Adult Cardiothoracic Training Program Supervision & Accountability Policy

[Last updated: 04/29/2022]

Please reference complete UW GME Institutional Supervision and Accountability Policy for additional definitions and background. This page is best viewed on desktop.

Responsibilities and Accountability

Each patient must have an identifiable and appropriately-credentialed and privileged attending physician (or licensed independent practitioner as specified by the applicable Review Committee) who is responsible and accountable for the patient’s care. This information will be available through direct communication, through the electronic medical record, and in the case of perioperative/periprocedural care, through the UW Medical Center OR Electronic Whiteboard, to residents/fellows, faculty members, other members of the health care team, and patients.

All perioperative/periprocedural patient care activities in elective and other scheduled cardiothoracic patients involving the fellow occur under close, predominantly direct, supervision by Cardiothoracic Anesthesiology faculty who are present at the patient care location.

From 16:00 to 06:30 on weekdays, and all day on weekend days and holidays, the coordinating attending anesthesiologist is the attending cardiothoracic anesthesiologist designated “C1” or “CT1” on the weekly schedule. If the attending cardiothoracic anesthesiologist designated “C1” or “CT1” is unavailable, supervisory responsibility devolves upon the attending cardiothoracic anesthesiologist designated “C2” or “CT2” on the weekly schedule.

Telephone and pager numbers for Cardiothoracic Anesthesiology faculty are listed on the weekly UW Medical Center Anesthesia Staffing Schedule (available online from the Department of Anesthesiology and Pain Medicine Schedules webpage, and in hard copy at the UW Medical Center Main OR Front Desk), and in urgent cases can be obtained from the UW Medical Center OR, front desk or charge nurse. UW Medical Center Cardiothoracic Anesthesiology faculty can also be contacted via the UW Medical Center paging operator.

The (Adult) Cardiothoracic Anesthesiology fellows, and faculty members must inform each patient of their respective roles in that patient’s care when providing direct patient care.

The program will provide the appropriate level of supervision for each fellow based on each fellow’s level of training and ability, as well as patient complexity and acuity. Supervision may be exercised through a variety of methods, as appropriate to the situation.

As part of their education program, fellows are given graded progressive responsibility according to the individual’s clinical experience, judgment, knowledge and technical skill. Each fellow must know the limits of their scope of authority, and the circumstances under which the fellow is permitted to act with conditional independence.

Supervision Definitions

To promote oversight of fellow supervision while providing for graded authority and responsibility, the following levels of supervision are recognized:

Direct Supervision

The supervising physician is physically present with the fellow and patient.

Indirect Supervision

With direct supervision immediately available: the supervising physician is physically within the hospital or other site of patient care and is immediately available to provide direct supervision. “Immediately available” is considered to mean within five (5) minutes of being contacted.

With direct supervision available: the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities and is available to come to the site of care in order to provide direct supervision within thirty (30) minutes.

Oversight

The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.

Fellow Competence & Delegated Authority

The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each fellow must be assigned by the program director and faculty members.

The program director must evaluate each fellow’s abilities based on specific criteria, guided by the milestones.

Faculty members functioning as supervising physicians must delegate portions of care to fellows based on the needs of the patient and the skills of each fellow.

Clinical Responsibilities by PGY-Level

PGY-1 Residents

PGY-1 residents are initially either directly supervised or indirect supervision with direct supervision immediately available (see definitions above). Please note that there are no PGY-1 residents in the (Adult) Cardiothoracic Anesthesiology program.

Intermediate Residents

Intermediate residents may be directly or indirectly supervised by an attending physician or senior resident/fellow but will provide all services under supervision. They may supervise PGY-1 residents and/or medical students; however, the attending physician is responsible for the care of the patient. Please note that there are no intermediate residents in the (Adult) Cardiothoracic Anesthesiology program.

Senior Residents

Fellows may be directly or indirectly supervised. They may provide direct patient care, supervisory care or consultative services, with progressive graded responsibilities as merited. Senior residents or fellows should serve in a supervisory role to medical students, junior and intermediate residents in recognition of their progress towards independence, as appropriate to the needs of each patient and the skills of the fellow; however, the attending physician is responsible for the care of the patient.

Direct supervision is always required for the following:

Induction of anesthesia
Initiation and management of extracorporeal membrane oxygenation (ECMO)
Interrogation and programming of cardiac implanted electronic devices
Perfusion management of cardiopulmonary bypass (in the context of the Cardiopulmonary Perfusion rotation)
Placement of chest drain
Placement of epidural catheter
Placement of CSF drainage catheter

Levels of Supervision for Common Specialty Clinical Activities and Invasive Procedures


Clinical Activity/Procedure	Resident level (PGY)	Location	Supervision Level
Clinical Activity/Procedure Anesthesia management during, and immediately after, termination of cardiopulmonary bypass	Clinical Activity/Procedure Fellow	Clinical Activity/Procedure ALL	Clinical Activity/Procedure Direct supervision for first three months of Cardiac OR rotation or until the fellow is deemed sufficiently competent for indirect attending supervision (whichever occurs later)
Resident level (PGY) Insertion/placement of TEE probe	Resident level (PGY) Fellow	Resident level (PGY) ALL	Resident level (PGY) Direct supervision for first ten (10) TEE probe insertions or until the fellow is deemed sufficiently competent for indirect attending supervision (whichever occurs later)
Location Insertion of CVC or pulmonary artery catheter	Location Fellow	Location ALL	Location Direct supervision for first three (3) insertions or until the fellow is deemed sufficiently competent for indirect attending supervision (whichever occurs later)
Supervision Level Interpretation, and documentation of findings, of echocardiographic study	Supervision Level Fellow	Supervision Level ALL	Supervision Level Oversight

Circumstances and events in which Supervising Faculty Member(s) MUST be contacted

Fellows must call the supervising attending physician

to discuss the perioperative/periprocedural management of any patient scheduled for a cardiothoracic surgery or other cardiovascular intervention that the fellow is assigned to provide anesthesia care for
whenever the fellow becomes aware of a requirement to provide perioperative/periprocedural anesthesia care for a patient undergoing unscheduled cardiothoracic surgery or other cardiovascular intervention
for any new admission of a cardiothoracic surgical critical care patient under the fellow’s care (applies only for critical care rotations)
for any significant change in the status of a patient under the fellow’s care

Supervision of Consults

Any consultation request received by a Cardiothoracic Anesthesiology fellow should be discussed with the supervising attending physician at the earliest opportunity, ideally within 30 minutes of the request being received.

For consultations in the context of the Cardiac OR and Thoracic OR rotations, between 06:30 and 16:00 on regular business days, the supervising attending physician is the attending cardiothoracic anesthesiologist designated “CT Coordinator” on the weekly UW Medical Center Anesthesia Staffing Schedule. From 16:00 to 06:30 on weekdays, and all day on weekend days and holidays, the coordinating attending anesthesiologist is the attending cardiothoracic anesthesiologist designated “C1” or “CT1” on the weekly schedule. If the attending cardiothoracic anesthesiologist designated “C1” or “CT1” is unavailable, supervisory responsibility devolves upon the attending cardiothoracic anesthesiologist designated “C2” or “CT2” on the weekly schedule.

Telephone and pager numbers for Cardiothoracic Anesthesiology faculty are listed on the weekly UW Medical Center Anesthesia Staffing Schedule, and in urgent cases can be obtained from the UW Medical Center OR Front Desk: 206-598-4270.

UW Medical Center Cardiothoracic Anesthesiology faculty can also be contacted via the Paging Operator: 206-598-6190.

For consultations in the context of the Cardiothoracic Intensive Care Unit (or another Critical Care Medicine) rotation, the supervising attending physician is the attending critical care physician on the Cardiothoracic Surgical Intensive Care Service (or the relevant other Critical Care Medicine Service, as applicable) at the time of receipt of the consult request.

Emergency Procedures

It is recognized that in the provision of medical care, unanticipated and life-threatening events may occur. The fellow may attempt any of the procedures normally requiring supervision in a case where death or irreversible loss of function in a patient is imminent, and an appropriate supervisory physician is not immediately available, and to wait for the availability of an appropriate supervisory physician would likely result in death or significant harm. The assistance of more qualified individuals should be requested as soon as practically possible. The appropriate supervising practitioner must be contacted and apprised of the situation as soon as possible.

Faculty Supervision Assignment

Faculty supervision assignments are of variable duration depending on circumstances but usually range from several hours to an entire day at a time and therefore are of sufficient length to assess the knowledge and skills of each fellow and to delegate to the fellow the appropriate level of patient care authority and responsibility.

Supervision of Handoffs

Program Handoff Policy can be found online in the Cardiothoracic Anesthesiology section of MedHub under Resources/Documents → Cardiothoracic Anesthesiology program policies.