Resident Orientation

1. Pediatric Radiology Section Resident Orientation Pediatric Radiology Section

2. Pediatric Radiology Resident Orientation • Goals & Objectives • Resident Assignments • Learning Materials • Critical Event Reporting • Fuji PACS Tips & Tricks

3. Pediatric Radiology Resident RotationGoals & Objectives The Six Core Competencies • Patient Care • Medical Knowledge • Interpersonal and Communication Skills • Professionalism • Practice-Based Learning and Improvement • Systems-Based Practice

4. Pediatric Radiology Resident RotationWeek 1-4 • Patient Care • Utilize Clinical Desktop for gathering pertinent patient information • Interview and examine patients when appropriate for accurate interpretation of radiological studies

5. Pediatric Radiology Resident RotationWeek 1-4 • Medical Knowledge • Identify normal/abnormal radiographs of the chest, heart, abdomen and skeleton including variable appearances at different ages • Evaluate chest radiographs of infants and children in intensive care units including • neonatal respiratory distress and its complications • congenital heart disease • radiographic findings associated with sickle cell disease • the normal appearance of various catheters and devices including endotracheal tubes, central venous lines, chest tubes and extra-corporeal membrane oxygenation devices

6. Pediatric Radiology Resident RotationWeek 1-4 • Medical Knowledge (Continued) • Evaluate the abdominal films of infants and children in intensive care units, to recognize: • pneumoperitoneum • small bowel obstruction • necrotizing enterocolitis • Identify pediatric orthopedic problems and their management, including: • fractures • scoliosis • developmental dysplasia of the hips • Legg-Calve Perthes • hip effusions/septic hip

7. Pediatric Radiology Resident RotationWeek 1-4 • Medical Knowledge (Continued) • Establish radiographic bone age • Become familiar with the plain radiographic findings in common pediatric conditions of ambulatory patients on chest, abdominal, and skeletal radiographs

8. Pediatric Radiology Resident RotationWeek 1-4 • Interpersonal & Communication Skills • Provide direct communication to the referring physician or appropriate clinical personnel when interpretation of a study reveals an urgent or unexpected finding, and document this communication in the radiological report using specific date and time. • Make preliminary review of inpatient, outpatient, NICU and PICU films, and discuss findings with the Staff Radiologist, dictate, and confer with pediatric residents. • Participate in daily presentation of radiographic findings of NICU and/or PICU patients to clinical teams, and relay any radiologic recommendations

9. Pediatric Radiology Resident RotationWeek 1-4 • Professionalism • Recognize limitations in personal knowledge and skills so as not to make decisions beyond the level of competence • Demonstrate altruism and compassion towards patients

10. Pediatric Radiology Resident RotationWeek 1-4 • Practice-Based Learning and Improvement • Learn to present cases at daily morning teaching conference • Prepare an end-of-rotation follow-up conference

11. Pediatric Radiology Resident RotationWeek 1-4 • Systems-Based Practice • Become aware of the basic necessities for coding and billing, including: • Ensuring there is a requisition from the doctor’s office • Providing accurate and sufficient information within the radiological report to support appropriate ICD-9 coding

12. Pediatric Radiology Resident RotationWeek 5-8 • Patient Care • Demonstrate knowledge of the levels of ionizing radiation related to specific imaging procedures and employ measures to minimize radiation dose to the patient. • Perform radiological examinationsappropriately and safely, assuring that the correct examination is ordered and performed

13. Pediatric Radiology Resident Rotation Week 5-8 • Medical Knowledge • With assistance from a Staff Radiologist, perform and evaluate fluoroscopic images of the gastrointestinal and genitourinary tract. • With assistance from a Staff Radiologist or Staff Sonographer, perform and evaluate: • cranial sonogram • renal sonogram • abdominal and pelvic sonograms • hip sonogram to evaluate for effusion

14. Pediatric Radiology Resident Rotation Week 5-8 • Medical Knowledge (Continued) • Evaluate computerized tomographic images of the chest, abdomen, pelvis and extremities. • Increase knowledge of pediatric plain radiographs and/or sonographic findings of children with emergent conditions including: • pneumonia, pneumothorax • congestive heart failure • appendicitis, intussusception • nonaccidental trauma, fractures • hip effusions

15. Pediatric Radiology Resident Rotation Week 5-8 • Interpersonal & Communication Skills • Same as weeks 1-4 and add • Review plain radiographs and be able to make recommendations for further evaluation with sonogram, contrast studies or CT with pediatric house officers

16. Pediatric Radiology Resident Rotation Week 5-8 • Professionalism • Same as weeks 1-4 and add • Recognize limitations in personal skill and knowledge in order to consult with senior residents and staff when needed • Be capable of making independent decisions on routine issues to become prepared for night call

17. Pediatric Radiology Resident Rotation Week 5-8 • Practice-Based Learning and Improvement • Same as weeks 1-4 • Systems-Based Practice • Same as weeks 1-4

18. Pediatric Radiology Resident RotationWeek 9-12 • Patient Care • Same as weeks 1-8

19. Pediatric Radiology Resident RotationWeek 9-12 • Medical Knowledge • Perform all fluoroscopic examinations except when complications are anticipated, with the consultation of the Staff Radiologist • Increase knowledge base regarding both common and uncommon pediatric conditions by plain radiograph, contrast studies and imaging, including some familiarity with the findings of pediatric body MR imaging • By the end of the rotation, have knowledge sufficient to pass the American Board of Radiology examination

20. Pediatric Radiology Resident RotationWeek 9-12 • Interpersonal & Communication Skills • Same as weeks 5-8 • Professionalism • Same as weeks 5-8 • Be capable of making independent decisions • Practice-Based Learning and Improvement • Same as weeks 5-8 • Systems-Based Practice • Same as weeks 1-8

21. Pediatric Radiology Resident Orientation • Goals & Objectives • Resident Assignments • Learning Materials • Critical Event Reporting • Fuji PACS Tips & Tricks

22. Resident Assignments • PICU • NICU • Fluoroscopy • MR/Reading Room • Ultrasound • CT (CT/MR) • Saturday and Holiday Coverage • Dictation System • Conferences

23. PICU • Organize, review and dictate all PICU and 7E/7W radiography studies • Review studies with Reading Room Staff • PICU Team Rounds at ~10:30am • After PICU dictations are completed, responsibilities include • 8E/8W/9E/9W/12W board, • outpatient and emergency room films • orthopedic clinic films

24. NICU • Organize, review and preview all NICU radiography studies • Review studies with CT/MR/US Staff • NICU Team Rounds at ~10:30am • After NICU dictations are completed, responsibilities include • 8E/8W/9E/9W/12W board, • outpatient and emergency room films • orthopedic clinic films

25. Fluoroscopy • Review the available information, confirm histories and plan specialized studies with the Staff Radiologist • Perform, review and dictate the studies • Read ESSE pediatric offices studies • After the flouro schedule is complete, the resident should come to the main reading room to help with other studies including the boards, out patients and orthopedic films

26. MR/Reading Room • When there are five residents/fellows • responsibility for the inpatient studies • orthopedic clinic films • outpatient films • emergency unit films • PICU/NICU films as needed. • assistance in fluoroscopy, sonography and CT when needed

27. Ultrasound • Coordinate the schedule with the staff radiologist and sonographers • Participate in selected ultrasounds • Review and dictate the studies • After the ultrasound schedule is complete, the resident should assist the main reading room with other studies including the boards, out patients and orthopedic films

28. CT(CT/MR) (5 or 4 trainees) • Review old and outside exams • Review history with the parents • Protocol for the scan • Perform, review and dictate the studies • After the CT/MR schedule is complete, the resident should assist the main reading room with other studies including the boards, out patients and orthopedic films • First responder for contrast teactions

29. Saturday and Holiday Coverage • Junior Residents • Begin at or before 7:30am • End sometime after 1:00pm • Senior residents • Begin at or before 7:30am • Stay until 5 PM. They will sign out to the night float • Senior residents may not switch with a 1st Year resident for Saturday Coverage • Monday Holiday Coverage • residents assigned to Monday holiday coverage are expected to read all in patient boards • service begins at 7:30 a.m and ends when the work is done

30. PowerScribe • Use Voice Recognition on • US • CT/MR • NICU • EU • GI/Fluoro • Ortho

31. PowerScribe Errors - History: Refusing to 8, weight loss and vomiting - Lobes the first 2006 - I used to 5 catheter • SLCH transcription is getting complaints about our reports. • The issue is escalating within SLCH and MIR. We must do a few things immediately: • The residents must proofread reports carefully before sending them to your IDX queue; the history field as especially prone to errors. • Staff will proofread the reports before signing • print out the erroneous reports • highlight the errors and give them to the residents.

32. BUSCON Dictation System • Enter your five number code • Scan Acc#1 • Scan Acc#2, …. • Scan DOB • Dictate • Press End

33. Addenda (Options for Dictation) • BEST METHODEnter a “C” before the A# to be addended. • C9541234 instead of A9541234 • ALTERNATE METHODEnter the A# without the leading “A” • 9541234 instead of A9541234 • ACCEPTABLE Generate addendum with the BUSCON system

34. 7:30 Conferences

35. Conferences • Pediatric Radiology Teaching Conference • Tuesday – Friday 7:30-8:30 • The resident assigned chooses Teaching File Cases to be shown as unknowns to the other residents • Pediatric Radiology Follow-up Conferences • Second and last Friday of the Rotation 7:30-8:30 • Each diagnostic radiology resident is responsible for presenting at least two cases • Definitive clinical and/or pathologic follow-up • Noon Conference • With very rare exception, all diagnostic radiology residents will be able attend. • The resident should know the history, physical findings, clinical course, correlative radiological and pathological findings.

36. Conferences • EU Conference • Last Wednesday of the rotation • EU picks cases and prepares history • We present the images • We all join in the discussion • MR Conference • Ultrasound Knobology

37. Pediatric Radiology Resident Orientation • Goals & Objectives • Resident Assignments • Learning Materials • Critical Event Reporting • Fuji PACS Tips & Tricks

38. Text Books GENERAL TEXTS • Pediatric Imaging (The Core Curriculum) by Marilyn J. Siegel and Brian D. Coley, M.D. (2006) • Fundamentals of Pediatric Radiology by Lane F. Donnelly M.D. (2001) • Practical Pediatric Imaging: Diagnostic Radiology of Infants and Childrenby Donald R., M.D. Kirks and N. Thorne Griscom, M.D. (1998) • Imaging of the Newborn, Infant, and Young Child by Leonard E. Swischuk (1997) • Caffey's Pediatric Diagnostic Imaging (2 Vol. Set) by Jerald P. Kuhn, Thomas L. Slovis, and Jack O. Haller (2003) SPECIALTY TEXTS • Pediatric Sonography by Marilyn J. Siegel (2001) • Pediatric Body CT by Marilyn J. Siegel (Editor) (1999)

39. Online Learning Materials • Prior Resident Follow-Up ConferencesM:\Pediatric Radiology Section Info\Pediatric Radiology Follow Up • Cleveland Clinic Pediatric Radiology https://www.cchs.net/pediatricradiology/

40. Pediatric Radiology Resident Orientation • Goals & Objectives • Resident Assignments • Learning Materials • Critical Event Reporting • Fuji PACS Tips & Tricks

41. Critical Event Reporting PURPOSE: Prompt transmission of accurate critical test results to the physician or nurse, with primary responsibility for the patient, is essential in ensuring timely diagnosis and treatment of patients served by the Radiology Department at Children’s Hospital of St. Louis.

42. Critical Event ReportingDefinitions Critical Test Result: A diagnostic test finding (i.e., “result”) that is significantly beyond the established normal variation as defined by each diagnostic testing service and as approved by the medical director. Critical results require prompt notification to the licensed care provider.

43. Critical Event ReportingDefinitions Read back: The process of confirming the accuracy of verbally or telephonically transmitted information or orders by writing down what was heard, then reading it back to the person who provided the information. Numbers are called out individually (e.g., “one, five” for fifteen, which could be heard as “fifty”).

44. Critical Event ReportingDefinitions Licensed Care Provider: The person authorized to act or intervene on behalf of the patient, usually a MD or APN. It may also be a RN or Pharmacist, acting on the basis of a medical staff-approved protocol or other written orders.

45. Critical Event Reporting Critical Events in the SLCH Radiology Department: * Hazardous line placement (e.g. CVL, ETT, GI catheters) * Child abuse * Evidence of increased intracranial pressure/impending herniation * New or enlarging hemorrhage and/or extra-axial fluid collections * Portal venous gas * Pneumothorax, substantial or under pressure * Pneumoperitoneum/bowel perforation This is the minimum list of events. Use discretion.

46. Critical Event ReportingDefinitions Documentation: Following notification, the Critical Test Resultswill be documented for the following items Date and Time of notification Name and title of person(s) notified The documentation will be recorded on the x-ray report by the reporting radiologists or the designated reporting staff.

47. Pediatric Radiology Resident Orientation • Goals & Objectives • Resident Assignments • Learning Materials • Critical Event Reporting • Fuji PACS Tips & Tricks

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