ENVIRONMENT Preoperative evaluation clinic, Preoperative holding area. Preoperative evaluation clinic, Postoperative care unit, Operating Room

Transcription

1 Goals and Objectives, Ambulatory Surgery Anesthesiology Rotation Michael Bishop, M.D. Pager 7863 Admin Asst. Julie Nguyen UCSD DEPARTMENT OF ANESTHESIOLOGY Ambulatory Surgery Anesthesiology Rotation GOALS AND OBJECTIVES PATIENT CARE: To provide the resident with clinical experience in the anesthetic management of adults and pediatric surgical patients that is compassionate, appropriate, efficient, safe and effective With assistance, conduct an efficient, focused, and comprehensive preprocedure/pre-anesthetic evaluation, including history, physical exam, and review available studies, under both elective and emergent conditions, for adult patients clinic, Preoperative holding Lecture, Skill, Practice and feedback Recognize, with assistance, when appropriate subspecialty consults are needed, (i.e., cardiology, pain management) clinic, Postoperative care unit, Operating Room Recognize with assistance when additional studies to establish a diagnosis or evaluate severity are appropriate clinic, Postoperative care unit, Operating Room Assign an accurate ASA classification clinic, Preoperative holding With supervision, develop a patient-specific management plan, with a reasonable alternate plan, for adult patients at all levels ASA classification, for both elective and emergent procedures; the plan should include consideration of pre-existing medical issues and patient requests, anticipate possible intraoperative difficulties and pursue strategies to prevent possible postoperative complications clinic, Preoperative holding Lecture, Skill, Practice and, Perform safe, efficient, timely and accurate pre-anesthetic checks of all pertinent equipment and supplies (such as anesthetic machines, compressed gas cylinders, airway management supplies, monitors, suction, medications, invasive devices, etc.), Skill Consistently demonstrate vigilance and attention to detail during all aspects of care, Simulation,

2 Consistently check the patient s identity, procedure to be performed, consent, and side to be blocked or operated on, when applicable preoperative holding, Simulation Demonstrate competence in bag-mask ventilation, conventional laryngoscopy and endotracheal intubation, insertion and use of LMA s, and safe use of the anesthesia machine and or ventilators, Skill, Simulation Demonstrate knowledge and safe use of various infusion devices Operating Room, Skill With assistance, demonstrate competence in in placement of peripheral IV s in awake and anesthetized patients, including external jugular IV s and large caliber lines for rapid infusion, Skill With assistance, demonstrate competence in placing central lines, including IJ/EJ/subclavian approaches efficiently, safely and accurately, Skill Correctly use train-of-four nerve stimulation to guide safe and effective use of neuromuscular blocking agents and to measure effectiveness of reversal agents Operating Room, Skill With assistance, demonstrate effective and efficient patient care during induction of anesthesia, as well as during periods of instability in the course of the anesthetic care (i.e., surgical bleeding, patient co-existing disease exacerbation, drug reaction, or other crisis), With assistance, interpret and responds appropriately to the information from patient monitors and laboratory data (including ECG, CO 2 waveform, CVP, PAC, I/O, ABG, Coagulation Panel, etc.), Choose rational and appropriate blood product transfusion therapy. Recognize and treat transfusion-related complications, With assistance, transfer care of the patient after anesthesia/procedure to responsible party (PACU or ICU nurse, etc.) in a manner that ensures patients safety and comfort and continuity of care Postoperative, ICU, Skill, With assistance, effectively manage malignant hyperthermia, including asking for immediate assistance and delegating tasks in order to ensure rapid and coordinated treatment Simulation Suite Lecture, Simulation Demonstrate knowledge of inclusion/exclusion criteria for surgical procedures performed in an Ambulatory Surgery setting, both hospital based and freestanding Lecture, practice and feedback, Case based discussion.

3 Demonstrate knowledge of inclusion/exclusion criteria for patients scheduled for surgical procedures to be performed in an ambulatory surgery setting, both hospital based and freestanding feedback, Case based discussion. Demonstrate knowledge of and facility with the various airway devices used in an ambulatory surgery setting especially with reference to head and neck surgery, operating room feedback Case based discussion and. Demonstrate knowledge of and facility with monitored anesthesia care (MAC), regional and total intravenous anesthesia (TIVA) techniques in the ambulatory surgery setting, operating room feedback, Case based discussion and. Demonstrate knowledge of criteria for discharge and disposition of patients from an ambulatory surgery setting, both hospital based and freestanding, operating room feedback, Case based discussion. MEDICAL KNOWLEDGE: To acquire the clinical and applied science knowledge pertinent to the management of the surgical patient. Describe anesthetic-induced changes in physiology and anesthetic implications of common medical problems in adults Exercises Describe the impact of surgical procedures on patient physiology Exercise Describe the pathophysiology of intraoperative events such as oliguria, hypotension, hypoxia, and cardiac rate and rhythm changes Exercise Describe the differences in pharmacologic properties of drugs within each drug class

4 Describe properties of common drug, including induction agents, opioids, inhalational agents, neuromuscular blocking and reversal agents, pressors, beta blockers, vasodilators Identify risk factors and perioperative considerations in patients with common medical problems in adults (e.g. CAD, COPD, GERD, DM, RAD, Obesity) List indications for invasive monitoring Discuss fluid and blood product management in the perioperative setting Describe the anatomy of epidural and subarachnoid space Discuss etiology and treatment approaches for intraoperative events, such as hypotension, hypoxia, tachycardia and oliguria Identify risk factors for postoperative nausea, and describe methods of prevention Discuss etiologies of postoperative hypoventilation Discuss etiologies of postoperative delayed awakening

5 Describe the mechanisms of acute pain and common perioperative treatment modalities Describe the pathophysiology, consequences and treatment of obstructive sleep apnea (OSA) and the implications for postoperative care and disposition of patients. Describe the pathophysiology, consequences and treatment of airway compromising lesions and the implications for perioperative and postoperative care and disposition of patients Discuss the use of intravenous and volatile anesthetic and adjunctive agents with special reference to the ambulatory surgery setting PRACTICE BASED : To be able to investigate and evaluate their own patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Search and access published material, including on-line electronic library textbooks and journals Conference, Independent Study, Operating room, Journal club evaluation, Understand EBM and integrate it into clinical practice Conference, Independent Study, Operating room evaluation, Practice self-evaluation and reflection Operating room, Conference with faculty advisor Debriefing after case or simulation, Written self-evaluation Assessment of daily debriefing, Discussion and review of written selfevaluation Identify own strengths, deficiencies, and limits in knowledge and expertise Operating room, Conference with faculty advisor Debriefing after case or simulation, Written self-evaluation Daily debriefing, Discussion and review of written selfevaluation Discuss and research relevant literature to support decision-making processes Preoperative Evaluation Clinic, Conference evaluation Seek formative feedback on performance Operating room Debriefing after case or simulation, Daily debriefing

6 Present in quality improvement practices pertaining to patient care Conference Evaluation of presentation, Admit to and seek help in remedying errors Operating room, Case based discussion Direct obsevation INTERPERSONAL AND COMMUNICATIONS SKILLS: Be able to demonstrate communication skills that result in effective information exchange and appropriate interaction with colleagues, surgeons, patients, and ancillary personnel CA-1 resident must be able to identify all and demonstrate competence in some of the characteristics and skills listed below Maintain comprehensive, timely, and legible medical records Operating room Lecture and discussion,, skill Review of anesthesia records Convey ideas and points effectively Operating room, Conference, Simulation suite, Simulation, Practice oral exam Convey urgency but not panic in urgent/emergent situations Operating room,, Simulation, Practice oral exam Encourage questions Preoperative Evaluation Clinic, Preoperative Room Establish and maintain eye contact Preoperative Evaluation Clinic, Preoperative Room Be approachable Preoperative Evaluation Clinic, Preoperative Room, Postoperative care unit Know role in crisis Postoperative, Simulation Suite, Skill

7 Listen and allows others to feel heard clinic, Preoperative Room, Postoperative care unit Make others feel comfortable in conversation clinic, Preoperative Room, Postoperative care unit,, Simulation Preempt/ prevent disputes clinic, Preoperative Room, Postoperative care unit,, Simulation Practice team approach Postoperative, Simulation Suite, Simulation PROFESSIONALISM: Be able to demonstrate commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. CA-1 resident must be able to identify all and demonstrate competence in some of the characteristics and skills listed below Answer pages promptly clinic, Postoperative Demonstrate respect, compassion or responsiveness to patient's concerns or needs clinic, Postoperative, Skill checklist and criteria

8 Demonstrate independence and initiative clinic, Postoperative Be punctual and reliable clinic, Postoperative Demonstrate superior work ethic clinic, Postoperative Demonstrate commitment to professional development Preoperative Evaluation Clinic, Conference, Case presentation, Journal Club presentation, Case presentation evaluation Adhere to departmental and university policy and procedures clinic, Postoperative Lecture and discussion, Handouts, Exhibit integrity in record keeping and medical records Operating Room Lecture, Skill, Anesthesia record review SYSTEMS-BASED PRACTICE: Be able to demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide health care that is of optimal value CA-1 resident must be able to identify all and demonstrate competence in some of the characteristics and skills listed below Practice cost-effective health care Lecture and discussion, Operating Room Rely on information technology tools related to patient care clinic, Classroom, Conference, Case based discussion, Journal Club presentation evaluation, Rely on consultations with other specialties (i.e., cardiology, pain management, ethics, etc.) clinic, Classroom, Conference, Case based discussion evaluation,

9 Considers cost-benefit analysis and cost awareness in patient care Able to discuss how health delivery systems differ and how this impacts patient care in the operating room Conference, Classroom Lecture, case-based discussion Case-based discussion and evaluation Participate in systems safeguards such as "timeout" and blood product transfusion protocol Operating Room Skill Demonstration, Understand the special medical, medicolegal and economic considerations inherent in the ambulatory surgery setting clinic, Classroom, Conference, Case based discussion evaluation