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Disclosures for Henny Heisler Billett, MD

Disclosures for Henny Heisler Billett, MD. In compliance with ACCME policy, ASH requires the following disclosures to the session audience: . 51 st ASH Annual Meeting ♦ New Orleans, LA. Disclosures for Elaine Muchmore, MD.

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Disclosures for Henny Heisler Billett, MD

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  1. Disclosures for Henny Heisler Billett, MD In compliance with ACCME policy, ASH requires the following disclosures to the session audience: 51st ASH Annual Meeting ♦ New Orleans, LA

  2. Disclosures for Elaine Muchmore, MD In compliance with ACCME policy, ASH requires the following disclosures to the session audience: 51st ASH Annual Meeting ♦ New Orleans, LA

  3. Teaching procedures and evaluating competence to H/O fellows ELAINE A. MUCHMORE, M.D. UC SAN DIEGO HENNY BILLETT, M.D. EINSTEIN/MONTEFIORE ASH PROGRAM DIRECTORS’ SYMPOSIUM, 12/3/09

  4. Goals of this session • Discuss the recent changes in ABIM requirements for procedural training and how these changes impact fellowship training • To give practical tools and metrics for fellowship TPDs

  5. IM residency requirements • At the end of training, as part of requirements for IM certification Board, TPDs must attest to each resident’s knowledge and competency to perform the procedures in: • Advanced cardiac life support • Drawing venous and arterial blood • Placing a peripheral venous line • Performing PAP smear and endocervical culture • ABIM: no minimum number of these procedures, but each resident should be an “active participant” five or more times • Graduates may not be qualified to do IM procedures previously thought to be common (paracentesis, LP, BM)

  6. (ABIM) H/O fellowship requirements • Procedures required: • BM aspiration and biopsy, including touch preps • Interpretation of peripheral blood smears, including manual • Administration of chemotherapeutic and biological agents through all therapeutic routes • Management and access of indwelling venous catheters; management of apheresis • To administer substances thru “all therapeutic routes”, H/O fellows need to be able to do: • LP • Paracentesis • This creates a disconnect between residency and fellowship requirements

  7. Competence in performance of procedures • The Joint Commission (2007) indicated that physicians requesting privileges for which hospital has no evidence of competence were required to have “focused evaluation” to qualify them • Fellows now clearly fall in this group, and must be checked off

  8. (Recommended) Components of focused evaluation • Didactics regarding indications, details of procedure, contraindications, potential complications • Literature references • UCSF site excellent for paracentesis, LP, central lines • “How to” videos (recommend NEJM series) • Paracentesis Thomsen, T, et al. (2006; 355:e21) • Lumbar puncture: Ellenby, M, et al. (2006; 354:e13) • Bone marrow: Malempati, S, et al. (2009;361:e28) • Step-by-step procedure guide • Quiz • Evaluator check-list • Simulation • Live patient

  9. Video: bone marrow

  10. Evaluator check-list example:bone marrow • Evaluate patient • Indications for bone marrow • Evaluate bleeding diathesis (history/exam) • Check routine labs (CBC) • Determine what tests on specimen need to be completed, making sure all tubes/slides available • Obtain patient’s (or health care proxy / next of kin) consent; check allergy status (local anesthetics) • “Time out” with bone marrow technician or evaluator • Position patient, confirm site, cleanse skin • Drape biopsy site, apply lidocaine. • Perform aspiration and biopsy checking with technician for adequacy of samples; make some smears, clot section • Discard needles in “sharps” container • Apply pressure dressing for 5 minutes, then ask patient to lie on back for 15 minutes before resuming normal activities • Apply band-aide for 24 hours; pt must check site for erythema or swelling.

  11. Bone marrow: focused evaluation questions • Issues: • How many procedures are enough? • Numbers are arbitrary! Bain studies showed no correlation between number of procedures and adverse events • What are complication data? • Bain BJH (2003) 121:949 • 54,890 procedures (table next slide) • 14 hemorrhage (1 death) • 7 needle-related incidents • 3 infections • Diversity of body habitus, bleeding dathesis • Who should be the supervisors and how should they be monitored?

  12. Summary • Paradigm shift has occurred: • Changing medical training and accreditation requirements have mandated fellowship program changes • Many training tools and models freely available to assist TPDs • Future: simulator training for most procedures

  13. Workshop • Even-numbered tables: • Develop procedure guides for • Peripheral Smears • Bone Marrows • Lumbar Punctures • Odd-numbered tables: • Develop evaluator check-list for evaluation of • Peripheral smears • Bone Marrows • Lumbar Punctures

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