Pediatric Cardiac Anesthesiology Training Supervision & Accountability Policy

[Last updated: 09/02/2022]

Please reference Policies | UW Graduate Medical Education 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 the daily OR schedule, sent to residents/fellows, faculty members, other members of the health care team, and patients.

The pediatric cardiac anesthesiology fellow 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 resident/fellow based on each resident/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, the fellow is 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 resident/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 resident/fellow and patient during the key portions of the patient interaction.

Indirect Supervision

a. 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 (within 15 – 30 minutes).
b. 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.

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 fellow based on the needs of the patient and the skills of each resident/fellow.

Clinical Responsibilities

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

Levels of Supervision for Common Specialty Clinical Activities and Invasive Procedures


Clinical Activity/Procedure	Supervision Level
Clinical Activity/Procedure Central Venous Access	Clinical Activity/Procedure 1 (Direct), until completion and recording of 5 directly supervised CVC insertions. Indirect supervision acceptable after 5 supervised insertions.

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

Initiation and termination of cardiopulmonary bypass
Endotracheal intubation/extubation
Significant clinical decompensation/cardiac arrest
Initiation of blood transfusion
Central line placement
Transesophageal echocardiography probe placement

Supervision of Consults

Pediatric cardiac fellows performing consultations on patients are expected to communicate verbally with their supervising attending, and at most within 24 hours of receiving consult.

Any fellow performing a consultation where there is credible concern for patient’s life or limb
requiring the need for immediate invasive intervention MUST communicate directly with the
supervising attending as soon as possible prior to intervention or discharge from the hospital, clinic or emergency department so long as this does not place the patient at risk. If the communication with the supervising attending is delayed due to ensuring patient safety, the fellow will communicate with the supervising attending as soon as possible. Fellows performing
consultations will communicate the name of their supervising attending to the services requesting consultation.

Examples of consults provided by anesthesiology residents include:

Consult for pre-operative evaluation and optimization
Consult for provision of sedation
Consult for airway management
Consult for vascular access
Consult for pain management
Consult for post anesthesia management

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 varied duration depending on the specific clinical service, but range from 8 to more than 40 hours/week and therefore are of sufficient length to assess the knowledge and skills of each resident/fellow and to delegate to the resident/fellow the appropriate level of patient care authority and responsibility.

Supervision of Handoffs

Indirect supervision is required for handoffs.

Supervision is not necessary during the following:

Phlebotomy
Insertion of peripheral intravenous catheters
Dressing changes
Suture insertion and removal
Nasogastric tube placement
Emergency intubation outside of the OR
Arterial line placement