[Neurocritical Care]
[Parkland Chief]
[Parkland Junior]
[Vascular Chief]
[Vascular Junior]
Neurocritical Care Curriculum
Site Director:  Venkatesh Aiyagari, MD, PhD
Location:  Zale Lipshy University Hospital and Parkland Memorial Hospital
Service Mission: Neurocritical Care is devoted to the comprehensive multisystem care of the critically ill neurological or neurosurgical patients. It attends to the unique needs of the brain and various elements of the ICU care that might otherwise be provided by multiple subspecialists (i.e. cardiology, pulmonary medicine, endocrinology, infectious disease, as well as neurology and neurosurgery). There are a variety of neurologic disorders that can render a patient critically ill. These include subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, brain tumor, traumatic brain and spinal cord injury, status epilepticus, neuromuscular diseases, and coma. Both neurosurgeon and neurologist need to be competent in the management of critically ill or post-operative neurologic patients. For this reason, neurosurgery and neurology residents are required to complete this rotation.
Core Competencies:
1. Patient Care:  Throughout this rotation, the resident will develop the cognitive and procedural skills necessary to provide optimal care to patients admitted to the Neurological Intensive Care Unit and/or patients with severe physiologic derangements in the perioperative setting. This will also supplement knowledge gained from other rotations.  Supervisory attendings will evaluate competence in the written evaluation.

      1) Resident will gather essential and accurate information by performing complete and clinically-relevant history and physical exams.
      2) Resident will understand how to order and interpret appropriate diagnostic tests.
      3) Resident will make informed diagnostic and treatment decisions by analyzing and synthesizing information.
      4) Resident will understand the limits of their knowledge and expertise and will use consultants and referrals appropriately.
      5) Resident will develop and carry out care plans as well as develop superb communication abilities.
      6) Resident will learn to perform ICU procedures competently and manage complications resulting from these procedures.
      7) Resident will routinely participate in conversations with family members to gather other clinical information, understand patient’s and families wishes.
      8) Resident will become competent in palliative care and end of life discussions
      9) Resident will appropriately coordinate for the safe transport of critically ill patients within the medical center.

2. Medical knowledge:  Basic knowledge with regard to neurocritical care and critical care medicine will be obtained through patient care, daily attending rounds, morning and noon conference, journal club, and background reading as detailed below, with reading to occur in a patient-specific fashion.

      1) To be familiar with neurocritical care and critical care medicine.
      2) To integrate general medical management with neurological, neurosurgical, and endovascular interventions.
      3) Develop core neurocritical care skills such as review of CT/MRI scans and management of ischemic and hemorrhagic stroke, traumatic brain injury, increased ICP, hydrocephalus, seizure, hypertension, cerebral salt wasting and vasospasm.
      4) To be familiar with the epidemiology and risk factors for commonly encountered ICU conditions including ischemic stroke, ICH, SAH, TBI, and seizure.
      5) Understand the systemic inflammatory response syndrome (SIRS), Sepsis and multi-organ dysfunction, common causes of shock and hemodynamic instability, Acute Lung Injury, ARDS, Acute Renal failure, Nosocomial infections, acute bleeding.
      6) General statistics ICU related morbidity, mortality, and costs to society, the healthcare system.
      7) Precise knowledge of Advanced Cardiac Life Support and ability to direct emergent/Code scenarios in a variety of clinical settings.
      8) To know the signs, symptoms, clinical course, complications and treatment of common post-operative conditions for neurosurgical specialty operations.
      9) To have a comprehensive understanding of the pharmacology of all commonly used medications in an ICU and other monitored clinical settings including;
            o   Sedative, analgesic and muscular relaxant drugs.
            o   Hemodynamic support with vasoconstrictors, inotropic agents and antihypertensive agents.
            o   Other specialized medications that are commonly only used in monitored settings including insulin drips, thrombolytics, some anti-rejection induction agents, antiarrthmic agents.
      10) To understand the role, principles and limitations of Physiologic monitoring, Diagnostic laboratory & radiological tests commonly used in the critical care setting.
      11) To understand the indications, techniques for placement, complication recognition & management of invasive intravenous catheters including arterial lines, central lines, introducers, cavity drains and thoracostomy tubes
      12) To know common chest/brain radiographical interpretation.
      13) To be familiar with current guidelines and standards of care developed by relevant medical organizations.

 3.  Practice-Based Learning and Improvement:  The resident will be responsible for tracking the number and diagnoses of patients seen and cared for. This data will be used to ensure that an adequate educational experience is obtained. These data can also be used by the resident in their 6-month self-evaluation (in conjunction with in-service scores) to direct further study.

      1) To use current evidence-based practice guidelines, and to obtain supervision when existing guidelines require supplementation with experience-based practices for individual cases.
      2) To keep logs of all major procedures including artery line, central line, LP, lumbar drain, ventriculostomy or intubation.
      3) To access and use on-line medical information as pertains to patients’ diagnosis and treatment in the form of reference texts, searches, electronic journals such as UpToDate, Web MD’s e-Medicine and other networked resources.
      4) To critically read and discuss the relevant scientific literature presented in Journal Club, for example) while seeking application to actual practice.
      5) To facilitate the learning by other health care professionals and trainees with regard to substance-related disorders. The type of health care professional and trainee will vary with the specific rotation.

 4. Interpersonal and Communication Skills: The residents will be assessed by evaluations of supervising faculty during patient care rounds or elective consultation services, 360-degree review from clinical work sampling, chart review, presentation skills, and contributions during team meetings.

      1) Resident will exhibit communication that is characterized by socio-cultural effectiveness.
      2) Resident will demonstrate the ability to develop highly effective therapeutic relationships with patients and families.
      3) To establish collaborative and effective working relationships with other staff members involved in patient care including supervisors, nurses, physician extenders (NPs, PAs), respiratory therapists, pharmacists, dieticians other physicians and trainees.
      4) To function effectively as a team member and leader such as in the multidisciplinary team meeting.
      5) Resident will communicate respectfully and effectively with other health professionals.
      6) Resident will be able to act in a consultative role to other physicians and health professionals.
      7) Resident will maintain comprehensive, timely, effective, and legible medical records.

5.  Professionalism :  The resident must remember that they represent the University of Texas Southwestern Medical Center’s Departments of Neurology and Neurosurgery with all of their actions and communications while on this rotation. The highest standards of professionalism must be maintained at all times, especially in interactions with patients or with other physicians. The resident will be responsible for tracking duty hours and reporting them to the supervisory attending. Competence in professionalism will be assessed by supervisory attendings, as well as by the 360-degree evaluation.

      1) Resident will document all relevant diagnostic and treatment encounters with patients through effective medical record keeping.
      2) Resident will demonstrate accountability, reliability, and punctuality during performance of all responsibilities and duties.
      3) Resident will demonstrate a balance between independence and recognition of limits of competence/experience
      4) Heightened awareness when engaged in procedures with higher than average complexity including difficult airway management, invasive lines in patients whose underlying conditions/physiognomy increase risk i.e., coagulopathy, morbid obesity, previous interventions.
      5) Resident will conduct oneself in an ethically and legally sound manner with respect to issues such as maintenance of treatment boundaries, patient confidentiality, informed consent, provision or withholding of clinical care, and good business practices.

 6.  Systems-Based Practice:  The case of critically ill patients in the ICU is quite different from other service. The resident must learn how to appropriately triage severity of illness and handle crises in a timely fashion. The resident will perform common ICU procedures. They will learn how to appropriately utilize ancillary services for optimal patient care. The resident will develop knowledge in appropriate billing. Competence will be evaluated by the 360-degree evaluation.

      1) To understand the managed care of critically ill and post surgical patients, and how one tailors a patient's treatment to the resources available without compromising quality care.
      2) To understand the quality improvement process and how to partner with health care managers and providers to assess, coordinate and improve care.
      3) To develop awareness of cost-effectiveness issues with post-operative and/or clinically unstable patients, and how these are managed in different treatment settings such as a Neurological ICU, PACU, other ICU or step-down unit.
      4) To act as a patient advocate for helping patients and families navigate through sometimes complex and bureaucratic systems related to their health-care needs, patient wishes and resources available.
      5) To appreciate the necessity and rationale for various program policies and procedures.

Educational Goals:

      1) Become familiar with brain resuscitation and cardiopulmonary care of critically ill neurological and neurosurgical patients.
      2) Learn to detect acute neurological changes and interpret test results, CT/MRI scan.
      3) Learn critical care management skills and bedside procedures (arterial & central lines, endotracheal intubation, lumbar puncture and lumbar drains).
      4) Develop proficiency with advanced life support techniques; different modes of mechanical ventilation, hemodynamic support with all pharmacologic agents, management of electrolyte disturbance, renal failure, arrhythmia, coagulopathy infection, shock and GI bleed.
      5) Understand the roles of ventriculostomy, ICP monitoring, ventilation support, hypertonic saline, vasoactive medications, fluid resuscitation, and blood products in brain protection.
      6) Become proficient at timely management of ischemic and hemorrhagic stroke, traumatic brain injury, increased ICP, hydrocephalus, seizure, hypertension, and vasospasm.

Resident Responsibilities:

      1) Evaluate all new ICU consultations and write H&P, progress notes, and ICU orders.
      2) Acquire information on overnight events from on-call residents and nursing staff.
      3) Examine patients and review flow chart, labs, meds, and X-ray/CT/MRI during the pre-rounds.
      4) Present case and discuss daily care plan during the rounds.
      5) Communicate with primary services (Critical Care, Neurosurgery, Neurointerventional Radiology, and Neurology) timely and professionally.
      6) Enter orders after rounds unless urgent and sign all verbal orders within 48 hours.
      7) Take care of the daily routines in order of priorities.
      8) Call the attending on all admissions, central line placement, intubation, any significant change in neuro status, or any questions related to the evaluation and management of unstable patient.
      9) Attend neurovascular and neurocritical care teaching conferences (7 AM Wednesday morning and noon Thursday).
      10) Attend required didactic conferences.
      11) Attend afternoon continuity clinic once per week as assigned. It is the resident’s responsibility to inform the ICU attending about upcoming absences due to continuity clinic.

6:30 am to 6 pm, 6 days per week. One 24 hour period per week (on average) will be completely free of clinical responsibility. The residents on the service should coordinate patient assignments on the weekends to ensure continuity of care.
Daily Rounds:
Pre-rounds: 6:30 - 8:00 AM
Attending Rounds: 8:00 -11:00 AM
Evening Vascular Rounds: 4:30 - 5:30 PM
Suggested Reading:

      Handbook of Neurocritical Care. by Anish Bhardwaj, Marek A. Mirski, John A. Ulatowski
      Neurological and Neurosurgical Intensive Care. by Allan H Ropper, Daryl R Gress, Michael N Diringer, and Deborah M Green.
      Chapters in Bradley and Daroff that relate to critical care with reading specific to cases that are seen.
      “Critical Care Neurology”, part of the Blue Book Series – editors David Miller & Eric Raps.
      The clinical practice of critical care neurology. Wijicks, E.


      Electronic evaluation by attending physician.
      Program director’s semi-annual review.


      1) Resident will be directly supervised throughout the day by the Critical Care fellow.
      2) Critical care attending will oversee daily rounds and direct the critical care fellow and rotating resident.
      3) Program director will oversee rotation to ensure educational goals are being met.

Last Updated Feb 2013