University of Wisconsin Madison Cardiovascular Medicine Fellowship Cardiac Electrophysiology Rotation Goals and Objectives

Transcription

1 University of Wisconsin Madison Cardiovascular Medicine Fellowship Cardiac Electrophysiology Rotation Goals and Objectives Goal: To provide cardiovascular medicine trainees with the background knowledge and technical skills necessary for the practice of electrophysiology Appropriate selection of patients for specialized EP studies, including arrhythmias and ablations Training Requirements: Level I requires at least two months of clinical cardiac electrophysiology rotation. During the course of their three-year general fellowship, each fellow is required to perform a minimum of 5 temporary pacemaker insertions and at least 20 elective cardioversions. Level II requires a minimum of 6 months of training in noninvasive arrhythmia management techniques. Exposure and proficiency in the performance and interpretation of other noninvasive tests related to the evaluation of patients who have arrhythmias should be part of the training. In addition to Level I requirements, the fellow is required to perform 25 remote interrogations and to function as the primary programming operator who interrogates, interprets, prescribes and reprograms devices in at least 100 patients. The fellow is also required to demonstrate skill and proficiency in tilt table testing. By the end of this rotation/experience fellows will be able to: Competency Level I Objectives Professionalism Be responsible for all EP patients on the procedure service and in the evening sign out to the cardiology resident on call. Display professionalism in carrying out clinical responsibilities, adhere to ethical principles, and be sensitive to patients from diverse cultural backgrounds. Recognize how a patient s background affects the patient s health care choices and wishes. Involve the patient and family to assist in decision making regarding care of the patient. Interpersonal and Communication Skills Evaluation: Professionalism will be observed and evaluated during the rotation by the attending electrophysiologist(s). Document a comprehensive pre-procedure note on the chart, obtain written informed consent and write procedure orders. Discuss the following day s schedule with the attending and write the names of all patients and their planned procedure on the EP board the evening before their procedure. Write a preliminary EP report in the chart, including: procedure indication, EP study findings, conclusions and final recommendations. Report should be completed at the end of the EP study. Demonstrate effective communication skills between doctor and patient/

2 family, consultant and health care team, and doctor and EP coordinator. Medical Knowledge Evaluation: Communication skills will be observed and evaluated during the rotation by the attending electrophysiologist(s). Supervise the administration of conscious sedation with midazolam and fentanyl, monitor pulse oximetry and be familiar with the use and doses of reversal agents such as naloxone and flumazenil. Perform electrical cardioversion of atrial fibrillation or atrial flutter. Supervise and interpret tilt table tests (required for Level II training). Administer sterile technique, including draping and prepping the groins and neck area for an EP study and the chest for device implantation. This includes flushing of all sheaths and hooking up catheter cables prior to groin instrumentation. Femoral vein access In general the rotating fellow is expected to be well versed in access of the femoral vein and femoral artery. Place temporary RV pacemakers via the right internal jugular vein, securing the lead to the skin, and testing pacing threshold and sensitivity. Effectively place intracardiac catheters following the guidelines for positions of the catheter and basic electrophysiologic studies (i.e., high right atrium, His bundle electrogram, RV apex). Understand concepts of sterility and be able to perform adequate hand scrub for electrophysiologic (EP) studies (2 minutes) and device implantations (5 minutes). The fellow should be aware that pacemaker pocket infections result from lax sterile technique. Recognize and interpret the format of intracardiac recordings from the high right atrium, His bundle electrogram, CS, and the RV apex. Understand the following basic electrophysiologic concepts: Sinus node function, AV nodal function, the concept of measuring a refractory period in the atrium, the ventricle, and the AV node, and programmed ventricular stimulation. Recognize the pattern of first degree AV block, second degree AV block, Type I and Type II on the His bundle electrogram, and third degree AV block. Have a general concept of the appearance of the intracardiac electrograms during supraventricular tachycardias (atrial tachycardia, AV nodal reentrant tachycardia, orthodromic AV re-entrant tachycardia) and ventricular tachycardia. Familiar with the essentials of pacemaker and defibrillator programming and be able to perform basic troubleshooting. The fellow should also be familiar with the following basic concepts: Capture thresholds (pulse width and pulse amplitude) Sensing of the native cardiac rhythm (undersensing and oversensing) Be familiar with different pacing models (single chamber, dual chamber, and biventricular). Interrogation of pacemakers and programming of basic parameters i.e., ventricular rate, output and sensitivity.

3 Evaluation: Medical knowledge will be assessed by administering a test at the beginning and end of the EP rotation, geared to the level of the trainee. Areas of weakness will be identified at the beginning, allowing extra attention during the rotation to be devoted to that area. Improvement will be documented on the post-test. Patient Care Practice-Based Learning Obtain femoral access and place the intracardiac catheters in the appropriate chambers Conduct intracardiac measurements of sinus node recovery times, AV block cycle length and AV node refractory period. Obtain the ventricular refractory period Evaluate the patient the day before the procedure and be familiar with the patient s history, physical findings, and pertinent laboratory data. Evaluate the patient post-procedure for complications Observe, evaluate, and write a comprehensive note on all EP consults and staff the case promptly with the EP attending Perform EP consults (inpatient ward service) Participate in Arrhythmia and Device Clinics under the supervision of an attending electrophysiologist Assimilate clinical data, make an assessment, and formulate a plan of care. Review the literature and read independently on patient problems to enhance his/her experience on the EP rotation. Evaluation: The fellow will evaluate his/her patient care and gauge improvement over the rotation. The fellow s performance will re reviewed by the attending electrophysiologist(s) who supervised the fellow s rotation. Systems-Based Practice Demonstrate an awareness of costs of various therapies and counterbalance that with the benefits to judge whether a given strategy is optimal for the patient. Effectively use health care resources without sacrificing health care quality to the patient. Evaluation: The fellow s attention to system-based practice will be observed and evaluated during the rotation by the attending electrophysiologist(s).

4 Competency Professionalism Interpersonal and Communication Skills Medical Knowledge Patient Care Level II Objectives Be responsible for all EP patients on the procedure service and in the evening sign out to the cardiology resident on call. The fellow will display professionalism in carrying out clinical responsibilities, adhere to ethical principles, and be sensitive to patients from diverse cultural backgrounds. The fellow will recognize how a patient s background affects the patient s health care choices and wishes. The fellow will involve the patient and family to assist in decision making regarding care of the patient. The fellow s professionalism will be observed and evaluated during the rotation by the attending electrophysiologist(s). Ability to document a comprehensive pre-procedure note on the chart, obtain written informed consent and write procedure orders Discuss the following day s schedule with the attending and write the names of all patients and their planned procedure on the EP board the evening before their procedure write a preliminary EP report in the chart, including: procedure indication, EP study findings, conclusions and final recommendations. Report should be completed at the end of the EP study. The EP fellow will demonstrate effective communication skills during the course of the rotation. The importance of good communication between doctor and patient/ family, consultant and health care team, and doctor and EP coordinator will be stressed. The fellow s communication skills will be observed and evaluated during the rotation by the attending electrophysiologist(s). In addition to the objectives already indicated at Level I, the cardiology fellow is expected to: Be competent in programming and follow-up management of all types of bradycardia pacing, biventricular pacing, and ICD systems. For Level II training alone, without training in pacemaker implantation: perform at least 100 CIED interrogations/programming and interpret 25 remote interrogations. For Level II training, including pacemaker implantation: perform 40 permanent pacemaker implantations with at least 20 single-chamber and 20 dual-chamber pacemakers. Supervise and interpret tilt table tests. Medical knowledge will be assessed by administering a test at the beginning and end of the EP rotation, geared to the level of the trainee. Areas of weakness will be identified at the beginning, allowing extra attention during the rotation to be devoted to that area. Improvement will be documented on the post-test. Evaluate the patient the day before the procedure and be familiar with the

5 Practice-Based Learning Systems-Based Practice patient s history, physical findings, and pertinent laboratory data. Evaluate the patient post-procedure for complications See, evaluate, and write a comprehensive note on all EP consults and staff the case promptly with the EP attending The fellow will gain practical experience by performing EP consults (inpatient ward service) and by participating in Arrhythmia and Device Clinics whenever possible under the supervision of an attending electrophysiologist. These experiences will require the fellow to assimilate clinical data, make an assessment, and formulate a plan. The fellow is expected to refer to the literature and read independently on patient problems to enhance his/her experience on the EP rotation. The fellow will evaluate his/her patient care and gauge improvement over the rotation. The fellow s performance will re-reviewed by the attending electrophysiologist(s) who supervised the fellow s rotation. The fellow will demonstrate an awareness of costs of various therapies and counterbalance that with the benefits to judge whether a given strategy is optimal for the patient. The fellow will learn to use health care resources wisely without sacrificing health care quality. The fellow s attention to system-based practice will be observed and evaluated during the rotation by the attending electrophysiologist(s). Reviewed by: MF/PR 1/2016