Goals and Objectives, Unit Anesthesia, CA-1 year UCSD DEPARTMENT OF ANESTHESIOLOGY SURGICAL INTENSIVE CARE UNIT ANESTHESIA GOALS AND OBJECTIVES, CA-1 YEAR PATIENT CARE: To provide the resident with clinical experience in the anesthetic management of adults and pediatric surgical patients that is compassionate, appropriate, and effective With assistance, conduct an efficient, focused, and comprehensive preprocedure/pre-anesthetic evaluation, including history, physical exam, and review available studies, under both elective and emergent conditions, for adult patients clinic, Preoperative holding area Lecture, Skill demonstration, Practice and feedback Recognize, with assistance, when appropriate subspecialty consults are needed, (i.e., cardiology, pain management) clinic, Postoperative care unit, Unit Lecture, Practice and feedback, Simulation Recognize with assistance when additional studies to establish a diagnosis or evaluate severity are appropriate clinic, Postoperative care unit, Surgical Intensive Care Unit Lecture, Practice and feedback, Simulation Assign an accurate ASA classification clinic, Preoperative holding area Lecture, Practice and feedback, Simulation With supervision, develop a patient-specific management plan, with a reasonable alternate plan, for adult patients at all levels ASA classification, for both elective and emergent procedures; the plan should include consideration of pre-existing medical issues and patient requests, anticipate possible intraoperative difficulties and pursue strategies to prevent possible postoperative complications clinic, Preoperative holding area Lecture, Skill demonstration, Practice and feedback, Simulation, Practice oral exam Perform safe, efficient, timely and accurate pre-anesthetic checks of all pertinent equipment and supplies (such as anesthetic machines, compressed gas cylinders, airway management supplies, monitors, suction, medications, invasive devices, etc.), Skill demonstration Consistently demonstrate vigilance and attention to detail during all aspects of care, Simulation, Practice oral exam
PATIENT CARE: To provide the resident with clinical experience in the anesthetic management of adults and pediatric surgical patients that is compassionate, appropriate, and effective Consistently check the patient s identity, procedure to be performed, consent, and side to be blocked or operated on, when applicable Unit, preoperative holding area, Simulation Demonstrate competence in bag-mask ventilation, conventional laryngoscopy and endotracheal intubation, insertion and use of LMA s, and safe use of the anesthesia machine and or ventilators, Skill demonstration, Simulation Demonstrate knowledge and safe use of various infusion devices Unit, Skill demonstration With assistance, demonstrate competence in in placement of peripheral IV s in awake and anesthetized patients, including external jugular IV s and large caliber lines for rapid infusion, Skill demonstration With assistance, demonstrate competence in placing central lines, including IJ/EJ/subclavian approaches efficiently, safely and accurately, Skill demonstration With assistance, demonstrate competence in placing and managing of arterial lines and Swan-Ganz catheters, Skill demonstration Correctly use train-of-four nerve stimulation to guide safe and effective use of neuromuscular blocking agents and to measure effectiveness of reversal agents Unit, Skill demonstration With assistance, demonstrate effective and efficient patient care during induction of anesthesia, as well as during periods of instability in the course of the anesthetic care (i.e., surgical bleeding, patient co-existing disease exacerbation, drug reaction, or other crisis) Lecture, Practice and feedback, Simulation, Practice oral exam With assistance, interpret and responds appropriately to the information from patient monitors and laboratory data (including ECG, CO 2 waveform, CVP, PAC, I/O, ABG, Coag Panel, etc.) Lecture, Practice and feedback, Simulation, Practice oral exam Choose rational and appropriate blood product transfusion therapy. Recognize and treat transfusion-related complications Lecture, Practice and feedback, Simulation, Practice oral exam With assistance, transfer care of the patient after anesthesia/procedure to responsible party (PACU or ICU nurse, etc.) in a manner that ensures patients safety and comfort and continuity of care Postoperative care unit, Unit, Skill demonstration, Practice oral exam
PATIENT CARE: To provide the resident with clinical experience in the anesthetic management of adults and pediatric surgical patients that is compassionate, appropriate, and effective With assistance, effectively manage malignant hyperthermia, including asking for immediate assistance and delegating tasks in order to ensure rapid and coordinated treatment Simulation Suite Lecture, Simulation Demonstrate proficiency in the recognition and competence in all management of the critically ill SICU patients Unit Demonstrate adequate knowledge base to formulate a complete differential diagnosis, institute appropriate initial supportive safe care, and request subsequent consultation as appropriate Unit With assistance, formulate initial (resuscitation focused) plans that center on Airway, Breathing, Circulation, and Neurological Function Unit Perform safe, efficient, timely, and accurate evaluation of the major organ systems (e.g. neurological, cardiovascular, pulmonary, gastrointestinal, genitourinary, infectious disease, immunological, hematological, endocrinological, integumentary, orthopedic) and demonstrate knowledge of organ systems Unit
PATIENT CARE: To provide the resident with clinical experience in the anesthetic management of adults and pediatric surgical patients that is compassionate, appropriate, and effective With assistance, conduct an efficient, focused, and comprehensive neurological evaluation, including pupil exam, Glasgow coma scale, sedation analgesia scores, and delirium scores under both elective and emergent conditions, for all SICU patients Unit With assistance, conduct an efficient, focused, and comprehensive pulmonary evaluation support and monitoring, including a report of the patient s airway status, ventilatory support (F I O 2, ventilation mode, respiratory rate, tidal volume, arterial blood gas, pulse oximetry results) and work of breathing (spontaneous breathing trials, weaning parameters) under both elective and emergent conditions, for all SICU patients Unit With assistance, conduct an efficient, focused, and comprehensive gastrointestinal evaluation, including the method of prophylaxis against stress ulcers, as well as the ability of the patient to tolerate enteral nutrition, vs. needs for parenteral nutrition, general bowel function, nutritional indices, and liver function (and pancreatic function when appropriate) under both elective and emergent conditions, for all SICU patients Unit With assistance, conduct an efficient, focused, and comprehensive genitourinary function status report on the renal status, including urinary output, BUN/Cr, need for dialytic therapies, risk for renal insufficiency, etc. The electrolyte and acid/base status is partly controlled by the kidneys and reviewed with the renal system under both elective and emergent conditions, for all SICU patients Unit
PATIENT CARE: To provide the resident with clinical experience in the anesthetic management of adults and pediatric surgical patients that is compassionate, appropriate, and effective With assistance, conduct an efficient, focused, and comprehensive infectious disease issues evaluation, including presence of fever, WBC count, gram stain, culture and sensitivity data, along with antibiotics being administered under both elective and emergent conditions, for all SICU patients Unit With assistance, conduct an efficient, focused, and comprehensive endocrinological evaluation, including tight control of glucose with insulin infusions as needed. Serum cortisol, thyroid function and other parameters are measured on an as needed basis Unit Proficient in the management of difficult emergency and trauma airway. Proficient in use of the adult and pediatric fiberoptic bronchoscope (FOB) for intubation, evaluation of airways, secretion management, and checking position of single and double lumen tubes Unit Develop expertise in placement and exchange of tracheostomy tubes, use of other airway management equipment, changing the ETT of patients with both difficult airways and severe respiratory failure Unit
PATIENT CARE: To provide the resident with clinical experience in the anesthetic management of adults and pediatric surgical patients that is compassionate, appropriate, and effective Become proficient in use of standard modes of mechanical ventilation (MV) including CMV, A/C, SIMV and pressure support. Become proficient in newer modes of MV TCPCIRV, APRV, HFV (several subsets), prone ventilation and permissive hypercapnea. Unit Develop experience using inhaled nitric oxide in selected patients with elevated PVR or sever ARDS recalcitrant to standard therapy Unit Develop expertise at weaning techniques, and in the application of pulmonary mechanics Unit Develop aseptic techniques for changing lines over a wire when needed Unit
PATIENT CARE: To provide the resident with clinical experience in the anesthetic management of adults and pediatric surgical patients that is compassionate, appropriate, and effective Become proficient at floating a Swan-Ganz (pulmonary artery) catheter Unit Learn to trouble shoot artifact and abnormalities in the arterial pressure catherer, Swan-Ganz catheter, and other invasive devices (e.g. intraaortic balloon counter pulsation devices) Unit Develop experience using the TEE on selected patients Unit Become proficient in the interpretation and trouble shooting of invasive neurological monitoring devices (E.g. ventriculostomy, Camino ) Unit
PATIENT CARE: To provide the resident with clinical experience in the anesthetic management of adults and pediatric surgical patients that is compassionate, appropriate, and effective Be able to program and write orders for the PCA devices Unit Develop experience with placement of thoracic epidurals in patients with thoracic trauma Unit Become proficient in the management of the patient with polysubstance abuse and or chronic pain in the acute pain setting (SICU) Unit
MEDICAL KNOWLEDGE: To acquire the clinical and applied science knowledge pertinent to the management of the surgical patient. Describe anesthetic-induced changes in physiology and anesthetic implications of common medical problems in adults Exercise Describe the impact of surgical procedures on patient physiology Exercise Describe the pathophysiology of intraoperative events such as oligouria, hypotension, hypoxia, and cardiac rate and rhythm changes Exercise Describe the differences in pharmacologic properties of drugs within each drug class Describe properties of common drug, including induction agents, opioids, inhalational agents, neuromuscular blocking and reversal agents, pressors, beta blockers, vasodilators Identify risk factors and perioperative considerations in patients with common medical problems in adults (e.g. CAD, COPD, GERD, DM, RAD, Obesity) List indications for invasive monitoring Discuss fluid and blood product management in the perioperative setting
MEDICAL KNOWLEDGE: To acquire the clinical and applied science knowledge pertinent to the management of the surgical patient. Describe the anatomy of epidural and subarachnoid space Discuss etiology and treatment approaches for intraoperative events, such as hypotension, hypoxia, tachycardia and oligouria Identify risk factors for postoperative nausea, and describe methods of prevention Discuss etiologies of postoperative hypoventilation Discuss etiologies of postoperative delayed awakening Describe the mechanisms of acute pain and common perioperative treatment modalities The principles of neuro resuscitation, neuroprotection and monitoring for patients with spinal cord injury and closed head injury. In addition, the perioperative management of other common neurosurgical conditions including ischemic strokes, intracerebral hemorrhage, aneurysm, a-v malformation, and brain tumor. SICU, Independent Study
MEDICAL KNOWLEDGE: To acquire the clinical and applied science knowledge pertinent to the management of the surgical patient. Principles of acute hemodynamic management for common ICU problems including dysrhythmias, hemorrhagic shock, septic shock, myocardial ischemia, idiopathic cardiomyopathy, neurogenic shock, and hypertensive crisis. Principles and practice of emergency airway management. Including intubations using direct laryngoscopy, fiberoptic bronchoscopy (FOB), or other "awake" techniques. The indications for and techniques of FOB for sampling bronchioalveolar lavage (BAL) and to open collapsed lung segments. Pathophysiology and management of acute lung injury, respiratory failure and ARDS, (including ventilator associated pneumonia, aspiration pneumonia, pulmonary contusion). As well as the application of simple and advanced ventilation techniques. Principles of early enteral feeding vs. Total parenteral nutrition, as well as gut dysmotility problems, and pancreatitis. Pathophysiology of liver failure, current and newer therapies for liver failure. Pathophysiology of renal insufficiency and failure. Understanding the complex dialytic strategies including the benefits of continuous veno-veno hemodialysis (CVVHD) vs. intermittent HD. Principles of RBC and blood factor replacement strategies. Supplementation of erythropoietin and other tools to minimize transfusion therapy. Pathophysiology of thrombosis, and modern approach to DVT prophylaxis, early recognition and treatment of pulmonary embolism. Physiology of coagulation system, and pathophysiology of DIC. Principles of infectious diseases, immune system dysfunction, and antibiotic usage.
MEDICAL KNOWLEDGE: To acquire the clinical and applied science knowledge pertinent to the management of the surgical patient. The pathophysiology of multi-system organ failure. The mechanisms of trauma and burn injury.
PRACTICE BASED : To be able to investigate and evaluate their own patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Search and access published material, including on-line electroninc library textbooks and journals Conference, Independent Study, Surgical Intensive Care Unit Case based discussion, Journal club Case based discussion and evaluation, Understand EBM and integrate it into clinical practice Conference, Independent Study, Surgical Intensive Care Unit Case based discussion Case based discussion and evaluation, Summarize and present articles at Journal club Conference, Journal club Journal club presentation Case based discussion and evaluation, Practice self-evaluation and reflection Unit, Conference with faculty advisor Debriefing after case or simulation, Written self-evaluation Assessment of daily debriefing, Discussion and review of written selfevaluation Identify own strengths, deficiencies, and limits in knowledge and expertise Unit, Conference with faculty advisor Debriefing after case or simulation, Written self-evaluation Daily debriefing, Discussion and review of written selfevaluation Discuss and research relevant literature to support decision-making processes Preoperative Evaluation Clinic, Surgical Intensive Care Unit, Conference Case based discussion Case based discussion and evaluation Design (at least twice a year) own study and improvement plan Conference with faculty advisor Written self-evaluation Discussion and review of written self-evaluation Seek formative feedback on performance Unit Debriefing after case or simulation, Daily debriefing Present in quality improvement practices pertaining to patient care Conference Case based discussion Evaluation of presentation, Admit to and seek help in remedying errors Unit, Case based discussion
PRACTICE BASED : To be able to investigate and evaluate their own patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are provided with a list of recommended textbooks and a syllabus with recommended readings containing information not normally found in the textbooks. Most importantly, patient care plans and protocols are designed to reflect the most recent evidence based medicine recommendations, and the foundation for these protocols and algorithms are reviewed in the daily didactic sessions. Throughout the rotation resident performance will be evaluated by the attendings. Feedback occurs on a daily basis during clinical teaching, and patient care rounds, and well as during didactic sessions which are almost exclusively interactive and conducted in a seminar fashion. Residents receive feedback form the other members of the patient care team, and from the patient and their families as well. Conference, Independent Study, Surgical Intensive Care Unit Conference, Independent Study, Surgical Intensive Care Unit, daily didactic sessions, daily didactic sessions, Daily debriefing, Daily debriefing The faculty member completes a resident performance evaluation form at the end of each one-month block (residents do 2 one month blocks). The evaluation is based upon their experience with the resident, as well as from feedback received from other faculty and members of the patient care team who worked directly with the resident during the rotation. Conference, Independent Study, Surgical Intensive Care Unit, daily didactic sessions, Daily debriefing
INTERPERSONAL AND COMMUNICATIONS SKILLS: Be able to demonstrate communication skills that result in effective information exchange and appropriate interaction with colleagues, surgeons, patients, and ancillary personnel CA-1 resident must be able to identify all and demonstrate competence in some of the characteristics and skills listed below Maintain comprehensive, timely, and legible medical records Lecture and discussion, Unit, skill demonstration Review of anesthesia records Convey ideas and points effectively Unit, Conference, Simulation suite, Simulation, Practice oral exam Convey urgency but not panic in urgent/emergent situations, Simulation, Practice oral exam Encourage questions Preoperative Evaluation Clinic, Preoperative holding area, Surgical Intensive Care Unit Establish and maintain eye contact Preoperative Evaluation Clinic, Preoperative holding area, Surgical Intensive Care Unit Be approachable Preoperative Evaluation Clinic, Preoperative holding area, Surgical Intensive Care Unit, Postoperative care unit Know role in crisis Unit, Postoperative care unit, Simulation Suite, Skill demonstration Listen and allows others to feel heard clinic, Preoperative holding area, Surgical Intensive Care Unit, Postoperative care unit
INTERPERSONAL AND COMMUNICATIONS SKILLS: Be able to demonstrate communication skills that result in effective information exchange and appropriate interaction with colleagues, surgeons, patients, and ancillary personnel CA-1 resident must be able to identify all and demonstrate competence in some of the characteristics and skills listed below Make others feel comfortable in conversation clinic, Preoperative holding area, Surgical Intensive Care Unit, Postoperative care unit, Simulation suite, Simulation Preempt/ prevent disputes clinic, Preoperative holding area, Surgical Intensive Care Unit, Postoperative care unit, Simulation suite, Simulation Practice team approach Preoperative holding area, Unit, Postoperative care unit, Simulation Suite, Simulation Be able to appreciate the anatomical, physiological, and cognitive development of an infant or child and how it applies to the practice of anesthesiology. Be able to explain and guide a child through a complete anesthetic preoperative history and exam, induction, maintenance of anesthesia, postoperative care, and pain control for a child in a competent and compassionate manner. Unit To be able to explain the risks and benefits of anesthesia to a parent that is informative, thorough, and reassuring. Be able to understand a parent s frame of mind when his/her child is about to undergo surgery and the stresses it can place on the family unit. Unit
PROFESSIONALISM: Be able to demonstrate commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. CA-1 resident must be able to identify all and demonstrate competence in some of the characteristics and skills listed below Answer pages promptly clinic, Preoperative holding area, Operating Room, Postoperative care unit Demonstrate respect, compassion or responsiveness to patient's concerns or needs clinic, Preoperative holding area, Operating Room, Postoperative care unit, Skill demonstration checklist and criteria Demonstrate independence and initiative clinic, Preoperative holding area, Operating Room, Postoperative care unit Be punctual and reliable clinic, Preoperative holding area, Operating Room, Postoperative care unit Demonstrate superior work ethic clinic, Preoperative holding area, Operating Room, Postoperative care unit Demonstrate commitment to professional development Preoperative Evaluation Clinic, Operating Room, Conference Case based discussion, Case presentation, Journal Club presentation, Case presentation evaluation Adhere to departmental and university policy and procedures clinic, Preoperative holding area, Operating Room, Postoperative care unit Lecture and discussion, Handouts, Exhibit integrity in record keeping and medical records Operating Room Lecture, Skill demonstration, Anesthesia record review
PROFESSIONALISM: Be able to demonstrate commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. CA- 1 resident must be able to identify all and demonstrate competence in some of the characteristics and skills listed below All resident interactions with patients, their families or their loved ones will be conducted with the highest level of professional and ethical standards. All management decisions will be based upon scientific foundations of medicine. However, application of these complex therapies will proceed in a humane and compassionate setting. All considerations for the initiation and cessation of invasive treatments will be with the informed consent of the patient or their surrogates to the degree possible. Unit Residents will also maintain a high degree of professionalism when interacting with other members of the patient care team, including faculty, nurses, fellows, residents, and medical students. The members of the primary team, and other consulting s will be apprised of any patient care decisions that directly impact their own plans with the patient in timely and collegial way. The residents will learn how to deal with and respect occasional dissenting opinions from these various team members, and help coordinate patient care with these individuals in a manner that places the patient first, and keeps all members of the team informed and engaged in a positive way. Unit
SYSTEMS-BASED PRACTICE: Be able to demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide health care that is of optimal value CA-1 resident must be able to identify all and demonstrate competence in some of the characteristics and skills listed below Practice cost-effective health care Lecture and discussion, Operating Room Case based discussion Rely on information technology tools related to patient care clinic, Operating Room, Classroom, Conference, Case based discussion, Journal Club presentation Case based discussion and evaluation, Rely on consultations with other specialties (i.e., cardiology, pain management, ethics, etc.) clinic, Operating Room, Classroom, Conference, Case based discussion Case based discussion and evaluation, Considers cost-benefit analysis and cost awareness in patient care Able to discuss how health delivery systems differ and how this impacts patient care in the operating room Conference, Classroom Lecture, case-based discussion Case-based discussion and evaluation Participate in systems safeguards such as "timeout" and blood product transfusion protocol Operating Room Skill Demonstration, Residents will learn the foundations of modern critical care management using evidence based data and protocols geared at decreasing complications, days on the mechanical ventilation, and total ICU length of stay. Conference, Independent Study, SICU, Case based discussion Residents will learn the benefit of having anesthesiologist intensivists involved in critical care management of SICU patients form both an overall patient outcome perspective. As perioperative physicians anesthesiologists not only provide a continuum of care between the operating room and the SICU. Anesthesiologists also possess a great deal of expertise in acute airway management, and ventilation management, sedation and analgesia, monitoring modalities, and cardiovascular support techniques. SICU Lecture and discussion, Case based discussion Residents will demonstrate sensitivity and awareness of the costs of health care delivery, and advocate for cost-consensus and effective patient care. SICU Lecture and discussion, Case based discussion