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U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Edward J. Cullen Jr., D.O June 2006 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Overview Overview page that tells what we do and how we try to coordinate with various organizations Background Nemours Vision, Mission, Values 9 Nemours Patient Centered Care and Excellence goals Nemours Education Mission The Institute of Medicine of the National Academies Goals for PICU Resident Rotation SCCM goals for PICU residents 13 TJU Pediatric Residency Program Considerations That Impact the Resident Educational Pediatric residency programs - new challenges ACGME work hour restrictions for residents Leapfrog Inititative 33 PICU Quality goals 34 Ideal PICU Resident Rotation PICU at Alfred I duPont Hospital for Children PICU attending staff numbers and multidisciplinary staff for PICU rotation including Ilene Sivikoff, PICU attending clinical, administrative, research, self- learning responsibilities and opportunity time for resident PICU Resident Rotation Participants PICU resident previous ICU experiences PICU resident previous procedure experience PICU resident previous pediatric code experience Resident self-reported comfort 49 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 levels pre PICU rotation Resident self-reported goals for PICU resident self-reported learning preferences Present PICU Rotation Curriculum 2005-2006 that includes PICU rotation web site, introduction, 4 week curriculum, interactive teaching rounds that serve as case based learning, Nemours Desktop resources, SCCM PICU Lectures, evidence based critically appraised topic on PICU problem, Journal Club, SCCM post test Incorporating PICU resident into the multidisciplinary PICU team in order to optimize safe, quality patient care. PICU Resident Maintenance Process, quality control questionnaires including various program evaluation forms, Acces Data Base, Survey, PICU Resident Rotation web site PICU Resident Rotation Activity Procedures performed with supervision by residents in PICU PICU resident scores SCCM national post test PICU attending comfort level with residents at end of rotation Evaluation of PICU Resident Rotation and Critical Care Physicians / PICU resident comments or suggestions about improving PICU rotation Experience of Previous PICU Residents during their First Year in Practice Previous PICU residents, in practice during first year – need to do PICU care 102 Previous PICU residents, in practice during first year – need to do procedures 105 Previous PICU residents, in practice during first year- comments about improving PICU 108 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 rotation Publications and Awards Publications 117 Abstracts 117 Teaching Award 118 Financial Resources Funding for resident teaching 120 Strengths 122 Weaknesses 123 Opportunities 123 Threats 123 Challenges 124 Suggested Curriculum for July 2006-June 2007 126 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Alfred I. duPont Hospital for Children Pediatric Critical Care Resident Rotation http://www.nemours.org/no/aidhc/picu/index.html (Username: picu Password: resident) Nemours' Pediatric Critical Care physicians supported by the multidisciplinary PICU team provide a pediatric critical care me dicine exposure for: Thomas Jefferson University Pediatric 2nd-year residents Thomas Jefferson University Emergency Medicine 2nd-year residents Christiana Care Health System Emergency Medicine 2nd-year residents Christiana Care Health System 2nd- and 3rd-year Medicine-Pediatric and Internal Medicine-Emergency Medicine residents 4th year medical students from various programs. Pediatric resident elective in Transport Medicine / Airway and Intubation Skills (Combined program with Nemours Anesthesiologist) Pediatric Anesthesia Fellows Alfred I duPont Hospital for Children Emergency Medicine 1st-year Fellows Christiana Care Surgical Trauma Critical Care Fellows We aim to introduce individual residents to the art of pediatric critical care in an environment where we need to balance: Consistent quality and safe bedside care of the critically ill child Residents' expectations for a productive educational experience Resident's PICU service obligations Resident's commitment to outsid e-of-PICU progra m expectations Resident’s restricted duty hours Pediatric GME and SCCM viewpoints on time committed to resident ICU exposure Critical care attendings' clinical, administ rative, research, and other educational responsibilities Health care economics. Since 1992, our PICU goals, curriculum, and future plans reflect ongoing development based on recommendations and observations from: American Medical Association, Graduate Me dical Education Guidelines for Intensive Care Experience (NICU and PICU). Graduate Medical Education Directory, American Medical Association, 1996-1997, p 184 SCCM Guidelines for Resident Physician Training in Critical Care Medicine Crit Care Med 1995; 23:1920-1923 General Guidelines for Resident Training in Critical Care Medicine New Horizons 1998;6:255-259 Institute of Medicine “ To Err is Human-Building a Safer Health Care System” Washington, DC: National Academies Press;1999 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Nemours Education Innovation Program (2001-2005) Accreditation Council for Graduate Medical Education (ACGME) Work Group on Resident Duty Hours (June 2002) Gainer AC, Knebel E, eds. Health Prof essions Education: A Bridge to Quality. Washington, DC: National Academy Press; 2003 Nemours Foundation Drive to Excellence and Commitment to Medical Education (2003) The State of Pediatrics Residency Training: A Period of Transformation of Graduate Medical Education. Pediatrics 2004;114-832-841 Guidelines for critical care medicine training and continuing medical education. CritCare Med 2004; 32 (1):263-272 Integrating the Institute of Medicine’s six quality aims into pediatric critical care: Relevance and applications. Pediatric Critical Care 2005;6(3):264-269 SCCM Pediatric ICU Resident Education Committee Alfred I duPont Hospital for Children Graduate Medical Education Office Continuous Quality Improvement via PICU nursing and PICU resident questionnaires Survey of practicing physicians who participated in our PICU rotation as residents Cooperation with the Thomas Jefferson University Pediatric Residency Program, Thomas Jefferson Emergency Medicine Residency Program, Christiana Care Emergency Medicine Residency Program and the Christiana Care Medicine Pediatrics Residency Program. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Freedom from disabling conditions To provide leadership, institutions, and services to restore and improve the health of children through care and programs not readily available, w ith one high standard of quality and distinction regardless of the recipient’s financial status. Respect ,Honor, Excel, Serve, Learn The Nemours Foundation has defined itself as an organization seeking to be excellent in the delivery of patient-centered care. A goal of the Nemours Foundation is to Become one of the top 10 pediatric re search centers in the United States Become a national resource for pe diatric subspecialty education Provide the national standard for pediatric patient and family education Education and research are important because the best practitioners thrive and contribute their best in an U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 The Institute of Medicine of the National Academies Committee on Health Pr ofession Education The Institute of Medicine of the National Academies states that medical education and training U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 The Accreditation Council for Grad uate Medical Education (ACGME) Residency Review and Institutional Review Committee Outcomes Project Residency programs must require its residents to obta U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 The American College of Critical Ca The American College of Critical Care Medicine of th U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Since not all trainees will be exposed to the entire leng th and breadth of clinical problems during their ICU experience, a core critical care curri culum taught by clinical experts should supplement the clinical experience. Case based education methodology is encouraged. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 6. Bronchopulmonary infections including bronchiolitis 7. Upper airway obstruction 8. Near drowning 9. Bronchopleural fistulas 10. Pulmonary mechanics and gas exchange 11. Oxygen therapy 12. Hyperbaric oxygenation 13. Mechanical ventilation a. Pressure and volume modes of mechanical ventilators b. Positive end-expiratory pressure, intermittent mandatory ventilation, continuous positive airway pressure, high-frequency ventilation, inverse ratio ventilation, pressure-support ventilation, volume support (airway pressure release ventilation, pressure-regulated volume control ventilation), negative pressure ventilation, differential lung ventilation, pressure control and noninvasive ventilation, spilt lung ventilation, one-lung ventilation c. Indications for and hazards of mechanical ventilation d. Barotrauma and volutrauma e. Criteria for extubation and weaning techniques f. Extracorporeal membrane oxygenation g. Permissive hypercapnia h. Liquid ventilation i. Pulmonary surfactant therapy j. High-frequency oscillatory ventilation 14. Airway maintenance a. Emergency airway management b. Endotracheal intubation c. Tracheostomy, open and percutaneous d. Long-term intubation vs. tracheostomy 15. Ventilatory muscle physiology, pathophysiology, and therapy, including polyneuropathy of the critically ill and prolonged effect of neuromuscular blockers 16. Pleural diseases a. Empyema b. Pleural effusion c. Pneumothorax d. Hemothorax 17. Pulmonary chylothorax, hemorrhage, and hemoptysis 18. Nitric oxide and prostaglandin therapies 19. Noninvasive ventilation 20. Positional therapy (i.e., prone position, rotational therapy) C. Renal Physiology, Pathology, Pathophysiology, and Therapy 1. Renal regulation of fluid balance and electrolytes 2. Renal failure: Prerenal, renal, and postrenal 3. Derangements secondary to alterations in osmolality and electrolytes 4. Acid-base disorders and their management 5. Principles of renal replacement therapy U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 1. Coma U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 a. Antibacterial agents in cluding aminoglycosides, penicillins, cephalosporins, quinolones, and newer emerging classes of antibiotics b. Antifungal agents c. Antituberculosis agents d. Antiviral agents e. Agents for parasitic infections 2. Infection control for special care units a. Development of antibiotic resistance b. Universal precautions c. Isolation and reverse isolation 3. Anaerobic infections 4. Sepsis definitions (sepsis, severe sepsis, septic shock) 5. Systemic inflammatory response syndrome U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 6. Acute perforations of the gastrointestinal tract 7. Ruptured esophagus 8. Acute inflammatory diseases of the intestine 9. Acute vascular disorders of the intestine, including mesenteric infarction U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 1. Prognostic indexes, severity, and therapeutic intervention scores 2. Principles of electrocardiographic monito ring, measurement of skin temperature and resistance, transcutaneous measurements 3. Invasive hemodynamic monitoring a. Principles of strain gauge transducers b. Signal conditioners, calibration, gain, adjustment c. Display techniques d. Principles of arterial, central venous, and pulmonary artery pressure U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 In addition to practical training in the following procedural skills, the resident must have an understanding of the indications, contraindications, complications, and pitfalls of these interventions. Due to the variability of individual training programs, practical experience may be limited for some procedures. A. Airway Management 1. Maintenance of an open airway in the nonintubated patient 2. Ventilation by bag-mask 3. Tracheal intubation 4. Management of pneumothorax B. Circulation 1. Arterial puncture and cannulation U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 The Thomas Jefferson Pediatric Residency Prog ram Goals for the Critical Care Rotation, Alfred I duPont Hospital for Children Based on the APA Educational Guidelines for Pediatric Residency (www.ambpeds.org/EGweb/index.cfm) as edited by Keith J. Mann, MD, Assistant Director of the Thomas Jefferson University Pediatric Residency Program (3/31/05): I. Resuscitation and Stabilization (PICU). Recognize the critically ill patient and initiate appropriate stabilization and/or resuscitative measures. A) Explain and perform steps in resuscitation and st abilization, particularly airway management, volume replacement, and resuscitative pharmacology. C) Function appropriately in codes and re suscitations as part of the PICU team. manage, under the supervision of an intensivist, common signs and symptoms seen in critically ill infa nts, children and adolescents in the intensive care A) Evaluate and manage, under supervision of an in tensivist, patients with signs and symptoms that present commonly to the intensive care unit (examples below): Cardiovascular: Acute life-threatening event, bradyc ardia, cardiopulmonary arrest, congestive heart failure, cyanosis, hypertension, hypotension, poor capi Endocrine: Signs and symptoms suggestive of hypo- and hyperglycemia and adrenal insufficiency/crisis GI: Abdominal distension, hematemesis and melena, icterus, peritoneal signs, vomiting III. Common Conditions (PICU). Recognize and manage, under the supervision of an intensivist, conditions that commonly present to the intensiv e care unit, using consultation when appropriate. A) Evaluate and manage, under the supervision of an intensivist, patients with conditions that present commonly to the intensive care unit (examples below): General: Burns (thermal, electrical), common intoxications, drug overdose, shock (cardiogenic, hypovolemic, distributive, toxic), inhalation inju ry, malignant hyperthermia, non-accidental trauma, submersion injury, toxic or caustic ingestion or inhalation injury, toxic shock syndrome Allergy Immunology: Anaphylaxis, life-threateni ng angioedema, Stevens Johnson Syndrome Cardiovascular: Arrhythmias, cardiac tamponade, co ngestive heart failure, cyanotic congenital heart disease, malignant hypertension U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 IV. GOAL: Diagnostic Testing (PICU). Utilize common di agnostic tests and imagin taining consultation as indicated A) Demonstrate understanding of common diagnostic tests and imaging studie s used in the PICU by Explain the indications for and limitations of each study. Know or be able to locate readily age-ap propriate normal ranges (lab studies). erties, including the use of sensitivity, specificity, positive predictive value, ne gative predictive value, likelihood ratios, and receiver operating characteristic curv es, to assess the utility of tests in B) Use appropriately the following laboratory and im aging studies when indicated for patients in the U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Serologic tests for infection (e.g., hepatitis, HIV). C-reactive protein, erythrocyte sedimentation rate. Therapeutic drug concentrations V. GOAL: Monitoring and Therapeutic Modalities (P ICU). Understand how to use the physiologic monitoring, special technology and therapeutic modalitie A) Demonstrate understanding of the monitoring te chniques and special treatments commonly used in the PICU by being able to: Discuss the indications, contraindications and complications. Have a basic understanding of the general tec hniques (e.g. Seldinger technique for central venous line placement). B) Use appropriately the following monitoring techniqu es in the intensive care unit under supervision of an intensivist: Central venous pressure monitoring Invasive arterial blood pressure monitoring Intracranial pressure monitoring U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 End-tidal carbon dioxide monitoring C) Utilize appropriately or be familiar with the follow ing treatments and techniques in the intensive care unit, including monitoring effects and anticipating potential complications specific to each therapy: Oxygen administration by cannula, masks, hood Positive pressure ventilation including non-inva sive modalities such as nasal/mask BiPAP/CPAP, bag and mask ventilation) Principles of ventilator management, intubation and extubation procedures and criteria Analgesics, sedatives, and paralytics Enteral and parenteral nutrition Blood and blood product transfusions Vasoactive drugs (pressors and inotropes) VI. GOAL: Death, Acute Illness/Injury and Terminal support to the acutely ill, injured or terminally ill child and his/her family. A) Discuss principles in the medical management of acutely ill, injured or terminally ill children, and demonstrate an understanding of the goals of trea tment, including relevant medical, legal, and psychosocial issues such as: Involving parents in decision-making processes Redirection of the goals of care Symptomatic management of pain, re spiratory distress, and nutrition Home hospice care "Do Not Resuscitate" orders and termination of life support B) Discuss the principles of counseling parents re garding treatment options for terminally ill children, including the integration of relevant cultural and religious or spiritual values. C) Describe the stages of the normal grieving process. D) Describe the common reactions of siblin gs to the impending death of a sibling. E) Counsel parents with regard to: The diagnosis of life-threatening illness U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 F) Describe how to formulate management plans for terminally ill patients, including: Pain/comfort management plan Outpatient plan for patients going home or to a hospice In-hospital, hospice-like plan for patients whose parents want them to remain in the hospital H) Understand one's personal response and feelings when dealing with death and dying, including: Personal belief and religious/spiritual belief systems related to disease and management of The need to share feelings with othe rs during times of stress or death Procedures Describe the following procedures, including how they work and Cardioversion/defibrillation Chest tube placement Endotracheal intubation Use a logical and appropriate clinical approach to the care of critically ill patients, applying principles of evidence-based decision-making and problem th serious illness and to their families, and arrange for on-going support or preventive services if needed. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 clinical, epidemiological and social-behavioral know ledge needed by a pediatrician; demonstrate the Demonstrate a commitment to acquiring the knowledge base expected of general pediatricians caring for seriously ill children under the guidance of an intensivist. Know and/or access medical information e fficiently, evaluate it critically, and apply it appropriately to care of patients in the PICU. Provide effective and sensitive communication with patients and families in the Demonstrate a commitment to carrying ou t professional responsibilities while Identify key aspects of health care system s, cost control, and mechanisms for U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 A Period of Transformation of Pediatric Graduate Medical Education There is an explosion of new basic knowledge (genomics, proteomics,neuroscience,developmental biology, translational research.). The pattern of pediatric care for sick children is changing, with substantial increase of acuity and complexity of illness in hospitalized children, often requiring clusters of subspecialists and advanced technology to provide quality care. Chronic medical conditions are much larger part of pediatric care. Acuity and demands of care in the community are raised. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 The Accreditation Council for Graduate Medical Education (ACGME) Work Group on Resident Duty Hours The Accreditation Council for Graduate Medical Education (ACGME) Work Group on Resident Duty U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 High Quality Education and Safe and Effective Patient Care • Priority of clinical and didactic education in the allotment of residents’ time and energies • Schedules of teaching staff structured to provide ready supervision and faculty support/consultation to residents on duty • Duty hour assignments that recognize that faculty and residents collectively have responsibility for patient safety and welfare • Monitor residents for the effects of sleep and fatigue by Program director and faculty with appropriate action when it is determined that fati gue might affect safe patient care or learning. • Education of faculty and residents in recognizin g the signs of fatigue and in applying preventive and operational countermeasures • Appropriate backup support when patient care responsibilities are difficult and prolonged, and if unexpected needs create resident fatigue sufficient to jeopardize patient care. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 http://www.leapfroggroup.org/ The Leapfrog Group is an initiative driven by organizati ons that buy health care who are working to initiate U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Quality Aims into Pediatric Critical Care Incorporating the best-research evidence, clinical expertise and patient values in order to achieve the best outcomes for the patient Provide impartial care for populations and to individuals that is free from bias related to race, A marker of the adequacy of pro cesses to achieve acceptable outcomes Timely and effective communication Available resources Provision of information, education, emotional support to families Attention to the physical comfort of families Involvement of family and friends in care Health care resources are delivered in a cost-e ffective and efficient manner while not jeopardizing quality Integrating the Institute of Medi cine’s six quality aims into pediatric critical care: Relevance and applications Pediatric Critical Care 2005; 6(3): 264-269 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Ideal Scenario Integrating PICU Resident Educat ion, Resident Duty Hours, Patient Care The education and training program should aim to: Provide Patient Centered Care Work in Interdisciplinary Teams Employ Evidence-based practices Apply Quality Improvement Utilize Informatics Medical education must be aligned with the desired health outcomes. The training program should integrate the Institute of Medicine’s Six Quality Aims into the Pediatric Critical Care environment. patients. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Medical Knowledge about established and evolving biom edical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals Professionalism , as manifested through a commitm ent to carrying out professional U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Residents at a minimum should be able to recognize, stabilize and begin resuscitation of critically ill patients until a critical care specialist is available. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 PICU multidisciplinary team Pediatric board certified critical care medicine physicians Pediatric double boarded critical care medici ne and anesthesiology trained physicians Pediatric critical care nurse practitioner PICU nurse manager PICU transport nurse manager PICU nurse educators PICU charge nurses PICU transport nurses Nursing students, externs PICU respiratory therapists PICU transport resp iratory therapists Respiratory therapy students PICU clinical pharmacists Clinical pharmacy students PICU nutrition specialists PICU social service personnel PICU clerical staff PICU Cerner representative PICU volunteers Pediatric critical care fellows Pediatric emergency medicine fellows Adult trauma surgery fellow Pediatric, medicine/pediatric, emergency medicine, emergency medicine/internal medicine residents Fourth year medical students Multidisciplinary PICU Educators Involved in Resident Education Clinical pharmacist (John Giamalis) (Ilene Sivikoff, Sherry Carroll) Ilene Sivikoff) Coordinate application paperwork for visiting reside nts and medical students with GME Office, various residency programs, Jeffline and Stentor. Prepare individual resident and medical student introduction folders. Assist with PICU Resident Education Data Base. Prepare and mail a yearly survey to previous PICU rotation residents who are now in their first year of practice or fellowship. Correspondence. (Anne Gallagher) U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Pediatric Critical Care Physicians Pediatric Critical Care Medicine Brian Binck MD Caroline Boyd MD (begins July 2006) Tania Burns MD Edward Cullen DO James Hertzog MD Scott Penfil MD Pediatric Anesthesiology & Critical Care Medicine Andrew Costarino MD Pediatric Critical Care FTE Physician Responsibilities Clinical (80%) Non-clinical (20%) Administration (0700-1600 weekdays & 0700-1800 weekends) Cover 22 medical / surgical PICU patients Coordinate Pediatric Transports for Alfred I duPont Hospital for Children PICU patient care rounds PICU family interactions Critical Care Medicine Fellow clinical & procedure supervision and training Resident clinical & procedure supervision and training cedure supervision and training On weekends and holidays: additional (1800-0700) back up clinical support for PICU and consultant coverage for pediatric, multi-system trauma patients at Shock Trauma Unit (SSTU), Christiana Care Hospital Primary PICU Patient Care Coverage (1600-0700 weekdays & 1800-0700 weekends) Cover 22 bed medical / surgical PICU Coordinate Pediatric Transports for Alfred I duPont Hospital for Children PICU patient care rounds PICU family interactions Critical Care Medicine Fellow clinical & procedure supervision and training Resident clinical & procedure supervision and training cedure supervision and training On weekends and holidays: additional (0700-1800) back up daytime clinical care support for PICU and consultant coverage for pediatric, multi-system trauma patients at Shock Trauma Unit (SSTU), Christiana Care Hospital U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Secondary PICU Patient Care Coverage (0700-1600 weekdays) Consult service for pediatric trauma at Christiana Care Shock Trauma Unit Assist with PICU clin ical care, procedures Coordinate family teaching and home discha rge planning for individual children with tracheostomy and chronic ventilator care. Assist with sedation for selected children in the EEG lab Assist with sedation services outside of the PICU Assist with central venous access outside of the PICU Mock Codes and Interactive Teach ing Sessions for PICU residents Secondary PICU Patient Care Coverage (1600-0700 weeknights) Consult service for pediatric trauma at Christiana Care Shock Trauma Unit Assist with PICU clin ical care, procedures Responsibilities for Critical Care Physicians wh o remain Engaged in the Specialty Practice of Crit Care Med 2004; 32 (1): 267 Develop an ever increasing measurable quantity of knowledge Regularly perform and teach an in Continue to augment his or her knowledge by assimilating appropriate new peer-reviewed published medical literature through self-directed learning. Develop and participate in CME activities de signed to enhance critical care knowledge. Teach others to identify the need for and provide care for all critically ill adult and /or pediatric patients. Continue to provide and teach cardiopulmonary and cerebral resuscitation including advanced techniques for all patients sustaining life-threatening events. Introduce and teach others new methods and use of devices for management of patients in respiratory failure. Develop and evaluate curriculum changes for ICU caregivers, fellows, and residents. Diagnose and treat a sufficient number of pati ents with critical illness using conventional and state-of-the –art approaches to maintain clinical proficiencies. Teach others to select, place and use appropriate m onitors for titrating therap y in any critically ill patient by demonstrating these skills in daily practice. Teach others infection control and monitor infection control practices of the unit. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Advance the clinical practice of CCM using evidence-based medicine techniques and through dissemination of findings by publishing case reports and clinical and basic science research. Develop and continue ongoing basic science and clinical studies designed to evaluate and improve care of the critically ill. Administrative Evaluate, modify and approve ICU hospital policies. Improve resource utilization and maintain patient care quality by planning for future needs for institutional and regional critical care resources. Develop programs and change unit, institution, an d regional practice to improve care of critically ill patients. PICU Hours 175 161 159 140 156 152 Secondary PICU Hours 158 155 166 142 162 160 Non-clinical Hours 73 74 97 96 88 63 Total Hours 406 390 422 378 406 375 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Sept 1994 - March 2006 Participants in PICU Educational Experience Program Thomas Jefferson University Pediatrics PGY2 234 Christiana Care Emergency Medicine 169 Thomas Jeferson University Emergency Medicine 143 Christiana Care Medicine Pediatrics 39 Medical Student 45 Alfred I duPont Hospital for Children ER Fellow 5 Pediatric Critical Care Nurse Practitioner Student 4 Thomas Jefferson University Pediatrics PGY3 3 Christiana Care Trauma Fellow 3 Thomas Jefferson University Anesthesia 2 Philadelphia College of Osteopathic Medicine St Luke's Hospital ER Resident 1 Thomas Jefferson PGY6 1 Tod Children's Hospital Resident 1 PICU residents’ ICU experiences before starting PICU rotation 100 TJU PediatricsMedicine - Pediatrics TJU ERChristiana ER PICU NICU Adult CCU Adult SICU Adult Trauma ICU U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Residents’ Intubation Experience before starting PICU rotation Residents’ Experience with Central Venous Line Placement in Children before starting PICU Rotation 100 TJU Pediatrics Medicine - Pediatrics TJU ERChristiana ER Intubation 1yr Intubation 1 yr Intubation adult 2 4 6 8 10 12 14 16 % TJU Pediatrics Medicine - Pediatrics TJU ERChristiana ER Int Jugular Subclavian Femoral U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Residents’ Experience with Central Venous Line Placement in Adults before starting PICU rotation 100 TJU Pediatrics Medicine - Pediatrics TJU ERChristiana ER Int Jugular Subclavian Femoral U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Residents’ Experience with Chest Tubes in Ch ildren and Adults before starting PICU rotation Residents’ Experience as Pediatric Code Leader and with Pediatric Code Procedures before starting PICU rotation 100 TJU Pediatrics Medicine - Pediatrics TJU ERChristiana ER Chest tube child Chest tube adult 2 4 6 8 10 % TJU PediatricsMedicine - Pediatrics TJU ERChristiana ER Code Leader Defibrillation Cardioversion External Pacer U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Residents’ Experience with A dult Code Procedures before starting PICU rotation Residents’ Self reported Comfor t Level with Evaluating and St abilizing a Critically Ill Child Before Starting PICU Rotation ( 0= no comfort…10 =independent ) 10 20 30 40 50 60 70 80 90 % TJU Pediatrics Medicine - Pediatrics TJU ERChristiana ER Defibrillation Cardioversion External Pacer TJU Pediatrics (102) Medicine - Pediatrics(24) TJU ER (58)Christiana ER (72) Number U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Residents’ Goals Prior to PICU Resident Rotation at Alfred I du Pont Hospital for Children 2005-6 n=13 2004-5 n=11 2003-4 n=27 2002-3 n=38 2001-2 n=39 2000-1 n=49 1999- 2000 n=53 1998-99 n=49 Procedures 4 5 11 16 22 25 30 26 Run a Code 4 2 4 17 15 14 20 20 Recognize and stabilize critically ill child 4 4 10 10 13 25 25 15 Manage pediatric critical care patients (critical care support) 6 5 13 18 9 18 23 25 Pediatric critical care drug familiarity 1 1 2 7 7 8 9 9 Learn Ventilators 2 1 8 5 3 8 5 Familiarity with specific critical care topics: Respiratory failure, Sepsis, DKA, Ingestion, Trauma, Seizure, Head Injury 3 5 3 1 8 5 6 Gain Comfort with Critically Ill Child 3 2 3 3 2 2 1 5 Handle problems that may see in an ER 1 2 3 Post op complications 1 2 2 2 physiology in children 1 3 1 1 Be able to discuss PICU sequelae with families in my practice 1 2 Deliver Bad News to families 1 1 1 Learn Arrythmias 1 1 Difficult airway 1 Stabilize for Transport 1 1 1 Invasive cardiopulmonary monitoring 2 Ventilator support for chronic vent dependent children 1 Familiarity with children with chronic medical issues 1 1 Organizational skills in PICU 3 Critical eval of article 1 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Residents’ Learning Preferences Prior To PICU Rotation 100 TJU Pediatrics Medicine - Pediatrics TJU ERChristiana Medical student Ask attending questions Direct patient care Daily rounds with attending Mock drill scenarios Check a medical textbook Formal Lectures Do a medline search Give a talk Formal Reading Program 10 70 80 % Ask attending questions TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER Medical student U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 100 Direct patient care TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER Medical student 10 20 60 70 % Daily rounds with attending TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER Medical student U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 10 20 30 40 50 60 % Mock drill scenarios TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER Medical student 10 20 30 40 50 60 70 % Check a medical textbook TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER Medical student U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 10 20 40 50 % Formal Lectures TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER Medical student 10 20 40 50 % Do a medline search TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER Medical student U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 10 20 40 50 % Give a talk TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER Medical student 10 20 40 50 % Formal Reading Program TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER Medical student U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 PICU Rotation Curriculum July 2005 – June 2006 PICU rotation web site U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Smith's Recognizable Patterns of Human Malformation 5th edition, 1997 Short Introduction to PICU Handouts that describes educational format and responsibilities. Logs for primary patients, procedures, duty hours Pre-rotation questionnaire Visiting residents receive Cerner and Novell computer training on day 1. Interactive teaching rounds T 0730. Case based discussions during morning multidisciplinary patient-care rounds. Critical care attending is available for resident supervision during the day and night. Critical care mentor is assigned to each PICU resident Radiology XRAY reviews in PICU daily Monday-Friday at 1030. PICU Mock Code each Friday at 1100. Critical car e physician directs the Mock Code; PICU nurse educators supply equipment and coordinate nursing and respiratory availability. Respiratory therapy provides a session on ventilators. The Alfred I duPont Hospital for Ch ildren medical librarian attends PICU patient care rounds each Friday. Evidence-based Journal Club monthly. Residents are asked to pick a PICU problem, ask a fo cused clinical question, search the medical literature and evaluate the validity, results and applicability of the findings to their patient. Copies of the resident’s critically appraised topic are forwar ded to their residency program . PICU residents present a PICU patie nt to hospital morning report on the second Tuesday and the third Thursday of each 4-week rotation block. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Orientation To PICU Resident Rotation Nemours Alfred I duPont Hospital for Children Principle Clinical Responsibility Examine your primary patient before mornin g and afternoon patient care rounds and frequently throughout the day and night if the child is unstable. Keep critical care physician updated with any changes in your primary patient’s condition. Know the general clinical course and plan of all PICU patients. Principle Educational Objective At the end of your PICU rotation, be able to recognize and stabilize a critically ill child or adolescent who presents with Acute Respiratory Failure Hemodynamic Instability Acute Neurologic insults Acute electrolyte and endocrine disorders Coagulation disorders Overdoses & Poisonings Patient Care: Resident Responsibilities PICU morning rounds begin at 0730 on week-days and 0800 on Sat/Sun and Holidays. It is expected that residents will examine their primary patients & collect necessary data before rounds. Residents will write a daily SOAP note on their primary patients. Name must be printed as well as signed at end of all notes and orders. Please do not pre-date transfer summaries Residents will put their names next to the critical care attendings’ names on the PICU room board for those primary patients that they are following. In the interest of patient continuity of care, before leaving for clinic, seminar or home, residents must check out in detail the updated clinical course of their primary patients with the resident who is designated on-call and the critical care attending. On Sat/Sun and Holidays, the on-coming resident and the resident from night call are each responsible for examining and collecting data on half the PICU patients before rounds and (username:picu /password:resident) in this order: Administrative Issues General Information Patient Responsibilities Order Entry (If write orders, need to place your Beeper number under your name) Transfer Out of PICU Algorithm Surgical NICU Coverage by PICU Rotation Resident Code Blue Difficult Airway Cart Presenting Patients on PICU Rounds Goals Curriculum U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 PICU Resident Education The primary PICU educational pro cess focuses on interactive teachin g during patient care rounds and ongoing bedside discussions with the critical care attending regarding on-going patient care. Additional educational resources incl ude Mock Codes, monthly journal cl Mentor One of the critical care physicians is assigned to a reside nt as a mentor. This is an informal process that provides the resident with an additional contact during the PICU rotation. Passwords Nemours Users Guides In teractive (UGI) Desktop Username: Password: Jeffline, Thomas Jefferson University on-line Medical Library Campus Key: Password: Username Password ISite PACS (Radiol : (http://172.25.100.152/default.asp) Username: Password: SCCM post-PICU rotation Password Nemours Users Guides Interactive (UGI) Desktop and follow directions for downloading. Those who do not have a password can also go to the above URL and Register. Tab Double Click the Bell on the desk for a Tour describing the basic Vividesk technology and an introduction to the on-line Users’ Guides To The Medical Literature Activities Tab U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Tab Search Engines: PubMed, Ovid, ACP Journal Club, Cochrane Library. MD Consult (includes access to Nelson’s Pediatrics, Harriett Lane). Practice Guidelines Journals (Connection to Journals via Jeffline). Article and Search Requests from Dela ware Academy of Medicine Library ( http://www.delamed.org which is located in the Library icon. Th e FAX number for the PICU is 302-651-5460. LexiComp (Alfred I duPont Hospital for Children Formulary) Micromedex. PedsCCM .(http:www.PedsCCM.org), Pediat ric Critical Care educational resources Tab Users’ Guides To The Medical Literature textbook. Learning Modules: Review Asking Questions, Aquiring Evidence, Appraising Therapy Search Engine instructions Calculators for evidence-b ased clinical practice Personal Evidence Project (Help with doin g a Critically Appraised Topic on-line) Practice PICU Rotation PICU Artic le Collection Resource Pediatric Lectures Radiology Review PedsCCM web site Epic Web connection Monitoring Activities During their first week, residents are asked to comp Contact Edward J.Cullen Jr., D.O. Phone: 302-651-5159 / email: ecullen@nemours.org Revised 10/3/05 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Expectations for PICU Residents reg arding Safe, Quality Patient Care Residents are members of our multidisciplinary team caring for critically ill or injured children and adolescents during their PICU rotatio n. They also are responsible for the provision of safe and effective patient care. Residents are supervised by Critical Care Physicians (Day & Night) during their training period in the PICU. It is expected that residents will interact profe ssionally with the nurses, respiratory therapists, unit clerks, consultants and families in the ongoing care of the children in the PICU. It is expected that residents will know the history and main clinical issues for each patient in the PICU It is expected that residents will examine assigned patients before formal rounds. It is expected that residents will examine their patie nts frequently throughout their hours in the PICU and that they will interact with the critical care ph ysician with any changes in the patients’ clinical It is expected that residents will learn and use ou r process for presenting patients on formal rounds It is expected that residents be prepared fo r and fully participate in patient care rounds. It is expected that residents will have a basic knowledge of the medical issues affecting the patient they are presenting on rounds It is expected that residents will exchange up-to-date patient information with on-coming day or night resident(s) It is expected that residents will not give verbal orders. It is expected that residents will learn and utilize the PICU Order Entry Algorithm on patients admitted to the PICU from the ER, Transport, home or Acceptance Notes for children transferred from OR, PACU or general hospital area. It is expected that residents will assist with discharge of patients to other facilities or home It is expected that residents will assist in co mmunicating patient updates to referring physicians. It is expected that residents will be acquainted with hospital Code responsibilities and review PALS algorithms for pulseless arrest , bradycardia, tachycardia with poor & adequate perfusion. It is expected that residents will be acquainted with the PICU Difficult Airway Cart U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Unit Clerk/Aide, Department of An esthesiology and Critical Care Each morning, Monday through Friday, checks a PICU patient printout from the power chart organizer. On Mondays, a check is also done for PICU patients present on the preceding Saturday and Sunday. Notes on a Physician Assignment –Tracking of PICU Patients Form when the child was admitted and where they were admitted from to unit clerk: (Signature/Date/Time) Accept and Transfer Medical Service Order Transfer Medical Services to ( ) Transfer to Service of ( ) Accepting Physician ( ) Contact accepting team resident wh en patient arrives on accepting unit U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Transfer to a Surgical Service with a General Pediatric Consult: PICU resident will directly c ontact the resident covering the surgical service to tell them that the child is now leaving the PICU. PICU resident will call the Pediatric Admitting Resident at 426-4800 Pediatric Admitting Resident will relay the information about the patient to the general pediatric consult attending and resident team involved. PICU Resident removes any specific PICU orders that not longer pertain to the patient’s care PICU Resident writes a Transfer Note in the patient's chart PICU Resident will give a pre-printed order form to unit clerk: (Signature/Date/Time) Accept and Transfer Medical Service Order Transfer Medical Services to ( ) Transfer to Service of ( ) Accepting Physician ( ) Contact accepting team resident wh en patient arrives on accepting unit.. PICU Resident will again speak to Admitting Resident about the clinical status of the patient when the child actually leaves PICU. Admitting Resident will update the appropr iate interns / residents on the general pediatrics accepting service. PICU resident will directly contact the Pediatric Admitting Resident at 426-4800. PICU resident gives the Pediatric Admitting Resident the information about the patient. Pediatric Admitting Resident will tell the e of the accepting service and the acce pting physician. Pediatric Admitting Resident relays the information about the patient to the new Interns and residents on accepting serv ice will discuss the patient’s status and care with the designated accepting attending. Pediatric Admitting Resident may direct the PICU Resident to also contact the senior U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 or Pediatric Subspecialty Service PICU Resident will notify the Pr ivate Pediatrician or Pediatri c Subspecialty Physician that the child is leaving the PICU PICU resident will directly contact the Pedi atric Admitting Resident at 426-4800 with the Service and name of Private Pediat rician or Pediatric Subspecialist Patient’s clinical course The Pediatric Admitting Resident will te which resident is covering the private pediatrician or pediatric subspecialty physician PICU Resident reviews the patient ’s clinical course with t will cover the patient on the private pediatrician or pediatric subspecialty service. PICU Resident writes a Transfer Note in the patient's chart PICU Unit Clerk will: Enter the resident written accept and transfer order into Cerner under the appropriate sections. Place a Transfer Cecklist on the front cover of the patient’s chart When the child is actually leaving the PICU. Contact the Admitting Resident (426-4800) Confirm with Admitting Resident that Se ysician are still the same Service and Accepting Physic ian as originally reported. If the Service or Accepting Physician ha s changed, the unit Clerk is to make the appropriate changes in Cerner. Have the Admitting Resident speak directly with the PICU Resident The individual patient’s PICU Nurse will U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 The Hospital Nursing Supervisor will: Contact the PICU Charge Nurse wh en the accepting room is ready. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Pre-Printed Form Accept And Transfer Medical Service Accept and Transfer Medical Service Order Transfer Medical Service to ( ) Transfer to Service of ( ) Accepting Physician ( ) Contact accepting team resident when patient arrives on accepting unit. Signature/Date/Time: U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Transfer Checklist Transfer to ___Surgical service Accepting physician name__ ___Surgical service with pediatric consult Accepting physician name__ ___General Pediatric service Accepting physician name__ ___Private Pediatrician service Accepting physician name__ ___Pediatric medical subspecialty service Accepting physician name__ ___ Admitting resident notified ___General surgery, neurosurgery, orthopedic, urology, ENT or Plastics resident notified ___Nursing Supervisor notified ___Accept and Transfer Medical Service order has been entered into Cerner ___Specific PICU orders that no longer pertain to U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Monthly Maintenance Plans Week Things to do Monday resident Resident ID PICU Profiles Exiting resident PICU Evaluations Resident Evaluations SCCM Post Test Primary Patient Data Hours U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Week Things to do Monday Ilene Sivikoff prepares initial draft of the PI CU resident rotation curriculum for next month rotation . After the draft is reviewed and approved by Dr Cullen, Ilene sends the next month’s curriculum to PICU Curriculum Distribution List Ilene Sivikoff enters attending c linical teaching days for present rotation period in data base Ilene Sivikoff enters scheduled lectures for the new month rotation in data base Dr Cullen enters the following in the PICU resident data base as they are done Mock Codes Interactive PICU Teaching Rounds Additional educational activity pe rformed by critical care physicians U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Week Things to do Monday, Tuesday, Wednesday Obtains Cerner training date / password for new residents as needed Notifies Stentor that resident will n eed access during time frame provided Obtains Jeffline password for visiting resident if needed Ilene Sivikoff prepares folder for new resident(s) U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Week Things to do Monday U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 July, August, September, October Dr Cullen will update PICU Resident Rotation Nemours site http://www.nemours.org/no/aidhc/picu/index.html November Ilene Sivikoff prepares mailing list of resident s who have been in PICU recently and are now out December Ilene Sivikoff mails surveys to residents. Self addressed mailing envelope also included in order to send back survey Dr Cullen enters survey data into PICU resident data base April, May, June Dr Cullen and Ilene Sivikoff prepare a Review of PICU Resident Rotation and Preparation of Goals / Curriculum for next academic year Dr Cullen updates PICU Resident Rotation Nemours site http://www.nemours.org/no/aidhc/picu/index.html U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Alfred I. duPont Hospital For Children Pediatric ICU Rotation Pre-Rotation Questionnaire Name PGY2 PGY3 TJU Pediatric Residency Program MCD ER TJU ER Other 1. Have you had any pervious ICU experience? Pediatric: Neonatal: Adult: MICU___ CCU___ SICU___ Trauma ICU___ 2. Which of the following procedures have you had experience with? If experience with infants and children, mark (P). If experience with adults, mark (A). Intubation of infant 1 year _____ Intubation of children 1 year and adolescents Intubation of adults Use of muscle relaxants for intubation Central Line Placement Internal Jugular Subclavian Femoral Vein Radial Femoral Posterior tibial Dorsalis pedis Chest tube placement Pigtail chest tube placement Emergency defibrillation Elective cardioversion _____ External pacemaker 3. Have you ever been in charge of an actual pediatric resuscitation? 4. In an actual infant or pediatric resuscitation, have you EVER personally provided: (Circle all that apply) a. Chest compressions U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 provided: (Circle all that apply) a. Chest compressions 8. You learn a new medical topic best by: Participating in daily unit rounds with an attending physician Formal lectures Asking attending physicians direct questions about present patients care Formal reading program that covers basic topics in the field of study Looking up the answers to your questions in a recent medical textbook Reviewing critically recent literatu re on pertinent patient problems as they arise during you r rotation (medline searches) Participating in mock drills regarding patient care scenarios Direct patient care with as many patients as possible Give a talk about what you are trying to learn U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 How comfortable do you feel evaluating and stabilizing a critically ill child. Scale: 0 = No exposure to base a decision on. 10 = Full independence 0 1 2 3 4 5 6 7 8 9 10 10. How comfortable do you feel recognizing and initially managing critically ill children with the following problems? Scale: 0 = No exposure to base a decision on. 10 = Full independence Acute respiratory Failure 0 1 2 3 4 5 6 7 8 9 10 Hemodynamic instability 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 Acute Neurologic Insults 0 1 2 3 4 5 6 7 8 9 10 Acute electrolyte and endocrine disorders 0 1 2 3 4 5 6 7 8 9 10 Acute renal failure 0 1 2 3 4 5 6 7 8 9 10 Coagulation disorders 0 1 2 3 4 5 6 7 8 9 10 Overdoses and Poisonings 0 1 2 3 4 5 6 7 8 9 10 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 11. Please carefully look over all the nine profiles below, which describe your ideal pediatric critical care experience regarding resident clinical supervision, resident procedural supervision, the teaching format and the resident evaluation process. Then rank all the profiles from 9 (best) to 1 (worst). Profile Clinical Procedural Teaching Style Resident Evaluation Rank Independent after Tightly structured with Scheduled formal lectures Oral interview with demonstrating ability close superv ision with prep reading attending Tightly structured with Fl exible with Independent study Oral interview with close supervision superv ision program attending Tightly structured with Tightly structured with Interactive patient rounds Essay response close supervision close supervision with attending to case scenarios Flexible with Independent after Interac tive patient rounds Oral interview with supervision demonstrating ability with attending critical care attending Flexible with Tightly structured with Independent study Presentation supervision close supervision program Flexible with Flexible with Scheduled lectures, Essay response supervision supervision reading preparation to case scenarios Independent after Independent afte r Independent study Essay response demonstrating ability demonstrating ability program to case scenarios Tightly structured with Independent after Scheduled lectures, Presentation close supervision demonstrating ability reading preparation Tightly structured with Flexible with Interactive patient rounds Presentation close supervision supervision with attending U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Critical Care Practice Pattern Surve --- 1 yr ---1-3 yr specialty? U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 6. How confident do you feel that you will be able to recognize and initially stabilize are the primary physician who must deal with childr present with the problems? U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 the primary physician who manages children and adolescents with the following acute, life threatening problems until they are ready from discharge from the hospital? Please circle for each problem below. Y=YES N=NO Cardiopulmonary Arrest Multiple Trauma Preoperative and postoperative management of pediatric surgical patients in the tubation and mechan Upper airway obstruction from Septic shock Hemodynamic instability requiring various Coma Intracranial hemorrhage Increased intracranial pressure monitoring and management Status epilepticus requiring multiple IV anticonvulsants iovascular and Acute renal failure Coagulation disorders such as DIC or thrombosis Child with Multiple Organ System Dysfunction Provide Sedation, Analgesia, and Neuromuscu lar Blockade to the Critically Ill ng central hyperalimentation U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 you request from the critical care attendings if you could do the one month second year resident PICU rotation at Alfred I. duPont Hospital for Children over again? 11. What additional course work or practicums have you taken that address pediatric U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Percent residents who performe d intubations in the PICU 5 10 15 20 25 30 45 % 012345 Number of Intubations TJU Pediatrics (86) Medicine -Pediatrics (16) TJU ER (54) Christiana ER (59) U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Percent residents who placed femora 5 10 25 30 35 40 % 01234567 Number pf femoral venous lines TJU Pediatrics (86) Medicine -Pediatrics (16) TJU ER (54) Christiana ER (59) 100 01234 Number of internal jugular venouslLines TJU Pediatrics (86) Medicine -Pediatrics (16) TJU ER (54) Christiana ER (59) U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Percent residents who placed subcl 100 012 Number of subclavian venous lines TJU Pediatrics (86) Medicine -Pediatrics (16) TJU ER (54) Christiana ER (59) U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Percent residents who placed ches 100 012 Number of chest tubes placed TJU Pediatrics (86) Medicine -Pediatrics (16) TJU ER (54) Christiana ER (59) Percent residents who performed defibrillations during the PICU 100 0123 Number of defirillations TJU Pediatrics (86) Medicine -Pediatrics (16) TJU ER (54) Christiana ER (59) U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Percent residents (n=215) who performed cardioversion during PICU rotation 0% Percent residents who performed extern 100 Number of external pacing TJU Pediatrics (86) Medicine -Pediatrics (16) TJU ER (54) Christiana ER (59) U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Percent residents who particip Percent residents who ran a pediatric code during the PICU rotation 100 012 Number ran a pediatric code TJU Pediatrics (86) Medicine -Pediatrics (16) TJU ER (54) Christiana ER (59) 10 20 30 40 60 70 % 012345 Number of pediatric code participation TJU Pediatrics (86) Medicine -Pediatrics (16) TJU ER (54) Christiana ER (59) U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 % correct TJU Pediatrics (69) Medicine -Pediatrics (11) TJU ER (38) Christiana ER (45) Medical student (17) U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 ng initial recognition and stabilization of a critically ill child 10= independence … 1=no confidence 5 10 15 20 25 30 35 % 10987654321 Comfort level post PICU TJU Pediatrics (80) 10 20 30 40 60 % 10987654321 Comfort level post PICU Medicine -Pediatrics (14) U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 TJU ER (46) 10987654321 Comfort Level post PICU Christiana ER (53) 10987654321 Comfort Level post PICU U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Voluntary self reported data from resid ents at the end of their PICU rotation Resident overall evaluations of PICU Rotation – Average scores on Likert Scale 4. Exceeds Expectations 1994 1995 1996 1997 3.4 3.75 3.4 1998 3.3 2.7 2.9 3.1 1999 3.3 3.0 3.5 3.3 2000 3.6 3.25 3.1 3.0 2001 3.4 4.0 3.1 2.7 2002 3.5 3.0 3.0 3.0 2003 3.25 3.0 3.0 2004 2005 2006 Combined 2004, 2005, 2006 Data from Pediatric Residency Program Forms - Evaluation of PICU Rotation: Overall score given to rotation (1) weak- (5) average rotation - 10( great rotation) (1) Poor (2)(3) Average (4)(5) Excellent Balance of service and education Overall organization of the rotation U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Residents’ comments about PICU Rotation 1997 Thomas Jefferson Pediatrics I feel I learned a great deal and gained c linical confidence. I woould like to do more. Great learning, Attending good I am very happy with the rotation and would recommend increasing the number of blocks scheduled here vs NICU. I am confident all other residents concur with the idea. Very little teaching this mont h-formally or informally. had expected a rotation strong in experience and t eaching/learning. Wish I could do additional time instead of so much NICU. I'm much more comfortable with certain types of patients now (eg DKA, Septic shock) Thomas Jefferson Emergency Medicine I feel that I've learned a lot in my 5 weeks and that the teaching was excellent. Highly recommend. Wonderful experience Excellent overall rotation. Excellent teach ing and involvement with attendings. Thank you for all your help and teaching. I really enjoyed and learned much from my month here. Except for the computer, I had a great time Christiana Care Emergency Medicine I had a very diverse and nice experience - thank you U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Christiana Care Medicine Pediatrics The rotation would be more solid an experience if there were discussions in either topics or complicated patients. There seemed to be minimal education in rounds; most of the day was spent trying to find things to do, with 6 residents on service. 1999 Thomas Jefferson Pediatrics Excellent lectures by attending ! Dr Cullen, shock and Dr Hertzog on rounds. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 2001 Thomas Jefferson Pediatrics Need more time! 4 weeks out of 36 months is unreasonable. Thomas Jefferson Emergency Medicine Except lack of procedures. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Residents comments -Strongest assets of PICU rotation The acuity. The atendings. Teaching by attending during rounds. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 PICU Resident overall evaluations of critical care attendings – average scores on Likert Scale 4. Exceeds expectations 1994 1995 1996 1997 1998 1999 2000 2001 3.8 3.6 3.5 2002 3.7 3.0 3.6 3.3 2003 3.1 3.0 2004 2005 2006 Cullen Thomas Jefferson Christiana Care MedPeds Thomas Jefferson Emergency Medicine Christiana Care Emergency Medicine 1994 1995 1996 1997 3.0 3.0 3.4 1998 3.4 4.0 3.6 3.7 1999 3.3 3.7 3.6 3.0 2000 3.2 3.3 3.1 3.3 2001 3.7 2.3 3.6 2002 3.5 3.0 3.6 3.0 2003 3.6 3.0 2004 2005 2006 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 Hertzog Thomas Jefferson Christiana Care MedPeds Thomas Jefferson Emergency Medicine Christiana Care Emergency Medicine 1994 1995 1996 1997 1998 1999 3.5 3.5 4.0 3.3 2000 3.4 3.25 3.3 3.3 2001 3.6 3.0 3.5 3.3 2002 3.4 3.0 3.3 3.4 2003 3.3 4.0 3.0 2004 2005 2006 Thomas Jefferson Christiana Care MedPeds Thomas Jefferson Emergency Medicine Christiana Care Emergency Medicine 1994 1995 1996 1997 1998 1999 3.7 4.0 3.9 4.0 2000 4.0 4.0 3.9 3.7 2001 3.5 4.0 3.75 4.0 2002 4.0 4.0 3.8 4.0 2003 4.0 4.0 4.0 2004 2005 2006 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 100 Effective Teacher – Ranking: 1 2 3 4 5 (best) Costarino Cullen Hertzog Penfil teacher 3.53 3.72 4.26 4.95 Overall rating of attending – 2004 Average score (1) weak (5) average (10) great Costarino Cullen Hertzog Penfil 6.57 7.32 8.12 9.6 Evaluation of attending PICU physician – 2005 Average score (1) Poor (2)(3) Average (4)(5) Excellent Burns Binck Costarino Cullen Hertzog Penfil Quality of 3 1.7 4.2 2.2 4.0 4.6 evaluation 3 1.7 4.0 2.8 4.0 4.6 Amount of teaching done by attendings (1) is not enough (2) just right (3) too much U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 101 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 102 self reported need to perform cardiopulmonary resuscitation on a child N=never D=daily W=w eekly M=Monthly Y=yearly child for respiratory failure during N=never D=daily W=w eekly M=Monthly Y=yearly 10 20 30 40 50 60 70 80 % NDWMY TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER 10 20 30 40 % NDWMY TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 103 orted need to treat a child with septic shock during their first year of practice N=never D=daily W=w eekly M=Monthly Y=yearly 10 20 30 40 50 60 70 % NDWMY TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 104 PICU participating residents (n=194) self reported need to manage a child with increased intracranial pressure monitoring during their first year of practice N=never D=daily W=w eekly M=Monthly Y=yearly 10 20 30 40 50 60 70 80 90 % NDWMY TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 105 PICU participating residents (n=195) self reported need to manage a child with multiple organ system dysfunction N=never D=daily W=w eekly M=Monthly Y=yearly 10 20 30 40 50 60 70 80 % NDWMY TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER reported need to place a central venous 10 20 30 40 50 60 70 80 90 % NDWMY TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 106 orted need to place a chest tube in a child during their first year of practice N=never D=daily W=w eekly M=Monthly Y=yearly 10 20 30 40 50 60 70 80 90 % NDWMY TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 107 reported need to defibrillate a child N=never D=daily W=w eekly M=Monthly Y=yearly 100 NDWMY TJU Pediatrics Medicine -Pediatrics TJU ER Christiana ER U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 108 on from residents (n=205) who are in their first year of practice More time with practicing intubation (in the OR if necessary) - in particular while maintaing in line U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 109 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 110 Even though I don't use the skills I learned in the PICU, I think it is very important to have learned them. It's important to be able to recognize a critically il l patient and to understand how they are treated, As a general pediatrician we educate parents about PICU care even if we don't perform it. Review EKGs more often. Discuss the basics of monito ring similar to discussion we had with respiratory therapy and ventilators. Part of one da U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 111 More intubations in older kids. Very pleased with PICU / ER training. More exposure to mock codes/codes, acute problems and less exposure to chronically sick kids with tracheostomy management. Since my needs will be for office stabilization,more exposure or code drills (mock) to better prepare for More experience treating trauma patients (if possible). More emphasis on conscious sedation guidelines Excellent overall month. Could probably have used more procedures. Excellent rotation. Continue Mock Codes. More procedures would be good. Acute (ED) dia gnosis and management of infants/neonates with U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 112 None I would not change anything about the rotation. The critical care attendings were great and I learned a tremendous amount which I use in practice on a daily basis. A longer rotation ! I loved the AI experience. It was a great rotation. I learned a lot in 1 month. More mock codes! Great tool. It was a gr eat experience. I had a great time at A.I. Pediatric ventilator management. Procedure lab. Adequate training provided in the 4 week block - no suggestions. More teaching about the basic acute ca re of "normal" children as opposed to care of chronic problems with chronically ill children. More procedures to be done by by residents and fellows instead of attendings while residents and fellows round. More acutely ill children from the ED as opposed to post-operative patients. Designated time in OR for intuba tions.More practice with IV access incl uding central lines. More time in NICU. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 113 Peds anesthesia for more intubations. More procedures. More mock codes. More simulations. Mock codes were great, but 1-2 x were cancelled; woul d like to have these mock codes at least 2x a week. More intubations. More critical procedures (central lines, chest tubes) More procedures and independent thinking. I think that the only thing to enhance the educational experience would be to spend more time in the PICU at duPont. More mock codes but not in such a formal setting. More airway management. Overall, great rotation. More Mock Codes More intubations - if not in PICU, in OR with anesthesia supervision. Continue Mock Codes or increase their frequency. Give residents the opportunity to have more input into critical care decisons with patients More hands on experience Patient volume limits procedure experience. Good mix of pathology More central lines. ICU rotation at AIDI is excellent. Not having fellows is a huge advantage. I would expand ventilator management and go through pediatric procedures. Otherwise, don't change a thing! More Mock Clinical Scenarios More teaching on acute stabilization of pediatric patients. It was an educational rotation Less post op. Patients & feeders/growers. I would like more training in acutely medically ill children, but with the numbers of patients, I know this is difficult in the one-month period. The biggest problem with the PICU rotation was that the majority of procedure opportunities were performed by the critical care attending without the re sident being allowed to attempt the procedure-the patients were deemed "too irritable". More intubations in the OR. Less time on the topic of ventilator management-too mu U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 114 I don't know that I would change anything. My present clinical situation may change but at least I've had a solid education. I felt like I needed more intubation experien ce, but I'm not sure how to increase that. More intubation, more ventilator management. Overall, my experience was excellent with you guys. More chest tubes, arterial lines. Spend a few days in the OR with McCloskey learning oral elective intubations More practice scenarios-clinical situations. Nothing. I feel it was an excellent experience. Few times per week, intensive discussion on critical care issues: DKA, increased ICP. Going through the cases in books provided for PICU rotation (they were excellent books). More PALS didactics. Don't turn us into clerks and just have us input orders. If you don't trust us, stay in house and work with us but let us be active in patient care and decision making. Perhaps ore didactic teachi ng since many pediatric critical illness situ ations occur so infrequently that they cannot be learned from experience alone. More experience with initial management of life th reatening illnesses or at least discussion and case scenarios Need more practical pr ocedural experiences. The rotation was well organized. Some of the learning was based on the clinical experience based on how sick the patients were - cannot be controlled. More procedure practice, including intubations. More procedures More independence in caring for the critically ill. Less time siting at the computer putting in orders for the attending. For ER resident, there are too many chronic children there. Encourage independent thinking and autonomy. More hands on procedures. Mock codes More PALS simulations. More didactic and skill sessions on procedures. Simulation. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 115 More intubation experience in the OR (probably not enough volume in PICU alone for this). More EKG U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 116 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 117 PICU Publications regarding PICU resident education U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 118 Cullen EJ, Lawless ST, Corddry DH (sponsored by John Stefano): Pediatric Anesthesiology/Critical Care, Critical Care Medicine received the Alfred I. duPont Division Teaching Award by the 2002-2003 Pediatric House Staff for excellence and commi tment to resident education. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 119 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 120 Financial Sources for Resident Teaching Physicians Nemours Foundation 10% of Nemours Physician salaried hours are expected to be spent in educational activity. Nemours Foundation provides a separate educational fund. Nemours practice site CEOs and department chairpersons distribute these funds to further support Nemours physicians’ educational activities. It is not known how much is actually available for PICU resident education . There is no specific RVU equivalent for educational activity. Graduate Medical Education Payment Program Centers for Medicare and Medicaid Services, Hea lth Resources and Services Administration, DME) funds directed towards resident salaries , physician teacher comp ensation and educational material. Hospital for Children receives no IME allotment for residents rotating in our PICU from non-pediatric programs. Historically, the DME allotment for PICU physicia ns to teach PICU residents at Alfred I duPont Hospital for Children is not available after you subt ract resident salaries from the available DME. Pediatric 2003;112(1):40-48 Multidisciplinary Team PICU Pharmacists, PICU Nurses and Nursing St aff Development, PICU Respiratory Therapists and Medical Reference Librarian participation in PICU resident teaching is covered by their respective cost centers. Educational Materials The Department of Anesthesiology & Critical Care, Alfred I duPont Hospital for Children provides funds for critical car e textbooks and other educational material as needed. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 121 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 122 of the PICU Resident Training Program 22-bed Medical & Surgical family oriented PICU unit Board certified pediatric critical care physicians Multidisciplinary patient care approach Pediatric critical care physician as ro le models and as supervisors of residents during the day and most of the night. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 123 of the PICU Resident Training Program Present GME payments do not fund pediatric critical care physician compensation for resident supervision and educational efforts. Funding for PICU nursing and respiratory therapy support is voluntary. There is lack of sufficient time to intr oduce residents to the PICU rotation. Large part of first PICU day for visiting resi dents is spent in computer training labs. Residents spend too much time entering orders through the Cerner computer entry system. Resident autonomy. Lacking a procedural lab for residents. Case based learning opportunities for residents not very formalized. As number of critical care physicians increases, strive to maximize formal resident educational experiences and mentoring concept. Participate in a Patient Simulation Lab being developed at Alfred I duPont Hospital for Children. The Nemours Foundation initiative with the Centre for He alth Evidence is establishing a clinical Nemours Desktop that will be able to track clinical activity a nd the pursuit of education around that activity. There is the potential for linking education and patient outcomes. Become more active with SCCM pediatric cr itical care resident educational committee. Coordinate PICU educational activity and resources with the proposed Nemours Children’s Hospital in Orlando, Florida. Become a national leader in providing PICU resident education. to the PICU Resident Training Program Educational activities do not produce RVU revenue. If the PICU resident educational experience was fully funded, funding could be lost if one could not show U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 124 How do we align PICU resident medical education with desired PICU health U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 125 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 126 PICU Rotation Curriculum July 2006 – June 2007 Suggestions for PICU Resident Rotation Curriculum for July 2006-June 2007 Pediatric resident PICU rotation is now 8 weeks during the PL2 year. The PICU rotation for Thomas Jefferson ER, Christiana ER, Christiana EMIM, Christiana Medicine- Pediatrics residents remains at 4 weeks. Residents and medical students from visiting programs will be considered for PICU rotations as long as there are not too many residents so that patient contact is not diluted for the scheduled residents. PICU rotation web site U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 127 Textbook of Pediatric Emergency Medicine Ludwig Fleisher Toxicologic Emergencies Lewis R. Goldfrank Toxicology Frord/Delaney/Ling Erickson The Pharmacologic Approach to Critically Ill Patients Chernow, Third Edition Principles and Practice of Intensive Care Monitoring Tobin Smith's Recognizable Patterns of Human Malformation 5th edition, 1997 Residents are given a short introduction to PICU on day 1. Residents are asked to complete a pre-PICU rotation questionnaire on-line. They are given handouts which describe the PICU educational format and responsibilities. They receive their Logs for primary patients, procedur U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 128 Residents are encouraged to ask focused clinical questio ns about patient care issues that arise during patient care rounds. They are encouraged to use the available re sources to search the most recent medical literature and evaluate the validity, results and applicability to th eir patients. This information can be shared during or after patient care rounds. If a resident does a formal critically appraised topic on a specific focused clinical question, consideration will be given to sending this to the pediatric residency program. The pediatric residency program in collaboration with the Centre for Health Evidence is starting a collection of pediatric critically appraised topics . Radiologist reviews PICU radiology studies in the PICU daily Monday-Friday at 1030. Night call residents are expected to be in the PICU no more than 30 hours from the time they arrived the day before. Residents will document what topics they have reviewed . (Handout with topics and a check box with room for comments.) PICU Mock Code each Friday at 1100. A designated cr itical care physician who is different from the PICU service physician directs the Mock Code; PICU nurse educators supply equipment and coordinate nursing and respiratory availability. All Mock Codes are docum ented in our PICU Resident Rotation Data Base. Respiratory therapy provides a session on ventilators. The Alfred I duPont Hospital for Ch ildren medical librarian attends PICU patient care rounds each Friday. Evidence-based literature reviews are emphasized. Evidence-based Journal Club is held monthly. This is prepared by the critical care attendings and fellows. Journal clubs are documented in the PICU Resident Rotation Data Base. PICU residents present a PICU patie nt to hospital morning report on the second Tuesday and the third Thursday of each 4-week rotation block. It is the responsibility of the PICU residents to designate which resident will present the chosen patient. Pediatric critical care attendings and fellows are encourag ed to give any formal l ectures they wish to the residents. Documentation of this extra educational activity should be emailed to DR Cullen who will enter the information into our PICU Resident Rotation Data Base. PICU residents, fellows , medical students, nurses and attending physicians can suggest the addition of pertinent articles to our PICU Article Collection. Request can be made to Dr Cullen who maintains this site at present. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 129 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 130 Considerations for Future Plans Continue to integrate SCCM Pediatric ICU Resident Education Committee recommendations into the Resident PICU curriculum. Continue to investigate the use of MedRite, Cerner and Epic in order to produce a computerized PICU patient care progress note that can be shared by residents, attendings, nurses, respiratory therapy, consultants and medical students. Continue to support the development of a simulati on lab in order to practice pediatric critical care scenarios, PICU mock codes, and selective critical care procedures. Develop mentor system into a program where individual needs of PICU residents are recognized and learning experience is optimized. This would require ad U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 131 Orientation To PICU Resident Rotation Nemours Alfred I duPont Hospital for Children Principle Clinical Responsibility Examine your primary patient before mornin g and afternoon patient care rounds and frequently throughout the day and night if the child is unstable. Keep critical care physician updated with any changes in your primary patient’s condition. Know the general clinical course and plan of all PICU patients. Principle Educational Objective At the end of your PICU rotation, you should be able to recognize and initially stabilize critically ill child or adoles cent who presents with Acute Respiratory Failure Hemodynamic Instability Cardiopulmonary arrest Acute Neurologic insults Acute electrolyte and endocrine disorders Coagulation disorders Overdoses & Poisonings Expectations for PICU Residents to ensure Safe, Quality Patient Care It is expected that residents will: Interact professionally with th e nurses, respiratory therapists, unit clerks, consultants and families in the ongoing care of the children in the PICU. Know the history and main clinical issues for each patient in the PICU Examine assigned patients before formal rounds. Examine their patients frequently throughout their hours in the PICU and that they will interact with the critical care ph ysician with any changes in the patients’ clinical course. Learn and use our process for presen ting patients on formal rounds Be prepared for and fully participate in patient care rounds. Have a basic knowledge of the medical issues affecting the patient they are presenting on rounds Exchange up-to-date patient information with on-coming day or night resident(s) Will not give verbal orders. Will learn and utilize the PICU Order Entry Algorithm Assist with discharge of patients to other facilities or home Assist in communicating patient updates to referring physicians. Be acquainted with hospital Code responsibilities and review PALS algorithms for pulseless arrest, bradycardi a, tachycardia with poor & adequate perfusion. Be acquainted with the PICU Difficult Airway Cart U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 132 Housekeeping Issues PICU morning rounds begin at 0730 on week-days and 0800 on Sat/Sun and Holidays. It is expected that you will examine their primar y patients & collect necessary data before rounds. Please do not pre-date transfer summaries Residents will put their names next to the critical care attendings’ names on the PICU room board for those primary patients that they are following. In the interest of patient continuity of care, before leaving for clinic, seminar or home, residents must check out in detail the updated clinical course of their primary patients with the resident who is designated on-call and the critical care attending. On Sat/Sun and Holidays, the on-coming resident and the resident from night call are each responsible for examining and collecting data on half the PICU patients before rounds and General Information Patient Responsibilities Order Entry (If write orders, need to place your Beeper number under your name) Transfer Out of PICU Algorithm Surgical NICU Coverage by PICU Rotation Resident Code Blue Difficult Airway Cart Presenting Patients on PICU Rounds Goals Curriculum The PICU Resident Rotation Web Site can be accessed at: (username:picu /password:resident) U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 133 PICU Resident Education The primary PICU educational pro cess focuses on interactive case-ba sed teaching during patient care rounds and ongoing bedside discussions with the critical care attending regarding on-going patient care. Additional educational resources incl ude Mock Codes, monthly journal cl Mentor One of the critical care physicians is assigned to a reside nt as a mentor. This is an informal process that provides the resident with an additional contact during the PICU rotation. Passwords Nemours Users Guides Interactive (UGI) Desktop Username: Password: Jeffline, Thomas Jefferson Univ ersity on-line Medical Library Campus Key: Password: Username Password ISite PACS (Radiol http://172.25.100.152/default.asp or http://stentor) Username: Password: SCCM post-PICU rotation Password Nemours Users Guides Interactive (UGI) Desktop and follow directions for downloading. Pediatric residents who have a Nemours email address can receive a password through this site under Registration. U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 134 Nemours Desktop Resources Browser Tab Double Click the Bell on the desk for a Tour describing the basic Vividesk technology and an introduction to the on-line Users’ Guides To The Medical Literature Activities Tab PICU Resident Rotation web site PICU Article Collection PICU Lectures Stentor acces to radiology studies (in hospital only) Tab Practice Guidelines Search Engines: PubMed, Ovid, ACP Journal Club, Cochrane Library. MD Consult (includes access to Nelson’s Pediatrics, Harriett Lane). Journals (Connection to Journals via Nemours Jeffline). PedsCCM Pediatric Critical Care educational resources Tab Users’ Guides To The Medical Literature textbook. Learning Modules: learn evidence based clinical practice at your own pace. Instructions on searching various medical search engines. Calculators for evidence-b ased clinical practice Personal Evidence Project (Help with doin g a Critically Appraised Topic on-line) Practice LexiComp (Alfred I duPont Hospital for Children Formulary) Micromedex. Epic Web connection Textbooks available in PICU Third Edition Fuhrman/Zimmerman Pediatric Critical Care Medicine Slonim / Pollock Pediatric Intensive Care, Third Edition Mark C. Rogers The Difficult Pediatric Airway Anesthesiology Clinics of North America Jalil Riazi, MD, Editor 1999 Management of Pediatric Trauma Buntain U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 135 Critical Heart Disease in Infants and Children Nichols, Cameron, Greeley, During their first week, residents are asked to comp Contact Edward J.Cullen Jr., D.O., Pediatric Critical Care Medicine Phone: 302-651-5159 email: ecullen@nemours.org Revised 6/7/06 U/Ecullen/Word/Educatio/Resident/Reports/PICUresidentreviewapril2006 136