Emory Family Medicine Procedures Curriculum and Procedural Competency

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Emory Family Medicine Procedures Curriculum and Procedural Competency

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EMORY FAMILY MEDICINE PROCEDURES CURRICULUM AND PROCEDURAL COMPETENCY

Procedures offered. * Indicates competency required prior to graduation. - # Indicates minimum required for competency evaluation.

OUTPATIENT PROCEDURES: - Anoscopy*- 2 - Cervical Polypectomy- 2 - Chest X-ray interpretation*- 5 (Plus a score of 8 out of 10 in the CXR quiz) - Colposcopy with endocervical curettage and biopsy- 5 (Plus a score of 8 out of 10 in the Colposcopy quiz) - Cryotherapy of the cervix-3 - Endometrial biopsy*-3 - Excision of thrombosed hemorrhoid-3 - EKG interpretation*-5 (Plus a score of 16 out of 20 in the EKG quiz) - Eye fluorescein exam*-3 - Flexible Nasopharyngolaryngoscopy (NPL)-3 - Flexible Sigmoidoscopy and biopsy-5 - Immobilization and stabilization of sprains and non displaced fractures*-3 - Incision and Drainage of Abscesses*-3 - Injection and aspiration of tendons, ligaments and muscles*-3 - IUD insertion/removal- 4/1 - Joint injection and aspiration – Knee, Subacromial/Shoulder, *-4 (4 total of any of these major joints and 2 of each of the joints below) Elbow, Wrist, Greater Trochanter, Carpal tunnel injections -2 - Keloid injections/removal-3/3 - Marsupialization of Bartholins cyst-3 - Pap smear*-3 - Radiofrequency and Cryocauterization procedures of skin*-3 - Simple skin Laceration repair*-3 - Skin surgery – Punch, Shave and Excisional biopsies*-4 - Treadmill stress testing-4 (Plus a score of 10 out of 12 in the TST quiz) - Vasectomy-N/A - Wart, Nail and Foreign body removal*-3 - Wet mount*-3 INPATIENT PROCEDURES: - Amniotomy/Artificial rupture of membranes-3 - Arterial line placement-5 - Central line placement-5 - Circumcision of newborn-5 - Endotracheal intubation/Mechanical ventilation-4 - Episiotomy repair-4 - Fetal scalp electrode/IUPC placement-3/3 - Foley catheter placement-3 - Interpretation of fetal monitor tracings-4 - Intravenous catheter placement-3 - Lumbar puncture-3 - Nasogastric tube placement-2 - Obstetric labor and delivery-40 - Paracentesis-5 - Thoracentesis-5 - Run codes-3

Procedure curriculum

This curriculum is intended to be Emory Family Medicine Resident’s guide to developing knowledge of, demonstrating ability to and documenting competency in the above listed procedures.

Goals: 1. Define requirements and expectations for procedural training during the residency. 2. Provide a structured educational experience so residents can develop thorough knowledge and skills in performance of the listed procedures. 3. Define procedural competency in line with ACGME requirements. 4. Provide a structured format for residents to achieve competency in the required procedures prior to graduation. 5. Document the number of procedures performed and indicate whether competency was attained to aid in credentialing. Page 3 of 9

Requirements and Expectations:

Residents should: 1. Read on or view performance of procedures prior to carrying out procedures with the attending physician. There are multiple resources available to accomplish this including Pfenninger and Fowler’s Procedures for Primary Care and NEJM training videos. 2. Know the indications, contraindications, risks and benefits of the procedure and be able to explain this to the patient and/or relatives of the patient and obtain informed consent. 3. Have knowledge of sterile techniques, management of complications, pain management and interpretation of results and know when to seek advice/consultation. 4. Adhere to Emory’s Universal protocol/Time out policy. See appendix 1. 5. Document all procedures performed and demonstrate competency to perform the required procedures prior to completion of the 3 year residency program. 6. Note: Residents seeking to perform procedures in their own half day clinic schedule (outside of procedure clinic) must have the approval of the faculty member precepting them during that half day clinic prior to scheduling the appointment. These appointments must be for 45 minutes.

Structured Educational Experience: A half day of didactics is offered every 3 months in the form of a procedure workshop on various procedures including Exercise Stress Test, Colposcopy, Flexible NPL to name a few. One half day every 3 months, residents on a rotational basis will be trained in certain procedures at the Emory Simulation Laboratory.

Procedural Competency: ACGME defines procedural competency as “Demonstrating appropriate manual technique and dexterity in performing the procedure; showing appropriate confidence and proficiency with all technical aspects of the procedure, demonstrating awareness of the indications, contraindications and complications of the procedure.”

Format for attainment of Competency: 1. Residents will receive several evaluations in their performance of procedures. This will include immediate feedback by the supervising attending, the procedure will be documented in the Emory Family Medicine Residency Procedural Passport or New Innovations with supervising attending evaluating the performance of the procedure in the “Comments” section 2. After a specified minimum number of a particular procedure has been performed, residents seeking to be deemed “competent” and capable of performing the procedure independently will inform a supervising attending.

3. A supervising attending must then observe the resident perform the procedure without assistance and the resident questioned on various aspects of the procedure including indications, contraindications and complications.

4. If the procedure is performed adequately and the resident correctly addresses the attending physicians questions, that resident can then be signed off as competent to perform that particular procedure.

Documentation: All procedures performed must be documented by the resident in the Procedural log book (passport) or New Innovations. If the resident has been deemed to be competent in a particular procedure, the attending physician must document “Competent” in the comments section- see format for attainment of competency. The attending physician should complete an evaluation form on every procedure performed by the resident. See Appendices 2 to 4.

NB: In other to be deemed competent in the following procedures: Colposcopy, Exercise stress test and EKG and CXR interpretation, you will need to pass a Quiz in addition to meeting the other minimum requirements of that particular procedure.

Oguchi Andrew Nwosu, MD, FAAFP.

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Appendix 1

Universal Protocol for Preventing Wrong Site/Procedure/Person Procedure and Performance of Time Out

Background: As part of Emory Healthcare’s comprehensive program to ensure patients receive safe and effective care in accordance to the Joint Commission’s Universal Protocol, the organization has established a standardized program involving a system of multiple, coordinated processes designed to reduce the likelihood of wrong site, wrong procedure and wrong person surgery/procedure. Specifically, the program addresses: 1. Conduction of a pre-operative/pre-procedure verification process 2. Site Marking 3. Time Out/Call-to-Order performed immediately prior to starting the procedure.

Note: Certain minor procedures such as venipuncture, peripheral IV placement, NG tube or urinary catheter insertion are not within the scope of the protocol, other procedures such as closed fracture reduction, suturing of superficial lacerations, incision/drainage of a skin abscess, joint injections/aspiration are excluded from the protocol. Also, where the patient’s clinical condition requires immediate performance of an invasive procedure related to a life-threatening emergency, requirements of the Universal Protocol are limited to a one-time verification of patient identity using two patient identifiers, such as name, date of birth and/or medical record number.

Conduction of a pre-operative/pre-procedure verification process

1. Active verification of the correct person, correct procedure and correct site. 2. Ensure that all relevant information like H & P, consents, labs results and x-rays as well as equipment needed for procedure are available and accurately match the patient.

Site Marking 1. Site marked before procedure performed with patient involved, if possible. 2. Marking methods includes: left/right distinction; the surface; multiple structures and levels.

Time-Out/Call-to-Order performed immediately prior to starting the procedure

1. Perform a time out just prior to the start of the procedure 2. The Time Out should be standardized; it is initiated by a nurse or designee; it involves immediate members of the procedure team and other active participants. 3. In the ambulatory setting, elements included in the Time-Out include verification of patient identity, correct site, correct procedure and documentation of written or verbal consent for procedure. 4. All other activities are halted during the time-out to focus on confirmation of the correct patient, procedure, site and other clinical elements.

Note: Where discrepancies are noted the nurse or designee will stop the procedure until the discrepancy is resolved to the satisfaction of the team before the procedure can commence All members of the team are highly encouraged to “speak up” to stop the procedure if any element of the checklist is not validated.

Appendix 2 Page 7 of 9

Evaluation of Procedure

Learner Name:______Patient’s MR #______Status: Resident: PGY 1_____ 2_____ 3_____ Date: ______Patient Age:_____ Consent Done ___Yes No___ Indication for Procedure______Time out done____ Yes ____No Appropriate: Yes ___ No___ Procedure: (check all that apply) Colposcopy______Punch/Shave/Excision biopsy______Endo Bx______IUD insertion______I & D Abcess______NPL ______Joint Injection______Other______

What # Procedure is this for the learner _____

Satisfactory Needs Improvement N/A

(1)Inspection ______(2)Anatomy Identification ______(3)Pathology Identification ______(4)Biopsy/Procedure Technique ______(5)Knowledge of Bleeding ______Control Methods (6)Therapeutic Plan Based ______on Results

Duration of Procedure:______Minutes Complications: None ______Yes(List) ______

Patient Discomfort: 0 1 2 3 4 5 (Unbearable)(Circle one) Has minimum number for competency evaluation been attained? _____Yes _____No (if no skip next question) Was this procedure performed well enough to count as a competent exam? Yes_____ No_____ If “No”, why not?______

Attending Faculty: Name ______Appendix 3 Evaluation of TMST Learner Name:______Patient’s MR#______Status: Resident: PGY 1_____2_____3_____ Date______Age:______Consent Done _____Yes _____No Correct Indication for Procedure______Yes _____No Time out done_____Yes _____No What number TMST is this for the learner? ______

What Protocol?_____Bruce _____Modified Bruce _____McNaughton _____Other

Satisfactory Needs Improvement Criteria Patient Examined ______Procedure Explained ______Knows criteria for stopping test ______Knows criteria suggestive and diagnostic of ischemia ______Was attentive to monitor and EKG’s ______Was attentive to patient ______Appropriate stopping point ______Appropriate interpretation ______Appropriate recommendation ______

Complications: None______Yes(List)______Has minimum number for competency evaluation been attained?_____Yes _____No (if no, skip next question) Patient discomfort: 0 1 2 3 4 5 (Unbearable) (Circle one) Was this TMST performed well enough to count as a competent (independent) procedure? Yes_____ No_____ If “No”, why not?______

Attending Faculty: Name______

Appendix 4 Evaluation of Rectosigmoidoscopy Page 9 of 9

Learner: Name______Patient’s MR#______Status: Resident: PGY 1_____2_____3_____ Date______Patient: Age______Consent Done_____Yes _____No

Indications for Procedure______Appropriate: Yes_____ No_____ Procedure: (Check all that apply) Anoscopy_____ Rigid Sigmoidoscopy_____ RRS: 30 cm____ 60 cm_____ What # FFS is this for the learner?_____

Satisfactory Needs Improvement Insertion ______

Negotiation of Sigmoid curve ______

Anatomy Identification ______

Pathology Identification ______

Appropriate Insertion Cessation ______

Visualization During Withdrawl ______Therapeutic Plan Based on Results ______

Insertion Depth Obtained: ______cms Duration of Procedure: ______minutes Complications: None______Yes(List) ______

Patient Discomfort: 0 1 2 3 4 5 (Unbearable) (Circle one) Was this endocopy performed well enough to count as a competent exam? Yes_____ No_____ If “No”, why not? ______

Attending Faculty: Name______

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