New Application: Pediatric Cardiology
Review Committee for Pediatrics
ACGME
515 North State Street, Suite 2000, Chicago, Illinois 60654  312.755.5000  www.acgme.org
COMMON SUBSPECIALTY SECTION
FACULTY RESEARCH
1. Complete the table below regarding the involvement of faculty in research. Add rows as necessary.
[PR II.B.5.b)]
# of current
IRB approved
research
Name
projects
Program Director:
Total # of
current
funded
research
projects
# of current
research
projects with
peer review
funding
(subset of
total # in
previous
column)
#
presentations
at national
scientific
# publications
meetings in in peer review
the last 5
journals in the
years
last 5 years
Key Faculty:
Research Mentors Who Are Not Key Faculty:
2. List active research projects in the subspecialty. Add additional rows as necessary.
Project title
Funding
source
Put an “X for
funding
awarded by
peer review
process
Pediatric Cardiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Years of
funding
(dates)
Faculty investigator and
role in grant (i.e. PI, Co-PI,
Co-investigator)
Updated 4/2015
Page 1 of 13
RESEARCH RESOURCES
1. Does the program provide research laboratory space and equipment? (if appropriate) [PR II.D.]
.................................................................................................................................... ☐ YES ☐ NO
2. Does the program provide financial support for research? ........................................... ☐ YES ☐ NO
3. Does the program provide computer and statistical consultation services? .................. ☐ YES ☐ NO
PROGRAM CURRICULUM
Goals and Objectives
Place an ‘X” in the box before the applicable response. [PR IV.A.2.]
Are there goals and objectives for all training
☐ YES ☐ NO
experiences?
Are they rotation and level specific?
☐ YES ☐ NO
How are they distributed?
☐ Hard Copy ☐ Electronic or web-based
If not web-based, when are they distributed to
☐ Prior to Each Rotation
☐ Annually
fellows?
☐ Once in Handbook
☐ Other
If not web-based, when are they distributed to
☐ Prior to Each Rotation
faculty?
☐ Annually
☐ Other
If web-based, do you send out reminders to access ☐ YES ☐ NO
them?
If yes, when do you send them?
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Collaboration between Programs
Are there meetings among the core Program
Director and subspecialty Program Directors?
How often do these meetings occur?
Who is typically involved in these meetings?
(check all that apply)
☐ YES ☐ NO
Click here to enter text.
☐ Core program director
☐ Subspecialty program director for this specialty
☐ Program directors from other subspecialties
General Subspecialty Curriculum
Topic
e.g., Biostatistics
Basic science as
related to the
Participants (place and X in the
appropriate column)
Where Taught in
Number of
Fellows in
Curriculum?
Structured
this
All
Residents &
(Name should Teaching Hours Discipline Subspecialty Subspecialty
match name in
Dedicated to
Will
Fellows
Fellows
conference list)
Topic Area?
Attend
Attend
Attend
Research
Course
14
X
Click here to
#
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☐
☐
enter text.
Pediatric Cardiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 2 of 13
Participants (place and X in the
appropriate column)
Where Taught in
Number of
Fellows in
Curriculum?
Structured
this
All
Residents &
(Name should Teaching Hours Discipline Subspecialty Subspecialty
match name in
Dedicated to
Will
Fellows
Fellows
conference list)
Topic Area?
Attend
Attend
Attend
Topic
application in clinical
subspecialty practice
Clinical subspecialty
Click here to
#
☐
☐
☐
content
enter text.
For the topics below, if the topic is not appropriate for your discipline (i.e., lab research for
fellows in developmental and behavioral pediatrics), enter N/A into column 1.
Biostatistics
Click here to
#
☐
☐
☐
enter text.
Lab research
Click here to
#
☐
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☐
methodology (if
enter text.
appropriate)
Clinical research
Click here to
#
☐
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methodology
enter text.
Study design
Click here to
#
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☐
enter text.
Grant preparation
Click here to
#
☐
☐
☐
enter text.
Preparation of
Click here to
#
☐
☐
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protocols for
enter text.
institutional review
board
Principles of evidenceClick here to
#
☐
☐
☐
based medicine/
enter text.
Critical literature
review
Quality Improvement
Click here to
#
☐
☐
☐
enter text.
Teaching skills
Click here to
#
☐
☐
☐
enter text.
Professionalism/Ethics
Click here to
#
☐
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enter text.
Cultural Diversity
Click here to
#
☐
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☐
enter text.
Systems-based
Click here to
#
☐
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practice (economics of
enter text.
healthcare, practice
management, clinical
outcomes, etc.)
Conferences
1. List regular subspecialty and interdepartmental conferences, rounds, etc., that are a part of the
subspecialty training program. Identify the "SITE" by using the corresponding number as appears
Pediatric Cardiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 3 of 13
on the first and second pages of this form. Indicate the frequency, e.g., weekly, monthly, etc., and
whether conference attendance is required (R) or optional (0). List the planned role of the fellow in
this activity (e.g., conducts conference, presents case and participates in discussion, case
presentation only, participation limited to Q&A component, etc.). Add rows as necessary.
Conference
Site #
Frequency
R/O
Role of the Fellow
2. Describe the mechanism that will be used to ensure fellow attendance at required conferences.
State the degree to which faculty attendance is expected, and how this will be monitored.
Limit the response to 50 words
Click here to enter text.
Scholarship Oversight Committee
1. Will there be a scholarship oversight committee for every fellow? ................................ ☐ YES ☐ NO
2. How often will the committee meet with the fellow? ................................................... # times per year
Fellow Research Activities
1. Describe how the program will ensure a meaningful supervised research experience for the fellows,
beginning in their first year and extending throughout their training.
Click here to enter text.
2. If faculty outside the division will be actively involved in mentoring the fellows, identify the mentors
and describe how liaisons will be created between these mentors and the fellows that allows for
meaningful accomplishment of research.
Click here to enter text.
Pediatric Cardiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 4 of 13
SPECIALTY-SPECIFIC SECTION
PROGRAM PERSONNEL AND RESOURCES [PR: VIII]
Other Professional Personnel
1. Indicate with a check mark the personnel who will interact regularly with fellows at each
participating site. [PR II.C.]
Team Members
Nurse Specialists trained in pediatric
cardiovascular techniques
Mid-Level Practitioners (e.g. clinical nurse
practitioners)
Social Workers
Psychologists
Cardiovascular Surgery PNPs or CNAs
PAs working with cardiologists, cardiovascular
surgeons or the heart transplant service
Intensive Care Nurses
Catheterization/Laboratory Technicians
Site #1
Site #2
Site #3
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2. For categories of personnel that are unavailable, describe how that function will be addressed in the
program.
Click here to enter text.
Support Facilities [PR VIII.C.5.]
1. Place a check mark in the appropriate spaces if these particular services are available at each of
the participating institutions in the program.
Available
Available
24 Hours/Day
Site #1 Site #2 Site #3 Site #1 Site #2 Site #3
1. Diagnostic imaging facilities [PR
VIII.C.5.a)]
a) Diagnostic
b) Flat Panel Detector
c) Angiocardiogram
1. Single- and Bi-plane
d) Digital computerized imaging
e) Cardiac MRI and/or CT scanning
f) Nuclear cardiology
2. Diagnostic & Interventional cardiac
catheterization laboratory facilities,
including physiological equipment as
follows: [PR VIII.C.5.b)]
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Pediatric Cardiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 5 of 13
a) Blood oxygen
b) Blood gas and pH analysis
c) Indicator-dilution techniques
d) Stress test
e) Cardiac output
f) Electrophysiology
g). Pressure
3. Echocardiography laboratory [PR
VIII.C.5.c)]
a) 2D
b) Doppler
c) Fetal
d) Transesophageal
4. Non-invasive electrophysiology
laboratory with facilities for performing
and interpreting [PR VIII.C.5.d)]:
a) Standard
b) Ambulatory
c) Exercise
5. Graphics laboratory for recording
Echocardiography, exercise testing,
Holter monitoring, etc.
6. Operating room(s) designed for pediatric
patients and equipped for
cardiopulmonary extracorporeal
circulation. The area must be equipped
with the following [PR VIII.C.5.g)]:
a) Appropriate bedside monitoring devices
b) Defibrillators
c) Cardiac pacing devices
7. Blood Bank [PR VIII.C.5.h)]
a) Type and cross-match blood
8. CT, UFCT
9. MRI
10. Continuous bedside monitoring
11. Exercise Testing
12. Transtelephonic telemetry
13. Clinical cardiac electrophysiologic
laboratory for invasive intracardiac
electrophysiological studies and catheter
ablation.
Available
Available
24 Hours/Day
Site #1 Site #2 Site #3 Site #1 Site #2 Site #3
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Pediatric Cardiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 6 of 13
2. If NO is indicated for any of the facilities and/or services in all the institutions above, explain how the
service is provided for patients. If the facility or service is concentrated in one institution, explain
how patients in the other institutions access these services or facilities.
Click here to enter text.
Inpatient Service/Outpatient Services
1. Indicate the availability of the following by checking the appropriate box. For inpatient services,
indicate the number of available beds.
Facility/Service
Space in an ambulatory setting for optimal
evaluation and care of patients
An inpatient area with full pediatric and related
services (including surgery and psychiatry)
staffed by pediatric residents and faculty
Pediatric intensive care unit (total number of
beds)
Neonatal intensive care unit (total number of
beds)
Cardiac Intensive Care Units (total number of
beds)
Other intensive care units where children < 18
years are cared for (total number of beds)
Site #1
Site #2
Site #3
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#
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2. For each location listed below where postoperative care is provided, indicate the planned role of the
fellow in that care for each of the following age groups: neonates, infants, children, and
adolescents.
Facility
Inpatient Area (exclusive of
intensive care)
PICU
NICU
CICU
Other ICU
Role of Cardiology Fellow in Patient Care
Designate as: Primary Provider (PP), Consultant (C)
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
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PATIENT POPULATION [PR VIII.C.6.]
Patient Data
1. Provide the following information for the most recent 12-month period. The same timeframe should
be used throughout the form.
Inclusive Dates:
From: Click here to enter a date.
Inpatient
Pediatric Cardiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
To: Click here to enter a date.
Site #1
Site #2
Site #3
Updated 4/2015
Page 7 of 13
Inpatient
1. Total number of admissions for whom the
pediatric cardiology service assumed major
clinical responsibility
a) Average daily census of patients on the
pediatric cardiology service
b) Number of new patients admitted each
year (“new” refers to those who are being
seen by pediatric cardiologists for the first
time)
c) Average length of stay of patients on the
pediatric cardiology service:
2. Number of consultations by pediatric
cardiologists on other inpatients
a) Are consultations provided to the NICU?
(Yes or No)
If yes, how many?
b) Are consultations provided to the PICU?
(Yes or No)
If yes, how many?
Ambulatory Visits
1. Is there a separate cardiology clinic? (Yes or
No)
2. If not, where are the ambulatory pediatric
cardiology patients seen (e.g. offices, clinics,
location?)
3. Number of pediatric cardiology ambulatory
visits per year available to fellows.
4. Of this number, how many are new patients?
(“new” refers to those who are being seen by
members of the pediatric cardiology service
for the first time.):
5. Number of pediatric cardiology clinic sessions
per week:
Site #1
Site #2
Site #3
#
#
#
#
#
#
#
#
#
Length
Length
Length
#
#
#
Choose an
item.
#
Choose an
item.
#
Choose an
item.
#
Choose an
item.
#
Choose an
item.
#
Choose an
item.
#
Site #1
Choose an
item.
Site #2
Choose an
item.
Site #3
Choose an
item.
Click here to
enter text.
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enter text.
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enter text.
#
#
#
1st Year:
2nd Year:
3rd Year:
#
#
#
6. Estimate the number of pediatric cardiology
clinics a fellow will attend per year in the
program.
2. Provide the following information for the most recent 12-month academic or calendar year for each
site used to provide a specific required experience, such as transplant, cardiology, intensive care,
etc. Duplicate this table as necessary. Note the same timeframe should be used throughout the
forms.
Site #1
Site #2
Site #3
Name of service:
Total number of fellows and residents on the
service
Pediatric Cardiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 8 of 13
Site #1
Site #2
Site #3
Total number of admissions to the service
Number of new patients admitted each year
(“new” refers to those who are seen by members
of the service for the first time.)
Average length of stay of patients on the service
Average daily census of patients on the service,
including consultations
Ambulatory Pediatric Cardiology Experience for All Years of Training
Add rows as necessary.
Name of
Experience
Use
Site/Other
Setting
Identifier
Duration of
Experience
(in wks/yr)
Number of
Sessions
Per Week
Per Fellow
Role of
Fellow in
Care of
Patients –
Designate as
Number of
Number of
Primary
Average
New
Return
Provider
Number
Patients Per Patients Per
(PP) or
Teaching
Fellow Per
Fellow Per Consultant
Attending
Session
Session
(C)
Per Session
List of Diagnoses
List 150 consecutive admissions (A) and consultations (C) by the Pediatric Cardiology service. Identify
the time period during which these admissions/consultations occurred. The date range should occur
within the same 12-month period used in previous sections. The dates must begin on the date the first
patient on the list was admitted and end with the date the 150th patient was admitted, (e.g., July 1, 2014
through October 20, 2014). Submit a separate list for each site that provides required rotations. Add
tables as necessary.
Site Name:
Inclusive Dates:
Patient ID
Number
Age
From (mm/dd/yy):
Cardiac Diagnosis
Pediatric Cardiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
To (mm/dd/yy):
Major Cardiac/Surgical Procedure(s)
Updated 4/2015
Page 9 of 13
Patient ID
Number
Age
Cardiac Diagnosis
Major Cardiac/Surgical Procedure(s)
Pediatric Cardiology Surgical Statistics
List 150 CONSECUTIVE cardiac operations on infants and children. Identify the time period during
which these admissions/consultations occurred. The date range should occur within the same 12month period used in previous sections. The dates must begin on the date the first patient on the list
underwent corrective heart surgery and end with the date the 150th patient underwent corrective heart
surgery, (e.g., July 1, 2014 through October 20, 2014). Submit a separate list for each site that provides
required rotations. Add tables as necessary.
Site Name:
Inclusive Dates:
Patient ID
Number
Age
From (mm/dd/yy):
Primary Cardiac Diagnosis
Pediatric Cardiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
To (mm/dd/yy):
Major Surgical Procedure(s)
Updated 4/2015
Page 10 of 13
Patient ID
Number
Age
Primary Cardiac Diagnosis
Major Surgical Procedure(s)
Pediatric Cardiac Catheterization Statistics
Supply patient statistics in the table below. The date range should occur within the same 12-month
period used in previous sections.
Site #1
Number of pediatric cardiac catheterizations during this interval:
Age 0 - 30 days
#
Age 1 - 12 months
#
13 months - 16 years
#
Over 16 years
#
Procedures
a) Therapeutic
1. Septostomies
#
2. Valvuloplasties
#
3. Placement of devices
#
b) Electrophysiologic
1. Diagnostic (EPS)
#
2. Therapeutic (Ablation)
#
c) Pacemaker placement
1. Transcutaneous
#
2. Permanent
#
Site #2
Site #3
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
#
Pediatric Procedures
Summarize the procedures available for fellow experience. Do not include procedures on a "private" or
"non-teaching" service which does not involve fellows. Indicate the total number performed, and the
number of deaths for each procedure (where applicable), (e.g., 12/2). This should include all
procedures in the same 12-month period used on previous pages.
CLOSED PROCEDURES
1. Shunts
2. PDA repair
3. Coarctation of aorta repair
4. Pulmonary artery banding
OPEN PROCEDURES
1. VSD closure
≥1 month and <1
<1 month of age
year of age
1-21 Years of age
Total Performed/# of Total Performed/# of Total Performed/# of
Deaths
Deaths
Deaths
#
#
#
#
#
#
#
#
#
#
#
#
#
Pediatric Cardiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
#
#
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Page 11 of 13
≥1 month and <1
<1 month of age
year of age
1-21 Years of age
Total Performed/# of Total Performed/# of Total Performed/# of
CLOSED PROCEDURES
Deaths
Deaths
Deaths
2. Semilunar valvotomy
#
#
#
3. Tetralogy of Fallot repair
#
#
#
4. Transposition repair
#
#
#
a. Simple
#
#
#
b + VSD or – VSD + PS
#
#
#
5. Secundum ASD closure
#
#
#
6. Primum ASD closure
#
#
#
7. Complete AV canal – repair
#
#
#
8. Pulm. Atresia + VSD, truncus
#
#
#
9. Single ventricle, tricuspid
#
#
#
atresia
10. Valve replacement (aortic,
#
#
#
mitral)
11. Pacemaker implants
#
#
#
12. Cardioverter defibrillator
#
#
#
NONINVASIVE DIAGNOSTIC
PROCEDURES
1. ECG
2. Fetal echocardiogram
3. Transesophageal
echocardiogram
4. 2-dimensional
echocardiogram
5. Nuclear medicine procedures
6. Stress tests with ECG
monitoring
7. Ambulatory ECG Monitoring
(Holter, Event)
0-30 Days of Age
Total Performed
#
#
#
1-12 Months of Age
Total Performed
#
1-21 Years of Age
Total Performed
#
#
#
#
#
#
#
#
#
#
#
#
#
EDUCATIONAL PROGRAM [PR IX.]
Inpatient Experiences
1. Describe the responsibilities that fellows will have for inpatients and how and by whom they
will be supervised.
Limit the response to 100 words
Click here to enter text.
2. State how many hours per week fellows will participate in rounds with faculty. Describe the
fellow’s role in rounds.
Limit the response to 100 words
Click here to enter text.
Pediatric Cardiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 12 of 13
Outpatient Experiences (If applicable)
1. Describe the responsibilities that fellows will have for outpatients and how and by whom
fellows will be supervised.
Limit the response to 100 words
Click here to enter text.
2. Describe the continuity of care experience fellows will receive during their period of
assignment to the outpatient clinic. To what extent will they have the opportunity to provide
outpatient care for patients whom they treated on the inpatient service? [PR IX.A.6.a)]
Limit the response to 100 words
Click here to enter text.
3. Describe the planned program learning activities which will provide experience in the general
competencies for residents. Examples of learning activities include: didactic lecture, assigned
reading, seminar, self-directed learning module, conference, small group discussion,
workshop, online module, journal club, project, case discussion, one-on-one mentoring.
Click here to enter text.
IF THERE ARE ANY UNIQUE SCENARIOS OCCURRING IN THE PROGRAM THAT DO NOT FIT WITHIN THE CONFINES
OF THIS FORM, PLEASE EXPLAIN.
Click here to enter text.
Pediatric Cardiology
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 4/2015
Page 13 of 13