Coronary Care Unit
I. Goals and Objectives:
The teaching program of the Coronary Care Unit is designed to provide the house officer with the knowledge and skills needed to diagnose and treat diseases of the heart including acute coronary syndromes, heart failure, rhythm disturbances, valvular disease, and hypertension. The house officer will be exposed to numerous diagnostic and treatment strategies including electrocardiography, echocardiography, heart catheterization and percutaneous interventions, as well as pharmacologic and mechanical approach to arrhythmias, hemodynamic monitoring in heart failure, pre transplant evaluation and non-invasive imaging. CCU patients are very diverse ethnically and socioeconomically, and are representative of the neighboring Montefiore communities.
The CCU rotation consists of one block of four weeks, with 24/7 coverage by the house officers. The CCU elective is available to all Internal Medicine pgy1s, pgy2s and pgy3s.
Residents work in teams under the supervision of the CCU cardiology fellow and the CCU Attending. The Attending physician is responsible for supervision of all patient care.
B. Level based Rotation Goals and Objectives:
- Patient Care: Learn to recognize the daily patient workload and to prioritize; to recognize the significance of a patient’s cardiologic conditions; to differentiate the acuity level of illness, to establish patient focused care.
- Medical Knowledge: Use discussions during daily rounds; use literature and reference sources to increase knowledge base, to learn application of guidelines for patient management; acquire basic knowledge in the areas of underlying pathophysiology and the clinical aspects of cardiac disease states.
- Professionalism: Learn to establish trust with critically ill cardiac patients and their families; to participate in teamwork. Exhibit honesty, reliability, and responsibility in patient care; demonstrate respect for patients and staff; attend conferences.
- Interpersonal Skills: Learn to write understandable and legible notes; to listen to patients and staff and communicate; to work effectively as a member of the health care team.
- Practice Based Learning and Improvement: Learn to understand limitations of knowledge; to use literature to improve your practice patterns; to accept feedback and change behavior; to ask for help when needed; learn from the outcomes of cardiac patients to improve outcomes in the future.
- System Based Practice: Learn to be an advocate for cardiac patients; accept and try to apply necessary devised guidelines; to develop understanding about the health care systems/structure and how it relates to patients requiring cardiac procedures.
- Patient Care: Prioritize the daily work load or cardiac patients and supervise the junior house staff appropriately; recognize the relative significance of a given patients list of cardiac conditions; recognize the acuity levels of illness; fully understand the indications, contraindications and risks of common and uncommon procedures; discuss risks/benefits native of patient’s with specialists.
- Medical Knowledge: Use literature and reference sources to increase knowledge base and share knowledge with junior house staff; demonstrate sophisticated knowledge in the areas of underlying pathophysiology an the clinical aspects of simple and complicated disease states; apply knowledge in the treatment of patients.
- Professionalism: Establish trust with patients and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients and staff and junior house staff who you are supervising; work with team to fulfill the needs of patients; lead health care team in patient care; understand limitations and ask supervisors for help when indicated; accept assignments graciously; attend conferences.
- Interpersonal Skills: Write understandable and legible notes and consultation reports; improve ability to listen to patients and staff and communicate verbally and nonverbally in a productive manner; work effectively as a member of the health care team, and be an example for your junior house officers.
- Practice Based Learning and Improvement: Understand limitations of knowledge; use references and literature to improve practice patterns; accept feedback and change behavior; ask for help when needed; learn from the outcomes of cardiac patients under your care and alter practice patterns to improve outcomes in the future; aid junior house staff in evaluating their practice patterns.
- System Based Practice: Advocate for patients; develop a sophisticated understanding about the health care system/structure and develop mechanisms to utilize ancillary services to benefit patients.
II. AREAS COVERED DURING CCU ROTATION
A. Principles, Physiology and Basic Sciences
- Understand physiology of the heart as a pump; of interaction between heart and cardiovascular systems; of coronary perfusion, conduction system, of neuro-humoral regulation.
B. Practical skills unique to Cardiology:
- History and physical examination, emphasis on heart rhythm, heart sounds, murmurs, blood pressure, peripheral pulses.
- Specific tests and procedures: Use and interpretation of electrocardiography, use of echocardiography, nuclear tests/cardiac CT and MRI
- Use of heart catheterization, coronary angioplasty/stents
- Use of electrophysiology studies, Holter monitor, pacemakers
- Preventive Care: Risk modification including cholesterol profile, life style modification, exercise, smoking cessation
- Patient education about major cardiac symptoms, early recognition, impact of early treatment
C. Approach to presenting complaints/problems:
- Chest pain or equivalent
- Sudden death/Cardiac arrest
D. Specific Diagnosis in Cardiology:
- Acute Coronary Syndromes
- Unstable angina (UA)
- Non ST elevation infarct (NSTEMI)
- ST elevation infarct (STEMI)
- Acute aortic dissection
- Pulmonary embolism
- Pericardial Tamponade
- Heart failure/Decompensated heart failure
- Brady/tachy arrhythmias
- Drug interactions
- Acute and chronic valvular disease
- Malignant hypertension
- Common congenital heart diseases (Tetraology, ASD, PS, Membranous VSD)
E. Treatment Modalities:
- Pharmacologic treatment
- Percutaneous coronary interventions
- Valvular surgery
- Balloon valvuloplasty
- Mechanical approach to arrhythmias
- Percutaneous valve replacement
- Mechanic hemodynamic support (IABP/PVAD)
- Therapeutic hypothermia
F. Technical Skills
- Central venous catheterization
- ECG interpretation
- Observation of right heart catheterization, placement of temporary pacemakers and arterial lines
- Acute reperfusion of STEMI
- Cardiogenic shock
- Decompensated Congestive Heart Failure/Pulmonary Edema
- Malignant hypertension
- Cardiac Tamponade
- Malignant brady/tachy arrhythmias
III. SCHEDULE OF ACTIVITIES
- Daily morning conferences from 7:30 to 8:30 am.
- Daily morning rounds by the CCU attending. These rounds include teaching sessions by the attending or the cardiology fellow. Distribution of literature
- Evening sign-out rounds with fellow and attending
- Daily consultation rounds by attendings of the various cardiology subspecialty sections
- Cardiology Grand Rounds – weekly
- Medical Grand Rounds – weekly
- Monthly conferences in Ethics/Dialysis/Modalities/Information Technology in Cardiology/Diabetes Management
- Monthly Controversial Cases in Cardiovascular Care Conference
IV. METHODS OF TEACHING COMPENCY ASSESSMENT
The house officers are evaluated continuously during their four weeks of service in the CCU. Importantly, there is continuous feedback to the house officers. The final evaluation is done through www.new-innov.com and the results are discussed in a meeting with the house officers. They are evaluated in terms of their overall clinical competence with the following categories: clinical judgment, medical knowledge, clinical skills, humanistic qualities, professionalism, medical care and continuing scholarships.
Revised August 2013 by Dr. Mark Menegus
Written 2006 by Dr. Robert Ostfeld
Dr. Sharon Silbiger
Dr. Jeffrey Weiss
Dr. John Loehner