August Congential Heart Disease

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August Congential Heart Disease Powered By Docstoc
					Revised February 19, 2008

                    GOALS AND OBJECTIVES

Rotation Coordinator:         Robert Wesley, M.D.
                              Subspecialty Education Coordinator
                              Department of Internal Medicine
                              University of Nevada School of Medicine
                              2040 W. Charleston Blvd., Suite 300
                              Las Vegas, Nevada 89102
                              (702) 671-2345


Educational Purpose

The purpose of this four week rotation is to provide education about diagnosis,
management and prevention of cardiovascular disorders, including ischemic heart
disease, cardiac dysrhythmias, cardiomyopathies, valvular heart disease, pericarditis,
myocarditis, endocarditis, congenital heart disease in adults, hypertension and disorders
of the veins, arteries, and pulmonary circulation.

The primary goal of this cardiovascular rotation is to educate the general internist in the
appropriate initial management of common cardiovascular disorders.

Teaching Methods

      The cardiology service is divided into cardiovascular critical care and cardiology
       consult services. The critical care service consists of two first year and two PGY-
       2 or year residents. Each resident is on call every fourth day.
      The cardiology consult service has two residents, PGY-1 to -3; there is no
       overnight call for the consult service.
      The critical care resident will provide care to patients with cardiovascular
       disorders under the supervision of cardiologist and in conjunction with
       cardiothoracic surgery, as needed.
      The senior resident will supervise, lead, manage and teach junior residents and
       medical students.
      Consult service residents will see the patient, write the initial consult note and
       then give final recommendations after reviewing the case with the cardiology
       attending. The consult service resident and CCU interns will also go to outpatient
       clinic each week.
      Daily rounds will occur with the attending physician at which time instruction in
       the unique aspects of the cardiac critical care and cardiac consultation will be
        provided. Residents will be required to continue their regular morning report and
        noon conference core curriculum. The resident and attending will review and
        discuss any required reading.

Mix of Diseases
Patients present a wide variety of acute and chronic cardiac problems that a cardiology
consultant may be requested to evaluate and care for. These include chest pain, dyspnea,
acute coronary syndrome ST-segment and non-ST segment elevation myocardial
infarction, congestive heart failure, ischemic and non-ischemic cardiomyopathies,
valvular heart disease, and pericardial disease. Perioperative cardiac consultation and
care is also provided.

Patient Characteristics
The patient population is diverse, male and female, of all ages from adolescent to
geriatric, representing most ethnic and racial backgrounds, from all social and economic
strata. The hospital serves primarily the indigent population of the city of Las Vegas.

Types of Clinical Encounters
Acute coronary syndrome admissions are cared for in the cardiac care unit (CCU). Post-
cardiac surgery care is provided in the cardiovascular care unit (CVCU). Residents
supervise interns in the provision of care in these units. Inpatient consultations are
performed upon request in all units of the hospital. Cardiac catheterization is performed
in the cardiac catheterization laboratory. Outpatient care, both consultation and
continuing cardiac care, are provided in the Lied Specialty Clinic.

Close interaction with various other healthcare team members including care managers,
discharge planners, home health agencies, inpatient nurses, telemetry technicians,
respiratory therapists, physical therapists, and patient care technicians occurs daily.

Resident Supervision
Residents have constant on site supervision as well as daily personal supervision in their
patient care. An attending cardiologist sees all cases and is available 24 hours daily.

Procedures and Services
Residents may participate in or observe procedures with the cardiologist including
bedside right heart catheterization, cardiac catheterization, echocardiogram performance
and interpretation, stress testing, and arterial blood gas sampling.

Cardiology Didactics

   1.      Morning Report: Critical care service and consult service residents are each
           required to present one cardiology case the month after rotation.
   2.      Noon Conference: Each resident is required to give a presentation on topic
           assigned by attending.

   3.      Rounds: Each resident is required to present articles/clinical trials as
           assigned by attending. Resident will be given written feedback about their
           presentation by attending physician.
   4.      Cardiology Conference: Every first Tuesday and last Friday of the month.

Core Reading Materials
      Harrison’s Principle’s of Internal Medicine, 16th ed., McGraw Hill
             Cardinal Manifestations of Disease, pp. 53 - 360.
             Disorders of the Cardiovascular System, pp. 1229 - 1345.
             Disorders of the Respiratory System, pp. 1407 - 1419.
      Arrhythmia - A guide to Clinical Electrocardiography, Sandoe E, Sigurd B;
             Verlag GmbH, Bergan, 1991
      Heart Disease - A Textbook of Cardiovascular Medicine. Braunwald E. (ed),
             8th ed., W.B. Saunders, Philadelphia, 1
      The Washington Manual of Medical Therapeutics, 32nd ed.
      Housestaff Syllabus, 1999
             Preoperative Cardiac Assessment and Preoperative Evaluation
      Resident EKG packet, available in departmental office
      Rapid Interpretation of EKG’s, Dubin, D, 6th ed., Cover publishing, 1998

Ancillary Educational Materials
       Subspecialty Texts of Neurology, Pulmonary Medicine, Nephrology,
       Endocrinology, Infectious Diseases, Rheumatology as well as General Medical
       References (Harrison’s Principles of Internal Medicine, Cecil’s Textbook of
       Medicine) are available 24 hours a day, seven days a week in the resident lounge.
       Savitt Medical Library On-Line
       Residents have access to the on-line services of Savitt Library (the main library of
       the University of Nevada - Reno) via their computer in the resident room, Suite
       300 of the 2040 W. Charleston Building. Access to this room is available 24
       hours a day, seven days a week.
       Full text is available for many peer-review journals including, but no limited to:
               ACP Journal Club
               Annals of Internal Medicine
               British Medical Journal
               Journal of the American College of Cardiology
               The Lancet
               New England Journal of Medicine

        Also available on-line:
               Harrison’s Principle’s of Internal Medicine, 14th ed.
               Merck Manual, 17th ed.
               Guide to Clinical Preventive Services, 2nd ed.
               The Cochrane Library

                Medline and GratefulMed Databases

Pathological Material and Other Educational Resources
Residents are encouraged to review the pathological reports on patients for whom they
have consulted or cared and to follow the hospital care of those patients. If a patient for
whom the resident has consulted or cared should die and have an autopsy, the resident is
encouraged to attend the post-mortem session.

Training Sites

         University Medical Center
         All of the inpatient cardiology consultation experience occurs at University
         Medical Center (UMC) under the supervision of one of the full-time cardiology

         Acute coronary care will occur in the coronary care unit at UMC.

          UNSOM Lied Specialty Care Clinic
         The resident will participate in the UMC outpatient cardiology clinic weekly
         under the supervision of the full-time cardiology attending.

Competency-based Goals and Objectives
Cardiovascular Rotation
       Learning Venues              Evaluation Methods                      Level Specificity

1.   Direct patient care/consultations     A.   Attending evaluation            R-1 = 1
2.   Attending Rounds                      B.    Direct Observation             R-2 = 2
3.   Residency core lecture series         C.    Nurse evaluations              R-3 = 3
4.   Self study                            D.   Written Examination
5.   Morning Reports                       E.   Resident/Self Evaluation
                                           F.   Patient Evaluation

Competency: Patient Care                          Learning        Evaluation          Level
                                                  Venues          Methods
Obtain an accurate history including              1,2             A, B, C, E          1, 2, 3
history of present illness, cardiac risk
factors, prior cardiac history including
hospitalizations, cardiac workup stress
testing, and cardiac catheterization if
Perform an accurate physical exam on              1, 2            A, B, C             1, 2, 3

patients with known or suspected
cardiovascular disease.
Obtain old records including, but not          1, 2            A, E              1, 2, 3
limited to, discharge summaries, results
of prior echocardiography, EKG, stress
testing results, and cardiac catheterization
Generate a differential diagnosis, define      1, 2, 3, 4, 5   A, B, D, E        1, 2, 3
and initiate therapeutic plan, and modify
therapy, as needed.
Appropriately initiate pharmacological         1, 2, 3, 4, 5   A, B, C, D, E     2, 3
treatment, modify dosing based on
clinical scenario, and manage adverse
Respond immediately to “CODE                   1, 2, 3, 4, 5   A, B, C, D, E      2, 3
HEART” (Acute Myocardial Infarction).
Initiate management (Oxygen, Aspirin,
Nitrates, Beta Blockers, etc., as
indicated), inform attending immediately,
discuss further treatment plan and
facilitate transport to catheterization lab
within time guidelines.
Provide initial consultation and direct the    1, 2            A, B, E            2, 3
management of patient with
cardiovascular disorders.
Recognize and initiate appropriate             1, 2, 3         A, E               2, 3
treatment and notify attending for
specific cardiovascular emergencies.
Monitor patient progress, respond to           1, 2            A, B, C, E      1, 2, 3
change in patient condition during
medical treatment and interventional
Identify and initiate corrective action for    1, 2, 3, 5      A, B, C, D, E   1, 2, 3
common laboratory abnormalities and
procedure complications.

Competency : Knowledge                         Learning        Evaluation      Level
                                               Venues          Methods

Know presentation and management of            1, 2, 3, 4, 5   A, B, D         1, 2, 3
common cardiovascular diseases (i.e.
stable/unstable angina, acute myocardial
infarction, aortic dissection, arrhythmias,
congestive heart failure).
Know indication for and interpretation of      1, 2, 3, 4      A, B, D, E      1, 2, 3

EKG, Chest X-ray, echocardiography
(recognize tamponade), and cardiac
Know types and indications of stress tests   1, 2, 3, 4   A, B, C, D, E      1, 2, 3
(interpretation optional).
Know indications, doses, and side effects    1, 2, 3, 4   A, B, D            1, 2, 3
of common cardiovascular medications.
Know BLS and ACLS protocols.                 1, 2, 3, 4   A, B, D            1, 2, 3
Know indications and understanding of        1, 2, 3, 4   A, D               2, 3
ambulatory EKG monitoring,
echocardiography, electrophysiological
testing (optional), left and right heart
catheterization and tilt table testing
Competencies: Interpersonal and              Learning     Evaluation         Level
Communication Skills                         Venues       Methods

Interact in an effective way with            1, 2         A, B, C            1, 2, 3
physicians, residents, nurses and medical
support staff.
Demonstrate understanding of patient         1, 2         A, B, C, D, E, F   1, 2, 3
preferences in diagnostic evaluation and
management of cardiovascular disorder.
Maintain accurate medical records.           1, 2         A, B, C            1, 2, 3
Serve as a patient advocate.                 1, 2         A, B, C, E, F      1, 2, 3
Ensure adequate transfer of information      1, 2         A, B, C, E         1, 2, 3
when transferring patient to care of
another physician.
Communicate efficiently and effectively      1, 2         A, B, C, E         1, 2, 3
with referring physician, regarding
diagnosis, treatment and follow-up.

Competency: Professionalism                  Learning     Evaluation         Level
                                             Venues       Methods

Treat team members, primary caregivers,      1, 2         A, B, C, E, F      1, 2, 3
and patients with respect and empathy.
Understand, practice and adhere to a code    1, 2         A, B, C, E         1, 2, 3
of medical ethics.
Participate actively in consultations and    1, 2         A, B, C            1, 2, 3
during rounds.
Attend and participate in all scheduled      3, 5         Attendance A       1, 2, 3

Competency: Practice-Based Learning Learning                  Evaluation          Level
                                             Venuses          Methods
Incorporate case studies with relevant       1, 2, 4, 5       A, E                2, 3
research outcomes and report those
findings during clinical rounds.
Review the outcomes of patient care in       1, 2, 4, 5       A, E                2, 3
order to reflect on the approach taken in
the delivery of care.
Utilize established practice guidelines for 1, 2, 4, 5        A, E                2, 3
individual diseases to devise care
Identify limitations of one’s medical        1, 2, 4, 5       A, E                1, 2, 3
knowledge in evaluation and
management of patients with
cardiovascular disorders and use medical
literature (primary and reference) to
address these gaps in medical knowledge.
Competency: System-Based Practice            Learning         Evaluation          Level
                                             Venues           Methods
Understand need for effective                1, 2, 3, 4       A, E                1, 2, 3
communication between multiple
caregivers (i.e. emergency room, critical
care unit, nurses, physicians, transporters,
outpatient clinic, catheterization lab,
radiology, chest pain center, echo
Understand clinical trial design and the     1, 2, 3, 4, 5    A, B, C, E          2, 3
statistical methods for evaluating
scientific studies, in cooperation with
attendings and research nurses/personnel.
Competency in reporting adverse events, 1, 2, 4               A, B, E             2, 3
near misses.

       A. Of Residents
       At the completion of each rotation, all clinical faculty are required to complete the
       standard ABIM resident evaluation form. All clinical faculty are encouraged to
       provide face-to-face feedback with the residents. The night-float resident is
       evaluated by one of the three service attending’s. In addition, residents may
       receive interim feedback utilizing the ABIM’s Praise and Early Warning cards.

       B. Of Rotation and Preceptor
               All residents are encouraged to evaluate the rotation, and the clinical
       faculty member, at the completion of the rotation. This evaluation form is

included at the end of this document. These evaluations are then converted to
type and shared anonymously with the clinical faculty.

The program director also discusses the rotation with the residents to ensure
rotation quality and satisfaction.

                       Cardiology Rotation Resident Check List

1. Evaluation reviewed at mid-month and end of rotation by the supervising faculty
member and resident.

2. Completed assigned readings

3. Attended all assigned activities (excluding scheduled time away, required clinics and

4. Completed required case report abstracts and/or posters if assigned by the supervising
faculty member.

5. Demonstrated understanding of the basic principals of cardiovascular care

6. Received verbal feedback from attending at end of rotation.

Intern/Resident Signature_________________________          Date___________________

Supervising Attending Signature____________________ Date___________________

All items must be completed for rotation credit and checklist returned to the
Department of Medicine by the rotation’s end.


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