anesthesia assistant program · ultrasound machine difficult intubation equip[ment syringe pumps iv...

1

Algonquin College Anesthesia Assistant Program

Clinical Rotation Handbook

2

Algonquin College Anesthesia Assistant Program

Clinical Rotation Handbook

Table of Contents page #

Introduction 3

Section 1: Guidelines for Mentors 5

Section 2: Goals and Objectives 7

Section 3: Discussion topics for Anesthesiologist Mentors 14

Section 4: Discussion topics for Anesthesia Assistant Mentors 21

Section 5: Case plans 22

Section 6: Technical Skills Log 27

Section 7: Evaluation 38

Section 8: Daily evaluation card 51

Section 9: Summary of instructions for students 53

3

Introduction

Welcome to your clinical rotation, the culmination of the Anesthesia Assistant Program!

The next few weeks are will be intense and challenging, but rewarding and enjoyable too.

During this time you are expected to practice and refine your technical skills, review and

consolidate the knowledge you have gained during the didactic part of the program and

begin to integrate it all in the care of patients in the perioperative setting.

Each student has a clinical mentor, a staff anaesthesiologist at your hospital who will

review your progress and will be the major resource person for you during your

placement. You should be booked frequently with this person, but not exclusively – to

allow for scheduling problems and to increase your exposure to alternate points of view

and methods of problem solving.

Your clinical mentors will have the Guidelines for Clinical Mentors document, detailing

your role. Please read it carefully and note that in every role, you will be acting under the

direct supervision of the attending anesthesiologist. During your clinical placement you

will are expected to be supervised by a staff anaesthesiologist and should not be left

alone with any anesthetized patients.

Section One is the “Guidelines for mentors” document that details the expectations for

your mentors and preceptors.

Section Two is a list of the goals and objectives that your will be expected to learn about

and achieve during your rotation.

Section Three covers discussion topics to be covered by your anesthesiologist

supervisors and mentors during your clinical rotation. Please sign these areas off as they

are covered. Read around them to review and expand on the material already taught in the

courses. It will be beneficial to record notes from discussions in the OR and to make

notes of specific questions you wish to discuss after reading up on the topic.

Section Four covers discussion topics to be covered by your Anesthesia Assistant

supervisors and mentors during your clinical rotation. Please sign these areas off as they

are covered.

Section Five covers a variety of cases and intra-operative problems. With the help of

your mentor you are required to develop an anesthetic plan for the patients presented. For

each of the complications, develop a differential diagnosis and treatment plan. It will be

beneficial to record any examples that you encounter in your practice.

Section Six allows you to keep a record of the basic technical procedures you perform or

assist with. A record of these competencies is expected and will be submitted for

completion.

4

Section Seven is a final evaluation that will be completed by your mentor to document

your progress during your rotation.

Section Eight is a sample of the daily evaluation card that will be used to track your

progress.

As you are well aware, this is a new programme for Algonquin College. The role of

Anesthesia Assistant is in evolution, and you are the ambassadors for your emerging

profession. We welcome any feedback you have about this course to improve for the

future.

Good luck!

Patti Murphy MD, FRCPC

Education Director

University of Ottawa, Department of Anesthesia

Box 249C

1053 Carling Avenue

Ottawa, Ontario

K1Y 4E9

[email protected]

(613) 761-4169

fax (613) 761-5209

5

Section 1: Guidelines for Mentors

To the mentors:

Thank you for agreeing to act as a clinical mentor to students in this program. As you are

aware, this is a new program, and the role of the Anesthesia Assistant (AA) is constantly

evolving, even as the course is progressing. CAS guidelines as to the scope of practice

for AAs are in evolution, so it is vital at this stage to clearly articulate our expectations

for the learners, both in terms of what we expect them to be doing by the end of their

training, and also what we expect of their supervising anesthesiologists.

Please not that during the duration of their clinical placement, students are not to be

left unsupervised in the care of patients.

The Anesthesia Assistant Program at Algonquin aims to educate graduate AAs to

function in the following roles (i.e. AFTER their clinical placement is completed):

1. Conscious sedation cases

The AA is expected to be able to assess the patient preoperatively in association with the

staff anesthesiologist, to administer sedation in accordance with the hospital protocols

and to monitor the patient throughout the procedure and until such time as the patient is

admitted to a recovery area and care is formally handed over to recovery room personnel.

The attending anesthesiologist must be immediately available throughout. Acceptable

staffing ratios for fully trained AAs would be one anesthesiologist to up to five AAs

depending on the complexity of the procedures being performed and assuming that the

geographical location of the cases allowed an immediate response from the

anesthesiologist.

2. Cases performed under regional block

The AA is expected to be able to assist the staff anesthesiologist with the placement of

the regional block and should be familiar with both the technical aspects of the procedure

and also the possible side effects and complications. The attending anesthesiologist must

be immediately available throughout.

3. Cases performed under general anesthesia

The AA is expected to have the technical skills and knowledge to assist the staff

anesthesiologist with the induction, maintenance and emergence phases of general

anesthesia. In the case of a stable patient during maintenance of anesthesia (ventilated or

spontaneously breathing), the AA would be able to monitor the patient for periods of up

to 30 minutes. The attending anesthesiologist would not have to be present in the OR but

would be immediately available.

In such cases where the patient is under general anesthesia, it is expected that the staff

anesthesiologist would supervise only one AA. It would be permissible for the attending

6

anesthesiologist to use that 30 minute time period, to place a regional block in the next

patient on the list but only if they were able to respond immediately and in person to any

concerns regarding the patient under general anesthesia. The role of the AA in this

situation would be to expedite the OR list and NOT to allow the staff anesthesiologist to

attempt to cover more than one OR. Intervals covered by the AA should be uneventful

and will NOT include induction, emergence or any period of predictable instability e.g.

clamping or unclamping of major blood vessels during vascular procedures or periods of

significant blood loss.

4. Other aspects of the AA role

The AA is also expected to assist the staff anesthesiologist in a variety of other situations

in terms of being able to perform tasks independently (eg insertion of IVs and arterial

lines), perform tasks under direct supervision (eg insertion of LMAs, intubation) or

assist the anesthesiologist (eg fibreoptic intubation, lung isolation, insertion of central

lines and pulmonary artery catheters, regional anesthesia procedures including spinals,

epidurals, peripheral nerve blocks and Biers blocks).

In addition to their technical skills regarding anesthetic equipment and monitoring

devices, AAs will function as an “extra pair of hands” for the staff anesthesiologist when

dealing with complex and/or unstable patients as detailed above and by performing other

tasks under the direction of the staff anesthesiologist such as checking blood and

preparing vasoactive medications.

Structure of the clinical placement

It is expected that each student will have one principal mentor who will supervise the

student on a regular and frequent basis. Students should be regularly, but not exclusively,

booked with their primary mentor.

Mentors should:

1. Discuss their progress at two weekly intervals throughout the placement and

be readily available to deal with any issues or problems.

2. Ensure that students are documenting the following items:

a. Cases performed

b. Technical skills log

c. Discussion topics covered

d. Case plans

There is a huge amount of material to be covered, and we want to ensure that

students make constant progress though the list in order to meet their objectives.

The College requires that competencies are documented in this way to enable

successful graduation from the course.

7

Section 2: Goals and Objectives

PROFESSIONALISM

1. Function as a Professional

a. Adheres to the scope of practice

b. Works with anesthesia care team to provide quality care

2. Function within Medical, Legal and Ethical Guidelines

a. Adheres to medical ethics

b. Adheres to standards of practice

c. Maintains confidentiality

COMMUNICATION

1. Demonstrate Effective Oral Communication Skills

a. Communicates effectively with patient and family

b. Communicates effectively with other members of the health care team

c. Teaches caregivers patient care and equipment skills

2. Demonstrate Effective Written Communication Skills

a. Documents patient procedures appropriately

HEALTH AND SAFETY

1. Effectively Manages Environmental Factors Associated with Work a. Uses appropriate self-protection when exposed to potentially hazardous situations such as :

Infectious agents

Hazardous chemicals

Radiation exposure

LASER

b. Uses appropriate body mechanics for lifting, transferring and transporting patients

c. Takes measures to prevent OR pollution (N2O, volatiles)

2. Carries Out Procedures using WHIMIS standards

a. Follows appropriate procedures to safely manage hazardous materials

b. Instruct others with regard to W.H.M.I.S.

c. Labels all infectious material bags for purpose of disposal

d. Uses hand washing technique

e. Follows standard Universal Precautions

EQUIPMENT

8

1. Clean and Disinfect Equipment

Uses appropriate cleaning and disinfecting procedures for the following equipment:

bronchoscopes

laryngoscopes

lighted stylette

LMA

Patient monitoring equipment

TEE

Ultrasound machine

Regional nerve stimulators

2. Maintains equipment

a. Performs preventative maintenance on the following equipment:

Ultrasound machine

Difficult intubation equip[ment

Syringe pumps

IV pumps

b. Calibrates equipment (Istat, Glucometer, Hemachron, Hemocue)

c. Maintains inventory

3.. Performs thorough Anesthetic machine checkout

4. Adheres to DOT and CSA regulations

ASSESSMENT

a. Takes a relevant patient history

b. Performs an appropriate physical examination of the patient

c. Interprets preop laboratory investigations correctly.

d. Correctly accesses lab information using hospital information technology

e. Discusses the patient with the attending anesthesiologist to develop an appropriate plan for

intraoperative management.

f. Educates patient regarding anesthesia procedures

ANESTHETIC MANAGEMENT (see subsections for more detailed objectives)

1. INDUCTION

Assists with the following types of induction:

a. IV

b. Modified/ Rapid-sequence

c. Inhalation

2. MAINTENANCE

Appropriate vigilance in monitoring patients

3. EMERGENCE

Takes steps to prepare patient for emergence from anesthesia:

Calls for staff presence

Adjusts level of anesthetic agent

Assesses/ reverses neuromuscular blockade

Optimizes analgesia

Adjusts ventilation to encourage spontaneous ventilation

Manages airway appropriately

9

MONITORING

1. a. Correctly applies standard monitors:

5 lead ECG

NIPB

SPO2

Temperature probe

PNS

Expired CO2

Correctly applies the following non-invasive monitors:

BIS

b. Prepares equipment for the following invasive monitors:

Arterial line

CVP

PA catheter

TEE

Cardiac output

c. Prepares ultrasound machine for use during line insertion

d. Correctly inserts arterial line.

2. Performs arterial and venous puncture, Uses indwelling catheters to collect blood samples

Correctly sends samples to lab for CBC, coagulation tests, crossmatch

Interprets results from blood samples

Evaluate results relative to patient clinical status

Recommends appropriate corrective actions based on lab results.

3. Performs arterial line insertion (see monitoring section)

4. Correctly uses I-Stat

Correctly uses glucometer

Correctly uses Hemachron

Correctly uses Hemocue

AIRWAY MANAGEMENT

1. Bag/ mask ventilation

Applies head tilt, chin lift , jaw thrust

Inserts oral airway

Inserts nasopharyngeal airway

10

2. Intubation

Prepares the following equipment:

Regular ETT

Oral/ nasal RAE ETT

Armoured ETT

LASER ETT

DLT

LMA/ Proseal

Combitube

Fast-track

Direct laryngoscope

Bougie

Fiberoptic scope/ DAVI cart

Glidescope

Lighted stylette

Bullard scope

Tube exchanger

Retrograde intubation kit

Cricothyrotomy kit

Describes correct use of the following accessory equipment

Glidescope

McCoy blade

Lighted stylette

Fiberoptic scope

Fast-track

Magill forceps

Stylets

Tube exchangers

DLT

LMA/ Proseal

Combitube

Direct laryngoscope

Bougie

Bullard scope


Cricothyrotomy kit

Troop pillow/ bath blankets for positioning

Assesses tube placement/seal

Performs oral intubation via direct laryngoscopy

Performs nasal intubation via direct laryngoscopy

Secures tube

Recognizes complications and takes action PRN

4. Perform extubation

Correctly assesses patient readiness for extubation Correctly performs adult extubation

Correctly assesses and manages patient post-extubation. Recognizes complications and takes

corrective action

5. Tracheostomy Tube exchange

Assists with exchange of existing tracheostomy tube

VENTILATION MANAGEMENT

11

Assesses the ventilation requirements relative to current patient status. Selects appropriate

ventilatory parameters

Evaluates initial patient response to mechanical ventilation, and adjusts parameters accordingly

Records appropriate ventilation data

MEDICATION

a. Correctly draws up routinely used induction, maintenance and emergence drugs

b. Correctly draws up routinely used emergency drugs

c. Actively practices preventative strategies to avoid medication errors

d. Demonstrates correct calculations when diluting medications

e. Demonstrates correct use of IV syringe pump

f. Demonstrated correct use and programming of IV infusion pumps

g. Correctly and safely administers medications used for conscious sedation

h. Correctly administers the following medications for maintenance of general anesthesia:

Opioids

Inhalation agents

Nitrous oxide

Neuromuscular blockers

Propofol infusion

POSITIONING

1. Assists with positioning in the following intraoperative positions:

Supine, arms abducted

Supine arms tucked

Supine, left uterine displacement

Prone, horseshoe

Prone, Mayfield tongs

Prone, Jackson table, (including Flip)

Lateral decubitus

Beach chair

Lithotomy

2. Safely able to move OR table with draped patient.

3. Assists with draping, following principles of sterility

FLUID MANAGEMENT

1. Prepares the following lines for administration of IV fluids:

Standard IV line (vented, non-vented)

PCA extension

Blood administration set

12

Hotline warmer

Level 1 warmer

2. Performs peripheral intravenous cannula insertion

3. Assists with central line insertion

4. Correctly sets up and runs the Cell saver

5. Correctly checks blood products

6. Correctly administers the following fluids:

Crystalloid

Colloid

Blood products

Mannitol

g. Monitors patient volume and electrolyte status

SUCTION

a. AIRWAY

Correctly suctions the airway using the following equipment:

Yankauer suction

Flexible suction

Bronchoscope

Assists with obtaining samples via bronchoscope

b Thoracic Suction. Correctly assembles/tests equipment

Assesses function of chest tubes

Monitors drainage

C. Gastric Suction

Correctly inserts Naso Gastric tube

Assesses correct placement.

Recognizes incorrect placement

Uses appropriate suction for NG drainage.

THERMOREGULATION

Demonstrates proper use of the following equipment:

Air warming blanket (Bair Hugger)

Fluid warming/ cooling mattress

(See monitoring, fluids sections)

Selects patients appropriately for warming/ cooling measures

REGIONAL ANESTHESIA

Correctly prepares local anesthetic for regional anesthesia after discussion with the attending

anesthesiologist

13

Prepares equipment for regional anesthesia:

Spinal

Epidural

CSE

Peripheral nerve block

Peripheral nerve catheter

IV block

Correctly manages peripheral nerve stimulator for peripheral nerve blocks

Uses safe injection technique for local anesthetic administration for nerve blockade.

COMPLICATIONS

1. Calls for help appropriately

2. Able to recognize, list a differential diagnosis for, and initiate management for the following

complications:

a. Hypertension

b. Hypotension

c. Hemorrhage

d. Tachycardia

e. Bradycardia

f. Patient movement

g. Leak/ disconnect

h. High airway pressure

i. Hypoxia

k. Hypercarbia

l. Hypoventilation/ apnea

PATIENT TRANSPORT

a. Selects appropriate equipment, monitors and drugs for an intra-hospital patient transport

b. Assemble equipment and ensure equipment function

pre-transport checkout

monitor and troubleshoot during transport

c. Monitors patient response during transport

d. Trouble-shoots during transport

ADMINISTRATION

a. Plans work schedules.

b. Applies cost containment procedures.

c. Develops policies and procedures.

d. Provides workload data. Conducts workload measurement

g. Participate in research as needed.

2. Develops, Implements quality assurance programs.

b. Evaluates processes, practices or equipment. Interprets findings. Makes recommendations

14

Section 2: Discussion Topics for Anesthesiologist Mentors

Read up on these topics yourself and then come to the OR prepared to discuss them with

your mentors. Be proactive in looking for the necessary information at your hospital.

I. Preoperative Issues

Topic Discussed

1. Preoperative history.

What are the components of a preop history that should be

gathered from every patient?

2. Preop physical examination.

How do you assess an airway for ability to intubate?

What are the indicators for potential difficult intubation/

ventilation?

Discuss normal heart sounds and the changes you might

expect to hear in common disease states.

Discuss breaths sounds and the changes you might expect to

hear in common disease states.

3. Review preoperative testing

What investigations are indicated prior to coming to the OR?

4. Review the concept of the anesthesia care plan.

Discuss how patient and surgical considerations contribute to the

anesthetic plan

Develop your own standardized approach to ensure that you take

all these issues into consideration every time.

What are the risks of anesthesia?

5. Airway management

How will the potential difficult airway cause you to modify your

15

anesthetic plan at every stage of the perioperative period?

Review the ASA algorithm for management of the difficult

airway.

6. Premedication.

Which drugs are commonly used?

Which of their usual medications do patients take on the day

of surgery?

Which of their usual medications do patients need to

discontinue?

How do you manage chronic pain meds preop?

How do you manage chronic anticoagulation?

How do you manage diabetic meds?

7. Fasting guidelines.

Discuss which patients should always be

considered as “full stomach” regardless of NPO

status.

Review current guidelines

8. What is your approach to the preoperative patient with

symptoms of URTI?

9. Review patient safety protocols in the pre and intra operative

periods.

What is the procedure for confirming patient

identity and confirming procedure preoperatively?

How do you ensure that the correct side for the

procedure has been identified and clearly

communicated to the whole team?

Preop pause

Discuss specific patient considerations:

o Patients unable to give consent

o Jehovah’s Witness patients

16

II. Intraoperative issues

Topic Discussed

1. Review infection control measures in the OR.

Principles of maintaining sterility during procedures

review separation of “dirty” and “clean” areas in the anesthesia

workspace,

review use of Universal Precautions

discuss accidental needle stick injuries

reinforce the importance/timing of prophylactic antibiotics

2. Discuss strategies for clear and effective communication in the

OR, crisis management

3. Review standards for monitoring under anesthesia.

What are the standard monitors?

Use of other commonly used monitors

Describe the indications for and the complications of arterial

line insertion.

Review the techniques, indications for and the complications

for central line insertion.

Describe the indications for and the complications of

pulmonary artery catheter insertion.

Review record keeping in the OR.

Difficult intubation letter

Standards for recording vital signs under anesthesia

4. Review induction of anesthesia

Rapid sequence induction vs. the usual IV induction of

anesthesia.

When is an inhalational induction used?

Review factors which would require and alteration in the

doses of drugs used for induction.

5. Airway management

ASA Difficult Airway Algorithm

Alternate methods of intubation

Indications and contraindications for the use of the

Laryngeal Mask Airway

Complications of intubation

17

Location and contents of the Difficult Intubation Cart at

your hospital.

Discuss patient positioning in the OR.

Complications of various

common positions used in the OR

Physiologic consequences of different patient positions

-

8. Discuss the creation of a perioperative analgesic plan.

Pain history preop

Effects of pain

Use of and complications of narcotic use in the surgical patient

Titration narcotics intraoperatively

Adjunctive medication

Regional analgesia

Review any pre-printed order sheets used for PCA and PCEA

administration.

Management of the chronic narcotic user

9. Review the importance of temperature control in the OR.

Risks and benefits of hypothermia

Temperature monitoring

Mechanisms of hypothermia

Management of perioperative heat loss

10. Perioperative fluid management.

Calculate perioperative fluid requirements

Risk factors for fluid deficits

Choices for fluid replacement.

Monitoring adequacy of fluid therapy

Consequences of over and under filling

Potential consequences and treatment of electrolyte

imbalances: potassium, sodium, calcium, pH.

11. Review the use of neuromuscular blocking agents.

Indications for neuromuscular blockade (NMB)?

Review the commonly used NMBs including doses.

Use of nerve stimulator

Adequacy of recovery from relaxants

18

Reversal agents

Causes of prolonged NMB

Specific contra-indications and phase two blockade with

succinylcholine

12. Maintenance

Different anesthetic volatiles

Risks and benefits of using nitrous oxide?

TIVA

Awareness

Use of BIS monitoring

13. Blood products.

Calculate allowable blood loss

Estimating blood loss in the OR

Blood conservation strategies

Risks of a single unit transfusion

Risks of massive transfusion

Blood checking procedures

Transfusion triggers

Coagulation and relevant tests used at your hospital.

Review types of blood products available and indications for

each.

Transfusion reaction under anesthesia

ISTAT, Hemocue, Hemachron, ACT

Cell saver

14. Post-operative nausea and vomiting (PONV).

Risk factors

Anti-emetics.

Prevention

15. Emergence from anesthesia.

Readiness for extubation?

Complications and management of premature extubation

Indications for post-operative intubation and/or ventilation?

16. Discuss the information necessary when taking over the care of the

anesthetized patient from another colleague.

Develop a checklist to cover all the necessary issues and to

confirm contact information for your colleague

In which situations is it NOT appropriate to accept hand over

of care?

19

17. Malignant Hyperthermia

OR preparation

What is Dantrolene? What is the dose and how is it prepared?

What are the challenges of administering dantrolene?

Differential diagnosis of an MH crisis.

Treatment protocol for an MH crisis.

18. How would you set up for a case of known latex sensitivity?

Risk factors

Items in the OR which contain latex.

Which parts of the anesthesia machine contain latex?

OR preparation

19. What are the indications for lung isolation?

Methods to achieve one lung ventilation (OLV)?

Describe the technique for insertion of double lumen tubes and

bronchial blockers.

Mechanical ventilation strategies during one-lung ventilation.

Risk factors and management of hypoxia on OLV

20. Discuss the management of procedures requiring cardiopulmonary

bypass.

Preparation to go on CPB

Preparations before weaning from CPB

Complications after prolonged periods on CPB

20

III. Postoperative issues

Topic Discussed

1. Handover of your patient to the PACU/ ICU nurses.

Review the patient history, intraop events

Postoperative management plan/ orders

When is it inappropriate to hand over care to the PACU

nurse?

Patients who are still intubated/ have a laryngeal mask in situ

2. PACU admission and discharge

- Criteria for discharge

- Surgical procedures requiring prolonged PACU stay

- Patient conditions requiring prolonged PACU stay e.g. OSA

- Indications for direct admission to ICU

21

Section 3: Discussion Topics for Anesthesia Assistant Mentors

Topic Discussed

WHIMIS standards Uses appropriate cleaning and disinfecting procedures for the following

equipment:

bronchoscopes

laryngoscopes

lighted stylette

LMA

Patient monitoring equipment

TEE

Ultrasound machine

Regional nerve stimulators

Preventative maintenance on the following equipment:

Ultrasound machine

Difficult intubation equip[ment

Syringe pumps

IV pumps

Maintains inventory DOT and CSA regulations

Calibrates ISTAT, Hemachron, Gucometer, Hemocue Administrative Responsibilities.

work schedules

cost containment

workload data, workload measurement

quality assurance programs

22

Section 4: Case Plans

a. List of cases

b. Sample of anesthetic plan

c. Blank anesthetic plan

Please complete the following anesthetic plan for each of the following

cases, and discuss one case per week with your mentor or other supervising

anesthesiologist.

Read up on each patient condition. Expect to be quizzed about the anesthetic

implications of each disease process and surgical procedure.

For each intra-operative complication, create a list of possible causes, and

outline your initial management steps.

a. List of cases

Week # Patient

condition

Surgical procedure Intraoperative

complication

1 Coronary

artery

disease

Open Hemicolectomy ST segment

depression on the

ECG monitor

2 Asthma

Laparoscopic

cholecystectomy

High airway pressure

3 Morbid

obesity

UPPP

(uvulopalatophagoplasty)

Low saturation

4 Alcoholic

cirrhosis

Hysterectomy

bradycardia

5 GERD

Craniotomy for brain

tumour (meningioma)

resection

hypertension

23

6 Chronic

renal

failure

Above knee amputation tachycardia

7 Diabetes

(Type 1

and Type

2)

Laminectomy Low airway pressure

8 Placenta

previa

Cesarean section Hypotension

b. Sample of anesthetic plan

Case:

Preop

Assessment Patient Considerations:

List the history, physical exam and lab

work that is appropriate for this patient

with their underlying pathology. What

are the presenting symptoms and physical

signs you would look for? What lab

abnormalities do you expect to find?

Surgical Considerations

What are the anticipated implications of the

planned surgery?

Orders Premed/ medication What premedication should be ordered for

this patient?

Other

Discussion

topics with

patient

What should be dicussed with this patient

preoperatively?

Intra-op

Monitors What monitors are indicated?

IV access/

expected

How much blood loss is anticipated for this

type of surgery? How big should the IV(s)

24

blood loss be, and where should they be placed?

Plan for pain

management

How painful is this procedure? Is a regional

block/ catheter, IV PCA appropriate?

Special

equipment

Do you need anything unusual, such as

ultrasound, BIS monitor, airway cart?

Position

What position will be used?

Duration of

surgery

How long will the surgery be? What impact

does this have on your pplan?

Type of

anesthetic

General? Regional? Local?

Airway plan ETT? LMA? Mask?

Ventilation

plan

Spontaneous ventilation or PPV? Best mode

of ventilation?

Induction What drugs and doses will you use?

Maintenance What drugs and doses will you use? What

problems do you anticipate?

Emergence What is your plan for emerging the patient?

Anticipated

complications

List problems for which the patient is at risk.

Assigned intraop complication for this case (from list in section a)

Differential

diagnosis

List all the possible causes/ contributing

factors

Management Describe your immediate assessment and

management

Postop

Pain

management

What is your plan? Is it the same as your

preop pain plan? What doses will you give of

what medication?

Disposition

of patient

Where does the patient go postop? Any

special orders that should be written?

25

c. Blank anesthetic plan

Case:

Preop

Assessment Patient Considerations:

Surgical Considerations

Orders Premed/ medication

Other

Discussion

topics with

patient

Intra-op

Monitors

IV access/

expected

blood loss

Plan for pain

management

Special

equipment

Position

Duration of

surgery

Type of

anesthetic

Airway plan

26

Ventilation

plan

Induction

Maintenance

Emergence

Anticipated

complications

Assigned intraop complication for this case (from list in section a)

Differential

diagnosis

Management

Postop

Pain

management

Disposition

of patient

27

Section 5: Technical Skills Log

OR setup

Minimum 20

Please consider the following in your assessment:

Ability to check the Anesthesia machine

Preparation of airway equipment

Preparation of appropriate drugs

Preparation of appropriate IV lines

Recognition of need for additional equipment

Date Comments Score Signature

28

IV insertion

Minimum 20

Date Comments Score Signature

29

Arterial line insertion

Minimum 5

Please include in your assessment:

Sterile technique

Insertion technique

Setting up equipment

Toubleshooting

Drawing blood samples

Date Comments Signature

30

Intubation (by direct laryngoscopy)

Minimum 10


Accurate preop assessment of the airway

Bag-mask ventilation, Oral/ nasal airway insertion

Laryngoscopy technique

Placement of ETT

Confirmation of position, Securing tube


31

Intubation (by alternate methods)


Accurate preop assessment of the airway

Bag-mask ventilation, Oral/ nasal airway insertion

Intubation technique

Confirmation of position

Securing tube

Date Technique used/ Comments Signature

32

LMA insertion

Minimum 10


Accurate preop assessment of airway

Rationale for use of LMA

Preparation of equipment

Correct insertion technique

Confirmation of LMA placement

Securing of LMA


33

Assisting with Fibreoptic Intubation

Minimum 3


Preparation of equipment

Assisting with airway topicalization

Assisting with intubation

Confirmation of position

Securing tube


Assisting with OLV (One Lung Ventilation)

Minimum 2

Please include in your assessment :

Knowledge of indications for lung isolation

Methods available, their advantages and limitations

Ability to assist with procedure

Knowledge of management of desaturation during OLV


34

Assisting with Central Venous Line/ PAC Insertion

Minimum 3 for CVP, 1 for PAC


Sterile technique

Knowledge of potential complications

Knowledge of relevant landmarks

Setting up equipment (including Ultrasound)

Recognition of CVP/ PAC/ PCWP waveform

Ability to perform CO measurements

Knowledge of immediate treatment of PA rupture


Assisting with peripheral nerve block/ catheter

Minimum 5


Sterile technique

Knowledge of relevant landmarks

Setting up drugs, monitors and equipment

Safe injection technique


35

Cases performed under conscious sedation

Minimum 15


Ability to perform initial preoperative assessment

Ability to recognize patients in at additional risk/AA supervision unsuitable

Demonstration of vigilant monitoring of the patient

Ability to administer and titrate appropriate sedative and analgesic agents

Administration of fluids and vasoactive agents

Prompt recognition of problems

Correctly initiates corrective measures

Date Type of case/ Comments Signature

36

Cases performed under regional anesthesia

Minimum 10










37

Cases under General anesthesia (Maintenance)

Minimum 20










38

Section Six: Evaluation

COMPETENCY DATE Method of

assessment

EVALUATION COMMENT/ Signature

PROFESSIONALISM

1. Function as a Professional

a. Adheres to the scope of

practice

O M

D

S I

b. Works with anesthesia care

team to provide quality care

O M

D

S I

2. Function within Medical,

Legal and Ethical

Guidelines

O M

D

a. Adheres to medical ethics O M

D

S I

b. Adheres to standards of

practice

O M

D

S I

c. Maintains confidentiality O M

D

S I

COMMUNICATION

1. Demonstrate Effective

Oral Communication

Skills

O M

D

a. Communicates effectively

with patient and family

O M

D

S I

b. Communicates effectively

with other members of the

health care team

O M

D

S I

c. Teaches caregivers patient

care and equipment skills

O M

D C

S I

2. Demonstrate Effective

Written Communication

Skills

a. Documents patient

procedures appropriately

O M

D

S I

HEALTH AND SAFETY

1. Effectively Manages

Environmental Factors

Associated with Work

a. Uses appropriate self-

protection when exposed to

potentially hazardous

situations such as :

Infectious agents

O M

D

S I

39


assessment


Hazardous chemicals

Radiation exposure

LASER

b. Uses appropriate body

mechanics for lifting,

transferring and transporting

patients

O M

D

S I

c. Takes measures to prevent

OR pollution (N2O,

volatiles)

O M

D

S I

2. Carries Out Procedures

using WHIMIS standards

O M

D

S I

Follows appropriate

procedures to safely manage

hazardous materials

O M

D

S I

Instruct others with regard to

W.H.M.I.S.

O M

D

S I

INFECTION CONTROL

Labels all infectious material

bags for purpose of disposal

O M

D

S I

Uses hand washing technique O M

D

S I

Follows standard Universal

Precautions

O M

D

S I

EQUIPMENT

1. Clean and Disinfect

Equipment

Uses appropriate cleaning and

disinfecting procedures for the

following equipment:

bronchoscopes

laryngoscopes

lighted stylette

LMA

Patient monitoring

equipment

TEE

Ultrasound machine

Regional nerve

stimulators

O M

D

S I

2. Maintains equipment O M

D

S I

d. Performs preventative

maintenance on the


Ultrasound machine

Difficult intubation

O M

D

S I

40


assessment


equip[ment

Syringe pumps

IV pumps

e. Calibrates equipment

(Istat, Glucometer,

Hemachron, Hemocue)

O M

D

S I

f. Maintains inventory O M

D C

S I

d.. Performs thorough

Anesthetic machine checkout

O M

D

S I

e. Adheres to DOT and CSA

regulations

O M

D

S I

PATIENT ASSESSMENT

1. Assessment O M

D

S I

a. Takes a relevant patient

history

O M

D

S I

b. Performs an appropriate

physical examination of the

patient

O M

D

S I

c. Interprets preop laboratory

investigations correctly.

Correctly accesses lab

information using hospital

information technology

O M

D

S I

d. Discusses the patient with

the attending anesthesiologist

to develop an appropriate

plan for intraoperative

management.

O M

D

S I

Educates patient regarding

anesthesia procedures

O M

D

S I

MANAGEMENT OF ANESTHESIA

INDUCTION

Assists with the following

types of induction:

IV

O M

D

S I

Modified/ Rapid-sequence

O M

D

S I

Inhalation

O M

D C

S I

41


assessment


MAINTENANCE

Appropriate vigilance in

monitoring patients

O M

D

S I

EMERGENCE

Takes steps to prepare patient

for emergence from

anesthesia:

Calls for staff presence

Adjusts level of anesthetic

agent

Assesses/ reverses

neuromuscular blockade

Optimizes analgesia

Adjusts ventilation to

encourage spontaneous

ventilation

Manages airway appropriately

O M

D

S I

MONITORING

a. Correctly applies

standard monitors:

5 lead ECG

NIPB

SPO2

Temperature probe

PNS

Expired CO2

b. Correctly applies the

following non-invasive

monitors:

BIS

O M

D

S I

S I

S I

S I

b. Prepares equipment

for the following

invasive monitors:

Arterial line

CVP

PA catheter

TEE

Cardiac output

O M

D

S I

c. Prepares ultrasound

machine for use

during line insertion

O M

D

S I

d. Correctly inserts

arterial line.

O M

D

S I

42


assessment


Performs arterial and venous

puncture, Uses indwelling

catheters to collect blood

samples

Correctly sends samples to

lab for CBC, coagulation

tests, crossmatch

Interprets results from blood

samples

Evaluate results relative to

patient clinical status

Recommends appropriate

corrective actions based on

lab results.

Performs arterial line

insertion (see monitoring

section)

Correctly uses I-Stat

Correctly uses glucometer

Correctly uses Hemachron

Correctly uses Hemocue

O M

D

S I

1.

Bag/ mask ventilation

Applies head tilt, chin lift ,

jaw thrust

O M

D

S I

Inserts oral airway O M

D

Inserts nasopharyngeal airway O M

D

S I

2. Intubation

Prepares equipment the


Regular ETT

Oral/ nasal RAE ETT

Armoured ETT

LASER ETT

DLT

LMA/ Proseal

Combitube

Fast-track

Direct laryngoscope

Bougie

Fiberoptic scope/ DAVI cart

Glidescope

Lighted stylette

Bullard scope

Tube exchanger

O M

D

S I

43


assessment



Cricothyrotomy kit

Demonstrates correct use of

the following accessory

equipment

Glydescope

McCoy blade

Fiberoptic scope

Fast-track

Magill forceps

Stylets

DLT

LMA/ Proseal

Combitube

Direct laryngoscope

Bougie

Glidescope

Lighted stylette

Bullard scope

Tube exchanger

Retrograde intubation

kit

Cricothyrotomy kit

Troop pillow/ bath

blankets for

positioning

O M

D

S I

Assesses tube placement/seal

Performs oral intubation via

direct laryngoscopy

Performs nasal intubation via

direct laryngoscopy

Secures tube O M

D

S I

Recognizes complications and

takes action PRN

O M

D

S I

4. Perform extubation

Correctly assesses patient

readiness for extubation

Correctly performs adult

extubation

O M

D

S I

Correctly assesses and

manages patient post-

extubation. Recognizes

complications and takes

corrective action

O M

D

S I

5. Tracheostomy Tube O M S I

44


assessment


exchange Assists with exchange of

existing tracheostomy tube

D C

VENTILATION MANAGEMENT

Assesses the ventilation

requirements relative to

current patient status. Selects

appropriate ventilatory

parameters

O M

D

S I

Evaluates initial patient

response to mechanical

ventilation, and adjusts

parameters accordingly

O M

D

S I

Records appropriate

ventilation data

O M

D

S I

MEDICATIONS

a. Correctly draws up

routinely used induction,

maintenance and emergence

drugs

O M

D

S I

b. Correctly draws up

routinely used emergency

drugs

O M

D

S I

c. Actively practices

preventative strategies to

avoid medication errors

O M

D

S I

d. Demonstrates correct

calculations when diluting

medications

O M

D

S I

e. Demonstrates correct use of

IV syringe pump

O M

D

S I

f. Demonstrated correct use

and programming of IV

infusion pumps

O M

D

S I

g. Correctly and safely

administers medications

used for conscious sedation

O M

D

O M D

45


assessment


h. Correctly administers the

following medications for

maintenance of general

anesthesia:

Opioids

Inhalation agents

Nitrous oxide

Neuromuscular

blockers

Propofol infusion

O M

D

S I

POSITIONING

2. Assists with

positioning in the

following

intraoperative

positions:

Supine, arms

abducted

Supine arms tucked

Supine, left uterine

displacement

Prone, horseshoe

Prone, Mayfield

tongs

Prone, Jackson table,

(including Flip)

Lateral decubitus

Beach chair

Lithotomy

O M

D

S I

2. Safely able to move OR

table with draped patient.

O M

D

S I

4. Assists with draping,

following principles

of sterility

O M

D

S I

FLUID MANAGEMENT

a. Prepares the

following lines

foradministration of

IV fluids:

Standard IV line (vented,

non-vented)

PCA extension

Blood administration set

Hotline warmer

Level 1 warmer

b. Performs peripheral

O M

D

S I

46


assessment


intravenous cannula

insertion

c. Assists with central

line insertion

d. Correctly sets up and

runs the Cell saver

e. Correctly checks

blood products

f. Correctly administers

the following fluids:

Crystalloid

Colloid

Blood products

Mannitol

g. Monitors patient

volume and electrolyte

status

SUCTION

a. AIRWAY

Correctly suctions the

airway using the


Yankauer suction

Flexible suction

Bronchoscope

Assists with obtaining samples

via bronchoscope

O M

D

S I

Thoracic Suction. Correctly

assembles/tests equipment

O M

D

S I

Assesses function of chest

tubes

O M

D

S I

Monitors drainage O M

D

S I

b Gastric Suction

Correctly inserts Naso Gastric

tube

Assesses correct placement.

Recognizes incorrect

placement

Uses appropriate suction for

NG drainage.

O M

D

S I

THERMOREGULATION

Demonstrates proper use of

the following equipment:

Air warming blanket (Bair

Hugger)

O M

D

S I

47


assessment


Fluid warming/ cooling

mattress

(See monitoring, fluids

sections)

Selects patients appropriately

for warming/ cooling

measures

O M

D

S I

REGIONAL ANESTHESIA

Correctly prepares local

anesthetic for regional

anesthesia after discussion

with the attending

anesthesiologist

O M

D

S I

Prepares equipment for

regional anesthesia:

Spinal

Epidural

CSE

Peripheral nerve

block

Peripheral nerve

catheter

IV block

O M

D

S I

Correctly manages peripheral

nerve stimulator for peripheral

nerve blocks

O M

D

S I

Uses safe injection technique

for local anesthetic

administration for nerve

blockade.

O M

D

S I

COMPLICATIONS

1. Calls for help appropriately

O M

D

S I

2. Able to recognize, list a

differential diagnosis for, and

initiate management for the

following complications:

O M

D

S I

a. Hypertension

O M

D

S I

b. Hypotension

O M

D

S I

48


assessment


c. Hemorrhage

O M

D

S I

d. Tachycardia

O M

D

S I

e. Bradycardia

O M

D

S I

f. Patient movement

O M

D

S I

g. Leak/ disconnect

O M

D

S I

h. High airway pressure

O M

D

S I

i. Hypoxia

O M

D

S I

k. Hypercarbia

O M

D

S I

l. Hypoventilation/ apnea

O M

D

S I

3. Perform Advanced Cardiac

Life Support Resuscitation

Protocols

O M

D C

S I

PATIENT TRANSPORT

a. Selects appropriate

equipment, monitors and

drugs for an intra-hospital

patient transport

O M

D

S I

b. Assemble equipment and

ensure equipment function

pre-transport checkout

monitor and troubleshoot

during transport

O M

D

S I

O M

D

S I

c. Monitors patient response

during transport

O M

D

S I

d. Trouble-shoots during

transport

O M

D

S I

ADMINISTRATION

a. Plans work schedules. O M

D

S I

b. Applies cost containment

procedures.

O M

D

S I

c. Develops policies and

procedures.

O M

D

S I

d. Provides workload data.

Conducts workload

O M

D

S I

49


assessment


measurement

g. Participate in research as

needed.

O M

D

S I

2. Develops, Implements

quality assurance

programs.

O M

D

S I

b. Evaluates processes,

practices or equipment.

Interprets findings. Makes

recommendations

O M

D

S I

50

Completion of Clinical Component of Anesthesia Assistant Program

This letter confirms that ____________________________________________________

completed the clinical component of the above course in the Ottawa Hospital

______________________ Campus, University of Ottawa Department of Anesthesia

between the dates of ________________ to _________________.

I have reviewed the student’s performance with the other members of my department and

confirm that they have achieved the competencies as listed in the accompanying

document from their main mentor, Dr._____________________.

Course Supervisor: ______________________________________________

Signature: _____________________________ Date: ________________

51

ALGONQUIN COLLEGE ANESTHESIA ASSISTANT DAILY EVALUATION

Please return this card to (Mentor’s name) _____________________________________

Student’s name: __________

Staff name: _____

Date: _________

SKILL SCORE

Prepares equipment 1 2 3 4 5

Patient assessment 1 2 3 4 5

Patient monitoring 1 2 3 4 5

Induction of anesthesia 1 2 3 4 5

Airway and ventilation management 1 2 3 4 5

Patient positioning 1 2 3 4 5

Fluid administration

Medication administration 1 2 3 4 5

Emergence 1 2 3 4 5

Transport to recovery or ICU 1 2 3 4 5

Use of personal protective equipment 1 2 3 4 5

Oral and written communication 1 2 3 4 5

Rating Scale 1 Significantly below expectations. Fails to perform skill adequately or does not

attempt to perform skill. Poor knowledge.

2 Does not meet expectations. Makes one or more critical mistakes. Gaps in

knowledge

3 Meets expectations. Without critical mistakes, may make minor mistakes. Minor

gaps in knowledge.

4 Exceeds expectations. Performs confidently without prompting, corrects minor

mistakes safely. No significant gaps in knowledge.

5 Outstanding. Anticipates issues, proactive. Knowledge level above average.

52

Type of cases on this date:

_________________________________________________________________

Technical Skills Witnessed:

_

Topics Discussed:

Comments (include strengths & weaknesses):

___________

53

Summary of Student Responsibilities

1. We will do our best to coordinate your schedule to give you a variety of

exposures to different types of cases, including general, regional, local/sedation,

thoracics, cardiac, neuro, vascular. You can assist us by identifying areas that you

have yet to cover as your rotation progresses so that we have the opportunity to

meet all your objectives.

2. During this rotation, you are considered a student, and are not to be left

unsupervised for patient care. This may be at odds with your usual role in the OR,

but those are the terms of your role as a student. Please remind your mentor of

this, and if there are any issues in this regard, please refer your staff to me.

3. Please hand a daily evaluation card to your supervising staff every day. Since they

will not be working with you all the time, your mentors will use this to track how

you are progressing.

4. Please ensure that you keep the following records:

a. Cases performed

b. Technical skills log

c. Discussion topics covered

5. Please complete one of the Case plans per week and review it with a staff

anesthesiologist.

Documentation of #3, #4, #5 above is required for successful completion of the program.

Please let me know if you are experiencing any difficulty with any aspect of this

program. I will do my utmost to assist you.

Patti Murphy MD, FRCPC

Education Director

University of Ottawa, Department of Anesthesia

Box 249C

1053 Carling Avenue

Ottawa, Ontario

K1Y 4E9

[email protected]

(613) 761-4169

fax (613) 761-5209