National Capital ConsortiumAnesthesiology Residency Manual

1. Program Introductiona. Mission Statement – To develop competent, board eligible

anesthesiologists prepared to care for patients seen in the military health care system and beyond.

b. Developing Competent Anesthesiologists. The goal for residency training in Anesthesiology in the NCC is to become a skilled, competent physician specializing in Anesthesiology who is an asset to the Military Health Care System, the US healthcare system and the profession.

i. The Accreditation Council of Graduate Medical Education (ACGME) defined the core competencies for physicians. The six competency domains are:

1. Patient Care2. Medical Knowledge3. Interpersonal Skills and Communication4. Professionalism5. Practice Based Learning6. Systems Based Practice

ii. The American Board of Anesthesiology (ABA) in conjunction with the Residency Review Committee for Anesthesiology (RRC) of the ACGME has defined how these competencies are represented in anesthesiologists. They have also defined the expectation for each level of trainee and defined milestones along the way to competency. Below are a list of the milestones for anesthesiology. Please see Table 1 for the indepth explanation of the milestones along the way to competency in each subdomain. Completion of Level I is the expected level of functioning for atrainee at the conclusion of internship. Completion of Level II is the expectation for a trainee at the conclusion of the second post graduate year in anesthesiology (PGY2) which is also known as the clinical anesthesia 1 year (CA1). Level III completion is the expectation for completion of PGY 3 or CA 2 year. Level IV completion is the expectation for graduation from residency.

1. Patient Carea. Preop evalb. Plan and conduct of anestheticc. Periprocedureal pain managementd. Management of complicationse. Crisis management

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f. Triageg. Acute and chronic painh. Airway managementi. Monitoring and Equipmentj. Regional anesthesia

2. Medical knowledge3. Systems based practice

a. Coordination of patient care within systemb. Patient safety and QI

4. Practice based learninga. Incorporation of QI into practiceb. Analysis of practice to identify areas for

improvementc. Self directed learningd. Education of families, other heath care providers and

students5. Professionalism

a. Responsibility to patients and societyb. Honesty, integrity and ethical behaviorc. Commitment to institution, colleagues, and

departmentd. Receiving and giving feedbacke. Maintain physical, emotional and mental health

6. Interpersonal and communication skillsa. Communicates with patients and familiesb. Communicates with professionalsc. Team and leadership skills

iii. Residents must attain competency in each area prior to graduation. It is expected that attaining competency will likely take the entire 36 months of an anesthesiology residency to become and consistently demonstrate competency in all areas. It is also normal for residents to become competent in different areas at different rates. Overall, the performance of a resident is measured and evaluated daily and over time. Evaluations and feedback are described below.

2. Description of the Program: a. Hospitals - The primary teaching hospitals of the department is the Walter

Reed National Military Medical Center (WRNMMC). The department provides anesthesia care for twenty operating rooms, several procedural suites, a pre-op holding area, the post- anesthesia care unit and an outpatient surgical admitting area. The WRNMMC Mother and Infant Care Center (MICC) has eight laboring beds and three additional operating

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rooms. WRNMMC also has a regional anesthesia area, 4 ICU’s, a pain clinic and conference space. There are mandatory rotations at Washington Hospital Center, Children’s National Medical Center, University of Maryland Baltimore’s Shock Trauma Unit, Landstuhl Regional Medical Center in Germany, INOVA Fairfax and the National Institutes of Health Clinical Center.

b. Staff - The anesthesia department is comprised of approximately sixty five full time anesthesiologists. Our teaching staff members are all either board certified by the American Board of Anesthesiology or are in the examination process. The department currently has among its members board certified anesthesiologists with subspecialty training in cardiovascular anesthesia, neurosurgical anesthesia, pediatric anesthesia, intensive care, obstetrical anesthesia, regional anesthesia, and pain management.

c. Training - The residency is a three or four year continuum (after completion of the PGY-1 year). The residency years of training are designated as clinical base year (CBY) for first post graduate year trainees (PGY1), clinical anesthesia 1 (CA1) for PGY2 and CA-2s or CA-3s for PGY 3 and 4s respectively. Residents may enter training at the CBY or CA1 level. Entrance as a CA1 requires completion of an ACGME accredited internship meeting the American Board of Anesthesiology’s (ABA) minimum requirements. These requirements can be found in the booklet of information on the ABA’s web site.

i. The CBY curriculum conforms to the requirements of the ABA for a clinical base experience. It must include 6 months of inpatient experience, 6 months of outpatient experience. The exact rotations and order will be determined by the PD and may be tailored to the CBY resident’s needs or availability of rotations.

ii. The majority of the CA-1 year (and particularly the first six months) are defined as "Basic Anesthesia Training". This is shown on the rotation schedule as general OR (GOR). The goal of these months is to provide the resident with adequate clinical material to learn the fundamentals of anesthesiology. Scheduling during these months is designed to give the resident a chance to achieve skill and confidence in the conduct of uncomplicated anesthetics. Because surgical scheduling is not always consistent with curriculum design, the resident is often required to participate, in some fashion, in cases beyond the resident’s skill level. Training in recognized sub disciplines of anesthesia is mainly confined to the CA-2 year however; six distinct subspecialty rotations are introduced in the CA-1 year because they serve as the foundation for further development. The CA 1 resident is usually scheduled to complete

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formal subspecialty rotations in Critical Care, Obstetrics, Regional Anesthesia, Chronic Pain Management, Preoperative Anesthesia Management, and the Post Anesthesia Care Unit. Each of these rotations has a set of goals that help achieve the broader objectives of the CA-1 year. The overall goals and objectives for these rotations are summarized in the Rotation Goals and Objectives. Although WRNMMC does not have a dedicated ambulatory anesthesia unit, it is recognized as a distinct “subspecialty" of anesthesiology because it does form the basis for most contemporary anesthesiology practices. The practice of ambulatory anesthesia occurs on a daily basis for most of the CA-1 and the non-subspecialty months of the CA-2 year.

iii. The second year of the three-year clinical anesthesia continuum is designed to present the resident with cases of increasing complexity. The year is divided into rotations that represent sub disciplines of anesthesiology. The purposes of the subspecialty rotations are to focus the resident's reading and clinical training on both the theoretical and basic science material of these areas. The goals and objectives described for the year in the residency’s Goals and Objectives are the benchmark of progress for promotion to the CA-3 year. The resident is expected to review these goals and objectives. During periods when the resident is assigned to a discrete subspecialty, he or she is expected to review the goals and objectives for that rotation before, during, and after the assigned month. Subspecialty rotations during the CA-2 year generally include two months at the Children’s National Medical Center for pediatric anesthesia, two to three combined months of cardiothoracic anesthesia at WRNMMC and Washington Hospital Center, two months of neuroanesthesia (one at WRNMMC and one at Johns Hopkins University Hospital), and one month of Obstetric Anesthesia, SICU, and Regional Anesthesia or Pain Management or both. At the end of the CA-2 year the resident should be ready to begin to assume the role of consultant in anesthesiology. Their knowledge base and skill level should be of sufficient sophistication as to allow the resident to concentrate on the most critical and challenging cases.

iv. During the CA-3 year the resident is given progressively more challenging cases in the operating room, and may be permitted to pursue additional months of elective specialty clinical anesthesia training and laboratory research. The resident MUST pass the ABA basic exam in order to advance to the CA-3 year. Residents who have not passes the exam due to a failure or due to not having taken

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the exam for some reason, may NOT enter their last year of training. They must be extended in training and will not be allowed to enter the CA3 year without passing the ABA basic exam.

3. Goals of the Programa. To instruct the resident in the theory and scientific foundation of

anesthesiology;b. To develop each resident’s potential to become a competent clinical

anesthesiologist;c. To allow each resident to achieve his/her full potential as an

anesthesiologist;d. To expose the resident to the full scope of clinical anesthesiology;e. To grant the resident a progressive increase in the level of his/her

responsibilities.f. To expect each resident to attain the capability of planning and managing a

broad range of anesthetics, ranging from simple to complex, in all age ranges, in patients with a wide spectrum of disease states;

g. To prepare each resident for a professional career in anesthesiology;h. To prepare each resident for successful completion of both the written and

oral examinations of the American Board of Anesthesiology; andi. To establish in each resident the motivation to maintain professional

development in the field of anesthesiology after the completion of the residency.

4. Educational Program Overview: The educational program of the NCC Anesthesiology Residency is multi-faceted and is comprised of several components

a. Orientation Program The residency program organizes, under the direction of the PD, an orientation program for all new residents during July of each year. The first week involves introducing the residents to the structure of the residency as well as the rules and regulations of the American Board of Anesthesiology. This is followed by the introductory program consisting of daily lecture by the departmental staff on the basic concepts of anesthesia. This program is supplemented with daily reading assignments from an introductory textbook. The Metrics Anesthesia Knowledge Test (AKT) is given before the course to assess each resident’s initial anesthesia related knowledge base.

b. Case-related Education The backbone of the educational program is the learning experience associated with the conduct of each case. As the resident interviews and examines a patient pre- operatively, he/she should carefully plan the patient’s anesthetic based on the patient’s medical condition, the complexity and length of the proposed case, the post-operative management of the patient (including pain management), and

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expected or possible complications that could be encountered related to the case. These factors should be discussed at length with the staff anesthesiologist with whom the resident will be working. Each case, even the routine ones, provides an opportunity to learn, and the resident must seize each opportunity during his/her residency. All meetings are mandatory and all trainees are expected to be prompt.

c. Scholarly Activity Trainees are required to complete at least one scholarly work. Examples (which are approved on an individual basis by the Scholarship Oversight Committee) include clinical or bench research, case reports, and literature reviews. While it is not a requirement to present nationally or to be published to complete residency training, a completed scholarly project must be deemed by the scholarship oversight committee to be worthy of submission for presenting or publishing.

d. Evidence Based Medicine All residents will be expected to complete a one-hour grand rounds presentation to the staff before the completion of CA-3 year. This will be a professional multimedia presentation on a topic that will educate and inform. Residents are expected to become subject matter experts and present new material from the literature; a basic anesthesia review of text book level evidence is inadequate. The overall goal for a resident is to prove they are able to take new information, combine it with preexisting knowledge of basic or clinical science and then show the ability to articulate the significance of the new data and how it changes or supports medical practice.

e. Quality Improvement (QI) Residents are also expected to complete QI project and any other academic presentations which are a routine part of the practice of medicine when indicated.

f. Department Morning Meetings Residents are expected to attend department meetings when indicated by the hospital department chief. Department meeting may cover medical knowledge or systems based practice issues which are germane to all department members. Currently there is a QI conference on Wednesday mornings and Departmental Grand Rounds on Thursdays.

g. Resident Didactic Seriesi. Academic day - Resident focused didactics will occur Thursday

afternoons. During academic day there will be one lecture given by the teaching chief resident and a journal club article presented by another resident designated by the PD, APD or chief resident. The schedule for topics and mandatory reading will be revised annually and disbursed separately from handbook. Attendance is mandatory for all residents except those who are on outside rotations, on leave or post call (to avoid a duty hour violation). Residents on “out-rotations” (not at WRNMMC) will attend the academic day

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afternoon event held every second Thursday of the month unless on leave, night float or post call.

ii. Oral board review – Monday at 0630 there will be an oral board review led by a faculty member designated by the PF

iii. Written board review – Tuesdays and Fridays at 0630 there will be a key word focused written board review led by a faculty member or senior resident assigned by the PD.

h. Resident Self-Study The NCC Anesthesiology Residency Program provides a wide range of educational opportunities for its residents. However, each resident must undertake a course of self-study to prepare himself/herself for the rigorous ABA Basic, Advanced and Applied Examinations. Each resident is expected to study a major anesthesiology textbook as well as subspecialty textbooks in cardiac, obstetric, pediatric, and neuroanesthesia. In addition, the journals Anesthesiology and Anesthesia and Analgesia are highly recommended for information regarding current progress in the field of anesthesiology. While it is not realistic to expect a resident to read all of the above-mentioned textbooks during the CA-1 year, the resident must continually endeavor to make progress in the acquisition of knowledge in the field of anesthesiology.

i. Physical and Electronic Library Access WRNMMC maintains the Darnall Medical Library where books and journals are physically maintained. The library is available 24 hours/day. The Anesthesiology departments maintain a collection of past and current textbooks in all subspecialties of anesthesia. These books are to be kept in the library at all times. The departments also maintain subscriptions of the major anesthesia journals (Anesthesiology and Anesthesia and Analgesia, Journal of Regional Anesthesia and Pain Medicine) that are also available for resident use.

In addition to physical libraries, there are also electronic resources available. The Darnall On line library, AMEDD virtual library and the USUHS electronic resources are available to residents. The USUHS ER catalog is a very robust collection of texts, journal access and access to many online data bases such as MDConsult and UpToDate. Access to the USUHS ER is available to all NCC residents. Computers with graphics, slide production, and literature search capability are widely available for resident and staff use. Only software installed by the department is authorized for resident use. Many resources on CD ROM are available for use on the computer. Internet access is also available for academic use. The internet has grown tremendously in its usefulness. Additional literature and interlibrary loan requests are available in the main hospital libraries and the USUHS Learning Resource Center (LRC). These resources are available at WRNMMC and USUHS.

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5. Examinations a. Anesthesia Knowledge Tests

i. All incoming CA-1 residents take the Metrics AKT-1 Examination in two parts during the first month of training. The pre-test is given prior to the orientation program to establish a baseline of anesthesiology knowledge for each resident. The post-test follows the program to determine how much information each gained. A follow-up exam is given after six months and twenty four months of training to help assess progress. The AKT-1 at one month may be cancel by the PD based on the need.

ii. AKT 6 months – All residents will take the AKT 6 as a measure of academic progress during the first portion of residency.

b. In training exams (ITE) - All residents take the ABA/ASA In-Service Training Examination (ITE) annually, administered in March. There is not exception to this requirement.

i. Residents scoring below the lower 25% will be placed on academic remediation.

c. ABA certifying examination seriesi. ABA Basic exam –

1. Requirement - Residents must take the ABA basic exam at their first opportunity. Residents are required to take this exam at their first opportunity as the ACGME tracks first time pass rate based on first eligibility as opposed to the first time a physician takes an exam.

2. Eligibility - Residents are eligible to take the exam after 12 months of satisfactory clinical anesthesiology training (the satisfactory completion of CA1 year). As per the ABA requirement, all training must be deemed to be satisfactory in order to be eligible for the ABA basic exam.

3. Failure – A resident who fails the ABA basic exam must receive an overall unsatisfactory evaluation from the CCC at its next meeting. This is more restrictive than the ABA’s policy of receiving an overall unsatisfactory evaluation after the second examination. This policy will be uniformly enforced beginning with the CA1 and CBY classes beginning in July 2016. Failure on this exam reflects a deficiency in the required basic knowledge for a CA2. The resident may still be advanced to the CA2 year, this is at the discretion of the CCC, EEC and PD. If academically advanced to CA2 year, the residents schedule may be altered for CA2 year based on the resident’s individual deficiencies.

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ii. ABA Advanced exam – Residents will take the ABA advanced exam in July after completion of residency or in July of the final months of training if a resident will finish training prior to 1 October of the same academic year. This means a resident graduating up to three months off cycle (e.g. a resident who missed 12 weeks of training after childbirth) must take the Advanced exam during July of their last months of training. The ACGME requires a 70% first time pass rate (at first eligibility) on the advanced exam. Trainees in their last months of residency who are off cycle and will graduate prior to 1 October are required to take the exam. Newly graduated former trainees are urged strenuously to take the exam at the first opportunity.

iii. ABA Applied examination – The graduate who passes the ABA Advanced examination is eligible to take the ABA Applied examination the following year. Graduates are strongly encouraged to take the examination in the first year of eligibility as the ACGME tracks pass rates at first opportunity.

d. Mock Oral Examinations - In addition to the above written examinations, the department administers mock oral examinations on a roughly quarterly basis. The exam is administered to simulate the ABA Oral Board Examination. The mock oral exam serves to introduce the resident to the oral exam process, and allows the staff to evaluate the resident’s taxonomic level of learning, academic progress, and verbal expression capability.

6. Administrative Overviewa. Professional Interactions

i. Staff- Resident Interactions: Staff anesthesiologists at the National Capital Consortium hospitals are graduates of an ACGME approved residency in anesthesiology, and are either board certified or in the examination process. Staff anesthesiologists serve as sources of guidance and information for the residents, as the residents evaluate and care for patients. Staff-resident interactions are expected to be cordial and mutually supportive, but conflicts will arise.

Residents must acknowledge the role of the staff anesthesiologist as the ultimate care provider for each patient. Each anesthesiologist or intensivist is credentialed by the hospitals to provide care and residents are credentialed to function under their direction. Anesthetic plans presented by the resident to a staff anesthesiologist are subject to approval of and modification by the

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staff anesthesiologist. The resident must accept the concept that anesthesia may be administered in a variety of ways, all of which may be acceptable and safe. It is the responsibility of the staff anesthesiologist to make the final decisions concerning the safe delivery of each anesthetic. When rotating through the intensive care unit, the intensivist holds the final responsibility for patient care.

If the resident feels that the plan dictated by the staff anesthesiologist or intensivist is not consistent with safe patient management, the resident may refuse to participate in the case. For cases in the main OR and in the labor and delivery suite, a resident must inform the medical director of the OR immediately (and the department chairman and the program director at the earliest convenient time) of his/her decision. The medical director has the responsibility for overseeing the flow of patients and support of the attending anesthesiologist and will make preparations for the case to proceed without the resident initially involved. The PD and department chief will serve as arbiters of the conflict and long term resolution. The resident must realize that a situation such as this is of the utmost gravity, and the situation must be viewed by the resident as unsafe anesthesia or a hostile working relationship.

Less serious conflicts occur between the resident and the staff from time to time. The resident is encouraged to discuss the conflict with the staff anesthesiologist. If the resident does not feel comfortable discussing the conflict with the staff anesthesiologist, or if the conflict cannot be resolved, the chief residents, APDs or PD should be consulted to act as an intermediary.

ii. Resident – CRNA interactions: Several certified registered nurse anesthetists serve as anesthesia care providers in the NCC hospitals. CRNA’s possess credentials as anesthesia care providers. By American Board of Anesthesiology mandate, a resident will not be supervised by a CRNA in the delivery of patient care. The resident-CRNA relationship is governed by guidelines of mutual professional respect and military courtesy. There may be times a resident and CRNA may both care for a patient (particularly in life threatening clinical situations for a patient) but an attending anesthesiologist must always be assigned, available and responsible for supervision of the resident.

b. Resident relationships with other hospital personnel – Residents are expected to maintain a good working relationship with physicians form other services and other hospital personnel. Their relationship is also governed by guidelines of mutual professional respect and military courtesy. Unprofessional interactions should be reported to the PD or department chair as soon as feasible.

c. Resident Supervision PoliciesEvery surgical, surgical critical care or pain management patient

who receives care by anesthesiology residents in the National Capital Area

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(NCA) is assigned an attending physician. This physician assumes complete responsibility for the care of this patient in the peri-operative or pain management period as dictated by customary practice, legal requirements, and standard of care. This responsibility applies during elective, emergent, or on-call patient care.

The NCC Anesthesiology Residency program is an educational program. Formal clinical education requires graded responsibility for both decision- making and the performance of technical skills over the course of training. Some procedures will be performed directly by the attending anesthesiologist. Residents, interns or medical students, however, will perform most procedures, with either direct or indirect attending physician supervision. In general, the independent performance of procedures by residents will not occur without the implementation of specific competency evaluation procedures.

Indirect supervision occurs when the responsible attending anesthesiologist is aware of the procedure and is available to assist or provide direct supervision if needed but is not physically present. In some of these instances, a senior anesthesia resident (CA-2 or 3) may provide direct supervision over junior residents and interns, depending on the complexity and risks of the procedure.

The attending physician is ultimately responsible for the patient’s care and as such will exercise due diligence in delegating his or her direct supervisory requirements taking into account the strengths and weaknesses of each resident and the immediate clinical requirements on a case-by-case basis.

The following routine levels of resident supervision are outlined and apply to all areas of the hospital where anesthesia/anesthetic care is provided:

Level I Attending anesthesiologist aware and immediately available but not present.Level II Attending anesthesiologist aware and immediately available or for a PGY2/CA 1 a PGY 3/CA 2 or a PGY 4/CA 3 may be supervise or for a PGY 3/CA-2 a PGY 4/CA 3 may supervise, at the discretion of the attending anesthesiologist.Level III Attending anesthesiologists will provide direct supervision for the following procedures unless they specifically indicate that they can be performed under indirect supervision.

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Intern/CBY Minimum Supervision LevelsSupervision Level

Procedure

I Routine peripheral intravenous line insertionArterial blood gas samplingArterial line insertionPreoperative evaluations (including Ambulatory Procedures Unit preoperative evaluations)PACU evaluationsRoutine postoperative pain consultations

II Placement of central linesChronic pain evaluations

III Moderate sedation and analgesia for minor proceduresModerate sedation and analgesia for cardioversionsBlood product administrationRoutine subarachnoid block or lumbar epidural anesthesiaTrigger point injectionsLumbar epidural steroid injectionEmergent intubations for codesRoutine labor analgesia for uncomplicated obstetric casesRoutine placement and testing of peri-operative lumbar epidural cathetersOther main operating room procedures at the discretion of the attending anesthesiologistInduction of general anesthesiaEmergence from general anesthesiaModerately invasive pain management procedures (transforaminal epidural steroid injections, posterior primary rami diagnostic blocks, facet injections)Moderately invasive regional anesthesia procedures (femoral nerve block, axillary nerve block)Invasive pain management procedures (IDET, discography, cervical epidural steroid injections)Invasive regional anesthesia procedures (lumbar plexus blockade, anterior approach sciatic nerve block, paravertebral blockade, thoracic epidural placement)All other procedures not listed

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PGY 2/CA 1 Minimum Supervision LevelsSupervision Level

Procedure

I Routine peripheral intravenous line insertionArterial blood gas samplingArterial line insertionPreoperative evaluations (including Ambulatory Procedures Unit preoperative evaluations)PACU evaluationsRoutine postoperative pain consultationsRoutine labor analgesia for uncomplicated obstetric cases after successful completion of dedicated obstetric anesthesia monthRoutine placement and testing of peri-operative lumbar epidural cathetersOther main operating room procedures at the discretion of the attending anesthesiologist

II Moderate sedation and analgesia for minor proceduresModerate sedation and analgesia for cardioversionsPlacement of central linesBlood product administrationRoutine subarachnoid block or lumbar epidural anesthesiaChronic pain evaluationsTrigger point injectionsLumbar epidural steroid injectionEmergent intubations for codes (attending anesthesiologist should be present if available)

III Induction of general anesthesiaEmergence from general anesthesiaModerately invasive pain management procedures (transforaminal epidural steroid injections, posterior primary rami diagnostic blocks, facet injections)Moderately invasive regional anesthesia procedures (femoral nerve block, axillary nerve block)Invasive pain management procedures (IDET, discography, cervical epidural steroid injections)Invasive regional anesthesia procedures (lumbar plexus blockade, anterior approach sciatic nerve block, paravertebral blockade, thoracic epidural placement)All other procedures not listed

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PGY 3/CA 2 Minimum Supervision LevelsSupervision Level

Procedure

I Routine peripheral intravenous line insertionArterial blood gas samplingArterial line insertionPreoperative evaluations (including Ambulatory Procedures Unit preoperative evaluations)PACU evaluationsRoutine postoperative pain consultationsRoutine labor analgesia for uncomplicated obstetric cases after successful completion of dedicated obstetric anesthesia monthRoutine placement and testing of peri-operative lumbar epidural cathetersModerate sedation and analgesia for minor proceduresModerate sedation and analgesia for cardioversionsPlacement of central linesBlood product administrationRoutine subarachnoid block or lumbar epidural anesthesiaChronic pain evaluationsTrigger point injectionsLumbar epidural steroid injectionEmergent intubations for codes (attending anesthesiologist should be present if available)Other main operating room procedures at the discretion of the attending anesthesiologist

II Induction of general anesthesia in ASA I or II patientsEmergence from general anesthesia in ASA I or II patientsModerately invasive pain management procedures (transforaminal epidural steroid injections, posterior primary rami diagnostic blocks, facet injections)Moderately invasive regional anesthesia procedures (femoral nerve block, axillary nerve block)

III Induction of general anesthesia in ASA III or greater patientsEmergence from general anesthesia in ASA III or greater patientsInvasive pain management procedures (IDET, discography, cervical epidural steroid injections)Invasive regional anesthesia procedures (lumbar plexus blockade, anterior approach sciatic nerve block, paravertebral blockade, thoracic epidural placement)All other procedures not listed

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PGY 4/CA 3 Minimum Supervision LevelsSupervision Level

Procedure

I Routine peripheral intravenous line insertionArterial blood gas samplingArterial line insertionPreoperative evaluations (including Ambulatory Procedures Unit preoperative evaluations)PACU evaluationsRoutine postoperative pain consultationsRoutine labor analgesia for uncomplicated obstetric cases after successful completion of dedicated obstetric anesthesia monthOther main operating room procedures at the discretion of the attending anesthesiologistRoutine placement and testing of peri-operative lumbar epidural cathetersModerate sedation and analgesia for minor proceduresModerate sedation and analgesia for cardioversionsPlacement of central linesBlood product administrationRoutine subarachnoid block or lumbar epidural anesthesiaChronic pain evaluationsTrigger point injectionsLumbar epidural steroid injectionEmergent intubations for codes (attending anesthesiologist should be present if available)Induction of general anesthesia in ASA I or II patientsEmergence from general anesthesia in ASA I or II patientsModerately invasive pain management procedures (transforaminal epidural steroid injections, posterior primary rami diagnostic blocks, facet injections)Moderately invasive regional anesthesia procedures (femoral nerve block, axillary nerve block)

II Induction of general anesthesia in ASA III or greater patientsEmergence from general anesthesia in ASA III or greater patients

III Invasive pain management procedures (IDET, discography, cervical epidural steroid injections)Invasive regional anesthesia procedures (lumbar plexus blockade, anterior approach sciatic nerve block, paravertebral blockade, thoracic epidural placement)All other procedures not listed

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SICU SUPERVISION POLICY

Anesthesiology-Surgical Intensive Care Unit Rotation

The Anesthesiology residency recognizes and supports the importance of graded and progressive responsibility in graduate medical education. This policy outlines the requirements to be followed when supervising Anesthesiology residents during their Surgical Intensive Care Unit (SICU) rotation. The goal is to promote assurance of safe patient care, and the resident’s maximal development of the skills, knowledge, and attitudes needed to enter the unsupervised practice of anesthesiology.

DEFINITIONS:

Supervising Physician:

A faculty physician (SICU attending or nighttime attending), or a fellow or more senior resident at the discretion of the faculty physician may serve in a supervisory role.

Supervision:

Three levels of supervision are recognized. They are:

Direct supervision : The supervising physician is physically present with the resident and the patient and prepared to take over the provision of patient care if/as needed.

Indirect supervision with direct supervision immediately available: The supervising physician is present in the hospital (or other site of patient care) and is immediately available to provide Direct Supervision. The supervisor may not be engaged in any activities (such as a patient care procedure) which would delay his/her response to a resident requiring direct supervision.

Oversight : The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

PROCEDURE: 17

The principles which apply to supervision of residents include:

The Critical Care Medicine service establishes schedules which assign qualified attending physicians and fellows to supervise at all times and in all settings in which Anesthesiology residents provide any type of patient care in the SICU. With supervision to be provided as delineated below.

The minimum amount/type of supervision required in each situation is determined by the definition of the type of supervision specified, but is tailored specifically to the demonstrated skills, knowledge, and ability of the individual resident. In all cases, the faculty member functioning as a supervising physician should delegate portions of the patient’s care to the resident, based on the needs of the patient and the skills of the resident.

Supervising physicians will directly supervise all invasive procedures in accordance with the NCC Anesthesiology Residency Resident Supervision Policy until the resident demonstrates competence to perform these procedures independently and has acquired the necessary clinical and procedural skills to perform them unsupervised. (An exception to the NCC Anesthesiology Residency Resident Supervision Policy is that the instead of an attending anesthesiologist, the resident may be supervised by a qualified fellow or faculty physician.) The final decision on supervision level is at the discretion of the faculty physician and will be individualized to the resident.

Senior residents serve in a supervisory role to more junior residents in recognition of their progress toward independence.

Residents should supervise interns and medical students in all facets of patient care as part of their progress toward independent practice.

All residents, regardless of year of training, must communicate with the appropriate supervising faculty

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member, according to these guidelines:

o prior to extubating a mechanically ventilated patient

o after new admissions or transfer

o prior to invasive procedures that are not emergent in nature

o when patients have major changes in status including (but not limited to) situations requiring cardiopulmonary resuscitation, death or escalation of ventilator or hemodynamic support, or a change in therapeutic plan

o prior to implementation of care that has significant risk such as administration of thrombolytic therapy or transport of an unstable patient

o prior to consultation with ancillary services

o prior to transferring or discharging any patients

In the event that the supervising physician to include the attending does not respond in a timely manner, the resident should hold on doing elective procedures. If the resident is unable to contact the supervising physician to include the fellow and attending, they should then contact the SICU director and/or the program director as needed. Faculty and residents are encouraged to exchange back up forms of communication.

In every level of supervision, the supervising faculty member must review progress notes and sign procedural notes and discharge summaries.

Call schedules are published and distributed to the hospital on a daily basis. Resident, Fellow, and Staff Contact information is included on this roster to facilitate the appropriate level of communication, and to allow for backup communication if a lower level trainee is unreachable.

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The attending physician serves as the supervising faculty member during each clinical rotation, and is the final authority in all diagnostic and therapeutic decisions.

The supervisory lines of responsibility for all rotations are specifically defined in the Goals and Objectives for each rotation. Categorized within each core competency, these goals progressively delineate increasing levels of responsibility and independence for the resident.

The level of supervision provided to a resident will gradually lessen as the resident progresses through the program at a rate that is dependent on the skills and accomplishments of the individual trainee.

The progressive decrease in the level of supervision required throughout the training is in keeping with the goal of the training program – to produce independent, competent anesthesiologists.

An overview of the progression of responsibility and independence expected of the resident during their SICU rotation follows. Specific learning objectives for each rotation are defined in the goals and objectives section, and are progressive from CA-1 through CA-3 years.

o CBY resident: The resident will be closely supervised by a supervising physician to ensure that he/she is acquiring the appropriate skills of history taking, physical examination, laboratory testing, interpretation of imaging studies, and performance of invasive procedures. Upon completion of their SICU clerkship the resident should be operating at the minimum of a reporter level at all times.

o CA-1 Resident: The resident will be closely supervised by a supervising physician to ensure

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that he/she is acquiring the appropriate skills of history taking, physical examination, laboratory testing, interpretation of imaging studies, and performance of invasive procedures. Upon completion of their SICU clerkship the resident should be operating at the minimum of an interpreter level.

o CA-2 Resident: The resident should develop a mastery of basic aspects of ICU care. The CA-2 is expected to show a higher degree of familiarity with critical care and to show mastery, not just basic understanding, of the principles of critical care. This is demonstrated through the addition of supervision of interns and junior residents, which CA-1 residents are not expected to show. The most important distinction between a critical care rotation as a CA-1 and CA-2 is in the level of performance expected by completion. CA-2s must perform at the level of a manger in order to gain credit for the rotation

o CA-3 Resident: CA-3 rotation should produce a physician with mastery of advanced aspects of critical care. The CA-3 is expected to show a higher degree of familiarity with critical care and to show mastery of advanced principles of critical care. CA-3s must show the capability to perform at the level of an educator in order to gain credit for the rotation. In addition CA-3s are expected to show an advanced understanding of systems based practice and will create work schedules and interface with key hospital managers such as the anesthesia floor runner/medical director and the hospital bed manager.

7. Resident Duties - It is expected that each resident will participate fully in all departmental activities as long as participation does not cause a duty hour violation. Resident participation in academic activities is mandatory. Certain duties have become time-honored components of the residency program, and are briefly outlined here.

The chief resident and department scheduling officer determine each resident’s

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daily assignment. Assignments are usually made by early afternoon of the day preceding the case (Friday afternoon for Monday cases). The resident is responsible for noting his/her assignment, checking the published OR schedule to find the names and locations of scheduled patients, and checking the add-on list for his/her OR for the next day. The resident should then perform a pre-operative evaluation on each in-patient scheduled in his/her room. The resident has full access to the charts for same-day surgery patients (out patients) in the Ambulatory Processing Unit (APU) at WRNMMC. A pre-operative evaluation or questionnaire will already be filled out in the chart. Usually lab results and consults which were outstanding the day of evaluation should be in the chart and should be checked. Residents should personally evaluate all in-patients, even if post call; you need to come in and see your pre-ops. It is not acceptable to have the call team perform your pre-op for you except when the patient arrives at the hospital after 1800 hours.

The resident is responsible for notifying his/her staff anesthesiologist of the proposed caseload for the next day. The resident should present each case in a concise manner; such as he/she would present a patient on morning ward rounds. An anesthetic plan should be presented, and the resident and anesthesiologist will arrive at a mutually agreed upon final plan. While we realize that the resident may not have had time for case related reading prior to presenting the case to his/her staff, a brief textbook review of the topic is advised prior to the morning meeting on the day of surgery. Staff should be notified prior to 2000 hours when possible.

On the morning of the procedure, the resident is responsible for completely setting up the operating room for the delivery of the anesthetic. Although the department employs several corpsmen (anesthesia techs) to assist in the basic stocking/supply of the operating rooms, it is the resident’s responsibility to assure that all equipment is obtained and is functioning prior to preparing the patient for anesthesia. Detailed procedures for operating room set-up will be discussed during the orientation program.

After setting up his/her equipment, the resident is responsible for preparing the patient for anesthesia. At the conclusion of the procedure, the resident, under the supervision of the staff anesthesiologist, completes the emergence of the patient from the anesthetic, and transports the patient to either the Post-Anesthesia Care Unit (PACU) or the ICU. After ensuring that the patient is stable, the resident gives report to the nurse at the bedside, and then expeditiously “turns over” his/her operating room to prepare for the next case.

Within 48 hours of the completion of the procedure the resident is responsible for making a post-op visit to each patient (unless the patient has been discharged or this will cause a duty hour violation), placing a post-op note on the patient’s chart,

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and informing the staff anesthesiologist of any anesthetic complications. This is a required standard of anesthesia care according to the American Society of Anesthesiologists (ASA). If a resident is unable to do so, they must inform the attending of this.

In addition to the operating room, residents will spend time assigned to either the Post-Anesthesia Care Unit or Ambulatory Patient/Procedures Unit (APU). While in the PACU, the resident is responsible for evaluating all admissions to the PACU, managing all post-operative problems and discharging patients at the appropriate time. All outpatients will be interviewed by the resident assigned to the APU at some point prior to their surgery. A staff member is appointed each day to serve as a consultant for the residents in PACU and APU, and rotation goals and objectives will be provided to the residents at the beginning of each PACU and APU rotation.

8. Resident Work Hours While the actual number of hours worked by residents on each rotation may vary, the program complies with the restrictions on duty hours outlined by the ACGME (ACGME link). In addition,

a. External and internal moonlighting is prohibited b. Work hours will be limited to 24-hour continuous duty time, with an

additional period up to 4 hours permitted for continuity of care/transition of care and educational activities.

c. Residents will be allowed one day in seven free from all patient care and educational obligations averaged over 4 weeks;

d. On average over 4 weeks, in house call will be no more than every third night

e. Residents will have adequate rest between duty periods. The ACGME requirement for time between duty hours depends on level of training. Junior residents must have 10 hours between duty period and senior residents must have 8 but should have 10 hours between duty period as well. The ACGME allows for exceptions for residents in the final stages of training preparing for independent practice.

f. I f a t a n y time t h ese po l i c i e s ar e v i o l a t e d o r y o u b e l i ev e t h e y a r e b ei n g v i o l a t e d y o u n eed to re po r t the i n ci d e n t to t h e C h i e f R e si d e n t s, Ass o c i a te P r o g ra m Di r ec t o rs o r t h e P rog r am Di rec t o r as soon as possible.

9. Evaluation of Resident Performance It is the expectation of the department that each physician who enrolls in the residency will successfully complete the program. However, the department recognizes its responsibility to the profession, to the patients who entrust their lives to us, and to society as a whole to provide the best possible care for our current and future patients. Therefore, we carefully evaluate the performance of each resident to ensure that he/she is fulfilling our expectations, and that the skills and personal qualities of the resident are consistent with the highest level of patient care. The department endeavors to apprise each

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resident of his/her progress on a frequent basis. The most common form of feedback is via informal written and verbal communication with the staff anesthesiologist with whom the resident has worked with on any given day. On a more formal basis, the resident receives end-of-month verbal and written evaluations following all specialty rotations (all rotations other than CA-1 General OR and CA-2/3 Advanced Clinical Anesthesia), as well as quarterly written evaluation from the PD or APD. The quarterly evaluations are in the form of a face to face meeting with PD and/or APD that reviews numeric and narrative evaluations from the previous 3 months. The evaluations are subjective, with the goals of informing the resident of his/her progress and also informing him/her of specific points which need to be improved upon. The evaluations are intended to be constructive.

The staff meets semiannually in the format of a Clinical Competence Committee, to review each resident’s performance. The committee reviews quarterly staff evaluations, evaluations from subspecialty rotations, daily evaluations, resident self assessments, and in-training examination scores. The progress of each resident is discussed in detail. If the committee concludes that the resident is making unsatisfactory progress, the resident is notified immediately and appropriate non-adverse or adverse remedial actions are initiated

10. Evaluation of Departmental Staff After each significant encounter, the residents are asked to evaluate the departmental staff. Furthermore, semiannually, each staff is formally, in writing, evaluated anonymously by the residents on the basis of clinical skills, intra-operative teaching, didactic lectures, and overall contribution to the department. The information is used to improve the overall quality of residency education.

11. Chief Residents The Program Director, in consultation with the Associate Program Directors, will appoint Chief Residents. Chief residents serve for the 12 months of their CA-3 year, spending on average 6 month term of that year as Administrative Chief at WRNMMC.

The Chief Resident serves as the administrative liaison between the residents and the staff. The Chief Resident is in charge of generating the monthly resident call schedules and coordinating the weekly resident conference. He/she is also responsible for coordinating the semiannual staff evaluation process in conjunction with the Associate Program Directors. Residents should regard the Chief Resident as their advocate, and should seek his/her counsel should problems arise with respect to the residency program. The Chief Resident is invited to attend all staff meetings, with the exception of the Clinical Competence Committee meetings.

12. Resident Call Responsibilities The call schedule for the following month is made by the acting Chief Resident. Any call schedule requests should be directed to the Chief Resident acting as administrative chief for the month. Each resident is responsible for noting his/her days of call. Should the resident wish to change his/her call schedule, he/she is responsible for finding an acceptable replacement. The change must then be cleared through the Chief Resident.

The most senior resident on call assumes the greatest responsibility. When both residents are of the same level of training, they can either work together to cover these responsibilities or one can assume the senior resident job. This should be decided at the beginning of the call period. At the conclusion of the day’s cases,

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the call residents should immediately report to the staff anesthesiologist on call or the floor runner to inform them that they are available to perform call duties. The senior resident on call is responsible for coordinating all OR/Anesthesia activities in conjunction with the staff anesthesiologist. The senior resident is also expected to act as the primary anesthesia provider in the hospital (under the direction of their staff) responding to the requests of all services appropriately. If there are questions about the proper response to a given request, the staff should be involved in the final decision.

The call team must ensure that one OR is completely prepared for an emergency case at all times. When rotating through Obstetric Anesthesia, the labor deck must be prepared for an emergency Cesarean section at all times. The “Code Bag” must be stocked and ready for use. (It should be checked at the beginning of each call shift.)

The Acute Pain Service is managed by the call team during call hours. At WRNMMC evening rounds are made on all epidural patients by the call team. The call team receives calls concerning complex pain patients and post-op epidurals and peripheral nerve catheters. Dealing with these calls in a timely manner is very important. Find a way (consult the senior resident and attending anesthesiologist) to handle these such that the patient is not forgotten or left in pain for substantial periods of time. If communication is unclear and you are not sure what the ward team wants, go to the patient’s bedside and determine his or her needs yourself so that you are sure you did the right thing for the patient.

Another responsibility of the call team is to help ensure a smoother start for the next day’s OR schedule. Keep track of any changes to the schedule. Have the OR nurse supervisor inform you of any changes as they are made. If a case is cancelled and a substitute case is added in its place, perform the pre-operative evaluations on these patients. Also perform pre-op evaluations on any added cases.

Staff members may vary in the degree to which they allow residents to independently begin and manage cases on call (within the bounds of the Resident Supervision Policy already stated). It is the policy of the department that a staff anesthesiologist be present in the hospital whenever a resident is involved in a case in progress (including laboring epidurals). The residents on call are instructed to notify the staff anesthesiologist whenever a case is posted. The residents are to always assume that the staff person desires to be physically present in the operating room or labor room whenever any procedure is performed or any case is initiated. The staff anesthesiologist on call may modify these instructions as desired, but until the residents are informed of this fact, they must not independently initiate any anesthetic procedure, with the exception of emergent intubations in a cardiac or respiratory arrest setting.

On the weekend, call begins promptly at 0700 (0630 for OB anesthesia), at which time the resident should be dressed in scrubs, ready to work. Weekday call in the main operating room for senior residents (CA2 or 3) usually begins at 1500 but may vary according to clinical picture. Weekday call in the main OR for CA1s begins at 0700. OB anesthesia call may also begin at 1500 but the reporting times may be moved to 0630 based on case load and if any other residents on OB that month are on leave. Residents are reminded that they are only allowed to take care of new patients for 24 hours after starting a duty or call period.

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At the conclusion of call the resident is not released until he/she checks out with the incoming floor runner or relieving OB anesthesia attending.

A recall list or alert roster is published monthly in addition to the call schedule. It lists the priority in which departmental staff and trainees are notified in the event of an emergency.

13. Leave and Meeting Policies The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Anesthesiology mandate that residents may not be absent from training for more than twenty working days per year averaged over the course of a residency. This includes leave days and days due to illness. The ACGME allows for residents to attend one pertinent scientific meeting/conference per year, of up to 5 business days duration, during their residency; these will not be counted as absences from residency and can be accounted for by the military as funded or unfunded TAD/TDY. Each resident is granted thirty days annual leave by the Navy/Army, but by ABA rules, no more than sixty working days may be taken over the course of the 36 months of residency. (An additional 10 days of leave may be allowed for every 6 months spent in training for which a resident does not receive credit from the American Board of Anesthesiology (ABA) as a result of a determination of unsatisfactory performance by the Clinical Competence Committee (CCC).) Each resident must keep track of his/her leave days, and should be able to prove that the ABA guidelines have been complied with. To request leave, the resident should submit written requests to the acting chief resident. When approved, the military leave papers will be initiated by the resident and submitted to the resident’s service- specific PD or APD for signature. When going on leave, the usual command procedures for check out and check in must be followed. Due to the heavy demand for leave in June, July, and August, the ability to grant leave may be limited during those months. In addition to regular leave, this program has adopted the NCC guidance on the management of maternal, parental, convalescent, and religious leave. For the 2014-15 academic year the guideline for leave is as follows:

a. Routing: All leave request should be routed to the acting chief resident, unless otherwise specified. The acting chief will maintain the leave books. Once leave is approved by the acting CR, military leave forms should be sent to the APD or PD for you specific service for signature. Please see the B company and Navy guidance for submitting leave requests.

b. Timing of requests: The chief residents will announce a date that they need the leave requests for each month. Any leave requests must be received prior to that date. (E.g. All leave requests for month X must be received by Y date.) Leave request after that date may also be made but the responsibility for covering call or other work commitments rests with the resident requesting leave, not the Chief Residents. The resident who wishes to take leave after a call schedule is posted is also responsible for ensuring no violation of the duty hours policy.

c. Maximum number of residents on leave or TDY at one time: There will be some flexibility, but as a general rule no more than 4 residents may take leave at any given time. Residents on OB or other subspecialty rotations at WRNMMC count towards that number. Residents in the SICU do not count towards that number if they take leave.

d. Rotations when leave is prohibited or discouraged:

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i. Prohibited: All mandatory outside rotationsii. Discouraged: (not for routine leave, only events of personal

significance – e.g. weddings, etc.) Must be approved by the PD Elective outside rotations (please inform the PD significantly in advance and make arrangements with outside rotation site coordinator significantly in advance)

iii. Permitted: (*only one week per month for subspecialty rotations)1. General OR2. Obstetrical Anesthesiology*3. Advanced Clinical Anesthesiology4. Pain medicine*5. APU*6. PACU*7. SICU*8. Regional, Neuro and Cardiac at WRNMMC (not during

outside rotations)*iv. Appeals process: Any grievances or appeals of decisions made by

the Chief Residents should be submitted in an email to the PD.v. SICU leave: Only one resident at a time may take leave while

rotating in the SICU. No resident may take more than one week of leave per SICU rotation. The senior resident for the SICU for each month is the determining authority on who can take leave when. The senior resident must send the call schedule including leave plan to the PD, APDs, and CRs prior to the start of the month. If no senior resident is present or if multiple residents of the same year group are rotating n the SICU, ten they may collectively agree who will be the call/leave schedule maker. If an amicable solution cannot be found among residents in the SICU, then they should refer the matter to the CRs to make a call/work schedule. If this is unsatisfactory then the APDs or PD should be made aware. Effective resolution must happen prior to the start of the rotation.

The policies and procedures that guide the implementation are outlined in the NCC Administrative Handbook which can be found at http://www.usuhs.mil/gme/NCCAdministrativeHandbook.docx

e. Substance Abuse - Each uniformed service has written policies concerning management of physician impairment; impaired residents are managed according to the policy of the uniformed service of which the resident is a member. Details of the services’ policies and management systems may be obtained from MTF Credentials offices. All policies concerning management of physician impairment include procedures for identification of impaired providers, limitation of privileges, surveillance, and

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rehabilitation. All residents have access to comprehensive rehabilitation services, to include inpatient treatment. Nonetheless, they are subject to zero tolerance policy for the user of illicit substances. All services maintain a “zero tolerance” with reference to use or abuse of controlled substances by officers. In the implementation of this policy, urine samples are obtained from all personnel on a random basis, and positive results are grounds for initiating an investigation by either the Navy or Army investigative services. Any officer accused of using a controlled substance may be subjected to a felony court martial, and if found guilty will be subject to imprisonment and/or fines, notification of state medical license boards of conviction, and discharge from the military. This policy applies even to first time offenders.

f. Policy on Harassment - Harassment, or discriminatory intimidation, can make many forms. It may be, but is not limited to, words, signs, jokes, pranks, intimidation, physical contact, or violence. Harassment is not necessarily sexual in nature; it may also be based on race, religion, color, sexual orientation, age, national origin, marital status, health, or handicapping condition. Sexual harassment may include unwelcome sexual advances, requests for sexual favors, or other verbal or physical behavior of a sexual nature when such conduct creates an intimidating environment, prevents an individual from effectively performing the duties of their position, or when such conduct is made a condition of employment or compensation, either implicitly or explicitly.

All faculty and residents are responsible for keeping the work environment free of harassment. Any faculty member or resident who becomes aware of an incident of harassment, whether by witnessing the incident or being told of it, must report it to their supervisor, or if the supervisor is involved in the harassment, to the next superior supervisor who is not involved in the harassment. Harassment that occurs between fellow workers outside of the work place is to be treated in the same way as harassment that occurs in the actual workplace. Incidents of harassment will be investigated and if necessary referred to the service member’s respective military command for action.

g. Policy on Adverse Actions and Due Process When a resident is identified as having deficiencies in knowledge, skills, attitudes or professional behavior, the program can institute remedial actions that may be non- adverse or adverse. Non-adverse remedial actions will be initiated in response to recurring evidence of deficiencies in Core Competencies as assessed through written evaluations by faculty, as reported by the Clinical Competency Committee, in response to scores less than the 25th percentile on national anesthesia examinations (including the Anesthesia Knowledge Test (AKT) (except the AKT day zero or one month exams) and the annual

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American Board of Anesthesiology In Training Examination) or on a case-by-case basis at the discretion of the Program Director. Non-adverse remedial action typically consists of the following plan: written and face-to-face counseling by the program director, a 3-4 month period of remediation guided by written goals and objectives agreed upon by both the resident and program director, and periodic assessments of progress by the education committee. Upon successful completion of a remediation period, documentation of remediation will remain at the level of the Program Director. In the event of an unsuccessful non-adverse remediation, documentation from that period may be included in adverse remedial actions. The policies and procedures that guide the implementation of adverse actions (probation, extension or termination) and breaches of military professionalism are outlined in the NCC Administrative Handbook (http://www.usuhs.mil/gme/NCCAdministrativeHandbook.docx).

h. Conflict Resolution and Grievance Procedures The resident occupies a position of subservience and dependency that makes him/her particularly vulnerable. This can discourage the type of frank dialogue necessary to address substantive issues of quality of training should such issues arise. This program has pathways by which complaints may be registered and mechanisms by which grievances may be resolved. The starting point is with any of the Chief Residents. However, if the problem cannot be resolved at that level, this program maintains an open door policy with respect to the Program Director and Associate Program Directors. If those methods prove ineffective then the resident may use the procedures outlined in the NCC administrative handbook (link: administrative handbook ) and quoted below:

i. Grievance Procedures Raised by Trainees (Issues other than training status):

1. The trainee should first report a grievance to his/her adviser or Program Director who will assist the trainee in identifying which pathways are appropriate to the situation.

2. Grievances involving administrative matters will be referred through the military chain of command or the hospital chain of administrative responsibility through their respective Director of Medical Education as appropriate.

3. For matters related to the military, the formal chain of command may be utilized up to the commanders of each facility, as may, on rare occasions the extraordinary pathway to the Inspector General of the respective facility.

4. Several mechanisms are in place to assist trainees with issues involving the program or Program Director:

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5. Issues raised by trainees may be more easily handled by the Resident Representative to the GMEC, the Intern Coordinator, or the respective Director of Medical Education. If a resolution is not achieved that is satisfactory to the trainee, the issue will be brought directly to the Executive Director [(301) 295-3638] or to the GMEC Executive Committee if a resolution is still not attained.

6. The NCC Resident Liaison Representative, also available to assist, is a neutral third party skilled in assisting trainees with resolving issues or problems and recommending appropriate resources. This individual is not in the military chain of command or associated with any particular training program. To set up an appointment, the NCC Resident Liaison Representative can be reached at (301) 319-0709 Monday through Friday, 0700 - 1530.

7. The NCC Trainee Helpline allows secure reporting via computer or telephone. The system is maintained and operated by EthicsPoint, a company dedicated to providing a safe reporting environment for institutions of higher learning, health care facilities, and public corporations. The NCC Trainee Helpline provides trainees the ability to electronically report issues at their convenience, day or night without scheduling an appointment. Additionally, the NCC Executive Director or the NCC Resident Liaison Representative can follow up and provide feedback through a confidential password-protected email account established and maintained by Ethics Point. Any trainee opting to use the NCC Trainee Helpline could elect to remain anonymous. The NCC has purchased this system primarily for the security it would provide users who desire this level of privacy.

8. Any resident representative to the GMEC may present grievances to the GMEC on behalf of an aggrieved trainee.

ii. Written records concerning evidence that a conflict exists, the current understanding of the nature of the conflict, and the measures already taken to resolve the conflict, should be maintained.

iii. For grievances involving residency termination determinations by the Hearing Subcommittee, see Section F, 7, d, iii.

iv. In exceptional cases, complaints where all available pathways for resolution have been exhausted may be made directly to the Accreditation Council for Graduate Medical Education (ACGME).

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Details are available on the organization's web page at: HtmlResAnchor www.acgme.org.

i. Transitions in Care Transitions of care between providers is a necessary part of the practice of medicine and especially so in anesthesiology. Anesthesiologists frequently are assigned for duty for time epochs rather than for care of individual patients. As a result there will be transitions of care of patients between anesthesiology residents and other anesthesia providers. Clinical assignments have been designed to minimize the number of patient care transitions. Refer to III C for a description of duty periods/clinical assignments. Residents must also recognize when they are fatigued to otherwise unable to provide care for a patient and should immediately transition care to another provider. Each patient who a resident cares for in the Operating Room must have one assigned attending anesthesiologist. At WRNMMC attendings staff one resident at a time so the first person available to transition care to in case of resident fatigue or other incapacitation is the assigned attending. Attendings also have a person to transition to if necessary in the back up call anesthesia provider. When residents must transition care due to fatigue or simply the end of a duty period, the NCC residency in anesthesiology has a structured patient care turnover process. This process ensures adequate communication and supervision appropriate for level of training at times of care transitions (see III B for supervision policy).

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Transition in Care GuidelineDemographics:

Allergies:

Problem list:

Medications:

Pertinent labs or studies:

Pending lab, studies or interventions:

Plan of care:

Code status:

Volume status, blood lost and blood available:

Airway issues:

Planned disposition and post-operative concerns:

Staff of record:

In addition, evaluation of resident competency in performing effective transitions of care (specific to level of training) will be reflected in rotation evaluations (addressing the competencies of patient care, interpersonal and communication skills, and systems-based practice).

The program’s supervision policies delineate the level of supervision to be in place at patient care transitions to ensure effective and safe patient care turnover.

The NCC residency in anesthesiology and the WRNMMC anesthesia department place phone and pager roster, daily work and call schedules at various places in the hospital. They can be found on the department shared drive, in the resident room, in the floor runner’s office, at the front desk of the operating room, in the obstetrical anesthesiology call room, and at the main desk of the labor and delivery suite. The widest possible dissemination of the schedules and contact list serves to inform the health care team of the attending and resident physicians currently responsible for each patient’s care and of their contact information.

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14. Summary The information in this manual is intended to acquaint the new resident with the NCC Department of Anesthesiology. It is not intended to be comprehensive, but it should give the resident the idea of the philosophy of the educational process in the department, and of the guidelines that govern the daily function of the department. The Walter Reed Department of Anesthesiology is a dynamic, evolving entity, and the guidelines presented here in will certainly change over time. The main goals of the department, however, will not change. We are committed to providing top quality patient care, expanding the horizons of knowledge in anesthesiology, and educating residents in such a manner as to allow them to achieve their full potential as an anesthesiologist.

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