LIVER TRANSPLANTATION – ON CALL GOALS & OBJECTIVES UCSF PGY 2 [Please note that all listed Goals & Objectives and Responsibilities & Expectations are IN ADDITION TO those listed in the UCSF Common Goals & Objectives document and IN ADDITION TO those required of more junior residents on this clinical assignment]] PATIENT CARE GOALS & OBJECTIVES 1. Interpret the results of focused clinical evaluations (history, physical examination, laboratory data) performed on patients undergoing evaluation for liver transplantation to a. Assess patients’ candidacy for liver transplantation b. identify the findings that constitute contraindications to proceeding with liver transplantation. c. Perform at least 6 clinical evaluations on patients with end-stage liver disease being assessed for liver transplantation, specifically incorporating the physical examination of the i. Chest ii. Abdomen iii. Lymphatic system (adenopathy) iv. Peripheral vascular system (pulses) v. Lower extremities vi. Neurologic system d. Assume primary responsibility (including writing immediate postoperative and subsequent orders) for the management of i. at least 5 immediately post operative liver transplant recipients ii. at least 4 critically ill liver patients in the intensive care unit iii. at least one patient in fulminant hepatic failure/acute liver failure 2. Develop a therapeutic plan incorporating the results of focused clinical evaluations (history, physical examination, laboratory data) performed on patients undergoing assessment for liver transplantation with a risk benefit analysis addressing a. Cardiac risk factors b. Infectious risk factors c. Rejection risk factors d. Risk of recurrence of disease (hepatocellular carcinoma, hepatitis B and C) 3. Develop and implement treatment plans for the following postoperative changes a. Decreased urine output b. Decreased blood pressure c. fever d. hemorrhagic shock e. respiratory failure f. renal failure 4. Identify and formulate a treatment plan for the following common technical complications that manifest in the immediate postoperative interval, including a. Hemorrhage b. Anastomotic complication i. Biliary 1. Stricture 2. Leak ii. Hepatic artery 1. Stenosis 2. Thrombosis c. Primary non function of liver transplant June 2010 5. Independently evaluate and develop management plans for liver transplant patients with a. Increased liver enzymes b. Hyperbilirubinemia c. Altered mental status d. Fever e. Hypotension 6. Manage patients with fulminant hepatic failure, including the following complications a. Renal failure b. Cerebral edema c. Hypoglycemia d. coagulopathy RESPONSIBILITIES & EXPECTATIONS 1. Be present to receive sign out of all in-house liver transplant patients from day time housestaff and NPs 2. Update daily census, including medications 3. Prepare patients for urgent liver transplantation, including ordering immediate preoperative tests, blood products, and obtaining informed consent. 4. Implement the clinical decisions made by the team in a timely manner a. Arrange consultations b. schedule diagnostic tests c. schedule therapeutic procedures 5. Notify the senior resident/fellow/attending if unable to implement the clinical decisions 6. Communicate the results of consultations, diagnostic tests and therapeutic procedures to the team in a timely manner MEDICAL KNOWLEDGE GOALS & OBJECTIVES 1. Analyze the indications and contraindications for liver transplantation. a. Specifically identify the findings (history, physical examination, laboratory tests, imaging studies) that would prevent proceeding with transplantation in the patient admitted urgently for liver transplantation. 2. Describe the significance of and clinical application of a. The Child-Pugh score b. The MELD system 3. Analyze treatment options to identify the optimal management of patients with the following complications of end-stage liver disease a. Massive GI hemorrhage b. Worsening encephalopathy c. Spontaneous bacterial peritonitis d. Septic shock e. Decompensation of chronic liver disease f. Hepatorenal syndrome 4. Describe and analyze the most common early-appearing technical complications after liver transplantation, in terms of a. Incidence b. Presentation c. Diagnosis d. Treatment e. prevention 5. Analyze common opportunistic infections in transplant recipients in terms of a. Presenting signs and symptoms b. Treatment c. Prevention June 2010 RESPONSIBILITIES & EXPECTATIONS 1. Complete the online ASTS curriculum module for liver transplantation TECHNICAL SKILLS GOALS & OBJECTIVES 1. Competently perform large volume paracentesis in at least 3 patients RESPONSIBILITIES & EXPECTATIONS 1. see UCSF Common Goals & Objectives PRACTICE-BASED LEARNING AND IMPROVEMENT GOALS & OBJECTIVES 1. analyze performance by maintaining a log of procedures performed and any associated complications 2. improve your clinical effectiveness and competence by a. Reviewing the outcomes of the patient care you provided with the fellows/attendings b. Incorporating their feedback into your subsequent patient care RESPONSIBILITIES & EXPECTATIONS 1. document patient outcomes by maintaining a log of patients treated and their clinical results 2. meet with the faculty education representative at least three times during the rotation (beginning, midpoint, exit) to review goals & objectives. INTERPERSONAL AND COMMUNICATION SKILLS GOALS & OBJECTIVES 1. communicate efficiently with the all members of the liver transplant team 2. communicate effectively with patients and families, recognizing the unique needs associated with a. long-standing chronic illness b. life-threatening acute liver failure c. terminal status receiving comfort care 3. accurately exchange pertinent clinical information at the time of sign-outs (to team members, from members) RESPONSIBILITIES & EXPECTATIONS 1. sign in at the start of your shift (evening) and sign out at the end of your shift (morning), efficiently and effectively transferring all relevant clinical information to all team members, including nurse practitioners and other housestaff involved in the care of the patient. 2. review discharge medications, particularly immunosupressants, with at least one post-transplant patient 3. complete discharge summaries the day before discharge 4. obtain informed consent for surgical procedures 5. obtain consent for postmortem examinations from family members. PROFESSIONALISM GOALS & OBJECTIVES June 2010 1. Incorporate ethical issues into independent decision-making for patient care in the following clinical situations a. organ donation b. brain death c. withdrawal of support for terminally ill patients 2. Maintain complete separation of the transplant team from the team caring for the patient who is a potential donor. 3. Communicate information regarding acute changes in any patient’s clinical status to the appropriate team members, as well as patients’ families in a timely and appropriate manner. RESPONSIBILITIES & EXPECTATIONS 1. see UCSF Common Goals & Objectives SYSTEMS-BASED PRACTICE GOALS & OBJECTIVES 1. Compare the cost of liver transplantation with the cost of intensive care of the patient with end stage liver diseases 2. Compare reimbursement for these costs. RESPONSIBILITIES & EXPECTATIONS 1. See UCSF Common Goals & Objectives June 2010 .