Cardiac Intensive Care Unit Rotation
The cardiac intensive care unit rotation enables fellows to achieve the knowledge, skills and attitudes of competent cardiologists in the care of patients with acute coronary syndromes and other complicated cardiovascular conditions. Fellows are expected to gain proficiency in the diagnosis and management of critical cardiac conditions. Learning occurs through hands-on, supervised clinical experiences, bedside teaching, attending rounds and divisional and departmental conferences.
Expert Training of Acute Cardiac Conditions
Attending physicians are expected to reinforce the understanding of the following about cardiovascular diseases treated by internists and cardiologists:
- Clinical presentation
- Etiology
- Natural history
- Pathogenesis
The rotation should enhance fellows understanding of the pathogenesis and management of acute cardiac conditions. Additionally, trainees in the rotation are expected to develop skills in:
- Clinical problem solving
- Communication
- Diagnosis
- Interpersonal skills
- Interviewing
- Navigating system issues impacting inpatient care
- Therapy
Fellows in the cardiac intensive care unit (CICU) rotation will play an integral role in the education of the house staff. Fellows are expected to contribute to rounds both by bringing in the appropriate literature for the house staff and providing perspective on clinical management. Senior fellows are expected to demonstrate increased clinical leadership and are provided with autonomy commensurate with their training level. Fellows are expected to be highly involved in patient care, be familiar with the results of diagnostic and therapeutic procedures, and review the actual tests as appropriate.
Appropriate utilization of the health system resources is particularly important in the CICU. When feasible, fellows are expected to do the following:
- Come in early prior to daily walk rounds
- Evaluate new admissions and acutely unstable patients
- Participate in decisions regarding additional testing, care and triage
Fellows are expected to communicate effectively with house staff, nursing staff, referring physicians, cardiologists and other members of the health care team.
ACGME Competencies Training
All fellows are expected to progress in the six Accreditation Council for Graduate Medical Education (ACGME) competencies. The CICU is particularly well-suited for practice-based learning, improvement and understanding a systems-based perspective. Senior fellows, in conjunction with attending staff, are expected to choose one relevant, focused area of CICU function and endeavor to evaluate and/or improve the overall quality in that area.
Principle Teaching Methods
Direct supervision of patient care: An attending physician provides supervision to all members of the CICU rotation team via direct patient care; the team includes PGY2 and PGY3 residents and a cardiovascular medicine fellow. The CICU fellow provides additional supervision to the resident team.
Case-based learning: The attending physicians walk rounds daily. Attending physicians are expected to teach on average 4.5 hours per week during team rounds in addition to discussing routine patient management. A fellow is expected to take a leadership and teaching role on rounds commensurate with his or her experience and knowledge. The expectation is that fellow leadership and teaching will progress during the training period.
Clinical CICU Training
Patient characteristics: The mix of patients is typical for a CICU in a tertiary/quaternary hospital and includes patients with:
- Acute pericardial conditions
- Acute decompensated heart failure (ADHF)
- Aortic dissection
- Cardiogenic shock
- Hypertensive emergencies
- Myocardial infarction
- Severe valvular disease
- Unstable angina
Procedures: Fellows have the opportunity to learn procedures under the direct supervision of attendings and qualified fellows (fellows who have documented satisfactory competency in these procedures). Procedures include:
- Arterial lines
- Balloon pumps
- Central venous lines
- Swan-ganz catheters
- Transvenous pacemakers
Principal Educational Materials
Fellows have access to the libraries located in both hospitals. Computer access to literature searching, online journals, UpToDate and textbooks is available on all wards. Fellows are expected to be proficient in obtaining requisite information on pathophysiology from standard textbooks and the medical literature. Current therapeutics should be guided by the medical literature with particular weight given to clinical guidelines and consensus statements issued by the following organizations, among others:
- American College of Cardiology
- American Heart Association
- Heart Failure Society of America
- Heart Rhythm Society and similar professional bodies
- Society for Coronary Angiography and Intervention
Objectives by Post-Graduate Year
The first-year fellows in the CICU rotation are expected to discuss the differential diagnosis and management plan in detail on every patient they see in the unit with the supervising attending. As they progress, they are expected to master the subject content necessary to care for patients with cardiovascular diseases.
In addition, senior fellows will develop maturity and sophistication of clinical judgment; this is demonstrated by their ability to understand the nuances of an individual patient's health, particularly when multiple active disease processes are present. Senior fellows are expected to demonstrate their experience by tailoring generally recommended therapy to individual patients. They are expected to be aware of leading-edge and experimental therapies that may be utilized for an individual patient. In addition, they are expected to take a prominent role in being advocates for their patients with complex issues when collaborating care across multiple disciplines.
Residents take call every fourth night and are responsible for all patients assigned to their service and when on-call assume full responsibility for the evaluation and management of all the patients seen on this service. With the assistance of an attending and fellow, they are responsible for formulating a diagnostic and therapeutic plan for all patients admitted. In order to ensure optimal patient care, residents are provided with 24-hour access to their supervising fellow, attending physician and consultants.
Senior residents and surgical specialties are always in the hospital and available for emergent consultation. The attending physician is immediately available through paging and speaks regularly with the senior resident during on-call periods. Fellows and attending physicians are available, usually within 30 minutes, for assistance with patient evaluation and for the performance of procedures. Attending physicians must document their involvement in the evaluation and management of patients daily.