Critical Care Unit

Critical Care Unit Competency Based Curriculum


Critical care medicine involves caring for the most acutely ill patients with a broad range of clinical problems and is often best achieved by adopting a team approach consisting of the general internist and critical care specialist or cardiologist as well as other subspecialists as indicated. Residents must learn to recognize critical illness and facilitate timely transfer of patients to the Intensive Care Units, but must also learn to allocate these limited resources appropriately to those patients most likely to benefit from this level of care. Residents will need to gain experience and a level of comfort in dealing with numerous difficult ethical and social issues including the initiation and withdrawal of life-support measures, advance directives, determination of brain death, and organ transplantation.

Principal Teaching/Learning Activities

-ICU Conferences (ICU)--Conferences will be held 2-3 times a week to discuss didaictic topic related specifically to the care of the critically ill patient. (see schedule at end of curriculum)

-Sign-out Rounds (SR) -- Every evening, Monday through Friday, the the senior residents (Chief Resident, or his/her designate will be present during the first few months of the academic year), supervise sign-out rounds, which are attended by the out-going day team and incoming ADMITTING team. These may include topical discussions.

-Attending/Management Rounds (AR) -- Each day the Attending physician responsible for care of patients on this service will meet with the residents to evaluate all patients and review plans for patient management. It will be on these occasions that residents are supervised in presentation skills, knowledge of patient, details of recordkeeping, interaction with other healthcare team members, communication with consultants and family members, and all other aspects of patient management.

-Grand Rounds (GR) -- Medical Grand Rounds are held each Wednesday from 8:00 -9:00 a.m. in the Medical Center Auditorium. Formats vary and include invited guests/visiting professor presentations, clinical-pathological conferences, morbidity and mortality conference, resident presentations, or other didactic, topical, or patient related topics.

- Turnover Rounds (TR)-- Turnover rounds occur at the end/beginning of each rotation and from 6:30- 7:30 a.m. daily. These facilitate transfers of patient care from one resident to another. (Sign in Rounds are a daily version of turnover rounds.)

-Autopsy Rounds (AuR) When a death occurs on any of the teaching teams the family is offered the option of performing an autopsy. If an autopsy is performed, we hold a multidisciplinary presentation of the findings that includes medicine, pathology, radiology, surgery, and/or ob/gyn residents and faculty that were involved.

-MKSAP study pan (MKSAP)-This self directed study plan helps residents stay on track with their didactic reading and helps them evaluate their medical knowledge (strengths and areas of deficit). Residents can help develop individualized study plans to fill in any knowledge gaps and reinforce what they already know. This also helps residents develop skills and habits needed for lifelong learning.

-In-Training Examination (ITE) -- All of our residents must take this examination annually for their own assessment of progress and for edification. When examination results become available, the program director discusses these individually with residents and counsels residents about individualized study programs to facilitate their acquisition of knowledge.

Description of Rotation/Assignment

Senior residents and interns are assigned to the ICU each month are. They may be assigned to work either day time or night time shifts. Patient care responsibilities are exclusively to patients in the medical ICU. These are supervised by patients' individual attending physicians. It is anticipated that increasingly patient care will become the primary responsibility of full-time intensivists. Daily multidisciplinary teaching rounds are made under the direction of a member of the attending staff usually with specialty training in pulmonary medicine or intensive care; these are distinct from management rounds.

Interns should arrive each morning sufficiently early to be intimately familiar with their patients for work rounds at c. 7:00 a.m. This will include reviewing graphic sheets, events of the preceding evening, and being familiar with all new admissions, diagnostic information, and therapeutic interventions; interns must be prepared to comprehensively present their patients on work and attending rounds. Senior residents have a responsibility to provide didactic information appropriate to individual patients' problems to their interns. They are expected to have relevant medical literature each morning to use to supplement discussion of patient management.

Work rounds will commence not later than 7:00 each morning. The senior residents serve as the team leaders. Whenever possible these rounds will be multidisciplinary in nature, incorporating all health personnel participating in the care of individual patients. This will include but need not be limited to nurses, respiratory therapists, social workers, nutritionists, case managers, discharge planners, and certainly attending physicians and consultants. Rounds will be made together, with the intensivist, as a team, assuring that all patients are seen and that all members of the team have familiarity with the problems of all patients in the unit. Work rounds must be made efficiently-- and it is for that reason that interns must be familiar with their patients prior to the beginning of work rounds. This is a time when it is essential that the residents, as a team, communicate with patients' attending physicians, and consultants as well as all of the ancillary medical staff involved in their care.

Teaching rounds, under the supervision an attending physician will occur daily. These rounds will be both patient care related and didactic in nature. They must include presentation and discussion of each patient, at the bedside.

Formal "sign-out" rounds are scheduled at 4:30 each afternoon; these should be supervised. All residents attend this session. During this time individual patients are reviewed, daily events assessed, and pertinent information passed on to the resident covering that evening. In addition, time will be set aside during this session for brief didactic discussion of topics according to the schedule enclosed.

A core ICU lecture series is held during the month. Resident attendance is expected.

Students, at 3rd and 4th year levels, will be incorporated into all of these activities. Their progress notes cannot be the official progress notes of record. This means that residents should countersign student notes but must record their own assessments. Students, by New Jersey Statute, are not permitted to write orders. They are encouraged to use a duplicate but unofficial order sheet to do so, for educational purposes, but these cannot be part of the permanent record.

It is required that residents acquire competence in certain procedures. Therefore the senior residents, together with interns, must aggressively and assertively insist on learning and doing all procedures on all patients under their care. Fellows, when present, can surely facilitate this. Similarly it is expected that residents will write all orders for all patients under their care. A reading and reference list will be appended.

Goals and Objectives

  1. The resident will need to understand the approach to and establish competence in the management of the following clinical presentations in the intensive care unit:
    • Acute abdominal pain
    • Acute chest pain
    • Acute intoxication
    • Acute liver failure
    • Acute renal failure
    • Altered mental status, coma
    • Hypotension, shock
    • Life-threatening arrhythmia
    • Massive gastrointestinal bleeding
    • Massive hemoptysis
    • Respiratory distress or failure
    • Severe hypertension
    • Status epilepticus
    • Multi organ failure
  2. The resident should understand and be capable of interpreting the following:
    • Hemodynamic monitoring
    • Telemetry monitoring
    • Arterial blood gases
    • Pulse oximetry
  3. Procedures

    Residents will learn, as appropriate to individual patients, the indications and contraindications and performance of those medical procedures required by the American Board of Internal Medicine and Residency Review Committee.

    The resident will have opportunity to develop competence in some or all the following procedures under direct supervision of a faculty member, fellow, or resident who is competent to teach the procedure:
    • Advanced cardiac life support
    • Arterial puncture for arterial blood gas
    • Bedside pulmonary function
    • Mechanical ventilation (basic)
    • Placement of arterial and central venous lines
    • Placement of nasogastric tube
    • Placement of pulmonary artery catheter
    • Insertion of temporary pacemaker
    • Placement of endotracheal tube


Assessment Methods (of Resident)

The evaluation methods that apply to these rotations include some or all of the following:

  • Evaluation of resident competence by faculty attendings (AE)- Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.
  • Mini CEXs may be used when warranted, particularly in the beginning of the academic year (CEX).
  • Self-evaluation by In-service training examination scores (ITE).
  • MKSAP study plan (MKSAP)
  • Participation and presentations at didactic conferences (DC)
  • Multi Source evaluations by patients and staff (MS)

Assessment Method (of Program)

Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.

Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.

Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.

Principle Educational Goals by Relevant Competency

In the tables below, the principle educational goals for the Faculty Inpatient Service rotation are indicated for each of the six ACGME competencies. The second column of the table indicates the most relevant principle teaching/learning activity for each goal, using the legend below.

* Legend for Learning Activities/Evaluation tools
AE-Attending Evaluations
AR- Attending Rounds
AuR- Autopsy Rounds
CEX-mini CEX
DC-resident participation/performance in didactic conferences
DPC-Direct Patient Care
GR- Grand Rounds
ICU-ICU conferences
ITE-In-Training Exam
MKSAP-Knowledge Self Study Plan
MS-Multisource evals
SR- Signout Rounds
TR-Turnover Rounds

1.) Patient Care

Goals and Objectives: PGY-1 Learning Activities* Assessment
Master basic patient interviewing skills DPC, AR, ICU AE, MS, CEX
Master basic patient exam skills DPC, AR, ICU AE, MS, CEX
Master basic psycho-social evaluation skills DPC, AR, ICU AE, MS, CEX
Define and prioritize patients' medical problems DPC, AR, ICU AE, MS, CEX
Generate and prioritize differential diagnoses DPC, AR, ICU AE, MS, CEX
Develop rational, evidence-based management strategies DPC, AR, ICU AE, MS, CEX
Goals and Objectives: : PGY-3 (in addition to above) Learning Activities* Assessment
Efficiently and effectively direct the initial evaluation and continued management of patients requiring hospitalization including appropriate discharge planning. DPC, AR, ICU AE, MS, CEX
Complete obtainment of certification in required Internal Medicine procedures. Supervises junior trainees in these procedures once certified to teach DPC, AR, ICU AE, MS, CEX
Systematically obtains and reviews all prior/obtainable medical records pertinent to patient care. DPC, AR, ICU AE, MS, CEX
Understands significance of all diagnostic test results affecting patient care. DPC, AR, ICU AE, MS, CEX
Clinical judgment – makes informed decisions using risk/benefit analysis based on sound scientific evidence, patient performance after informed consent and consultation with consultants and more senior physicians (attending). DPC, AR, ICU AE, MS, CEX
Begin to function as independent primary care givers DPC, AR, ICU AE, MS, CEX

2.) Medical Knowledge

Goals and Objectives: : PGY-1 Learning Activities* Assessment
Read and expand clinically applicable knowledge base of the basic and clinical sciences DPC, AR, ICU, MKSAP, GR AE, MS, MKSAP, DC
Access and critically evaluate medical information and scientific evidence relevant to patient care DPC, AR, ICU, MKSAP, GR AE, MS, MKSAP, DC
Goals and Objectives: : PGY-3 (in addition to above) Learning Activities* Assessment
Develop medical knowledge about each patient illness so as to be able to make independent decisions based on scientific evidence and patient preference. DPC, AR, ICU, MKSAP, GR AE, MS, MKSAP, DC
Demonstrates knowledge by leading discussions on areas of pathophysiology concerning patient care including ongoing management of hospitalized patients. DPC, AR, ICU, MKSAP, GR AE, MS, MKSAP, DC
Demonstrates ability to access information from 3 different sources and to synthesize sources into an indepth understanding. DPC, AR, ICU, MKSAP, GR AE, MS, MKSAP, DC
Develop medical knowledge adequate to practice independently DPC, AR, ICU, MKSAP, GR AE, MS, MKSAP, DC

3.) Practice- Based Learning and Improvement

Goals and Objectives: : PGY-1 Learning Activities* Assessment
Identify and acknowledge gaps in personal knowledge and skills DPC, AR, ICU, ITE, MKSAP AE, MS, MKSAP, DC
Develop and implement strategies for filling gaps in knowledge and skills DPC, AR, ICU, ITE, MKSAP AE, MS, MKSAP, DC
Accepts guidance from more experienced physicians and uses scientific evidence and practice outcomes for practice improvement. DPC, AR, ICU, GR AE, MS, DC
Readily acknowledges practice omissions (errors) determined by self or supervisors and takes corrective measures. DPC, AR, ICU AE, MS
Goals and Objectives: : PGY-3 (in addition to above) Learning Activities* Assessment
Continues to progressively reduce practice omissions/commissions from R-1, R-2 levels. DPC, AR, ICU AE, MS
From medical knowledge and patient care experiences is able to question patient care practices not supported by scientific evidence/evidenced based care. DPC, AR, ICU, GR, MKSAP AE, MS, MKSAP
Develop PI skills to use in independent practice DPC, AR, ICU AE, MS

4) Interpersonal Skills and Communication

Goals and Objectives: : PGY-1 Learning Activities* Assessment
Communicate effectively with patients and families DPC, AR, ICU AE, MS, CEX
Communicate effectively with physician colleagues at all levels DPC, AR, ICU AE, MS, CEX
Communicate effectively with all non-physician members of the health care team to assure comprehensive and timely care of patients DPC, AR, ICU AE, MS, CEX
Present patient information clearly, in notes and during presentations DPC, AR, ICU AE, MS, CEX
Goals and Objectives: : PGY-3 (in addition to above) Learning Activities* Assessment
Successfully communicate with patients and families that may be considered difficult (angry, anxious, etc) advanced level DPC, AR, ICU AE, MS, CEX
Become fascicle at discussing difficult issues such as end of life care and delivering bad news DPC, AR, ICU AE, MS, CEX
Effectively teach students and junior trainees to improve their communication skills DPC, AR, ICU AE, MS, CEX

5) Professionalism

Goals and Objectives: : PGY-1 Learning Activities* Assessment
Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues while maintaining confidentially. DPC, AR, ICU AE, MS, CEX
Always act in a moral, honest professional manner, and maintain appropriate relations with patients. DPC, AR, ICU AE, MS, CEX
Respect and defend each patient's autonomy and privacy and always act in the patients' best interest DPC, AR, ICU AE, MS, CEX
Goals and Objectives: : PGY-3 (in addition to above) Learning Activities* Assessment
Understand the principles of moral and ethical behavior required of an independent practitioner DPC, AR, ICU AE, MS, CEX
Become familiar with actual or potential conflicts of interest; particularly those involving personal financial gain. DPC, AR, ICU AE, MS, CEX

6) Systems-Based Practice

Goals and Objectives: : PGY-1 Learning Activities* Assessment
Understand and utilize the multidisciplinary resources necessary to care optimally for patients DPC, AR, ICU AE, MS
Collaborate with other members of the health care team to assure comprehensive patient care DPC, AR, ICU AE, MS
Use evidence-based, cost-conscious strategies in the care of patients DPC, AR, ICU AE, MS
Goals and Objectives: : PGY-3 (in addition to above) Learning Activities* Assessment
Develop lifelong strategies to optimize care for individual patients as an independent practitioner DPC, AR, ICU AE, MS

Reference List

*All residents are expected to read about their patients in an appropriate general medicine text. In addition, a vast variety of print and on-line reference material is available through the library (24-hour access for all residents) and the on-line portal. Specific reading material will be recommended and/or distributed during rounds. Because it is frequently updated, extensively referenced, and includes abstracts of reference articles, the program highly recommends UpToDate as an adjunctive information source. MDConsult is also a valuable resource and residents should become familiar with use as a rapid search engine for clinical information.

1. The ICU Book by Paul Marino
2. MKSAP- Pulmonary and Critical Care.
3. Useful Websites