) Pediatric Anesthesiology/Critical Care, Alfred I. duPont Hospital for Children, Wilmington, DE: The mismatch between attending (Attnd) and Resident (Res) desired education delivery styles in pediatric intensive care (PICU). Abstract of Pediatric Research 1997; 41:1774A Nadkarni VM, Cullen EJ, Lawless ST, McCloskey J, Corddry DH: Jefferson Medical College, Alfred I. duPont Hospital for Children, Wilmington, DE: Resident pediatric specific cardiopulmonary resuscitation experience prior to entering a second year PICU rotation. Critical Care Medicine 1999; 27(1) (Supplement):A102 Cullen EJ, Lawless ST, Nadkarni VM, McCloskey J, Corddry DH: Pediatric Anesthesia and Critcal Care, Alfred I. duPont Hospital for Children, Wilmington, DE (sponsored by John L. Stefano): Adjusting to resident learner (RL) needs during pediatric (PICU) rotation. Abstract of Pediatric Research 1999; 42:76A Cullen EJ, Lawless ST, Nadkarni VM, McCloskey J, Corddry DH: Pediatric Anesthesiology and Critical Care Medicine, Alfred I. duPont Hospital for Children, Wilmington, DE (sponsored by John L. Stefano): Does pediatric ICU (PICU) residency curriculum match general pediatric practice (GP) needs? Abstract of Pediatric Research 1999; 42:76A Cullen EJ, Lawless ST, Nadkarni VM, McCloskey J, Corddry DH: Pediatric Anesthesiology and Critical Care Medicine, Alfred I. du Pont Hospital for Children, Wilmington, DE (sponsored by John L. Stefano): U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 36
Slide 37: PICU resident learner (RL), resident educator (RE) and utility scores. Abstract of Pediatric Research 1999; 42:76A Cullen EJ, Stephen Lawless, Vinay Nadkarni, Scott Penfil, James H Hertzog, David H Corddry, Alfred I duPont Hospital for Children, Wilmington, DE. GME Reimbursement for PICU Resident Teaching, Is It Enough? Crit Care Med 2000; 28 (12) (Suppl.), A146, 424 PICU Poster Presentations regarding PICU resident education Cullen EJ, Lawless ST, Nadkarni VM, McCloskey J, Corddry DH, Kettrick RG (sponsored by Alan Spitzer): Department of Anesthesia/Critical Care, Alfred I. duPont Hospital for Children, Wilmington, DE: Assessing resident (RES) education in pediatric ICU (PICU). American Pediatric Society, the Society for Pediatric Research, Washington, D.C., May, 1996. Cullen EJ, Lawless ST, Corddry DH (sponsored by John Stefano): Pediatric Anesthesiology/Critical Care, Alfred I. duPont Hospital for Children, Wilmington, DE: The mismatch between attending (Attnd) and resident (RES) desired education delivery styles in pediatric intensive care (PICU). American Pediatric Society/The Society for Pediatric Research, Washington D.C., May, 1997. Cullen EJ, Lawless ST, Corddry DH: Pediatric Anesthesiology/Critical Care, Alfred I. duPont Hospital for Children, Wilmington, DE: The mismatch between attending and resident desired education delivery styles in pediatric intensive care. Tenth Annual Pediatric Critical Care Colloquium, Hot Springs, AK, September, 1997 Edward J Cullen Jr, Stephen Lawless, Vinay Nadkarni, Scott Penfil, James H Hertzog, David H Corddry, Alfred I duPont Hospital for Children, Wilmington, DE. GME Reimbursement for PICU Resident Teaching, Is It Enough? Accepted for poster presentation, 30 th International Educational & Scientific Symposium, Society of Critical Care Medicine, San Francisco, Feb 2001. Crit Care Med 2000; 28 (12 Suppl.):A146, 424 PICU Teaching Award Critical Care Medicine received the Alfred I. duPont Division Teaching Award by the 2002-2003 Pediatric House Staff for excellence and commitment to resident education. Weaknesses of the PICU Resident Training Program Present DME payments from GME resources do not fund pediatric critical care physician compensation for resident supervision and educational efforts. Funding for PICU nursing and respiratory therapy support is voluntary. There is lack of sufficient time to introduce residents to the PICU rotation. Large part of first PICU day for visiting residents is spent in computer training labs. Residents spend too much time entering orders through the Cerner computer entry system. Resident autonomy. Lacking a procedural lab for residents. Case based learning opportunities for residents not very formalized. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 37
Slide 38: Attempted mentor system lacked concrete objectives for the individual resident and individual critical care physician. All residents don’t voluntarily fill out pre and post-rotation questionnaires and tests. Very few residents voluntarily complete the SCCM post-PICU rotation test. This limits a complete picture of residents’ expectations and evaluation of the PICU experience. There is minimal time during the PICU day for residents to do a critically appraised topic. There is a lack of a structured objective process to show competency acquisition by residents There is a lack of a criterion-referenced assessment as opposed to norm-referenced assessment of resident’s performance during the PICU rotation. There is a non-existent exit interview with residents to review evaluations Lack of Access Data Base technical support. Limited critical care attending availability for multiple PICU resident formal educational sessions Opportunities for the PICU Resident Training Program Participate in a Patient Simulation Lab being developed at Alfred I duPont Hospital for Children in order to practice pediatric critical care scenarios, PICU mock codes, and selective critical care procedures. The Nemours Foundation initiative with the Centre for Health Evidence is establishing a clinical Nemours internet resource (Nemours Infolink) that will be able to track clinical activity and the pursuit of education around that activity. There is the potential for linking education and patient outcomes. Become more active with SCCM pediatric critical care resident educational committee. Coordinate PICU educational activity and resources with the proposed Nemours Children’s Hospital in Orlando, Florida. Become a national leader in providing PICU resident education. Evaluate how our training program equates to patient outcomes in the wider community Add to individual critical care physician academic activity for academic promotion Investigate the use of MedRite, Cerner and Epic in order to produce a computerized PICU patient care progress note that can be shared by residents, attendings, nurses, respiratory therapy, consultants and medical students. Develop a mentor system where individual needs of PICU residents are recognized and learning experience is optimized. This would require additional critical care physicians in order to meet the educational demands. Continue to integrate any resident Observed evaluation tools developed by the ACGME. ACGME competency based outcomes must be observed and documented for each resident. To evaluate competency, one needs to directly observe and assess learners performing the tasks of real world future practice. Critical care physicians should receive training and the resources to carry out this responsibility. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 38
Slide 39: A Criterion-referenced assessment is preferred where the learner’s performance is compared with a predetermined threshold or standard as opposed to the peer comparison of norm-referenced assessment. Competencies must be defined with appropriate benchmarks and performance standards set in terms of thresholds. Consider transition PICU Resident Rotation Data Base to the Alfred I duPont Hospital for Children GME office. As number of critical care physicians increases, strive to maximize formal resident educational experiences and mentoring concept. Expand case based scenarios. Accommodate the Fundamental Critical Care Support course to the pediatric ICU. Over the first 3 days of the PICU rotation, offer this course to the PICU resident group as the main didactic part of their PICU rotation Introduce formal interactive sessions on ARDS, Septic Shock, Traumatic Brain Injury that require resident preparation: o ARDS (include basic mechanical ventilation support / ECMO support) o Resident / Medical Student  Prepares for topic: • Reads article from PICU Article Collection on Nemours Desktop o Sevransky JE, Levy MM, Marini JJ. Mechanical ventilation in sepsis-induced acute lung injury/acute respiratory distress syndrome: an evidence-based review. Crit Care Med 2004; 32(11Suppl):S54853.</SMALL • Review the SCCM powerpoint on the topic o Nemours Ingolink: Activities Tab, PICU Lectures, Course Catalog: Open up ARDS topic • Find one article in the PedsCCM Evidence Based Journal Club relating to the topic, read the review and bring this info to meeting to add to discussion. o Under Reviews by Topic, search the Title space for acute respiratory distress. Several reviews will appear. Choose one to read and bring to the session for discussion. o Primary PICU Resident / Medical Student Education Attending  Overview of basic topic o Attending & Resident / Medical Student  Case-based discussion : requiring resident feedback – applying basic info to patient care o Septic shock and multisystem dysfunction (include CRRT) o Resident / Medical Student  Prepares for topic: • Reads article from PICU Article Collection on Nemours Infolink o Carcillo JA, Fields AI. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002; 30(6):1365-78.</SMALL • Review the SCCM powerpoint on the topic o Nemours Infolink:, Activities Tab, PICU Lectures, Course Catalog: Open up Septic Shock • Find one article in the PedsCCM Evidence Based Journal Club relating to the topic, read the review and bring this info to meeting to add to discussion. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 39
Slide 40: o o Under Reviews by Topic, search the Title space for septic shock or sepsis. Several reviews will appear. Choose one to read and bring to the session for discussion. Primary PICU Resident / Medical Student Education Attending  Overview of basic topic in whatever format desired Attending & Resident / Medical Student  Case-based discussion : requiring resident feedback – applying basic info to patient care o o Traumatic Brain Injury Management (Guidelines ) o Resident / Medical Student  Prepares for topic: • Reads article from PICU Article Collection on Nemours Infolink o Adelson PD, Bratton SL, Carney NA, Chesnut RM, du Coudray HE, Goldstein B, Kochanek PM, Miller HC, Partington MD, Selden NR, Warden CW, Wright DW. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Chapter 17. Critical pathway for the treatment of established intracranial hypertension in pediatric traumatic brain injury. Pediatr Crit Care Med 2003; 4(3Suppl):S65-7. • Review the SCCM powerpoint on the topic o Nemours Infolink: Activities Tab, PICU Lectures, Course Catalog: Open up Traumatic Brain Injury • Find one article in the PedsCCM Evidence Based Journal Club relating to the topic, read the review and bring this info to meeting to add to discussion. o Under Reviews by Topic, search the Title space for brain injury. Several reviews will appear. Choose one to read and bring to the session for discussion. o Primary PICU Resident / Medical Student Education Attending  Overview of basic topic in whatever format desired o Attending & Resident / Medical Student  Case-based discussion : requiring resident feedback – applying basic info to patient care  Revamp the PICU Rotation to include more didactic: Practice Based Evidence (0700: 3 days during the first week) • Introduction to practice based evidence resources on Nemours Infolink • Review PedsCCM Evidence Based Journal Club resources • Develop a working knowledge of Personal Evidence Project on the Nemours Infolink in order to address specific PICU problems. Evidence Based Project Presentations by Residents (0700: 3 days during last week ) • Each resident presents a critically appraised topic review on a pediatric critical care problem Case Based Lectures (0700: 2 days a week during weeks 2 and 3 of rotation) Respiratory failure Shock DIC ARF U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 40
Slide 41: Neurologic intensive care Procedure Lab (1300 – 1500: Monday during weeks 2,3 and 4) Intubation, LMA, PIV, IO. CVL, A line, Chest tube / pigtail, Pericardiocentesis, Cardioversion, Defibrillation Pediatric Simulator (1300-1500: Tuesday during weeks 2,3 and 4) • Pediatric Code Scenarios • PICU scanarios Multiple organ Failure Septic shock ARDS DIC Neurologic compromise ARF requiring CRRT Nutritional support Threats to the PICU Resident Training Program Educational activities do not produce RVU financial revenue for critical care attendings. If the PICU resident educational experience was fully funded, funding could be lost if one could not show that residents who complete a 1 or 2 month PICU rotation are proficient in the ACGME competencies using criterion-referenced assessment specific for PICU residents and that this eventually leads to improved patient outcomes. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 41
Slide 42: Appendix U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 42
Slide 43: Background U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 43
Slide 44: Nemours Vision Freedom from disabling conditions Nemous Mission To provide leadership, institutions, and services to restore and improve the health of children through care and programs not readily available, with one high standard of quality and distinction regardless of the recipient’s financial status. Nemours Values Respect , Honor, Excel, Serve, Learn Nemours Drive to Excellence and Education Goals The Nemours Foundation has defined itself as an organization seeking to be excellent in the delivery of patient-centered care. A goal of the Nemours Foundation is to • Become one of the top 10 pediatric research centers in the United States • Become a national resource for pediatric subspecialty education • Provide the national standard for pediatric patient and family education Education and research are important because the best practitioners thrive and contribute their best in an environment of not only intellectual rigor, vitality and inquisitiveness, but also ethics, patient focus and personal commitment. Research and education are not ends in themselves; they are means to increase the probability of excellent patient care. Nemours provides resources to fund education and research because it is their belief that the best outcomes derive from the best people who are constantly challenged and encouraged to seek improvement and change – on behalf of the patient. Nemours Vision, June 2003 Nemours Strategic Process Improve Children’s Health through Research and Education 2007 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 44
Slide 45: The Institute of Medicine of the National Academies Committee on Health Profession Education The Institute of Medicine of the National Academies states that medical education and training organizations are encouraged to develop outcomes based education system that better prepares clinicians to meet both the needs of patients and the requirements of a changing health system. Education and training programs are encouraged to adopt a set of five core competencies: Provide Patient Centered Care Work in Interdisciplinary Teams Employ Evidence-based practices Apply Quality Improvement Utilize Informatics Committee on the Health Profession Education Summit, “Health Professions Education: A Bridge to Quality” U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 45
Slide 46: The Accreditation Council for Graduate Medical Education (ACGME) Residency Review and Institutional Review Committee Outcomes Project Residency programs must require its residents to obtain competencies in the 6 areas below to the level expected of a new practitioner. Toward this end, programs must define the specific knowledge, skills, and attitudes required and provide educational experiences as needed in order for their residents to demonstrate: 1. 2. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health 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 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 Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population 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. ACGME, Outcome Project http://www.acgme.org/outcome/comp/compMin.asp 3. 4. 5. 6. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 46
Slide 47: Considerations that Impact the Resident Educational Experience U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 47
Slide 48: A Period of Transformation of Pediatric Graduate Medical Education There is an explosion of new basic knowledge (genomics, proteomics, neuroscience, developmental biology, translational research.). The pattern of pediatric care for sick children is changing, with substantial increase of acuity and complexity of illness in hospitalized children, often requiring clusters of subspecialists and advanced technology to provide quality care. Chronic medical conditions are much larger part of pediatric care. Acuity and demands of care in the community are raised. There is a shift to a learner-centered, competency-based system of education driven by the desired outcomes of training. Quality improvement activities must encompass residents and their supervising attending physicians in addition to other professional and staff to be effective at the institutional level. Medical education must be aligned with the desired health outcomes. The challenge is to create a vision of medical education that spans the continuum medical school through practice. The Future of Pediatric Education II advocates for research centers for pediatric medical education to continuously evaluate impact of training on outcomes. Pediatrics.2001;105(suppl):163-212 Educators and professionals are challenged to focus on outcomes, both clinical and educational, that in turn inform the provision of health care and the educational process. Only through the practice of evidencebased education can we positively impact the ultimate outcome of our educational efforts: the quality of health care delivered to our patients. To evaluate competency, one needs to directly observe and assess learners performing the tasks of real world future practice. This calls for “authentic assessment” - “assessment that looks at performance and practical application of theory” A criterion-referenced assessment is suggested as opposed to norm-referenced assessment. In Criterionreferenced assessment, the learner’s performance is compared with a predetermined threshold or standard as opposed to the peer comparison of norm-referenced assessment. Competencies must be defined with appropriate benchmarks and performance standards set in terms of thresholds. Suggested methods of evaluation: record reviews; chart stimulated recall; checklists of observed behaviors, global ratings, standardized patients, OSCEs, simulations and models, 360-degree assessments, portfolios, multiple-choice examinations, procedure logs, patient surveys. ACGME has identified 4 tools used most frequently: direct observations with a checklist; 360-degree evaluations; educational portfolios; cognitive test (only one that has been tested in standardized versions for validity and reliability). Greatest challenge in the shift to a competency-based system of education is the increased faculty time and resources that will be required to implement competency-based evaluation of trainees In order to promote an educational process that focuses on clinical and educational outcomes, with selfdirected practice-based learning as the process for achieving desired outcomes, we must have both academic and community-based faculty role models that implement these principles as a habit of practice. We need to move in the direction of evidence-based education as we study the impact of educational interventions and assessment methods with the same rigor that we use to address clinical and basic science issues. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 48
Slide 49: A first step is to embrace the IOM competencies that we expect of our learners. Chair of the Pediatric Education Steering Committee of the Federation of Pediatric Organizations (FOPO) looking at a redesign of residency training – looking at the links between educational and clinical outcomes as on of its goals. Workplace of a residency program is a complex and intense environment that includes long hours of continuous work, responsibilities of caring for sick patients, and increasing complexity and acuity of patient care. Teams in hospitals are interdisciplinary, less hierachial, and compromised of skilled professionals who share clinical responsibilities and rely on each others’unique skill sets. Communication skills, teamwork and professionalism are as basic to residency training now as technical and clinical skills. Need to work with system to coordinate care for acute and complex patients. Complexity of patient care, significant responsibility, teams of professionals with specialized knowledge, the challenge to learn independent decision-making in a team environment and new duty hours: context in which issues of work-life balance emerge. Changes in resident work hours and alternative providers of care such as hospitalists may impact on opportunities for resident learning; their impact should be monitored closely for both improvement in the work environment and possible limitations in learning opportunities. Faculty workload and satisfaction need to be assessed during this transition period of graduate medical education. We are challenged to create a community of learners that not only espouses but balances personal and professional life; build a training infrastructure with a foundation that is learner centered and based on the 6 ACGME competencies and a care delivery system that is patient centered and based on the IOM competencies. The goal is to provide the optimal health and well being of our children. The State of Pediatrics residency Training: A Period of Transformation of Graduate Medical Education Pediatrics 2004;114-832-841 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 49
Slide 50: The Accreditation Council for Graduate Medical Education (ACGME) Work Group on Resident Duty Hours The Accreditation Council for Graduate Medical Education (ACGME) Work Group on Resident Duty Hours in June 2002 set rules for resident duty hours . The goal is to simultaneously foster high-quality education and patient care and resident well-being. The only way residency programs and their sponsoring institutions can achieve a true “education” program as well as provide high quality clinical care, is by attending to the issue of resident duty hours and by placing a higher value on resident education and safe patient care than on meeting service demands. Duty Hours are defined as all clinical and academic activities related to the residency program, i.e. patient care (inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. Duty Hours • • • • 80 hours per week, averaged over 4 weeks, inclusive of all in-house call activities One day off out of seven, averaged over 4 weeks, One day is defined as one continuous 24hour period free from all clinical, educational and administrative activities. No in-house call more than once every three nights averaged over 4 weeks. In-house call is defined as those duty hours beyond the normal work day when residents are required to be immediately available in the assigned institution. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics and maintain continuity of medical and surgical care as defined in Specialty and Subspecialty Program Requirements. No new patients may be accepted after the 24 hours of continuous duty. 10 hours off between duty periods and after in-house call. Probation or accredidation withdrawal for facilities that do not comply • • • Institutional Oversight • • Monitoring of program’s policies governing resident duty hours by the sponsoring institution. Requiring sound educational justification of any increases above the 80 hour limit • An annual report to the sponsoring institution’s governing body on duty hour compliance • Institutional policies on patient care activities external to the educational program (moonlighting), prospective approval of these activities, and monitoring their effect on performance in the educational program • Counting time spent in patient care activities external to the educational program that occur in the primary programs institution toward the weekly duty hour limit • Requiring programs and their sponsoring institutions to have policies and procedures to monitor and support the physical and emotional well-being of residents • Requiring sponsoring institutions to monitor the demands home call places on residents in all programs, and making adjustments as necessary to address excessive demands and fatigue • Patient care support services for IV, phlebotomy, and transport activities to reduce resident time spent on these routine activities U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 50
Slide 51: High Quality Education and Safe and Effective Patient Care 0 • Priority of clinical and didactic education in the allotment of residents’ time and energies 2• Schedules of teaching staff structured to provide ready supervision and faculty support/consultation to residents on duty 3• Duty hour assignments that recognize that faculty and residents collectively have responsibility for patient safety and welfare 4• Monitor residents for the effects of sleep and fatigue by Program director and faculty with appropriate action when it is determined that fatigue might affect safe patient care or learning. 5• Education of faculty and residents in recognizing the signs of fatigue and in applying preventive and operational countermeasures 6• Appropriate backup support when patient care responsibilities are difficult and prolonged, and if unexpected needs create resident fatigue sufficient to jeopardize patient care. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 51
Slide 52: 7 8 Leapfrog Group for Patient Safety http://www.leapfroggroup.org/ The Leapfrog Group is an initiative driven by organizations that buy health care who are working to initiate breakthrough improvements in the safety, quality and affordability of healthcare for Americans. It is a voluntary program aimed at mobilizing employer purchasing power to alert America’s health industry that big leaps in health care safety, quality and customer value will be recognized and rewarded. The Leapfrog Group for Patient Safety focuses on three practices that have tremendous potential to save lives by reducing preventable mistakes in hospitals. Computer Physician Order Entry (CPOE) Prescriptions in hospitals should be computerized. With computerized prescription systems, doctors enter orders into a computer rather than writing them down on paper, and the prescription can be automatically checked against the patient's current information for potential mistakes or problems. For example, before the doctor can complete the prescription order, the computer would check to see if the new prescription would interact badly with another drug the patient is taking, or if the patient has a known allergy to it. This type of system also reduces mistakes that occur from misreading a doctor's handwriting. Studies show a computerized prescription system can reduce serious medication mistakes by up to 86 percent. Evidence-based Hospital Referral (EHR) It is important to select hospitals with proven outcomes or extensive experience with specific high-risk conditions or procedures that have a high risk of death or complications. The best way to determine which hospitals are the best at performing certain high-risk treatments or procedures is by knowing the actual results their patients experience. A few states have systems set up in which hospitals report this information publicly, but most do not. The best alternative is to track how many of a certain type of high-risk treatment or procedure a hospital performs each year. Over 100 scientific studies have demonstrated a relationship between a hospital's annual number of certain high-risk treatments and procedures and patient outcomes. Patients who go to hospitals that frequently perform these high-risk treatments or procedures, or to hospitals that have demonstrated a good record for patient outcomes, have the best chance of surviving and successfully recovering. ICU Physician Staffing (IPS) "Intensivists," physicians specially trained to care for critically ill patients in Intensive Care Units (ICUs), should staff ICUs. More than four million patients are admitted to ICUs each year in the U.S. and more than 500,000 of these patients die. Studies reveal that at least one in ten patients who die every year in ICUs would have an increased chance to live if intensivists were present in the ICU and managing their care for at least eight hours per day. While not every hospital's intensive care unit can assure 8 hours per day of intensivist care,because there is a shortage of intensivists in the United States, this staffing level is an important factor to consider when choosing a hospital if your doctor expects that you are likely to stay in an ICU during your hospitalization. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 52
Slide 53: Integrating the Institute of Medicine’s Six Quality Aims into Pediatric Critical Care Safety • Improving patient safety through reducing medical errors and adverse events in the high-risk PICU environment. Effectiveness • Incorporating the best-research evidence, clinical expertise and patient values in order to achieve the best outcomes for the patient Equity • Provide impartial care for populations and to individuals that is free from bias related to race, ethnicity, insurance status, income or gender. Timeliness • A marker of the adequacy of processes to achieve acceptable outcomes o Timely and effective communication o Available resources o Experience and competency of physician, nursing and technical staff o Presence of pediatric intensivists and pediatric critical care fellows o Multidisciplinary critical care teams Patient-Centeredness • • • Provision of information, education, emotional support to families Attention to the physical comfort of families Involvement of family and friends in care Efficiency • Health care resources are delivered in a cost-effective and efficient manner while not jeopardizing quality Integrating the Institute of Medicine’s six quality aims into pediatric critical care: Relevance and applications Pediatric Critical Care 2005; 6(3): 264-269 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 53
Slide 54: Education of trainees in the intensive care unit W.Christopher Croley MD, Daivid M. Rothenberg MD, FCCM Critical Care Medicine 2007;35(2)(Suppl):S117-S121 The focus in improving education in critical care medicine must begin early in medical school training and further be promoted during residency if there is to be an increase in intensivists in the hospital workforce. This is “critical” to healthcare reform movements that are endorsing full-time critical care coverage in US urban intensive care units. There is, therefore, a need for more novel approaches in educating trainees in critical care medicine to better prepare future physicians to manage acutely ill patients and improve patient safety. The Cone of Learning, devised by Edgar Dale in 1969 describes the most effective means by which knowledge is retained and forms the foundation by which critical care medicine education can be built: After 2 weeks we tend to remember… 10% of what we READ 20% of what we HEAR 30% of what we SEE 50% of what we HEAR and SEE Cone of Learning Reading Hearing Words Looking at Pictures Watching a Movie. Looking at an Exhibit. Watching a Demonstration. Seeing It Done on Location. Participating in a Discussion. Giving a Talk. Doing a Dramatic Presentation. Simulating the Real Experience. Doing the Real Thing. Nature of Involvement Verbal Receiving Verbal Receiving Verbal Receiving Visual Receiving Passive Passive Passive Passive 70% of what we SAY 90% of what we both SAY and DO Receiving/Participating Doing Active Active Residents in critical care medicine acquire knowledge primarily through process of active learning, by participating in daily bedside teaching rounds and by administering patient care, and by passive learning in the forms of lectures, morbidity and mortality conferences, and journal clubs. Suggestions that seem to improve learning in residency curricula in critical care medicine: • altering time of didactic sessions from after rounds in the afternoon to early in the morning before rounds. • Partial task simulators (airway mannequins, central vein models) • Virtual reality simulators • Residency programs must incorporate and develop methods to evaluate the core competencies as outlined by the ACGME. Evaluation processes include: computerized based self-study, objective structural clinical examinations, standardized patients or simulated scenarios. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 54
Slide 55: • • • • Evidence –guided education rather than evidence-based education as a way to influence curricular changes by utilizing not only outcome studies, but also patient safety data and continuous quality improvement analyses. Teaching skills for delivering bad news by means of standardized patients and role playing. Teaching end-of-life issues by incorporating into the simulation of a death scenario. Postmortem process of debriefing. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 55
Slide 56: Ideal Scenario Integrating PICU Resident Education, Resident Duty Hours, Patient Care Medical education must be aligned with the desired health outcomes. The goal is to provide the optimal health and well being of our children. The education and training program should aim to: • Provide Patient Centered Care • Work in Interdisciplinary Teams • Employ Evidence-based practices • Apply Quality Improvement • Utilize Informatics The training program should integrate the Institute of Medicine’s Six Quality Aims into the Pediatric Critical Care environment. • Safety • Effectiveness • Equity • Timeliness • Patient-Centeredness • Efficiency In addition to being an environment in which excellence in patient care is the foundation for learning to care for the critically ill and injured patient, the critical care environment should be an intensivist-directed, residents and PICU multidisciplinary team in order to optimize patient care. Prioritizes the resident’s educational and clinical experience so that they spend time on activities that don’t detract from the educational experience. Computer order entry system should be operational but not interfere with timely care of the PICU patient. Schedule PICU critical care attending staff in such a way that they are: o Available for supervision of residents day and night in the PICU o Available for clinical back-up support for residents in the PICU especially at night and during very busy periods if they become overwhelmed or sleep deprived. Training programs must define the specific knowledge, skills, and attitudes required and provide educational experiences as needed in order for their residents to demonstrate: • Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health • 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 • 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 • Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals • Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population • 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. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 56
Slide 57: Learning in critical care medicine is optimized when the learner is intimately exposed to and participates in the cognitive and technical aspects of care. Training should include a structured process that progressively transfers increasing levels of responsibility for decision making, ensures continued training in the practical aspects of care, and provides training and experience in the administrative and management functions of the PICU. Optimize patient safety and quality of care while providing PICU residents with sense of autonomy. Case based education methodology encouraged Incorporate suggestions that seem to improve learning in residency curricula in critical care medicine such as: altering time of didactic sessions from after rounds in the afternoon to early in the morning before rounds; Partial task simulators (airway mannequins, central vein models); virtual reality simulators. In addition to practical training in procedural skills, the resident must have an understanding of the indications, contraindications, complications, and pitfalls of these interventions. In order to promote an educational process that focuses on clinical and educational outcomes, with selfdirected practice-based learning as the process for achieving desired outcomes, we must have both academic and community-based faculty role models that implement these principles as a habit of practice. Pediatric critical care research projects should be available for resident participation. On completion of an ACGME approved graduate education program in a clinical specialty of medicine (e.g., anesthesiology, internal medicine, pediatrics, or surgery), each resident physician will have • developed a measurable quantity of knowledge • learned a set of observable skills • demonstrated adequate decision making • shown a caring and compassionate attitude for patients who are critically ill. Residents at a minimum should be able to recognize, stabilize and begin resuscitation of critically ill patients until a critical care specialist is available. ACGME competency based outcomes must be observed and documented for each resident. To evaluate competency, one needs to directly observe and assess learners performing the tasks of real world future practice. Critical care physicians should receive training and the resources to carry out this responsibility. A Criterion-referenced assessment is preferred where the learner’s performance is compared with a predetermined threshold or standard as opposed to the peer comparison of norm-referenced assessment. Competencies must be defined with appropriate benchmarks and performance standards set in terms of thresholds. The impact of changes in resident work hours and alternative providers of care on opportunities for resident learning should be monitored closely both for improvement in the work environment and possible limitations in learning opportunities. Create a community of learners that not only espouses but balances personal and professional life. Available time and financial resources for critical care physicians in order to meet the educational objectives outlined by the SCCM for those who continue to be involved in critical care medicine. Evidence-based education must be used to study the impact of educational interventions and assessment methods with the same rigor that we use to address clinical and basic science issues. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 57
Slide 58: Evidence –guided education rather than evidence-based education as a way to influence curricular changes by utilizing not only outcome studies, but also patient safety data and continuous quality improvement analyses. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 58
Slide 59: Challenges During a 4 or 8 week PICU rotation, what minimum specific pediatric critical care information and skills do pediatric and emergency medicine residents really need? How do we know that the information we are teaching is correct and up to date? How do we best present information & skills to residents during their PICU rotation? How do we incorporate criterion-referenced assessments of the individual resident’s performance? How do we best directly observe and document that individual PICU residents have met the desired ACGME competencies during their PICU rotation ? How do we evaluate if the PICU rotation provides individual residents with the skills to recognize and stabilize a critically ill child or adolescent in their future practices? How do we optimize patient safety and patient quality of care while providing PICU residents with a sense of autonomy? How do we align PICU resident medical education with desired PICU health outcomes? How do we finance our PICU resident educational system? How do we show that a fully funded PICU resident educational experience leads to improved patient outcomes? U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 59
Slide 60: PICU Alfred I duPont Hospital for Children U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 60
Slide 61: PICU multidisciplinary team Pediatric board certified critical care medicine physicians Pediatric double boarded critical care medicine and anesthesiology trained physicians Pediatric critical care nurse practitioner PICU nurse manager PICU transport nurse manager PICU nurse educators PICU charge nurses PICU nurses PICU transport nurses Nursing students, externs PICU respiratory therapists PICU transport respiratory therapists Respiratory therapy students PICU clinical pharmacists Clinical pharmacy students PICU nutrition specialists PICU social service personnel PICU clerical staff PICU Cerner representative PICU volunteers Pediatric critical care fellows Pediatric emergency medicine fellows Adult trauma surgery fellow Pediatric, medicine/pediatric, emergency medicine, emergency medicine/internal medicine residents Fourth year medical students Multidisciplinary PICU Educators Involved in Resident Education Clinical pharmacist (John Giamalis) Nursing staff development (Kim Englert RN, Ruth Lebet RN) Respiratory therapy clinical instructors (Debbie Marckese RRT, Dawn Slehorst RRT) Reference Librarian (Lynne Joshi) Social Service (Andre Bowen) Critical care physician secretarial support (Ilene Sivikoff, Jennifer McIntyre) Secretarial Support for PICU Resident Educational Experience ( Ilene Sivikoff) Coordinate application paperwork for visiting residents and medical students with GME Office, various residency programs, Jeffline and Stentor. Prepare individual resident and medical student introduction folders. Assist with PICU Resident Education Data Base. Prepare and mail a yearly survey to previous PICU rotation residents who are now in their first year of practice or fellowship. Correspondence. PICU Cerner representative (Shelly Reeves) U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 61
Slide 62: Pediatric Critical Care Physicians Pediatric Critical Care Medicine FTE Brian Binck MD Tania Burns MD Edward Cullen DO James Hertzog MD Scott Penfil MD Pediatric Critical Care Medicine 50% FTE Andrew Costarino MD Chairman Anesthesiology and Critical Care Pediatric Anesthesiology Pediatric Critical Care Medicine Caroline Boyd MD Pediatric Cardiac Critical Care and Pediatric Critical Care Medicine Glenn Stryjewski MD Associate Director Pediatric Residency Program and Pediatric Critical Care Medicine Pediatric Critical Care FTE Physician Responsibilities Provide 24 hours a day, 365 days a year accessible, safe, compassionate, quality patient and family centered care for critically ill children and adolescents. Clinical (80%) • Expected minimum yearly RVU from patient care per FTE is 8000 • Patient care Non-clinical (20%) • Expected non-clinical yearly RVU equivalents per FTE is 2000 • • • Administration Education (Fellow, resident, medical student, nurses, PALS, national meetings, etc.) o Educational activities needed for academic promotion Research Primary PICU Patient Care Coverage (0700-1600 weekdays & 0700-1800 weekends) • Cover 22 medical / surgical PICU patients • Coordinate Pediatric Transports for Alfred I duPont Hospital for Children • PICU patient care rounds • PICU family interactions • Critical Care Medicine Fellow clinical & procedure supervision and training • Resident clinical & procedure supervision and training • Medical student clinical & procedure supervision and training • On weekends and holidays: additional (1800-0700) back up clinical support for PICU and consultant coverage for pediatric, multi-system trauma patients at Shock Trauma Unit (SSTU), Christiana Care Hospital U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 62
Slide 63: Primary PICU Patient Care Coverage (1600-0700 weekdays & 1800-0700 weekends) • Cover 22 bed medical / surgical PICU • Coordinate Pediatric Transports for Alfred I duPont Hospital for Children • PICU patient care rounds • PICU family interactions • Critical Care Medicine Fellow clinical & procedure supervision and training • Resident clinical & procedure supervision and training • Medical student clinical & procedure supervision and training • On weekends and holidays: additional (0700-1800) back up daytime clinical care support for PICU and consultant coverage for pediatric, multi-system trauma patients at Shock Trauma Unit (SSTU), Christiana Care Hospital Secondary PICU Patient Care Coverage (0700-1600 weekdays) • Consult service for pediatric trauma at Christiana Care Shock Trauma Unit • Assist with PICU clinical care, procedures • Coordinate family teaching and home discharge planning for individual children with tracheostomy and chronic ventilator care. • Assist with sedation for selected children in the EEG lab • Assist with sedation services outside of the PICU • Assist with central venous access outside of the PICU • Mock Codes and Interactive Teaching Sessions for PICU residents Secondary PICU Patient Care Coverage (1600-0700 weeknights) • Consult service for pediatric trauma at Christiana +Care Shock Trauma Unit • Assist with PICU clinical care, procedures Monthly Scheduled Hospital Hours for a Pediatric Critical Care Medicine FTE Year Primary PICU Hours Secondary PICU Hours Sedation for Magnetic Resonant Imaging Non-clinical Hours Total Hours 2000 JanDec 160 172 0 2001 JanDec 159 157 0 2002 JanDec 147 171 0 2003 JanDec 134 147 0 2004 JanDec 157 163 0 2005 JanDec 152 162 0 2006 JanDec 117 104 0 2007 Jan Apr 103 115 30 73 405 73 389 96 414 96 377 85 405 63 377 69 290 63 311 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 63
Slide 64: Responsibilities for Critical Care Physicians who remain Engaged in the Specialty Practice of Critical Care Medicine Crit Care Med 2004; 32 (1): 267 • • • • • • Develop an ever increasing measurable quantity of knowledge Regularly perform and teach an increasingly broader set of skills Continue to demonstrate advanced, ethical decision making Serve as role model for a compassionate and caring attitude toward patients who are critically ill. Serve as role model for the intensivist-directed multiple-professional team model of patientcentered care for all ICU patients. Perform the following: Clinical • • • • • • • • • • • • • • • Continue to augment his or her knowledge by assimilating appropriate new peer-reviewed published medical literature through self-directed learning. Develop and participate in CME activities designed to enhance critical care knowledge. Teach others to identify the need for and provide care for all critically ill adult and /or pediatric patients. Continue to provide and teach cardiopulmonary and cerebral resuscitation including advanced techniques for all patients sustaining life-threatening events. Introduce and teach others new methods and use of devices for management of patients in respiratory failure. Develop and evaluate curriculum changes for ICU caregivers, fellows, and residents. Diagnose and treat a sufficient number of patients with critical illness using conventional and state-of-the –art approaches to maintain clinical proficiencies. Teach others to select, place and use appropriate monitors for titrating therapy in any critically ill patient by demonstrating these skills in daily practice. Teach others infection control and monitor infection control practices of the unit. Teach medication safety and cost-effectiveness of therapeutic decision making. Increase the skills of ICU nurses and ancillary personnel in caring for critically ill patients by acting as the ICU team leader and providing in-service education. Model effective communication with patients, families, and members of the health care team about treatment decisions and patient prognosis. Support patients, their families and other members of the healthcare team through the trauma of critical illness. Develop collaborative and productive relationships with other specialist physicians and model joint clinical planning in managing complex ICU problems. Identify ethical issues and lead discussions involving patients, families, and members of the healthcare team in making treatment decisions. Research • • Advance the clinical practice of CCM using evidence-based medicine techniques and through dissemination of findings by publishing case reports and clinical and basic science research. Develop and continue ongoing basic science and clinical studies designed to evaluate and improve care of the critically ill. Administrative • Evaluate, modify and approve ICU hospital policies. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 64
Slide 65: • • • • • • • Improve resource utilization and maintain patient care quality by planning for future needs for institutional and regional critical care resources. Develop programs and change unit, institution, and regional practice to improve care of critically ill patients. Develop programs and document improvement in patient safety monitoring and error production. Use existing tool sets to assess patient and family satisfaction and direct the development of new tools when appropriate. Develop high-quality relationships with other healthcare providers. Teach the business of medicine. To achieve these continuing competencies: • Commit to professional development and lifelong learning by achieving board certification and re-certification in CCM; regular attendance at CME activities and individual self-studies; produce publications related to education or research studies; attestations from colleagues, peers, patients, nurses, allied health professionals, and hospital administrators that include quality reports, patient lists and outcome statistics. Specific credentials, cognitive and procedural skills are outlined in the appendix of the published guidelines. Crit Care Med 2004; 32 (1): 267 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 65
Slide 66: Financial Sources for Resident Teaching Physicians Nemours Foundation 10% of Nemours Physician salaried hours are expected to be spent in educational activity. Nemours Foundation provides a separate educational fund. Nemours practice site CEOs and department chairpersons distribute these funds to further support Nemours physicians’ general educational activities.. There is no specific RVU financial equivalent for educational activity although the Departments of Anesthesiology and Critical Care have a non-clinical RVU equivalent to show productivity in areas other than clinical. Graduate Medical Education Payment Program Centers for Medicare and Medicaid Services, Health Resources and Services Administration, Children’s Hospitals Graduate Education Payment Program provides GME funds divided between Indirect Medical Education (IME) funds to the teaching hospital and Direct Medical Education (DME) funds directed towards resident salaries, physician teacher compensation and educational material. Historically, Alfred I duPont Hospital for Children receives no IME allotment for residents rotating in our PICU from non-pediatric programs. Historically, the DME allotment for PICU physicians to teach PICU residents at Alfred I duPont Hospital for Children is not available after you subtract resident salaries from the available DME. Pediatric 2003;112(1):40-48 PICU Resident Educational activity can be used to apply for academic promotion. Multidisciplinary Team PICU Pharmacists, PICU Nurses and Nursing Staff Development, PICU Respiratory Therapists and Medical Reference Librarian participation in PICU resident teaching is covered by their respective cost centers. Educational Materials The Department of Anesthesiology & Critical Care, Alfred I duPont Hospital for Children provides funds for critical care textbooks and other educational material as needed. Secretarial Support for PICU Resident Educational Program The Department of Anesthesiology & Critical Care, Alfred I duPont Hospital for Children provides secretarial financial support. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 66
Slide 67: Participants Completing a PICU Educational Experience Nemours Alfred I. duPont Hospital for Children Sept 1994 - June2007 Program Thomas Jefferson University Pediatrics PGY2 Christiana Care Emergency Medicine Thomas Jeferson University Emergency Medicine Christiana Care Medicine Pediatrics Medical Student Alfred I duPont Hospital for Children ER Fellow Pediatric Critical Care Nurse Practitioner Student Thomas Jefferson University Pediatrics PGY3 Christiana Care Trauma Fellow Anesthesia Fellow Thomas Jefferson University Anesthesia Resident Philadelphia College of Osteopathic Medicine PGY1 St Luke's Hospital ER Resident Thomas Jefferson PGY6 Tod Children's Hospital Resident Albert Einstein Hospital Resident Total Number 258 187 157 43 50 5 4 3 1 2 2 1 1 1 1 1 717 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 67
Slide 68: Snapshot of Resident PICU Rotation Activity Pre-PICU Rotation Residents’ Critical Care Experiences and Expectations Residents' Previous Intensive Care Unit Experience 500 400 Number 300 200 100 0 PICU NICU Adult ICU Adult CCU Adult Adult SICU Trauma Unit Yes No Residents' Previous Intubation Experience 350 300 250 200 Number 150 100 50 0 Intubation Intubation Intubation Adults Children < 1 year Children > 1 year Age Age Yes No U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 68
Slide 69: Residents' Previous Pediatric Central Line Experience 500 400 Number 300 200 100 0 Internal Jugular Subclavian Yes No Femoral Residents' Previous Adult Central Line Experience 300 250 200 Number 150 100 50 0 Internal Jugular Subclavian Yes No Femoral U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 69
Slide 70: Residents' Previous Adult Arterial Catheter Experience 500 400 Number 300 200 100 0 Radial Femoral Posterior Tibial Dorsalis Pedis Yes No Residents' Previous Pediatric Arterial Catheter Experience 500 400 Number 300 200 100 0 Radial Femoral Posterior Tibial Dorsalis Pedis Yes No U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 70
Slide 71: Residents' Previous Chest Tube Experience 400 300 Number 200 100 0 Adult Yes No Pediatric Residents' Previous Pigtail Chest Tube Experience 600 500 Number 400 300 200 100 0 Adult Yes No Pediatric U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 71
Slide 72: Resident's Previous Defibrillation Experience 500 400 Number 300 200 100 0 Adult Yes No Pediatric Residents' Previous Cardioversion Experience 500 400 Number 300 200 100 0 Adult Yes No Pediatric U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 72
Slide 73: Residents' Previous External Pacemaker Experience 500 400 Number 300 200 100 0 Adult Yes No Pediatric Residents' Previous Leader of a Pediatric Code 500 400 Number 300 200 100 0 Direct a Pediatric Code Yes No U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 73
Slide 74: Self reported Comfort Level Before Starting PICU Rotation as regards to Evaluating and Stabilizing a Critically Ill Child (10 = independent …1 = no comfort) Residents' Pre PICU Comfort Level with Pediatric Acute Respiratory Failure 80 70 60 50 Number 40 30 20 10 0 10 9 8 7 6 5 4 3 2 1 Comfort Level U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 74
Slide 75: Residents’ Goals Prior to Starting PICU Resident Rotation at Alfred I duPont Hospital for Children Number (%) Individual residents may have had several different goals. Goal Procedures Run a Code Recognize and stabilize critically ill child Manage pediatric critical care patients (critical care support) Pediatric critical care drug familiarity Learn Ventilators Familiarity with specific critical care topics: Respiratory failure, Sepsis, DKA, Ingestion, Trauma, Seizure, Head Injury Gain Comfort with Critically Ill Child Handle problems that may see in an ER Post op complications Critical care physiology in children Be able to discuss PICU sequelae with families in my practice Deliver Bad News to families Learn Arrythmias Difficult airway 20062007 n=12 3 (25%) 2 (17%) 3 (25% 8 (67%) 20052006 n=13 4 (31%) 4 (31%) 4 (31%) 6 (46%) 1 (8%) 20042005 n=11 5 (45%) 2 (18%) 4 (36%) 5 (45%) 1 (9%) 2 (18%) 5 (45%) 20032004 n=27 11 (41%) 4 (15%) 10 (37%) 13 (48%) 2 (7%) 1 (4%) 20022003 n=38 16 (42%) 17 (45%) 10 (26%) 18 (47%) 7 (18%) 8 (21%) 3 (8%) 20012002 n=39 22 (56%) 15 (38%) 13 (33%) 9 (23%) 7 (18%) 5 (13%) 1 (3%) 20002001 n=49 25 (51%) 14 (26%) 25 (51% 18 (37%) 8 (16%) 3 (6%) 8 (16%) 19992000 n=53 30 (57%) 20 (38%) 25 (47%) 23 (43%) 9 (17%) 8 (15%) 5 (9%) 19981999 n=49 26 (53%) 20 (41%) 15 (31%) 25 (51%) 9 (18%) 5 (10%) 6 (12%) 3 (23%) 2 (16%) 3 (23%) 2 (18%) 3 (11%) 3 (8%) 1 (3%) 2 (5%) 2 (4%) 2 (4%) 2 (4%) 3 (6%) 1 (2%) 1 (2%) 3 (6%) 2 (4%) 1 (2%) 5 (10%) 1 (9%) 2 (5%) 1 (3%) 1 (2%) 2 (4%) 1 (3%) 1 (3%) 1 (3%) 1 (2%) 1 (2%) 1 (2%) U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 75
Slide 76: Goal Stabilize for Transport Invasive cardiopulmonary monitoring Ventilator support for chronic vent dependent children Familiarity with children with chronic medical issues Organizational skills in PICU Determine if pediatric critical care a career possibility Critical evaluation of article 20062007 n=12 20052006 n=13 20042005 n=11 20032004 n=27 20022003 n=38 20012002 n=39 1 (3%) 20002001 n=49 19992000 n=53 1 (2%) 2 (4%) 1 (2%) 19981999 n=49 1 (2%) 1 (8%) 1 (2%) 3 (6%) 1 (2%) 1 (2%) 1 (8%) 1 (4%) 1 (3%) Resident Learning Preferences 80 70 60 50 % 40 30 20 10 0 71 69 Ask attending 64 53 48 38 31 28 26 Patient Care Rounds Patient Care Mock Drills Check textbook Formal Lectures Medline Searches Reading Program Preference Give Talk U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 76
Slide 77: Snapshot of Resident PICU Rotation Activity Procedures Performed During PICU Rotation 250 PICU Participants March 1998 through January 2007 Some residents had more than 1 of the selected procedures All procedures are supervised by critical care physician staff Intubations and Tracheostomy Changes by Residents During PICU Rotation 249 250 200 143 150 100 50 0 Intubations 12 Change a Trach 118 Yes No Central Venous Lines Placed by Residents During PICU Rotation 250 200 150 Number 100 50 0 Femoral Venous Line 14 Internal Jugular Venous Line 20 Subclavian Venous Line 148 113 Yes No 247 241 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 77
Slide 78: Arterial Catheters Placed By Residents During PICU Rotation 250 200 Number 150 100 50 0 Radial Arterial Line r 74 187 205 Yes 56 No Femoral Arterial Line Centesis Performed By Residents During PICU Rotation 300 250 200 Number 150 100 50 0 23 Thorax 3 Pericardium 5 Peritoneum Yes No 238 258 256 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 78
Slide 79: Chest Tubes Placed By Residents During PICU Rotation 250 200 Number 150 100 50 0 28 233 219 Yes No 42 Chest Tube Pigtail chest tube Lumbar Punctures Performed By residents During PICU Rotation 150 150 100 Number 50 0 111 Yes No Lumbar Puncture U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 79
Slide 80: Code Procedures Performed By Residents During PICU Rotation 300 250 200 Number 150 100 50 0 6 Defibrillation 0 Cardioversion 7 External Pacemaker Yes No 255 261 254 Code Participation By Residents During PICU Rotation 300 250 Number 200 150 100 50 0 Participate in Pediatric Code Run a Pediatric Code 22 110 151 239 Yes No U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 80
Slide 81: Deliverying Bad News To Families By Residents During PICU Rotation 135 135 130 Number 125 120 Yes 125 No Deliver Bad News to Fanmlies SCCM PICU Resident Average Test Scores 76 74 72 70 % 68 66 64 62 60 72 70 66 76 A B C D SCCM Test Version U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 81
Slide 82: Comfort Level of 280 Residents After Their PICU Rotation as Regards Caring for Children and Adolescents with Critical Care Issues Comfort Levels: 10 independent….1 no comfort at all Acute Respiratory Failure 140 120 100 Number 80 60 40 20 0 1 5 51 22 2 2 0 0 81 122 Residents' Comfort Level After PICU Rotation 10 9 8 7 6 5 4 3 2 1 Hemodynamic Instability 120 100 80 Number 60 40 20 0 1 7 50 23 3 3 0 0 117 78 Residents' Comfort Level After PICU Rotation 10 9 8 7 6 5 4 3 2 1 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 82
Slide 83: Sepsis 140 120 100 Number 80 60 40 20 0 1 8 47 29 2 2 0 0 117 75 Residents' Comfort Level After PICU Rotation 10 9 8 7 6 5 4 3 2 1 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 83
Slide 84: Acute Neurologic Insults 120 100 80 Numbers 60 40 20 0 1 5 40 118 83 29 1 4 0 0 Residents' Comfort Level After PICU Rotation 10 9 8 7 6 5 4 3 2 1 Acute Electrolyte & Endocrine Issues 120 100 80 Numbers 60 40 20 0 1 7 42 26 1 3 0 0 119 79 Residents' Comfort Level After PICU Rotation 10 9 8 7 6 5 4 3 2 1 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 84
Slide 85: Acute Renal Failure 120 100 80 Number 60 40 20 0 1 6 39 27 4 1 0 0 77 118 Residents' Comfort Level After PICU Rotation 10 9 8 7 6 5 4 3 2 1 Coagulation Issues 140 120 100 Number 80 60 40 20 0 1 8 36 78 125 26 1 4 2 0 Residents' Comfort Level After PICU Rotation 10 9 8 7 6 5 4 3 2 1 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 85
Slide 86: Overdoses & Poisonings 120 100 80 Number 60 40 20 0 1 10 40 25 3 1 0 0 75 118 Residents' Comfort Level After PICU Rotation 10 9 8 7 6 5 4 3 2 1 Overall Comfort Level 160 140 120 Number 100 80 60 40 20 0 151 103 46 23 1 2 3 1 0 0 Residents' Comfort Level After PICU Rotation 10 9 8 7 6 5 4 3 2 1 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 86
Slide 87: Self reported data from residents at the end of their PICU rotation From PICU Data Base – Resident overall evaluations of PICU Rotation – Average scores on Likert Scale 4. Exceeds Expectations 3. Meets expectations 2. Needs Improvement 1. Major area of deficiency Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Thomas Jefferson Pediatrics Christiana Care MedPeds Thomas Jefferson Emergency Medicine Christiana Care Emergency Medicine 3.4 3.3 3.3 3.6 3.4 3.5 3.25 2.7 3.0 3.25 4.0 3.0 3.0 3.75 2.9 3.5 3.1 3.1 3.0 3.4 3.1 3.3 3.0 2.7 3.0 3.0 Evaluation of PICU Rotation: Combined 2004, 2005, 2006 Data from Pediatric Residency Program Forms Overall score given to rotation (1) weak- (5) average rotation - 10( great rotation) Average score = 7.94 (Range 4 – 10) Rotation Quality (1) Poor (2)(3) Average (4)(5) Excellent Goals of rotation defined and clear Time to complete goals and objectives Balance of service and education Overall organization of the rotation 3.83 3.58 3.08 3.54 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 87
Slide 88: PICU Rotation Evaluation - 2004, 2005, 2006 Combined Results from Our PICU Resident Data Base Overall score given to rotation (1) weak- (5) average rotation - 10( great rotation) Residency Program Thomas Jefferson Pediatrics (n=10) Thomas Jefferson Emergency Medicine (n=6) Christiana Care Emergency Medicine (n=2) Christiana Care Medicine Pediatrics (n=3) Medical Student (n=4) Average (Range)Overall Score Given to Rotation 8.3 (Range 7-10) 7.2 (Range 4-10) 8.5 (Range 8-9) 5.7 (Range 2-8) 8.3 (Range 7-9) 1- Strongly disagree 2- Disagree 3-Neutral 4 -Agree 5 -Strongly Agree I was made aware of expectations of rotation I was a valuable member of the team I was given appropriate level of independence I was given appropriate level of support/backup I was expected to think independently during the rotation I increased my knowledge base during the rotation I improved my physical exam skills during the rotation I improved my communication skills during the rotation I improved my technical skills during the rotation I felt that my expectations of the rotation were met I was given feedback about my performance 1 – Is not enough 2 – Is just right 3- Is too much Number of patients seen during rotation Time spent in conferences and lectures Time spent in contact with patients Amount of teaching done by fellow residents Amount of teaching done by attendings Duration of rotation 2.2 1.08 1.96 1.04 1.8 1.88 4.4 4.3 4.1 4.3 4.0 4.6 4.3 3.9 3.4 3.7 3.2 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 88
Slide 89: Resident OVERALL EVALUATION of PICU Rotation Thomas Jefferson University Hospital-Emergency Medicine 2006-2007 Respondents (n=10) Unsatisfactory 1-2 Satisfactory 3-4 Good 5-6 Excellent 7-8 Conference Teaching Rounds Attending Teaching Resident Teaching Ease of Consultation Call Schedule Overall Evaluation Average Evaluator Average Score 6.0 5.9 6.0 5.0 6.6 4.4 5.8 5.7 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 89
Slide 90: EVALUATIONS of PICU ROTATION - MED-PEDS RESIDENT (n=4) 2006 - 2007 Number Responses Rotation Quality Poor Goals of rotation defined and clear Time to complete goals and objectives Balance of service and education Overall organization of the rotation Personal Goals I improved my history taking skills I improved my physical exam skills I improved my decision making I improved my knowledge base I improved my communication skills I improved my technical skills Nursing Staff Patient Care Skills Communication skills Professionalism Respiratory Staff Patient Care Skills Communication skills Professionalism Unit Clerks Communication skills Professionalism 1 1 2 2 1 1 4 4 4 1 1 3 2 2 1 1 1 1 2 2 2 4 2 1 3 1 2 3 1 1 Fair Average Very Good 3 3 3 4 Superior 1 1 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 90
Slide 91: ROTATION EVALUATION FORM – Thomas Jefferson University Hospital-Pediatrics July 2006-June 2007 1 = Low Score 5 = High Score Rotation Quality Goals of rotation defined and clear 0 0 1 0 2 0 3 3 4 16 5 22 Total 41 100% 0% 0% 0% 7% 39% 54% Time to complete goals and objectives 0 0 1 0 2 2 3 8 4 16 5 15 Total 41 100% 0% 0% 5% 20% 39% 37% Balance of service and education 0 0 1 0 2 3 3 10 4 18 5 10 Total 41 100% 0% 0% 7% 24% 44% 24% Overall organization of the rotation 0 0 1 0 2 1 3 10 4 21 5 9 Total 41 100% 0% 0% 2% 24% 51% 22% Personal Goals I improved my history taking skills 0 0 1 0 2 5 3 9 4 19 5 8 Total 41 100% 0% 0% 12% 22% 46% 20% I improved my physical exam skills 0 0 1 1 2 3 3 7 4 22 5 8 Total 41 100% 0% 2% 7% 17% 54% 20% I improved my decision making 0 0 1 0 2 0 3 10 4 11 5 20 Total 41 100% 0% 0% 0% 24% 27% 49% I improved my knowledge base 0 0 1 0 2 1 3 3 4 12 5 25 Total 41 100% 0% 0% 2% 7% 29% 61% I improved my communication skills 0 0 1 0 2 0 3 7 4 22 5 12 Total 41 100% 0% 0% 0% 17% 54% 29% U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 91
Slide 92: I improved my technical skills 0 1 1 2 2 5 3 10 4 15 5 8 Total 41 100% 2% 5% 12% 24% 37% 20% Nursing Staff Patient Care Skills 0 0 1 0 2 0 3 2 4 10 5 29 Total 41 100% 0% 0% 0% 5% 24% 71% Communication Skills 0 0 1 0 2 0 3 3 4 11 5 27 Total 41 100% 0% 0% 0% 7% 27% 66% Professionalism 0 0 1 0 2 0 3 5 4 10 5 26 Total 41 100% 0% 0% 0% 12% 24% 63% Respiratory Staff Patient Care Skills 0 1 1 0 2 0 3 2 4 12 5 26 Total 41 100% 2% 0% 0% 5% 29% 63% Communication Skills 0 1 1 0 2 0 3 3 4 13 5 24 Total 41 100% 2% 0% 0% 7% 32% 59% Professionalism 0 1 1 0 2 0 3 2 4 15 5 23 Total 41 100% 2% 0% 0% 5% 37% 56% Unit Clerks Communication Skills 0 0 1 1 2 0 3 9 4 9 5 22 Total 41 100% 0% 2% 0% 22% 22% 54% Professionalism 0 0 1 1 2 0 3 10 4 7 5 23 Total 41 100% U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 92
Slide 93: 0% 2% 0% 24% 17% 56% U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 93
Slide 94: Residents’ comments about PICU Rotation 1997 Thomas Jefferson Pediatrics I feel I learned a great deal and gained clinical confidence. I would like to do more. Great learning, Attending good I am very happy with the rotation and would recommend increasing the number of blocks scheduled here vs NICU. I am confident all other residents concur with the idea. Very little teaching this month-formally or informally. Had expected a rotation strong in experience and teaching/learning. Wish I could do additional time instead of so much NICU. I'm much more comfortable with certain types of patients now (eg DKA, Septic shock) Thomas Jefferson Emergency Medicine I feel that I've learned a lot in my 5 weeks and that the teaching was excellent. Highly recommend. Wonderful experience Excellent overall rotation. Excellent teaching and involvement with attendings. Thank you for all your help and teaching. I really enjoyed and learned much from my month here. Except for the computer, I had a great time Christiana Care Emergency Medicine I had a very diverse and nice experience - thank you Feel more comfortable with sick kids and determining if kid is sick The PICU was interesting and all the attendings were friendly, willing to teach, and clinically excellent. Good nursing staff and clerical staff Christiana Care Medicine Pediatrics 1998 Thomas Jefferson Pediatrics Wished more time here. Need longer time for broader exposure I only did 4 weeks. Six to 8 weeks would probably be better. Very minimal teaching during morning rounds. Not enough teaching. Attendings did procedures that should be done by residents. Not able to attend grand rounds or morning report. Not being involved in decision making- many times nurses would just talk to attending about patients without involving residents. Needs less residents / more patients for proper experience. Thomas Jefferson Emergency Medicine It was just a slow month for me. Need more opportunities for procedures. It's nobody's fault that this month was slow and I'm a "white cloud" during my calls. Christiana Care Emergency Medicine However, I feel that there were too many residents on service, making it difficult to see/have an adequate number of patients. I also feel that some admissions to the PICU were not warranted and took away from true PICU learning experience. I don't feel that the level of acuity or the volume of patients was adequate to give me the level of confidence I need to manage critically ill children. The textbook (Peds Intensive Care) was surprisingly not too helpful. Too much irrelevent discussion, not enough useful information. Rotation was great. I just am not sure that I would comfortable running a pediatric code yet. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 94
Slide 95: Christiana Care Medicine Pediatrics The rotation would be more solid an experience if there were discussions in either topics or complicated patients. There seemed to be minimal education in rounds; most of the day was spent trying to find things to do, with 6 residents on service. 1999 Thomas Jefferson Pediatrics Excellent lectures by attending ! Dr Cullen, shock and Dr Hertzog on rounds. Complicated patients with wide variety of diagnosis, interesting and challenging. Adds depth to understanding how to manage patients in general. I feel I've should have been exposed to it during our intern year with some resident supervision. Good rotation. Wish I had seen more acute problems and less chronic problems. Thomas Jefferson Emergency Medicine Although we had many interesting and educational patients, I do not feel comfortable with certain procedures (I.e. intubations) that will be an absolute necessity in my career. Wish there were more critical patients. Thank you. Great rotation. Everyone from nursing, respiratory, attending was very helpful / friendly/ I felt very comfortable and enjoyed the month very much. Christiana Care Emergency Medicine Christiana Care Medicine Pediatrics Overall a good experience. 2000 Thomas Jefferson Pediatrics Not a bad rotation overall-good teaching, interesting patients, a few procedures. BUT weren't we supposed to be doing critical care? The attendings are universally wonderful. They provide a good amount of teaching on rounds. I wish when attendings went to the bedside to evaluate a patient and change management, I wish I could be present so I could understand the reasoning behind the changes and what patient findings led to the changes. This happened 25% or so. Thomas Jefferson Emergency Medicine I must also say how incredible the nurses are, especially Mary Beth, Jill, Steph and Sandy who taught me so much. Residents need independence. Christiana Care Emergency Medicine Enjoyable time and educational. Good month. I learned a lot of relevant things without being bogged down with information that I will never use again. We had a few very sick kids and a lot of kids for "observation". Learned a lot from a few-wish there had been more sick kids. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 95
Slide 96: Christiana Care Medicine Pediatrics I enjoyed the exposure to ill patients, though I found much of the structure of PICU frustrating. 2001 Thomas Jefferson Pediatrics Need more time! 4 weeks out of 36 months is unreasonable. Thomas Jefferson Emergency Medicine Except lack of procedures. There should be a better efficiency in resident staffing, call schedules. Christiana Care Emergency Medicine Need more independent thought. Less order entry. More procedures. Christiana Care Medicine Pediatrics 2002 Thomas Jefferson Pediatrics Encouraged about a career in critical care. I felt that the continuity of attendings is an area that needs improvement. Great rotation, interesting cases. Great attendings. Got procedures (central line, intubation). Thomas Jefferson Emergency Medicine Christiana Care Emergency Medicine Christiana Care Medicine Pediatrics 2003 Thomas Jefferson Pediatrics I had a great rotation, learned a lot and gained confidence in caring for seriously ill children. Thomas Jefferson Emergency Medicine Christiana Care Emergency Medicine Excellent EBM emphasis during this month. Many opportunities for literature research. This month was good in all the ways I have said already. The one thing that wasn't so useful was following the kids who had chronic problems or were just waiting for teaching. Maybe there should be kids that are made "non-teaching" so that out time isn't spent getting numbers and repeating notes on kids that we're very unlikely to learn anything from. Christiana Care Medicine Pediatrics U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 96
Slide 97: 2004 Thomas Jefferson Pediatrics What are the strongest assests of this rotation? The attendings (EC,JH, SP) and Nick Variety of patients seen, independence is given How would you improve this rotation? Too many patients for one person to manage on-call Any other comments about this rotation? Thomas Jefferson Emergency Medicine What are the strongest assests of this rotation? Attending teaching, on-line lectures Knowledge of attendings How would you improve this rotation? More structured lecturing Allow us to do procedures & discuss patients into Any other comments about this rotation? Overall enjoyed rotation Christiana Care Emergency Medicine What are the strongest assests of this rotation? Dr. Penfil is one of the best teachers that I have had. How would you improve this rotation? Remove chronic kids from the PICU Any other comments about this rotation? Fellows usually got first crack at procedures Christiana Care Medicine Pediatrics What are the strongest assests of this rotation? Dr. Penfil is an excellent teacher and role model How would you improve this rotation? Scheduled didactic sessions on ICU issues. Any other comments about this rotation? I did zero procedures. Nick a good teacher 2005 Thomas Jefferson Pediatrics What are the strongest assests of this rotation? Attendings did a lot of teaching Certain attending teachings. Opportunity to gain confidence Teaching by Dr. Penfil, exposure to procedures Teaching on rounds, mock codes, call, nursing staff Acuity of patients, step learning curve Procedures, exposure to ICU/ventilators, physiology U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 97
Slide 98: How would you improve this rotation? More variety of patients Post-call round 1st . Continue mock cods More teaching on other rounds, round on post-call More exposure to basic procedures like IV, art stick More procedures for residents Any other comments about this rotation? Efficiency on rounds makes a big difference in how s Residents left out of loop. Nurses go to attending Please give residents more feedback Anesthesia resident got to do most of the procedures Great Thomas Jefferson Emergency Medicine What are the strongest assests of this rotation? Variety of patient conditions How would you improve this rotation? Institute night float in PICU as well - 5p-7a Any other comments about this rotation? Have short call to 11p then late night flat start Christiana Care Emergency Medicine What are the strongest assests of this rotation? How would you improve this rotation? Any other comments about this rotation? Christiana Care Medicine Pediatrics What are the strongest assests of this rotation? Good learning experience How would you improve this rotation? Simplifying order entry system ,it was frustrating Any other comments about this rotation? Medical Student What are the strongest assests of this rotation? Opportunity to work with different attendings How would you improve this rotation? More bedside physical exams. More hands on equip Any other comments about this rotation? I enjoyed it very much U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 98
Slide 99: 2006 Thomas Jefferson Pediatrics What are the strongest assests of this rotation? The attendings & fellows were great teachers How would you improve this rotation? Any other comments about this rotation? Thomas Jefferson Emergency Medicine What are the strongest assests of this rotation? Teaching rounds. Dr. Penfil was the best. Great experience with critically ill children How would you improve this rotation? Greater chance at trying procedures Any other comments about this rotation? Post-call residents should present all of his/her patients first Christiana Care Emergency Medicine What are the strongest assests of this rotation? Varierty of patients and pathology. How would you improve this rotation? Any other comments about this rotation? Difficult to effectively use CERNER Order System Christiana Care Medicine Pediatrics What are the strongest assests of this rotation? Volume of children seen How would you improve this rotation? Any other comments about this rotation? Very frustrating rotation overall. Learned little Medical Student What are the strongest assests of this rotation? Knowledge of the attendings and fellows, diversity How would you improve this rotation? Time for case discussion/lecture Any other comments about this rotation? U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 99
Slide 100: 2006 – 2007 Thomas Jefferson University Hospital-Emergency Medicine Comments and Recommendations: This was a great rotation for me. I enjoyed this rotation. Too many calls. Too few procedures I learned a tremendous amount during rounds and appreciated the desire of attendings to teach. The rotation as a whole was beneficial in that I now feel comfortable in the management of critically ill children. However the month at Dupont is very frustrating in that the residents are often demoted to the role of clerks and secretaries. A significant portion of our time is spent doing paperwork and filling orders while the attendings and fellows actually manage the patients. The computer system is counter-intuitive in that is slows everyone down. Oftentimes, management decisions are made without us and plans of actions are initiated without our knowledge. Teaching is also an issue. Glenn S. did a fantastic job during rounds being efficient but at the same time making a point to teach us something everyday. Other attendings however do not ascribe to this philosophy. What are the best assets? Dr. Penfil was outstanding- a great role model and very knowledgable about the most recent evidencebased medicine practices. Scope of illnesses seen in the PICU. Acuity of patients. - Dr.s Penfil and Stryjewski are excellent teachers and allow a good balance b/t autonomy & supervision. I appreciate their willingness & patience in allowing residents to perform procedures. - The PICU staff was very friendly and welcoming. No one hesitated to help me out as I learned the system there. Good attending teaching. Attending teaching; nursing staff interest in patient care. How can the service be improved? The computer order system is terrible. I spent hours trying to put in orders. It is counter-intuitive when trying to find an order (trying to guess what it is listed under) and time is wasted. In addition patients needed to be registered in the computer immediately upon arrival, not when the parent can go down to registration. This lead to a medical error while I was in the PICU- the written orders were not entered properly (medical decision-making plays a role when ordering and a clerk should not be held responsible for this). The patient suffered as a result and I think it maybe could have been avoided if a physician could have entered the orders. More procedures, difficult since the fellow took/did the procedures. At times, personal patients could become monotonous (cases of tracheomalacia, where pt is there for observation, weaning on vent, and parent teaching - after 3 days, no real teaching value) More short, sit-down teaching about specific PICU topics by attendings during slow times could be beneficial. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 100
Slide 101: Allow residents to perform all procedures first It would have been nice if all of the mock codes were done. It only ended up occurring 2 out of the 4 weeks during the rotation. At times, rounds dragged on because of multiple distractions such as incoming phone calls. Perhaps a second attending could be assigned to take incoming calls while rounds take place. July 2006 –June 2007 Thomas Jefferson University Pediatric Residents Evaluation of PICU Rotation Comments: • • • Got to do lots of procedures. There were times at night that I felt a little unsupported. This was difficult because it was my first time in the PICU and being alone at night felt uncomfortable. I was glad to be able to do some procedures. I feel overall education in the PICU is poor. Many of the attendings do not teach. Roles are not well defined and many times the resident is being treated like an intern. The resident is not given the chance to take histories on their own or come up with plans. Certainly, with some ICU patients who need immediate intervention, this is not possible, but I felt like the residents are not given the chance to think on their own. When a patient is admitted, the fellow and the attending don't even give the resident a chance to talk to the patient first of make a plan on their own. Roles for the fellow and NNP aren't well defined either. Teaching on rounds is inconsistent, although it improved as the rotation went on. There is no discussion/feedback regarding admissions- which would be useful in cases where a pt arrives to the floor needing immediate stabilization or when there is something in the pt's history or physical exam that would cause an otherwise routine care plan to change. There are several times when pertinent teaching points could be made, but are not. I got to intubate a non-infant! I have heard the complaints about lack of teaching (as brought up at our retreat), but I think the attendings that were on service with me were diligent about teaching on rounds (but no formal lectures were given outside of rounds) Residents don't do procedures because the fellows are there. Teaching on the rotation was excellent. I wish as residents we played more of a role in the decision making and were able to do more procedures. In response to the resident concerns with the lack of teaching, we are being given reading assignments, which are, in theory, a decent idea, but which seem more like 'busywork'. The topics are pre-chosen and sometimes are not relevant to the patients currently in the PICU. The best of the teaching has occurred at the bedside, but again the quality of the teaching is variable. The most useful of the teaching revolves around the potential complications of the patient's disease, or the prognosis. The least useful moments at the bedside are spent complaining about administrative issues in the hospital or comparing of DuPont to other hospitals. I had an excellent experience this time around in the PICU. However, I continue to be confused by the role of Eileen, the Nurse Practitioner. I find it extremely undermining that she is having conversations with families of my patients and examining them daily. It makes for too many cooks in the kitchen. The only criticism I have about the PICU is there needs to be more autonomy for the residents when a • • • • • • • U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 101
Slide 102: fellow is working with them. It is very frustrating when you work with a fellow who makes multiple major changes on a patient, who you are supposed to be the primary caregiver on and you have no idea. This can also be unsafe for the patients at times. Also, residents should have first shot for all procedures on their patients. • • Did not get to do any procedures as fellows needed experience Clerks are rude to the residents and make it nearly impossible to get sheets to write progress notes in the morning. We nearly have to beg to get blank progress notes which slows us down and is absolutely unnecessary. Nurses in the PICU are some of the best in the hospital and I enjoyed working with them. Just completed 2 weeks, looking forward to next 4 weeks The nurse's and respiratory staff are excellent, great to work with and great teachers! Excellent support staff. Lack of procedures is concerning. Get to do basic procedures such as LP and ABG, but concerned about being boxed out/lack of exposure to fem lines, etc. Otherwise teaching is variable depending on attending. Nurses and respiratory staff are excellent. In other words, as residents, don't want to be reciting numbers and then be excluded from procedures so fellow can do them all. I was able to participate in procedures, good teaching (attending dependent); felt more comfortable with critical care by the end of 6 weeks I thought the rotation was pretty good, and Drs. Penfil and Hertzog did a good job teaching. Dr. Cullen's lectures were good to hear and work through. Still concerned about lack of procedures outside of LPs and ABGs such as central lines/intubations that are offered to/allowed for residents, especially with two first year fellows and one particularly incompetent one. In general, the staff in the PICU is among the best in the hospital. my only concern is the role of Eileen, the nurse practitioner. I do not understand what her role is, and how she is a part of the care team. iIalso do not understand why she is examining our patients in the mornings and talking with the families about care. It is undermining to the residents as the primary care givers, and is confusing to families. If she is going to do this, she should carry her own patients, and not meddle in the care of the resident's patients. I did not do a lot of admissions during my most recent time in the PICU, so I did not improve my history taking skills very much. I also did not get to perform very many procedures, so my technical skills did not improve. You can tell that the PICU attendings care about education and want to teach, but sometimes they are still struggling to do so in an effective manner. I don't think this is necessarily their fault, but just the nature of the environment. It is ridiculous that the daily progress notes are hidden behind the clerk's desk and we as residents have to ask for them everyday!!! It really treats the residents like children, we can judge when we need them and when we don’t need them!!! It is ridiculous that progress notes continue to be hidden behind the clerks' desk and we have to beg to get them in the morning and on rounds. We are all adults and since the residents are the only people who use the forms, we should have complete access to them whenever we want. If the clerks have to hold them cause they are so expensive, they should have to stamp forms everyday for our use rather than hold them for ransom. Almost all nurses in the PICU are amongst the best I've worked with. As a whole, they are spectacular. • • • • • • • • • • • • U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 102
Slide 103: However, a couple of them openly appear to dislike working with residents. Some of them will go straight to the attending with a question when residents are nearby and available, which can be frustrating and strongly diminishes not only the learning experience but is bad for patient care since it leaves the residents out of the loop with what is happening with their patients. Also, a couple of times, nurses in the PICU did not let me start an IV when it needed to be placed. I was disappointed by this since I had heard that they were strong believers in letting the residents do this. The only time I got to start an IV was when the attending told the nurse that I should do it. • Some attendings are better than others at teaching. Most of the time, we are unable to go to noon lectures due to being busy the PICU is at the time. PICU Resident overall evaluations of critical care attendings – average scores on Likert Scale 4. Exceeds expectations 3. Meets expectations 2. Needs improvement 1. Major area of deficiency Costarino Thomas Jefferson Pediatrics 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Christiana Care MedPeds Thomas Jefferson Emergency Medicine Christiana Care Emergency Medicine 3.8 3.7 3.1 3.0 3.0 3.6 3.6 3.5 3.3 Cullen Thomas Jefferson Christiana Care Thomas Jefferson Christiana Care U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 103
Slide 104: Pediatrics 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 MedPeds Emergency Medicine Emergency Medicine 3.0 3.4 3.3 3.2 3.7 3.5 3.6 4.0 3.7 3.3 3.0 3.0 3.6 3.6 3.1 2.3 3.6 3.4 3.7 3.0 3.3 3.6 3.0 3.0 Hertzog Thomas Jefferson Pediatrics 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Christiana Care MedPeds Thomas Jefferson Emergency Medicine Christiana Care Emergency Medicine 3.5 3.4 3.6 3.4 3.3 3.5 3.25 3.0 3.0 4.0 4.0 3.3 3.5 3.3 3.3 3.3 3.3 3.4 3.0 Penfil Thomas Jefferson Christiana Care Thomas Jefferson Christiana Care U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 104
Slide 105: Pediatrics 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 MedPeds Emergency Medicine Emergency Medicine 3.7 4.0 3.5 4.0 4.0 4.0 4.0 4.0 4.0 4.0 3.9 3.9 3.75 3.8 4.0 3.7 4.0 4.0 4.0 Critical Care Attendings Effective Teacher – 2004 Ranking: 1 2 3 4 5 (best) Average score Effective teacher Costarino 3.53 Cullen 3.72 Hertzog 4.26 Penfil 4.95 Overall rating of attending – 2004 (1) weak (5) average (10) great Overall rating of attending Costarino 6.57 Cullen 7.32 Average score Hertzog 8.12 Penfil 9.6 Amount of teaching done by attendings (1) is not enough (2) just right (3) too much Average score = 1.83 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 105
Slide 106: Evaluations of Critical Care Attendings and Fellows Combined 2004, 2005, 2006 Scores by PICU Residents (n=16) (PICU Resident Data Base) Scoring System: 1-Strongly Disagree 2-Disagree 3- Neutral 4-Agree 5-Strongly Agree Average Scores: Valued my presence Binck 4.0 2.0 4.0 5.0 4.0 2.0 3.0 5.0 4.0 1.0 4.0 4.0 4.0 1.0 4.0 4.0 4.0 1.0 3.0 4.0 Burns 4.0 4.0 1.0 4.0 5.0 3.0 4.0 4.0 1.0 5.0 2.0 4.0 4.0 3.0 5.0 2.0 4.0 3.0 2.0 5.0 2.0 4.0 2.0 2.0 4.0 2.0 Costarino 3.0 3.4 4.5 5.0 3.0 3.0 3.2 4.5 5.0 4.0 4.0 3.2 4.5 5.0 4.0 4.0 3.4 5.0 4.0 4.0 3.2 4.5 4.0 5.0 4.0 Cullen 4.6 5.0 4.5 4.0 4.0 4.0 4.0 4.0 4.0 3.75 3.6 4.3 3.5 4.0 4.6 4.0 4.3 3.5 3.0 3.75 4.3 4.3 3.5 4.0 3.75 Hertzog 3.5 4.3 4.0 3.75 5.0 3.5 4.0 3.7 4.0 5.0 2.75 4.0 4.3 3.75 5.0 3.5 4.0 4.3 4.0 5.0 3.75 3.6 4.7 4.0 5.0 McCloskey 4.0 Penfil 3.5 4.3 4.5 3.7 4.0 4.0 4.75 5.0 5.0 4.3 4.0 4.0 5.0 5.0 5.0 4.7 5.0 4.0 5.0 4.3 5.0 5.0 5.0 4.0 5.0 4.7 5.0 5.0 5.0 5.0 Stryjewski 4.0 Boyd 4.0 Slamon 4.0 4.3 5.0 4.0 5.0 4.3 4.0 3.5 5.0 5.0 5.0 4.5 5.0 4.3 4.0 4.0 5.0 4.3 5.0 4.5 Encouraged me to think independently 5.0 4.0 3.5 4.0 Took time to teach me 5.0 5.0 3.5 4.0 Effective teacher 5.0 5.0 3.5 4.0 Effective role model for residents 5.0 5.0 3.5 4.0 Overall critical care attendings’ rating by PICU Residents Scoring System: 1 – Weak Averages: Overall rating Binck 8.0 2.0 8.0 Burns 4.0 2.0 9.0 6.0 Costarino 6.6 8.5 8.0 7.0 Cullen 7.6 8.3 6.0 7.0 7.5 Hertzog 7.0 7.0 7.5 7.3 10.0 McCloskey 10.0 Penfil 9.75 10.0 9.0 9.3 9.0 Stryjewski 10.0 Boyd 7.0 Slamon 10.0 8.7 8.0 7.0 5 – Average 10 - Great U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 106
Slide 107: 10.0 Survey Results of Former PICU Residents (n=227) During Their First Year Out Of Residency Comfort Level recognizing and stabilizing critically ill children and adolescents in heir respective practices Comfort Level 7% 29% 0% 1%2% 9% 14% 38% 3 4 5 6 7 8 9 10 Frequency of having to deal with a critical care issue: acute respiratory failure, hemodynamic instability, sepsis, acute neurologic insult, acute electrolyte & endocrine issue, acute renal failure, coagulation issue, overdoses & poisoning. Pediatric Critical Care Intervention 14% 4% 3% 45% 34% Never Yearly Monthly Weekly Daily U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 107
Slide 108: Primary physician who cares for critically ill children and adolescents in the hospital Primary Physician Who Cares for a Critically Ill Child in the Hospital 16% 84% Yes No Frequency of performing critical procedures: Maintain Airway, Bag Mask Ventilation, Tracheal Intubation, Change Tracheostomy Tube, Remove upper airway foreign body, Temporary surgical airway, Chest tube, Central line, Pulmonary artery catheter, Arterial catheter, Pericardiocentesis, Interpret EKG, Transcutaneous pacing, Elective cardioversion, Defibrillation Pediatric Critical Care Procedures 12% 4% 3% 26% 55% Never Yearly Monthly Weekly Daily U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 108
Slide 109: Comments on improving the PICU Resident Rotation from previous PICU residents 1994 – 2004 (n=222) who were surveyed in their first year of practice Thomas Jefferson University Pediatric Residents More time with practicing intubation (in the OR if necessary) - in particular while maintaining in line traction. Management of multiple trauma in the first few hours in ER setting. Going with transport for initial assessment and stabilization. Working more on IV access. More hands on line placement, intubation and running codes. We should have more PICU experience required in our training.(As chief resident we have very little clinical duties). More case presentations when census is low, where residents work through the management of example patients. More practice codes I felt this was an excellent experience. Although I do not use these skills on a regular basis, my experience in the PICU provides confidence that I would be able to provide critical care until more intensive care became available. Yes, to update and maintain certain skills that although will not be used often, are very important when the need arises Nothing additional. Have an anesthesia day to practice / learn intubation of older children with teeth. We rarely had opportunities to intubate larger children and adolescents during the whole residency. In my setting, the only thing we should rarely encounter would be respiratory distress or seizures. More attempts at extubations would be helpful. Continued mock code scenarios More mock code practices, since fortunately the real ones don't happen that often in peds. More Mock code experiences in stabilizing patients. Get good at handling emergency equipment and what to do on transports. Acute management of neurologic emergencies (status epilepticus, increased ICP, etc.) Additional time to perhaps spend with a trauma service (I.e., MCD). Practice with intubation of the older child (perhaps with cadaver if available). No change. Continue with weely mock codes More procedures. Initial evaluation, stabilization of acutely ill child. Evaluation of floor patients for appropriate ICU transfer. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 109
Slide 110: Maximize opportunities to perform invasive procedures. I felt very prepared although I am in an office setting. Recognize very sick children who may present to my office. It was a great rotation. I would have had more time in the ICU altogether. I don't think that one month is enough to appreciate and feel comfortable with anything. Perhaps 2 to 3 days in OR practicing ET intubation and airway management in non-urgent situations. More bedside teaching. Longer or additional PICU rotation (I month is not enough exposure). Attendings should encourage more independent thought by residents. Would have liked more time in the PICU. Emphasis on early recognition of acute disorders when possible. Do > 1 month in PICU. The rotation was more than adequate. Perhaps more autonomy / experience when performing procedures. (e.g. lines, intubation) More mock codes addressing endocrine, cardiac arrest, brain injury monitoring and management. More Procedures-even if not in real patients, arterial lines, central access (not umbilical), pericardiaocentesis. I had very few seriously/critically ill children during my 1 1/2 months in the PICU. More bad luck than anything. Lectures on different types of shock/ anaphylaxis No suggested changes. Fortunately and unfortunately there are not many children requiring aggressive resuscitation or procedures. The ability to do more procedures would have been helpful. As a primary pediatrician, I feel my one month in the PICU was very educational. Possibly doing more mock codes I would have liked more experience in initially stabilizing patients (mock codes, etc.). I am in a strictly outpatient setting and have had little need to do more than the initial stabilization. More lectures and discussions regarding disease process seen in PICU, the course of these diseases prior to presenting to the PICU and post-PICU care / follow up. Practice of initial stabilization / code situations. Nothing. I felt very prepared for my fellowship in PICU. Nothing really different. Although I am not as clinically involved this year, I feel like I had an excellent education in the PICU and that I am well prepared for emergencies. It really was one of my favorite rotations of residency. Excellent teaching. More "hands on" training - procedures, etc. Frequent "drills" on acute management / stabilization. HAND WRITTEN ORDERS! Nothing. Although I am not providing critical care now, the experience was very helpful and enjoyable. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 110
Slide 111: Allow residents to perform procedures including intubations, CVL placement. Guidance in placing PICU lines. Even though I don't use the skills I learned in the PICU, I think it is very important to have learned them. It's important to be able to recognize a critically ill patient and to understand how they are treated, As a general pediatrician we educate parents about PICU care even if we don't perform it. Review EKGs more often. Discuss the basics of monitoring similar to discussion we had with respiratory therapy and ventilators. Part of one day spend going over the monitors, etc. Allow residents to do more procedures. Great rotation. Well organized, lots of teaching. Good amount of patients and pathology. More mock codes. Nothing additional, especially when considering my current specialty situation . Now I have exposed to other PICU, I thought at duPont our PICU patient were more respiratory / general peds patient such as DM, asthma, RSV. At UCLA, there are more end stage multiorgan failure patients and more procedures to do. The only thing I thought I wasn't very comfortable with procedures, I didn't do that many. How to best manage a critically ill child and stabilize the child with limited resources, I.e.: in rural office setting. More hands on management of patients. More hand on experience. More of attending explaining why/how to manage various situations instead of telling you what to do. Mock codes very helpful-try to have these more frequently. More mock codes- the PICU and/or ER rotations are two best settings to practice this. No other rotations give consistent practice with this. I scored will above the national average for critical care section of pediatric boards (my highest section). Thanks for the prep. The knowledge is helpful. In the current setting I have hospitalists and intensivists within easy reach. I was very happy with my PICU rotation. More office based interventions in critically ill patients. More basic sepsis, airway with intubation, DKA, asthma, and less post-op transplant, spinal fusion, exNICU management. I don't see many critically injured patients at my present position, however we have a crash cart in our office just in case. The PICU rotation was very valuable as a 3rd year resident being in charge at Christiana or Jefferson. I believe residents should do 8 weeks of PICU. One month is not enough! The exposure is limited in a 1 month time span. More opportunities to do procedures. More mock codes, More exposure to very ill patients and a wider range of problems (not really something the attendings can change). The only limitation to the rotation was low patient volume and generally lower acuity than may be seen elsewhere. Both are a function of patient population base not rotational setup. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 111
Slide 112: Yes, mainly because there were multiple chronic patients (> 1/2 of census) when I did my PICU therefore did not see much acute pediatric intensive care. I realize that this changes on a regular basis. I did not intubate one child in PICU or place any femoral lines or manage an OD/Poisoning, cardiac abnormalities or arrythmias. More intubations in older kids. Very pleased with PICU / ER training. More exposure to mock codes/codes, acute problems and less exposure to chronically sick kids with tracheostomy management. Since my needs will be for office stabilization, more exposure or code drills (mock) to better prepare for patients who "go bad" in the office setting. Management of airway, recognizing impending airway obstruction. Management of DKA. No Endocrinologist; have to deal with new onset DKA. Electrolyte, fluid management. Since I am only clinical 1 day a week in my fellowship, I have not encountered critical care although I did have to rule out malignant hyperthermia once. Think there should be fewer residents on this rotation. I think our experience is diluted by residents with little commitment to the rotation of program. More trauma experience. More procedures. The fellows and attendings did the procedures while I was there - I placed zero central lines and observed 6. None. Even though I am not practicing pediatric medicine currently (but will) I would have wanted more opportunity for procedures even if it means practicing on dummies. Also, more code practice even it is just a walk thru so that you can think on your feet quickly without all this mayhem. More mock code situations. Sedation for procedures. Nothing different. More procedures done by residents: endotracheal tubes, CVL,arterial lines, pneumothorax drainage. Need more than one month in PICU setting. Need to be forced to come up with a plan before hearing attending plan. More mock codes or mock "crisis" situations. Christiana Care Medicine-Pediatric Residents More experience treating trauma patients (if possible). More emphasis on conscious sedation guidelines for procedures, I.e. lumbar punctures, etc. Pain management.Fluid / electrolytes. Bronchospasm / acute asthma. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 112
Slide 113: Given present situation,nothing. However, would have liked more procedures in the PICU. I felt like I did not do any procedures. Less post op surgical patients. More procedures if possible would be useful. Mock codes without pediatric equipment or labs available might be useful for preparation in some outpatient settings. More mock situations or practice scenarios; more lectures. I had almost none since it was around holiday time. More work with peripheral IVs. More opportunities for procedures (including simple IVs). More active participation in acute management/resuscitation. Continue weekly well organized mock codes. Thomas Jefferson University Emergency Medicine Residents Excellent overall month. Could probably have used more procedures. Excellent rotation. Continue Mock Codes. More procedures would be good. Acute (ED) diagnosis and management of infants/neonates with metabolic abnormalities and /or congenital cardiovascular disorders. For me as a ED attending, time spent in the ED is more akin to the kind of treatment I do. An intense Ped ED month in addition to PICU would be better. More procedures including central lines and chest tubes, etc. More exposure to acutely ill children in an ED setting. More experience intubating children. Review surgical airway in pediatrics. Mock Codes were helpful. None I would not change anything about the rotation. The critical care attendings were great and I learned a tremendous amount which I use in practice on a daily basis. A longer rotation ! I loved the AI experience. It was a great rotation. I learned a lot in 1 month. More mock codes! Great tool. It was a great experience. I had a great time at A.I. Pediatric ventilator management. Procedure lab. Adequate training provided in the 4 week block - no suggestions. More teaching about the basic acute care of "normal" children as opposed to care of chronic problems with chronically ill children. More procedures to be done by residents and fellows instead of attendings while residents and fellows round. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 113
Slide 114: More acutely ill children from the ED as opposed to post-operative patients. Designated time in OR for intubations. More practice with IV access including central lines. More time in NICU. More protocols for meeting common critical illnesses in peds such as DKA, Asthma, Croup, etc. rather than each attending doing their own potourri of treatments. More pediatric sedation / anesthesia. How to deal with parents of both very ill children and children that are relatively ill but whose parents believe they are near death. In other words, parents can be unreasonable with respect to their children's care. More procedures. Emphasis on initial resuscitation of the critically ill child (as ED physician). Mock codes helped a lot ! No request, Excellent rotation. I would spend "down time" in the OR with the anesthesiologists practicing intubations or reviewing meds More Mock Codes More intubations. More mock codes. Emphasis on PALS and APLS classes. Adequate training for my private care setting. More procedures. Sepsis management. Procedural skills (intubation/lines, etc.).The mock codes gave me a great learning tool that continues to serve me well. Status epilepticus. More intubations / more lines. More pediatric sedation. Peds anesthesia for more intubations. More procedures. More mock codes. More simulations. Mock codes were great, but 1-2 x were cancelled; would like to have these mock codes at least 2x a week. More intubations. More critical procedures (central lines, chest tubes) More procedures and independent thinking. I think that the only thing to enhance the educational experience would be to spend more time in the PICU at duPont. More mock codes but not in such a formal setting. More airway management. Overall, great rotation. More Mock Codes U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 114
Slide 115: More intubations - if not in PICU, in OR with anesthesia supervision. Continue Mock Codes or increase their frequency. Give residents the opportunity to have more input into critical care decisions with patients More discussion of what can be done in a pre-PICU setting where the child is being stabilized, but often has to wait for transfer for several hours. Christiana Care Emergency Medicine Residents More hands on experience Patient volume limits procedure experience. Good mix of pathology. More central lines. ICU rotation at AIDI is excellent. Not having fellows is a huge advantage. I would expand ventilator management and go through pediatric procedures. Otherwise, don't change a thing! More Mock Clinical Scenarios More teaching on acute stabilization of pediatric patients. It was an educational rotation Less post op. Patients & feeders/growers. I would like more training in acutely medically ill children, but with the numbers of patients, I know this is difficult in the one-month period. The biggest problem with the PICU rotation was that the majority of procedure opportunities were performed by the critical care attending without the resident being allowed to attempt the procedure-the patients were deemed "too irritable". More intubations in the OR. Less time on the topic of ventilator management-too much detail for the ER doctor. Overall, it was a great month- the one on one with the attending is unmatched by any other inpatient month I have done. I don't know that I would change anything. My present clinical situation may change but at least I've had a solid education. I felt like I needed more intubation experience, but I'm not sure how to increase that. More intubation, more ventilator management. Overall, my experience was excellent with you guys. More chest tubes, arterial lines. Spend a few days in the OR with McCloskey learning oral elective intubations More practice scenarios-clinical situations. Nothing. I feel it was an excellent experience. Few times per week, intensive discussion on critical care issues: DKA, increased ICP. Going through the cases in books provided for PICU rotation (they were excellent books). More PALS didactics. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 115
Slide 116: Don't turn us into clerks and just have us input orders. If you don't trust us, stay in house and work with us but let us be active in patient care and decision making. Perhaps ore didactic teaching since many pediatric critical illness situations occur so infrequently that they cannot be learned from experience alone. More experience with initial management of life threatening illnesses or at least discussion and case scenarios Need more practical procedural experiences. The rotation was well organized. Some of the learning was based on the clinical experience based on how sick the patients were - cannot be controlled. More procedure practice, including intubations. More procedures More independence in caring for the critically ill. Less time sitting at the computer putting in orders for the attending. For ER resident, there are too many chronic children there. Encourage independent thinking and autonomy. More hands on procedures. Mock codes More PALS simulations. More didactic and skill sessions on procedures. Simulation. Airway experience in OR setting since few ICU intubations. More procedures! More intubations (I didn't get any). More specific focus on the more common acute emergencies, such as status epilepticus, anaphylaxis, status asthmaticus, multiple trauma, and sepsis in the infant. I am at a setting which does not see pediatric patients - which is unfortunate because I do not want to loose the skills which I've learned. I would have liked the opportunity for more procedures in the PICU. More intubation experience in the OR (probably not enough volume in PICU alone for this). More EKG interpretation. More ventilator management. More vascular access (IJ / subclavian). Transtracheal jet ventilation (set up and procedure); insertion central venous catheters. One to two days of anesthesia practicing child intubation. Thanks for a great rotation. Intubate children with ventilator management. Central line and arterial line placement. No changes. More didactics about crtitical care, reviewing risks, benefits and indications of procedures not often performed. More didactics since the clinical experience is very unpredictable, for example, most of your patients are chronic non-ill patients and / or post-op non-ill patients. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 116
Slide 117: Need to have a larger role on managing very sick children, i.e. be the team leader. The fellow has usurped this role from residents. Good rotation. No specific recommendations. Good learning experience. Dedicated 1 hour lectures from PICU attendings More exposure to conscious sedation. More procedures (all central lines went to the fellow). More teaching on details of sedation. Guess more procedures because in my ER I can always look something up, but there is no substitute for experience with a procedure, I.e., airway and central lines. More procedures. More emergent airway management. I.e. intubation, initial ventilator management, venous access emergently, central lines. Had a tough case: 3 month old idiopathic pulmonary hemorrhage. Rushed back from triage without history with near respiratory arrest. Very difficult to maintain oxygenation until PEEP was increased to 30-40. No oscillator available. Patient maintained by BVM throughout transport while being flown to AIDI PICU. Round table discussions led by resident, guided by attending.on acute management of life threatening illnesses. As much (i.e. more) procedural training. Overall my PICU experience was great and has led to my current level of confidence in treating the acutely ill child. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 117
Slide 118: , collaborative multiple-professional team model of patient-centered care for all PICU patients. Resident training program must conform to ACGME Resident Duty Hour Guidelines. Resident should be an integral part of the multidisciplinary team that cares for critically ill and injured children and adolescents. Encourage accurate and timely communication between critical care physician U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 118
Slide 119: Quality Control U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 119
Slide 120: Alfred I. duPont Hospital For Children Pediatric ICU Rotation Pre-Rotation Questionnaire Name PGY2 PGY3 TJU Pediatric Residency Program MCD ER TJU ER Other 1. Have you had any pervious ICU experience? Pediatric: Neonatal: Adult: MICU___ CCU___ SICU___ Trauma ICU___ 2. Which of the following procedures have you had experience with? If experience with infants and children, mark (P). If experience with adults, mark (A). Intubation of infant <1 year _____ Intubation of children > 1 year and adolescents _ Intubation of adults Use of muscle relaxants for intubation Central Line Placement Internal Jugular Subclavian Femoral Vein Arterial Catheter Placement Radial Femoral Posterior tibial Dorsalis pedis Chest tube placement Pigtail chest tube placement Emergency defibrillation Elective cardioversion _____ External pacemaker Have you ever been in charge of an actual pediatric resuscitation? a. yes b. no In an actual infant or pediatric resuscitation, have you EVER personally provided: (Circle all that apply) a. Chest compressions b. Any form of ventilation (i.e. Mouth to mouth, mouth to mask, BVM, ET) c. Specifically Mouth to Mouth (or Mouth to Barrier Device) ventilation d. None of the above 3. 4. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 120
Slide 121: 5 .WITHIN THE PAST 2 YEARS ,in an actual infant or pediatric resuscitation, have you personally provided: (Circle all that apply) a. Chest compressions b. Any form of ventilation (i.e. Mouth to mouth, mouth to mask, BVM, ET) c. Specifically Mouth to Mouth (or Mouth to Barrier Device) ventilation d. None of the above At duPont hospital for Children, what is the number you call to activate a code blue ? What do you anticipate learning from this PICU rotation that will prepare you for your pediatric or emergency medicine career goals? 6. 7. 8. You learn a new medical topic best by: Participating in daily unit rounds with an attending physician Formal lectures Asking attending physicians direct questions about present patients care Formal reading program that covers basic topics in the field of study Looking up the answers to your questions in a recent medical textbook Reviewing critically recent literature on pertinent patient problems as they arise during your rotation (medline searches) Participating in mock drills regarding patient care scenarios Direct patient care with as many patients as possible Give a talk about what you are trying to learn U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 121
Slide 122: 9. How comfortable do you feel evaluating and stabilizing a critically ill child. Scale: 0 1 2 3 0 = No exposure to base a decision on. 10 = Full independence 4 5 6 7 8 9 10 10. How comfortable do you feel recognizing and initially managing critically ill children with the following problems? Scale: 0 = No exposure to base a decision on. 10 = Full independence Acute respiratory Failure 0 1 2 3 Hemodynamic instability 0 1 2 3 Sepsis 0 1 2 3 4 4 4 4 5 5 5 5 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 8 8 8 8 8 8 8 8 9 9 9 9 9 9 9 9 10 10 10 10 10 10 10 10 Acute Neurologic Insults 0 1 2 3 Acute electrolyte and endocrine disorders 0 1 2 3 4 5 Acute renal failure 0 1 2 3 4 4 4 5 5 5 Coagulation disorders 0 1 2 3 Overdoses and Poisonings 0 1 2 3 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 122
Slide 123: 11. Please carefully look over all the nine profiles below, which describe your ideal pediatric critical care experience regarding resident clinical supervision, resident procedural supervision, the teaching format and the resident evaluation process. Then rank all the profiles from 9 (best) to 1 (worst). Profile 1. 2. 3. 4. Clinical Independent after demonstrating ability Tightly structured with close supervision Tightly structured with close supervision Flexible with supervision Procedural Tightly structured with close supervision Flexible with supervision Tightly structured with close supervision Independent after demonstrating ability Teaching Style Scheduled formal lectures with prep reading Independent study program Interactive patient rounds with attending Interactive patient rounds with attending Resident Evaluation Oral interview with attending Oral interview with attending Essay response to case scenarios Oral interview with critical care attending Rank 5. 6. 7. 8. 9. Flexible with supervision Flexible with supervision Independent after demonstrating ability Tightly structured with close supervision Tightly structured with close supervision Tightly structured with close supervision Flexible with supervision Independent after demonstrating ability Independent after demonstrating ability Flexible with supervision Independent study program Scheduled lectures, reading preparation Independent study program Scheduled lectures, reading preparation Interactive patient rounds with attending Presentation Essay response to case scenarios Essay response to case scenarios Presentation Presentation U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 123
Slide 124: Critical Care Practice Pattern Survey for Previous Alfred I. duPont Hospital for Children PICU Rotation Residents 1. How long have you been in practice? ---< 1 yr ---1-3 yr 2. Have you achieved board certification in your specialty? ---YES ---NO 3. Type of present practice setting ---Private pediatric practice ---Private combined pediatric and adult practice ---Group pediatric practice ---Group, combined pediatric and adult practice ---Multispecialty pediatric practice ---Multispecialty practice (adult and children) ---Hospital based pediatric practice ---Hospital based adult and pediatric practice ---Emergency Room Practice ---Community Hospital (adult and children) ---University Hospital (adult and children) ---Children’s Hospital ER ---Fellowship Type ____________ ---Basic Science Research ---Other ___________________ 4. Population base of present practice location ---<20,000 ---21,000-50,000 ---51,000 - 100,000 ---101,000- 500,000 ---501,000- 1,000,000 --->1,000,000 5. WHICH of the following did you formally attend during your residency program? ---BLS for Healthcare Provider ---PALS ---APLS ---ATLS ---ACLS U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 124
Slide 125: 6. How confident do you feel that you will be able to recognize and initially stabilize any acutely ill or injured child or adolescent who presents to you in your present clinical setting? Circle your confidence level on a scale from 1 to 10 (10 being the most confident.). 1 2 3 4 5 6 7 8 9 10 7. In your present clinical setting, how often do you find that you are the primary physician who must deal with children and adolescents who initially present with the following acute, life threatening problems? Please circle the appropriate letter next to each problem below. D=Daily, W=Weekly, M=Monthly, Y=Yearly, N=Never Cardiopulmonary Arrest Multiple Trauma Preoperative and postoperative management of pediatric surgical patients in the PICU Acute respiratory failure requiring intubation and mechanical ventilation Upper airway obstruction from foreign bodies and infection Septic shock Hemodynamic instability requiring various inotropes, pressors and vasodilators Coma Intracranial hemorrhage Increased intracranial pressure monitoring and management Status epilepticus requiring multiple IV anticonvulsants Overdoses and poisonings requiring intensive respiratory, cardiovascular and neurologic support Acute electrolyte and endocrine disorders Acute renal failure Coagulation disorders such as DIC or thrombosis Child with Multiple Organ System Dysfunction Provide Sedation, Analgesia, and Neuromuscular Blockade to the Critically Ill child Talk with parents about a child who is dying or suddenly dies from a serious illness or injury Withhold or withdraw life support from a child or adolescent Discuss DNAR for a seriously ill or injured child or adolescent D D D D D D D D D D D D D D D D D D D D W W W W W W W W W W W W W W W W W W W W MY MY M M M M M M M M M M M M M M Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N N N N N N N N N N N MY MY MY MY U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 125
Slide 126: 8. In your present clinical setting, are you the primary physician who manages children and adolescents with the following acute, life threatening problems until they are ready from discharge from the hospital? Please circle for each problem below. Y=YES N=NO Cardiopulmonary Arrest Multiple Trauma Preoperative and postoperative management of pediatric surgical patients in the PICU Acute respiratory failure requiring intubation and mechanical ventilation Upper airway obstruction from foreign bodies and infection Septic shock Hemodynamic instability requiring various inotropes, pressors and vasodilators Coma Intracranial hemorrhage Increased intracranial pressure monitoring and management Status epilepticus requiring multiple IV anticonvulsants Overdoses and poisonings requiring intensive respiratory, cardiovascular and neurologic support Acute electrolyte and endocrine disorders Acute renal failure Coagulation disorders such as DIC or thrombosis Child with Multiple Organ System Dysfunction Provide Sedation, Analgesia, and Neuromuscular Blockade to the Critically Ill Child Child or adolescent requiring central hyperalimentation Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N N N N N N N N N N U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 126
Slide 127: 9. In your present clinical setting, how often do you find yourself having to perform the following procedures on children and adolescents? Please circle the appropriate letter next to each procedure below. D=Daily, W=Weekly, M=Monthly, Y=Yearly, N=Never Maintenance of an open airway in the nonintubated patient Placement of an LMA Ventilation by bag-mask systems Tracheal intubation Acutely change a tracheostomy tube Removal of upper airway foreign bodies Temporary surgical airway Management of pneumothorax Placement of a peripheral IV Placement of an intraosseous needle Insertion of central venous catheters Insertion of pulmonary artery catheter and interpretation of hemodynamic data Insertion of arterial catheters Pericardiocentesis for acute tamponade Dynamic electrocardiogram interpretation Transcutaneous pacing Elective Cardioversion Defibrillation D D D D D D D D D D D D D D D D D D W W W W W W W W W W W W W W W W W W M M M M M M M M M M M M M M M M M M Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N N N N N N N N N U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 127
Slide 128: 10. After seeing what is expected from you in your present clinical situation, what would you request from the critical care attendings if you could do the one month second year resident PICU rotation at Alfred I. duPont Hospital for Children over again? 11. If your confidence level on question 6 was less than 7, what could we have done to improve this? 12. What additional course work or practicums have you taken that address pediatric critical care competencies? U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 128
Slide 129: Connecting Patient Care and Resident Education U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 129
Slide 130: PICU Order Entry Flowchart Role Responsible Process to be followed Clipboard with nameplate stamped order sheet will be maintained, in the file box outside each Patient’s room. If not stamped with nameplate, the patient’s full name and MR# must be handwritten on the order sheet. This clipboard may be kept in the patient’s room during high acuity times, to facilitate capture of all orders in written form. The physician will write patient orders legibly and completely, including pager # for clarification. Medication orders must include full name of the medication, dose, route and frequency. Physician gives written order to and communicates verbally with patient’s nurse or respiratory therapist. . Physician Order Entry Physician RN or RCP If the physician places an order into CERNER his/herself, he/she will always communicate with bedside RN or RCP, that an order was placed and the urgency of this order. RN or RCP Nurse or respiratory therapist reviews order for accuracy. This is regardless of computer physician entry or handwritten. RCP will enter own Respiratory orders. If orders are unclear or questionable, clarify/verify with the physician Physician or RN will bring the written order to the assigned clerk and verbally communicate time sensitivity of the order and/or any unusual data in the order (non-formulary medications for example). Physician RN The clerk will enter the orders into CERNER. While entering orders, the clerk is not expected to do other tasks, such as page or answer phones (except in emergency situations). As each order is placed into CERNER, the clerk will place a “√” next to each and every order, as it is completed. “Entered + FAXed by _______________, Date/time” will be placed at the end of the orders entered. If Respiratory Care orders are included on this order sheet, the RCP will be notified by the clerk, though the physician should have already discussed with both RN and RCP. If “Interaction” or “Allergy“ warnings occur, the clerks can not override these warnings. The physician will have to place that particular order. FAX all handwritten orders to Pharmacy U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 130
Slide 131: CLERK The clerk will take printed computer generated order and handwritten order to the assigned RN for review and signature. If necessary, the clerk may page the nurse to the desk to pick up the orders. The nurse MUST BE GIVEN the orders to check immediately. In the computer: Document that the order has been reviewed by signing off on the “Nurse Review” screen of the patient’s “Power Chart” (HIS). Manual or Handwritten Orders: Are to be documented by the RN as accurate by placing a “√” (in red), followed by the date, time and signature. RN RN Medication Orders: Prior to administration Check physician's order for the five rights of administering medications: The right drug, right patient, right dose, right time/frequency, right route, prescribed by calculating the dose by weight or m2, using the appropriate resource. If orders are unclear or questionable, RN must clarify with the physician and/or pharmacy. /mnt/generator/20120204/1287358/p/6weZmVi7iH-/src/slide/2006-2007-Review-and-2007-2008Preparation.doc U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 131
Slide 132: Process for Patient Transfer Out of PICU PICU attending • • Decides that child is ready to be transferred out of the PICU Notify the general pediatrician or the pediatric consultant requested by orthopedics via the transfer beeper 435-0042 and provide a patient summary PICU Charge Nurse • Requests patient room assignment from the Hospital Nursing Supervisor or Bed Coordinator • Notify PICU resident with actual bed assignment when available • • Review the patient transfer sheet for completeness and countersign the patient transfer sheet before the patient leaves the PICU. Remove completed transfer sheet from patient’s chart after the child leaves the PICU and place the transfer checklist in Ruth Lebet’s office PICU Resident: • Notify the Surgical or Surgical Subspecialty Resident for the transfer of general surgery , ENT, Plastics, Orthopedics, Urology and Trauma patients. o PICU resident will directly contact the resident covering the surgical service, tell them that the child will be leaving the PICU and give them any updates as indicated. Notify the Pediatric Admitting Resident (426-4800) for the transfer of the following children out of the PICU: general pediatrics, private pediatrician, pediatric sub-specialists, neurosurgery , solid organ transplant, trauma patients with isolated head trauma, any surgical service that is requesting a pediatric consult. o The PICU resident will have to have the name of the private pediatrician if the child is to be transferred to a private pediatrician. Notify the senior resident of the accepting pediatric team if so instructed by the pediatric admitting resident and provide more clinical details. Write a Transfer Note in the patient's chart for all children being transferred out of the PICU. Remove any specific PICU orders from Cerner that not longer pertain to the patient’s care After the PICU Charge Nurse confirms the actual bed location for the child being transferred out of the PICU o Resident fills out a pre-printed order form “Accept and Transfer Medical Service Order” with the information below and gives it to the unit clerk  Transfer Medical Services to ( )  Transfer to Service of ( )  Accepting Physician ( )  Contact accepting team resident when patient arrives on accepting unit  Signature/Date/Time Notify the Admitting Resident again just before the child leaves the PICU with an update of children being transferred to general pediatrics, private pediatrican, pediatric sub-specialists, neurosurgery , solid organ transplant, trauma patients with isolated head trauma, any surgical service that is requesting a pediatric consult. If there is a delay leaving the PICU, the Transfer Note must be updated before the child actually leaves the PICU • • • • • • • Pediatric Admitting Resident • Assigns pediatric patients coming out of PICU to the appropriate service team. • Provides the PICU resident with the name of the accepting service and the accepting physician if the accepting service is general pediatrics. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 132
Slide 133: • • • • Relays the information about the patient coming out of the PICU to the new resident accepting team. May direct the PICU Resident to also contact the senior resident of the accepting team to give more detailed interactions before patient transfer out of PICU Updates the accepting resident team if the PICU resident updates them with new information that has occurred during the time period between deciding to send the child out of the PICU and the actual transfer time. When the PICU Unit Clerk calls, confirm that the Service and Accepting Physician are still the same Service and Accepting Physician as originally reported PICU Unit Clerk will: • Enter the resident written “Accept and Transfer Medical Service Order” into Cerner under the appropriate sections. o Transfer Medical Services to ( ) o Transfer to Service of ( ) o Accepting Physician ( ) o Contact accepting team resident when patient arrives on accepting unit Place a Transfer Checklist on the front cover of the patient’s chart and assist PICU Nurse to make sure checklist is complete When the child is actually leaving the PICU. o Remind the PICU resident to speak with Admitting Resident (426-4800). Help to coordinate this conversation taking place Confirm with Admitting Resident that Service and Accepting Physician are still the same Service and Accepting Physician as originally reported o .If the Service or Accepting Physician has changed, the unit Clerk is to make the appropriate changes in Cerner. • • • Individual patient’s PICU Nurse • Discuss child’s clinical course and ongoing needs with the accepting nurse Individual patients Respiratory Therapist • Discuss child’s clinical course and ongoing needs with the accepting respiratory therapy team The nurse who receives the patient upon transfer from the PICU • Contact the accepting team resident immediately when the patient arrives on the accepting unit. Resident / Intern on the accepting service • Interns and residents on accepting service will examine the patient, review and adjust orders and immediately discuss the patient’s status and care with the designated accepting attending PICU Designated Nurse / Physician Follow-Up Team: • Usually the day after transfer, there is a follow-up visit by designated PICU nursing staff and critical care attending to ask the patient, family, accepting nurses and physicians for feedback on the transfer process from the PICU to the general hospital area.  Comments are entered on the original transfer check off sheet and the transfer sheet is returned to the PICU Nurse Manager PICU Nurse Manager or designee • Store the completed patient transfer check-off sheets • Present the completed patient transfer sheets for quality review at the weekly PICU Leadership Meetings. U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 133
Slide 134: Pre-Printed Form Accept And Transfer Medical Service Accept and Transfer Medical Service Order Transfer Medical Service to ( Transfer to Service of ( Accepting Physician ( ) ) ) Contact accepting team resident when patient arrives on accepting unit. Signature/Date/Time: U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 134
Slide 135: Transfer Checklist PICU Attending: ___ Accepting attending physician notified Accepting physician name______________________________ PICU Resident: ___ Admitting resident notified of decision to transfer, and re-notified at time of actual transfer out of PICU ___ General surgery, neurosurgery, orthopedic, urology, ENT, Plastics, Trauma resident notified Resident Transfer Note completed and updated if there is a long delay between planned and actual transfer . ___ Specific PICU orders that no longer pertain to patient care have been removed from order set ___ Accept and Transfer Medical Service Order given to PICU Unit Clerk PICU Charge Nurse: ___Nursing Supervisor notified ___PICU Resident notified when bed available PICU Bedside Nurse: ___All medications packed including refrigerated meds. ___Breast milk packed ___All Belongings Packed ___ Nurse to Nurse clinical report completed PICU Respiratory Therapist: ___ Respiratory therapy to respiratory therapy clinical report completed PICU Clerk/Aide: ___Chart Complete with Blue Plate ___Data Base Completed, Standard of Care, Physical Assessment ___Old Records Packed ___Accept and Transfer Medical Service Order placed in Cerner ___ Coordinate a phone conversation with the PICU resident and the pediatric admitting resident (426- 4800) when the child actually ready to leave PICU ____Confirm with Pediatric Admitting Resident that Service and Accepting Physician are still the same Service and Accepting Physician as originally reported. If there is a change, update Cerner. PICU Attending _________________________ PICU Resident_____________________ PICU Nurse________________________ PICU Respiratory Therapy_______________________ PICU Charge Nurse___________________ PICU Unit Clerk_____________________ Transfer Date / Time ____________________________ PICU Designated Nurse / Physician Follow-Up Team ___Follow-up visit to review transfer from PICU to general hospital area: Comments: Edward J. Cullen Jr. D.O. Pediatric Critical Care Revision 10/2/06 U/Ecullen/Word/Educatio/PICU Resident Review 2007 and Plans 2008 135