Loyola University Medical Center

Gottlieb Memorial Hospital

MacNeal Hospital

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Education, Rotations, Program Goals & More

Fellowship Program Rotation Goals and Objectives

Loyola Medicine's Neurocritical Care Fellowship program trains physicians to be clinically competent in the management of critical neurologic illness and management of medical problems in critically ill neurologic patients.

This fellowship also provides the opportunity to complete a research project(s). The skills acquired will enable a graduating fellow to direct a neurosciences intensive care unit and comprehensively care for critically ill neurologic patients in the academic or private setting.

The program is designed over a two year period of time as mandated by UCNS for fully accredited neurocritical care fellowship programs. Trainees are immersed in bedside critical care experiences with progressive patient care and team leadership responsibilities leading toward independent practice.

In the first year, the emphasis is on the development of clinical skills to manage critically ill patients by rotating in various ICU settings and therefore establishing a solid foundation of general critical care skills. This is accomplished by having mandatory rotation in the MICU, SICU, anesthesia and NICU.

The second year is spent building upon the first year fundamentals with emphasis on increasing independence in the management of a multidisciplinary team to care for critically ill patients in the neurological intensive care unit albeit with continued faculty supervision. Trainees spend the majority of the second year in the NICU.

The six ACGME Core Competencies are key components of the training program and the goals and objectives are organized within this framework.

Patient Care

Development of clinical skills in recognition and management of critical neurologic illness involves participation in direct management of patients admitted to the NICU.

Fellows will be trained under the supervision of neurointensivists to interpret neurologic symptoms and signs including the potential for neurologic deterioration, interpretation of neuroimaging and electrophysiology, initial management of acute brain and spine injury, and management of systemic complications.

In the second year, the goal of the fellowship is to build on the knowledge, clinical skills, and practices/attitudes, acquired in the introductory NICU, SICU, MICU and anesthesia rotations, for care of patients in the NICU. The second year fellow also demonstrates increasing independence in leading a multidisciplinary critical care team.

The basic curriculum is applicable to both the first and second years of the fellowship with focus on particular patient care and medical knowledge objectives on specific clinical rotations.

Patient Care Goals and Objectives – Years One and Two

  1. To facilitate increasing independence of the fellow in managing critically ill neurological patients in the NICU and other ICUs.
  2. To facilitate patient care as a team leader in multidisciplinary rounds with residents, other fellows, nurses, and other health care professionals.

Patient Care Goals and Objectives – Year Two

  1. To build on the patient care base of neurologic issues, introduced in the first year, and demonstrate further abilities in the direct management of critically ill patients in the NICU, based on the first year experiences in the general critical care units as well as the first year NICU rotations.

Medical Knowledge

Goals and objectives for this ACGME competency are part of the curriculum for individual rotations but are discussed as a longitudinal process over the fellowship’s two year course since much of the activity takes place in the context of ongoing weekly conferences, self-study modules, and national meetings.

The goal is to expand the fellow's knowledge base by reviewing the literature in general critical care, neuro-critical care, and related topics in general neurology, vascular neurology, and neurosurgery.

Ongoing assigned topics from textbooks, reviews, journal articles (including journal club), local conferences (at Loyola) and national conferences will be emphasized and, as part of the medical knowledge assessment, topic reviews will be mandated. The following specific objectives are listed below:

Neurocritical Care Knowledge Base – Year One

  1. To study and master anatomic, physiologic and clinicopathologic correlates of various Neurocritical care disease states including (but not limited to):
    1. acute brain injury
    2. neurovascular syndromes
    3. seizures and status epilepticus
    4. neurologic manifestations of systemic organ dysfunction
    5. cerebral edema and various lesions related to brain swelling (i.e. hydrocephalus, abscess, tumors, liver failure, ADEM)
    6. To study basic neuropharmacology, and the mechanism of action, interactions and side effects of medications and interactions with other drugs.
    7. To explore medical ethics, conflict resolution, and and interpersonal dynamics in the NICU
    8. Diagnosis and management of elevated ICP

An additional goal of the medical knowledge base in the first year is to gain a foundation of general critical care issues in the context of rotations in general medical, surgical, and anesthesia units so as to apply those skills in the care of critical neurologic illness in the NICU setting.

In addition to clinical teaching on these units, textbooks, article and journal reviews on general critical care topics will be emphasized as well as attendance at conferences.

  1. Medical knowledge will be assessed in areas including (but not limited to):
    1. Acute and chronic respiratory failure
    2. Hypertensive and hypotensive emergencies
    3. Other cardiovascular disorders
    4. Shock syndromes
    5. Multi-organ system failure
    6. Sepsis and sepsis/SIRS syndrome
    7. Other infectious disorders
    8. Acute metabolic disturbances, including overdosages and intoxication syndromes
    9. Electrolyte and acid-base disorders
    10. Other metabolic, nutritional, and endocrine effects of critical illness
    11. Hematologic and coagulation disorders associated with critical illness
    12. Use of paralytic agents, sedatives, and analgesic drugs
    13. Effects of other drug, toxic, or environmental exposures in the ICU.

Medical Knowledge Base - Year Two

In the second year, the fellow will continue with the study of neurologic critical care issues, and general critical care issues, listed in the first year with particular integration of the latter topics into neurologic practice.

Additionally, as part of the medical knowledge base competency, the expansion of knowledge in clinical research within the second year will further emphasize the following additional topics (that also apply to practice-based learning):

  1. Epidemiologic core principles and their applications to the NICU
  2. Evidence based medicine principles and outcomes research principles including further exploration as related to the NICU
  3. Including testing paradigms (ie including ROC analysis, likelihood ratio etc)

Practice-based learning and Improvement

Practice-based learning and improvement is an ongoing process that is taught longitudinally throughout the fellowship on all of the mandatory and elective clinical rotations. The following specific objectives are listed below:

  1. Demonstrating ability to evaluate, assess, and recommend effective management strategies and recognize risks and benefits of different strategies
  2. Demonstrating ability to use electronic systems for clinical care and obtaining and evaluating up-to-date evidence-based information related to individual patients
  3. Demonstrating ability to critically evaluate medical literature
  4. Demonstrating understanding and applicability of practice guidelines
  5. Developing additional experience in supervising and teaching medical students and residents in the first year.
    1. In the first and second year:
      1. Demonstrating experience in leading a multidisciplinary collaborative team and coordinating patient care with neurosurgeons, neurointerventionalists, other neurologists, nurses, and other health care professionals.
      2. Facilitating education of medical students, residents, and allied health care students, via fellow -led teaching rounds, didactic lectures, and dissemination of relevant journal articles (especially in the second year of the fellowship)
  6. Identifying quality improvement opportunities, and actively participating in quality improvement and patient safety activities, especially in the second year of the fellowship
  7. Learning about issues of cost-effective utilization of medical technology and diagnostic studies, balancing the cost with the potential for management alteration
  8. Actively participating in discussion and appraisal of clinical studies on the effectiveness of ICU interventions

Interpersonal and Communication Skills

Development of interpersonal and communications skills is also an ongoing process that is taught longitudinally throughout the fellowship on all of the mandatory and elective clinical rotations.

The objectives of the fellowship related to this competency include the following:

  1. Developing effective listening skills to obtain information from patients, families, and other health care professionals, and awareness of the importance of both verbal and non-verbal communications skills.
  2. Developing concise and precise presentation of patient information to other health care professionals.
  3. Ensuring the quality of written communications including documentation of patient encounters that are timely, accurate, organized, and complete and ensuring the quality of follow-up written communications to patients and health care professionals.
  4. Effective communication of complex critical care issues to patients, and families, in a manner which promotes patient/family comprehension of medical complexities and patient/family participation in the patient care process.
  5. Promotion of an understanding of the importance of informed consent and the need for accurate communication and documentation of that consent.
  6. Promoting to the fellow the importance of caring and respectful behaviors, when interacting with patients/families and co-workers, and emphasizing the need for a team approach in the ICU setting.
  7. Developing successful oral presentation skills (relating both to patient care and scholarly presentations) so that presentations and lectures are well-organized, accurate, and stylistically well-presented.

Professionalism

Promoting an inherent sense of professionalism, as an integral part of the NICU fellow’s professional identity, is of the utmost importance for the NICU fellow’s future career as a leader in the neurointensive care arena.

The objectives related to this competency are taught as part of every clinical rotation and all other fellowship activities. The overall goal is to instill within the NICU fellow a sense of professional identity and commitment to patients, and their families, colleagues, and other health care professionals.

As part of the specific objectives of the fellowship related to this competency, the fellow will:

  1. Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diverse patient populations.
  2. Demonstrate respect for patients’ cultural, ethnic, religious and socioeconomic backgrounds in providing patient care.
  3. Understand the ethical implications of devastating neurological illness as evaluated in the intensive care unit setting.
  4. Demonstrate appreciation of end-of-life care, and issues regarding provision or withholding of care.
  5. Regularly review one’s own skills and knowledge, realize limitations and respond to other’s evaluation of his/her professional performance.
  6. Demonstrate a commitment to excellence in clinical practice through the establishment of life-long learning habits and continuing medical education.
  7. Show an awareness of the importance of accurate and timely documentation of medical records, maintenance of certification/fellowship paperwork, and other professional activities.
  8. Accept responsibility, commensurate with level of training and expertise, and be aware of the limits of individual knowledge and experience.

System-Based Practice

System-based practice is taught as part of the clinical rotations, but also in the context of didactic materials including texts, manuscripts, and course lectures, and as part of clinical research activities in a longitudinal fashion.

The overall goals are for the fellow to:

  1. Appreciate the complexity of interactions within the NICU
  2. Recognize the inherent limits within a healthcare organization, and society-at-large, that need to be dealt with to provide efficient and rational care to individual patients
  3. Promote the fellow’s commitment to continual quality improvement at the individual, unit-based, institutional, and societal levels.

Specific fellowship objectives include:

  1. Demonstrating knowledge of healthcare delivery systems.
  2. Recognizing the limitations of resources in healthcare and demonstrating an ability to act as an advocate for patients within social and financial constraints.
  3. Participating in utilization review and complying with documentation requirements in medical records.
  4. Developing an awareness of practice guidelines as well as community, national and allied health professional resources which may enhance the quality of life of patients with neurologic illness.
  5. Developing the ability to lead and delegate authority to healthcare teams needed to provide comprehensive care for patients with neurological disease.
  6. Utilizing appropriate consultation and referral for the optimal clinical management of patients with complicated medical illness and providing effective consultation to other healthcare professionals.
  7. Learning about issues of cost-effective utilization of medical technology and diagnostic studies balancing the cost with the potential for management alterations.
  8. Implementing quality assurance practices and quality improvement practices including preventive practices in the ICU to mitigate against iatrogenic and nosocomial complications.