Resident Supervision / Procedure-specific Credentialing

Residents at all levels in the Department of Pediatrics are supervised by faculty on a daily basis. The ultimate responsibility however, for resident supervision rests with the Program Director. 

On the inpatient wards and in the intensive care units, the supervising resident has direct responsibility for ongoing daily patient care. The supervising resident also has the responsibility to supervise and educate both students and PGY-1 and PGY-2 residents in the care of their patients and to review all orders written on patients in their service.

The attending physician for all inpatient wards, ICU's, and nurseries provides on-site feedback and supervision on a daily basis for all patients. The supervising or admitting resident must call the attending physician for all new admissions and for any deterioration or significant change in a patient's status. The attending physician is available at all times by phone and beeper if not immediately on site. The attending physician evaluates all patients on a daily basis and all new patients in less than 24 hours. For any inpatients who are co-managed by Pediatrics and another service (e.g. Surgery), the faculty supervisor for the Pediatric residents is the Pediatric attending physician.

In the ambulatory areas, residents at all levels are supervised directly by faculty, except that the Pavilion Senior Resident may provide supervision to lower level residents and students under the oversight of the faculty. For PGY-1 residents, faculty must see all patients. For upper level residents, the faculty may not directly see all patients, but they are available on-site for questions and direction. Faculty review all patient care management decisions and sign all clinic resident charts.

In the Emergency Room, ED faculty are present in-house on a 24-hour basis. Faculty see and evaluate all patients after the residents present the patients and plan for care. All patients admitted after hours to the hospital from the ED must be first evaluated by an ED faculty member. 

Residents are expected to develop increasing independence for patient care during the residency training program. As PGY-1s, residents are expected to admit new patients and to take care of their assigned patients under the supervision of the PGY-3 resident and faculty. AS PGY-2s, residents are expected to develop a faculty determined level of independence in the management of their patients with commensurate less supervision is required from the PGY-3 resident and faculty. The PGY-2 resident should also begin to develop leadership skills by supervising the team when the PGY-3 resident is not immediately available. All residents are expected to teach students and lower level house staff when in a supervising role. As PGY-3s, residents are expected to assume a supervisory role in all patient service areas under the direction of the faculty.

As appropriate for the individual resident, attending staff allow residents progressively increasing responsibility for independent patient care. If a resident is placed on probation for unsatisfactory performance or unprofessional behavior, any requirements for increased supervision will be made known to the attending physician by the Program Director.

Procedure-specific Credentialing and Supervision Guidelines

Throughout all three years, the resident is expected to document performance of certain procedures. Procedure specific credentialing is required for promotion, graduation and subsequently for licensing and hospital credentialing after residency. The resident is expected to document proficiency in all required procedures (see below) by obtaining faculty certification of all satisfactorily performed procedures and recording them via the on-line, Clin-Web system even if the procedure does not usually call for a procedure note and even if a procedure note is also written (e.g. all procedures performed in the ED must be written on the ER paperwork).

The following procedures, listed by training level, number required and degree of risk and faculty supervision, require documentation of proficiency. The number in parenthesis preceded by # is the minimum number of the relevant procedure that residents are expected to successfully perform by the end of the applicable training year. This is also the number necessary for being credentialed to perform the specific procedure independently or to supervise another resident in the performance of the procedure. If the Roman numeral in parenthesis describing the expected proficiency status is I, the resident is not required to master performance of the procedure but should understand how the procedure is performed and when to use it. 

PL-1 Year
(* Proficiency status in parenthesis)

Placement of Intravenous Line (#3) (III)
Venipuncture (#3) (III)
Bladder Catheterization (#3 male and #3 female) (III)
Gastric Tube Placement, with/without Lavage (#3) (III)
Suture Lacerations (#3) (III)
Wound Care (#3) (III)
Intramuscular Injection (#3) (III)
Intradermal/Subcutaneous Injection (#3) (III)
Local/Topical Anesthesia (#3) (III)
Tympanometry Interpretation (#3) (III)
Audiometry Interpretation (#3) (I)
Vision Screening (#3) (I)
Hearing Screening (#3) (I)
Administration of Inhalational Meds (#3 nebulizer and #3 MDI with or without spacer) (III)
Peak Respiratory Flow [perform and interpret] (#3) (I)
Chest Physiotherapy (#3) (I)
Drainage Subungual Hematoma (#1) (I)
Developmental Screening Test (#3) (III)
Reduction/Splinting Simple Dislocation [Nursemaid’s] (#1) (III)
Incision & Drainage of Superficial Abscess (#3) (III)
Simple Removal of Foreign Body [ear, nose or conjunctiva] (#1) (III)
Gyn Evaluation of Prepubertal Female (#1) (III)
Gyn Evaluation of Pubertal Female (#3) (III)

Umbilical Artery Catheter Placement (#6) (III)
Umbilical Vein Catheter Placement (#3) (III)
Arterial Puncture (#3) (III)
Endotracheal Intubation (#6 neonate and #3child or adolescent) (III)
Lumbar Puncture (#3) (III)
Circumcision (#6) (III)
Digital Block Anesthesia (#3) (III) 
Immobilization Common Fractures (#3) (III)
Immobilization Cervical Spine to include understanding of guidelines for placement and removal (#3) (III)
Neonatal Resuscitation (#6) (III)
Intraosseous Line Placement (#3) (III)



Promotion Criteria: 
Proficiency/Competency at performing all level one procedures.


Proficiency Status:

I (Cognition) -- Resident is not required to master performance of this  procedure but should understand how it is performed and when to use it.

III (Autonomy) - Resident must master performance of these procedures. 

PL-2 Year
(* Proficiency status in parenthesis)

Sexual Abuse Exam/Evaluation (#3) (III)

Tracheostomy Tube Replacement (#3) (III)
Arterial Line Placement (#3) (III)
Central Venous Line Placement (#3) (III)
Pediatric Cardiopulmonary Resuscitation (#2) (III)
Exchange Transfusion Newborn (#1) (I)
Burn Management (1st & 2nd degree) (#3) (III)
Pain Management [e.g. PCA] (#3) (III)
Thoracocentesis (#3) (III)
Conscious Sedation (#3) (III)

Promotion Criteria: 
Proficiency/Competency at performing all level one and level two procedures.

Proficiency Status:

I (Cognition) -- Resident is not required to master performance of this procedure but should understand how it is performed and when to use it.

III (Autonomy) - Resident must master performance of these procedures. 

PL-3 Year
(* Proficiency status in parenthesis)

Suprapubic Tap (I)

Chest Tube Placement (#3) (III)



Promotion Criteria: 
Proficiency/Competency at performing all level one, two and level three procedures.

Proficiency Status:

I (Cognition) -- Resident is not required to master performance of this procedure but should understand how it is performed and when to use it.

III (Autonomy) - Resident must master performance of these procedures. 

References: Walsh-Sukys, MC & Krug, SE. Procedures in Infants and Children.
W.B. Saunders, 1997