Curriculum Guidelines for

A Medical Student Rotation in Ambulatory Anesthesia

Society for Ambulatory Anesthesia (SAMBA) Education Committee

Approved: February 27, 2004

MEDICAL STUDENT CURRICULUM (ONE TO THREE DAYS)

1. Name the five types of ambulatory surgical facilities and discuss the advantages and disadvantages of each.
2. Name at least five goals of preoperative screening
3. For a given patient, determine what laboratory tests and consultations are indicated
4. List the ASA NPO Guidelines
5. Name drugs that reduce the risk of aspiration or its consequences
6. Name risk factors for postoperative nausea and vomiting
7. Give risk factors for aspirations
8. State a reasonable regimen for prophylaxis of PONV
9. Give a protocol or regimen for treating postoperative nausea and vomiting
10. Discuss the risks of muscle relaxants as it pertains to postoperative course
11. Discuss the relative value of anxiolytic medication compared to physician-patient communication
12. Name at least three modes of administration of midazolam.
13. Compare and contrast induction techniques for children and adults
14. For a given patient and procedure, discuss the benefits of a given anesthetic technique
15. Compare and contrast the advantages and disadvantages of sodium pentothal or propofol for induction
16. Name at least six factors prolonging PACU stay
17. Describe what is meant by a short-acting fast emergence anesthetic (S.A.F.E.) anesthetic
18. Discuss the ASA standards for monitoring
19. Discuss the relative merits and disadvantages of using a laryngeal mask airway for a given procedure
20. Discuss the unique problems associated with administering anesthesia outside the OR (e.g., CT, MRI, ECT, endoscopy, etc.)
21. Discuss the advantages and disadvantages of regional anesthesia for a particular procedure
22. Demonstrate an intravenous regional anesthetic
23. Demonstrate an axillary block, three-in-one, sciatic, interscalene, wrist, or an ankle block
24. Demonstrate a spinal or an epidural
25. Demonstrate how to establish a mask airway
26. Demonstrate endotracheal intubation
27. Demonstrate placement of an LMA
28. Demonstrate intravenous catheter insertion
29. State Phase I and Phase II PACU discharge criteria
     

SAMBA Curriculum Guidelines for

The Anesthesia Resident Rotation in Ambulatory Anesthesia

Society for Ambulatory Anesthesia (SAMBA) Education Committee

Approved: November 15, 2005
 

Philosophy
The ambulatory setting involves a unique approach to the practice of anesthesia.

Goal
The resident will become acquainted with and develop skills in the practice of ambulatory anesthesia.

Overview of Clinical Experience
Management of a minimum of 75 patients undergoing ambulatory surgery including:

• 20 peripheral nerve blocks for patients undergoing surgical procedures
• 20 general anesthetics emphasizing rapid emergence
• 20 monitored-anesthesia-care cases ranging from anxiolysis to deep sedation

Involvement in the management of acute postoperative pain, including familiarity with intravenous techniques, oral pain medication and other pain-control modalities

Participate in a structured ambulatory postanesthesia care experience of at least two days duration, involving direct care of patients in the postanesthesia care unit and responsibilities for management of pain, hemodynamic changes, and emergencies related to the postanesthesia care unit under the supervision of designated faculty who must be readily and consistently available for consultation and teaching.

ACGME Objectives

Patient Care
The resident will:

• Provide patient care that is compassionate, appropriate and effective for the promotion of health, prevention of illness, and the treatment of disease. To this end, the resident will be able to:
• Gather accurate, essential information from all sources, including medical interviews, physical examinations, medical records and diagnostic/therapeutic procedures.
• Identify the main aspects of the history and physical examination relevant to patients undergoing surgery in the ambulatory setting and determine appropriate laboratory tests.
• Select patients for ambulatory anesthesia and assess the severity of common diseases including, but not limited to hypertension, renal disease, neurological disorders, cardiovascular disease, diabetes, pulmonary disease and obesity.
• Make recommendations about preventive, diagnostic and therapeutic options and interventions that are based on clinical judgment, scientific evidence, and patient 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 their 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.

Medical Knowledge
Residents are expected to demonstrate knowledge of established and evolving biomedical, clinical and social sciences, and the application of their knowledge to patient care and the education of others, and apply an open-minded, analytical approach to acquiring new knowledge. The resident will access and critically evaluate current medical information and scientific evidence, and apply this knowledge to clinical problem solving, clinical decision making, and critical thinking. To this end, the resident will:

• Evaluate patients and assume progressive responsibility in a supervised setting.
• Demonstrate competence in assessing patients rapidly in the ambulatory perioperative settings.
• Demonstrate the skills required to recognize patients requiring immediate intervention.
• When appropriate, demonstrate the skills necessary for resuscitation and stabilization of patients.
• Describe the pharmacology of local anesthetics and the physiologic effects of neural blockade, including side effects and toxicity.
• Discuss the importance of duration of blockade in ambulatory anesthesia.
• Compare and contrast the roles of regional anesthesia and systemic analgesics in post-operative pain control.
• Discuss the concept of preemptive analgesia and how to implement it in the ambulatory setting.
• Discuss appropriate choices and techniques of neuraxial anesthesia to minimize time to discharge and post-anesthetic complications (e.g., spinal headache).
• Describe the anatomy of the peripheral nervous system and how it relates to regional anesthesia.
• Discuss indications and contraindications for regional anesthesia and which techniques are appropriate for which procedures.
• Discuss the utility of depth of anesthesia monitoring in the ambulatory setting.
• Describe options for managing a regional anesthetic that is incomplete or shows prolonged latency of onset.
• Discuss the pharmacology of rapidly acting agents, including opioids, sedative-hypnotics, volatile anesthetics and muscle relaxants.
• Describe various techniques of IV sedation.
• Discuss techniques of general anesthesia to minimize post-operative problems (e.g., sedation, pain, shivering, nausea, unplanned admission).
• Define criteria for PACU bypass, PACU discharge and discharge from the same-day recovery unit.
• Explain the importance of turnover time and personnel management in the successful operation of an ambulatory surgery center.
• Describe techniques and procedures to 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.

 

Practic -Based Learning and Improvement
The resident will:

• Use scientific evidence and methods to investigate, evaluate, and improve patient care practices and demonstrate this by referring to the appropriate literature (See appendix A).
• Identify areas for improvement and implement strategies to enhance knowledge, skills, attitudes and processes of care.
• Analyze and evaluate practice experiences and implement strategies to continually improve the quality of patient practice.
• Develop and maintain a willingness to learn from errors and use errors to improve the system or processes of care and demonstrate this by attending at least one Quality Assurance meeting during the rotation.
• 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)

 

Interpersonal and Communication Skills:
The resident will:

• Demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and members of their and other health care teams.
• Provide effective and professional consultation to other physicians and health care professionals and sustain therapeutic and ethically sound professional relationships with patients, their families, and colleagues.
• Use effective listening, questioning, narrative and nonverbal skills to communicate with patients and families.
• Interact with consultants and referring physicians in a respectful, appropriate manner.
• Maintain comprehensive, timely, and legible medical records.
• Give appropriate discharge and follow up instructions to patients and their families.
• Perform evaluations of the attending staff and rotation.

 

Professionalism:
The resident will:

• Demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession and society.
• Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues.
• Demonstrate sensitivity and 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.

 

Systems-Based Practice:
The resident will:

• Demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care.
• Access and utilize the resources, providers and systems necessary to provide optimal care.
• Identify the limitations and opportunities inherent in various practice types and delivery systems, and develop strategies to optimize care for the individual patient.
• Apply evidence-based, cost-conscious strategies to prevention, diagnosis and disease management.
• Collaborate with other members of the health care team to assist patients in dealing effectively with complex systems and to improve systematic processes of care.

Appendix A

Society for Ambulatory Anesthesia Educational Bibliography for Subspecialty Anesthesia Residency & Fellowship Training in Ambulatory Anesthesia, 2004; http://sambahq.org/professional-info/ed-guidelines-intro.html
 
 

Curriculum Guidelines for

A Fellowship in Ambulatory Anesthesia

Society for Ambulatory Anesthesia (SAMBA) Education Committee

Approved: February 27, 2004

 

Philosophy: The ambulatory setting involves a unique approach to the practice of anesthesia

 

Goal: To become expert in the practice of ambulatory anesthesia

 

1. Develop expertise in ambulatory (outpatient) anesthesia for orthopedic (especially that lending itself to regional techniques), general, gynecologic, otorhinolaryngologic, pediatric and urologic surgery
2. Become a peripheral nerve block specialist
3. Staff the postanesthesia care unit (PACU), "PACU Bypass," and same-day surgery recovery (SDSR) unit (aka "phase II recovery")
4. Supervise two or more operating rooms
5. Take charge of (coordinate) anesthesia staffing and OR scheduling
6. Design clinical pathways for common outpatient procedures
7. Design clinical research appropriate to the ambulatory setting
8. Practice in the interdisciplinary setting and provide medical direction of the entire ambulatory care process

 

CONTENT

I. Scope and Duration of Training

II. Institutional Organization

III. Program Director and Faculty

IV. Facilities and Resources

V. The Educational Program

VI. Scholarly Activity

VII. Consultant Skills

VIII. Evaluation

 

I) Scope and Duration of Training:

• Scope of Training: Ambulatory anesthesia training is a sub-specialty focused on the perioperative management of patients receiving anesthesia in the ambulatory setting. Fellowship training should be concerned with the development of expertise in the practice, theory, and literature, of ambulatory anesthesiology.
• Duration of Training: The time required for sub-specialty training in ambulatory anesthesia will be twelve months, of which 75% will be dedicated to the clinical practice of ambulatory anesthesia. The remaining 25% may be devoted to research activities (no more than 20%), and/or other clinically relevant areas. The MINIMUM duration of training shall be 1 year. Anything less than one year will not qualify the graduate to use the title "fellow or fellowship" in the diploma language

 

II) Institutional Organization:

• Relationship to a Core Program: Institutions with sub-specialty training in ambulatory anesthesia must have a direct affiliation with an ACGME accredited residency in anesthesiology. If the institution in which the fellowship is based is other than the primary institution of an accredited residency, a written agreement linking the two, and an evaluation protocol consistent with ACGME-approved standards for residency programs must be pre-requisites.
• Institutional Policy and Resources: The fellowship must be recognized and approved by the institution's division of Medical Education.

 

III) Program Director and Faculty:

• Program Director: The Director of the fellowship program must be an ABA Board-Certified anesthesiologist (or foreign graduate equivalent) who has either completed one year of fellowship training in ambulatory anesthesia, or has been a dedicated practitioner of ambulatory anesthesia for greater than five years. The program director must also have an academic and/or clinical affiliation with the ACGME accredited institution.
• Faculty: The majority of the faculty in the training program must be Board-Certified in Anesthesiology. A division of the faculty in the training program must also demonstrate an expertise in ambulatory anesthesia. The number of faculty in a program may vary based on the number of fellows in training, however a minimum ratio of two full time ambulatory anesthesia faculty for each fellow in training must be maintained.

 

IV) Facilities and Resources:

• Equipment: Suitable equipment for the performance of a wide variety of ambulatory anesthetic techniques must be available.
• Support Services:

1. At least one anesthesia technician familiar with all of the requisite equipment for the conduct of ambulatory anesthesia must be on staff
2. Pharmacy support for the maintenance of medications necessary for the conduct of ambulatory anesthesia must be in place

• Library: A departmental library, or portion of the institutional library, dedicated to anesthesiology with literature specific to the practice of ambulatory anesthesia must be maintained.

 

V) The Educational Program:

•     Clinical Education: The clinical program will serve as the cornerstone of the fellowship training in ambulatory anesthesia.

    In order to achieve the necessary level of expertise, fellows should be familiar with the indications, contraindications, techniques, and complications of techniques, which include, but are not limited to, the following:

    200 General Endotracheal anesthetics
    200 General laryngeal mask airway anesthetics
    200 Monitored anesthesia care anesthetics
    100 Regional anesthetics (Examples below)

    axillary blocks
    interscalene blocks
    sciatic nerve blocks
    ankle blocks
    supraclavicular/infraclavicular blocks
    femoral nerve blocks
    popliteal fossa blocks
    neuraxial blocks - including epidurals, spinals, and combined spinal-epidural techniques

    Fellows should complete daily case logs to track their clinical experiences. These logs should be reviewed regularly with the appropriate faculty advisor.

    Fellows must be able to show competency in the following areas:

• demonstrate rational selection of anesthetic technique for specific clinical situations
• demonstrate safe and appropriate preoperative patient preparation and management
• demonstrate safe and appropriate postoperative patient management
• demonstrate cost-effective management decisions

 

• Didactic Educational Program: A didactic and educational program specifically dedicated to ambulatory anesthesia practice shall be offered. i) A weekly lecture or discussion series that covers topics relevant to, but not limited to ambulatory anesthesia, shall be held no fewer than 24 times per year.

1. A “ Journal Club" (current literature review) shall be held at least once monthly. Fellows shall present articles at least twice in twelve months with an attending anesthesiologist as an advisor.
2. A lecture or case conference specifically designed for fellows and supervised, or given, by a qualified faculty member shall occur at least once per month.
3. Fellows shall be expected to deliver a Grand Rounds lecture including a relevant literature review at least once during the course of the fellowship.
4. Fellows should appreciate the practice of ambulatory anesthesia from a multidisciplinary approach including joint conferences with surgical or medical colleagues.
5. Fellows shall have the opportunity to demonstrate teaching ability to junior residents during the academic year.

    By completion of the accredited program, the fellow is expected to have a working knowledge base consisting of the following:

• an understanding of the general attributes of ambulatory anesthetic pharmacology
• an understanding of the indications and contraindications for major anesthetic techniques
• an understanding of the complications of ambulatory anesthetic technique
• an understanding of the outcome studies related to the influence of ambulatory anesthesia on perioperative outcome
• a familiarity with major scientific studies related to ambulatory anesthesia

 

VI) Scholarly Activity:
Fellows shall have the opportunity to participate in clinical and/or laboratory research and be given appropriate non-clinical time to become involved in research already in progress, or to develop an original project. In either case, an appropriate attending anesthesiologist must be available to mentor and assist the fellow. By the end of the accredited program, the fellow will be expected to complete an academic project. The types of activities that will qualify as academic projects include a research paper submitted to a peer-reviewed journal and presented; a clinical audit, to be designed and formulated with recommendations; a review article submitted to, and accepted by, a peer-reviewed journal; or a book chapter.
There will be discussion prior to commencement of the fellowship as to which of the above alternatives the fellow would like to pursue. If an original project is planned, the research protocol must be submitted with sufficient notice in order to complete the project in the time frame of the fellowship.

 

VII) Consultant Skills:

• Communication Skills: Fellows should possess communication skills sufficient to solicit and impart information. The fellow must be able to clearly delineate options available to the patient regarding ambulatory anesthesia as well as the risks and benefits in a manner that is understandable to the patient.
• Collaboration Skills: Fellows must be able to work in a team environment, communicating and cooperating with surgeons, nurses, pharmacists, and all members of the perioperative team.

  

  By the end of the fellowship, fellows will be able to:

• delineate the roles of other members of the team
• communicate clearly in a professional and collegial manner that facilitates the achievement of patient care goals
• formulate care plans that utilize the multidisciplinary team skills, such as a plan for facilitated recovery

 

VIII) Evaluation:

• Per ACGME Residency Guidelines, the attending faculty will be evaluated by the fellows twice annually.
• Written evaluations of fellows by all faculty with whom they have worked shall occur on a monthly basis and be reviewed quarterly. The results of these evaluations shall be recorded and reviewed with the fellows by the program director no less often than every six months.