Intensive Care Unit
I. Rationale
Critical Care Medicine is an important aspect of Family Medicine since the family physician often serves as
the primary provider for the acutely ill patient requiring ICU care. This may be in an environment
requiring independent care or may in the collaborative role with other specialists. A concentrated block
for learning basic knowledge and skills will speed the acquisition of this knowledge in the PGY 1 year of
residency.
II. Goals
Residents will be evaluated on the following six competencies, eventually achieving the expected level of
a board certified family physician. Achievement of satisfactory performance levels for all six competencies
will be necessary for successful completion of the rotation.
III. Objectives
Competencies
At the completion of residency training, a family medicine resident should:
A. Be able to perform standardized comprehensive critical care assessments and develop acute
treatment plans. (Patient Care, Medical Knowledge)
B. Be able to optimize treatment plans using a systematic approach to medical decision-making and
patient care, combining scientific evidence and clinical judgment with patient values and
preferences. Knowledge should be evidence-based and from nationally recognized resources.
(Systems-based Practice, Practice-based Learning and Improvement)
C. Coordinate admissions, inpatient care, and throughput within the hospital system. (Systemsbased Practice)
D. Demonstrate the ability to communicate in multiple modalities with patients, families, other
health care providers, and administrators. Effective communication is central to the role of the
family physician to promote efficient, safe, and high quality care. (Interpersonal and
Communication Skills, Professionalism)
E. Recognize self limitations with regards to practice and seek consultation with other health care
providers to provide optimal care. Assess medical information to support self-directed learning
(Medical Knowledge, Practice-based Learning and Improvement)
F. Demonstrate compassion, empathy, and sensitivity towards hospitalized patients and appreciate
that informed adults with decision-making capacity may refuse recommended medical treatment.
(Professionalism)
Medical Knowledge/Patient Care
A.
Recognize the critically ill patient through rapid response, assessment of, and initiation of
management of the ICU patient.
1. Evaluate and appropriately transfer critically ill patients to the ICU and identify rational criteria for
admission to the ICU.
2. Rapidly assess the patient and initiate emergency management as needed to stabilize the
patient.
3. Utilize organ system management and rapid response to changes in patient condition.
4. Essential clinical conditions for diagnosis and initial management in intensive care training
include:
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a. Cardiovascular (hypertensive crisis, congestive heart failure, acute myocardial infarction,
arrythmias, unstable angina, pulmonary embolus, hypotension, shock, pericardial
tamponade)
b. Pulmonary (respiratory distress, hypoxia, asthmatic crisis, exacerbations of chronic
obstructive pulmonary disease, pneumonia)
c.
Infectious Disease (sepsis, meningitis, pneumonia, urosepsis, hyperthermia)
d. GI (acute gastrointestinal bleeds, acute abdomen, bowel obstruction, ileus, liver failure)
e. Metabolic/ endocrine (acute and chronic renal failure, electrolyte imbalance, acid-base
imbalance, dehydration, diabetic ketoacidosis, hyperosmolar states)
f.
Hematologic (acute anemias, transfusion evaluation, administration, and reaction)
g. Neurologic (cerebrovascular accident, TIA/RIND, loss of consciousness, coma, agitated
states, brain death, syncope, status epilepticus, alcohol withdrawal syndromes, post arrest
management, acute mental status changes)
h. Psychiatric (drug overdose, suicide attempt)
i.
Post surgical (intubation, pain management, fluid balance, monitoring)
j.
Trauma (multiple trauma, myocardial contusion, pneumothorax, hypothermia from exposure,
cerebral and cervical trauma)
5. Describes and uses criteria for transfer from the intensive care unit.
6. Learn procedures, technologies, and medications essential to stabilization and management of
the ICU patient.
a. Demonstrates competence in these skills during residency:
Arterial blood gas, obtaining and interpretation
Cardioversion, emergency
Central line placement
Code management
CXR interpretation, portable and routine PA & LAT
DKA management
EKG interpretation
Endotracheal tube insertion
External pacemaker use
Fluid and electrolyte management
Heparinization
Lumbar puncture
Nasogastric tube insertion
Thoracentesis
Thrombolysis initiation
Ventilator, initial set-up
b. Additional skills beneficial for demonstrating competence if the resident anticipates
practice in an isolated environment without readily available consults and with prolonged
patient transfer time are:
Arterial line placement
Chest tube placement and management
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Cricothyroidotomy
Initiation of nipride, dopamine, nitroglycerine, and amiodarone drips
Nasotracheal tube insertion
Pericardiocentesis, emergency
Swan-Ganz insertion and interpretation of measurements
Temporary pacemaker placement
Ventilator management
Ventilator, weaning
c. Procedures useful for exposure during training with anticipated need for consultant input in
practice:
Antiarrhythrnic drips, initiation and management
Cardioversion, elective
Initiation, management, and weaning of nipride, dopamine, dobutarnine, nitroglycerine,
and lidocaine drips
Paralysis of agitated patient
Sengstaken-Blakernore tube placement
Swan-Ganz management
Tracheostomy
Ventilator management including specific management of ARDS and other complex
Respiratory patients
d. Demonstrate sterile technique as appropriate to the procedures performed.
Learning Activities
X
Attending Rounds
X
Multidisciplinary Rounds
X
Grand Rounds
Sub-Specialty Conference
X
Morning Report
X
Didactics
Other
Evaluation Methods
Attending Evaluation
Program Dir
Review
360 ᵒ evaluation
Other
X
X
Research Conference
Ethics/Comm. Conference
Specialty Conference
Noon Conference
Faculty Supervision
Procedures
Directly Supervised Procedures
In-Training Exam
Videotape Review
X
X
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Readings
Morning Report
Faculty Supervision
and Feedback
Quarterly Review
Interpersonal and Communication Skills/Professionalism
A. Learn communication with the patient in the ICU including discussion of treatment options and
appropriate expectations of outcomes of the disease process or the treatment.
1. Focuses communication to the patient when competent.
2. Utilizes writing, family members, signs, or other methods to encourage patients who are
unable to talk to express their needs.
3. Communicates with the patient, even if apparently unresponsive, before performing,
invasive or painful procedures.
4. Communicates with family members present about procedures to be performed and
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discusses with the patient and appropriate family whether they should or want to be present
during the procedure.
5. Presents options of treatment to patients (and families) in a non-judgmental manner,
weighing the pertinent positives and negatives and anticipated likelihood of these occurring.
B. Communicate regularly with the family and hold family meetings as necessary for information
regarding patient care, condition, and life-support conditions.
1. As the primary physician for the patient, identifies times when family meetings are necessary
for communication of material or to make health care decisions.
2. Identify the primary caretaker or decision maker in the family
3. Assists families on reaching consensus on decisions.
4. Identify the appropriate family members for consents and will identify circumstances where
court orders or guardianship are necessary.
5. Use appropriate condition terminology to communicate with families and will be able to add
information regarding prognosis and anticipated time course.
6. The resident will discuss parameters of life support decisions with patients and families to
facilitate informed decision-making.
C. Recognize when additional family support is needed and involves social workers, mediators and/or
clergy in facilitating family meeting and /or resolving conflict.
D. Recognize the importance of respectful and frequent nursing – physician interaction in the care of the
ICU patient.
E. Responsible for coordination of a consultant team as appropriate for patient care.
1. Consults recognizing the limitations of their own knowledge and abilities.
1. Consultants will be utilized when diagnosis and/or management remain in doubt over an
unduly long period of time, especially in presence of life-threatening illness; (b) when
unexpected complications arise; (c) when hazardous and/or highly technical procedures are
planned; and (d) when standard of care in the community is to include a consultant in care
of that patient's diagnosis.
2. Communicates regularly with the consultants, analyze the recommendations, and plan a
course of care for the patient that recognizes the patient's needs and the input of a
consultant as a specialist in their specific area of expertise.
3. Other team members such as the PharmD, dietitian, physical therapist, psychologist, etc. will
be consulted as benefits the particular patient to improve the patient's recovery.
F. Learn methods of communicating "bad news" to patients and their families.
1. Communicates information regarding worsening condition or death of a patient with
compassion.
2. Identify stages of reaction in patients and families and recognize the necessity of repeating
information for patients and families at different stages in the course of an illness.
3. Identify support systems to assist patients and families in dealing with the ethical or difficult
decisions.
Learning Activities
X
Attending Rounds
X
Multidisciplinary Rounds
Grand Rounds
Sub-Specialty Conference
X
Morning Report
Didactics
X
Other
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X
X
Research Conference
Ethics/Comm. Conference
Specialty Conference
Noon Conference
Faculty Supervision
Procedures
X
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Readings
Evaluation Methods
X
Attending Evaluation
Program Dir
Review
360 ᵒ evaluation
X
Other
Directly Supervised Procedures
In-Training Exam
Morning Report
Faculty Supervision
and Feedback
Quarterly Review
Videotape Review
Systems-Based Practice
A. Learns the appropriate documentation, coding, and billing for intensive care patients.
1. Communicate with consultants regarding diagnoses for billing.
2. Thoroughly documents patient care including noting time spent for patient management
and charting.
3. Assists the attending in completing billing cards for the patients.
B. Learns to evaluate cost and efficacy of technology and medications utilized in the intensive care unit.
1. Analyzes management from a risk/benefit and efficiency of work-up knowledge base.
2. Works with the attending, faculty on addressing issues of patient care raised by managed
care personnel.
C. Learns time-efficient methods of caring for ICU patients and their families.
1. Demonstrates knowledge of organ system and problem-based management and utilize flow
sheets and other efficiency methods for tracking patient care.
2. Identifies the family member or members who serve as the care-takers or decision members
in the family and assist the family in utilizing key contacts for dissemination of information.
3. Utilizes the phone, computer information, thorough written orders, and selected key times
for in-person patient examination to minimize travel time and optimize management time
spent with critically ill patients.
4. Develops collegial relationships with the ICU staff to encourage contact regarding changes in
patient status and develop mutual trust between physician and nursing staff.
Learning Activities
X
Attending Rounds
X
Multidisciplinary Rounds
Grand Rounds
Sub-Specialty Conference
X
Morning Report
Didactics
X
Other
Evaluation Methods
X
Attending Evaluation
Program Dir
Review
360 ᵒ evaluation
Other
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X
Research Conference
Ethics/Comm. Conference
Specialty Conference
Noon Conference
Faculty Supervision
Procedures
Directly Supervised Procedures
In-Training Exam
Videotape Review
X
X
X
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Readings
Morning Report
Faculty Supervision
and Feedback
Quarterly Review
Practice-based Learning and Improvement
A. Learns ethical and medico-legal issues associated with intensive care medicine.
1. Analyzes management decisions from an ethical decision making knowledge base.
2. Thoroughly instructs family members and regarding DNR status, withdrawal of care
decisions, consent for procedures, and decisions not to treat.
3. Appropriately identifies people to give consent for the patient.
4. Utilizes medico-legal criteria for determining competence when necessary for patient
management.
5. Utilizes the ethics committee for consultation and education in case management.
B. Evaluates what level of intensive care medicine they plan to provide in the future and modifies future
education to achieve their goals.
1. Residents who plan ICU care as part of their practice should seek out ICU patients for
management, integrate additional ICU experience into associated rotations, encourage
attendings to seek them out on call for ICU related procedures, and may elect additional ICU
experience.
C. Learns resources for rapid information acquisition necessary for intensive care medicine and
resources for continuing education in management of the intensive care unit patient.
1. Accesses information from on-line computer searches.
2. Identify manuals and texts in the ICU and personal resources that are readily accessible and
user-friendly for immediate information acquisition.
3. Identify and utilize core content for view, monographs, intensive care meetings, journals,
advanced life support courses, and intensive care specialists to remain up-to-date in
knowledge and skills for providing patient care.
Learning Activities
X
Attending Rounds
X
Multidisciplinary Rounds
X
Grand Rounds
Sub-Specialty Conference
X
Morning Report
X
Didactics
X
Other
Evaluation Methods
Attending Evaluation
Program Dir
Review
360 ᵒ evaluation
Other
X
X
X
X
X
Research Conference
Ethics/Comm. Conference
Specialty Conference
Noon Conference
Faculty Supervision
Procedures
Directly Supervised Procedures
In-Training Exam
Videotape Review
X
X
X
X
X
Outpatient Clinics
Direct Patient care
Resident Seminar
Journal Club
Readings
Morning Report
Faculty Supervision
and Feedback
Quarterly Review
III. Instructional Strategies (see above)
A. Initial evaluation and triaging of patient to the intensive care unit.
B. Completing an H&P, assessment, differential diagnosis, and plan to be presented to the senior
resident or faculty member as appropriate to the particular setting.
C. Writing admitting orders, including labs and diagnostic testing, to initiate work-up and stabilize
the patient.
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D. The resident performs an examination and evaluation of patient status at least daily and more
often as patient condition requires, Charts daily notes and addendums as appropriate for
significant change in patient condition or arrival of significant findings affecting the management
of the patient.
E. The resident is responsible for admission, transfer, and discharge summaries and for code and/or
death summary notes as necessary.
F. The resident is expected to accurately communicate findings and changes in status of patients to
senior residents and faculty and not to operate in isolation.
G. Night call for the ICU and Family Practice service including evaluation of problems as they arise,
analysis of the problems, consultation with senior resident as indicated by severity of the problem
and resident's level of competence, management of the problem, and documentation of steps
taken in response to the identified problem.
H. Working rounds with the pulmonary and cardiology fellow assigned to the unit for the month.
I. Didactics during ICU teaching rounds including conferences from faculty and fellows.
J. Associated rotations for additional intensive care experience. Emergency Room including adult,
pediatric, and gynecologic; Family Practice; Cardiology; General Internal Medicine; Pediatric
Wards; General Surgery Inpatient.
IV. Evaluation strategies (see above)
A.
B.
C.
D.
E.
F.
Rotation evaluation by critical care faculty, fellows, and IM residents (ICU block rotation)
Rotation evaluation by Emergency Room faculty (ER rotations)
Longitudinal evaluations by Family Medicine faculty (family medicine service)
Chart critique by faculty, senior residents, and fellows
Procedure competence certification
Family Medicine Conference presentations or Mortality and Morbidity Family Medicine Conference
attendance
G. Family medicine In-training exam profiles
H. Resident evaluation of rotation and faculty
V. Implementation Methods
Note: A concentrated block rotation in PGYI will speed acquisition of intensive care skills. The longitudinal
experience on the Family Practice Service at Emory Dunwoody Hospital is integrated with general adult
medicine training and will be supervised by the Family Medicine faculty. The residents will follow the
family medicine service, hospitalist and community physician patients while on the Family Medicine
Service / Internal Medicine Service. They will also follow their own continuity patients requiring
hospitalization in and out of the ICU over the next two years of training, allowing opportunities to
maintain and further enhance management skills in this area of patient care. See the Family Practice
curriculum for further discussion of implementation methods.
Location: The block rotation will be at Grady Memorial Hospital.
Grady Memorial Hospital,
69 Jesse Hill Jr. Drive
Atlanta, GA 30303
Dr. Greg Martin, Director of ICU @ Grady
Chiefs 2-12-13: Victor Yung-Tao Wu (vywu@emory.edu)
Francois Rolling (frollin@emory.edu)
Contact: The resident is expected to call the senior internal medicine resident on the appropriate ICU
team the day prior to determine where and when they are expected and to confirm the anticipated
schedule regarding the half day of family practice center time. If patient assignments are already clear,
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the resident should plan on discussing the patients with the residents who is leaving, or arriving early to
review off-service notes. Problems with the assignment, identifying the team or the Attending, or other
logistical factors should be addressed to the chief resident who can be contacted through the CLH paging
system. A good source of practical information on rotation logistics is also maintained in the intern
survival guide on the Emory Family Medicine home page under the Resident link (www.fpm.emory.edu)
Continuity clinic: One half day per week.
Call/Vacation: Call at night will cover the MICU at Grady providing exposure to a full range of intensive
care problems. Call will be every fourth night. There will be no additional family practice call. No vacation
is allowed on this rotation.
Supervision: Grady ICU attending physician / Critical care fellows / Internal Medicine resident
Conferences: The resident is expected to attend the evening research conference series unless on call
that night. They are excused Thursday AM didactics at Emory Dunwoody this month. ICU lectures / noon
conferences are daily requirements for all of the ICU teams at Grady.
Reading: Resident should read one of the following monographs during the month and turn in the
assessment test with a score of >90%.
AAFP Monographs: Update on Heart Failure (#298), Fluids and Electrolytes (#320), Stroke (#256),
Perioperative Care (#263), CAD / MI (#270), Pain (#275), Chronic Lung Disease (#282), Infectious
Diseases (#296)
VI. Bibliography
th
Bleck TP, Dellinger RP, Dries DJ, el al. ACCP Critical Care Medicine Board Review. 20 ed. Northbrook, Il:
American College of Chest Physicians; 2009
Brenner M. Current Clinical Strategies: Critical Care Medicine. Current Clinical Strategies Publishing; 2006.
Marini JJ, Wheeler AD. Critical Care Medicine: The Essentials. 3rd ed. Philadelphia, Pa: Lippincott Williams
& Wilkins, 2006.
Marino PL. The ICU Book. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2006.
th
McLean B, Zimmerman JL. Fundamental Critical Care Support. 4 ed. Mount Prospect, Il: Society of
Critical Care Medicine; 2007.
Irwin RS, Rippe JM. Manual of Intensive Care Medicine. 5th ed. Philadelphia, Pa: Lippincott Williams &
Wilkins, 2009.
Kollef MH, Bedient TJ, Isakow W, et al. The Washington Manual of Critical Care. Philadelphia, Pa:
Lippincott Williams & Wilkins, 2007.
VII. Website Resources
American Academy of Family Physicians. www.aafp.org.
American College of Chest Physicians. www.chestnet.org.
American College of Physicians. www.acponline.org.
American Hospital Organization. www.aha.org.
Association of American Medical colleges. www.aamc.org.
Institute for Healthcare Improvement. www.ihi.org.
Society of Critical Care Medicine. www.sccm.org.
Society of Hospital Medicine. www.hospitalmedicine.org.
Additional medical information resources can be found in the intern survival guide.
Last Updated April 19, 2013