ambulatory
Rotation: Anesthesia for Ambulatory Surgery
- Definition — Anesthesia for Ambulatory
Surgery is a one-month rotation for the CA-1 resident which will provide training
and learning in the perioperative care of the Same Day Surgery patient.
- Curriculum — The majority of the rotation is spent
in the Doctor's Office Center Same Day Surgery Unit. Appropriate cases will
be assigned in the University Hospital when deemed appropriate, including
outpatient studies such as MRI, GI studies, ECT, etc. The resident will be
exposed to patients of all ages, from pediatric to geriatric, and to all types
of cases commonly seen in an ambulatory center. The experience will include
exposure to the systematic process of the preoperative management of the ambulatory
patient. Emphasis will be placed upon all issues related to sending home a
comfortable patient following surgery on the same day. A one-month block in
the yearly didactic schedule is dedicated to Anesthesia for Ambulatory Surgery.
- Clinical Duties with Learning Pathways
- Perform thorough preoperative evaluations, recognizing the importance
of history and physical, preoperative disease states, and pediatric congenital
abnormalities commonly seen in Same Day Surgery. Demonstrate knowledge
of NPO requirements for various age groups. Be familiar with various chronic
medications which patients may be taking preoperatively and the implications
with regard to anesthetic management. The anesthetic plan is then formulated
and discussed with the ambulatory attending.
- Have thorough working knowledge of the use of anxiolytics, sedatives,
and opioids as premedicants, especially for use in the ambulatory setting.
The resident will be able to identify those patients requiring preoperative
medication and demonstrate the appropriate and judicious use of premedicants
in the ambulatory patient, ideally achieving a goal of having a calm patient
entering the operative suite.
- Demonstrate knowledge of the choices of anesthetic regimens for ambulatory
anesthesia (regional vs. general vs. local with sedation) and show the
ability to choose the appropriate management for each case. The resident
will be able to discuss the choices not only with the attending and patient
but also with the surgeon, working with him/her to accomplish the safest
and most appropriate technique for the intended procedure. Be receptive
to surgeon's concerns without compromising patient care.
- Routinely accomplish a rapid room turnover, which requires a thorough
understanding of all pharmacokinetic and pharmacodynamic parameters of
commonly used anesthetic agents so as to accomplish a timely emergence
from anesthesia. Tracking is done by the attending utilizing recorded
times in the nursing records. Achievement of a goal of fifteen-minute
turnover time routinely is considered optimal.
- Demonstrate knowledge of anesthesia required for various special procedures
including laser surgery; lithotripsy, and anesthesia in remote locations
(MRI, CT, nuclear radiation, EMG studies, GI studies, ECT, and cardioversion).
Attend special lectures given by faculty members of these various departments
and pass all safety/competency exams required by University Hospital.
The resident will be evaluated by faculty on the thoroughness of the anesthesia
set up in remote locations, knowledge of the safety factors involved,
and case implementation. At least ten cases in remote locations should
be documented in the case log.
- Safely transport patients to the PACU, which is of special concern when
transporting patients from remote locations. This requires knowledge of
the risks of prolonged transport times following emergence from anesthesia,
complete preparedness of emergency equipment, and appropriate use of monitoring
equipment. Evaluation is based upon the safe delivery of a stable patient
to the PACU.
- Have knowledge of possible anesthetic complications in the PACU. Special
emphasis should be placed upon those factors which have the potential
to delay discharge, including but not limited to delayed awakening, emesis
prevention and management, and recognition of and distinction between
surgical postoperative complications. Complications will be documented
by the resident in his/her case log and discussed with the attending.
The Director of Ambulatory Anesthesia will review charts daily and track
these complications. All morbidities will be documented and discussed
in accordance with department and hospital Performance Improvement standards.
- Plan for postoperative pain management preemptively, including judicious
use of narcotics, analgesics, and local anesthetics. Discuss the risks
and benefits of the various modalities with the attending, the patient
and family, and surgical team so as to prepare and implement a pain management
plan in the preoperative period and continued through the postoperative
period, including the PACU and home. Evaluation is by the faculty and
is multifactorial, encompassing not only the presentation and implementation
of the plan but also via patient and nursing surveys.
- Demonstrate knowledge of postoperative discharge criteria, including
Phase I recovery, pain control, antiemesis management, complications;
and Phase II discharge instructions. Evaluation is by Ambulatory faculty,
reviewing all charts on a daily basis, tracking the resident's appropriate
use and documentation of discharge criteria. All unplanned admissions
are recorded by the resident and discussed at the department Performance
Improvement meeting, in accordance with PI standards.
- The resident is expected to participate in all didactic sessions during
the Ambulatory Anesthesia block period. He/she will read all assigned
material and prepare case and journal discussions. Evaluation is based
upon attendance, active participation in group discussion, and use of
evidence based medicine principles.
- References — Residents are expected to complete required
readings from major textbooks (e.g. Miller, Barash) during the three year
program. In addition, selected journal articles will be provided, and the
following references are suggested to help you meet your learning objectives:
- Anesthesia for Ambulatory Surgery (Wetchler)
- Outpatient Anesthesia (White)
- Ambulatory Anesthesia: A Problem Oriented Approach (McGoldrick)
- Atlas of Regional Anesthesia (Katz)
- Objectives — attached
- Evaluation — All learning objectives will be evaluated
as stated in section V. Each resident will receive at the beginning of the
rotation a topic card for discussion by the Director of Ambulatory Anesthesia
or his designee. When the resident has prepared and presented this information
to the satisfaction of the DOAA or the supervising attending, the card must
be signed by the attending. It is the resident's responsibility to fulfill
these responsibilities as well as to turn in the card to the Resident Education
Committee (in the person of Ms. Venino).
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Ambulatory Anesthesia
Attending responsibilities — Each resident has responsibilities
that he must meet in order to complete the rotation successfully. Similarly,
we have the responsibility to ensure that the resident has the environment,
the mechanism, and didactic information to meet his learning objectives, as
well as the documented evaluation of these objectives. To that end, the resident
will be presenting to you on a topic for discussion or an activity which requires
your assistance. They are as follows:
- Recite NPO orders for adult and pediatric patients
- Discuss anesthetic complications seen in the ambulatory PACU setting.
- Discuss post-operative discharge criteria.
- Regional anesthesia case discussions for ambulatory patients (total of two,
one each of lower and upper limb surgery).
- Present thorough preoperative evaluations with comprehensive plan (five).
When each topic has been addressed to the attending's satisfaction, he/she
will sign that portion of the topic card.
In addition, the following learning objectives require your assistance and
[evaluation]:
- Demonstrate appropriate and judicious use of premedicants in the ambulatory
patient [360-degree evaluation].
- Demonstrate understanding of pharmacokinetic and pharmacodynamic factors
of commonly used anesthetic agents to accomplish timely emergence from anesthesia
[target turn-over time of fifteen minutes in 80% of cases]
- Plan for and implement preemptive post-operative pain management [360-degree
evaluation]
- Appropriate use of discharge criteria [ten patients]
- Participate in the systematic process of the preoperative evaluation of
ambulatory patients by reviewing charts in PAT, in which abnormalities or
issues may be present and are known by the attending [thirty charts with 90%
accuracy]
- Demonstrate effective professional interaction with faculty, staff, surgeons,
and patients [360-degree evaluation for five random patient encounters].
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