Cardiac Care Unit
Cardiac Care Unit Competency-Based Curriculum
Overview
Cardiac care medicine involves caring for some of the most acutely ill patients with a broad range of clinical problems and is often best achieved by adopting a team approach consisting of the general internist, cardiologist, critical care specialist, as well as other subspecialists as indicated. Residents must learn to recognize critical cardiac illness and facilitate timely transfer of patients to the CCU, but must also learn to allocate these limited resources appropriately to those patients most likely to benefit from this level of care. Residents will need to gain experience and a level of comfort in dealing with numerous difficult ethical and social issues including the initiation and withdrawal of life-support measures, advance directives, determination of brain death, and organ transplantation. Residents function under the direct supervision of a Cardiologist who also serves as the teaching attending for the month. They receive training for various procedures in the cardiac unit which include arterial lines, swanganz catheters, central line placements and management of patients on the Intra aortic balloon pump.
Principal Teaching/Learning Activities
-Sign-out Rounds (SR) -- Every evening, Monday through Friday, the the
senior residents (Chief Resident, or his/her designate will be present
during the first few months of the academic year), supervise sign-out
rounds, which are attended by the out-going day team and incoming ADMITTING
team. These may include topical discussions.
-Teaching Attending Rounds (AR) – Attending rounds format will vary depending on the preference of the attending cardiologist. There should be discussion of the patients with concurrent teaching.. At the very least this should include bedside rounds on the new patients and others whom the resident/attending feel should be seen by the team. If possible beside rounds should be done on all patients.
-Management Rounds (MR) -- Each day the attending physicians and cardiologists
responsible for care of patients will meet with the residents to review
specific aspects of patient management. It will be on these occasions
that residents are supervised in details of recordkeeping, interaction
with other health care team members, communication with consultants and
family members, and all other aspects of patient management.
-Grand Rounds (GR) -- Medical Grand Rounds are held each Wednesday from
8:00 -9:00 a.m. in the Medical Center Auditorium. Formats vary and include
invited guests/visiting professor presentations, clinical-pathological
conferences, morbidity and mortality conference, resident presentations,
or other didactic, topical, or patient related topics.
- Turnover Rounds (TR)-- Turnover rounds occur at the end/beginning of each rotation and from 6:30- 7:30 a.m. daily. These facilitate transfers of patient care from one resident to another. (Sign in Rounds are a daily version of turnover rounds.)
-Patient Safety and Quality Improvement Conference (PSQI) –Formerly the Morbidity and Mortality Conference. We now have a monthly conference dedicated to identifying issues that affect patient safety. The issues maybe as varied as knowledge gaps in care for patients with unusual diseases to errors that occur in the course of care. There is a discussion about the residents' role in preventing such issues in the future. If warranted an action plan is made with follow up at subsequent meetings.
-Autopsy Rounds (AuR) When a death occurs on any of the teaching teams the family is offered the option of performing an autopsy. If an autopsy is performed, we hold a multidisciplinary presentation of the findings that includes medicine, pathology, radiology, surgery, and/or ob/gyn residents and faculty that were involved.
-MKSAP study pan (MKSAP)-This self directed study plan helps residents stay on track with their didactic reading and helps them evaluate their medical knowledge (strengths and areas of deficit). Residents can help develop individualized study plans to fill in any knowledge gaps and reinforce what they already know. This also helps residents develop skills and habits needed for lifelong learning.
-In-Training Examination (ITE) -- All of our residents must take this examination annually for their own assessment of progress and for edification. When examination results become available, the program director discusses these individually with residents and counsels residents about individualized study programs to facilitate their acquisition of knowledge.
Description of the Rotation
Junior residents and interns are assigned to the CCU each month either during the daytime or nighttime hours. Patient care responsibilities are exclusively to patients in the medical CCU. They are supervised by patients' individual attending physicians and the teaching cardiologist for the month.
Teaching rounds, under the supervision an attending physician, will occur for at least 4 ½ hours weekly, but done properly will occur at least 1 ½ - 2 hours daily, and occasionally on weekends. These rounds will be more didactic in nature than management rounds. They must include presentation and discussion of each patient, at least in part, at the bedside. While it is appropriate to review certain academic topics in the conference room, rounds cannot neglect bedside medicine. Indeed they are best conducted solely at the bedside.
Students, at 3rd and 4th year levels, will be incorporated into all of these activities. Their progress notes of cannot be the official progress notes of record. This means that residents should countersign student notes but must record their own assessments. Students, by New Jersey Statue, are not permitted to write orders. They are encouraged to use a duplicate but unofficial order sheet to do so, for educational purposes, but these cannot be part of the permanent record.
Competency-Based Goals and Objectives
The goals of the CCU experience will be for residents to gain understanding of the clinical features, diagnostic aspects, differential diagnosis, pathophysiology and management of cardiovascular disorders that require critic care. Residents will gain knowledge of:
- Cardiovascular physical exam
-
Cardiovascular medicine testing modalities-understanding the indications
for, interpretation of, and risks of diagnostic testing used for critically
ill patients including:
i. EKGs
ii. Pulmonary artery catheterization
iii. Coronary angiography and intervention
iv. Emergency cardioversion
v. Temporary pacemakers
vi. Stress Testing
vii. electrophysiology tests -
Common cardiovascular disease states
a. Coronary and peripheral arterial disease/acute coronary syndrome
b. Congestive Heart Failure /cardiogenic shock
c. Systemic and Pulmonary Hypertension
d. Valvular heart disease
e. Arrhythmias
g. Degenerative or systemic diseases affecting the cardiovascular system
h. HTN emergencies
i. Endocarditis
j. Pericarditis, pericardial effusion & tamponade
k. Aortic dissection
l. Congenital heart disease
Evaluations
Assessment Methods (of Resident)
The evaluation methods that apply to these rotations include some or all of the following:
- Evaluation of resident competence by faculty attendings (AE)- Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.
- Mini CEXs may be used when warranted, particularly in the beginning of the academic year.
- Self-evaluation by In-service training examination scores
- MKSAP study plan (MKSAP)
- Participation and presentations at didactic conferences (DC)
- Multi Source evaluations by patients and staff (MS)
Assessment Method (of Program)
Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.
Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.
Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.
Principle Educational Goals by Relevant Competency
In the tables below, the principle educational goals for the Cardiac Care service assignment are indicated for each of the six ACGME competencies. The second column of the table indicates the most relevant principle teaching/learning activity for each goal, using the legend below.
* Legend for Learning Activities (See preceding for descriptions)
AE-Attending Evaluations
AR- Attending Rounds
AuR- Autopsy Rounds
DPC-Direct Patient Care
GR- Grand Rounds
ITE-In-Training Exam
MKSAP-Knowledge Self Study Plan
MR- Management Rounds
MS-Multisource evals
SR- Signout Rounds
TR-Turnover Rounds
Competency Based Goals & Objectives:
1) Medical Knowledge
| Goals and Objectives-PGY1 | Learning Activities* | Assessment |
| Describe the epidemiology, genetics, natural history, clinical expression of the CV illness encountered in the inpatient setting. | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Summarize an approach to the evaluation of the common presentations of CV diseases (CAD, ACS, CHF, valvular diseases, pericardial diseases, aortic diseases, arrhythmias, conduction disorders) | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Describe structure and function of heart (myocardium, calves, coronaries, conduction system), pericardium, aorta. | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Generate and prioritize differential diagnoses for patients with CV disease | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Develop rational, evidence-based management strategies for patients with CV disease | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Goals and Objectives-PGY2/3 (In addition to above) | Learning Activities* | Assessment |
| Summarize an approach to the evaluation of acute CV presentations | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Understand the indications for admission to the CCU | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Interpret diagnostic tests used in the evaluation of outpatients with acute CV Illness | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Demonstrate ability to critically appraise and cite literature pertinent to the evaluation acute CV disorders. | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
2) Patient Care
| Goals and Objectives-PGY1 | Learning Activities* | Assessment |
| Effectively perform a comprehensive history and complete physical examination in patients with acute CV symptoms | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Appropriately select and interpret laboratory, imaging, and pathologic studies used in the evaluation of acute CV disorders | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Goals and Objectives-PGY2/3 (In addition to above) | Learning Activities* | Assessment |
| Construct a comprehensive treatment plan and assess response to therapy. | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Counsel patients concerning their diagnosis, planned diagnostic testing and recommended therapies. | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Utilize validated instruments in the assessment of function and quality of life to monitor and adjust therapy. | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
3) Practice-Based Learning and Improvement
| Goals and Objectives-PGY1 | Learning Activities* | Assessment |
| Identify and acknowledge gaps in personal knowledge and skills in the care of hospitalized and ambulatory patients with related diseases | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Develop and implement strategies for filling gaps in knowledge and skills of patients related diseases | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Integrate and apply knowledge obtained from multiple sources to the care of inpatients and outpatients | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Demonstrate ability to critically assess the scientific literature | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Goals and Objectives-PGY2/3 (In addition to above) | Learning Activities* | Assessment |
|
Effectively use technology to manage information, support patient care decisions, and enhance both patient and physician education. |
DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Demonstrate ability to critically assess the scientific literature | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Set and assess individualized learning goals | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Analyze clinical experience and employ a systematic methodology for improvement | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
| Develop and maintain a willingness to learn from errors, and use errors to improve the system or processes of care | DPC, MR, AR, MKSAP | AE, MKSAP, MS |
4) Interpersonal Skills and Communication
| Goals and Objectives-PGY1 | Learning Activities* | Assessment |
| Apply empathy in all patient encounters | DPC, MR, AR | AE, MS |
| Demonstrate effective skills of listening and speaking with patients, families and other members of the health care team | DPC, MR, AR | AE, MS |
| Present patient information concisely and clearly, verbally and in writing | DPC, MR, AR | AE, MS |
| Goals and Objectives-PGY2/3 (In addition to above) | Learning Activities* | Assessment |
| Reliably and accurately communicate the patient's and his/her family's views and concerns to the attending | DPC, MR, AR | AE, MS |
| Compose clear and timely admission and progress notes and consultations | DPC, MR, AR | AE, MS |
| Counsel patients, families and colleagues regarding side effects and appropriate use of specific medications, providing written documentation when appropriate | DPC, MR, AR | AE, MS |
| Teach colleagues effectively | DPC, MR, AR | AE, MS |
5) Professionalism
| Goals and Objectives-PGY1 | Learning Activities* | Assessment |
| Be prompt and prepared for all clinical duties | DPC, MR, AR | AE, MS |
| Recognize the importance of patient primacy, patient privacy, patient autonomy, informed consent, and equitable respect and care to all | DPC, MR, AR | AE, MS |
| Respect patients and their families, staff and colleagues | DPC, MR, AR | AE, MS |
| Goals and Objectives-PGY2/3 (In addition to above) | Learning Activities* | Assessment |
| Model ethical behavior by reporting back to the attending and referring providers any key clinical findings | DPC, MR, AR | AE, MS |
| Demonstrate integrity | DPC, MR, AR | AE, MS |
| Respond to phone calls and pages promptly | DPC, MR, AR | AE, MS |
6) Systems-Based Practice
| Goals and Objectives-PGY1 | Learning Activities* | Assessment |
| Demonstrate effective collaboration with other health care providers, including nursing staff, ancillary staff, therapists, primary care physicians, and consultants in the care of patients with related diseases | DPC, MR, AR | AE, MS |
| Develop an understanding of the hospital resources available to the evaluation and management of patients with problems encountered by the subspecialty. | DPC, MR, AR | AE, MS |
| Demonstrate a knowledge of and commitment to the rules governing confidentiality of patient information. | DPC, MR, AR | AE, MS |
| Goals and Objectives-PGY2/3 (In addition to above) | Learning Activities* | Assessment |
| Discuss how the health care system affects the management of inpatients with related diseases. | DPC, MR, AR | AE, MS |
| Determine cost-effectiveness of alternative proposed interventions. | DPC, MR, AR | AE, MS |
| Design cost-effective plans based on knowledge of best practices | DPC, MR, AR | AE, MS |
| Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the health care system, cost of the procedure, insurance coverage, and resources utilized | DPC, MR, AR | AE, MS |
Procedures
Residents will have the opportunity to observe and when possible perform the procedures listed. In addition, residents will learn, as appropriate to individual patients, the indications and contraindications and the performance of those medical procedures required by the American Board of Internal Medicine and Residency Review Committee (as detailed in the inpatient general medicine curriculum) and perform all procedures on patients under their care.
- Arterial Bloog Gas
- Arterial -line
- Cardioversion/chemical electrical
- Cardiac catheterization
- Chemical and exercise stress testing
- Electrocardiograpy
- Electrophysiology
- Echocardiography
- External pacemaker
- Intra aortic balloon pumps
- Pacemaker indications and management
- Pericardiocentesis
- Swan Ganz Catheter Placement
- Telemetry monitoring
- Tilt-table testing
Residents will have the opportunity to develop technical proficiency in ACLS resuscitation
Reference List
*All residents are expected to read about their patients in an appropriate general medicine text. In addition, a vast variety of print and on-line reference material is available though the library (24-hour access for all residents) and the on-line portal. Specific reading material will be distributed during the rotation. Because it is frequently updated, extensively referenced, and includes abstracts of reference articles, the program highly recommends UpToDate as an adjunctive information source. MDConsult is also a valuable resource and residents should become familiar with use as a rapid search engine for clinical information
Textbooks/Journals:
- Harrison's Principles of Internal Medicine, Cardinal Manifestations of Disease, Chapters on Chest Discomfort and Palpitations, Alterations in Circulatory and Respiratory Functions and Disorders of the Cardiovascular System.
- Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine
- Annals of Internal Medicine – Update in Cardiology
Websites/Guidelines
- Acute Coronary Syndromes/ST-Elevation Myocardial Infarction:
- Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction:
- Percutaneous Coronary Intervention
- Coronary Artery Bypass Graft Surgery
- Arrhythmias/Electrophysiology
- Ventricular Arrhythmias and Sudden Cardiac Death
- Atrial Fibrillation
- Supraventricular Arrhythmias
- Valvular Heart Disease
- Perioperative Care
- Heart Failure