Neurocritical Care Service Curriculum
Description of Rotation or Educational Experience
The Neurocritical Care Service (NCCS) is based at Harborview Medical Center.
Trainees participate in the care of critically ill Neurosurgical patients in a collaborative
working relationship with Neurosurgery. The NCCS is multidisciplinary in nature, with
faculty, fellows, and residents from several departments on the service. Trainees are
expected to learn a method of systematic approach to complex and/or critically ill or
injured neurosurgical adult and pediatric patients. Knowledge will be obtained through a
combination of clinical experience, didactic lectures and directed reading.
Patient Care
Goal
Trainees must be able to provide patient care that is compassionate, appropriate, and
effective for the treatment of health problems and the promotion of health. Trainees are
expected to gain expertise in the care of critically ill patients with a variety of
neurosurgical diagnoses.
Trainees are Expected to Develop Competency in:
 Evaluation and management of core problems in critical care medicine including
life-threatening hypotension, hypertension, gastrointestinal bleeding, acute renal
failure, acute respiratory failure, infectious disease, endocrine emergencies
 Evaluation and management of problems specific to critically ill neurosurgical
patients, including intracranial hypertension, cerebral vasospasm, acute spinal cord
injury, status epilepticus and severe acute cerebrovascular accidents.
 Experience in diagnostic and therapeutic procedures including bronchoscopy,
pulmonary artery catheterization, thoracentesis, central venous catheter insertion,
arterial cannulation, tube thoracostomy, and percutaneous tracheotomy.
 Communication skills with patients and families regarding prognosis and care
plans, including end-of-life care
Objectives
 Obtain appropriate intravenous and intra-arterial access for patients requiring
vasoactive agents or large volume resuscitation
 Initiate appropriate resuscitation for shock of varying causes
 Initiate appropriate therapy for patients with acute hypertension
 Interpret intracranial pressure changes in the context of other data to assess
appropriate therapy for patients with traumatic brain injury and other causes of
cerebral edema
 Interpret Transcranial Doppler studies to determine the presence and severity of
cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage
 Initiate appropriate therapy in patients with acute respiratory failure of various
causes
 Implement volume and pressure modes of ventilation and demonstrate the ability
to troubleshoot problems that develop during the course of mechanical ventilation.
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 Assess readiness for liberation from mechanical ventilation and fitness for
extubation
 Implement different methods of sedation for intubated and non-intubated patients.
• Perform safe, quick and efficient bronchoscopy in patients with possible
ventilator-associated pneumonia.
 Insert a pulmonary artery catheter and interpret the hemodynamic data provided
by the catheter.
 Safely and efficiently insert a thoracostomy tube for evacuation of air or fluid
from the pleural space
 Gain experience in the performance of percutaneous tracheotomy
 Initiate parenteral and enteral nutrition and evaluate the adequacy of nutritional
status and electrolyte balance.
 Conduct patient care conferences with the patients and/or family members to
update clinical status and discuss overall goals of care, including palliative care.
Medical Knowledge
Goal
Trainees must demonstrate knowledge of established and evolving biomedical, clinical,
epidemiological, and social-behavioral sciences, as well as the application of this
knowledge to patient care.
Trainees are Expected to Gain Competency in the Following:
 Basic and advanced neurophysiologic principles, including control of cerebral
blood flow, determinants of intracranial pressure, etc.
 Patterns and management of central neurologic injury, with focus on
subarachnoid hemorrhage, cerebral vasospasm, and traumatic brain injury
 Medical complications in critically ill neurosurgical patients, including shock,
respiratory failure, endocrine abnormalities, and nosocomial infections
Objectives
 Describe basic neuroanatomy and apply to interpretation of neuroimaging
techniques
 Learn the causes of major morbidity and mortality after aneurismal subarachnoid
hemorrhage, and potential preventive and therapeutic interventions
 Understand principles of hypertensive, hypervolemic hemodilution therapy for
cerebral vasospasm
 Understand principles of neurophysiologic monitoring, including ICP monitor
placement and interpretation, retrograde jugular venous catheter (SjO2) placement and
interpretation, Transcranial Dopplers
 Identify causes and treatment of acute respiratory failure
 Identify causes and treatment of hypotension and shock
 Understand causes of disordered sodium balance and appropriate evaluation and
treatment
 Identify common causes and sources of nosocomial infection in critically ill
patients, and appropriate evaluation and antibiotic selection
Practice- Based Learning and Improvement
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Goal
Trainees must demonstrate the ability to investigate and evaluate their care of patients, to
appraise and assimilate scientific evidence, and to continuously improve patient care
based on constant self-evaluation and life long learning. Trainees are expected to
develop skills and habits to be able to :
Competencies
 Locate, appraise and assimilate evidence from scientific studies related to their
patients’ health problems
 Use information technology to optimize learning
 Participate in the education of patients, families, students, residents and other
health professionals, as documented by evaluations of a resident’s teaching
abilities by faculty and/or learners
Objectives
 Perform effective evidence-based patient care and bedside education of residents
and other staff
 Prepare and deliver an assigned rotation-specific didactic lecture, which will be
evaluated by the rotation faculty
Systems Based Practice
Goal
Trainees must demonstrate an awareness of and responsiveness to the larger context and
system of health care, as well as the ability to call effectively on other resources in the
system to provide optimal health care. Trainees are expected to:
Competencies
 Coordinate patient care within the health care system relevant to their clinical
specialty
 Work in interprofessional teams to enhance patient safety and improve patient
care quality
Objectives
 Effectively coordinate critical care within a complex inderdisciplinary
environment
 Participate in monthly NCCS Morbidity and Mortality/Quality Improvement
Conference
Professionalism
Goal
Trainees must demonstrate a commitment to carrying out professional responsibilities
and an adherence to ethical principles. Trainees are expected to demonstrate:
Competencies
 Compassion, integrity, and respect for others
 Responsiveness to patient needs that supersedes self-interest
Objectives
 Work as part of a multidisciplinary care team and incorporate the opinions of
other providers including neurosurgeons, nurses, pharmacists, nutritionists and
therapists into effective and efficient patient care
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Interpersonal and Communication Skills
Goal
Trainees must demonstrate interpersonal and communication skills that result in the
effective exchange of information and teaming with patients, their families, and
professional associates. Trainees are expected to:
Competencies
 Communicate effectively with patients and families across a broad range of
socioeconomic and cultural backgrounds
 Communicate effectively with physicians, other health professionals, and health
related agencies
 Work effectively as a member of leader of a health care team or other professional
group
Objectives
 Develop effective and respectful relationships with nursing staff, neurosurgical
colleagues, and patients
Teaching Methods
Several different teaching methods are employed on this rotation including
- Bedside Rounds with Case Discussion and Review: The trainees on the service are
directly supervised by board-certified Critical Care attending physicians with whom all
cases are reviewed in depth at least once daily. Registered pharmacists, respiratory
therapists and critical care nurses also participate in the daily patient assessment and
help educate the trainees through this involvement.
- Didactic Sessions: Faculty conduct formal didactic teaching sessions for the trainees at
least three times per week.
- Scheduled Educational Conferences: In addition to didactic sessions with faculty,
trainees are encouraged to attend scheduled teaching conferences including the
Multidisciplinary ICU Conference, the Neurocritical Care/Neurosurgical Conference,
and Respiratory Critical Care Conference, all at Harborview Medical Center.
- Reading Materials: An electronic syllabus is available that includes rotation-specific
information as well as articles pertinent to other aspects of critical care. In addition,
attending physicians provide additional teaching materials, usually in the form of
journal articles, pertinent to the cases being managed by the service at any given time.
Assessment Method (Trainees)
At the end of the rotation, the trainees receive oral feedback from every attending with
whom they interact for a significant period of time (greater than 5 days). Attending
physicians also complete written evaluations of the trainees in which they rate the
resident on a nine-point scale in each component of clinical competence (eg. Patient
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care, medical knowledge, practice-based learning environment, interpersonal and
communication skills, professionalism, system-based learning, educational attitudes,
leadership and overall clinical competence).
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Assessment Method (Program Evaluation)
At the end of the rotation, trainees are required to complete written evaluations focused
on the quality of the curriculum as well as the extent to which the goals and objectives
of the rotation have been met. In addition, trainees complete written evaluations of each
attending physician with whom they have interacted for a significant amount of time
(greater than 5 days) and have the opportunity to provide verbal feedback at the time
they sit down for a face-to-face evaluation session with their attending physician.
Level of Supervision
Residents work under the direct supervision of a board-certified Critical Care faculty
and a critical care fellow throughout the rotation. That attending physician rounds with
the trainee staff, examines and reviews the care of every patient at least once daily and
writes daily progress notes. The faculty physician is available for questions and input
regarding patient care on a 24-hour basis.
Graduated responsibility is granted to trainees according to their level of training and
development. Residents at the R2 and R3 level are in general closely supervised by the
attending and fellow, whereas residents at the R4 level are granted more autonomy in
decision making and performing procedures. Fellows are expected to function at a
supervisory level, and to engage in high-level decision making with a reasonable
degree of autonomy. Fellows are charged with organizing the team, and actively
participate in resident education.
While residents will perform many procedures such as arterial or central venous
cannulation independently of the faculty physician, the residents are supervised by the
attending when performing bronchoscopy, endotracheal intubation, thoracostomy, and
percutaneous tracheotomy.
Educational Resources
An electronic syllabus is available that includes rotation-specific information as well as
articles pertinent to other aspects of critical care. In addition, attending physicians
provide additional teaching materials, usually in the form of journal articles, pertinent
to the cases being managed by the service at any given time.
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