Goals and Objectives: Inpatient Neurocritical Care Rotation

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Acute neurologic disease that is seen in the inpatient setting has become increasingly complex and intertwined with systemic medical illness. The skillset needed to manage patients with acute brain injury and concurrent critical systemic illness is highly specialized and in demand. Neurocritical Care has been at the forefront of delivering treatments to improve care and physiologic understanding of acute brain injury.

Training occurs in the 18-bed Neuro ICU at the NYPH-Columbia campus and the 14-bed Neuro ICU at the NYPH-Cornell campus under the supervision of faculty neurointensivists. Upon completion, fellows are proficient in the complex management of a wide range of acute brain injury in critically ill patients. 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 during their fellowship.

These educational goals are met through a series of clinical experiences in Neurocritical Care (supervised clinical practice in the Columbia and Cornell neurocritical care units), regularly scheduled seminars and conferences in critical care, neurological surgery, neuroradiology, and neurology, regularly scheduled simulations, multidisciplinary conferences (neurovascular, epilepsy, critical care grand rounds), procedures sessions and individual projects.

INDEX OF COMPETENCIES:

PC=Patient Care; MK=Medical Knowledge; PBLI=Practice-Based Learning & Improvement; ICS=Interpersonal & Communication Skills; Prof=Professionalism; SBP=Systems-Based Practice

This is a two-year fellowship. 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, 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 with acute brain injury:
- Neurologic: Consistent completion of a thorough neurologic exam on critically ill adults with acute brain injury. Interpretation of intracranial multimodality physiologic monitoring (ICP waveform, cerebral oxygenation, cerebral microdialysis, intraparenchymal and intraventricular monitors, depth electroencephalography, and regional cerebral blood flow). Interpretation of neuroimaging including transcranial Doppler, computed tomography, and magnetic resonance imaging.
- Respiratory: Recognition of patients requiring mechanical ventilation (both invasive and non-invasive), and management of endotracheal intubation for uncomplicated airway. Performance of therapeutic and diagnostic bronchoalveolar lavage. Management of mechanical ventilation settings for patients with ongoing critical pulmonary conditions such as ARDS and neurogenic pulmonary edema.
- 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: Fellows will be able to evaluate coagulation status based on blood and rotational thromboelastography testing, evaluate and manage hypercoagulable conditions, and correct intrinsic and extrinsic coagulopathies. 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 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: 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 critically ill patients with acute brain injury
Recognizing common diagnoses in neurocritical care such and developing a comprehensive differential diagnosis regarding etiology. Examples include (but are not limited to):
- Aneurysmal and non-aneurysmal subarachnoid hemorrhage
- Acute ischemic stroke – including presentations with administration of tissue plasminogen activator and neurovascular intervention
- Acute hemorrhagic stroke
- Status epilepticus and refractory status epilepticus
- Hypoxic-ischemic encephalopathy
- Infectious causes for severe acute encephalopathy
- Severe presentations of neuromuscular disease including ALS requiring mechanical ventilation, acute inflammatory demyelinating polyneuropathies, and myasthenic crisis
- Moderate and severe traumatic brain and spine injury
- Neurogenic shock
- Increased intracranial pressure and herniation syndromes
- Brain death
Developing and executing a therapeutic management plan for patients with common diagnoses in neurocritical care (as detailed above)
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 by:

Recognizing and independently managing common cases of severe acute brain injury including:
- Aneurysmal and non-aneurysmal subarachnoid hemorrhage
- Acute ischemic stroke – including presentations with administration of tissue plasminogen activator and neurovascular intervention
- Acute hemorrhagic stroke
- Status epilepticus and refractory status epilepticus
- Hypoxic-ischemic encephalopathy post-cardiac arrest
- Infectious causes for severe acute encephalopathy
- Severe presentations of neuromuscular disease including ALS requiring mechanical ventilation, acute inflammatory demyelinating polyneuropathies, and myasthenic crisis
- Moderate and severe traumatic brain and spine injury
- Neurogenic shock
- Increased intracranial pressure and herniation syndromes
- Brain death
Applying basic knowledge of the following general critical care issues:
1. Cardiorespiratory resuscitation
2. Hematologic and coagulation disorders
3. Effects of critical illness on endocrine, metabolic, and nutritional aspects of patient health
4. Ethical and legal aspects of neurosurgical critical care
5. Cardiopulmonary monitoring, hemodynamic monitoring, and medical instrumentation including central venous access and arterial line placement
6. Trauma as it relates to neurologic disease
7. 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 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 inpatient neurology, ED (Emergency Department) and consult arenas, by:

Supervising patient care activities in the neurology inpatient, ED, and consult arenas.
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 neurocritical 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.
Preparing manuscript(s) for submission to medical literature.

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 with acute brain injury:
- Neurologic: Completion of a thorough neurologic exam on critically ill adults with acute brain injury with instruction of junior fellows and residents as needed. Implementation of multimodality monitoring software and interpretation intracranial multimodality physiologic monitoring (ICP waveform, cerebral oxygenation, cerebral microdialysis, intraparenchymal and intraventricular monitors, depth electroencephalography, and regional cerebral blood flow). Interpretation of neuroimaging including transcranial Doppler, computed tomography, and magnetic resonance imaging.
- 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 with acute brain injury
Recognizing severe presentations of common diagnoses in neurocritical care and develop a comprehensive treatment plan. Examples include (but are not limited to):
- Aneurysmal and non-aneurysmal subarachnoid hemorrhage
- Acute ischemic stroke – including presentations with administration of tissue plasminogen activator and neurovascular intervention
- Acute hemorrhagic stroke
- Status epilepticus and refractory status epilepticus
- Hypoxic-ischemic encephalopathy
- Infectious causes for severe acute encephalopathy
- Severe presentations of neuromuscular disease including ALS requiring mechanical ventilation, acute inflammatory demyelinating polyneuropathies, and myasthenic crisis
- Moderate and severe traumatic brain and spine injury
- Neurogenic shock
- Increased intracranial pressure and herniation syndromes
- Brain death
Exhibiting leadership of a multi-specialty Leading a multi-specialty team of physicians, medical students and allied health professionals in patient management in the neurocritical care unit.