Knowledge of general critical care is an increasingly complex, essential component of patient care in the neurocritical care unit. The skillset needed to manage patients with acute brain injury and concurrent critical illness is highly specialized and in demand.
The general critical care rotations are mandatory and occur in the Medical ICU, Surgical ICU, Cardiac ICU as one week blocks for a total four weeks during both years 1 and 2 of fellowship. Fellows may choose to complete their ICU electives at either NYPH-Columbia campus or NYPH-Cornell campus. Upon completion, fellows are proficient in the complex management of a wide range of critical care issues that may arise in patients with severe acute brain injury. The following set of core educational objectives is designed to clearly communicate the expectations of neurocritical care fellows in terms of knowledge, skills and attitudes in critical care during their electives.
These educational goals are met through a series of clinical experiences in general critical care settings, regularly scheduled seminars and conferences in general critical care subjects, multidisciplinary conferences (case conference, critical care grand rounds), and individual projects.
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INDEX OF COMPETENCIES: PC=Patient Care; MK=Medical Knowledge; PBLI=Practice-Based Learning & Improvement; ICS=Interpersonal & Communication Skills; Prof=Professionalism; SBP=Systems-Based Practice |
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This rotation is comprised of four 1-week rotations during both years of training. At the end of the first year, the fellows are expected to demonstrate the following:
Objective 1 (PC, ICS, PBLI, MK): Demonstrate proficiency in all medical and diagnostic procedures considered to be essential for the area of general critical care by:
- Demonstrating competence in the following procedural critical care skills, applications of advanced technology and instrumentation for monitoring the physiologic status of patients with general critical care issues:
- Respiratory: Recognition of patients requiring mechanical ventilation (both invasive and non-invasive) as pertinent for patients with critical illness. Management of mechanical ventilation settings for patients with ongoing critical pulmonary conditions such as ARDS and neurogenic pulmonary edema.
- Cardiac: Interpretation of cardiac telemetry and interpretation of echocardiography and cardiac output monitoring on critically ill patients
- Renal: Evaluation of renal function based on blood and urinary laboratory results. Evaluation of renal function based on imaging studies including renal ultrasound and computed tomography of the abdomen and pelvis.
- Gastrointestinal: Appropriate nasogastric tube placement, use and interpretation of enteral feeding, and management principles of percutaneous enteral devices.
- Hematologic: Fellows will be able to evaluate and manage hypercoagulable conditions, and correct intrinsic and extrinsic coagulopathies issues. Fellows will show appropriate selection and use of transfusion products
- Infectious disease: Fellows will be proficient in classification of common infections in critically ill patients and apply isolation techniques. Fellows will interpret and apply principles of pharmacokinetics, drug interactions, and management of antibiotic therapy.
- Nutritional: Fellows will demonstrate appropriate application of parenteral and enteral nutrition in. Fellows will appropriately monitor, assess metabolism and nutrition of patients
- Physical therapy: Fellows will be familiar with use of specialized beds, traction, and fixation devices for specific injuries
- Critical care ultrasound: Proficiency in obtaining basic cardiac ultrasound views of the inferior vena cava, cardiac TTE windows (parasternal long, parasternal short, apical 4-chamber view, subcostal view), and lung ultrasound.
- Communicating with patient families current and projected clinical courses for patients with vascular neurologic issues
- Recognizing common diagnoses in critical illness such and developing a comprehensive differential diagnosis regarding etiology. Examples include (but are not limited to)
- Cardiorespiratory resuscitation
- Hematologic and coagulation disorders
- Effects of critical illness on endocrine, metabolic, and nutritional aspects of patient health
- Ethical and legal aspects of neurosurgical critical care
- Cardiopulmonary monitoring, hemodynamic monitoring, and medical instrumentation including central venous access and arterial line placement
- Trauma as it relates to neurologic disease
- Physiology, pathophysiology, diagnosis and treatment of cardiovascular, gastrointestinal, neurologic, endocrine, musculoskeletal, infectious, and respiratory system disorders in patients with critical illness
- Developing and executing a therapeutic management plan for patients with common diagnoses in critical illness
- Participating in a multi-specialty team of physicians, medical students and allied health professionals in patient management.
Objective 2 (MK): Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social behavioral sciences, as well as the application of this knowledge to patient care in general critical care by:
- Applying basic knowledge of the following general critical care issues:
- Cardiorespiratory resuscitation
- Hematologic and coagulation disorders
- Effects of critical illness on endocrine, metabolic, and nutritional aspects of patient health
- Ethical and legal aspects of neurosurgical critical care
- Cardiopulmonary monitoring, hemodynamic monitoring, and medical instrumentation including central venous access and arterial line placement
- Trauma as it relates to neurologic disease
- Physiology, pathophysiology, diagnosis and treatment of cardiovascular, gastrointestinal, neurologic, endocrine, musculoskeletal, infectious, and respiratory system disorders in patients with critical illness
Objective 3 (ICS, MK, PBLI): Acquire and demonstrate the ability to synthesize and apply knowledge and understanding gained from basic science, clinical research, and information technology to provide accessible information to patients and support one’s own education by:
- Leveraging information technology to gather the most up-to-date scientific evidence to make informed decisions regarding diagnostic and therapeutic interventions.
- Proficiently using information technology to manage information, access on-line medical information, support their own education, and apply this information in the clinical care of patients.
- Finding, assessing, and assimilating the best evidence for clinical decision-making and continuously evaluating and improving patient care practices.
Objective 4 (SBP, PROF, ICS): Leverage knowledge of medical systems and regulatory requirements of medical training and practice by:
- Participating in analysis of safety event(s)
- Disclosing patient safety events to patients and their families (simulated/actual) with guidance from mentor as needed
- Performing patient safety and/or quality improvement project(s)
- Delivering patient-centered care with focus on individual needs of patient and family
- Leading interdisciplinary patient-centered care
- Advocating for safe and effective transitions of care
- Adjusting individual practice to address needs of specific patient populations
- Modifying individual practice to optimize care within a broader health care system
Objective 5 (SBP, ICS, PROF): Demonstrate professionalism and expertise in using the system of care in a way that is beneficial and essential for patients, by:
- Effectively communicating with other members of the health care team (i.e., other physicians, nurses, social workers, etc.) to coordinate and optimize patient care.
- Advocating for quality patient care and assisting patients in dealing with system complexities.
- Functioning as a team member to facilitate and optimize patient care.
- Demonstrating effective listening skills and providing patients the opportunity to explain their problem and concerns.
- Actively participating in the education of patients, families, medical students, residents and other health care professionals.
- Demonstrating superior interpersonal and communications skills with professional associates and other health care providers.
Objective 6 (ICS, PROF, PC): Demonstrate the ability to interact and communicate with patients in a manner that is culturally sensitive and patient-centered, by:
- Demonstrating respect, compassion, integrity, and responsiveness to the needs of patients, their families and society that supersede self-interest.
- Providing care that is sensitive to each person’s age; gender; and cultural, economic, and social circumstances.
- Demonstrating clear, understandable, and effective interpersonal and communication skills to counsel and educate patients and their families.
- Demonstrating a commitment to ethical practices pertaining to patient privacy and autonomy, the provision or withholding of clinical care, confidentiality of patient information, informed consent, and conflict of interest and business practices.
- Creating and sustaining a therapeutic and ethically sound patient-physician relationship.
- Creating and sustaining an environment where patients and their families feel comfortable asking questions about the patients’ diseases and treatments.
- Promoting an environment that supports shared decision making by including patients and families in decisions and choices about treatment.
- Effectively and empathetically delivering bad news to patients and their families.
Objective 7 (ICS, PROF, SBP): Demonstrate the ability to interact, communicate and work effectively with clinical and ancillary staff in the medical ICU, surgical ICU, and cardiac ICU, by:
- Obtaining and providing appropriate consultation.
- Carrying out respectful and effective communication with: colleagues, nurses, and ancillary staff in a way that encourages cooperation and patient-based care.
Objective 8 (PROF): Demonstrate the ability to conduct oneself in a professional manner by:
- Consistently exhibiting a professional appearance; neat, well-groomed, conservative attire in compliance with the hospital dress code
- Consistently demonstrating professional attitudes consistent with being a physician, with an emphasis on responsibility, compassion, sensitivity to diverse patient populations and cultures.
- Continuously adhering to ethical principles, confidentiality, informed consent and a commitment to excellence and on-going professional development.
- Exhibiting dependability, responsibility and self-respect.
- Arriving for clinical duties and completing work in a timely manner and with appropriate attention to detail
- Consistently demonstrating personal integrity and altruism.
- Serving as a role model for residents and medical students.
Objective 9 (PROF, ICS): Demonstrate teaching skills by:
- Providing instruction to residents and medical students in critical care.
- Exhibiting leadership in advising, teaching and supervising residents and medical students.
At the end of the second year of neurocritical care fellowship, the fellows are expected to demonstrate the following:
Objective 1 (PC, ICS, PBLI, MK): Demonstrate mastery in all medical, diagnostic, and surgical procedures considered to be essential for the area of practice by:
- Demonstrating competence in the following procedural neurocritical care skills, applications of advanced technology and instrumentation for monitoring the physiologic status of critically ill patients:
- Respiratory: Recognition of patients requiring mechanical ventilation (both invasive and non-invasive), and management of endotracheal intubation for uncomplicated and complicated airway. Performance of therapeutic and diagnostic bronchoalveolar lavage, and supervision of junior fellows. Management of complex mechanical ventilation settings for patients with ongoing critical pulmonary conditions such as severe ARDS, including initiation of neuromuscular blockade, prone ventilation, and inhaled pulmonary vasodilators.
- Cardiac: Interpretation of cardiac telemetry, arterial line waveform interpretation, and interpretation of echocardiography and cardiac output monitoring.
- Renal: Evaluation of renal function based on blood and urinary laboratory results. Evaluation of renal function based on imaging studies including renal ultrasound and computed tomography of the abdomen and pelvis.
- Gastrointestinal: Appropriate nasogastric tube placement, use and interpretation of enteral feeding, and management principles of percutaneous enteral devices.
- Hematologic: Proficiency in completion and interpretation of point-of-care rotational thromboelastography. Proficiency in evaluation and management hypercoagulable conditions, and correction intrinsic and extrinsic coagulopathies. Appropriate triggering and management of severe hemorrhage requiring massive transfusion protocol
- Infectious disease: Fellows will be proficient in classification of common infections in critically ill patients and apply isolation techniques. Fellows will interpret and apply principles of pharmacokinetics, drug interactions, and management of antibiotic therapy.
- Nutritional: Fellows will demonstrate appropriate application of parenteral and enteral nutrition in. Fellows will appropriately monitor, assess metabolism and nutrition of patients with critical illness and concomitant acute brain injury
- Physical therapy: Fellows will be familiar with use of specialized beds, traction, and fixation devices for specific injuries.
- Critical care ultrasound: Mastery in obtaining basic cardiac ultrasound views of the inferior vena cava, cardiac TTE windows (parasternal long, parasternal short, apical 4-chamber view, subcostal view), and lung ultrasound. Proficiency in advanced critical care ultrasound views including diastology and non-invasive cardiac output monitoring by ultrasound.
- Communicating with patient families current and projected clinical courses for critically ill patients
- Recognizing severe presentations of common diagnoses in general critical care and develop a comprehensive treatment plan.
- Exhibiting leadership of a multi-specialty team of physicians, medical students and allied health professionals in patient management in the neurocritical care unit.
Objective 2 (MK): Demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social behavioral sciences, as well as the application of this knowledge to patient care by:
- Applying advanced knowledge of the following general critical care issues:
- Cardiorespiratory resuscitation
- Hematologic and coagulation disorders
- Effects of critical illness on endocrine, metabolic, and nutritional aspects of patient health
- Ethical and legal aspects of neurosurgical critical care
- Cardiopulmonary monitoring, hemodynamic monitoring, and medical instrumentation including central venous access and arterial line placement
- Trauma as it relates to neurologic disease
- Physiology, pathophysiology, diagnosis and treatment of cardiovascular, gastrointestinal, neurologic, endocrine, musculoskeletal, infectious, and respiratory system disorders in patients with critical illness
- Supervising residents and students in the diagnosis, evaluation and treatment of neurocritical care issues
Objective 3 (ICS, MK, PBLI): Acquire and demonstrate the ability to synthesize and apply knowledge and understanding gained from basic science, clinical research, and information technology to provide accessible information to patients and support one’s own education by:
- Leveraging information technology to gather the most up-to-date scientific evidence to make informed decisions regarding diagnostic and therapeutic interventions.
- Proficiently using information technology to manage information, access on-line medical information, support their own education, and apply this information in the clinical care of patients.
- Finding, assessing, and assimilating the best evidence for clinical decision-making and continuously evaluating and improving patient care practices.
Objective 4 (SBP, PROF, ICS): Leverage knowledge of medical systems and regulatory requirements of medical training and practice by:
- Participating in analysis of safety event(s)
- Disclosing patient safety events to patients and family (simulated/actual) with guidance from mentor as needed
- Performing patient safety and/or quality improvement project(s)
- Delivering patient-centered care with focus on individual needs of patient and family
- Leading interdisciplinary patient-centered care
- Advocating for safe and effective transitions of care
- Adjusting individual practice to address needs of specific patient populations
- Modifying individual practice to optimize care within a broader health care system
Objective 5 (SBP, ICS, PROF): Demonstrate professionalism and expertise in using the system of care in a way that is beneficial and essential for patients, by:
- Effectively communicating with other members of the health care team (i.e., other physicians, nurses, social workers, etc.) to coordinate and optimize patient care.
- Advocating for quality patient care and assisting patients in dealing with system complexities.
- Functioning as a team member to facilitate and optimize patient care.
- Demonstrating effective listening skills and providing patients the opportunity to explain their problem and concerns.
- Actively participating in the education of patients, families, medical students, residents and other health care professionals.
- Demonstrating superior interpersonal and communications skills with professional associates and other health care providers.
Objective 6 (ICS, PROF, PC): Demonstrate the ability to interact and communicate with patients in a manner that is culturally sensitive and patient-centered, by:
- Demonstrating respect, compassion, integrity, and responsiveness to the needs of patients, their families and society that supersede self-interest.
- Providing care that is sensitive to each person’s age; gender; and cultural, economic, and social circumstances.
- Demonstrating clear, understandable, and effective interpersonal and communication skills to counsel and educate patients and their families.
- Demonstrating a commitment to ethical practices pertaining to patient privacy and autonomy, the provision or withholding of clinical care, confidentiality of patient information, informed consent, and conflict of interest and business practices.
- Creating and sustaining a therapeutic and ethically sound patient-physician relationship.
- Creating and sustaining an environment where patients and their families feel comfortable asking questions about the patients’ diseases and treatments.
- Promoting an environment that supports shared decision making by including patients and families in decisions and choices about treatment.
- Effectively and empathetically delivering bad news to patients and their families.
Objective 7 (ICS, PROF, SBP): Demonstrate the ability to interact, communicate and work effectively with clinical and ancillary staff in critical care areas, by:
- Supervising patient care activities in critical care areas
- Obtaining and providing appropriate consultation.
- Carrying out respectful and effective communication with colleagues, nurses, and ancillary staff in a way that encourages cooperation and patient-based care.
Objective 8 (PROF): Demonstrate the ability to conduct oneself in a professional manner by:
- Consistently exhibiting a professional appearance; neat, well-groomed, conservative attire in compliance with the hospital dress code
- Consistently demonstrating professional attitudes consistent with being a physician, with an emphasis on responsibility, compassion, sensitivity to diverse patient populations and cultures.
- Continuously adhering to ethical principles, confidentiality, informed consent and a commitment to excellence and on-going professional development.
- Exhibiting dependability, responsibility and self-respect.
- Arriving for clinical duties and completing work in a timely manner and with appropriate attention to detail
- Consistently demonstrating personal integrity and altruism.
- Serving as a role model for residents and medical students.
Objective 9 (PROF, ICS): Demonstrate teaching skills by:
- Providing instruction to residents and medical students in critical care.
- Exhibiting leadership in advising, teaching and supervising residents and medical students.
Objective 10 (MK, ICS, PBLI): Participate in scholarly activities by:
- Presenting scholarly work with appropriately detailed subject reviews at Grand Rounds, and local, regional, and national meetings.