Course/Rotation Title: INTENSIVE CARE UNIT / CARDIAC CARE UNIT
Date of Last Review/Update:
5/08
Course/Rotation Director: Dan Doyle, MD
Location of clinical encounters
Inpatient % time = 100%
(Check all that apply)
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Wards
[X]
ICU
[X]
ED
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Other (please specify)
Outpatient% time = 0%
(Check all that apply)
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Clinic
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Home
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Other (please specify)
Course/Rotation description with educational purpose/value
The goal of this rotation is to prepare future general internists with the skills and knowledge to
appropriately evaluate, treat and triage patients with illness requiring ICU/CCU care. The ICU
rotation and its CCU component are directed by ABMS-certified critical care physicians and
cardiologists.
Resident coverage in our 10 bed combined ICU/CCU has been designed as follows. Three teams
per block are assigned to the rotation. No categorical resident can perform more than 6 ICU
months during their three years of training. Call schedule is Q3 except Saturdays (Float team is
pulled into the ICU at 7:00 am and functions as the on-call team).
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There will be three teams of two housestaff in the medical ICU
o One PGY2 or 3 and one PGY1 per team
o Named RED, GREEN and BLUE TEAMS
o The PGY3 house officer will assign the resident and intern pairings
Each team will have primary responsibility for the patients they admit to the ICU.
o The resident and intern will function as a team. It is expected that the intern will
have thorough knowledge of their patients. It is the resident’s responsibility to
support the intern in a manner that accomplishes this goal. Deficiencies in
knowledge about a patient and in providing quality care to a patient will reflect
equally on the resident as well as on the intern.
o They will do the history and physical or transfer acceptance note
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o The patient will initially be presented on rounds by the resident
o The patients will be subsequently be presented daily by the intern
o It is expected that the intern and the resident will have prerounded on their
patients before work rounds with the intensivist.
 They will know what events have transpired since they signed out the
patient
 They will have reviewed all pertinent available laboratory and imaging
data and they will have reviewed consultations, progress notes and nursing
notes
 They will have examined the patients
 The intern will therefore be prepared to present the patient, their findings
and have some thoughts of a plan to address their patients’ problems
 The resident will complete the daily GOAL sheet
 The intern will keep the problem list updated
 When on duty, they (preferably the intern) will be responsible for writing
all orders on their patients
 The intern will be responsible for writing the progress notes on their
patients on a daily basis. Progress notes will not be completed by multiple
house officers
 The team, if on duty, will write transfer orders and transfer notes for their
patients.
The “post call” team will present the new patients they admitted
o If one team accrues a disproportionate number of patients the PGY3 resident will
balance the assignments amongst the other two teams. The intensivist will be
informed of this adjustment in patient assignments during daily rounds.
o The patient will then be the primary responsibility of the new team.
o The “post call” team will complete rounds, progress notes and sign out by noon
o They will sign out their patients to the “on call” team
 Sign out will include but not be restricted to an updated problem list, a list
of clinical issues and lab studies to check and other relevant clinical
information
The “on call” team will do all admissions, get sign out from the other two teams and
cover patients in the absence of the other two teams.
o The intern will admit patients to the ICU along with their resident
o The intern will do the history and physical and the resident should be prepared to
present the new patient the next day
The “pre call” team will be available to do procedures in the ICU
o They will remain in the ICU until 16:30
o They will sign out their patients to the “on call” team
o If the “on call” team is occupied with an admission, they may support the “on
call” team with the care of ICU patients during the day
The pre call and post call teams will get sign out each morning from the on call team
before starting their prerounds.
MC/EF Team
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o Assigned to the ICU as On-Call team every Saturday, Post call team every
Sunday.
o The rotation schedule has been designed such that all residents have at least
one day off in 7 (average days off during month >5), no resident can average
>80 hours per week, 10 hours off are guaranteed between shifts, and no
resident has primary responsibility for patients for more than 24 hours or can
work for more than 30 hours.
B. Documentation
 The formal admission history and physical examination is the responsibility of the
intern or medical student assigned to the patient.
 All intern and student history and physicals must be reviewed by the senior
resident, cosigned and accompanied by a senior level admit note.
 All medical student progress notes must be reviewed and signed by the senior
supervising resident (or intern if resident is unavailable).
 Documentation is a permanent part of the medical record. If a mistake in
documentation occurs, a single line through the error with the editors initials
noted is the only appropriate form of correction.
 All documentation should be signed legibly, dated and timed in accordance with
Berkshire Medical Center medical records policies.
 All covered patients must have a daily house officer/student progress note.
 Please see appendix for appropriate content and form of history is, physicals,
progress notes, accept notes.
C. Communication
 All admission to the Berkshire Medical Center covered service must involve
communication between the admitting attending physician and the house officer
reviewing at a minimum the pertinent aspects of the case, differential diagnosis,
and further evaluation and management steps.
 All covered patients must be reviewed daily with the attending physician of
record or their coverage.
 Any change in status of a covered patient must be reviewed as soon as possible
with attending of record or their coverage.
D. Transfers
 Residents are responsible for following the resident transfer procedure
E. Order Writing
 Residents are responsible for following resident order writing procedures
F. Team Census
 See BMC Team Census Regulations (ICU)
Types of Clinical Encounters: (PLEASE SPECIFY)
 Initial evaluation and triage of patients with serious illness both on floor and in ED
 Admission and follow up of all patients in the ICU
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Mayday team
MET team
Sepsis Team
See below under patient care & procedures
Types of Patients: (PLEASE SPECIFY)
[X]
[X]
[X]
Adults of all ages
Male
Female
Mix of Diseases: Included but not limited to (adapted form FCIM curriculum):
 Acid Base abnormalities
 Acute decomposition of valvular disease
 Acute MI
 Acute Pancreatitis
 Acute Renal Failure
 Aortic dissection
 ARDS
 Decompensated heart failure
 DIC
 DKA
 Dysrhythmias
 Electrolyte imbalance
 GI bleeding
 Hypertensive crises
 Liver failure
 Meningitis
 Multi-organ Dysfunction Syndrome
 Pneumonia
 Pulmonary Embolism
 Respiratory Failure
 Sepsis
 Shock: Hypovolemic, Cardiogenic, Distributive
 Stroke: hemorrhagic, ischemic
 Toxidromes
Types of Procedures: (PLEASE SPECIFY):
 ACLS
 Abdominal paracentesis
 Arterial puncture
 Arterial line
 Arthrocentesis
 Central venous line placement
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Lumbar puncture
Nasogastric intubation
Thoracentesis
Endotracheal intubation
Electrical cardioversion
Swan Ganz Catheter Insertion
Interpret ECG
Interpret Chest and Abdominal plain imaging
Interpret peripheral blood smears
Interpret urinalysis
Describe the level of supervision by faculty:
[X]
[X]
[X]
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Attending staff will supervise and precept all patient care activity directly or indirectly.
Attending staff will provide mid rotation feedback
Attending staff will provide end-of-rotation feedback
Other (please specify)
Teaching Rounds: The ICU is an open unit and the majority of patients in the unit are usually
under the care of their primary care physicians. Thus, the assigned Critical Care Pulmonologist
responsible for daily (teaching rounds in the ICU occur 7 days per week) teaching rounds is able
to focus the sessions on education rather than purely on management. Format follows the
RRCIM PR V.E.1. “Teaching, or attending, rounds must be patient-based sessions in which
current cases are presented as a basis for discussion of such points as interpretation of clinical
data, pathophysiology, differential diagnosis, specific management of the patient, the appropriate
use of technology, the incorporation of evidence and patient values in clinical decision-making,
and disease prevention." "Teaching rounds must include direct resident and attending interaction
with the patient, and must include bedside teaching and the demonstration of interview and
physical examination techniques.” In addition, formal cardiology teaching rounds occur weekly.
Competency Based Objectives/Expectations. Please see see Competencies and
Graded Expectations with additional items specific to this rotation as below:
Patient Care (PC)
 General (applicable to all PG years)
o Evaluation and management of the patient suffering from acute myocardial
ischemia (also MK).
o Causes of acute respiratory failure and the indications for initiating ventilatory
support as well as the management of the ventilator-supported patient (also MK).
o Principles of diagnosis and management of the patient suffering from acute fluid
and electrolyte disorders including acute renal and hepatic failure (also MK).
o Causes and principles of management of the patient in shock (also MK).
o Etiologies and evaluation of the patient suffering from an acute alteration in
mental status (also MK).
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o Indications for the use of the Swan-Ganz catheter, the interpretation of the
information provided by the catheter, and the complications associated with its
use (also MK).
o Pertinent history and physical examination of the patient suffering from acute
myocardial ischemia.
o Initiation and subsequent management of ventilator support.
o Management of shock patients, including establishing venous access and the
management of vasoactive medications including placement and management of
Swan-Ganz catheterizations.
o Evaluation and management of the patient suffering from an acute alteration in
mental status from a neurologic, metabolic, or toxic etiology.
o Admissions: Initial patient evaluation.
o Work rounds: Subsequent patient management
o Radiology rounds: Evaluation of critical care radiology data
o Attending rounds: Case discussion and didactic sessions
o Discussion sessions: Urgent problem-solving
PG1
o Clear, complete and well-structured H&Ps. Past medical history will go beyond
simple lists, and include all important clinical detail..
 Be especially detailed and accurate with the HPI.
o All admission medications will be “explained/accounted for” in the medical
history / past medical history
 Complete the Medication Reconciliation Form completely and accurately.
o Presented cases will include a review of old records (where appropriate), which
will be incorporated into a chronologically correct history.
 When rounding, always be able to report the patient’s home meds, and the
current problem list.
 Focus on a problem oriented assessment and plan (A&P). Do NOT wait
for the attending to create the differential diagnoses and plan.
PG2 are responsible for above. In addition:
o Be sure the students and interns are “on track” with their responsibilities and
expectations.
o Be ready to jump in during intern presentations to assist. If the intern fails to
present data, misinterprets data, or can not present a coherent A&P it is fully
expected you will help them to improve (chief residents and program directors are
available for teaching advice).
o Delegate appropriately, but be aware of all the teams’ patients’ problem lists,
work-up status and expected disposition.
o Look at the “big picture”; prioritize appropriately depending upon clinical
circumstances and hospital logistics.
o Goal sheets will be completed by senior resident. Goal sheets should be started
before rounds and completed after each patient is seen. Goal sheets should be
reviewed with the ICU charge nurse and placed on the nurses’ flow sheets. Goal
sheets should be reviewed before sign-out at the end of the day
o Update Common Problem List sheet daily
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PG3 are responsible for above. In addition:
o Function as a junior attending.
o Anticipate the actions of the attending, and act accordingly.
 Don’t let the attending “beat you to the punch” on questions, teaching or
patient care.
o Goal sheets will be completed by senior resident. Goal sheets should be started
before rounds and completed after each patient is seen. Goal sheets should be
reviewed with the ICU charge nurse and placed on the nurses’ flow sheets. Goal
sheets should be reviewed before sign-out at the end of the day
Medical Knowledge
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PG1
o Be able to give indications/contraindications, dosage guidelines and potential
adverse reactions to any medication a person is taking upon admission.
 Critically evaluate the appropriate continuation/discontinuation of each
home medication in light of the current clinical condition.
 Be alert to possibility that a medication is causing / contributing to the
patient’s problem.
o Be prepared to present a differential diagnosis for the patient’s chief complaint, as
well as any abnormalities found on physical exam, lab testing or imaging.
o Be able to give important negatives and positives in history & physical exam,
based upon knowledge of the pathophysiology and natural history of a given
disease state encountered.
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PG2 are responsible for above. In addition:
o Demonstrate expanded knowledge of disease states and pathophysiology.
o Demonstrate increasing understanding of the interrelationship between different
disease states and therapeutic interventions.
o Expand awareness of predictable adverse reactions/complications of treatment.
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PG3
o Be a voice of authority on rounds.
 Demonstrate senior-level knowledge of common disease states and a
ready comfort level in their management.
 Demonstrate knowledge of less common and more complex conditions
and management plans.
 Be able to cite Evidence Based literature on clinical situations encountered
on rounds.
Practice-Based Learning
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Seeks out resources independently to gain increased knowledge and understanding of
disease states with which the trainee is unfamiliar.
Demonstrates facility with hospital based online databases (OVID, Cochrane,
PubMed).
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PG2 & 3 should demonstrate teaching and assessment of areas of weakness needing
assistance for the PG1 members of the team
Interpersonal and Communication Skills
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Develops a therapeutic relationship with patients & their families such that they look
to the resident as their primary physician contact.
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Professionalism
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Develops a true sense of ownership and responsibility for all care their patients
receive.
Shows respect to and is able to learn from Respiratory Therapy, ICU Nursing and
other ancillary ICU staff.
System-Based Practice:
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Ability to work as part of a multidisciplinary team in caring for patients with critical
illness.
Understanding the principles of withholding/withdrawing life support and advanced
directives.
Check Any Methods Used For Teaching and Assessment:
[ ] Ambulatory Clinic (feedback written & verbal)
[ ] Annual In-service Exam (feedback written)
[X] Attending Rounds (feedback written & verbal)
[ ] Board Review (feedback written examination)
[ ] Cancer Conference
[X] Case Management Evaluation (360 degree written evaluation)
[X] Chart Stimulated Recall & Feedback (feedback verbal)
[X] Direct Observation and Feedback (feedback written & verbal)
[ ] GME Core Curriculum
[ ] Interns Report (feedback written & verbal)
[ ] Journal Club (feedback written & verbal)
[X] Medical Record Review (feedback written & verbal)
[X] Mentor Feedback (feedback written & verbal)
[ ] Monthly End of Elective Exam (feedback written)
[X] Monthly Mini CEX (feedback written & verbal)
[X] Monthly Competency Based Written Evaluation
[X] Morning Report (feedback written & verbal)
[ ] Multidisciplinary Rounds Feedback (feedback verbal)
[X] Nursing Evaluation (360 degree written evaluation)
[X] Patient Evaluation (360 degree written evaluation)
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[X] Patient Management Discussions (feedback written & verbal)
[ ] Procedure Logs
[ ] Performance improvement Multidisciplinary Morbidity and Mortality
(feedback written & verbal)
[ ] Semi Annual Program Director Feedback (feedback written &
verbal)
[ ] Student Evaluation (feedback written & verbal)
[X] Supervised Sign-In Rounds (feedback written & verbal)
[ ] Supervised Sign-Out Rounds (feedback verbal)
[ ] Other _______________________________
Other Policies:
The Course Director recognizes that the trainee is accountable to all BMC Residency and GME
Personnel Policies and Procedures. The Course Director recognizes that the residents are
expected to attend all continuity clinics and mandatory educational conferences unless excused
by the Program Director or Chief Medical Resident with advanced notice.
Check The Educational Materials Used (beyond direct patient care):
[X] Reading List (Please Specify):
1.
2.
3.
4.
5.
6.
Critical Care Medicine - the Essentials.
The Washington Manual.
Marriot, Practical ECG.
Mechanical Ventilation, Chest, 104(6):1833-59.
The Textbook of Cardiac Life Support.
Diagnostic Strategies in Disorders of Fluid, Electrolyte and Acid-base Hemostasis,
AJM 72:490-519.
7. The Acute Respiratory Distress Syndrome, NEJM 332:27-37.
8. Hurst, The Heart.
9. Shoemaker, Textbook of Critical Care.
10. CD ROM titles - ICU Resource room
[X] Review of Appropriate Radiology Images:
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Unless otherwise specified it is expected that the ICU team personally reviews all
films ordered on their patients
[X] Review of Appropriate Pathology:
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Unless otherwise specified it is expected that a member of the ICU team will
personally review all pathology specimens with the attending Pathologist on patients
for who the team is caring
[X] Review of Appropriate Laboratory Data
[X] Articles from the Literature:
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It is expected that the ICU senior will pull, review, and disseminate information from
relevant articles useful in the care of patients being cared for.
[ ] Case Studies
[ ] Other (Please Specify):
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