The overall purpose of the CVICU rotation is to provide trainees with a comprehensive training experience in the evaluation and management of common cardiac disorders as well as training experience in evaluation and management of other life threatening illnesses that may present with cardiovascular manifestation. This intensive training experience is designed to expose the trainee to both acute presentations of cardiac dysfunction and ensure that the fellow acquires the necessary clinical and procedural skills to care for cardiac disorders routinely encountered in the practice of cardiology. Each cardiology fellow will rotate on the CVICU service for two months during the course of their fellowship. On this rotation, the fellow will learn how to evaluate and manage patients with acute coronary syndromes, including cardiac arrest and cardiogenic shock, cardiac dysrhythmias, congestive heart failure, valvular heart disease, myocardial and pericardial heart disease, and aortic and hypertensive emergencies.Fellows will be introduced to and become proficient in the performance and interpretation of a number of cardiac procedures including, but not limited to, pulmonary artery catheter placement, temporary venous pacemaker insertion, intra-aortic balloon pumps management, and elective cardioversion. Review and integration of laboratory, radiographic, hemodynamic, and cardiac diagnostic studies will be emphasized during this clinical rotation. During this rotation the development of a strong mentoring relationship with clinical faculty is developed and emphasizes leadership skills for managing a healthcare team.
In the CVICU, medical residents are primarily responsible for all patients. The fellow is responsible for supervising the house-staff teams assigned to the CVICU and assists in the management of the CVICU patients. The fellow is responsible for those patients admitted to the CVICU who are admitted under the care of the cardiology faculty physician. The CVICU fellow will coordinate management of such patients under the direction of that faculty member. A dedicated CVICU attending physician will oversee all aspects of the fellow’s duties and will make twice daily rounds with the fellow. Teaching rounds are held daily with all members of the CVICU team. The fellow will pre-round on any critically ill patients and discuss significant patient management issues from overnight with the post-call team. The fellow will actively assist the house staff with management of critically ill patients and will be readily available to answer any questions regarding patient management throughout the day. The fellow, together with the attending, will be jointly responsible for core curriculum teaching as required for the education of the house staff. This will include didactic lectures as well as daily teaching on patient care related issues. The fellow will supervise the performance of all invasive procedures performed by house staff on cardiology inpatients in the CVICU. Weeknight and weekend call responsibilities are outlined in the section on call. All critically ill patients and any issues that need follow-up overnight will be checked out in a detailed manner to the on-call fellow. It is the responsibility of the CVICU to be intimately involved in the management of the CVICU patients. The CVICU fellow should be aware at all times of the status and treatment plan of these patients. The CVICU fellow should also be aware of the status and plan for the CHF/TXP service patients, although most of the fellow responsibilities for these patients will fall to the CHF/TXP fellow.
The attending physician, fellow, and house staff will provide a team-based, patient-centered approach toward patient care and teaching as it relates to the etiology, pathogenesis, clinical presentation, natural history, and treatment of the various general cardiac disorders seen on this service. The fellow will be responsible for the day to day management of the CVICU as set forth during daily morning rounds. The attending will review the fellow’s presentation, review and constructively critique the fellow’s plan of care, confirm the fellow’s physical exam findings, and review and confirm the fellow’s notes. As appropriate, the attending will review and supplement the fellow’s teaching of the other members of the team. The attending may assign readings or other learning activities as necessary. The attending will supervise the fellow during invasive procedures based on the level of the fellow’s skills.
- Obtain comprehensive training in inpatient management of cardiac disorders including: acute myocardial infarction and acute coronary syndromes, cardiac dysrhythmias including all forms of conduction block, acute and chronic congestive heart failure, valvular heart disease, myocardial and pericardial disease, and adult congenital cardiac disease. Additionally, acute aortic syndromes, hypertensive emergencies, pulmonary hypertension, peripheral and extracranial cerebrovascular disease are commonly managed on this service. (A, B)
- Evaluate patients in the CVICU who may have cardiac disorders by taking a thorough problem-directed history, performing a careful physical examination, and generating a differential diagnosis and plan of care. (A, B, F)
- Gain basic understanding of the indications, use limitations, and complications of cardiac diagnostic studies. (A, B)
- Gain basic training and experience in the use of pharmacologic and non-pharmacologic options for treating acute and chronic coronary ischemic syndromes, CHF, dysrhythmias, cardiogenic shock, valvular heart disease, adult congenital heart disease, peripheral vascular disease, and extracranial cerebrovascular disease. (A, B)
- Understand the indications, risks, and benefits of thrombolytic therapy, diagnostic cardiac catheterization, PCI, CABG, valve surgery, percutaneous valvuloplasty, cardiac pacemakers, ICDs, resynchronization devices, IABPs, pulmonary artery catheters, elective cardioversion, PFO/ASD closure, peripheral vascular stenting, and carotid stenting. (A, B)
- Learn when to request appropriate cardiology subspecialty, vascular surgery, and cardiothoracic surgery consultation. (B, F)
- Learn to recognize and manage cardiac emergencies. (A, B)
- Explain the etiology, pathogenesis, clinical presentation, and natural history of major cardiac disorders including MI, CHF, atrial and ventricular dysrhythmias, heart block, hypertensive emergencies, acute aortic emergencies, acute and chronic myocardial and pericardial disease states. (A, B)
- Practice integrative, patient-centered, team-based medical care, incorporating evidenced based therapies and “best practices,” as outlined by ACC and AHA practice guidelines. (A, B, C, F)
- Review all cardiac studies directly related to patient care activities to increase learning opportunities and enhance clinical and integrative skill sets. (A, B)
- Gain an appreciation for the role of the ancillary staff members, including the nurses, clerical staff, lab and x-ray technicians, pharmacy staff, social workers, and chaplains. (D, E, F)
Level Specific Goals and Objectives:
Junior Fellows (first year fellows)
Every cardiovascular patient in the CVICU will be primarily managed by the fellow with close faculty supervision as part of a team with internal medicine residents. The fellows will initially assess patients admitted to the service. The faculty will review the history and physical findings with the team as well as any pertinent laboratory studies. The team will then formulate a plan with the faculty. The fellow will perform any necessary procedures in the care of the patient (arterial lines, central venous access, bedside echocardiograms, cardioversions, intubations). The fellow may also be involved in procedures performed in the catheterization lab.
Senior Fellows (second year fellows and above)
In addition to the goals and objectives of junior fellows, senior fellows will be given more independence in decision making and communication with the patient and health care team.
Patient Characteristics/Mix of Diseases/Types of Clinical Encounters:
Training occurs at the UIHC and provides a wide range of pathology and a diverse patient population. Both men of women of all adult ages and of various ethnic backgrounds are seen. Clinical encounters are primarily centered on evaluations of critically ill patients in the emergency room, other inpatient units and patient transferred from community hospitals to the CVICU. Performance of invasive procedures is common and includes hemodynamic monitoring catheters (pulmonary artery catheters, arterial lines, and central venous lines), intra-aortic balloon pumps, temporary venous pacemakers, elective and emergent cardioversions, and intubations.
The attending will review the fellow’s presentation, review and constructively critique the fellow’s plan of care, confirm the fellow’s physical exam findings, review and confirm the fellow’s notes, and review and supplement the fellow’s teaching of other members of the team. The attending may assign readings or other learning activities. The attending will supervise the fellow in the performance of procedures. The fellow will assume progressive levels of responsibility for patient care and procedure performance under the supervision of the attending.
- The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
- The fellow’s progress will be reviewed verbally mid-rotation.
- A standard fellow evaluation form will be completed by the supervising physician at the end of the rotation.
- The final evaluation will be based on the fulfillment of the rotation objectives as determined by:
- Personal observation during interaction with the fellow.
- Evidence of extensive literature reviews appropriate for the individual patient and topic.
- Ability to construct a logical management plan.
- Inclusion of appropriate physical examination.
- Appropriateness of use of diagnostic tests.
- Correct interpretation of diagnostic tests.
- Appropriate selection of pharmacologic and non-pharmacologic therapies.
- Competent performance of cardiac procedures relative to the fellow’s level of training.
- Appropriate follow-up.
- Feedback from other team members, other healthcare providers, and patients.
- University of Iowa Hardin Medical Library (Up to Date, electronic journals including New England Journal of Medicine, Circulation, Journal of the American College of Cardiology, Journal of the American Medical Association and Medline)
- Heart Disease: A Textbook of Cardiovascular Medicine (9th ed) Eugene Braunwald, editor