Medical College of Wisconsin Pediatric Cardiac Critical Care Senior Instructorship

GOAL
To gain knowledge and skill needed to effectively care for complex cardiac patients admitted to a PICU as part of a multidisciplinary team.

OBJECTIVES

Medical Knowledge

• Explain the patterns of physiologic alterations that commonly occur in pediatric patients with congenital and acquired cardiac disease who are admitted to the PICU.
• Explain the physiology and pathophysiology of common and uncommon diseases and processes that affect children with cardiac disease admitted to the PICU.
• Explain the rationale for changes in patient management in response to changes in physiological status in the pre- and post-operative period.
• Explain the rationale for appropriate use of monitoring devices.
• Acquire new knowledge and demonstrate its application in areas such as echocardiography, electrophysiology, diagnostic imaging of heart function, adult congenital heart disease, and cardiac catheterization, ECMO and VAD (impella, Berlin Heart, HM3) management.

Patient Care

• Based on a focused history and physical examination, develop and implement a plan of care for initial resuscitation and stabilization of patients with congenital and acquired cardiac disease in the pre- and post-operative period.
• Obtain and use results of a thorough history and physical examination to appropriately revise the plan of care that optimizes cardiac function and outcomes.
• Make informed decisions about therapeutic interventions and diagnostic testing based on clinical experiences, acquired information, up-to-date scientific evidence and clinical judgment to assist others in developing the plan of care.
• Demonstrate situational awareness about patient changes in response to the plan of care and assist others in developing and implementing a new plan.
• Adapt and adjust, under supervision but with increasing autonomy, the patient’s management in response to changes in the patient’s physiologic status.
• Collaboratively supervise others in performance of the appropriate ICU technical procedures and daily care.

Communication and Interpersonal Skills

• Explicitly obtain and use information from patients, families and other health care professionals to assure patient-centered care.
• Facilitate multi-disciplinary discussions focused on improving the plan of care.
• Document patient care, providing thorough, concise and organized information in daily progress notes and consultative notes.
• Lead care conferences and assure results of the conference are disseminated to appropriate personnel.

Practice-based Learning and Improvement

• Analyze experiences during service weeks to develop a plan for continued improvement in all competency areas.
• Expand your literature review to develop content expertise as it relates to the care of children with congenital and acquired cardiac disease.
• Demonstrate a change in practice based on feedback obtained from attendings and evaluations.
• Present at least one journal club as well as research in progress presentation at the appropriate conference series.
• Submit at least one abstract of your scholarly activity to a national peer-reviewed conference.

Systems-based Practice

• Demonstrate team leadership, including identifying and accessing additional resources to complete tasks, addressing the learning needs of the team and collaboratively creating a plan of care for the team of cardiac patients.
• Create a plan of care for the patients and present to the supervising attending prior to morning work rounds.
• Lead morning work rounds, raising appropriate teaching points/issues of concerns for discussion by the team.
• Assure that safety and cost issues are covered by the team during morning work rounds through review and modification of specific issues (e.g., presence of central lines, other invasive procedures, daily lab orders).
• Facilitate multi-disciplinary care team management of patients by interacting with team fellows/attendings in a timely fashion (e.g., Cardiology/ Cardiovascular Surgery team, Infectious Disease, Neurology, Palliative Care).
• Disclose slips, lapses and errors to appropriate personnel.

Professionalism

• Discuss cultural and personal issues of patients/families that affect decisions regarding patient care.
• Recognize personal biases that may conflict with patient/families and resolve conflicts in favor of the patient/family when possible.
• Actively seek input of the family/patient and healthcare team, demonstrating respect for their concerns.
• Accept responsibility and demonstrate accountability for own actions and those of the health care team.
• Demonstrate leadership through role modeling for junior colleagues.

Clinical and Research Components
The instructors in this one-year program provide twenty weeks of clinical service on the cardiac critical care unit. After a brief orientation, they are expected to co-lead the team with a cardiac intensivist, providing all components of patient care (assessment, medical decision-making and management plans) under supervision but with increasing autonomy.

Eligible instructors have completed their scholarly requirements during their prior three year critical care/cardiology fellowship. Each instructor is assigned to a scholarly oversight committee and encouraged to participate in ongoing scholarship which may include authoring a manuscript or initiating a new, focused study. Mentoring is provided and advisors are assigned to assure ongoing involvement. They present their research in progress during the fellowship weekly research meeting and meet with the team to present a final analysis of their work prior to completion of this one year program.

Supervisory and Patient Care Responsibilities
Instructors are assigned to one of two teams caring for the patients in the Cardiac Intensive Care Unit. The team consists of resident(s), pediatric nurse practitioner(s) and junior fellow(s). Expectations of the Cardiac Critical Care Instructor/Fellow includes: data gathering, assessment and creation of a management plan for all patients on the team; supervision of the other team members, guiding them in similar activities; maintaining situational awareness (including prioritization of tasks) and responding to changes in patient status, implementing the plan when possible. They are expected to provide their assessment and management plan to the supervising physician on rounds and with all unexpected changes. The timing of this discussion changes over the course of the year as increasing autonomy is awarded to the instructor.

Call responsibilities include assessment and management of all patients in the Cardiac Critical Care Unit, demonstrating situational awareness including predicting and prioritizing. Call is under supervision with increasing autonomy awarded as the fellow demonstrates competency.

Responsibilities while on cardiology-based rotations include full integration into the cardiology team, providing assessments, medical decision making and patient management as appropriate and with supervision.

Clinical Procedural Requirements
Instructors are expected to demonstrate procedural skills consistent with a new graduate of a Pediatric Critical Care Fellowship.

Additional procedural skills for acquisition in the cardiology rotations include: basic interpretation of echocardiography and MRI studies; explanation of EP and cardiac catheterization risks/benefits and expected data acquisition. Procedural skill acquisition is expected to achieve a basic level (i.e., not at the cardiologist level of expertise, but sufficient to understand the risks/benefits, acquire basic psychomotor skills and interpret studies at a novice to advanced beginner level).

Didactic Sessions
Instructors are expected to attend both critical care and cardiology educational offerings. Teaching strategies include: didactic presentations, interactive discussions, and simulations. The list of expected attendance includes the following conferences:

• Weekend sign-out: Mondays, 6:30-8 a.m.
• ICU research conference: Mondays, 12-1 p.m.
• Prenatal fetal echo: 3rd Monday, 4:30-5:30 p.m.
• Echo review: Tuesdays, 8-8:30 a.m.
• M & M cardiac case review: 4th Tuesday, 4:30-5:30 p.m.
• Cardiac ICU lecture: 1st/3rd Tuesday of every month, 12-1 p.m.
• Echo review: Wednesdays, 8-8:30 a.m.
• ICU core conference: Wednesdays, 12-1 p.m.
• Cardiac surgical conference: Thursdays, 7-9 a.m.
• EP tea rounds: 3rd Thursday, 4-5 p.m.
• Cath tea rounds: 2nd and 4th Thursday, 4-5 p.m.
• EP review: 1st Friday, 7-8 a.m.
• Transplant conference: 2nd Friday, 7-8 a.m.
• Cath review: 3rd Friday, 7-8 a.m.
• Cath/EP M & M: 3rd Friday, 7-8 a.m.

• Blocks consisting of 1-4 weeks duration for one year
• Cardiac ICU service (22 weeks)
  • 4 weeks acting as ICU fellow
  • 8 weeks senior fellow
  • 10 weeks CICU attending
  • Overnight call frequency – 6 calls/month
• REQUIRED Cardiology and Operating Room (OR)/Anesthesia subspecialty rotations (16 weeks)
  • 4 weeks OR/Anesthesia
  • 4 weeks Echocardiography
  • 4 weeks Catheterization
  • 2 weeks Electrophysiology
  • 2 weeks Transplant/Heart Failure
  • Responsibilities/experiences vary based on rotation (see below)
• Additional ELECTIVE rotations based on interests (10 weeks)
  • General PICU attending time (total 4 weeks)
  • 2 weeks of Adult Congenital Heart Disease
  • Elective time to do any cardiology rotation (not required)
• Vacation (4 weeks)
• Research – optional although encouraged if there are any particular interests
• Physician supported transport call moonlighting opportunity (optional)

ICU Rotations

Cardiac ICU orienting fellow (4 service weeks)

• Direct patient care for cardiac ICU patients
• Educational role to junior trainees to include medical students, residents, and critical care fellows
• Paired with senior critical care fellow to allow for orientation to unit, hospital and appropriate practices, policies and procedures

Cardiac ICU senior fellow (16 service weeks)

• Direct patient care for cardiac ICU patients
• Educational role to junior trainees to include medical students, residents, and critical care fellows
• Call is variable on the month during the rotation as follows:
  • 6 call nights/month from July to September
    • Paired with critical care fellow in July in order to provide orientation and assistance to the hospital during call nights
    • Solo call in August and September
    • IMPORTANT: Some calls in July and August will be PICU attending call based on the scheduling for PICU attending service time (see schedule)
  • 6 call nights/month from October through December as senior fellow on call for critical care fellow on routine call schedule
    • IMPORTANT: These calls will be organized, when possible, with Dr. Szadkowski in association with known surgical scheduling to provide a broad clinical exposure.

Cardiology Rotations

Echocardiography (4 weeks)

• Provide general understanding of echocardiography in variable clinical situations
  • Outpatient lab
  • OR (TEE)
  • Inpatient echocardiograms
• Attendance at echocardiogram review conferences
  • 3rd Monday of every month = Prenatal fetal echo (4:30-5:30 p.m.)
  • Every Tuesday = Echo review (8-8:30 a.m.)
  • Every Wednesday = Echo review (8-8:30 a.m.)
  • Every Friday = Echo Q/A (7-8 a.m.)

Cardiac catheterization (4 weeks)

• Inpatient consulting service at CHW (Drs. Susan Foerster and Todd Gudausky)
• Attendance and preparation of all cases
• Attendance at catheterization review conferences
  • 2nd and 4th Thursday = Cath tea rounds (4-5 p.m.)
  • 3rd Friday of every month = Cath review (7-8 a.m.)
  • 3rd Friday of every month = Cath/EP M & M (7-8 a.m.)

Electrophysiology (4 weeks)

• Inpatient consulting service at CHW
• Outpatient service at CHW (Drs. Anoop Singh and Joshua Kovach)
• Attendance and preparation of all cases
• Attendance at conferences discussing cases
  • 3rd Thursday of every month = EP tea rounds (4-5 p.m.)
  • 1st Friday of every month = EP review (7-8 a.m.)
  • 3rd Friday of every month = Cath/EP M & M (7-8 a.m.)

Transplant/heart failure/ventricular assist devices (4 weeks)

• Inpatient consulting service at CHW
• Outpatient service at CHW
• IMPORTANT: It is expected that fellows are engaged in all patients with VADs regardless of the timing of this rotation
• Attendance at monthly transplant meetings
  • 2nd Friday of every month = Transplant conference (7-8 a.m.)

Adult congenital heart disease (4 weeks)

• Inpatient consulting service at CHW and Froedtert Hospital
  • Drs. Mike Earing, Peter Bartz, Scott Cohen, and Salil Ginde
• Outpatient service at CHW

Cardiac Anesthesia Rotations

Cardiac anesthesia (4 weeks)

• Dedicated rotation to cardiac OR
• Preoperative evaluation/planning
• Operative attendance and procedural skills
• Postoperative troubleshooting

Other Interests

Additional rotations (4 weeks)

• Additional clinical time related to fellow-specific interests in subspecialties listed above
• Rotations of fellow interest NOT listed above should be discussed with Dr. Hoffman/Russell to determine feasibility and appropriate contact information

Instructors are assigned to a specific ICU team and supervised by a board certified pediatric intensivist with advanced cardiac critical care training. Instructors are expected to meet with their supervising physician prior to rounds each day and discuss their plan of care. They are granted increasing autonomy based on their performance although have ongoing supervision throughout the year.

Each instructor is assigned to one of the Associate Program Directors (who is also a cardiac critical care specialist) as an advisor and meets on a regular basis (at least monthly). Mentorship needs are discussed and a Scholarship Oversight/Career Development Committee created based on those needs. A minimum of three faculty (with one outside of the Critical Care section) is led by the assigned Associate Program Director. This committee meets a minimum of twice during the year, more frequently if the instructor chooses to initiate a new scholarly project.

Each instructor is invited to the Scientific Writing Course offered by our section to obtain feedback and input on any manuscripts or abstracts in preparation.

Each faculty member who works with the instructor, either during a daytime rotation or a night call, receives an evaluation notification for completion. Completion rates are tracked and reminders provided until completion occurs. The evaluation is based on the six competencies and may be customized for non-ICU rotations. These evaluations are available for instructor review electronically. Faculty and instructors are strongly encouraged to have face-to-face feedback at the end of a service experience. Additional information is obtained during Critical Care section meetings to identify strengths and areas for improvement. The summative assessment of the electronic evaluations occur twice each year at the bi-annual review, held with the instructor’s Associate Program Director, the Research Director and the Program Director. Comparative data based is available when there are sufficient trainees to maintain some anonymity.

The section of program leaders for 4th year fellowships currently utilize the PCICS formalized match system.

Although Children's Wisconsin does participate in the match, please reach out to Adam Szadkowski, MD, aszadkowski@mcw.edu, to verify our current status and participation in the program. If the match program has completed and we did not fill a position, we do consider applicants outside of the match.

To participate in the one-year cardiac instructorship, candidates must have successfully completed an accredited fellowship in Pediatric Critical Care Medicine or Cardiology and be board eligible (i.e., be eligible for certification in both Pediatrics and Pediatric Critical Care Medicine or Cardiology), obtain a valid Wisconsin license and a DEA number.

The Critical Care Division provides clinical care at Children’s Wisconsin, a 306-bed free standing, pediatric hospital that provides comprehensive care for neonates, infants, children, and adolescents as well as adults with congenital diseases. Children's has 73 NICU beds, 72 PICU beds (including a 24 bed dedicated CICU unit), 24,000 annual admissions and more than 20,000 surgical procedures annually. We are the region’s only level 1 pediatric trauma center. Children's Wisconsin Emergency Department is certified by the American College of Surgeons as a Level 1 Trauma Center and Level 1 Children’s Surgery Center.

Children's is home to the internationally renowned Herma Heart Institute – one of the top programs in the United States for the medical and surgical treatment of heart disease and congenital heart defects in children and adults. The Herma Heart Institute conducts 15,000 outpatient visits throughout the state each year, and we continue to be a high volume congenital heart surgery program in the nation with 300 open-heart surgeries and 700 total heart procedures per year. The institute is nationally recognized for its accredited pulmonary hypertension program, echocardiography, and adult congenital heart disease programs. The Herma Heart Institute’s robust innovation infrastructure additionally offers faculty the opportunity for internal pilot and seed funding for cardiac research, quality improvement, novel biomedical devices, or clinical innovation projects.

Learn about the Herma Heart Institute

Milwaukee is one of the Midwest’s best-kept secrets and a prime location for the Medical College of Wisconsin’s main campus. A one-of-a-kind city with a vibrant and diverse culture, this charming, yet metropolitan must-see is just 90 minutes north of Chicago and nestled on the coast of Lake Michigan. Whether you’re catching a show at Summerfest, the world’s largest music festival, immersing yourself in the old world charm of the Historic Third Ward or taking in the sights and sounds of one of the many cafés, beer gardens or restaurants that line the city’s riverbank and shoreline, Milwaukee never disappoints. Find out why MCW students, faculty and employees take pride in calling Milwaukee home.

Mentorship during fellowship is very important. Mentors offer unique guidance because they have been in your position and are sharing their experience for your benefit. Throughout the pediatric cardiac critical care fellowship training you will work closely with our core group of 9 CICU faculty members who will offer advice, guidance and feedback along the way. Fellows are also encouraged to be involved or attend regional, national, and international conferences when possible.

The Pediatric Critical Care faculty includes a total of 34 board certified/eligible pediatric critical care specialists. Of these, eleven (11) have additional training in the care of patients with acquired and congenital heart disease; three of these are also board certified in Pediatric Anesthesia. One has practiced in the cardiac setting for a significant portion of his 15 years of practice. These 11 faculty members provide care for children admitted to the 24-bed cardiac critical care unit. In addition, there are 25 board/certified/eligible pediatric critical care specialists who participate in the conferences and mentoring of our fellows while caring for patients in our non-cardiac ICU areas (44 beds).

Cardiac Critical Care Faculty

• Matt Amidon, DO
• Becky Bertrandt, MD
• George Hoffman, MD
• Cory McFall, MD
• Rob Niebler, MD
• Jake Scott, MD
• Adam Szadkowski, MD
• Justinn Tanem, MD
• Nathan Thompson, MD
• Raji Venkitachalam, MD
• Martin Wakeham, MD

Additional faculty who are actively involved in teaching of our fellows include other subspecialists from cardiology, cardiovascular surgery, and anesthesiology. The key representatives for these areas are listed below:

• Robert (Jake) Jaquiss, MD; Pediatric Cardiac Surgery
• Peter Bartz, MD; Pediatric Cardiology
• Scott Cohen, MD; Adult Congenital Heart Program
• Susan Foerster, MD; Cardiac Catheterization
• Peter Frommelt, MD; Echocardiography
• Alexander Raskin, MD; Heart Failure
• Anoop Singh, MD; Electrophysiology
• Nikki M Singh, MD; Heart Transplantation
• George Hoffman, MD; Pediatric Anesthesiology

Meet our entire Critical Care team

American Board of Pediatrics (ABP) has requested the following to justify moving forward with the sub-board initiative for pediatric cardiac critical care: 1) standardized core curriculum and learning objectives, 2) professional societal support, and 3) demand and number of individuals interested in a sub-board.

PCICS (Pediatric Cardiac Intensive Care Society) is the professional society that has endorsed the sub-board initiative.

The manuscript entitled "Standardized Training for Physicians Practicing Pediatric Cardiac Critical Care" was submitted to PCCM. Interval update: The manuscript was accepted for publication to PCCM on June 10, 2021, which fulfills ABP request (see above).

ABP recommended that the next step as a potential bridge to a sub-board should be the development of Pediatric Cardiac Critical Care specialized testing for Maintenance of Certification (MOC).

PCICS 4th year fellowship PD sub-committee is well positioned to functionalize standardized training using the contents of the manuscript.