EPA: Severe Acute or Necrotizing Pancreatitis (Evaluation & Management)

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Date of Assessment*

Phase of Care*

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Evaluation

Management

Evaluation: Patient Communication

Respectfully COMMUNICATES BASIC FACTS about the condition to a patient/caregiver(s) but INCONSISTENTLY USES APPLICABLE LANGUAGE SERVICES and audio/visual aids

AS ABOVE and CUSTOMIZING COMMUNICATION to overcome barriers and cultural differences and using applicable language services and audio/visual aids

Respectfully communicates with a patient/caregiver(s) across barriers and cultural differences to ELICIT A PERSONALIZED CARE PLAN IN A SHARED DECISION-MAKING PROCESS for a straightforward presentation

Customizes communication based on individual patient characteristics and preferences across barriers and cultural differences in a COMPLEX OR CRITICAL SITUATION

Not applicable/not observed

Evaluation: Patient Care

Obtains an H&P with cultural humility and identifies pancreatitis, including common causes (gallstones, EtOH), but may not be able to determine etiology or grade the severity of pancreatitis

Uses lab data and CT scan findings (Balthazar score) to determine degree of severity; identifies end-organ failure. Evaluates for necrotizing pancreatitis, including CT interpretation; identifies patient w/ SIRS/fluid sequestration.

AS ABOVE AND demonstrates understanding that air/gas in the pancreatic bed on CT imaging is indicative of possible infection

Demonstrates COMPRENHENSIZE knowledge of varying presentation and progression (eg, acute necrotizing pancreatitis, acute peripancreatic fluid collections, pseudocysts, WOPN, infected necrosis).

Not applicable/not observed

Evaluation: Complications

NEEDS SUPPORT TO EVALUATE a critically ill patient requiring resuscitation for end-organ failure, and demonstrates LIMITED KNOWLEDGE of systemic pathophysiologic responses to severe/necrotizing pancreatitis (eg, SIRS, fluid sequestration)

Demonstrates UNDERSTANDING OF POTENTIAL COMPLICATIONS (eg, bleeding, gastric outlet obstruction, biliary obstruction, abdominal compartment syndrome), REQUIRING GUIDANCE TO COMPLETE THE EVALUATION

Demonstrates understanding of the signs and symptoms of acute bleeding (eg, pseudoaneurysm), abdominal compartment syndrome, and end-organ failure associated with severe acute pancreatitis and ADAPTS MANAGEMENT FOR THIS EVOLVING CLINICAL SITUATION

IDENTIFIES AND MANAGES ALL COMPLICATIONS associated with severe/necrotizing acute pancreatitis (eg, abdominal compartment syndrome, gastric outlet obstruction, biliary obstruction, pseudoaneurysm bleeding)

Not applicable/not observed

Management: Medical Knowledge*

Initiates BASIC INITIAL THERAPIES (IV fluids & pain control), REQ ASSIST FOR MOST ASPECTS OF MANAGEMENT FOR SEVERE/NECROTIZING PANCREATITIS, including strategies for nutritional support & critical care resus/support for end-organ failure

Understands benefit of EARLY ENTERAL FEEDING STRATEGIES in severe/necrotizing pancreatitis & resus in hemodynamic instability using endpoints: lactate, base deficit, UOP; REQ ASSIST FOR END-ORGAN FAILURE MANAGEMENT (ventilator, AKI) & feeding intolerance

Knows perc drain, not debridement, is preferred approach for infected necrosis w/in 4 wks. Engages IR in arterial bleeding. KNOWS STEP-UP APPROACH (1st step is drain placement); unsure of criteria for endo vs surg necrosectomy. ADJUSTS APPROACH AS NEEDED.

Considers TIMING OF LAP CHOLE (resolving pancreatitis, no infected necrosis, & delaying interventions for pseudocysts until mature wall). SELECTS ENDO OR SURG OPTIONS (MIS/open) FOR NECROSECTOMY/PSEUDOCYST DRAINAGE. MANAGES END-ORGAN FAILURE (ARDS & AKI)

Not applicable/not observed

Management: Evidence-Based Practice*

IDENTIFIES GUIDELINES for management of infected pancreatic necrosis such as the “step-up approach,” using a least invasive to most invasive strategy, REQUIRING ASSISTANCE TO APPLY THESE GUIDELINES

Demonstrates UNDERSTANDING OF EVIDENCE-BASED CONSENSUS GUIDELINES for management of infected pancreatic necrosis (step-up approach) & APPLIES GUIDELINES in STRAIGHTFORWARD anatomic considerations (fluid collections accessible percutaneously or surgically)

USES EVIDENCE-BASED GUIDELINES to guide use of antibiotics, route and timing of nutritional support, and MANAGEMENT of infected pancreatic necrosis

APPLIES EVIDENCE-BASED GUIDELINES BUT CAN ADAPT to a complex and nuanced situation as required (eg, fistula to duodenum or colon, failure of step-up approach)

Not applicable/not observed

Management: Communication with Others*

REQUESTS CONSULTATION FROM SPECIALTY SERVICES WITH ASSISTANCE and performs handoff regarding the basic elements of care but has DIFFICULTY COORDINATING AND COMMUNICATING WITH MULTIPLE SPECIALTIES regarding complex care

Requests individual CONSULTATION FROM SPECIALTY SERVICES (IR consult for drain placement). NEEDS GUIDANCE IN COMPLEX CLINICAL SITUATION req coordination across services; NEEDS GUIDANCE regarding key elements to emphasize during HANDOFF OF COMPLEX PT

Provides COMPREHENSIVE INFORMATION when requesting INTERDISCIPLINARY CONSULTATIONS and uses closed-loop feedback and active listening to incorporate feedback from all team members when coordinating care

COORDINATES INTERDISCIPLINARY CARE with colleagues in other disciplines (eg, GI, IR, social work, home health)

Not applicable/not observed

Management: System Based Practice*

RESPECTFULLY COMMUNICATES with a patient/caregiver(s) but does not consider the importance of addressing alcohol use disorder if applicable

Identifies the importance of ENGAGING IN DISCUSSIONS ABOUT MANAGING ALCOHOL USE DISORDER in relevant settings

Discusses options for ENGAGING IN A PROGRAM OF RECOVERY OR THERAPY with a patient with alcohol use disorder

ADDRESSES SOCIAL BARRIERS to successful discharge related to alcohol use disorder or access to care after discharge and engages a patient/caregiver(s) in these difficult discussions

Not applicable/not observed

Overall Performance*

Based on your observation, what level of autonomy would you trust the resident to perform this task at the next encounter?

Limited Participation: Learner has basic knowledge and skills, attending does show and tell

Direct Supervision: Attending provides active help

Indirect Supervision: Attending provides passive help

Practice Ready: Attending is available but is not needed for routine cases/presentations, but input may be needed for complex cases

Comment*

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