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SAMBA OBA Curriculum

SOCIETY for AMBULATORY ANESTHESIA
OFFICE-BASED ANESTHESIA CURRICULUM

Created by: Shireen Ahmad, M.D. & Fred E. Shapiro, D.O.

Reviewed by SAMBA Taskforce on Ambulatory and Office –based Anesthesia:

Chair: Shireen Ahmad, M.D.

Members:  Barbara S. Gold, M.D.; Beverly K. Phillip, M.D.; Douglas G. Merrill, M.D., Burton S. Epstein, M.D.; Frances F. Chung, M.D.; Tong J. Gan, M.D.; Girish P. Joshi, M.D.; D. Janet Pavlin, M.D.; Jeffrey B. Brand, M.D.; Jeffrey L. Apfelbaum, M.D.; John A. Dilger, M.D.; Kathrine E. McGoldrick, M.D.; Kumar G. Belani, M.D.; Lee A. Fleisher, M.D.; Lucinda L. Everett, M.D.; Maryann Vann, M.D.; Walter G. Maurer, M.D.; Meena S. Desai, M.D.; Patricia A. Kapur, M.D.; Peter M. Glass, M.D.; Raafat S. Hanallah, M.D.; Rebecca S. Twersky, M.D.; Thomas W. Cutter, M.D. 

Approved by SAMBA Board of Directors: May 2010

Goal of Rotation:

To provide the resident with a comprehensive experience in the anesthetic management of ambulatory surgical patients in an office based environment.

Cognitive Objectives:

Upon completion of the office based anesthesia rotation the resident will:

  • Demonstrate an understanding of  the perquisites for establishment of  a safe office anesthesia environment
  • Demonstrate a knowledge of the anesthesia related safety requirements for establishing an office base anesthesia practice.
  • Demonstrate knowledge of the factors which determine the types of surgeries suitable for office based anesthesia.
  • Demonstrate an understanding of the requirements for the appropriate selection of ambulatory patients for office based anesthesia, including issues of risk, age, time requirements and possibility of complications.
  • Demonstrate an understanding of the  type of instructions to be given to an ambulatory patient prior to office based surgery
  • Demonstrate an understanding of the limitations placed on pre-anesthetic medication by the outpatient status.
  • Demonstrate an understanding of the criteria that determine whether a patient can be managed with a regional nerve block, major conduction anesthesia, or general anesthesia in an office based setting.
  • Demonstrate a knowledge of the types of anesthetic agents that would be most suitable for an outpatient office based procedure.
  • Demonstrate knowledge of the pharmacology, pharmacokinetics, and other information necessary to make an appropriate selection of an anesthetic plan for office based surgery procedures.  
  • Demonstrate knowledge of the necessary conditions for discharge from the recovery room to the patient’s home.
  • Demonstrate an understanding of the causes of delayed emergence and discharge and strategies for facilitating the recovery process.
  • Demonstrate an understanding of the unique issues associated with the treatment of pain and postoperative nausea and / vomiting in the office based arena.
  • Demonstrate an understanding of the issues and challenges of management of medical emergencies in the office location.
  • Demonstrate an understanding of the key factors affecting clinical outcomes and strategies for preventing complications in office based anesthesia.


Skills Objectives:

Upon completion of the office based anesthesia rotation the resident should be able to:

  • Demonstrate the skills necessary to deliver safe and appropriate anesthetic care in an office setting
  • Demonstrate the ability to perform rapid turnover between cases.
  • Demonstrate skill in the techniques necessary for rapid emergence from general anesthesia.
  • Demonstrate the ability to perform neuroaxial regional block for appropriate ambulatory office based procedures. 
  • Demonstrate skill in conducting a pre-anesthetic interview specific for office-based surgery patients, both in person and over the telephone.
  • Demonstrate the ability to conduct a postanesthetic follow up interview over the telephone, following office based procedures.
  • Demonstrate the ability to manage emergency situations efficiently in an office based location.
  • Demonstrate familiarity with individual state regulations relating to office based anesthesia.
  • Demonstrate familiarity with billing code compliance, occupational safety, equipment selection and maintenance and emergency protocols.

General Core Competencies:

PATIENT CARE OBJECTIVES
Residents must be able to provide patient care that is compassionate, appropriate and effective care for patients undergoing ambulatory surgery procedures in the office setting, under the supervision of a faculty member. Residents are expected to:

  • Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families
  • Gather essential and accurate information about their patients, in order to provide effective patient care.
  • Counsel and educate patients and their families regarding ambulatory anesthetic issues. 
  • Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence and clinical judgment, relevant to office-based scenario.
  • Develop an anesthetic management plans for safe and effective perioperative care of the patient that is aimed at preventing postoperative adverse outcomes.
  • Perform competently all medical and anesthetic  procedures considered essential for the safe conduct of office based anesthesia
  • Use information technology to support patient care decisions and patient education.
  • Work with health care professionals, including those from other disciplines, to provide patient-focused care in the office location.

PRACTICE-BASED LEARNING AND IMPROVEMENT OBJECTIVES
Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to: 

  • Demonstrate an investigatory and analytical thinking approach to clinical situations involving patient care in the office location
  • Identify areas of weakness in the practice and perform practice-based improvement activities using a systematic methodology
  • Locate, appraise and assimilate evidence from scientific studies related to the practice of ambulatory anesthesia in the office setting 
  • Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness relating to office based anesthesia.
  • Develop skills in the use of information technology to access on-line medical information through MEDLINE, CINAHL, PSYCHINFO, etcetera
  • Develop the skills to critically appraise the medical literature related to office based anesthesia.
  • Demonstrate the ability to design, develop, and implement high quality improvement  programs unique to the situation presented in office based anesthesia setting 
    unique to the situation presented in office based anesthesia setting  ie maintaining standard of care in multiple sites with diverse practices.
  • Facilitate the learning of colleagues and other health care professionals, both informally and with formal presentations.

INTERPERSONAL and COMMUNICATION SKILLS OBJECTIVES
Residents must be able to demonstrate interpersonal behavioral and communication skills that result in effective information exchange and teaming with patients, their patient’s families, and professional associates. Residents are expected to:

  • Create and sustain a therapeutic and ethically sound relationship with patients
  • Develop effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills
  • Develop effective leadership skills and the ability to work effectively with other members of the health care team.


PROFESSIONALISM OBJECTIVES
Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to the diversity of the patient population. Residents are expected to: 

  • Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development
  • Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices
  • Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities

SYSTEMS-BASED PRACTICE OBJECTIVES
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:

  • Develop an understanding of the impact of anesthesiology practices on other health care professionals, the health care organization, and the larger society.
  • To appreciate the value and learn  about marketing skills necessary to create a safe successful office based anesthesia practice ( eg. similar to those used in the practice of pain management)
  • Understand the differences between anesthesiology practice and delivery systems in the office location and practice in the hospital based location, including methods of ensuring patient safety, controlling the cost of care and allocating  resources
  • Practice cost-effective anesthetic care and resource allocation without compromising the quality of care
  • Advocate for quality patient care and assist patients in dealing with system complexities
  • Partner with health care managers and health care providers to assess, coordinate, and improve health care and gain an understanding of how these activities can affect systems performance.

Duration:

One month during the CA-III year.
Faculty leader: ____________________________________________________

Record Keeping:

  • Residents must keep track of all cases and procedures performed for the annual report to the ABA.
  • Residents must maintain a timely completion of all of their medical records.

Evaluation:

Throughout the rotation, faculty should complete evaluations of the resident’s performance. The Residency Program with the oversight of the Education Committee of the Anesthesiology Department, and input from the faculty, nurses, peers and patients, should utilize the following evaluation tools to determine whether an individual resident has achieved mastery of the six general core competencies and in each of the specified rotational competencies.

  • 360-Degree evaluation instrument
  • Oral exam
  • Written in-training examinations
  • Faculty evaluations (ABA) – daily
  • Case logs
  • Simulator training sessions
  • Scholarly activity
  • Case presentations
  • Research projects

References:

1 Hausman L, Rosenblatt M: Office Based Anesthesia: in: Barash PG, Cullen BF, & Stoelting RK (eds):  Clinical Anesthesia, 6th. ed. J.B. Lippincott Company, Philadelphia, PA 2008. Pages: 1345-57
2 Twersky RS, Philip BK (eds): Handbook of Ambulatory Anesthesia 2nd. ed. Springer  Science +  Business Media, LLC. 2008. Pages: 283-324
3 Steele SM, Nielsen KC, Klein SM (eds): Ambulatory Anesthesia & Perioperative Analgesia. McGraw-Hill  Companies, Inc., 2005. Pages: 345-355
4 Shapiro FE (ed):  Manual of Office-Based Anesthesia Procedures. Lippincott Williams & Wilkins. 2007
5 American Society of Anesthesiologists. Office-based Anesthesia: Considerations for Anesthesiologists in  Setting Up and Maintaining a Safe Office Anesthesia Environment, from ASA Committee on Ambulatory    Society for Ambulatory Anesthesia(SAMBA) Committee on Office-Based Anesthesia. Available at:  http://www.asahq.org/publicationsAndServices/office.pdf. 2008