Dear Cardiology Fellow: by E9o0sv

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									  UMDNJ - SOM
  CARDIOLOGY
  FELLOWSHIP




   2010-2011
PROGRAM MANUAL




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                                                 Table of Contents
Welcome Letter                                                       1
Introduction                                                         2
Fellow’s File / Required Elements                                    3
AOA/ ACOI Professional Documents                                     4
Basic Standards for Fellowship Training – Internal Medicine          5
Basic Standards for Residency -- Cardiology                          6
Basic Standards for Residency – Electrophysiology                    7
Basic Standards for Residency – Interventional Cardiology            8
Seven Core Competencies of the Osteopathic Profession                9
Dept. of Cardiology – Core Competency Workbook / Plan                10
Program Overview                                                     11
Program Philosophy                                                   11
General Description                                                  11
Training Tracks                                                      11
Requirements for Completion                                          11
Monthly Service Evaluation (Core Comp.Attach. A/B)                   11
Procedure Logs                                                       11
Conferences/Lecture/Didactic Function                                11
Academic Lecture Program                                             11
Morning Report                                                       11
Teaching Objectives                                                  12
Scientific Research Requirement                                      13
Cardiovascular Services / General Information                        14
Clinical Cardiology                                                  15
Inpatient Service                                                    15
Admissions                                                           15
Discharges                                                           15
Transfers                                                            15
Outpatient Service                                                   15
Medical Intensive Care Unit                                          15
Surgical Intensive Care Unit                                         15
Electrophysiology / Pacemaker Services                               16
Non-Invasive Laboratory                                              17
ECG Covered Topics                                                   17
ECG Syllabus                                                         17
Echocardiography                                                     18
Nuclear Cardiology                                                   19
Cardiac Catheterization                                              20
Night/Weekend/Holiday Call Coverage                                  21
Maggie’s Law                                                         21
Vacation Scheduling                                                  22
Conferences                                                          23
Fellow Dress Code                                                    24
UMDNJ-SOM Housestaff Immunization & Health Requirements              25
Reporting Forms                                                      26
Corrective Actions As per CIR                                        27
CIR                                                                  28
Miscellaneous                                                        29
NPI Application                                                      29
2010-2011 Rotation Schedule (Subject to Change)                      29

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2010-2011 Thursday Lecture Schedule (Subject to Change)     29
Department of Cardiology Contact Information                29
State of New Jersey Uniform Ethics Code                     30
Universal Protocol ~ Wrong site, wrong, person prevention   31




Revised 04/13/2010




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Dear Cardiology Fellow:

I would like to welcome you to the 2010-2011 UMDNJ-SOM / South Jersey Heart Group Cardiology Fellowship Program. We
look forward to an exciting clinical and academic year. Enclosed you will find the cardiology fellowship manual. Please refer to it
should you have any questions regarding any policies or procedures regarding the fellowship.

Enclosed / attached are your rotation, lecture and office schedules as well. I need to make it perfectly clear that there are NO
exceptions for missing weekly clinic hours. Your preceptor will discuss with you particular requirements that need to be
fulfilled during this clinical time.

Kate Jurman is the fellowship program coordinator. I need to express that you maintain communication with her. You’ll be
expected to keep your contact information up to date with her including home, cell and pager numbers, as well as your preferred
email addresses, as most program notifications come through the program coordinator. Please remember to check your e-
mail on a daily basis, as it is the preferred method for reminders and updates. Our South Jersey Heart Group Website
calendar is also a good source for updated information. Please remember to check it on a regular basis.

Quarterly meetings and evaluations are held during the academic year. Evaluations include a thorough review of your logs and
monthly service evaluations. This is also your quarterly forum for program feedback. Your research project will also be
evaluated every quarter for appropriate progress. As you know, your scientific research project is an absolute requirement in
order to graduate the program and receive your fellowship certificate. More information regarding the research project is
available in this manual. The quarterly meeting is two-part: First, we have a general meeting including the program director,
coordinator, chief fellow and all of the fellows; then, each fellow and chief fellow meets with the program director individually to
discuss their progress. I am also available at any time you need to talk to me.

Your procedure logs are one of the most important parts of your fellowship. Without them you cannot be credentialed at any
level. Not only does the AOA require log submission but hospitals frequently require more than just a letter from the program
director verifying your credentials. This year, all procedure logs will be completed using our New Innovation RMS, the same
software suite used to log duty hours.

You will note that in addition to your monthly schedule there are mandatory academic times to which you must adhere. Other
than clinic hours, Thursday afternoons from 1:00pm until 5:00pm are designated academic time and must be attended. If you
cannot attend for a valid reason, you must notify Kate or myself. As well, you will be expected to attend the cardiothoracic
surgical morbidity and mortality meeting at Our Lady of Lourdes, Camden, usually held the second Thursday of every month
from 7:30am until 9:00am in the 3rd floor Main conference room, and as well the cath lab peer review meetings held the first
Friday of every month from 7:30am-8:30am in the 3rd floor cath lab film reading room. Both of these experiences are to help you
understand the process that takes place during surgeries and caths as well as outcomes and procedures. Please be aware that
dates and times of these conferences change often, please consult your monthly fellowship schedule for an exact date
and time.

One other important point that must be mentioned is that in all of your consults, admit notes and history and physicals you must
address an OMT/ biomechanical examination and its relationship to cardiology. This must be performed in both review of
systems as well as the physical exam and will be scrutinized heavily. The AOA is very strict regarding this evaluation.

Lastly, there will be a year end examination to help us to identify the strengths and weaknesses of individual fellows as well as
the program. The examination is designed to test your skills at your particular fellowship year. Although this is not a formally
graded examination, it will be discussed with each of you individually and certainly your growth throughout the program will be
monitored by these year-end exams.

We look forward to an exciting year. As always, Kate and I are here to help you in anyway possible and look forward to starting
the year!

Sincerely,


John N. Hamaty, D.O., FACC, FACOI
Program Director




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Introduction

The administration, hospital staff and ancillary services would like to extend to you a warm welcome on the beginning
of this new academic year at the University of Medicine and Dentistry of New Jersey – School of Osteopathic
Medicine (UMDNNJ-SOM) and South Jersey Heart Group (SJHG). We are proud of the fact that we are able to
provide the best in medical care while maintaining a warm and friendly atmosphere of a small hospital environment.
You will find our institution to be a comfortable learning environment while also being academically challenging.

This manual is written with two intents in mind. First, we hope that it provides a means of orienting new fellows to the
operations of the various departments at UMDNJ and SJHG and to ease your transition from your previous internal
medicine residency training into cardiology fellowship training. Second, we hope that it provides a reasonable
complete and precise guideline for you to use in your day to day activities at UMDNJ and SJHG. This manual is not
meant to be a fixed and rigid document, but rather a flexible guide that can be changed and updated in the ever
changing field of cardiology and improved upon based upon your input and of its various authors.

The cardiology fellowship training program of the UMDNJ-SOM is an AOA approved three-year program designed to
provide excellence in training in the diseases of the cardiovascular system. This manual provides the specific
definitions, requirements and curriculum which govern the program. The manual will be updated on an annual basis
as new and important issues such as new diagnostic and treatment modalities and new training requirements
surface. Presently our program meets and exceeds the requirements of the basic standards for training in cardiology
as developed by the ACOI and approved by the AOA. Intrinsic to the standards of training is an emphasis on the
recommendations of the American College of Cardiology / American Heart Association / American College of
Osteopathic Physicians / American College of Physicians recommendations as delineated in the COCATS
documents.




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Fellow’s Files / Required Elements

A requirement of the program is a complete and updated fellow’s file which will include all of the required documents
of the AOA and ACOI and other documents pertinent to the successful management of fellow training and processing
issues. A complete file will promote a more complete record useful to the program and the fellows. Such items are
needed for the fellow as he or she applies for staff privileges in ensuing years and items needed for mandatory ACOI
compliance and inspections.

Your fellowship documents / files are maintained by the program coordinator and updated on an as-needed basis.
Post-fellowship, your records will be digitized and archived, and available for your credentialing needs.

Required Elements:

    1.    Completed UMDNJ-SOM OPTI Fellowship Application
    2.    Three original letters of recommendation
    3.    Current copies of all medical licensing
    4.    Current copies of CDS / DEA
    5.    Emergency Contact (Name, Telephone Number)
    6.    Certificate of medical school graduation
    7.    Copy of internship and residency training
    8.    Medical School Transcripts
    9.    Undergrad transcripts
    10.   Copy of certificate of National Board Completion
    11.   Documentation of active membership in the AOA / ACOI
    12.   Current CV



AOA / ACOI PROFESSIONAL DOCUMENTS

American Osteopathic Association
American College of Osteopathic Internists

Included in this section is the most recent update of Basic Standards for Fellowship Training in Internal Medicine
Subspecialties; Basic Standards for Residency Training in Cardiology; Basic Standards for Training in Clinical
Cardiac Electrophysiology and Basic Standards for Residency Training in Interventional Cardiology as set forth by
our governing bodies the American Osteopathic Association and the American College of Osteopathic Internists. If
amendments and / or deletions of these basic standards or complete revisions occur at any time these will be
provided to you immediately so that you can update your fellowship manual. For the 2010-2011 academic year we
will also be including our Core Competency plan and workbook for our training program. Included is a full outline of
all seven core competencies of the osteopathic profession which will give you a better understanding of the
progression of the workbook and plan. This will be further discussed at orientation, and will be an ongoing part of
your training and evaluation process throughout the academic year.




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BASIC STANDARDS FOR FELLOWSHIP TRAINING
IN INTERNAL MEDICINE SUBSPECIALTIES
American Osteopathic Association and the American College of Osteopathic Internists
Revised, BOT 2/2008
Subspecialty Basic Standards for Fellowship Training In Internal Medicine

INTRODUCTION
These are the basic standards for fellowship training in subspecialty internal medicine as established by the American College of
Osteopathic Internists (ACOI) and approved by the American Osteopathic Association (AOA). These standards are designed to
provide the osteopathic fellow with advanced and concentrated training in the subspecialties of internal medicine and to prepare
the fellow for examination for certification in those subspecialties.
STANDARD I – MISSION
The mission of the subspecialty osteopathic internal medicine training program is to provide fellows with comprehensive
structured cognitive and procedural clinical education in both inpatient and outpatient settings that will enable them to become
competent, proficient and professional osteopathic subspecialty internists.
STANDARD II – EDUCATIONAL PROGRAM GOALS
All subspecialty osteopathic internal medicine programs must formulate goals that will allow the fellows to apply the following
core competencies:
A. Osteopathic Philosophy and Osteopathic Manipulative Medicine;
B. Medical Knowledge;
C. Patient Care;
D. Interpersonal and Communication Skills;
E. Professionalism;
F. Practice-Based Learning and Improvement;
G. Systems-Based Practice.
STANDARD III- INSTITUTIONAL REQUIREMENTS
A. In order to provide an osteopathic subspecialty training program, an institution must meet all the requirements of the AOA as
formulated in the Basic Documents for Postdoctoral Training and must have an AOA approved and functioning program in
internal medicine and the subspecialty. The number of fellows in the subspecialty training program may not exceed the number
approved by the AOA.
B. The institution must provide a sufficient patient load to properly train a minimum of two
(2) fellows in the subspecialty. New programs must have a minimum of one approved position per training year to begin. Any
program without functioning subspecialty fellows for three (3) consecutive years shall be considered lapsed in accordance with
AOA policy.
C. The institution’s department of internal medicine shall have at least one (1) physician certified in the appropriate subspecialty
of internal medicine by the AOA and one other Basic Standards for Fellowship Training in Internal Medicine Subspecialties,
physician certified in that subspecialty by the AOA or the American Board of Medical Specialties. One of the AOA-certified
physicians shall be designated as the program director. Other qualified physicians participating in the training of fellows must
submit their curricula vitae and must be approved by the program director. The program director shall be appointed for an
appropriate period of time to assure program continuity.
D. The institution must bear all direct and indirect costs of AOA on-site reviews and their preparation.
E. The institution must comply with all the institutional requirements stipulated in the Basic Standards for Residency Training in
Internal Medicine of the AOA and ACOI, including all of the following areas:
1. Sufficient resources for a quality training program;
2. Notification of the AOA and ACOI of any major change in leadership or governance;
3. Library resources;
4. Study and on-call facilities;
5. Supervised ambulatory site for continuity of care training;
6. Program description;
7. Written policy and procedures manual;
8. Fellow contracts;
9. Fellow certificates;
10. Work hours policy;
11. Fellow files;
12. Timely submission of required materials;
13. Affiliation agreements.
STANDARD IV- PROGRAM REQUIREMENTS AND CONTENT
A. The general educational content of the program must include:

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1. The neuromuscular component of disease processes in the subspecialty. This
component shall be provided in both clinical and didactic formats.
2. Development of basic cognitive skills and knowledge as pertaining to normal physiology and pathophysiology of body systems
relevant to the subspecialty and the correlating clinical applications of medical diagnosis and management.
3. Opportunity throughout for exposure to issues the fellow will face as a practicing clinician, including health policy, managed
care, health administration, medical ethics, medical liability and practice management.
4. A list of learning objectives to determine learning expectations at yearly training levels.
5. A formal didactic structure including journal clubs, morning reports, case conferences and other programs. Attendance at
these meetings must be documented and faculty must participate in these meetings. This documentation must be made
available during an on-site program review.
6. A written curriculum must be provided for all fellows.
7. The program shall provide adequate exposure to medical research/review skills and methods of presentation, including
information related to changes in the health care delivery system. Documentation of research activities must be kept on file.
Requirements for preparation and submission of medical manuscripts are listed in Appendix A. All fellows must complete one
research project and submit an appropriate research paper during their subspecialty training. A fellow must describe the name
and type of project planned on the first year resident annual report that is submitted to the ACOI. For all fellowships except those
that are only one year in duration, if the planned project is a case project, it must be submitted to the ACOI six months prior to
completion of the fellowship so the Council on Education and Evaluation can ensure that the quality of the report is acceptable
according to the guidelines outlined in Appendix A. For fellowships that are only one year in duration, the case report may be
submitted at the completion of the fellowship. If the planned project is a report of an original clinical research study, the fellows
must submit this report by the completion of their training.
8. All programs must have a credentialing method in place that verifies competence in a procedure before allowing a fellow to
perform that procedure independently.
B. The specific educational content and program requirements for each subspecialty are attached and organized as follows:
1. Educational Program Duration.
2. Facilities and Resources.
a. Description of specific resources required for the subspecialty.
3. Specific Program Content.
a. Clinical requirements.
b. Technical skills requirements.
c. Ambulatory requirements.
d. Specific program content for knowledge areas.
4. Specific Faculty Requirements
C. At least 80% of the graduates of each AOA-approved subspecialty internal medicine fellowship program, averaged on a three
year rolling basis, must take the subspecialty certifying examination of the American Osteopathic Board of Internal Medicine.

STANDARD V- FACULTY AND ADMINISTRATION
A. Program Director
1. The program director of the subspecialty fellowship programs shall possess the following qualifications:
a. have practiced in the subspecialty for a minimum of three (3) years;
b. be in active practice in the subspecialty.
2. The program director must attend the Annual ACOI Congress on Medical Education for Resident Trainers a minimum of every
other year. Attendance must occur during the first year of appointment. It is also recommended that any physician anticipating
appointment to the position of program director of a fellowship program attend the Congress prior to assuming the position.
3. The program director must comply with all the other requirements for program directors as described in the Basic Standards
for Residency Training in Internal Medicine of the AOA and the ACOI. (Standard V.B.)
B. Faculty Qualifications and Responsibilities
1. There must be at least two faculty members of the subspecialty participating in the training program, including the program
director. Faculty must be either AOA- or ABIM-certified, or in the process of being certified. Faculty must be recertified in the
subspecialty within the period specified by the certifying body.
2. Osteopathic faculty must teach the application of osteopathic principles and practice in the subspecialty.
3. Faculty must meet all the other requirements as listed in the Basic Standards for Residency Training of the AOA and ACOI.
(Standard V.C.)
STANDARD VI - FELLOW REQUIREMENTS
A. Applicants for fellowship training in subspecialty internal medicine must:
1. Have graduated from an AOA-accredited college of osteopathic medicine.
2. Have completed an AOA-approved internal medicine residency program or an ACGME approved internal medicine program
for which AOA approval has been ranted.
3. Be, and remain, a member of the AOA during fellowship training.
4. Be appropriately licensed in the state in which the training is conducted.
B. During the training program all fellows must:
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1. Submit a fellow annual report to the ACOI by July 31 of each calendar year.Final reports of fellows who complete the program
in months other than June must be submitted within thirty (30) days of completion of the training year. Failure to submit the
annual report to the American College ofOsteopathic Internists:
• within sixty (60) days of the required date will result in the assessment of a $100 late fee for review of the training year;
• within one (1) year of the required date will result in the assessment of a $500 late fee for review of the training year; and
• there will be a $250 late fee for review of each additional fellowship year that is delinquent for one or more years. If, by
completion of the program, all of the annual reports are incomplete, the ACOI Council on Education and Evaluation may
require that the fellow repeat training.
2. Attend a minimum of 70% of all educational meetings as directed by the program director. Fellows must also participate in
appropriate professional staff activities such as tumor boards, mortality review, quality assurance, critical care committees,
pharmacy and therapeutics, infection control and clinical pathologic conferences, and they must participate in institutional
resident/intern/student education.
3. Participate in a research component as indicated in Standard IV.A.7.
4. Complete a service evaluation after each rotational assignment.
5. Maintain a procedures log of all required procedures with a copy to be kept in the Department of Medical Education. Although
not required by the ACOI, it is strongly recommended that in addition to the file copy of the procedures log, each fellow maintain
a permanent copy of all logs and annual reports for use in future privilege requests.
6. Participate in an annual evaluation of program goals and curriculum.
7. Maintain ambulatory continuity logs.
8. Maintain a current e-mail address and provide it to the ACOI upon entering the program.
9. Function in an ethical and professional manner.
STANDARD VII- EVALUATION
A. Each subspecialty internal medicine fellowship program must conform to the standards for evaluation as described in the
Basic Standards for Residency Training in Internal Medicine of the AOA and the ACOI.

APPENDIX A
Requirements for Preparation and Submission of Medical
Manuscripts, Research Papers and Progress Reports
A. All manuscripts must be typed and submitted in an appropriate format acceptable for publication in a standard scientific
refereed journal.
B. An abstract must accompany each manuscript. The cover sheet must list the program for which credit is to be applied and a
statement that the fellow is the primary author, or performed substantive participation in the study and that the paper has been
reviewed and approved. This must be signed and attested to by the program director. Manuscripts shall be submitted in one of
the following formats only:
1. A case presentation of a first reported case or other unusual manifestations of a disease which will add to the medical
literature, which should include a review of the literature and discussion (acceptable only if submitted for publication).
2. A report of an original clinical research study approved by the program director and the institutional review board.
3. A case presentation and discussion which challenges existing concepts of diagnosis or treatment and thus recommends
further investigation. Initially, the fellow should submit a written proposal to the program director for review and approval as
fulfilling the writing requirement. All projects must be performed and prepared under the supervision of the program director or
another physician approved by the program director. Completed manuscripts must be submitted to the ACOI as described in
Standard IV.A.7.




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MEDICAL WRITING AND RESEARCH COVER SHEET

This medical writing and research paper entitled:
______________________________________________________________________________________________________

______________________________________________________________________________________________________

is being submitted/in progress by:
__________________________________________________________________________, DO
(Name of fellow)
______________________________________________________________________________
(Training institution)

for the ____________________________ program, training dates __________ to __________
(Program type, e.g. cardiology, GI, etc.)

__________________________________________________________, DO ______________
(Signature of fellow) (date)

__________________________________________________________,DO/MD ____________
(Signature of program director) (date)

The above signatures attest to the fact that the attached work has been performed by the fellow noted, and has been reviewed
and approved by the program director.




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BASIC STANDARDS FOR RESIDENCY TRAINING IN CARDIOLOGY
American Osteopathic Association and the American College of Osteopathic Internists
Specific Requirements For Osteopathic Subspecialty Training In Cardiology

This is part of the Basic Standards for Fellowship Training in Internal Medicine Subspecialties, which govern and define training
in the subspecialties. The Basic Standards are incorporated into this document by reference.
I. Education Program - The residency training program in cardiology shall be three (3) years in duration and shall provide
supervised clinical experience and didactic programs to enable the resident to develop sufficient skills and knowledge in the
performance and interpretation of cardiovascular diagnostic modalities, and in the care of patients with cardiovascular diagnoses.
II. Facilities and Resources
A. Inpatient and outpatient facilities with an appropriate number of patients of a wide age range and a broad variety of
cardiovascular disorders;
B. Laboratories for cardiac catheterization, electrocardiography, exercise and pharmacologic stress testing, Doppler
transthoracic and transesophageal echocardiography and ambulatory ECG monitoring;
C. Facilities for nuclear cardiology, including ventricular function assessment, myocardial perfusion imaging and the study of
myocardial viability;
D. Facilities for management of patients with arrhythmias, including electrophysiologic testing, arrhythmia ablation, signal
averaged ECGT and tilt table testing as well as the evaluation of patients for pacemakers and implantation of pacemakers and
automatic defibrillators;
E. Faculty and resources for clinical research;
F. Modern intensive care facilities;
G. Surgical program for all cardiac procedures and surgical intensive care services;
H. Facilities for assessment of peripheral vascular disease, pulmonary function and cardiovascular radiology;
I. Faculty and program for diagnosis and follow-up care of patients with congenital heart disease;
J. Faculty and facilities involved in the instruction of preventive cardiology, risk factor modification, management of lipid disorders
and cardiac rehabilitation;
K. Access to comprehensive library facilities;
L. Ambulatory clinic facilities where the trainee will follow an independent panel of patients for a minimum of one-half day per
week on a continuity basis for the entire 36 month program.
III. Specific Program Content
A. Integration of Osteopathic Principles and practice in the treatment of patients with cardiovascular disorders;
B. A core curriculum in the basic medical sciences of cardiovascular medicine, to include physiology, anatomy, histology and
pharmacology;
C. A clinical sciences curriculum that shall include formal, regularly scheduled lectures, cardiac catheterization conference,
mortality and morbidity review and literature review. Teaching rounds must be conducted in a regular and organized fashion;
D. There shall be Training in the principles of operation and function, indication, limitation, risk vs. benefit ratio and cost
effectiveness of the various technical procedures used in the diagnosis, therapy and management of cardiovascular disorders;
E. Procedural Training
Procedural training shall adhere to the guidelines established by the Core Cardiology Training Symposium (COCATS) as
approved by the American College of Cardiology:
Level 1: Basic level of training required of all trainees to be competent as consulting cardiologists;
Level 2: Additional training in one or more specialized areas enabling a cardiologist to perform or interpret specific procedures at
an intermediate skill level;
Level 3: Advanced training in a specialized area enabling a cardiologist to perform, interpret and train others to perform and
interpret specific procedures at a high skill level.
1. Level 1 training shall be achieved in all areas by all trainees;
2. Level 2 training shall be required of all trainees intending to achieve primary operator status in the areas of cardiac
catheterization, echocardiography and nuclear cardiology;
3. Level 3 training shall be offered based on faculty and facilities for any or all of the above areas of expertise;
4. Training and attainment of competency in electrophysiology and interventional cardiology may not be accomplished during the
36 month cardiology fellowship. This may be accomplished by separate programs requiring 12 months of additional training in
the area of interest;
5. Rotational requirements include a minimum of: Eight (8) months clinical non-laboratory practice activity with a minimum
of three (3) months in the CCU/ICU;
Four (4) months of echocardiography;
Four (4) months or a minimum of 100 cases in the cardiac catheterization laboratory;
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Two (2) months in electrophysiology and pacemaker service;
Four (4) months of ECG, Stress Testing, Holter interpretation and various stress modalities;
The remaining 12 months shall include exposure to pediatric cardiology, transplant cardiology and other areas of interest as
determined by the Program Director.
F. Specific Rotation Requirements
1. Clinical Cardiology
Clinical cardiology must encompass a broad range of cardiac disease states. The trainees must spend a minimum of eight
months in clinical cardiology. This experience must include daily inpatient management of cardiovascular diseases and
cardiology consultation. At least three of these months must be spent by the trainee in the coronary care unit or the intensive
care unit during the trainee’s 36-month program. If the trainee has extensive coronary care unit experience from his/her internal
medicine residency, then this requirement can be met by ongoing patient interaction in the CCU supervising medical residents
over the three-year period. Either alternative must enable the trainee to gain exposure to hemodynamic monitoring,
postoperative patient care, as well as other aspects of critical/acute care cardiology; i.e.: myocardial infarction, congestive heart
failure, postoperative coronary artery bypass grafting and transplant.
2. Cardiac Catheterization and Interventional Cardiology
A minimum of four months in cardiac catheterization must be spent by the trainee, or exposure to a minimum of 100 cases.
During this time, the trainee must gain exposure to valvular hemodynamics, right and left cardiac catheterization and limited
exposure to interventional cardiology. The trainee must participate in a minimum of 300 left heart catheterizations as primary
operator to achieve Level II proficiency. The trainee must also maintain a procedure log for accurate documentation. Level II
trainees must also perform at least 10 intraaortic balloon pumps during the 36-month training period.
3. Non-Invasive Testing
a. Exercise Stress Testing, Electrocardiography and Nuclear Cardiology The trainee must spend at least two months in the
exercise testing facility. As an alternative, this may be incorporated into other rotations, such as heart station or noninvasive. This
is to expose the trainee to all types of exercise testing. The trainee at the end of his/her time, By completion of the fellowship, the
trainee must be capable of performing and interpreting the electrocardiographic portion of the treadmill and pharmacological
testing. The trainee must also be competent in the test protocols and the appropriateness of ordering tests. A minimum
interpretation of 150 exercise tests should be performed. Dobutamine and stress echocardiography requirements are in addition
to this. Interpretation of standard 12-lead electrocardiograms should be incorporated in the entire 36-month training period. In
order for the trainee to become proficient in interpretation and gain exposure to a wide variety of ECG abnormalities, it is
recommended that a minimum of 3,500 studies be reviewed.
4. Echocardiography
a. The trainee must spend a minimum of four months in the echocardiography lab. As an alternative, this maybe incorporated in
other rotations such as heart station or noninvasive. During this time, the trainee will gain exposure in performing and interpreting
2 D and M Mode echocardiography and cardiac Doppler. A minimum of 300 studies must be interpreted to obtain Level II
proficiency in echocardiography. These studies must include a wide variety of cardiac abnormalities, such as valvular heart
disease, endocarditis, prosthetic valve evaluation, myocardial ischemia, primary and secondary diseases of the heart, pericardial
disease and diseases of the great vessels.
b. The trainee must have attained proficiency in standard 2 D and M Mode echocardiography and cardiac Doppler prior to or
parallel with obtaining expertise in transesophageal echocardiography. A minimum of 25 intubations supervised by an
experience transesophageal echocardiographer, as well as performing 50 transesophageal echocardiographs are necessary to
achieve proficiency in this area.
c. The trainee must obtain proficiency in standard echocardiography prior to or parallel with obtaining proficiency in stress
echocardiography and dobutamine echocardiography. A minimum of 100 stress/dobutamine echocardiographic studies are
recommended for proficiency in this area.
5. Nuclear Medicine
Individuals wishing certification in nuclear medicine/nuclear cardiology require special training. The Nuclear Regulatory
Commission (NRC) has set specific guidelines for licensure in this field. Trainees interesting in obtaining licensure must adhere
to these guidelines.
6. Electrophysiology
The trainee must have a minimum of two months of electrophysiological exposure. During this time, the trainee must gain
exposure to the appropriateness of electrophysiological studies, interpretation of basic electrophysiological studies, technique
involved, indication for pharmacological and non pharmacological management of arrhythmias and indications for temporary and
permanent pacemakers. A minimum of 10 temporary transvenous pacemakers should be inserted during the 36-month training
period, as well as a minimum of eight elective cardioversions in the 36-month training period. Exposure to permanent pacemaker
insertion must be available to cardiovascular trainees. A minimum of 50 permanent pacemaker implantations must be performed.
The ability for the trainee to participate in pacemaker follow-up is mandatory for those performing pacemaker implantation. One
hundred (100) pacemaker follow-up visits must be performed. The pacemaker clinic must allow the trainee to gain experience in
a variety of pacemaker programmers, as well as pacemaker follow-up and management.
7. A model rotation schedule for the three year general cardiology fellowship is posted on the ACOI website (www.acoi.org).
G. Ambulatory Clinical Experience


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Ongoing outpatient clinical experience is mandatory for all cardiovascular trainees. At least one-half day per week in an
outpatient setting with appropriate supervision throughout the 36-month period must be provided. This will allow the
cardiovascular trainee to gain experience and exposure in the management of cardiovascular problems in the outpatient setting.
H. Elective Time
1. Four months elective time should be allotted to the trainee to pursue special interest in other fields of cardiology; i.e., Adult
Congenital Disease, Lipid Management, Preventive Cardiology, Transplant/Cardiomyopathy, or to allow extra time in areas in
which the trainee may be deficient.




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                            Seven Core Competencies of the Osteopathic Profession

Throughout your training, you have undoubtedly heard, and will, without question, continue to hear about the seven core
competencies of the osteopathic profession. Please familiarize yourself with these very basic tenets of training, as they are the
fundamental basis of all fellowship evaluations. All fellow case presentations must reflect all seven core competencies; each
monthly fellow evaluation of service addresses each competency, and the fellow is evaluated on each competency during every
rotation, etc. The following section fully explains each of the seven core competencies; also, attached is our fellowship core
competency workbook / plan. If you have any comments, questions or concerns on how these competencies will be fulfilled
during your training, please consult this section of the manual, or ask your program coordinator .

         Osteopathic Philosophy and Osteopathic Manipulative Medicine
         Medical Knowledge
         Patient Care
         Interpersonal and Communication Skills
         Professionalism
         Practice-Based Learning and Improvement
         Systems-Based Practice

Competency 1: OSTEOPATHIC PHILOSOPHY /OSTEOPATHIC MANIPULATIVE
MEDICINE

DEFINITION:
Residents are expected to demonstrate and apply knowledge of accepted standards in Osteopathic Manipulative Treatment
(OMT) appropriate to their specialty. The educational goal is to train a skilled and competent osteopathic practitioner who
remains dedicated to life-long learning and to practice habits in osteopathic philosophy and manipulative medicine.

REQUIRED ELEMENTS:

1. Demonstrate competency in the understanding and application of OMT appropriate to the medical specialty.

2. Integrate Osteopathic Concepts and OMT into the medical care provided to patients as appropriate.

3. Understand and integrate Osteopathic Principles and Philosophy into all clinical and patient care activities.

Competency 2: MEDICAL KNOWLEDGE

DEFINITION:
Residents are expected to demonstrate and apply knowledge of accepted standards of clinical medicine in their respective
specialty area, remain current with new developments in medicine, and participate in life-long learning activities, including
research.

REQUIRED ELEMENTS:

1. Demonstrate competency in the understanding and application of clinical medicine to patient care.


Competency 3: PATIENT CARE

DEFINITION:
Residents must demonstrate the ability to effectively treat patients, provide medical care that incorporates the osteopathic
philosophy, patient empathy, awareness of behavioral issues, the incorporation of preventive medicine, and health promotion.

REQUIRED ELEMENTS:

1. Gather accurate, essential information for all sources, including medical interviews, physical examinations, medical records,
          and diagnostic/therapeutic plans and treatments.

2. Validate competency in the performance of diagnosis, treatment and procedures appropriate to the medical specialty.
                                                                                                                                32
3. Provide health care services consistent with osteopathic philosophy, including preventative medicine and health promotion
that are based on current scientific evidence.


Competency 4: INTERPERSONAL AND COMMUNICATION SKILLS

DEFINITION:
Residents are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain
professional relationships with patients, families, and other members of health care teams.

REQUIRED ELEMENTS:

1. Demonstrate effectiveness in developing appropriate doctor-patient relationships.


2. Exhibit effective listening, written and oral communication skills in professional interactions with patients, families and other
health professionals.

Competency 5: PROFESSIONALISM

DEFINITION:
Residents are expected to uphold the Osteopathic Oath in the conduct of their professional activities that promote advocacy of
patient welfare, adherence to ethical principles, collaboration with health professionals, life-long learning, and sensitivity to a
diverse patient population. Residents should be cognizant of their own physical and mental health in order to effectively care for
patients.

REQUIRED ELEMENTS:

1. Demonstrate respect for patients and families and advocate for the primacy of patient’s welfare and autonomy.


2. Adhere to ethical principles in the practice of medicine.

3. Demonstrate awareness and proper attention to issues of culture, religion, age, gender, sexual orientation, and mental and
physical disabilities.

Competency 6: PRACTICE-BASED LEARNING AND IMPROVEMENT

DEFINITION:
Residents must demonstrate the ability to critically evaluate their methods of clinical practice, integrate evidence-based medicine
into patient care, show an understanding of research methods, and improve patient care practices.

REQUIRED ELEMENTS:
1. Treat patients in a manner consistent with the most up-to-date information on diagnostic and therapeutic effectiveness.

2. Perform self-evaluations of clinical practice patterns and practice-based improvement activities using a systematic
methodology.

Competency 7: SYSTEMS-BASED PRACTICE

DEFINITION:
Residents are expected to demonstrate an understanding of health care delivery systems, provide effective and qualitative
patient care within the system, and practice cost-effective medicine.

REQUIRED ELEMENTS:

1. Understand national and local health care delivery systems and how they impact on patient care and professional practice.

2. Advocate for quality health care on behalf of patients and assist them in their interactions with the complexities of the medical
system.
                                                                                                                                       33
                               Core Competencies Workbook
A. How are you implementing training in the seven Core Competencies?

List objectives and expectations for each below or on an attached separate sheet:

     1.   Osteopathic Philosophy/Osteopathic Manipulative Medicine
          Fellows are being trained in osteopathic philosophy and osteopathic manipulative medicine via a DVD-ROM education series, in
          addition to monthly didactic lecture. The objective is that they demonstrate competency in his/her understanding and application of
          OMT.
          Department of Cardiology Fellows are expected to:
          1. Integrate osteopathic concepts and OMT into patient care as appropriate; and, that they and understand and integrate
          osteopathic principles and philosophy into clinical and patient care activities as appropriate.

     2.   Medical Knowledge
          All fellows will receive comprehensive training in echocardiography, nuclear medicine and electrophysiology as part of the three-year
          program. Morbidity and mortality conferences are held once a month to review missed information, inappropriate management,
          technical errors, etc.. Fellows present structured critical appraisals of articles verbally s part of their journal club responsibilities.
          Preparation for patient care. The fellows are encouraged to present research papers at a variety of scientific meetings. Self
          directed learning. Feedback from attending physicians and faculty. Core and curriculum conferences. Information obtained from
          literature search, Braunwald club, Journal club is then applied to their patient population and monitored by their attending supervisor
          and program director. Fellows must demonstrate knowledge about established and evolving biomedical, clinical and cognate (e.g.
          epidemiological and sociobehavioral) sciences and the application of this knowledge to patient care.
          Department of Cardiology Fellows are expected to:
          1.          Demonstrate an investigatory and analytic thinking approach to clinical situations
          2.          Know and apply the basic clinically supportive sciences which are appropriate to the cardiovascular discipline.
          3.          Analyze practice experience and perform practice-based improvement activities using a systematic methodology.
          4.          Locate, appraise, and assimilate evidence from scientific studies related to their patient’s health problems.
          5.          Obtain and use information about their own population of patients and the larger population from which their patients are
                      drawn.
          6.          Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on
                      diagnostic and therapeutic effectiveness.
          7.          Use information technology to manage information, access on-line medical information; and support their own education.
          8.          Facilitate the learning of students and other healthcare professionals.

     3.   Patient Care
          Training includes daily opportunities to practice and improve interpersonal and communication skills interacting with patients,
          patient’s families and health care staff. Training also includes daily opportunities to communicate with patients about their diagnosis
          and treatment plans. Daily opportunities to develop a professional approach while interacting with patients and healthcare staff in
          the OR, on the floor and in ambulatory facilities. Morbidity and Mortality conferences are held monthly to review missed information,
          inappropriate management, technical errors etc. Fellows have access to the internet which enables their medical education and
          provides information relevant to patient care. Information obtained from literature search, Braunwald club, Journal Club etc., is then
          applied to their patient population and monitored by attending physicians and faculty. Fellows must be able to provide patient care
          that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.
          Department of Cardiology Fellows are expected to:
          1. Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families.
          2. Gather essential and accurate information about their patients.
          3. Make informed decisions about diagnostic and therapeutic intervention based on patient information and preferences, up-to-date
          scientific evidence, and clinical judgment.
          4. Develop and carry out patient management plans.
          5. Counsel and educate patients and their families as appropriate.
          6. Use information technology to support patient care decisions and patient education.
          7. Perform competently all medical and invasive and non-invasive procedures considered to be essential for the area of practice.
          8. Provide health care services aimed health problems or at maintaining health.
          9. Work with health care professionals, including those from other disciplines, to provide patient-focused care.

     4.   Interpersonal and Communication Skills
          Fellows observe attending physicians and faculty interacting with patients on a daily basis. Training includes daily opportunities to
          practice and improve interpersonal skills and interacting patients and healthcare staff; daily opportunities to develop professional,
          ethical, and humanistic approach while interacting with patients and health care staff; daily opportunities to communicate about
          patients by writing in patient charts. Fellows must be able to demonstrate interpersonal and communication skills that result in
          effective information exchange and teaming with patients, their families and professional associates.
          Department of Cardiology Fellows are expected to:
          1. Create and sustain a therapeutic and ethically sound relationship with patients.

                                                                                                                                                34
           2.    Use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning and writing
                 skills.
           3.    Work effectively with others as a member or leader of a health care team or other professional group.

     5.    Professionalism
           All fellows will receive training in the form of didactic lecture and seminar in medical ethics. Professionalism is modeled by attending
           physicians, faculty, chief fellows, nurses, preceptors, etc. Training includes daily opportunities to develop a professional and ethical
           approach while interacting with patients and healthcare staff in the OR, on the floor and in ambulatory facilities. Faculty and
           attending physicians discuss issues related to gender, culture, age and disability when in the clinical setting. Fellows must
           demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse
           patient population
           Department of Cardiology Fellows are expected to:
           1. Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-
                  interest; accountability to patients and society, and the profession; and a commitment to excellence and on-going professional
                  development.
           2. Demonstrate a commitment to ethical principles pertaining to provision or withholding of critical care, confidentiality of patient
                  information, informed consent, and business practices.
           3. Demonstrate sensitivity and responsiveness to patients’ culture, age, gender and disabilities.

     6.    Practice Based Learning and Improvement
           Morbidity and mortality conferences are held once a month to review missed information, inappropriate management, technical
           errors, etc. Preparation for and participation in evidence based Journal Club. Fellows present structured critical appraisals verbally
           as part of their journal club responsibilities. Preparation for patient care. The fellows are encouraged to present research papers at
           a variety of scientific meetings. Monthly journal clubs are used as an avenue to discuss research design and statistical analysis.
           Didactic lectures by faculty and attending physicians and visiting professionals. Self-directed learning. Feedback from attending
           physicians and faculty. Fellows must be able to investigate and evaluate their patient care practices, appraise and assimilate
           scientific evidence, and improve their patient care practices.
           Department of Cardiology Fellows are expected to:
           1. Analyze practice experience and perform practice-based improvement activities using systematic methodology.
           2. Locate, appraise, and assimilate evidence from scientific studies related to their patients health problems
           3. Obtain and use information about their own population of patients and the larger population from which their patients are
                 drawn.
           4. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on
                 diagnostic and therapeutic effectiveness.
           5. Use information technology to manage information, access online medical information and support their own education.
           6. Facilitate the learning of student and other healthcare professionals

     7.    System Based Practice Competencies
           These issues are discussed in Fellow didactics to create awareness of cost without reducing quality of patient care. Faculty and
           attending physicians serving as role models afford an opportunity for fellows to witness cost effective healthcare in practice. Fellows
           regularly deal with a multi-system, multi-task health care arena that provides them ample opportunities, if sought after, with
           understanding the component of well thought out patient management and efficient health care delivery system with effective cost
           management and quality medical care. Daily opportunities to be a patient advocate and provide information and coordination to the
           patient for his and her own understanding and ability to deal with the multifaceted and sometimes problematic dealings with health
           care managers and third party providers. Fellows must demonstrate knowledge about established and evolving biomedical, clinical
           and cognate (e.g. epidemiological and sociobehavioral ) sciences and the application of this knowledge o patient care.
           Department of Cardiology Fellows are expected to:
           1.         Demonstrate an investigatory and analytic thinking approach to clinical situations.
           2.         Know and apply the basic and clinically supportive sciences which are appropriate to the cardiovascular discipline.
           3.         Analyze practice experience and perform practice based improvement activities using a systematic methodology.
           4.         Locate, appraise and assimilate evidence from scientific studies related to their patient’s health problems.
           5.         Obtain and use information about their own population of patients and the larger population from which their patients are
                      drawn.
           6.         Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on
                      diagnostic and therapeutic effectiveness.
           7.         Use information technology to manage information, access online medical information; and support their own education.
           8.         Facilitate the learning of other students and fellows and other healthcare professionals.

B. How are you evaluating each resident/ fellow?
         Each fellow will be evaluated for his or her performance at the completion of each month of training by the trainer of that service.
         Fellows are further evaluated bi-annually at the completion of an individual case presentation. Each of the core competencies is
         addressed in this evaluation. Evaluations that fall out of the expected performance levels will be addressed on a case-by-case basis
         and may be prompt specific remedies as determined by the program director. The evaluations are meant as a tool to be used for
         the director and fellow to follow his or her progress of learning. A new 360 degree evaluation will be used beginning academic year
         2006-2007. It will consist of the fellow(s) being evaluated by persons with whom they work. Patients, nurses and fellow housestaff
         will complete these evaluations. They will be given unannounced. The evaluations of the program are due at the end of each
         rotation. Failure to comply will result in a meeting with the director. Further delays will result in corrective action at the discretion of
         the program director.
                                                                                                                                                 35
           Form Currently Used: Attachment A ; 360 degree evaluation forms

     C.     How is each resident/fellow evaluating each rotation and the teaching faculty,
          resident(s) and fellow(s) on that rotation?
            Each fellow will provide feedback in the form of a formal evaluation form that critiques the teaching and training he/she is receiving.
            Honest evaluation in this area is helpful in improving the quality of the training that this program can offer. Evaluations should be
            completed in a timely fashion.
            Form currently used: Attachment B

D. Beginning with the end of the 2005-2006 academic year, the program director must complete an AOA Program Director’s Annual
Evaluation Report every year for each intern, resident and fellow in their program. The last page of the Annual Report is to be
completed only for housestaff in the final year of their program. We must have copies of this report for the trainees file.
          Appendix E has been completed and submitted to UMDNJ-SOM /GME prior to the completion of this report; copies of which are
     attached hereto.

E. How are you presenting core competencies in your orientation program for new housestaff?
All housestaff new to the system are required to attend part of the Internship Orientation which includes Core Competencies Orientation. In
other words, GME already reviews the core competencies with out of system housestaff coming into your programs as part of the Internship
Orientation program. We will only need to know how you will cover the competencies with someone coming from another program mid year.
(Very rare.) Core competencies are addressed in detail in our program manual and are 1) updated annually and distributed to all fellows at
orientation.

F. What two methods of assessment are you using to evaluate the housestaff on core competencies?
Fellows bi-annual evaluations and 360 degree evaluations; Monthly service rotation evaluations (Attachment A); Faculty supervisors evaluate
the application of fellows knowledge daily as they supervise them in both in and outpatient settings as well as ambulatory clinic settings;
Competency will be evidenced through journal club activities and research paper activity; Faculty and attending physicians monitor fellows
understanding of core competencies and how it directly affects the overall patient care system; Fellows are evaluated bi-annually at the
completion of a case-presentation at which all 7 core competencies must be addressed. Core competency areas are evaluated annually as
part of the fellow’s end of year comprehensive examination.

Attachments:           Attachment A, adapted for Dept. of Cardiology, Attachment B, adapted for Dept. of Cardiology
                       Appendix E, completed for 2005-2006 Dept. of Cardiology Fellows

Submitted 06/30/2010

___________________________________
John N. Hamaty, D.O. FACC, FACCOI,
Program Director




                                                                                                                                               36
General Program Description

Overview
The three-year osteopathic cardiology fellowship training program at UMDNJ-SOM is an AOA approved program that provides
comprehensive training in cardiovascular diseases with exposure to all facets of cardiology. Satisfactory completion of this
program will provide American Osteopathic Board of Internal Medicine (AOBIM) eligibility, leading to Board certification. Eligible
physicians for enrollment in this program must be graduates of an AOA accredited medical school who have satisfactorily
completed and osteopathic internship, atleast two years of an AOA approved Internal medicine residency, or three years of an
“alternative pathway” internal medicine residency. Osteopathic physicians completing allopathic residencies may seek retroactive
AOA approval as set by the AOA guidelines.

All fellows will receive comprehensive training in echocardiography, nuclear medicine and electrophysiology as part of the three-
year program. Fulfillment of the recommendations of the ACC for adult cardiology training is expected upon successful
completion of this program.

Program Philosophy
The UMDNJ-SOM program is deeply committed to providing the best training in cardiovascular disease possible. A standard of
excellence is achieved and maintained by strictly adhering to and complying with AOA / ACOI Basic Standards of Residency
Training in Cardiology which is based upon the standards and recommendations of the American College of Cardiology. The
program will be closely maintained by review, audit and input from the program director, attending physicians and fellows.

General Description
The basic cardiology fellowship program is an AOA approved program that upon satisfactory completion will provide board
eligibility by the AOBIM in cardiovascular diseases. This is a well rounded adult cardiology training program that promotes
excellence in the field of cardiovascular diseases. Graduates will secure exceptional exposure in this field that should more than
further satisfy additional credentialing in pursued hospital privileges and professional societies.

Training Tracks
This program will offer two tracks of training, a non-invasive clinical cardiology track and an invasive/non-invasive track leading to
independent operator status in diagnostic heart catheterization and angiography. Additionally, training in the invasive track will
satisfy the pre-requisites needed for further training in interventional cardiology should the trainee elect to pursue it and both
tracks provide the pre-requisites for further training in non-invasive or electrophysiology training.

Non-Invasive Track                                           Invasive Track
9 Months clinical cardiology                                 8 Months clinical cardiology
5 Months cardiac/surgical/intensive care                     5 Months cardiac/surgical/intensive care
8 Months nuclear cardiology/ECG/Stress testing               6 Months nuclear cardiology/ECG/Stress testing
6 Months echocardiography                                    6 Month echocardiography
4 Months cardiac cath lab                                    8 Months cardiac cath lab
2 Months electrophysiology                                   2 Months electrophysiology
2 Months electives                                           1 Month elective
  (Includes vacation and nuclear certification)                (Includes vacation and nuclear certification)

Satisfactory completion of the non-invasive track can lead to level two (independent operator status) expertise in
echocardiography and satisfy pre-requisites for licensing in nuclear medicine. Satisfactory completion of the invasive track can
lead to independent operator status in cardiac catheterization and angiography, and level two expertise (independent operator
status) in echocardiography.)

Requirements for Completion
All fellows must have successfully completed all the academic requirements as outlined in this document and as specified in the
requirements for training by the AOA. Additionally, the fellow must maintain completion and submission of an acceptable fellow
research paper. The fellow is expected to maintain the proper decorum and professionalism expected of a physician, that is, no
outstanding disciplinary issues, violations as indicated in this document must be breached.




                                                                                                                                  37
Annual Fellowship Inservice Examination

As part of your formal evaluation process for this fellowship there will be a mandatory year end examination necessary for your
program. This examination will be used to determine your competency for the year, and will be used as an assessment tool to
determine your eligibility to proceed to the next academic year. There will not be a formal grade assigned to the examination but
it will be a document to compare your performance with your peers within your class as well as your peers within the entire
fellowship. The examination will be graded and returned to you. There will be a formal discussion post-examination and an
opportunity for you to ask, and have answered, any exam related questions. The purpose of this is to help you to find your
strengths and weaknesses and to set goals and objectives for the next training year. This document, as well, will be reviewed
with you at your last quarter evaluation.
The program will use this examination to understand your strengths and weaknesses and to develop a program specifically for
you to help you to improve your individual fund of knowledge.


Fellow Performance Evaluation (Monthly Rotation) / Core Competency Attachment A
Fellow Evaluation of Service (Monthly Rotation) / Core Competency Attachment B
Each fellow will be evaluated for his or her performance at the completion of each month of training by the trainer of that service.
Evaluations that fall out of the expected performance levels will be addressed on a case by case basis and may prompt specific
remedies as determined by the program director. The evaluations are meant as a tool to be used for the program director and
fellow to follow his or her progress of learning through the program. Fellows will also be evaluated annually via a 360 degree
evaluation. This evaluation consists of evaluations being done by the people you work with and for. Patients, peers, and support
staff will complete these evaluations in addition to attending physicians. They will be given unannounced and the results of
which will be discussed with the fellow at the following quarterly evaluation. Monthly evaluations of service are due at the end of
each month and are to be turned in to your program coordinator. Failure to comply may result in a meeting with the program
director. Further delays will result in corrective action at the discretion of the program director.

Likewise, each fellow will provide feedback in the form of a formal evaluation form that critiques the teaching and training he/she
is receiving. Honest evaluations in this area are helpful in improving the quality of training that this program can offer.
Evaluations musts be completed promptly at the end of each rotation along with the attending rotation evaluation.

Procedure Logs / Tracking Protocol
It is critically important for satisfactory completion of cardiology fellowship training and for further considerations of staff privileges
in hospitals where fellows may practice that an accurate record of required procedures be maintained. It is also and AOA/ACOI
requirement that certain procedures (as listed in the Annual Resident Report) are logged and submitted annually. All required
clinical procedures that are part of training requirements are maintained by the program coordinator for quantifying and record
keeping purposes. Logs are collected and reviewed on a quarterly basis. (Due two/three weeks prior to quarterly evaluations)
Beginning July 1st, 2008 all procedure logs will be done utilizing New Innovations RMS software, much like duty hours
are logged. Your logs must be accurate, complete and on time. A record of all procedures will be part of your permanent record
and will be used for future inquiries from hospitals and professional societies to which you wish to apply.

The following procedures require logs:
     Nuclear Stress Testing
     Echocardiography /Echo Stress Testing
     Transesophageal echocardiography / Intubations / Conscious sedation
     Cardiac Catheterization / Conscious Sedation
     Office Patients (Specify New Pt. Vs. Follow-up)
     Inpatient Consults / Continuity Log
     EP (tvp/ permanent pacer placement, cardioversion)

Also recommended:
Special / Miscellaneous Procedure Log: Pulls and insertions, Swans, etc.

Cardiovascular disease training requires excellence in several laboratory skills and proper exposure and documentation is critical
to the eventual credentialing in order to perform these skills as an adult cardiologist. Careful, comprehensive maintenance of a
procedure log is a necessity and represents the fellow’s record when applying for future privileges in their hospitals of practice.
The log forms used by the fellowship are contained herein and it is a program requirement that is updated quarterly. Failure to
properly document any procedures can result in a loss of credit for these procedures and could significantly impact on the
fellow’s future privileges and ability to graduate from the fellowship.



                                                                                                                                       38
Duty Hours:
All cardiology fellows are required to log their duty hours on New Innovations. Hours can be logged at any time during the
month, and must be complete by 4:00pm on the last day of the month. It is necessary to log all duty types accurately, i.e.,
rotation / office hours / education session as well as the correct location. Your NI duty hours are used by multiple institutions for
tracking work hour policy compliance as well as for Medicaid and medicare billing purposes.

Conferences / Lectures / Didactic Functions
It is expected that the fellow attend as many of the offered didactic conferences that he/she can in order to be exposed to the
academic that our program has to offer. While not all fellows will be able to attend all after hour dinners, lectures, conferences
etc., it is expected that a concerted effort be made to attend as many functions as possible within reason. There are, however,
some didactic functions which require mandatory attendance. For these functions, you will receive advance notice.
A monthly Journal club is held at the South Jersey Heart Group office in Cherry Hill. You can find the monthly articles for Journal
club on the SJHG website. Each fellow will present an article in detail including statistical relevance, practice applications and an
appropriate critique. Journal club articles must be submitted in PDF format to the chief fellow not later than the 3rd or 4th of each
month. Journal club is held on the third Wednesday of every month.
Braunwald club is a fellow driven series designed to enhance your learning. This is in preparation for cardiovascular boards.
The schedule for Braunwald is posted on the SJHG website calendar. Braunwald club is routinely held in the SJHG Cherry Hill
office.
A monthly ECG conference is held during our weekly Thursday lecture series. Strips are made available for review in advance
on our sjhg website, and following the monthly conference, answers and additional ECG training information can also be found
on the website. This conference is also fellow driven and led by Dr. Siegal.

Academic Lecture Program
Every Thursday your academic time is from 1pm-5pm. During these times your formal academic lectures will be given by the
attending staff and visiting lecturers. You will also participate by giving several formal, well-researched case presentations.
Your case presentations will address all 7 core competencies and be evaluated on those same core competencies by
an attending faculty member. Lecture topics include, but are not limited to cath, echo, case review and a broad range of other
topics geared toward making this a well rounded academic experience. Unless otherwise noted, lecture begins PROMPTLY at
1:00pm in the SJHG Cherry Hill office and attendance is mandatory. If you are unable to attend lecture for any reason, please
notify the program director or program coordinator in advance.


Fellow Case Presentation

The object of the case presentation is to pick a topic for you to learn and master. I strongly encourage basic cardiovascular
disease states such as valvular heart disease, coronary disease and congestive heart failure. In conjunction with the case the
fellow should also provide follow up care and management of that disease state. The case must follow the guidelines in
addressing all seven (7) core competencies. You will be graded based on these core competencies and your outline of these
during your case presentation.

Lastly, the last 15 minutes of the topic should refer to the standard of care guidelines provided for that disease state. These are
accessible on the acc.org website or any other standardized guideline reference.

I want to emphasize that the case should be appropriate for your level of training. An example for the first years would be basics
of ischemic heart disease, stress testing, heart failure and or valvular heart disease. A second year case may involve
complexities of the care involving aggressive hemodynamic monitoring or cath lab interpretation. A third year course should be a
master of it’s topic, it’s appropriate management and follow-up of patient with complex and multiple disease states.

I would be happy to discuss your case with you prior to presentation. Again, the goal of this lecture is to help you to learn and
understand a particular topic with reference to the standard guidelines and treatment and management.

Morning Report
Nearly every morning at 8am morning report is help which provides a review of interesting cases presenting in the hospital or
lectures on pre-specified topics. South Jersey Heart Group supervises morning report at Our Lady of Lourdes on Thursday from
8-9am and at Kennedy Memorial Hospital on Thursday from 7-8am. There will be scheduled morning reports at Kennedy
Memorial Hospital, Stratford; these will be assigned and a mandatory function.

During most of the academic year a grand rounds conference will be held on Wednesday afternoons that will usually be lectures
from both full and part-time faculty and also visiting lecturers. These are mandatory if you are on a rotation in the institution.
Also, each fellow will present grand rounds two times a year at Stratford and at Our Lady of Lourdes.


                                                                                                                                 39
                                           CARDIOLOGY FELLOWSHIP
                                        CASE PRESENTATION EVALUATION


FELLOW:_____________________________ATTENDING PHYSICIAN:___________________________

TOPIC:________________________________________________________________________________

DATE:_____________________________________


1 = Did Not Meet Basic Standards   2= Met Minimum Standards     3= Met All Standards         4= Exceeded All Standards

Osteopathic Philosophy / Osteopathic Manipulative Medicine                  (1)        (2)         (3)      (4)
1. Osteopathic concepts and/or OMT was integrated into
    Presentation.                                                                                        
Medical Knowledge
1. Demonstrated Competency in the understanding and application
   Of clinical medicine as applied to topic presented.                                                   
2. Knows and applies the foundations of clinical and behavioral
   Medicine.                                                                                             
3. Demonstrates strong understanding of standard of care
   Guidelines for presented disease state.                                                               
Patient Care:
1. Gathered accurate, essential information from all sources
   Including histories and physical exams, medical records,
   Diagnostic/ therapeutic plans and treatments.                                                         
2. Validated competency in the performance of diagnosis, treatment
   And management.                                                                                       
3. Provided Insight into health care consistent with osteopathic
   Philosophy, including preventative medicine and health promotion
    Based on current scientific evidence and guidelines.                                                 
Interpersonal and Communication Skills:
1. Exhibited effective written and oral skills, both with regard to
Doctor/patient/peer relationships; as well as in preparation and
Presentation of this case.                                                                               
Professionalism:
1. Adhered to ethical principals in the practice of medicine                                             
2. Demonstrated awareness and proper attention to issues of
   Culture, religion, age, gender, sexual orientation, and mental
   And physical disabilities.                                                                            
Practice-Based Learning and Improvement:
1. Addressed presentation in a manner consistent with the most
   Current information on diagnostic and therapeutic effectiveness                                       
2. Understood and applied research methods, medical informatics
   And the application of technology as applied to medicine                                              
Systems-Based Practice:
1. Demonstrated awareness of local health care delivery system
   And how it affects patient care and professional practice.                                            


                                                                                                                         40
                           Please Complete Both Sides of Form

                               CARDIOLOGY FELLOWSHIP
                            CASE PRESENTATION EVALUATION


Written Comments:

Strong Points:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________

Areas for Improvement:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________


____________________________________    _____________________________________
Primary Evaluator                       Printed Name                    Date



___________________________________     _____________________________________
Fellow Signature (After Review)         Print Name                       Date



____________________________________
Program Director                Date




                                                                                   41
Teaching Objectives
The following guidelines have been established on the basis of standards as set forth in the Basic Standards for Residency
Training in Cardiology, which in turn is based upon recommendation of the American College of Cardiology. These teaching
objectives are to be used by fellows as specific, time-oriented goals and by the attending physicians as teaching guidelines.
Reaching these goals by completion of fellowship is expected. The timetable for individual trainees may vary depending
primarily on the scheduling of electives.

First Year
Upon completion of the first year of training the fellow should be able to:
     1. Be able to conduct a complete and comprehensive history; especially cardiovascular history and be able to confidently
         assess the patients needs for further testing and treatment.
     2. Perform a complete and comprehensive physical examination especially of the cardiovascular system, which includes
         thorough palpation and auscultation of the heart and blood vessels and categorize the cardiac and vascular
         abnormalities based upon the examination.
     3. Understand and recognize the osteopathic abnormalities associated with pathology of the cardiovascular system.
     4. Understand the basic electrocardiogram and be adept at interpreting the vast majority of the electrocardiographic
         abnormalities that are clinically encountered.
     5. Recognize the chest radiographic manifestations of diseases of the heart and great vessels and understand the normal
         structures of the heart and cardiac silhouette.
     6. Know the indications and usefulness of the echocardiographic and doppler studies of the heart and be able to
         recognize the normal structures seen on two-dimensional and M-Mode echocardiography. A fundamental
         understanding of ultrasound imaging and doppler flow including color signal definitions should also be attained. The
         common abnormalities of the echocardiographic examination should also be attained.
     7. Understand the indications, contra-indications and basic interpretations of exercise and ambulatory
         electrocardiography and arrhythmia monitoring.
     8. Have a fundamental understanding of the radiopharmaceuticals used in nuclear cardiology and a basic ability to
         recognize normal and abnormal findings, along with the indications for the various studies.
     9. Understand the basics of the electrophysiologic examination and its indications and contraindications.
     10. Recognize the more common arrhythmias and their evaluation and treatments.
     11. Understand the fundamentals of artificial pacing, its indications and usefulness. Additionally, a basic recognition of
         pacemaker malfunction; and uses and operation of defibrillators should be attained.
     12. Understand the indications and contra-indications of cardiac catheterization. And be able to interpret the basic cardiac
         angiogram and hemodynamic tracings.

Second Year
Upon successful completion of the second year of training the fellow should be able to:
    1. Have adequately attained all of the requirements of the first year of training as noted above.
    2. Perform a highly accurate cardiovascular history such that his diagnostic skills are approaching the accuracy of the
        attending cardiologist.
    3. Perform a highly accurate cardiovascular physical examination with the ability to comprehensively determine the
        presence and nature of any cardiac structural abnormalities and vascular pathology. Recognition of essentially all the
        murmurs and heart sounds should be mastered
    4. Interpret with high accuracy essentially all the electrocardiographic abnormalities encountered in clinical practice.
    5. Perform an exercise stress study independently and be able to provide an accurate interpretation of the findings.
    6. Accurately interpret any ambulatory arrhythmia study encountered in clinical practice.
    7. Perform a hands-on echocardiographic study with attainment of all the views used in the study to degree that it is
        interpretable.
    8. Interpret essentially all of the abnormalities of the echo and doppler study.
    9. Interpret most of the nuclear studies typically encountered in clinical practice.
    10. Understand the basic findings of the electrophysiology study.
    11. Accurately read most cardiac angiograms.
    12. Thoroughly understand the hemodynamics of most of the cardiac abnormalities typically encountered in clinical
        practice.
    13. Understand the array of pacemaker parameters and settings used for the cardiac abnormalities encountered.
    14. Dictation of basic echocardiography and stress testing as well as cath will begin with supervision.




                                                                                                                             42
Third Year
Upon successful completion of the third year the fellow should be able to:
1. Have adequately attained all of the requirements of the second year of training.
2. Have mastered all of the facts of invasive and non-invasive testing, and clinical findings, and be able to understanding
     it to a depth that he/she can provide teaching of all of the material at a student and resident level.
3. Have completed an AOA approved fellow research paper.
4. Proficiently teach and mentor fellow physicians.
5. Mastered dictation of all cardiovascular studies.




                                                                                                                         43
Scientific Research Requirement

The AOA and ACOI require that one scientific research project be submitted by each cardiology fellow during his or her training.
Please refer to the AOA/ACOI research requirements and guidelines as listed below. In order to provide for a scientific research
report that meets AOA/ACOI requirements and that is submitted in a timely fashion, it will be required that each fellow provide a
periodic progress report during the fellowship. A timetable has been established as follows.

Citi Program for IRB approval (Due January 30th, first year of fellowship):
Completion of this online program is a first and necessary part of your fellowship research project. This online program must be
completed absolutely not later than January 30th of your first year of fellowship. Please furnish your program coordinator with a
copy of your completion certificate.

First report (due end of first year)
By midway through the first year of the fellowship program each fellow should have already established a least the type of report
(original research, case report) title, and co-investigators (authors) who will be involved in his or her project. At the very least, a
project outline should already be established, such as hypothesis, methods, patient groups etc. This is due to the ACOI by the
end of the first year.

Second Report (due July 1st of the third fellowship year)
By the end of he second year of training, the fellow should have essentially completed their research project and have it
submitted in initial rough draft. This will allow enough additional time for any needed changes, corrections etc. so that a final
report, ready for submission can be completed on time.

Third Report (due December 30th of third year of training)
The final product, ready for submission to the ACOI, should be given to the program director by the last day of December. The
reports will then be copied and filed and subsequently submitted to the ACOI prior to the required deadline, which is by
December of the third year. Case presentations must be in December of the third year. The ACOI will have it reviewed and if
need be, any changes can be made prior to graduation.




                                                                                                                                   44
                                       Scientific Research Project
                                            Progress Report


NAME:____________________________________

DATE:____________________________________

PART I (Due June 30th of First Year of Fellowship)
Requirements:
Category:
____________ Original Research
____________ Case Presentation

Project Title:______________________________________________________

________________________________________________________________

Author(s):________________________________________________________

________________________________________________________________

Please attach project outline (hypothesis, methods, patient groups, etc.)

PART II (Due July 1st Third Year of Fellowship)
Requirements:
Initial Rough Draft
Date Submitted:____________
Date Reviewed and Returned by Program Director:____________

PART III (Due December 30th, Third year of fellowship)
Requirements:
Completed Report (As outline in ACOI requirements)
Date Submitted:____________
Date Accepted:____________
Date Reviewed and Returned by Program Director:____________

Project Submitted to ACOI:

Date:____________



Revised 01/19/2009




                                                                            45
Cardiovascular Services / General Information

Included in this section of your fellowship manual is information for specific services in our cardiology fellowship training program.
The outlines provide an introduction to the service and the fellow’s expectations; additional information will be given once rotating
through that service. These are general guidelines to orient you to the particular service but some minor variations may exist,
depending upon the specific trainer to which you are assigned. Naturally, each trainer will have slightly different expectations
and methods of conducting his or her service and it is expected that the fellow comply with the wished of he individual trainer.
Every attempt will be made on each service for the trainers to achieve 100% compliance with the teaching objectives. It is
expected that each trainer will be fair in his or her evaluation of the fellow and it is also expected that the fellow be fair in his or
her evaluation of the service and the trainer.

Clinical Cardiology
Responsibilities will include inpatient care and outpatient department evaluations. Each attending will have his or her own
approach to rounds, teaching etc. The general guidelines regarding fellows responsibilities are outlines below.

Inpatient Service:
During the fellow’s assignment to a clinical cardiology service you are expected to
     1) Supervise any students, interns and residents presently assigned to that service
     2) Provide comprehensive admissions, histories and physicals, daily management and discharge instructions of the
          comprehensive care of the patients
     3) Provide thorough and accurate progress notes to be presented to the attending cardiologist and
     4) Provide any requested academic presentations to the attending physician and assigned house staff for mutual learning
          purposes.

Admissions
Admissions to the hospital are your responsibility. The complete history and physical must be written to specifically address all
cardiovascular issues. An assessment and plan must be outlined. A complete review of systems and physical are to be
documented OMM evaluation with treatment options must be documented. You are responsible for discussion and presentation
to an attending physician. Also the house staff must be taught and their H&P must be reviewed.

A problem list should be included on every patient note. It includes room for listing all diagnosis and pertinent study results and
procedures. This should be completed on admission and updated during hospitalization as necessary. Completeness and
accuracy is important since this form becomes part of the patient’s permanent record. The usefulness of this form cannot be
overstated. It becomes very useful for evening and weekend and weekend on-call fellow when he/she is asked to evaluate a
patient he/she is unfamiliar with. Sign out to the person on call is essential for all critical patients.

Daily care is also your responsibility. You are expected to act as an attending. You should see all patients and discuss the
cases with the house staff. It is expected that you begin to develop a differential diagnosis and institute a plan. As you develop
your skills during training, more responsibility should be taken. As always, an attending will be available to round.
Discharges
Upon discharge a standard discharge summary needs to be completed at the time of discharge. Up to date problem lists
significantly facilitate completion. A standard set of discharge orders must also be written for each patient. These orders must
include a discharge diet, follow-up instructions, activity instructions, medications and other instructions such as endocarditis
prophylaxis, scheduling of outpatient visits and testing, etc. It is preferred that these orders are written on the day before
discharge. These orders are used by the nurses for patient teaching purposes and unit secretaries for scheduling purposes,
such as follow-up stress test, outpatient visits, etc. Prescriptions for the patient should also be written for Saturday discharges;
this prevents the Saturday on-call fellow from being inundated with unnecessary work. Remember you will be on Saturday call
too! Help each other out. All aspects of the discharge form must be filled out. If a patient is intolerant to medicines that are
normally used for that disease state, this must be addressed. You must dictate that it is contraindicated or not medically
necessary.
Transfers
When a patient requires transfer to another service, for example, the Medical Intensive Care Unit, the transfer orders and a
summary should be written. The attending whose service the patient is transferred to must be specified in the orders. Verbal
sign out to the transferring service is required.

When a patient is transferred from another service, likewise they should be accompanied by orders, transfer note and a verbal
sign-out (no verbal sign out is usually given from the Surgical Intensive Care Unit). The receiving fellow should review the
transfer orders to check for completeness and should see the patient on the same day of transfer.

Patients that get transferred from another hospital to OLOL must have the H&P done and orders written for transfer.
                                                                                                                                    46
Outpatient Service
Fellows are expected to attend the various outpatient activities assigned during each particular service such as private and
clinical office hours, and part of the requirements is long-term care and follow-up care of patients throughout his/her three years
of training. You are required to attend clinic ½ day per week for 36 months and maintain a log of patients seen. All patient
encounters must be kept in the log. Please note new patient encounters versus follow-up visits. The program coordinator keeps
these logs in your file. I would recommend you also keep a copy for yourself.

If an outpatient requires admission at the time you are seeing him/her, one dictation and an admission history and physical is all
that is required. Please note during the dictation that it is a history and physical when dictating.

Miscellaneous
Additional instructions regarding your service responsibilities will be given to you by each individual attending cardiologist. Each
physician has his/her own special way of doing things and therefore more specific guidelines cannot be given at this time.
Please be attentive to the wishes of your attending cardiologist since he/she is the only one who is ultimately responsible for the
patients care. It is hoped for that you will be able to attend all educational activities such as conferences, journal club etc., while
on all services at UMDNJ; please make your attending cardiologist aware of your attendance to these functions. If you need to
be inaccessible from your service for any period of time during the day, such as to leave the building to run an errand, etc.,
please choose an opportune time to do so and do not leave the service without the permission of the attending physician.
Arrange for coverage during your period of absence.

Fellows may elect to seek specific clinical rotations in areas such as pediatric cardiology, congestive heart failure clinics, lipid
clinics, etc. but only as approved in advance by the program director. All of the requirements noted above also apply to any of
the clinical options. No outside rotations will be granted outside of Southern New Jersey.

CCU Rotation

While assigned to any of the critical care services (CCU,ICU,CVU,SICU) the fellow will be required to:
    1) Supervise all assigned house staff
    2) Provide comprehensive progress notes for presentation to the attending staff
    3) Provide academic presentations as assigned to him/her
    4) Rapidly assess and attend to any appropriate emergency department admissions or in house emergent or urgent
         unstable patients already in one of the unites or in need of a transfer to the appropriate unit
    5) Timely and efficient treatment and ultimate transfer of a unit patient to a general medical or step down floor
    6) Provide courteous interaction with the nursing staff and other ancillary staff involved in the critical care of the patient
         and likewise is expected to involved these ancillary personnel in his/her academic presentations and teaching so as to
         promote a sense of unity and learning progress as a cooperative critical care team.
    7) While in the coronary care unit you are responsible for all intraoperative transesophagealechocardiograms performed
         on the surgical patients. You are to get down to the operating room before patients are placed on bypass and perform
         the pre-operative TEE. You then should return to the intensive care unit and begin your rounding responsibilities. The
         post-operative TEE’s are usually performed mid-morning and you are to go back and perform the post-op procedures.
         The remainder of the time in the CCU is dedicated to patient care, rounding with housestaff and writing appropriate
         notes on patients. It must be emphasized that your responsibilities are to all of the patients in the unit regardless of
         what group they are from. You will oversee the resident in performing any procedures.

Please refer to the subspecialty basic standards for specific numbers for certification. All TEE’s must be maintained on a log and
supplied to your program coordinator.

Surgical Intensive Care Unit

Intensive Care Fellow Responsibilities

The fellow, when on duty in the Intensive Care Unit:
     1) Is in the unit at all times, carries a beeper and notifies the charge nurse when leaving the ICU.
     2) Is in charge of the care of all patients in the ICU and serves as a focal point of communication between surgeon,
          cardiologist, anesthetist and family. He should be personally certain that all problems are brought to the attention of
          the ICU staff. You are required to provide care to all cardiology group patients.
     3) Discusses each postoperative patient immediately upon arrival in the ICU with the anesthetist, the surgeon and the
          physician in charge of the ICU.


                                                                                                                                   47
4)   Discusses with the anesthetist and physician in charge of the patient the immediate postoperative orders. Fellow
     coordinates patient care with the primary nurse.
5)   The ICU fellow should fill out the doctor’s order form of each assigned patient as completely and clearly as possibly,
     including medication, IV fluids, etc. These may be changed as necessary. SICU does not use verbal orders! Accepts
     verbal orders from attending physicians.
6)   Check pacemaker function and availability of standby equipment when the patient is being paced.
7)   Writes a note in the chart of each assigned patient daily. The note should include pertinent procedures such as
     subclavian and arterial line insertions, dialysis, catheter insertion, cardioversion, etc. The note should also detail drug
     infusions, wound condition, foley catheter and chest tube drainage and pertinent physical findings.
8)   Writes a full consultation note when consultation is requested. You may not dictate consults. Makes every effort to
     speak directly to the consultant to minimize communication problems and delays. No consults are to be ordered
     without direct approval of the ICU staff, primary surgeon or primary cardiologist.
9)   You are responsible to coordinate care with the appropriate cardiothoracic surgeon. Please be advised that Our Lady
     of Lourdes Hospital the ultimate patient responsibility in the SICU is the surgeons and therefore you must respect
     those decisions. Please commit to your recommendations on the chart, but all orders should be discussed with the
     appropriate attending.


Revised 05/25/2010




                                                                                                                            48
After Hour PT/INR Management Policy




                                      49
Electrophysiology / Pacemaker Services

During assignment to the EP services the fellow will be exposed to all of the aspects that this subspecialty entails. He/she will be
required to perform EP consultations that often will require the evaluation of ecg’s and rhythm strips. He will be required to
perform complete admissions, history and physicals and complete patient work-up.
Responsibilities in the lab will be under the direction of the attending. Exposure to all lab aspects of EPS including pacemakers,
ICD’s and biventricular pacers will be provided. Office management of EP patients will be at the Washington Twp. and Cherry
Hill offices.

                                                    Electrophysiology Syllabus

Importance:

Complex cardiac arrhythmias are managed with expertise in cardiac electrophysiology, the use of implantable pacemakers,
ICD’s, antiarrhythmic agents and techniques utilizing electrophysiologic mapping and ablation.

Scope of the Training:

Within the cardiology core training program, level 1 training will comprise of atleast 2 months of clinical cardiac electrophysiology
rotation. This will assist the trainee to:

         Acquire knowledge in the diagnosis and management of brady and tachy arrhythmias

         Learn the indications and limitations of invasive EP testing, ambulatory ECG monitoring, event recorders and stress
          testing for arrhythmia assessment.

         Gain experience in the arrhythmia consultation service.

         Learn the fundamentals of cardiac pacing; recognize normal and abnormal pacemaker function and learn indications
          for temporary and permanent pacing.

         Learn indications for ICD’s and biventricular pacing.

         Understand pacing modes, interrogation, programming and surveillance of pacers and ICD’s.

         Learn/perform cardioversions.

         Learn indications for tilt table testing for evaluation of syncope.

         Gain exposure to interpretation of complex arrhythmias on the surface ECG.


                                                       EP Fellowship Lectures

                    Introduction to EP        Cardiac Cellular Electrophysiology       Cardiac Channelopathies

              Indications for EP Testing      SVT       Management of AFib/Flutter       VT       Antiarrhythmic Drugs

    Syncope – Diagnosis and Management              Pacemakers – Temporary / Permanent          Pacemakers – Trouble Shooting

                         Sudden Cardiac Death and ICD Trials           ECG Review       EP Tracing Review




                                                                                                                                  50
Non-Invasive Laboratory

The non-invasive laboratory offers training in electrocardiography and echocardiography. Fellows rotating on the service will
participate in the interpretation of ecg’s and the performance and interpretation of transthoracic echocardiograms. The daily
organization of activities will be discussed at the beginning of the rotation. The following are general guidelines regarding
activities in the laboratory.

Electrocardiography
Electrocardiograms performed on both inpatients and outpatients are reviewed by the fellows. EKG’s are delivered to the
reading room. Fellows should spend time between echocardiography cases reviewing ekg’s.

Basic EKG interpretation
Most ekg tracings come with computer-generated interpretation. They have to be reviewed and approved or properly revised (on
an interpretation sheet) first by the fellows and then by the attending cardiologist (on the ekg space allotted for interpretation)
before editing and rendering of final reports by the ekg technicians.

Some ekg tracings recorded by the floor nurses using ekg machines come without computer interpretation capability will come
with an interpretation sheet. This sheet must be completed and initialed by the fellow.
     1. Complete the form with rate, intervals and axis.
     2. Identify the rhythm
     3. Comment on abnormalities of condition (arrhythmias, intraventricular conduction delays etc.)
     4. Comments on abnormalities of the P waves, QRS complex, ST segment, T waves
     5. Note any other abnormalities (infarction, hypertrophy, etc.)
     6. Note any changes from previous tracings
     7. When pacing is present, comment on evidence for sensing and capture, the appropriate chambers paced (when
           possible based upon the tracing) and the abnormalities or pacing.




                                                                                                                               51
EKG TOPICS


                                      2009/   2010-                                            2009/   2010-
EKG TOPICS                            2010    2011                                             2010    2011
GENERAL                                               ATRIAL ARRHYTHMIAS
                    Measurments                                   Premature atrial beats
                       Calibration                                 Ectopic Atrial Rhythm
                         P waves                              Ectopic Atrial Tachycardia
                         Q waves                         Paroxysmal Atrial Tachycardia
                    QRS complex                            Multifocal Atrial Tachycardia
                        ST waves                                             Atrial Flutter
                          T waves                                        Atrial Fibrillation
      General approach to EKGs                        JUNCTIONAL RHYTHMS
ATRIAL ABNORMALITIES                                                   Junctional rhythm
            left atrial abnormality                               Junctional tachycardia
           right atrial abnormality                      AV nodal reentrant tachycardia
VENTRICULAR ABNORMALITIES                             VENTRICULAR ARRHYTHMIAS
      Left ventricular hypertrophy                      Prmature ventricular complexes
     right ventricular hypertrophy                                     VT vs. Abberency
        biventricular hypertrophy                          Idiopathic ventricular rhythm
    Hypertrophic cardiomyopathy                       Accelerated idioventricular rhythm
         Left bundle branch block                               Ventricular Tachycardia
       Right bundle branch block                                       Ventricular Flutter
 Intraventricular conduction delay                                Ventricular Fibrillation
                                                                 Polymorphic ventricular
     Left anterior fascicular block                                         tachycardia
    Left posterior fascicular block                                 Torsades de Pointes
AXIS DEVIATION                                        ATRIOVENTRICULAR BLOCKS
               Left axis deviation                                     First degree AVB
              Right axis deviation                              Second degree Mobitz I
ISCHEMIA, INJURY, INFARCT                                       Second degree Mobits II
     Ischemia (T wave inversion)                                            2:1 AV block
      Injury (subepicardial injury)                       Third degree (complete) ABB
    Injury (subendocardial injury)                    PREEXCITATION
                         Q waves                                  Wolff-Parkinson-White
                           Inferior                            AV renetrant tachycardia
                         Posterior                     Lown-Ganong-Levine Syndrome
                          Anterior                        Mahaim type of Preexcitation
                           Lateral                            localization of bypass tract
                 Pseudoinfarction                     DRUGS
                         acute MI                                                  Digoxin
                         recent MI                                Antiarrhythmic Agents
            age undetermined MI                                Psychotropic Agents
                                                      ELECTROLYTE
                            old MI                    ABNORMALITIES
    reciprocol ST and T changes                                            Hyperkalemia
ST AND T WAVE CHANGES                                                       Hypokalemia
                 Primary changes                                          Hypercalcemia
             Secondary changes                                             Hypocalcemia
PERICARDITIS                                                         Hypermagnesemia
                       Pericarditis                                   Hypomagnesemia
PULMONARY DISEASE                                                  Sodium abnormalities
                            COPD                                        pH abnormalities
       Acute pulmonary embolus                        CENTRAL NERVOUS SYSTEM

                                                                                                               52
CONGENITAL HEART
DISEASE                                               CNS effects
                         ASD     HYPOTHERMIA
                         VSD                         Hypothermia
                         PDA     MISCELLANEOUS
                  Coarctation      Mitral valve prolapse syndrome
          Pulmonary stenosis                skeletal abnormalities
            Tetology of Fallot      Nonspecific ST and T changes
           Ebstein's Anomaly                        Prolonged QT
                Dextrocardia                   Abnormal U waves
      Corrected Transposition         Misplacement of Limb Leads
ARRHYTHMIAS                       Misplacement of precordial leads
SINUS RHYTHMS                            Poor R wave progression
         Normal sinus rhythm                          Low voltage
            Sinus Arrhythmia     PACEMAKERS
           Sinus Bradycardia                    Pacemaker codes
           Sinus Tachycardia                      Single chamber
                Sinus Pause                        Duel Chamber
                 Sinus Arrest
              Sinoatrial Block




                                                                     53
Echocardiography


During the rotation in the echo laboratory the fellow will be responsible in working closely with the echo technician in an effort to
obtain hands on skills with the ultimate goal of becoming expert in obtaining a complete echocardiographic and Doppler study.
He/she will interpret the majority of the studies done within the laboratory and review these studies with the attending cardiologist
in order to learn proper interpretation skills. He/she will be responsible for the careful handling of the esophageal probe and
learn proper manipulation and imaging with the probe under the supervision of the attending cardiologist. At times he/she may
be required to complete an interpretation report or dictate a comprehensive report. The fellow will also be responsible for
exercise and pharmacological stress testing during his rotation through the echo laboratory, including non-echocardiographic
stress testing as his/her time allows. At the beginning of the second year, the fellow will begin to learn dictation of echos. M-
mode studies will be evaluated and discussed. It is well recognized that the technical staff have a great deal of expertise to offer
the fellows in the acquisition of technically excellent images. The technologists are also skilled in interpretation. The fellow
should approach his/her experience in the echo lab as a student recognizing that his/her teachers will be technical as well as the
physician staff. The physician staff will be more oriented towards the instruction in the interpretation of echocardiograms.
Evaluations of fellow will reflect their acquisition of both technical and interpretive skills and will be based upon the judgments of
both the technical as well as the physician staff.

Standards for Image Acquisition
In this section is a checklist of standard views required on all transthoracic echocardiograms as well as additional reviews
required for specific clinical problems. It is expected that on each study the fellow will acquire images in the standard format.

Even a specific view is technically suboptimal is should be acquired on tape to demonstrate that an attempt was made to acquire
the image. It also will serve as an opportunity to instruct the fellow on how to improve suboptimal image when they occur.

The fellow should take the opportunity to do a brief cardiac examination on the patient prior to performing an echo. The should
guide the fellow in the use of color flow doppler during acquisition of each of these five views.

Specific techniques for identifying valvular lesions and other abnormalities will be taught in the laboratory. A checklist will be
used to assure that standard views are obtained and that in-depth investigation of specific cardiac abnormalities occurs with all
cases. For quality assurance, 2 echos per month will be read and logged on the forming the noninvasive lab.

2-D Study
Each study should have at least 10 beats of each of the following views:
     1) Parasternal long axis (include off-axis tricuspid view)
     2) Parasternal short axis (include off-axis tricuspid/ pulmonic views)
     3) Apical Four chamber
     4) Apical Two chamber
     5) Subxiphoid
Doppler
When indicated, all valves should be interrogated by doppler. The specific valves and lesions include:
Aortic Stenosis:      Flow velocities from
                                Apical Four Chamber
                                Suprasternal Notch – Pedoff transducer
                                Right Upper parasternal – Pedoff transducer
Aortic Insufficiency: Color flow and PW when color flow signal poor
                                Parasternal Long axis
                                Parasternal Short axis
                                Apical Four chamber
Mitral Stenosis:                Pressure half-time measurements from
                                Apical four chamber
                                Apical Two chamber
Mitral Insufficiency: Color flow and PW when color flow signal poor
                                Parasternal Long axis
                                Apical Four chamber
                                Apical two chamber
Tricuspid Insufficiency:        Color flow and PW when color flow signal poor
                                Parasternal Long axis (off-axis tricuspid view)
                                Parasternal Short axis (off-axis tricuspid view)
                                Apical four chamber
                                Subxiphoid
                                                                                                                                  54
Interpretation of Transthoracic Echocardiograms

Immediately following the completion of the study, the study should be reviewed by the attending cardiologist or the senior
noninvasive fellow (at the discretion of the attending cardiologist.) The fellow performing the procedure should write up the study
with the following format:

Chamber measurements (from M-mode and 2D)
Doppler measurements
2-D Narrative
         Chamber sizes
         Left ventricular function
         Right ventricular function (if abnormal)
         Aortic valve morphology and function
         Mitral valve morphology and function
         Tricuspid valve morphology and function
         Pulmonic valve morphology and function (if abnormal)
         Other abnormalities
                    LVH
                    Intracardiac masses
                    Pericardial abnormalities
                    Aortic abnormalities
                    Septal defects

Doppler Narrative (may immediately follow the related 2D findings)
        Valve abnormalities (regurgitation or stenosis)
        Shunts
        Other flow abnormalities
        Estimated systolic or mean PA pressure
        LV dp/dt
        Estimated systolic RV pressure (in VSD)
        Pressure half-time of AR flow velocity


Reporting of transthoracic echocardiograms
If the study was performed on a patient from the outpatient clinic, the attending cardiologist ordering the study should be called
as soon as the study has been reviewed. The hand-written report is then given to the secretary for the transcription and
signature of the attending cardiologist.

Transesophageal Echocardiography
Indication of Transesophageal Echocardiography (TEE)

Ambulatory Patients:
    1. Difficult and inadequate TTE
    2. Evaluation of prosthetic valve malfunction
    3. Evaluation of bacterial encocarditis
    4. Evaluation of intracardiac mass
    5. Evaluation of aortic dissection
    6. Evaluation of congenital heart disease, especially atrial septal defect and patent foramen ovale
    7. Better assessment of severity of mitral regurgitation
    8. Evaluation of the source of systemic emboli
Operating Room and ICU or ER settings:
    1. Cardiac evaluation in open chest trauma patients
    2. Pre-operative evaluation of valvular or congenital lesions
    3. Immediate postoperative assessment of the results of cardiac or aortic surgery
    4. Monitoring of left ventricular function during surgery
    5. Checking of intracardiac air immediately after surgery
    6. Evaluation of the cause of heart failure or low output state after surgery
    7. Evaluation of cardiac tamponade after surgery



                                                                                                                               55
Procedures for performing TEE:

    1.   Informed consent is obtained
    2.   Nothing by mouth for at least 4 hours prior to TEE
    3.   Sedation, if required, using Versed, Demerol or Valium, etc.
    4.   Xylocaine or Benzocaine local anesthetic gargle and orapharnageal spray to facilitate probe entry
    5.   Nasal oxygen and suction stand-by
    6.   Every 3 minute check of blood pressure, pulse and oxygen saturation, the latter if preceded by IV sedation
    7.   Patient lies in left lateral position with head anteflexed
    8.   Introduction of TEE probe through mouth into esophagus and further advanced into stomach
    9.   Imaging at 3 standard position, namely: gastric, lower esophageal and high esophageal with proper flexion and rotation
         of the probe

    Interpretation of the TEE:
    While manipulating the TEE probe to optimize the cardiac images, structural findings are noted and with the aid of color flow
    imaging, flow patterns across the valves and the intracardiac defects are observed. Important findings are communicated to
    the surgeons whenever the examiner see fit. Video recording of the displayed images are made for permanent record.

    Procedures for reporting results of TEE:

    The TEE report includes not only the TEE findings but also the pre-medications given, the patients tolerance of the
    procedure and the presence or absence of complications and proper remedial steps undertaken and the final outcome.

    Emergency TEE:
    Emergency TEE at night or during the weekend is performed by echo attending on call.

    Dobutamine Echocardiography

    Indications:
    1. Detection of viable hibernating myocardium
    2. Diagnosis of significant CAD in patients unable to exercise
    3. Cardiac risk stratification post-MI inpatients unable to exercise
    4. Pre-operative cardiac risk evaluation

    Contra-indications:
    1. Significant uncontrolled ventricular arrhythmias
    2. Atrial fibrillation with uncontrolled ventricular response
    3. High grade AV block
    4. Severe hypertension (Systolic >200 mmHg / Diastolic >120 mmHg)
    5. Hemodynamic instability
    6. Severe valvular disease
    7. Unstable angina
    8. Acute myocardial infarction within the past 5 days
    9. New York Heart Association Class III or IV
    10. Hypertrophic cardiomyopathy
    11. Technically poor echocardiographic windows
    12. Allergy to dobutamine
    13. Atropine is contra-indicated in patients with glaucoma and prostatism

    Before Dobutamine Echocardiography:
    1. Schedule the test with Echo personnel before entering the order into the computer system
    2. Beta-blocker therapy should be discontinued 24-48 hours prior to study
    3. Nothing by mouth (except for medications) for three hours prior to testing

    Evening and Weekend Studies
    There will be instances in which transthoracic echocardiograms are necessary during the evenings and on weekends. In all
    such instances the attending on-call should be notified. If a fellow who is on call is experienced in echocardiography, he or
    she may perform the study. The study should be discussed with the echocardiography attending as well as with the
    physician ordering the study. When performing echo, all studies must be recorded and documented, even if it is brief and or


                                                                                                                             56
     technically limited. Technicians are available 24 hours a day to guide your study. An attending must be notified if a stat
     study is to be done.

     Transesophageal echocardiograms requested as urgent or emergent procedures must be performed in collaboration with
     the echocardiography attending on-call. Advanced fellows meeting case-load requirements for credentials in
     echocardiography may be allowed to do emergent or emergent echocardiograms at the discretion of the echocardiography
     attending on-call, but it is expected that this will occur infrequently and the attending must be present.

     Please refer to current policies and procedures for all STAT echos and order accordingly.
     Electrocardiography and Exercise Stress Testing
During the nuclear cardiology rotation and at times during echo and clinical rotations the fellow will be responsible in learning the
proper and safe way to perform treadmill and pharmacologic stress testing. He/she will need to be able to properly assess the
patient and determine the appropriateness of the test being performed and adequately explain the procedure to the patient and
obtain a signed consent. He/she will supervise the test from beginning to end and act accordingly to the needs of the patient
should any complications or instability occur. He will provide the interpretation of the study, review it with the attending
cardiologist for accuracy, and provide a completed interpretation form for dictation. It is important that he/she learn the proper
dosing of any pharmacologic agents used in testing and know how to accurately calculate and assess the proper intravenous
concentration of the drug as prepared by the pharmacy.

Nuclear Regulatory Commission requirements for nuclear certification will be met over the course of three years for the
noninvasive track. You must perform a certain number of studies and dictate as well. Also you will have the appropriate lectures
and exposure to nuclear agents. You will perform the daily quality assurance testing in the nuclear lab with the nuclear medicine
technologist.

Every month you will complete the four nuclear quality assurance studies and complete the form and turn it in to the technologist
for evaluation.

Nuclear Cardiology

In addition to the responsibilities noted for exercise stress testing above, there are specific expectations of the fellow during his
assignment to nuclear cardiology. The nuclear regulatory commission has very specific requirements for any personnel working
in a laboratory that uses radioactive materials and these requirements must be referred to an adhered to in a strict manner. The
fellow will need to learn the proper handling of these materials and know their pharmacology and uses in clinical cardiology.
Proper and accurate description to the patient is needed and at times consents for their use must be obtained by the fellow. The
fellow will learn how to evaluate and interpret the nuclear studies under the guidance of an attending physician, and learn the
optimum agents and their limitation for each clinical situation.


Reporting Hours during Stress Rotation at SJHG / Cherry Hill

Effective July 1st, 2007 all fellows on a stress rotation at SJHG/CH will report to the Cherry Hill office not later than 6:30am on
Tuesday and Wednesday in order to complete the morning nuclear QA. This time may change to 6:00am depending on patient
scheduling; please check with Fran the day before for your exact reporting time. This daily QA is part of your nuclear
credentialing process. The fellow will do the morning QA on those days and give copies of the daily report to Kate for archiving;
Fran will counter-sign the report. Fran will go over the QA form with you, as there are tasks done on a weekly, monthly, bi-
monthly and quarterly basis. You will be responsible to complete the daily and weekly items; and ideally will be exposed at some
point during your rotation to those procedures performed on a quarterly basis. Some of these objectives will be discussed during
your Nuclear Stress lectures.
The goal of this initiative is to give the fellow proficiency in the nuclear lab in order to prepare for credentialing at an independent
operator status.




                                                                                                                                    57
CARDIAC CATHETERIZATION LABORATORY
CURRICULUM

GOALS AND OBJECTIVES:
Educational purpose and rationale or value as part of training of interventional cardiologist

Per COCAT requirements, exposure to percutaneous interventions will occur during your three years of cardiac catheterization
training. As a first year fellow, general observation regarding PTCA / stents will be performed. Educational experience will
include cath / PTCA case conference. You will be exposed to indications and contraindications of these procedures, patient
selection and techniques utilized to perform these procedures.

Second and third year fellows will build on the first year base with the addition of gaining understanding of the catheters / devices
and drugs used in the treatment of patients with coronary artery disease and acute myocardial infarction, as well as improved
patient selection as dictated by the literature and the attending physician staff. You will become familiar with indications and
contraindications of primary angioplasty as supported by medical literature.

Per COCAT requirements you will gain exposure and hands on experience at the discretion of the attending physicians. This is
NOT a level 3 training program for interventional cardiology so your academic and hands on training experience is limited to
Level I certification which is defined as exposure to interventional cardiology.

The American College of Cardiology training guidelines states that programs that do not have an interventional program should
have exposure to cardiac intervention and this is provided in our program at Our Lady of Lourdes Medical Center under the
direction of the interventional cardiologists.

All trainees should learn the appropriate selection of patients for cardiac catheterization, both left and right heart, and the
specifics outlined below.

         Learn the risks and benefits of cardiac catheterization.
         Learn how to assess which patients are at risk for developing renal failure and to minimize that risk.
         Learn how to take a history for dye induced allergic reactions and to minimize that risk.
         Learn the use of pre-medications and medications in the cath lab for conscious sedation.
         Learn indications for the use of ionic vs. nonionic contrast media.
         Become familiar with how to organize the schedule of a busy laboratory performing same day outpatient to inpatient to
          emergency procedures.
         Learn how to acquire a pre-catheterization history and physical and document the same.
         Learn the technique of obtaining arterial and venous access.
         Learn the technique of left and right heart catheterization, and right heart biopsy.
         Learn how to interpret the results of a left and right heart catheterization.
         Learn how to convey the results of a catheterization in the patient chart.
         Learn how to remove arterial and venous sheaths and maintain hemostasis.
         For groins with larger arterial puncture sites, learn the use of mechanical device compression to gain hemostasis.

The above goals require invasive fellows to develop extraordinary set of communication and interpersonal skills. These skills are
honed daily with the teaching and guidance from attending physicians.

Methodology of Teaching Goals and Objectives
Principal Teaching Method
The principal method for teaching will be directly interacting with the patient, scrubbing in shoulder to shoulder with the attending
physician and interpreting the results of a catheterization with the attending physician.

The catheterization laboratory currently performs 2,000 procedures per year. These include coronary intervention, diagnostic left
heart catheterization for patients with valvular heart disease and chest pain disorders, right heart catheterization for patients with
congestive heart failure and diagnostic catheterization for patients being evaluated for organ transplantation such as liver and
kidney.




                                                                                                                                  58
It is the responsibility of the attending physician to be an example for the invasive fellow particularly in terms of interpersonal and
communication skills to patients and patient’s families. Through personal example of the attending physician will show the
invasive fellows how to implement system-based practice as well as practice-based learning. The invasive fellow will be a role
model for the general cardiology fellow in the cath lab. The senior fellow will take the lead role in the cath lab and introduce the
first, second and third year fellows to the nuances of he cath lab and will remain a teaching tool o the general cardiology fellows.

Educational Content
Mix of Disease

The recommended text is Grossman’s Fifth Edition of Cardiac Catheterization.

Formal conferences consist of a monthly cardiac catheterization conference. This conference will stress the relation of history
and physical findings to the hemodynamic and angiographic criteria for the selection of patients for medical, surgical and
interventional therapy. Interaction with the cardiac surgeons at this conference is very important. The relation of non-invasive to
invasive testing will be stressed. The presentation of original non-invasive studies will be important.

There is a mix of social economic status among our patients providing an abundant supply of diverse patient
population. Through example the invasive fellow will learn responsiveness to the needs to patients in all social
economic groups. This will include a commitment to respect and compassion towards all patients. All fellows will
strive to excellence and ongoing professional development.

Method of Evaluation

Fellows will be evaluated by written critique on a monthly basis with input from all academic cath lab attendings. This critique will
include interpersonal skills, knowledge of cardiology, technical skills in the cath lab and the quality of the cath conference
presentations. Likewise, the fellow will evaluate the cath rotation and attendings on a monthly basis. These written evaluations
will be made available to and discussed with the fellow during quarterly evaluations.


Patients for Cardiac Catheterization
Patients who will be going for cardiac catheterization will be worked up and pre-medicated by the catheterization fellow and the
cath film will be reviewed by the catheterization attending with the clinical attending and you, the assigned fellow.

The cath results are almost always discussed with the patient and their family on the same day. It is usually the fellow’s
responsibility to discuss these results, write a note and record the results on the face sheet; however, this is left up to the
discretion of the attending physician.

YOU MUST SEE EVERY CATH PATIENT AND EXAMINE THEM PRIOR TO PERFORMING ANY PROCEDURE ON A
PATIENT.

You must identify yourself as a fellow in training prior to any patient contact.

Specific iodine prep is outlined as well as elevated creatinine. Please see the protocol sheet.

Adult Cardiac Catheterization Laboratory

General Instructions:

We are performing cases daily between 7:00am to 5:30pm. Our morbidity and mortality from cardiac catheterization are better
than the national average. Our prime concerns are the safety of the patient, patient care, then teaching.

You are responsible for a full and complete evaluation of the patient prior to the cath. The patient should be presented to the
attending and the case discussed.

To meet these requirements, we ask you to follow the instructions carefully and to read the enclosed article, which may be
helpful to you.

Everyone in our labs is willing to help you train as an invasive cardiologist and we ask for you full cooperation.

The list of patients for catheterization for the next day will be available in the late afternoon, and can be found in our OLOL office.


                                                                                                                                    59
EACH PATIENT SHOULD THEN BE SEEN BY THE FELLOW AND EXAMINED WITH PARTICULAR ATTENTION PAID TO
THE FOLLOWING:

Cardiac Catheterization and Angiography
The fellow will be expected to provide the proper pre-catheterization work up and preparation of his/her assigned patients and be
knowledgeable enough to adequately explain the procedure to the patient and obtain informed consent. He will work exclusively
under the guidance of an attending cardiologist who will be scrubbed with the fellow during the performance of the procedure.
Under the attending cardiologists instruction the fellow will be given various levels of hands on involvement in the lab. Ultimately,
the fellow would be expected to be capable of performing a complete study under the guidance of an attending if he/she is
enrolled in the invasive track, while the expectations of the non-invasive fellow would be less. He needs to learn the proper
procedure for obtaining homeostasis at the completion of arterial and venous puncture studies such as manual pressure and the
use of clamps and various other devices used in the closure of the puncture site. He/she will be responsible for providing the
appropriate pre and post cath orders for the patient and the supply of discharge instructions for the safe transition to the
outpatient for his or her return to home. He/she is expected to be capable of learning the accurate interpretation of any obtained
hemodynamics and angiograms, and may be expected to provide a written interpretation for the patient’s records. During the
course of this rotation the fellow will need to be able to learn the appropriate options of care for the patient based upon the
hemodynamic findings and angiograms (i.e., surgical, medical, catheter based treatment options). You will have regularly
scheduled cath conferences which are a mandatory didactic fellowship function.

Pre-cath Instructions:
Pre-cath orders should be written the evening before the procedure. Routine orders are as follows:
     1. NPO past midnight
     2. Prep both groin and arm only as indicated
     3. Pre-med with Benadryl 50mg p.o.
These medications should be administered at 6:30am for all first morning cases and “on=call” for all other cases. Dosages of
pre-medications may be adjusted in individual cases (elderly, COPD, thin patients, etc). Management of diabetic patients should
be discussed with the attending prior to the cath. Generally these patients should be scheduled early in the morning if possible,
especially insulin dependent diabetic patients, severe CHF, etc. Patients with allergy to contrast, protocols are available and will
be given to you during your rotation. Coumadin should be discontinued before admission. If a patient is on Heparin, it should be
discontinued at least 2 hours prior to cath except for patients with unstable angina.

     4.   The catheterization procedure and risk should be discussed with the patient and their family. The family should be
          asked in the next day (in the morning, if possible.) Contact the attending and discuss the cases and procedures
          planned.
     5.   Informed consent must be obtained by the fellow after explaining the procedures to the patient. The cath lab booklet
          must be given to the patient.

     During Catheterization and Post-Catheterization Instructions:
     1. During the cath lab procedure, please remember that the patient is awake. Unnecessary talk or discussion is not
          allowed.
     2. DO NOT GIVE ANY INFORMATION TO THE PATIENT, since the finding s on video or not as good as one the cine
          film.
     3. At the end of each case, the progress note must be written detailing the type of procedure done, any complications, the
          attending that performed the procedure, the location of the catheter entry, and the post-cath status of the pulses. Also
          a brief preliminary report should be written. The day following the catheterization, a short follow-up note should be
          placed on the chart.
     4. All calculations, ejection fractions, A-V differences, and oxygen consumption values should be calculated and filled out
          on the data sheet. Please discuss with the appropriate attending regarding any questions.
     5. All data sheets and pressure tracings must be delivered to the Cath Lab office by the end of the same day
     6. Post-cath orders are to be completed by the fellow and reviewed by the attending.
     7. The cath site should be examined for the presence of a hematoma and the peripheral pulses should be evaluated. A
          note should then be recorded on the daily progress note sheet. The cath lab attending must be notified of all
          complications resulting from catheterization. Also, all complication report forms should be sent to the Cath lab office,
          since it has to be entered into the database of the cath lab.




                                                                                                                                 60
                                                  Contrast Dye Allergy Prophylaxis:
                                                   Assess with individual attending.
                                                      Cath Lab Protocols

I.         Iodine Allergy
           Prednisone 40 mg. 10pm. Night before procedure
           Zantac 150 mg.             6am Day of procedure

II.        Creatinine                       1.5 – 2.0 OR
           GFR                              < 60 on CMP
           I. Mucomyst                      600 mg. P.O. BID One day before procedure
           II. 3 Amps. NaHCO3 +1000cc D5/W
               100 cc/hr. Start 1 hr. before procedure

           Creatinine                 > 1.2
           STOP nephrotoxic drugs especially NSAIDS pre-cath

III.       Latex Allergy: Notify pre-admission testing and cath-lab Patient needs isolation upon admission

Thank You,
Anil G. Kothari, M.D,
05/26/06

       Cathlab Equipment
       Lead aprons, glasses and any other cath lab equipment will be purchased by OLOL. These arrangements must have prior
       approval from the Program Director before speaking to the Cath Lab director for purchasing. This is done on a group basis,
       not on an individual basis.

       Appointments to order your lead will be scheduled with the appropriate parties by your program director and/or program
       coordinator.




                                                                                                                             61
Night / Weekend / Holiday Call Coverage

The fellow call schedule will be decided by the program director. Responsibilities include two weeknight calls per week
unless you are on the weekend. Weekend call will involve approximately 14 weekends per year. Call begins 5:00pm Friday
and ends Monday 9:00am. You will be first call for all hospitals and outpatient calls. There is a backup attending on call
with you. You are expected to address the calls and make decisions as a junior attending. Any issue may be discussed
with the attending. You are responsible to go into the hospital if the situation warrants it. Again, each case should be
discussed with the attending if warranted. You are not required to stay in house for the calls.

                          Holiday coverage is one major and one minor holiday per calendar year.

Rounding in the hospitals will be with an attending. You are responsible to decide how the weekend rounds will be divided
with the attending. Full notes and plan are to be done by the fellow. Notes are to be on the charts by the time the attending
rounds. You will then discuss the case with the attending and your plan will be evaluated.

                                                    *** Call Changes***

Any and all call changes must be requested and Kate notified before 3pm, in order for the website to be updated
and accurate. Call changes after 3pm, unless absolutely emergent will not be accepted.
If emergency changes occur, fellows must notify attending on call to let them know that changes have occurred.




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63
64
65
66
67
Vacation Scheduling

    Each fellow will be granted 4 weeks of vacation time (20 work days) each academic year. Vacation scheduling forms are
    available from the program coordinator. Requests for vacations must be submitted by the first of the month preceding the
    month in which the vacation will occur. For example, the vacation is October, time off must be formally requested by
    September 1st. It is preferred and highly encouraged that fellows try to avoid taking vacation time while on clinical service
    at UMDNJ. If you need vacation time during these scheduled vacations, please discuss this need in advance with your
    program director.

    Your program coordinator maintains a time-off book, before requesting any time off, please consult the book to make sure
    that there is adequate fellow coverage. Blank time off and conference request forms are in the book and are turned in to the
    program coordinator for approval.

    After completion and submission of your time off request, both the program director and the chairman of cardiology will
    review the request and all reasonable requests will be honored on a first-come, first-served basis.

    It is expected that prior to leaving for vacation you complete all of your responsibilities such as medical records; discharge
    summaries, catheterization reports, nuclear and echo QA, monthly service evaluations, monthly timesheets, etc. If a fellows
    medical records etc. are significantly behind or other requirements have not been brought up to date, this could possibly
    lead to a denial for requested vacation. Staying up to date with your responsibilities should not be difficult.

    The 20 days of vacation time given each year must be used during that academic year and cannot be carried out into the
    next academic year unless a special circumstance exists and permission is granted by the program director and chairman of
    the department. Any unapproved or un-notified absence from the hospital could possibly result in loss of vacation time as
    judged by the program director. If you become ill and cannot report to your rotation, please follow the protocol as listed in
    the manual.

    Addendum—
    This document will be a formal attachment to your cardiology manual. It is to clarify the vacation, personal leave and family
    leave time off. This is in conjunction to the agreement between the University of Medicine and Dentistry of New Jersey-
    School of Osteopathic Medicine and the Committee of Interns and Residents. As you know in this agreement it states
    clearly what amount of time off you have available to you. One area that needs clarification is the requirement for fellowship
    and coordination in conjunction with your time off. If you were to utilize all of the time that is available to you, you would not
    meet the attendance requirements to graduate from your fellowship. Therefore, effective immediately, you will have your 4
    weeks off per year. In addition you may take an additional 3 personal days and 5 sick days. Any additional time taken
    beyond this must be made up in order to graduate from your fellowship.

    I would like to be clear that certainly this time is available to you and you may utilize it in its appropriate fashion, but after
    vacation, personal and 5 sick days the time must be made up before you can graduate from the fellowship program. All
    time off, regardless of the reason must be submitted in writing on the appropriate form.

Conferences

Please refer to Conference Policy addendum




                                                                                                                                  68
                          3001 Chapel Avenue Suite 101 Cherry Hill NJ 08002




                              FELLOW TIME OFF REQUEST


NAME: ______________________________________________

DATE SUBMITTED:__________________________________

DATES REQUESTED:

__________________ VACATION       PERSONAL COMP DAY SICK DAY

__________________ VACATION       PERSONAL COMP. DAY SICK DAY

__________________ VACATION PERSONAL COMP.DAY SICK DAY

__________________ VACATION PERSONAL COMP. DAY SICK DAY


FELLOW SIGNATURE:__________________________________________________




Approved:__________________________

Not Approved:______________________




                                                                              69
                          3001 Chapel Avenue Suite 101 Cherry Hill NJ 08002




                                 CONFERENCE REQUEST


NAME: ______________________________________________

DATE SUBMITTED:__________________________________

DATES REQUESTED: **TWO WORK DAYS ONLY**

__________________ CONFERENCE NAME_____________________________

__________________ CONFERENCE NAME_____________________________

__________________ CONFERENCE NAME_____________________________


FELLOW SIGNATURE:__________________________________________________




Approved:__________________________

Not Approved:______________________




                                                                              70
Fellow Dress Code
Fellows are expected to maintain the highest professional standards of dress and behavior. At all times the fellows should have
a legible name tag and / or hospital identification badge in plain view. You are issued two (3) new lab coats at the beginning of
the year. Your lab coats are expected to be clean, neat and pressed at all times.

Appropriate male attire includes shirt with tie*, dress pants (no denims), no open- toe shoes / sandals and a white UMDNJ-SOM
issued Lab coat with name tag and identification badge in view. Appropriate female attire includes dresses, skirts or dress pants
(not denim) with appropriate blouses; no open-toe shoes/ sandals and a white UMDNJ-SOM issued lab coat with name tag and
identification badge in plain view.

Scrubs are the property of the medical center and are to be worn only when in the respective medical center(s).
                       Scrub suits are not to be worn outside or removed from the medical centers.

         cleaned on a regular basis to prevent cross-contamination and the transmission of infection
** Please refer to attached policy addendum for complete dress code guidelines.**

                                    Kennedy Memorial Hospital – University Medical Center
                                      Dress Code Guidelines – Students and House Staff
It is the policy of the Kennedy Healthy System that all care givers present a professional appearance. General dress should
reflect good judgment and create a favorable, positive image as a representative of the medical profession, SOM and Kennedy
Health System.
Medical students, interns, residents and fellows are expected to look and dress professionally when in any patient care area.
This includes the hospitals, family health center, surgical center, health care center and wound care center.

Personal Appearance Guidelines:
      Kennedy ID badges must be visible at all times
      \White coats are to be worn at all times in the hospital, even if wearing scrubs
      Attire, including lab coats, must be clean, pressed and in good condition
      Clothing that is torn, even if the tear is part of the design, is not acceptable
      Shoes must be clean and functional for work responsibilities. Closed toe shoes must be word in patient related areas.
          Clean clogs are acceptable in the OR’s and L and D
      Hosiery / socks must be worn with all types of shoes in patient related areas
      Hair, including facial hair, must be neatly trimmed. Specific areas / specialties may restrict the length of hair due to
          infection control and personal / patient safety
      Hair longer than shoulder length should be tied back in patient care areas for infection control reasons
      Men are expected to wear shirts with collars unless wearing scrubs
      Jewelry may be worn around the neck, wrists, ankles or ears provided it is safe and not excessive. In general, body
          piercing is not acceptable, but it is recognized that some piercing may have religious / cultural significance and may be
          tastefully worn
      Fingernails must be clean, neat and well groomed at all times and kept and ¼ inch in length. Freshly applied, non-
          chipped nail polish in a soft color is acceptable
      Artificial nails are not permitted due to their harboring more bacteria than natural nails
The following articles of clothing are not acceptable in patient care areas:
      Blue jeans
      Tee-Shirts
      Sweatshirts
      Halter tops
      Shorts / Capri pants
      Shirts with writing on them
      Sandals or flip-flops
      Skirts / dresses more than two inches above the knee

Any medical student or house staff member who does not adhere to the dress code may be asked to leave the facility
by a member of the medical staff, manager or administrator. He/she may return to the facility when the attire meets
acceptable standards.

** Program manual addendum 12/14/2007/kmj

                                                                                                                                71
Corrective Actions

Grievance Procedure (as per the CIR contract)

    1.   Purpose. The purpose of this procedure is to assure prompt, fair and equitable resolution of disputes concerning terms
         and conditions of employment arising from the administration of the Agreement by providing the sole and exclusive
         vehicle set forth in this article for adjusting and setting grievances. In no event shall matters concerning academic or
         medical judgment by the subject of a grievance under the provisions of this article. Matters pertaining to non-
         reappointment shall be grievable under this agreement only upon this basis of claimed violations involving
         discriminatory treatment in violation of Discrimination or Article VII, individual contracts.
    2.   Definition. A grievance is an allegation by housestaff officer of the housestaff organization of the University of
         Medicine and Dentistry of New Jersey, an Affiliate of the Committee of Interns and Residents (hereinafter referred to as
         HOUMDNJ/CIR) that there has been:
               a. A breach, misinterpretation or improper application of he terms of this agreement; or,
               b. An improper or discriminatory application of, or failure to act pursuant to, the written rules, policies or
                    regulations of the University or statutes to the extent that any of the above established terms and conditions
                    of employment which are matters which intimately and directly affect the work and welfare of housestaff
                    officers and which do not significantly interfere with inherent management prerogatives pertaining to the
                    determination of public policy.
    3.   Preliminary Informal Procedure. The parties agree that all problems should be resolved, whenever possible, before the
         filing of a grievance and encourage open communication between the University and the housestaff officer so that
         resort to the formal grievance procedure will no normally be necessary.
         A housestaff officer may orally present and discuss a grievance with his or her Chief resident, or with the University’s
         approval, an appropriate designee, who may, if the circumstances warrant, arrange an informal conference between
         the appropriate administrator and the grievant. The grievant may, at his or her option, request the presence of a CIR
         representative during attempts at informal resolution of the grievance. If the housestaff officer exercises this opinion,
         the administrator may determine that such grievance be moved to the first step. Informal discussion shall not serve to
         extend the time within which a grievance must be filed, unless such is agree to in writing by the University official
         responsible for the administration of the first formal step of the grievance procedure.

         Any disposition of a grievance by a Chief Resident will be subject to confirmation by an appropriate administrator.

    4.   Formal Steps.
             a. Step One. If the grievance is not informally resolved, the CIR may file a written request for review with the
                  appropriate Dean or designee within thirty (30) calendar days after the date on which the act(s) occurred or
                  twenty-one (21) calendar days from the date on which the individual housestaff officer should reasonably
                  have known of it’s occurrence.

                   The Dean or designee shall review the grievance and where he or she deems it appropriate, witness may be
                   heard and pertinent records received. The hearing shall be held within fourteen (14) calendar days of receipt
                   of the grievance, and the decision shall be rendered in writing to the housestaff officer within fourteen (14)
                   calendar days following the conclusion of the review.


              b.   Step two. If the CIR is not satisfied with the disposition of he grievance at Step One, the CIR may appeal to
                   the vice-president of human resources or his/her designee within fourteen (14) calendar days of receipt of
                   the step one decision. Hearings must be scheduled within fourteen (14) calendar days, excluding holidays,
                   of receipts of the appeal. The decision shall be rendered in writing to the housestaff officer and the CIR
                   representative within fourteen (14) calendar days from the conclusion of the hearing.

                   If the grievance involves a non-contractual grievance as defined above, the Vice-president for human
                   resources may alternatively within fourteen (14) calendar days of receipt of the appeal, convene a committee
                   described below which shall hear the merits of the grievance and shall deliver its findings to the vice
                   president of human resources within fourteen (14) calendar days following the date of its hearing. The
                   committee shall consist of two (2) members appointed by the housestaff officers who shall be officers with
                   atleast two (2) years of service at the University and three (3) members appointed by the vice president for
                   human resources, one of whom shall be the associate vice president for academic administration or his/her
                   designee who shall serve as chairperson. For the purposes of conducting the housestaff and two (2)
                   members appointed by the vice president for human resources.

                                                                                                                               72
                   The vice-president for human resources will review the committee’s recommendation as to the disposition of
                   the grievance and within fourteen days following receipt of the committee’s written report and
                   recommendation render a final and binding decision to the grievant.

                   No complaint informally resolved or grievance resolved at either step one or two shall constitute a precedent
                   for any purposes unless agreed to in writing by the vice president for human resources and CIR acting
                   through its representative.

              c.   Step Three. If the grievance involves a contractual violation of the agreement as
                   Defined above, the CIR may, upon written notification to the vice-president for human resources or his / her
                   designee, appeal he step two decision to arbitration. Said notice must be filed with the public employment
                   relations commission within twenty-one (21) calendar days following receipt of the step two decisions. It
                   must be signed by a CIR representative or official.

                   The arbitrator shall conduct a hearing and investigation to determine the facts and render a decision for the
                   resolution of the grievance. The parties agree that the decision of the arbitrator shall be final and binding.
                   The arbitrator shall neither add to, subtract from, modify, or alter the terms of this agreement or determine
                   any dispute involving the exercise of a management function, which is within the authority of the University
                   as set forth in Article III (management rights). Arbitration shall be confined solely to the application and/or
                   interpretation of this agreement and the precise issue(s) submitted. The arbitrator shall not substitute his or
                   her judgment for academic or medical judgments, nor shall the arbitrator review such decisions except for the
                   purpose of determining whether the decision has violated this agreement. Any cost resulting from this
                   procedure shall be shared equally by the parties.

                   Arbitrators shall be selected, on a case-by-case basis, under the selection procedure of the public
                   employment relations committee.


    5.   Procedural Rules.
             a. A grievance must be filed at Step One within twenty-one (21) calendar days from the date on which the act(s)
                  which is the subject of the grievance occurred or twenty-one (21) calendar days from the date on which the
                  individual housestaff officer should reasonably have known of it’s occurrence.
             b. Where the subject of a grievance suggests it and where the parties mutually agree, such grievance may be
                  initiated at, or moved to, Step Two of this process.
             c. Time limits provided for in this Article may be extended by written mutual agreement of the parties at the
                  level involved.
             d. No reprisal of any kind shall be taken against any housestaff officer who participates in this grievance
                  procedure.
             e. Where a grievance directly concerns and is shared by more than one housestaff officer, such group
                  grievance may, upon mutual agreement properly be initiated at the first level of supervision common to the
                  several grievants. The presentation of such group grievance will be by the appropriate HOUMDNJ/CIR
                  representatives and one of the grievants designated by the HOUMDNJ/CIR. A group grievance may be
                  initiated by the HOUMDNJ/CIR. Where individual grievance concerning the same matter are filed by several
                  gievants, I shall be the option of the university to consolidate such grievances for hearing a group grievance
                  provided the time limitations expressed elsewhere herein are understood to remain unaffected.
             f. Should a grievance not be satisfactorily resolved, or should the employer not respond timely as prescribed
                  above either after initial receipt of the grievance or after movement of the grievance to Step Two, the grievant
                  may exercise the option within twenty-one (21) calendar days to proceed to the next step.
             g. If, at any step in the grievance procedure, the university decision is not appealed within the appropriate
                  prescribed time, such grievance will be considered closed and there shall be no further appeal or review.

Disciplinary Action (as per the CIR contract)

Housestaff officers may be disciplined or discharged for cause. Disciplinary actions shall be grievable, and in the event the
involved housestaff officer files a grievance, the burden of proving just cause shall be upon the university.

The University shall give five (5) working days advance notice, in writing, of any intended disciplinary action to the affected
housestaff officer and the CIR. The notice shall state the nature and the extent of discipline, the specific charges against the
housestaff officer and describe the circumstances upon which each charge is based.



                                                                                                                              73
A housestaff officer whom University has given notice of disciplinary action may be removed from service without (5) working
days notice where his/her continued presence is deemed to imperil patient safety, public safety, or the reassignment shall be
contained in the University’s written notice of intended disciplinary action. Where a housestaff officer has been removed from
service, the University may concurrently remove the housestaff officer from its payroll.

If it is later discovered that the housestaff officer was wrongly removed from service, the housestaff officer shall be reinstated
with full back pay. In addition, if the housestaff officer, as a result of the wrongful removal from service, is required to work
beyond the end of the residency year to complete his or residency, the housestaff officer shall remain on university payroll until
such time as the residency has been completed.

Appeals of disciplinary actions shall be presented at Step Two of the grievance procedure. Such appeals shall be made within
14 days of receipt of the charges and disciplinary penalty. A hearing must be held within fourteen calendar days, excluding
holidays, of receipt of the appeal.

The step two decision by the vice president of human resources or his/her designee may be appealed to arbitration by filing with
the public employee relations commission. Such an appeal must be filed within twenty-one (21) calendar days of receipt of he
written step two decision.

Arbitration decisions in disciplinary actions shall be made in accordance with step three of the grievance procedure. The remedy
in disciplinary actions will be limited to back pay and/or reinstatement to the housestaff officer’s position. Housestaff officers may
not seek post-residency damages under this agreement. However, this agreement shall not preempt or preclude a housestaff
officer from seeking appropriate relief for any post-residency damages in any judicial forum or administrative agency.

Additional Grievance Policies / Our Lady of Lourdes Medical Center

While on service at any of the Our Lady of Lourdes hospital institutions (Camden, Burlington) you will follow all of the practice
and procedures outlined in your manual as well as for the institution of Our Lady of Lourdes Hospital. If a grievance arises at
Our Lady of Lourdes Hospital, Camden Division, Dr. Jan Weber will be the intermediary regarding this grievance between you
and the parties involved. As program director, I certainly will be involved in the process, but Dr. Weber would have final
discretion regarding final resolution regarding any grievance. I encourage you to meet with Dr. Weber immediately and to notify
this office immediately should a grievance arise.




                                                                                                                                  74
NPI Application:

All UMDNJ-SOM cardiology fellows must apply for and receive their NPI number before the end of their first
month of fellowship. While this is not currently state mandated, it is ever becoming more and more of a
necessity. If you already have an NPI, please give that number to your program coordinator. If you do not,
please plan on applying for one.

Fellows can apply for their individual NPI number online at:

https://nppes.cms.hhs.gov/NPPES/Welcome.do

The application is free and should take about 20 minutes to complete and about 10 days to process.

For further information, read the attached article.




                                                                                                       75
Universal Protocol for the prevention of wrong site, wrong procedure, wrong person surgery



                                             KENNEDY MEMORIAL HOSPITALS – UNIVERSITY MEDICAL CENTER


Policy:      Universal Protocol for the                                               Manual:           Operating Room/Same
             Prevention of Wrong Site,                                                                    Day Surgery
                         Wrong Procedure, Wrong
                         Person Surgery


Function: Patient Care                                                                Policy Number:             3.22/324


Implementation Date: April 2000                                                       Page:                      1 of 8
Last Revision:       October 2006


Author:      Daniel Herriman                                                          Distribution:              Medical Staff
             Perioperative Nurse Managers                                                                        Surgical Services




                                                         Universal Protocol for the Prevention of Wrong Site,
                                                             Wrong Procedure, Wrong Person Surgery

POLICY:
The purpose of this policy is to structure the responsibilities of members of the surgical team in preventing wrong-site, wrong procedure, and wrong person
surgery. This process involves a pre-operative verification process, marking of the surgical site and a “Time Out” which is done immediately prior to the start of
the surgical procedure. It is usually referred to a “Universal Protocol.” Every member of the team has specific responsibilities to prevent errors.

PURPOSE:

Patient Selection

This policy applies to patients undergoing procedures involving right/left distinction, multiple structures (such as fingers or toes), or multiple levels (such as spinal
surgery).

It is not necessary to mark the surgical area where:
             The surgical side or level is readily apparent to all operating room personnel because the site has been identifiably marked prior to arriving in the
              operating room (e.g., breast lumpectomy with pre-operative needle localization).

            The surgical incision and planned procedure are midline, do not involve spinal segments and are not affected by laterality e.g., thyroidectomy,
             uvulectomy, mid line sternotomy, Cesarean section and laparotomy and laparoscopy. In endoscopic and laparoscopic procedures where the target
             site is for organs that are paired, site marking is required to indicate the intended side, even though the site of insertion of the instrument is midline.
             The patient should be marked near the proposed site or near the proposed incision/insertion site.

            Cardiac catheterization and other interventional procedures for which the site of insertion is not predetermined.

            The marking of teeth is also exempt from the site marking requirement BUT, indicate operative tooth name(s) on documentation OR mark the
             operative tooth (teeth) on the dental radiographs or dental diagram.

            In spinal surgery where the approach is anterior. (It is encouraged that determination of spinal level be determined intraoperatively)

SCOPE:
            Order requirement – none
            Consent requirement - none
            Responsibilities – Surgical Team
            Approval - None
            Definition of Terms – none
            Equipment –none


                         Procedure                                                                                   Key Points
A. The Operating Surgeon:

      1.     To identify the correct surgical/procedure site, the
             surgeon/physician performing the procedure checks
             medical records, films, and other indicators of proper
             surgery site. When appropriate and patient status

                                                                                                                                                                      76
                             Procedure                                      Key Points
            permits participation (awake and aware), the
            surgeon/physician asks the patient to indicate the correct
            surgical site.

      2.    After proper identification has taken place, the
            surgeon/physician performing the procedure marks the
            surgical site at or near the incision site. The site is to be
            marked with the physician’s initials. Do Not mark any
            non-operative site(s) unless necessary for some other
            aspect of care.

      3.    Marking may take place in the preoperative area or in
            the operating room prior to the patient receiving any
            sedation.

      4.     Using a surgical marker to sign/initial the operative site
            of the patient.
            An “X” is not used to identify the
            correct or incorrect site.
           Do not write over pressure sensitive areas (carotid
            artery) or in cosmetically sensitive areas. It is
            acceptable to sign in areas immediately adjacent to the
            surgery site.
           If a diagnostic imaging study is used to determine the
            correct site and the patient or record (e.g., the X-ray
            lacks a right or left mark) does not substantiate the
            correct site, an X-ray or an image intensifier is used prior
            to making an incision to verify the site.

      5.    The surgeon is not to proceed with surgery unless the
            signature is visible after prepping/draping the area for
            surgery unless it is technically or anatomically impossible
            or impractical to do so.

      6.    It is not appropriate to mark the side of the patient that is
            not to be operated on.


B.    Nursing Personnel

            1.    Blades will be removed from the scrub table and
                  passed off to the circulator when the case is
                  opened.
            2.    Blades are not to be returned to the table until the
                  time out portion of the universal protocol is
                  completed.
            3.    If the case does not require a blade no
                  instrumentation is to leave the scrub table until the
                  time out is completed.

C.    Other Surgical Team Members

 As part of the Universal Protocol, it is the responsibility of the
surgical team to conduct a “Time Out” prior to the initiation of the
procedure. The process takes place with every member of the
surgical team (Surgeon, Anesthesiologist/Anesthetist, Circulating
Nurse, Scrub Nurse, and Resident if present). Time out is to be
conducted immediately prior to incision or initiation of the
surgery or procedure.
All activity ceases in the OR/Procedure room while the time out
is being conducted.

      1.    The universal protocol is conducted utilizing the medical
            record and the patient identification band.

      2.    The surgical permit is reviewed and the patient is
            identified by name and medical record number against
            patient identification band.

      3.    The team will confirm laterality, multiple structures or
            levels and the signature/initials of the operating surgeon
            at the proper site.

      4.    The team will confirm procedure to be performed is the

                                                                                         77
                                   Procedure                                       Key Points
                   correct procedure.

             5.    The team will confirm that the patient’s position is
                   correct.

             6.    Review of the chart will include review of the patient
                   allergies. The statement of “no known allergies” will be
                   used or the allergies that the patient has identified will be
                   reviewed as part of this process.

             7.    The circulating nurse is responsible for confirming with
                   the surgeon the availability of correct implants and any
                   equipment or special requirements.

     D.      Anesthesia Department

1.           1. Anesthesiologist/ Anesthetist
2.              administer anesthetic agents only
3.              after the correct site has been
4.              marked by the surgeon’s
5.              signature/initials.

     Special Considerations for Spinal Surgery

     The Operating Surgeon

     1.      Reviews all necessary documents that indicate the level at
             which to operate.

     2.      For posterior approaches, marks the operative site with a
             radiographically visible marker and positions the patient on the
             operative table.

     3.      Obtains and interprets pre-incision radiographs to assure the
             proper operative level and exposure.

     4.      Uses reliable techniques to again identify the level intra-
             operatively:

            Exposes the lamina at the operative site.

            Marks the intended level using an instrument or clip at the level
             of the exposed lamina.

            Performs an intra-operative spinal radiograph to determine the
             exact location and level. Personally interprets the X-ray with
             the marking in place

            Indelibly marks the site using a cautery, stitch, or “bone bite”
             before moving the X-ray marker.

     5.      The orthopedic and radiology departments will collaborate in
             implementing using a consistent “level” terminology. The
             preferred terminology will define spinal interspaces by their
             upper and lower limits (e.g. “L3-4”, not “L3”) when reporting all
             spinal levels.

     E.      Discrepancies

             A discrepancy at any point in time must stop the case from
              proceeding until resolved.
             All team members and patient (if possible) must agree on the
              resolution to the identified discrepancy.
             The discrepancy and resolution must be documented by the
              registered nurse.


     F.      Special Considerations

            For ophthalmology surgery a site mark will be made adjacent
             to the eye and must be visible after the patient is prepped and
             draped. Adhesive markers must only be used as an adjunct to
             the site marking.

                                                                                                78
                             Procedure                                   Key Points

    Adhesive markers may be applied when team members need
     to perform a treatment (i.e. anesthesia block) or medication
     administration prior to site marking and should follow the
     patient identification process.

    In the case of a surgical emergency, a site mark maybe
     omitted, but a surgical "time out" should be performed unless
     the risk outweighs the benefit.


    If a patient refuses to have the site marked, the patient's
     physician will review with the patient the rationale for site
     marking. If the patient still refuses site marking, the physician
     will document this in the medical record. The patient's
     operative/procedure consent will be validated with the patient
     as to right procedure and right site in place of marking. This
     document will then be used during the surgical "time out" to
     validate correct site.




AGE SPECIFIC TECHNICAL CONSIDERATIONS: None

DOCUMENTATION: None

REFERENCES:
    1.  Administrative Decision

ORIGINAL APPROVAL DATE : April 2000

REVIEW DATES Annually through December 2005

REVISION DATES: January 2005, October 2006

APPROVAL OF REVISIONS:
Perioperative Management Committee
Service Line Committee, Perioperative Services




                                                                                      79
UMDNJ-SOM / South Jersey Heart Group P.C. Cardiology Fellowship Manual, updated, June 30th, 2010.


______________________________                    ______________________
John N. Hamaty, D.O., FACC, FACOI                 June 30th, 2010
Program Director

__________________________                        _____________________
Kate Jurman, CMA                                  June 30th, 2010
Program Coordinator




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