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Altoona Family Physicians

AFP Inpatient/Critical Care Goals and Objectives

Resident Year:                       PGY1

 AFP Faculty Contact:           Jennifer Good, MD

 Rotation description and general goals (also see AFP Inpatient Service Goals and Objectives):

             Each intern is designated as a “Critical Care” intern during one of her three months on the inpatient service.  The goal of the designation is to allow the intern to obtain more concentrated exposure to critically ill patients, and also allow them to focus their individual study (both general and case based learning) on critical care topics.  While the intern is designated the “Critical Care” intern, she is expected to admit and follow all the critically ill patients on the AFP inpatient service.  In the unlikely event that there is an unexpected number of ICU patients on the service, no intern is expected to have more than 4 – 5 ICU patients at any given time.

             While on this rotation residents are expected to arrive on time for morning report at 7:15 am on weekdays and at a mutually agreeable time for all on the weekends.  Residents are expected to be present at sign-out rounds with the night float team at 6:00 pm each evening.  It is expected that at least one representative from the medicine team be available to round on each day on the weekend, while ensuring that each resident has a total of 4 days off during the entire month long rotation.  Scheduled vacation is not permitted during this rotation.

 Teaching Methods:  the inpatient family medicine affords many opportunities for teaching, including but not limited to:

 ·         Didactic teaching:  There is a noon conference four to five days a week which covers a broad range of clinical topics.  Attendance at these conferences is mandatory. 

·         Clinical teaching:  The inpatient family medicine team makes daily, bedside teaching rounds with the faculty attending physician.  Additionally, there is ample opportunity for interaction with specialty attending physicians through their consultative role in assisting with patients. 

·         Morning report:  Morning report occurs daily and most days a faculty physician is in attendance. 

Supervision:

·         PGY1 level residents have immediate supervision by a PGY2 or PGY3 level resident that is available in the hospital at all times. 

·         There is a faculty on-call at all times available by pager should assistance be required by any resident in dealing with questions while on the inpatient family medicine or night float rotation. 

·         Each patient on the inpatient family medicine service is seen and examined daily by the faculty attending (including weekends). 

·         Faculty are apprised of any procedure being done by the resident while on the inpatient service and are expected to supervise that procedure if either the resident or faculty feels supervision is necessary. 

Resident Evaluation: 

            Each resident on the inpatient family medicine rotation is evaluated using a competency-based evaluation tool at the end of the rotation.  These evaluations are reviewed by the family medicine faculty quarterly and reviewed with the resident at the resident’s quarterly evaluation.  Occasionally, situations arise which require more immediate feedback and in these situations the resident is given feedback by the faculty on the inpatient service, the faculty advisor or the program director.  Specific resident evaluations include:

·         Evaluation by resident peers (senior resident is evaluated by the intern; the intern is evaluated by the senior resident). 

·         Evaluation by the faculty attending on inpatient.  (As each faculty is on inpatient for one week, the resident may by evaluated independently by three to four faculty members in a one month rotation). 

·         Evaluation by nursing staff and case management staff. 

Program Evaluation: 

·         Each resident (intern and senior resident) is expected to complete a written evaluation of the inpatient rotation and each inpatient faculty each month that they are on inpatient.

·         The inpatient curriculum is reassessed annual as part of the Altoona Family Physicians annual curricular review.

 SAMPLE SCHEDULE: 

PGY 1

 Educational Resources:

 AFP Critical Care Handbook—this is a handbook with several recent review articles (and a couple of not so recent articles) on a number of critical care topics. 

www.utdol.com:  This is a subscription-based resource but is available at the Altoona Hospital Library.  It is a great place to get started with specific critical care questions. 

http://sccmwww.sccm.org/ricutest/Login.aspx:  This is a service from the Society of Critical Care Medicine with ICU lectures designed specifically for residents.  A log-in is required.  We anticipate that this will be operational after July 1, 2009.  Each resident will be required to do 5 core lectures during their month as the critical care intern, including pre- and post-tests. 

www.pacep.org:  This website is designed to help to understand hemodynamic monitoring using a pulmonary artery catheter.  There are a number of tutorials to help to understand clinical indications for a PA catheter (yes, there are still a few) and how to use the hemodynamic data it provides.  The site is free but it requires registration. 

http://www.ccmtutorials.com/rs/index.htm

            This is an on-line tutorial that deals with different aspects of mechanical ventilation.  May be more in depth than necessary.  Other tutorials for critical care topics are available.

PGY 1:

·         Complete an admission history and physical examinations on all patients admitted to the ICU.  These history and physicals will be dictated into the hospital dictation system at the time of admission.  These H & Ps are reviewed by the attending physician on the inpatient service.  Additionally, a small number of each resident’s H & Ps are provided to the faculty advisor for review.

·         Write admission orders for each patient admitted to the ICU at the time of the patient’s admission.  It is expected that these orders will be legible, and reflect an appropriate diagnostic and therapeutic approach to the patient’s medical problems.  These admission orders are reviewed by the senior resident (either on AFP service or night float) and the inpatient attending.

·         See each patient daily (once by the daytime inpatient team and once by the night float resident) and writing a legible and informative progress note.  The progress note will follow a “SOAP” format.  These progress notes will be reviewed by the attending physician on the inpatient service.

·         It is generally expected that the “critical care” intern will provide care for the critically ill patient until that patient is discharged from the hospital.

·         Complete a discharge summary on each of their patients upon discharge from the hospital.  These discharge summaries are to be done within 24 hours of the patient’s hospital discharge and follow a standard format (see resident handbook).  Compliance with this requirement is ensured by the Altoona Regional Health Systems HIM department.

·         Understand the differential diagnosis and treatment for various types of acute respiratory failure.

·         Understand basic principles initiating and weaning the patient from mechanical ventilation.

·         Understand the differential diagnosis of hypotension and shock and management of hypotension with fluids and pressors.

·         Understand ICU monitoring, including the use of the PA catheter, CVP and invasive arterial BP monitoring and end-tidal CO2 monitoring.

·         Understand the indications for renal replacement therapy in the ICU.

·         Understand the acute treatment of endocrine emergencies, including DKA, adrenal crisis, thyroid storm and myxedema coma.

·         Understand how to evaluate and treat acute gastrointestinal hemorrhage.

·         Understand the appropriate use of IV sedation and analgesia in the ICU.

·         Residents are expected to complete a minimum of 5 RICU lectures (including post-tests) while serving as the critical care intern beginning July 1, 2009.

·         Read on a regular basis about the cases that they are seeing on the AFP Inpatient/Critical Care service. 

·         Present patients daily at morning report.  It is expected that these presentations be accompanied by a current, evidence based treatment plan.  These presentations will be assessed by the faculty members in attendance at morning report and the resident given feedback via rotation evaluations. 

·         Present interesting cases weekly at the all-residency family medicine rounds.  It is expected that the resident at the time of these presentations can serve as the “expert in the room” and is aware of the most appropriate diagnostic and treatment modalities for the patient.

·         Locate, appraise and assimilate evidence from scientific studies related to their inpatients’ health problems.

·         Utilize information technology to optimize learning.

·         Participate in the education of patients and their family members.

·         Participate in the education of medical students and other residents through presentations and discussions at morning report, teaching and attending rounds and in a more formal setting at weekly family medicine rounds.

Communication with colleagues/continuity of care

·         Establish face-to-face contact with their hospitalized inpatient’s PCP following noon conference daily to keep their primary care physician apprised of the patient’s inpatient course.  If the primary care physician is not at noon conference, or an emergency keeps the hospital resident from noon conference, a brief update can be sent to the primary care resident through the EMR.

·         Send a brief discharge note (including all medication changes and outstanding problems/diagnostic tests) to the primary care physician through the EMR at the time of the patient’s hospital discharge.

·         Communicate effectively with physicians, other health professionals and health related agencies.

·         Act in a consultative role to other physicians and health professionals.

·         Maintain comprehensive, timely and legible medical records.

·         Ensure safe transition of patient care with complete sign-out in the morning and evening and communication with primary care physician.

Communication with patients

·         Create and sustain a therapeutic and ethical relationship with patients.

·         Provide appropriate patient education on diagnoses and treatment plans based on the literacy level of patients and their caregivers.

·         Responsibility in patient care by responding in a timely fashion (< 20 minutes) to all pages.  Their attention to this requirement will be assessed in rotation-end evaluations by nursing staff.

·         Compassion, integrity and respect for others.

·         Sensitivity and responsiveness to a diverse patient population, including, but not limited to diversity in gender, age, culture, race, religion, disabilities and sexual orientation.

·         Respect for patient privacy and autonomy

·         Regularly contact other health professionals caring for their patients in the hospital, including but not limited to nursing staff, case management staff, respiratory therapists, physical and occupational therapists and pharmacists.  This objective will be assessed in part by evaluations done at rotation end by nursing and case management staff 

·         Work effectively in the Altoona Regional Health System and cooperate with hospital-wide quality initiatives, such as DVT prophylaxis, infection control protocols, stroke protocols etc.

·         Request specialty consultation when indicated.

·         Incorporate considerations of cost awareness and risk-benefit analysis in patient care.

·         Work within interdisciplinary teams in order to provide quality, comprehensive inpatient care.

·         Participate in identifying system error and in implementing potential systems solutions.