Pediatric Intensive Care Unit
Goals and Objectives
The goal of the MGH PICU rotation is to develop the ability of junior residents to evaluate and manage critically ill children with a broad range of medical and surgical problems. The rotation is based in an 8-bed referral pediatric intensive care unit. Residents are the primary caregivers for their patients, under the close supervision of critical care attendings and fellows. Residents care for patients in the PICU admitted with both medical and/or surgical problems. The objectives of this rotation are designed to further the residents’ development of competency in the following six areas:
I. Patient Care
II. Medical Knowledge
III. Practice-Based Learning and Improvement
IV. Interpersonal and Communication Skills
V. Professionalism
VI. Systems-Based Practice
I. Patient Care
Residents will have primary responsibility for the management of PICU patients from the time of admission until transfer to the inpatient floor or another facility, or discharge.
At the time of admission, the resident will perform a complete history and physical and review any medical records that accompany the patient. Emergent needs of the patient will be addressed immediately. After evaluating the patient, the resident will formulate a differential diagnosis and plan appropriate diagnostic and therapeutic interventions, in coordination with the intensive care team.
Through thoughtful review of diagnostic results and frequent reassessment of the patient, the resident will reconsider the clinical status of the patient, along with the differential diagnoses on a continuing basis, making changes to management plans as appropriate. Residents will be directly involved in decision-making regarding patient readiness for step-down of care.
At all times, it is the resident’s responsibility to educate and work with the patient and family, maintaining a strong therapeutic alliance, and prioritizing Family Centered Care
As medically indicated, residents will perform appropriate diagnostic and therapeutic procedures after obtaining informed consent from the patient and/or family, with supervision from the PICU staff. Residents will document procedures in the chart and in their personal logbooks. On this rotation, these may include:
- arterial puncture
- bag mask ventilation
- central line placement
- endotracheal intubation
- intravenous catheter placement
- thoracentesis and chest tube insertion
- venipuncture
During this rotation, residents are expected to further develop their proficiency in the following areas related to the intensive care of critically ill children:
- cardiopulmonary resuscitation
- extracorporeal membrane oxygenation
- initial evaluation and resuscitation of critically ill patients
- invasive ICP monitoring
- management of shock
- mechanical ventilator management
- sedation and analgesia
II. Medical Knowledge
Residents will draw from the wide range of patient diagnoses requiring admission to a referral intensive care unit to broaden their exposure to complex disease processes.
The patient population at this city-based referral center includes patients admitted for complex, rare, or multi-organ system disease, trauma, cardiac surgery, general surgery and transplantation. In addition to patients from the metropolitan Boston area, residents will care for those children transferred from outside hospitals for higher levels of care, including nitric oxide therapy, extracorporeal membrane oxygenation, and pediatric surgical interventions.
During this rotation, it is expected that residents will manage patients diagnosed with, but not limited to:
- Acute Traumatic Brain Injury
- Congenital Heart Disease (including post-operative patients)
- Diabetic Ketoacidosis
- Liver Transplantation
- Respiratory Failure
- Sepsis/Septic Shock
- Upper Airway Disease (including stridor, foreign bodies, congenital anatomical abnormalities)
- Toxic Ingestions/Poisonings
- Renal Failure
- Trauma (including MVA, spinal cord injury, self-inflicted)
III. Practice-Based Learning and Improvement
In caring for patients, residents will utilize a broad range of published medical information available through web-based resources, as well as print textbooks and the hospital library. It is expected that decisions about patient care will be informed by review, synthesis and application of studies available in the literature.
Residents will take part in daily radiology rounds, reviewing radiologic imaging of their patients with the PICU team.
Residents will attend regular lectures on topics important to the care of critically ill children given by the intensive care unit staff.
On this rotation, residents will facilitate the learning of pediatric medicine by the PL-1 Emergency Medicine resident rotating in the PICU. All residents will take an active role teaching fourth year Harvard and visiting medical students during rotations in the PICU.
IV. Interpersonal and Communication Skills
Residents will take part in daily collaborative interdisciplinary team rounds, which include intensive care attendings and fellows, surgical and transplant attendings, intensive care nurses, respiratory therapists, pharmacists, and medical students. Residents collaborate with other team members including subspecialty consultants, social workers, dietitians, occupational and physical therapists, chaplains and other support staff.
This rotation will stress the importance of coordination of care among various medical, surgical and subspecialty services. Residents will facilitate discussion among clinician members of the team and the family.
Residents will meet regularly with parents to listen to their concerns and keep them updated on their child’s condition and care plan. Family-Centered Care is a standard of care in the PICU.
Daily notes in the chart clearly documenting patients’ progress, diagnostic results and ongoing plan will be completed in order to maintain an accurate medical record and share information among team members. More frequent entries will be made when a patient’s status is rapidly changing.
When leaving the rotation, an off-service summary will be prepared and made part of the medical record.
Residents will provide feedback to students and attendings on an ongoing basis throughout the rotation, completing written evaluations at the completion of the rotation. Similarly, they will receive regular verbal feedback and a final written evaluation from the PICU attending that will be placed in their permanent record. Residents will use constructive feedback to guide their efforts in ongoing learning and self-improvement.
V. Professionalism
Residents will interact with an extremely ethnically and socio-economically varied patient population that is treated in this referral intensive care unit. Patients will include those living in local communities, as well as those transferred to MGH because of emergent and complex medical problems. Transferred patients include those from northern New England and western New York, as well as international patients.
Residents will care for patients independent of their ability to pay for services.
Residents will provide compassionate, empathic and culturally sensitive communication with patients and families. They will be particularly sensitive to the unique situation of parents of critically ill and dying children. They will demonstrate sensitivity and responsiveness at all times to patients’ culture, gender, sexual orientation and disabilities.
Maintenance of patients’ confidentiality will be of highest priority.
Residents will at all times demonstrate ethical and professional behavior. During this rotation, in particular, residents will deal with issues of end of life care and withdrawal of support, potential for long-term disabilities and chronic illness.
When appropriate, residents will utilize the MGH Ethics Consultation Service to facilitate team meetings to discuss difficult issues.
Residents will ensure that patients and families give informed consent for all aspects of care.
VI. Systems-Based Practice
Residents are expected to provide high quality, but cost-effective health care. They will collaborate with case managers and other team members to begin discharge planning before patients are transferred to the inpatient floor.
The resident will communicate regularly with the patient’s primary care physician, documenting these contacts in the medical record.
At all times, residents will act in accordance with the legal mandate in the Commonwealth of Massachusetts to report any suspicions of child abuse or neglect, being familiar with the process by which such suspicions are reported. The MGH Child Protection Consultation Team will be a unique resource for residents working in the complex referral atmosphere of this rotation.
