Electrophysiology

Educational Purpose:  The educational purpose of this rotation is to provide fellows with the knowledge, experience, and skills necessary to manage patients with tachy- and brady-arrhythmias, channelopathies, syncope, and prevention and treatment of sudden cardiac death.  Fellows will be exposed to a variety of diagnostic procedures including electrocargiography, ambulatory monitoring using Holter monitors, tilt-table testing, challenge testing (such as Flecainde for Brugada Syndrome), and invasive electrophysiology testing.  Fellows will also be exposed to implantation of cardiac devices including pacemakers, defibrillators, and cardiac resynchronization devices and will be allowed to participate in such procedures.  Exposure to cardiac device interrogation, trouble-shooting, and programming is also a valuable part of this rotation.  Fellows will participate in the consultative care of patients from both cardiac and non-cardiac services at all training sites.  The mix of patients in each teaching environment will differ; however, the methods of evaluation and goals will be the same.  

By the end of the rotation, the fellow will have a sufficient knowledge base to diagnose and manage patients with complex arrhythmias and electrophysiologic conditions.  This will be achieved by participation in a variety of diagnostic and treatment procedures (listed above) along with daily rounds with the attending physician.  Through consultation, they will have acquired skills in interpreting and communicating findings professionally in dealing with requesting physicians, with a high level of professionalism. 

Overall Goals:
To become competent in the provision of comprehensive guidance to physicians and care to patients with cardiac illnesses that co-exist with other conditions that evolve to dominate the clinical presentation (COMPETENCIES: patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning, systems-based practice)
To learn how to apply evidence-based, cost conscious strategies to diagnose and manage hospitalized patients (COMPETENCIES: patient care, medical knowledge, practice-based learning)
To learn to function as a member of a multidisciplinary team (COMPETENCIES: patient care, professionalism, interpersonal and communication skills, systems-based practice)
To be able to participate in patient education in regard to their cardiovascular conditions, including prevention and therapy (COMPETENCIES: interpersonal and communication skills, professionalism) 
To effectively participate in discussions of patient care with providers in other medical disciplines and specialties (COMPETENCIES: Patient care, interpersonal and communication skills, professionalism)
To have an understanding of utilization of resources and appropriate levels of care in patients with various cardiac electrophysiologic conditions (COMPETENCIES: medical knowledge, practice-based learning, systems-based practice)

Competency-Based Learning Objectives:
Acquire the medical knowledge to understand the indications for the medical necessity of a diagnostic electrophysiology study (COMPETENCIES: patient care, medical knowledge)
Acquire knowledge for interpretation of basic intracardiac electrograms (COMPETENCIES:  patient care, medical knowledge)
Evaluate patients with complex ventricular arrhythmias and effectively communicate with the patient, their families, and referring physicians for an appropriate plan of care (COMPETENCIES: patient care, interpersonal skills and communication, systems based practice)
Evaluate, troubleshoot, and program pacemakers, defibrillators and cardiac resynchronization devices (COMPETENCIES: medical knowledge)
Acquire quality assessment improvement in evaluating and performing basic procedure understanding in electrophysiology (COMPETENCIES: practice-based learning and improvement, systems based practice)
Foster an attitude of life-long learning and critical thinking skills that will be gained by experience and incorporating new developments (COMPETENCIES: medical knowledge, professionalism)

Goals & Objectives by PGY Level:
PGY 4:
1.   Develop a strong understanding and expertise in electrocardiography and Holter monitor reading
2.   Acquire the medical knowledge to understand the indications for the medical necessity of a diagnostic electrophysiology study, acquire knowledge for interpretation of basic intracardiac electrograms, evaluation of patient’s with complex ventricular arrhythmias, trouble-shoot and program various types of devices, and understanding patient selection and indications for the need of an electrophysiology study and device implantation.
3.   Acquire quality assessment improvement in evaluating and performing basic procedure understanding in electrophysiology
4.   Foster an attitude of life-long learning critical thinking skills that will be gained by experience and incorporating new developments.
5.   Review pre-procedure laboratory and non-invasive studies
6.   Identify possible contra-indication for an electrophysiology study and/or device implantation
7.   Introduction to the interpretation of intracardiac electrograms
8.   Acquire knowledge on how to handle life-threatening complications from an arrhythmia point

PGY 5:
1.   Continue to build upon the skills developed in the PGY 4 year




PGY 6:
1. Continue to build upon PGY-4 and 5 goals and objective
2. Develop more expertise in regards to understanding the indications for  diagnostic electrophysiology study, interpretation of intracardiac electrograms, evaluation of patient’s with complex ventricular arrhythmias, trouble-shoot and program various types of devices, and understanding patient selection and indications for the need of an electrophysiology study and device implantation.
3. Further develop technical skills in the electrophysiology lab in regards to the insertion of devices, ablations, EP studies, pre and post procedural managements of patients, and complications related to procedures. 

Mix of Diseases:  Fellows will be exposed to patients with a wide range of cardiovascular disorders and complications of other diseases or procedures at varying degrees of progression (from initial presentation and diagnosis to end-stage disease), as well as to patients referred to the Electrophysiology service for diagnostic or therapeutic procedures.  Patients seen by the Electrophysiology fellow will include a full range of adults and selected adolescent patients, from a comprehensive mix of ethnic and racial origins.  At JMH and UMH, the gender mix will be balanced; at the VAMC, the majority of patients will be male.  Cardiac electrical conditions encountered and managed typically include but are not limited to the following:  Atrial fibrillation, Atrial Flutter, Supraventricular Tachycardia, Ventricular Arrhythmias, as well as Wolff-Parkinson-White and other congenital diseases/channelopathies.  Furthermore, pregnant patients may be encountered.

Teaching Methods: 
Patient-Centered Teaching/Learning:   Case-based teaching will take place at the bedside or in clinic, and/or during the presentation to the attending, with visits to the electrophysiology procedure laboratories.  Emphasis will be placed on the approach and evaluation of the patient complaint, application of evidence-based medicine, as well as the approach to efficiently searching for answers to clinical questions.  Fellows are expected to identify knowledge gaps and search for answers to their questions on a routine basis.
Conferences/Didactic Learning:  Fellows are expected to attend the Division of Cardiology Fellows’ Core Curriculum Lectures given throughout the academic year in addition to the departmental Grand Rounds.  Attendance at the EP Core Lecture series is encouraged.

Procedures:
Learning Aspects of Pre-Procedural Phase (Patient Care, Medical Knowledge, and Professionalism)
Patient selection and understanding indications for the need of an electrophysiology study and device implantation.
Establish a patient-physician relationship
Obtain informed consent after discussing alternative therapies with patients

Review pre-procedure laboratory and non-invasive studies
Identify possible contra-indication for an electrophysiology study and/or device implantation

Learning Aspects of Procedural Phase (Patient Care and Medical Knowledge)
Appropriate knowledge on the different available catheters and devices 
Interpretation of intracardiac electrograms
Procedure pharmacotherapy and conscious sedation 
Acquire knowledge on how to handle life-threatening complications from an arrhythmia point

Learning Aspects of Post-Procedural Phase (Patient Care, Medical Knowledge, and Professionalism, System-Based Practice, and Practice-Based Learning)
Post-procedural vascular access care
Post-procedural orders and pharmacotherapy
Post-procedure wound care
Medical record documentation and procedure dictation
Patient discharge and follow-up medical therapy/care planning
Communicating results to patient’s family and consultants.

Evaluations: Fellows will be evaluated by their supervising attending physician(s) using a competency-based system on New Innovation.  Feedback will be provided during and at the end of the rotation.

Supervision Policy: Direct/Indirect with direct supervision immediately available.

Team Structure:
One supervising attending physician
One dedicated electrophysiology fellow
1-3 general cardiology fellows

Attending Responsibilities:
Supervises and assumes ultimate responsibility for care and management of patients on the service
Conducts daily rounds with the fellows on the service and device a daily plan of care
Responsible for providing verbal and written feedback to the fellow
Supervises all procedures performed by the fellow

Fellow Responsibilities:
Respond to all consultations and present each consultation to the attending faculty member.
o The EP consult pager is carried by the fellow on the EP Service during normal working hours and by the fellow on night/weekend/holiday call at other times
Initial consultation:
o All consults must be seen on the day that the consultation is requested, and of course, immediately in the case of emergencies.  Emergency consults requiring cardiac intensive care are to be referred promptly to the fellow assigned to the CCU. 
o Obtain the initial history and physical examination of all new consultations including a thorough review of prior treatments, laboratory testing, imaging studies, etc.  Obtain outside records when available.
o Formulate a plan of care that will be presented to the attending physician.  Communicate this plan of care to the primary/consulting physicians
o Dictates initial reports as part of the patient’s medical record
o In general, the fellow will assign some consults to the resident and evaluate others as the primary evaluator
Fellows will be responsible for the daily follow up of patients on the service and conducting rounds with the attending to formulate a plan of care.  The fellow will document the plan in a formal note (dictated or written in the electronic record preferred) and communicate the plan with the primary care team and other members of the multidisciplinary team when appropriate.
Fellows will participate in procedure (see above) under the supervision of their attending.  They will determine indications and contraindications for these procedures and review finding with the attending to see how care will be changed.  Fellows will be responsible for post-procedural care along with dictation of the procedure.
Responsible for keeping a log of all procedures in New Innovations
Attends all divisional conferences
Attend assigned Cardiology clinics 
Completes a written evaluation of the attending


EKG and HOLTERS
Educational Purpose:  This rotation is carried out as part of the EP rotations at JMH and VAMC.  The educational purpose of this rotation is to provide fellows with the knowledge and experience necessary to provide interpretations of electrocardiograms (EKGs), rhythm strips, and ambulatory monitor (Holter monitor – HM) recordings.  The rotation is structured for the fellow to interpret routine 12 lead EKGs and rhythm strips daily, as well as HMs, under the supervision of an attending physician.  The rotation also includes the interpretation of preoperative and emergency EKGs, and reporting results back to requesting physicians. 

By the end of this rotation, the fellow is expected to be able to interpret EKGs at a level commensurate with an individual with cardiovascular training, and to be knowledgeable in the scientific basis for electrocardiography, the application of the principles of electrocardiography to electrocardiographic interpretation, the functioning of an electrocardiographic service within the Institution, and application of electrocardiography to practice of cardiovascular medicine.  The fellow should also become proficient at communicating professionally with the physician requesting the electrocardiographic service, especially if a marked abnormality is noted.

All EKGs read by the fellow will be reviewed by a supervising attending who will provide feedback when necessary.  The fellow will be evaluated by the attending as part of the comprehensive evaluations system in the institutional community.  

Overall Goals:
Become competent in the interpretation of a broad array of EKGs and HMs, and in the application of such interpretations in clinical context.  (COMPETENCIES: medical knowledge, professionalism, interpersonal and communication skills, practice-based learning, systems-based practice)
Learn how to use electrocardiographic procedures in a cost-effective manner to diagnose and manage patients in a variety of settings including hospitalized patients, outpatients, and emergency room patients. (COMPETENCIES: patient care, medical knowledge, practice-based learning, systems-based practice)
Learn to function as a member of a multidisciplinary team within the cardiovascular disease service mission (COMPETENCIES: patient care, professionalism, interpersonal and communication skills, systems-based practice)
Be able to participate in education of physicians on non-cardiovascular services, in regard to the use and limitations of EKG services (COMPETENCIES: interpersonal and communication skills, professionalism)
Effectively communicate EKG findings of immediate clinical significance to providers in other medical disciplines and specialties (COMPETENCIES: Patient care, interpersonal and communication skills, professionalism)
Have an understanding of appropriate utilization of these resources (COMPETENCIES: practice-based learning, systems-based practice)

Competency-Based Learning Objectives:
Demonstrate competency in interpretations of electrocardiograms (EKGs), rhythm strips, and ambulatory monitor (Holter monitor – HM) recordings (COMPETENCIES: patient care, interpersonal and communication skills)
Formulate a description of diagnostic considerations based upon the EKG findings (COMPETENCIES: patient care, medical knowledge).
Demonstrate organizational skills necessary to integrate the findings into the systems available to give access of other physicians to the interpretations (COMPETENCIES: practice-based learning, system-based practice)
Demonstrate the ability to identify and distinguish artifacts from clinically important variations on electrocardiographic recordings (COMPETENCIES: practice-based learning, medical knowledge)
Efficiently and effectively document in writing the observations, measurements, and conclusions, that will be entered into the medical record (COMPETENCIES: medical knowledge, system-based practice, practice-based learning, interpersonal and communication skills)
Demonstrate effective communication with consulting providers, and other physicians and supporting staff (COMPETENCIES: communication and interpersonal skills, professionalism)
 
Mix of Diseases:  Fellows will be exposed to a wide range of EKG recordings of normal and abnormal cardiovascular states and complications of other diseases that may alter such recordings, as well as to patients who require electrocardiographic clearance for diagnostic or therapeutic procedures.  

Teaching Methods:
Patient-Centered Teaching/Learning:  Teaching will take place in the heart station, and/or during the presentation to the attending, with additional discussions during conferences.   Fellows are expected to identify knowledge gaps and search for answers to their questions on a routine basis.   
Conferences/Didactic Learning:  Fellows are expected to attend the Division of Cardiology Fellows’ Core Curriculum Lectures given throughout the academic year in addition to the departmental Grand Rounds.  

Procedures:  Fellows may participate in the placement and removal of Holter monitors.  Please see section H for details of electrophysiology procedures encountered during that rotation

Pathologic Material/Educational References: 
The fellows will review EKGs, chest X-rays, cardiac catheterizations, CT scans, stress tests and echocardiograms as indicated by the patient’s cardiac condition.  
Up to Date: http://www.uptodate.com/home/index.html
PubMed: www.ncbi.nlm.nih.gov/pubmed/ 
Text books:  Cardiology textbooks are available in the Hospital Library and the Calder Medical Library.
Institutional access for http://www.cardiosource.org  and CardiosourcePlus with ACCSAP7.

Evaluations: Fellows will be evaluated by their supervising attending physician(s) using a competency-based system on New Innovation.  Feedback will be provided during and at the end of the rotation.

Supervision Policy: Direct/Indirect with direct supervision immediately available.

Team Structure: 
One Supervising Attending (may alternate on a daily schedule)
At least 1 fellow

Attending Responsibilities:
Supervises and assumes ultimate responsibility for the interpretation of EKG and HM recordings
Responsible for providing verbal and/or written feedback to fellow regarding EKG and HM readings

Fellow Responsibilities:
Responsible for all initial EKG and HM interpretations that will then be reviewed by the attending physician
Responsible for alerting referring or consulting physicians of abnormal results when appropriate
Responsible for keeping a log of HM interpretations in New Innovations

JMH Electrophysiology Service - Rotation

  1. Rounds/Consults
      1. The Cardiology Fellow is expected to lead the consultative service. In conjunction with any Residents/Students/ANPs, the Cardiology Fellow should see or direct primary EP consults. No consults should be turned down. The cardiology Fellow should develop an initial impression and plan and present to the EP Attending and/or EP Fellow. Patient followups should also be managed by the Fellow.
      2. Generally The EP Fellows see the post procedure patients that they were involved with. The Cardiology Fellow should communicate w EP Fellow to ensure all patients are seen
      3. Maintain list of all patients on service
      4. Dictate/write notes on timely basis
    1. Device Interrogation /Checks-
      1. The Cardiology Fellow is expected to interrogate all patients on the service. He/She should not rely on “call the rep.” For those Fellows with less experience in interrogation of devices, the Cardiology Fellow should ask help from the EP Fellow/Attending and /or can have the Rep provide technical assistance

    2. ECG / Holters

      1. Obtain MUSE ACCESS

      2. Mon-Fri: The 1st and or 2nd year on EP rotation will be expected to read all assigned ECGs (3rd year fellows are not required to ECG reading)

        1. Contact UMH ECG reader in the morning to arrange a time to review ECGs

      3. Holters - Mon-Fri: The cardiology fellow on the EP rotation will be expected to read all assigned Holters

        1. Contact UMH ECG reader in the morning to arrange a time to review ECGs

    3. Clinic

      1. In addition to regularly assigned clinic, the EP clinic occurs on Wednesdays and fellow should participate along with the assigned faculty

    4. Procedures

      1. The Cardiology fellow on the EP service is not expected, but is certainly welcome to participate in any ongoing procedures
      2. It is recommended that they take the opportunity to observe and/or participate in procedures during their rotation, to include but not be limited to:
        1. Electrophysiology studies
        2. Pacemaker and ICD implantation
        3. Ablation of SVT
        4. Ablation of atrial fibrillation
        5. Ablation of ventricular tachycardia
        6. Left atrial appendage closure
      3. For 3rd year fellows doing the EP elective should make every effort to observe/participate in procedures in the cath lab.
    5. Conferences

      1. Attend Monday & Thursday EP conference/Rounds

    6. Academic Expectations

      1. Present 10-15’ at one of our conferences of an interesting case or research project or literature review

        1. Case can be from consult service, EP lab, device trouble shooting

        2. Have appropriate references


    UMH Electrophysiology Service - Rotation

    1. Rounds/Consults
        1. The Cardiology Fellow is expected to lead the consultative service. In conjunction with any Residents/Students/ANPs, the Cardiology Fellow should see or direct primary EP consults. No consults should be turned down. The cardiology Fellow should develop an initial impression and plan and present to the EP Attending and/or EP Fellow. Patient followups should also be managed by the Fellow.
        2. Generally The EP Fellows see the post procedure patients that they were involved with. The Cardiology Fellow should communicate w EP Fellow to ensure all patients are seen
        3. Maintain list of all patients on service
        4. Dictate/write notes on timely basis
      1. Device Interrogation /Checks-
        1. The Cardiology Fellow is expected to interrogate all patients on the service. He/She should not rely on “call the rep.” For those Fellows with less experience in interrogation of devices, the Cardiology Fellow should ask help from the EP Fellow/Attending and /or can have the Rep provide technical assistance

      2. ECG

        1. Obtain MUSE ACCESS

        2. Mon-Thursday: Read  50 ECGs/day in MUSE and then review with the UMH ECG Reader of the day

          1. Contact UMH ECG reader in the morning to arrange a time to review ECGs

      3. Clinic

        1. In addition to regularly assigned clinic, attend Mitrani Clinic on Monday morning or Friday. Check with Mitrani regarding which date to attend which also would be affected whether Fellow has Friday JMH Clinic

      4. Procedures

        1. The Cardiology fellow on the EP service is not expected, but is certainly welcome to participate in any ongoing procedures
        2. It is recommended that they take the opportunity to observe and/or participate in procedures during their rotation, to include but not be limited to:
          1. Electrophysiology studies
          2. Pacemaker and ICD implantation
          3. Ablation of SVT
          4. Ablation of atrial fibrillation
          5. Ablation of ventricular tachycardia
          6. Left atrial appendage closure
        3. For 3rd year fellows doing the EP elective should make every effort to observe/participate in procedures in the cath lab.

      5. Conferences

        1. Attend Monday & Thursday EP conference/Rounds

      6. Academic Expectations

        1. Present 10-15’ at one of our conferences of an interesting case or research project or literature review

          1. Case can be from consult service, EP lab, device trouble shooting

          2. Have appropriate references

      Educational References: 

        Recommended Textbooks:

      •  Further Recommended Reading:
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