Medical Procedures Policy
Introduction:
Consistent with both the American Board of Internal Medicine (ABIM) as well as the Alliance
for Academic Medicine (AAIM) the Berkshire Medical Center Internal Medicine Residency
recognizes that importance of procedural training as a crucial element in internal medicine
training. The Berkshire Medical Center curriculum is based principals outlined in the 9th Edition
Textbook for Internal Medicine Education Programs.
I. Procedures are broken down into the following categories:
A. Must be done by all residents to receive certification by the ABIM
a. Venipuncture
b. Arterial puncture
c. IV line placement
d. Pap Smear
e. EKG interpretation
f. ACLS
g. Ankle Brachial Index
B. Required by Berkshire Medical Center for Graduation:
a. Abdominal Paracentesis
b. Thoracentesis
c. Lumbar Puncture
d. Central Venous Catheter Placement
e. Arterial Catheter Placement
f. Endotracheal Intubation
g. Urethral Catheterization
h. Nasogastric Intubation
C. Other Procedures Which Trainees May Electively Gain Proficiency In:
a. Bone Marrow Biopsy – during Heme/Onc rotation
b. Skin Biopsy – during Derm and Primary Care rotation
c. Simple Suturing – during ED and Primary Care
d. Advanced Trauma Life Support – at special request of resident
e. Pulmonary Arterial Catheter Placement – ICU rotation
f. Arthrocentesis
II. To be “signed out” to do procedures independently residents must:
A. Demonstrate knowledge of:
a. Indications for procedure
b. Contraindications for procedure
i. Recognition of complications
ii. Management of complications
c. Alternatives to invasive procedure
d. Appropriate pain management for procedure
e. Sterile Technique
f. Proper specimen handling
g. Interpretation of results
B. Prior to performing any invasive procedure the resident must have familiarized
themselves with the literature contained in either:
a. Appropriate NEJM procedure video See Curriculum Appendix C– search under
procedure video).
b. **For Central lines the U/S video contained under Central Lines in Appendix C,
must be viewed prior to first central line placement.
c. Appropriate chapter in Irwin and Rippe’s text, Intensive Care Medicine; latest
edition.
d. Appropriate Up-To-Date chapter
e. Further instruction is available as part of Intern Orientation, ICU rotation,
Elective rotations in: Oncology, Interventional Radiology, ED, Ambulatory
Medicine, Dermatology, Orthopedics, Rheumatology, Cardiology Elective, etc.
C. No procedure may be performed independently until:
a. Resident has been supervised by a colleague with privileges to perform
procedure independently.
b. Resident has satisfactorily performed:
i. Five supervised procedures for:
1. Central Lines
a. One of the five supervised procedures must be done with
an attending and signed off as “competent to perform
independently”
b. Certified as having attended the U/S simulation course
2. Intubations
ii. Three supervised procedures for:
1. All other procedures listed in section I above.
2. Exceptions to need for three supervised procedures:
a. ACLS (ACLS training is in lieu of requirement)
b. Ankle Brachial Index (low risk / non invasive procedure)
iii. Satisfactory performance can ONLY be documented using the
procedure log which is distributed to all residents and available through
the Internal Medicine Residency Office.
iv. Once the minimum number of supervised procedures has been performed
and documented, please ask Pat Armstrong to notify John Gottung or
Michelle Franklin by email so they may update the ICU log that you are
“signed out” and can perform the procedure independently.
v. Exceptions to the number of required supervised procedures can be
granted by the Chair of Medicine, at the request of a trainee, if
appropriate documentation of prior training is found to be acceptable to
Berkshire Medical Center privilege requirements.
c. For central lines: in addition to performing five supervised procedures resident
must be signed out in the proper use of the U/S machine. Certification in U/S
guidance can be achieved through:
i. Documented attendance of a certification course which will be held
during orientation and throughout the academic year or,
ii. Documented placement of at least one central line using U/S guidance
and signed off on by a physician certified in the use of U/S guidance.
D. Failure to Achieve Procedural Competency:
a. Any resident who has not achieved competency in the require procedures (IA
and IB above) by six months prior to graduation must make an appointment with
the program director to review barriers to achieving competency and create a
plan for correcting deficiencies.
II.
BMC procedure for all invasive interventions:
A. Never perform a procedure independently with which you are not comfortable
B. For Central lines: always utilize U/S guidance and follow other BMC central line
policies.
C. Never independently perform a procedure for which you have not yet been deemed to
have procedural competency (as defined above).
D. Always ask for help if needed.
E. Never perform a procedure without (unless an immediately life threatening
emergency):
a. Discussing the planned procedure with the attending of record.
b. Obtaining written (or verbal with a witness) informed consent from the patient
or their proxy.
F. Always document procedure both in patient chart as well as Procedure Log.
G. Always inform attending of record and patient/family immediately of any
complications.
H. Always perform post procedure assessment of the patient.
I. Always make sure any specimens obtained in the course of the procedure are handled
correctly and in an expedited way (it is the performing resident’s responsibility to
assure proper disposition of specimen).