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UCSF General Surgery Residency Program Supervision Policies

I. POLICY STATEMENT

The UCSF General Surgery residency program requires active supervision of all residents in the program by an appropriately credentialed Medical Staff member with the supervision documented in the medical record.

Every patient must have an identifiable, appropriately-credentialed and privileged attending physician who is responsible and accountable for that patient’s care. This information must be available to residents, fellows, faculty, other members of the health care team, and patients. Residents, fellows, and faculty must inform each patient of their respective roles in that patient’s care when providing direct patient care. This information must be available to residents, faculty members, other members of the health care team, and patients

Residents must be provided with prompt and reliable systems for communication with attending physicians.

II. REASON FOR POLICY

This policy describes specific supervision policies for residents in the general surgery residency program at UCSF. Per ACGME common program requirements, the program must ensure that all resident clinical activities be appropriately supervised, and that the appropriate levels of supervision are exercised in specific clinical settings.

These policies outline the minimum levels of supervision that are required, and the attending physician responsible for patient care must determine if a higher level of supervision is warranted on a case-by-case basis. This should be informed by an assessment of an individual resident’s clinical competency and level of training.

III. DEFINITIONS

  1. Direct Supervision: The supervising physician is physically present with the trainee during the key portions of the patient interaction; or, the supervising physician and/or patient is not physically present with the trainee and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology.
  2. Indirect Supervision: The supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance and is available to provide appropriate direct supervision.
  3. Oversight: The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

Supervising physician: 1) attending physician with credentials to perform the procedure or activity at the clinical site in question or 2) a surgical resident at the PGY2 level or higher whose supervision level is designated as “oversight”.

Resident: This policy applies to all clinical residents in the UCSF General Surgery Residency Program, including the following:

  • All categorical General Surgery Residents PGY1-5
  • Non-designated preliminary surgery residents PGY1-2
  • Designated preliminary PGY1 residents in OMFS, Ophthalmology, and Interventional Radiology

Faculty attending physician: A physician on the medical staff, credentialed in the procedure or activity at the clinical site where the procedure or activity is occurring.

IV. PROCEDURES

A. Principles

The attending physician is responsible for the care provided to individual patients. All residents function under the supervision of appropriately credentialed attending physicians.

Residents as individuals must be aware of their limitations. Failure to function within graduated levels of responsibility or to communicate significant patient care issues to the responsible attending physician may result in the removal of the resident from patient care activities.

PGY1 residents must initially be directly supervised until competency is obtained. This assessment will be informed by entrustable professional activity microassessments, rotation evaluations, skills lab evaluations, and direct observations by faculty, residents, and other providers.

All procedures performed in the operating room must be directly supervised by an attending physician for the key portions of the procedure

B. Competencies (Table of Procedures)

Below is a table of procedures indicating which procedure a surgical resident may perform, with and without supervision. In all cases the clinical situation, the experience of the specific resident and the judgment of the more senior residents and/or the

      PGY
Procedure  12345
airway management, stable/unstable, trauma      DS DS DS DS DS
anesthesia              
  local   DS O O O O
  field block   DS IS IS IS IS
  peripheral nerve block   DS IS IS IS IS
ankle-brachial index     DS/IS O O O O
arterial line (I/R)     DS DS DS IS IS
arthrocentesis              
  lower extremity   DS DS DS DS DS
  upper extremity   DS DS DS  DS DS
bladder (Foley) catheter (I/R)      DS/IS O O O O
bladder irrigation     DS/IS O O O O
blood gases (arterial)     DS/IS O O O O
bronchoscopy     DS DS DS DS DS
cardiopulmonary resuscitation               
  closed   DS DS DS DS DS
  open   DS DS DS DS DS
cardioversion     DS DS DS DS DS
cast/splint (Ap/R)              
  for fracture   DS DS DS DS DS
  for immobilization/protection   DS DS DS DS DS
central line (femoral/jugular/subclavian)               
    insert DS DS DS DS/IS DS/IS
    remove DS/IS IS IS IS IS
chest tube              
    insert DS DS IS IS IS
    remove DS/IS IS O O O
colonoscopy, with/without biopsy      DS DS DS DS DS
compartment pressure measurement      DS DS/IS IS IS IS
conscious sedation     DS DS DS DS DS
cricothyroidotomy     DS DS DS IS IS
cultures (urine/sputum/wound)      DS/IS O O O O
cutdown              
  venous             
    insert DS DS DS DS DS
    remove DS/IS IS IS IS IS
  arterial             
    insert DS DS DS DS DS
    remove DS/IS DS/IS DS/IS IS IS
defibrillation     DS DS IS IS IS
Doppler study              
  venous   DS/IS O O O O
  arterial   DS/IS O O O O
  graft/fistula   DS/IS O O O O
drug administration              
  intravenous   DS IS IS IS IS
  intra-arterial   DS DS DS DS DS
esophagogastroduodenoscopy (EGD)      DS  DS  DS DS DS
endotracheal suctioning      DS/IS IS IS IS IS
endotracheal/nasotracheal intubation      DS DS DS DS DS
gastric lavage     DS/IS IS IS IS IS
incision & drainage, abscess/fluid collection/cyst      DS DS/IS IS IS IS
laceration repair     DS/IS IS IS IS IS
laryngoscopy     DS DS DS DS DS
long intestinal tube (I/R)      DS/IS IS IS IS IS
lumbar puncture     DS DS DS DS DS
mediastinal tube              
    insert DS   DS DS DS DS
    remove DS/IS IS IS IS IS
nasal packing              
  anterior   DS DS DS DS DS
  posterior   DS DS DS DS DS
nasogastric tube (I/R)      DS/IS IS IS IS IS
pacemaker/pacer wires, transthoracic               
    insert DS  DS DS DS DS
    remove DS/IS IS IS IS IS
pacemaker/pacer wires, transvenous               
    insert DS DS DS DS DS
    remove DS DS DS DS DS
paracentesis/acute PD catheter      DS DS DS DS DS
Percutaneoue fine needle aspiration/drainage/biopsy for fluid collection, cyst, abscess, mass      DS/IS IS IS IS IS
Peripheral IV (I/R)     DS/IS IS IS IS IS
perform/interpret lab tests (spin Hct/do UA/EKG/      DS/IS IS IS IS IS
pericardiocentesis     DS DS DS DS DS
peritoneal lavage     DS DS DS DS DS
phlebotomy (including blood cultures)      DS/IS IS IS IS IS
pleurodesis     DS DS DS DS DS
rectal tube (I/R)     DS/IS IS IS IS IS
remove foreign body     DS DS DS IS IS
sclerosis, other (eg, seroma)      DS DS DS DS DS
sigmoidoscopy/anoscopy               
  with biopsy   DS DS DS DS DS
  without biospy   DS DS DS DS DS
sutures/staples (I/R)     DS/IS IS IS IS IS
thoracentesis     DS DS DS DS DS
thoracotomy, emergency      DS DS DS DS DS
tracheotomy     DS DS DS DS DS
wound dressing change/vac change      DS/IS O O O

Legend

DS = Direct Supervision  

IS = Indirect Supervision    

= Oversight        

DS/IS = Direct supervision, until competency is achieved, then indirect supervision          

I = insertion          

R = removal

V. Site-Specific Guidelines

SF-VAMC

ZSFG

Kaiser Permanente

Mandatory Attending Notification Policy

Call an Attending directly (or positively ascertain that an Attending has been notified) upon the following situations:

  • Death (even if expected)
  • Cardiac arrest
  • Respiratory failure either requiring intubation or significantly increased O2 demands
  • Severe respiratory distress
  • Airway issues
  • Transfer to ICU or higher level of care
  • Concern that patient needs a procedure or operation
  • A new need for acute dialysis
  • Bleeding requiring transfusion
  • Hypotension/hemodynamic instability
  • Symptomatic and severe hypertension
  • Significant new arrythmia
  • Suspected MI
  • Suspected PE
  • New onset severe chest pain
  • New onset severe abdominal pain
  • Abrupt deterioration in neurologic exam or profound decreased mental status
  • Significant change in neurovascular exam of extremity
  • Patient or family wishes to speak to the attending
  • Patient wishes to be discharged AMA
  • Any other significant change in clinical status of patient that is of major concern.
  • Any new admission.
  • The arrival of a patient accepted in transfer from another institution.

Service specific criteria, e.g.

  • KTU: abrupt loss of urine output in recent kidney transplant pt that was previously making urine; ultrasound showing vascular/ureteral problem.
  • LTU: ultrasound showing absence of hepatic arterial flow
  • VASCULAR: loss of a pulse or Doppler signal that was present earlier
  • PLASTICS: abrupt change in signal /duskiness of free flap

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