Department of Anesthesiology
Division of Critical Care

Fellow Education

Anesthesiology Critical Care Fellowship Goals and Objectives

I.  OVERALL GOALS AND OBJECTIVES

The overall goal of the University of Michigan Anesthesiology Critical Care Training Program is to develop competent anesthesiology intensivists in the theory, diagnosis, and treatment of critical care related disorders across a broad spectrum of patients, treatment settings, and levels of care. Fellows will focus on several broad areas of clinical, administrative, educational and research areas to develop the needed skills to practice state of the art critical care in the broadest settings as well as the needed administrative skills to manage a critical care delivery system. During the training period and upon completion of the program, anesthesia critical care fellows will gain clinical experience in all the components delineated in the ABA revised critical care curriculum for Anesthesia critical care training(see bottom of document) as well as;

1. Develop the cognitive and procedural skills necessary to provide optimal care to patients admitted to an Intensive Care Unit and/or patients with severe physiologic derangements in the perioperative setting.
2. Achieve proficiency in the recognition and management of problems commonly encountered in the intensive care unit
3. Gain experience with longitudinal care for patients with complex medical conditions.
4. Develop proficiency with advanced life support techniques; different modes of mechanical ventilation, continuous renal replacement therapies, hemodynamic support with all pharmacologic agents, Intra-aortic balloon pumps, Ventricular Assist devices, ECMO.
5. Gain experience with the supervision of a team of health care providers; ie medical students, fellows, nurses, respiratory therapists etc.
6. Develop more sophisticated knowledge of critical care principles, monitoring and therapeutic technologies, as well as current guidelines and standards of care developed by relevant medical organizations such as the Society of Critical Care Medicine, the American Boards of Anesthesiology & Surgery.
7. Provide opportunities to develop teaching and research skills.
8. Provide expert consultation and training to other physicians and professionals involved in managing critically ill or unstable patients in a variety of clinical settings; ie an ICU, step-down unit, PACU, patient ward, emergency department.
9. Gain experience in the Administrative processes required to manage an ICU as well as a critical care service.
10. Evaluate and incorporate new treatment techniques in a rapidly growing, empirically based field.

        
The following overall objectives, arranged by general competencies, apply to all anesthesia critical care fellows during all rotations.  Methods used to assess those competencies are listed in parentheses after item.

A.     Medical knowledge.  Medical knowledge is obtained by participating in direct patient care in the ICU and during clinical electives, attending didactics including core critical care lectures and supervision, doing reading, asking questions and participating in the Society of Critical Care Medicine’s Multidisciplinary Critical Care Knowledge Assessment Program (MCCKAP). (Medical knowledge is assessed by clinical supervision, discussion during didactics, Tri-annual checklist evaluation of core competencies, MCCKAP exam, and ultimately by passing the critical care boards.)
               Specific objectives:

1. To be familiar with the epidemiology and risk factors for commonly encountered critical care conditions including the systemic inflammatory response syndrome (SIRS), Sepsis and multiorgan dysfunction, common causes of shock and hemodynamic instability, Acute Lung Injury, ARDS, Acute Renal failure, Nosocomial infections, acute bleeding. Knowledge of epidemiology also includes:
2. Relative prevalence rates and risks for individuals based on previous clinical conditions, type of surgical or procedural interventions, demographics such as age, gender.
3. General statistics ICU related morbidity, mortality, and costs to society, the healthcare system.
4. Precise knowledge of Advanced Cardiac Life Support and ability to direct emergent/Code scenarios in a variety of clinical settings.
5. To know the signs, symptoms, clinical course, complications and treatment of  common post-operative conditions for general, thoracic, vascular, cardiac, urologic, orthopedic, neurosurgical and other surgical specialty operations.
6. Advanced management of specialized patient populations including post-cardiotomy, mechanical support devices including extra-corporeal life support (ECMO), Solid organ transplantation.
7. To have a comprehensive understanding of the pharmacology of all commonly used medications in an ICU and other monitored clinical settings including;
   • Sedative, analgesic and muscular relaxant drugs.
   • Hemodynamic support with vasoconstrictors, inotropic agents and antihypertensive agents.
   • Other specialized medications that are commonly only used in monitored settings including insulin drips, thrombolytics, some anti-rejection induction agents, antiarrthmic agents.
8. To understand the role, principles and limitations of Physiologic monitoring, Diagnostic laboratory & radiological tests commonly used in the critical care setting including;
   • Indications, techniques for placement, complication recognition & management of invasive intravenous catheters including arterial lines, central lines, introducers, cavity drains and thoracostomy tubes
   • Knowledge of common chest radiographical interpretation especially for location of intravenous/arterial catheters and airway tubes
   • Knowledge of common laboratory tests including blood chemistries, microbiology interpretation.
9. To be familiar with current guidelines and standards of care developed by relevant medical organizations such as the Society of Critical Care Medicine, the American Boards of Anesthesiology & Surgery.

B.  Patient Care (Patient care is assessed by clinical supervision, 360 degree evaluation, Tri-annual checklist evaluation & procedure logs.)

1. Fellows will gather essential and accurate information by performing complete and clinically-relevant history and physical exams.
2. Fellows will understand how to order and interpret appropriate diagnostic tests.
3. Fellows will make informed diagnostic and treatment decisions by analyzing and synthesizing information.
4. Fellows will understand the limits of their knowledge and expertise and will use consultants and referrals appropriately.
5. Fellows will develop and carry out care plans as well as develop superb communication abilities.
6. Fellows will perform a variety of invasive procedures competently including the ability to correct complications resulting from these procedures.
7. Fellows will routinely participate in conversations with family members to gather other clinical information, understand patient’s and families wishes.
8. Fellows will become competent in palliative care and end of life discussions
9. Appropriate and timely coordination for the safe transport of critically ill patients from other health care centers to the appropriate ICU setting to or from the University of Michigan.

C.  Practice-Based Learning and Improvement (Assessed by review of procedure logs, follow-through on questions posed during supervision, attendance at didactics, performance as discussion leader at Journal Club and other presentations, review of clinical practice during M&M and review of Tri-annual evaluations.)

1.  To keep logs of all major procedures including difficult airway, bronchoscopy, ECHO exams, and specialized patient situations; ECMO, ventricular assist devices.

2.  To use current evidence-based practice guidelines, and to obtain supervision when existing guidelines require supplementation with experience-based practices for individual cases.

3.  To access and use on-line medical information as pertains to patients’ diagnosis and treatment in the form of reference texts, searches, electronic journals such as UpToDate, Web MD’s e-Medicine and other networked resources as made available through the University of Michigan Health System Medical Library (http://www.lib.umich.edu/medsearch/).

4.   To critically read and discuss the relevant scientific literature presented in Journal Club, for example) while seeking application to actual practice.

5.    To facilitate the learning by other health care professionals and trainees with regard to substance-related disorders.  The type of health care professional and trainee will vary with the specific rotation.

D. Interpersonal and Communication Skills (Assessed by evaluations of supervising faculty during patient care rounds or elective consultation services, 360-degree review from clinical work sampling; chart review; presentation skills, and contributions during team meetings.)

1. Fellows will exhibit communication that is characterized by socio-cultural effectiveness.
2. Fellows will demonstrate the ability to develop highly effective therapeutic relationships with patients and families.
3. To establish collaborative and effective working relationships with other staff members involved in patient care including supervisors, nurses, physician extenders (NPs, Pas), respiratory therapists, pharmacists, dieticians other physicians and trainees.
4. To function effectively as a team member and leader such as in the multidisciplinary team meeting.
5. Fellows will communicate respectfully and effectively with other health professionals.
6. Fellows will be able to act in a consultative role to other physicians and health professionals.
7. Fellows will maintain comprehensive, timely, effective, and legible medical records.

           
E.  Professionalism (Assessed by evaluations of supervising faculty during patient care rounds or elective consultation services, 360-degree review from clinical work sampling; chart review; presentation skills, attendance & contributions during team meetings.

1. Fellows will document all relevant diagnostic and treatment encounters with patients through effective medical record keeping.
2. Fellows will demonstrate accountability, reliability, and punctuality during performance of all responsibilities and duties.
3. Fellows will demonstrate a balance between independence and recognition of limits of competence/experience
   • Heightened awareness when engaged in procedures with higher than average complexity including difficult airway management, invasive lines in patients whose underlying conditions/physiognomy increase risk ie coagulopathy, morbid obesity, previous interventions .
4. Fellows will conduct oneself in an ethically and legally sound manner with respect to issues such as maintenance of treatment boundaries, patient confidentiality, informed consent, provision or withholding of clinical care, and good business practices.

F.  Systems-Based Practice (Assessed by clinical supervision, compliance with program and institutional policies and procedures, and completion of University of Michigan Health System mandatories.)

1. To understand the managed care of critically ill and post surgical patients, and how one tailors a patient's treatment to the resources available without compromising quality care.
2. To understand the quality improvement process and how to partner with health care managers and providers to assess, coordinate and improve care.
3. To develop awareness of cost-effectiveness issues with post-operative and/or clinically unstable patients, and how these are managed in different treatment settings such as a surgical ICU, PACU, other ICU or step-down unit.
4. To act as a patient advocate for helping patients and families navigate through sometimes complex and bureaucratic systems related to their health-care needs, patient wishes and resources available.
5. To appreciate the necessity and rationale for various program policies and procedures.

II. ROTATION-SPECIFIC GOALS AND OBJECTIVES

General Surgical ICU at UMMC {SICU}

The SICU is a 20 bed ICU that accepts and manages patients who have undergone a variety of general and specialty surgical procedures including all gastrointestinal procedures, some trauma (The majority of trauma is managed in a dedicated trauma ICU), liver, renal and pancreas transplantation, as well as all surgical specialties other than cardiothoracic. The ICU team is comprised of an anesthesiology or surgical intensivists, a senior and junior anesthesiology resident and a multidisciplinary team of allied health care providers.

The overall goals for this rotation are to understand and develop skills in the assessment, initial resuscitation, management and recovery of post surgical patients from a wide variety of surgical disciplines including general, vascular, transplantation, orthopedic, urologic, head & neck surgery. The critical care fellows spend from 3- 4 months directly managing all aspects of patient care, triag decisions, coordinating transfers into and out of the SICU. The critical care fellow gradually assumes more supervisory responsibilities overseeing the care delivered by multidisciplinary teams of junior and senior residents from anesthesiology and surgical specialties including procedures. Specific goals of this rotation also include;

1. Diagnosis and management of sepsis related to gastrointestinal causes including gastrointestinal radiology such as computerized tomography, ultrasound and contrast studies

2. Advanced respiratory failure strategies including different modes of conventional mechanical ventilation, oscillatory ventilation, ECMO support

3. Extra-Corporeal Life Support techniques including appropriate selection for and institution of ECMO support, management dilemmas including bleeding, ventilator management during ECMO, trailing patients off support and ethical issues related to appropriate continuation or withdrawal of ECMO support.

4. Exposure to the widest variety of antimicrobial therapeutics for primary and nosocomial infections including resistant organisms, based on national guidelines, and local empiric ID epidemiology

5. General ICU outcome models (APACHE III), use for both groups of patients and appropriate use of these models for individual patient decision making.

6.Evaluation and delivery of appropriate  nutrition support especially in highly catabolic patients with limited ability to tolerate conventional nutrition strategies

7.Objective methods to monitor adequacy of nutrition support including resting energy expenditure, mathematical models of calories needed.

B. Cardio Thoracic /Cardiovascular Center ICU at UMMC {TICU/CVC}

The TICU/CVC ICU is currently a 14 bed ICU that accepts and manages patients who have undergone cardio-thoracic operations of the heart, lungs or chest including aortic diseases. In June, 2007, the new CVC ICU will open to 24 beds including all the former TICU patients but also all vascular surgical patients. The ICU team is comprised of an anesthesiology or surgical intensivists, a senior and junior anesthesiology resident, rotating cardiology and cardiac anesthesiology fellows as well as a dedicated ICU physician extender team of nurse practitioners and physician assistants and a multidisciplinary team of allied health care providers.

The overall goals for this rotation are to understand and develop skills in the assessment, initial resuscitation, management and recovery of post surgical cardiothoracic patients including experience with mechanical assist support for the failing heart, issues related to  heart and lung transplantation and experience with diseases and operations involving the thorax, and aorta. The critical care fellows spend from 2-3 months directly managing all aspects of patient care, triag decisions, coordinating transfers into and out of the TICU/CVC. The critical care fellow gradually assumes more supervisory responsibilities overseeing the care delivered by multidisciplinary teams of junior and senior residents from anesthesiology as well as ICU physician extenders including nurse practitioners and physician assistants. Specific goals of this rotation also include;

1. Management of post cardiotomy patients from a variety of cardiac surgical specialties including patients with advanced coronary artery disease, heart failure, valvular disorders.

2. Recognition & management of post-cardiotomy heart failure including primary cardiogenic shock, univentricular or biventricular failure, cardiac tamponade.

3. Initial resuscitation and timely management of significant post cardiothoracic surgical and non surgical causes of hemorrhage including extraordinary procedures such as bed-side thoracotomy wound opening

4. Echocardiography related to cardiothoracic critical care to diagnosis and manage hemodynamic instability

5. Significant exposure to modern hemodynamic pharmacology including vassopressors, intropes, anti-hypertensives and the necessary invasive monitoring required for their appropriate use.

6. Advanced cardiac failure support including mechanical assist devices;

a] Left, right and biventricular assist devices for temporary, bridge to transplant and destination therapies

b] Extra-Corporeal Life Support techniques for cardiac vs. respiratory support including appropriate selection for and institution of ECMO support, management dilemmas including bleeding, ventilator management during ECMO, trailing patients off support and ethical issues related to appropriate continuation or withdrawal of ECMO support.

7. Management issues related to heart and lung transplantation including specialized pharmacology, immunosuppressive therapeutics and evaluation for early organ rejection.

8. Diagnosis and management of infections of the mediastinum

9. Specialized ventilator management issues after thoracic surgery for primary lung disorders

10. Outcomes and use of outcome data related to cardio-thoracic surgery.

C. General Medical ICU Rotation at the UMMC{MICU}

The MICU is a 20 bed general medical ICU that accepts and manages a variety of serious medical disorders or complications requiring intensive care. The ICU team is comprised of medical/pulmonary intensivists, pulmonary ICU fellows, senior and junior medical residents as well as a multidisciplinary team of allied health care providers. Emphasis is on expanding a rational differential diagnosis, implementing an appropriate diagnostic plan while resuscitating and managing complex medical conditions will be highlighted during this rotation.

1. Management of acute and chronic causes of respiratory failure will have a central place during this rotation including advanced management of acute lung injury/ ARDS
2. The fellow will obtain experience in a variety of non-surgical conditions requiring ICU care including

• diagnosis and management of sepsis from a variety of non-surgical causes
• Complications from complex/rare medical conditions especially connective tissue disorders, inflammatory conditions, immunosuppressed states
• Acute and chronic causes of hepatic
• Complications related to malignancies including immunosuppression, bone marrow transplantation

3. Chronic conditions that periodically worsen and require intensive therapies including chronic respiratory diseases, infections such as HIV, seizure disorders
4. Acute management of toxin, alcohol and drug exposures/overdoses
5. Ethical issues surrounding care of debilitated patients or those with advanced age or terminal conditions

Clinical Electives Goals and Objectives

Core competencies for Anesthesiology fellows rotating through specific elective rotations will be the same as above. The educational program of the fellowship will include both specific teachings during specific elective rotations including didactics associated with that rotation as well as core lecture series and other didactics associated with the fellowship. Evaluations of the fellows and by the fellows of the rotation will be performed as indicated in the general goals and objective section above. The faculty or program director from the specific elective rotation will provide immediate feedback and a summary evaluation of the fellow to the ICU fellowship program director in a timely fashion after the specific rotation. The ICU fellows will have the opportunity to evaluate the elective as well using the Med-Hub system.

1. Echocardiography

The goals of this elective are to obtain advanced training in the use of both trans-esophageal and trans-thoracic echocardiography including the principles of ultrasound, 2-D ultrasound and the standard views required to obtain a complete exam of the heart. Experience in obtaining TEE will primarily be obtained by performing and reviewing TEE exams in the cardiac ORs. The ICU fellow will spend 1 month performing TEE exams in the cardiac ORs with both the Cardiac Anesthesia faculty as well as the general cardiology faculty when they perform TEEs either in the ORs or the general floor. Trans-thoracic echo experience will primarily be obtained by observing the cardiologist or cardiology echo technicians perform bedside exams, with opportunity to actively participate in these exams as well as the daily cardiology review of all echo exams performed. Monthly echo conferences will also be attended by the ICU fellow in either the Anesthesiology or Cardiology departments. Specific areas of interest will include;

1. Principles of ultrasound
2. Standard views determined by the American Society of Echocardiographers and Society of Cardiovascular Anesthesiologist guidelines for comprehensive intra-operative echo exam.(A&A 1999;89, 870-84)
3. Indications and contraindications of TEE including esophageal disorders.
4. Recognition and initial management of TEE related complications
5. Echo diagnosis of hypovolemic states, acute myocardial ischemia, acute & chronic causes of cardiac failure, external cardiac compression including tamponad, and right ventricular overload states including pulmonary embolism and evaluation of cardiac valvular disorders and aortic disorders including aortic dissection

2. Acute Renal Consultations and Dialysis Service

The goals of this elective include experience in the diagnosis and management of acute renal insufficiency and failure especially related to ICU conditions such as shock, pre-renal states, inflammatory diseases and toxin exposures such as intravascular contrast materials. The ICU fellow will participate in Nephrology consultations, with supervised discussions related to the pathophysiology and management of acute renal disorders with the nephrology faculty and fellows. Specific areas of interest pursued will include;

1. Laboratory and Diagnostic test to identify the type and cause of renal failure

2. Principles of renal replacement therapies including intermittent and continuous dialysis

3. Different modes of hemodialysis

4. Different methods of CRRT including convective vs diffusion.

5. Dialysis access methods including temporary and permanent venous access

6. Management of life-threatening complications related to acute renal failure

7. Modifications to pharmacologic and nutrition support for patients receiving dialysis


Acute Infectious Diseases Consult Service

The ICU fellows will spend from 2 to 4 weeks performing acute infectious disease consultations with the goal that they will expand their diagnostic and antimicrobial therapeutic knowledge. The fellows will be supervised by the ID consult team faculty and fellows. Specific aims of the rotation will include;

1. Broader awareness of the range of antimicrobial therapeutics available for acute life threatening infections

2. Appropriate Diagnostic strategies including laboratory and radiological methods to determine the presence and extent of an infectious etiology

3. Expanded knowledge of how to manage resistant organisms including patient isolation techniques, and rational use and discontinuation of antimicrobials

4. Exposure to chronic infectious diseases that will be encountered in the ICU setting.

5. Experience working with infectious disease consultants to improve collaborative care in the ICU.

Educational Program
Clinical Components

The subspecialty trainee in ACCM must gain clinical experience in the following areas:
1.  Airway maintenance and management.

2.  Mechanical ventilation.

3. Devices which supply supplemental oxygen.

4. Indications of and techniques for emergency and therapeutic treatment of conditions requiring thoracentesis and/or tube thoracotomy.

5. Emergency and therapeutic fiberoptic Laryngotracheobronchoscopy.

6. Assessment and evaluation of pulmonary function.

7. Cardiopulmonary resuscitation. Residents must be certified in ACLS and ATLS prior to completion of their ACCM training. The program must provide access to this training.

8. Placement and management of arterial, central venous and pulmonary arterial catheters.

9. Emergency and therapeutic placement of pacemakers.

10. Pharmacologic and mechanical support of circulation.

11. Evaluation and management of central nervous system dysfunction.

12. Recognition and treatment of hepatic and renal dysfunction.

13. Diagnosis and treatment of sepsis.