200809 CARDIOLOGY FELLOWSHIP GUIDELINES

ST.LUKE'SEPISCOPALHOSPITAL/TEXASHEARTINSTITUTEDIVISIONOFCARDIOLOGY20082009FELLOWSHIPGUIDELINES

Revised09/2008

200809CARDIOLOGYFELLOWSHIPGUIDELINES


Revised09/2008

Index

LinesofResponsibility 2

RotationsClinicalRotations 7CCU,ICU,ECG 8SLMT 10Echocardiography 13PeripheralVascular 20NuclearMedicine 21EPS/Holter/Pacemaker 28CathLab 29Transplant/HeartFailure 34InvasiveCardiology 36InterventionalCardiology 36AmbulatoryCare 36Evaluations 38

ChartProceduresDictation 39ProgressNotes 39Orders 39

NightCallCCUFellow 40CardiologyHouseOfficer 41SecondCall(IntvlFellow) 42TelemetryHouseOfficer 43OtherCoverage 43HurricaneCoverage 43

Beepers 44

MealsWhileonCall 44

PhotographicServices 45

TimeoffSickLeave 46VacationandHoliday 46PersonalLeave 47EducationalLeave 47LeaveofAbsence 50TimewithoutPay 51

LaundryLaboratoryCoats 52

Conferences 52

ERCoverage 52

CoverageofCCU 53

ICU1&2,PACU 53

Floors 53

ArrhythmiaCenter 53

ProcedureDocumentation 54

Research 56

FellowDutyHours 56

Moonlighting 57

QualityEnhancement 57

InterventionalCardiology 59

ResidentSelection 60

Promotion/Reappointment 63

PositionDescriptions 65

PathwaysforTraining 78

GeneralProgramGoals&Objectives


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LinesofResponsibility

The lines of responsibility listed below are organized by a general classification of thecurrentservicerotationsavailableduringcardiovascularsubspecialtytraining.

Clinicalservice/consultationPGY4 7: The fellow assigned to a clinical or consultative service will have primary

responsibility forpatientevaluationandmanagementunderthesupervisionoftheattending physician assigned to the rotation. Responsibilities of the fellow inaddition to patient management include participation in daily teaching rounds,generationofordersandappropriatedocumentation.

Supervising Physician (Attending Physician for service): Assignment of patients forcare. Supervision of clinical evaluation and management. Provision of verbal andwrittenfeedbacktothefellowshiptrainee.

UnitsPGY4: Thefellowassignedto thecoronarycareunit rotationhasprimaryresponsibility

fornewadmissionstothecoronarycareunitduringworkinghoursfrom7:30amto4:30pm. Thecoronarycareunit fellowwill also respond tocalls forurgentcarethat includehemodynamic instability,newadmission formyocardial infarctionandthe performance and interpretation of procedures necessary on patientswho arecurrently located in the coronary care unit or destined for transfer there.Procedures performedmay include: placement of intra aortic balloon pump, theplacement and interpretation of monitoring Swan Ganz catheters, temporarypacing, arterial and central venous lines. The attending physician caring for thepatientinquestionwillhaveprimaryresponsibilityforthesupervisionofproceduresand discussion of interpretation of results. The fellow is also responsible forparticipation indaily teachingroundswiththeattendingphysicianassignedtothecoronary care unit rotation aswell as participation in thenoninvasive diagnosticimagingconferencethatisheldeachWednesdaymorning.

PGY5&6:Theresponsibilityofupperlevelfellowsonthecoronarycareunitrotationwillbe in the ongoing management of patients on their clinical service who areadmittedtotheunits.Theirresponsibilitieswillincludedailymanagementdecisionsand participation in teaching rounds. They will assist in the performance ofnecessary procedures and interpretation of results providing supervision to thePGY4fellowandacceptingthesupervisionandguidanceoftheattendingphysician.

Supervising Physician (Physician assigned inmonthly rotation): Performance of dailydidacticteachingroundsanddiscussionofrelevantpatientmanagementguidelines.Provisionofverbalandwrittenfeedbacktothefellowshiptrainee.

Imaging/diagnosticrotationsPGY4:Ontheimaginganddiagnosticservices,thePGY4fellowhasprimaryresponsibility

for supervision of performance of diagnostic testing that may include treadmilltesting, pharmacologic stress testing, echographic imaging and observation ofmagneticresonanceimaging.ThePGY4fellowisresponsiblefordiscussionoftherisks and benefits of the planned procedure with the patient. PGY4 fellows will


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assist and learn the techniques and basic knowledge required for imageinterpretationandreportgenerationwiththeassistanceofupperlevelfellowsandthesupervisingphysicians.

PGY5&6: The upper level fellow assigned to imaging/diagnostic rotations has primaryresponsibility for the initial image interpretationandpreliminaryreportgeneration.The responsibilities also include assistance of the PGY4 fellow in performance ofnecessary diagnostic tests and introduction to the basic knowledge required forinterpretation and report generation. During the echocardiography rotation,PGY5&6 fellows are responsible for a discussion of the risk/benefit of requestedtransesophageal echo studies with the patient. They are responsible forpreparationofthepatientandperformanceofthenecessarydiagnosticstudyunderthesupervisionoftheattendingechophysician.

Supervising Physician (Imaging laboratory director): Supervision of relevant imaginglaboratory and ancillary care personnel. Performance of daily didactic teachingroundsanddiscussionofimageinterpretation.Performanceofatleastonedidacticlecture on imaging technique or interpretation. Provision of verbal and writtenfeedbacktothefellowshiptrainee

CatheterizationLaboratoryPGY4 7: The responsibilities of the fellow assigned to a catheterization laboratory

rotation are the assistance of the performance of necessary procedures withresponsibilities for basic procedures attendant to their level of training andexpertise.Theywilllearnthenecessarytechniquesfortheperformanceofsafeandeffective cardiac catheterization and hemodynamic manipulation. They will beresponsible for primary image interpretation and the generation of a preliminaryreport. Final reports and review of procedure performance and managementdecisionsaretheresponsibilityofthesupervisingphysician.

Supervising Physician (Attending Physician): Assignment of patients for care.Supervisionofprocedureperformancewithassignmentoffellowdutiesattendanttoleveloftrainingandexpertise.Oversightandinstructioninresultinterpretationandreporting.Provisionofverbalandwrittenfeedbacktothefellowshiptrainee.

OutpatientclinicrotationPGY4 7: During the day weekly outpatient clinic, the fellow is responsible for

primary patientevaluationandmanagementdecisionsonnewpatientsaswell asthosescheduled forongoing followupandcontinuityofcare. Patientevaluationandmanagement decisionswill be reviewedwith the supervising physician. Thefellowisresponsiblefornecessarychartdocumentation.

SupervisingPhysician(AttendingPhysicianforclinic):Assignmentofpatientsforcare.Supervisionofclinicalevaluationandmanagement.Provisionofverbalandwrittenfeedbacktothefellowshiptrainee.


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ResearchPGY4: ThePGY4fellowisresponsibleforthechoiceofaphysicianmentorwhowillassist

indevelopingorassociatingthefellowwithanongoingorplannedresearchproject.The fellow is responsible for learning the necessary techniques and statisticalknowledgebase required toperforma researchproject. Bytheendof thePGY4year,thefellowisexpectedtogenerateideasforanewresearchproject.

PGY5&6: Upper level fellowsareresponsibleforperformanceofongoingprojectsandgeneration of new research projectswhen appropriate. Theywill be assisted bytheir mentor/supervising physician in arranging funding and pursuing thepublicationofresearchprojectsinapeerreviewedjournal.

Supervising Physician (Assistant Director of Cardiology Research): Coordination ofongoing research. Supervision of research staff and assistance with practicalmattersofresearchinplanningoroperation.

Mentor: provision of guidance in development, funding, completion and publication offellowresearch.

CalldutyPGY4: CalldutyduringthePGY4yearconsistsofprimaryresponsibilitytothecoronary

careunit. This includestheadmissionofpatientswhohavebeenassignedtothecoronary care unit. Additional responsibilities include response to calls toresuscitation from cardiovascular collapse and urgent care management forhemodynamic instability. Theyare responsible for theperformanceofnecessary,emergencyproceduresand interpretationofresultswith theadviceorsupervisionoftheattendingphysician.

PGY5&6: Upper level fellows are responsible oncall duty that occurs approximatelythree times monthly. The primary duty is performance of initial evaluation ofpatients referred to the chest pain evaluation unit. This responsibility includesperformance of the initial history and physical examination, appropriatedocumentationanddevelopmentofadiagnosticplan.Thesedutiesarecarriedoutwith theadviceand supervisionof thepatientsattendingphysician. Inaddition,theupper level fellowhasprimaryresponsibility for the initialmanagementofSTsegmentelevationmyocardialinfarctionthatisrecognizedintheemergencycenterorinthehospitalsettingoutsidethecoronarycareunit.Thisresponsibilityincludesthe initial clinical evaluation and the development of a diagnostic plan,administrationofmedical therapy includingthrombolyticdrugsorthecoordinationof urgent transfer to the cardiac catheterization laboratory for primaryrevascularization.InthecourseoftheinitialevaluationofSTelevationmyocardialinfarction, the upper level fellowmay be required to assist or be responsible forresuscitation from cardiovascular collapse secondary to ventriculardysrhythmiaorheart block and may be required to assist or perform placement of intra aorticballoon pump, temporary pacemaker, arterial line or Swan Ganz monitoringcatheter.Thedutiesoftheupperlevelfellowoncalldonotincludeassistancewiththeperformanceofan initialdiagnosticcardiaccatheterizationorrevascularizationprocedure upon the patient with ST segment elevationmyocardial infarction. Allpatient management decisions are discussed with the attending physician


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responsibleforthepatientinquestion.Supervising Physician (Attending Physician): Assignment of patients for care.

Supervisionofclinicalevaluationandmanagement.Provisionofverbalfeedbacktothefellowshiptrainee.

ResponsibilityfornonteachingpatientsIn the event of life threatening emergency, the responsibility of theCardiology residentwillapplytopatientsofteachingandnonteachingphysiciansalike.

In the event that the Cardiology Resident disagrees with themanagement plan of theattending physician, the attending physician will be responsible for all subsequentmanagementdecisions,ordersandexaminationsthataredeemednecessary.

In the absenceof life threatening emergency, thenonteachingattending is responsibleforallexaminationsandmanagementdecisionsforhis/herpatient.

ElectrophysiologyTrainingLinesofResponsibilityPGY7&PGY8Fellowisresponsiblefor:

1) Preprocedureevaluationofoutpatientsarrivingforproceduresonweekdays.2) Participationinteachingrounds.3) PerformanceundersupervisionofEPrelatedprocedures.4) Managementandcareofpatientsfollowingprocedures.5) Generationofacompletethoughtprocessandformulationoftreatmentoptionsin

preparingacomprehensiveEPreport.6) Performing, analyzing and discussing tilt test, pacemaker and ICD testing and

troubleshootingaswellasothernoninvasiveEPtesting.7) Attendingday/wkcontinuityclinic.8) Preparingcasestudies,conferencesandJournalclubs.9) Participatinginresearchproject.10)Interact, teach, and serve as consultant to lower level cardiology fellows.

ResponsibilityfornonteachingpatientsWhen aphysiciancaring foranonteachingpatient requestsanEPconsult from theEPTeachingfaculty, thenthatpatientsbecomesteachingforthereasonsandproblemforwhichaconsultwasrequested.

Undertheabovecircumstances,theCCEPfellowwillrespondandattendEPemergenciesofsuchpatient.CCEPfellowwillfollowandmanageanypostEPprocedurecareofsuchpatient.

TheCCEPfellowdoesnotcarryacodebeeperandisnotrequiredtoanswerforsuchcalls.

Inallotherinstances,theCCEPfellowhasnoroleorresponsibilitytowardsnonteachingpatientsbutwillprovideemergencymedicaltreatmentifheencounterssuchpatientinthehospital.


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Supervising Physician (EP Attending Physician): Assignment of patients for care.Supervisionofclinicalevaluationandmanagement.ProvisionofverbalfeedbacktotheEPfellowshiptrainee.


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ROTATIONS

A. ClinicalRotations

1. Workupallassignedadmissionstothesection.Onsectionstowhicharesidentor student is assigned, and where he or she has performed the primaryadmission history and physical, the Fellow's note will be a brief cardiologyresume.

2. Assist inall catheterizationson thesectionas timeand responsibilitiespermit.AllcathdatashouldbecompletedbytheFellow.

3. Follow all patients on the section throughout hospitalization however, thedegreeofFellowparticipationwillvary,dependingontherotation.

4. At the time of patient's discharge from the hospital, on certain rotations, adictationsummaryofthehospitalcaremayberequired.Thesummaryshouldbe in your name and that of the attending physician, indicating copies toappropriatesurgicalconsultsandreferringphysician.(SeeDictationProceduresformoreinformation.)

5. ParticipateinECGinterpretationwiththegrouptowhichtheFellowisassigned.The schedule for ECG interpretation is posted in the ECG reading room. Alltracings interpreted by the fellow must be labeled with his/her Bayloridentificationnumberinordertobecreditedforthatinterpretation.


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B. CCU,ICU,ECGRotation

1. Goals

a. Proficiency in the management of unstable angina, Acute MyocardialInfarctionanditscomplications.

b. Proficiencyinindications,contraindications,complications,andefficacyofinterventionsinacutecoronarysyndromes.

c. Proficiencyinbedsidehemodynamicmonitoring.

d. Proficiencyininterpretationandmanagementofarrhythmias.

2. Responsibility

a. Assignment isprimarily in theCCUICUarea. TheFellowisresponsiblefor acute cardiac care, which will include management of acutemyocardial infarction and its complications, bedside hemodynamicmonitoring, interpretation of arrhythmias, and intracavitary rhythmrecordings.ResponsibilityincludesallotherCCUpatientmanagementaswell,asgoodmedicalcaredictates.

b. AdmissionnotesaretobemadeoneachpatientadmittedtoCCUbytheCCU fellow. Admissions by service which have a fellow should behandledbythatfellowunlessheisunavailable(cathlab,etc).

c. Rounds on selected patients will be made with the staff M.D. who isassignedtoCCUforthemonth.

d. ReceivestatusreportsonacutepatientchangesfromCCUNursingStaffandinitiateappropriatechangesintherapy,ifrequired.

e. AttendthebimonthlymeetingsoftheCCUcommittee.

f. Assigned to carry the Code Blue beeper and serve as the cardiologyconsultanttothecodeteamforthetimeperiod7:30a.m.to4:30p.m.ThemedicineresidenthasprimaryresponsibilityascodeleaderincodesoutsidetheCCU.

g. PreparethePathologyConferenceforThursdayat4:00p.m. InterpretECGtracingsasassigned.

h. Transesophagealrecordingandpacing(seecall)


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i. Attend monthly CCU Quality Enhancement Committee Meeting, 2nd

Tuesdayofeachmonth,intheExecutiveBoardRoomonthe5thfloor.

j. Attendmonthly CPR CommitteeMeeting held 1st Tuesday, every othermonthbeginninginFebruaryat7:00aminG169.

k. Supervisionofcentralvenouslinesandarteriallineinsertionbymedicineresidentsifsuchsupervisionisrequested.

Note: PatientsadmittedtoCCU/ICUbygeneralinternistsorbynonteachingdoctorsarenotcoveredbytheCCUFellow(exceptforemergencycare).

3. CCUAttendingresponsibilities:

a. A member of the Teaching Faculty is assigned to serve as the CCUattendingforonemonthduration.TheCCUfellowandattendingwillbenotified on the first day of the month by the Fellowship Office. Theassignmentrosterispublishedannually(JulythroughJune).

b. Willbeavailableonadailybasis,atapredeterminedtime,toserveasaconsultant to theCCUFellow fordiscussionof selectedpatientsandtoreviewinterestingelectrocardiograms.

c. Meetforonehour,threetimesweekly,withtheCCUFellowtospecificallyreview topics in the CCU Fellows Learning Syllabus, including theACC/AHAGuidelinesfortheManagementofAcuteMyocardialInfarction.Threehoursperweekwillpermitcoveringofallofthesyllabusmaterialeachmonth.


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C. St.Luke'sMedicalTower(OMT)RotationClinicalResponsibilities

General:TheOMTrotationhasbeendesignedtoestablishyourcompetencyinthepracticalaspects of noninvasive cardiology testing in the outpatient setting. Areas of study include:Echocardiography, Treadmill stress testing,MV02 testing, pharmacological stress testing, TwaveAlternans, andCardiacRehabilitation. Your teacherswill be themedicaland technicalstaffactuallyperformingtheseevaluations.

Orientation: Your primary contact and supervisor is SharonBroussard, AssistantDirector ofNoninvasive Cardiology/Cardiac Rehabilitation. Individuals reporting to her have beeninstructedtoguideyouineachofthetestingareas.

Readingmaterial:Appropriatetextbooksareavailable.Computerwith full internetaccessisavailableintheOMTlabforaccessingpublishedtrainingguidelines,themedicalliteratureandcompletingacademicassignments.

MedicalStaffCoverage:Forindividualtests,areadingrosterismaintainedbythemanagementofNoninvasivecardiology.Rosterdoctorswilloverreadexamsandreturnedsignoffsshouldbereviewed.Callthisdoctorifquestions.Echocardiography:severaloftheechocardiographymedical staff have been assigned routine reading days during the month. Formal echoreadoutsarenotdailyoccurrencesandthereadouttimemayvary.WorkcloselywithStafftomake sure that these sessions are set up in advance with the doctor so that the time isadheredtoandstudiesareprereadorchangesinschedulearenoted.

Evaluation:Theattendingofthemonthwillperformamidmonthandendofmonthreview.TheOMTAssistantDirectorandstaffmaintaincheckofflistsofgoalforthemonthwhichcanbereviewed.

CardiacRehabilitation:Acheckoffstyleevaluationsheetshouldbecompletedduringthemonth.

Echocardiography:Workwiththeechoanalystandsonographerforbasicscanningininterpretation.Medicalstaffwillevaluatedirectly.FellowsshouldsaveprintoutcopiesoftheirpreliminaryHeartLab interpretations tobesubsequentlycomparedwith finalized(overread)staffinterpretationsintheeventthatoneononereviewisnotpossible.

Stress testing: A check off style evaluation sheet should be completed during themonth.

Policies:1. ProvidephysiciancoverageontheNoninvasiveCardiologytestingfloor,including

CardiacRehab,duringOMTbusinesshours.

2. Respondtoall"CodeBlue"callsonthe9th,10th,and11thfloor.

3. Evaluate patients in theNoninvasiveCardiology testingareasas requestedbyareastaff.


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4. Assist in the admission of all patients to St. Luke's Episcopal Hospital fromNoninvasiveCardiologyandCardiacRehab.

PharmacologicalStressTesting

2. AssistandbackupnurseadministeringI.V.dipyridamolefornuclearcardiologystresstesting.

3. AdheretowrittenguidelinesandpoliciesprovidedbyOMTManagement.

ExerciseLab

1. Work closelywith theNurses, exercisephysiologistsand thenuclearmedicinetechnologists.

2. Reviewpatients'clinicaldatatoruleoutcontraindicationstotesting.

3. Actasaleaderduringexercisetestingandassistinpatientmonitoring.

4. Performpatient evaluations pre, during or postexerciseas requestedby thestaff.

5. ProvideapreliminaryinterpretationforeachexerciseECGtestsperformed

6. Reviewattendingphysician'sfinalinterpretationforeachexercisetest.

7. Setaside"problem"orinterestingcasesforreviewwithcardiologystaff.

8. ContactDr.Stainback(5295530/pager10492)oranyoftheteachingstaffforadviceregardingdifficultclinicalsituations.

CardiacRehabilitation

1. Remainonthe11thfloorduringallexercisesessions.(Sessionsbeginat7:30A.M.onMonday,Wednesday,andThursdayand8:00A.M.onTuesdayandFriday)

2. Reviewrehabpatients'chartswiththestaffonaweeklybasis.

3. Presentonepatienteducationclassforparticipantseachmonth.

4. Interactwithpatientsasscheduleallows.


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Echocardiography

1. Observeechoexaminationsandinterpretations.

2. Perform IV saline contrast or Echo contrast agent injections for thesonographerifneeded.

3. Performing&interpretingechocardiograms:Learnbasicechoexamwiththesonographeranddopreliminaryinterpretation.Proficientlyperformingandinterpreting>602D&Dopplerexamsoverthecourseof2monthsonthetowerrotationwillcredityouwithonemonthofechocardiographyforlevelIIorII+echo.Thisextramonthofechodoesnotcounttowards3mostotalneededforlevelIorfor12mostotalforlevelIII(althoughyoumaystillapplythenumbersofstudiesperformedandinterpretedforyourtotalsinthosecases).

4. PreparenoonnoninvasiveconferencesasrequestedbyChiefCardiologyFellow.


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EchocardiographyCourseDescription:Levels1,2&3

A.INTRODUCTION

OurprogramobservesthethreetraininglevelsdescribedintheACC/AHAClinicalCompetenceStatementonEchocardiography,JACCVol.41(4)2003.Traineesshouldconfirmthattheyhavepassedtheircurrentleveloftrainingbyschedulingaformalreviewmeetingwiththemedicaldirectorduringmonths2and5.Thedifferentlevelsrequireminimumnumbersofexaminationsperformedandinterpreted.Inordertoobtainanadequatecasemix,fellowsshouldgenerallyexceedtheminimumcasenumberrequirementsforanidealtrainingexperience.Traineesmustlearntoperformcompleteandtechnicallyadequateechoexamsroutinely.Moreover,theechoexamshouldadequatelyanswertheclinicalquestionathand. Reportingshouldbetimelyandconveynotonlytheobjectivedata,butprovideappropriatesynthesisthatispracticalforclinicalmanagement.Accordingly,traineeswillbeevaluatedontheirabilitytounderstandreferredcasesprospectively,developtheirfundofclinicalcardiologyknowledgeandphysicalexamskills.Traineesshouldcommunicateimportantechofindingstotheresponsibleechomedicalstaffandreferringphysicianswiththeproperlevelofurgencyanddecorum.Labprotocols,standardsandaccreditationareemergingrequirementsthatareincorporatedintotheprogram.

B.LEARNINGOBJECTIVES&EXPECTATIONS

1. Examindicationandappropriateness(chartreview,H&P)2. Correlatephysicalexamfindings(auscultation)3. Technicalability(scanning)4. Interpretationindependentprereadswithstaffoverread.5. Reporting:timely,concise,providessynthesis6. Patientcare:Echotraineesmustalwaysbeavailableinthelab

6.1.Examineandtreatpatientsexperiencingsymptomsorinstability6.2. InjectcontrastfortechswhenRNsnotable(certainfloors)6.3.Otherpatientcareactivities,backupforstresslab

7. Q/Ameasures(participationbyallleveltraineesrequired)7.1.EchoMRIcorrelationconference

7.1.1. alternateWednesdays8:00AMMRIreadingroom,radiology,B17.1.2. Preparecasesinadvance7.1.3. CompletecorrelationsheetsdelivertoSueMaisey,Manager.

7.2.StressEchoreviewconference7.2.1. alternateThursdays1:00PMechoreadingroom7.2.2. Preparecasesinadvance7.2.3. CompletecorrelationsheetsdelivertoSueMaisey,Manager

7.3.Criticalresultsnotificationdata(echoworksheetandfinalreportsummary)8. LabPoliciesforpatientsafety,procedures,reportingandaccreditation.

8.1.GeneralSLEHandJointCommissionpolicies


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8.1.1. Contact=ElizabethPhashe,RN(supervisor)documentation&consent.8.2. IntersocietalCommissionfortheAccreditationofEchoLaboratories(ICAEL).

8.2.1. Contact=SueMaisey,Manager8.3.Statoroncallexamissues

8.3.1. Contact=echotechoncall8.3.2. Contact=Upperlevelechofellowoncall8.3.3. Contact=MedicalDirectorordesignee/oncallmedicalstaff

9. Learning9.1.Scanningoneononewithtechsprogressingtoindependentscanning9.2.Reviewscannedexamswithmedicalstaff9.3.Readingongoing,seetextlist,below&onlineresourcesavailableinlab.9.4.Lecturesattendcomprehensiveyearlongbimonthlynoonecholectureseries9.5.Physicsofultrasoundlectureseries(6hours,Jan&Feb)timesTBA9.6.Dailyreadoutsessionswithassignedmedicalstaff9.7.JournalClubfellowdirected

10.Feedback&Evaluation10.1. Fellowevaluationforms10.2. Meetwithmedicaldirectorwheneverneeded10.3. Scheduleformalreviewwithmedicaldirectorduringmonths2&510.4. Level3traineesshoulddiscusslabissuesfrequentlywithmedicaldirector.10.5. Discussprogressorconcernswithanyoftheteachingmedicalstaff10.6. Inserviceexamination

C.LABHOURS

Echofellowsshouldreporttothelabby7:30AM.Specialproceduresbeginat7:30AM(nursesarriveat7:00AM).BeginfinalizingexamreportsfromthenightbeforeASAP.

D.TRAININGLEVELS

Level1

Minimumtrainingmonths: 3 Minimumperformedsurfaceechoexams: 75 Minimuminterpretedsurfaceechoexams: 150

Thisleveloftrainingisintroductoryandprovidesbasicscanningandinterpretationskillsformostcommoncardiovascularpathology.Level1trainingisneededinordertobeboardeligibleforcardiovasculardiseasecertification.Level1isnotconsideredadequatetrainingforindependentinterpretationofsurfaceechocardiogramsorforbecomingeligibleasamedicalstaffmemberinanICAELaccreditedlab.Note:TheSt.LukesMedicalTowerclinicalrotationmaybecounttowardsechotraining.If,overtwomonthsinthetowerecholabafellowperformsandinterpretsasignificantnumberofexams(>60performedandinterpreted)withfeedback,thetraineewillearntheequivalentof1monthechotraining.Discusswithmedicaldirectorat2&5monthreviewmeeting.


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Level2TransthoracicEcho

Minimumcumulativetrainingmonths: 6 Minimumperformedsurfaceechoexams: 150(75additional) Min.interpretedsurfaceechoexams: 300(150additional)

Thistraininglevelshouldprovidetheskillsnecessaryforindependentinterpretationofabroadspectrumofcardiovascularpathology,includingcommonlyencounteredcongenitalheartdiseaseusingstandardtechniques,includingechocontrastagents.Foradvancedtechniques,complexcongenitalandunusualcases,thebackupofalevel3echocardiographermaybeneeded.Note:ICAELecholabaccreditationstandards:medicalstaffmembersmusthavelevel2trainingorabove.Iflevel2trained,thelabsMedicalDirectormustfirsthavehad1yearpracticeexperiencefollowingtrainingwithaminimumof600echointerpretedduringthepracticeyear.

Level2+StressEcho:

Stressechocertificationrequireslevel2transthoracicechotraining(6mos).However,thestressechoexperiencemaybeginatanytime.ALevel1traineemaynotindependentlyperformorsuperviseastressechoinourlab.Withpriorexperienceandmedicalstaffapproval,Level2andLevel3traineesmaysuperviseandperformstressechosindependently.Note:Fellowsmustnotdiscussstressechoresultswithapatientorfamilyuntilinterpretationandapprovalbytheresponsiblemedicalstaffmember.

Minimumcumulativetrainingmonths 6(level2) MinimumSEperformed+interpreted: 100

Level2+TEE

TEE:PermissionfromtheMedicalDirectorisrequired.AlistofapprovedTEEtraineeswillbeprovidedtothenursingandmedicalstaff.Trainingmaybeginonlyafterthetraineehasmetlevel2requirements(150TTEperformedand300interpreted)andnosoonerthanthe5thmonthoftraining.ForTHIfellows,TEEexaminationsperformedatotherhospitalsmaynotbeappliedtowardsTEEcredentialingnumbers.Note:MedicalStaffshouldbepresentforprobeinsertionandexam.

Minimumcumulativetrainingmonths: 8 esophagealintubations,gastroscope 5 (GIserviceDr.L.Hochman) Min.TEEsperformedandinterpreted: 50 (singleoperatorwithprobe

insertion)

TEEskillscanbeeasilyacquiredbymostoperatorswiththeminimumrecommendednumberofexams(50).ExcellenceinTEErequiresandextensivebaseofsurfaceechoknowledgeandexperienceinadditiontoastrongcasemix.Inourexperience,50TEEsdoesnotprovideandadequatecasemix.Patientvolumesgenerallyallow>100exams


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pertraineeevenwhenstartingTEEsafterthe5thmonthofechotraining.

Level3

Minimumcumulativeechomonths 12 Consecutivemonthsinthelab 6 TEEsperformed&interpreted >50(300ideal+intraop) SEsperformed&interpreted >100 Allexamsperformed(TTE,TEE,SE) 300(150additional) Allexamsinterpreted 750(450additional) Significantexposuretoadultcongenital(mayrotatefor1moonpediecho,TCH) Knowspecialtechniques:contrast,3D,parametricmodalities,emerging Publishapprovedechorelatedresearchproject Superviselabpersonnel Teachjuniortrainees Coordinatelabspecialprocedureschedule CoordinatelabQ/Ameetings Coordinatesonographerclinicallectureseries(bimonthlybyfellow) NBEcomprehensivecertification(ASCeXAM)recommended Workcloselywithmedicaldirector

Level3traineesshouldbeproficientinperformance,interpretationandteachingofstandardsurfaceechoardiograms,stressechosandTEEs.Casemixshouldincludethebroadspectrumofcardiovascularpathology.Specialtechniquesshouldbelearned.Anechorelatedresearchprojectshouldbestartedearlyonwithapublicationdraftsubmittedpriortodeparture.Thelevel3traineecompletingourprogramshouldbeabletorunatertiarycardiovascularcenterteachingecholab.

PerioperativeTEE:

ThisuniqueexperienceisavailableforcardiologytraineesattheTHI.Becauseexperiencedcardiologistsmaybecalleduponforbackupincomplexintraoperativecases,alllevel3andinterestedlevel2+TEEtraineesarestronglyencouragedtogainadditionalintraoperativeTEEexperience.ThelaboratoryparticipatesinthetrainingofcardiovascularanesthesiologyfellowsforperioperativeNBETEEcertification.Foranesthesiologists,thisrequiresstudyof300TEEcaseofwhich150mustbebothperformedandinterpretedbythetrainee.CardiologyfellowsmentoringofCVanesthesiologyfellowsonsharedcaseshasproventobeinvaluablefortheirlearning.TherearenoformallyacceptedcardiologytraineeintraoperativeTEEtrainingguidelines.Casesshouldbesupervisedbythecardiologyservicemedicalstaff.CVanesthesiafellowssettingupeachcaseshouldbeinstructedtopagethecardiologyTEEfellowforparticipation.

Min.recommendedMVrepair 20 Min.recommendedothervalve,etc. 20 Min.recommendedcongenital 10 Min.recommendedtotalwithgoodcasemix 50


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AseparatePerioperativeTEEexperiencecanbenoted(ifappropriatelydocumented)onatraineesfinalcertificationletter.

E.READINGLIST

Level1&2Readcovertocover:

TextbookofClinicalEchocardiography,3rdEdition(2004)CatherineM.Otto,MD

OR

TheEchoManual,3rdEdition(2006)JaeK.Oh,MD&JamesB.Seward,MD

And

CardiovascularMedicine,3rdEdition(2007)WillersonJT,CohnJN,WellensHJJ,HolmesDR,editorsChapters:

5IntrotoEcho:Stainback,MD9Normalandabnormalanatomy,Anderson&Becker,MDs11Echoadultcongenital,Kovach,MD21Echoevaluationofvalvularheartdisease,Stainback,MD35EchoevaluationofCAD,Coulter,MD61Echoincardiomyopathies,Coulter,MD

Level2(takingNBE)&Level3:

FeigenbaumsEchocardiography,6thEdition(2004)HarveyFeigenbaum,MD,WilliamArmstrong,MD

PrincipalsandPracticeofEchocardiography(1994)ArthurE.Weyman,MD(SomewhatdatedBibleofechodetaileddescriptionsofmanyunchangingaspects)

UnderstandingUltrasoundPhysics:FundamentalsandExamReview(2004)SidneyK.Edelman,PhD(ContentcoveredinwinterTHIPhysicsofUltrasoundlectureseriesbySid)

Echorelatedclinicalpractice&trainingguidelines:ComprehensivecollectionofDownloadablepdffilesorderedbypublicationdatehttp://asecho.org/ ASEguidelines


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Selecteddocumentsarerequiredreading: 2007AppropriatenessCriteriaforTransthoracicandTransesophageal

Echocardiography RecommendationsforChamberQuantification,JASE,December2005 RecommendationsforEvaluationoftheSeverityofNativeValvular

RegurgitationwithTwoDimensionalandDopplerEchocardiography,JASE,July2003

ACC/AHA/ASEGuidelineUpdatefortheClinicalApplicationofEchocardiography:SummaryArticleJASEOctober2003

ACC/AHAClinicalCompetenceStatementonEchocardiography,JACCFebruary2003.

StandardizedMyocardialSegmentationandNomenclatureforTomographicImagingoftheHeart,JASE,May2002

RecommendationsforQuantificationofDopplerEchocardiography,JASE,September2001

F.NOONECHOLECTURESERIES(AlternateTuesdaysConsultCardiologyNoonConfSchedulefordates)

Title Faculty1 IntroductiontoEchocardiography RaymondStainback,

MD2 EchoEmergencies RaymondStainback,

MD3 Introductiontosurfaceechothe2Dviews StephanieCoulter,MD4 IntroductiontotheEchoDopplerexam. HishamDokainsh,MD5 TEE:Basictechnique,views,potentialcomplications JosephNavarijo,MD6 Echocardiography:ContemporaryevaluationofLV

systolicfunctionHishamDokainish,MD

7 Echocardiography:EvaluationofRVFxnandPulmonaryHypertension

KumudhaRamasubbu,MD

8 Echocardiography:DiseasesofthePericardium StephanieCoulter,MD9 Echocardiography:MitralRegurgitation RaymondStainback,

MD10 Echocardiography:MitralStenosis RaymondStainback,

MD11 Echocardiography:LVOTobstruction(AorticStenosis) RaymondStainback,

MD12 Echocardiography:AorticRegurgitation RaymondStainback,

MD13 Echocardiography:TricuspidandPulmonaryValve

DiseaseRaymondStainback,MD

14 Echocardiography:Endocarditis SheilaHeinle,MD15 EchocardiographyofCardiomyopathies StephanieCoulter,MD16 EchocardiographyandCoronaryArteryDisease/MI StephanieCoulter,MD


19

Revised09/2008

17 Echocardiography:EchoDopplerAssessmentofLVDiastolicFunction

HishamDokainish,MD

18 Echocardiography:ProstheticValveDysfunction HishamDokainish,MD19 Echocardiography:AssessmentofPFOsandASDs JosephNavarijo,MD20 StressEcho:evaluationofcoronaryarterydisease ArunimaMisra,MD21 Echocardiographyandclinicalmanagementinteresting

casesDavidAguilar,MD

22 Echocardiographysroleinmanagementofatrialarrhythmias

AmyWoodruff,MD

23 Echocardiography:DiseasesoftheAorta AllisonPritchett,MD24 Echocardiography:AdultCongenitalHeartDisease WayneFranklin,MD25 Echocardiography:Mmodeexam SalimVerani,MD25 Echocardiography:Establishedandemergingusesfor

contrastagentsSheilaHeinle,MD


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Revised09/2008

PeripheralVascular

1STYEAR

1. The fellow orientation is oneweek long and is scheduled during the echorotation.

2. The fellow is responsible for contacting the PVL supervisor (X52134) orManager(56574)andschedulingoneweektraininginadvance.

3. Thefellow isresponsibleforcompletingthePVLchecklistattheendofthePVrotation.

4. The training requires that the fellow complete 40 hours uninterruptedexperiencefortheweek.

Theobjectivesinclude:1. Become familiar with the diagnostic equipment used for noninvasive

evaluationoftheperipheralvascularsystem.2. BecomefamiliarwiththenoninvasiveproceduresperformedinthePVL.3. Identify normal and abnormal findings with ultrasound and

plethysmography.4. Obtainabasicknowledgeofultrasoundphysicsandvasculartechnology.5. Identifygroincomplicationsusingultrasound.6. Knowledge and skill in performing ultrasound guided pseudoaneurysm

compression.7. Knowledgeregardingcurrentcardiovascularandperipheralvascularresearch

studiesperformedindepartment.8. Participateinweeklyvascularconference.

3rdYEAR

1. The fellow is responsible for contacting the PVL supervisor (X 52134) orManager(56574)andschedulingonemonthtraininginadvance.

Theobjectivesinclude:1. Acquire advanced skill and knowledge in noninvasive evaluation of the

peripheralvascularsystem.2. Identifynormalandabnormalfindingswithultrasoundandplethysmography3. Identifygroincomplicationsusingultrasound.4. Knowledge and skill in performing ultrasound guided pseudoaneurysm

compression.5. Participateinweeklyvascularconference.6. Presentminivascularlecturestonursingstaff/vasculartechnologystaff.7. ParticipatewithP.Vasresearchprogram.

Any fellowwhowishestoextendthetraining in thePeripheralVascularLaboratorymusthaveapprovalfrombothDr.JamesM.WilsonandDr.GeorgeReul.


21

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22

Revised09/2008

NUCLEARMEDICINEDEPARTMENTOVERVIEW

TheNuclearMedicineDepartment(theDepartment)ofSt.LukesEpiscopalHospital(SLEH,theHospital)operatesthreeimaginglaboratories:GeneralNuclearMedicineonthe26th flooroftheHospital,CardiovascularNuclearMedicine(CVNM)onthe3rd flooroftheHospital,andOutpatientNuclearMedicine(primarilycardiac)onthe11th flooroftheOQuinnMedicalTower(SLMT).TheDepartmentalsoservestheTexasHeartInstitute(THI).TheDepartmentisstaffedbynuclearmedicinephysiciansandscientistswhoaremembersoftheNuclearMedicineSectionoftheDepartmentofRadiologyofBaylorCollegeofMedicine(BCM,Baylor)andwhomakeupthemajorityoftheHospitalsNuclearMedicineServiceandbytechnologistsandothersupportpersonnelwhoareHospitalemployees.MembersofthefacultyalsoprovidecertainnuclearmedicineservicesatSt.LukesCommunityMedicalCenterintheWoodlands(CMCW),TexasChildrensHospital(TCH),PETImagingofHouston(PIH),andotherfacilities.

MembersoftheNuclearMedicineSectionfacultywhoareactiveatSLEH/THIinclude:RameshDhekne,M.D.

Dr.DhekneisAssociateChiefoftheNuclearMedicineServiceandDirectorofGeneralNuclearMedicine.HeiscertifiedbyABNMandisanAssociateProfessorofRadiology.

PatrickFord,M.D.Dr.Fordisafacultynuclearmedicinephysician.HeiscertifiedbyABNMandisaClinicalAssistantProfessorofRadiology.

EdGiles,M.S.Mr.GilesistheAssistantRadiationSafetyOfficeratSLEH/THI.HeiscertifiedbytheAmericanBoardofRadiologyinDiagnosticRadiologicPhysicsandtheAmericanBoardofScienceinNuclearMedicine.HeisanInstructorofRadiology.

WarrenMoore,M.D.Dr.MooreisChiefoftheNuclearMedicineServiceandDirectorofCVNM.HeiscertifiedbyABIMandABNMandisanAssociateProfessorofRadiology.

PaulMurphy,Ph.D.Dr.MurphyisAssistantChiefoftheNuclearMedicineServiceandtheRadiationSafetyOfficerforSLEH/THI.HeiscertifiedbytheAmericanBoardofScienceinNuclearMedicineandisaProfessorofRadiology.

OtherDepartmentpersonnelyoumayencounterincludetechnologistsandclericalstaffmembers,andparticularlyLeticiaAlanisWilliams,B.S.,RT(N)NuclearMedicineManagerRandyBarker,B.S.,RT(R),RT(N),CNMTTechnologistSupervisorforGeneralImagingCindyGentry,B.S.,CNMTNuclearMedicineQualityCoordinatorMarlyGonzalez,B.S.,CNMTTechnologistSupervisorforCVNMBryanFritz,B.S.RadiationSafetyTechnicianJoeKnisel,M.S.NuclearMedicineInformationSystemsManager

RoutinediagnosticandtherapeuticnuclearmedicineservicesareavailableintheSLEH


23

Revised09/2008

laboratories,8a.m.to5p.m.,MondayFridayexceptforofficialHospitalholidays.MyocardialperfusionstudiesfortheCardiacObservationUnitandforobservation(POS)patientsareavailable8a.m.to10p.m.MondayFridayand8a.m.to8p.m.SaturdayandSunday,exceptforofficialHospitalholidays.StudiesareperformedintheSLMTonavariableschedule.Otherwise,mostmedicallyurgentnuclearmedicineservicesareavailable24hours/day,7days/weekonanoncallbasisandcanbearrangedbycontactingtheNuclearMedicineDepartment(8323553126duringregularhours)ortheNuclearMedicinetechnologistorphysicianoncallthroughtheHospitalpageoperator(8323554146).CertainnuclearmedicineprocedurescanbeperformedatthepatientsbedsideintheICUs,buttherearesignificantregulatoryandtechnologicalrestrictionsonsomeofthesestudies.BecausethequalityofthestudyisusuallymuchbetterwhenperformedwithfixedbasecamerasinoneoftheDepartmentslaboratories,portableorbedsidestudiesshouldonlybeorderedwhenitisreallymedicallynecessarythatthepatientnotbemovedfromtheICU.IftheorderforthestudydoesnotspecificallyindicatethatthestudyistobeperformedintheICU,thepatientwillbebroughttotheNuclearMedicinelaboratory.Asummaryofavailabletests,indications,physiologicmechanisms,andpatientpreparationsisavailableinthepublication,NuclearMedicineDepartmentReferenceManual,onlineviatheSLEHSource.

InterpretationsofSLEH/SLMTnuclearmedicinestudiesareavailableonthedaythestudyiscompleted.Reportscompletedduringregularbusinesshours(85,MF)areavailablethroughtheHospitalInformationSystem(HIS)assoonastheyareread(exceptwhenthecomputersystemisdown).Duringregularbusinesshours,reportsarealsoavailableintheNuclearMedicineDepartmentoffice(Y2614)orbycalling8323552270.ReportscompletedafterregularhoursareusuallysentasfaxedpreliminaryreportstothepatientsnursingunitsandarethereforeusuallynotintheHospitalscomputersystemuntilthefollowingworkday.AnyphysicianwithaquestionregardingnuclearmedicineservicesingeneralorregardingaparticularpatientorclinicalproblemisencouragedtocontactaNuclearMedicinephysician.

NUCLEARMEDICINEDEPARTMENTCONTACTS

Mainnumber... 8323553126Y2601

GeneralNuclearMedicine(26th fl,SLEH). 8323552272Y2626CardiovascularNuclearMedicine(3rd fl,SLEH).. 8323553732P327OutpatientNuclearMedicine(11th fl,SLMT)... 8323558201

RadiationSafetyOffice 8323553141Y2611

Reports(85,MF) 8323552270Y2614


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Revised09/2008

LeticiaAlanisWilliams,B.S....... 8323552692Y2601ARandyBarker,B.S.... 8323558927Y2660CindyGentry,B.S. 8323556448Y2601DRameshDhekne,M.D. 8323552608Y2618EPatrickFord,M.D.. 8323552065Y2618CEdGiles,M.S. 8323554949Y2621AMarlyGonzalez,B.S. 8323553806P327BryanFritz,B.S... 8323554948 Y2611DJoeKnisel,M.S. 8323553884Y2621BWarrenMoore,M.D. 8323553126Y2601BPaulMurphy,Ph.D 8323553440Y2611CTayakaShaw.8323554119Y2601C

DEPARTMENTMISSION

ThemissionoftheNuclearMedicineDepartmentofSt.LukesEpiscopalHospitalistoprovidehighqualitydiagnostic,therapeutic,andconsultativenuclearmedicineservicesforpatientsandphysiciansattheHospitalanditsMedicalTowerandtopromotethescienceandpracticeofnuclearmedicinebyprovidingeducationalopportunitiesfortraineesinnuclearmedicineandbyparticipationinresearchinvolvingtheuseofnonsealedsourcesofradioactivematerials.

EDUCATIONALSCOPE

TheeducationalportionoftheDepartmentsmissionspecificallyincludestheeducationofhealthcareprovidersandothersinvariousaspectsofnuclearmedicine.Inaccomplishingthismission,membersoftheServiceandtheDepartmentroutinelyparticipateinBaylorCollegeofMedicinetrainingprogramsformedicalstudents,residents,andfellowsandintheHoustonCommunityCollegeNuclearMedicineTechnologyProgram.Fromtimetotime,traineesfromotherinstitutions,privatepractitioners,commercialrepresentatives,andmembersofthepublicmayalsobepresentintheDepartmentandattendinterpretationandotherteachingsessions.


25

Revised09/2008

OVERVIEWOFCARDIACNUCLEARMEDICINETRAINING

AmericanBoardofInternalMedicinecertificationinCardiovascularDiseasesrequires"competenceintheinterpretationofradionuclideprocedures."ForSLEH/THICardiologyfellows,thisisachievedbyacombinationofdidacticlecturesandpracticaltrainingandexperience. Specificgoals,objectives,andcurriculahavebeendevelopedforeachmonthlynuclearcardiologyrotationandwillbereviewedwiththefellowatthebeginningofeachrotation.

DidacticLectures:TheCoreLectureSeriesincludesabriefoverviewofthemostcommonlyusedtechniquesincardiacnuclearmedicineincludingperfusionandfunctionalimaging.Additionaltopicsarecoveredovera2yearcycleintheNuclearCardiologyportionoftheNoninvasiveCardiologylectureseries.

NuclearMedicine1:AllfellowsintheSLEH/THICardiologyprogramcompletetwoonemonthrotationsintheCVNMLaboratory.ThesecollectivelyconstitutetheNuclearCardiology1(Nuc1)rotation.FacultyreviewsessionsareavailableduringtheNucIrotation.Astructuredtextreadingandwrittenquizscheduleoverbothmonthsisrequired.Practicalexperienceinprocedureperformanceandinterpretationisalsoobtainedduringtherotation.Thisclinicalrotation,inconjunctionwithdidacticlectures,allowsthefellowtodevelopanunderstandingoftheapplications,advantages,andpitfallsofradioisotopeimagingastheyapplytopatientswithknownorpossiblecardiacdisease.Together,theseactivitiesmeettherequirementsof(a)theAccreditationCouncilforGraduateMedicalEducationResidencyReviewCommitteeforCardiovascularDisease(ACGMERRCCD)fortrainingofcardiologyfellowsinnuclearcardiology,(b)theAmericanCollegeofCardiology(ACC)COCATS2(2/2006revision)Level1trainingforradioisotopeimaging(Basictrainingrequiredofalltraineestobecompetentconsultantcardiologists(and)conversantwiththefieldofnuclearcardiologyforapplicationingeneralclinicalmanagementofcardiovascularpatients),and(c)theAmericanBoardofInternalMedicineforeligibilityfortheCardiovascularDiseasesubspecialtyexamination.ThisleveloftrainingwillnotmeettherequirementsforlicensuretouseradioactivematerialsandwillnotprovideeligibilityfortheCertificationBoardofNuclearCardiology(CBNC)examination.

NuclearMedicine2:Fellowsseekingauthorizeduser(AU)physicianstatusonaradioactivematerials(RAM)licenseand/orCBNCcertificationwillrequireadditionaltrainingaftercompletionoftheNuc1rotation.TheportionofthisadditionaltrainingperformedatSLEHisdesignatedcollectivelyastheNuclearCardiology2(Nuc2)rotationandincludesaminimumof3additionalonemonthclinicalrotationsinCVNM,aresearchproject,andcertainothertasksdescribedindetailintheNuc2rotationmanual.AdidactictrainingcourseinbasicsciencesisalsorequiredbutisnotprovidedasapartoftheCardiologyfellowship.

Anyfellowwhowishestobecomeanauthorizeduserforradioactivematerials(RAM)mustachieveatleastACCLevel2training(Additionaltrainingin(aspecializedarea)thatenablesthecardiologisttoperform(and/or)interpretspecificproceduresatan


26

Revised09/2008

intermediateskilllevel)andthefellowshouldcontacttheDirectorofCVNM(Dr.WarrenMoore,8323553126)nolaterthanthespringofthefirstyearoffellowshiptodiscusstherequirementsforsuchlicensure.OfficialregulationsvaryfromstatetostateandwilldefinitelychangebetweennowandApril2008.Thesearesubjecttoadditionalchangesatanytime.CurrentminimumrequirementsforlicensureinTexasincludeatleast80hoursofdidactictraining(notprovidedbySLEH/THI)inbasicsciencesrelatedtotheuseofnonsealedradioactivematerialsandapproximately620hoursofclinicaltrainingintheNuclearMedicineDepartment(foraminimumtotalof700hours).ThisadditionaltrainingthatisrequiredforRAMlicensureisnotarequiredpartofthefellowship,andacceptanceforsuchtrainingisnotguaranteed(duetospace,personalperformance,andotherconsiderations).Five1monthCVNMclinicalassignments(Nuc1plusNuc2),aresearchproject,andotherlocalrequirementsexistforACCLevel2trainingatSLEH.Dependingonfederalandstateguidelines,localrequirements,andthefellowsexactrotationschedule,limitsexistonleaveandabsencesduringnuclearmedicinerotations.(Forexample,fellowsseekingtomeetLevel2criteriashouldnotplantoexceedatotalof15daysofabsence(foranyreasonexceptclinicandpostcallperiods)duringthefiveclinicalmonthsandshouldnotplantotakemorethan1weekofvacationorotherleaveduringthefifthmonth.Fellowsexceedingtheselimitsmayrequireadditionalclinicalmonthstomeetlicensurehourrequirements,andtheavailabilityofthistrainingatSLEHisnotguaranteed.

NuclearMedicine3:AnyfellowwhowishestopursueACCLevel3training(advancedtraining(whichenables)acardiologisttoperform,interpret,andtrainotherstoperformandinterpretspecificproceduresatahighskilllevelandsufficienttopursueanacademiccareerordirectanuclearcardiologylaboratory)willberequiredtocomplete12monthsoftrainingincardiacnuclearmedicine.FellowsinterestedinthisoptionshouldcontactDr.Mooreasearlyaspossibleinthecourseofthefellowshiptodiscussthismatterindetail.AmaximumofoneLevel3positionisavailable,andrequestsmaycomefrominsideoroutsideofBaylor.

PURPOSES

PURPOSES:TherearetwopurposesfortheNucIrotationintheCardiovascularNuclearMedicine(CVNM)LaboratoryatSLEH:patientsafetyandtraineeeducation.1. The Nuc I Cardiology fellow, as the representative of the Cardiology Section, is

responsiblefortheimmediatemedicalsafetyofpatientsbeingexaminedintheCVNMLaboratory during regular hours. (After hours coverage is provided by the fellowcovering the Cardiac Observation Unit or others.) This applies primarily to patientsundergoingstresstests,butincludesallpatientswhomaybeseeninthelaboratory.

2. TheNucICardiologyfellow,asatrainee/learnerintheNuclearMedicineDepartment,hasanopportunityandresponsibilitytolearnabouttestproceduresandclinicalapplicationsofcardiacnuclearmedicine.

GOALS

ThegoalsoftheNuc1rotationaredirectedatthefulfillmentofthepurposeslistedabove.Whilepatientsafetyisofgreatimportance,knowledgeandskillsrelatedtothatpartof


27

Revised09/2008

theoverallpurposeoftherotationareundertheauspicesoftheCardiologySectionandareaddressedinmanypartsofthefellowship.Traininginstresstestingandmanagementofgeneralpatientsafetyisthereforenotamajoreducationalfocusofthenuclearmedicinefacultyduringtherotation.Accordingly,thegoalsandobjectivesoftherotationdescribedhereareheavilyweightedtowardpracticalandtheoreticaleducationincardiacnuclearmedicine.

GENERALGOALS:Theprimarygoaloftrainingincardiacnuclearmedicineisthatallfellowsshouldunderstandthebasicprinciplesofradioisotopeimaging,howtochoosethebestradioisotopetesttoordertoansweraspecificclinicalquestionforanindividualpatient,andhowtoapplytheinformationcontainedinreportsofcardiacnuclearmedicineprocedurestothecareofindividualpatients.Itisexpectedthatfellowswillprogressivelydevelopknowledgeandskillsrelatedtoperformanceandinterpretationofcardiacnuclearmedicineimagingstudies.

SPECIFICGOALS:ThespecificgoalsoftheNucIrotationareto:1. providetrainingandexperiencesothatthefellowcanappropriatelyrequest

radioisotopeproceduresforpatientsandsothatthefellowcanassessthequalityandreliabilityofradionuclideproceduresandinterpretationsperformedbyothers

2. provideexperiencewithradioisotopeproceduresasanadjuncttocardiacstresstestingbyvariouspharmacologicandexercisemethods

3. meettherequirementsoftheACGMERRCCDandABIMCDfortrainingandboardeligibility

4. providetrainingandexperiencenecessarytopassradionucliderelatedcomponentsoftheABIMCDexamination

5. meetACCLevel1trainingcriteriaforradionuclidestudies6. meet,asfaraspossibleinthetimeallowed,therecommendationsdevelopedby

theSocietyofNuclearMedicine(SNM)forbasictrainingofcardiologyfellowsinradioisotopeprocedures.

OBJECTIVES

AttheendoftheNucIrotation,thefellowisexpectedtobeableto1. Assess the advisability and selection/modification of stress testing (by exercise or

pharmacologic means) in individual patients with respect to the relative risks andbenefitsofthetesttobeperformed,particularlywithrespecttotheadjunctiveuseofradioisotopesinstresstests.

2. Discuss the basic scientific principles of radionuclide imaging instrumentation andradiopharmacy.

3. Listradionuclidetechniquesforassessmentofknownorsuspectedcardiacconditions.4. Discuss the clinical applications and indications for widely available radionuclide

techniques(suchasmyocardialperfusionimaging,firstpassandequilibriumbloodpoolimaging, and infarct imaging) as well as positron emission tomography. (This willinclude the indications, contraindications, expected results, and technical and clinicalsituationsthatmayaffectthevalidityofstudyresults.)

5. Describethekeyproceduralandtechnicalcomponentsofcommonradionuclide


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Revised09/2008

procedures.6. Provide basic interpretations of common radionuclide cardiac procedures. (This will

includeevaluationofthetechnicalqualityofthestudyaswellasanunderstandingofthephysiologicinformationportrayedandtheclinicalconsequencesofthestudyinthepatientscare.)

7. Discussbasicprinciplesof radiationsafetyandappropriate recommendationsastheyapply to patients undergoing diagnostic radionuclide cardiac procedures and to thepublicandtopersonnelworkinginthisenvironment.


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Revised09/2008

EPS/Devices,NonInvasiveEvaluations

1. Objectives

FamiliarizethecardiologyFellowwiththeevaluationandmanagementofpatients with arrhythmias as well as diagnostic and therapeutic proceduresinvolved.

2. SuggestedDurationoftheRotation

Twomonthsminimumpreferablyduringthesecondyear

3. EPS

TheFellowshouldbefamiliarwithallpatientsundergoingEPSwillparticipateactivelyintheEPprocedureandwillreviewalltracingsinvolvedinitwillpresentatleastonecaseeverytwotofourweeksinconferencewillreviewatleastonearticleeveryweekandparticipateinEPJournalClub.

4. DeviceClinic

Pacemaker/ICDfollowupandtroubleshooting.

The Fellow, during the rotation, will be involved in the interrogation andreprogramming of single and dual chamber pacemaker and ICDs with atleast ten opportunities assessing dual chamber devices. Follow proceduredocumentationguidelines(sectionXV).

5. Micro Twave alternans. Fellow will get exposure to performance andinterpretationofthistest.

6. TiltTabletesting.Fellowwillbeabletogainexperienceregardingindication,properperformanceandinterpretationofthetilttest.

7. Forpurposesoffuturepracticeandboardcertificationcapabilities,theFellowwillbe expected to be familiarwith the task force reports on indications forEPS,Pacemakeranddevicesaswellasotherpertinentguidelines.

8. TheEPfellowisresponsibleforthepreliminaryinterpretationofallinpatientpacemakerandICDchartsonadailybasis.AllreportswillbeplacedintheArrhythmiaCenterforinterpretation.

ThefellowonEProtationwillevaluateconsultsontheservice.


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Revised09/2008

H. CardiacCathLab

1. GeneralInformation

The Cardiac Cath Lab operates from 7:30a.m. to 10:30p.m., Monday thruThursday, 8:30a.m. to 10:30p.m. on Fridays, and 7:30a.m. to 7:30p.m. onSaturdaysandSundays. A team isoncall fromemergencycasesasneeded.Thecallcrewcanbenotifiedviathepageoperatorat(832)3554146.Hospitalscrubsmustbeworninthecathlabs,anduniversalprecautions(cap/mask/shoecovers/eyeprotection)mustbefollowedduringcases.Foodanddrinksarenotallowedintheprocedurerooms,sterilecore,orhallways.

2. Access

The male physicians dressing room is located at the front entrance of thecardiaccathlabroom.Femalephysiciansmaychangeinthestafflockerroomaccessibleviathebreakroom.Asecuritysystemisusedtocontrolaccesstothearea however, your SLEH badge will be encoded so it is recognized by thebadgereader.Scrubsarecurrentlystoredinthelockerroomandalockerwillbe assigned by the Chief Fellow. Mary Jones communicates with Security toensurebadgesarecodedcorrectly.

3. Schedule

Toscheduleacaseinthecardiaccathlab,callext52251between8:00a.m.and 5:00p.m Monday through Friday. The preliminary cardiac cath labscheduleisproducedbetween3:00p.m.and4:00p.m.eachdayforthenextworkingday.ThescheduleispostedinsidetheCathLabImagingCenteratthe entrance closest to the Holding Area. The original copy is postedovernight for physicians to note schedule changes, cancellations, or patientorder this copy isnot tobe removed. Inaddition, copiesof thescheduleareavailableattheCathLabImagingCenter.

AWaiting List is started after thepreliminary schedule isposted (faxed)orwhentheschedulebecomesfull. TheWaitingList ispostedbytheHoldingArea desk next to the tube system. Addon cases can be scheduled bycallingext52251until 5:00p.m.orext56650until7:00p.m.weekdays. Toadd on cases after 7:00p.m. for the next working day, simply add theinformation to the posted waiting list. The following information aremandatorytoensurethattheaccuracyofthescheduledprocedure:patientscomplete name, date of birth, medical record number, physician who isscheduled toperform theprocedure,procedure(s) tobeperformed,patientlocation,timeofdayadded. Pleasedonotremovethewaitinglist! Thefinalschedule is completed at 6:30a.m. the day of the procedure. Waiting listcases will be worked into the schedule throughout the day. Although theschedule is finalized at 6:30a.m., the schedule is subject to changes


31

Revised09/2008

throughout the day. In the event of an emergency case during normalworkinghours,theemergencycasewillbeplacedinthefirstavailableroomaheadofscheduledcases.

4. Pagers

PhysicianpagersshouldbecheckedinwiththeHoldingAreasecretarywhileyouareworkinginthecardiaccathlab.Theholdingareasecretarywillrespondtoyourpagesandlogmessages.Allemergencycallswillbetransfertothroughtoyour room. Between cases and before leaving the lab, please check yourmessages.Thestaffintheroommaynotconsistentlyansweryourpagestheyareprimarilyresponsibleformonitoringthepatientintheroom.

Thecathlabstaffwillnotifyfellowspriortothebeginningofacaseviapager.Fellows are not paged for scheduled first cases and should be available at7:00a.m.Allfirstcasesaregenerallypreppedanddrapedby7:30a.m.MondayThursdayandat8:30a.m.onFridays.

5. ProtectiveEquipment

One lead apron (full protection only) and one pair of lead glasses with sideshieldsarepurchaseforeachphysiciantouseduringtheirfellowship.Youareresponsible to keep track of your personal lead apron. The cath labwill notprovideadditionalleadapronsduringyourfellowship.Allordersmustbeplacedwiththesupervisorofthesupplyarea(KimHalliburton56704)intheCardiacCath Lab. Radiation badges are also provided to each fellow seememo.Radiationbadgesmustbewornwhenever in theCardiacCathLabs. Monthlyreadings are posted above the badge holder in the Holding Area. Radiationbadgesarerequiredtobecheckedmonthly.Thereisa$3.00feepayabletotheCardiacCathLabforanylostradiationbadge.

6. MiscellaneousOperations

1,3,4,10SingleplaneroomRM2 SwingRoom2xraytablesand1singleplaneImagingsystem5,6,11,8 BiplaneEPSRooms7,8,9 PeripheralRooms(singleplane,RM8isbiplane)

All scrub sinks are located outside theprocedure rooms in theouter corridor.Sinks located inside each room are for cleaning dirty equipment. All staff,fellowsandphysicianarerequiredtoscrubpriortoeachcase.

7. Staffing

The Cardiac Cath Lab staff is composed of personnel from different medicaldisciplines. Each room is staffed with at least one RN. At least one RN is


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Revised09/2008

available in each procedure room throughout cases. The Cardiac Cath Techshave experience as LVNs, radiology technologist (RTR), registered invasivecardiovascular specialist (RCIS), cardiovascular technologist (CVT), respiratorytherapist (RT)orother relatedhospital training. EachroomhasadesignatedchargepersonorRoomleaderwhoisresponsiblefortheroomsscheduleandpersonnel. The Cardiac Cath Labs schedule coordinator is responsible forfacilitatingthescheduleofalllabsinthedepartmentaswellascoordinatingthefollowingdaysschedule.TheCardiacCathLabHoldingAreaisstaffedwithRNsandcathassistants(patientcareassistants).AseniorHoldingAreanurseisinchargeofthatareaandisavailabletoassistyou.

Kristen Turner, Vice President, is accountable for the Cardiac Cath Labs,Operating Rooms and Perioperative Services, Non Invasive Cardiology,CardiologyFellows,andTransplantServices.TheManagerofCardiacCathLabOperations is Derrick Johnson, RN. He is responsible for daytoday CardiacCath Lab operations and personnel. A Cardiac Cath Lab supervisor, GwenRangel,orDerrickJohnson,isavailabletotalkwithpatientsorfamilymembersthat need support/assistance. A computerized database ismaintained in thedepartmentwhichenablesdataretrieval.NoeSalinasisthedepartmentsLeadAnalystfortheCardiologyInformationSystem.Heandhisassistantcanassistin data retrievals. All requests for information should be in writing and aresubjected to approval requestwill be completed as expeditious aspossible.BridgetVanBurenistheScheduleCoordinatorfortheCardiacCathLabsandisresponsible for organizing the next days schedule. Kim Halliburton is theSupervisorfortheCardiacCathLabsupplies.

8. FilmlessAngiograms

SLEHCardiacCathLabisafilmlessenvironment.TheCardiacCathLabPACSsystem is located in RM O601. You can review cath lab angiograms andhistorical angiograms (past 3 years), special procedure angiograms, HybridSuiteangiograms,digitalxrayimages,CTimages,MRimages,echoimagesandreports.AllCardiacCathLab imagescanberetrievedimmediatelyaftertheprocedureiscompleted.

Todoso,thereviewerneedstooccupyavacantworkstationandlaunchtheEncompassapplication.Theprimaryuserinterfacehasseveralbuttonsinacolumn on the left. The user must double click on the button labeledPrimary Database. This will cause the list of current patients to bedisplayed. If the patient in questionwas had a cath lab procedure in thepast,theusercanissueaqueryandretrievehistoricalimagesfromthepast3years.ThequeryfunctionislaunchedbypressingtheSearchbutton.Aqueryformisdisplayed.PresstheClearAllFieldsintheupperrightoftheform, and then type the first four charactersof the lastname in thenamefield. ClickOK.Thiswillproduceashortlistofpatientsfromwhichtheusercanselectthestudiesofinterest.


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9. FYI

a. Retrieving historical cines may take 1 3 days because of offsitestorage.Acathnumberistheeasiestwaytoretrieveanhistoricalcinefilms (films prior to July 2001) or patient procedural folder. The cathnumber is a sevendigit number assigned to each patient who comesthroughthecathlabeachday.Thelasttwodigitssignifytheyeartheprocedurewasperformed.(e.g.0330802).Thepatientsfullnameanddate of procedure can also be used, but this requires additional time.Historicalcinescannotbelocatedutilizingmedicalrecordnumbers.

b. AllscheduledpatientsmusthaveacompletedHistoryandPhysicalthatisnomorethan30daysoldwithanupdatenotethatissigned,datedandtime prior to the CCL procedure starting, a signed consent for theappropriate procedure that is counter signed, dated and timed by thephysicianandawitness

c. As note above, prior to theprocedureall scheduledpatientmusthavethefollowing:

i. PatientConsentforthecardiaccathlabprocedureii. H&Pwithin30daysiii. Or,UpdateToH&P(ifoutpatient)iv. ASAClassification(formoderatesedationv. MallampattiScore(airwayassessment)

all of which must be signed by the cardiologist prior to starting theprocedure.

6. Requiredlabresultsseememo.

d. After each procedure, the staff may request information relate to thepatientsconditionfromeitherthefellowortheattendingphysicianpriorto leaving the procedure room. Fellows most often complete PostProcedureOrders and PostProcedureNotesthe later requires thecardiologist signature. Fellows are urged to use the printed PostProcedure Notes since it includes all the elements required by thehospitalandotherregulatoryagencies.Allelementsmustbecompleted.Signature,DateandTimearerequiredonallentriesinthepatientchart.

e. Statelawsrequirethatallpersonnelwhoareexposedtoclinicalradiationarerequiredtoweararadiationmonitoringbadge.JointCommissionalsorequiredthathospitalsmonitortotalradiationdosesreceivedbypatientsduringclinicalradiationprocedures.Radiationdosereceivedbyapatientthatequaltoorexceeds1,500rads(15,000mGy)duringasingleeventorcumulativedoseinasinglefieldwithin12monthsisareportableSentinelEvent. SLEH Cardiac Cath Lab Advisory Committee (CCLAC) opted to


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Revised09/2008

observe cumulative dose over a 6months time frame. During theprocedure, the CCL staff will prompt you when the patient received800rads (8,000 mGy) and again at 1200rads (12,000 mGy). If therequirement isexceededthecardiologist isexpectedtodecideif it is inthebestinterestofthepatienttocontinuetheprocedure.Anyexposureequal to or exceed 1,200rads (12,000 mGy) is sent to the RadiationSafetyOfficer for review to determinewhether or not a sentineleventhasoccurred.

f. Attached is a Power Point presentation of the Joint Commissioncompliancestandards.

10. IMPORTANTPHONENUMBERS(832)355XXXX)

Reservations/Scheduling(CardiacCathLab) 52251CardiacCathLabMainNumber 56650RequestforallCinesordiagrams56677orvoicemail 56645CVOutpatientNursingUnit(CVOPorOP) 53346Cooley6B(PostInterventionalUnit) 59620Cooley6A(CardiacICU) 59610CCU1&CCU2 56610&56620

Room# Phone# RoomLeaderHoldingArea 56650 AlexandraCarter,RN1 55601 YvonneSingletary,RN2 55602 JanieYanez,RN3 55603 TerrieEarl,RN4 55604 MichaelMcBee,RN5 55605 VirginiaGomez,RN6 55606 SueRohauer,RN7 55607 DamirMesic,RN8 55608 None9 55609 CarlNolan,RN10 55610 LarryBrown,RN11 55611 RangyYoung,RCES

KristenTurner,VicePresident 56599DerrickJohnson,Manager,CCLClinicalOperations 56602or56767GwenRangel,Supervisor,ClinicalOperations 56766KimHalliburton,Supervisor,Inventory 56704BridgettVanBurenAmos,CathLabScheduleCoordinator 54394RosaEstrada,AdministrativeAssistant 56602NoeSalinas,LeadAnalyst 56685


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Revised09/2008

I. Transplant/HeartFailureRotation

Goals:Thepurposeofthisrotationwillbetoallowthecardiologyfellowtogaininsightintothemanagementofpatientswithendstagecongestiveheartfailure.Patientswillbeseeninbothandinpatientandoutpatientsettingandallaspectsofheartfailuremanagementwillbeseenwhileontheservice.Fellowswillreceivetraininginmedicalmanagementwithinvasivehemodynamicmonitoringandtailoredmedicaltherapy,electrophysiologicalmanagementincludingbiventricularpacingandothernovelpacingtherapiesfortheheartfailurepatient,andfinallysurgicaltherapiesincludingcardiactransplantationandleftventricularassistdevicetherapy.Duringthisrotationthefellowwilllikelyidentifyareasinwhichthefacultyisparticipatinginresearchandresearchopportunitiesareavailabletofellowswhodevelopalongerterminterestinpatientswithendstagecongestiveheartfailureandcardiactransplantation.

1. TrainingMethods

a. Clinical:FellowshavetheresponsibilitytoroundMondaythroughFridayandberesponsibleforsupervisionofpatientsontheinpatientheartfailureandcardiactransplantrotation.Patientswillalsobeseenintheemergencydepartmentandcongestiveheartcliniconanadhocbasis.

b. DidacticlecturesareaccompaniedwiththeseroundsandtherearetwoweeklydidacticsessionsonTuesdaymorningandFridaymorning.Attendingswillrequestthatfellowsparticipateintheseteachingsessionsoccasionallyreviewliteratureforthese.

c. SelfLearning:ThefellowwillbeaskedtopresentatopicduringtheWednesdaynoonconferencetootherfellowsandthestaffofthetransplantsection.Thisconferenceisopentoanytopicrelatedtoheartfailureortransplantmedicinethatwouldinterestthefellow.Inaddition,whilenotrequired,fellowsareabletoattenddonororganprocurementsandreviewbiopsyspecimenswiththeanatomicpathologist.

2. ResponsibilitiesoftheCardiologyFellow

RoundsMondaythroughFriday. Progressnotesonpatients. Followupallorderedstudiesonadailybasis. Presentationofpatientsforrounds. Fellowsshouldbeavailablefrom6:30amto6pmforconsultationandurgent

patientsseenintheemergencydepartmentorintheclinic. TheprimarycardiologyattendingstowhomthefellowswillreportareDrs.

Bogaev,Civitello,Delgado,Kar,andLoyalkathefellowmayroundinconjunctionwithsurgicalattendings,Drs.Frazier,Gregoric,andCohnaswell.

Otherfellowsmaybeontheserviceatthesametimeastherotatingfellow


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Revised09/2008

inparticular,twoheartfailure/cardiactransplantfellows,inadditiontoonesurgicalfellow.Inaddition,thefellowmayworkwithnursepractionersintheinpatientoroutpatientsetting.

Fellowswillbeabletoperformproceduresprimarily,rightheartcatheterization,endomyocardialbiopsy,andtheoccasionalleftheartcatheterizationandintraaorticballoonpumpplacement.However,thisserviceisnotdesignedasacathlabrotationandshouldnotbeconsideredassuch.

3. EvaluationwillbeinthestandardformataspreferredbytheBaylorCollegeofMedicineandallevaluationswillbereviewedwiththefellowpriortofinalization.

4. SuggestedReadings:ThefellowsaregivenaUSBdrivewithsentinelheartfailurearticlestoreadduringtheirrotation.Inaddition,severalrecommendtextbooksforreferenceinclude:

a. HeartFailure,Editors:PooleWilsonandColuccib. CongestiveHeartFailure:Pathophysiology,DifferentialDiagnosisand

ComprehensiveApproachtoTherapy,SecondEdition,Editors:HosenpudandGreenberg

c. CardiacTransplantation,Editors:KirklinandYoung


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Revised09/2008

InvasiveCardiology

Experience in invasive cardiac diagnosis will be obtained during individual clinicalrotations.AHA/ACCFellowshipguidelinesrecommend12monthswith300proceduresas a minimum requirement. ACC/AHA Guidelines for clinical training in Cardiologyrequire 12month experience and 300 procedures for trainiees wishing to pursueinterventionaltraining.

InterventionalCardiology(UpperLevel)

The interventional rotation is designed to enhance the skills of thirdyear Fellows inpercutaneoustransluminalangioplastyprocedures.Fellowswillbeassignedtospecificcatheterization laboratoriesduringthistwomonthrotation,wheretheywillparticipatein all teaching interventional cases performed. AHA/ACCguidelines recommend300interventionalproceduresfortrainingininterventionalcardiology.

AmbulatoryCare

1. Guidelines: ACGMEGuidelines require ambulatory consultativeandcontinuingcareexperiencetooccurat leastdayeachweekthroughoutthelengthofthetrainingprogram

2. ContinuityClinicassignmentswillbemadebytheCardiologyEducationofficeto anAttending Faculty Preceptors outpatient office, to begin inAugustofthe 1st year of Fellowship. This assignment will continue throughout all 3years. A specific morning or afternoon onehalf day per week will beidentified and serve this function throughout the year. Continuity Clinicassignmentwillsupersedeallotherduties,with theexceptionoftheperiodof duty in the CCU and the SLMT during which period attendance atcontinuityclinicwillbesuspended.

3. Fellowperformancewillbegradedbythesupervisingattendinginawrittenevaluation quarterly. The attendingwill review these evaluationswith theFellow.

4. ItistheresponsibilityoftheFellowtogivesufficientadvancenoticeofabsencefromthecontinuityclinic,becauseofleaveorvacation,tothefacultysupervisorandtheirofficemanager/staff,forpatientschedulingpurposes.

5. The specific program content of the ambulatory care experience is excerptedfromtheGMEDirectory200405(P108)asfollows:


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V. SPECIFICPROGRAMCONTENT

A. PatientCareExperienceTheavailableinpatientandambulatorycarepatientpopulationmustprovideexperiencewith those illnesses that are encompassed by, and help to define, the subspecialty.Such experience should include sufficient number of patients over the age of 70 toprovide substantial opportunities in themanagement of the complexphysical, social,andpsychologicalproblemsprevalentinelderlypatients.Subspecialtyprogramsmustincludethefollowingeducationalcomponents:1. Experiencewithambulatorypatients

a. Consultativeaswellascontinuingcaremustoccuratleastdayeachweek throughout the length of the training program. (Note: Trainingprogramsincriticalcaremedicineareexemptfromthisrequirement.)

b. Onsite faculty members primary responsibilities must include thesupervisionandteachingofresidents.Onsitesupervisionaswellastheevaluationoftheeducationalexperiencemustbedocumented.

c. Thepatientvolumeintheambulatoryenvironmentmustbelargeenoughto provide adequate numbers of new and return patients. Residentsshould, onaverage,be responsible for fromone to threenewpatientsandthreetosixreturnpatientsduringeachdaysession.

2. Experiencewithcontinuityambulatorypatientsa. The residents should haveanopportunity to followapanelofpatients

withadiversityofdisease.b. Theresidentsclinicalexperienceswithambulatorypatientsmustprovide

residentstheopportunitytoobserveandtolearnthecourseofdisease.


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Revised09/2008

Evaluations

1. Each attending will record, for your file, an evaluation of yourperformanceontheirservice.Youshouldsigntheseevaluationsand,ifyou have any questions or comments, address them before theevaluationsareplacedinyourpermanentfile.

2. You will be asked to evaluate verbally the instructors on each servicerotation. This is done in the context of a quarterlymeetingwith Dr.WilsonandtheotherFellowsinyouryear.

3. Youwill also be asked to evaluate the instructorsandservice foreachrotation.ThisisdonebycompletionoftheRotationEvaluationForm.Toassure confidentially the form is distributed by the FellowshipCoordinator.AtypedsummaryoftheevaluationsisgiventoDr.Wilsonevery6months.

6. Youwill alsobeevaluatedbyyour continuity clinicattendingandhavetheopportunitytoevaluateyourcontinuitycliniconasemiannualbasis.

7. 360oevaluationswillbeperformedonthefollowingservices:CCU,Echo,Cathlab,NuclearLab,SLMT,andMRI.

8. Periodicallyyouwillhavetheopportunitytoevaluatealloftheteachingstaff.


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Revised09/2008

CHARTPROCEDURES

A. Dictation

l. Historiesandphysicals, consultationsor statdictationshouldbeonthechartasquicklyaspossible.

2. Dictationmaybecompletedbyusingdictaphoneordialing53650.

B. ProgressNotesandCompletionofHospitalCharts

1. Progressnotesinthehospitalchartarerequireddailyormorefrequentlyifindicated.

2. Before transferring a patient fromeither the Recovery Room/IntensiveCareUnitsor theCCU,abriefprogressnote is requireddescribingthepatient's course of treatment and listing any problems which thephysicianassumingresponsibility forthepatientinthefutureshouldbeaware.

3. Upon thepatient'sdischargefromthehospital,completingalldictation,fillingout thechart's face sheet,aswell as checking for signatureswillgreatly lightentheworkloadof theStaffPhysicianandFellowatalaterdate.

C. Orders

1. Ordersshouldbewrittendated,timed,andsignedbythephysician.

2. Although verbal orders or telephone orders are discouraged, routine(nontreatment) orders are acceptable but must be signed by theorderingphysicianwithinsixhours.

Verbal orders or telephone orders may be given to registered nurses andlicensedvocationalnursesonly.


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Revised09/2008

NIGHTCALL

A. CCUFellow

ThefirstyearFellowswillbeoncallonarotatingbasis.

1. TheCCUFellowmustremaininthehospital,andbeavailableforroutineandemergencycalls concerningallpatientsattendedby thecardiologyteachingstaff. Thepageoperatormustbe informedofanychange inthecallschedule.

2. This obligation begins at 4:30 p.m. on weekdays and 8:00 a.m. onweekends and ends at 7:30 a.m. on weekdays and 8:00 a.m. onweekends.

3. Aroomisprovidedonthe6TH floornexttoCCUinwhichthephysicianoncallmaysleep.Thekeypadnumberis7890*

4. TheFellowoncall is cardiologyconsultantof the"CodeBlue"teamforthehospital.TheFellowisrequiredtoattendallCodeBluesandassistas needed. However, all immediate postcode care (transfer note,orders),otherthanpatientswhocodeintheCCUaretheresponsibilityofthecodeblueresident.

5. TheCCUfellowshouldbethefirstpersoncalledwithcardiologyissuesonallICUpatientsthatarecoveredbyateachingcardiologist.Noncardiacissuesshouldbereferredtotherelevantconsultantserviceiftheyareonthe case. The CCU fellow should field calls for noncardiac issues onpatientsforwhomateachingcardiologist istheprimaryphysician,ifnoappropriateconsultantisonthecase.

6. TheCCUfellowwillevaluateERpatientswithpresumedcardiacillnessifrequestedbydirectcommunicationbyateachingcardiologist.

7. The Fellow on call can do STAT echocardiogram ormay call the echotechnicianoncall,usingthepageoperatoratext.54146.

8. The transesophageal stimulator and catheters are kept in the EKGequipmentroom(P305).CalltheEKGtechniciantobringtheequipmentandEKGmachine.

9. TheCCU fellow isNOT responsible for performingconsultsonpatientsalready in the hospital. However, if time allows, he may do this ifrequestedbyateachingcardiologist.

10. The CCU fellow is responsible for making requested programming


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Revised09/2008

changes (not electrophysiology consultation) to implanted pacemakersand defibrillators when the pacemaker RN is not on duty. ThepacemakerRNisondutyMF8AM5PM(exceptholidays).Itistheresponsibilityoftherequestortoidentifywhichbrandofdeviceistobereprogrammed.

B. CardiologyHouseOfficer(CHO)1. Admissions and crosscoverage which are the responsibility of the

CHOinclude:a. AlladmissionstoandcrosscoveragefortheChestPainCenter

from7PMto7AM,MF,and24hourcoverageonweekends.b. Newadmissionsto6CooleyBTelemetryforpatientswhohave

a teaching cardiologist as theprimary attending from7PM to7AM,MF,and24hourcoverageonweekends.

c. Cross coverage for all cardiac issues for6CooleyB telemetrypatientsifateachingcardiologistisonthecase.

d. Assistancewithmanagementofpatientswhohaveundergonepercutaneous revascularizationordiagnosticcatheterizationbyateachingcardiologist.ThiswillincludeassistancewithsheathwithdrawalandurgentevaluationasrequestedbytheprimaryM.D.ornursingstaff.

e. NonTelemetry admission and holding note for patientsadmittedtoCardiologyTeachingStaff.

f. CardiacStressTestsrequiresupervisionbyCHOfrom7PMto10PMMF,and24hourcoverageonweekends.

2. The initial management of acute myocardial infarction is a primaryresponsibilityoftheCHO:a. An urgent response will be required for patients with ST

segmentelevationandnewLBBB.Theinitialmedicalcareandcoordination of revascularization efforts for all patients withacutemyocardial infarction(includingpatientsofnonteachingattending physicians) is the responsibility of the CardiologyHouse Officer. Patients requiring urgent referral for directrevascularization (angioplasty) will have an initial history,physical examination and reasons for referral documented inthemedicalrecordbytheCardiologyHouseOfficer.

b. Admissionhistory,physicalexaminationandroutinecareordersfor patients who do not have STsegment elevation or newLBBB myocardial infarction are the responsibility of thephysician to whom the patient is admitted or theresident/fellowship trainee responsible for the nursing unit towhichthepatientisadmitted.

c. Coordination of medical care directly related to the initialadministration of thrombolytic drugs or the referral for directrevascularization for all patients with acute myocardialinfarction.


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Revised09/2008

d. Management of all emergency procedures and necessaryresuscitationofpatientswithacutemyocardialinfarctionintheemergencycenter.

e. Performanceofallemergencyproceduressuchasplacementofa temporary pacemaker or intraaortic balloon pump, inpatients with acute myocardial infarction in the emergencycenter.

f. TheCardiologyHouseOfficerwillabandonallcurrentactivitiesto respond to an acute myocardial infarction (STsegmentelevation/NewLBBB).

g. Management decisions will be discussed with the attendingphysician.

h. Duetotheemergencynatureofacutemyocardial infarction,theresponsibilityoftheCardiologyHouseofficer,inthesettingof STsegmentelevationornewLBBBwill apply to teachingandnonteachingphysiciansalike.i. IntheeventthattheCardiologyHouseOfficerdisagrees

with themanagement plan of the attending physician,the attending physician will be responsible for allsubsequent management decisions, orders andexaminationsthataredeemednecessary.

ii. Duringregularworkinghours(6AMuntil7PM)thenonteaching attending is responsible for all examinationsandmanagementdecisionsforhis/herpatient.

3. ResponsibilitiesoftheCardiologyHouseOfficerwillnotinclude,a. Documentation of admission history and physical examination

forpatientsadmittedtotelemetryunitsortheCCU.b. Coordinationofcareforpatientsofnonteachingattendingsin

whom there is no apparent need for urgent revascularization(i.e.,absenceofSTsegmentelevationornewLBBB).

c. Initialclinicalevaluationofallpatientswithacomplaintofchestpain. The first determination of the probable cause ofdiscomfort is the responsibility of the emergency centerphysician.

C. SecondCall(InterventionalFellow)

1. An additional senior fellow is assigned each day to assist or renderbackupadviceandassistancetothefirstyearCCUFellowoncall.Thesecond call (Interventional fellow) is not required to remain in thehospital.

2. In the event a patient is admitted with acute myocardial infarction,requiring emergency catheterization and/or TCA, the InterventionalFellowwillassisttheattendingphysicianduringtheprocedure.


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Revised09/2008

D. TelemetryHouseOfficer(THO)

The Telemetry House Officer (THO) is a house officer appointed by theDepartment of Medicine to cover certain areas of the hospital, nights andweekends. Responsibilities of the THO are defined by the Department ofMedicineandtheirareasofcoverageareenumeratedonpages26a,and26b.

E. OtherCoverage

AreasofcoveragebythehouseofficersareenumeratedonTheSource.

F. HurricaneCoverage

ActivationWarning:Typically4872hoursbeforetheactualteamis"calledin",therewillbeanotificationthatactivationisupcoming.

Activation:Typically"hurricaneactivation"willoccur24hoursbeforestormlandfall.

Whoisontheteam?Whenthe"activation"occurs,itisexpectedthatwhoeverisoncallfortheNEXTTWOdayswillbepartoftheteam,plusoneinterventionalfellow." Ifyouareexpectedtobeontheteam,andcannot,forwhateverreason,bepresentitisyourresponsibilitytofindcoverage.Interventionalfellowswilldecideamongstthemselveswhowillcover.

Expectationsoftheteam:Ifyouarescheduledtobeoncallwithinthenext48hoursfollowing"activation",thenyouareexpectedtoreporttothehospitalwithclothes/accessoriesforapossiblestayofupto34days(absoluteworstcasescenario).Youareexpectedtoremaininthehospitalfortheentiretime,butareonlyexpectedtoworkwhenyouwereoriginallyscheduledunlessanothercoveragearrangementismadebetweentheteammembers. Food,water,shelter,airconditioning,runningplumbing,andpatientsareprovidedbythehospital.

Payback:Ifyouarecalledinandhavetoworkmorethanjusttheshiftyouwereoriginallyscheduledfor(saytheteamremainsinhouseforthreedays),thenyouwillbepayedbackwithextravacationdays.Examples:

1. ActivationiscalledTuesdayatNoon. CCUfellowsforWedandThursday,CardiHoesforWednesdayandThursday,and1interventionalfellowmakeuptheteam.

2. ActivationiscalledWedatNoon. Wednesdaypeoplearesafe,CCUfellowsforThursandFriday,CardiHoesforThursandFriday,and1interventionalfellowmakeuptheteam.


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Revised09/2008

**Again,ifyouhaveswitchedcall,haveothercommitments(smallkids)ifyouareontheschedule,thenyouwillneedtofindsomeonetocover.

BEEPERS

A. TheCCUbeeper iskeptbytheFellowassignedtotheCCUrotation,MondayFridayfrom7:30a.m.to4:30p.m.

B. After4:30p.m.duringtheweekand8:00a.m.ontheweekend,thebeeperiscarriedbytheFellowonfirstcall(CCUFellow).

C. Thebeepermustbepersonallygiventothephysicianassumingdutyeachnightor weekend day and it is never to be left unattended between shifts.Information regarding very sick patients and problems will be transmittedverbally at the time of beeper exchange. (Batteries for replacementmay beobtained inNetwork Services [Lower level, Blue Elevators] or theNoninvasiveLaboratory.)

D. TheCardiologyHouseOfficer(CHO)beeperispickedupintheCardiologyHouseOfficecallroom(P624)bytheassignedFellowoncallandkeptfrom7:00p.m.to7:00a.m.

MEALSWHILEONCALL

AllCardiologyoncallFellows,areentitledtoCallMealTickets.MealticketsforthemonthmaybeobtainedthroughtheMedicalStaffServicesDepartment,RoomG127,8:00a.m.to4:00p.m.,MondaythroughFriday,excludingHolidays.Ticketsmustberedeemedduringthemonthforwhichtheyareissued.

MealticketswillbeavailableforpickuptwodayspriortotheendofthemonthunlessthosetwodaysshouldfallonaweekendorHoliday.Inthatcase,mealticketsshallbeavailabletwoworkingdaysbeforethebeginningofthemonthifthecallscheduleisavailable.

Topickupmealtickets,ResidentsmustbringtheirSchoolidentificationbadge.ResidentswillberequiredtosignforthemealticketsonthecallscheduleinMedicalStaffServicestoverifythattheyhavereceivedtheirmealtickets.

Residentsshallberesponsiblefortheirmealtickets.Mealticketslostorstolenwillnotbereplaced.AResidenttradingcallwithanothershallberesponsibleforprovidinghis/heroncallmealticketsfortheday(s)tradedtothenewresidentoncall.Mealticketsnotredeemedduringthemonthforwhichtheyareissuedshallbevoidontheseconddayofthefollowingmonth.PLEASENOTE: EXPIREDTICKETSWILLNOTBEACCEPTEDINTHEBERTNERAVENUECAF.

Meal tickets may only be redeemed in the Bertner Avenue Caf. No change or


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Revised09/2008

credit will be given. Residents must sign the appropriate ticket in front of thecashieratthetimethemealticketisbeingredeemed.IfyouhaveanyquestionsorconcernspleasecontactConsueloBartonat(832)3554200.

PHOTOSTATIC&PHOTOGRAPHICSERVICES

A. The SLEH Cardiology Division has photocopy machines available for use byCardiology students and Fellows. Certain amounts of reproduction arenecessarytofacilitateresearchandtraining.Abusesoftheprivilegeforpersonalorvoluminousreproductionhandicapstheoperationsoftheusingdepartmentsandplacesanunnecessaryfinancialburdenonthefundingsource.Thecopiersarecontrolledbycodenumbersandtheusageisreviewedperiodically.

B. Reproduction of smaller quantity is available at Jesse Jones Medical Library.ContacttheCardiologyFellowshipCoordinatorforassistance.

C. Power Point or transparencies or will be used for visual presentation for allconferences. Transparenciesmaybeobtained from theCardiologyFellowshipOffice.

D. Written approval for graphics or artwork necessary for journal publicationMUSTbeobtainedfromtheFellowshipCoordinatorBEFOREpaymentcanbemade.


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Revised09/2008

TIMEOFF

A. SickLeave(IncludingMaternity)

1. Each Fellow is allowed 14 calendar days paid sick leave per academicyear.Unusedsickdayswillbecarriedforwardandbeavailableineachsubsequentacademicyear.Thesedaysmaybeusedonlyintheeventofan actual illness. A physician's statement is necessary if the illnessextendsbeyond3consecutiveworkingdays.ATimeOffRequestmus

Documents

200809 CARDIOLOGY FELLOWSHIP GUIDELINES