Frequently Asked Questions: Emergency Medicine Review Committee for Emergency Medicine ACGME

Transcription

1 Frequently Asked Questions: Emergency Medicine Review Committee for Emergency Medicine ACGME Question Participating Sites What other major specialties would demonstrate a major educational commitment to the emergency medicine program? Examples of other major specialties that indicate a major educational commitment may include ACGME-accredited internal medicine, obstetrics and gynecology, and surgery programs. I.B.7] Program Personnel and Resources What other faculty qualifications are The Review Committee would accept certification by the American Osteopathic Board of acceptable to the Review Emergency Medicine (AOBEM), and certification by a subspecialty board sponsored or Committee? cosponsored by the American Board of Emergency Medicine (ABEM). It would also accept recent residency or fellowship graduates (within the past two years) actively working toward II.B.2] certification by these boards for faculty appointment. Are there any qualifications specific to emergency medicine faculty members in reference to supervision? II.B.2] Can non-abem/aobem boardcertified faculty members see patients in the Emergency Department? II.B.2] Yes. Faculty members providing supervision to emergency medicine residents on emergency medicine rotations must have appropriate qualifications relative to the patient population for which they provide emergency medicine resident supervision. For example, a faculty member board-certified in both pediatrics and pediatric emergency medicine would be qualified to supervise emergency medicine residents on pediatric cases, but not adult cases. Faculty members solely board-certified in pediatrics may not supervise emergency medicine residents in the Emergency Department. Presence of non-qualifying faculty members in the department is acceptable only if they do not directly supervise residents Accreditation Council for Graduate Medical Education (ACGME) Page 1 of 11

2 Which physician faculty members are included in the required core program faculty-to-resident ratio of 1:3? II.B.6] What are examples of acceptable scholarly activity for faculty members? II.B.6.d)] The core physician faculty members that are counted in this ratio include the chair/chief of emergency medicine, the program director, associate program director(s) if applicable, and other faculty members who meet the definition of a core physician faculty member. 1. PEER REVIEW-This would include original contributions of knowledge published in journals listed in Thomson Reuters (formerly ISI) Web of Knowledge or MEDLINE. Abstracts, editorials, or letters to the editor would not qualify. Submissions to online venues, with the exception of Med Ed PORTAL, would not qualify. 2. NON-PEER REVIEW-This would include all submissions to journals or online venues that do not fulfill peer-review criteria. This would also include abstracts, editorials, or letters to the editor submitted to peer-reviewed journals and which have not undergone the rigorous, blinded, multiple peer-review process. This category also includes educational videos, DVD s, and podcasts. 3. TEXTBOOKS/CHAPTERS-This would include submissions for which the faculty member served as editor, section editor, or chapter author. 4. PRESENTATION AT LOCAL/REGIONAL/NATIONAL ORGANIZATIONS-This would include invited presentations at meetings, such as abstracts (posters), expert panel discussions, serving as a forum leader, or grand rounds presentations. Grand rounds presentations at the home institution, unless at an outside department, would not qualify. 5. COMMITTEE MEMBERSHIP/LEADERSHIP-This would include elected or appointed positions in nationally recognized organizations. Membership alone would not qualify. 6. EDITORIAL SERVICES-This category would include services as an editor, editorial board member, reviewer, or content expert. Serving as an abstract reviewer or grant reviewer would also qualify. 7. GRANTS-This criteria can only be satisfied by the awarding of a grant Accreditation Council for Graduate Medical Education (ACGME) Page 2 of 11

3 Why is there a faculty staffing ratio, It is important that each program maintain sufficient levels of faculty staffing coverage in the how is it calculated, and does it Emergency Department in order to ensure adequate clinical instruction and supervision, as well need to be calculated for all areas of as efficient, high quality clinical operations. The Review Committee uses a faculty staffing ratio the Emergency Department? of 4.0 patients per faculty hour or less as a guideline in this determination. This may be calculated in the following manner: II.B.8] (Patient visits per year/faculty hours per day)/365 days per year = Patients per faculty hour Example: ((70,000 patients per year/55 faculty hours per day)/365 days per year) = approximately 3.5 patients per faculty hour What is considered adequate space for patient care? II.D.1.(a)] What should a written consultation protocol include? Faculty staffing ratios only need to be provided for acute critical care areas, and not for fast track or urgent care areas. The Review Committee recommends that the Emergency Department should have one treatment room for every 2000 visits, and a minimum of 120 square feet for every individual patient care space. Each treatment room should be approximately 500 gross square feet (including walls, hallways, staff stations, etc.). As an example, an Emergency Department with 40,000 annual patient visits should have 20 treatment rooms with a total of 10,000 square feet. Rapid emergency rooms (ERs) (fast track or urgent care) should have one treatment room for every 4000 patient visits. The protocol should include written agreements for the transfer of patients to a designated hospital that provides the needed clinical service. II.D.4.a)] What are the maximum average throughput times for the Emergency Department? The suggested maximum average throughput times for Emergency Department patients is four hours for discharged patients, and eight hours for admitted patients to arrive on the floor, excluding observation patients. II.D.4.b)] Resident Appointments Why is the minimum number of residents per year set to six? III.B.2] A minimum of six residents per year is needed in order to achieve a major impact in the Emergency Department to ensure meaningful attendance at emergency medicine conferences, to provide for progressive responsibility, and to foster a sense of residency program and departmental identity. The Review Committee recognizes there may be unique instances in 2012 Accreditation Council for Graduate Medical Education (ACGME) Page 3 of 11

4 Why does the Review Committee review resident attrition? III.B.2] Educational Program What are examples of acceptable scholarly activity for residents? IV.B.2] What types of experiences do NOT count as didactic experiences? IV.A.3.a)] What are some suggested formats or methodologies programs may use for planned didactic experiences? IV.A.3.a).(1)] How much individualized interaction instruction is acceptable and what qualifies? IV.A.3.c).(1)] which a program may not fill all resident positions or may have a resident leave the program. Resident attrition may impact residents work and learning environment, may serve as an indicator for an unstable educational environment. Examples of suitable resident scholarly activities include: preparation of a scholarly paper, such as a collective review or case report; active participation in a research project, or formulation and implementation of an original research project; or an Emergency Department quality improvement project. Daily experiences, such as morning report or change of shift teaching, in which not all residents are consistently present and which are informal, do not meet requirements to be included as part of the five hours of didactic experience per week, due to quality and availability concerns. Recommendations for the majority of educational activities include: small-group techniques, such as break-out groups, serially repeated conference sessions, or practicum sessions; or large-group planned educational activities. Programs may utilize individualized interactive instruction for up to 20 percent of the planned educational experiences or didactics (i.e., on average, one hour out of the five hours per week of planned educational activity). The goal of individualized interactive instruction is to give program directors the ability to adjust curricular needs to the individual needs of each of their residents. It is important to note that simply reading or answering questions does not meet the requirements for planned educational activities. In order for an activity to qualify as individualized interactive instruction, the following four criteria must be met: 1. The program director must monitor resident participation Accreditation Council for Graduate Medical Education (ACGME) Page 4 of 11

5 2. There must be an evaluation component. 3. There must be faculty oversight. 4. The activity must be monitored for effectiveness. How does the Review Committee document resident attendance at 70 percent of the planned emergency medicine didactic experiences? Examples of individualized interactive instruction might include: A resident prepares for and takes a quiz or test, and receives timely feedback about his or her performance from a faculty member. A resident spends additional time in the simulation lab or cadaver/animal lab because he or she needs more practice with a certain procedure. Residents who are doing poorly on quizzes/tests participate in board review study sessions with colleagues or faculty members. Attestation and completion pages are not acceptable to the Review Committee as evaluation. Use of audio, video, or podcasts alone constitutes passive learning and is not considered interactive learning. Proprietary systems, such as PolyCom or Skype, that allow for real-time questions and answers, do qualify as active/interactive participation. Verification is cross-checked by reviewing an eight-week conference block and averaging resident attendance for that eight-week period. IV.A.3.c).(5)] How does the Review Committee define a major resuscitation? IV.A.5.b).(2).(a).(v)] A major resuscitation is patient care for which prolonged physician attention is needed, and interventions such as defibrillation, cardiac pacing, treatment of shock, intravenous use of drugs (e.g., thrombolytics, vasopressors, neuromuscular blocking agents), or invasive procedures (e.g., cut downs, central line insertion, tube thoracostomy, endotracheal intubations) are necessary for stabilization and treatment. Each resident must have the opportunity to make admission recommendations and direct resuscitations Accreditation Council for Graduate Medical Education (ACGME) Page 5 of 11

6 Which procedures need to be logged and are there minimum numbers for each one? IV.A.5.b).(2).(c).- IV.A.5.b).(2).(c).(xvii).(a)] The following key index procedures (minimum numbers indicated) are required to be logged by residents: Adult medical resuscitation 45 Adult trauma resuscitation 35 Anesthesia and pain management * Cardiac pacing 6 Central venous access 20 Chest tubes 10 Cricothyrotomy 3 Dislocation reduction 10 Emergency department bedside ultrasound * Intubations 35 Lumbar puncture 15 Pediatric medical resuscitation 15 Pediatric trauma resuscitation 10 Pericardiocentesis 3 Procedural sedation 15 Vaginal delivery 10 Vascular access * Wound management * Selected key index procedures should consequentially impact patient care, and ideally facilitate competency assessment initiatives across disciplines. Who is responsible for determining procedural competency? IV.A.5.b).(2).(c).- IV.A.5.b).(2).(c).(xvii).(a)] *The program director must assess each resident s competency in these procedures. Minimum numbers have not been set. The primary responsibility for the determination of procedural competency rests with the program director and the faculty. The Review Committee accredits programs, and does not certify or credential individuals Accreditation Council for Graduate Medical Education (ACGME) Page 6 of 11

7 Other than minimum numbers, is The Review Committee expects programs to assess the competency of residents to perform all there anything else that the program key index procedures. At the time of program review, the program will need to demonstrate how is required to do in order to it assesses competency of residents for 3 procedures. One of the selected procedures must be demonstrate resident competency ED bedside ultrasound. assessment? IV.A.5.b).(2).(c).- IV.A.5.b).(2).(c).(xvii).(a)] What percentage of procedures performed in simulated environments (simulation setting/cadaver lab/animal lab) can count toward minimum procedure numbers? IV.A.5.b).(2).(c).-IV.A.5.b).(2).(c). (xvii).(a)] What are the required elements of the curriculum and how can these be met? No more than 30 percent of required logged procedures performed in simulated settings can be counted toward procedure numbers with the exception of rare procedures, namely pericardiocentesis, cardiac pacing and cricothyrotomy. One hundred percent of these rare procedures may be performed in the lab. Sixty percent (e.g., 21.5 months/23.5 blocks out of 36 months) of the required experiences must be in the Emergency Department under the supervision of emergency medicine faculty members. This includes: IV.A.6.a)] four months/blocks of critical care five full-time equivalent (FTE) months/blocks of pediatric patients 0.5 months of obstetrics or 10 low-risk normal spontaneous vaginal deliveries Do step-down units meet the critical care program requirement? The remainder of the time may be electives. No, step-down units do not meet this program requirement, as the same type of patient management is required. IV.A.6).(a).(1)] 2012 Accreditation Council for Graduate Medical Education (ACGME) Page 7 of 11

8 How are pediatric experiences that are longitudinal calculated? IV.A.6.a).(2))] What should a program do if does not have enough pediatric patient visits to meet the requirements? IV.A.6.a).(2))] Can pediatric critical care months count towards the critical care months required? IV.A.6.(a).(1) and IV.A.6.a.(2).(b)] Who are out-of-hospital emergency personnel? IV.A.6.d)] Evaluation What assessment methods can be used to evaluate the competencies, including procedures and resuscitations that are required annually? V.A.1.b).(4).(a) and V.A.1.d)] To calculate longitudinal pediatric patient encounters, multiply the number of general Emergency Department months or four-week blocks by the percent of pediatric patients. For example, if 15 percent of patients are pediatric and the resident spends 20 months in the Emergency Department (e.g. 20 months x.15 = 3 or the equivalent of 3 months) therefore the resident would need two additional months of dedicated pediatric experiences. A program that doesn t meet the required numbers of pediatric patient visits can balance a deficit of patients by offering dedicated rotations in the care of infants and children. Yes, any month(s) in a pediatrics critical care setting may also satisfy the critical month requirements. Examples of out-of-hospital emergency personnel include Emergency Medical Technician- Ambulance (EMT-A), Emergency Medical Technician-Basic (EMT-B), Emergency Medical Technician-Defibrillator (EMT-D), Emergency Medical Technician-Paramedic (EMT-P). The Review Committee recommends the following competency assessment methods: annual competency assessment, procedural competency, and resuscitation competency. Annual Competency Assessment The programs must define competencies that are expected for each year or level of education, taking into account the defined ACGME core competencies and milestones. Multiple tools or methods may be used to evaluate these competencies as indicated in the Milestones document. The Review Committee will review the competencies or outcomes expected for each year or level of education, the measurable competency objectives for each year or level of education, how these objectives are measured, and how deficiencies are remediated. Resuscitation Competency The Review Committee expects programs to assess resident 2012 Accreditation Council for Graduate Medical Education (ACGME) Page 8 of 11

9 How will resident advancement be affected if a resident needs remediation? competency in the resuscitation of critical patients, including both adult and pediatric medical and trauma resuscitations. At the time of program review, a program will need to demonstrate how it assesses competency in one type of resuscitation. The program may use a variety of techniques including simulations and direct observations. Deficiencies in specific areas do not necessarily mean a resident should be held back in progressing to the next year or level of education; however, plans must be in place to achieve the required competencies. V.A.1.e.] Resident Duty Hours in the Learning and Working Environment Can residents be supervised by The Review Committee will accept licensed or certified individuals on occasion to supervise licensed independent practitioners? residents in unique educational settings within the scope of their licensure or certification. Examples may include physician assistants, nurse practitioners, clinical psychologists, licensed [Program Requirement VI.D.1] clinical social workers, certified nurse midwives, certified registered nurse anesthetists and doctors of pharmacy. Oversight by a faculty physician member during these situations is required. Can residents from other specialties supervise emergency medicine residents? VI.D.2] Under which circumstances can a first-year resident be supervised indirectly with supervision immediately available? [Program Requirement VI.D.5.a).(1)] Residents from other specialties must not supervise emergency medicine residents on any emergency medicine rotation. Programs must assess the independence of each first-year resident based upon the six core competencies in order to progress to indirect supervision with supervision immediately available. Various required experiences may necessitate different sets of skills. For example, if a resident is deemed to have progressed to indirect supervision with supervision immediately available while rotating in the Emergency Department, this may not be the case in a subsequent required experience if it is the resident s first experience for another rotation such as medical intensive care unit (MICU) or trauma surgery Accreditation Council for Graduate Medical Education (ACGME) Page 9 of 11

10 What does the Review Committee consider an optimal clinical workload? [Program Requirement VI.E] Who should be included in the interprofessional teams? [Program Requirement VI.F] How much time should a resident have off between shifts? [Program Requirement VI.G.5.b)] Other How must a request for a permanent change in resident complement be submitted? A resident in the Emergency Department at the very beginning of the program should have a smaller workload than a resident at the same level in the same rotation at the end of that academic year. Each program must adhere to their graduated responsibility policy. This of course may vary by area of service, based upon each individual s level of achieved competence (knowledge, skills and attitudes), and based upon patient acuity. The milestones must be used to assess each resident s competencies. Both insufficient patient experiences and excessive patient loads may jeopardize the quality of resident education. Examples of professional personnel who may be part of interprofessional teams, all members of which must participate in the education of residents, include advanced practice providers, case managers, child-life specialists, emergency medical technicians, nurses, pain management specialists, pastoral care specialists, pharmacists, physician assistants, physicians, psychiatrists, psychologists, rehabilitative therapists, respiratory therapists, and social workers. Per the Common Program Requirements, residents must have at least eight hours off between shifts, and should have 10 hours off. In Emergency Medicine, the scheduled clinical shift is the basis for the required time off and allows the other clinical time (finishing documentation, handing off, etc.) to count towards the total duty hours each week. Consequently, it is the Review Committee s expectation that if a resident works an 8-hour, 9- hour or 10-hour shift, he or she should be scheduled for 10 hours off between work periods; if a resident works a 11-hour shift, he or she should be scheduled for 11 hours off between work periods; if a resident works a 12-hour shift, he or she should be scheduled for 12 hours off between work periods. All time (clinical and educational) counts toward the total average time cap per week. A request for a change in resident complement, as with a request for a change in program format, must be submitted through the ACGME s Accreditation Data System (ADS). The designated institutional official (DIO) of the sponsoring institution must sign off on the change within ADS before it can be processed and acted upon by the Review Committee. Additional data that must be submitted with the request in ADS is outlined in the Resident Complement document that can be found in the main section of the Review Committee s web page Accreditation Council for Graduate Medical Education (ACGME) Page 10 of 11

11 How long does it take for the Review Committee to communicate its decisions regarding complement change requests? Normally, the Committee is able to respond with an answer to a request for a complement change in approximately two-to-three weeks. Occasionally, requests will need to be reviewed at the time of the Committee s next meeting. Review Committee staff members at the ACGME will contact the program to indicate if this is the case. Complement increase requests will not be reviewed between the date the agenda closes for a Committee meeting and the last date of that meeting. In order to be reviewed within two-tothree weeks of submission, all complement increase requests must be submitted through ADS, and approved by the DIO within ADS, no later than the agenda closing dates posted on the Review Committee s web page on the ACGME website. 11/01/ Accreditation Council for Graduate Medical Education (ACGME) Page 11 of 11