ROTATION DESCRIPTION FORM PGY2 CRITICAL CARE

ROTATION DESCRIPTION FORM PGY2 CRITICAL CARE Rotation Title Medicine Intensive Care Unit (MICU) Level of Learner PY4 PGY1 PGY2, Critical Care Specialty (Introductory Experience) Preceptor(s) Stacy Campbell-Bright, Brian Murray Preceptor Contact Stacy.Campbell-Bright@unchealth.unc.edu; Brian.Murray@unchealth.unc.edu Service Area Details (operational/clinical environment, description of service area) The Medicine Intensive Care Unit (MICU) Introductory Experience rotation is an inpatient acute care experience designed to develop a PGY2 Critical Care resident's skills in participation in a multidisciplinary critical care environment. PGY2 Critical Care residents will be exposed to a variety of disease states and supportive care issues commonly encountered in critical care, as well as rare cases and patient care issues that are unique to a specialty center. The rotation is designed to be fast-paced and challenging for learners of all ability and experience levels. Learning will be accomplished with a mixture of self-directed exploration, active participation in the care environment, patient-based discussions, and scheduled topic discussions. PGY2 Critical Care residents will refine advanced pharmacotherapeutic skills in the identification and resolution of drug therapy problems in the critically ill medicine population. Beyond the expansion of a knowledge base in critical care medicine, emphasis for the rotation will be placed on the further development of critical thinking skills, time management abilities, and communication skills that will be essential to patient care practice in any setting. The goal of the PGY2 Critical Care resident is to be capable of functioning as an independent member of the multidisciplinary team in a proactive manner. The MICU is a 30-bed ICU that serves as the primary care area for critically ill patients with non-surgical issues at UNC. The Medicine Intensive Care service often covers 30-35 patients, some boarded in other intensive care units within UNC. The service is divided into two rounding teams, each led by a Pulmonary / Critical Care attending and fellow and staffed by medical residents. Housestaff provides 24-hour coverage. The structure is multidisciplinary, with active participation by all members of the medical team. This includes nurses, respiratory therapists, dietitians, and case managers, in addition to physicians and pharmacists. PGY2 Critical Care residents will be assigned to a preceptor with one of the rounding teams and will be expected to be responsible for all of the patients on that team. Residents will be afforded a high level of autonomy, with the goal of functioning independently by the second half of the rotation. An active presence in the ICU is encouraged for all learners, and order verification will be an expectation during this rotation unless otherwise noted. Description of Rotation Activities: - Patient Care Pre-rounds residents are expected to collect and analyze appropriate patient information, and to be prepared to identify

potential medication-related issues and make recommendations. A sufficient amount of time should be allotted each morning to prerounds preparation to ensure completeness and familiarity with the information gathered. Potential recommendations may be discussed with the preceptor before rounds. - MICU Core Lecture Series (attendance Highly Recommended) residents are encouraged to attend a morning session intended for house staff education. Topics covered are informative but do not always pertain to pharmacy practice (ex. ventilator management, ARDS, acid/base). These sessions are 30 minutes in duration and generally occur immediately before rounds begin. - Patient Care Rounds residents are expected to attend patient care rounds, to be appropriately attentive and professional, and to make recommendations as appropriate for the patients that they are covering. Active participation during rounds will be encouraged throughout the month. The level of autonomy on rounds will be high generally, a preceptor will observe rounds for at least the first half of the rotation. Residents will be expected to help facilitate the patient care plan determined on rounds this will include order verification unless otherwise noted, and will also include making sure that medications are available to be administered, and implementing parts of the care plan or plan as necessary (entering verbal orders, ordering drug levels, calling central pharmacy, etc.) - Patient Discussion after rounds or in the afternoon, residents will discuss patients and their medical problems in depth with the preceptor. This will serve as a time to identify problems, discuss the differential diagnosis, develop a plan for pharmacotherapy and, follow up on interventions, and provide targeted education on specific disease states and supportive care issues that are pertinent to the patients currently on service. These discussions will serve as a key educational component of the rotation and should be expected to take place daily. - Post-Rounds Follow-Up residents will be expected to follow up on all recommendations and outstanding issues after rounds. Residents are expected to resolve these issues reliably and in a timely manner. It is also expected that residents will follow up on recommendations during rounds (was the recommendation accepted and why / why not? What was the outcome of the therapeutic intervention? Are further adjustments to the plan necessary given the patient s current condition? Etc.) This is a critical part of patient in the ICU setting and will be a point of emphasis on this rotation. - Topic Discussion 1-2 times a week in addition to POD, residents will participate in structured topic discussions with the preceptor. Topics will be chosen at the beginning of the month, but may change if necessary or as requested. Residents will be provided with some background reading, but are encouraged to add additional depth with a literature search. Residents will be required to lead at least one of these topic discussions during the month. Potential topics are listed elsewhere in this document. Number of topic discussions will depend on patient care needs and time available. - Transitions of Care residents are required to assist with transitions of care activities, including medication reconciliation for all patients prospectively identified as high- or intermediate-risk for readmission and any patients identified by the resident or the preceptor as needing follow-up of home medication regimen issues. Discharge counseling and communication with accepting teams for patients changing level of care will be expected for eligible patients. A warm hand-off will occur whenever a patient is transferred to a different level of care (step-down status or floor status) this will entail a direct communication with the pharmacist on the accepting team,

highlighting reason for admission, active ongoing issues, the current pharmacotherapy plan, and issues that need follow-up. This communication should happen in a timely manner, no later than after rounds on the following day. - Documentation of Patient Care Activities Residents will at a minimum maintain the Pharmacy Sign-Out and document interventions on pharmacy consults, high-priority medications, and transitions of care per departmental policy. Residents may also utilize the Pharmacy Plan notes and I-VENT follow-up notes as desired and appropriate. Residents will also be responsible for documenting adverse drug events (ADE) or other medication-related issues in the Patient Occurrence Reporting System (PORS) as appropriate. - Drug Information residents will respond to drug information requests from the interdisciplinary team, during and after rounds, using appropriate literature resources or knowledge base. For complicated questions, time may be required to complete a thorough literature search and follow-up should be completed after rounds or the following day. Emphasis will be placed on the ability to determine the actual need in the drug information request, and the ability to appropriately evaluate available literature to formulate a response. Residents will be expected to respond in a timely manner, taking into consideration the acuity and complexity of the request. - Critical Care Pharmacotherapy Inservice each month, residents are required to deliver one 30-minute in-service to the MICU house staff during a morning session. The topic will be chosen by the resident and can take a variety of forms common topics include sedation, vasopressor agents, neuromuscular blockade, toxicology, and antibiotics. A slide set or handout of some kind will be required. The preceptor will review the presentation for content and is responsible for providing feedback. - Journal Club residents will lead a journal club discussion on one recent and relevant article in the critical care literature. A handout is not required, but appropriate assessment of background literature and the methods of the study is expected. - Co-precepting if the opportunity is available, residents will also be involved in co-precepting of pharmacy students and/or PGY1 residents. This will include participation as a leader in patient discussion and topic discussion. Assistance with formal evaluation of PY4 students and PGY1 residents will be expected. Hours of Rotation Monday through Friday, 7AM 5PM - Hours may vary slightly from day to day depending on rotational and off-rotation responsibilities - will occur daily from 8AM Noon - Time before rounds should be spent pre-rounding and identifying patient care issues to be addressed learners should plan to arrive to rotation with adequate time to prepare for patient care rounds and patient discussion - Activities after patient care rounds will vary from day to day but will include: patient, follow-up on patient care issues, and planned / unplanned rotation-related learning opportunities (i.e. topic discussion, small group POD lecture) Required Meetings/Conferences Weekly/Monthly Activities Educational Activities

First Day Meeting This meeting will be held on the first day of rotation, and will serve as an opportunity to: - Review the syllabus - Give an overview of the MICU and the rotation - Establish preceptor and resident expectations - Work on a calendar for the rotation Weekly meeting with preceptor Residents will meet with their preceptor once per week (generally at the end of the week) to provide and receive feedback on the rotation and their performance Wrap-up Meeting / Final Evaluation To be held within 3 business days of completion of the rotation this meeting will provide an opportunity to offer final feedback, both from the resident and preceptor perspective, and to complete the resident s final evaluation Critical Care Conference (3 rd Tuesday of each month, Noon 1PM) A monthly multidisciplinary meeting aimed at continuing education of practitioners in critical care. Seminars will be presented by experts in a variety of specialty areas. End Goals of Rotation (by the end of the rotation, what should the learner be able to do? Critical Care POD (Tuesdays and Fridays, approximately 90min each) Targeted at the PGY1 level, these sessions, led by one of the critical care preceptors or PGY2 critical care resident, is attended by PGY1/PGY2 and PY4 learners. Readings will be assigned ahead of time and posted on the critical care group website, and we will have an active discussion of common disease states and supportive care issues in critically ill patients. Topics will be selected by survey each month and will be scheduled prior to the start of rotation. Student Seminar (Wednesdays, 12-1) Session featuring PY4 students presenting on selected topics. Attendance at seminar is required for scheduled PGY1 residents. Case Conference (Thursdays, 3-5) Educational sessions taught by residents and students, focusing on core learning objectives of a pharmacy residency program. Attendance at case conference is required for PGY1 residents. In-service Presentation (see Description of Rotation Activities ) Journal Club (see Description of Rotation Activities ) Topic Discussions (see Description of Rotation Activities ) - Demonstrate in-depth knowledge of disease states and pharmacology commonly encountered in the Medicine ICU and in the supportive care of critically ill patients, including primary literature - Formulate a daily patient problem list and present patients in a problem-oriented manner, highlighting each pharmacotherapy problem as well as differential diagnosis, drug therapy, parameters, and endpoints of therapy - Develop a daily pharmacotherapy plan for each patient, including medication recommendations and necessary laboratory orders - Collect and critically assess all clinically relevant data to facilitate and management of pharmacotherapy plan, as well as necessary interventions - Perform therapeutic drug for critically ill patients for the following medications: aminoglycosides, vancomycin, phenytoin,

digoxin, tacrolimus, cyclosporine, voriconazole, posaconazole, and others - Document daily therapeutic plans, interventions, goals, and appropriately - Communicate at an appropriate level with other healthcare professionals, including attending, fellows, and residents, interns, nurses, respiratory therapists, dietitians, and other pharmacy colleagues in order to optimize drug therapy - Round with the medical team and make appropriate recommendations for and drug therapy with limited clinical oversight - Effectively collect and analyze appropriate pharmacotherapy literature to respond to drug information requests from the medical team, patient, or family members - Implement plans and document activities appropriately per departmental policy - Function independently as the primary pharmacy presence for an ICU team - When appropriate, participate in the clinical precepting of PY4 pharmacy students and PGY1 residents Core Topics Covered on this Rotation (Highlighted) I. Organ-System Related A. Pulmonary 1. Acute respiratory distress syndrome/acute lung injury 2. Status asthmaticus 3. Acute COPD exacerbation 4. Pulmonary embolism 5. Pneumothorax and hemothorax 6. Drug-induced pulmonary diseases B. Cardiovascular 1. Arrhythmias 2. Pulmonary edema/congestive heart failure exacerbations 3. Acute coronary syndromes 4. Hypertensive emergencies 5. Acute aortic dissection 6. Pericardial tamponade 7. Shock and related problems a. cardiogenic b. septic c. hypovolemic/hemorrhagic d. anaphylactic e. neurogenic (spinal) C. Renal D. Neurology 1. Status epilepticus 2. Intracranial pressure management 3. Traumatic brain injury 4. Ischemic stroke 5. Subarachnoid hemorrhage 6. Intracerebral hemorrhage 7. Spinal cord injury 8. Critical illness polyneuropathy 9. Diabetes insipidus 10. Syndrome of inappropriate antidiuretic hormone 11. Cerebral salt wasting E. Gastrointestinal 1. Acute upper and lower gastrointestinal bleeding 2. Severe pancreatitis 3. Fistulas 4. Ileus F. Hepatic 1. Liver failure 2. Hepatorenal syndrome 3. Complications of cirrhosis

1. Acute renal failure 2. Acid-base imbalance 3. Fluid and electrolyte disorders 4. Rhabdomyolysis 5. Contrast-induced nephropathy 6. Drug-induced kidney diseases 4. Drug-induced liver diseases G. Dermatology 1. Burns 2. Stevens Johnson syndrome 3. Toxic epidermal necrolysis 4. Erythema multiforme H. Immunology 1. Acute transplant rejection 2. Graft-versus-host disease 3. Systemic inflammatory response disease (SIRS) I. Endocrine 1. Relative adrenal insufficiency 2. Diabetic ketoacidosis/nonketotic coma 3. Thyroid storm/icu hypothyroid states 4. Hypoglycemia & hyperglycemia J. Hematology 1. Coagulopathies 2. Drug-induced hematologic disorders 3. Drug-induced thrombocytopenia 4. Anemia of critical illness 5. Blood loss and blood component replacement K. Psychiatry 1. ICU psychosis 2. Sleep disturbances 3. Neuroleptic malignant syndrome 4. Substance abuse /alcohol withdrawal syndromes II. Specific Considerations A. Infectious Diseases 1. CNS infections 2. Complicated intra-abdominal infections 3. Infections in the immunocompromised host 4. Pneumonia III. Supportive Care A. Nutrition 1. Enteral nutrition 2. Parenteral nutrition 3. Nutrition considerations in special patient populations 4. Immune-modulation B. Analgesia C. Sedation D. Delirium E. Neuromuscular blocking agents (rapid sequence intubation, ICU paralysis) F. Venous thromboembolism prophylaxis G. Stress ulcer prophylaxis H. Bowel regimens I. Devices 1. Intravascular devices 2. Mechanical ventilation 3. Continuous renal replacement therapies 4. Chest tubes 5. Sequential compression devices 6. Intra-arterial balloon pumps and LVADs 7. Ventriculostomies 8. Peripheral nerve stimulators 9. Bispectral index

5. Endocarditis 6. Sepsis 7. Wound infection 8. ICU fever B. Pharmacokinetics and Pharmacodynamics C. Toxicological emergencies D. Pediatric and Neonatal Considerations (optional) E. Bioterrorism and Mass Casualty Events RLS Goal Based Evaluation Goal Description Type of Goal Activity Targeting Goal /Objective Outcome R1: Demonstrate leadership and practice management skills. 1.1 Exhibit essential personal skills of a practice leader. 1.1.1 Practice self-managed continuing professional development with the goal of improving the quality of one s own performance through selfassessment and personal change. Characterization Weekly meetings and final evaluation with preceptor Preparation for patient care activities, patient discussion, and topic discussion 1.1.2 Demonstrate commitment to the professional practice of critical care pharmacy through active participation in the activities of local, state, and/or national professional organizations concerned with the health care of critically ill patients. Characterization Co-precepting of PY4 students and PGY1 residents, including participation in evaluations Self-directed learning, research and responding to drug information requests N/A 1.1.3 Demonstrate the ability to make considered but rapid decisions in intense Characterization

situations where time is at a minimum. Post-rounds follow-up Serve as primary responder for medical emergencies in the MICU and secondary responder for medical emergencies in the medical tower 1.2 Contribute to the critical care practice area s leadership and management activities. 1.2.1 Use effective negotiation skills to resolve conflicts 1.2.2 Use group participation skills when leading or working as a member of a committee or informal work group. 1.3 Exercise practice leadership. 1.3.1 Demonstrate a commitment to advocacy for the optimal care of patients through the assertive and persuasive presentation of patient care issues to members of the health care team, the patient, and/or the patient s representative(s). 1.3.2 Explain the nature of mentoring in pharmacy, its potential connection with achievement, and the importance of willingness to serve as mentor to appropriate individuals. 1.3.3 Demonstrate a caring attitude toward critically ill patients and their representative(s). 1.3.4 Explain the general processes of establishing and maintaining a critical care pharmacy residency program. Characterization Comprehension Characterization Comprehension Post-rounds follow-up Post-rounds follow-up Transitions of care activities Weekly meetings and final evaluation with preceptor Co-precepting of PY4 students and PGY1 residents Transitions of care activitites N/A Outcome R2: Optimize the outcomes of critically ill patients by providing evidence-based medication therapy as an integral part of an interdisciplinary team. 2.1 Establish collaborative professional relationships with other members of the interdisciplinary critical care team. 2.1.1 Implement a strategy that establishes cooperative, collaborative,

communicative, and effective working relationships with other members of the interdisciplinary critical care team 2.2 Prioritize the delivery of care to critically ill patients. 2.2.1 Devise a plan for deciding which critical care patients to focus on if given limited time and multiple patient care responsibilities. 2.3 Act in accordance with a covenantal relationship with the patient. 2.3.1 Formulate a strategy to guide care for a critically ill patient and interaction with the patient s family that reflects the acceptance of a covenant with the patient for that patient s care 2.4 Collect and analyze pertinent patient information 2.4.1 Collect and organize all patient-specific information needed to identify, prevent, and resolve medication and specialized nutrition support-related problems in order to provide appropriate evidence-based recommendations in critically ill patients with complex conditions. 2.4.2 Assess the information base created for a critically ill patient for adequacy to identify problems and design a therapeutic regimen. Analysis Evaluation Post-rounds follow-up Respond to drug information requests from the medical team and nursing staff Patient care pre-rounds and patient care rounds Post-rounds follow-up Patient Serve as primary responder for medical emergencies in the MICU Patient care pre-rounds and patient care rounds Patient Post-rounds follow-up Transitions of care activities Pre-rounds, patient care rounds Pre-rounds, patient care rounds

2.4.3 Determine the presence of any of the following problems in a critically ill patient's current medication or specialized nutrition support therapy: Analysis Pre-rounds, patient care rounds 2.4.4 Prioritize a critically ill patient s health care needs. Analysis Pre-rounds, patient care rounds 2.5 Design evidence-based therapeutic regimens for critically ill patients. 2.5.1 Specify therapeutic goals for a critically ill patient incorporating the principles of evidence-based medicine that integrate patient-specific data, disease and medication-specific information, ethics, and, when possible, quality-of-life considerations. 2.5.2 Design a regimen that meets the evidence-based therapeutic goals established for a critically ill patient; integrates patient-specific information, disease and drug information, ethical issues and, when possible, quality-of-life issues; and considers pharmacoeconomic principles 2.6 Design evidence-based plans for critically ill patients. 2.6.1 Design an evidenced-based plan for a critically ill patient s therapeutic regimen that effectively evaluates achievement of the patientspecific goals. Pre-rounds and patient care rounds Pre-rounds and patient care rounds Pre-rounds, patient care rounds

2.7 Recommend regimens and plans for critically ill patients. 2.7.1 Recommend an evidence-based therapeutic regimen and corresponding plan in a way that is systematic, logical, accurate, timely, and secures consensus from the critical care interdisciplinary team. Documentation activities as described discussion with the preceptor 2.8 When appropriate, implement selected aspects of critical care patients regimens and/or plans. 2.8.1 When appropriate, order a therapeutic regimen for a critically ill patient according to the health system s procedures. 2.8.2 When appropriate, follow organizational procedures to implement (e.g., order tests) the plan. 2.9 Evaluate critically ill patients progress and redesign regimens and plans. 2.9.1 Accurately assess the critically ill patient s progress toward the therapeutic goal(s) and the absence of adverse drug events. Evaluation Post-rounds follow-up Pre-rounds, patient care rounds 2.9.2 Redesign an evidence-based therapeutic plan for a critically ill patient as necessary based on evaluation of data and therapeutic outcomes. Pre-rounds, patient care rounds

2.9.3 Collect outcomes data based on the patient s response to therapy. Pre-rounds, patient care rounds 2.10 Collect outcomes data based on the patient s response to therapy. 2.10.1 When given a patient who is transitioning out of the critical care setting, communicate pertinent pharmacotherapeutic information to the receiving health care professionals. Patient Transitions of care activities as described Documentation activities as described 2.11 Document direct patient care activities appropriately. 2.11.1 Appropriately select direct patient-care activities for documentation. Analysis Documentation activities as described Outcome R3: Demonstrate excellence in the provision of training, including preceptorship, or educational activities for health care professionals and health care professionals in training. 3.1 Provide effective education or training to health care professionals and health care professionals in training. 3.1.1 Explain the differences in effective educational strategies for health care professionals and for various levels of health care professionals in training. Comprehension Critical Care POD Journal club In-service to medical house staff 3.1.2 Design an assessment strategy that appropriately measures the specified objectives for education or training and fits the learning situation. Patient discussions and topic discussions with preceptor In-service to physician group

3.1.3 Use skill in the four preceptor roles employed in practice-based teaching (direct instruction, modeling, coaching, and facilitation). Critical Care POD Topic discussion Co-precepting PY4 students and PGY1 residents In-service to physician group Journal club Critical Care POD Topic (resident will lead at least one) Co-precepting of PY4 student or PGY1 resident 3.1.4 Use skill in case-based teaching. Co-precepting of PY4 student or PGY1 resident In-service to house staff 3.1.5 Use public speaking skills to speak effectively in large and small group situations. Critical Care POD In-service to house staff Critical Care POD Journal club Topic Outcome R4: Demonstrate the skills necessary to conduct a critical care pharmacy research project. 4.1 Conduct a critical care practice research project using effective project management skills.

4.1.1 Identify a topic of significance for a critical care pharmacy research project. 4.1.2 Formulate a feasible design for a critical care pharmacy research project. 4.1.3 Secure any necessary approvals, including IRB and funding, for one s design of a project. 4.1.4 Implement a critical care pharmacy research project as specified in its design. 4.1.5 Effectively present the results of a critical care pharmacy research project. 4.1.6 Successfully employ accepted manuscript style to prepare a final report of a critical care pharmacy research project. 4.1.7 Accurately assess the impact, including sustainability if applicable, of the residency project. Evaluation Outcome R5: Participate in the management of medical emergencies. 5.1 Participate in the management of medical emergencies 5.1.1 Exercise skill as a team member in the management of medical emergencies as exhibited by certification in the American Heart Association Advanced Cardiac Life Support and, if applicable, Pediatric Advanced Life Support. Outcome E1: Evaluate medication profiles 1.3 Evaluate critically ill patients medication orders and/or profiles. 1.3.2 Assess a critically ill patient s medication profile for appropriateness following existing standards of practice and the organization s policies and procedures. Evaluation Serve as primary responder for medical emergencies in the MICU Serve as secondary responder for medical emergencies in the medical tower Pre-rounds Order verification Outcome E3: Practice Leadership 3.1 Exhibit additional personal skills of a practice leader 3.1.1 Speak clearly and distinctly in grammatically correct English or the alternate primary language of the practice site. Complex Overt Response Patient discussion 3.1.2 Use listening skills effectively in performing job functions.

3.1.3 Use correct grammar, punctuation, spelling, style, and formatting conventions in preparing all written communications. 3.1.4 When communicating, use an understanding of effectiveness, efficiency, customary practice and the recipient's preferences to determine the appropriate type of, and medium and organization. Outcome E5: Teaching skills 5.2 Exercise teaching skills essential to pharmacy faculty. 5.2.2 Prepare and deliver didactic instruction on a topic relevant to the specialized area of pharmacy residency training. 5.2.3 Develop and deliver cases for workshops and/or exercises for laboratory experiences. 5.2.4 Serve as a preceptor or co-preceptor utilizing the four roles employed in practice-based teaching (direct instruction, modeling, coaching and facilitation). 5.2.5 Develop a teaching experience for a practice setting (e.g., introductory or advanced pharmacy experience). 5.2.6 Design an assessment strategy that appropriately measures the specified educational objectives for the class session, module, course, or rotation. Analysis Analysis Post-rounds patient care activitites Documentation of patient care activities Topic discussion Inservice CC elective lecture Case conference CC elective Lecture Case conference Inservice Topic discussion Co-precepting Topic discussion Co-precepting Case conference Co-precepting CC elective lecture