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.

Practice-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

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