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Supervision Policy

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 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. Primary (on-service) and backup (e.g. Day Float or Ward Senior) residents are jointly accountable, with their supervising faculty, for ensuring the quality and safety of our patient care. Primary residents are required to ask for backup when needed and backup residents are required to provide such without reprisal.

We’ve chosen not to specify exactly when backup must be requested on account of patient volume, as there are many variables affecting this issue—not just the number of patients waiting to be seen, but the acuity of illness, the experience level of the resident, etc. However, supervising faculty will insist on the primary resident’s calling in the backup if they detect the need for such. There are also some condition-specific requirements for communicating with faculty set forth below.

Finally, our nursing, allied health, and other clinical colleagues should remember that while residents provide much front-line care, especially in the hospital, every patient has an attending physician ultimately responsible for his or her care. Should a clinical concern arise that appears not to be adequately addressed by the resident, the issue should be escalated to the attending physician.

Levels of Supervision

The levels of supervision used in this policy are defined by the ACGME Common Program Requirements:

  1. Direct Supervision: The supervising physician is physically present with the resident and patient. Outpatient clinics and bedside teaching rounds are generally conducted under direct supervision.

  2. Indirect Supervision
     
    1. with direct supervision immediately available: The supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide direct supervision. Daytime consultations are generally conducted in this way.
       
    2. with direct supervision available: The supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by telephone or other electronic means and is available to provide direct supervision. Nighttime consultations are generally conducted in this way.
       
  3. Oversight: The supervising physician is available to provide review of procedures / encounters with feedback provided after care is delivered. This type of supervision is generally limited to after-hours patient / family telephone calls fielded by residents. Even in that circumstance, however, a resident may always call his or her supervising attending for advice when needed.

Progressive Resident Responsibility over Time

PGY-1 Residents

Neurology interns spend the majority of the year completing off-service rotations in internal medicine and other specialties, along with a few rotations in neurology. Each program’s respective supervision policy will apply to the neurology PGY-1 residents. During the neurology rotations, the PGY-1 resident will be indirectly supervised with direct supervision immediately available.

PGY-2 Residents

Neurology residents entering the neurology-specific portion of the training program will, for their first few weeks of training, be indirectly supervised with direct supervision immediately available. PGY-3 and PGY-4 residents, fellows, or attending staff may supervise the PGY-2s during this month. As PGY-2 residents gain experience, they will transition to being indirectly supervised with direct supervision available. Each case is staffed with the attending physician at the time of admission or consultation, or very shortly thereafter.

PGY-3 and PGY-4 Residents

Neurology residents at the senior levels are indirectly supervised with direct supervision available. At the beginning of the PGY-3 year, residents still staff cases at the time of consultation. The Clinical Competency Committee (CCC) will determine each year when senior residents may admit patients from the emergency department and consult in the various hospital units, with the attending physician staffing the patient the following day. If the resident’s performance necessitates it, the CCC may also re-institute the requirement for a senior resident to staff all cases in real-time.

When admitting or consulting independently, the senior resident must complete the H&P or consultation note by 0800 the following day and co-sign the note to the faculty physician who was on call at the time of the consultation.

The attending physician must be contacted to discuss any patients who the resident feels are beyond his or her level of competence or who fall into any of the categories listed below. In particular, all patients who are to be discharged directly from the emergency department must be discussed with an attending physician. Other situations requiring attending involvement are listed below.

Clinical Situations Requiring Communication with Faculty

Stroke codes

PGY-2 residents in the first few weeks of training will run stroke codes under the direct supervision of a senior resident, fellow, or attending. Thereafter, supervision for stroke codes will generally correspond to the rules above for the resident’s PGY level. It is up to the stroke attending on call to determine for each individual case and each individual resident how much supervision is required. For example, in a straightforward case, the stroke attending may allow a competent PGY-2 resident to give alteplase under indirect supervision. In a more complicated case or with a less experienced resident, he or she may elect to directly supervise the evaluation and treatment.

Seizures and status epilepticus

For immediate clinical decision-making, e.g. when status epilepticus must be ruled out with a STAT bedside study or patient undergoing continuous EEG monitoring may have had a seizure, residents preliminarily interpret EEGs under indirect supervision, with direct supervision available from the epilepsy or neurophysiology fellow or the attending epileptologist. Final EEG reports are always signed by the attending epileptologist.

Patients with super-refractory status epilepticus can be difficult to manage. To improve the care these patients receive, the epilepsy team can take a more active role in their management. Input from the epilepsy team is an optional service that can be requested at the attending neurologist's discretion (usually the consult attending).

Brain death exams and post-anoxic coma prognosis

Neurology residents must perform at least one such exam under the direct supervision of a senior resident or fellow or the attending physician. Once the resident has done so, he/she may perform them under indirect supervision with direct supervision available and also serve as supervisor for the more junior residents performing such exams.

Other specific situations

Regardless of PGY level or the specific clinical condition, residents are expected to discuss with their attending physicians in a timely manner all patients who:

  • Are to be discharged from the emergency department
  • Have an unknown diagnosis
  • Manifest a severe neurological deterioration
  • Require transfer to an intensive care unit
  • Transition to palliative care
  • Leave the hospital against medical advice

Procedural Supervision

Lumbar punctures

Neurology residents (including PGY-1s) will be directly supervised by a qualified resident, fellow, or attending physician in the successful performance of 3 lumbar punctures (LPs). The multiple sclerosis clinic advanced practice providers (APPs) are highly experienced in performing LPs and may teach residents how to perform the procedure; the APP’s physician supervisor is the attending supervisor for LPs performed in that clinic.

The first 3 LPs must be documented in MedHub. Once a resident successfully completes the required 3 procedures, he or she may perform the procedure with indirect supervision with direct supervision available and also supervise other trainees.

Residents must first discuss the procedure with the attending physician if:

  1. Platelets are < 100,000
  2. INR > 1.3
  3. The patient is on any antithrombotic other than aspirin
  4. The patient has not had any brain imaging
  5. The patient has brain imaging showing a mass lesion
  6. The patient is uncooperative or combative
  7. The procedure is being done under an emergency situation without consent of the patient or family
  8. There is visible skin infection (shingles, cellulitis, ulceration) in or near the area where LP is to be performed

Electromyogram (EMG) and nerve conduction studies (NCS)

In the PGY-2 and PGY-3 years, neurology residents performing EMG and NCS are directly supervised by a neurophysiology fellow or attending physician. Depending on the complexity of the case and the resident’s level of competence as judged by the attending, PGY-4 residents may be permitted to perform the studies under indirect supervision, with direct supervision immediately available.

Deep brain stimulator (DBS) adjustment prior to surgery or MRI

Neurology residents may need to turn on and turn off DBS for patients undergoing surgical procedures or MRI studies. A neurology resident will be directly supervised in this procedure by a resident, fellow, or attending for one procedure. The movement disorders APP can also teach residents how to do this; as with LPs, the supervising physician for this procedure is that APP’s supervising physician. After one supervised adjustment, the resident can do so thereafter with oversight level of supervision.

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.

Needle muscle biopsies

Neurology residents may assist in this procedure with direct supervision of the attending physician.

Skin punch biopsies

Neurology residents may assist in this procedure with direct supervision of the attending physician.

Peri-cranial nerve blocks

For the following procedures, neurology residents will be directly supervised by a qualified resident, fellow, or attending physician for 5 procedures. Similar to LPs and DBS and VNS adjustments, the headache clinic APPs can teach residents how to perform the blocks, with that APP’s supervising physician serving as the supervisor of these procedures. Once a resident successfully completes the required 5 procedures, he or she may perform these procedures with oversight level of supervision and also supervise other trainees:

  • Botox injection for migraine
  • Trigger point injections
  • Occipital nerve blocks
  • Supraorbital nerve blocks

EMG-guided Botox injections

Neurology residents may assist in these procedures with direct supervision of the attending physician.

 

Latest revision: 10-11-2019

Justin A. Sattin, MD