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Download the manual for Fellowship in Pediatric Emergency ....doc Document Transcript

  • 1. University of Rochester Pediatric Emergency Medicine Fellowship Manual 2009-2010 Director: Anne Brayer, MD 1
  • 2. Table of Contents Introduction...................................................................................................................................................................5 About this Manual.........................................................................................................................................................5 Program Goals..............................................................................................................................................................6 Program Objectives......................................................................................................................................................6 Expectations for the PEM Fellow................................................................................................................................7 Important Phone Numbers........................................................................................................................................10 Hospital Phones and Paging.....................................................................................................................................10 Faculty Core Pediatric Emergency Medicine Faculty (2009).................................................................................11 General Emergency Medicine Faculty........................................................................................................12 Fellows Current............................................................................................................................................................13 Alumni............................................................................................................................................................13 Curriculum Overview.................................................................................................................................................15 Training Goals by Year and Category......................................................................................................................16 Sample Yearly Block Schedule.................................................................................................................................18 Sample Clinical Schedule..........................................................................................................................................19 Peds Grad Curriculum...............................................................................................................................................20 EM Grad Curriculum...................................................................................................................................................21 Emergency Department Policy for Scheduling Vacation/CME and Time-Away..................................................22 Sample PEM Fellows Schedule Requests...............................................................................................................23 The Educational Program..........................................................................................................................................24 PEM Clinical Experience Other Clinical Experience Teaching/Conferences Research ....................................................................................................................................................................29 Master of Science.......................................................................................................................................................32 2
  • 3. Tracks ....................................................................................................................................................................34 Continuing Medical Education..................................................................................................................................35 PEM Training Program Rotations.............................................................................................................................36 Administration...............................................................................................................................................36 Adult Emergency Medicine..........................................................................................................................38 Anesthesia.....................................................................................................................................................42 Child Abuse (REACH)...................................................................................................................................44 EM Orthopedics/Peds Orthopedics/Sports Med........................................................................................46 Emergency Medical Services.......................................................................................................................48 Obstetrics and Gynecology.........................................................................................................................50 Pediatric Emergency Department...............................................................................................................52 Pediatric Intensive Care Unit (PICU)...........................................................................................................59 PEM Research...............................................................................................................................................63 Emergency Psychiatry..................................................................................................................................65 Reading Electives..........................................................................................................................................67 Toxicology......................................................................................................................................................68 Trauma............................................................................................................................................................73 Ultrasound......................................................................................................................................................76 Program Contacts.......................................................................................................................................................79 Procedures..................................................................................................................................................................80 Sample Procedure Log.................................................................................................................................81 PEM Fellow Delineation of Competencies...............................................................................................................84 Institutional Oversight/Monitoring of Resident/Fellow Duty Hours......................................................................87 Institutional Policy on Resident/Fellow Duty Hours...............................................................................................89 PEM Fellows Work Hours Policy..............................................................................................................................90 Sample Virasert Contract...........................................................................................................................................92 Virasert Guidelines.....................................................................................................................................................93 PEM Fellowship Evaluation Process........................................................................................................................95 Core Competencies.......................................................................................................................................95 Sample Evaluation Forms............................................................................................................................98 Credentialing Standards..........................................................................................................................................105 Policy on Moonlighting............................................................................................................................................108 Sample Moonlighting Request Form........................................................................................................110 Sample Moonlighting Hours Tracking Form............................................................................................111 Professional Liability Insurance.............................................................................................................................112 3
  • 4. Resident and Fellows Benefits...............................................................................................................................114 University Leave of Absence..................................................................................................................................116 Disability ..................................................................................................................................................................118 Substance Abuse......................................................................................................................................................120 Patient Safety Policy................................................................................................................................................121 Sample PEM Fellowship Contract..........................................................................................................................123 Dress Code Policy....................................................................................................................................................125 HIPPA ..................................................................................................................................................................126 Disciplinary Procedures and Appeals Policy........................................................................................................127 4
  • 5. INTRODUCTION The Pediatric Emergency Medicine (PEM) Fellowship Program at the University of Rochester is an accredited training program, with tracks for graduates of either Pediatrics (3-year program) or Emergency Medicine (2-year program) residencies. The program is primarily administered by the University’s Department of Emergency Medicine, with close ties to the Department of Pediatrics. The Pediatric Emergency Department of Golisano Children’s Hospital at Strong is located adjacent to the Adult Emergency Department at Strong Memorial Hospital. The Pediatric ED has approximately 28,000 visits per year, while the Adult ED has 95,000 annual visits. The Pediatric ED serves as the tertiary care referral center for 14 counties surrounding the Rochester area, totaling over 1 million people. The Emergency Department is the Regional Level 1 Trauma center for the Finger Lakes Region. Dedicated pediatric ED nurses are specialists in the care of ill and injured children. The Golisano Children’s Hospital, has 51 general pediatric inpatient beds, an intermediate care unit, a 22-bed critical care unit, a normal newborn nursery, and a 52-bed intensive care nursery Our interdisciplinary team includes members of all pediatric subspecialties. The patient population is heterogeneous, with regard to social background, place of residence (inner city, suburban, and rural), and medical needs (acute illness care, diagnostic evaluation, and management of chronic medical problems). The Division of Pediatric Emergency Medicine consists of six boarded Pediatric Emergency Medicine physicians and four fellows. Division research centers on the health services issues, including the interface between primary care and emergency medicine, care of children in poverty, injury prevention, prehospital care, improving the quality of emergency care, decision analysis, head injuries, asthma, and toxicology. In addition, the Division is one of the study sites involved in the national PEM research network referred to as the Pediatric Emergency Care Applied Research Network (PECARN). The Pediatric Emergency Medicine Fellowship has been in existence at the University of Rochester since 1992. In addition to providing excellent clinical training, and superb research training, the PEM Fellowship offers the opportunity to pursue a Master’s in Public Health. PEM fellows are an integral part of our faculty, and they are provided with the tools and support necessary to be successful pediatric emergency medicine physicians. This is your Fellowship! Suggestions for improvements in the program are encouraged. About This Manual Fellows are expected to be familiar with the contents of this manual at the beginning of the fellowship. Throughout the year, additional important information will be communicated to fellows via regular mail and/or E-mail. E-mail is the primary mode of communication, thus, fellows are expected to check their E-mail frequently and to keep up to date. 5
  • 6. PROGRAM GOALS The goal of the University of Rochester Pediatric Emergency Medicine Fellowship Program is to train pediatricians and emergency medicine physicians for full-time faculty positions in Pediatric Emergency Medicine (PEM). We place an emphasis on excellent academic training. Fellowship training prepares the physician to: 1. Provide excellent patient care. 2. Have thorough knowledge of pediatric emergency medicine and related fields. 3. Conduct independent research studies. 4. Teach the principles and practices of pediatric emergency medicine. 5. Competently administer of pediatric emergency medicine programs. Graduates of the program are typically eligible to sit for the pediatric emergency medicine subspecialty board examination. PROGRAM OBJECTIVES Train Pediatric Emergency Medicine physicians to: A. Achieve a high level of competence in the evaluation and treatment of infants, children, and adolescents who present to the Emergency Department. Graduates should be proficient in the management of medical, surgical, traumatic, psychiatric, psycho-social, and other conditions of childhood. An emphasis is placed on the management of acute problems. In addition, we aim to train Pediatric Emergency Medicine physicians to have familiarity with the evaluation and management of common adult emergencies, and of common non-emergency aspects of in-patient Pediatrics. B. Achieve a high level of understanding and competence in the management of a tertiary care referral center's Pediatric Emergency Department in the context of the continuum of management of sick or injured children. Also including the family, primary care physicians, the 911/prehospital system, poison control center, community emergency departments, in-patient units, other specialists, and community resources. C. Achieve familiarity and competence with prioritizing the emergency care of multiple patients. D. Develop and refine effective interpersonal skills through patient care, staff and multidisciplinary interactions. E. Instill and model a high degree of ethical conduct. F. Develop an awareness of the cost-effective and time-efficient use of diagnostic studies in pediatric emergency medicine while maintaining quality of care. G. Develop an understanding of prehospital practices and the interactions between prehospital providers and the Pediatric Emergency Department. H. Develop an understanding of medico-legal aspects of the practice of pediatric emergency medicine. I. Appreciate the role of preventive medicine and its interaction with pediatric emergency medicine. J. Appreciate the role of academic excellence and leadership in the practice of pediatric emergency medicine, including mentorship by current pediatric emergency medicine academicians. K. Develop the skills and motivation necessary to continue self-education in pediatric emergency medicine beyond the completion of residency training, including reading and critical evaluation of the relevant literature. L. Provide training for personal techniques for physician wellness while pursuing a career in pediatric emergency medicine. M. Effectively function as a member of the emergency medicine, pediatrics, and pediatric emergency medicine professional communities. N. Develop skills to become an effective researcher, including research design, administrative management of research projects, the conduction of research, interactions with study subjects, research ethics, presentation of research, and manuscript and abstract authorship. O. Develop a high level of understanding in biostatistics, epidemiology, research ethics, and related disciplines through university graduate courses. 6
  • 7. P. Develop skills as an effective teacher of other health professionals at all levels. Q. Successfully complete the pediatric emergency medicine subspecialty board examination. R. Obtain an appropriate job placement. EXPECTATIONS FOR THE PEM FELLOW The PEM fellow has a complex job, with many expectations. The following is a list of the expectations. Remember: The only dumb question is the one that isn’t asked. When in doubt, please ask. Clinical 1. Arriving on time for all clinical shifts is an important courtesy in emergency medicine. 2. Prompt and reliable attendance at all activities of “outside” rotations; remember you are our ambassador! 3. Schedule requests must be filled out for every month and are due on the 15th day two (2) months proceeding the scheduled month. Work with the schedule maker to help him/her understand where you will be during that month – do not simply assume that, because you will be on an outside rotation, you will not be scheduled. Outside rotations are generally devoted to that rotation, with few or no ED shifts; this applies most notably but not exclusively to your PICU, OB, and Trauma rotations. Please see detailed description of rotations within this manual for specifics. 4. The bulk of you clinical PED shifts should be scheduled during your PED blocks. 5. When you are working in the Pediatric ED during your first year, you are expected to primarily evaluate patients. This allows you the opportunity to “cherry pick” cases that are challenging and unique in order to expand your knowledge and procedural skills. In the years two and three, you will be expected to assume leadership and precepting roles. 6. You are expected to learn as much as possible about being in charge during clinical shifts. Strive to develop a sense of all the patients in the Pediatric ED whenever possible. Learn to develop a “sixth sense” of patient or systems problems either before they start, or early in the problem resolution process. 7. All ED clinical shifts will be either worked, or appropriate substitution will be arranged. Coverage arrangements are your own responsibility. Schedule changes must be noted on the master schedule in the Pediatric Emergency Department, and you must notify the support staff responsible for scheduling. 8. Procedure logs must be completed for all relevant procedures. Currently, a computer-based system is in use. (For details, refer to the “Procedures” section of this manual.) 9. During PED block, PEM fellows are expected to be available during the day for interesting procedures and cases. Please contact the PED day shift attending about your availability. 10. PALS, ACLS, ATLS are required. Teaching/Conferences 1. Provide clinical “bedside” teaching of trainees while on ED shifts. 2. You are expected to give presentations at several PEM conferences each year, including, case conference, core PEM topics, morbidity and mortality conferences and journal clubs. 3. The fellow will lead 3 EM Departmental Teaching Fellow Conferences per year. This hour of resident lectures is a shared responsibility amongst the PEM Fellows, the Sports Medicine Fellows and the EMS Fellows. 4. The fellows may prepare and present several teaching sessions at the EM core conferences each year. 5. You are also encouraged to participate in the Department of Pediatrics’ conferences. 6. Being a PALS instructor is not required but is strongly encouraged. Similarly, ATLS, ACLS, PEPP, etc. teaching may be beneficial, but is not required. 7
  • 8. EXPECTATIONS FOR THE PEM FELLOW, CONT’D Research 1. Completion of at least one research project is required. Ideally, this will be published and presented at a national scientific meeting. 2. You should schedule regular meetings with your research advisor over the course of your research efforts. If you are encountering problems with your research, you should notify the program director as early as possible. 3. Note that those expecting Pediatric Emergency Medicine sub-board certification through the American Board of Pediatrics (ABP) have a “research requirement.” You should familiarize yourself with the terms of this requirement. Details are provided in this manual 4. Five (5) public health courses, including research ethics, biostatistics, and epidemiology. Your grades are generally your business, but grades below B- should be reported to the fellowship director, as they will require repeating the course and reimbursement to the department. 5. Enrollment in the Master of Science program is available but is not required. You do not have to be accepted into the Master of Science program to take public health courses. The opportunity to purse a Master of Science (with the University of Rochester tuition benefits) is a unique feature of our program, conferences and clinical shifts will be rearranged so you can complete the required coursework for the Master of Science. 6. Occasionally, offers to write book chapters come up, or you encounter cases that are appropriate for publication as a “case report.” These experiences are valuable, but should not get in the way of more important activities. Many fellows do 1-2 of these sorts of things during their training. You should discuss these opportunities with your faculty advisor, or fellowship director who can help you decide if there’s time in your schedule, compared to the academic value of the proposed project. 7. Significant “facetime” is expected during your research blocks. Administration/Division Affairs 1. Regular attendance at division meetings and teaching sessions is mandatory. 2. Be active in a few areas of practice improvement of system based practice in the Pediatric ED. 3. Keep abreast of research and other activities are going on among faculty and other fellows; you will learn a lot and may end up getting active in some things, yourself. Regular attendance at the ED Research meetings is mandatory. Administration/Departmental Affairs: ED 1. Regular attendance at Grand Rounds is strongly encouraged. 2. Attendance at relevant department teaching conferences is encouraged. Administration/Departmental Affairs: Pediatrics 1. Participation in Department of Pediatrics activities is generally optional, but encouraged. These include Grand Rounds and Morning Report. 2. Giving an occasional noon Pediatrics residents conference is nice, too, but not required. Evaluations 1. Fellows must evaluate each block. 2. Fellows must evaluate the PEM faculty on an annual basis. 3. Fellows will be evaluated by responsible faculty following each block and semi-annually by PEM faculty 4. Semi-annual updates with the fellowship director must be scheduled and attended. 8
  • 9. EXPECTATIONS FOR THE PEM FELLOW, CONTD Personal Conduct 1. We expect professional behavior at all times. 2. Negative comments about colleagues, consultants, prehospital personnel, or private practitioners are to be avoided, whether in our own ED, other ED’s and ESPECIALLY in the presence of patients or their families. Real problems may be dealt with through the existing QA process. 3. We expect a high level of diligence, energy, and enthusiasm from our fellows. 4. Regarding scheduling, fellows must do what attendings do: work with the fellowship director, ED departmental scheduler and work with those making the schedules for the outside rotations. 5. We adhere to the NYS and the ACGME resident work hour rules. These are clearly outlined in the moonlighting section of this manual. Please know these rules. If you believe you are in violation of these rules, you must contact the fellowship director immediately. Action will be taken to modify your schedule so you can be in compliance with the rules. 6. For courses, you must sign up yourself and work the schedule to make things fit. When problems arise, make them known to us early, so that we may deal with them effectively. 7. Significant “face time” is expected: when not required elsewhere, fellows should be present in their office fairly regularly, where they can participate in the day-to-day goings-on of an academic division and department. However, taking days off for needed home life, when not in conflict with the job, is allowed. 8. You will be required to do certain tasks at regular intervals, such as diversity training, getting a physical, filling out evaluations, work hours surveys, getting fitted for protective equipment, etc. Although sometimes onerous, doing these things promptly makes life easier and is part of professional life. 9. Fellows will remain in Rochester, and participate in usual Fellowship activities, through the end of the training period. Leaving early detracts from the training experience, (even if clinical requirements have been met), and will not be allowed. An off-site elective may be arranged, with permission of the fellowship director. 10. Fellowship contracts typically begin July 1st and end June 30th 3 years later. (Or 2 years for EM residency graduates). Although, clinical hours may be completed prior to June 30th of this third year. Fellowship training is not done until 33 months have been completed for graduates of PEDS residency, and 22 months for graduates of EM residency. 11. Fellows should carefully read and be familiar with the admission requirements to sit for Pediatrics EM subspecialty boards. 12. Fellows should be very familiar with the contents of the PEM fellow’s manual. 9
  • 10. IMPORTANT PHONE NUMBERS Program Director for Pediatric Emergency Medicine: Anne F. Brayer, MD Office Home Beeper Secretary: 463-2934 473-0827 275-1616: 3843 Tawni Biggins 463-2942 PEM Fellowship Coordinator Office Jessica Mead 463-2926 Division Chief Director of Pediatric Emergency Medicine: Colleen O’Neil Davis, MD, Office Home Beeper Secretary: MPH 463-2931 275-1616:1137 Tawni Biggins 463-2942 Program Director for Emergency Medicine Residency: Flavia Nobay, MD Office Home Beeper Secretary: 463-2935 275-1616:4319 Michelle Abraham 463-2940 Department of Emergency Medicine Chair: Latha Stead Office Home Beeper Secretary: 463-2970 275-1616: Tawni Biggins 463-2970 HOSPITAL PHONES AND PAGING If you know the beeper number of the person you wish to reach, dial 275-1616 and the appropriate number. The hospital also maintains paging operators around the clock, with whom you can reach from any hospital phone by dialing 275-2222. Most of the telephones in the hospital are for local calls only. The ED secretary phones have long-distance capability. University telephones may not be used for personal long distance calls. 10
  • 11. FACULTY PEDIATRIC EM CORE FACULTY All are Pediatric ED attending physicians, and all participate actively in teaching PEM fellows in several settings, including weekly PEM conferences and EM teaching conferences. In addition, there are several General Emergency Medicine attendings that work clinically in the PED, as well as participate in the teaching and research curriculum. Name Title/Position Training Research Interests Mohamed Badawy, MD Assistant Professor Pediatric Residency: New York Medical Pediatric Trauma College, Valhalla, NY Head Injuries PEM Fellowship: University of Rochester, Ken Graf award for Research in EM Rochester, NY Anne Brayer, MD Associate Professor Pediatric Residency: Children’s Hospital of Injury Prevention PEM Fellowship Director Pittsburgh, Pittsburgh, PA Toxicology Director of Injury Free Coalition for Kids PEM Fellowship: University of Rochester, Closed Head Injury Rochester, NY Tele-medicine Clinical research Colleen O’Neil Davis, MD, Associate Professor Pediatrics Residency: University of Pre-hospital Care MPH Chief, Pediatric Emergency Medicine Rochester, Rochester, NY Residency Education Aeromedical Liasion Pediatric Cardiology Fellowship: University Clinical research of Rochester, Rochester, NY Madelyn Garcia, MD Assistant Professor Pediatric Residency: University of Rochester Pediatric EM Fellowship: University of Rochester, Rochester, NY Sharon G. Humiston, MD, Associate Professor Pediatric Residency: University of Iowa International Expert on Childhood MPH School of Medicine, Iowa City, IA Immunizations Marc Lampell, MD Senior Instructor Pediatric Residency: The Children’s Hospital of Buffalo, Buffalo, NY Ann M. Lenane, MD Associate Professor Pediatric Residency: SUNY Upstate Evaluation of Abused Children Medical Director, Referral & Evaluation of Medical Center, Syracuse, NY Abused Children Clinic (REACH). Pediatric Ambulatory/Emergency Medical coordinator of the Monroe County Fellowship: Children’s Hospital Medical Multidisciplinary Case Review Team Center, Cincinnati, OH Co-Chair AAP District I Committee on Child Abuse 11
  • 12. EMERGENCY MEDICINE CORE FACULTY All take part in EM teaching conferences by lecturing and/or actively participating. Name Jeffrey Bazarian, MD, MPH Runs Monthly Evidence-based Journal Club Brian Blyth, MD Teaches the Neurology Block for EM residents Eric Davis, MD Regional EMS Director; Director, EME Fellowship, Co-preceptor for prehospital elective Rollin (Terry) Fairbanks, MD, MS, NREMTP EMS rotation preceptor, coordinator on the annual board review series, resident research advisor/preceptor; instructor for the resident PALS, ACLS, and ATLS classes; member of EM resident advisory board; teaches EMS, critical care, and patient safety/medical error topics; attending for pediatric and adult ED’s Charlie Inboriboon, MD Assistant Residency Director, EM. Coordinates EM residency lecture schedule and Grand Rounds Michael Kamali, MD Vice-Chair of Emergency Medicine, and Chief of Emergency Department Clinical Affairs Kate O’Hanlon, MD Outline curriculum and organizes the teaching schedule for the EM residents Joel Pasternack, MD Runs EM / Orthopedics QA Conference; teaches suturing practicum; Attending in Pediatric & Adult Emergency Department Sandra Schneider, MD Previous Chair of Emergency Medicine Runs toxicology rotation and EM Administrative rotation. Manish Shah, MD Director, EMS Research; teaches in EMS, research, and Geriatrics Matthew Spencer, MD Assistant Director, EM Residency Program, coordinates clinical EM rotations (trauma bay) Linda Spillane, MD Previous director, EM Residency Program; Assistant Dean of Medical Simulation, coordinates simulation sessions Kenneth Veenema, MD, MBA Director, Sports Medicine Fellowship; lectures on sports medicine / orthopedic topics. 12
  • 13. FELLOWS Fellow Fellowship Medical School Residency/Postdoctoral Education Dates Elizabeth Murray, DO 2007-2010 University of New England College of Osteopathic Dartmouth Medical Center, Children’s Hospital at Dartmouth Medicine Lebanon, NH Biddeford, ME Kirsten Rindal, MD 2008-2010 Oregon Health Sciences University School of Medicine University of Rochester Dept. EM, Rochester NY Portland, OR Asim Abbasi 2009-2012 The University of Toledo College of Medicine University or Rochester Dept Pediatrics, Rochester NY Kiran Raman 2009-2012 University of Massachusetts Medical School University or Rochester Dept Pediatrics, Rochester NY ALUMNI Our graduates have achieved success in a variety of practice settings: Name Position Location of Practice Sallie P. Mady, MD Instructor of Pediatrics Pediatric Emergency Medicine 1992-1994 Attending Physician Framingham Union Hospital 115 Lincoln Street Framingham, MA 01702 Teresa Herbert, MD Attending Pediatrician 4 Brook Forest Drive 1993-1995 Private Pediatric Practice Arden, NC 28704 Marita Rafael, MD Attending Pediatrician, Pediatric Emergency Medicine Children’s Medical Center of South Texas 1993-1995 Corpus Christi, TX Anne F. Brayer, MD Associate Professor Department of Emergency Medicine 1994-1996 Emergency Medicine University of Rochester, Strong Memorial Hospital & Pediatrics 601 Elmwood Ave., Box 655 Rochester, NY 14642 Wendy Sacks, MD Not currently practicing 1992-1996 Summer A. Smith, MD Director, Pediatric Emergency Medicine Swedish Medical Center 1995-1998 510 East Hampden Avenue Englewood, CO 80110 13
  • 14. Name Position Location of Practice Mark A. Hostetler, MD, MPH Associate Professor & Director University of Chicago 1997-1999 Pediatric Emergency Medicine One Children’s Place Pediatric EM Fellowship Director St. Louis, MO 63110-1077 Mohamed K. Badawy, MD Assistant Professor, Emergency Medicine & Pediatrics Department of Emergency Medicine 1999-2002 University of Rochester, Strong Memorial Hospital 601 Elmwood Ave., Box 655 Rochester, NY 14642 Dante A. Pappano, MD Senior Instructor, Emergency Medicine & Pediatrics Department of Emergency Medicine 2001-2004 University of Rochester, Strong Memorial Hospital 601 Elmwood Ave., Box 655 Rochester, NY 14642 Madelyn Garcia, MD Senior Instructor, Emergency Medicine & Pediatrics Department of Emergency Medicine 2002-2005 University of Rochester, Strong Memorial Hospital 601 Elmwood Avenue. Box 655 Rochester, NY 14642 Kevin O’Gara, MD Assistant Professor, Rochester General Hospital Rochester General Hospital 2003-2006 Colleen E. Markevicz, MD Attending Physician, Pediatric Emergency Medicine Rochester General Hospital 2004-2007 Micheyle Goldman, DO Attending Physician Joe DiMaggio’s Children’s Hospital 2005-2008 1000 Joe DiMaggio Drive Hollywood, FL 33021 Seema Bhatt, MD Assistant Professor of Clinical Pediatrics Cincinnati Children’s Hospital Medical Center 3333 Burnett Ave ML 2008 2006-2009 Cincinnati, OH 45229 Robert Deutsch, MD Attending Physician, Pediatric Emergency Medicine Saint Barnabas Medical Center 2006-2009 Emergency Medical Associates 651 West Mount Pleasant Avenue Livingston, NJ 07039 14
  • 15. CURRICULUM OVERVIEW The curriculum consists of a wide variety of rotations to ensure a complete range of training that is required of a Pediatric Emergency Medicine physician. The year is divided into 13 blocks, each consisting of four weeks. Attached is an outline of the curriculums. Graduates of pediatric residencies will need a three-year program, and graduates of emergency medicine residencies will require a two-year curriculum. 13 blocks – 4 weeks each Vacation – Total 4 weeks [out of PED/Research blocks only] For Graduates of a Pediatrics Residency (3 Year Program): Year 1 ¼ block of orientation 6 ½ blocks ED 1 block Anesthesia 1 block PICU 1 block Toxicology 1 block Trauma 1 block Research ¾ block Ultrasound ¼ block Emergency Psychiatry ¼ block Reading Elective Required Courses: Fall Semester: Epidemiology, Statistics Spring Semester: Other course(s) offered by the Department of Community and Preventive Medicine, approved by the Fellowship Director Year 2 6 ½ blocks ED 1 block Emergency Medicine Orthopedics/ Pediatric Orthopedics/Sports Medicine 1 block Elective ½ block OB/Gynecology ½ block EMS ½ block Child Abuse/REACH Clinic 2 blocks Research 1 block Ultrasound Required Courses: Fall Semester: Ethics Spring Semester: Other course offered by the Department of Community and Preventive Medicine, approved by the Fellowship Director Year 3 6 blocks ED 2 blocks Electives 1 block Administration/Teaching 4 blocks Research 15
  • 16. For Graduates of an EM Residency (2 Year Program): Year 1 ¼ block Orientation ¼ block Reading Elective 8 blocks ED 1 block Anesthesia ½ block Pediatric 1 block PICU 1 block Research 1 block Elective Required Courses: Fall Semester: Epidemiology, Statistics Spring Semester: Other course(s) offered by the Department of Community and Preventive Medicine, approved by the Fellowship Director Year 2 7 blocks ED 1 block Pediatric Clinic 1 block Elective 1 block NICU ½ block Administration ½ block Child Abuse/REACH Clinic 2 blocks Research Required Courses: Fall Semester: Ethics Spring Semester: Other course(s) offered by the Department of Community and Preventive Medicine, approved by the Fellowship Director TRAINING GOALS, BY YEAR AND CATEGORY The following are the minimum training goals for trainees, and are also the requirements for promotion and graduation. Specific policies regarding promotion, probation, graduation, and termination, are also published annually by the University of Rochester’s Office of Graduate Medical Education, in such publications as the “Resident Manual for Medical and Dental Programs.” If they are in conflict, the University’s policies should take precedence. Research Year 1 Identification of a research mentor, and an area of special research interest. Background reading in this area well underway. Has RSRB approval for conducting research. Year 2/3 Research project completed. Hypothesis-driven paper submitted for peer-reviewed publication; meets research requirement for ABP PEM sub-board certification. Preferably: Abstract submitted for presentation to professional scientific meeting. Teaching Year 1 Has taught a variety of learners in several settings: clinical, conferences, labs. Has learned from constructive feedback how to improve teaching. Year 2/3 Continue to improve teaching skills. Has gone outside his/her “comfort zone” either by teaching topics not in areas of most expertise or learners not in usual categories. Has taught EMS personnel, nurses, students, residents, fellows, and faculty. Is an effective teacher. Teaching evaluations uniformly favorable. 16
  • 17. Clinical Knowledge and Procedures Year 1 Has mastered the large majority of the subject material of Pediatric Emergency Medicine, as demonstrated in patient interactions, faculty evaluations, and in-service exam scores. Has performed a variety of procedures required/noted by PEM sub-board (and noted them on procedure log). Has passed (defined as no 1/5 and no more than two 2/5 areas on rotation evaluation) all clinical rotations; rotations not passed have been or will be made up. Year 2/3 Well-versed in all areas of Pediatric Emergency Medicine. No major knowledge deficits. Familiar with critical evaluation of clinical literature. In-service exam scores suggest ability to pass PEM sub-board exam. Has performed nearly all procedures required/noted by PEM sub-board (and noted them on procedure log). Has passed (defined as no 1/5 and no more than two 2/5 areas on rotation evaluation) all clinical rotations and made up any that have not been passed. Administrative Year 1 Has participated in PEM division meetings and some administrative activities. Aware of administrative and ethical issues confronting the Pediatric ED attending physician. Year 2/3 Has successfully completed (passed, as defined above) the required administrative and EMS rotations. Understands EMS issues. Good understanding of the administrative component of the job of a PEM physician. Academic Year 1 Has successfully begun coursework in epidemiology / research design / biostatistics. Can participate meaningfully in journal club. Year 2/3 Has successfully completed (C or better grades) all required coursework in epidemiology / research design / biostatistics and research ethics. Skillful critical reader of the medical literature. Citizenship/Other Year 1 Participates in departmental, divisional, and fellowship affairs as requested. Completes required tasks, such as evaluations, physical exam forms, and TB mask fittings, among others. On-time for clinical shifts. Professional behavior. Meets University requirements for trainees. Year 2/3 Continues to participate in departmental, divisional, and fellowship affairs as requested. Completes required tasks, such as evaluations, physical exam forms, and TB mask fittings, among others. On-time for clinical shifts. Professional behavior. Meets University requirements for trainees. Continues functioning as a trainee until training program is completed. 17
  • 18. SAMPLE OF YEARLY BLOCK SCHEDULES PEM FELLOWS SAMPLE PEM FELLOWSHIP PROGRAM SCHEDULE 2009-2010 ROTATION ROTATIONS Blocks PERIOD 1ST YEAR FELLOW 2ND YEAR FELLOW 3RD YEAR FELLOW 1: 6/24/09-7/23/09 Orientation/ Peds ED Orthopedics Research 2: 7/24/09-8/20/09 Peds ED Research Research 3: 8/21/09-9/17/09 Peds ED Peds ED Peds ED 4: 9/18/09-10/15/09 Peds ED Elective Peds ED 5: 10/16/09-11/12/09 Toxicology Peds ED Peds ED 6: 11/13/09-12/10/09 Peds ED Peds ED/OB Peds ED 7: 12/11/09-1/7/10 Peds ED Peds ED Elective 8: 1/8/10-2/4/10 Elective Anesthesia Research 9: 2/5/10-3/4/10 Peds ED Peds ED Research 10: 3/5/10-4/1/10 PICU Ultrasound Administrative 11: 4/2/10-4/29/10 Research Peds ED Peds ED 12: 4/30/10-5/27/10 Psych/Ultrasound Peds ED Research 13: 5/28/10-6/23/10 Trauma EMS/Child Abuse Peds ED * Vacation – Total 4 weeks [out of PED/Research blocks only] 18
  • 19. PEDIATRIC ED SCHEDULE Daily schedule of attending physicians and fellows in the pediatric emergency medicine department. 19
  • 20. JUL.09 PEDS PEDS PEDS PEDS-FACULTY PEDS-FELLOWS TRAUMA O/N EM Grads Curriculum # of # of PED Shifts/Block Conference Attendence DatePeds Grads Curriculum 0700-1500 1500-2300 Blocks # of 2300-0700 Weeks # of PED Shifts/Block 1730-2330 1500-2300 2330-0730 Shifts/Block** Conference Attendance Adult Blocks Weeks Year 1 1-W Year 1 BADAWY BRAYER FAIRBANKS ABBASI MURRAY Orientation Orientation 0.25 0.25 1 1 2 0 Peds EM Conference 2 Peds EM Conference 2-ThED GARCIA Reading Elective BADAWY 6.5 BRAYER 0.25 26 1 RAMAN 13 12 to 2 Peds EM Conference 0 Peds EM Conference Anesthesia 1 8 4 32 2 0 Anesthesia 3-F ED LAMPELL GARCIA BADAWY ABBASI 14 Peds EM Conference PICU Anesthesia 1 1 4 4 0 2 Anesthesia 0 PICU 4-S ToxicologySPILLANE Pediatric LAMPELL 1 0.5 BADAWY 4 2 LENANE RINDAL to 6 4 0 Toxicology, PEM Conference^ Peds EM Conference Trauma PICU 1 1 4 4 0 0 PICU 0 PICU 5-S Research BRAYER FAIRBANKS LAMPELL 1 1 LENANE 4 4 RINDAL to 8 6 1 Peds EM Research 8 to 10 Peds EM Conference, EM Conference, EM Research 6-M Ultrasound BRAYER HUMISTON 0.75LAMPELL 3 YAWMAN ABBASI 1 Research 0 Peds EM Conference Emergency Psychiatry Elective 0.25 1 1 4 1 0 Peds EM Conference^ 6* Peds EM Conference 7-T Reading Elective SPILLANE Required Classes DAVISC 0.25 GARCIA 1 MURRAY 0 0 Required Classes Statistics Fall: Epidemiology. 8-W HUMISTON DAVISC BRAYER ABBASI MURRAY Fall: Epidemiology, Statistics Spring: Other courses 7-11:30Spillane/Humiston 9-ThSpring: Other Courses 11:30-3 LAMPELL MURRAY RINDAL Year 2 10-F Humiston LAMPELL HUMISTON LENANE RAMAN Year 2 ED 7 28 14 Peds EM Conference 11-SEDPediatric Clinic BRAYER SPILLANE 6.5 1 DAVISC 26 4 LENANE ABBASI 12 11 or 3 Peds EM Conference Peds EM Conference EMO Elective 1 1 4 4 0 0 Peds EM Conference 6* Peds EM Conference 12-SElective HUMISTON BRAYER BADAWY 1 1 LENANE 4 4 RAMAN 4* 0 NICU 0 NICU Conference Peds EM Conference OB/Gynecology 13-MAdministration LAMPELL DAVISC 0.5 0.5 BADAWY 2 2 RINDAL ABBASI 0 0 OB/Gynecology 2 Peds EM Conference EMS Abuse/REACH Clinic Child 0.5 0.5 2 2 1 1 to 2 Child Abuse 0 Peds EM Conference^ 14-TChild Abuse/REACH Clinic SPILLANE Research LAMPELL 0.5 2 GARCIA 2 8 MURRAY 1 8 to10 Peds EM Conference, EM 0 Child Abuse / Peds EM Conference Research 2 8 6 to 8 Research 1 to 2 Peds EM Conference, EM Research 15-W LAMPELL DAVISC BRAYER ABBASI MURRAY UltrasoundClasses Required 1 4 3 to 4 0 Peds EM Conference 16-ThRequired HUMISTON Fall: EthicClasses BADAWY LAMPELL RAMAN Fall: Ethics Courses Spring: Other 17-FSpring: Other Courses GARCIA BADAWY LAMPELL RINDAL 18-S * One elective may be free of shift responsibilities HUMISTON GARCIA DAVISC ABBASI Year 3 ^Pediatric EM Conference when available and if no conflicts 19-SED total time = 110 shifts 1st year ==> 100 shifts 2nd years PED BADAWY HUMISTON O'GARA 6 24 RINDAL 12 11 to 3 Peds EM Conference 20-M Electives Courses: Epidemiology, Biostatatistics, Ethics, and82 other courses Required BADAWY 2 4* 0 Peds EM Conference KAMALI SPILLANE YAWMAN RINDAL Administration/Teaching Vacation: Total of 4 weeks/year out of ED or 1research only 4 4 0 Peds EM Conference 21-TResearch BRAYER LAMPELL 4 O'GARA 16 Dawson MURRAYto 6 4 1 to 2 Peds EM Conference, EM Research 22-W PASTERNACK LAMPELL BRAYER ABBASI MURRAY * One elective may be free of shift responsibilities 23-Th^Pediatric HUMISTON EM Conference when available and if no conflicts DAVISC BADAWY ABBASI PED total time = 90 shifts/year ==> 270 shifts/ 3 years 24-FAdult ED total time - 9 shifts PASTERNACK 14 shifts (year 2) + 19 shifts (year 3)RAMAN shifts LAMPELL (year 1) + BADAWY ==>42 25-S **Mosts of Adult Shifts should be done in ED BADAWY BRAYER PASTERNACK or Research months, however under some circumstances these may needed to be done during other rotations RAMAN 26-S HUMISTON BRAYER LAMPELL MURRAY 20 27-M FAIRBANKS DAVISC LAMPELL MURRAY 28-T BRAYER PASTERNACK BADAWY RAMAN
  • 21. EMERGENCY DEPARTMENT POLICY FOR SCHEDULING VACATION/CME AND TIME-AWAY Graduates of an emergency medicine residency program must complete total of 22 months of training in order to be eligible to graduate from the fellowship and sit for the PEM ABEM boards. It is important that graduates of a pediatric residency must complete a total of 33 months of training in order to be eligible to graduate from the fellowship and sit for the PEM ABP boards. The fellow is encouraged to discuss any potential problems that may interfere with their responsibilities as fellows with the fellowship director. If a leave from work in necessary, the fellowship director can help guide the fellow through the various types of leave. Rationale • Providing adequate ED clinical coverage in an organized and predictable manner is a core requirement in the Department of Emergency Medicine. • Providing predictable Time-Away for academic and personal activities is also extraordinarily important. • Requirements for advance travel planning for Time-Away necessitate lead time longer than the current 8 week cycle for requests and 4 week cycle of notification. • This policy applies to all ED attending coverage scheduled by Dept. EM. Procedures 1. A Time-Away request schedule will be maintained as a calendar made available to Faculty to request blocks of time free of clinical shifts. 2. No more than 3 faculty can request Time-Away for vacation for any given week. 3. Time-Away request is inclusive ONLY of the shifts on the dates noted (0800 to 2400). If early am travel on the first vacation day is expected, please cross-off night shift on the schedule request—do not have to request as a vacation day. 4. During periods of key national meetings (SAEM, ACEP, AAP), no vacation or other time-away can be expected to be scheduled (can be considered after the clinical schedule has been finalized). Personal Time-Away before OR after (but not both) a meeting can be scheduled in the usual manner. 5. Priority to attend a key national meeting will be: a. Key national officer b. Presenting author or lecturer c. Committee member d. Mentor to presenting author or lecturer e. Inability to attend previous year’s meetings 6. A separate request will be in place for the following periods, with requests made by August 10 of each year (with October schedule request). a. November/December holidays: Thanksgiving, Christmas, New Years i. Only 1 of the 3 can be requested off. ii. Holiday travel cannot span both Christmas and New Years. b. President’s Week i. Preference given to Faculty with school-age children, and to those same Faculty who did not get time off the previous year. ii. Only 1 of the 2 weekends can be requested. 7. Flexibility of all the above is at the discretion of the Scheduler. 8. Policy can be modified at the discretion of the Chair.
  • 22. SAMPLE PEM FELLOWS SCHEDULE REQUEST Physician Name ______________________ Rotation name Dates # ED shifts 1._________________________________________________________ 2. _______________________________________________________ 3. _______________________________________________________ 4. _______________________________________________________ Vacation Dates __________________ September 09 PEM FELLOWS SCHEDULE REQUESTS SUN MON TUE WED THUR FRI SAT -1 -2 -3 -4 -5 15-23 15-23 15-23 15-23 15-23 23-07 23-07 23-07 23-07 23-07 -6 -7 -8 -9 -10 -11 -12 15-23 15-23 15-23 15-23 15-23 15-23 15-23 23-07 23-07 23-07 23-07 23-07 23-07 23-07 -13 -14 -15 -16 -17 -18 -19 15-23 15-23 15-23 15-23 15-23 15-23 15-23 23-07 23-07 23-07 23-07 23-07 23-07 23-07 -20 -21 -22 -23 -24 -25 -26 15-23 15-23 15-23 15-23 15-23 15-23 15-23 23-07 23-07 23-07 23-07 23-07 23-07 23-07 -27 -28 -29 -30 15-23 15-23 15-23 15-23 23-07 23-07 23-07 23-07 Please return to Jessica by July 15, 2009 Comments:
  • 23. THE EDUCATIONAL PROGRAM I PEM CLINICAL EXPERIENCE PEM fellows will be expected to work significant clinical time in the Pediatric ED. Majority of the shifts will be in the evenings, concentrated during Pediatric ED rotation blocks, although some shifts are likely to occur during other rotations. Fellows will also work some additional shifts during the Pediatric ED blocks in a supervisory role, with an attending backup. During the last year, there are opportunities for the fellow to be the sole supervising attending. II OTHER CLINICAL EXPERIENCE The University of Rochester’s fellowship in PEM is based at the Golisano Children’s Hospital, which is part of Strong Memorial Hospital. Extensive clinical time is spent in the Pediatric Emergency Department. Other required rotations consist of Adult Emergency Medicine, Pediatric ICU, Trauma, Toxicology, Pediatric Anesthesia, Orthopedics/Sports Medicine, Child Abuse, and EMS. A wide variety of electives in Adolescent Medicine, Allergy/Immunology, Dental, Dermatology, Endocrine, ENT, General Pediatrics/Private Pediatric Practice, Genetics, Hematology/Oncology, Infectious Diseases, Immunology, Neurology, Ophthalmology, Pulmonology, Renal, Surgery; may also be arranged. III TEACHING / CONFERENCES Fellows participate in special experiences to learn how to teach. They are expected to teach medical students and residents in formal settings and at the bedside. They are expected to lead several PEM conferences/year, one PICU/ED conference/year, two journal clubs/year and three ED departmental teaching fellow conferences/year. In addition to these are teaching requirements, the fellow may seek out additional teaching opportunities in a variety of settings including suture labs, cadaver labs, and the Department of Pediatrics. 1) PEM Fellows Conferences The weekly PEM Conferences are geared toward PEM Fellows and are intended as training conferences. Each PEM Fellow is expected to present regularly at these conferences. There is a rotating format for the conferences: PEM Journal Club, core medical topic, core surgical/trauma topic, and PEM research. At each conference, one fellow is also responsible for presenting a recent case, including the history, physical exam, results, diagnosis, and any journal articles related to the case. In addition, the fellow discusses one interesting complex case/year at the combined PICU/ED conference held every other month. Below is a sample agenda a PEM Fellows conference. Day of week and time changes periodically as to avoid conflicts with other activities. 2 hours/week Sample Agenda 12:00 PM– 12:15 PM Weekly Staff Update 12:15 PM – 1:00 PM Fellows Case Conference 1:00 PM – 2:00 PM PEM topic / Journal Club / Research Presentation Fellows’ Conferences (Types of Conferences): • Case Presentation • M&M • Jeopardy • Lecture • Journal Club • SOCS (Scholarly Oversight Committee) Meeting*  Changed to FELLOWS’ RESEARCH UPDATE * NOTE CHANGES
  • 24. Scheduling/Conflicts: The schedule for 2009-2010 has been made with consideration given to each fellows’ rotation blocks and vacations, as well as so that each fellow is assigned an equal number of conference presentations. ONLY JESSICA MAKES CHANGES TO THE SCHEDULE which is saved on the S drive. While it is understandable that conflict may arise and fellows may want to “trade” or “switch” conferences, THE DATES/TIMES FOR ANY GIVEN CONFERENCE IS NOT NEGOTIABLE. THEY ARE SET IN STONE. If you cannot give a conference that you are assigned, you may ask a colleague to give that conference for you, and must set up a trade that you both consider fair. You CANNOT switch the date/time/type of conference, ONLY the person presenting the conference. (Example: Murray is giving Journal Club on 8/5/10, but can’t do it. She can ask others to give it for her and they can decide if she has to “pay them back later” or they can be nice and do the extra presentation “for free”. But regardless, on 8/5/10 a Journal Club should be presented!!! ) Developing Your Career Portfolio: Please make sure you E-mail Jessica a copy of EVERYTHING you do so that she can save a paper copy of it in your fellowship binder. You will review these with Anne at your evaluations. Plus, it’s a great way to see all that you’ve done in the 3 years of fellowship (and a safety net in case your computers crash to have a copy of your work). 1. Case Presentation a. A case you have personally been involved with. b. Format – PowerPoint presentation to include the following: i. Chief complaint ii. HPI/PE/labs/imaging – Copy the ED chart and have printouts of all pertinent documentation – e.g. labs/EKGS/Outside ED workups/consultant notes. iii. Allow group to participate in generating differential diagnosis and plan iv. Patient follow-up  i.e. What ended up happening to them? This means getting printed up Op-notes, PICU paperwork, etc. v. Take home points  Each case should have a “Pearl” associated with it, or why you were drawn to the case in the first place. This can be a clinical pearl, interesting physical exam finding, unusual EKG tracing, discussion about
  • 25. management (you decide). At minimum there should be some work done for the presentation that makes this point. Thus, at least look up the diagnosis on e-medicine or UpToDate and review for the group. 2. M & M a. A case you have personally been involved with AND you think provides a starting point for a group discussion. (Examples from the past have included issues with long EMS resuscitations, or treatment of DKA patients with incorrect IVF, cases where the consultant did not agree with the attending assessment/plan). When choosing a case for M & M, ask yourself, how will this presentation change our management as a group? What will be my “Take Home Points”? b. Format – same as above with more in depth review of the literature pertinent to your take home point. This means at minimum a review of the topic using e-medicine, UpToDate, MEDLINE, reference texts and review articles. c. Conference Outline - Provide a 1 page outline to use as a guide for conference. i. Patient name, MR number, date of ED visit, Diagnosis, Dispo (admit, admit ICU, D/C, died), Take Home Point(s) for discussion, reference article you give out to the group. d. Supporting Items - Make sure to bring supporting items in case questions arise – (e.g. arrhythmia cases- copy EKGs, EMS rhythm strips, hypotensive shock patients where the choice of pressor is the issue – copy the resuscitation ED chart or the PICU one. e. Article - Bring one article to distribute to the group - can be review article, or trial, or case series (you decide). 3. Jeopardy a. This is a scheduled conference that occurs 4-5 times a year (each fellow is responsible for one Jeopardy presentation a year). It serves the purpose of Board Review for topics that don’t lend themselves well to lecture format. b. Format - Please use the Jeopardy Template (Jessica to save a copy to the S Drive) so that they are all the same. i. Each Jeopardy will be on a certain topic (already assigned). ii. Include pictures, EKGs, etc to keep it interesting. Use PEM Board review books to get your questions, or design them yourselves. iii. Please make sure to be familiar with ALL the answer choices on the multiple choice questions, as this is a board review and we want to maximize learning.
  • 26. 4. Lectures a. This is your chance to teach the faculty and your fellow colleagues about a given topic in depth. b. When you are done with your fellowship, these will become the “core lectures” you will take with you and re-use for years. Thus, choose wisely. Pick topics that will interest your audience. Ideas include: (1) using Fleisher and Ludwig chapter headings as a guide you could pick signs/symptoms as a lecture and review in general, or (2) Choose one topic from a case you cared for and really review the literature on it in depth. c. Format – PowerPoint ~ 45 minutes long with time for questions/answers at the end. i. You must review the literature for these lectures. ii. Include interesting pictures/imaging/tracings – remember, when you leave SMH you’ll want actual patient pictures (de-identified, of course) for future lectures. d. TIMELINE – You are responsible for looking at the conference schedule ahead of time and planning your time accordingly. You will be responsible for letting Jessica and I know your topic at least 1 month ahead of time. This will force you to commit and ensure that you have enough time to work on it and do a good job. IF no topic has been chosen at least one month prior to your scheduled lecture, then a topic will be assigned to you. 5. Journal Club a. In order to be useful to all, Journal Clubs must be prepared before hand and articles distributed to all (electronically as an E-mail attachment) at least the 1 week prior to scheduled presentation. Preferably, remind people about at the fellow’s conference the week before and if you have paper copies, distribute them at conference. b. Format – DOESN’T have to be PowerPoint, but must be a very structured exercise. i. DO NOT 1. Give out your article the day before 2. Open Journal Club with the comment, “This is a terrible study” 3. Allow participants to ramble on tangents and only criticize without giving constructive or insightful critique 4. Say, “I have no idea what that statistical test is, let alone how to interpret it” If you picked the article, figure it out before you present! ii. DO
  • 27. 1. Introduce your Journal Club with an opening anecdote, “I chose this article because I had the following issue/question” 2. Bring an outline (can be for yourself) that we follow. 3. Please ask Mohamed or Colleen Davis to provide you a copy of their handouts that go over in detail how to critique any given type of article. 4. Pick a GOOD article –one that answers a question you or your colleagues had. 6. SOCS Meeting  changed to  Fellows’ Research Update a. As part of the ACGME requirements for PEM fellowship training, fellows are required to conduct “meaningful research/scholarly activity”, guided by faculty overseers that form the SOCS committee. These meetings (Fellow Research Update), which are on the schedule every 2 months, are to help keep your research on track. b. These are working meetings – i.e. the more you bring to the table, the more you get out of it, so come prepared. As they are scheduled one year in advance, no fellow should ever come to these meetings without at least a clear idea of where their research is. Even if you are a first year fellow, tell us what your interests are, who you’ve met with, etc. c. Format – Very shortly, you will be provided with the “Steps” required in order to fulfill your research requirement for fellowship/MPH/sitting for PEM boards. There will be a binder at this meeting where we track your progress and save whatever you have done to date (rough drafts, ideas, etc). d. Goals: i. Understand all the steps required by PEM fellowship/MPH program to fulfill requirements ii. Learn about dates/timelines – You should make sure to leave each meeting with a clear “next step” to pursue. e.g. When does the next ED research committee meet? Can I get my work done for that one? When is the next meeting (AAP, SAEM, ACEP) – when are those abstracts due? Can I get my work done for that? iii. Raise issues – if you can never meet with you committee, or are “getting lost” – speak up – use this as a trouble shooting session. Of course, Anne will want to know ASAP if this is happening to help you. iv. Get feedback – faculty at this meeting are captive audience – just think, you don’t have to set up an appointment to ask their opinions. Don’t be timid- share your ideas/bring drafts (no matter how rough). SOCS Committee Meetings You are responsible for setting up your own SOCS Committee and arranging these regular meetings. Given people’s time-commitments and how hard it is to coordinate schedules, you may have to meet with your SOCS committee members individually. YOU SHOULD GET A SIGN IN SHEET FOR EACH MEETING YOU HAVE and GIVE IT TO JESSICA TO KEEP. SOCS Committee should be the same people as you have on your MPH committee.
  • 28. 2) Department of Emergency Medicine Conferences Department of Emergency Medicine has weekly teaching sessions for the EM residents. PEM Fellows are expected to attend topic-appropriate Emergency Medicine core conferences. They may also prepare and present several teaching sessions at these core conferences each year. They are expected to have an active role in the various M&M and QA conferences, if they were involved with the patients being presented. In addition, PEM Fellows are required to conduct 2 monthly Peds Hour Conferences/year. Conference Frequency EM Grand Rounds 2nd Thursday, Monthly EM Core Lectures/Conferences Weekly Morbidity & Mortality Monthly EM Resident Peds Hour Monthly, expected to give 2 conferences/year to EM Residents ED Research Conference Bi-monthly EKG/X-Ray Weekly Toxicology Teaching Bi-monthly EM Case Conference Weekly EM/Orthopedics QA Conference Monthly EM Trauma QA Conference Monthly EM Quality Conference Monthly EM Journal Club Monthly 3) Department of Pediatrics Conferences PEM Fellows are urged to participate in the Department of Pediatrics conferences. In addition, they contribute as consultants at Pediatrics morning report. PEM Fellows typically present at some Pediatrics noon conferences; these are the core topic teaching conferences for the Pediatrics Residency. 4) Pediatric Fellows Academic Core Curriculum Fellows in the Department of Pediatrics attend a series of conferences throughout the year on a variety of topics. Some (but not all) of the topics are not only pertinent, but required for PEM fellows. You will be notified of the schedule when it becomes available. IV RESEARCH A. Research Project 1) Overview Every Pediatric Emergency Medicine Fellowship Program is expected to engage fellows in specific areas of scholarly activity to allow acquisition of skills in the critical analysis of the work of others; to assimilate new knowledge, concepts, and techniques related to the field of one’s practice; to formulate clear and testable questions from a body of information/data so as to be prepared to become effective subspecialists and to advance research in pediatrics; to translate ideas into written and oral forms as teachers; to serve as consultants for colleagues in other medical or scientific specialties; and to develop as leaders in their fields.
  • 29. All fellows will be expected to engage in projects in which they develop hypotheses or in projects of substantive scholarly exploration and analysis that require critical thinking. Areas in which scholarly activity may be pursued include, but are not limited to: basic, clinical, or translational biomedicine; health services; quality improvement; bioethics; education; and public policy. Fellows must gather and analyze data, derive and defend conclusions, place conclusions in the context of what is known or not known about a specific area of inquiry, and present their work in oral and written form to their Scholarship Oversight Committee (see below) and elsewhere. The Scholarship Oversight Committee (SOCS) in conjunction with the trainee, the mentor, and the program director will determine whether a specific activity is appropriate to meet the ABP guidelines for scholarly activities. In addition to biomedical research, examples of acceptable activities might include a critical meta-analysis of the literature, a systematic review of clinical practice with the scope and rigor of a Cochrane review, a critical analysis of public policy relevant to the subspecialty, or a curriculum development project with an assessment component. These activities require active participation by the fellow and must be mentored. The mentor(s) will be responsible for providing the ongoing feedback essential to the trainee’s development. 2) The Work Product of Scholarly Activity Involvement in scholarly activities must result in the generation of a specific written “work product,” which may include: • A peer-reviewed publication in which a fellow played a substantial role • An in-depth manuscript describing a completed project • A thesis or dissertation written in connection with the pursuit of an advanced degree • An extramural grant application that has either been accepted or favorably reviewed • A progress report for projects of exceptional complexity, such as a multi-year clinical trial 3) The Scholarship Oversight Committee Review of scholarly activity will occur at the local level. Each fellow must have a Scholarship Oversight Committee. The Scholarship Oversight Committee should consist of three or more individuals, at least one of whom is based outside the subspecialty discipline; the fellowship program director may serve as a trainee’s mentor and participate in the activities of the oversight committee, but should not be a standing member. This committee will: • Determine whether a specific activity is appropriate to meet the ABP guidelines for scholarly activity • Determine a course of preparation beyond the core fellowship curriculum to ensure successful completion of the project • Evaluate the fellow’s progress as related to scholarly activity • Meet with the fellow early in the training period and regularly thereafter • Require the fellow to present/defend the project related to his/her scholarly activity • Advise the program director on the fellow’s progress and assess whether the fellow has satisfactorily met the guidelines associated with the requirement for active participation in scholarly activities
  • 30. 4) Commitment 1. Each Fellow must sign a SOCS Fellow Contract and turned into the Program Administrator. 2. Each Faculty Member must sign a SOCS Faculty Contract and turned into the Program Administrator. 3. The fellow must meet with their members of their SOCS committee at least 4 times per year. At each meeting, a SOCS committee meeting form must be filled out and turned into the Program Administrator. These documents will be placed into your portfolio. 4. All the Fellows and the members of their SOCS committee will meet semi-annually with the Fellowship Director. 5. The Fellowship Director will not sign off on the ABP Scholarly Work Product Form which is needed for you to sit for the boards until a completed acceptable work product has been reviewed by each of the Fellow’s SOCS committee members. 5) Semi-Annual Presentations Each Fellow will discuss their career goals to the group in a 15 minute presentation with a 15 minute discussion period. Please present in the following format: • Clinical Progress • Education Progress • Administrative Responsibilities • Research Progress B. Formal Course Work Fellows are required to complete five courses: a. One semester of biostatistics b. One semester of epidemiology c. One semester of research ethics d. Two other electives in research methodology (e.g., questionnaire design, decision analysis, design of clinical trials) C. Masters of Science: Clinical Investigation Track Beginning in Fall 2007, the Department of Community and Preventive Medicine (CPM), as part of the recently awarded NIH Clinical Translational Sciences Institute grant, will offer a new Masters program that focuses on health services research training for clinicians. Those completing this program receive the degree, Master of Science (Clinical Investigation). The program focuses on clinical and population based research training for investigators with prior clinical training or for those enrolled in a clinical training program, such as medical school. The primary objective of this program is to train individuals to combine clinical knowledge and population-based research in an academic program that awards a recognized credential indicating expertise in clinical epidemiology, research study design, clinical decision-making, and the evaluation of health care services. PEM Fellows may complete this program without tuition fees. Attached is the current curriculum. Additional information can be found on the department’s web site at: www.urmc.rochester.edu/cpm/education Individuals eligible for this program must have a post-graduate degree in medicine or another health- related discipline. The core courses required are epidemiology, biostatistics, health institutions, environmental and occupational health, and social and behavioral health. The degree is completed with
  • 31. a mentored research experience, usually in conjunction with a post-doctoral fellowship program in the student’s medical field. The mentored research project begins concurrently with coursework, and in most cases will extend beyond completion of courses until the project produces an article accepted for publication in a peer-reviewed journal. MASTER OF SCIENCE CURRICULUM Master of Science: Clinical Investigation Curriculum Course Credits Semester BST 463: Introduction to Biostatistics 4 I PM 415: Introduction to Epidemiology 3 I PM 482: Clinical Evaluative Sciences 3 I IND 503: Ethics in Research 1 I BST 525: Introduction to Health Informatics 3 I Elective 3 I PM 424: PC SAS 2 II BST 465: Design of Clinical Trials 3 II PM 484: Medical Research and Cost-Effectiveness 4 II Analysis PM 416: Advanced Epidemiologic Methods OR 3 I Advanced Biostats Elective 3 II Total 33 CORE REQUIREMENTS PM 415 Principles of Epidemiology This course provides an introduction to epidemiological concepts of disease and interventions to ameliorate them. The course discusses population-based aspects of disease, morbidity and morality statistics, basic study designs (cross-sectional, case-control, cohort and clinical trials), and the use of epidemiological data to draw conclusions about disease causation. At the end of the course, students should have a broad view of denominator-based medicine and be prepared for higher-level courses in epidemiological methods. PM 429 PC-SAS This course will present an introduction to the SAS system for Windows. The focus of the course will be on data management and statistical analysis using SAS. The student will gain an understanding of SAS as a research tool through the completion of a research project of their own design. Prerequisites: BST 463 or equivalent and knowledge of MS Windows.
  • 32. IND 503 Ethics in Research This course covers a broad range of topics and attempts to address issues that many researchers are likely to face in their careers. A very practical approach is adopted in order to avoid deep philosophical debates, which, although of great interest, are unlikely to be helpful. A description of the University’s policies and procedures in dealing with misconduct in research is included. Attendance is mandatory. STATISTICS REQUIREMENT BST 463 Introduction to Biostatistics Basic statistical and data-analysis methods in medical research. Topics include summarizing and displaying data, elements of probabilities estimation, confidence intervals, hypothesis tests, and methods for comparing means and proportions, and regression analysis. The MINITAB statistical package is introduced and used. The course is strongly use-oriented, stressing practical understanding and interpretation. BST 525 Introduction to Health Informatics Computer applications in health care and biomedicine. BST 465 Design of Clinical Trials Design, conduct, and analysis of clinical trials. Sample size, power, and randomization. Coordination, data management, compliance, interim analysis, and reporting procedures. RESEARCH METHODS REQUIREMENT PM 416 Epidemiologic Methods This course is designed to provide an in-depth coverage of the quantitative methodological issues associated with population-based epidemiological research. Issues specific to study design, conduct, and analysis are emphasized. Topics to be covered include: issues in study design, topics in measurement, methods of data collection, confounding, effect-modification, and multivariate analytic techniques. Prerequisite: PM 415 Principles of Epidemiology and one semester of graduate level statistics or permission of the instructor. OR an advanced biostatistics course of the student's choice. PM 482 Clinical Evaluation & Outcomes This course covers the types of study design and settings available for original observations about clinical interventions and practice patterns. It focuses on the use of patient populations and databases as laboratories for the generation of new knowledge and information. Ways to improve the outcome and efficiency of personal health services through evaluating their effectiveness, quality, appropriateness, and cost are explored. The material covered will introduce the methods, databases and settings available for such studies. Prerequisite: one semester of graduate level statistics or of epidemiology. PM 484 Cost Effectiveness Research Decision analysis is increasingly used to evaluate alternative choices in clinical practice and to enlighten and inform health policy determinations. In this course, students will be introduced to the concepts underlying the quantitative analysis of medical decisions. They will be provided with the basis to understand decision and cost-effectiveness analysis, which appear in the clinical and health services research literature as well as to be able to set up and perform such analysis themselves. Prerequisite: one semester of graduate level statistics.misconduct in research is included. Attendance is mandatory. ELECTIVES 2 one-semester courses with 3 credits.
  • 33. RESEARCH Mentored Research Experience to culminate in research paper suitable for publication. ADMINISTRATION The fellows are exposed to multiple administrative functions within the Department of Emergency Medicine. They assume an active role within our division and are a vital part of our weekly staff updates, which focuses on issues such as census, staffing, communications, finances, complaints, protocols, and quality assurance. During one block, the fellows participate in a formal curriculum lead by the Department and Division Directors that tackle the tasks involved in managing an active department. In addition, the fellows are expected to participate in at least one departmental or hospital committee of their choice. TRACKS The Pediatrics Emergency Medicine Fellowship consists of two tracks. One is a Research Track, which is designed for those who plan on pursuing an academic research career, and obtaining their Master of Science. The other is a Clinical Educator Track, which is designed for those who plan to purse a clinical career. The first year will be the same for both the Research Track and the Clinical Educator Track. During the first year, it is expected that every fellow will complete a total of 4 courses. 1) Research Track This track will allow time for completion of the Masters of Science (Clinical Investigator) though the Department of Community and Preventive Medicine at the University of Rochester. During the second and third year, time is allotted for the completion of coursework. Clinical Requirements for Years 1-3 90 shifts/year Coursework Guidelines Year 1: Fall Introduction to Epidemiology and Biostatistics Spring 2 Courses (elective or required) Summer Introduction to SAS Year 2: Fall Ethics and Other (elective or required) Spring 2 Courses (elective or required) Year 3: Fall 2 Courses (elective or required) Spring 1 Course (elective or required), completion of research project 2) Clinical Educator Track This track will involve additional clinical time and additional responsibilities of teaching medical students and residents during the PED blocks. Clinical requirements for Clinical Educator Track Year 1: 90 shifts/year Year 2 & 3: 120 shifts/year
  • 34. Coursework Guidelines Year 1: Fall Introduction to Epidemiology and Biostatistics Spring 2 Courses Year 2: Fall Ethics Year 2/3: Clinical Educator Symposium/Conference Additional Teaching Responsibilities in Year 2 and 3 • One lecture per PED/Research block to the Pediatric Residents • One lecture per PED/Research block to the Emergency Medicine Residents • One teaching project/year for years 2 and 3. CONTINUING MEDICAL EDUCATION The fellows are encouraged to attend several national meetings and conferences during their fellowship. Fellows are given a stipend $2000 annually to spend on continuing medical education. The Fellowship Director must approve these expenses.
  • 35. PEM TRAINING PROGRAM ROTATIONS Rotation: Administration Location: Department of Emergency Medicine, Strong Memorial Hospital Year Of Training: Year 3 Rotation Length: 4 weeks Contact Person: Anne Brayer, MD PED Shifts: Required – (one 8hr shift per week) Call: None Required Clinic: None Required Conferences: Peds Ed Conference Required Projects: Directed readings assigned by Dr. Schneider Educational Goals and Objectives: Upon completion of this rotation the PEM fellow will be able to: 1. Plan and carry out an administrative project. 2. Develop an understanding of quality assurance. 3. Discuss capitation and managed care and the effect on the Emergency Department. 4. Demonstrate an understanding of physician contracts. 5. Assist with the day-to-day management decisions with the Chair and Clinical Director of the Department of Emergency Medicine. 6. Assist with the financial management decision making of the Department. 7. Describe the day-to-day interactions with hospital administration and the medical staff. 8. Develop an understanding of cost containment and health care financing 9. Understand the basics of medical-legal and risk-management concerns in the ED. 10. Demonstrate an understanding of systems factors that contribute to medical errors. Description of Didactic Experiences: The administrative rotation consists of a series of meetings with various administrators and a series of discussions/exercises under the direction of Sandra Schneider, MD. The purpose of the rotation is to learn from administrators what their job is, how they got there, how to be them, and gleam any pearls of wisdom about leadership and administrative roles in medicine. The PEM fellow will attend meetings of the Management Team, the Quality Assurance Council, Morbidity & Mortality Review, SMH Department Heads & Supervisors Meeting, as well as the Rochester Area ED Director’s meeting. The trainee also has individual discussion time with the Chair of Emergency Medicine, the Medical Director of Emergency Medicine, the Program Administrator of Emergency Medicine, and the (Pediatric) Nurse Manager of Emergency Medicine. During this rotation, each trainee is given a “paper”
  • 36. emergency department to “run”. The trainee experiences administrative responsibilities including schedule making, negotiation, budgeting, and contracting with managed care. The PEM fellow may be required to develop, implement and assess a project to improve clinical care, under the supervision of the Director of Clinical Operations. Trainees are also required to attend regular Pediatric Emergency Medicine teaching conferences during this rotation. You are to meet weekly with the fellowship director to discuss experiences. It is expected that you attempt to set up meetings with the following individuals: Anne Brayer– PEM Fellowship Director Colleen Davis– Chief, Division of PEM Sandra Schneider– Former Chair of EM, ACEP Flavia Nobay– EM Residency Director William Varade– Peds Residency Director Spencer Studwell– Legal Nina Schor– Chair of Pediatrics Patsy Pangia– Nurse Manager Heather Hare– Public Relations Karen Eisenberg– Development Office Suggested reading for the rotation includes: Aghababian, RV., et.al. Emergency Medicine, The Core Curriculum, 1998. Section 20. Fisher, R., Ury, W., Getting to Yes (Residents are supplied with a copy at the beginning of the rotation. Evaluation and Feedback Process Trainees are evaluated in writing at the end of each rotation using a standardized evaluation form by the supervising faculty. Evaluations of the fellow’s performance are compiled for the fellow review at the semi- annual meeting with the program director. Each fellow is also asked to evaluate the educational value of each rotation in writing, at the completion of the rotation. Fellows are asked to refer to the goals and objectives of the rotation when filling out these evaluations. If a rotation coordinator identifies a performance problem, he/she is encouraged to discuss the problem with the trainee directly prior to the end of the rotation such that the trainee has time to correct the problem and successfully complete the rotation. Problems of an urgent nature regarding an individual trainee on a particular rotation are immediately brought to the attention of the program director. These issues are addressed by the program director with the trainee concerned without delay. Fellow performance evaluations are routinely reviewed with each fellow at the time of semi-annual evaluations. If significant performance issues not previously addressed are encountered, they are addressed at that time. Rotation evaluations that are completed by the trainees are reviewed by the Program Director. Feedback about rotations is also solicited at annual program reviews. If a consistent problem or concern is identified, the program director contacts the responsible rotation director about any concerns as well as ways in which the rotation might be improved.
  • 37. Rotation: Adult Emergency Medicine Location: Department of Emergency Medicine; Strong Memorial Hospital Rotation Length: 42 shifts over 3 years Year Of Training: Year 1, 2, and 3 Contact Person: EM Chief Resident PED Shifts: None Work Hours: Wednesday overnight in the Trauma bay, 11:30pm-7:00am Required Clinic: None Required Conferences: Peds ED Conference Role: Physician in the Trauma Bay Educational Goals and Objectives Upon completion of this rotation, the PEM fellow will be able to: 1. Recognize life-, limb- and organ-threatening diseases and injuries in the adult patient. 2. Expand his/her knowledge base through clinical encounters, didactic teaching, case discussion and a program of self-study, of the specific disease entities represented by the following chief complaints in both pediatric and adult patients: a. Abdominal Pain & Distention, Nausea & Vomiting, Hematemesis, Hematochezia, Dysphagia, Jaundice, Hiccups, Rectal Pain, Constipation, Diarrhea, Melena. b. Cardiac Arrest, Chest Pain, Palpitations, Edema, Hypertension, Hypotension, Syncope c. Rash, Pruritus & Urticaria d. Burns, Bites & Stings, Hyperthermia, Hypothermia & Cold Injury, Drowning, Foreign Bodies e. Earache, Epistaxis, Sore Throat, Dental Pain, Diplopia, Vision Loss, Ocular Pain, Tinnitus & Hearing Loss f. Anemia, Abnormal Bleeding, Lymphadenopathy g. Allergic Reactions h. Fever & Infections i. Musculoskeletal Pain, Neck Pain, Extremity Pain j. Altered Mental Status, Seizures, Ataxia, Headache, Coma, Dysesthesia, Dysphasia, Tremors k. Substance Abuse, Elder Abuse, Domestic Violence l. Dysuria, Hematuria, Urinary Retention, Urinary Incontinence, Testicular Pain & Masses, Sexually Transmitted Diseases m. Stridor, Dyspnea, Wheezing, Coughing, Cyanosis, Hemoptysis, Smoke Inhalation n. Trauma, Shock, Fractures & Dislocations o. Poisoning & Overdose p. Dehydration, Fatigue, Weakness, Weight Loss 3. Expand his/her knowledge base through clinical encounters, didactic teaching, case discussion and a program of self-study, of the presentation and management of the following specific disease entities in adult patients: a. Abdominal & Gastrointestinal Disorders including:
  • 38. Esophageal Spasm & Reflux, Varices & Mallory-Weiss Syndrome, Hepatitis, Cholecystitis & Cholelithiasis, Acute Pancreatitis, Gastritis & Peptic Ulcer Disease, Small Bowel Obstruction, Appendicitis, Ulcerative Colitis, & Hemorrhoids Mesenteric Vascular Disease, Ulcerative Colitis, Regional Enteritis, Diverticular Disease, Volvulus, Infectious Bowel Disorders, Spontaneous Bacterial Peritonitis. b. Cardiovascular Disorders including: Ischemic Heart Disease & Cardiac Failure, Pericarditis, Arrhythmias, Thromboembolism & Thrombophlebitis, Cardiomyopathy, Endocarditis, Pericardial Effusion & Tamponade, Arrhythmias & Conduction Blocks, Congenital Abnormalities in Adulthood, Thrombolytic Therapy, Cardiovascular Pharmacological Agents, Pacemakers & Implantable Defibrillators. c. Cutaneous Disorders including Cellulitis, Abscesses and Erysipelas, Fungal Infections, Infestations, Pityriasis, Purpura & Petechiae and Urticaria d. Endocrine and Metabolic Disorders including: Acid-Base Disturbances and Diabetic Ketoacidosis, Hyperosmolar Coma and complications of Diabetes Mellitus, Hyper- and Hypothyroidism, and Thyroiditis e. ENT Disorders including Epistaxis and Peritonsillar Cellulitis and Abscess f. Environmental Disorders including Electrical and Lightning Injury, Smoke Inhalation, and Temperature-Related Injuries g. Eye Disorders including Blepharitis, Chalazion and Conjunctivitis, Corneal Abrasions and Burns, Foreign Bodies, Hyphema, Iritis and Periorbital Cellulitis h. Hematologic Disorders including Sickle Cell Disease i. Neurologic Disorders Including Stroke and Subarachnoid Hemorrhage, Meningitis and Spinal Cord Compression j. Immunologic Disorders including Sarcoidosis, SLE, Anaphylaxis, Angioneurotic Edema and Drug Allergies k. Infectious Disorders including Gram-Negative and Positive Sepsis, Meningococcemia, Toxic Shock Syndrome and Mycobacterial Infections, HIV Syndromes and Other Viral Diseases l. Musculoskeletal Disorders including Septic Arthritis and Gout, Low Back Syndromes, Overuse Syndromes and Soft Tissue Infections m. Neurologic Disorders Including Stroke and Subarachnoid Hemorrhage, Meningitis, Bell's Palsy, Guillain-Barre Syndrome and Myasthenia Gravis n. Disorders Related to Pregnancy including Ectopic Pregnancy, Hyperemesis Gravidarum, Endometritis and Mastitis, Eclampsia and Pre-Eclampsia o. Psycho behavioral Disorders including Organic Syndromes, Alzheimer's Disease, Intoxications and withdrawal p. Renal Disorders Including Urethritis and Pyelonephritis q. Respiratory Disorders Including Upper Airway Obstruction, Pneumothorax, Asthma and Obstructive Lung Disease, Aspirated Foreign Bodies and Pulmonary Infections, Upper Airway Obstruction, Pneumothorax, Asthma and Obstructive Lung Disease, Pleural Effusions, Hyperventilation Syndrome and Pulmonary Infections r. Toxicology including General Principles and Poisonings Involving Acetaminophen, Alcohols, Anticonvulsants, Antidepressants, Caustic Agents, Cocaine, Iron, Sedatives and Hypnotics and Stimulants s. Traumatic Conditions including Cervical Spine Fractures and Other Spinal Cord Injuries, Corneal Abrasion and Foreign Bodies, Hyphema, Rib Fractures, Flail Chest, Aortic Rupture and Pulmonary Contusion, Intra-Abdominal Organ Injury, Skull Fractures and Intracranial Hematomas, Aortic Rupture and Pulmonary Contusion, Intra-Abdominal Organ Injury, Injuries Of The Female and Male Genitalia, Trauma In Pregnancy and Injury Prevention
  • 39. t. Urogenital and Gynecological Disorders including Ovarian Cyst and Torsion, Vaginitis, Endometriosis and Dysfunctional Uterine Bleeding, Cervicitis, Pelvic Inflammatory Disease and Salpingitis, Epididymitis, Prostatitis and Genital Lesions 4. Be able to properly chart Emergency Department patient encounters and visits. 5. Be able to present complete relevant patient summaries. 6. Effectively utilize information from the Emergency Department Nursing records as part of the patient assessment. 7. Communicate effectively with pre-hospital care providers and integrate into the clinical database information from both pre-hospital care records and providers. 8. Utilize appropriate diagnostic studies in a time-efficient and cost-effective manner. 9. Maintain and submit to the PEM Program Director a record of all procedural skills performed. 10. Have been taught/performed the following procedures: a. Fracture/Dislocation Immobilization Techniques including Splinting, Spine and Cervical Immobilization and Management of Patients on Backboards b. Defibrillation c. Arthrocentesis d. Thoracentesis e. Laryngoscopy and Intubation f. Regional Nerve Blocks and IV Anesthesia g. Control Of Epistaxis including Anterior Nasal Packing and Cautery h. Hemodynamic Techniques including Central Venous Access (Femoral, Jugular, Subclavian) i. Thoracostomy 11. Have observed and participated as a team member in the following: a. Adult Cardiopulmonary resuscitation b. Multiple trauma resuscitation 12. Understand and use appropriate interpersonal skills to work collaboratively with other ED staff in managing patients through a team approach in the emergency department. 13. Simultaneously manage and give accurate sign-out when appropriate, while ensuring both compassion and vigilance in patient care. 14. Properly activate and interact with the trauma team. 15. Perform safe and appropriate patient disposition including patient education, advocacy, risk management and follow-up arrangements. 16. Recognize clinical situations that require preventive strategies and be able to initiate those strategies. 17. Be able to initiate appropriate consultation and referrals in a timely and professional manner. 18. Become familiar with the use of available information resources, including traditional references, on-line databases, medical literature databases and specialty consultants to identify and institute the most appropriate management for clinical problems. 19. Establish a practice of on-going self-education in emergency medicine. 20. Become familiar with and develop personal techniques for stress management, physical and mental health, and critical incident stress debriefing to promote wellness through the emergency medicine career. Description Of Clinical Experiences Pediatric Emergency Medicine fellows will work shifts in the Adult ED at Strong Memorial Hospital, a Level I Emergency Department with a census of about 70,000 patients per year. The Strong Memorial Hospital is the primary clinical site for the ACGME-accredited University of Rochester Emergency Medicine residency program. They will primarily work overnight shifts in the critical care/trauma bay area of the ED. Shift assignments will adhere to New York State and ACGME guidelines for resident work hours. The fellow will
  • 40. care for a wide range of patients of all ages, conditions and acuities while functioning at the level of an upper level EM resident to fulfill the objectives listed above. PEM fellows perform invasive diagnostic, therapeutic and monitoring procedures indicated for patients under their care as appropriate for their level of skill and competence. The PEM fellow will not have a supervisory role in this setting, but will be expected to teach and share his/her expertise with colleagues and medical students. On-site 24-hour supervision is provided by board certified or board prepared physicians with faculty appointments in Emergency Medicine. All cases are presented to the EM Attending prior to the patient's discharge. Evaluation And Feedback Process: PEM fellows, through the program coordinator, will be responsible for distributing standard evaluation forms to at least two Emergency Medicine faculty members semi-annually. These evaluations will be reviewed by the Program Director, with the PEM fellow at the semi-annual evaluation. PEM fellows are also encouraged to ask the attending on duty for feedback about his/her performance at the end of each shift. He/she will be required to keep a log of all procedures. The log will be reviewed at each semi-annual evaluation to be certain that the fellow has ample experience to perform invasive procedures and to participate in resuscitations. If a faculty member identifies a performance problem, he/she is encouraged to discuss the problem directly with the fellow prior to the end of the rotation so that the trainee has time to correct the problem and successfully complete the rotation. Problems of an urgent nature regarding an individual trainee on a particular rotation should be brought to the immediate attention of the program director. These issues are addressed by the program director with the PEM trainee without delay. PEM fellows are also asked to assess each emergency medicine rotation during the semi-annual evaluation (or immediately if there are significant or specific problem areas). This feedback is used by the program director to identify and correct problems.
  • 41. Rotation: Anesthesia Location: Strong Memorial Hospital Year Of Training: Year 1 Rotation Length: 4 weeks Contact Person: Ashwani Chhibber, MD PED Shifts: Required –(2 shift per block) Work Hours: 7 am-4pm Call: None Required Clinics: None Required Conferences: Anesthesia Required Projects: None Educational Goals and Objectives Upon completion of this rotation the PEM fellow will be familiar with: 1. Airway Management a) Hands-On Experiences i) Endotracheal Intubation ii) Bag-Valve-Mask iii) LMA b) Education i) Rapid Sequence Intubation (1) Definition/Goals Of RSI (2) Drugs (a) Appropriateness (b) Doses ii) Approach To The Difficult Airway 2. Anesthesia a) Hands-On Experiences i) Actual Experience With Various Types Of Cases Requiring Anesthesia b) Education i) Definitions – Anesthesia, Analgesia, Induction, Etc. ii) Commonly Used Anesthetic Agents iii) Conscious Sedation From The Anesthesiology Point-Of-View iv) Approach To Anesthetic Emergencies Description Of Clinical Experiences 1. Clinical Expectations: a. General expectation is that fellows will be present for weekday OR schedule and required teaching conferences b. Trainees may need to be excused for graduate coursework or EM Dept. needs – these are to be kept to a minimum
  • 42. c. Scheduling should be arranged between trainees and supervising attending physician in advance, so that expectations are clear 2. Supervision: a) General supervision by anesthesia residents or nurse anesthetists expected, but overall supervision is to be by anesthesiology attending physician b) Immediate feedback should be given if problems are identified c) Unresolved or major problems should be brought to PEM program director’s attention. Evaluation And Feedback Process: PEM fellows, through the program coordinator, will be responsible for distributing standard evaluation forms to one to two anesthesia faculty members for the block. These evaluations will be reviewed by the Program Director, with the PEM fellow at the semi-annual evaluation. PEM fellows are also encouraged to ask the attending on duty for feedback about his/her performance at the end of each shift. He/she will be required to keep a log of all procedures. The log will be reviewed at each semi-annual evaluation to be certain that the fellow has ample experience to perform invasive procedures and to participate in resuscitations. If a faculty member identifies a performance problem, he/she is encouraged to discuss the problem directly with the fellow prior to the end of the rotation so that the PEM trainee has time to correct the problem and successfully complete the rotation. Problems of an urgent nature regarding an individual trainee on a particular rotation should be brought to the immediate attention of the program director. These issues are addressed by the program director with the PEM trainee without delay. PEM fellows are also asked to assess the anesthesia rotation during the semi-annual evaluation (or immediately if there are significant or specific problem areas). This feedback is used by the program director to identify and correct problems.
  • 43. Rotation: Child Abuse (REACH) Location: Department of Emergency Medicine, Strong Memorial Hospital Year Of Training: Year 2 Rotation Length: 2 weeks Contact Person: Ann Lenane, MD PED Shifts: Required – (1 shift per block) Work Hours: Per Dr. Lenane Call: No first call Required Clinics: 9:00 AM – 1:00 PM, Tuesdays, Wednesdays and Fridays, REACH Clinic located in Child Advocacy Bivona Center 275 Lake Avenue, Rochester Required Conferences: Child Abuse/ Peds EM Fellows Conference Required Presentations: None Educational Goal and Objectives Upon completion of this rotation the PEM fellow will be able to: 1. Identify risk factors for child physical and sexual abuse 2. Obtain an appropriate medical and psychosocial history from the parents of a child being evaluated for sexual abuse. 3. Understand the process of the forensic interview of children being evaluated for sexual abuse 4. Perform an appropriate examination for sexual abuse. 5. Utilize culposcopy for evaluation of child sexual abuse. 6. Describe the significance of the various types of physical findings in sexually abused children. 7. Describe the interactions between the systems/agencies that become involved in cases of child abuse. 8. Understand the rights of adolescents as both perpetrators and victims of sexual abuse. 9. Collect forensic evidence in cases of sexual assault. 10. Interact appropriately with families in cases of sexual abuse Description of Clinical Experiences: The REACH Program provides social and medical assessments for children and families of children for sexual abuse. This will include learning to use a culposcope for the medical examinations. The PEM fellow will “shadow” the REACH attending physician/nurse practitioner in the medical assessment of these children. The PEM fellow will also “shadow” the social worker in her interactions with the families including observing the forensic interviews of children. The PEM fellow will also accompany the REACH physician on call in assessments of any inpatients admitted with concerns of child abuse including analyzing the radiological, laboratory evidence, communicating with the protective and law enforcement personnel as well as the floor team and other medical consultants. Work hours will adhere to the New York State and ACGME guidelines for resident work hours. A faculty member faculty will supervise the fellow at all times.
  • 44. Evaluation and Feedback Process: Trainees are evaluated in writing at the end of each rotation, using a standardized evaluation form, by the supervising REACH program attending.. The pediatric emergency medicine training program director personally reviews the evaluations as they are returned. Evaluations of trainee performance are reviewed at the semi-annual meeting between the trainee and the program director. Each trainee is asked to evaluate the educational value of each rotation in writing, at the completion of the rotation. Trainees are asked to refer to the goals and objectives of the rotation when filling out these evaluations. Should problems arise, supervisory REACH personnel will make them known early to the trainee, to allow time for remediation during the rotation. The PEM program director will be notified immediately should serious problems arise.
  • 45. Rotation: Emergency Medicine Orthopedics/Pediatric Orthopedics/Sports Medicine Location: Department of Emergency Medicine, Strong Memorial Hospital Year Of Training: 2nd Year Rotation Length: 4 weeks Contact Person: 1. EMO EM Chief Residents 2. Sports Medicine Ken Veneema, MD 3. Pediatric Orthopedics Gary Tebor, MD, PA Kim Ingraham 4. Acute Fracture Clinic Clinton Crossings (Monday-Friday) PED Shifts: Required – None (No trauma shifts) Work Hours: 1. EMO: 12 shifts in 4 weeks 2. Pediatric Orthopedics: Attend Clinic 1-2 per week 3. Sports Medicine Clinic: Attend 1-2 per week 4. Acute Fracture Clinic: Attend 1-2 per week Call: No Call Required Clinic: Pediatric Ortho Sports Medicine Fracture Clinic Required Conferences: Peds EM Fellows Conference Required Projects: None Educational Goals & Objectives Upon completion of this rotation the PEM fellow is expected to be able to: 1. Obtain a directed orthopedic history and perform a detailed musculoskeletal exam. 2. Obtain proper radiological studies to evaluate the spine and extremities. 3. Be familiar with the interpretation of orthopedic radiographs and describing abnormalities 4. Understand the classification systems for common upper and lower extremity fractures. 5. Understand the important basic aspects in decision making regarding definitive treatment of fractures (open vs. closed ). 6. Understand the Salter-Harris classification of epiphyseal plate fractures and the differences in management for common extremity fractures in the skeletally immature individual. 7. Recognize and institute appropriate initial management for the complications of common fractures. 8. Demonstrate the ability to reduce common dislocations. 9. Be familiar with the approach to the irritable hip in childhood 10. Be familiar with techniques for appropriate application of splints and casts 11. Be familiar with the approach to spine trauma in childhood. 12. Demonstrate the ability to perform a closed reduction of common uncomplicated fractures. 13. Communicate effectively with orthopedic surgeons working collaboratively to determine an appropriate plan of care and time frame for patient follow-up. 14. Recognize orthopedic conditions that should be referred to a tertiary care center.
  • 46. Description Of Clinical Experiences Under the general supervision of the pediatric orthopedics faculty: 1. PEM trainees are to be considered members of the orthopedic consultation team, and participate fully in management of appropriate orthopedic patients. 2. PEM trainees should be included in on-call schedules and in management of orthopedic patients 3. Participation at orthopedic trauma-related clinics i. Pediatric trauma/fracture clinic ii. Pediatric urgent care orthopedics clinic iii. Learning casting/splinting techniques in the Cast Room. Hours 1. General expectation is that fellows will be present for weekday clinical and educational experiences. 2. PEM trainees may need to be excused for graduate coursework or EM Dept. needs – these are to be kept to a minimum. 3. Scheduling should be arranged between PEM trainees and supervising attending physician (or designate, such as chief resident) in advance, so that expectations and scheduling are clear. 4. Overall supervision is to be by faculty/attending pediatric orthopedic faculty member(s). Evaluation and Feedback Process PEM fellows, through the program coordinator, will be responsible for distributing standard evaluation forms to one or two Orthopedics/Pediatric Orthopedics/Sports Medicine attendings for the block. These evaluations will be reviewed by the program director with the fellow at a semi-annual evaluation meeting. At the completion of the rotation, the trainee is required to evaluate the educational value of the rotation in writing. The fellow should refer to the goals and objectives of the rotation when completing this evaluation. Performance evaluations are routinely reviewed with each fellow at the time of semi-annual evaluations. If significant performance issues not previously addressed are encountered, they are addressed at that time. If a rotation attending identifies a performance problem, he/she is encouraged to discuss the problem with the trainee directly prior to the end of the rotation such that the trainee has time to correct the problem and successfully complete the rotation. Problems of an urgent nature regarding an individual trainee on a particular rotation are brought immediately to the attention of the program director. These issues are addressed by the program director with the trainee concerned without delay. Rotation evaluations that are completed by the trainee are reviewed by the Program Director. Feedback about rotations is also solicited at annual program reviews. If a consistent problem or concern is identified, the program director contacts the responsible rotation director about any concerns as well as ways in which the rotation might be improved.
  • 47. Rotation: Emergency Medical Services Location: Department of Emergency Medicine; Strong Memorial Hospital Year Of Training: Year 2 Rotation Length: 2 weeks Contact Person: Jeremy Cushman, MD PED Shifts: Required – (1-shift per block) Work Hours: Per Dr. Cushman Call: 3 eight-hour ride alongs required Required Conferences: Total Immersion Experience (3 ride alongs required prior to this experience) provide direct patient care on 10-hour shift with Henrietta VA under direct supervision of MD/EMT-P (Dr. Syrett) Meet with all 5 EMS physician members to review directed readings. (Total five one-hour meetings) Peds EM Fellows Conference when available Required Projects: 1 EMS lecture to local EMS providers (See Sharon Chiumento to schedule.) Medical Command Review – with Dr. Fairbanks Educational Goals and Objectives: Upon completion of this rotation the PEM fellow will: 1. Understand EMS systems, their administrative establishment, and community support. 2. Be familiar with the function of and be able to participate in state, regional and local EMS organizations. 3. Be familiar with both regional and national EMS structure and levels of service. 4. Be able to participate in the prehospital assessment and management of critically ill patients. 5. Be familiar with ground EMS equipment, protocols, and communications systems. 6. Be able to foster effective interpersonal relations between hospital staff and EMS personnel. 7. Understand the importance of and be able to participate in prehospital outreach activities, education and prehospital quality management. 8. Be familiar with current EMS research and have the opportunity to develop new EMS research projects. 9. Be able to provide ground and air medical command. 10. Be familiar with hazardous material and disaster management both in the prehospital and hospital setting. 11. Develop skill in directing and educating prehospital personnel. Description of Clinical Experience: The EMS rotation consists of three main components over a 2 week period. 1. In hospital component: The resident will meet with all Division of EMS physician members. Preassigned reading will be given to the resident to facilitate an active discussion with the supervising physician. Topics cover many aspects of EMS and utilize a number of teaching
  • 48. methods. 2. Out of hospital component: Through a number of ways the resident will experience all aspects of EMS care in Rochester. The will have an opportunity to provide direct patient care and will be expected to attend EMS meetings. They will also prepare and present a lecture to local EMS providers. 3. Optional Education component: Residents will be given the opportunity to participate in EMS research, protocol development and quality assurance project which if successfully completed would qualify for the required CQI/research projects required for resident graduation. Description of In Hospital Component: The resident will be scheduled to meet with the following physicians to discuss the listed topics. Eric Davis, MD – Regional Medical Director- 1hour Manish Shah, MD – Director of EMS Research, Medical Director- Rural Metro Medical Services- 1 hour Terry Fairbanks, MD,/EMTP – Medical Director- Monroe Ambulance, 90 minutes Colleen Davis, MD – Pediatric Emergency Medicine- 1 hour Jeremy Cushman, MD – Monroe County EMS Medical Director
  • 49. Rotation: Obstetrics and Gynecology Location: Highland Hospital Year Of Training: 2nd year Rotation Length: 2 weeks Contact Person: Ruthann Queenan, MD and OB Chief Resident PED Shifts: None Work Hours: 6:45 AM – 5:30 PM (Mon-Fri), weekends when on-call Call: Yes, Scheduled by OB chief resident (q 3rd) Required Clinics: Endovaginal Clinic (Patient evaluation and ultrasound experience) (Rachel Phelps, MD) Required Conferences: OB/Gynecology Required Projects: None Educational Goals and Objectives Upon completion of this rotation the PEM fellow will be able to: 1. Complete an obstetrical history and physical exam. 2. Describe the mechanisms of a normal vaginal delivery and common abnormal presentations. 3. Have experience in performing uncomplicated vaginal deliveries. (trainee should perform > 10 normal vaginal deliveries) 4. Describe the acute management of eclampsia and pre-eclampsia, placenta previa and abruptio placenta. 5. Describe how to diagnose and manage the woman with premature rupture of membranes, prolapsed cord, uterine rupture and multiple births. 6. Have familiarity with maternal and fetal conditions necessitating emergency cesarean section. 7. Have observed or surgically assisted in the performance of a cesarean section. 8. Manage the initial care of the newborn from the obstetrical perspective. 9. Demonstrate knowledge about the diagnosis and treatment of suspected ectopic pregnancy, spontaneous abortion, ovarian torsion, sexually transmitted diseases, and other common problems. 10. Demonstrate the ability to recognize and manage postpartum complications including retained products, endometritis and mastitis. 11. Admit and follow patients admitted to the OB and the GYN services. 12. Compassionately interact with families during the stress of illness and during the delivery experience. 13. Become proficient in doing GYN exams. 14. Become familiar with indications for transferring patients with GYN/Obstetrical problems to a tertiary referral center. 15. Be familiar with evaluation of emergency department gynecology patients, including those being evaluated for sexual assault.
  • 50. Description of Clinical Experiences For about half of the rotation, PEM trainees work at the level of junior OB/GYN residents assigned to the obstetrical service where their primary assignment is to the Labor and Delivery Suite. Trainees admit, examine, and attend/participate in normal spontaneous vaginal deliveries. They may observe or assist as necessary in emergency cesarean sections or difficult deliveries. For the other portion of the rotation, PEM trainees work at the level of junior OB/GYN residents assigned to the Gynecology Service, where their primary assignment is to the gynecology in-patient, clinic, and consulting service. Trainees admit, examine, and participate in the care of women with gynecologic illnesses in the in-patient, outpatient clinic, and consultation settings. Duty hours and call schedules are arranged by the OB/GYN chief resident and are similar to the call schedule for OB/GYN residents. Work hours adhere to New York State and ACGME guidelines for resident work hours. Fellows will be supervised by attending physicians and upper level residents in the Department of Obstetrics and Gynecology at all times during the rotation. Evaluation and Feedback Process Trainees are evaluated in writing at the end of each rotation using a standardized evaluation form by the supervising attendings and upper level residents. The pediatric emergency medicine training program director personally reviews the evaluations as they are returned. Evaluations of fellows performance are reviewed at the semi-annual meeting between the trainee and the program director. Each trainee is asked to evaluate the educational value of each rotation in writing, at the completion of the rotation. Trainees are asked to refer to the goals and objectives of the rotation when filling out these evaluations. Should problems arise, supervisory OB/GYN personnel will make them known early to the trainee, to allow time for remediation during the rotation. The PEM program director will be notified immediately should serious problems arise.
  • 51. Rotation: Pediatric Emergency Department Location: Department of Emergency Medicine, Strong Memorial Hospital Year of Training: Year 1, 2, and 3 Rotation Length: 2-4 weeks Contact Person: Anne Brayer, MD Pediatric ED shifts 11-14 shifts per block (depending on year of training) Work Hours: Clinical Shifts plus shadowing daytime attending 3 times per month Call: None Required Clinics: None Required Conferences: Pediatric EM Faculty – Fellow weekly conference Peds EM – PICU monthly conference EM Grand Rounds – strongly encouraged EM Resident Conferences – strongly encouraged EM Research Conference – strongly encouraged Required Presentations: Case conference for Peds EM Faculty- Fellows meetings Educational Goals and Objectives Upon completion of this rotation the PEM fellow will: 1. Develop cognitive skills in pediatric emergency medicine and gain sufficient knowledge to dispense emergency care. To become proficient in the management of medical, surgical, traumatic, psychiatric, psychosocial, and other conditions of childhood (Figure 1). 2. Gain expertise in pediatric emergency procedures (Figure 2). 3. Understand and coordinate the activities of the Pediatric Emergency Department as the pediatric referral center for 14 surrounding counties. 4. Develop skills as a teacher of emergency pediatrics to medical students, pediatric residents, emergency medicine residents, and other health care providers through on-site precepting. 5. Develop the ability to organize the emergency care services necessary to operate a pediatric emergency department. Achieve competence with prioritizing the emergency care of multiple patients. 6. Acquire communication and interpersonal skills necessary to facilitate care and interact with professionals in other specialties, primary care providers, pre-hospital professionals, patients, and their caretakers. 7. Develop an understanding of cost-effective and time-efficient use of diagnostic studies in pediatric emergency medicine, while maintaining quality of care. 8. Demonstrate increasing level of responsibility and ability to work independently over the 2/3 year training period. Attending back-up is readily available.
  • 52. Description of Clinical Experiences PEM trainees are primarily assigned to the Pediatric ED for several rotations in each year of the training program. They are also assigned in part to the Pediatric ED as additional clinical experience during some electives; that clinical time is also described in this document. PEM trainees function as “junior attendings” during their Pediatric ED rotations. During their first year, they typically see complicated, interesting, or otherwise appropriate patients primarily, in conjunction with a supervising attending physician. As their experience grows, they take on more of a supervisory role. During their second and third years, they transition more into a supervisory role, including teaching and precepting, while maintaining flexibility to see patients primarily. During these years, an increasing number of ED shifts will be scheduled without direct attending physician on-site supervision – “solo” shifts. A supervising attending physician will be on-call at all times for backup. Trainees beyond the first year who are specifically on a Pediatric ED rotation are expected to spend four hour periods during day shifts, chosen and scheduled by the trainees themselves, working in the Pediatric ED specifically in a junior-supervisory fashion. These periods do not appear on the regular clinical schedule, and do not “count” toward the departmental required minimum Pediatric ED clinical commitment. These periods are specifically to provide additional supervisory experience to the trainees. The number of these shifts required varies with the chosen track. Work hours adhere to New York State and ACGME guidelines for resident work hours. Evaluation and Feedback Process: Because of the recurrent nature of these experiences, trainees are evaluated by attending physicians in a cumulative format before the trainees’ semi-annual meeting with the program director. The pediatric emergency medicine training program director personally reviews the evaluations as they are returned. Should problems arise sooner, supervisory attending physicians will make them known early to the trainee, so that they may be worked on immediately. The PEM program director will be notified immediately should serious problems arise. Evaluations of trainee performance are reviewed at the semi-annual meeting between the trainee and the program director. In addition, the fellows will evaluate each member of the PEM faculty on a semi-annual basis. The PEM Fellowship Director and PEM Division Director will review these. At the completion of the rotation, each trainee is also asked to evaluate the educational value of the rotation in writing. Trainees should refer to the goals and objectives of the rotation when filling out the evaluation.
  • 53. Figure 1: Cognitive Skills In Pediatric Emergency Medicine (To Be Gained Through Pediatric ED And/Or Other Rotations) Endocrine/Metabolic Disorders: • Adrenal Insufficiency • Diabetic Ketoacidosis • Electrolyte Abnormalities • Hypoglycemia • Syndrome Of Inappropriate ADH Environmental Emergencies: • Burn Wounds • Diving And Barotrauma • Domestic And Wild Mammalian Bites • Envenomation • Heat Illness • High Altitude Illness • Hypothermia And Cold Injuries • Inhalation Injuries • Plant Dermatitis • Radiation Injuries • Submersion Injuries Gastrointestinal Diseases: • Acute Abdomen • Biliary Tract Disease • Foreign Body Ingestion • Gastroenteritis • Hepatitis • Inflammatory Bowel Disease • Pancreatic Disease • Reye’s Syndrome Hematology: • Anemia • Chemotherapeutic Drug Toxicities • Disseminated Intravascular Coagulation • Henoch-Schönlein Purpura • Hemolytic Uremic Syndrome • Hemophilia • Idiopathic Thrombocytopenic Purpura • Major Childhood Cancers And Acute Complications • Neutropenia • Sickle Cell Disease Crises And Complications
  • 54. Infectious Diseases: • Antimicrobial Therapy Principles • Brain Abscess • Communicable Childhood Diseases And Infection Control • Febrile Infant Management: • Occult Bacteremia • Septic Shock • HIV Disease • Lymphangitis • Meningitis • Meningococcemia • Osteomyelitis • Pericarditis • Periorbital/Orbital/Buccal Cellulitis • Pneumonia • Pyelonephritis • Sepsis • Septic Arthritis • Staphylococcal Scalded Skin Syndrome • Tic-Borne Disease • Toxic Shock Syndrome • Tuberculosis Neonatal Medicine: • Apnea Of Prematurity • Congenital Heart Disease And Associated Dysrhythmias • Diaphragmatic Hernia • Gastroesophageal Reflux • Metabolic Diseases • Neonatal Resuscitation • Seizures • Sepsis • Sudden Infant Death Syndrome Neurology: • Coma • Degenerative Neurologic Entities • Increased Intracranial Pressure • Guillain-Barre Syndrome • Seizures
  • 55. Neurosurgery: • Arteriovenous Malformations And Aneurysm - Brain Stem Examination - Coma Scales (Modified For Infants) - Congenital Anomalies - Hydrocephalus - Neoplasm - Ventriculoperitoneal Shunt Infections/Malfunctions Psychiatric Disorders: • Acute Psychosis • Childhood Depression • Eating Disorders • Suicide Attempt/Gesture Pulmonary: • Aspiration Syndrome • Asthma • Bacterial Tracheitis • Bronchiolitis • Bronchopulmonary Dysplasia • Croup • Cystic Fibrosis • Epiglottitis • Pneumonia Resuscitation: • Advanced Life Support • Assessment Of Abgs • Asystole • Basic Life Support • Cardioversion And Defibrillation • Electrocardiographic Interpretation • Life-Threatening Arrhythmias • Respiratory Failure • Resuscitation Physiology • Shock Symptom/Sign Complexes: • Abnormal Respiration - Shortness Of Breath - Stridor/Wheezing - Tachypnea/Bradypnea/Apnea • Altered Neurologic Status - Altered Mental Status - Ataxia/Weakness - Irritable Infant/Combativeness - Syncope/Dizziness Miscellaneous Symptoms:
  • 56. • Cough • Dysuria/Vaginal Discharge/Bleeding • Emesis/Diarrhea • Eye/Ear/Nose Discharge/Bleeding • Fever • Hematemesis/Hematochezia • Limp • Urticarial/Ecchymotic/Vesicular Rash Pain Syndromes: • Abdominal Pain • Chest Pain • Ear, Throat, Tooth Pain • Extremity Pain/Disuse/Limp • Headache • Neck/Back Pain • Scrotal/Pelvic Pain Urology/Nephrology: • Acute Scrotum: - Epididymitis - Orchitis - Testicular Torsion - Testicular Tumor - Torsion Of The Appendix Testis • Acute Urinary Obstruction - Calculus Disease Of The Urinary Tract - Genitourinary Trauma - Hematuria - Hernia/Hydrocele - Sexually Transmitted Diseases - Urinary Tract Infection Other: • Acute Complications Of Chronic Disease • Anaphylaxis • Common Exanthems
  • 57. Figure 2: Technical Skills (To Be Gained Through Pediatric ED And/Or Other Rotations) Airway And Life-Saving Skills: • Basic Life Support Procedures • Bag-Valve-Mask Oxygenation/Ventilation • Cardioversion • Defibrillation • External Pacing • Intubation • Nasotrachea • Orotracheal • Needle Cricothyrotomy • Rapid-Sequence Induction Other: • Digital Block • Local Anesthesia • Conscious Sedation • Spinal Taps • Foreign Body Removal (Eye, Ear, Nose) • Tracheostomy Tube/Gastrostomy Tube Replacement • Cervical Spine Immobilization • Gastric Lavage • Hernia Reduction • Paraphimosis Reduction • Suprapubic Tap • Thoracentesis • Vascular Access: - Arterial - Cutdown/Femoral, Saphenous - Intraosseous - Percutaneous Central Venous - Percutaneous Peripheral Venous • Wound Care Skills: - Abrasion Management - Abscess Incision And Drainage - Burn Care - Dressing Application - Felon Management - Laceration Repair - Minor Amputation Management - Nail Bed Injury Management
  • 58. Rotation: Pediatric Intensive Care (PICU) Location: Golisano Children’s Hospital at Strong, PICU Year of Training: Year 1 Rotation Length: 4 weeks Contact Person: Jeff Rubenstein, MD PED Shifts: None Work Hours: Workday: Pre-rounds – 7:30 AM Sign-out – 4:00 to 4:30 PM Call: To be scheduled in coordination with the PICU Fellows, approximately every 5th night Required Clinic: None Required Conferences: PICU teaching conference 3X per week 9:00 –10:00 AM (usually Tues/Thurs/Sat) PICU Fellow/Faculty Conference 12:00 -1:30 Tuesday Required Presentations: None Overview of Pediatric Intensive Care The pediatric intensive care unit is a 22 bed (12 PICU beds, 4 cardiac care unit beds, and 8 intermediate care unit beds) multi-specialty unit that cares for all medical and surgical pediatric patients for the 14 county region requiring intensive care except for some bone marrow transplant recipients. There is an average of 750-800 admissions per year to the unit. PEM trainees rotate through the intensive care unit for one 4- week blocks during their training program. Pediatrics residents, critical care fellows, third and fourth year medical students, and emergency medicine residents may also be part of the rotation. The pediatrics or emergency medicine resident "on call" formally admits and assumes primary responsibility for patients admitted to the intensive care unit on an every third day/night basis. PEM trainees take calls on a similar basis, and assume supervisory roles or take primary responsibility, as designated by the supervising physician. All trainees go home following a 24 hour call period at the completion of the morning lecture and/or attending rounds. The trainees are supervised by one of seven board certified/eligible pediatric intensivists and critical care fellows at times. The intensivists rotate through the unit in 1 to 2 week blocks for daytime coverage with rotating nightly "on call" coverage. Educational Goals and Objectives Goal 1: Recognition and Management Of Isolated And Multi-Organ System Failure And Assessment Of Its Reversibility Objectives: a. Understand physiologic basis of disease, organ function, and pathophysiology. b. Understand the interdependence of organ system function. Goal 2: Understanding Of The Variations In Organ System Dysfunction By Age Of Patient Objectives: a. Recognize that the incidence of specific diseases as an age dependent process. b. Recognize the normal ranges of vital signs by patient age. c. Appreciate the impact and developmental differences on the patient and their family during a critical illness.
  • 59. Goal 3: Integration Of Clinical Assessment And Laboratory Data To Formulate Management And Therapeutic Plans For Critically Ill Patients Objectives: a. Recognize the appropriate timing and need for laboratory studies, including considering the cost and discomfort for the patient. b. Understand the appropriate use and timing of radiological evaluations. c. Determine daily plan of care integrating laboratory data and radiographs with clinical findings as guided by the attending intensivist. Goal 4: Invasive and non-invasive techniques for monitoring and supporting pulmonary, cardiovascular, cerebral, and metabolic functions Objectives: a. Exposure to and use of pulse oximetry, non-invasive blood pressure monitoring, arterial line placement and pressure monitoring, capnography, intracranial pressure catheter placement and monitoring, central venous pressure catheter placement and monitoring, and pulmonary artery catheter placement and monitoring. b. Understand the indications, contraindications, and adverse effects of the above. c. Exposure and/or experience with intubation and management of mechanical ventilation. Goal 5: Participation in decision making in the admitting, discharge, and transfer of patients in the intensive care unit Objectives: a. Understand the indications for admission of patients to the intensive care unit. b. Understand the appropriate timing to either transfer or discharge patients from the intensive care unit. Goal 6: Resuscitation, stabilization, and transportation of patients to the intensive care unit and within the hospital Objectives: a. Understand the appropriate type of monitoring and care needed for in-hospital and between hospital transfers of critically ill and injured children. b. Understand the amount, type, and timing of fluid for resuscitation of children with shock. c. Understand the indications and usage of inotropic drugs for cardiovascular support of critically ill and injured children. d. Understand the indications for advanced airway management and intubation in critically ill and injured children. Goal 7: Understanding of the appropriate roles of the generalist pediatrician, subspecialty consultants, and the intensivist in this setting Objectives: a. Establish and maintain effective communication with each child's primary pediatrician. b. Understand the indications for initiation of subspecialty consultations and effectively communicate medical problems to consultant. Goal 8: Understanding the appropriate roles of the general pediatric practitioner and the intensivist in the care of surgical patients. Objective: a. Participation in preoperative and postoperative management of surgical patients. Goal 9: Evaluation and management of patients following traumatic injury Objectives: a. Participation in management of children with traumatic injuries. b. Participation in management of head injured children.
  • 60. Core Curriculum 1. Formal Educational Series a. Bedside rounds occur twice daily with nursing, social work, and attending intensivist. b. Didactic core lectures (see below for discussion of topics) held 3 - 4 times weekly, given by one of the attending intensivist or fellows. c. Pediatric pharmacologist may give additional didactic lectures. d. Monthly ethics conference with philosophist/ethicist and pediatric social workers. e. Daily review of radiographs with pediatric radiologist. f. Trainees attend daily morning report and weekly pediatric grand rounds g. Team meetings with parents and appropriate staff held when needed. 2. Self-Educational and Reading Experiences a. Trainees are given selected readings that relate to topics from core lecture series as well as articles relevant to individual patients. b. Medline, pub med, and micro Medix accessible 24 hours from the computer terminal in the intensive care unit. c. Poison control available 24 hours to relate information over the phone or via fax to the intensive care unit. d. Abbreviated critical care library available in the intensive care conference room. 3. Assessment a. Trainee Performance: Verbal feedback given throughout rotation as deemed appropriate. The attending intensivist(s) at the completion of each rotation will complete a written evaluation. b. Attending Performance: Trainees complete an anonymous evaluation of the intensivist(s) at the completion of each rotation. This is coordinated by the PICU faculty. Rotation evaluation: written and verbal feedback obtained by the PICU faculty from the trainees at the completion of each rotation. 4. Lecture Series Topics c. Oxygen delivery and shock d. Hemodynamic monitoring e. Inotropic agents f. Sedation/Analgesia/Muscle Relaxation g. Modes of mechanical ventilation h. Rapid Sequence Intubation i. Respiratory failure and ARDS j. Head trauma and elevated intracranial pressure k. Management of severe asthma l. Management of poisonings and overdoses m. Fluids/Electrolytes/Nutrition n. Near-drowning o. Management of diabetic ketoacidosis p. Management of status epilepticus q. Diagnosis and management of upper airway obstruction r. Management of children with traumatic injuries s. How to talk with families of critically ill and injured children t. Management of arrhythmias in the ICU setting u. Physiology of congenital heart disease and post-operative repair management v. Management of burn and inhalation injuries PEM trainees may be asked to give one or more lectures in these or other relevant areas during their rotations.
  • 61. Evaluation and Feedback Process: Trainees are evaluated at the end of each block by 2 supervising attendings. It is the responsibility of the PEM fellow to supply the names of two attendings who they feel can evaluate their performance. The pediatric emergency medicine fellowship director personally reviews the evaluations as they are returned. Performance evaluations are routinely reviewed with each fellow at the time of semi-annual evaluations. If significant performance issues not previously addressed are encountered, they are addressed at that time. If a rotation attending identifies a performance problem, he/she is encouraged to discuss the problem with the trainee directly prior to the end of the rotation such that the trainee has time to correct the problem and successfully complete the rotation. Problems of an urgent nature regarding an individual trainee on a particular rotation are brought immediately to the attention of the program director. These issues are addressed by the program director with the trainee concerned without delay. Rotation evaluations that are completed by the trainees are reviewed by the Program director. Feedback about rotations is also solicited at annual program reviews. If a consistent problem or concern is identified, the program director contacts the responsible rotation director about any concerns as well as ways in which the rotation might be improved.
  • 62. Rotation: PEM Research Location: Department of Emergency; Strong Memorial Hospital Rotation Length: 2-4 weeks Year of Training: Any year of PEM training Contact Person: Your Research Mentor PED Shifts: Between 4 and 8 shifts Work Hours: Per Research project Required Clinic: None Call: None Required Conferences: EM Research Conference Peds Fellow Conference Required Presentations: Per Research project Educational Goals and Objectives: Upon completion of this rotation the PEM fellow will be able to: 1. Perform background reading for research 2. Design of a hypothesis-driven PEM research project 3. Successfully negotiate the research approval process (Departmental, IRB, etc.) 4. Conduct of a hypothesis-driven PEM research project 5. Write-up the research findings as a paper suitable for peer-review/presentation at a scientific meeting 6. If applicable, meet the ABP research requirements for PEM sub-board certification 7. Ultimately complete at least one PEM research project, working with a research mentor Not all goals and objectives will be met during each rotation, but they should all be met by the completion of the training program. Description of Experience 1. Research This program is extensive and is described below. It encompasses both the research project (experiential) and the formal course work components. There is an opportunity to pursue a Master’s degree in Public Health through the University of Rochester. For those Fellows who choose to complete their Master of Science, their clinical load will be adjusted accordingly. a. Research Project: All Fellows are required to plan, design, and conduct a research project. This includes: Project Selection: Fellows may choose a research project in an area currently being studied by faculty members of the Department of Emergency Medicine or Pediatrics, or in an area of interest to them. Research is primarily conducted in other University departments, with appropriate PEM faculty oversight. Department faculty regularly provides an annual summary of their research activities, and fellows are encouraged to collaborate on a research project with a particular faculty member. IRB approval is required. The Program Director must approve all PEM Fellows’ research projects.
  • 63. Mentorship: Mentorship is an important part of research training. Each fellow will have a mentor for his or her research. Presentation: Presentation of research results is strongly encouraged. This is usually done at a national meeting of a Pediatric or Emergency Medicine research society. Fellows typically present their ongoing research at the annual national meeting of PEM fellows (attendance is funded by the Department). Publication: In general, fellows must have a peer-reviewed research publication accepted to sit for the PEM Board Certification exam. We require fellows to submit at least one manuscript to a peer-reviewed journal. 2. Formal Course Work Fellows are required to complete five courses: e. One semester of biostatistics f. One semester of epidemiology g. One semester of research ethics h. One semester of design of clinical tracks i. One other elective in research methodology (e.g., questionnaire design, decision analysis) Clinical duties during Research rotations are kept light. It will include a few shifts in the Pediatric Emergency Department. These experiences are described in the “Pediatric Emergency Department” rotation description. Evaluation and Feedback Process Because of the recurrent and independent nature of the research experience, trainees are evaluated by the PEM faculty and other involved mentors in a cumulative format before the trainees’ semi-annual meeting with the program director. Should specific problems arise sooner, the faculty research mentor will make them known early to the trainee, so that they may be worked on immediately. The PEM program director will be notified immediately should serious problems arise. Evaluations of the trainee’s performance are reviewed at the semi-annual meeting between the trainee and the program director. Each trainee is also asked to evaluate the educational value of each rotation in writing, at the completion of the rotation. Trainees are asked to refer to the goals and objectives of the rotation when filling out these evaluations.
  • 64. Rotation: Emergency Psychiatry Institution: Strong Memorial Hospital, Psychiatric Emergency Dept. Year of Training: 1st and 2nd Rotation Length: 1 week Contact Person: No identified person in the department, Fellow should arrive at CPEP at 9:00am on the first day of rotation PED Shifts: 1 for the block Work Hours: 9:00-5:00 M-F Call: None Required Clinic: None Required Conferences: PEM Fellows Conference when available Required Presentations: None COMPETENCY BASED GOALS AND OBJECTIVES Through their words and behaviors fellows will: Patient Care: • Demonstrate the ability to perform a suicide risk assessment. • Identify patients requiring urgent psychiatric evaluation and treatment vs. outpatient referral. Medical Knowledge: • Describe the characteristics and causes of acute delirium. • Describe the manifestations of acute psychosis. Interpersonal and Communication Skills: • Communicate effectively and knowledgeably with psychiatry staff and consultants. Professionalism: • Interact professionally with patients and psychiatry faculty/staff. Systems-Based Practice: • Become knowledgeable about New York State regulations regarding voluntary and involuntary psychiatric assessment/hospitalization of adults and minors. Practice-Based Learning and Improvement: • Apply knowledge/readings to patient care.
  • 65. DESCRIPTION OF CLINICAL EXPERIENCES AND RESPONSIBILITIES: Each fellow receives a rotation description and required reading assignment at the beginning of each rotation. The resident will rotate for 1 week in the psychiatric ED under the supervision of emergency psychiatry faculty and senior psychiatry residents. Fellows will have an opportunity to perform mental health assessments and will follow-up on the eventual treatment and disposition (home vs. admission vs. medical referral) of the patients they evaluate. DESCRIPTION OF DIDACTIC EXPERIENCE: Fellows will also attend didactic sessions related to emergency psychiatry offered by the department of psychiatry, during their rotation. Suggested readings: • Rosen’s Emergency Medicine, 5th edition, Section VII (Psychiatric and Behavioral Disorders), pages 1541-1583. • Kaplan’s Comprehensive Textbook of Psychiatry, 6th edition, (Psychiatric Emergencies), pages 1739-1765. • Kaplan’s Comprehensive Textbook of Psychiatry, 6th edition, (Delirium), pages 729-732 • Zeman PM, Schwartz HI, Hospitalization: Voluntary and Involuntary. In R Rosner (ed), Principles and Practice of Forensic Psychiatry, Chapter 17, pages 111-117, 1994. • Litwack TR, Kirschner SM, Wack RC. The Assessment of Dangerousness and Predictions of Violence: Recent research and future prospects. Psychiatric Quarterly, 64(3): pages 245-273, 1993. EVALUATION AND FEEDBACK: Fellows are evaluated in writing at the end of each rotation using the E-Value on-line system which contains a competency based evaluation form designed specifically for each rotation. Using the E-Value system, residents select the faculty and upper level residents and fellows with whom they worked. This generates evaluation requests that are then tracked by the fellowship coordinator. Evaluations of fellow performance are compiled for the fellow to review at the semi-annual meeting with the fellowship director. If a fellow is performing marginally during the rotation, the service attending is encouraged to meet with the EM fellow to discuss deficiencies prior to the end of the rotation, so the fellow has an opportunity to improve his or her performance. The web based evaluation system, E-Value, also alerts the program coordinator/program director of marginal performance ratings, so learning issues can be promptly addressed. Fellows are required to maintain an accurate procedure log during the rotation. Evaluations of fellow performance and the procedure log are reviewed as part of the semi-annual meeting with the Fellowship Director. Each fellow is asked to evaluate the educational value of each rotation in writing, at the completion of the rotation and as part of the annual program review. Fellows are asked to refer to the objectives of the rotation when filling out these evaluations. The Curriculum Committee reviews composite rotation
  • 66. evaluations annually. Feedback from fellows and faculty is taken into consideration when planning rotations for the following academic year. Rotation: Reading Electives Location: Department of Emergency Medicine; Strong Memorial Hospital Year Of Training: Any year of PEM training; 2-4 weeks Contact Person: Self-directed PED Shifts: Two shifts per week Work Hours: Self-scheduled Educational Goals And Objectives Upon completion of this rotation the PEM trainee will: 1. Have an in-depth understanding of the selected topic, including: a. Relevant physiology b. Relevant pathology c. Relevant patient characteristics d. Relevant treatments and outcomes e. Controversies f. Performance of medical/surgical procedures (as appropriate or relevant to PEM practice) 2. Be able to effectively teach an aspect of the area to the PEM faculty/trainees Description of Clinical Experiences: Before beginning a reading elective, PEM trainees will identify one or more faculty mentors, and establish a set of areas to cover, and a minimum reading list. During the elective, trainees will meet with the faculty mentor on a regular basis to discuss their progress. Special experiences, such as workshops or courses, may be included as well. At least one teaching session, at which the trainee will present an aspect of what has been covered to the PEM faculty/trainees, should also be arranged. Clinical duties during reading electives are kept light and it will include a few shifts in the Pediatric Emergency Department. These experiences are described in the “Pediatric Emergency Department” rotation description. Evaluation and Feedback Process: Trainees are evaluated in writing at the end of the elective using a standardized evaluation form by the supervising faculty member(s). The pediatric emergency medicine training program director personally reviews the evaluations as they are returned. Evaluations of trainee performance are reviewed at the semi- annual meeting between the trainee and the program director. Each trainee is asked to evaluate the educational value of each rotation in writing, at the completion of the rotation. Trainees are asked to refer to the goals and objectives of the rotation when filling out these evaluations. Should problems arise, the supervising faculty should make them known early to the trainee, to allow time for remediation during the rotation. The PEM program director will be notified immediately should serious problems arise.
  • 67. Rotation: Toxicology Location: Poison Control Center; Strong Memorial Hospital Contact Person: Rotation Length: 4 weeks Year Of Training: Year 1 PED Shifts: Between 4-6 per block Work Hours: Monday – Friday 9AM – 5PM Call: 2 nights per week Required Clinic: None Required Conferences: One daily conference – time varies Poison Center Tox Conference – Last Friday of Block Peds EM Fellows Conference Required Projects: One Conference – Presented to Poison Center Staff last Friday of Block Educational Goals and Objectives: Upon completion of this rotation the PEM trainee will be able to answer the following questions: 1. What is a poison? 2. What is a poison center? 3. How is the poison center approach different from the medical approach? 4. What is decontamination? The PEM trainee will also be able to: 1. Describe and contrast pathophysiology and management of ASA, APAP, and TCA overdoses. 2. Describe and contrast pathophysiology, management, and antidotes for ethylene glycol and methanol. 3. Describe and contrast pathophysiology, management, and antidotes for snakebite. 4. Describe and be able to implement management of: organophosphate and carbamate insecticides, carbon monoxide, methemoglobinemia, caustics 5. Describe and contrast pathophysiology and management of digitalis, calcium channel blockers, and beta-blockers. 6. Choose one topic to be researched in depth and presented to SPI’s. 7. Choose one topic to be researched in depth and presented at EM Thursday morning toxicology conference (10-12). Welcome To The Finger Lakes Regional Poison And Drug Information Center (FLRPDIC) We welcome you to the FLRPDIC and look forward to working with you as you expand your knowledge of toxicology. Below is a brief overview of the expectations of the rotation and your role as toxicology fellow. Many PEM trainees have found Poisoning and Drug Overdose, edited by Kent Olson and found in the bookstore, a useful reference for the rotation and as a quick reference on the job. Overview And Expectations Of The Experience A SPI is a Specialist in Poison Information. Most of the SPIs are CSPIs, which means they have passed a national certification exam. The SPIs and CSPIs are nurses and pharmacists with special training in
  • 68. toxicology. The first day of the rotation, the Specialist in Poison Information (SPI) will review the history and functioning of the Poison Center (PC), the databases and references, the Toxicall system of documentation, and the hospital cases that require follow up. The PEM trainee will follow up on all hospitalized patients as necessary Monday through Friday, either by rounding on the patients in SMH or by telephone with the other hospitals. If a toxicology consult is requested, the PEM trainee is first call and will be notified by the SPI. After reviewing the information with the SPI, the PEM trainee will contact the toxicologist for discussion and management, and if away from the PCC, will call the SPI who will initiate a three-way conference call with the requesting physician and document the call. If the patient is at SMH and/or the trainee is in the operations center, the trainee will document the consult. If outside of business hours, the SPI will document the call. The PEM trainee is expected to see all patients who come into the Strong ED during the day, Monday through Friday, regardless of whether a consult has been requested, as part of the toxicology rotation. The managing director, DR Benitez, will meet with the PEM trainee on a daily basis to review the cases and discuss management and issues in toxicology. The trainee may be asked to come in to see SMH patients at any time when on call, depending on the severity of the overdose and/or at the request of the toxicologist. A presentation on a subject of interest or concern is part of the rotation and will presented in the monthly ED toxicology meeting or in the operations center. To access the toxicology database, double click on Healthcare Series and then select toxicology and type in the substance. Follow the menu but the best place to start is with the overview. The PEM trainee can access Micromedex on the Intranet, but Poisindex, which is the database for toxicology, is only available in the Poison Center. We document and submit our data to the American Association of Poison Control Centers through the Toxicall system. Double click on the Toxicall icon and select resident 1. The password will be of the trainee’s choosing and Cheryl, one of the SPIs or Dr. Benitez will set the trainee up on the first day of the rotation. The SPI that is holding the orientation will go over Toxicall entries. Each chart that the trainee begins or adds a note to, needs to be cosigned by the SPI. Use the SOAP format for an initial call, a narrative for a follow up call. The trainee will also need to sign the note with his/her name and title. It is preferred that trainees do not use abbreviations if possible. Finally, the trainee should make sure to document the unit of measurement with drug levels, for example, Acetaminophen 22mcg/ml, Aspirin 16 mg/ dl, Lithium 1.2mEq/L, etc. When doing a hospital call back, the information necessary to obtain depends on the ingestion. Look up the substances on the Poisindex, if necessary, and research the expected effects of the ingestion. As a general rule, we need to know the mental status, vital signs, labs, treatments, response to the treatments, symptoms, if additional help is required (pacer, vent) and on stable patients, the expected disposition. As an example, in an Acetaminophen overdose, the mental status usually isn’t altered and “vital signs stable” is adequate, but for an Aspirin overdose, mental status and exact vital signs are very important. The SPI will give the trainee direction, if needed. We prefer the callbacks to be done in the morning by 11am and throughout the day as necessary. Please review any findings with the SPI who will cosign the note. Below are the telephone numbers of our toxicologists. We will ask the trainee for pager and home phone numbers and will make a calendar of the trainee’s call dates and days off. The PEM trainee can choose one 24-hour period a week to be off call each week of the rotation. We also note the time the trainee is in weekly ED conference on the calendar.
  • 69. Evaluation and Feedback Process Trainees are evaluated at the end of each block by the supervising attending. The pediatric emergency medicine fellowship director personally reviews the evaluations as they are returned. Performance evaluations are routinely reviewed with each fellow at the time of semi-annual evaluations. If significant performance issues not previously addressed are encountered, they are addressed at that time. If a rotation attending identifies a performance problem, he/she is encouraged to discuss the problem with the trainee directly prior to the end of the rotation such that the trainee has time to correct the problem and successfully complete the rotation. Problems of an urgent nature regarding an individual trainee on a particular rotation are brought immediately to the attention of the program director. These issues are addressed by the program director with the trainee concerned without delay. Rotation evaluations that are completed by the trainees are reviewed by the Program Director. Feedback about rotations is also solicited at annual program reviews. If a consistent problem or concern is identified, the program director contacts the responsible rotation director about any concerns as well as ways in which the rotation might be improved.
  • 70. Figure 4 – Common References Toxicology Databases Poisindex Identidex Drugdex Tomes Reprorisk Martindale Dosing and Therapeutic Tools Drug Interaction Facts MSDS Intox Reference Books – Toxicology Goldfrank’s Toxicologic Emergencies Haddad and Winchester Poisoning and Drug Overdose Ellenhorn Medical Toxicology Casaret & Doul’s Toxicology Bates, et.al. Paediatric Toxicology Grant Toxicology of the Eye Reference Books – Pharmacy Drug Facts and Comparisons AHFS Drug Information Physician’s Drug Reference Pediatric Dosage Handbook Drug Information Handbook DiPiro’s Pharmacotherapy The Sanford Guide to Antimicrobial Therapy Trissel’s Handbook of Injectable Drugs Remington’s Pharmaceutical Sciences The Harriet Lane Handbook Reference Books – Chemical and Biological Chemical and Biological Warfare Chemical Warfare Agents – Toxicology and Treatment Chemical Warfare Agents Jane’s Chem-Bio Handbook Medical Aspects of Chemical and Biological Warfare Reference Books – Chemicals Hazardous Chemicals Desk Reference Hazardous Materials Handbook The Merck Index Sax’s Dangerous Properties of Hazardous Material A Comprehensive Guide to the Hazardous Properties of Chemical Substances Clinical Toxicology of Commercial Products
  • 71. Reference Books – Environmental Texts Wilderness Medicine Snake Venom Poisoning Handbook of Mushroom Poisoning The Wise Garden Encyclopedia AMA Handbook of Poisonous and Injurious Plants The Lawrence Review of Natural Products Herbal Drugs and Phytopharmaceuticals Breastfeeding Reference Books – Lactation and Pregnancy Drugs in Pregnancy and Lactation Drug Therapy in Obstetrics and Gynecology Catalog of Teratogenic Agents Reference Books – Veterinary Veterinary Pharmaceuticals and Biologicals A Field Guide to Common Animal Poisons Veterinary Drug Handbook Toxicology Web Sites http://intranet.urmc.rochester.edu/InfControl/Bioterrorism.hym www.fda.gov FDA news www.cdc.gov Infectious disease issues www.msdssearch.com MSDS information www.NaturalDatabase.com Botanical and natural products www.intranet.urmc.rocherster.edu/pharmacy Formulary at SMH www.lycaeum.org Drugs of abuse www.snopes2.com Urban legends www.aapcc.org American Association of Poison Centers www.ace.orst.edu/info/nptn Pesticides
  • 72. Rotation: Trauma Location: Department of Surgery; Strong Memorial Hospital Rotation Length: 4 weeks Year of Training: Year 1 Contact Person: Mark Gestring, MD and Surgical chief PED Shifts: None Work Hours: 7:00 AM –7:00 AM (24 hour shifts) Call: To be determined Required Clinic: Trauma clinic (optional) Required Conferences: Wed M&M conference (4pm-5pm) Thurs Case conference, Grand Rounds (7am-10am) Required Presentations: None Educational Goals and Objectives: Upon completion of this rotation the PEM trainee will be able to: 1. General Trauma Management b. Initially assess critically injured trauma patients. c. Calculate a revised trauma triage score and GCS. d. Perform rapid venous access and rapid volume repletion of the critically injured patient. e. Review rationales for the initial operative management of general trauma patients and burn patients. f. Participate in the convalescent/recuperative hospital management phase of critically ill patients. g. Resuscitate common life-threatening conditions in this setting. h. Perform comprehensive physical assessments of critically injured patients. i. Utilize the laboratory in initial assessment of critically burned and injured patients. j. Utilize imaging modalities in initial assessments of critically injured patients. k. Appropriately monitor, diagnose and treat trauma patients admitted to the floor. l. Assist Social Services with the discharge planning of trauma patients. m. Assist with short-term follow-up and re-integration of discharged convalescent trauma patients. n. Interact effectively with patients and their families in the setting of acute traumatic injury and death. o. Interact effectively with staff members of the trauma stabilization team, and other consultants. 2. Burn Management a. Stabilize and initially manage patients with burns to the skin. b. Calculate fluid requirements for the patient with a burn injury. c. Manage patients with pulmonary inhalation injury.
  • 73. 3. Spinal Cord a. Stabilize potential spinal column injuries. b. Perform a complete physical exam and be able to estimate the cord level involved based on the physical exam. c. Evaluate other injuries in the setting of spinal column injury. d. Assist with the hospital care of the spinal cord injured patient. 4. Central Nervous System a. Present a diagnostic overview of head trauma. b. Describe the approach to emergency department and general intensive care of the head injured patient. c. Describe the role of current imaging techniques in the diagnosis of Neurologic trauma. d. Evaluate and make dispositions for the head injured patient. e. Interpret skull and spinal column x-rays. 5. Maxillofacial a. Diagnose and initially manage trauma to the face and neck. b. Be aware of factors, which may contribute to airway compromise in the setting of Maxillofacial trauma. 6. Orthopedics a. Describe techniques of emergency reduction of hip and knee dislocations. b. Perform common splinting techniques in the setting of multi-system trauma. 7. Know the indications, contraindications and complications of the following procedures. a. Peritoneal Lavage b. Abdominal Ultrasound c. Emergency Intubation in the setting of Trauma d. Surgical Airway techniques e. Central Line placement f. Tube Thorocostomy g. Open Chest Thorocotomy h. Become proficient at Tube Thoracostomy and Central Venous Line placement. i. Review injury Epidemiology and mechanisms and be able to describe the basics of injury prevention and control. Description Of Clinical Experiences: The PEM trainee will be assigned to the SMH General Surgery Trauma Service. SMH is a Regional Trauma Center, Regional Burn Center, and Spinal Cord Injury Center with demonstrated clinical, education, and research capabilities. The trainee will see and manage patients in the Trauma Rooms of the SMH Emergency Department, the Operating Room, the Surgical ICU, the general hospital wards, the general surgery clinic, and burn clinic. During this rotation there will be no primary trainee responsibilities to the Pediatric Emergency Department. Trainees participate in trauma work rounds and attending rounds and are an integral part of the trauma team. While functioning as a member of the Trauma/Burn Service, the trainee will follow multiply injured patients from the Emergency Department resuscitative stage to the Operating Room and then through the post- operative period. They will scrub for cases and view the gross pathology of traumatic illness and the
  • 74. surgical techniques used to treat it. Post-operative care will allow the trainee to gain experience in wound care and with the various post-operative complications of traumatic illnesses. The ability to initially manage critically injured patients, direct their care in the pre-hospital system, appropriately refer traumatized patients, interact with the definitive trauma care provider, and work within a system of Trauma Care is important to the practice of Emergency Medicine and Pediatric Emergency Medicine. This rotation will foster these abilities, and provide insight into the practice style of trauma surgeons and the system within which they operate. PEM trainees act as a member of the trauma team during the day and take calls at night. PEM trainees will take calls on a schedule similar to those of resident members of the trauma team, as arranged by the upper level surgical resident/chief. The schedule will adhere to New York State and ACGME Guidelines for resident work hours. Description Of Didactic Experiences: ATLS training will typically have been completed prior to the rotation. PEM trainees are required to attend trauma rounds and are relieved of their responsibilities to attend pediatric emergency medicine teaching conferences. The rotation includes Trauma, Morbidity and Mortality and other quality assurance conferences. Recommended Reading For The Rotation 1. ATLS Provider Manual-ACS 2. Roberts and Hedges: Clinical Procedures in Emergency Medicine, 3rd ed., 1998. 3. Tintinalli J, Ruiz E, and Krome RL: Emergency Medicine, 5th ed., 2000. Evaluation and Feedback Process PEM trainees are evaluated in writing at the end of each rotation using a standardized evaluation form by the supervising attendings. The training program director personally reviews the evaluations as they are returned. Evaluations of performance are compiled for review at the semi-annual meeting with the program director. , At the completion of the rotation, each trainee is also required to evaluate the educational value of the rotation in writing. Trainees are asked to refer to the goals and objectives of the rotation when filling out these evaluations. Trainee performance evaluations are routinely reviewed with each fellow at the time of their six month evaluations. If a rotation coordinator identifies a performance problem, he/she is encouraged to discuss the problem with the trainee directly prior to the end of the rotation such that the trainee has time to correct the problem and successfully complete the rotation. Problems of an urgent nature regarding an individual trainee are brought immediately to the attention of the training program director. These issues are addressed by the program director with the trainee concerned without delay.
  • 75. Rotation: Ultrasound Location: Department of Emergency Medicine; Strong Memorial Hospital Rotation Length: 3 weeks first 2 years of fellowship Contact Person: Jefferson Svengsouk, MD PED Shifts: 1 shift per block first year, 3-4 shifts per block second year Work Hours: 45 hours/week Call: No Call Optional Clinics: Endovaginal Experience at Dr. Queenan’s office Required Conferences Peds EM Fellows Conference Required Presentations: 1 hour conference on cross-sectional anatomy case conference reviewing ultrasound Duty Log: Duty Log – Residents and Fellows are required to Iog in work hours and daily image numbers Other Requirements: Orientation: Emergency Ultrasound CD-ROM (10 hours) Self-study of lecture notes Ultrasound laboratory (1 day with Dr. Svengsouk) Ultrasound Test #1- must pass with min. score of 80% to be certified to use the ED ultrasound machine First Day of rotation: Review Ultrasound lecture videos (8 hours) Ultrasound Test #2- prior to onset of ultrasound rotation Overview of Ultrasound Provisional and full credentials in the use of the emergency department ultrasound machines must be authorized by the ED Chairperson in conjunction with the ED Director of Ultrasound. 1. Provisional Credentials Candidates who have completed training equivalent to either (a) or (b) as described below, and have completed orientation to the ED ultrasound machines, may be granted provisional credentials: a. A formal ultrasound course including the topics of physics and instrumentation, and the primary applications of limited emergency ultrasound, which include trauma, pelvis, cardiac, abdominal aortic aneurysm, biliary, and renal; b. A series of one-day, single-application format courses, with both didactic and laboratory components, covering the primary applications of emergency ultrasound, under the supervision of a fully credentialed emergency department physician. i. Single application-specific provisional credentials may be granted following a course in that primary application.
  • 76. ii. In general, examinations obtained under provisional credentials will not be used for clinical decision-making unless reviewed by a fully credentialed sonographer. c. In progressing to full credentialing, images of all examinations obtained will be submitted to an ED fully credentialed physician or sonographer for review for adequacy. Images should be labeled with patient name, medical record number, and date, with identification and interpretation data entered into the Emergency Medicine ultrasound database. Candidates will be given a progress update every three months, with advisement of any need for additional instruction. 2. Full Credentials Candidates who have received training equivalent to that required for provisional credentials in all six primary applications of emergency ultrasound, and have completed orientation to the ED ultrasound machines, may be granted full credentials after demonstrating a minimum number of adequate documented and reviewed ultrasound examinations as recommended by the Emergency Ultrasound Guidelines of the American College of Emergency Physicians. Approximately 50% of the examinations should be clinically indicated. a. General emergency ultrasound privileges (application not specific) may be granted after a minimum of 150 examinations, of which 25 should be in each of the primary applications. b. Privileges may be granted for training experiences obtained at outside institutions meeting the training requirements as defined above. c. Fully credentialed sonographers may use limited ultrasound in the Emergency Department for patient- care decisions. All patient-care utilization of the ED ultrasound machines must be documented in the medical record, and images and examination data must be entered into the Emergency Medicine ultrasound database. 3. Continuing Certification of Full Credentials The Emergency Ultrasound Guidelines of the American College of Emergency Physicians recommends continuing medical education in ultrasound after the initial training phase as well as continuous use of the technology to maintain skills and familiarity with technology. A goal of 40 hours of ultrasound- related CME including initial training is suggested by the Society of Academic Emergency Medicine Ultrasound Task Force. 4. CME may include journal club, conference lectures, morbidity and mortality conferences, hands-on training courses, structured reading, videotapes, or other formats. At the University of Rochester Medical Center, a minimum average of 6 hours of CME per year will be required to maintain full privileges in emergency ultrasound, equivalent to one hour for each of the six primary applications of emergency ultrasound. 5. Continuous Use of Ultrasound Technology A minimum average of 24 indicated ultrasound examinations per year would be required to maintain full privileges in emergency ultrasound. Quality Assurance: Quality assurance review will evaluate faculty ultrasound examination performance no less than every three months for newly credentialed faculty, and no less than every six months for faculty credentialed over three months. Educational Goals and Objectives: Upon completion of this rotation the PEM trainee will be able to obtain and interpret images in the following primary applications of emergency ultrasound: 1. Trauma a. Demonstrates right kidney, diaphragm, liver, hepatorenal space, right paracolic gutter b. Demonstrates subcostal view of heart c. Demonstrates left kidney, diaphragm, spleen, splenorenal space, left paracolic gutter d. Demonstrates bladder
  • 77. e. Describes possible appearances and areas of small and large fluid collections 2. Pelvis a. Demonstrates longitudinal and transverse views of uterus in transabdominal and/or endovaginal ultrasound b. Demonstrates endometrial stripe c. Demonstrates vagina and cul-de-sac d. Differentiates definitive intrauterine pregnancy (IUP) from probable abnormal IUP, no definitive IUP, and definitive ectopic pregnancy. e. Demonstrates adnexal structures 3. Cardiac a. Demonstrates the following views of heart: i. Parasternal long axis ii. Parasternal short axis iii. Apical four chamber iv. Subcostal b. Differentiates pericardial effusion from pleural effusion c. Recognizes gross wall motion abnormalities 4. Abdominal Aortic Aneurysm a. Demonstrates longitudinal and transverse views of aorta b. Differentiates aorta from inferior vena cava 5. Biliary a. Demonstrates longitudinal and transverse views of gallbladder b. Correctly identifies pathology (stone, sonographic Murphy sign, wall thickening, pericholecystic fluid, dilated common bile duct) 6. Renal a. Demonstrates longitudinal and transverse views of kidneys. b. Recognizes hydronephrosis c. Recognizes echogenicity suggestive of nephrolithiasis The Director of Emergency Ultrasound will review continuing certification under these requirements on an annual basis. Evaluation And Feedback Process Trainees are evaluated in writing at the end of each rotation using a standardized evaluation form by the supervising attending. The training program director personally reviews the evaluations as they are returned. Evaluations of performance are compiled for review at the semi-annual meeting with the program director. Each trainee is asked to evaluate the educational value of each rotation in writing, at the completion of the rotation. Trainees are asked to refer to the goals and objectives of the rotation when filling out these evaluations. Trainee performance evaluations are routinely reviewed with each fellow at the time of their six month evaluations. If a rotation coordinator identifies a performance problem, he/she is encouraged to discuss the problem with the trainee directly prior to the end of the rotation such that the trainee has time to correct the problem and successfully complete the rotation. Problems of an urgent nature regarding an individual trainee are brought immediately to the attention of the training program director. These issues are addressed by the program director with the trainee concerned without delay.
  • 78. PROGRAM CONTACTS Rotation Title/Position Contact Person Phone Number REQUIRED: Administrative Sandra Schneider, MD 463-2943 Secretary Tawni Biggins 463-2942 Adult ED ED Chief Resident Anesthesia Director Ashwani Chhibber, MD 5-7066 Susan Catalano 5-1385 Child Abuse Director, REACH Ann Lenane, MD 463-2942 Pediatric/ED Secretary Tawni Biggins 463-2942 EMO Gary Tebor, MD 5-1395 Ken Veneema, MD 5-3443 EMS Director Jeremy Cushman, MD 3-4796 Secretary Serpil Aktas 3-4793 NICU Director Robert Sinkin, MD 5-2972 Neonatology OB/GYN Res. Director Thomas McNanley, MD 1-6734 Secretary Melanie Page 5-9042 Pediatric Radiology Deborah Klein, MD (in 3-3935 Radiology) PICU Critical Care Jeffery Rubenstein, MD Secretary Psychiatry Robert Redondo, MD 3-5447 Toxicology Director & Assoc. Medical Dir. Sandra Schneider, MD 3-4155 Poison & Drug Secretary Tawni Biggins 3-4155 Information Center Trauma (Adult) Director, Adult Trauma Mark Gestring, MD (ATLS is prerequisite Amy Mills in Surgery) Ultrasound ED Jefferson Svengsouk, MD 463-2946 Secretary Katie Hillman 463-2945
  • 79. PROCEDURES Overview The Procedure Logging feature of the E-Value - Residency Management Software allows physicians (and/or administrators or other designated personnel) to record procedures they have performed, assisted, or observed and to designate a supervisor who can confirm that the procedure was completed successfully. Optionally, a corresponding diagnosis can also be recorded with this procedure. This diagnosis can be either a free form text entry or a selection from a drop down list of diagnoses and ICD codes. The selected supervisor can be notified via E-mail that he/she has a procedure awaiting confirmation. Within a department/division, a list of procedures and CPT codes is created. A grouping capability exists to allow long lists of procedures to be organized into more manageable, shorter lists. Likewise, the list of diagnoses can be organized into groups. Credentialing can be handled either automatically or manually. For each procedure, a target number of successfully confirmed procedures needed to attain credentialed status are specified. In manual mode, an administrator can be notified when that target is reached and a physician’s credentialing status for a specific procedure can be updated. The number of procedures “required” is for PEM fellows. If in automatic mode, this is done without administrator intervention. Procedures can be logged by physicians and confirmed by an attending supervisor via the on-line screens. Competencies 1. Create a Patient List 2. Add a Visit 3. Confirm a Visit 4. Run two reports 5. The Resident Visit Summary 6. Resident Visit Totals E-Value System 1. Log on to https://www.e-value.net/index.cfm
  • 80. Figure 5: Resident Procedure Log Summary: Sample Emergency Medicine - Procedures Back Procedure Name Abbreviation # Required CPT Code Aortic Ultrasound 25 Arterial Blood Gas - adult 1 Arterial Blood Gas - child 1 Arterial Line 2 Arthrocentesis 2 Bag Valve Mask 1 Biliary Ultrasound 25 Bladder Ultrasound 25 Cardiac Pacing (external or internal) - simulated 6 Cardiac Pacing (external) - actual 6 Cardiac Pacing (internal) - actual 6 Cardiac Ultrasound 25 Cardioversion/Defibrillation - simulated 10 Cardioversion/Defibrillation - actual 10 Casts 2 Central Venous Line - femoral, adult 5 Central Venous Line - femoral, pediatric 5 Central Venous Line - internal jugular 10 Central Venous Line - subclavian 10 Chest Compression 6 Chest Tube Thoracostomy - actual 15 Chest Tube Thoracostomy - lab/simulated 5 Conscious Sedation 20 Conversion of SVT 6 Corneal Foreign Body Removal 2 Cricothyrotomy - actual 3 Cricothyrotomy - simulated 3 Digital Nerve Block 1 ED Thoracotomy 1 External Jugular IV Catheter Placement 2 Foley Catheter-female 1
  • 81. Foley Catheter-infant 1 Foley Catheter-male 1 Foreign Body Removal 6 Gastric Lavage 1 Gastrostomy Tube Change 1 Incision and Drainage 1 Interosseous Line 1 Intubation - lab/simulator/cadaver 5 Intubation - nasotracheal 4 Intubation - orotracheal, adult 40 Intubation - orotracheal, pediatric 5 Laceration Repair - complex 5 Laceration Repair - nailbed injury 3 Laceration Repair - simple 50 Laryngeal Mask Airway 2 Lumbar Puncture - adult 8 Lumbar Puncture - pediatric 8 Medical Resuscitation - adult 60 Medical Resuscitation - pediatric 20 Nasal Cautery 2 Nasal Packing - anterior 1 Nasal Packing - posterior 2 Needle Thoracostomy 1 NGT Placement 2 Other 1 Paracentesis 2 Paralytic Agent Use 2 Pediatric Resuscitation 2 Pelvic Exam 2 Pelvic Ultrasound - transabdominal 25 Pelvic Ultrasound - transvaginal 25 Pericardiocentesis - actual 3 Pericardiocentesis - simulated 3 Peripheral IV - extremity, adult 1 Peripheral IV - extremity, child 1
  • 82. Peritoneal Lavage - actual 5 Peritoneal Lavage - lab/simulated 3 Rapid Sequence Induction 10 Reduction - Finger Dislocation 1 Reduction - Fracture 2 Reduction - Non-Shoulder Dislocation 6 Reduction - Shoulder Dislocation 6 Regional Nerve Block 2 Renal Ultrasound 25 Sexual Assault Kit 1 Slit Lamp Exam 2 Splint - closed fractures 25 Splint - thumb spica 5 Splint - wrist 5 Surgical Resuscitation (Non-Traumatic) - adult 2 Surgical Resuscitation (Non-Traumatic) - pediatric 2 Swan-Ganz Catheter 2 Thoracentesis 2 Tracheostomy Tube Change 1 Trauma Resuscitation - adult 40 Trauma Resuscitation - pediatric 20 Trauma Ultrasound 25 Umbilical Line 2 Vaginal Delivery 15 Venipuncture 1 National PEM Procedure Database The University of Rochester is part of a National PEM Procedure Database. Semi-annually we submit the numbers of certain procedures to the National PEM Fellowship Directors Committee. As a group we are trying to determine the numbers of procedures that fellows typically perform, as well as predict the number that would need to be performed to be credentialed by board. Department of Emergency Medicine Pediatric Emergency Medicine Fellow Delineation of Competencies
  • 83. PEM Fellow’s Name:________________________ DIRECT SUPERVISION: PEM Fellows may perform specific treatment or a procedure with direct visual supervision of the patient’s attending physician or another privileged physician. GENERAL SUPERVISION: Attending physician or another privileged physician’s presence is not required during the PEM Fellow’s performance of the specific treatment or procedure; however, the supervising physician is readily available and furnishes the overall direction and control over the resident. DELINEATION OF COMPETENCIES DESCRIPTIONS DIRECT SUPERVISION: All procedures that are not identified below under General Supervision, or approved independently below as Special Procedures, must be performed under direct supervision. GENERAL SUPERVISION: General competencies for PEM Fellows in Emergency Medicine are defined as those standard, usual, and customary competencies acquired in the course of the acquisition of their actual degree and any other educational programs that qualify the PEM Fellow for this training program. Included are those activities appropriate in the diagnosis and treatment of patients with diseases diagnosed and treated by their supervising faculty. PEM Fellows who are approved under General Supervision may perform the following procedures: the evaluation, diagnosis, provision of a consultative opinion, completion of the appropriate medical record, documentation of care, communication with patients and family regarding treatment and provision of emergency care in accord with service privileges and within scope of their training program. In addition, the following procedures are approved under general supervision: order writing, prescription writing, peripheral intravenous line insertion, venipuncture, arterial blood sampling, blood culture, naso-gastric tube placement, simple laceration repair, incision and drainage, digital nerve block, splinting, Foley catheter placement, removal of drains, clips and skin sutures, lumbar puncture, and defibrillation. PEM Fellows are required, but not limited, to train in advanced cardiac life support, advanced pediatric life support, advanced trauma life support, use of restraints, pain management, HIPAA, moderate sedation, and mandatory in-service. SPECIAL PROCEDURES: The special procedures identified below are granted by proof of competency and approval by the training Program Director. Special procedures will always be performed under direct supervision unless approved, dated, and signed below. Approved DATE DESCRIPTION SMH/HH Aortic Ultrasound __________________________ _ Arterial Blood Gas (adult) __________________________ _ Arterial Blood Gas (pediatric) __________________________ _ Arterial Line __________________________ _ Arthrocentesis __________________________ _ Bag Valve mask __________________________ _ Biliary Ultrasound __________________________ _ Bladder Ultrasound __________________________ _
  • 84. Approved DATE DESCRIPTION SMH/HH Cardiac Pacing external or internal - simulated __________________________ _ Cardiac Pacing (external or internal) - actual __________________________ _ Cardiac Pacing (external) - actual __________________________ _ Cardiac Pacing (interna) - actual __________________________ _ Cardiac Ultrasound __________________________ _ Cardioversion/Defibrillation-simulated __________________________ _ Cardioversion/Defibrillation-actual __________________________ _ Casts __________________________ _ Central Venous Line—femoral, adult __________________________ _ Central Venous Line—femoral, pediatric __________________________ _ Central Venous Line -Internal jugular __________________________ _ Central Venous Line -Subclavian (pediatric) __________________________ _ Chest Tube thoracostomy actual __________________________ _ Chest Tube thoracostomy lab/simulated __________________________ _ Conscious sedation __________________________ _ Corneal foreign body removal __________________________ _ Cricothyroidotomy - actual __________________________ _ Cricothyroidotomy - simulated __________________________ _ Digital Nerve Block __________________________ _ ED thoracotomy __________________________ _ External Jugular IV Catheter Placement __________________________ _ Endotracheal Intubation __________________________ _ Foley Catheter-female __________________________ _ Foley Catheter-infant __________________________
  • 85. Approved DATE DESCRIPTION SMH/HH _ Foley Catheter-male __________________________ _ Gastric lavage __________________________ _ Gastrostomy Tube Change __________________________ _ Incision and drainage __________________________ _ Interosseous Line __________________________ _ Intubation – lab/simulator/cadaver __________________________ _ Intubation –nasotracheal __________________________ _ Intubation – orotracheal, adult __________________________ _ Intubation - orotracheal, pediatric __________________________ _ Laryngeal Mask Airway __________________________ _ Lumbar puncture (adult) __________________________ _ Lumbar puncture (pediatric) __________________________ _ Medical resuscitation - adult __________________________ _ Medical resuscitation - pediatric __________________________ _ Nasal cautery __________________________ _ Nasal Packing – anterior __________________________ _ Nasal Packing - posterior __________________________ _ Needle thoracotomy __________________________ _ NGT Placement __________________________ _ Other __________________________ _ Paracentesis __________________________ _ Paralytic Agent Use __________________________ _ Pediatric Resuscitation __________________________ _
  • 86. Approved DATE DESCRIPTION SMH/HH Pelvic Exam __________________________ _ Pelvic Ultrasound – transabdominal __________________________ _ Pelvic Ultrasound - transvaginal __________________________ _ Pericardiocentesis - actual __________________________ _ Pericardiocentesis - simulated __________________________ _ Peripheral IV - extremity, adult __________________________ _ Peripheral IV - extremity, child __________________________ _ Peritoneal lavage - actual __________________________ _ Peritoneal lavage – lab/simulated __________________________ _ Rapid sequence Induction __________________________ _ Reduction – Finger Dislocation __________________________ _ Reduction - Fracture __________________________ _ Reduction – Non Shoulder Dislocation __________________________ _ Reduction - Shoulder __________________________ _ Regional nerve blocks __________________________ _ Renal Ultrasound __________________________ _ Sexual Assault Kit __________________________ _ Slit Lamp Exam __________________________ _ Splint – closed fractures __________________________ _ Splint –thumb spica __________________________ _ Splint –wrist __________________________ _ Surgical Resuscitation (Non-Traumatic) – Adult __________________________ _ Surgical Resuscitation (Non-Traumatic) – __________________________ pediatric _ Swan Ganz catheter __________________________
  • 87. Approved DATE DESCRIPTION SMH/HH _ Thoracentesis __________________________ _ Tracheostomy Tube Change __________________________ _ Trauma resuscitation - adult __________________________ _ Trauma resuscitation pediatric __________________________ _ Trauma Ultrasound __________________________ _ Umbilical line __________________________ _ Vaginal delivery __________________________ _ Venipuncture __________________________ _ ================================================================================= =========================== Based on the assessment measures established by the Department of Emergency Medicine, the above named PEM Fellow has been authorized to practice the competencies as delineated above. _________________________________________________ Program Director’s Signature
  • 88. INSTITUTIONAL OVERSIGHT/MONITORING OF RESIDENT/FELLOW DUTY HOURS I. Educational Process A. All new trainees are instructed regarding the institution's duty hour policies at general and program- specific orientation sessions. B. Full descriptions of institutional policies regarding duty hours, monitoring activities and moonlighting are available to all trainees and faculty via the GME website (see Resident/Fellow Manual for Medical and Dental Programs). C. Program directors must distribute departmental policies regarding duty hours to residents and faculty. The program directors will communicate with program faculty/trainees regarding changes in duty hour policies or changes in trainee/faculty work hours to accommodate duty hour requirements. II. Monitoring Process a) Internal Measures 1. Twice yearly, the GME office will conduct an internal audit of all trainees in ACGME/ABMS sponsored programs within the university. a. All trainees receive instructions for completing the survey on the E*Value online evaluation system. The instructions state that completion of the survey is mandatory. b. Trainees are instructed to record all their activities over a specific, consecutive 4-week period of time, including off time and vacation. c. Program Coordinators and Program Directors have access to the information entered on the E*Value duty hours calendars and are responsible for verifying the completeness of the trainee’s entries. d. Once the program notifies the GME office that its data is complete, the GME office reviews the information for compliance. e. When all data is confirmed, an Institutional Duty Hours Report is created. The report has the following headings: • Department Name • Program Name • Percent of trainees that actually completed the survey • Number of trainees who were asked to complete the survey • Number of trainees without one 24-hour period off in each seven-day period • Number of violations (number of incidences trainees were without 24-hours off in seven days) • Number of trainees who worked more than 80 hours in a week • Number of violations (number of incidences more than 80 hours in a week was worked) • Number of trainees who worked more than 27 hours in a shift • Number of violations (number of incidences shifts longer than 27 hours were worked) This report summarizes the totals in each of the categories listed above for each program. It is used by administration to evaluate the program's overall compliance. The report also shows the totals for all programs, which helps to monitor institutional compliance. f. Data from the reports are evaluated and distributed as described in reporting process.
  • 89. 2. As part of each program's Internal Review process, work hours are evaluated by the survey team. a. The program is required to provide a copy of its work hours policy and general guidelines regarding trainee work hours, such as typical start and end times for daily work, method and amount of in-house and pager call, etc. b. Recent data from internal audits and external (NYS) audits regarding the program are provided by the GME office to the review committee. c. Faculty and trainees are questioned during the review regarding the program's compliance with work hour regulations and promotion of safe patient care practices. b) External Measures 1. NYSDOH has informed all training programs within NYS that unannounced visits will occur on at least an annual basis for all training institutions. The University of Rochester and its trainees will participate fully in this NYS monitoring process. 2. The ACGME will evaluate a program's compliance with duty hour regulations as part of regularly conducted site visits. This may include surveying trainees prior to a site visit and discussing duty hour compliance with trainees and faculty during the visit. The University of Rochester and its trainees will participate fully in this accreditation-based monitoring process. III. Reporting Process A. Data from internal GME office surveys are discussed at meetings of the GME Committee (GMEC). Aggregate results are distributed to program directors, department chairs, program coordinators, university administrators and the Office of Counsel B. Programs out of compliance are asked to evaluate their data. If compliance cannot be obtained easily by alteration of trainee schedules, the program director and department chair are asked to meet with the Associate Dean for Graduate Medical Education (SSADGME), Chief Operating Officer (COO) of the hospital, and a representative from the Office of Counsel to develop a plan to facilitate compliance. C. Concerns regarding work hours discussed at program internal reviews are documented in the internal review report and discussed by the GMEC. D. Concerns regarding work hours found as part of ACGME external reviews are reviewed when accreditation status letters are discussed at GMEC. E. Findings from NYS work hour audits are shared with GMEC, program directors, chairs, trainees, the Office of Counsel, and hospital/university administrators. If the institution is found to be out of compliance by NYS, the SSADGME, COO, and Office of Counsel will draft a correction/monitoring plan that meets state requirements. F. At least two times a year the SSADGME presents a report regarding work hours compliance to the organized medical staff of the institution (Clinical Chiefs and Chairs and the Medical Center Executive Committee) as well as to the Joint Committee on the Quality of Care which consists of the University of Rochester Medical Center Board Subcommittee on the Quality of Care and the Strong Memorial Hospital Quality Assurance Committee. This report includes information from all internal and external monitoring events. Each of these committees may assist the SSADGME in assuring institutional compliance with duty hour requirements.
  • 90. INSTITUTIONAL POLICY ON RESIDENT/FELLOW DUTY HOURS The following policy is consistent with those outlined by the New York State (NYSDOH) and the Accreditation Council on Graduate Medical Education (ACGME). The University of Rochester is committed to providing residents with a sound academic and clinical education, which must be carefully planned and balanced with concerns for patient safety and resident well-being. Each program must ensure that the learning objectives of the program are not compromised by excessive reliance on residents to fulfill service obligations. Didactic and clinical education must have priority in the allotment of residents' time and energies. Duty hour assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients. 1. Supervision of Residents a) All patient care must be supervised by qualified faculty. The program director must ensure, direct, and document adequate supervision of residents at all times. Residents must be provided with rapid, reliable systems for communicating with supervising faculty. b) Faculty schedules must be structured to provide residents with continuous supervision and consultation. c) Faculty and residents must be educated to recognize the signs of fatigue and adopt and apply policies to prevent and counteract its potential negative effects. 2. Duty Hours a) Duty hours are defined as all clinical and academic activities related to the residency program, ie, patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. b) Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities (NYSDOH has placed an additional limit of 84 hours for any one week.) c) Residents/fellows must be provided with 1 day in 7 free from all educational and clinical responsibilities, inclusive of in-house and pager call. One day is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities. d) Adequate time for rest and personal activities must be provided. This should consist of a10 hour time period and must consist of at least an 8 hour time period between all daily duty periods and after in-house call. e) The NYSDOH requires strict adherence of institutions to its duty hour standards. Because state law supersedes accreditation requirements, all University of Rochester programs will comply with the 80 hour per week maximum. The GMEC will not consider approving a 10% increase in hours as described in ACGME duty hour requirements. 3. On-Call Activities The objective of on-call activities is to provide residents with continuity of patient care experiences throughout a 24-hour period. In-house call is defined as those duty hours beyond the normal work day when residents are required to be immediately available in the assigned institution. a) In-house call must occur no more frequently than every third night, averaged over a four week period. b) Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to 3 additional hours to participate in didactic activities and transfer care of patients.
  • 91. c) No new patients may be accepted after 24 hours of continuous duty. d) At-home call (pager call) is defined as call taken from outside the assigned institution. 1. The frequency of at-home call is not subject to the every third night limitation. However, at- home call must not be so frequent as to preclude rest and reasonable personal time for each trainee. Residents/fellows taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities. 2. When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80-hour limit. 3. The program director and the faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue. 4. Moonlighting a) No resident will be required to engage in moonlighting. Each program may determine if moonlighting activities will be allowed. b) Because residency education is a full-time endeavor that only full-time trainees can engage in, the program director must monitor moonlighting hours to ensure that moonlighting does not interfere with the ability of the resident to achieve the goals and objectives of the educational program. c) Each resident/fellow must obtain written permission from his/her program director prior to engaging in any moonlighting activities. The written permission form and record of hours worked will become part of the resident's departmental file. d) Hours devoted to moonlighting must be added to training program work hours and reported on all work hour surveys. At no time should a trainee exceed work hour regulations through a combination of training program plus moonlighting activities. e) The program director is responsible for monitoring the effect of these activities upon performance and withdrawing permission to moonlight if necessary. f) See moonlighting section of this GME manual for additional information. 5. Oversight a) Each program must have written policies and procedures consistent with the institution's requirements for resident duty hours. These policies must be distributed to the residents/fellows and faculty. Monitoring of duty hours is required with frequency sufficient to ensure appropriate compliance. b) Faculty and residents must be educated to recognize the signs of fatigue and to apply proactive and operational counter measures. The program director and faculty must monitor residents/fellows for the effects of sleep loss and fatigue and respond in instances when fatigue may be detrimental to resident performance and well being. c) Back-up support systems must be provided when patient care responsibilities are unusually difficult or prolonged or if unexpected circumstances create resident fatigue sufficient to jeopardize patient care. PEM FELLOWS WORK HOURS POLICY The PEM Fellowship Program will be in compliance with the NY State legal requirements, ACGME, and UR GME Office policies (see current UR GME Office Resident Manual) regarding trainee work hours. 1. The average workweek will not exceed 80 hours in a four-week period. 2. Trainees will not be scheduled to work more than 24 consecutive hours, with an additional 3-hour period available for transfer of patient information. 3. There will be at least one unscheduled 24-hour period each week. 4. Moonlighting time must be included in the above.
  • 92. 5. Trainees must adhere to the above, and bring potential non-compliance to the attention of a supervisor or the Program director when it is recognized. 6. PEM Fellows on non-Pediatric ED rotations are expected to conform to the above policy, as specified by the UR GME policy. 7. Regulations are different for surgical services; PEM fellows on occasional rotations with surgical services are expected to follow the guidelines for trainees in that program, again, in accordance with UR GME policy. The Details 1. Work Days a. ED Rotations b. 12 consecutive clinical hours c. Plus 3 hours buffers (non-clinical/admin/teaching) d. Outside Rotations e. 24 consecutive clinical hours f. Plus 3 hours buffers (non-clinical/admin/teaching) g. 10 hours off between clinical shifts h. 8 hours off before each of the 5 required classes i. (Epi/Biosats/Ethics/+ 2 others) j. Attendance in required classes counts towards workday hours k. Attendance in all other classes that are not required l. should not be counted towards work day hours 2. Work Week a. Work week starts on Sunday at 12:00AM and ends Saturday at 11:59PM b. ED Rotation: 60 hour clinical week c. Outside Rotations: 80 hour work week d. One 24 hour period off each week 3. Moonlighting a. Fellows must have 8 hours off after moonlighting shift before non-clinical work (class/administrative/teaching). b. Fellows must have 10 hours off after moonlighting shift before clinical hours. c. All moonlighting hours must be recorded and submitted to the program coordinator on a monthly basis by the 5th work day in the month following the moonlighting event. This will be reviewed by the program director for compliance. i. Fellows rotating in the Pediatric ED who fail to attend at least 80% of scheduled conferences during the block are not permitted to moonlight in the following block. (PEM, PICU/ED, EM Research). ii. Moonlighting privileges will be suspended if the fellow owes more than 150 clinical hours.
  • 93. VIRASERT CONTRACT: SAMPLE A fellow in any of the Pediatric Fellowship Programs may work as an independent attending in the URMC Pediatric Emergency Medicine Department. The fellow will be able to evaluate and mange low to medium acuity patients as an independent practitioner. The fellow may be able to manage and evaluate patients of higher severity, such as patients requiring resuscitation or admission but will require supervision by a Pediatric Emergency Medicine (PEM) faculty attending. For these patients the PEM faculty will write a note and bill for their services. These are basic pediatric illnesses, for which: (1) the Fellow is board certified or board eligible in Pediatrics or Emergency Medicine, and (2) the Fellow is adequately trained to treat. These services are outside the scope of their Pediatric Fellowship Program. A separate hourly salary will be paid for these services. The Fellow may bill for these services in his/her own name. Money generated from these services will be collected by the ED Associates Billing Group. All moonlighting activities must be reported on the PEM moonlighting form and the GME work hours survey and will not place the Fellow or the Institution in violation of Section 405.4 of the New York State Health Code. _________________________________ _________________ Fellow Date _________________________________ _________________ PEM Fellowship Director Approval Date _________________________________ _________________ Director, Division of Pediatric Emergency Medicine Approval Date _________________________________ _________________ GME Office Approval Date ____________________________ ______________ Compliance Office Approval Date
  • 94. VIRASERT GUIDELINES Strong Memorial Hospital Pediatric Emergency Department ViraSert System Yes No General Considerations • Age: 0-18 years • Potentially violent patients • Expected length of stay: • Suspected child abuse Note: Patients meeting 2-3 hours • Psychiatric complaints Family Express Criteria • No likely admissions • ETOH intoxication/drug abuse should be triaged to Family Express • Vital Signs within limits (see (patient or family) below) • Known HIV / AIDS • Minor MVCs (may have had • No current alteration in mental brief LOC) with normal status mental status now • Intentional ingestions • Accidental ingestions (with • Likely need for conscious sedation, normal mental status) major communicable disease • (Varicella, TB, measles) • Likely to need procedure and uncooperative (e.g. suture in your child) Vital Sign Parameters < 1 year 1-8 years 8 years to Adult Heart Rate 100-200 70-160 50-130 Respiratory Rate 20-80 16-40 12-30 Blood Pressure Not < 75 Not < 80 Not < 90 (Systolic) System Yes No Fever (actual or reported) Any fever > 2 months old Toxic appearance If < 2 months, afebrile Lethargy Head • Closed head injuries with • Altered mental status brief LOC • Vomiting > 2 times • Seizures (chief c/o) • Actively seizing • Severe headaches Eyes • New onset periorbital • Suspected orbital cellulitis or cellulitis treatment failures • Chemical splashes • Alkaline splashes • Suspected corneal • Significant foreign bodies abrasions (any age) • Suspected globe injury
  • 95. System Yes No Ears • Ear Trauma Major lacerations/trauma • Ear Ache • Foreign bodies Nose/Throat/Mouth Nosebleeds • Allergic reactions with lip, tongue or throat swelling • Severe trismus Chest • Asthma • Room air oximetry < 93% • Fever and cough • Severe respiratory distress • Chest • High suspicion of/known TB • Trauma/musculoskeletal • Likely to need CXR complaints • Hemoptysis GU Male: Abdominal pain • Testicular pain/swelling • Abdominal pain > 12 years old (female) • Vaginal bleeding/discharge Female: Abdominal pain • Suspected abuse/assault (<12 years old) GI Vomiting/diarrhea • Syncope • Any RLQ pain Mild to moderate dehydration • Bilious vomiting • Significant hematemesis or rectal bleeding Skin • Moderate burns • No circumferential burns • Lacerations (at discretion of MD- • No full thickness burns > 5% BSA check with M at beginning of shift) • Toxic appearance with rash • Rashes: such as • Petechiae/purpura • Generalized urticaria • Allergic reactions with respiratory • Wound infections symptoms • Cellulitis • Varicella Musculoskeletal Musculoskeletal pain – not obviously • Open fracture in need of x-rays • Neurovascular compromise • No suspected femur fractures • Hot, swollen joints
  • 96. PEM FELLOWSHIP EVALUATION PROCESS Overview PEM fellows are formally evaluated semi-annually. The Program Director conduct the evaluation sessions. Evaluations are unhurried, typically lasting 1-½ -2 hours. As the evaluation proceeds, the trainee is encouraged to respond, explain, and question as is appropriate. A description of significant problems encountered during the period is solicited. Phase I: Block Rotation Evaluation 1. Fellows are evaluated after each rotation on each of the six core competencies (see later section): a. By supervising attending physicians following each (non-Pediatric ED, non-Research) rotation. b. At least semi-annually by the Pediatric Emergency Department faculty regarding performance in that setting; c. At least semi-annually by research mentor(s) regarding research progress. 2. Fellows meet (at least) semi-annually with the program director for a more comprehensive evaluation. a. A standard review form is completed and signed by the program director and the trainee. 3. Fellows are required to evaluate each of their rotations for learning value upon completion. 4. Fellows are to update their procedure logs on an ongoing basis. 5. Fellows are required to evaluate faculty semi-annually. These evaluations are shared with the faculty at their annual reviews. CORE COMPETENCIES PATIENT CARE Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. 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 • make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up- to-date scientific evidence, and clinical judgment • develop and carry out patient management plans • counsel and educate patients and their families • use information technology to support patient care decisions and patient education • perform competently all medical and invasive procedures considered essential for the area of practice • provide health care services aimed at preventing health problems or maintaining health • work with health care professionals, including those from other disciplines, to provide patient-focused care
  • 97. MEDICAL KNOWLEDGE Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to: • demonstrate an investigatory and analytic thinking approach to clinical situations • know and apply the basic and clinically supportive sciences which are appropriate to their discipline INTERPERSONAL AND COMMUNICATION SKILLS Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients’ families and professional associates. Residents are expected to: • create and sustain a therapeutic and ethically sound relationship with patients • use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills • work effectively with others as a member or leader of health care team or other professional group PROFESSIONALISM Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse 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 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 PRACTICE-BASED LEARING AND IMPROVEMENT 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: • analyze practice experience and perform practice-based improvement activities using a systematic methodology • locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems
  • 98. • obtain and use information about their own population of patients and the larger population from which their patients are drawn • apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness • use information technology to manage information, access on-line medical information; and support their own education • facilitate the learning of students and other health care professionals SYSTEMS-BASED PRACTICE Residents must demonstrate an awareness of and responsiveness to the large 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: • understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice • know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources • practice cost-effective health care and resource allocation that does not compromise quality of care • advocate for quality patient care and assist patients in dealing with system complexities know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance Phase IV: Final/Exit Evaluation Upon completion of the training program, a final evaluation is performed. A standard review form is used, and signed by the program director and the trainee.
  • 99. EVALUATION OF FELLOW BY FACULTY: SAMPLE FORM University of Rochester/Strong Memorial Hospital Department of Emergency Medicine Pediatric Emergency Medicine Fellowship Training Program Evaluation of Fellow by Faculty Name of Fellow Level of Fellow: Rotation: Faculty Evaluator: Dates of Contact: (please print) Signature of Evaluator: Date: INSTRUCTIONS: Please circle, or place ”X,” for one number in each of the following scales (1-9). Mark “Not Applicable” for any evaluation criterion that does not apply to this training experience. Values “4-6” correspond to the expected level of competence and should be used for the majority of fellows. In evaluating the fellow’s performance, use, as your standard, the level of knowledge, skills, and attitudes expected for a “satisfactory” fellow at this stage of training. For any component that needs attention, or is rated as 3 or less, please provide specific comments and recommendations on the comments page. Please be as specific as possible, including reports of critical incidents and/or outstanding performance. If the training experience emphasizes skills or behaviors that are not included in the numerical scales provided here, please use the “Comments” section to describe the fellow’s performance. This information is confidential. Please return the form in an envelope (or email it) to the fellowship coordinator, Tawni Biggins, Emergency Medicine, Box 655. Do not fax this form. 1. PATIENT CARE a) Interviewing and History Skills ____-Not Applicable UNSATISFACTORY - Uses jargon. Cuts off OUTSTANDING - Excellent interviewing skills. answers prematurely. Insensitive to patient’s Alert to patient’s cues. Follows all leads. cues. History frequently incomplete and/or 1 2 3 4 5 6 7 8 9 History complete, focused, accurate. inaccurate. b) Physical Examination Skills ____-Not Applicable UNSATISFACTORY – Omits major elements. OUTSTANDING - Comprehensive. Pertinent Misses important signs. Lacks concern for to differential diagnosis. Proper focus on patient’s privacy, comfort, and dignity. 1 2 3 4 5 6 7 8 9 particular problems. Notes all findings. Special effort to respond to patient’s needs for privacy, comfort, and dignity. c) Diagnostic Testing ____-Not Applicable UNSATISFACTORY- Fails to order appropriate OUTSTANDING – Always considers clinical tests. Orders by rote. Fails to follow-up on utility of tests. Defines most economical results. 1 2 3 4 5 6 7 8 9 sequence of testing. d) Case Write-ups, Presentations, and Chart Documentation ____-Not Applicable UNSATISFACTORY – Omits major elements. OUTSTANDING – Concise. Comprehensive, Incomplete differential diagnosis and with appropriate problem focus. Inclusive formulations. Disorganized presentations. 1 2 3 4 5 6 7 8 9 differential diagnosis. Informed Careless/tardy write-ups. analysis/formulations. Well documented. e) Diagnostic and Therapeutic Planning ____-Not Applicable UNSATISFACTORY – Inconsistent with data. OUTSTANDING – Always reflects data. Fails to integrate new information. Fails to Accurately interprets results and integrates consider allergies, interactions, risk/benefit of 1 2 3 4 5 6 7 8 9 new data. Always considers allergies, tests or treatment. interactions, risk/benefit. f) Clinical Judgment ____-Not Applicable UNSATISFACTORY – Cannot identify what’s OUTSTANDING – Identifies and accurately important. Illogical. Fails to reach correct ranks major and minor problems. clinical decisions. 1 2 3 4 5 6 7 8 9 Consistently logical. Reaches correct decisions. Able to identify possible life- threatening causes of patient’s condition. 2. KNOWLEDGE a) General Medical Knowledge ____-Not Applicable
  • 100. UNSATISFACTORY – Inadequate knowledge OUTSTANDING – Consistently demonstrated base. Frequent error in recall. Insufficient broad base of knowledge. Accurate recall. reading. Questions naïve or uninformed. 1 2 3 4 5 6 7 8 9 Reads extensively. Questions indicate sophisticated level of understanding. b) Knowledge Base in Pediatric Emergency Medicine ____-Not Applicable UNSATISFACTORY – Inadequate Knowledge OUTSTANDING – Consistently demonstrated base. Frequent error in recall. Insufficient broad base of knowledge. Accurate recall. reading. Questions naïve or uninformed. Reads extensively. Questions indicate 1 2 3 4 5 6 7 8 9 sophisticated level of understanding. 3. PRACTICE-BASED LEARNING AND IMPROVEMENT a) Use of Scientific Literature ____-Not Applicable UNSATISFACTORY – Ignores scientific OUTSTANDING – Appraises the usefulness evidence for care of patient’s problems. Is of scientific evidence for the care of patient’s unaware of study designs and statistical problems. Demonstrates knowledge of methods necessary to evaluate scientific 1 2 3 4 5 6 7 8 9 statistical methods necessary to evaluate studies. scientific studies. b) Self-improvement/Self-awareness ____-Not Applicable UNSATISFACTORY - Fails to perform self- OUTSTANDING – Constantly evaluates own evaluation. Lacks insight, initiative, and resists performance. Incorporates feedback into or ignores feedback. 1 2 3 4 5 6 7 8 9 improvement activities. c) Use of Information Technology ____-Not Applicable UNSATISFACTORY - Fails to use information OUTSTANDING – Effectively uses technology technology to enhance patient care or to 1 2 3 4 5 6 7 8 9 to manage information for patient care and expand knowledge base. self-improvement d) Motivation ____-Not Applicable UNSATISFACTORY – Passive and uninvolved. OUTSTANDING – Enthusiastic. Seeks Rarely takes initiative. Requires reminders to responsibility. Works hard. Makes a major meet basic commitments. 1 2 3 4 5 6 7 8 9 contribution to the team. e) Teaching Supervision of More Junior Trainees ____-Not Applicable UNSATISFACTORY – Provides no direction. OUTSTANDING – Enthusiastic teacher. Misses assigned sessions. Makes Develops materials and programs. Makes inappropriate assignments. Gives derogatory 1 2 3 4 5 6 7 8 9 learning –need-specific assignments. feedback. Provides understanding remediation. 4. INTERPERSONAL & COMMUNICATION SKILLS a) Relationships with Patients and Families ____-Not Applicable UNSATISFACTORY – Lacks respect for OUTSTANDING – Listens and explains patients and/or families. Fails to listen or sensitively. Consistently responsive, even explain. Often unavailable or insensitive. 1 2 3 4 5 6 7 8 9 with difficult or challenging patients and families. b) Relationships with Professionals ____-Not Applicable UNSATISFACTORY – Uncooperative. Lacks OUTSTANDING – Inspires trust, admiration, respect and sensitivity for others. Fails to meet and best efforts from colleagues and co- commitments. Excuses own failures. 1 2 3 4 5 6 7 8 9 workers. Extremely reliable. 5. PROFESSIONALISM ____-Not Applicable UNSATISFACTORY – Lacks respect, OUTSTANDING – Always demonstrates compassion, integrity, and honesty. Disregards respect, compassion, integrity, and honesty. need for self-assessment. Fails to Teaches/role models responsible behavior. Is acknowledge errors. Does not consider needs totally committed to self-assessment and for patients, families, and colleagues. Does not 1 2 3 4 5 6 7 8 9 willingly acknowledges errors. Always display responsible behavior. considers needs of patients, families, and colleagues.
  • 101. 6. SYSTEM-BASED LEARNING ____-Not Applicable UNSATISFACTORY – Unable to OUTSTANDING – Effectively access/mobilize outside resources; actively accesses/utilizes outside resources; resists efforts to improve systems of care; does effectively uses systematic approaches to not use systematic approaches to reduce error 1 2 3 4 5 6 7 8 9 reduce errors and improve patient care; and improve patient care; does not order tests enthusiastically assists in developing systems’ in a cost-effective manner. improvement; orders tests in a cost-effective manner. 7. SKILLS a) General Procedural Skills ____-Not Applicable UNSATISFACTORY – Awkward. Often OUTSTANDING – Careful preparation. overlooks details of preparation or technique. Skillful technique. Invariably assures comfort Insufficient concern for patient’s comfort or 1 2 3 4 5 6 7 8 9 and safety. Exceeds expectations for safety. Fails to meet minimum standards of progress. progress. b) Management of Critically Ill and Injured Patients ____-Not Applicable UNSATISFACTORY – Fails to identify OUTSTANDING – Always selects most appropriate or needed measures. Lacks appropriate measures or approach. Methods confidence. Actions taken are inadequate. include fine qualities. Anticipates pre- and Unaware of proper preparation/follow-up 1 2 3 4 5 6 7 8 9 post-intervention issues. Recognizes and requirements for specific measures. adapts rapidly to mid-intervention Overestimates own ability. Requires constant complications. Appropriately confident and supervision and correction. self-assured. Comments Please provide the following comments regarding the PEM Fellow’s performance: 1. General comments: 2. What areas did the Fellow perform well? 3. What areas need improvement?
  • 102. EVALUATION OF ROTATION BY FELLOW: SAMPLE FORM University of Rochester/Strong Memorial Hospital Department of Emergency Medicine Pediatric Emergency Medicine Fellowship Training Program EVALUATION OF ROTATION BY FELLOW Your Name: ________ Today’s Date: _______________ Rotation: Dates of Rotation: _______________________ Principal Supervisors: ________________________________________________________ Circle the appropriate grade: Unsatisfactory Poor Average Very Good Excellent Diversity of patient care 1 2 3 4 5 Opportunity for technical procedure 1 2 3 4 5 Opportunity for direct patient care 1 2 3 4 5 Opportunity for teaching/supervision 1 2 3 4 5 Responsible faculty clearly defined 1 2 3 4 5 Acceptable quality of supervision 1 2 3 4 5 Acceptable relationship with ancillary staff 1 2 3 4 5 Appropriate number of hours & shifts 1 2 3 4 5 Feedback given to Fellow 1 2 3 4 5 OVERALL RATING OF ROTATION 1 2 3 4 5 1. What was the best thing about this rotation? 2. What was the worst thing about this rotation? 3. Did it meet its education objectives? Why or why not? Yes. See above. 4. What advice would you have for improving this rotation? 5. Other comments regarding this rotation: none
  • 103. EVALUATION OF EMERGENCY MEDICINE FACULTY BY PEM FELLOW: SAMPLE FORM University of Rochester/Strong Memorial Hospital, Dept. of Emergency Medicine Pediatric Emergency Medicine Fellowship Training Program EVALUATION OF EMERGENCY MEDICINE FACULTY BY PEM FELLOW EM Faculty Attending: ________________________________________ Date: ____________ PEM Fellow Evaluator (optional): ________________________________________________ Please circle the appropriate grade: Direct Clinical Teaching NA 1 2 3 4 5 rarely involved in usually teaches sought after as teaching teacher Direct Clinical Supervision NA 1 2 3 4 5 rarely supervises usually active supervises supervision Manual Skills Training: Teaching Fellows Procedures NA 1 2 3 4 5 rarely usually always Accessibility NA 1 2 3 4 5 rarely available usually available always available Lectures NA 1 2 3 4 5 rarely effective usually effective always effective Guidance NA 1 2 3 4 5 provides no occasional active as mentor mentorship mentor Interpersonal Interactions: Personable, Enthusiastic, Helpful NA 1 2 3 4 5 rarely usually rarely OVERALL PERFORMANCE 1 2 3 4 5 unsatisfactory average outstanding Narrative Evaluation:
  • 104. FELLOW SELF EVALUATION: SAMPLE FORM PEM Fellow Semi-Annual Update Fellow Self Evaluation (To be completed prior to your update) Fellow: ____________________________________ Date: ___________ Clinical knowledge and performance: Research: Teaching Activities: Participation in Division Activities: Coursework: Overall: Areas of special concern / other: Anticipated plan for the next 6 months:
  • 105. PROGRAM FINAL EVALUATION: SAMPLE FORM University of Rochester FINAL EVALUATION Office of Graduate Medical Education (to be completed by the Program Director) Trainee Name: __________________________________________ Program: ______________________________________________ Highest PGY Level Attained: _______________________________ Training Start Date: ____________________ Training End Date: ____________________ Patient Care: Competent Not Competent Medical Knowledge: Competent Not Competent Interpersonal and Communication Skills: Competent Not Competent Professionalism: Competent Not Competent Practice-Based Learning and Improvement: Competent Not Competent Systems-Based Practice: Competent Not Competent Specifics regarding level of performance for each of the above can be found in departmental records. To your knowledge has this physician: 1. Any pending professional misconduct proceedings or NO YES pending malpractice actions? Judgments or settlements? 2. Ever been suspended or had his/her privileges NO YES restricted or terminated? 3. Ever been denied a certificate of completion of NO YES training for any reason? 4. Ever resigned or withdrawn his/her association with NO YES your program to avoid the imposition of disciplinary measures? 5. Ever voluntarily surrendered his/her license to avoid NO YES discipline, revocation or termination? 6. Do you know of any health problems, either physical NO YES or mental, including substance abuse, which might affect his/her performance in patient care? 7. To your knowledge, has the applicant ever been NO YES convicted of a crime? ======================================================================= A YES to any of the above questions in this section should have an explanation attached. This section applies to trainees who have NOT completed a full residency/fellowship program: This trainee successfully completed ______ years/months of a ________ residency/fellowship This section applies to trainees who have completed an ACGME/ABMS/CDA-accredited program: This trainee successfully completed a(n) _____________________________ residency/fellowship. In the opinion of the program director and program's faculty, this trainee has demonstrated sufficient professional ability to practice competently and independently. NO YES Director Signature: ______________________________ Date: _______________________
  • 106. Trainee Signature: ____________________________ Date _____________________
  • 107. CREDENTIALING STANDARDS Policy On Credentialing For All Clinical Activities The following policy on resident/fellow credentialing has been developed to conform to the New York State Health Code and Section MS.6.9/MS.6.9.1 of the Standards of the Joint Commission on Accreditation of Healthcare Organizations. Credentialing Each Program director will delineate those activities that a resident in the program will be able to perform under general supervision. General supervision means that a supervising physician/dentist does not need to be physically present while the resident performs the clinical activity/procedure, provided the resident: (1) has permission from the physician/dentist to perform the clinical activity/procedure, and (2) has documented adequate training (i.e., has been credentialed) to perform the clinical activity/procedure. Each program will have a process in place to verify trainee competence prior to allowing him/her to perform activities under general supervision. When a trainee has completed the credentialing process, the program director/coordinator will have a method to record a trainee's completing the credentialing process under general and direct supervision. This will be kept at the program level and transferred at intervals to the Medical Staff Office via an updated Delineation of Competencies form by individual. Advanced Level Credentialing Residents entering our programs at advanced levels who have been credentialed for clinical activities/procedures at another institution may be credentialed by the Program Director after reviewing the credentialing documents from the other institution if those materials are adequate. If the advanced resident has not been credentialed by another institution, the Program Director has the right to modify that resident/fellow's clinical activity and procedure credentialing process after reviewing the nature of that resident’s prior training and clinical experience. Though the manner in which the advanced resident is credentialed may be different than a resident entering at the first year level, it will still be necessary for the Program Director to maintain on file any internal or external documentation of the credentialing process for that resident, and to provide an updated Delineation of Competencies to the Medical Staff Office. Updated by GMEC 2/12/01, 4/21/03
  • 108. Strong Health System Credentials & Privilege Review Non-curricular Graduate Assistant Staff Activity APPLICANT PAGE 1 OF 2 I,__________________________________________________ (please print name) am requesting privileges at: Highland Hospital  Strong Memorial Hospital  Other_____________________ (please specify) in the Department(s) of ____________________________________________________________for the purpose of providing patient care as a dependent practitioner from ___/___/___ through ___/___/___. My Social Security Number is ______________________, my date of birth is ____________, and my New York State License number is ________________________. I am a citizen of ___________________. Signature ___________________________________________ Date ___________________ TRAINEE PROGRAM DIRECTOR ________________________________________ (applicant’s name) is currently a ____-year  resident  fellow in the ________________________ Training Program. I will be responsible for assuring that this trainee does not exceed New York State 405 code regulations regarding work hours for trainees, and for notifying the Medical Staff Office if this trainee receives an unsatisfactory semi-annual evaluation. I have reviewed the attached Delineation of Privilege form(s) for the Department(s) of ______________________________ and verify that the above-named trainee is qualified and capable of assuming these privileges as a dependent practitioner. Signature __________________________________________ Date ____________________ Program Director EMPLOYING DEPARTMENT CHAIR Signature _______________________________________ Date _________________ Department Chair CREDENTIALS AND PRIVILEGE REVIEW  Confirmation of background and training (Medical School, Internship, other training, etc.) through the GME Office  Verification of malpractice insurance Based on the above assurances from the applicant’s Program Director, review by the Chief of Service employing the trainee, and upon review of the appointment information, in accordance with the Medical Staff Bylaws, the Chair of the Credentials Committee forwards this application to the Associate Medical Director: with no objections noted with restrictions as noted on page 2 of this form. Chair, Credentials Committee ________________________________ Date __________________ Associate Medical Director __________________________________ Date __________________
  • 109. Page 2 to complete: Applicants must provide an answer for each of the following questions and provide a full explanation to any “Yes” response. 1. Have any professional liability suits been filed against you that are currently pending in this or any other state? __ Yes __ No 2. Have any professional liability judgments and/or settlements been made against you __ Yes __ No or on your behalf? 2. Have you ever been the subject of a National Practitioner Data Bank adverse action report? __ Yes __ No 4. Has your employment, medical staff appointment, affiliation, or clinical privileges ever been voluntarily or involuntarily suspended, diminished, revoked, refused, or limited in any hospital or health care facility, including to avoid disciplinary action? __ Yes __ No 5. Has your license to practice your profession in any jurisdiction ever been limited, suspended, revoked, denied, or subject to probationary conditions? __ Yes __ No 6. Have you ever voluntarily or involuntarily relinquished your license to practice your profession in any state? __ Yes __ No 7. Have you ever been subject to disciplinary action proceedings by a state or professional body, e.g. OPMC? __ Yes __ No 8. Do you have any pending misconduct proceedings against you in this or any other state? __ Yes __ No 9. Have you ever been convicted of, or are you currently under investigation for a misdemeanor or felony in any jurisdiction? __ Yes __ No 10. Have you ever been cited for violation of patient rights as set forth by the NYS Department of Health or any other state department of health? __ Yes __ No 11. I attest that the information provided on this form is true and accurate. __ Yes __ No 12. I understand that any misrepresentation, misstatement, or omission from this form could result in the immediate rejection or revocation of this request. __ Yes __ No 13. I am currently able to perform the clinical privileges that I have requested. __ Yes __ No 14. I am not currently using any illegal drug, nor have I during the past two years. __ True __ False Explanation for any “Yes” answers: _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ ______________________________________________________ ______________________ Signature of Applicant Date ************************************************************************************** Restrictions from Credentials Committee: _____________________________________________________________________________________________
  • 110. POLICY ON MOONLIGHTING This document can also be found at http://extranet.urmc.rochester.edu/urmcmso/ credentialing/MoonlightingApplication.pdf. Moonlighting is defined as clinical activities outside of a residency or fellowship training program, for which the trainee is paid on an hourly or other rate, in addition to the approved salary for a trainee at his/her training level. Professional activities outside the training programs are prohibited to the extent that they may interfere with training program responsibilities. Each department must have its own policy on outside activities, which may be more restrictive than that of the institution. No resident may be required to moonlight. Prior to seeking such employment, Residents and fellows who wish to engage in outside activities (moonlighting): 1. Are required to have written approval from the Chairman or Program Director using the Moonlighting (extra shift) Request Form and the Credentials & Privilege Review forms 2. Must be in good standing in the training program in full time status 3. Should seek written assurance of malpractice and workers’ compensation coverage from any outside employer 4. Must have a valid New York State medical license 5. May use the institutional DEA number assigned to the affiliated hospital at which the resident is moonlighting as well as your own suffix; alternatively, obtain your own Federal DEA number 6. Must hold a MD, DO, DDS or DMD degree 7. MDs and DOs clinical training shall include completion of at least one year in an approved residency training program, which may include a Transitional Year or a year in a designated subspecialty 8. Must have a primary appointment in an accredited residency or fellowship program sponsored by the University of Rochester 9. Must have his/her performance monitored to ensure that he/she remains in good standing in his/her training program as documented by satisfactory evaluations (semiannually). If the trainee receives an unsatisfactory evaluation at any time or is terminated from his/her program, the moonlighting appointment will be immediately terminated. If a trainee receives an unsatisfactory evaluation, moonlighting may not be renewed for the remainder of the training program. The Medical Staff Office will be notified in any event. Approval to moonlight (assume extra shifts) is granted through the end of the current academic year and must be requested for each subsequent year. If a Resident or Fellow engages in professional activities outside of the training program, the hours devoted to that activity must be added to the training program work hours and must be reported on the Office for Graduate Medical Education work hours survey, and to the Chair and Program Director on any departmental work hours surveys. The trainee is responsible for reporting all moonlighting activity to the program director. The program director is responsible for monitoring the trainee's moonlighting (extra shift) activity and maintaining records of the activity in the trainee's departmental file. The total hours must comply with the number of hours a resident may work as detailed in the University's duty hour policy. Usual trainee duty hours plus moonlighting (extra shift) hours added together must not cause trainees to violate duty hour limits. (See Institutional Policy on Resident/Fellow Duty Hours.) Residents/fellows must be supervised by a member of the attending staff at SMH and Highland Hospital for all Strong Health moonlighting (extra shift) activities. That attending physician will be the physician of record
  • 111. for all patients cared for by the moonlighting trainee. Supervision will be comparable to that required when residents/fellows engage in activities which are part of the training program. The moonlighting (extra shift) activities may be under general supervision if the resident/fellow has been appropriately credentialed to perform the specific activities under general supervision; if not, the resident/fellow must be directly supervised by the attending physician. Residents/fellows may moonlight (take on extra shifts) in their own or other Departments at SMH and HH. The employing Department is responsible for maintaining records that the trainee has been appropriately credentialed (see Policy on Credentialing for All Clinical Activities) and privileged to perform the relevant moonlighting activities under general supervision. The employing Department is also responsible for (extra shift) monitoring the status of the appointment through the Credentials & Privilege Review Office. CATEGORIES OF MOONLIGHTING at Strong Health Facilities Supervised Extra Work Shifts Works dependently as credentialed, supervised by the attending of record. Payment is by extra compensation. Professional liability insurance provided by Strong Health covers these activities. Requires privileges through the Credentials & Privilege Review Office. Services rendered by residents under general supervision may not be billed. However, attending physicians may bill for services when the Teaching Physician regulations for rendering and documenting services are followed. For questions related to billing for clinical services in these settings, please contact the Compliance Office (5-1609). Credentials & Privilege Review Office Request for moonlighting (extra shift) privileges requires completion of packet, which includes: Completion of Non-Curricular Resident Activity Form (including all signatures as required) Copy of current valid New York State License to practice Medicine Copy of Current CV Completed Health Assessment Form Signed SMH Statement of Assurances Supervised Extra Work - (elective part of program) Paid electives coordinated by the program result in additional annual stipend in an equal amount for all residents at the same level of training. This arrangement must be approved by the Graduate Medical Education Committee. No additional appointments are required, as this is part of the program. Professional liability insurance for residency training covers these activities. (If all residents in the program do not pursue the electives, then the experience must be done as above). Services rendered by residents under general supervision may not be billed. However, attending physicians may bill for services when the Teaching Physician regulations for rendering and documenting services are followed. For questions related to billing for clinical services in these settings, please contact the Compliance Office (5-1609).
  • 112. STRONG HEALTH MOONLIGHTING (extra work shift) REQUEST FORM I, ______________________________________, am requesting permission to moonlight. I recognize the following: 1. My moonlighting activities cannot interfere with my regular training program responsibilities. 2. I must accurately report moonlighting hours in semiannual work hours surveys conducted by the Office of Graduate Medical Education. 3. My total work hours must be in accordance New York State Health Care Code, Section 405 and ACGME standards. • I cannot work more than eighty (80) hours per week. I understand that NYS further defines the weekly time limit to be a maximum of 84 hours. • I cannot work longer than 24 consecutive hours (plus 3 hours of transfer of care time). • I should have at least ten (10) hours of non-work time between shifts. • I must have one 24-hour period free from clinical duties each week. 4. I will inform my Program Director of my moonlighting shifts so that this activity may be monitored by my program. 5. I understand that professional liability insurance provided to me for my residency program duties will only cover moonlighting activities at Strong Memorial Hospital or Highland Hospital. 6. I possess a current unrestricted New York State medical or dental license. 7. I understand that if I do not have my own Federal DEA number that I can use the institutional DEA number assigned to the hospital at which I am moonlighting and use my assigned suffix. 8. For activities that will take place at Strong Memorial or Highland Hospital, I will secure Medical Staff privileges (at each hospital) before I begin any outside work. 9. I will not report any cases done during moonlighting on an ACGME case log system because I understand these cases to have been done outside of my standard training program. 10. I understand that approval to moonlight is granted through the end of the current academic year and must be requested for each subsequent year. Failure to comply with the above may result in withdrawal of permission to moonlight or other disciplinary actions. I further understand that if I am placed on probation by the residency program, or if my program director is concerned that my clinical performance has been negatively affected I will no longer be allowed to moonlight. I understand the number of hours that need to be reported to the program and will not knowingly put myself and my program in violation of the New York State Health Care Code, Section 405 or ACGME regulations. _____________________________________________________________________________________ Signature of Resident Date I have reviewed with the trainee his/her plans to moonlight. The planned activities will not violate the New York State Heath Care Code Section 405 and ACGME regulations, and I approve of this trainee’s request. I will monitor and maintain records of these activities. _____________________________________________________________________________________ Signature of Program Director Printed Name of Program Director Date c: Departmental File Office for Graduate Medical Education Credentialing Office (SMH, HH)
  • 113. Moonlighting Hours Tracking Form: Sample MOONLIGHTING SCHEDULE BLOCK #_____ SUN MON TUE WED THU FRI SAT WEEK 1 WEEK 2 WEEK 3 WEEK 4 Total # Clinical hours: ________ Total Conference hours: ________ Total # Moonlighting hours: ________ Total Required Class hours ________ Total hours __________ ------------ -------- ------------------------------------------------------------------------ Moonlighting must be approved by the fellowship director (see moonlighting policy). Work hours must adhere to the following guidelines. 1. Work Days i. ED Rotations - 12 consecutive clinical hours - Plus 3 hours buffers (non-clinical/admin/teaching) ii. Outside Rotations - 24 consecutive clinical hours - Plus 3 hours buffers (non-clinical/admin/teaching) iii. 10 hours off between clinical shifts iv. Attendance in required classes counts towards workday hours v. Attendance in all other classes that are not required vi. should not be counted towards work day hours 2. Work Week i. Work week starts on Sunday at 12:00AM and ends Saturday at 11:59PM ii. ED Rotation: 60 hour clinical week iii. Outside Rotations: 80 hour work week iv. One 24 hour period off each week 3. Moonlighting i. Fellows must have 8 hours off after moonlighting shift before non-clinical work (class/administrative/teaching). ii. Fellows must have 10 hours off after moonlighting shift before clinical hours. iii. All moonlighting hours must be recorded and submitted to the program coordinator by the 5 th work day in the month following the moonlighting event. This will be reviewed by the program director for compliance. iv. Fellows rotating in the Pediatric ED who fail to attend at least 80% of scheduled conferences during the block are not permitted to moonlight in the following block. (PEM, PICU/ED, EM Research). v. Moonlighting privileges will be suspended if the fellow owes more than 150 clinical hour
  • 114. PROFESSIONAL LIABILITY INSURANCE Professional liability insurance is provided by the University’s insurance program for only those activities that are an approved component of the training program. Rotations to Affiliated hospitals are insured by the Affiliated hospital. Extra shifts worked at Highland or Strong Memorial hospitals are insured under the University’s insurance program. There is NO coverage under the University’s program for professional activities outside the scope of the residency program nor for moonlighting at non-Strong Health facilities, nor while on vacation or disability. Professional liability insurance information for residents or fellows for year 2009 follows: CARRIER: MCIC Vermont, Inc., an RRG ADDRESS: University of Rochester Medical Center Attn: Insurance Administrator PO Box 278979 Rochester, NY 14627-8979 Phone: 585-758-7606 Fax: 585-272-9311 POLICY NUMBER: PR1108 COVERAGE FORM: Claims-made. MCIC will provide coverage for any claim arising out of an incident that occurred during your participation in the MCIC program (this is commonly referred to as “tail” coverage or an Extended Reporting Endorsement). “Tail” will be provided as long as the URMC remains a shareholder in MCIC Vermont, Inc. or its successor and MCIC Vermont, Inc. or its successor remains in the business of issuing insurance policies covering events occurring during the related policy year. COVERAGE SCOPE: Limited to activities required to complete an approved program of medical education POLICY TERM: 01/01/2009 to 01/01/2010, coverage automatically terminates upon conclusion of training program at the University of Rochester Medical Center or the Strong Partners Health System COVERAGE LIMITS: $3,500,000 per claim No annual aggregate CLAIM HISTORY: Available upon receipt of written request from the insured physician or to a third party upon receipt of a release signed by the insured physician. There is a 30 business day response timeframe to claim history requests. Contact the GME Office. TO REPORT A CLAIM contact the Risk Manager on-call at 585-758-7600 The insurance policy is a modified claims-made policy, which covers claims, or adverse medical incidents actually reported to the company during the policy year. The claim or medical incident must also have occurred after the coverage under this program was obtained. Claims related to services rendered prior to a trainee’s coverage under this program should be covered by the insurance carried by that practitioner at the time the service was rendered. As a modified claims-made policy, MCIC will provide coverage for any claim arising out of an incident that occurred during a trainee’s participation in the MCIC program (this is commonly referred to as “tail” 114
  • 115. coverage or an Extended Reporting Endorsement). This “tail” coverage will be provided as long as the University of Rochester Medical Center remains in the MCIC insurance program and the Company still issues new policies. The University of Rochester Medical Center is responsible for securing and paying for alternative insurance coverage for you should it withdraw from the MCIC program or if MCIC no longer continues to issue new policies. Of course, no coverage will be provided for any claims that arise out of services rendered after an insured physician terminates participation in the insurance program. 115
  • 116. UNIVERSITY OF ROCHESTER SUMMARY OF BENEFITS FOR RESIDENTS AND FELLOWS (TRAINEES) 2009 - 2010 11/06/2008 Category Benefit Professional Professional liability insurance is provided by the University’s insurance program for activities that are required to complete an ACGME-approved Liability program of medical education. The same policy also covers Strong Health moonlighting activities. During rotations to other hospitals, coverage is Insurance provided by the affiliated hospital. The coverage form is claims-made and is modified to include “Tail” Coverage. (Malpractice) Health Care Effective the date of appointment. Choice of 4 plans that provide hospital, surgical and medical coverage;. Plans Wellness Trainees enrolled in the University Health Care Plans can receive a free biometric screening and complete an annual Health Assessment for a $100 Program incentive. Dental Assistance Traditional Dental Assistance Plan is available upon appointment. Assists with preventive, as well as basic and major restorative dental expenses. Plan Medallion Dental Plan is offered during Open Enrollment period for coverage effective January 1st. This plan provides a higher schedule of benefits; trainees contribute a share of the premium. Group Auto & Group rates for auto and home insurance policies. Paid for by the resident or fellow by convenient payment options of payroll or bank account Home Insurance deduction. University Home New homeowners in Sectors 4 or 6 of the City of Rochester are eligible for $3,000 from the University, $3,000 from the City and up to $3,000 from Ownership either Advantage Federal Credit Union or Canandaigua National Bank & Trust. Incentive Program Flexible Allows trainees to put aside money tax-free to cover eligible out-of-pocket medical/dental or dependent care expenses. FSA elections must be made Spending during the fall open enrollment for the next calendar year. Accounts (FSA) University-paid Coverage equal to 150% of annual salary, with minimum of $15,000 ($7,500 if part-time) and maximum of $50,000 ($25,000 if part-time). Paid for Basic Term Life by the University. Insurance Employee-paid May enroll for Group Universal Life (GUL) or Group Optional Term (GOTL) coverage of 1 to 6 times annual salary, up to a maximum of $1,500,000 Optional Group immediately upon appointment. Paid for by the trainee. If optional GUL or GOTL is elected, you are also eligible to purchase Group Term coverage Life Insurance for your spouse/domestic partner and dependent children. Sick Leave Plan Full salary is continued during sick leave for up to the full period of the one-year appointment or according to the University’s schedule under the Sick for Short-Term Leave Plan for Short-Term Disability, whichever provides the greater benefit. Disability Long-Term Must choose full LTD coverage and meet service criterion, then when totally disabled for more than six months, guarantees 60% of up to $60,000 per Disability (LTD) year of covered salary. Paid for by the University for trainees. Benefits are provided until normal social security retirement age. Graduating house Plan staff officers are able to convert to an individual policy, up to $3,000/month, without any medical underwriting. Supplemental URMC house staff officers can apply for a supplemental policy during their program. Coverage can raise coverage beyond 100% of income and Disability defer as much as $9,000/month of guaranteed coverage to protect future earnings. Medical and financial underwriting is required during the initial Insurance application process. Coverage can provide lifetime benefits and a selection of options. Vacation Trainees receive at least three weeks of vacation per year. Additional vacation time and/or time for attendance at scientific or medical meetings may be allowed at the discretion of the Department. Retirement Trainees are immediately eligible to make voluntary tax-deferred contributions to TIAA-CREF and/or Mutual Funds (T. Rowe Price, Vanguard and Program Fidelity), but are not eligible to receive a University Direct Contribution. Tuition Benefits Full-time residents and fellows are eligible upon appointment for tuition waiver at the U of R for up to 2 credit courses in each relevant period (e.g. for Self semester or quarter). 116
  • 117. Tuition Benefits Spouses/domestic partners of full-time residents and fellow are eligible upon appointment for tuition waiver at the U of R for 1 course in each for relevant period at 50%. Spouse/Domestic Partner Leave of Absence Trainees may be eligible for Family Medical Leave Act or the University’s Leave of Absence program. Detailed information is available in the Resident Manual which is available on the GME web site. Effect of Leave Any Leave of Absence, Short-Term Disability or other time off which results in the trainee’s failure to meet the minimum requirements for training on Training time set forth by the appropriate board will result in an extension of the trainee’s training program. Lab Three lab coats are provided to new trainee at orientation. Three lab coats are provided each year to continuing trainees in January/February and in Coats/Scrubs selected programs for continuing trainees a combination of lab coats and scrubs. No laundry services are provided. /Laundry Services Meals The GME Office provides $7/meal for scheduled in-house, overnight call. Call Rooms Call rooms are provided for those programs who require their trainees to have in-house, overnight call. Athletic Facilities All employees of Strong Memorial Hospital are eligible to join the Medical Center’s Fitness & Wellness Center, or the Robert B. Goergen Athletic Center on River Campus. Credit Union Employment by the University entitles you to become a member of the Advantage Federal Credit Union. Short Term The Office for Graduate Medical Education can assist you in securing a short term, interest-free loan of up to $500, as available. Loans Life Support Strong Memorial Hospital will pay for trainee training in BLS, ACLS, ATLS, NRP, or PALS as deemed necessary by the program. Training 117
  • 118. UNIVERSITY LEAVE OF ABSENCE A leave of absence, which is defined as an excused absence without pay, is a privilege that may be granted to SMH residents/fellows at the discretion of the program director. Absences due to illness are covered under the Sick Leave Plan for Short-Term Disability. Dependent care and Paternity Leave is covered under the Family and Medical Leave Act. Guidelines A. Reasons for a Leave of Absence A leave of absence may be granted for personal reasons. B. Length of Leave A leave of absence may be granted for not more than 12 months. Leaves granted for less than 12 months may be extended, if requested prior to expiration, for up to a total absence of 12 months. A Short-Term Leave of Absence may be granted for up to 30 working days (maximum of six weeks) in a calendar year. C. Benefits 1. Hospital paid health insurance and Dental Assistance premiums will be continued. Resident contributions to the health insurance premium will continue to be the resident’s/fellow’s responsibility while on Leave of Absence. 2. University paid Basic Life Insurance will be continued. Optional Life Insurance will also be continued unless the house officer signs a form canceling this portion of the coverage. Individuals who do not cancel Optional Life Insurance during a leave will be billed for their normal share of the premium. 3. Full and Limited Long Term Disability (LTD) Insurance is suspended during a leave unless an individual is on leave for full-time study for an advanced degree or for active work in education or research. Residents/fellows on leave for these purposes who choose to continue Full LTD will be billed for their normal share of the premium. 4. Tuition benefits for the resident/fellow are suspended unless he/she has a tuition waiver or reimbursement for a course in progress approved before the effective date of the leave. D. Return from Leave A resident/fellow on leave is assured of their position at the conclusion of the leave. The resident/fellow must keep the program apprised of his/her plans periodically, and in a timely fashion so as not to interfere with the scheduling of rotation assignments. When a date of return is known, the resident/fellow must notify the Program Director to confirm arrangements for return to active status. Required length of notice may vary widely by program and it is the responsibility of the resident/fellow to provide notice in accordance with individual program requirements. A minimum notice of one month is desirable and is requested if feasible. A resident’s/fellow’s failure to return from a leave will result in termination of employment. E. It is up to the individual programs to determine if any portion of an extended leave of absence must be made up, either in accordance with the Special Requirements of that discipline or at the program director's discretion. Should the resident/fellow be required to make up all or part of a leave, he/she will continue to be paid by the program at the salary level commensurate with the appointment and job description. 118
  • 119. Procedures A. The resident/fellow will present to the Program Director in writing a formal request for a leave of absence no less than thirty (30) days prior to the beginning date of the leave. In the case of an emergency, this time period may be waived. This request will include reason for leave, dates of leave, and expected return date. B. The Program Director, acting for the Department/training program, will decide and notify the resident/fellow in writing as to whether or not the request has been approved. C. The Program Director and resident/fellow will work out any coverage issues while the resident/fellow is on leave. D. The resident's/fellow’s personnel action form (610), written request and approval from the program director, and completed Request for Leave of Absence form, will be signed off in the resident's/fellow’s Department and forwarded to the Office for GME for signature. The original request for leave form will be kept in the Office for GME with a copy in the resident’s/fellow’s file. E. Residents/fellows are not required to exhaust their vacation allocation prior to taking a Family Medical Leave or a University leave. 119
  • 120. DISABILITY The University of Rochester – Policy: 339 Policy: The Sick Leave Plan for Short-Term Disability pays all or part of basic salary for an eligible faculty or staff member who has a disability which is not job-related and which prevents the individual from carrying on University duties and responsibilities. Benefits may be payable for a period of days, weeks, or months (up to a maximum of a full year) and are determined by the individual's position and length of service. Workers' Compensation benefits apply in cases of job-related disability. The Sick Leave Plan for Short- Term Disability may supplement Workers' Compensation payments required by law. Guidelines: 1. Sick leave may not be used to cover absence caused by illness of a member of the family, nor for absences other than those caused by personal disability of the faculty or staff member. 2. Coverage During Job-Related Disability The Sick Leave Plan covers absence due to non-job-related disability. Separate but similar benefits apply to job-related disability, which occurred in the capacity as a University of Rochester employee. See Policy #271, Workers' Compensation. 3. Coverage During Leave of Absence During an approved leave of absence, faculty and staff members who become disabled within four weeks of the effective date of leave may qualify for statutory sick leave benefits during the period of disability. 4. Coverage During Layoff* During a temporary or indefinite layoff, an individual who becomes disabled within four weeks of the effective date of layoff may qualify for statutory sick leave benefits during the period of disability. *This section does not apply to faculty. 5. Coverage on Retirement, Termination or on Change to Ineligible Status Faculty and staff members who become disabled within four weeks after retirement, termination of employment or change to an ineligible status may qualify for statutory sick leave benefits during the period of disability. 6. Continuation of Other Benefits During Sick Leave Active** faculty and staff receiving benefits under the Sick Leave Plan continue eligibility for enrollment in the following benefit plans: Health Care Plan, Dental Assistance, Long-Term Disability, Life Insurance, Retirement Program, and Tuition. Vacation and Holiday accruals also continue. **For individuals whose statutory sick leave benefits begin after the effective date of leave of absence, layoff, retirement, termination or change to an ineligible status, benefit plans suspension or cancellation date(s) will apply 120
  • 121. Figure 6: Schedule of Sick Leave Benefits SCHEDULE OF SICK LEAVE BENEFITS PROVIDED FOR STRONG MEMORIAL HOSPITAL RESIDENTS AND FELLOWS For regular full-time and part-time Strong Memorial Hospital Residents and Fellows, full salary is continued during sick leave for up to the full period of the one-year appointment or according to the following schedule, whichever provides the greater benefit: if length of University service for up to at beginning of disability is: 2 months* less than 2 years 4 months** 2 but less than 4 years 6 months 4 but less than 6 years 8 months 6 but less than 8 years 10 months 8 but less than 10 years 12 months 10 years or more *plus four months of statutory sick leave benefits **plus two months of statutory sick leave benefits (Statutory sick leave benefits provide half pay up to $170 per week.) NOTE: Successive periods of disability caused by the same or a related injury or illness are considered a single period of disability if separated by less than three months. 121
  • 122. SUBSTANCE ABUSE The University of Rochester Personnel Policy/Procedure – Policy: 151 Updated: 2/00 Subject: Alcohol & Drug Problems, and Emotional Illness Applies to: All Faculty and Staff Policy: The University, with emphasis on maintaining a safe and efficient work environment, is concerned for the well being of faculty and staff and those they serve. Drug abuse, alcoholism, and emotional problems are recognized as illnesses and should be treated as such. Department heads and supervisors are expected to assist faculty and staff in seeking professional care, as well as to provide support and encouragement and to make reasonable adjustments to assist individuals during rehabilitation periods. The Employee Assistance Program is available to employees and supervisors who need advice and assistance. Guidelines: A. Supervisors should evaluate and document misconduct or job performance problems, including interpersonal relations affecting the work as job performance issues. B. Individuals may use accrued Sick Leave benefits during periods of rehabilitation provided medical certification is received from a health care provider. C. When a period of rehabilitation is expected to exceed six months, an eligible faculty or staff member may apply for benefits under the Long-Term Disability Plan. D. When recommended by the faculty or staff member's health care provider in consultation with the Office of Human Resources, departments should be prepared to make short-term job adjustments upon an individual's return to work following absence for treatment or rehabilitation. Reasonable job performance standards should be maintained. 1. The University reserves the right to require a faculty/staff member to undergo a health assessment which may include testing for controlled substances if there is cause for reasonable suspicion that the individual has a substance abuse problem. 2. After an absence for rehabilitation and treatment for use of controlled substances, a faculty or staff member may be required to agree to random drug testing for a period of time as a condition of continued employment. Upon returning to work, failure to agree to testing or to successfully pass such tests will result in termination. Procedures: A. When faculty or staff members indicate that job performance problems are due to alcoholism, drug abuse, or emotional illness, or if the supervisor has valid reasons to believe that this may be the case, the faculty or staff member should be referred to the Employee Assistance Program, or a faculty or staff member may seek treatment through other available resources. A. When drug abuse, alcoholism or emotional illness results in unsatisfactory or unacceptable job performance, the supervisor should inform the faculty or staff member in writing stating the nature of the unsatisfactory or unacceptable job performance, and outlining the necessary steps that the individual is expected to take to ensure that performance standards are met. B. If a faculty or staff member fails to start or sustain a recommended treatment program for drug abuse, alcoholism or emotional illness, and continues to fail to meet performance standards, he/she may be terminated due to misconduct or unsatisfactory job performance. Supervisors should refer problems of alcoholism, drug abuse or emotional illness to the Employee Assistance Program. 122
  • 123. UNIVERSAL PRECAUTIONS – PATIENT SAFETY The University of Rochester Policy: 158 II.Policy: The University requires staff to wear/use safety or personal protective equipment when assigned work that may cause injury or illness. III.Guidelines: 1. Requirements and Standards: 1. In accordance with the OSHA Personal Protective Equipment Standard (29 CFR 1910.132) each department is required to perform a hazard evaluation of those work areas or jobs where hazards are likely to be present. (See Job Hazard Assessments in the UR Personal Protective Equipment (PPE) Plan available from University Risk Management and Environmental Safety’s (URMES) web site). Examples of recognized hazards include chemical and radiological exposures, sharp objects which may cut or puncture the skin, excessive noise, heavy objects which may fall onto the feet or head, flying debris which may be inhaled or strike the eyes, laser or other non-ionizing radiation sources, blood borne pathogens and other biohazards, and any other hazard which may cause injury, illness or impairment by inhalation, absorption, ingestion, injection, or mechanical action. 2. Staff members in designated positions are required to wear appropriate protective equipment during work hours. Individuals represented by collective bargaining agreements receive benefits in accordance with those agreements. Note: Personal protective equipment shall not be used in areas where administration or engineering controls are feasible and provide protection equal to or greater than that offered by personnel protective equipment. 3. Supervisors are responsible to ensure that all personal protective equipment provided by the University or by the employee is capable of providing adequate protection and is properly maintained. 4. Supervisors are responsible to provide staff with site specific training to ensure that they have the knowledge to know when/how to use and maintain personal protective equipment. 5. All protective equipment must meet standards of the American National Standards Institute (ANSI), or other regulatory agencies (e.g. National Institute of Occupational Safety and Health (NIOSH). 6. Departments are responsible for costs related to the use of personal protective equipment to include the initial purchase of equipment, fit testing, medical examinations, training (and materials), service and maintenance and associated supplies. 7. Supervisors are responsible for maintaining records verifying compliance with training, completion of medical examinations, purchase and replacement dates of equipment and/or other relevant information. 2. Enforcement: 1. Supervisors are responsible for enforcing all safety equipment requirements on an ongoing basis. 2. Staff not complying with safety requirements will not be allowed to work and will be on leave without pay until they comply with requirements. 123
  • 124. IV.Procedures: 1. Department heads (or designees) will establish procedures for procurement of safety equipment in accordance with Section II A. Safety equipment such as non-prescription safety glasses, hard hats, protective earplugs or muffs, gloves and respirators will be provided at no cost to the employee by the department. Employees may be reimbursed for or provided a voucher to cover the partial or whole cost of personal protective equipment (e.g. safety footwear or prescription safety glasses) when the probationary period is successfully completed. Departments will determine a reasonable allowance for such equipment. Safety footwear will be replaced not less frequently than every twelve months. Safety footwear damaged beyond repair due to a work-related incident, rather than normal wear, may also be replaced if approved by the department head or designee. An incident report (S115) must be completed by the employee's supervisor, or Security if appropriate, and sent to URMES. 124
  • 125. PEM FELLOWSHIP CONTRACT AGREEMENT OF APPOINTMENT This contract is made between __Name of fellow__ and The University of Rochester Strong Memorial Hospital, 601 Elmwood Avenue, Rochester NY 14642 for the purpose of graduate medical education in Ped Emer Med at the PGY# level in consideration of the mutual obligations set forth below. This Contract is entered into for the purpose of defining the formal and continuing relationship between Strong Memorial Hospital and ____________________ during the participation in a graduate medical education program and supersedes any prior contracts for the same purpose and covering the same time period. TERM: Commencing on 07/01/20XX and ending on 06/30/20XX. COMPENSATION: The total compensation to the Resident for the term shall be based on the annualized salary of $XX,XXX.XX to be paid in monthly installments. BENEFITS: Residents are provided benefits in accordance with University policies and procedures as applicable to residents. Detailed information regarding the vacation, professional liability, disability, and life insurance, medical and dental insurance, retirement plan, Leave of Absence (including effect on satisfying completion of program) and Family Medical Leave Act (including Parental Leave) and sick leave can be found in the Resident Manual located at http://www.urmc.rochester.edu/SMD/gme/office.html. A summary of these benefits is provided on the Summary of Resident Benefits table located on the same web site. Hard copies of both documents are also available from the Office for Graduate Medical Education. Mental Health Services are provided through the health insurance coverage. This list is not intended to be exclusive of other benefits which are in existence. The University reserves the right to amend or alter any of these benefits during the contract year. RESIDENT RESPONSIBILITIES: Each trainee must agree to be bound by the Hospital policies and rules and regulations that relate to his/her activities as a trainee. These can be found in the Resident Manual and the Strong Memorial Hospital Policy Manual. These policies may be amended at any time. Every trainee is expected to complete the full term of his/her contract. If, because of personal extenuating circumstances, a trainee must break his/her contract, the resident must give at least two months notice to the Office for Graduate Medical Education and the Department in which he/she is training. INSTITUTION’S RESPONSIBILITIES: The Institution is committed to providing a quality educational experience to the trainees in an environment that encourages and promotes a scholarly environment. This environment is characterized by appropriate supervision by the attending teaching staff and adequate on- call facilities. In addition, residents are provided a meal allowance for each night they take call in the hospital and are provided three labs coats upon appointment and replacements as needed each subsequent year. Coats are available through the Office for Graduate Medical Education. The Resident Manual which is distributed to all residents and fellows with this contract, and to programs each July provides detailed information regarding all policies and procedures including those on Physician Impairment and Substance Abuse, Policies on Harassment, and the Residency Closure/Reduction Policy. These policies and procedures can be amended at any time. 125
  • 126. PROFESSIONAL ACTIVITIES OUTSIDE OF PROGRAM: Professional activities outside the training programs (moonlighting) are prohibited to the extent that they may interfere with training program responsibilities. Each department has its own policy on outside activities. All require the chairman and program director's prior approval. The University does not provide professional liability insurance coverage for resident moonlighting activities. Residents should seek written assurance of malpractice and workers' compensation coverage from any outside employer, and must have a valid New York State medical license and Federal DEA number prior to seeking such employment. Hours engaged in such activities must be reported to the program director and must be added to the trainee’s program hours. The total hours must comply with the number of hours a trainee may work as detailed in the New York State Health Code Section 405. CONDITIONS OF REAPPOINTMENT: All appointments (contracts) are for a period of one year. Residents may be reappointed for each subsequent year of training contingent upon the resident’s satisfactory completion of the previous post-graduate year. The University may terminate this contract at any time when a resident’s performance is not satisfactory. Appointment or reappointment does not constitute an assurance of successful completion of the residency program or post-graduate year. Satisfactory completion is based on satisfactory performance by the resident as measured by individual department standards. A resident whose performance has not been satisfactory or who has failed to meet the level of competence for continuation in the program in the current year, or reappointment in a subsequent year, as determined by his/her department, will be notified after completing a period of probation of at least three months. In such circumstances of termination during the year, the resident will be given one month’s salary and benefits in lieu of notice. The process for appealing such judgments is documented in the Disciplinary Procedures and Appeals Policy in the Resident Manual. SUSPENSION AND/OR TERMINATION OF TRAINEE: If, in the judgment of the program director or department chairman, a trainee is impaired or his/her performance is such that the safety of patients is threatened, the trainee may be suspended pending further review. Written confirmation of the suspension and planned review shall be given to the trainee promptly, following review of the notice by the Associate Dean for Graduate Medical Education. ACCEPTANCE: I have read this contract and agree to accept this appointment as offered for the period above. In accepting this appointment, I certify that I have reviewed the Resident Manual and agree to abide by the rules and regulations of the University of Rochester, and in particular the Medical Center and its component parts. Fellows Signature Program Director in Ped Emer Med Associate Dean for Graduate Medical Education PLEASE RETURN YOUR SIGNED CONTRACT WITHIN TWO WEEKS OF RECEIPT TO: THE OFFICE FOR GRADUATE MEDICAL EDUCATION, BOX 126
  • 127. DRESS CODE POLICY – EMERGENCY DEPARTMENT All Administrative RN – LPN Physician – PA’s Staff Associates PCT – ED Aides NP’s – Med Students  No open toe shoes Dress attire should be professional/ Shirts - white or colored shirt/  White coats encouraged in Adult  University ID badge at or above business casual blouse, tunic top, or turtleneck, no ED waist level. Stickers or pins, etc. denim fabric  Ties encouraged for males, and must not obscure photo or name. Not acceptable: This includes: equivalent professional dress for  Wear cosmetics and perfume in  Jean pants, jean skirts or shorts,  No tee shirts of underwear style females moderation no cargo pants or overalls of any or tee shirts with logos on them  Scrubs may be worn as either kind (exception: pediatric and ED full sets or as scrub-top alone.  Wear personal jewelry that is modest and safe.  Short skirts or dresses mid thigh specific shirts, i.e. Mercy Flight).  Hair longer than shoulder length or above  No sleeveless/cap sleeve, midriff should be pulled back  Keep fingernails well groomed and no longer than ½” beyond  No sweat suits/shirts, tee shirts or low cut blouses or tie shirts. the fingertip.  No midriff, low cut blouses or tie  No sweatshirts, sweaters shirts. Scrubs -- when worn, should be complete top/bottom attire:  Each unit may outline a scrub policy, avoiding colors which are worn by PCT, USA and transport staff (i.e.: navy, royal)  Garments worn under scrub tops must adhere to the shirt section of the Standards of Professional Attire for Nursing with the exception that white tee shirts may be worn under scrub tops.  Hair longer than shoulder length should be pulled back 127
  • 128. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA) What is HIPAA? On April 14, 2003, a new federal law went into effect that greatly limits the information that can be given on hospital patients, significantly changing the way we may have worked with reporters in the past. The U.S. Congress passed the Health Insurance Portability and Accountability Act (HIPAA) in 1996 with the goal of protecting the privacy and security of patients’ health information. Hospitals, nursing homes, physician practices, medical and nursing schools, insurers and others now must comply with stringent new privacy requirements or face stiff financial and even criminal penalties. Among HIPPA’s provisions are standards for releasing medical information about patients to the media. Hospitals now maintain a directory that includes only a patient's name, location in the hospital, general condition and religious affiliation. Patients have the choice to be included in the directory or to opt out. If a patient chooses to be listed in the directory, limited information on the patient may be released as long as a reporter has a patient’s correct first and last name. In addition, HIPPA does not allow the release of any information on a minor (under age 18); regardless if a name is supplied, without specific prior consent by the parent. For more details about HIPAA, please sign on to the UR web site listed below. http://intranet.urmc.rochester.edu/HIPAA/ 128
  • 129. DISCIPLINARY PROCEDURES AND APPEALS POLICY These procedures are applicable to all residents and are intended to protect the rights of residents, patients, the training program, and to ensure fair treatment for all parties. The primary responsibility for defining the standards of academic performance and personal professional development rests with individual departments and program directors. In each program, there must be clearly stated bases for evaluation and advancement. At least semi-annually, each resident’s performance must be evaluated against these standards, and a written summary assessment prepared. This summary will document in some manner that it has been reviewed with the resident, and a copy shall be made available to the training program. The written assessment will then become part of the resident’s record in both the program and Office for Graduate Medical Education. 1. Immediate Termination: Immediate termination can occur if a resident puts patients, other health care professionals, employees or third parties at risk, or compromises the integrity of the program. The bases for immediate termination include but are not limited to suspension or revocation of the resident’s license or permit; incompetence; misconduct; any conduct that has the potential to jeopardize patient safety or the quality of patient care, is disruptive of hospital operations, is a serious violation of URMC policy, is a serious violation of law or regulation, or is conduct constituting criminal activity. If the resident is terminated, his/her appointment shall end immediately and no probationary period is required. Residents who are terminated will receive one month’s salary and benefits in lieu of notice. Credit for training may be given in the event of any satisfactory performance prior to termination, per the guidelines of the individual board. Reporting obligations related to conduct constituting professional misconduct is covered separately in the policy on Professional Misconduct. 2. Termination After Probation: When a resident’s performance is not commensurate with his/her appointed level of training, notification of the deficiencies must be made, in writing, to the resident by the program director with copies to the Associate Dean for Graduate Medical Education (ADGME). A plan to correct deficiencies, which includes the manner and time frame in which the deficiencies will be corrected, and the consequences of not correcting the deficiencies within the time frame, should be a part of this notice. There should, however, be a probation period of at least three months, which may be extended to a maximum of six months, before a decision is made to terminate a resident. A letter to the resident, which specifies the period of probation, must indicate the possible outcomes (full reinstatement to the program, continued probation, termination). In the case of termination, the end of the appointment is immediate and one additional month of salary is paid to the resident in lieu of notice. The resident is to be notified in writing of this action with a copy of the letter to the ADGME. The resident does not continue to work after the notice of termination. Credit for training may be given for periods of satisfactory performance, per the guidelines of the individual board. If deficiencies in professional competence that may endanger patients arise during the probationary period, the resident may be terminated or suspended immediately (as described above) after consultation with the ADGME. 129
  • 130. 3. Non-Renewal of Contract After Probation: In the event of non-renewal of a resident’s contract, at least four months notice prior to contract expiration should be provided to the resident. There should be a probation period of at least three months prior to a decision not to renew a contract. If the end of the resident’s probation period is within four months of the end of the contract year, the fact that the resident is on probation will serve as notice that the contract may not be renewed if the probation is not remediated successfully. The notice of non-renewal of contract will be made in writing to the resident with a copy to the ADGME. If the primary reason for the non-renewal occurs within the four months prior to the end of the contract, the program must provide the resident with as much written notice of the intent not to renew as the circumstances will reasonably allow. The resident will continue to work at his/her appointed level of training through the end of the contract period. Full credit for the year may be given to the resident at the discretion of the Program Director and guidelines of the individual board. In cases of non-renewal of contract, the trainee will be terminated at the end of the contract period. If deficiencies in professional competence that may endanger patients arise during the probationary period, the resident may be terminated or suspended immediately after consultation with the ADGME. 4. Delayed Promotion of a Resident: If a resident has not met the program standards sufficiently in his or her current training level, the program may make a decision not to promote a resident to the next level of training. The resident should be notified of this decision as soon as circumstances reasonably allow, prior to the end of the contract year. The notice should outline the remediation steps to be accomplished prior to the resident’s advancement to the next level. An official period of probation may or may not be indicated. The resident will be paid at his or her present level until they are advanced to the next level. These rules will also apply to residents whose performance has been acceptable but have not completed the required number of weeks of training during the contract period. If the resident does not successfully complete the remediation plan, the process listed above for termination will apply. 5. Independent Evaluations: In order to determine an appropriate plan to address a resident performance problem, a program director, in consultation with the ADGME, may require an independent evaluation of a resident when the program director has a reasonable basis to believe that a resident’s performance is affected by an impairment including, but not limited to a medical, mental health or substance abuse problem. The purpose of the evaluation is to determine the resident’s ability to perform his or her clinical duties and responsibilities. See also the Resident Impairment Policy. 6. Suspension: A resident may be suspended from clinical activities by his/her program director, department chair or the chief medical officer of Strong Health. This action may be taken in any situation in which continuation of clinical activities by the resident may compromise URMC operations, the program, or the safety of patients, employees, the resident, or third parties. Bases for suspension include but are not limited to potential threat to the safety of patients or others, quality of care concerns, a suspension or loss of the resident’s licensure, potential impairment of the resident, debarment from Medicare or other federal program, potential misconduct by the resident, or potential incompetence. A resident may also be suspended pending an investigation of an allegation of any of the above concerns. At the discretion of the Program Director, the resident may also be offered a voluntary leave of absence pending investigation. Such voluntary leave shall be for no longer than one week, at which time the resident will be automatically suspended unless the investigation has been completed and a decision favorable to the resident has been made. Unless otherwise directed by the program chair, a resident suspended from clinical services may participate in other program activities. Suspension may be with or without pay at the discretion of the program director. The resident must be notified in writing, with a copy to the ADGME, of the reasons for the suspension. The 130
  • 131. notice of suspension must be reviewed with the resident, who must sign and date indicating the material has been reviewed with him/her. The resident may appeal the suspension to the Senior Associate Dean of Medical Education. The resident must appeal the decision within 5 working days of the suspension by written appeal to Senior Associate Dean. The Dean shall make the final decision with respect to the appropriateness of the suspension. Within 10 working days of a decision to suspend the clinical privileges of a resident, the program director must determine if the resident may return to clinical activities and/or whether further action is warranted including but not limited to counseling, warning letter, probation, fitness for duty evaluation, medical leave of absence, or termination. Written notification of the program director’s decision should be given to the resident with a copy to the ADGME. If further investigation is needed before a determination can be made, the program director shall so notify the resident, but must complete the investigation within an additional 10 working days from the date of the suspension. The resident must cooperate fully with the investigation. APPEALS When a resident receives notice of termination, non-renewal or non-promotion by the Program director, he/she shall have the right to appeal such action. Performance evaluations or the placement on probation cannot be appealed. To initiate the appeal process, the resident shall notify the Associate Dean for Graduate Medical Education. This notice shall be in writing, and must be delivered to the Associate Dean for Graduate Medial Education within ten (10) working days of the resident’s notification by the Program Director. Such notification must include the reasons for the requested formal appeal. Failure to notify the Associate Dean for Graduate Medical Education within the prescribed time frame will terminate the appeal process at this point. The expected duration of this appeal process is approximately 3-4 months from the time the resident receives written notice of the adverse action from his/ her department. If the resident is an Exchange Visitor on a J1 visa and he/she has received a notice of dismissal from the program, every effort will be made to expedite the process so that the resident may appear in person before the ad hoc committee. Within ten working days of receipt of the request for appeal, the Associate Dean for Graduate Medical Education will appoint an ad hoc committee, and will notify the resident and the members of the ad hoc committee in writing of the committee’s appointment with a copy to the program director and chair. The chair of said ad hoc committee will be a member of the Graduate Medical Education Committee, and one additional faculty member and one resident will comprise the committee. Eligible faculty for the ad hoc committee are defined as full-time physician faculty members of clinical departments in the School of Medicine with the rank of Assistant Professor or higher, and may not be members of the department which sponsors the resident’s program. The resident member of this committee must be from a department other than that which sponsors the aggrieved resident’s program. The Office for Graduate Medical Education will provide administrative support to the ad hoc committee and will notify the aggrieved resident, the members of the ad hoc committee, the program director, department chair and the 131
  • 132. Associate Dean for Graduate Medical Education of the time and place of the meeting. The meeting shall occur within 30 days of the committee’s appointment. Prior to the meeting, the department should submit the resident’s departmental file and any other materials on which it bases its decision to the Office for Graduate Medical Education, for distribution to the committee. To preserve the confidentiality of anonymous evaluations, the appeal mechanism does not entitle the aggrieved resident to review his/ her complete departmental file. Upon written request, the resident will be provided with a photocopy of summary evaluations, and photocopies of any correspondence to the resident from the program, before the committee meeting is held. The process of the meeting will not rigidly prescribed, except that, the resident shall be given the opportunity to appear before the committee and will be allowed to be accompanied by an advocate who is not an attorney. The resident should be prepared to present evidence for rescinding the action. The program director should appear and be prepared to present evidence for upholding the action. The meeting shall be confidential and open only to the committee members and a note taker. If either the program director or resident would desire individuals with factual information regarding the decision of the department, above and beyond information in the file, to appear before the committee, the interested party may make the appropriate arrangements. The meeting may only be rescheduled under extraordinary circumstances at the discretion of the chair of the ad hoc committee. At the discretion of the chair, the program director and resident may question their own witnesses If the committee decides that additional information is required, the chair may request written materials and additional meetings, which may occur beyond the 30-day time period referenced above. The ad hoc committee’s scope of review shall be to determine: • whether there was adequate documentation on which to base the disciplinary decision, and • whether the appropriate procedures (e.g. notice of deficiencies, plan of remediation) were followed. In cases where ad hoc committee determines that the department either failed to follow procedures or lacks adequate documentation for its decision, committee will recommend to GME the appropriate resolution considering all the circumstances. The ad hoc committee’s decision shall be communicated to the Associate Dean for Graduate Medical Education within thirty (30) days of the hearing. The preparation of the committee’s final report shall be the responsibility of the Chair of the ad hoc committee. If in the interest of a thorough review of the resident’s appeal, additional information is required which cannot be obtained in sufficient time to meet this thirty (30) day time period, that time period may be extended by the Chair and the resident will be so notified by the Chair. The ADGME will then present the ad hoc committee’s report to the GMEC at its next regularly scheduled meeting. The GMEC will consider the ad hoc committee’s report and recommendations. Voting members of the GMEC will make a decision as to whether to confirm, modify or reverse the Ad Hoc Committee’s decision. GMEC will make its 132
  • 133. decision based on a closed ballot vote, with the resident’s program director excused. The majority of the voting members must be present to call a vote. The Associate Dean for Graduate Medical Education shall make notification to the resident of the GMEC’s decision in writing with a copy to the Program director and Chair. If the resident or program director wishes to appeal the decision of the GMEC, he/she may do so in writing to the Senior Associate Dean for Medical Education within ten working days of the date of the written notice of the GMEC’s decision from the Associate Dean for Graduate Medical Education. Failure to request an appeal within the prescribed time frame will operate as a waiver of appeal. The Office for Graduate Medical Education will provide a copy of the resident’s file and all documentation from the ad hoc Committee’s review of the resident’s initial appeal to the Senior Associate Dean for Medical Education. The process of this final appeal is at the discretion of the Senior Associate Dean’s decision is final. He/she has the authority to confirm, reverse or modify the GMEC’s decision. He/she will make the decision within 10 working days of receiving the file and will notify the resident of his/her decision with a copy to the ADGME. Policy Inconsistency and Modification In the event that any of the terms of this policy are inconsistent with the terms of any other policy including but not limited to the impairment and professional misconduct policy, the Senior Associate Dean For Medical Education shall have the authority to resolve the inconsistency. This policy may be modified or amended at any time. Updated versions of this policy will be posted periodically on the University of Rochester website. 133