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  • 1. UNIVERSITY OF TEXAS MEDICAL SCHOOL AT HOUSTON DIVISION OF CARDIOLOGY MANUAL FOR FELLOWS IN CLINICAL CARDIAC ELECTROPHYSIOLOGY POLICIES AND PROCEDURES 2006 - 7
  • 2. TABLE OF CON T E N T S PROGRAM GOALS, OBJECTIVES AND COMPETENCIES 5 EP Inpatient Service 5 EP Consult Service 9 Invasive EP 12 Electives 15 OTHER CLINICAL RESPONSIBILITIES 26 EKG, Holter, Transtelephonic Monitoring, and Signal-Averaged EKG Interpretation Pacer and Device Clinic Teaching Outpatient Clinic RESEARCH OPPORTUNITIES -3-
  • 3. 28 DIDACTIC SCHEDULE 28 ANCILLARY COURSES 33 Advanced Cardiac Life Support (ACLS) Radiation Safety Course OTHER CLINICALLY RELATED MATTERS 33 Medical Licensure -4-
  • 4. Professional Liability Insurance OTHER PERTINENT INFORMATION 34 Fellowship Office Night Call Call Rooms Beepers & Paging Uniforms Offices Parking Photocopying Professional Society Memberships Educational Materials Time Cards/ Leave Policy Educational Leave Job Opportunities Bookstores Libraries -5-
  • 5. Evaluations and Personnel Files Meals USEFUL TELEPHONE NUMBERS 39 -6-
  • 6. The purpose of this Manual is to describe all practical aspects of the Fellowship Program in Clinical Cardiac Electrophysiology at the University of Texas - Houston. The Manual supplements the Manual for Cardiology Fellows and the Graduate Medical Education Trainee Handbook and is updated annually at the beginning of the academic year. The fellowship consists of a minimum of 18 months and a maximum of 2 years training, at the end of which the fellow will or should have met the requirements for the American Board of Internal Medicine examination in clinical cardiac electrophysiology. Educational credit for 6 – 12 months of electrophysiology training performed in other accredited training programs may be granted at the discretion of the fellowship director and credited toward the completion of this fellowship. PROGRA M GOALS , OBJECTIVE S AND COMP E T E N C I E S -7-
  • 7. The first goal of the CCEP fellowship is to provide qualified cardiologists with a balanced, structured and scholarly experience in clinical electrophysiology. Diagnosis and management of clinical arrhythmias is emphasized using both invasive and noninvasive techniques. The second goal is to encourage scholarly productivity by providing opportunities for both basic and clinical research. Toward these ends, specific educational objectives for each clinical rotation have been established. I . Me d i c a l Kno w l e d g e an d Pat i e n t Car e The following knowledge, skills, and attitudeobjectivesaddressthe competencyareas of patientcare and medical knowledge by rotation. EP Inp a t i e n t Servic e Goa l : Fellows must demonstrate knowledge about established and evolving concepts in clinical cardiac electrophysiology that are pertinent to the management of patients with known or suspected cardiac arrhythmias and those at risk for serious arrhythmias. Kno w l e d g e : CCEP Fellows will demonstrate knowledge of: 1. clinical arrhythmia syndromes, including -8-
  • 8. a. sinus node dysfunction, b. atrioventricular and intraventricular conduction delay and block, c. supraventricular and ventricular tachyarrhythmias, d. unexplained syncope, e. aborted sudden cardiac death, f. palpitations, g. Wolff-Parkinson-White syndrome, h. prolonged QT syndromes, and i. other inherited and acquired arrhythmia syndromes, 2. arrhythmia diagnosis, showing compentence in interpretation of 12 lead ECG’sand ECG telemetry recordings, 3. inpatient management of clinical bradyarrhythmias and tachyarrhythmias, 4. usefulness and limitations (sensitivity, specificity, positive and negative accuracy) of noninvasive and invasive cardiac arrhythmia testing, -9-
  • 9. 5. indications, contraindications, risks and limitations of nonpharmacologic CCEP procedures and therapy, including ablation, surgery and device implantation, 6. indications for, interrogation and programming of, and monitoring of pacemakers, defibrillators (ICD’s) and cardiac resynchronization therapy (CRT) devices, 7. indications for, pharmacology, pharmacokinetics and effects of antiarrhythmic drugs 8. implementation of clinical trial data in the management of arrhythmia patients. Skill s : Fellows will develop and demonstrate technical proficiency in: 1. care of patients in the cardiac care unit and cardiac telemetry units, 2. performance of bedside procedures, including temporary pacemaker placement, 3. interpretation of noninvasive testing relevant to arrhythmia diagnosis and treatment, such as: a . relevant imaging studies, including chest -10-
  • 10. radiography, b . electrocardiograms, c . tilt testing, d . continuous in-hospital recordings, e . signal-averaged ECG recordings, f . T wave alternans analysis, g . Exercise and pharmacologic stress test ECG recordings, 4. care of patients with pacemakers, ICD’s and CRT devices, 5. performance and interpretation of invasive CCEP procedures, and care of the arrhythmia patient before and after invasive procedures, 6. clinical decision making regarding invasive EP procedures and patient management 7. performance and interpretation of invasive electrophysiologic testing, including: a . electrode catheter introduction and positioning in atria, ventricles, coronary sinus, His bundle area and pulmonary artery, -11-
  • 11. b . endocardial electrogram recording, including an understanding of amplifiers, filters and signal processors, and measurement of intervals c . programmed stimulation to obtain conduction times and refractory periods, and to initiate, terminate and entrain tachycardias, d . pharmacologic stimulation, and e . activation sequence mapping recording, including electroanatomic mapping, 8. performance of therapeutic catheter ablation for a variety of arrhythmias, including: a . AV nodal reentry tachycardia, b . AV reentry associated with accessory pathways, c . atrial tachycardia, d . atrial flutter, e . atrial fibrillation, f . AV junction ablation and modification, and g. ventricular tachycardia, 9. implantation of pacemakers, ICD’s, CRT devices,and implantable event recorders, including: -12-
  • 12. a . device programming, b. noninvasive programmed stimulation for arrhythmia induction through the device, c . defibrillation threshold testing, d . lead extraction, e . cardiac resynchronization therapy, and f. final prescription of antitachycardia pacing, defibrillation and cardiac resynchronization therapies, and 1 0 . teaching at the bedside and in didactic conferences. Atti t u d e s : Fellows must maintain and apply investigatory and analytic thinking in approaching clinical situations. Dem o n s t r a t e d by : Trainees will be principally taught by their supervising CCEP attending physician who supervises the clinical care of patients by fellows. Instruction and experience will be provided at the bedside and during teaching rounds using interactive discussion. Additional teaching will occur through structured didactic conferences. Invasive procedures are proctored directly by the attending physician. -13-
  • 13. In turn, fellows demonstrate their comprehension and synthesis of subject matter by teaching medical students on formal clinical rounds. The importance of continuous self-initiated independent study during training is emphasized with the realization that this should be a lifelong commitment. Fellows regularly describe instructive patient encounters at clinical case and ECG conferences, providing an opportunity to demonstrate analytic skills. Ev a l u a t i o n : Fellows are evaluated at the end of each rotation. The evaluation surveys knowledge, skills, satisfactory progressive scholarship and professional growth and includes: 1. Fellow evaluations 2. Observed patient encounters 3. Random chart reviews 4. Patient surveys 5. Surveys of allied health professionals 6. Procedure logs 7. Communication and literature review evaluations -14-
  • 14. Re m e d i a t i o n : The program director will semi-annually review the fellow’sperformance and will: 1. identify any specific knowledge deficits, 2. document all knowledge areas requiring remediation or additional concentration, 3. develop an individualized learning plan, along with the fellow, for remediation of specific knowledge deficiencies. Ge n e r a l Cou r s e Des cri p t i o n: The Cardiology Inpatient service (CCU Team) at Hermann Hospital is oriented toward management of acute ischemic syndromes, arrhythmias, congestive heart failure, and chronic ischemic heart disease. Private cardiologists and UT faculty cardiologists admit patients to these teams for purposes of patient care. The team consists of one attending cardiologist, one general cardiology fellow, four Internal Medicine residents and four interns, and 3 - 4 medical students. Cardiac Electrophysiology Staff serve as rotating attending physicians on the inpatient service, along with other Cardiology faculty. CCEP Staff also serve as consultants to the team at -15-
  • 15. all times. One CCEP Fellow serves as an arrhythmia consultant to the team, coordinating invasive and non-invasive electrophysiologic services. The CCEP Fellow rounds with the team and may write progress notes to supplement the comments of others. Patients who undergo surgery are still followed by the team, although direct involvement in patient care become consultative until the patient transfers out of the CVICU and back to the cardiology units. All Swan-Ganz catheter insertions, transvenous pacing catheter insertions and other invasive bedside procedures must be done by or under the direct supervision of the Cardiology or CCEP fellow, according to the level of skill and expertise of each resident and fellow. Attending Staff and senior Fellows are available to assist and supervise Fellows not yet skilled in a particular procedure. Attending Rounds with the UT Staff Attending assigned to the team for the month generally are held from 10:00 AM to 12:00 noon every day. The schedule may be modified on an individual basis depending upon work activities, etc. The level of supervision provided by the attending will depend upon the complexity of the case and the ability and experience of the particular residents and fellows involved. The housestaff should -16-
  • 16. be the primary caretakers, working under the direction of the Fellows and the Attending Physician. In general, physician orders should be written by the Resident or Intern, except in emergency situations or when patient care can be expedited, in which case the Attending Staff and Fellows may do so. While serving on the EP Inpatient service, the CCEP Fellow serves as the primary fellow on invasive EP procedures involving patients on that service, following the procedures described under “Invasive EP” below. The CCEP Inpatient fellow is typically involved in the care of 5 – 15 patients with a maximum of 20 patients. If this maximum number is reached, the fellow should inform the program director who will assign one of the other CCEP or general Cardiology fellows to assist with this service. The CCEP Inpatient fellow will also serve as second backup to the Invasive CCEP and EP Consult Fellows for performing procedures in the EP labs. Occasional patients may be designated as “Non- teaching patients”. In those instances, the attending staff physician is directly responsible for all aspects of the individual’s care. Cardiology and CCEP Fellows, -17-
  • 17. housestaff and students will not routinely participate in the care of these individuals, however may perform specific tasks at the discretion of the attending staff. As with all inpatients, emergency medical services will be administered to non-teaching patients by CCEP Fellows in the course of their duties on the Code Team or as a bystander until the attending staff physician is directly available to assume those responsibilities. EP Con s u l t S e r v i c e Goa l : Fellows must demonstrate knowledge about established and evolving concepts in clinical cardiac electrophysiology that are pertinent to the management of patients on non- cardiology inpatient services with known or suspected cardiac arrhythmias and those at risk for serious arrhythmias in the presence of co- morbidities. Kno w l e d g e : CCEP Fellows will demonstrate knowledge of: 1. clinical arrhythmia syndromes, including b. sinus node dysfunction, c. atrioventricular and intraventricular conduction delay and block, -18-
  • 18. d. supraventricular and ventricular tachyarrhythmias, e. unexplained syncope, f. aborted sudden cardiac death, g. palpitations, h. Wolff-Parkinson-White syndrome, i. prolonged QT syndromes, and j. other inherited and acquired arrhythmia syndromes, 2. arrhythmia diagnosis, showing compentence in interpretation of 12 lead ECG’sand ECG telemetry recordings, 3. inpatient management of clinical bradyarrhythmias and tachyarrhythmias, 4. usefulness and limitations (sensitivity, specificity, positive and negative accuracy) of noninvasive and invasive cardiac arrhythmia testing, 5. indications, contraindications, risks and limitations of nonpharmacologic CCEP procedures and therapy, including ablation, surgery and device implantation, -19-
  • 19. 6. indications for, interrogation and programming of, and monitoring of pacemakers, defibrillators (ICD’s) and cardiac resynchronization therapy (CRT) devices, 7. indications for, pharmacology, pharmacokinetics and effects of antiarrhythmic drugs 8. implementation of clinical trial data in the management of arrhythmia patients. Skill s : Fellows will develop and demonstrate technical proficiency in: 1. consultation to physicians in other disciplines, 2. care of patients in the cardiac care unit and cardiac telemetry units, 3. performance of bedside procedures, including temporary pacemaker placement, 4. interpretation of noninvasive testing relevant to arrhythmia diagnosis and treatment, such as: a . relevant imaging studies, including chest radiography, b . electrocardiograms, -20-
  • 20. c . tilt testing, d . continuous in-hospital recordings, e . signal-averaged ECG recordings, f . T wave alternans analysis, g . Exercise and pharmacologic stress test ECG recordings, 5. care of patients with pacemakers, ICD’s and CRT devices, 6. performance and interpretation of invasive CCEP procedures, and care of the arrhythmia patient before and after invasive procedures, 7. clinical decision making regarding invasive EP procedures and patient management 8. performance and interpretation of invasive electrophysiologic testing, including: a . electrode catheter introduction and positioning in atria, ventricles, coronary sinus, His bundle area and pulmonary artery, b . endocardial electrogram recording, including an understanding of amplifiers, filters and signal -21-
  • 21. processors, and measurement of intervals c . programmed stimulation to obtain conduction times and refractory periods, and to initiate, terminate and entrain tachycardias, d . pharmacologic stimulation, and e . activation sequence mapping recording, including electroanatomic mapping, 9. performance of therapeutic catheter ablation for a variety of arrhythmias, including: a . AV nodal reentry tachycardia, b . AV reentry associated with accessory pathways, c . atrial tachycardia, d . atrial flutter, e . atrial fibrillation, f . AV junction ablation and modification, and g. ventricular tachycardia, 10. implantation of pacemakers, ICD’s, CRT devices,and implantable event recorders, including: a . device programming, b. noninvasive programmed stimulation for -22-
  • 22. arrhythmia induction through the device, c . defibrillation threshold testing, d . lead extraction, e . cardiac resynchronization therapy, and f. final prescription of antitachycardia pacing, defibrillation and cardiac resynchronization therapies, and 1 1 . teaching at the bedside and in didactic conferences. Atti t u d e s : Fellows must maintain and apply investigatory and analytic thinking in approaching clinical situations. Dem o n s t r a t e d by : Trainees will be principally taught by their supervising CCEP attending physician who supervises the clinical care of patients by fellows. Instruction and experience will be provided at the bedside and during teaching rounds using interactive discussion. Additional teaching will occur through structured didactic conferences. Invasive procedures are proctored directly by the attending physician. In turn, fellows demonstrate their comprehension and synthesis of subject matter by teaching medical students on formal clinical rounds. -23-
  • 23. The importance of continuous self-initiated independent study during training is emphasized with the realization that this should be a lifelong commitment. Fellows regularly describe instructive patient encounters at clinical case and ECG conferences, providing an opportunity to demonstrate analytic skills. Ev a l u a t i o n : Fellows are evaluated at the end of each rotation. The evaluation surveys knowledge, skills, satisfactory progressive scholarship and professional growth and includes: 1. Fellow evaluations 2. Observed patient encounters 3. Random chart reviews 4. Patient surveys 5. Surveys of allied health professionals 6. Procedure logs 7. Communication and literature review evaluations Re m e d i a t i o n : The program director will semi-annually review the fellow’sperformance and will: -24-
  • 24. 4. identify any specific knowledge deficits, 5. document all knowledge areas requiring remediation or additional concentration, 6. develop an individualized learning plan, along with the fellow, for remediation of specific knowledge deficiencies. Ge n e r a l Cou r s e Des cri p t i o n: The EP Consult service provides consultation on cardiac arrhythmias for all other services and requesting physicians at Hermann Hospital and rarely at M D Anderson Cancer Center. It consists of an attending physician, a general Cardiology Fellow on EP elective and a CCEP Fellow. The Fellows are expected to evaluate all consult patients on the day the consult is requested and to promptly discuss the case with the CCEP faculty. Written consultation notes are left in the medical record in a timely fashion and direct communication with the primary service is expected. The fellows should make daily rounds on all patients on the team and are expected to write daily progress notes on all patients with active CCEP problems. Attending rounds are conducted daily and the time will vary according -25-
  • 25. to the clinical schedule. The CCEP and rotating fellow are typically responsible for 5 – 10 patients each with a maximum of 20. If this maximum number is reached, the fellow should inform the program director who will assign one of the other fellows to assist with this service. Invasive bedside procedures on consult service patients are to be done by the Fellows under the supervision of the attending staff. The CCEP consult fellow supervises tilt table testing performed by trained nursing staff in the President Bush Center. CCEP consult fellows attend Pacemaker/ Device Clinic for two half-days weekly, at the least. The CCEP Fellow serves as the primary fellow on invasive EP procedures involving patients on the consult service, following the procedures listed under “Invasive EP”. The CCEP consult fellow and rotating cardiology fellow are responsible for reading 12 lead ECG’s, Holter monitors and transtelephonic monitoring results on a daily basis under the supervision of the CCEP consult attending staff. S/he also serves as first backup to the Invasive CCEP Fellow for performing other procedures in the EP lab. Emergency consults (5:00 pm to 8:00 am and weekends) are first seen by the in-house cardiology resident. The resident must then -26-
  • 26. discuss the case with the in-house cardiology fellow, who also sees the patient, if necessary. During these hours, the on-call CCEP fellow and attending physician should be notified of the consult and the fellow’s assessment; they will be available to return to the hospital to assist directly in the care of the patient as needed. Inv a s i v e EP Goa l : Fellows will demonstrate comprehension of arrhythmia mechanisms and management as they develop technical proficiency in the performance and analysis of invasive CCEP procedures in the outpatient setting. Kno w l e d g e : CCEP Fellows will demonstrate knowledge of: 1. clinical arrhythmia syndromes, including k. sinus node dysfunction, l. atrioventricular and intraventricular conduction delay and block, m. supraventricular and ventricular tachyarrhythmias, n. unexplained syncope, -27-
  • 27. o. aborted sudden cardiac death, p. palpitations, q. Wolff-Parkinson-White syndrome, r. prolonged QT syndromes, and s. other inherited and acquired arrhythmia syndromes, 2. arrhythmia diagnosis, showing compentence in interpretation of 12 lead ECG’sand ECG telemetry recordings, 3. outpatient management of clinical bradyarrhythmias and tachyarrhythmias, 4. indications, contraindications, risks and limitations of nonpharmacologic CCEP procedures and therapy, including ablation, surgery and device implantation, 5. indications for, interrogation and programming of, and monitoring of pacemakers, defibrillators (ICD’s) and cardiac resynchronization therapy (CRT) devices, 6. indications for, pharmacology, pharmacokinetics and effects of antiarrhythmic drugs, as adjunctive maneuvers in the invasive electrophysiology lab, -28-
  • 28. 7. implementation of clinical trial data in the management of arrhythmia patients. Skill s : Fellows will develop and demonstrate technical proficiency in: 1. care of outpatients with known and suspected arrhythmias and those at risk for serious arrhythmias, 2. care of patients with pacemakers, ICD’s and CRT devices, 3. performance and interpretation of invasive CCEP procedures, and care of the arrhythmia patient before and after invasive procedures, 4. clinical decision making regarding invasive EP procedures and patient management 5. performance and interpretation of invasive electrophysiologic testing, including: a . electrode catheter introduction and positioning in atria, ventricles, coronary sinus, His bundle area and pulmonary artery, -29-
  • 29. b . endocardial electrogram recording, including an understanding of amplifiers, filters and signal processors, and measurement of intervals c . programmed stimulation to obtain conduction times and refractory periods, and to initiate, terminate and entrain tachycardias, d . pharmacologic stimulation, and e . activation sequence mapping recording, including electroanatomic mapping, 6. performance of therapeutic catheter ablation for a variety of arrhythmias, including: a . AV nodal reentry tachycardia, b . AV reentry associated with accessory pathways, c . atrial tachycardia, d . atrial flutter, e . atrial fibrillation, f . AV junction ablation and modification, and g. ventricular tachycardia, 7. implantation of pacemakers, ICD’s, CRT devices,and implantable event recorders, including: -30-
  • 30. a . device programming, b. noninvasive programmed stimulation for arrhythmia induction through the device, c . defibrillation threshold testing, d . lead extraction, e . cardiac resynchronization therapy, and f. final prescription of antitachycardia pacing, defibrillation and cardiac resynchronization therapies, and 8. teaching at the bedside and in didactic conferences. Atti t u d e s : Fellows must maintain and apply investigatory and analytic thinking in approaching clinical situations. Dem o n s t r a t e d by : Invasive procedures are proctored directly by the attending physician. The importance of continuous self-initiated independent study during training is emphasized with the realization that this should be a lifelong commitment. Fellows regularly describe instructive patient encounters at clinical case and ECG conferences, providing an opportunity to demonstrate analytic -31-
  • 31. skills. Ev a l u a t i o n : Fellows are evaluated at the end of each rotation. The evaluation surveys knowledge, skills, satisfactory progressive scholarship and professional growth and includes: 1. Fellow evaluations 2. Observed patient encounters 3. Random chart reviews 4. Patient surveys 5. Surveys of allied health professionals 6. Procedure logs 7. Communication and literature review evaluations 8. Procedural skills checklist Re m e d i a t i o n : The program director will semi-annually review the fellow’sperformance and will: 7. identify any specific knowledge deficits, 8. document all knowledge areas requiring remediation or additional concentration, 9. develop an individualized learning plan, along with -32-
  • 32. the fellow, for remediation of specific knowledge deficiencies. The Invasive CCEP Fellow participates in the initial evaluation of all patients scheduled for invasive EP studies who are not on either the Inpatient EP or EP Consult services, and develop skills in invasive techniques under the direction of the Attending Staff. This Fellow is primarily responsible for outpatients undergoing invasive procedures. S/ he sees patients prior to the procedure, taking a complete history and physical, reviewing the chest X-ray, ECG and laboratory data. The patient is then instructed on the procedure, and informed consent is obtained. The day of the procedure, the Fellow performs the procedure under the direct supervision of the Attending Staff to the level of his/her experience and skill. The fellow discontinues sheathes as appropriate and ensures adequate hemostasis. After the procedure, the Fellow notifies the accepting house staff and writes post-procedure orders, as appropriate, and completes the physicians’procedure report. The Fellow reviews the results of the procedure with the Attending staff prior to completion of the final report. -33-
  • 33. The invasive CCEP Fellow writes a note on the chart the evening of the procedure, noting adequacy of hemostasis, status of wounds and distal pulses and commenting on any other consequences or potential complications that may have occurred. This fellow also checks postoperative chest films on any patient who has undergone subclavian or jugular venous catheterization and/or device implantation and notes the results in the evening note. Resumption of anticoagulant and other necessary medication is ensured in a timely fashion and with appropriate monitoring. The Attending is to be notified of any significant complications immediately and such are documented in the chart. For patients still hospitalized or under observation on the day following the procedure, wound checks are performed by the CCEP invasive fellow and examination results noted in the medical record. Discharge orders and follow-up instructions are written and communicated to the patient by the fellow when the patient is stable for discharge. To provide for continuity of care, patients who subsequently undergo other procedures or surgery are followed by the same CCEP Fellow who was involved in the initial procedure. El e c t i v e s -34-
  • 34. Goa l : Fellows will enrich their training experience in cardiac electrophysiology and supplement experience in areas of special interest or deficiency, such as Pacemaker/ Device Clinic and basic electrophysiology research. Extramural electives in pediatric CCEP or special research facilities may be arranged on a case- by-case basis. Kno w l e d g e : Depending upon the nature of the elective experience, CCEP Fellows will demonstrate knowledge of: 1. clinical arrhythmia syndromes, including t. sinus node dysfunction, u. atrioventricular and intraventricular conduction delay and block, v. supraventricular and ventricular tachyarrhythmias, w. unexplained syncope, x. aborted sudden cardiac death, y. palpitations, z. Wolff-Parkinson-White syndrome, aa.prolonged QT syndromes, and bb.other inherited and acquired arrhythmia -35-
  • 35. syndromes, 2. arrhythmia diagnosis, showing compentence in interpretation of 12 lead ECG’sand ECG telemetry recordings, 3. inpatient management of clinical bradyarrhythmias and tachyarrhythmias, 4. usefulness and limitations (sensitivity, specificity, positive and negative accuracy) of noninvasive and invasive cardiac arrhythmia testing, 5. indications, contraindications, risks and limitations of nonpharmacologic CCEP procedures and therapy, including ablation, surgery and device implantation, 6. indications for, interrogation and programming of, and monitoring of pacemakers, defibrillators (ICD’s) and cardiac resynchronization therapy (CRT) devices, 7. indications for, pharmacology, pharmacokinetics and effects of antiarrhythmic drugs 8. implementation of clinical trial data in the management of arrhythmia patients. -36-
  • 36. Skill s : Depending upon the nature of the elective experience, Fellows will develop and demonstrate technical proficiency in: 1. care of patients in the cardiac care unit and cardiac telemetry units, 2. performance of bedside procedures, including temporary pacemaker placement, 3. interpretation of noninvasive testing relevant to arrhythmia diagnosis and treatment, such as: a . relevant imaging studies, including chest radiography, b . electrocardiograms, c . tilt testing, d . continuous in-hospital recordings, e . signal-averaged ECG recordings, f . T wave alternans analysis, g . Exercise and pharmacologic stress test ECG recordings, 4. care of patients with pacemakers, ICD’s and CRT devices, 5. performance and interpretation of invasive CCEP -37-
  • 37. procedures, and care of the arrhythmia patient before and after invasive procedures, 6. clinical decision making regarding invasive EP procedures and patient management 7. performance and interpretation of invasive electrophysiologic testing, including: a . electrode catheter introduction and positioning in atria, ventricles, coronary sinus, His bundle area and pulmonary artery, b . endocardial electrogram recording, including an understanding of amplifiers, filters and signal processors, and measurement of intervals c . programmed stimulation to obtain conduction times and refractory periods, and to initiate, terminate and entrain tachycardias, d . pharmacologic stimulation, and e . activation sequence mapping recording, including electroanatomic mapping, 8. performance of therapeutic catheter ablation for a variety of arrhythmias, including: -38-
  • 38. a . AV nodal reentry tachycardia, b . AV reentry associated with accessory pathways, c . atrial tachycardia, d . atrial flutter, e . atrial fibrillation, f . AV junction ablation and modification, and g. ventricular tachycardia, 9. implantation of pacemakers, ICD’s, CRT devices,and implantable event recorders, including: a . device programming, b. noninvasive programmed stimulation for arrhythmia induction through the device, c . defibrillation threshold testing, d . lead extraction, e . cardiac resynchronization therapy, and f. final prescription of antitachycardia pacing, defibrillation and cardiac resynchronization therapies, and 1 0 . teaching at the bedside and in didactic conferences. 1 1 . laboratory investigation of cellular and molecular -39-
  • 39. cardiac electrophysiology. Atti t u d e s : Fellows must maintain and apply investigatory and analytic thinking in approaching clinical situations. Dem o n s t r a t e d by : Trainees will be principally taught by the supervising CCEP attending physician. Instruction and experience will be provided at the bedside and during teaching rounds using interactive discussion. Additional teaching will occur through structured didactic conferences. Invasive procedures are proctored directly by the attending physician. In turn, fellows demonstrate their comprehension and synthesis of subject matter by teaching medical students on formal clinical and/ or research rounds. The importance of continuous self- initiated independent study during training is emphasized with the realization that this should be a lifelong commitment. Fellows regularly describe instructive patient encounters at clinical case and ECG conferences, providing an opportunity to demonstrate analytic skills. Ev a l u a t i o n : -40-
  • 40. Fellows are evaluated at the end of each rotation. The evaluation surveys knowledge, skills, satisfactory progressive scholarship and professional growth and includes: 1. Fellow evaluations 2. Observed patient encounters 3. Random chart reviews 4. Patient surveys 5. Surveys of allied health professionals 6. Procedure logs 7. Communication and literature review evaluations Re m e d i a t i o n : The program director will semi-annually review the fellow’sperformance and will: 1. identify any specific knowledge deficits, 2. document all knowledge areas requiring remediation or additional concentration, 3. develop an individualized learning plan, along with the fellow, for remediation of specific knowledge deficiencies. -41-
  • 41. The following competenciesare the sameacrossrotations. II . Int e r p e r s o n a l an d Com m u n i c a t i o n Sk i l l s Goa l : Fellows must demonstrate the knowledge, skills, and attitudes necessary to develop and maintain appropriate interpersonal relationships and to communicate effectively with patients, families, colleagues, and the public. Kno w l e d g e – Fellows will demonstrate knowledge of: 1. Appropriate interviewing techniques 2. Communication techniques Skill s – Fellows will be able to: 1. Demonstrate the ability to obtain, interpret, and evaluate consultations from other medical specialties including general and interventional cardiology and cardiovascular surgery: -42-
  • 42. a. Knowing when to solicit consultation and having sensitivity to assess need for consultation b. Discussing consultation findings with patients and their families c. Evaluating the consultation findings 2. Serve as an effective consultant to other medical specialists and community agencies This shall include: a) Communicating effectively with the requesting party to refine the consultation question b) Maintain the role of consultant c) Communicate clear and specific recommendations d) Respect the knowledge and expertise of the requesting party 3. Demonstrate the ability to communicate effectively with patients and their families by: a) Gearing all communication to the educational/intellectual levels of patients and their families -43-
  • 43. b) Providing explanations of clinical arrhythmias and the associated invasive and noninvasive management techniques (both verbally and in written form) that are jargon-free and geared to the educational/intellectual level of patients and their families c) Providing preventive education that is understandable and practical as applicable d) Respecting the patients’cultural, ethnic, and economic backgrounds e) Developing and enhancing rapport and a working alliance with patients and families 4. Maintain medical records and written prescriptions that are legible and up-to-date. These records must capture essential information while simultaneously respecting patient privacy and be useful to health professionals outside infectious disease. 5. Recognize the need for and effectively use interpreters when necessary. -44-
  • 44. 6. Present up-to-date information to students and residents in an organized fashion. 7. Provide feedback to students, residents and other professionals. Atti t u d e s : Fellows will: 1. Maintain an attitude of respect for others, even those with differing points of view. 2. Exhibit culturally sensitive, professional, ethically sound behavior in all patient and professional interactions. 3. Maintain an attitude of interdisciplinary collaboration. 4. Maintain a polite and courteous attitude at all times. Dem o n s t r a t e d by : Chart documentation; direct observation; teaching others; professional -45-
  • 45. relationships; formal presentations; independent learning; seeking feedback on communication and performance Ev a l u a t i o n : Fellows are evaluated at the end of each rotation. The evaluation surveys knowledge, skills, satisfactory progressive scholarship and professional growth and includes: 1. Fellow evaluations 2. Observed patient encounters 3. Random chart reviews 4. Patient surveys 5. Surveys of allied health professionals 6. Communication and literature review evaluation Re m e d i a t i o n : The program director will regularly review the fellow’s performance and will: -46-
  • 46. 1. Identify any specific deficits. 2. Document all areas requiring remediation or additional concentration. 3. Provide additional recommendations for remediation of specific deficiencies. III . Pra c t i c e Ba s e d Lea r n i n g an d Imp r o v e m e n t Goa l : Fellows must demonstrate the knowledge, skills, and attitudes necessary to initiate self-directed and independent learning. Fellows must keep abreast of current information and practices relevant to clinical cardiac electrophysiology. Kno w l e d g e : Fellows will demonstrate knowledge of: 1. Research methodology, including critical assessment of professional journal articles. 2. Principles of evidenced- based medicine. -47-
  • 47. 3. Awareness of available information technologies and the ability to access them. Skill s : Fellows will be able to: 1. Demonstrate the ability to obtain, interpret, and evaluate up-to-date information from the scientific and practice literature to assist in the quality care of patients. This shall include, but not be limited to: a) Use of medical libraries b) Use of information technology, including Internet-based searches and literature databases (e.g., Medline) c) Use of drug information databases. d) Active participation, as appropriate, in educational courses, conferences, and other organized educational activities both at the local and national levels. e) Conducting and presenting reviews of current research in such formats as journal clubs, grand rounds, and/or original publications -48-
  • 48. 2. Assess the generalizability or applicability of research findings to patients in relation to their sociodemographic and clinical characteristics. The physician shall demonstrate an ability to critically evaluate the relevant medical literature. 3. Evaluate caseload and practice experience in a systematic manner. This may include: a) Case- based learning b) The review of patient records and outcomes c) Obtaining appropriate supervision and consultation d) Maintaining a system for examining errors in practice and initiating improvements to eliminate or reduce errors Atti t u d e s : Fellows will: 1. Maintain an attitude of inquiry and scholarship, recognizing the need for life long learning. 2. Maintain openness and flexibility in treatment approaches with patients, assimilating new knowledge in patient care practices. -49-
  • 49. Dem o n s t r a t e d by : Self-directed inquiry guiding clinical care of patients; formal presentations which include literature review, and teaching others. Ev a l u a t i o n : Fellows are evaluated at the end of each rotation. The evaluation surveys knowledge, skills, satisfactory progressive scholarship and professional growth and includes: 1. Fellow evaluations 2. Observed patient encounters 3. Random chart reviews 4. Patient surveys 5. Surveys of allied health professionals 6. Communication and literature review evaluation Re m e d i a t i o n : -50-
  • 50. The program director will regularly review the fellow’sperformance and will: 1. Identify any specific deficits. 2. Document all areas requiring remediation or additional concentration. 3. Provide additional recommendations for remediation of specific deficiencies. IV . Pro f e s s i o n a l i s m an d Eth i c a l Be h a v i o r Goa l : Fellows must demonstrate the knowledge, skills, and attitudes necessary to practice professionally responsible, ethical and compassionate care in clinical cardiac electrophysiology. Kno w l e d g e : Fellows will demonstrate knowledge of: 1. The impact of gender, culture, religion, socioeconomic factors, and family structures and systems on issues pertaining to clinical cardiac electrophysiology. -51-
  • 51. 2. The different roles a CCEP specialist might fulfill in different settings. 3. Legal issues relevant to clinical cardiac eletrophysiology. 4. Ethical issues in clinical cardiac electrophysiology. This includes knowledge of the American Board of Internal Medicine code of ethics. 5. Ethical issues important in the conducting of research with humans and the role of the Committee for the Protection of Human Subjects. Skill s : Fellows will be able to: 1. Respond to communications from patients and health professionals in a timely manner. If unavailable, the physician shall establish and communicate back-up arrangements. 2. Use medical records for appropriate documentation of the course of illness and its treatment. -52-
  • 52. 3. Provide continuity of care including appropriate consultation, transfer, or termination of patients. 4. Demonstrate ethical behavior, integrity, honesty, professional conduct, compassion and confidentially in the delivery of patient care, including obtaining informed consent/assent, and declaring conflict of interest. 5. Demonstrate respect for patients and colleagues as individuals, by showing sensitivity to their age, culture, disabilities, ethnicity, gender, socioeconomic background, religious beliefs, political affiliations, and sexual orientation. 6. Demonstrate appreciation of end-of-life care and issues regarding provision or withholding of care. 7. Acknowledge responsibility for his or her decisions and demonstrate commitment to the review and remediation of his or her professional conduct. -53-
  • 53. 8. Promote the highest standards of medical healthcare to the public and participate in the review of the professional conduct of his or her colleagues. 9. Demonstrate responsible conduct of research by application to and communication with the Committee for the Protection of Human Subjects and Contracts and Grants in developing research protocols and by participating in the conduct of clinical research trials. Atti t u d e s : Fellows will: 1. Maintain an attitude of inquiry and scholarship, recognizing the need for life long learning. 2. Maintain openness and flexibility in treatment approaches with patients, assimilating new knowledge in patient care practices. Dem o n s t r a t e d by : Self-directed inquiry guiding clinical care of patients; formal -54-
  • 54. presentations which include literature review, and teaching others. Ev a l u a t i o n : Fellows are evaluated at the end of each rotation. The evaluation surveys knowledge, skills, satisfactory progressive scholarship and professional growth and includes: 1. Fellow evaluations 2. Observed patient encounters 3. Random chart reviews 4. Patient surveys 5. Surveys of allied health professionals 6. Communication and literature review evaluation Re m e d i a t i o n : The program director will regularly review the fellow’sperformance and will: 1. Identify any specific deficits. -55-
  • 55. 2. Document all areas requiring remediation or additional concentration. 3. Provide additional recommendations for remediation of specific deficiencies. V . Sy s t e m s Ba s e d Pra c t i c e Goa l : Fellows must demonstrate the knowledge, skills, and attitudes necessary to manage effectively in multiple, diverse, complex systems of care to provide effective treatment, consultation and referrals for patients. Kno w l e d g e : Fellows will demonstrate knowledge of: 1. Basic concepts of systems theory. 2. How fellows and residents’patient care practices and related actions impact component units of health care delivery. -56-
  • 56. 3. Systems- based approaches for controlling health care costs and allocating resources. Skill s : Fellows will be able to: 1. Advocate for patients within a variety of systems. 2. Partner with insurance and managed care companies to meet patient needs. 3. Strive to practice cost-effective health care and resource allocation that does not compromise the quality of care. Atti t u d e s : Fellows will: 1. Maintain an attitude of interdisciplinary collaboration, advocacy and cooperation. 2. Maintain flexibility in adapting to the needs and expectations of different settings and systems. -57-
  • 57. 3. Maintain the patient’sbest interest as the top priority. Dem o n s t r a t e d by : Care of patients; interactions with other agencies involved in the care of patients; consultation with other professionals; participation in Quality Assurance, Utilization Review and Performance Improvement Committees; self-directed independent learning; and teaching others. Ev a l u a t i o n : Fellows are evaluated at the end of each rotation. The evaluation surveys knowledge, skills, satisfactory progressive scholarship and professional growth and includes: 1. Fellow evaluations 2. Observed patient encounters 3. Random chart reviews 4. Patient surveys 5. Surveys of allied health professionals -58-
  • 58. 6. Communication and literature review evaluation Re m e d i a t i o n : The program director will regularly review the fellow’sperformance and will: 1. Identify any specific deficits. 2. Document all areas requiring remediation or additional concentration. 3. Provide additional recommendations for remediation of specific deficiencies. INPATIE N T TEACH I N G FACILITIE S Hermann Hospital serves as the primary site of clinical training. Consultative services are also rarely performed at the Lyndon B. -59-
  • 59. Johnson General Hospital and the University of Texas M. D. Anderson Cancer Center. While primary responsibilities vary with each rotation, fellows are always expected to assume an active role in patient care and in the teaching of nurses, medical students, house staff and general cardiology fellows. Participation in clinical research activities is expected and integrated throughout all clinical rotations. In addition, dedicated research electives are available. HERMANN HOSPITAL Chief of Medicine: 6411 Fannin Bruce Kone, MD Houston, Tx 77030 Chairman, Department of Internal Medicine Phone: (713) 500- 6500 Chief of Cardiology: David McPherson, MD (713) 500- 6559 Principal Teaching Method: On clinical rotations, trainees will be principally taught by their supervising CCEP -60-
  • 60. attending physician. The faculty is a full-time employee of UT-Houston or has a clinical appointment at the institution. The rotations in the hospital provide the academic and intellectual environment for acquiring the knowledge, clinical skill and judgement necessary for the training of a CCEP fellow. The supervising physician is expected to give guidance to residents and to define the goals and educational content of each rotation in accordance with the extablished curriculum. Instruction and experience will be provided at the bedside and during teaching rounds using interactive discussion. Additional teaching will occur through scheduled didactic lectures and conferences. The importance of continuous self-study during training is emphasized with the realization that this should be a lifelong commitment. Fellow Evaluation: Fellows are evaluated at the end of each -61-
  • 61. rotation by the responsible attending CCEP physician by way of the on-line GMEIS system. The evaluation surveys knowledge, skills, satisfactory progressive scholarship and professional growth. Each fellow is responsible for acknowledging the completed form. The fellow may respond to evaluations in writing or on-line. Fellows keep a running log of procedures and copies are submitted semi- annually to the fellowship office. Faculty Evaluation: Faculty are evaluated on-line by both CCEP and general cardiology fellows rotating on the EP service at the end of each rotation. Fellows are also invited to comment on the educational content and value of the rotation in writing. Fellows actively participate in the fellowship committee that oversees the curriculum. -62-
  • 62. OTHE R CLI N I C AL RES P O N S I B I L I TI E S EKG Reading Monday - Saturday The CCEP Consult Fellow and rotating general Cardiology Fellow will participate in daily ECG reading, beginning at 8:00 AM, along with the students, housestaff and other Cardiology Fellows, whenever not immediately involved in the care of a specific patient. They will also read Holter monitors, signal-averaged ECG’s, T wave alternans tests, tilt table tests and transtelephonic monitoring recordings daily. All interpretation will be supervised directly by the Attending Staff. Pacemaker/Device Clinic Monday - Friday The Pacemaker/Device Outpatient Clinic is open daily in the Memorial Hermann Hospital President Bush Center for Cardiovascular Medicine (heart center) for monitoring, programming and troubleshooting of pacemakers and defibrillators. Device checks are also performed routinely in the Cardiology Clinic. Inpatient pacemaker and device recipients are seen at the bedside for patient education and monitoring. -63-
  • 63. All recipients of new devices are to be educated and enrolled in long- term follow-up prior to hospital discharge. Pacing and sensing thresholds will be checked and any necessary reprogramming performed prior to discharge, as well. The CCEP Consult Fellow is expected to attend Pacemaker/ Device Clinic for two half-days weekly, at the least, and is primarily responsible for seeing clinic inpatients and outpatients requiring medical attention under the supervision of the Attending Staff. All CCEP Fellows are encouraged to spend any additional time available in the Clinic gaining supplemental experience in programming and troubleshooting. Teaching Aside from routine teaching of housestaff and students on the Inpatient and Consult rotations, each fellow will be asked on occasion to give formal lectures on various topics to housestaff, medical students, nurses and technical staff, as well as sessions on physical diagnosis and ECG interpretation to second year medical students. In addition, each fellow will be expected during the course of the year to research, prepare and deliver two formal presentations on CCEP topics or to present research findings for one or more of the following: -64-
  • 64. the EP/ECG conference, CCEP Core Curriculum and/ or Cardiology Grand Rounds. CCEP Fellows are also expected to prepare presentation of material for CCEP Case Studies and CCEP Journal Club conferences. Outpatient Clinic CENTER FOR CARDIOVASCULAR MEDICINE UT Professional Building 6410 Fannin, Suite 600 Houston, Tx 77030 Medical Director: Richard Smalling, MD, PhD Director: Melinda Geruckos Phone: (832)-325- 7357 Independent of all clinical rotations, each CCEP fellow will attend outpatient clinic one or two half days weekly at the Center for Cardiovascular Medicine. A faculty member will be available to discuss all new patient referrals to electrophysiology and assume responsibility for all patients seen by the fellow. Patients referred from outside physicians require a follow up letter after the patient has been seen. -65-
  • 65. All charts and charge documents must be signed (electronically or by hand) by the faculty member. When any fellow is scheduled to be on leave, it is the fellow's responsibility to cancel his/her clinic. This is done by notifying the head nurse, the appointment clerks, and the nursing staff. It is required that a colleague be designated to take patient calls during the fellow's absence. -66-
  • 66. RE S E A R C H OPPORT U N I T I E S All CCEP Fellows are encouraged to participate liberally in research projects. A list of ongoing clinical and basic research projects will be made available to each fellow at the beginning of each year. Fellows will also be encouraged to design and carry out their own clinical and/or basic projects under the advice of a sponsoring attending physician/ scientist. Fellows are expected to participate in screening, enrollment and data collection on research subjects for whose clinical care they are responsible during the course of their clinical rotations. More active participation in study design, grant application, IRB approval, data analysis, abstract presentation and manuscript submission is strongly encouraged. Familiarity with and adherence to all university policies and procedures in the conduct of medical research is required. The following resources describe university policies and procedures:
  • 67. Committee for the Protection of Human Subjects Coordinator: Cynthia Edmonds UCT 750 Chairperson: Anne H. Dougherty, MD 7000 Fannin (drop-off MSB 2.104a, 8 am – noon, Monday – Friday) 713-500-3985 [www.uth.tmc.edu/ut_general/research_acad_aff/orsc/cphs.htm] Animal Welfare Committee Coordinator: Cynthia Edmonds UCT 750 Chairperson: Sharon Crandell, MD 713-500-3985 (drop off MSB 2.104a, 8 am – noon, Monday – Friday) [www.uth.tmc.edu/ut_general/research_acad_aff/orsc/awc.htm] Contracts and Grants Sr. Grants Specialist: Katherine Moore 713-500-5847 713-500-3032 [www.osp@admin4.hsc.uth.tmc.edu]
  • 68. DIDACTIC SC H E D U L E In didactic CCEP conferences, the following curriculum will be emphasized: • Basic electrophysiology, including formation and propagation of normal and abnormal impulses, autonomic nervous control of cardiac electrical activity, and mechanisms of clinically significant arrhythmias and conduction disturbances, • Evaluation and management of patients- both ambulatory and hospitalized- who have clinical syndromes resulting from bradyarrhythmias or tachyarrhythmias, • Indications for and interpretation of noninvasive diagnostic studies, including esophageal, scalar and signal-averaged ECG, ambulatory electrocardiography, continuous in-hospital cardiac monitoring, exercise testing, tilt testing, T wave alternans and relevant imaging studies, • Indications for, techniques and interpretation of diagnostic intracardiac electrophysiologic studies, and techniques of performing these studies,
  • 69. • Indications for, techniques and effects of noninvasive therapeutic techniques, including esophageal and transcutaneous pacing, cardioversion, defibrillation, and cardiopulmonary resuscitation, • Indications for, techniques and effects of invasive therapeutic techniques, including pacemaker and cardioverter-defibrillator implantation and catheter and surgical ablation of/for arrhythmias, • Pharmacology, pharmacokinetics, and use of antiarrhythmic agents and other drugs that affect cardiac electrical activity. Conferences specific to the CCEP fellowship include: Clinical EP Teaching Rounds Objective: To present current arrhythmia inpatients to the EP service and discuss diagnosis and management strategies. Bedside teaching rounds will be conducted on arrhythmia inpatients on both the cardiology and consult services on Mondays at 10:00 AM, beginning in the CCU. Attending physicians, CCEP fellows, Cardiology fellows rotating on the EP service, nurses, physicians’assistants and research associates will attend. Cases will be presented by the CCEP and Cardiology fellows and discussed by the group as a whole. Rationale for diagnosis and management will be emphasized and
  • 70. alternative strategies debated. Underlying organic heart disease and co- morbidities, pharmacokinetics, drug interactions, and ethical considerations will be discussed as applicable to each individual case. Attendance is required except when a fellow is immediately needed for the care of a specific patient. CCEP Core Lecture Objective: To supplement academic areas covered in clinical rotations and provide a well-rounded foundation in both basic and clinical cardiac electrophysiology. Emphasis will be placed on basic electrophysiology, autonomic nervous control of the heart, pharmacology, pacing and defibrillation physics and technology, ablation physics and technology and clinical research and trials. On the 1 st Thursday of each month at 4:00 PM in the Hermann Cath Lab conference room, CCEP fellows and Cardiology fellows rotating on the EP service will attend a lecture on electrophysiology topics with an emphasis on topics not fully covered on the clinical rotations or in other conferences. Attendance is mandatory. CCEP Journal Club
  • 71. Objective: To review the current literature in cardiac electrophysiology, develop skills in critical scientific and statistical analysis and ethical considerations. Implications of new findings for development of ongoing and future research projects will be discussed. On the 2nd and 4th Thursdays of each month at 4:00 PM in the Hermann Cath Lab conference room, the CCEP fellows and Cardiology fellows on the EP rotation will meet with attending physicians to review current journal articles. Each fellow will be responsible for presenting an article, with particular attention to methods, statistical analysis and results. Discussion will include a critical appraisal of the methods and ethics and discussion of the importance of the findings. Attendance is mandatory. CCEP Case Studies Objective: To review in depth interesting invasive EP procedures and analyze results, with emphasis on mechanisms of arrhythmogenesis and effective diagnostic and therapeutic maneuvers. Patient outcomes will also be discussed in order to review and optimize morbidity and mortality. The same group will meet on the 3rd Thursday of each month in the
  • 72. Hermann Cath Lab Conference Room for a detailed discussion of interesting and instructive invasive EP cases. Each fellow will be responsible for assembly of materials to present a case to the group, beginning with history and physical exam, pertinent ECG’sand labs, intracardiac tracings and noncontact 3-dimensional maps. All adverse outcomes of all invasive studies will be presented at the following conference and discussed by the group. Attendance is mandatory. Cardiology Core Lecture Series A core series of didactic lectures on the main topics in cardiovascular medicine will be given every Monday, Tuesday and Friday from 12:00 to 1:00 pm in the UT ground floor lecture rooms. Attendance by CCEP fellows is encouraged. The lectures begin in August and run through June. Hemodynamic Conference An interactive hemodynamic conference is held every Tuesday morning from 7:00 to 8:00 AM by Dr. Smalling or one of the other catheterization attendings in the cath lab conference room. A cardiac catheterization fellow will present a case, which will be discussed in detail, with regard to critical evaluation of hemodynamics, imaging
  • 73. physics, invasive monitoring, and specific procedural considerations. CCEP fellows are encouraged to attend. Medical Grand Rounds Tuesdays, 1:00 p.m., Room 3.001 MSB All fellows are expected to attend except when dealing with clinical emergencies. Clinic-Pathological Conference Mondays, 12:00 noon, MSB 3.001. All fellows are encouraged to attend. Cardiac Catheterization Conference Thursdays 5:00-6:00 p.m. in 2103 MSB. The cath fellows will present history, physical exam, labs, EKGs, x-rays, noninvasive studies and the actual cath films. Usually, two or three cases are presented and discussed with the medical and surgical staff. CCEP fellows are encouraged to attend. Cardiology Grand Rounds Thursdays, 12:00 noon, Room 2.135. These are special lectures often presented by guest speakers with a clinical emphasis. CCEP fellows are
  • 74. expected to attend. Morbidity and Mortality (M&M) Conference M&M Conferences are held in conjunction with the cardiology staff meeting on every first Monday of the month from 5:00 to 6:00 PM in the Birch Room, Hermann Hospital. All fellows on the clinical services are expected to attend. Cardiovascular Surgery Grand Rounds Fridays, 7:00 am, Room 2.135. These are special lectures often presented by guest speakers with a clinical emphasis on CV surgery. CCEP fellows are encouraged to attend.
  • 75. 2006- 2 0 0 7 Car d i o l o g y Did a c t i c Sch e d u l e Monday tuesday wednesday thursday friday Week 10:00 7:00 HC 12:00 7:00 1 CCEP TR 12:00 CGR CVSGR 12:00 CCL 16:00 12:00 CCL CCEP CL CCL 17:00 M&M Week 10:00 7:00 HC 18:30 CJC 12:00 7:00 2 CCEP TR 12:00 CGR CVSGR 12:00 CCL 16:00 12:00 CCL CCL CCEP JC 17:00 CCC Week 10:00 7:00 HC 12:00 7:00 3 CCEP TR 12:00 CGR CVSGR 12:00 CCL 16:00 12:00 CCL CCEP CS CCL 17:00 CCC
  • 76. Week 10:00 7:00 HC 12:00 7:00 4 CCEP TR 12:00 CGR CVSGR 12:00 CCL 16:00 12:00 CCL CCEP JC CCL 17:00 CCC Week 10:00 7:00 HC 12:00 7:00 5 CCEP TR 12:00 CGR CVSGR 12:00 CCL 16:00 12:00 CCL CCEP FF CCL 17:00 CCC CCEP TR = CCEP Teaching Rounds CCL = Cardiology Core Lecture HC = Hemodynamics Conference CJC = Cardiology Journal Club CGR = Cardiology Grand Rounds CCEP CL = CCEP Core Lecture M&M = Cardiology Morbidity & Mortality CCC/ CV = Combined Cardiology/ CV Surgery Conference CCEP JC = CCEP Journal Club
  • 77. CCC = Cardiac Cath Conference CCEP CS = CCEP Case Studies Conference CCEP FF = CCEP Fellow Fry CVSGR = CV Surgery Grand Rounds
  • 78. ANCILLARY COU R S E S Advanced Cardiac Life Support (ACLS) ACLS certification is required for all fellows, and it is the fellow's responsibility to keep certification current. Courses are offered through the Hermann Hospital Life Flight Office. Registration forms for the course can be obtained at the Life Flight Office, Robertson Pavilion, phone (713) 704-4014. A list of additional courses offered in the Houston area is available through the American Heart Association at (713) 610-5000. Radiation Safety Course The UTHSC Radiation Safety Division offers a short course in Radiation Safety several times a year. It is expected that each fellow will complete this course successfully within the first three months of his/her first year of the Cardiology fellowship. CCEP Fellows who have not already completed this course or an equivalent one at another institution will also be required to do so within the first three months of the first year. Call (713) 500-5840 to enroll.
  • 79. OTHE R CLI N I CALLY RELATE D MATTER S Medical Licensure Those fellows entering the program on an Institutional Permit may choose to apply for a permanent license during fellowship training. Applications are requested from the Texas State Board of Medical Examiners, 1812 Centre Creek Drive, Suite 300, P. O. Box 149134, Austin, TX 78714-9134; phone (512) 305- 7010. The process is lengthy and detailed; it is recommended that application instructions be followed carefully. At the current time, the State Board does not accept National Board exams for licensure in Texas. The FLEX is being phased out and will be replaced by the new USMLE (United States Medical Licensing Exam) as the national exam for licensure. The Medical School's liaison with the State Board is Ms. Florinda Guerra in the Office of Academic Affairs, phone (713) 500- 5151. After obtaining a permanent license, a Texas Department of Public Safety (DPS) registration number must be obtained prior to application for a Federal DEA number. The DPS phone number is (512) 424- 2150. NOTE : An institutional permit does not entitle a fellow to assume professional activities outside of the fellowship program.
  • 80. Professional Liability Insurance Professional liability insurance is provided through the University of Texas System Professional Liability Self-Insurance Program at no cost to the fellow. A current Institutional Permit or a current permanent Texas license is necessary to obtain insurance coverage. Cop i e s of ren e w e d IP ’ s or Tex a s lic e n s e s mu s t b e su b m i t t e d e a c h ye a r to co n t i n u e co v e r a g e . PLI co v e r a g e will b e su s p e n d e d im m e d i a t e l y if yo u all o w you r Tex a s lic e n s e or IP to ex p i r e . The fellow will be covered by PLI when performing his/her assigned duties within the program. Such coverage is only at the affiliated hospitals and clinics to which the fellow is assigned through the program. Current limits of coverage are $100,000/ $300,000. PLI provided does not cover any professional activities other than those assigned through the program OTHE R PERTI N E N T IN F O R M A TI O N Fellowship Administrative Offices
  • 81. The Cardiology Fellowship office is located in MSB 1.432 (Medical School Building, by the Orange elevators). Julisa Anaya is the coordinator of the fellowship program and facilitates communication between fellows and the University. Please be sure to inform Julisa of any change in home address or phone number. Also, you will need to make sure the office has current copies of any licenses you may hold (DPS, DEA, Texas licenses). Pl e a s e info r m th e offi c e in ca s e of an y em e r g e n c i e s , illn e s s or oth e r mat t e r s rel a t i n g to th e pro g r a m or th e p e rf o r m a n c e of you r dut i e s as so o n as po s s i b l e , or at th e lat e s t wit h i n 2 4 ho u r s of th e oc c u r r e n c e (71 3) 5 0 0 - 6 5 7 7 . Night Call A General Cardiology Fellow will remain in-hospital 24 hours daily on a rotating schedule at Hermann Hospital. In addition, CCEP Fellows will be on beeper call for arrhythmia intervention and consultation. All EP inpatients will be seen on Saturdays by the CCEP Fellow on call according to a rotating schedule. The CCEP fellow on-call for Sunday is also responsible for preparing inpatients for EP procedures scheduled for Monday. The CCU and the General Cardiology service fellows will carry a code beeper and run all codes on the days their team is on
  • 82. long call. At night, the code beeper will be passed to the in-house fellow on call beginning at 6:00 pm. The call fellow will provide coverage until 7:00 am the following day. The call fellow will also approve emergency echocardiograms and emergency nuclear studies as necessary. The cardiology consult resident will see all follow-up consults on the weekend and discuss them with the on-call fellow. New consults will be covered by the on-call fellow and the attending on call for that particular service. The call schedule for fellows is published by the 15th of the month for the following month. If you hav e sp e c i a l req u e s t s su c h as s c h e d u l e d va c a t i o n s , et c . , you mu s t inf o r m on e of th e ch i e f car d i o l o g y fel l o w s in wri t i n g by th e 1 5 th of th e pri o r mo n t h . Als o , if ch a n g e s ar e ma d e to th e cal l s c h e d u l e aft e r it is pu b l i s h e d , you ar e re s p o n s i b l e for not if y i n g all co n c e r n e d part i e s ( i . e ., H e r m a n n pa g e op e r a t o r , fell o w s h i p offi c e , car d i o l o g y an s w e r i n g servi c e an d all oth e r par t i e s wh o re c e i v e th e cal l s c h e d u l e ) . Th er e is a lis t on th e FAX ma c h i n e in MS B 1. 2 4 6 . Duty Hours Maximum total duty hours for CCEP fellows will be consistent with ACGME guidelines and general Cardiology policies. Work hours are
  • 83. limited to 80 hours/week, with at least one 24-hour off-duty period per week. Shifts will be limited to a maximum of 24 consecutive hours. No in-house call is regularly scheduled, however CCEP fellows on call may be required on occasion to return to the hospital after hours to attend to arrhythmia emergencies. Call Rooms A call room is provided for fellows taking in-house call at Hermann Hospital. The room is located in Cullen Pavilion, Room C236. Keys to the call room are issued through the Hermann Hospital House Staff Affairs Office. A deposit is required. Beepers and Paging Long distance beepers are provided for each fellow. In-house, the system can be accessed on a Herman Hospital (713-704-XXXX) number by dialing "185" and the five digit pager number. From outside the hospital, the system can be accessed by dialing (713) 605- 8989, then the pager number and return number at the respective prompts. Digital paging may be done through www.metrocall.com and adding an initial “00”to the beeper number. The Hermann Hospital page operator can be reached at (713) 704-4284. The Cardiology answering service can
  • 84. be reached at (713) 428- 6300. Uniforms Two lab coats will be provided to each Fellow at the beginning of the academic year. The University of Texas- Houston Fellowship Program provides laundry services for Fellows. To have white coats laundered, Fellows can deposit them in the utility closet for Cardiology room 1.246. Clean coats may be picked up in this same room. Offices Subject to availability, the CCEP Fellows shall have desk space in the President Bush Center. Two PC’s(IBM and MacIntosh) and PowerPoint projection equipment are available for the general use of the fellows. A key may be obtained in the fellowship office. Parking Currently, off-site parking is provided to clinical Fellows at a reduced rate. Connecting bus and rail passes are available through the Hermann Hospital House Staff Affairs Office. Photocopying
  • 85. Photocopying is provided at two locations: 1) Cardiology divisional offices 1 st floor MSB, and 2) TMC Medical Library Each Fellow will be provided with a code number with which to operate these machines. It is expected that photocopying will be primarily for journal articles (i.e., not for entire books). DO NOT give the code number to anyone, including students and residents. Professional Society Memberships Fellows are encouraged to become Associates in the Heart Rhythm Society and the Houston Electrophysiology Society during their first year. Fees are modest for fellows in training, compared to the benefits. Other cardiology societies, particularly the American College of Cardiology and the Cardiac Electrophysiology Society, also offer educational benefits. For further information and application forms, please contact the fellowship office. Educational Materials The fellowship program has purchased a videotape series entitled “Mayo Cardiovascular Board Review”. These tapes are for the use of the Fellows and are located in the fellowship office. A $20 deposit is
  • 86. required to check out a tape, and will be refunded upon return of the tape. Tapes may be checked out one at a time, and must be returned within one week. A late charge of $1 per day will be assessed for late returns. A video library of electrophysiology topics, including Arrhythmia SAP and EPSAP are also available in Dr. Dougherty’soffice (MSB 1.246) Materials may be checked out but must be returned within one week. A file of resource materials and key articles in electrophysiology is also maintained in Dr. Dougherty’soffice, as well as a file of prior journal club articles, and these materials may be photocopied. Time Cards/Leave Policy Each Fellow is required to submit a time card each month. The fellowship office completes these and Fellows are asked to sign them. Vacation will be accrued at a rate of three calendar weeks (21 days) per year and sick leave at a rate of eight (8) hours per month of employment, not to exceed 30 days. To take vacation leave, the Fellow must complete a Leave Request Form (available in the fellowship office) one week pri o r to leaving, and must obtain the signature of the attending to whom the Fellow will be assigned during the vacation, as
  • 87. well as the signature of the fellowship director. It is the Fellow’s responsibility to arrange the clinical coverage during his/her absence. Absences for maternity/paternity must be covered by any accrued vacation and sick leave. If this is not sufficient time to cover the required length of absence, the Fellow must request of the Fellowship Committee a specific period of unpaid leave. NOTE : In the instance of Fellows presenting research data at an approved educational meeting, absences will not be deducted from the educational leave balance. The Division of Cardiology will pay airfare and accommodations (only once per year) only if prior arrangements are made according to Division procedures. Job Opportunities Job opportunities will be posted by e-mail and in the fellowship office. Also posted are educational opportunities and other items of interest to Fellows. Bookstores Major’sScientific Books is a fairly large medical bookstore located at 7205 Fannin (713/799-9922). The UT bookstore is smaller, but has
  • 88. most basic texts. It is located in the basement of the MSB and is easy to reach. Libraries The Jesse H. Jones Medical Library, the main medical library for the Texas Medical Center, is located directly behind the Medical School, is open seven days per week until 11:00 PM (with shorter hours on weekends), and has virtually all journal and text material needed. Its electronic database is available through the Houston Academy of Medicine located in the library. The Kirkendall Library is the medical residents’library. It is small, but conveniently located on the first floor of the Medical School Building and has most of the current medical journals on display. Evaluations and Personnel Files In compliance with the guidelines of the American Board of Internal Medicine, each fellow will be evaluated by the respective attending faculty member upon completion of each rotation. Fellows are responsible for reviewing and acknowledging the comments and cosigning. They have the right to review their files, which are kept in the fellowship office. The CCEP fellowship director will meet with each
  • 89. CCEP Fellow twice yearly to review his/her progress. Meals The Hermann Hospital Cafeteria, 1 st floor of the Robertson pavilion, is open daily for breakfast, lunch and dinner. A discount is given if an ID badge is shown.
  • 90. U S E F U L TELEP H O N E NUMBER S NAME TITLE/ CONTACT ROOM PHONE PAG E-MAIL # E Julisa Anaya Fellowship Coordinator 1.432 500-6577 Julisa.Anaya@uth.tmc.e du Anne Dougherty, MD CCEP Fellowship Director 1.234 500-6590 2469 Anne.H.Dougherty@uth 2 .tmc.edu Sheryl Murphy, RN, NP Nurse Practitioner; 1.246 500-6598 2365 Sheryl.Jablonski@uth.t Research Coordinator 8 mc.edu Sonya Emmert Administrative Assistant 1.234 500-6590 Sonya.K.Emmert@uth.t mc.edu Hermann Cath Lab 704-2360 Cath Lab 1 (EP) Mary Meyer, RN, EP 704-3221 Mary_Meyer@mhhs.org
  • 91. Coordinator Hermann Center for Danielle Obert, RN HPB # 832-325- dobert@ucplus.org Cardiovascular Medicine 600 7375 Coumadin Clinic Kristie Hall, PharmD HPB # 704-2624 andrea_hall@mhhs.org Kenneth Chong, PharmD 600 CCU 704-3112 CVICU 704-4765 3E Cullen 704-4111 3W Cullen 704-4551 ER 704-4060 Hermann Transfer Office 704-2500 M.D. Anderson Cardiology 792-6245

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