Education

NEPHROLOGY INTENSIVE CARE UNIT ROTATION

Each first year fellow rotates on the Intensive Care Unit rotation with a supervising nephrology faculty member on patients who are in various intensive care units for three months of the training.   The intensive care units include the Medical Intensive Care Unit, the Coronary Care Unit, the Surgical Intensive Care Unit, the Cardiac Surgery Intensive Care Unit, the Neurology Critical Care Unit, and patients in various “step-down” units as well as patients in Oncology and others located in the Weinberg Building.  Fellows are expected to make evaluations and then present history, physical findings, and assessment and plans to the nephrology teaching faculty member.   There may be a Johns Hopkins Bayview nephrology fellow, medical resident, urology resident or anesthesia fellow assisting the nephrology fellow.  

Educational Goals:

The ICU service builds the foundations for a broad knowledge base in inpatient nephrology, by providing fellows exposure and opportunities to manage tertiary and quarternary referral patients, as well as managed primary care patients. 

1. The fellow is expected to develop competency in providing compassionate and thorough care to a medically and socially diverse group of hospitalized patients.
2. Fellows serve as team leaders on these consultation services and have opportunities to develop teaching, leadership, and management skills with residents and students.
3. One purpose of this rotation is to provide the first year fellow with the education and experience necessary to become proficient in inpatient consultation nephrology in the intensive care unit setting.

Objectives:

Patient Care

Each fellow will rate as valuable the importance of being a nephrologist to a medically and socially diverse group of patients

Each fellow will be able to obtain and document a complete history and physical, formulate a thorough assessment and plan, and communicate this assessment to the primary care team

Each fellow will demonstrate the ability to make daily assessments of their patients and convey that information to the team through a variety of methods, including daily written progress notes

Specific educational goals are to provide clinical experience and opportunities to gain expertise in:

1. Acute renal failure in the ICU setting and in oncology patients including the approach, differential diagnosis, performance of urinalysis, radiologic assessment, and treatment;
2. Fluid, electrolyte and acid-base disorders in the ICU setting and in oncology patients, including the approach, differential diagnosis and treatment of the above;
3. Principles and practice of continuous renal replacement therapy, hemodialysis and possibly peritoneal dialysis, including choice of optimal dialysis modality in the ICU setting;
4. Drug dose modification in patients undergoing all forms of renal replacement therapy;
   Recognition of short-term complications of renal replacement therapy and dialysis access.

Medical Knowledge

The fellow will demonstrate a knowledge and understanding of the pathophysiology, diagnostic evaluation, and therapeutic management of a core group of renal diseases described above.

By the end of the ICU month, each fellow will have attended and participated in the educational activities listed in the teaching methods section.

By the end of the ICU month, each fellow is encouraged to complete some of the recommended readings (below)

Communication Skills

Each fellow will demonstrate effective communication skills with the attending physician by discussing each consultation in a timely fashion

Each fellow will discuss the ongoing care of each patient with the appropriate attending daily

Each fellow will demonstrate effective teaching and feedback skills with interns, residents and medical students.

Each fellow will model effective interpersonal communication skills with patients, families, and allied health professionals

Professionalism

Each fellow will demonstrate compassion and understanding to a group of socially, economically and racially diverse group of patients

Each fellow will rate as comfortable his/her ability to assume the leadership role on the nephrology healthcare team

Each fellow will model appropriate team function by including allied health professionals in management discussions

Practice-Based Learning and Improvement

The fellow will incorporate basic knowledge of evidence-based medicine in evaluation and management of patient medical problems

Each fellow will continue the process of acquiring skills and documenting the procedures required by the ABIM, as listed in the procedure summary

Each fellow will model practice based learning and effective information seeking in the daily care of patients

Systems-Based Practice 

The resident will demonstrate an awareness of issues cost-effective medicine in patient care, by discussing the cost implications of a case/month with the attending physician

Each fellow will rate as valuable the contributions of other members of the health care team into management plans for patients

Each fellow will routinely evaluate the socioeconomic needs of his/her patients, including health insurance, access to care and copayments necessary to provide care

By the end of ICU month, each fellow will have assumed care for patients of colleagues on the team and effectively transferred care of his/her own patients when not in the hospital 

Teaching Methods: 

Teaching methods include rounds with the nephrology faculty member and review of renal biopsies with the renal pathologist.   In addition, radiological studies obtained are reviewed and if needed direct consultation is obtained from radiology attending faculty members.  During the year there are didactic sessions on ICU Nephrology presented in the July Core Lecture series, Core Curriculum Conference, and Renal Rounds.  Suggested reading may include papers distributed by the teaching faculty member.  There is access to PUBMED and Up-To-Date as well as other electronic medical literature databases in the fellows’ office and all public workstations in the hospital.  Specific medication dosing guidelines can be found in Drug Prescribing in Renal Failure Dosing Guidelines for Adults, 4^th Ed. by Aronoff, et al.    Suggested reading for various aspects of renal replacement therapy include The Handbook of Dialysis, 3^rd Ed. by Daugirdas, et al.* and Principles and Practice of Dialysis by Henrich.  Other topics may be covered in the Primer on Kidney Diseases, 2^nd Ed. provided by the National Kidney Foundation*, The Kidney, 4^th Ed, by Brenner, Principles and Practice of Nephrology, by Jacobson and Poisoning and Drug Overdose by Winchester.

*Texts provided to each fellow; the other texts available in the Fellow’s office.

Mix of Diseases:

Diseases seen on this rotation include acute renal failure in the intensive care unit from all causes such as sepsis, liver failure causing hepato-renal syndrome,  intra-operative hypotension, post-operative complications, non-kidney transplant medication induced renal failure and post bone marrow transplant renal failure, rapidly progressive glomerulonephritis from vasculitis), acid–base and electrolyte disturbances, and chronic kidney disease and End Stage Renal Disease patients requiring intensive care unit care (diabetes, hypertension, chronic glomerulonephritis, chronic tubulointerstitial disease, genetic kidney diseases ((Autosomal Dominant Polycystic Kidney Disease)), HIVAN, SLE). 

Patients' Characteristics:

Patients followed include those admitted to the various Intensive Care Units with acute renal failure in the following settings:  post operative; status post myocardial infarction or severe cardiomyopathy; respiratory failure; liver failure; sepsis; neurologic emergency; oncology therapy or complications.  Patients may have underlying chronic kidney disease or End Stage Renal Disease which requires care in an intensive care unit.  Patients may be transferred from the general consultation service to the Intensive Care Unit service if they have become acutely ill and are transferred to an Intensive Care Unit.  There is an average daily census of between 10-20 patients in the Intensive Care Unit Nephrology rotation. Some patients over the age of 70 are included in this rotation and fellows experience aspects of geriatric nephrology.

Types of Clinical Encounters:

Patients seen are as inpatient consultation in one of the intensive care units. There are no primary service patients on this rotation.

Procedures:

Procedures may include performance of native renal biopsies, urinalysis, placement of temporary vascular access for hemodialysis and continuous renal replacement therapies as well as hemodialysis, peritoneal dialysis and chronic renal replacement therapy treatment.  Please see general curriculum regarding methods of evaluation of procedures and definition of proficiency.  Nephrology teaching faculty members supervise these procedures unless not on the premises at the time of the procedure, or if the fellow has performed 10 vascular access procedures satisfactorily.  

Services:

Fellows on this rotation will be asked to take care of patients by providing an outstanding standard of care as stated by the six core clinical competencies.  Procedures involved are for patient care purposes.

Reading List:

1. Kroh UF, H.T., Steinhauber W, Management of Drug Dosing in Continuous Renal Replacement Therapy. Seminars in Dialysis, 1996. 9: p. 161-165.
2. Macias WL, C.W., Acid-Base Balance in Continuous Renal Replacement Therapy. Seminars in Dialysis, 1996. 9: p. 145-151.
3. Monoson P., M.R., Nutritional Considerations in Continuous Renal Replacement Therapies. Seminars in Dialysis, 1996. 9: p. 152-160.
4. Palevsky, Continuous Renal Replacement Therapy Component Selection: Replacement Fluid and Dialysis Solutions. Seminars in Dialysis, 1996. 9: p. 107-111.
5. Sigler, M.H., Transport characteristics of the slow therapies: implications for achieving adequacy of dialysis in acute renal failure. Adv Ren Replace Ther, 1997. 4(1): p. 68-80.
6. Denton MD, Chertow  GM, Brady HR, “Renal-dose” dopamine for the treatment of acute renal failure:  Scientific rationale, experimental studies and clinical trials.  Kidney International (Perspectives in Clinical Nephrology), 1966  49: p. 4-14.
7. Berns JS and Ford PA,  Renal Toxicities of antineoplastic drugs and bone marrow transplantation.  Seminars in Nephrology, 1997.  17(1): p. 54-66.
8. Davenport A, Renal replacement therapy in the patient with acute brain injury. AJKD, 2001. 37(3): p. 457-466.
9. Schor N, Acute renal failure and sepsis syndrome. Kidney International (Nephrology Forum), 2002. 61: p. 764-776.
10. Paganini EP, Depner T, Wensley D, The acute dialysis quality initiative – Part III: Solute control (Treatment dose). Adv Ren Replace Ther, 2002. 9(4): p. 260-264.
11. Schetz M, Leblanc M, Murray PT, The acute dialysis quality initiative – Part VII: Fluid Composition and Management in CRRT. Adv Ren Replace Ther, 2002. 9(4): p. 282-289.

Pathologic Material:

 Fellows review patient percutaneous renal biopsies as well as other pathologic material with attending renal pathologists and teaching nephrology faculty members.

Other Educational Resources:

Other educational resources may be purchased via the fellow’s stipend.  Courses are offered throughout the year by The Johns Hopkins School of Medicine regarding various topics, including Computer Skills by the Welch Library.

Method of Evaluation:

The fellow is evaluated using the ABIM form for Evaluation of Clinical Competence, Categories evaluated include the core competencies of Patient Care, Medical Knowledge, Practice Based Learning , Interpersonal and Communication Skills, Professionalism, Systems Based Learning, evaluation of procedures above, and Moral and Ethical Behavior, and Overall Clinical Competence as a Specialist In Nephrology.  The American Board of Medical Specialties Generic Form for Global Ratings of Resident Performance, and the Mini-Clinical Evaluation Exercise (CEX) form are also used which evaluate the 6 core competencies.  Please see general Curriculum for details of the evaluation. These evaluations are filled out every six months by the supervising Nephrology attending.  The fellow evaluates the teaching of the Nephrology attending using the form provided.

Responsibilities/Supervision:

The nephrology fellow is responsible for the initial evaluation of new Nephrology Intensive Care Unit patients and follows up on existing patients on this Intensive Care Unit rotation.  There may be a Johns Hopkins Bayview nephrology fellow, medical resident, Urology resident, Anesthesiology fellow, and/or medial student who rotate with the team and who may participate in the initial consultation and follow up of patients.   It is the Nephrology fellows’ responsibility for ensuring the evaluation, assessments and plans are similar to their own for each patient.  The nephrology fellow contacts the nephrology teaching faculty member prior to the start of any form of renal replacement therapy and writes initial orders for these therapies.  The nephrology fellow communicates any concerns to the nephrology faculty member that might mandate review of the patient prior to rounds scheduled later in the day. 

The nephrology teaching faculty member discusses patients and reviews the medical notes presented to the faculty member by the nephrology fellow on a daily basis.  The attending confirms the history, physical findings, assessment and plans after reviewing and examining the patient.  The teaching faculty member discusses any modifications of the above with the fellow that differs from the fellow’s initial assessment.

The nephrology fellow contacts house officers or other staff regarding recommendations from the fellow and attending.  The nephrology faculty member may feel the need for personal communication with some physicians as well.   Procedures are supervised by the nephrology faculty member unless the attending is physically not on the premises at the time of the procedure.  All biopsies are performed with a nephrology teaching faculty member present.  The fellow and attending jointly decide on patients who no longer need to be actively followed during the Nephrology Intensive Care Unit rotation.

(Revised 7/1/05)