Supervision of Resident Activities

Guidelines

The purpose of these guidelines is to ensure patient safety, enhance the quality of patient care, and improve the training experience of residents. Consistent with the philosophy of progressively increasing individual responsibility, these guidelines are intended to provide the trainee the opportunity for graded levels of responsibility.

These guidelines apply to all residents enrolled in the Core Surgery and General Surgery Training Programs, and attending surgeons of all integrated and affiliated institutions who are involved with the UCLA General Surgery and Core Surgery Training Programs.

General Guidelines

1. The supervision and communication between the attending surgeon and any resident should exceed that required to ensure that the clinical care delivered meets the established community standard of care.
2. The resident can identify and contact a responsible attending surgeon for a given patient at all times.  NO CURBSIDE CONSULTS.
3. In the event that an attending surgeon is not available to provide supervision, he or she must designate an alternate or covering attending and identify that person to the resident.
4. For ambulatory or non-urgent care, an attending surgeon is required to be available on-site at the facility during daytime hours of operation.
5. For inpatient admissions, an attending surgeon or supervising resident will be notified of the admission and such notification will be documented in the admitting resident's admission note. An attending surgeon will personally see and evaluate each assigned inpatient admission within twenty-four (24) hours of admission, and co-sign the resident's admitting note or create their own written or printed documentation.
6. For inpatients, residents should maintain ongoing communication at least one (1) time per day with the designated attending surgeon. The attending surgeon should document such communication by co-signing the resident's progress note, or the resident will include in his progress note that the case has been discussed with the attending surgeon.
7. It is assumed that there is a mutual responsibility on the part of both the resident and attending surgeon to recognize the need for increased frequency and quality of communication, and attending surgeon participation in the following circumstances:

a.    limited experience of the resident

b.    increased acuity of the patient's condition (e.g. transfer to intensive care unit, need for higher level of clinical care, etc.

c.    higher risk of complication or mortality associated with the clinical intervention being considered

d.    end of life decisions or initiation of "no CPR" order per hospital protocol

Lines of Supervision and Communication

Consistent with the philosophy of graded levels of responsibility, it is expected that the resident will directly communicate with, and be, in turn, supervised by the most senior supervising resident on their assigned surgical team. In turn, it is expected that the most senior supervising resident will directly communicate with the designated attending surgeon. In urgent of emergent situations, immediate communication with the attending surgeon by any resident on the team is expected. 

• Supervision of PGY-1 Residents - Indirect supervision (the supervising physician (a senior resident or attending) is immediately available to provide direct supervision) is allowed for:

a. Patient Management Competencies:

•         evaluation and management of a patient admitted to hospital, including initial history and physical examination, formulation of a plan of therapy, and necessary orders for therapy and tests.

•         pre-operative evaluation and management, including history and physical examination, informed consent, formulation of a plan of therapy, and specification of necessary tests

•         evaluation and management of post-operative patients, including the conduct of monitoring, and orders for medications, testing, and other treatments

•         transfer of patients between hospital units or hospitals

•         discharge of patients from the hospital

•         interpretation of laboratory results

b. Procedural Competencies

•         performance of basic venous access procedures, including establishing peripheral intravenous access

•         placement and removal of nasogastric tubes and Foley catheters

•         arterial puncture for blood gases

• Direct supervision - (the supervising physician is physically present with the resident and patient) is required until competency is demonstrated for:

a. Patient Management Competencies

•         initial evaluation and management of patients in the urgent or emergent situation, including urgent consultations, trauma, and emergency department consultations (ATLS required)

•         evaluation and management of post-operative complications, including hypotension, hypertension, oliguria, anuria, cardiac arrythmias, hypoxemia, change in respiratory rate, change in neurologic status, and compartment syndromes

•        evaluation and management of critically-ill patients, either immediately post-operatively or in the intensive care unit, including the conduct of monitoring, and orders for medications, testing, and other treatments

•         management of patients in cardiac or respiratory arrest (ACLS required)

b. Procedural Competencies

•         carry-out of advanced vascular access procedures, including central venous catheterization, temporary dialysis access, and arterial cannulation

•          repair of surgical incisions of the skin and soft tissues

•         repair of skin and soft tissue lacerations

•          excision of lesions of the skin and subcutaneous tissues

•          tube thoracostomy

•          paracentesis

•          endotracheal intubation

•          bedside wound debridement