Stanford University Anesthesiology Residency Program

revised: April 13, 2011 Stanford University Anesthesiology Residency Program Rotation Goals, Objectives and Assessment for Residents Core Curriculum for Ambulatory Anesthesia Rotation Duration: 2 weeks Rotation Director: Suma Ramzan MD

Philosophy and Description:

The Ambulatory Anesthesia Rotation at Stanford University Medical Center offers a broad experience in issues specific to the outpatient setting. The ambulatory setting involves a unique approach to the practice of anesthesia. The resident will become acquainted with and develop skills in the practice of ambulatory anesthesia. Senior (CA 2 and 3) level residents are eligible for this 2 week rotation. Residents will work in the Ambulatory Surgery Center (ASC) operating rooms. Supervision will be provided by the attending anesthesiologist who is the ASC scheduler for the day. Resident attendance at the departmental afternoon weekly lecture series and morning grand rounds is expected. It is also expected that residents spend time outside of clinical work for independent reading. Journal articles related to anesthesia for ambulatory surgery will be provided for review.

The resident clinical experience will include:

1. Management of a minimum of 30 patients undergoing ambulatory surgery including 10 general anesthetics emphasizing rapid emergence and 10 monitored-anesthesia-care cases ranging from anxiolysis to deep sedation. 2. Involvement in the management of acute postoperative pain, including familiarity with intravenous techniques, oral pain medication and other pain-control modalities. 3. Supervision of a junior resident during a minimum of 2 days, including discussing an anesthetic plan, and guiding and teaching the junior resident in patient care. 4. Understanding the dynamic management and scheduling issues unique to an ambulatory surgical center.

Modality for Resident Performance Assessment:

Residents will be evaluated in the 6 core competencies (medical knowledge, patient care, interpersonal and communication skills, professionalism, practice based learning and improvement, and systems based practice) using specific web-based evaluation forms completed by supervising faculty. Evaluation will occur at the end of the 2-week rotation. Residents must keep an accurate online log of procedures performed. An outline of core competencies with rotation objectives, instructional activities, and evaluations is outlined below in more detail.

A. Self Assessment The resident checks off each criterion below as the material is mastered. Self reflection on your own competencies is expected.

B. Faculty Assessment The rotation director faculty will review your self assessment, your written projects and your evaluation by the nurses.

Modified from the “SAMBA Curriculum Guidelines for The Anesthesia Resident Rotation in Ambulatory Anesthesia” written and approved by the Society for Ambulatory Anesthesia (SAMBA) Education Committee on November 15, 2005. Specific Goals and Objectives For Ambulatory Anesthesia Residents

GOALS INSTRUCTIONAL Core OBJECTIVES EVALUATION ASSESSMENT ACTIVITIES Competencies Medical  Evaluate patients and assume progressive . Journal Articles . Faculty  Discussion with Knowledge: responsibility in a supervised setting. . Intraop teaching Rotation attending regarding  Demonstrate competence in assessing by attending Evaluations prophylactic treatment Residents are patients rapidly in the ambulatory . Preop and https://stanford.med of patients for PONV expected to perioperative settings. PostOp Note hub.com) and check in PACU for demonstrate  Demonstrate the skills required to . Weekly, . Review of successful prevention knowledge of Resident Lectures presentation  Evaluation by attending established and recognize patients requiring immediate intervention. . Grand Rounds . AKT 6 of resident’s turnovers evolving . Practice oral  When appropriate, demonstrate the skills . Journal Club  Observation by biomedical, clinical exams and social necessary for resuscitation, intubating . Annual Stanford attending of placement . Annual in- sciences, and the difficult airways and stabilization of Anesthesia Resident of LMA successfully training exam application of their patients. Refresher Course within 5 minutes from knowledge to  Discuss the concept of preemptive (ASARRC) induction and use of patient care and analgesia and how to implement it in the . CME airway devices to the education of Conference chosen by successfully intubate others, and apply ambulatory setting. resident patients. an open-minded,  Discuss appropriate choices and analytical approach techniques of neuraxial anesthesia to  Discussion with to acquiring new minimize time to discharge and post- attending regarding knowledge. The anesthetic complications (e.g., spinal patient care issue resident will access headache). related specifically to and critically  Discuss the utility of depth of anesthesia ambulatory surgery evaluate current monitoring in the ambulatory setting.  Discuss pros and cons medical information  Discuss the pharmacology of rapidly of neuraxial anesthesia and scientific in ASC evidence, and acting agents, including opioids, sedative- apply this hypnotics, volatile anesthetics and muscle  Supervised use of knowledge to relaxants. awareness monitoring clinical problem  Describe various techniques of IV in ASC solving, clinical sedation.  Conduct IV sedation on decision making,  Discuss techniques of general anesthesia patients without patient and critical thinking. to minimize post-operative problems (e.g., feeling discomfort/pain sedation, pain, shivering, nausea, while maintaining unplanned admission). spontaneous ventilation  Define criteria for PACU bypass, PACU  Reflection and discharge and discharge from the same- discussion of things you day recovery unit. can do to improve  Explain the importance of turnover time PACU discharge and and personnel management in the things that result in successful operation of an ambulatory patient admission after surgery center. same day surgery.  Describe techniques and procedures to  Completion of checklist minimize "down time" of the operating room and of the surgical staff.  Discuss the difference between "home- readiness" and "street fitness."  Differentiate between freestanding, hospital-affiliated and hospital-based surgery centers.  Discuss protocols for handling unplanned admission, acute emergencies and emergency hospital transfer.  Discuss the role of the anesthesiologist in office-based anesthesia practice.  Describe state, local and federal guidelines for regulation of office-based surgery and anesthesia.

 Discuss the role of the medical director of an ambulatory surgery center. GOALS OBJECTIVES INSTRUCTIONAL EVALUATION ASSESSMENT Core ACTIVITIES Competencies Patient Care:  Gather accurate, essential information . Journal articles . Faculty  Discussion with from all sources, including medical . Intraop teaching Rotation attending regarding The resident will interviews, physical examinations, medical by attending Evaluations medical problems provide patient care records and diagnostic/therapeutic . Grand Rounds . ASC Nursing discovered in the that is procedures. . ASARRC Staff Evaluation preop evaluation compassionate, . CME conference appropriate and  Identify the main aspects of the history that affect your effective for the and physical examination relevant to chosen by resident anesthesia promotion of patients undergoing surgery in the management when health, prevention ambulatory setting and determine conducting a same of illness, and the appropriate laboratory tests. day surgery treatment of  Select patients for ambulatory anesthesia  Discussion with disease. . and assess the severity of common attending to list the diseases including, but not limited to the pros and cons of hypertension, renal disease, neurological regional v.s. general disorders, cardiovascular disease, anesthesia for diabetes, pulmonary disease and obesity. ambulatory surgery  Make recommendations about preventive,  Observation by diagnostic and therapeutic options and attending of preop, interventions that are based on judgment, intraop and postop scientific evidence, and patient care of patients. preference.  Discuss with patients the risks and benefits of regional and general anesthesia and monitored anesthesia care, especially as they pertain to their condition and surgery.  Develop, negotiate and implement effective patient management plans and integration of patient care.  Discuss, negotiate and implement preoperative preparation, including using psychological preparation, anxiolytics, opioids, antacids and antiemetics.

 Discuss, negotiate and implement preemptive and multimodal analgesia and antiemetic techniques. GOALS INSTRUCTIONAL Core OBJECTIVES EVALUATION ASSSESSMENT ACTIVITIES Competencies Effective  Demonstrate interpersonal and . Modeling by . Faculty  Evaluation by Interpersonal and communication skills that enable them Faculty Rotation attending Communication to establish and maintain professional . In-Service Talk Evaluations  Evaluate skills: relationships with patients, families, . Grand Rounds . ASC Nursing presentation. and members of their and other health . Anesthesia Staff Evaluation  Review nurses 360 To demonstrate care teams. Crisis Resource evaluation on interpersonal and  Provide effective and professional Management (ACRM) residents communication skills consultation to other physicians and that result in effective  Observation by health care professionals and sustain information exchange attending of a and teaming with therapeutic and ethically sound timeout performed by patients, their families, professional relationships with patients, resident and nurses. and other health their families, and colleagues.  Observation by professionals  Use effective listening, questioning, attending of narrative and nonverbal skills to resident’s communicate with patients and participation with families. patient positioning  Interact with consultants and referring and communication physicians in a respectful, appropriate with surgeons manner. regarding any  Maintain comprehensive, timely, and issues. legible medical records.  Review cases with  Give appropriate discharge and follow attending up instructions to patients and their  Completion of families. checklist

 Perform evaluations of the attending staff and rotation. GOALS INSTRUCTIONAL Core OBJECTIVES EVALUATION ASSESSMENT ACTIVITIES Competencies Practice based  Use scientific evidence and methods to . Intraop teaching . Faculty  Evaluation by learning and investigate, evaluate, and improve by attending Rotation attending and improvement: patient care practices and demonstrate . Journal articles Evaluations discussion during this by referring to the appropriate . Grand Rounds . Review of cases To demonstrate literature. Presentation  Reflect on things you practice-based  Identify areas for improvement and learned that you learning and implement strategies to enhance need to improve on improvement that knowledge, skills, attitudes and involves investigation  Completion of and evaluation of their processes of care. checklist own patient care,  Analyze and evaluate practice appraisal and experiences and implement strategies assimilation of to continually improve the quality of scientific evidence, patient practice. and improvement in  Develop and maintain a willingness to patient care learn from errors and use errors to improve the system or processes of care.  Use information technology or other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education. To this end, the resident will demonstrate the ability to use the available inter- and intranet resources (e.g., Medline and hospital-based IT services)

GOALS INSTRUCTIONAL Core OBJECTIVES EVALUATION ASSESSMENT ACTIVITIES Competencies Systems-based  Demonstrate both an understanding of the . Modeling by . Faculty  Discussion regarding Practice: contexts and systems in which health care Faculty Rotation aspects of the overall is provided, and the ability to apply this . Collaboration Evaluations system of care that To demonstrate an knowledge to improve and optimize health with nurses and can be improved awareness of and care. nursing management upon with emphasis responsiveness to  Access and utilize the resources, . Grand Rounds on efficiency and the larger context providers and systems necessary to safety in the ASC and system of health care and the provide optimal care.  Discussion about ability to effectively  Identify the limitations and opportunities common reasons for call on system inherent in various practice types and unexpected resources to delivery systems, and develop strategies hospitalization of provide care that is to optimize care for the individual patient. ambulatory surgical of optimal value  Apply evidence-based, cost-conscious patients. strategies to prevention, diagnosis and  Define the concepts disease management. of fast-tracking” and  Collaborate with other members of the “home readiness” health care team to assist patients in  Complete checklist dealing effectively with complex systems and to improve systematic processes of care

GOALS INSTRUCTIONAL Core OBJECTIVES EVALUATION ASSESSMENT ACTIVITIES Competencies

Professionalism:  Demonstrate behaviors that reflect a . Modeling by . Faculty . Write medical notes in commitment to continuous faculty Rotation EPIC on all patients under To demonstrate a professional development, ethical . Self-Directed Evaluations your direct care commitment to practice, an understanding and Reading . Attendance preoperatively. professional . Presentation at Lectures . Discuss with an sensitivity to diversity and a responsibilities, . Grand Rounds . Updating attending one difficult adherence to ethical responsible attitude toward their Case Logs ethical dilemma principles, and patients, their profession and sensitivity to diversity. . Complete encountered in ASC society. documentation . Attendance at lecture  Demonstrate respect, compassion, . ASC Nursing . Completion of integrity, and altruism in Staff Evaluation checklist relationships with patients, families, . Obtain feedback from and colleagues. nurses and their 360  Demonstrate sensitivity and evaluation responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues.  Adhere to principles of confidentiality, scientific/academic integrity, and informed consent.  Recognize and identify deficiencies in performance and give constructive feedback. They will demonstrate this in their evaluations of medical students and faculty.