UCSF Anesthesia & Pulmonary Critical Care Fellowship at SFGH 4E ICU
ACGME Competency-based Goals and Objectives – SFGH Surgical, Trauma, and Neuro ICU
OVERVIEW
Anesthesia and Pulmonary Critical Care fellow will spend 1 month rotating through the Surgical,
Trauma, and Neuro Intensive Care Unit (MICU) at SFGH. The 4E ICU at SFGH is an open unit, which
means the ICU team is responsible primarily for airway and ventilator management, sedation,
anxiolytic, and pain medication therapy, and placement of invasive lines (arterial, central, and
pulmonary artery catheters). The 4E ICU team serves as the primary team for ENT, OMFS, plastic
surgery, orthopedic surgery, gynecology/obstetrics, and urology services.
The 4E team is comprised of:
 Anesthesia Critical Care, Neurocritical Care, or Trauma Surgical Critical Care Attending
 Critical Care Fellow(s)
 4th year medical students
 PGY 2-3 anesthesia, surgical, emergency medicine residents
 PGY 1 surgery intern
 Nursing – bedside nurse, charge nurse, and 4E ICU nurse manager
 Respiratory therapist
 Critical Care Pharmacy
Fellows are expected to develop the skills to function at an attending level, yet still allow the resident
to retain a majority of the autonomy in clinical decision making. These skills include playing a lead
role in managing the ICU Team, determining patient care plans, participating in ICU triage,
supervising the residents during procedures, being available to assist the residents with complex
cases, and organizing teaching sessions for the residents. Rotation experiences include care for
patients with a diverse and sometimes complicated set of medical and psychosocial conditions.
Educational objectives are organized according to Accreditation Council for Graduate Medical
Education (ACGME) Internal Residency Review Committee (IRRC) competencies.
GOALS

To understand the pathophysiology of the critically ill surgical patient
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To understand the indications for and techniques for managing invasive central monitoring,
airway management, mechanical ventilation, patient sedation, and pain & anxiety control for the
care of patients with multiorgan failure, recent trauma, or perioperatively.

To teach and supervise the residents in the care of patients with critical illness using evidencebased medicine approach
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To develop an appropriate treatment plan using a team-based approach
OBJECTIVES
Fellows must demonstrate effective interpersonal, teamwork, and communication skills in interactions
with patients, families, consultants, and other members of the health care team
Interpersonal Communication Skills
 Communicate effectively with all members of the healthcare team and other consultants
 Communicate with patients and their families in easily understood and culture-sensitive language
UCSF Anesthesia Critical Care Fellowship – SFGH ICU Rotation
ACGME Competency-based Goals and Objectives
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Communicate with patients and families in their primary language (through an interpreter, if
appropriate)
Work effectively as a member of a professional group
Consistently demonstrate sensitivity to patients from different cultures and socioeconomic status
Maintain comprehensive, timely, and legible medical records
Professionalism
 Demonstrate respect, compassion and integrity toward patients and all members of the
healthcare delivery team
 Demonstrate a commitment to excellence and on-going professional development
 Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical
care, confidentiality of patient information, informed consent, and resource utilization
 Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities
 Maintain comprehensive, timely, and legible medical records
 Synthesize clinical information and present assessment, test/lab results clearly to colleagues
 Return pages and phone calls in a timely manner
Medical Knowledge
 Cardiovascular:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
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Describe four types of shock and its complications.
Recognize myocardial infarctions and its complications.
Recognize cardiac dysrhythmias and conduction disturbances.
Distinguish between thrombus, air, fat, and amniotic pulmonary emboli.
Describe cardiac tamponade and other pericardial diseases.
Discuss vasoactive and inotropic therapy
Define pulmonary hypertension and cor pulmonale.
Derive equations of oxygen transport and utilization.
Classify management of hypertensive emergencies and urgencies.
Distinguish between cardiogenic and non-cardiogenic pulmonary edema
Recognize implications of sternal fractures and cardiac contusions in the traumatized patient
Respiratory:
a. Define the following three types of respiratory failure:
1. Hypoxemic, include acute respiratory distress syndrome
2. Hypercarbic
3. Acute on chronic respiratory failure.
b. Discuss the methods to diagnosis bronchopulmonary infections.
c. Recognize impending respiratory failure and indications for and techniques of intubation,
including appropriate equipment and drug choice
d. Summarize the causes of ARDS and the appropriate management of the mechanical
ventilator in patients with ARDS.
e. Summarize rescue therapies to treat severe hypoxemia and when to use them
f. Know the indications and contraindications for noninvasive mechanical ventilation
g. Summarize tests used to measure pulmonary mechanics and gas exchange.
h. Describe the following terms used with mechanical ventilation:
1. Presssure and volume ventilators
2. PEP, IMV, CPAP, PSV, AC
3. NIPPV
4. Barotraumas
5. Volutrauma
6. HFV, IRV, ECMO
7. Permissive hypercapnia.
i. Discuss the criteria for weaning mechanical ventilation and weaning techniques.
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j.
k.
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Renal:
a.
b.
c.
d.
e.
f.
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Define different causes of ventilatory muscle failure including polyneuropathy of critical
illness, prolonged effects of neuromuscular blockers.
Summarize the diagnosis and therapy of pleural diseases (including empyema, effusions,
pneumothorax, hemothorax).
Describe renal regulation of fluid balance and electrolytes.
Summarize the diagnosis of renal failure and categorize into prerenal, renal, and post renal.
Recognize derangements secondary to alterations in osmolarity and electrolytes.
Differentiate acid-base disorders and their management
Define principles of hemodialysis, peritoneal dialysis, ultrafiltration, CAVH, and CVVH.
Describe the presentation and treatment of rhabdomyolysis.
CNS:
a. Define coma and list examples of the following causes of coma:
1. Metabolic
2. Traumatic
3. Infectious
4. Lesions
5. Ischemia
6. Drugs.
b. Describe brain death evaluation and certification.
c. Recognize different types of stroke, treatments, hemodynamic goals, and indications and
contraindications for thrombolytic therapy.
d. Summarize the diagnosis and management of persistent vegetative state.
e. Describe the management of status epilepticus.
f. Describe the appropriate use of sedative and analgesic medications in the critical care
setting, including the significance of delirium in the ICU.
g. Familiarize oneself with the side effects of sedative, analgesic, anxiolytic, and antipsychotic
medications.
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Metabolic and Endocrine:
a. Describe the evaluation of nutritional needs including indirect calorimetry.
b. List the pros and cons of enteral vs. parenteral nutrition.
c. Describe the importance glucose control in the ICU
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Infectious Disease:
a. Describe the pathophysiology of systemic inflammatory response syndrome (SIRS) and
sepsis.
b. Describe the appropriate management of MRSA infection and bacteremia.
c. Describe the appropriate algorithm for the selection of a particular antibiotic agent for different
types of infections.
d. Formulate an approach to the critically ill HIV-infected patient.
e. List the most common nosocomial infections in the hospitalized patient and describe your
algorithm for the selection of a particular antibiotic agent.
f. Formulate an algorithm for the evaluation of fever in the ICU patient.
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Hematology:
a. Describe the following acute defects in hemostasis
1. Thrombocytopenia
2. Disseminated intravascular coagulation
UCSF Anesthesia Critical Care Fellowship – SFGH ICU Rotation
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3. Anticoagulation
4. Fibrinolytic therapy.
b. Explain the difference between the following blood therapy components:
1. Platelets
2. Red blood cells
3. Fresh frozen plasma
4. Coagulation factor concentrates
5. Albumin
6. Cryoprecipitate.
c. Understand implication of and reversal of common anticoagulant medications in the recently
traumatized patient
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GI/GU:
a. Describe the differential diagnosis and work-up for gastrointestinal bleeding.
b. Contrast complications found in acute vs. chronic liver failure and the appropriate
management of decompensated hepatic failure.
c. Identify management goals and treatment of pancreatitis
d. Recognize ventilator, pharmaceutical, and surgical management strategies for abdominal
compartment syndrome
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Postoperative & Trauma:
a. Describe the initial approach to the traumatized patient including ATLS
b. Familiarize oneself with implications of and common injuries in particular mechanisms of
injury (fall from height, vehicular accidents, gun shot wounds, stab wounds, crush, etc)
c. Describe the different invasive neuromonitors (EVD, SjVO2, PBtO2) and their purposes
d. Recognize classes, signs, and symptoms of hemorrhage
e. Recognize signs and symptoms of worsening neuro pathology including cerebral
herniation, edema, and vasospasm
f. Know the unique aspects of airway management with C-spine precautions
g. Understand fluid resuscitation goals in the postoperative, trauma, and burn patients
h. Identify compartment syndrome of the extremities in the postoperative and traumatized
patient
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Pediatrics
a. Familiarize oneself with normal range hemodynamics of the pediatric patient of various
ages
b. Understand the unique aspects of airway management, selection of ETT size, and
ventilator management in the pediatric patient
c. Learn weight-based dosage of common medications including pain, sedative, and
anxiolytic medications
d. Work in coordination with pediatric service for cohesive and comprehensive care
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Pregnancy
a. Identify the normal physiology, hemodynamic, and respiratory parameters of the pregnant
patient
b. Learn the anatomic and hemodynamic implications of a gravid uterus in resuscitation and
trauma
c. Recognize signs of fetal asphyxiation and the employment of fetal heart rate monitoring
and maternal tocodynameter monitors
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Miscellaneous:
a. Summarize the initial approach to the management of multisystem organ failure.
b. Define the principles of arterial, central venous and pulmonary artery pressure monitoring,
indications for placement, and appropriate discontinuation.
UCSF Anesthesia Critical Care Fellowship – SFGH ICU Rotation
ACGME Competency-based Goals and Objectives
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c. Recognize complications of placement of invasive catheters.
d. Identify patients who are candidates for pain management with epidural catheters or
peripheral nerve catheters.
e. Describe the assessment of cardiac function and derived hemodynamic parameters.
f. Diagram the organization and staffing of critical care units.
g. Demonstrate understanding of the principles of triage and resource allocation.
h. Describe your approach to the dying patient, including end-of-life discussions with the patient
and the patients’ family.
i. Discuss ethical considerations, dilemmas, and family support for patients
j. Analyze the use of surrogate decision-makers, advanced directives, and DNR/DNI orders.
k. Learn overall requirements for nutritional support, DVT prophylaxis, peptic ulcer prophylaxis,
and VAP prophylaxis.
l. Observe all best practices when placing all central venous catheters, including the use of
strict barrier precautions to reduce the rate of blood stream infections.
m. Summarize the uptake metabolism and excretion of common drugs
1.
Antibiotics
2.
Antiarrhythmics
3.
Sedatives
4.
Analgesics
5.
Neuromuscular blocks.
l. Ultrasound
m. Early mobility
Patient Care
 Interact with patients and their families with respect, clarity, sensitivity and care
 Gather essential and accurate information about patients by closely communicating with the
patient, patients’ family/friends, members of the healthcare team, and the appropriate consultants
 Make informed decisions about diagnostic and therapeutic interventions based on patient
information and preferences, up-to-date scientific evidence, and clinical judgment
 Develop and carry out patient management plans
 Use information technology to support patient care decisions and patient education
 Perform competently all medical and invasive procedures considered essential for the area of
practice and supervise the residents doing these procedures when appropriate
 Work with health care professionals, including those from other disciplines, to provide patientfocused care
Practice-based Learning and Improvement
 Analyze practice experience and perform practice-based improvement activities using a
systematic methodology
 Apply knowledge of study designs and statistical methods to critique the literature on diagnostic
and therapeutic effectiveness of interventions performed in the ICU
 Use information technology to manage information, access on-line medical information; and
support their own education
 Facilitate the learning of students, residents, and other health care professionals on the ICU team
Systems-based Practice
 Demonstrate an awareness of the larger context and system of health care and the ability to
effectively provide critical care that is of optimal value
 Understand how their patient care and practices affect other health care professionals, the health
care organization, and the larger society and how these elements of the system affect their own
practice
 Practice cost-effective, evidence-based health care and resource allocation that does not
compromise quality of care in the ICU
 Advocate for quality of patients care and assist patients in dealing with critical illness
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ACGME Competency-based Goals and Objectives
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Know how to partner with health care managers and health care providers to assess, coordinate,
and improve health care discharge planning and transition from critical care to outpatient care
Participate in ongoing quality improvement and practice improvement initiatives in the 4E ICU
Identify problems with healthcare delivery and systems-based solutions
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ACGME Competency-based Goals and Objectives
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