Milestones: Years 1-3
Interns spend their first month of residency in both the Emergency Department (10 shifts) and training sessions. Classroom training is used to introduce new residents to a broad range of patient concerns that ED physicians evaluate and treat. Residents also participate in simulation sessions to work through common ED presentations in addition to a 2-day ultrasound lab to learn and practice technique. In cadavar lab, residents have hands-on experience with essential procedures such as cricothyroidotomy, paracardiocentesis, intubation, central lines, chest tubes, and thoracotomy.
PROGRAM YEAR 1 - The resident demonstrates milestones expected of an incoming resident:
- Recognizes abnormal vital signs.
- Performs and communicates a reliable, comprehensive history and physical exam.
- Determines the necessity of diagnostic studies.
- Constructs a list of potential diagnoses based on chief complaint and initial assessment.
- Knows the different classifications of pharmacologic agents and their mechanism of action. Consistently asks patients for drug allergies.
- Recognizes the need for patient re-evaluation.
- Describes basic resources available for care of the emergency department patient.
- Manages a single patient amidst distractions.
- Identifies pertinent anatomy and physiology for a specific procedure. Uses appropriate Universal Precautions.
- Describes upper airway anatomy. Performs basic airway maneuvers or adjuncts (jaw thrust/chin lift/oral airway/nasopharyngeal airway) and ventilates/oxygenates patient using BVM.
- Discusses with the patient indications, contraindications and possible complications of local anesthesia. Performs local anesthesia using appropriate doses of local anesthetic and appropriate technique to provide skin to sub-dermal anesthesia for procedures.
- Describes the indications for emergency ultrasound.
- Prepares a simple wound for suturing (identify appropriate suture material, anesthetize wound and irrigate). Demonstrates sterile technique. Places a simple interrupted suture.
- Performs a venipuncture. Places a peripheral intravenous line. Performs an arterial puncture.
- Passes initial national licensing examinations (e.g., USMLE Step 1 and Step 2 or COMLEX Level 1 and Level 2).
- Adheres to standards for maintenance of a safe working environment. Describes medical errors and adverse events.
- Describes members of ED team (e.g., nurses, technicians, and security).
- Uses the Electronic Health Record (EHR) to order tests, medications and document notes, and respond to alerts. Reviews medications for patients.
- Describes basic principles of evidence-based medicine.
- Demonstrates behavior that conveys caring, honesty, genuine interest and tolerance when interacting with a diverse population of patients and families.
- Demonstrates basic professional responsibilities such as timely reporting for duty, appropriate. dress/grooming, rested and ready to work, delivery of patient care as a functional physician. Maintains patient confidentially. Uses social media ethically and responsibly. Adheres to professional responsibilities, such as conference attendance, timely chart completion, duty hour reporting, procedure reporting.
- Establishes rapport with and demonstrate empathy toward patients and their families. Listens effectively to patients and their families.
- Participates as a member of a patient care team.
PROGRAM YEAR 2 - The resident is advancing and demonstrates additional milestones, but is not yet performing at a mid-residency level:
- Recognizes when a patient is unstable requiring immediate intervention. Performs a primary assessment on a critically ill or injured patient. Discerns relevant data to formulate a diagnostic impression and plan.
- Performs and communicates a focused history and physical exam which effectively addresses the chief complaint and urgent patient issues
- Orders appropriate diagnostic studies. Performs appropriate bedside diagnostic studies and procedures.
- Constructs a list of potential diagnoses, based on the greatest likelihood of occurrence. Constructs a list of potential diagnoses with the greatest potential for morbidity or mortality.
- Applies medical knowledge for selection of appropriate agent for therapeutic intervention. Considers potential adverse effects of pharmacotherapy.
- Monitors that necessary therapeutic interventions are performed during a patient's ED stay.
- Formulates a specific follow-up plan for common ED complaints with appropriate resource utilization.
- Task switches between different patients.
- Performs patient assessment, obtains informed consent and ensures monitoring equipment is in place in accordance with patient safety standards. Knows indications, contraindications, anatomic landmarks, equipment, anesthetic and procedural technique, and potential complications for common ED procedures. Performs the indicated common procedure on a patient with moderate urgency who has identifiable landmarks and a low-moderate risk for complications. Performs post-procedural assessment and identifies any potential complications.
- Describes elements of airway assessment and indications impacting the airway management. Describes the pharmacology of agents used for rapid sequence intubation including specific indications and contraindications. Performs rapid sequence intubation in patients without adjuncts. Confirms proper endotracheal tube placement using multiple modalities.
- Knows the indications, contraindications, potential complications and appropriate doses of analgesic/sedative medications. Knows the anatomic landmarks, indications, contraindications, potential complications and appropriate doses of local anesthetics used for regional anesthesia.
- Explains how to optimize ultrasound images and identifies the proper probe for each of the focused ultrasound applications. Performs an eFAST.
- Uses medical terminology to clearly describe/classify a wound (e.g., stellate, abrasion, avulsion, laceration, deep vs superficial). Classifies burns with respect to depth and body surface area. Compares and contrasts modes of wound management (adhesives, steri-strips, hair apposition, staples). Identifies wounds that require antibiotics or tetanus prophylaxis. Educates patients on appropriate outpatient management of their wound.
- Describes the indications, contraindications, anticipated undesirable outcomes and complications for the various vascular access modalities. Inserts an arterial catheter. Assesses the indications in conjunction with the patient anatomy/pathophysiology and select the optimal site for a central venous catheter. Inserts a central venous catheter using ultrasound and universal precautions. Confirms appropriate placement of central venous catheter. Performs intraosseous access.
- Resident develops and completes a self-assessment plan based on the in-training examination results. Completes objective residency training program examinations and/or assessments at an acceptable score for specific rotations.
- Routinely uses basic patient safety practices, such as time-outs and 'calls for help'.
- Mobilizes institutional resources to assist in patient care. Participates in patient satisfaction initiatives.
- Ensures that medical records are complete, with attention to preventing confusion and error. Effectively and ethically uses technology for patient care, medical communication and learning.
- Performs patient follow-up.
- Demonstrates an understanding of the importance of compassion, integrity, respect, sensitivity and responsiveness and exhibits these attitudes consistently in common/uncomplicated situations and with diverse populations.
- Identifies basic principles of physician wellness, including sleep hygiene. Consistently recognizes limits of knowledge in common and frequent clinical situations and asks for assistance. Demonstrates knowledge of alertness management and fatigue mitigation principles.
- Elicits patients' reasons for seeking health care and expectations from the ED visit. Negotiates and manages simple patient/family-related conflicts.
- Communicates pertinent information to emergency physicians and other healthcare colleagues.
PROGRAM YEAR 3 - The resident continues to advance and demonstrate additional milestones. The resident demonstrates the majority of milestones targeted for residency:
- Manages and prioritizes critically ill or injured patients. Prioritizes critical initial stabilization actions in the resuscitation of a critically ill or injured patient. Reassesses after implementing a stabilizing intervention. Evaluates the validity of a DNR order.
- Prioritizes essential components of a history given a limited or dynamic circumstance. Prioritizes essential components of a physical examination given a limited or dynamic circumstance.
- Prioritizes essential testing. Interprets results of a diagnostic study, recognizing limitations and risks, seeking interpretive assistance when appropriate. Reviews risks, benefits, contraindications, and alternatives to a diagnostic study or procedure.
- Uses all available medical information to develop a list of ranked differential diagnoses including those with the greatest potential for morbidity or mortality. Correctly identifies "sick versus not sick" patients. Revises a differential diagnosis in response to changes in a patient's course over time.
- Considers array of drug therapy for treatment. Selects appropriate agent based on mechanism of action, intended effect, and anticipates potential adverse side effects. Considers and recognizes potential drug to drug interactions.
- Identifies which patients will require observation in the ED. Evaluates effectiveness of therapies and treatments provided during observation. Monitors a patient's clinical status at timely intervals during their stay in the ED.
- Formulates and provides patient education regarding diagnosis, treatment plan, medication review and PCP/consultant appointments for complicated patients. Involves appropriate resources (e.g., PCP, consultants, social work, PT/OT, financial aid, care coordinators) in a timely manner. Makes correct decision regarding admission or discharge of patients. Correctly assigns admitted patients to an appropriate level of care (ICU/Telemetry/Floor/ Observation Unit).
- Employs task switching in an efficient and timely manner in order to manage multiple patients.
- Determines a backup strategy if initial attempts to perform a procedure are unsuccessful. Correctly interprets the results of a diagnostic procedure.
- Uses airway algorithms in decision making for complicated patients employing airway adjuncts as indicated. Performs rapid sequence intubation in patients using airway adjuncts. Implements post-intubation management. Employs appropriate methods of mechanical ventilation based on specific patient physiology.
- Knows the indications, contraindications, potential complications and appropriate doses of medications used for procedural sedation. Performs patient assessment and discusses with the patient the most appropriate analgesic/sedative medication and administers in the most appropriate dose and route. Performs pre-sedation assessment, obtains informed consent and orders appropriate choice and dose of medications for procedural sedation. Obtains informed consent and correctly performs regional anesthesia. Ensures appropriate monitoring of patients during procedural sedation.
- Performs goal-directed focused ultrasound exams. Correctly interprets acquired images.
- Performs complex wound repairs (deep sutures, layered repair, corner stitch). Manages a severe burn. Determines which wounds should not be closed primarily. Demonstrates appropriate use of consultants. Identifies wounds that may be high risk and require more extensive evaluation (example: x-ray, ultrasound, and/or exploration).
- Inserts a central venous catheter without ultrasound when appropriate. Places an ultrasound guided deep vein catheter (e.g., basilic, brachial, and cephalic veins).
- Demonstrates improvement of the percentage correct on the in-training examination or maintain an acceptable percentile ranking.
- Describes patient safety concepts. Employs processes (e.g., checklists, SBAR), personnel, and technologies that optimize patient safety (SBAR= Situation - Background - Assessment - Recommendation). Appropriately uses system resources to improve both patient care and medical knowledge.
- Practices cost-effective care. Demonstrates the ability to call effectively on other resources in the system to provide optimal health care.
- Recognizes the risk of computer shortcuts and reliance upon computer information on accurate patient care and documentation.
- Performs self-assessment to identify areas for continued self-improvement and implements learning plans. Continually assesses performance by evaluating feedback and assessment. Demonstrates the ability to critically appraise scientific literature and apply evidence-based medicine to improve one's individual performance.
- Recognizes how own personal beliefs and values impact medical care; consistently manages own values and beliefs to optimize relationships and medical care. Develops alternate care plans when patients' personal decisions/beliefs preclude the use of commonly accepted practices.
- Consistently recognizes limits of knowledge in uncommon and complicated clinical situations; develops and implements plans for the best possible patient care. Recognizes and avoids inappropriate influences of marketing and advertising.
- Manages the expectations of those who receive care in the ED and uses communication methods that minimize the potential for stress, conflict, and misunderstanding. Effectively communicates with vulnerable populations, including both patients at risk and their families.
- Develops working relationships across specialties and with ancillary staff. Ensures transitions of care are accurately and efficiently communicated. Ensures clear communication and respect among team members.
Aug 25, 2016