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 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 should always feel safe to raise concerns about the care they are participating in. Residents and fellows should never hesitate to admit that they need help, don’t know something, may have committed or identified an error, etc. Never be afraid to ask for help, say that you’re not sure how to do something, or raise other patient care concerns; the neurology residency program and neurovascular fellowship program will never retaliate against anyone taking such actions in good faith.
Chain of Command
Fellows should never feel isolated and out of their depth, as there is always more experienced backup available. 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, backup is available in the form of senior residents and fellows. Following is the chain of command for neurology patients:
- 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.
- Neurovascular Fellow: Will be listed in the call pool in WebXchange when they are on service and/or taking call.
- Attending physician. Always listed in the call schedules.
- Fellowship program director. Not always available on pager, but telecommunications can call his/her cell phone at any time.
Levels of Supervision
Supervisory Lines of Responsibility
- All patient care by the fellow is supervised by qualified faculty
- All on-duty faculty and fellows are available by pager at all times
- All fellows on affiliate rotations (vascular neurosurgery, etc.) are supervised by the assigned faculty physicians in that field at that participating site
The levels of supervision used in this policy are defined by the ACGME Common Program Requirements:
- Direct Supervision: the supervising physician is physically present with the resident and patient.
- Indirect Supervision: The supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the fellow for guidance and is available to provide appropriate direct supervision.Fellows provide much inpatient care, and some outpatient VA care, with this type of supervision. Even when fellows provide consultations, or answer patient calls overnight without discussing with an attending physician in real-time, the attending faculty nonetheless are available to provide guidance to any fellow on any case at any time.
- Oversight: the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.
Vascular neurology fellows may be supervised for patient clinical encounters at any level during the course of the year, but it is expected that most patient encounters will be supervised at the levels of without direct supervision immediately available to oversight. The attending physician must be immediately made aware of any unexpected deterioration of a patient under the care of the fellow. Lumbar puncture is learned to proficiency during neurology residency, and supervision will be at the oversight level. Reperfusion treatments for stroke are also be learned to proficiency during neurology residency, and will be a primary focus of the fellowship experience. Supervision for this will usually be without direct supervision immediately available, although the attending physician is always able to provide direct supervision in a short timeframe by driving in from home at any time. The transfer protocol is that the fellow will verbally check out all patients when leaving duty to both the resident and attending for that patient.
Neurovascular fellows will have graduated from a neurology residency program in good standing and will be given responsibilities in accordance with that level of training. After one month of indirect supervision with direct supervision available, they will be expected to practice with oversight in a majority of cases but will always have faculty-level backup available if needed. They will be expected to staff patients with junior and senior residents for in-hospital and emergency department consults and admissions. While the fellow does not need to call the attending for admissions to the stroke service or other services, patients being discharged from the emergency department should be staffed with an attending physician prior to leaving. They will also be in the rotation for telestroke call and will independently evaluate patients through that system once they are credentialed at the referring hospital.
Specific Clinical Conditions
Fellows in the first month of training will run stroke codes under the indirect supervision with direct supervision immediately available. After that month, if the fellow has shown the appropriate acumen, they will be expected to run stroke codes without direct supervision available but only with the understanding that they are expected to contact the on-call faculty member with any concerns or difficult cases. For patients who may be candidates for endovascular therapy (large vessel ischemic strokes), the fellow must immediately notify the stroke attending on call to facilitate coordination with the on-call neuroendovascular specialist. As the year progresses, the fellow may assume the responsibility of contacting the neuroendovascular attending directly.
Brain death exams
Neurovascular fellows will have performed brain death exams during residency, including apnea tests. During their fellow year, they will be expected to do them under indirect supervision with direct supervision available.
Other critical illnesses
Regardless of PGY level or the specific clinical condition, residents and fellows are expected to discuss with their attending physicians in a timely manner all patients who:
- Manifest a severe neurological deterioration
- Require transfer to an intensive care unit
- Transition to palliative care
- Leave the hospital against medical advice
Occasionally patients admitted to the stroke service will require lumbar punctures for diagnostic purposes (vasculitis, subarachnoid hemorrhage, etc.). Fellows will have become proficient during their neurology residencies to perform lumbar punctures without direct supervision required. In a planned lumbar puncture is expected to be particularly difficult though, it is expected that the fellow will coordinate with the attending in order to do it under direct supervision.
Latest revision: 09/16/2021
Jamie Ellilott, MD, PhD