immunosuppression, surgical critical care

Transcription

1 Rotation: Resident Level: Essential Content Areas/Expertise: Transplant Surgery PGY1 Abdomen and its contents, alimentary tract, immunosuppression, surgical critical care Goal: To develop residents who are able to identify, diagnose, and treat transplant related problems and deliver this care in a compassionate, efficient, contemporary, evidence based manner. Residents will work as members of an interdisciplinary team both in conferences and during active clinical care. Core Competency: Patient care Assessment and Management Describe perioperative management of: Benign and malignant hepatobiliary disease Patients undergoing liver and kidney transplants Complex vascular access for dialysis patients Care of adult and pediatric patients undergoing solid organ abdominal transplantation Perform and communicate a comprehensive history and physical examination of patients, including a 14 point review of systems Understand the importance of defining a complete, multidisciplinary treatment care plan prior to initiating operative management Wound Healing Identify appropriate versus inadequate wound healing Differentiate wound healing by primary closure, delayed primary closure, and healing by secondary intention Identify and Initiate management of dehiscence, evisceration, and extensive wound debridement Identify and differentiate wound complications: infection, hematoma, and seroma Recognize clinical parameters that predict impaired wound healing in transplant patients Fluids and Electrolytes Write perioperative intravenous fluid orders for patients following routine and complex transplant operations taking into consideration operative factors, patient factors, and current metabolic status Understand the assessment of intravascular volume status in the postoperative patients and appropriate response to correct to a euvolemic state Perioperative Care Identify indications for evaluation for liver transplantation, kidney transplantation, pancreas transplantation. Identify algorithms for decision making regarding dialysis access placement. Calculate and monitor nutritional goals Understand the role of total parenteral nutrition in the malnourished or nutritionally at risk patient Assist and assume graduated responsibility in the comprehensive perioperative management of transplant patients including one full day a week in the outpatient Vascular Access clinic Recognize signs and symptoms of postoperative complications including but not limited to: Postoperative hemorrhage Anastomotic leak Wound infection or seroma

2 Bowel obstruction Closed suction drainage malfunction Hepatic insufficiency Organ allograft rejection Evaluate and manage postoperative complications promptly and communicate assessment to the supervising surgical team member in a timely fashion Provide timely and accurate documentation of all assessments, plans, interventions, and transfers of care Participate in high fidelity patient review for handoffs and sign outs with necessary team members Surgical and Technical Skills Perform handwashing before and after every patient encounter Comply with all patient safety initiatives and report concerns to supervising surgical faculty Describe rationale and technique of minimizing tissue injury during surgical procedures Perform suture placement and removal in the clinic, bedside, and operating room Participate in operations and procedures commensurate with level of experience as determined by the supervising surgical residents and surgical oncology faculty Obtain hemostasis Identify common surgical instruments, suture materials and their proper use Manage central venous catheters, urinary catheters, nephrostomy tubes as well as transhepatic drains Insert, maintain, and remove operative tubes and drains Evaluate and explain management of complications in common surgical problems in surgical oncology patients Establish and maintain sterile technique; practice isolation precaution when indicated Core Competency: Medical Knowledge Anatomy Identify anatomic landmarks of the: liver kidneys vascular anatomy as pertinent to dialysis access Recognize anatomic abnormalities on physical examination Diagnostic studies and laboratory Request appropriate consultations Order and interpret diagnostic studies in a cost effective manner Verify radiographically appropriate placement of central lines, endotracheal tubes, chest tubes, drains Identify indications, risks, benefits, and potential complications of radiographic and laboratory studies Develop an initial understanding of normal and abnormal radiologic anatomy as it relates to the problems typically seen in surgical oncology patients Become familiar with radiographic studies including but not limited to: MRI and CT scan Contrast studies Identify the role of endoscopic intervention in the management of patients with end stage liver

3 disease Pathophysiology Understand the basic progression of organ dysfunction in patients with end stage liver and kidney disease Explain some of the fundamental pathophysiologic derangements critical to the development and treatment of some of the following conditions: Portal hypertension cirrhosis acute and chronic renal failure congenital anomalies Hepatocellular cancer Identify alternative treatments to transplantation in patients with end stage liver and kidney disease Pharmacology and pharmacokinetics Identify common drug interactions Develop a basic understanding of some of the mechanisms for commonly used systemic antineoplastic agents (e.g., chemotherapy) Explain mechanisms of action of immunosuppression agents commonly used in solid organ transplantation Explain common side effects of immunosuppression agents used in solid organ transplantation List appropriate antimicrobial therapy for: Empiric surgical site infection prophylaxis Empiric treatment of sepsis Methicillin resistant Staphylococcal infections Genetics Identify the important management keys relevant to patients with hepatocellular cancer Identify the role of surveillance and prophylactic resections for patients with cirrhosis as they relate to cancer development Understand the importance of working in multidisciplinary teams with our genetic counselors for appropriate management of patients with familial genetic syndromes Transplant Understand the basic principles of transplantation Understand the role of patient selection, multidisciplinary team evaluation in patients undergoing sold organ transplantation Identify differences in outcome measurement including graft and patient survival Understand the role of systemic therapy, radiation therapy, and surgical therapy in the control of distant disease, regional disease, and local disease Understand the mechanisms of organ allocation in the United States Explain the role of organ procurement organizations, UNOS in organ allocation Culture/ethnicity Recognize and respect of healthcare practices, communication customs, and beliefs of ethnic and cultural groups Identify commonalities in people s medical conditions that transcend culture and ethnicity Identify biases and barriers between the healthcare community and cultural/ethnic groups Core Competency: Interpersonal and Communication Skills Document a comprehensive history, examination, assessment, and plan for assigned surgical

4 patients Document timely daily progress notes that describe clinically important issues or changes in patient care plans Write routine orders (admission, preoperative, postoperative) and communicate urgent or emergent orders to the nursing staff Document and revise essential patient care information on the Transplant patient census in a timely fashion Present patient information on rounds and at transitions of care with emphasis on patient safety Present assessment and plan for all assigned patients on daily faculty rounds Apply information from daily faculty rounds into patient care including medical chart information Discuss medical errors or professional mistakes honestly and openly within the context of quality improvement to promote patient safety, trust, and self learning Communicate effectively with patients, family, nursing staff, residents, physician assistants, fellows, and faculty, and the public across socioeconomic and cultural backgrounds Patient and Family Communication/Education Provide accurate, straightforward information to patients and families in a compassionate and understandable manner Use informed consent properly Listen with cultural, ethnic, gender, racial, and religious sensitivity Core Competency: Professionalism Adhere to all ACGME work hour policies as set forth by the Department of Surgery and supported by the Division of Surgical Oncology Demonstrate competent work ethic by consistently and dependably carrying out duties with honesty, integrity, self motivation, and self discipline Use available resources when ethical, medical, or professional problems arise Strive to provide excellence in the delivery of surgical care and patient safety including participation in Quality Improvement projects such as regular participation in our scheduled Transplant multidisciplinary conferences including: Multidisciplinary Liver Selection Committee Multidisciplinary Kidney Selection Committee Division of Transplant Resident Education Conference including Journal Club and Morbidity and Mortality discussion Hepatocellular Cancer Multidisciplinary Conference Prepare in advance for faculty rounds, operative cases, and outpatient clinic Accurately report duty hours on a daily basis and prospectively identify and communicate potential work hour issues to the supervising residents Transplant faculty Participate in regular Department of Surgery educational conferences and activities Adhere to institutional code of conduct, demeanor, behavior, and attire Recognize capabilities and limitations of self, team, and institution Respect all individuals Care for patients compassionately by consistently demonstrating respect for patient privacy, dignity, and autonomy Log cases and duty hours and complete evaluations in a timely fashion Core Competency: Practice based learning and improvement Read assigned readings and identify materials for self study regarding Transplantation

5 Use independent self study and assessment programs Identify common sources of medical errors, and explain steps to avoid or minimize them Self reflect about adverse events and near misses to improve patient safety and care Participate in education of medical students and other learners Explain how to recognize and manage postoperative complications Incorporate formative and summative feedback from team members and rotation faculty to identify areas of weakness and improve overall performance Independently access, appraise and apply information from relevant texts and evidence based literature to care of the patient using: SCORE Online UTSW reference textbooks Online American Society of Transplant Surgeons Curriculum for Residents via the Academic Universe (available to UTSW residents) Core Competency: Systems based practice Identify barriers to accessing health care for patients across cultural, economic, racial backgrounds Participate in discussion and development of a cost effective patient management plan that analyzes risks and benefits Collaborate with institutional resources, such as social services, home health, etc., for effective discharge planning Acquire specific information about rehabilitation services, indications for referral and potential benefits Identify system issues that may contribute to medical mortality and communicate these to the Transplant team Follow up with reference physician post operative/discharge about patient s care Access and transfer patient s medical records when appropriate Apply appropriate documentation for coding and billing

6 Rotation: Transplant Surgery Resident Level: Essential Content Areas/Expertise: PGY4 Abdomen and its contents, alimentary tract, skin, soft tissues, immunosuppression, surgical critical care Goal: To develop residents who are able to identify, diagnose, and treat transplant related problems and deliver this care in a compassionate, efficient, contemporary, evidence based manner. Residents will work as members of an interdisciplinary team both in conferences and during active clinical care. Core Competency: Patient care Assessment and Management Describe perioperative management of: Benign and malignant hepatobiliary disease Patients undergoing liver and kidney transplants Complex vascular access for dialysis patients Care of adult and pediatric patients undergoing solid organ abdominal transplantation Assess and supervise PGY1 and intermediate surgical housestaff in the assessment and management of above conditions Model behaviors for PGY1 and intermediate surgical housestaff by assuming responsibility for the perioperative and outpatient management of assigned patients Ask for guidance effectively in unusual, confusing, or complex surgical problems or patients Perform, provide direct supervision for, and communicate a comprehensive history and physical examination of patients, including a 14 point review of systems Participate and lead discussion for the development of a complete, multidisciplinary treatment care plan prior to initiating operative management Identify patients at risk for complications following major and minor transplant procedures and take measures to minimize the risk of adverse events as well as monitor early signs of adverse events Formulate differential diagnosis for common surgical oncology problems Provide meaningful consultations and communicate these plans to requesting treatment teams in a respectful, comprehensive, timely fashion with the assistance of supervising surgical faculty Wound Healing Identify appropriate versus inadequate wound healing Assist PGY1 and intermediate residents, and medical students in wound management Differentiate wound healing by primary closure, delayed primary closure, and healing by secondary intention and treat accordingly Identify and Initiate management of dehiscence, evisceration, and extensive wound debridement Identify and differentiate wound complications: infection, hematoma, and seroma Recognize clinical parameters that predict impaired wound healing in transplant patients and take measures to optimize wound healing in those patients at greatest risk Critical Care and Perioperative care Apply basic tenets for surgical care in the design and implementation of a management plan for optimal patient care in the perioperative and outpatient setting Provide comprehensive care for all patients in the ICU and standard postoperative setting

7 Describe the anatomy, pathophysiology, and management for commonly seen diseases encountered in the Transplant population including but not limited to: Cirrhosis Portal hypertension Liver tumors Acute and chronic renal failure Initiation of dialysis KDOQI guidelines for dialysis access Actively incorporate basic science principles into patient care plans Assess, document, and manage perioperative risk factors for diseases and conditions Identify indications for operative and non operative treatment of common Transplant surgical problems Calculate and monitor nutritional goals Understand the role of total parenteral nutrition in the malnourished or nutritionally at risk patient Assist and assume graduated responsibility in the comprehensive perioperative management of Vascular Access patients including one full day a week in Transplant outpatient clinic Recognize signs and symptoms of postoperative complications including but not limited to: Postoperative hemorrhage Wound infection or seroma Anastomotic leak Acute cellular rejection Closed suction drainage malfunction Hepatic insufficiency Delayed graft function Evaluate and manage postoperative complications promptly and communicate assessment to the supervising surgical team member in a timely fashion Provide timely and accurate documentation of all assessments, plans, interventions, and transfers of care Participate in high fidelity patient review for handoffs and sign outs with necessary team members Surgical and Technical Skills Perform handwashing before and after every patient encounter Comply with all patient safety initiatives and report concerns to supervising surgical faculty Describe rationale and technique of minimizing tissue injury during surgical procedures Perform as primary surgeon with graduated responsibility during common and complex Transplant and Vascular Access including but not limited to: Vascular access for dialysis Living donor and deceased donor kidney transplantation Understand the basic steps involved in orthotopic liver transplantation Describe technical steps and necessary decisions and options during operative procedures Evaluate and explain management of complications in common surgical problems in transplant patients Establish and maintain sterile technique; practice isolation precaution when indicated Core Competency: Medical Knowledge Anatomy Understand the complex multidimensional topographic and functional anatomy of the following

8 structures particularly as they relate to abdominal organ transplantation: Liver, kidney Abdominal organs, particularly the liver, pancreas, biliary tree, and retroperitoneum including layered three dimensional neurovascular anatomy Recognize anatomic abnormalities on physical examination and radiographic studies Teach other learners on the team about critical anatomic landmarks and the importance of anatomic familiarity during resection Diagnostic studies and laboratory Request and provide appropriate consultations Order and interpret diagnostic studies in a cost effective manner. Appropriately discuss the indications and results with radiological, endoscopic, and surgical faculty, housestaff, patients, and families for: MRI CT scan EUS and ERCP Interventional radiology procedures including drainage procedures of the biliary tree Vascular access contrast studies and interventional radiology procedures Develop an initial understanding of normal and abnormal radiologic anatomy as it relates to the problems typically seen in surgical oncology patients Identify the role of endoscopic intervention in the management HCC Interpret the following findings based on imaging studies Hepatic segmental anatomy and tumor location Acceptability of vascular anatomy for creation of vascular access for dialysis Placement of peritoneal dialysis catheters Evidence for intraabdominal metastatic disease as it pertains to HCC Underlying liver insufficiency Anastomotic leak and deep tissue infection Pathophysiology Understand the basic progression of end stage organ disease (liver, kidney, pancreas) Explain some of the fundamental pathophysiologic derangements critical to the development and treatment of some of the following cancers: cirrhosis portal hypertension acute and chronic renal failure Hepatocellular cancer Understand the purpose and rational for both preoperative and postoperative systemic and radiation therapy in patients with HCC. Participate in the decision making and treatment planning for patients in need of multimodality therapy particularly as it relates to the selection and sequencing of non operative treatment modalities Pharmacology and pharmacokinetics Describe some of the mechanisms for commonly used systemic anti neoplastic agents (e.g., chemotherapy, hormonal agents) Explain the indications for : Liver transplant Kidney transplant

9 Pancreas transplant Dialysis access for hemodialysis Select appropriate antimicrobial therapy for: Empiric surgical site infection prophylaxis Empiric treatment of sepsis Methicillin resistant Staphylococcal infections Oversee TPN orders with the assistance of the Nutrition team, manage TPN complications, and make decisions regarding the initiation and cessation of TPN Adjust for influence of hepatic and renal insufficiency in the administration, dosing, and selection of perioperative medications Genetics Identify the important management keys relevant to patients with commonly encountered familial genetic syndromes Identify the role of surveillance and prophylactic resections for patients with genetic syndromes as they relate to hepatic cancer Understand the importance of working in multidisciplinary teams with our genetic counselors for appropriate management of patients with familial genetic syndromes Identify and refer patients for evaluation by Genetics counseling team Transplant Understand the basic principles of immunosuppression Understand the role of patient selection and multidisciplinary evaluation process ofr listing of patients for kidney and liver transplant Identify differences in outcome measurement including graft and patient survival Understand the role of systemic therapy, radiation therapy, and surgical therapy in the control of distant disease, regional disease, and local disease Explain the role of both non operative and operative palliation for patients with both resectable and unresectable cancers. Participate in the multidisciplinary discussion of patients in need of cancer palliation recognizing the important, but not always primary, role of surgery in the palliation of symptoms for cancer patients with end stage liver disease Assist in the teaching of these important transplant concepts to PGY1 and intermediate residents as well as all learners on the service Culture/ethnicity Recognize and respect of healthcare practices, communication customs, and beliefs of ethnic and cultural groups Identify commonalities in people s medical conditions that transcend culture and ethnicity Identify biases and barriers between the healthcare community and cultural/ethnic groups Independently access, appraise and apply information from relevant texts and evidence based literature to care of the patient using: SCORE Online UTSW reference textbooks Online MD Anderson Surgical Oncology Handbook (made available by the Division of Surgical Oncology to all residents through the UT Southwestern Library) Core Competency: Systems based practice Identify barriers to accessing health care for patients across cultural, economic, racial

10 backgrounds Participate in discussion and development of a cost effective patient management plan that analyzes risks and benefits Collaborate with institutional resources, such as social services, home health, etc., for effective discharge planning Acquire specific information about rehabilitation services, indications for referral and potential benefits Identify system issues that may contribute to medical mortality and communicate these to the surgical oncology team Follow up with reference physician post operative/discharge about patient s care Access and transfer patient s medical records when appropriate Apply appropriate documentation for coding and billing Core Competency: Interpersonal and Communication Skills Document a comprehensive history, examination, assessment, and plan for assigned surgical patients Document timely daily progress notes that describe clinically important issues or changes in patient care plans Write routine orders (admission, preoperative, postoperative) and communicate urgent or emergent orders to the nursing staff Document and revise essential patient care information on the surgical oncology patient census in a timely fashion Present patient information on rounds and at transitions of care with emphasis on patient safety Present assessment and plan for all assigned patients on daily faculty rounds Apply information from daily faculty rounds into patient care including medical chart information Discuss medical errors or professional mistakes honestly and openly within the context of quality improvement to promote patient safety, trust, and self learning Communicate effectively with patients, family, nursing staff, residents, physician assistants, fellows, and faculty, and the public across socioeconomic and cultural backgrounds Patient and Family Communication/Education Provide accurate, straightforward information to patients and families in a compassionate and understandable manner Use informed consent properly Listen with cultural, ethnic, gender, racial, and religious sensitivity Core Competency: Professionalism Adhere to all ACGME work hour policies as set forth by the Department of Surgery and supported by the Division of Transplant Surgery Demonstrate competent work ethic by consistently and dependably carrying out duties with honesty, integrity, self motivation, and self discipline Use available resources when ethical, medical, or professional problems arise Strive to provide excellence in the delivery of surgical care and patient safety including participation in Quality Improvement projects such as regular participation in our scheduled Surgical Oncology multidisciplinary conferences including: Multidisciplinary Liver Selection Committee Multidisciplinary Kidney Selection Committee Division of Transplant Surgery Resident Education Conference including Journal Club and Morbidity and Mortality discussion

11 Hepatocellular Cancer Multidisciplinary Conference Prepare in advance for faculty rounds, operative cases, and outpatient clinic Accurately report duty hours on a daily basis and prospectively identify and communicate potential work hour issues to the supervising residents Transplant faculty Participate in regularly scheduled Surgical Oncology conferences including: Multidisciplinary Liver Selection Committee Multidisciplinary Kidney Selection Committee Division of Transplant Resident Education Conference including Journal Club and Morbidity and Mortality discussion Hepatocellular Cancer Multidisciplinary Conference Participate in regular Department of Surgery educational conferences and activities Adhere to institutional code of conduct, demeanor, behavior, and attire Recognize capabilities and limitations of self, team, and institution Respect all individuals Care for patients compassionately by consistently demonstrating respect for patient privacy, dignity, and autonomy Log cases and duty hours and complete evaluations in a timely fashion Core Competency: Practice based learning and improvement Read assigned readings and identify materials for self study regarding Transplantation Use independent self study and assessment programs Identify common sources of medical errors, and explain steps to avoid or minimize them Self reflect about adverse events and near misses to improve patient safety and care Participate in education of medical students and other learners Explain how to recognize and manage postoperative complications Incorporate formative and summative feedback from team members and rotation faculty to identify areas of weakness and improve overall performance Independently access, appraise and apply information from relevant texts and evidence based literature to care of the patient using: SCORE Online UTSW reference textbooks Online Resident Academic Universe from the ASTS