New Application: Pediatric Critical Care Medicine

New Application: Pediatric Critical Care Medicine

Review Committee for Pediatrics

ACGME

COMMON SUBSPECIALTY SECTION

Institutions

Using the table below, provide a summary of the program’s leadership and support staff, including the name and percent FTE protected time. 1.0 FTE is greater than or equal to 40 hours per week. Add rows as needed.[PR I.A.2.-3.]

Pediatric Critical Care MedicineUpdated 4/2016

Program Leadership / Name / % FTE Protected Time for the Administration of the Program (excluding Scholarly Activity)
Program Director / Name / #%
Associate Program Director(s) / Name / #%
Title / Name / #%
Title / Name / #%
Title / Name / #%
Title / Name / #%
Title / Name / #%
Administrative/Support Personnel / Number of Administrative Personnel / % FTE in This Fellowship Program for Each
e.g., Fellowship Coordinator / 1 / 100%
e.g., Administrative Assistant / 1.5 / 100%/50%
Title / # / #%
Title / # / #%
Title / # / #%
Title / # / #%
Title / # / #%

Pediatric Critical Care MedicineUpdated 4/2016

Faculty Research

Complete the table below regarding the involvement of faculty members in research. Add rows as needed. [PR II.B.5-5.b).(3); II.B.5.f)-f).(2)]

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Name / # of Current IRB-Approved Research Projects / Total # of Current Funded Research Projects / # of Current Research Projects with Peer-Review Funding (Subset of Total # in Previous Column) / # of Presentations at National Scientific Meetings in Last 5 Years / # of Publications in Peer-Review Journals in Last 5 Years
Program Director:
Name / # / # / # / # / #
Physician Faculty Members within the Program Subspecialty (e.g., for a Pediatric Gastroenterology Program, Only List the Pediatric Gastroenterology Faculty Members):
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #
Non-Physician Research Mentors or Physician Faculty Members from Other Subspecialties:
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #

Pediatric Critical Care MedicineUpdated 4/2016

2.List active research projects in the subspecialty. Add rows as needed. [PR II.B.5.-5.b).(3); II.B.5.f).(1)-(2)]

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Project Title / Funding Source / Place An "X" if Funding Awarded by PeerReview Process / Years of Funding (Dates) / Faculty Investigator and Role in Grant (i.e., PI, Co-PI, Co-Investigator)
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /

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Research Resources

1.Does the program provide research laboratory space and equipment?...... ☐ YES ☐ NO

2.Does the program provide financial support for research?...... ☐ YES ☐ NO

3.Does the program provide computer and statistical consultation services?...... ☐ YES ☐ NO

Program Curriculum

Goals and Objectives

Are there goals and objectives for all training experiences?[PR IV.A.2.] / ☐ YES ☐ NO
Are these rotation- and level-specific?[PR IV.A.2.] / ☐ YES ☐ NO
How are they distributed? [PR IV.A.2.] / ☐ Hard copy ☐ Electronic or web-based
If not web-based, when are they distributed to fellows?[PR IV.A.2.] / ☐ Prior to each rotation☐ Annually
☐ Once in handbook☐ Other
If not web-based, when are they distributed to faculty members?[PR IV.A.2.] / ☐ Prior to each rotation
☐ Annually
☐ Other
If web-based, are reminders sent to access them?[PR IV.A.2.] / ☐ YES ☐ NO
If YES, when are the reminders sent?[PR IV.A.2.] / Click here to enter text. /

Collaboration among Programs

Are there meetings among the core program director and subspecialty program directors? [PR II.A.4.s)] / ☐ YES ☐ NO
How often do these meetings occur? [PR II.A.4.s).(1)] / Click here to enter text. /
Who typically participates in these meetings? (check all that apply) [PR II.A.4.s)] / ☐ Core program director
☐ Subspecialty program director for this specialty
☐ Program directors from other subspecialties

General Subspecialty Curriculum

Topic / Where Taught in Curriculum (Name Should Match Name in Conference List) / Number of Structured Teaching Hours Dedicated to Topic Area / Participants (Place An "X" in the Appropriate Column)
Fellows in this Discipline Attend / All Subspecialty Fellows Attend / Residents and Subspecialty Fellows Attend
e.g., Biostatistics / Research Course / 14 / X
Basic science as related to the application in clinical subspecialty practice [PR IV.A.6.a).(3)] / Click here to enter text. / # / ☐ / ☐ / ☐
Clinical subspecialty content [PR IV.A.6.a).(3)] / Click here to enter text. / # / ☐ / ☐ / ☐
For the topics below, if the topic is not appropriate for the discipline (e.g., lab research for fellows in developmental behavioral pediatrics), enter N/A in Column 2 (Where Taught…).
Biostatistics [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Lab research methodology (if appropriate) [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Clinical research methodology [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Study design [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Grant preparation [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Preparation of protocols for Institutional Review Board [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Principles of evidence-based medicine/critical literature review [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Quality improvement [PR IV.A.6.a).(6)] / Click here to enter text. / # / ☐ / ☐ / ☐
Teaching skills [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Professionalism/ethics [PR IV.A.5.e] / Click here to enter text. / # / ☐ / ☐ / ☐
Cultural diversity [PR IV.A.5.e).(5)] / Click here to enter text. / # / ☐ / ☐ / ☐
Systems-based practice (economics of healthcare, practice management, clinical outcomes, etc.) [PR IV.A.5.f)] / Click here to enter text. / # / ☐ / ☐ / ☐

Conferences

1.List regular subspecialty and interdepartmental conferences, rounds, etc. that are a part of the program. Identify the "Site" by using the corresponding number as it appears in the Accreditation Data System (ADS) portion of the application. Indicate the frequency (e.g., weekly, monthly) and whether conference attendance is required (R) or optional (O). List the planned role of the fellow in this activity (e.g., conducts conference, presents case and participates in discussion, case presentation only, participation limited to Q&A component). Add rows as needed.[PR IV.A.6.a).(2)-(4)]

Pediatric Critical Care MedicineUpdated 4/2016

Conference / Site # / Frequency / Attendance Required (R) or Optional (O) / Role of the Fellow
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /

Pediatric Critical Care MedicineUpdated 4/2016

2.Describe the mechanism that will be used to ensure fellow attendance at required conferences. State the degree to which faculty member attendance is expected, and how this will be monitored.[PR IV.A.6.a).(2)]

(Limit response to 50 words)

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Scholarship Oversight Committee

1.Will there be a Scholarship Oversight Committee for every fellow? [PR IV.B.2.b)]...... ☐YES ☐ NO

2.If YES, how often will the committee meet with the fellow? [PR IV.B.2.b)]...... # times per year

Fellow Research Activities

1.Describe how the program will ensure a meaningful supervised research experience for fellows beginning in their first year and extending throughout their training.[PR IV.B.2.a)]

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2.Identify any research mentors outside the division that will be actively involved in mentoring fellows, and describe how liaisons will be used between these mentors and the fellows to allow for meaningful accomplishment of research. [PRIV.B.2.c)]

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The Learning and Working Environment

Night Float/Night Shift

If the program requires night experiences, indicate the frequency of these experiences each year, and describe how they are structured to ensure educational value to fellows. [PR VI.F.6.a)]

(Limit response to 200 words)

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SPECIALTY-SPECIFIC SECTION

Program Personnel and Resources [PR VIII]

Other Professional Personnel

Indicate with a check mark the personnel who will interact regularly with fellows at each participating site. [PRVIII.B.1]

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Team Members / Site #1 / Site #2 / Site #3 / Site #4
Mid-level providers (NPs, PAs, etc.) / ☐ / ☐ / ☐ / ☐ /
Respiratory therapist / ☐ / ☐ / ☐ / ☐ /
Social Work / ☐ / ☐ / ☐ / ☐ /
Pharmacist/Pharmacologist/Toxicologist / ☐ / ☐ / ☐ / ☐ /
Pediatric Nutritionist / ☐ / ☐ / ☐ / ☐ /
Child life specialist / ☐ / ☐ / ☐ / ☐ /
Speech therapist / ☐ / ☐ / ☐ / ☐ /
Ethicist / ☐ / ☐ / ☐ / ☐ /
Bioengineer / ☐ / ☐ / ☐ / ☐ /
Statistician/epidemiologist / ☐ / ☐ / ☐ / ☐ /

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For categories of personnel that are unavailable, describe how that function will be addressed in the program.

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Faculty Disciplines for Pediatric Subspecialties

In the table below, indicate the number of faculty that are present in each of the required disciplines [PR: II.B.2.e)-II.B.2.e).(2); VIII.A.2.a)-VIII.A.2.c)]:

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Discipline / Number of Essential Faculty
Site #1 / Site #2 / Site #3 / Site #4
PEDIATRIC SUBSPECIALTIES
Pediatric cardiology / # / # / # / # /
Pediatric emergency medicine / # / # / # / # /
Pediatric endocrinology / # / # / # / # /
Pediatric gastroenterology / # / # / # / # /
Pediatric hematology/oncology / # / # / # / # /
Pediatric infectious diseases / # / # / # / # /
Neonatal-perinatal medicine / # / # / # / # /
Pediatric nephrology / # / # / # / # /
Pediatric pulmonology / # / # / # / # /
Pediatric rheumatology / # / # / # / # /
SPECIFIC TO PEDIATRIC CRITICAL CARE MEDICINE
Congenital cardiac surgery / # / # / # / # /
Physical medicine and rehabilitation / # / # / # / # /
Pediatric surgery / # / # / # / # /
Transplant Surgery / # / # / # / # /
Trauma Surgery / # / # / # / # /
Anesthesiology / # / # / # / # /
Child and adolescent psychiatry / # / # / # / # /
Neurology with specialty qualification in child neurology / # / # / # / # /
Medical Genetics / # / # / # / # /
Neurological surgery / # / # / # / # /
Orthopaedic Surgery / # / # / # / # /
Otolaryngology / # / # / # / # /
Pathology-Anatomic and Clinical / # / # / # / # /
Radiology-Diagnostic / # / # / # / # /

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Facilities and Services

Support Services Available 24 Hours Per Day

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Site #1
(Yes/No) / Site #2
(Yes/No) / Site #3
(Yes/No)
Micro-chemistry and hematology laboratory
[PR VIII.C.2.a)] / Choose an item. / Choose an item. / Choose an item. /
Blood gas laboratory
[PR VIII.C.2.b)] / Choose an item. / Choose an item. / Choose an item. /
Diagnostic bacteriology and virology laboratories
[PR VIII.C.2.c)] / Choose an item. / Choose an item. / Choose an item. /
Blood bank
[PR VIII.C.2.d)] / Choose an item. / Choose an item. / Choose an item. /
Facilities for special radiographic imaging including computerized axial tomography, radionuclide scanning, angiography, magnetic resonance imaging, ultrasonography. If any of these are not available, indicate.
[PR VIII.C.2.e)] / Choose an item. / Choose an item. / Choose an item. /
Cardiac catheterization facility
[PR VIII.C.2.f)] / Choose an item. / Choose an item. / Choose an item. /
Capabilities for portable studies, including radiology, echocardiography, and electroencephalography
[PR VIII.C.2.g)] / Choose an item. / Choose an item. / Choose an item. /
Acute hemodialysis capability
[PR VIII.C.2.h)] / Choose an item. / Choose an item. / Choose an item. /
Other Available Support Services
Clinical toxicology laboratory
[PR VIII.C.3.a)] / Choose an item. / Choose an item. / Choose an item. /
Nuclear medicine facilities
[PR VIII.C.3.b)] / Choose an item. / Choose an item. / Choose an item. /
Pulmonary function testing laboratory
[PR VIII.C.3.c)] / Choose an item. / Choose an item. / Choose an item. /
Screening laboratory for inborn errors of metabolism
[PR VIII.C.3.d)] / Choose an item. / Choose an item. / Choose an item. /

Pediatric Critical Care MedicineUpdated 4/2016

Will fellows provide care in other settings beside the PICU?[PR IX.A.4]...... ☐YES ☐NO

If yes, use a bulleted list to identify the site(s) and their role (e.g., cardiac ICU – primary provider; burn unit – consultant)

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Pediatric Intensive Care Units[PR VIII.C.4]

Provide the following information for the pediatric intensive care unit (or its equivalent used by the program) in each site.Provide the requested information for the most recent 12 month period. If a single site has more than one intensive care unit used by the training program, copy this tableas necessary.Site numbers should be consistent with ADS.

Inclusive Dates: / From (mm/dd/yy): / mm/dd/yy / To (mm/dd/yy): / mm/dd/yy /

Pediatric Critical Care MedicineUpdated 4/2016

Pediatric Intensive Care Unit / Site #1 / Site #2 / Site #3
Number of beds / # / # / # /
Average daily census
[PR VIII.C.4.b)] / # / # / # /
Average length of stay / # / # / # /
Annual number of admissions / # / # / # /
PGY1 / PGY2 / PGY3 / PGY1 / PGY2 / PGY3 / PGY1 / PGY2 / PGY3
Planned number of fellows assigned to the PICU (do not include those fellows covering only nights and weekends with no daytime responsibilities) / # / # / # / # / # / # / # / # / # /
Planned average number of patients per fellow per week / # / # / # / # / # / # / # / # / # /
Planned average number of consultations outside the ICU provided by each fellow per week / # / # / # / # / # / # / # / # / # /

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Provide the following information for the most recent 12-month academic or calendar year for each site used to provide a specific required experience, such as transplant, cardiology, intensive care, etc. Note the same timeframe should be used throughout the forms. Duplicate the table for each required experience, as necessary.[PR VIII.C.4.a).(1)]

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Site #1 / Site #2 / Site #3
Name of service / Click here to enter text. /
Total number of fellows and residents on the service / # / # / # /
Total number of admissions to the service / # / # / # /
Number of new patients admitted each year (“new” refers to those who are seen by members of the service for the first time.) / # / # / # /
Average length of stay of patients on the service / # / # / # /
Average daily census of patients on the service, including consultations / # / # / # /

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12-Month Summary-Inpatient Service

1.Summarize how many pediatric patients in the followingcategories were admitted to or consulted on by the critical care service at the primary site.This should include patients in the same 12-month period used on the previous page.

ICU Patients / Number of patients available to fellows
Number on critical care medicine service / Number seen in consultation or on a shared service
Multi-system Trauma
[PR VIII.C.4.b)] / # / # /
Cardiovascular Surgery
[PR VIII.C.4.d)] / # / # /
Neurologic or neurosurgical problems [PR VIII.C.4.c)] / # / # /
Solid organ transplantation
[PR VIII.C.4.c)] / # / # /

2.If the program does not meet the minimum number of patients as specified in the program requirements, provide an explanation as to how fellows will become competent in those areas.If participating institutions are used to supplement the experience at the primary site, replicate and complete the table above for each site.[PR VIII.C.4.a).(1).(a)]

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List of Diagnoses

List 100 consecutive admissions and consultationsby the Pediatric Critical Care service.Identify the time period during which these admissions/consultations occurred. The date range should occur within the same 12-month period used in previous sections. The dates must begin on the date the first patient on the list was admitted and end with the date the 100th patient was admitted, (e.g., July 1, 2014 through October 20, 2014).Submit a separate list for each site that provides required rotations. Duplicate tables as necessary.

Site Name: / Click here to enter text. /
Inclusive Dates: / From: / mm/dd/yy / To: / mm/dd/yy /

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Patient ID / Length of ICU stay / Primary Critical Care Diagnosis / Major Procedures
Number / Age
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Pediatric Critical Care MedicineUpdated 4/2016