Created by SAMBA Taskforce on Ambulatory and Office – based Anesthesia:

Chair: Shireen Ahmad, M.D.

Members:  Barbara S. Gold, M.D.; Beverly K. Phillip, M.D.; Douglas G. Merrill, M.D.;Burton S. Epstein, M.D.; Frances F. Chung, M.D.; Tong J. Gan, M.D.; Girish P. Joshi, M.D.; D. Janet Pavlin, M.D.; Jeffrey B. Brand, M.D.; Jeffrey L. Apfelbaum, M.D.; John A. Dilger, M.D.; Kathrine E. McGoldrick, M.D.; Kumar G. Belani, M.D.; Lee A. Fleisher, M.D.; Lucinda L. Everett, M.D.; Maryann Vann, M.D.; Walter G. Maurer, M.D.; Meena S. Desai, M.D.; Patricia A. Kapur, M.D.;Peter M. Glass, M.D.; Raafat S. Hanallah, M.D.; Rebecca S. Twersky, M.D.; Thomas W. Cutter, M.D.

Approved by SAMBA Board of Directors: May 2008

I.  INTRODUCTION

A.  Definition and Scope of the Subspecialty
Ambulatory anesthesia is the subspecialty of anesthesiology devoted to the preoperative, intraoperative and postoperative anesthetic care of patients who undergo ambulatory surgery procedures.

B.   Educational Philosophy
While virtually all anesthesiologists are able to provide safe perioperative care for patients undergoing routine diagnostic and therapeutic ambulatory procedures, few trainees have gained sufficient clinical experience and training during residency to provide optimal care for the patient who has a complicated medical condition or who is undergoing a complex ambulatory surgeries. In order to provide high quality, cost-conscious, clinical care to patients undergoing ambulatory surgical procedures, there is a need for anesthesiologists with additional skills in clinical care and judgment, research, teaching, and administration.

C.   Educational Goals
The fellowship program in Ambulatory Anesthesia will prepare the anesthesiologist to:

• Provide expert anesthesia care for many common ambulatory surgeries (e.g.,orthopedics, general, gynecologic, otorhinolaryngologic, pediatric, ophthamologic, podiatric and urologic)
• Select appropriate patients, anesthetics, and procedures
• Provide perioperative anesthesia care for a patient in an office-based setting
• Perform basic peripheral nerve blocks
• Staff the postanesthesia care unit (PACU), PACU bypass unit, and same-day surgery recovery unit (phase II recovery)
• Supervise two or more operating rooms
• Take charge of (coordinate) anesthesia staffing and OR scheduling
• Design clinical pathways for common outpatient procedures
• Design clinical research for the ambulatory setting
• Practice in an interdisciplinary setting with medical direction of the entire ambulatory care process
• Provide administrative leadership in an ambulatory facility

D.   Program Duration
Subspecialty training in ambulatory anesthesiology shall comprise a minimum of 12 months duration after satisfactory completion of a residency program in anesthesiology as required for entry into the examination system of the American Board of Anesthesiology. 75 percent of the fellowship will be dedicated to the clinical practice of ambulatory anesthesia. The remaining 25 percent (and no less than 20 percent), may be devoted to research activities, administration education and/or other clinically relevant areas. The MINIMUM duration of training shall be 1 year. Anything less than one year will not qualify for the use of the title “fellow or fellowship” in the diploma language

II.  INSTITUTIONS

A.   Sponsoring Institution
Institutions with sub-specialty training in ambulatory anesthesia must have a direct affiliation with an ACGME accredited residency in anesthesiology. If the institution in which the fellowship is based is other than the primary institution of an accredited residency, a written agreement linking the two, and an evaluation protocol consistent with ACGME-approved standards for residency programs must be pre-requisites. The fellowship must be recognized and approved by the institution’s division of Medical Education.  A single sponsoring institution will assume responsibility for the entire program.  This responsibility will extend to all fellow assignments at all participating sites.

B.   Participating Site
1.     Assignment to a site must be based on an educational rationale that is integral to the program curriculum and that has clearly stated activities and objectives. Because multiple sites participate, there must be assurance of the continuity of the educational experience.

2.    Assignment to a participating site requires a letter of agreement with the sponsoring institution. Such a letter of agreement should:

a)   identify the faculty who will assume both educational and supervisory responsibilities for fellows

b)   specify faculty responsibilities for teaching, supervising, and evaluating fellows (Part VI in this document)

c)   specify the duration and content of the educational experience

d)   state the policies and procedures that govern fellow education during the assignment

C.   Relationship to the Core Residency Program
There must be close cooperation between the core residency program and the subspecialty training program. The division of responsibilities between residents in the core program and the ambulatory anesthesiology fellow must be clearly delineated. The presence of an ambulatory anesthesiology fellowship must not be permitted to compromise the clinical experience and the number of cases available to the residents in the core program in anesthesiology.

D.   Institutional Policy
There should be an institutional policy governing the educational resources committed to the ambulatory anesthesiology program.

III.   PROGRAM  PERSONNEL AND  RESOURCES

A.   Program Director
1.    A single Program Director is responsible for the operation of the entire program at the sponsoring institution and the participating sites.

2.    The Program Director, together with the faculty, administers the program and establishes a stable educational environment during an appointment period that is adequate to maintain continuity of leadership.

3.    The Program Director must have the following qualifications:

a)   expertise in ambulatory anesthesia as well as documented educational and administrative abilities

b)   experience in anesthesia care for ambulatory surgery patients beyond the requirements for completion of a core anesthesiology residency

c)   Board certification in anesthesiology

d)   an appointment in good standing on the medical staff of the sponsoring institution

e)   a license to practice medicine in the state in which the sponsoring institution is located

4.  The Program Director’s responsibilities are as follows:

a)   to oversee and organize the activities of the educational program at all sites participating in the program

b)   to select fellows in accordance with program, departmental, and institutional policies

c)   to make time for substantial leadership in the program and in the supervision of the fellows

d)   to prepare a written outline of the educational goals of the program with respect to the knowledge, skills, and other attributes of fellows for each rotation or other program assignment. This statement must be distributed to fellows and members of the teaching staff.

e)   to guide fellows through explicit written descriptions of supervisory lines of responsibility for the care of patients. Such guidelines must be communicated to all members of the program staff via reliable systems for interaction with supervisory physicians.

B.   Faculty
1.    At each participating institution, there must be a sufficient number of faculty with documented qualifications to instruct and supervise the fellows in the program. Although the number of faculty members will vary, at least 3 faculty members must participate, and these should be equal to or greater than 2 full-time equivalents, including the Program Director. A ratio of no less than one full-time equivalent faculty member to one fellow shall be maintained at any given site.

2.    The faculty must devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities. They should have a strong interest in the education of fellows and must support the goals and objectives of the program.

3.    The qualifications of the physician faculty are as follows:

a)   The physician faculty must be in good standing at the  institution participating in the program.

b)   The physician faculty must possess the requisite subspecialty expertise, experience, and competence in clinical care and teaching as well as documented educational and administrative abilities in ambulatory anesthesia.

c)   There must be evidence of active participation by qualified physicians with expertise in adult ambulatory anesthesia beyond the requirement for completion of a core anesthesiology residency.  Faculty must have a continuous and meaningful role in the program.

IV.   FELLOW APPOINTMENTS

A.   Eligibility Criteria
The Program Director must comply with the criteria for fellow eligibility as specified in the institutional requirements.

B.   Number of Fellows
The number of fellows will be based upon the adequacy of resources for fellow education (e.g., the type and volume of patients and clinical material available for education), faculty-fellow ratio, institutional funding, and the quality of faculty teaching.

C.   Fellow Transfers
To determine the acceptable level of education for fellows who are transferring from another fellowship program, the Program Director must receive written verification of previous educational experiences and a statement of the fellow’s performance evaluation before acceptance into the program. The Program Director is required to verify fellowship education for fellows who may leave the program before completion of their education.

D.   Appointment of Fellows and Other Students
The appointment of fellows and other specialty fellows or students must not dilute or detract from the educational opportunities available to regularly appointed fellows.

V.   PROGRAM  CURRICULUM

A.   Goals
The program must include a written statement that outlines the educational goals with respect to the knowledge, skills, and other attributes of fellows for each major assignment and for each level of the program. This statement must be distributed to fellows and faculty and must be reviewed with fellows before their assignments.

B.   Objectives
The program must include well-organized and effective clinical, didactic, research, and administrative curricula with clearly stated objectives. All educational components of the program should fulfill the program goals. A written statement of these objectives must be given to each fellow. Fellows must participate in the clinical subject areas through a structured program.

1.  Clinical Education

The clinical program will serve as the cornerstone of the fellowship program in ambulatory anesthesia. Clinical opportunities will consist of managing the preoperative, intraoperative, and postoperative care of patients who need various ambulatory surgical procedures. The minimum duration of clinical training is 6 months.  Rotations must consist of a comprehensive experience including, but not limited to, the following areas:

a)   Core requirements (1 month for each)

• • office-based anesthesia
  • ambulatory surgery center
  • perioperative medicine
  • regional anesthesia for ambulatory surgery
  • pediatric ambulatory anesthesia
  • administrative and leadership training including practical experience in daily management.

b)  Clinical experience should include rotations for the following surgeries:

• orthopedic
• arthroscopic, foot
• gynecologic
• laparoscopic, hysteroscopic
• genitourinary
• general
• laparoscopic
• thoracic, thoracoscopic
• mediastinoscopic
• vascular
• neurosurgical
• ENT/ophthalmologic
• oral
• plastic
• interventional radiology

c)   To achieve the necessary level of expertise, fellows must be familiar with the indications, contraindications, techniques, and complications of anesthetic techniques, which include, but are not limited to, the following:

• 400 general anesthetics
• 100 Sedation/ Analgesia (MAC)
• 100 regional anesthetics (at least 25 each of 4 or more blocks):
• axillary
• interscalene
• sciatic nerve
• ankle
• supraclavicular/infraclavicular
• femoral nerve
• popliteal fossa

d)  Fellows must complete daily case logs to track their clinical experiences. These logs shall be reviewed regularly with the faculty advisor.

2.  Didactic Education

A didactic program specifically dedicated to ambulatory anesthesia practice will be offered, and the fellow will participate as an attendee and a presenter. The fellow will read at least one textbook and selected journal articles relating to ambulatory anesthesia. Other parts of didactic education include the following:

a)   Weekly—An hour-long lecture or discussion series that will cover relevant topics shall be held no fewer than 24 times per year.

b)   Monthly—A Journal Club  to review current literature shall be held at least once monthly. Fellows shall present articles at least twice in 12 months with a faculty advisor.

c)   Monthly—A lecture or case conference specifically designed for fellows and supervised or given by a qualified faculty member shall take place at least once per month.

d)   Once—A Grand Rounds lecture with a literature review will be presented at least once during the course of the fellowship.

e)   Recommended—Joint conferences with surgical or medical colleagues are recommended to help the fellow appreciate the practice of ambulatory anesthesia from a multidisciplinary perspective.

f)   Ongoing—Fellows will have the opportunity to teach residents during the academic year.

3.  Research Education

Fellows will participate in research or other scholarly activities supervised by qualified faculty.  Participation in on-going clinical research projects is an essential component of the program.

To perform meaningful research the fellow will have protected time, either in blocks or concurrent with clinical rotations.  The research curriculum will include instruction in research design and methodology as well as the conduct of clinical protocols, evaluation, and interpretation of data.  The fellow must demonstrate evidence of research productivity (e.g., publication in peer-reviewed journals or abstracts presented at national anesthesiology society meetings).

4.  Administrative Education

The program must have the resources for an administrative experience to develop competency in leadership, management and organizational skills required of a Medical Director, such as

a)  delineating the roles of other members of the team

b)  communicating clearly in a professional and collegial manner to achieve  patient care goals

c)   formulating care plans that use multidisciplinary team skills such as a plan for patient recovery

d)   understand the logistics of  establishing and conducting an office based anesthesia program

The fellow will have the following administrative opportunities:

a)  participation in the daily decision-making in the operating rooms and in the development and analysis of quality tracking studies

b)  training in organizational team behavior and human resource management

c)  participation in budgeting and other financial aspects of managing a surgical facility

VI.    EVALUATION

A.   Of the Fellow
The fellowship program must demonstrate an effective mechanism for assessing the fellow’s performance throughout the program and for using the results to improve performance. Attitude, interpersonal relationships, fund of knowledge, manual skills, decision-making skills, and critical analysis of clinical situations will be evaluated. Written feedback is given at midpoint and at the end of every rotation.   Assessment includes the following:

1.    Methodology for the accurate assessment of competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.

2.    Regular and timely feedback of at least semi-annual written evaluations. Such evaluations are maintained in a record that is accessible to each fellow.

3.    Use of results, including evaluation by faculty, patients, peers, self, and other professional staff, to achieve progressive improvements in competence and performance.

The final evaluation must include a review of the fellow’s performance during the period of education and should verify that the fellow has demonstrated sufficient professional ability to practice competently and independently. The final evaluation is part of the fellow’s permanent record maintained by the institution.

B.   Of the Faculty
The performance of the faculty must be evaluated by the program. The evaluations should include a review of faculty teaching abilities, commitment to the educational program, clinical knowledge, and scholarly activities. This written evaluation by the fellows is confidential.

C.   Of the Program
The educational effectiveness of a program must be evaluated regularly in a systematic manner.

1.    Representative program personnel (e.g., the Program Director, representative faculty, and one fellow) must review program goals and objectives and their effectiveness.   This group conducts a formal meeting at least annually for this purpose. In the evaluation process, the group considers written comments from the faculty and the fellows’ confidential written evaluations. If areas for improvement are noted, the group should prepare an explicit plan of action, which should be approved by the faculty and documented in the minutes of the meeting.

2.    Fellow performance and outcome assessment is used to evaluate the educational effectiveness of the fellowship program. Performance of graduates on the certification examination is one measure of the program’s effectiveness. A process should be maintained for using assessment results to improve the fellowship program.

3.    Periodic evaluation of patient care (quality assurance) is mandatory. Subspecialty fellows in ambulatory anesthesia shall participate in continuous quality improvement, utilization review, and risk management programs.

VII.   JOB  PLACEMENT

Upon completion of the program, fellows will be assisted in finding professional positions and in preparing curriculum vitae and interview strategies.

VIII.   EXPERIMENTATION  AND  INNOVATION

Since responsible innovation and experimentation are essential to improving professional education, experimental projects along sound educational principles are encouraged. The sponsoring institution and program are jointly responsible for the quality of education offered to fellows for the duration of such a project.