Our Culture of Safety
Ours is an interdisciplinary team effort designed to provide the best possible care for our patients as we develop the clinical skills in the next generation of child neurologists. We strive to maintain in our program a culture of safety, meaning not only that the safe and appropriate care of our patients is always paramount, but also that our trainees and colleagues are always empowered to raise concerns about the care in which they’re participating. Residents should never hesitate to admit that they need help, don’t know something, may have committed or identified an error, etc. The program will never retaliate against anyone taking such actions in good faith.
Chain of Command
Residents should never feel isolated and out of their depth, as there is always more experienced backup available. Junior and senior residents are jointly accountable, with their supervising faculty, for ensuring the quality and safety of our patient care. Junior residents are required to ask for backup when needed and senior residents are required to provide such without reprisal. We’ve chosen not to specify exactly when backup must be called in due to the many variables affecting this issue. However, supervising faculty will insist on the junior resident’s calling in the senior if they detect the need for such. Similarly, our nursing, allied health, and other clinical colleagues should know that if a patient appears to not be receiving the proper care from a junior resident, senior backup is available according to the following chain of command:
- Junior resident. Listed as first call in all call schedules on WebXchange
- Senior resident. In order to avoid misdirected pages after hours, the senior resident is not always listed in WebXchange, but there is always someone on call—just call telecommunications (2-2122) to have the neurology senior resident paged.
- Attending physician. Always listed in the call schedules.
- Residency program director. Not always available on pager, but telecommunications can call his/her cell phone at any time.
Lines of Supervision
Roles
Child Neurology Residents are physicians in training. They learn the skills necessary for their chosen profession through didactic sessions, reading and providing patient care under the supervision of Attending Staff physicians. As part of their training program, residents are given progressively greater responsibility according to their level of education, experience and ability.
Responsibilities
Child Neurology Residents are part of a team of professionals who care for patients. The professional team includes an attending physician, resident, other licensed practitioners such as NPs and PAs, and other trainees such as residents from other specialties and medical students. Residents may provide care in both the inpatient and outpatient settings. They may serve on a team that provides direct patient care, or may be part of a team that provides consultative service. Each member of the team is dedicated to providing excellent patient care.
All residents evaluate patients by obtaining medical histories and perform physical exams with special emphasis on the neurological exam. They will establish diagnoses and create problem lists. They will develop a plan of care in conjunction with other team members. They will document the history and exam and medical decision making as required by hospital policy. Residents will write orders for diagnostic studies, consultations, treatment interventions, and any other service required for the care of a patient. They will interpret the results of laboratory and other diagnostic testing. Residents will initiate and coordinate admissions and discharges of patients. They will participate in in various procedures under appropriate supervision. Residents will discuss the patient’s status and plan of care with the attending physician and team on a regular basis. During PGY 4 or 5, child neurology residents will be expected to supervise junior-level adult neurology residents and medical students.
Supervision
In any physician training program, it is incumbent on the physician to be aware of his or her own limitations in managing a given patient, and to consult a more experienced physician when necessary. When a resident requires supervision, this may be provided by a qualified member of the medial staff, or by a trainee who is authorized to supervise the patient’s management or procedure independently.
In the clinical learning environment, each patient must have and will have an identifiable attending physician who is ultimately responsible for the patient’s care, including care provided by trainees. This information will be available to residents, patients and other hospital staff. Residents and attending staff will inform all patients of their respective roles in each patient’s care. In all resident care cases, the ultimate responsibility for the patient rests with the attending physician who supervises resident activities.
PGY5 Child neurology residents may supervise PGY3 and PGY4 residents. PGY5 residents may only be supervised by attending Child neurologists.
Levels of Supervision
The following levels of supervision are mandated by the ACGME Common Program Requirements, effective 1 July 2011:
- Direct Supervision
- The supervising physician is physically present with the resident and patient during the key portions of the patient interaction.
- Indirect Supervision
- The supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident for guidance and is available to provide appropriate direct supervision.
- Oversight
- The supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered
Child Neurology Residents are supervised for patient care and performance of procedures as follows:
Clinical Supervision
PG3 Training year
Child Neurology residents entering the neurology-specific portion of the training program will initially be supervised for all patient encounters at a minimum level of indirect supervision with direct supervision immediately available. PG4 and PG5 child neurology residents, PG3 or PG4 adult neurology residents or attending staff may supervise in this setting. As PG3 residents gain experience, minimum supervision level will change to indirect supervision with direct supervision available. The timing of this will vary for each resident. On a monthly basis, senior level residents and supervising staff will meet and decide whether a PG3 level resident has gained enough experience for this level of supervision, typically expected after the 4th month of neurology training.
PG4 Training year
Child neurology residents at the PG4 year are supervised for all patient encounters at a level of at least indirect supervision. In specific instances defined by the attending physician, supervision for patient encounters may occur at the oversight level.
PG5 Training year
Child neurology residents at the PG5 year may be supervised for patient clinical encounters at any supervisory level. However, it is expected that most patient encounters will be supervised at the oversight level.
Residents providing patient care in the ICU setting, or where ‘end-of-life’ and brain death determinations are being made, supervision must be at a minimum of indirect supervision available. In particular, attending staff must immediately be made aware of sudden neurological deterioration of a patient under the care of a child neurology resident.
Procedures Supervision
*All procedures will be documented in MedHub with supervisor signature.*
- Lumbar Puncture
A PG3-PG5 child neurology resident will be directly supervised in the performance of 3 lumbar punctures. Once a resident successfully completes the required 3 procedures, he or she may supervise other trainees in performance of lumbar puncture or perform the procedure with oversight level of supervision. This also applies to PG1 and PG2 residents while they rotate on the neurology services.
Required documented number of procedures during training: 15
- TPA administration for stroke
Initially, a child neurology resident will be directly supervised by an attending physician for TPA administration. Child Neurology residents must participate in the decision to administer TPA to stroke patients (whether or not TPA was actually administered) for a minimum of 20 patients before he/she can administer TPA with indirect supervision with direct supervision available.
Required documented number of procedures during training: 3
- EEG interpretation
All EEGs are reviewed and interpreted with an attending physician or neurophysiology fellow. Prior to finishing the program, a child neurology resident will have reviewed and interpreted a minimum of 30 EEGs and created a minimum of 30 EEG reports in order to be recommended for credentialing for this privilege.
Required documented number of procedures during training: 30
- Vagus nerve stimulator (VNS) adjustment
Similar to DBS above, a resident will be directly supervised by a qualified practitioner for a single patient care episode before being permitted to perform the procedure with oversight supervision.
Required documented number of procedures during training: 2
- Electromyogram studies (EMG)/ Nerve Conduction Studies (NCS)
Child neurology residents are directly supervised by attending staff for a minimum of 5 patient studies. The resident may then perform studies with oversight supervision if approved by supervising attending physician.
Required documented number of procedures during training: 5
- Needle muscle biopsies
Child neurology residents may assist in this procedure with direct supervision of the attending physician.
Required documented number of procedures during training: 1
- Skin punch biopsies
Child neurology residents may assist in this procedure with direct supervision of the attending physician.
Required documented number of procedures during training: 1
- Botox administration
Child neurology residents may assist in this procedure with direct supervision of the attending physician.
Required documented number of procedures during training: 5
Procedures will be documented in a procedure log in MedHub.
Last revision: 4/27/2021, Adam Wallace
