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:

A) 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.

B) 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:

A) 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.

B) Institutional Policy and Resources: The fellowship must be recognized and approved by the institution's division of Medical Education.

III) Program Director and Faculty:

A) 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.

B) 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:

A) Equipment: Suitable equipment for the performance of a wide variety of ambulatory anesthetic techniques must be available.

B) Support Services:
i) At least one anesthesia technician familiar with all of the requisite equipment for the conduct of ambulatory anesthesia must be on staff
ii) Pharmacy support for the maintenance of medications necessary for the conduct of ambulatory anesthesia must be in place

C) 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:

A) 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

B) 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.

ii) 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.
iii) 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.
iv) Fellows shall be expected to deliver a Grand Rounds lecture including a relevant literature review at least once during the course of the fellowship.
v) Fellows should appreciate the practice of ambulatory anesthesia from a multidisciplinary approach including joint conferences with surgical or medical colleagues.
vi) 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:

A) 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.

B) 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:

A) Per ACGME Residency Guidelines, the attending faculty will be evaluated by the fellows twice annually.

B) 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.

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