ROTATION DESCRIPTION FORM PGY1 Rotation Title Medicine Intensive Care Unit (MICU) Level of Learner PY4 PGY1 PGY2 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) rotation is an inpatient acute care experience designed to develop a PGY1 resident's skills in participation in a multidisciplinary critical care environment. PGY1 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 selfdirected exploration, active participation in the care environment, patient-based discussions, and scheduled topic discussions. Beyond the expansion of a knowledge base in critical care medicine, emphasis for the rotation will be placed on the development of critical thinking skills, time management abilities, and communication skills that will be essential to patient care practice in any setting. 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 25-35 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. PGY1 pharmacy residents will be assigned to a preceptor with one of the rounding teams. The number of patients covered will vary depending on time of the year and learner experience, but as a goal, PGY1 residents will be expected to cover all patients for their rounding team by the end of the month with appropriate clinical supervision. Level of independence will also vary by learner, but will be expected to be higher towards the end of the residency year and progress throughout the course of a rotation month. An active presence in the ICU is encouraged for all learners, but order verification will not be an expectation during this rotation unless otherwise discussed with the preceptor. 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. These problems and potential interventions are to be discussed with the preceptor daily before rounds, unless or until a higher level of autonomy is achieved. A sufficient amount of time should be allotted each morning for pre-rounds preparation to ensure completeness and familiarity with the information gathered. - MICU Core Lecture Series (attendance HIGHLY encouraged) 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 depend on the comfort level of the resident and the preceptor, and is expected to progress throughout the course of the rotation generally, a preceptor will attend 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 does not include order verification unless otherwise discussed, but will include making sure that medications are available to be administered, and implementing parts of the care plan or monitoring 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 monitoring, 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 in some form on a daily basis. - 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 monitoring in the ICU setting and will be a point of emphasis on this rotation. - Topic Discussion At least 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. A list of potential topics can be found on the critical care group s website. - Transitions of Care residents are required to assist with transitions of care activities, including medication reconciliation for those patients prospectively identified as high- or intermediate-risk for readmission or any patients identified by the resident or preceptor as having home medication issues that require follow-up. Activities may also include discharge counseling and communication with accepting teams when the patient changes levels of care. 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. This will include participation as a leader in patient discussion and topic discussion, oversight of transitions of care activities, as well as assistance with formal evaluations. Hours of Rotation Monday through Friday, 7AM 5PM - Hours may vary slightly from day to day depending on patient care and off-rotation responsibilities - will occur daily beginning at 8-8:30AM and should be expected to last until 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 those listed in the Description of Daily Activities Required Meetings/Conferences 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 Weekly/Monthly Activities Educational Activities 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 are available on the critical care group website, and we will have
- 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. 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 ) End Goals of Rotation (by the end of the rotation, what should the learner be able to do? - Demonstrate in-depth knowledge of disease state and pharmacology commonly encountered in the care of critically ill patients - 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, monitoring 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 monitoring and management of the pharmacotherapy plan - Perform therapeutic drug monitoring 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 monitoring 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 monitoring and drug therapy with clinical oversight - Collect and analyze appropriate pharmacotherapy literature to respond to drug information requests from the medical team - Implement plans and document activities appropriately per departmental policy - When appropriate, participate in the clinical precepting of PY4 pharmacy students
Goal /Objective Description Type of Goal Activity Targeting Goal Outcome R1. Patient Care 1.1 In collaboration with the health care team, provide safe and effective patient care to a diverse range of patients, including those with multiple co-morbidities, high-risk medication regimens, and multiple medications following a consistent patient care process 1.1.1 Interact effectively with health care teams to manage patients medication therapy 1.1.2 Interact effectively with patients, family members, and caregivers Transitions of care med rec 1.1.3 Collect information on which to base safe and effective medication therapy Drug information requests Pre-rounding Patient discussion 1.1.4 Analyze and assess information on which to base safe and effective medication therapy Patient discussion Topic discussions 1.1.5 Design or redesign safe and effective patient-centered therapeutic regimens and monitoring plans (care plans) Patient discussion Topic discussions 1.1.6 Ensure implementation of therapeutic regimens and monitoring plans (care plans) by taking appropriate follow-up actions 1.1.7 Document direct patient care activities appropriately in the medical record or where appropriate Documentation according to departmental policy 1.1.8 Demonstrate responsibility to patients Transitions of care / med rec 1.2 Ensure continuity of care during patient transitions between care settings 1.2.1 Manage transitions of care effectively Transitions of care / med rec 1.3 Prepare, dispense, and manage medications to support safe and effective drug therapy for patients 1.3.1 Prepare and dispense medications following best practices and the organization s policies and procedures 1.3.2 Manage aspects of the medication-use process related to formulary management 1.3.3 Manage aspects of the medication-use process related to oversight Profile review
of dispensing Order verification Outcome R2. Advancing Practice and Improving Patient Care. 2.1 Demonstrate ability to manage formulary and medication-use processes, as applicable to the organization 2.1.1 Prepare a drug class review, monograph, treatment guideline, or protocol 2.1.2 Participate in a medication-use evaluation 2.1.3 Identify opportunities for improvement of the medication-use 2.1.4 Participate in medication event reporting and monitoring Documentation of ADE 2.2 Demonstrate ability to evaluate and investigate practice, review data, and assimilate scientific evidence to improve patient care and/or the medication-use 2.2.1 Identify changes needed to improve patient care and/or the medication-use 2.2.2 Develop a plan to improve the patient care and/or the medicationuse 2.2.3 Implement changes to improve patient care and/or the medicationuse 2.2.4 Assess changes made to improve patient care or the medicationuse Evaluating 2.2.5 Effectively develop and present, orally and in writing, a final project report Outcome R3. Leadership and Management 3.1 Demonstrate leadership skills 3.1.1 Demonstrate personal, interpersonal, and teamwork skills critical for effective leadership 3.1.2 Apply a process of on-going self-evaluation and personal performance improvement 3.2 Demonstrate management skills 3.2.1 Explain factors that influence departmental planning Understanding 3.2.2 Explain the elements of the pharmacy enterprise and their Understanding relationship to the health care Precepting Weekly formal feedback
3.2.3 Contribute to departmental management 3.2.4 Manages one s own practice effectively Time management Outcome R4. Teaching, Education, and Dissemination of Knowledge 4.1 Provide effective medication and practice-related education to patients, caregivers, health care professionals, students, and the public (individuals and groups) 4.1.1 Design effective educational activities Inservice / Topic discussion Journal club 4.1.2 Use effective presentation and teaching skills to deliver education Inservice / Topic discussion Journal club 4.1.3 Use effective written communication to disseminate knowledge Inservice / Topic discussion Journal club 4.1.4 Appropriately assess effectiveness of education Inservice / Topic discussion 4.2 Effectively employs appropriate preceptor roles when engaged in teaching students, pharmacy technicians or fellow health care professionals 4.2.1 When engaged in teaching, select a preceptor role that meets learners educational needs Precepting Topic discussion 4.2.2 Effectively employ preceptor roles, as appropriate Precepting / Topic discussion Outcome E1. Research 1.1 Conduct and analyze results of pharmacy research 1.1.1 Design, execute, and report results of investigations of pharmacyrelated issues 1.1.2 Participate in prospective and retrospective clinical, humanistic, and economic outcomes analysis Outcome E5. 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 according to the organization s policies and procedures Code blue coverage