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National Capital Consortium
Anesthesiology Residency Manual
1. Program Introduction
a. 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 Care
2. Medical Knowledge
3. Interpersonal Skills and Communication
4. Professionalism
5. Practice Based Learning
6. 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 Care
a. Preop eval
b. Plan and conduct of anesthetic
c. Periprocedureal pain management
d. Management of complications
e. Crisis management
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f. Triage
g. Acute and chronic pain
h. Airway management
i. Monitoring and Equipment
j. Regional anesthesia
2. Medical knowledge
3. Systems based practice
a. Coordination of patient care within system
b. Patient safety and QI
4. Practice based learning
a. Incorporation of QI into practice
b. Analysis of practice to identify areas for
improvement
c. Self directed learning
d. Education of families, other heath care providers and
students
5. Professionalism
a. Responsibility to patients and society
b. Honesty, integrity and ethical behavior
c. Commitment to institution, colleagues, and
department
d. Receiving and giving feedback
e. Maintain physical, emotional and mental health
6. Interpersonal and communication skills
a. Communicates with patients and families
b. Communicates with professionals
c. 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
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(MICC) has eight laboring beds and three additional operating 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
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development. The CA 1 resident is usually scheduled to complete
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 nonsubspecialty 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
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have not passes the exam due to a failure or due to not having taken
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 Program
a. 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; and
i. 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 post5
c.
d.
e.
f.
g.
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operative management of the patient (including pain management), and
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.
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.
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.
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.
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.
Resident Didactic Series
i. 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
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
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resources are available at WRNMMC and USUHS.
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 series
i. 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
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deficiencies.
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 Overview
a. 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
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anesthesiologist are subject to approval of and modification by the
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 Policies
Every 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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Supervision
Level
I
Intern/CBY Minimum Supervision Levels
Procedure
Routine peripheral intravenous line insertion
Arterial blood gas sampling
Arterial line insertion
Preoperative evaluations (including Ambulatory Procedures Unit preoperative
evaluations)
PACU evaluations
Routine postoperative pain consultations
II
Placement of central lines
Chronic pain evaluations
III
Moderate sedation and analgesia for minor procedures
Moderate sedation and analgesia for cardioversions
Blood product administration
Routine subarachnoid block or lumbar epidural anesthesia
Trigger point injections
Lumbar epidural steroid injection
Emergent intubations for codes
Routine labor analgesia for uncomplicated obstetric cases
Routine placement and testing of peri-operative lumbar epidural catheters
Other main operating room procedures at the discretion of the attending
anesthesiologist
Induction of general anesthesia
Emergence from general anesthesia
Moderately 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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Supervision
Level
I
II
III
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PGY 2/CA 1 Minimum Supervision Levels
Procedure
Routine peripheral intravenous line insertion
Arterial blood gas sampling
Arterial line insertion
Preoperative evaluations (including Ambulatory Procedures Unit preoperative
evaluations)
PACU evaluations
Routine postoperative pain consultations
Routine labor analgesia for uncomplicated obstetric cases after successful
completion of dedicated obstetric anesthesia month
Routine placement and testing of peri-operative lumbar epidural catheters
Other main operating room procedures at the discretion of the attending
anesthesiologist
Moderate sedation and analgesia for minor procedures
Moderate sedation and analgesia for cardioversions
Placement of central lines
Blood product administration
Routine subarachnoid block or lumbar epidural anesthesia
Chronic pain evaluations
Trigger point injections
Lumbar epidural steroid injection
Emergent intubations for codes (attending anesthesiologist should be present if
available)
Induction of general anesthesia
Emergence from general anesthesia
Moderately 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
Supervision
Level
I
PGY 3/CA 2 Minimum Supervision Levels
Procedure
Routine peripheral intravenous line insertion
Arterial blood gas sampling
Arterial line insertion
Preoperative evaluations (including Ambulatory Procedures Unit preoperative
evaluations)
PACU evaluations
Routine postoperative pain consultations
Routine labor analgesia for uncomplicated obstetric cases after successful
completion of dedicated obstetric anesthesia month
Routine placement and testing of peri-operative lumbar epidural catheters
Moderate sedation and analgesia for minor procedures
Moderate sedation and analgesia for cardioversions
Placement of central lines
Blood product administration
Routine subarachnoid block or lumbar epidural anesthesia
Chronic pain evaluations
Trigger point injections
Lumbar epidural steroid injection
Emergent 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 patients
Emergence from general anesthesia in ASA I or II patients
Moderately 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 patients
Emergence from general anesthesia in ASA III or greater patients
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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Supervision
Level
I
II
III
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PGY 4/CA 3 Minimum Supervision Levels
Procedure
Routine peripheral intravenous line insertion
Arterial blood gas sampling
Arterial line insertion
Preoperative evaluations (including Ambulatory Procedures Unit preoperative
evaluations)
PACU evaluations
Routine postoperative pain consultations
Routine labor analgesia for uncomplicated obstetric cases after successful
completion of dedicated obstetric anesthesia month
Other main operating room procedures at the discretion of the attending
anesthesiologist
Routine placement and testing of peri-operative lumbar epidural catheters
Moderate sedation and analgesia for minor procedures
Moderate sedation and analgesia for cardioversions
Placement of central lines
Blood product administration
Routine subarachnoid block or lumbar epidural anesthesia
Chronic pain evaluations
Trigger point injections
Lumbar epidural steroid injection
Emergent intubations for codes (attending anesthesiologist should be present if
available)
Induction of general anesthesia in ASA I or II patients
Emergence from general anesthesia in ASA I or II patients
Moderately 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)
Induction of general anesthesia in ASA III or greater patients
Emergence from general anesthesia in ASA III or greater patients
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:
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
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:
The principles which apply to supervision of residents include:
18

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.

19
All residents, regardless of year of training, must communicate with
the appropriate supervising faculty 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.
20

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 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
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
21
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,
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.
22
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. If at any time these policies are violated or you believe they are being
violated you need to report the incident to the Chief Residents, Associate
Program Directors or the Program Director 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
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
23
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,
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.
24
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.
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
25
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 servicespecific 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:
i. Prohibited: All mandatory outside rotations
ii. 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 OR
26
2.
3.
4.
5.
6.
7.
8.
Obstetrical Anesthesiology*
Advanced Clinical Anesthesiology
Pain medicine*
APU*
PACU*
SICU*
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
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
27
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 nonadverse 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
American Board of Anesthesiology In Training Examination) or on a caseby-case basis at the discretion of the Program Director. Non-adverse
remedial action typically consists of the following plan: written and face-toface 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,
28
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:
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
29
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).
Details are available on the organization's web page at:
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
30
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 Guideline
Demographics:
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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