The Center for Advanced Surgery in the Gill Building is the venue for most ambulatory surgical cases at the University of Kentucky. It is organized with the goal of providing safe anesthesia care that includes rapid induction, emergence, and recovery, with minimal side-effects. Anesthesiology residents will spend a month-long rotation in each of the CA-1 and 2 years to learn techniques that contribute to that overall goal. Specifically, upon completion of the rotation, the resident will be able to:
• Make appropriate patient selection for an ambulatory surgery center
• Safely care for patients in a way that results in fast emergence and discharge
• Understand the operations of a freestanding surgery center

Also important are competencies in the following six areas. These are in addition to the objectives for the CA-1 and 2 rotations, which are shown in green and in italics.
1. Patient Care
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the provision of anesthesia care in the surgery center setting. Residents are expected to:
• Identify the main aspects of the history and physical examination relevant to patients undergoing surgery in the ambulatory setting and determine appropriate laboratory tests.
• Perform a concise preoperative assessment and evaluate whether the patient is appropriate for the ambulatory anesthesia setting.
• Discuss with patients the risks and benefits of regional and general anesthesia and monitored anesthesia care, especially as they pertain to their condition and their surgery.
• Discuss indications and contraindications for regional anesthesia and which techniques are appropriate for which procedures.
• Describe options for managing a regional anesthetic that is incomplete or shows prolonged latency of onset.
• Describe various techniques of IV sedation.
• Discuss techniques of general anesthesia to minimize post-operative problems (e.g., sedation, pain, shivering, nausea, unplanned admission).
• Use appropriate premedication and preoperative discussion to prepare a patient for ambulatory anesthesia
• Efficiently and safely administer all types of regional and ambulatory anesthetics with minimal supervision.
2. Medical Knowledge
Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to:
• Select patients for ambulatory anesthesia and assess the severity of common diseases such as cardiovascular disease, diabetes, obstructive lung disease and obesity.
• Discuss preoperative preparation - including using psychological preparation, anxiolytics, opioids, antacids and antiemetics.
• Discuss preemptive and multimodal analgesia and antiemesis techniques.
• Discuss the importance of duration of blockade in ambulatory anesthesia.
• Discuss appropriate choices and techniques of neuraxial anesthesia to minimize time to discharge and post-anesthetic complications (e.g., spinal headache).
• Describe the anatomy of the peripheral nervous system and how it relates to regional anesthesia.
• Discuss the pharmacology of rapidly acting agents, including opioids, sedative-hypnotics, volatile anesthetics and muscle relaxants.
• Read selected articles relating to ambulatory anesthesia, which vary by residency level and will be provided for you by the Faculty.
3. Practice-based Learning Improvement
Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to:
• Compare and contrast the roles of regional anesthesia and systemic analgesics in post-operative pain control.
• Discuss current controversies in the ambulatory anesthesia literature, including determining "home-readiness" and "street fitness."
• Utilize the performance measurement information provided to them after the first week in the rotation to improve their performance through the rotation. Examples of such information are wakeup times, induction times, and length of PACU stays.
4. Interpersonal and Communication Skills
Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Residents are expected to:
• Maintain open communications with the nursing staff to facilitate rapid and coordinated movement of the patient through different milestones of the perioperative process.
• In the process of the pre-operative visit, communicate effective with the patient and family in order to provide reassurance.
5. Professionalism
Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:
• Understand the varying tasks that are required for a patient to have a successful experience in an ambulatory surgery center and appreciate the teamwork required to facilitate this.
• Understand the dynamics between surgeon and anesthesiologist when there is disagreement about case selection for outpatient care.
• Understand their role in the institution’s Corporate Compliance Plan.
6. Systems-based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:
• Differentiate between freestanding, hospital-affiliated and hospital-based surgery centers.
• Discuss protocols for handling unplanned admission, acute emergencies and emergency hospital transfer.
• Discuss the role of the medical director of an ambulatory surgery center.
• Explain the importance of turnover time and personnel management in the successful operation of an ambulatory surgery center.
• Describe techniques and procedures to minimize "down time" of the operating room and of the surgical staff.
• Define criteria for PACU bypass, PACU discharge and discharge from the same-day recovery unit.
• Discuss the role of the anesthesiologist in office-based anesthesia practice.
• Describe state, local and federal guidelines for regulation of office-based surgery and anesthesia.
• Spend at least one day out of the OR managing pre-operative and post-operative problems, including the decisions for discharge home.
• Spend at least one day out of the OR in an acting medical director capacity. This may be in conjunction with the day referenced above.

RESIDENT ASSESSMENT
Assessment will be made by the following methods:
• During the first several days of the rotation, a pre-test will be given to each resident that will assess their level of knowledge of principles involved in ambulatory anesthesia.
• At the end of the rotation, a post-test will be given that addresses the same subject matter as the pre-test. Scores will be compared, with particular attention paid to growth in knowledge.
• The Housestaff Rating form will also be used.

PREREQUISITES
Completion of the CA-2 year.