RESIDENT HANDBOOK

2019-2020

DEPARTMENT OFEMERGENCY MEDICINE

LAC+USC MEDICAL CENTER

Revision 01 2020

OUTLINE OF CONTENTSTopic Page

Residency Office Personnel 2

Overview of Clinical Rotations 3

Mission and Aims 4

Goals and Objectives 5

Clinical & Conference Attendance 5-9

Clinical Education and Work Hours 8

Elective Rotations 9

Resident Wellness 9-11

Scholarly Activity, Conferences and Grants 11-12

Quality Improvement 12-13

GMEC / Education Committee 13

Guidelines on use of Social Media 13

Sample Moonlighting Approval Form 14

Procedure and Patient Follow-Up Logs 15-18

Fatigue Education and Transitions of Care 19-22

Medical-Legal Issues 23

Medical Licensure 24-25

Acknowledgement Signatures 26

This handbook is a living document and is updated at least once a year. The most up to date version can be found online at lacuscem.com under “Residency Resources”.

RESIDENCY OFFICE PERSONNEL

Ramin Tabatabai MD, MACM, FACEP, FAAEM Program DirectorDavid Diller MD Associate DirectorAarti Jain MD Assistant DirectorJessica Osterman MD Assistant DirectorRyan Raam MD Assistant DirectorTodd Schneberk MD Assistant Director

Jonathan Wagner MD Clerkship DirectorTaku Taira MD Assistant Clerkship Director

ADMINISTRATIVE STAFFBecky O’Neal, C-TAGME 323-409-6614 Residency AdministratorMarisela Lorenzana 323-409-7053 Residency CoordinatorDemia Bernardez Residency Secretary

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OVERVIEW OF CLINICAL ROTATIONS 2019-2020

PGY 1 Rotations

Location Length Responsible DepartmentLAC+USC DEM/Peds ED 24 weeks LAC+USC Emergency MedicineInternal Medicine 4 weeks LAC+USC Emergency MedicineMICU 4 weeks LAC+USC Dept. of MedicineCCU 4 weeks LAC+USC Dept. of MedicineSICU/Trauma 4 weeks LAC+USC Dept. of SurgeryEM Ultrasound 2 weeks LAC+USC Emergency MedicineOrthopedics 2 weeks LAC+USC Dept. of Orthopedic SurgeryPsychiatric ED 2 weeks LAC+USC Dept. of PsychiatryAnesthesia 2 weeks LAC+USC Dept. of AnesthesiaVacation 4 weeks

PGY 2 Rotations

Location Length Responsible DepartmentLAC+USC DEM/Peds ED 30 weeks LAC+USC Emergency MedicineMICU 4 weeks LAC+USC Dept. of MedicinePediatric ICU 4 weeks LBMMC/Miller Children’s HospitalCommunity Hospital ED 3 weeks USC Verdugo Hills HospitalObstetrics 3 weeks Good Samaritan HospitalEM Ultrasound 2 weeks LAC+USC Emergency MedicineEMS 2 weeks LAC+USC Emergency MedicineVacation 4 weeks

PGY 3 Rotations

Location Length Responsible DepartmentLAC+USC DEM/Peds ED 36 weeks LAC+USC Emergency MedicineElective 5 weeks LAC+USC Community Hospital ED 4 weeks USC Verdugo Hills HospitalToxicology 3 weeks LAC+USC Emergency MedicineVacation 4 weeks

PGY 4 Rotations

Location Length Responsible DepartmentLAC+USC DEM/Peds ED 34 weeks LAC+USC Emergency MedicineElective 6 weeks LAC+USC Community Hospital ED 4 weeks USC Verdugo Hills HospitalPeds ED/Community EM 4 weeks LBMMC/Miller Children’s HospitalVacation 4 weeks

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MISSION & AIMS

MISSION: The Emergency Medicine (EM) residency training program at LAC+USC began in 1971 and is one of the oldest and longest-running EM residency programs in the country. We continue to be leaders in the specialty through educational innovation, research and leadership, as well as the training of clinically and procedurally competent emergency medicine physicians. The program is dedicated to the mission of our safety-net hospital to provide emergency access to the citizens of Los Angeles County regardless of their ability to pay. We pride ourselves on delivering a high-level of culturally competent care to our patient population. As a large Level I Trauma Center, our residents train in a clinical learning environment that is rich in pathology, acuity, procedural experience and cultural diversity. The clinical experience is complimented by an equally rich educational experience. Our training philosophy embraces the concept of graduated responsibility to empower junior residents to grow comfortably into the role of confident, autonomous senior residents who possess the leadership skills necessary to handle any clinical scenario. Critical to our mission is the promotion of wellness and resilience among our residents, faculty and supporting staff. Over 600 physicians have graduated from our program – the largest alumni body of emergency medicine specialists both in the United States and internationally. Our family of graduates has excelled in every aspect of the field, and is well represented in academic medicine, research, subspecialty practice, community leadership, and public service. Ultimately, our vision is to be recognized as a national exemplar in providing culturally-sensitive, holistic, patient-centered care in a learning environment rich in diversity, inclusiveness, and wellness.

RESIDENCY PROGRAM AIMS: 1) To train outstanding clinicians who achieve excellence in procedural and clinical competence through an innovative, dynamic educational program for EM residents 2) To provide efficient and evidenced-based emergency care to our patients while preserving resident teaching and resident autonomy 3) To foster and promote an environment of wellness and job satisfaction for both resident trainees and faculty, while developing best practices to reduce physician burnout 4) To recruit and train a diverse group of residents who are compassionate and invested in caring for the underserved, underrepresented, and marginalized people of Los Angeles County and beyond 5) To develop a framework for professional development by creating a mentorship infrastructure that promotes partnership with community-based organizations, production of original scholarship, and participation in national organizations and meetings, including both local and national speaking and leadership opportunities.

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GOALS AND OBJECTIVES

Goals and objectives for all rotations are provided online (found on MyEvaluations and on the www.lacuscem.com website). Year-specific competency-based goals and objectives are available for each rotation.

CLINICAL & CONFERENCE ATTENDANCE

ATTENDANCE AND CLINICAL RESPONSIBILITIES

ABSENCES If an absence is unavoidable, residents must first notify the Residency Office Faculty Officer-of-the Day (OD). This is listed on amion. The Residency Office OD will then notify the DEM resident administrative officer of the day (DEM Resident OD). This information can also be found on amion.com. The Resident OD will assess the need for back-up call and will make the appropriate notifications in conjunction with the Residency Office OD. This applies to both DEM and all off-service rotations. While on off-service rotations, we do not provide back-up coverage on outside rotations and we must be mindful of how we navigate a necessary absence. If you must miss a day during an outside rotation, you must notify the appropriate personnel at that site (GME coordinator or supervising attending/resident). You must also notify the PD here at LAC+USC.

During ED rotations, a junior and senior call resident is assigned on amion. The Residency Office OD and Chief OD will adhere to the following guidelines in deciding which on-call resident will need to report to shift in the case of a callout. 1. if the resident that needs coverage is a fourth year resident in a 2-Star role aka Resus or north, then

the fourth year senior call person is called in to cover2. if the resident that needs coverage is a fourth year resident but is working in an area where they

could have a junior work in their place (e.g. Peds/Jail/West) then a junior call resident may get called in to cover (the rationale is to always protect the senior call person since they can only cover 4th year shifts whereas the junior can cover everything but the two-star shifts).

3. if a junior resident calls out or gets pulled, you call in the junior call person and protect the senior.

Failure to make the appropriate notifications when you are absent may result in disciplinary action. Failure to be available during your on-call hours will also result in disciplinary action (if you are found to be moonlighting while on call, this is grounds for dismissal from the program).

TRADES All parties involved with clinical shift trades must conduct these trades via amion and obtain final approval from residency office administration. It is the responsibility of the trading parties to notify the residency office of any potential work hour violations or other extra-clinical responsibilities that may arise from trades. For trades to be official, they must be listed on amion. Failure to obtain the proper approval for trading clinical shifts may result in loss of trade privileges and/or other disciplinary action to be determined by the residency office.

ATTENDANCE AT PROTECTED EDUCATIONAL ACTIVITES

Attendance at planned educational activities is considered in exactly the same way by the department as clinical responsibilities. 100% resident attendance and punctuality for all protected educational

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activities is expected. Respect the time of your colleagues and faculty who voluntarily prepare educational materials for your benefit by showing up promptly to your modules at 730a (early is on time, on time is on time, and late is unprofessional).The RRC requires that every resident attend a minimum of 70% of scheduled educational conferences. There are some specific circumstances when you will not be able to attend conference. These circumstances include:

1. You are on vacation 2. You are on PICU 3. You are on SICU, MICU, CCU or IM wards and your patient care duties prevent you from

attending EM rounds (Note: You should be excused for rounds for the majority of the days)4. Unable to attend because of work hour limits such as back-to-back night shifts

The following are further guidelines to follow when you have night shifts before or after conference days:  What does the ACGME/EM RRC say?: "The Review committee does not have an expectation regarding time off between block didactic sessions followed by a clinical shift; however, programs must review the appropriateness of resident conferences following an evening or night shift based on the duration of the program's clinical shifts, didactic schedules, and resident fatigue. Resident should be provided the opportunity to adjust their individual attendance at didactic sessions scheduled between clinical shifts when necessary to mitigate excessive fatigue."

The following are our program’s recommendations for conference attendance when conference is preceded or followed by a night shift (you will receive conference credit if you follow these guidelines):

1) BACK TO BACK NIGHTS: - You should NOT attend conference in this scenario

2) YOU WORK A LATE SWING SHIFT THE NIGHT BEFORE CONFERENCE (6p-3a, 4p-2a) - We do not expect you to attend conference the following day

3) YOU WORK THE NIGHT SHIFT BEFORE CONFERENCE BUT YOU DO NOT WORK THE NIGHT OF CONFERENCE (Wednesday 11p-7a or 7p-7a shifts): - You can attend conference, but we recommend that you leave conference by 10a to ensure that you get sufficient rest post-night - NOTE: If a resident feels too fatigued to attend conference after a night shift, it will be left to their discretion to depart at a time allowing for safe arrival at home, including going straight home after shift. It should be noted that 70% conference attendance is required so residents must take it upon themselves to plan for future attendance and asynchronous learning activities when fatigue prevents conference attendance after night shifts.

4)  YOU WORK THE FULL NIGHT SHIFT AFTER CONFERENCE (7p-7a or 6p-3a) : - You can attend conference, but we recommend that you leave conference by 10a to ensure you get sufficient rest before your night shift- EXCEPTION: If you are working an 11p-7a shift the night AFTER conference, you are expected to attend all of Grand Rounds that day.

5) YOU WORK A SWING SHIFT THE DAY BEFORE CONFERENCE (3p-11p, 3p-12a) - You can attend conference the next day

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- If you work the 3p-11p shift the day before conference, we expect that you attend the 730a module the next day- If you work the 3p-12a shift the day before conference, we expect that you attend Grand Rounds at 9a (you are more than welcome to attend Module if you are not excessively fatigued)

6) YOU WORK A LATE NIGHT SHIFT AFTER CONFERENCE (4p-2a, 6p-3a) :- You can attend conference (assuming you did not work the night before), but you can EITHER show up to conference at 730a and leave by 10a OR show up to conference at 10a (either scenario will get you conference credit).

The residency office aims to minimize scheduling of back-to-back night shifts and late Wednesday swing shifts (4p-2a and 6p-3a) during conference days to avoid these absences. Residents will be scheduled such that they can achieve 70% conference attendance by attending all eligible conference days. We also ask that you avoid trading INTO back-to-back nights and Wednesday late night swing shifts as it will lower the number of conferences you are able to attend.

ATTENDANCE RECORD

Attendance will be recorded electronically at the beginning of every Thursday conference day. Punctuality is expected unless a resident is completing clinical duties in the department..Residents will be given their current attendance percentages every three months so that they may monitor their own compliance.

The residency office will counsel residents who fail to meet the 70% requirement well in advance of graduation in order for corrections to be made via improved attendance and asynchronous learning. Not meeting this requirement will result in removal of moonlighting privileges, ineligibility for consideration as a Chief Resident and may result in the resident needing to attend conferences after graduation.

INDIVIDUALIZED INTERACTIVE INSTRUCTION (III) CREDIT

If a resident must miss conference, these absences may be made up through individualized interactive instruction learning. The following are examples of acceptable III that can be submitted for conference credit:

1. Presenting at Journal Club2. Attending a cadaver lab or simulation session 3. Taking a practice test and reviewing the answers with a faculty member4. Participating in a group board review session5. Attending lectures at a national conference or board review course6. Online lecture viewing with summary of material and real time discussion with a faculty member7. Academic Life in EM (ALiEM) AIR Series (Approved Instructional Resources)

Residents are free to come up with activities and submit these to the residency office, but final approval must be official prior to conference credit being given .

The hours counted for these activities may consist of up to 20% of conference time. These hours must be submitted to Dr. Osterman within 60 days of completion in order to receive credit.

THURSDAY CONFERENCE DAYS AND CLINICAL DUTIES

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On Thursdays where the resident is scheduled for a 7a-7p shift in the DEM, the resident will be relieved of clinical duties from 7a-1p to attend rounds. Attendance to conference in these instances is expected and residents should treat this attendance as a clinical obligation given that shifts in the clinical areas are being covered in order to make attendance possible. Residents are required to return to the clinical areas to which they were ordinarily assigned for any cancelled conference or segment of cancelled conference time.

The code bag will be carried by a fourth year resident during conference. The resident who is listed as the carrier of the code bag during a conference day is responsible for picking up the code bag from the clinical areas prior to conference. It will not be the responsibility of the resident completing a night shift to bring the bag to conference

CLINICAL EDUCATION AND WORK HOURS (formerly Duty Hours)

80-HOUR   RULE Note: This ONLY applies for OFF-SERVICE ROTATIONS- it is impossible for us to violate this rule in the EDRULE: "Clinical and educational work hours must be limited to no more than 80 hours per week, averaged over a four-week period, inclusive of all in-house clinical and educational activities, clinical work done from home, and all moonlighting."RULE: Residents must be scheduled for a minimum of one day in seven free of clinical work and required education (when averaged over four weeks)EXAMPLE: If you work 85 hours on the first week of the rotation, that is not a violation by itself. However, if you average 85 hours (or any number greater than 80) over the course of 4 weeks, this IS a violation. If at any point during any of your off-service rotations you are at risk of violating hours, please notify me ASAP so that I can speak with the off-service team and ensure that this does not occur over the course of any rotation. 

ED   CLINICAL   HOURS RULE: "A resident must have at a minimum a scheduled break equal to the scheduled length of the shift within the 24-hour period that includes the shift."  EXAMPLES: - If you work a 7p-7a shift, you must have 12 hours before the next night shift (you cannot return until 7p)- If you work a 3p-11p shift, you must have 8 hours off before the next shift (you cannot return until 7a)- If you work a 3p-12a shift, you must have 9 hours off before the next shift (you cannot return until 9a)

CLINICAL   HOURS   + DIDACTICS RULE: "The Review committee does not have an expectation regarding time off between block didactic sessions followed by a clinical shift; however, programs must review the appropriateness of resident conferences following an evening or night shift based on the duration of the program's clinical shifts, didactic schedules, and resident fatigue. Resident should be provided the opportunity to adjust their individual attendance at didactic sessions scheduled between clinical shifts when necessary to mitigate excessive fatigue."- Please see above under “ATTENDANCE AT PROTECTED EDUCATIONAL ACTIVITES” for specific guidelines

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ELECTIVES

There is a Guide to Electives in EM that can be found online (www.lacuscem.com). Additional experiences may be pursued within the institution subject to the approval of the residency office. Goals and objectives for all standard elective rotations are provided online. Goals and objectives for non-standard elective rotations can be created with program director consultation.

Electives may be done in a wide variety of areas, including clinical, administrative or research, but must be approved by the Program Director. The residency office must be notified about plans for electives a minimum of 4 weeks prior to their initiation. Completed elective forms should provide a description for all elective time and must be signed by a supervising faculty member (or designee from an off-service elective).

Clinical Elective rotations at non-County institutions are allowable ONLY if the resident takes a leave of absence without pay and malpractice insurance is provided by the receiving institution. It is the responsibility of the resident to make sure that malpractice insurance is provided when at non-County institutions. Health insurance coverage may also be lost during such leave.

RESIDENT WELLNESS

1) QUESTION: Who can I contact if I would like mental health support during residency training?

ANSWER: There are multiple pathways to obtain mental health support during residency including: - All interns are scheduled for an “opt-out” session with our on-site clinical psychologists

during their PG1 year to ensure they are connected with our professional support network. This is a great opportunity to check-in regarding any challenges or concerns.

- Additional confidential appointments are available with our on-site clinical psychologists at any time during training (Tobi Fishel PhD- - tfishel@usc.edu and Melanie Drane LMFT- drane@usc.edu)

- 24 Hour Mental Health Hotline: 323-409-6925- If you feel comfortable discussing with PD or member of Residency Office, we will work

with you to facilitate scheduling of appointments

2) QUESTION: If I experience an adverse or difficult clinical event, what do I do?

ANSWER: There are multiple pathways to debrief after challenging clinical cases including: - Debriefing in real-time with your senior residents or attending physicians - Debriefing after your shift with your senior residents or attending physicians- Non-clinical debriefing time is available through our Peer to Peer Support Program that is

held during protected time at Grand Rounds - Activating the H3 Team (Helping Healers Heal) to conduct an individual or group debrief.

The H3 Team is available 24-hours a day to provide emotional and mental health support for all providers after a difficult case.

3) QUESTION: If I experience any threats to the learning environment including but not limited to sexual harassment, sexual assault, discrimination, workplace bullying, micro-aggressions, who can I contact?

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ANSWER: You can contact your Program Director, any member of the Residency Office, the Program Coordinator, our GME Wellness Director (Dr. Tobi Fishel PhD- tfishel@usc.edu), your DIO (Dr. Larry Opas MD- opas@usc.edu), any trusted Faculty Member and/or you can contact the SAFE Committee (see below for details):

SAFETY, FAIRNESS, AND EQUITY (SAFE) FOR POST-GRADUATE PHYSICIANSPURPOSE: All residents and fellows enrolled in ACGME-accredited training programs must have a safe and supportive learning and working environment in which they are free to raise concerns, problems, grievances, and complaints, and report breaches in personal and professional standards of others. The Sponsoring Institution recognizes that physicians enrolled in ACGME training programs are potentially vulnerable to a variety of unprofessional behaviors in the learning and working environment. This policy serves to ensure that a safe learning and working environment exists for post-graduate physicians to report such concerns.

POLICY: The Graduate Medical Education Committee (GMEC) of the Medical Staff at the SponsoringInstitution will ensure that multiple avenues are available for physicians in training to report concerns, including anonymously. Reported concerns will be investigated in a manner compliant with legal standards, the County Policy of Equity, the USC Policy for Equity and Diversity, and California Evidence Code 1157. Retaliation for reporting concerns is forbidden by law and County and University Policy.The GMEC will maintain a Subcommittee for Safety, Fairness, and Equity (SAFE) that is comprised of individuals with a business need to know about confidential, sensitive personnel matters. The Subcommittee will receive complaints of a sensitive nature and investigate in parallel with investigations by law enforcement and County and/or University authorities. All matters involving allegations of sexual assault affecting physicians enrolled in ACGME accredited training program will also be investigated by members of the Violence Intervention Program (VIP), who are providers with special expertise in such investigations. The findings of the VIP investigators will be reported to the GMEC’s SAFE Subcommittee. For other sensitive matters, the Subcommittee will investigate as circumstances dictate.

PROCEDURE: A. Reporting OptionsOptions for reporting concerns or events experienced by physicians enrolled in ACGMEaccredited training programs in an anonymous and/or confidential manner include, but not limited to:1. The relevant Program Director or Associate Program Directors2. The Designated Institutional Official (DIO)3. The Assistant DIO for SAFE oversight in collaboration with DIO and GMEC4. The Director of Resident Wellness (Tobi Fishel - tfishel@usc.edu)5. The Chief Medical Officer or their designee6. A 24 hour hot line (323) 409-LINE maintained by the GME Office for this purpose7. The hospital’s Safety Intelligence system8. Any member of the GMEC9. Dean, Keck School of Medicine of USC10.County Office of Equity11.USC Office of Equity and Diversity12.ACGME Office of Resident Affairs

B. Anonymous and Confidential ReportingReports via any of the options in Section A may be made confidentially or anonymously at

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the resident(s) request, in all matters except those in which there is a legal mandate, or a mandate by County Policy of Equity or USC Policy for Equity and Diversity to report the matter to higher authority/investigatory bodies.

C. InvestigationsA GMEC subcommittee will be maintained that is chaired by the Assistant DIO for SAFE, and is additionally comprised, at a minimum, of the DIO (1) (ex officio), two (2) peer-selected residents, two (2) faculty members of whom one (1) is a member of the GMEC, and one (1) member of the VIP. The LAC+USC Medical Center CMO will also be an ex officio member. Other members may be appointed as deemed necessary by the DIO and the Assistant DIO for SAFE. This subcommittee is authorized by the Medical Staff to conduct 1157-peer-review protected investigations of sensitive matters involving resident physicians. The subcommittee will report relevant findings to the GMEC as a standing agenda item and to other authorities (e.g., law enforcement, County or University officials) when appropriate, consistent with County and University policy. Reports regarding resident safety, professionalism, sexual assault, violence, or other sensitive matters may come to the SAFE Subcommittee via any reporting mechanism described in section A above, or via County or University officials via the DIO or CMO. The SAFE Subcommittee will determine if a separate investigation is needed, and if so, how best to conduct it.All reports involving allegations of sexual assault that involve a resident/fellow physician will be investigated. Such investigations will be initiated by notifying the on-call member of theViolence Intervention Program (VIP), who will conduct an expeditious investigation of the event, given their specialized expertise in such matters. All SAFE Subcommittee investigations will be conducted under 1157-peer reviewed protections given that they are conducted on behalf of the GMEC as mandated by this Medical Staff policy. The results of such investigations will be reported to the DIO for consideration at the GMEC subcommittee, as well as to other parties as appropriate, as described in the Policy above. If a report is received that involves a member of the Subcommittee, that individual will be recused from receipt of information, conduct of investigation, or participation in subcommittee deliberations or recommendations, and if necessary, a temporary replacement will be assigned by the subcommittee Chair or the DIO to participate in their stead.

SCHOLARLY ACTIVITY, CONFERENCES & GRANTS

According the ACGME, every resident must participate in scholarship during training. We provide a structured Scholarly Activity Plan to ensure that each resident meets this requirement prior to graduation. Expectations are as follows:

- PG1 Year: Interns are provided with an overview of the Scholarly Activity Plan- PG2 Year: PG2’s will identify their faculty mentor and will commit to a plan of action

toward their scholarly activity project- PG3 Year: Execution of plan toward scholarly activity (elective time can be used toward

advancing scholarly projects)- PG4 Year: If by PG4 year, a resident has not completed a scholarly project, elective time

will be dedicated toward completing the project

1. QUESTION: What counts as resident scholarly activity?ANSWER: All of the following will count toward the program’s definition of Scholarly Activity:

a. Peer Review – This refers to resident participation in the dissemination of knowledge through the preparation of a scholarly paper published in journals indexed in PubMed, including original

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contributions of knowledge published in journals listed in Thomson Reuters (formerly ISI), Web of Knowledge, or MEDLINE®. Abstracts, editorials, or letters to the editor do not qualify. Submissions to online venues, with the exception of Med Ed PORTAL, do not qualify.

b. Non-Peer Review – This includes all submissions to journals or online venues that do not fulfill the peer-review criteria. This also includes abstracts, editorials, collective review, case reports, letters to the editor of peer-reviewed journals, educational videos, DVDs, and podcasts.

c. Textbooks/Chapters – This includes resident participation in the writing and submission of such works where the faculty mentor served as the chapter author.

d. Conference Presentations – This refers to presentations at local, regional, or national organizational meetings, including the presentation of abstracts and posters, panel discussions, and serving as forum leader.

e. Participation in Research – This refers to active participation in a research project, or formulation and implementation of an original research project, including funded and non-funded basic science or clinical outcomes research, as well as active participation in an Emergency Department quality improvement project.

2. QUESTION: If I have an abstract, poster, or lecture accepted for a national conference, can I obtain funding for travel? ANSWER: Yes, there is an opportunity for funding but you MUST obtain approval for funding PRIOR to paying for registration or travel fees. Please contact the following members of the department: Program Director: Ramin Tabatabai <ramintab@usc.edu>Program Administrator: Becky O'neal boneal@med.usc.eduDepartment Coordinator: Kaufman, Lorien <Lorien.Kaufman@med.usc.edu>

3. QUESTION: If I apply for a grant who do I notify?ANSWER: If you plan to apply for any research or non-research grant, please notify all of the following members of the department 30 days PRIOR to the Grant Deadline due date: Sanjay Arora <sanjayar@usc.edu>Jonathan Lam <ChunNok.Lam@med.usc.edu>Ramin Tabatabai <ramintab@usc.edu>

The reason is that each grant will need to go through the proper channels to ensure that you will be able to successfully retrieve the funding for your grant. Applications and budgets should be finalized 10 business days prior to application due date as grants and budgets must be reviewed by the Dean’s office prior to approval.

QUALITY IMPROVEMENT

RESIDENT QI EDUCATION & EXPERIENCE

Residents will all participate in a longitudinal QI experience during their training. During PG2 year, residents will participate in two separate didactic sessions (“Understanding the anatomy of a QI project” and “QI evaluation methods”). During PG3 years, residents will be provided the option to participate in any ongoing departmental QI initiative with one of our faculty QI Champions (Dr. Shoenberger, Dr. Buckingham, Dr. Oh, Dr. Luu, Dr. Kearl). If a resident has not participated in a QI

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project by PG4 year, he or she will dedicate an elective block toward participation in a QI project with faculty mentorship.

Additionally, PG3 and PG4 residents have the opportunity to apply to the Healthcare Administration Scholars Program (HASP). HASP is a two-year educational program provides senior residents & fellows with formal training in healthcare administration through didactics, exposure to hospital leadership, mentorship, and hands on experience, to use those skills to work on a longitudinal Quality Improvement project to improve patient care. The curriculum includes bimonthly didactics from LAC+USC QI experts from the Schools of Medicine, Public Policy, Business and Engineering, and leaders from the Los Angeles community.

REPORTING PATIENT SAFETY EVENTS

Events occurring at the LAC+USC Medical Center are reported via the Safety Intelligence link on the LAC+USC Home Page. https://safetyintelligence.lacounty.gov/DHS/

Events occurring at the Verdugo Hills Hospital are reported via the Incident Reporting button on each Desktop.

GMEC / EDUCATION COMMITTEE

The Departmental Educational Committee (GMEC) consists of 2 residents who are peer-selected from each class, core faculty members, as well as the Chief Residents and all members of the residency office. The Committee meets monthly and reviews the clinical and academic curriculum. Additionally, any residents who would like to join the meetings are encouraged to attend and to bring suggestions and concerns to these meetings. The Program also holds quarterly residency town hall meetings where any ongoing issues can be raised or discussed. Issues raised in these general open forums will be brought to the GMEC for resolution. Faculty input and feedback regarding the Program is also solicited at monthly faculty meetings and issues raised there will also be brought to the GMEC meetings.

The GMEC/Education Committee meetings are open to all members of the LAC+USC DEM community and formal minutes are taken and distributed to all committee members.

GUIDELINES ON USE OF SOCIAL MEDIA

Social media (Facebook, Blogs, YouTube, Twitter, WhatsApp, etc) should be used with great caution. Information is not your property once posted and may lead to unintended consequences either in the immediate future or in the years to follow. Assume that patients, hospital or departmental administrators or potential future employers will be able to see your posts. Make sure you would be comfortable sharing the information posted. Remember that HIPAA compliance applies to all forms of media. HIPAA violations are serious offenses that can result in your immediate termination. This will be discussed in detail during resident orientation.

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SAMPLE MOONLIGHTING APPROVAL FORM

DEM RESIDENT MOONLIGHTING POLICYCOMPLIANCE DOCUMENT

(**To be completed during semiannual evaluations**)

Date ____________

1. ___________________ IS IS NOT (circle) permitted to moonlight with the limitations and regulations set forth in the departmental moonlighting policy.

Requirements for moonlighting include being current with residency program requirements. This includes:-up to date follow-up logs-up to date procedure and ultrasound logs-meeting the 70% conference attendance requirement-achieving a minimum score of 76% on the ABEM in-training examination

Reason for denial of moonlighting privileges:

(1) Not in good academic or administrative standing(2) Previous violation of moonlighting policy(3) Judgment of the Program Director based on resident’s progress in the department or concerns

regarding well-being

____________________________________Signature of Program Director (or Designee)

2. I verify that I am in continued compliance with the departmental moonlighting policy.

Institutions where moonlighting is occurring Maximum Numbers of Hours/Month

___________________________________ ____________

___________________________________ ____________

____________________________________Signature of Resident

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PROCEDURE AND PATIENT FOLLOW-UP LOGS

Residents must maintain records of certain procedures performed during their training. This is required by the ACGME and will be a part of the credentialing process for employment after residency. In addition, in order for the Program Director to certify resident competence in invasive procedures for any outside moonlighting position, or for credentialing requests for full time positions following graduation, there must be documentation that the resident has successfully completed the procedures in question.

Residents are responsible for recording their own procedures on the MyEvaluations residency management system when they are rotating outside of the DEM. Procedures that are recorded in ORCHID will be entered into MyEvaluations by residency admin staff on behalf of the resident.

The following are guidelines for the minimum number of procedures that must be recorded during residency:

GUIDELINES FOR PROCEDURES AND RESUSCITATIONS

Numbers include both patient care and laboratory simulations Adult medical resuscitation Adult trauma resuscitationCardiac pacingCentral venous accessChest tubes Procedural sedationCricothyrotomyDislocation reductionIntubations Lumbar Puncture Pediatric medical resuscitation Pediatric trauma resuscitationPericardiocentesisVaginal deliveryED Bedside Ultrasound**

45356201015 31035151510 310150

**the division of ED Ultrasound in the DEM has different, more robust requirements.

Other key index procedures which will be assessed but do not have minimum numbers are:

Anesthesia and Pain ManagementVascular AccessWound management

RESUSCITATION DEFINITIONS

The ACGME defines a major resuscitation as “patient care for which prolonged physician attention is needed and interventions such as defibrillation, cardiac pacing, treatment of shock, intravenous use of

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drugs (e.g., thrombolytics, vasopressors, neuromuscular blocking agents), or invasive procedures (e.g., cut downs, central line insertion, tube thoracostomy, endotracheal intubations) that are necessary for stabilization and treatment.”

The following are some more specific guidelines about what each of the above procedures consists of:

Adult Medical Resuscitation: any adult (>= 18 years) meeting any one of the following requirements: Administration of > 2L fluid bolus intravenously Administration of any vasoactive drug intravenously (e.g. metoprolol, labetolol, esmolol,

diltiazem, nitroprusside, magnesium sulfate, phenytoin, lidocaine, amiodarone, epinephrine, atropine)

Administration of any blood product (e.g. packed RBCs, platelets, FFP, cryoprecipitate, factor VII)

Administration of any drip (e.g. octreotide, insulin, naloxone, D10W or higher concentration) Admission to the ICU Hypotensive patients (systolic BP < 90 mmHg)

Note that only one resident can claim to perform a medical resuscitation per patient. An exception to this rule is for the patient who is in the DEM so long that he/she becomes unstable multiple times, requiring several separate attempts at resuscitation.

Adult Trauma Resuscitation: any injured adult (> 18 years) meeting any one of the following requirements:

Administration of blood products in the ED Administration of >2L crystalloid in the ED Admission to SOU for observation Admission to the SICU for further care of traumatic injuries Admission directly to the operating room (RB’d) for repair of traumatic injuries Any patient for which a “Trauma Team Activation” (TTA) was called

Cardioversion/Pacing: includes any of the following Administration of adenosine for chemical cardioversion of SVT Performance of vagal maneuvers for chemical cardioversion of SVT Electrical cardioversion (e.g. SVT, Vtach, Vfib, Torsades) Administration of atropine for symptomatic bradycardia Transthoracic pacing Transvenous pacing

Central Venous Access: self-explanatory: Femoral vein, subclavian vein, internal jugular vein.

In addition to recording those lines that you place, you may also take credit for lines that you supervise, as long as the person placing the line is not an EM resident (e.g. an ICU resident or intern).

Chest Tube: Self-explanatory. Also includes thoracentesis. Please include simulations and cadaver procedures as well.

In addition to recording those chest tubes that you place, you may also take credit for chest tubes that you supervise, as long as the person placing the chest tube is not an emergency medicine resident (e.g. an ICU resident or intern).

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Procedural Sedation: this includes administration of any of the wide variety of agents available to the ED (e.g. etomidate, methohexital, propofol, ketamine, fentanyl + versed) for sedation in order to perform a procedure, while monitoring the ABC’s of the patient during sedation. Some examples of procedures which might require procedural sedation include:

Orthopedic manipulation (joint relocation, fracture reduction) Laceration repair Sedation for CT scanning (e.g. pediatric patient, combative patient) Abscess I&D Changing a damaged endotracheal tube over a Bougie

Cricothyrotomy: self-explanatory. Also includes needle cricothyrotomy. Please include simulations and cadaver procedures as well.

Reduction: relocation of dislocations (e.g. shoulder, hip, elbow, finger) reduction of fractures (e.g. Boxer’s fractures, distal radius fractures), whether the injury is

splinted or casted.

Intubation: self-explanatory. Please include simulations as well.

Lumbar Puncture: self-explanatory.

Pediatric Medical Resuscitation: similar to adult medical resuscitation, any child (<18 years) meeting any one of the following requirements:

Brought in by EMS after a 9-1-1 call Administration of > two 20cc/kg crystalloid boluses intravenously Administration of any vasoactive drug intravenously (e.g. metoprolol, labetolol, esmolol,

diltiazem, nitroprusside, magnesium sulfate, phenytoin, lidocaine, amiodarone, epinephrine, atropine)

Administration of any blood product (e.g. packed RBCs, platelets, FFP, cryoprecipitate, factor VII)

Administration of any drip (e.g. octreotide, insulin, naloxone, D10W or higher concentration) Any patient admitted to the PICU Any patient who is hypotensive

Pediatric Trauma Resuscitation: similar to adult trauma resuscitation, any injured child (<18 years) meeting any one of the following requirements:

Administration of blood products in the ED Administration of two or more 20 cc/kg bolus crystalloid in the ED Admission to SOU for observation Admission to the surgical ICU or PICU for further care of traumatic injuries Admission directly to the operating room (RB’d) for repair of traumatic injuries Any child brought to USC for “Trauma Center Criteria” (note that this includes more than just

“TTA’s”)

Pericardiocentesis/Thoracotomy: self-explanatory. All simulation or cadaver procedures should be entered.

Vaginal Delivery: do not count C-sections

BEDSIDE ULTRASOUND REQUIREMENTS17

All residents are required to meet the LAC+USC Ultrasound Division requirements for competency in bedside ultrasound. This includes both the required didactic hours provided in the residency curriculum, as well as proctored examinations during the course of the residency over a full spectrum of the core indications (FAST, RUQ, OB/GYN, Renal). Examinations are proctored and over-read by a registered diagnostic sonographer or faculty member who is similarly qualified. The ultrasound division will do a formal orientation and will explain all requirements for participation in the ED ultrasound program.

GUIDELINES FOR PATIENT FOLLOW UP LOGS

Patient follow-up is the cornerstone of practice-based learning. Regular follow-up is a requirement of the training program, and is facilitated by a computerized logging system on MyEvaluations. In an effort to maximize the educational utility of the follow-ups, we have integrated evidence-based learning, self-reflection, and meta-cognition into our write-ups. Follow-ups can be done on patients that were seen primarily, signed out to you, or seen on off service rotations. The template for patient follow-ups is available on MyEvaluations. The PowerPoint templates that you submit will serve as cases for our weekly Grand Rounds Morning Reports.

One patient follow-up will be required every 3 months (PG1’s are exempt from submitting a patient follow-up for the first quarter). For HIPAA compliance, all follow-ups should be submitted through MyEvaluations.

Due dates are as follows: September 30th (PGY 2,3,4)December 31st (All Levels)March 31st (All Levels)June 30th (All Levels)

PROCEDURAL COMPETENCY ASSESSMENT

For the purposes of hospital credentialing, each resident must be observed and evaluated by a faculty member performing all of the commonly performed emergency medicine procedures (listed below) before being able to perform these without direct (bedside) supervision. Procedures may also be performed and evaluated in the simulation lab.

Evaluation forms requiredCentral venous access

Femoral vein 5Internal jugular vein 5Subclavian vein 5

Thoracostomy 1Advanced airway management/endotracheal intubation 1Cricothyroidotomy 1

Procedural sedation, endotracheal intubation, vaginal deliveries, and thoracotomies within the DEM are always to be performed under direct faculty supervision.

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FATIGUE & TRANSITIONS OF CARE

What are the department’s expectations for charting on shift?- We expect that you finish charts on admitted, transferred, observation and signed-out patients

prior to leaving your shift. - Discharged patient charts do not need to be completed prior to the end of your shift but should

be completed within 24-48 hours - If you are behind in your documentation on a 12-hour shift, the final hour of your shift should

be dedicated to charting, performing any incomplete Medical Screening Exams, and entering holding orders for the next provider. Non-critically ill patients should be screened. Critically ill patients must be evaluated.

The following is an educational document for fatigue mitigation during training: The USC Department of Emergency Medicine

Educational Document on Resident Fatigue

Why the need for fatigue and sleep education?

1) The ACGME work hour guidelines call for the “education of faculty and residents in recognizing the signs of fatigue” and “applying operational countermeasures,” and mandate the inclusion of sleep education in all residency programs.

2) It is well documented that physicians outside the sleep medicine specialty regularly under-diagnose or misdiagnose sleep disorders despite the high prevalence of sleep disorders.

Physiologic factors that cause sleepiness

Wakefulness and sleep are governed by a homeostatic drive for sleep and circadian influences on alertness. When adults get less than 5 hours of sleep per night, the homeostatic drive to sleep rises sharply which results in increased sleepiness and decreased cognitive performance. It is lack of sleep (not room temperature, a large lunch, boring lecture, dim lights, etc.) that causes sleepiness.

Excessive Daytime SleepinessExcessive daytime sleepiness (EDS) can be due to a variety of factors.

1) Insufficient quantity of sleep - usually less than 8 hours per night.2) Sleep fragmentation – this can be from actual breaks in sleep (e.g., a pager going off) or from the

anticipation of being interrupted.3) Circadian rhythm disruptions – result from a mismatch between environmental demands on the

individual and endogenous circadian sleep wake rhythms (night shifts).4) Primary sleep disorders – OSA, narcolepsy, insomnia.

Sleep requirementsEverybody has slightly different optimal sleep requirements. Most individuals need between 6

-10 hours of sleep per 24-hour period (8-hour average). Significant cognitive deficits occur with less than 5 hours of sleep per day. One night of suboptimal sleep can decrease cognitive performance 25%. Also, as sleep is missed, one begins to accumulate a “sleep debt”. Sleep debts continue to accumulate over time until adequate recovery sleep is obtained. It often takes 2 days to correct a sleep

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debt. Sleep debt results in slower response times, altered mood and motivation, and reduced morale and initiative.

Interaction of Circadian Rhythms and SleepCircadian rhythms, including the sleep wake rhythm, are intrinsic physiologic processes with a

“free-running” cycle length of a little over 24 hours. Sleep and wakefulness are regulated by two coupled processes (the two-process system).

1) The homeostatic process – regulates length and depth of sleep.2) Circadian rhythms – influence the timing and duration of daily sleep/wake cycles.

Myth: You can “learn to function or adapt” to less-than-optimal sleep through training. No. Sleep is a biological imperative. Performance will always be impaired with inadequate sleep.

Consequences of sleep deprivation

-Decreased cognitive skills-Immune system dysfunction-Behavioral problems-Impaired motor skills (e.g., driving)-Decreased professionalism – less patience, moodier, less compassionate

Focus on SafetyThere is strong evidence linking sleep loss to occupational hazards and motor vehicle crashes. Among emergency physicians, there is a particularly strong correlation between motor vehicle crashes and driving following night shifts.Additionally, several studies show a much greater percentage of occupational blood-borne pathogen exposure among residents and students during night periods.

Sleep Loss and Fatigue – Impact on Medical EducationLike everything else, learning is impaired when residents are sleep deprived. This not only includes retention of data, but also motivation and interest in learning.

Signs of Sleep Loss and FatigueObjective measurements of sleepiness in sleep deprived individuals do not correlate well with subjective perceptions of sleepiness by individuals. That is, you are often sleepier than you may realize. It is common for sleep deprived individuals to underestimate their level of sleepiness. This same problem with subjective perception of sleepiness also applies to the perception of when you fall asleep. Studies have shown that people tested in sleep laboratories frequently cannot tell when they have fallen asleep (i.e, they may have drifted off and not realized it). Put together, this has significant implications for when individuals are trying to decide if they are “fit for duty” (or driving home).

Warning signs of fatigue- inattention- forgetfulness- difficulty staying on-task

Alertness ManagementThe best remedy for sleepiness is sleep. Napping has been shown to help.

Napping20

“Prophylactic naps” – brief naps prior to 24-hour periods of sleep deprivation have been shown effective in decreasing sleep deprivation.

“Therapeutic naps” – frequent (every 2-3 hours) brief (fifteen minute) naps during long periods of wakefulness also improve function.

The time of day most refractory to fatigue countermeasures (e.g., naps) is the circadian nadir, 2am-9am.

Caution – When discussing naps, consideration must be given to sleep inertia. Sleep inertia is incomplete arousal from sleep. It manifests as slowed speech, substantial performance deficits, poor memory, and impaired decision making. Sleep inertia is most likely to occur when waking from deep sleep. Therefore, you should time your naps so that you wake up before entering deep sleep (nap less than 30 minutes). Sleep inertia can be reversed with adequate stimulation (caffeine/physical activity) and/or time.

Healthy Sleep Habits- Try to get at least 8 hours of sleep per night.- Use regular a bed time and wake time.- Use relaxation techniques prior to sleep.- Use a comfortable sleep environment (cooler temperatures, darkness, and minimize

noises)- Avoid eating large meals prior to sleep.- Avoid strenuous physical and mental activities within 3 hours of sleep.

Drowsy DrivingSigns of Drowsy Driving

o trouble focusingo trouble keeping eyes openo noddingo repeated yawningo drifting from your laneo not remembering the last few miles driveno closing eyes at the stoplight

Risk factors for Drowsy Drivingo sedating medicationso alcohol consumptiono primary sleep disorderso driving alone

Safe driving techniqueso don’t drive when drowsyo use a taxi if tiredo take a 20-minute nap and/or drink coffee prior to going homeo pull over if you notice signs of fatigue and take a nap

Techniques that don’t worko turning up the radio

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o opening a windowo chewing gumo putting cold air/water on faceo hard slapping of face

Pharmacologic InterventionsMelatonin – not useful according to several studies on emergency physiciansHypnotics (e.g., Ambien) – only useful for short-term useAmphetamines – badAlcohol – does make you sleepy, but it causes greater fragmentation of sleep during the night

(therefore, bad)Caffeine – “Strategic consumption” is acceptable.

Half life is 3 – 7 hours.Regular use leads to tolerance.Can fragment sleep and decrease total sleep time

Night ShiftsYou cannot adjust to night shifts quickly – It takes one week for circadian rhythms to adjust.Circadian adjustments lead to physical and mental symptoms – (e.g., Jet Lag).Forward or “clockwise” (day/evening/night) shift rotations are easier to adapt to.

Strategies for adapting to Night Shifts- Sleep in adequate blocks when not working (i.e., don’t put off sleep to do other things).- Nap before your shift.- Expose yourself to bright lights when on shift.- Avoid light exposure in the morning after your shift (e.g., when driving home).- Consider using sunglasses for the drive home.

All handout information came from the SAFER Task Force educational program. A copy of the complete program is available through the residency office and the GME office.

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MEDICAL LEGAL ISSUES

MALPRACTICE LITIGATION

There is a possibility that you may become involved in malpractice litigation before you complete your training at a Los Angeles county facility. Any adverse malpractice involvement at a County facility may affect you upon completion of your training and may result in reporting to the National Practitioner Data Bank.

If there is any accident, complication or bad result that might develop into a claim or lawsuit against you or the County, it should be reported immediately to the supervising attending physician, Program Director and Risk Management. The PD and Risk Management will support you through the process in the event that claim or lawsuit is filed. It may be prudent for you to seek independent legal advice on any incident that may develop into a claim or other legal action.

Risk Management

SUBPOENAS TO A WITNESS

More commonly, residents are involved with the legal system as material witnesses in criminal or civil matters. If you receive a legal subpoena to appear or be on call for court, please follow the instructions on the subpoena or call the District Attorney/Defender or other attorney responsible (provided on the subpoena itself) to speak with them directly. Do not access the patient’s chart and we Often, being cooperative and reachable by the attorney can help you avoid a court appearance. If you must be absent to appear in court, the same rules apply as with any other absence – you must notify the residency office.

Residency office faculty have experience with this process and are available to assist you once you have been subpoenaed.

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COMPLIANCE WITH HIPAA REGULATIONSThe Department of Emergency Medicine seeks to maintain the highest level of respect for patient privacy. This is especially important to consider in the age of electronic medical recordsTo be fully compliant and protect yourself from potential personal liability:

1) Please log out of ORCHID anytime you step away from a computer (press the “Exit” icon on the top menu. 2) Be advised that audits of patient records may occur:- You should only access records that are directly related to your job duties (read as: patients under your direct care)- Access outside of normal clinical duties will be monitored and audited- Anyone accessing or altering protected health information / patient records without justifiable need may face serious consequences, up to and including termination- All users are responsible for any activity under their login, regardless of who was at the keyboard. Do not share your login information with anyone.

As a reminder, HIPAA violations are NOT just an internal matter. Clinical providers and staff who violate HIPAA place themselves at significant personal risk to both civil and criminal liability, in addition to institutional sanctions.Additionally, you will not be able to download any material from a county computer onto a personal USB drive. You will need to use an approved, encrypted device. Also, the county requires all employees to use their DHS issued email address. You can access your County email through your smartphone.

MEDICAL PHOTOGRAPHY

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Photographs or videos of patients (or patient information) must only be done with written consent of the patient. Failure to abide by this policy may result in disciplinary action and termination.

LICENSURE

California Medical Board

1. Postgraduate Training License

A Postgraduate Training License (PTL) will be required for all residents participating in an ACGME accredited postgraduate training program in California in order to practice medicine as part of their training program. A PTL must be obtained within 180 days after enrollment in the program and will not be required to be renewed.

A copy of the resident’s Postgraduate Training License must be on file in order to allow employment. Failure to be licensed within 180 of enrollment will automatically cause an interruption in the continuation of training and suspension of employment without pay until a valid PTL is obtained or the resident’s employment is terminated at the discretion of the program director.

2. Physician’s and Surgeon’s License

Third year residents who have completed 36 months of ACGME accredited training and will be continuing enrollment in an ACGME accredited training program will have 90 days to obtain their Physician’s and Surgeon’s License. During the 90 days, they may continue all their clinical activities related to their training program in California.

The resident must cease all clinical activities in California if they completed their 36 months of ACGME-accredited training and is no longer enrolled in an ACGME accredited training until they obtain a Physician’s and Surgeon’s License.

Drug Enforcement Agency Registration

Unless the Medical Center’s Medical Director or Chief of Staff issues a specific written exemption, licensed residents are required to obtain and use their assigned DEA registration number. A copy of the DEA license must be on file in the Office of Graduate Medical Education and the appropriate department office. All residents (PGY3 and above) must present documentation that they have applied for or possess a current DEA registration. Failure to do so will result in suspension of employment without pay until the deficiency is corrected.

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Residency Handbook and Professional Responsibilities

I have reviewed the Residency Handbook with the Program Director, Dr. Ramin Tabatabai, and I understand its contents.

I understand and accept that I have a professional responsibility to:

a) assure of the safety and welfare of patients entrusted to my care;b) provide patient- and family-centered care;c) assure that when I report for duty I am fit to work;d) manage my time before, during, and after clinical assignments;e) recognize signs of impairment, including illness and fatigue, in myself and in my peers;f) attend to lifelong learning;g) monitor my patient care performance improvement indicators; and,h) honestly and accurately report duty hours, patient outcomes, and clinical experience data.

I have read and understand the Policy on Moonlighting.

______________________________ _____________________ Resident Signature Date

______________________________ Resident Name Printed

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