CCU

Educational Purpose:  The educational purpose of this rotation is to provide fellows with the knowledge and skills necessary to diagnose and manage acute cardiac conditions requiring critical care management such as decompensated heart failure, hypertensive emergencies, acute myocardial infarct, acute coronary syndromes, aortic dissection and other common cardiac conditions encountered by the general internist and cardiologist.  Rotation in the CCU at JMH, VAMC, and UMH are assigned during the first and/or second years.  The educational goals are the same, independent of year of rotation and hospital; however, at UMH, the CCU rotation enriches the learning opportunities for fellows with direct experience in the postoperative care of cardiac surgical patients.  

Overall Goals:
To be competent in the provision of comprehensive care in patients diagnosed with common cardiac disease requiring intensive care unit setting, including cardiac surgical patients.  (COMPETENCIES: patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning, systems-based practice)
To learn how to apply evidence-based, cost conscious strategies to diagnose and manage hospitalized patients in acute cardiac unit, including cardiac surgical patients. (COMPETENCIES: patient care, medical knowledge, practice-based learning)
To learn to function as a member of a multidisciplinary team treating critically ill patients, including cardiac surgical patients. (COMPETENCIES: patient care, professionalism, interpersonal and communication skills, systems-based practice)
To be able to participate in family meetings and be an effective communicator (COMPETENCIES: Interpersonal and communication skills, professionalism)
To have an understanding of utilization of resources and appropriate levels of care in patients with common cardiac disorders in the critical care unit, including cardiac surgical patients. (COMPETENCIES: medical knowledge, practice-based learning, systems-based practice)

Competency-Based Learning Objectives:
Function as effective team leaders and teachers in caring for critically ill patients. (COMPETENCIES: patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning, systems-based practice)
Demonstrate competency in history and physical examination of patients with common cardiac conditions. (COMPETENCIES: patient care, interpersonal and communication skills)  
Discuss the diagnosis and management of patients with the cardiac conditions and complaints listed below. (COMPETENCIES: medical knowledge, interpersonal and communication skills)
Demonstrate the organizational skills necessary to supervise the care of patients in the coronary critical care unit.  (COMPETENCIES: patient care, practice-based learning, system-based practice)
Effectively cross-cover other patients on the critical care service when other team members are not available (COMPETENCIES: professionalism, patient care, interpersonal and communication skills)
Function effectively as a member of a multidisciplinary team (COMPETENCIES: interpersonal and communication skills, professionalism, system-based practice, patient care)
Demonstrate effective communication with patients, families, colleagues and staff (COMPETENCIES: communication and interpersonal skills, professionalism)
Demonstrate ability to oversee effective discharge planning from the intensive care unit to the step-down telemetry unit.  (COMPETENCIES: patient care, medical knowledge, systems-based practice)
Demonstrate an understanding of the indications and contraindications for various types of procedures, including hemodynamic invasive monitoring with Swan-Ganz catheters, arterial catheter monitoring, intra-aortic balloon pump, ventricular assist devices, temporary pacing, central lines and ventilator support. Continue to develop proficiency in interpretation of EKG’s and demonstrate working knowledge and management of common cardiac disorders and complaints. (COMPETENCIES: patient care, medical knowledge, systems-based practice)

Medical Knowledge:
Fellows should be proficient in identifying and interpreting the following elements of the physical examination:
o Blood pressure – pulses paradoxus, orthostatics
o Pulse examination – venous pulsations (JVD, hepatojugular reflux, v-waves) and arterial (carotid, femoral, and pulse character), etc
o Palpation – LV impulse (locate and characterize), thrill, RV heave
o Auscultation – identify and perform extra-maneuvers in the following
Regurgitant murmurs (AI, MR, TR)
Stenotic murmurs (AS, MS)
HCM
S3 and s4 
Split s2
A2 comparison to P2
Pericardial rub
Midsystolic click
Fellows will be proficient in the diagnosis and initial management of the following complaints/disorders:
o Chest pain and acute coronary syndromes (Unstable angina, NSTEMI, and STEMI)
o Acute myocardial infarction including indications for acute reperfusion therapy with thrombolytics and/oracute angioplasty
o Decompensated heart failure (systolic and diastolic) including indications for hemodynamic monitoring, inotropic support, or mechanical circulatory support
o Tachyarrhythmias including both supraventricular (atrial fibrillation, atrial flutter, atrial tachycardiac, AVNRT, AVRT, etc) and ventricular (VT, VF, etc)
o Bradyarrhythmias including indications for temporary pacing
o Acute valvular heart disease or decompensation of chronic valvular disease
o Pulmonary emboli
o Aortic dissection
o Pericardial disease (tamponade, acute pericarditis, etc) including indications and techniques for percutaneous drainage of pericardial effusion in the emergent setting
Fellows will develop proficiency in the interpretation of EKGs with the following conditions:
o Acute MI, atrial fibrillation, supraventricular tachycardia, ventricular tachycardia, AV blocks (1st, 2nd, 3rd degree), pericarditis, LVH, etc
Fellows will appropriately order and understand the indications and contraindications, as well as complications associated with the following tests/procedures:
o Central line placement
o Arterial line placement
o Cardiac catheterization
o Intra-aortic balloon pump
o Swan-Ganz catheter
o Temporary transvenous pacemakers
o Emergency pericardiocentesis

Goals & Objectives by PGY Level:
PGY 4:
1.   Function as effective team leaders and teachers in caring for critically ill patients. 
2.   Demonstrate competency in history and physical examination of patients with common cardiac conditions. 
3.   Discuss the diagnosis and management of patients with the cardiac conditions and complaints listed below
4.   Demonstrate the organizational skills necessary to supervise the care of patients in the coronary critical care unit.  
5.   Demonstrate effective communication with patients, families, colleagues, staff, and other members of an integrated care team
6.   Demonstrate an understanding of utilization of resources and appropriate levels of care in patients with common cardiac disorders in the critical care unit and demonstrate ability to oversee effective discharge planning from the intensive care unit to the step-down telemetry unit.  
7.   Demonstrate an understanding of the indications and contraindications for various types of procedures, including hemodynamic invasive monitoring with Swan-Ganz catheters, arterial catheter monitoring, intra-aortic balloon pump, temporary pacer, central lines and ventilator support. 
8.   To learn to function as a member of a multidisciplinary team treating critically ill patients, including post-operative cardiac surgical patients.  

PGY 5:
1.   Further build upon the skills, goals and objectives developed in PGY 4 year.

Mix of Diseases:  Fellows will be exposed to patients with a wide range of cardiac conditions including but not limited to acute coronary syndrome (UA, NSTEMI, STEMI), heart failure, cardiogenic shock, arrhythmias, pulmonary embolism, aortic dissection, pericardial disease, and valvular heart disease.  Patients cared for will be over the age of 18 and will be well balanced in terms of male and female patients.  Pregnant patients with acute cardiac conditions will also be encountered.

Teaching Methods:
Patient-Centered Teaching/Learning:  Case based teaching will take place in the patient’s room and/or during the presentation to the attending. Emphasis will be placed on the approach and evaluation of the patient complaint, evidence based medicine, as well as means to efficiently search for answers to clinical questions.  Fellows are expected to identify knowledge gaps and search for answers to their questions on a routine basis.   
Conferences/Didactic Learning: Fellows are expected to attend the Division of Cardiology Fellows’ Core Curriculum Lectures given throughout the academic year in addition to the departmental Grand Rounds.  Wednesday morning clinical conference will be held at 8am for the CCU at Jackson Memorial Hospital.

Procedures:  Fellows will perform appropriately focused history and physical exams based on the clinical presentation.  They will increasingly develop proficiency in several procedures including:
o Central and arterial line placement
o Swan-Ganz catheter insertion and monitoring
o Temporary transvenous pacemaker placement
o Cardiac catheterization
o Intra-aortic balloon pump placement and monitoring
o Emergency pericardiocentesis
o Management of ventricular assist devices (percutaneous or otherwise)

Pathologic Material/Educational Resources: 
The fellows will review EKGs, chest X-rays, cardiac catheterizations, CT scans, stress tests and echocardiograms as indicated by the patient’s cardiac condition.  They will also routinely review telemetry monitoring on patients under their care.
Up to Date: http://www.uptodate.com/home/index.html
Harrison's Principles of Internal Medicine: http://www.accessmedicine.com/resourceTOC.aspx?resourceID=4
PubMed: www.ncbi.nlm.nih.gov/pubmed/ 

Text books:  Cardiology textbooks are available in the Hospital Library and the Calder Medical Library.
Institutional access for http://www.cardiosource.org  and CardiosourcePlus with ACCSAP7.

Evaluations: Fellows will be evaluated by their supervising attending physician(s) using a competency-based system on New Innovation.  Feedback will be provided during and at the end of the rotation.

Supervision Policy: Direct/Indirect with direct supervision immediately available.

Team Structure: 
One supervising attending
One cardiology fellow
Team residents
o JMH  = 3 (sometimes 4) 2nd and 3rd year residents
o VAMC = 1 resident and 2 interns
o UMH = 3 (sometimes 4) 2nd and 3rd year residents, 1 intern
Observers and visiting students may at time participate in the team structure

Attending Responsibilities:
Supervises and assumes ultimate responsibility for the care of the patients on the service.
Conducts daily rounds with the team during which he/she reviews clinical information, formalizes management plan, and performs patient-centered teaching.
Responsible for providing verbal and written feedback to the fellow

 Fellow Responsibilities:
Participates in daily rounds and shares responsibility with the attending for seeing that care plans are implemented appropriately for all patients in the CCU
Provide immediate supervision of medical care provided to patients in the CCU by both the housestaff and nurses
Provides assistance and supervision of all invasive procedures performed in the CCU and the documentation of that procedure in the patient’s medical record
Play an educational role for housestaff and other members of the integrated care team and assist with any research projects within the CCU
Assist the resident teams in determining patients appropriate for CCU level of care
The fellow is expected to keep the CCU attending informed of any major changes in a patient’s condition or treatment and must reach out to the supervising attending should any questions arise
At JMH, the fellow will be responsible for preparing interesting cases and didactics for discussion at the Wednesday Morning Report held at 8:00am in the Central 4 conference room
At UMH, the fellow will be responsible for rounding and writing notes on the post-cardiac surgery patients along with the attending and communicating with the primary surgical team
Provide appropriate sign-out to the fellow on-call in the evenings and weekends.

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