Electrophysiology Fellowship Schedule, Policies
and Expectations

All Cardiac Electrophysiology Fellows need to complete the following UOHI orientation within 4 weeks of starting:

1. Paceart + Carelink Training. Contact charge nurse in the Device Clinic to arrange an orientation session to these systems. This training needs to be completed prior to your first night of EP Call.

2. Radiation training and orientation to UOHI EP lab imaging. Contact Brenda Zeran-Joyce (BZeran-joyce@ottawaheart.ca) to arrange for training prior to your first day in the EP Lab.

3. Sterile Technique Training. Contact Simon Gagne (sgagne@ottawaheart.ca) to arrange training prior to your first day in the EP Lab.

4. Hand ties and suturing. Many fellows come untrained in hand ties and proper suturing techniques. This is not unexpected but all fellows must become proficient at basic suturing and hand ties. Contact Lesley Heil (LHeil@ottawaheart.ca) for practice suture material and needle drivers. Basic proficiency is expected prior to your first day in the EP lab.

5. Device Clinic Policies and Procedures Manual. This is available in the physician’s room in the Device Clinic. If you have any questions arising after you read this please speak to Drs Redpath or Birnie. This must be thoroughly reviewed prior to your first day in the Device Clinic.

If you need guidance, don't hesitate to contact one of the senior fellows or Dr. Golian. Questions are expected. 

We aim to make your experience as enjoyable and educational as possible. To accomplish all goals, Fellows must be present at the Heart Institute 5 days/week. We will make every effort to balance clinical days with non-clinical days so that you can pursue other academic interests (research, self-directed learning). However, this will be subject to your clinical/learning objectives and progress.

Clinical Days

As a Clinical Fellow, it is our goal that you develop and successfully acquire expertise in Cardiac Electrophysiology. To ensure adequate clinical exposure you will be assigned clinical duties in cardiac electrophysiology lab, device clinic, outpatient clinic and ward service. On your assigned day(s), it is expected that you function as junior staff with a major responsibility in the managing outpatients, producing consultation letters, education of residents, performing cardiac electrophysiology procedures and "troubleshooting". Depending on Fellow availability, your individual educational and clinical needs, you will be assigned a share of clinical days.

Cardiac Electrophysiology Lab/Procedure Room

In the cardiac electrophysiology lab, each fellow is assigned to a specific lab with a specific staff. Whenever possible, assignments will be tailored to the learning level of the Fellow (i.e., First year Fellows will be preferentially assigned to non-complex cases to maximize learning).

The lab schedule is available by 3pm on the preceding day. Fellows must review all aspects of all cases for the next day. On the evening prior to the procedure, all scheduled patients admitted to hospital should be seen, consented and orders written. Out patient charts are available (and should be reviewed) in the Day Unit or the PAU the evening before. All previous OR notes should be reviewed. Device clinic chart should be reviewed for patients with existing devices. All patients who go to the lab need a brief note summarizing the history, indications, pertinent lab results, focused physical exam and consent process.

Fellow are must use a standardized consent template in their note indicating that patient understood and agreed to the procedure (see Appendix 1). Also % risks of procedure should be written on consent form (see UOHI EP group pt literature for % risks).

Out patients arrive for cardiac procedures at 7:00 am. Patients scheduled later in the day may arrive later to the Day Unit or PAU. On your assigned clinical day, you are expected to meet with the outpatient and review the history, medications, allergies and pertinent lab tests and consent the patient. The first patient of the day must be consented by 7:30 am.

If there is a possible contra-indication to proceeding with the cardiac procedure, Fellows must as soon as possible contact the responsible Electrophysiology Staff directly to clarify the list order/test indications. Typical examples of need to alter the list order include no beta-HCG in a premenopausal woman, recent anticoagulants, low platelets, possible sepsis, etc.

You are expected to participate in the cardiac electrophysiology case to the best of your ability. The attending physician will be present at all cases but their involvement will vary depending on the learning level of the Fellow. We request that all Fellows report cardiac electrophysiology procedures similarly (see Appendix 2 and 3). All Fellows are expected to follow-up on their patients with procedural complications because this is an important component of Electrophysiology training and patient care. Fellows are to review patients with complications on a daily basis (including weekends) with a summary note in the chart documenting follow-up and any concerns. Patients may be signed off when care for the complication is resolved.

Ward Service

It will be expected that Fellows participate in clinical electrophysiology ward duties. Fellows are responsible for rounding on all patients, seeing new in patient consults and reviewing all patients with the EP staff of the week. It is expected that all new consults will have a consult note typed in EPIC to be cosigned by the EP staff. A list of all patients followed by the inpatient cardiac electrophysiology service is available on EPIC (the 'Green Service' list; you will need to be added to this). Fellows are responsible for keeping the list up to date. The list must be fully updated at the end of each day. Also please do thorough verbal handover to next fellow coming on ward service.

Ward fellows may be assisted by residents or medical students. It is expected that you function as junior staff with a major responsibility in the managing outpatients and education of junior residents. Be sure to check all notes written by residents/students, and add a concise 'EP fellow note' addition as required.

Cardiac Electrophysiology Fellows are not responsible for reviewing cases from the community during the regular workday. These calls from the community looking for advice on EP management should generally be directed to the staff EP physician on call. In the evening and weekends these calls may come to the fellow. Please contact your Staff for advice as needed.

Device Clinic

The day in Device Clinic begins at approximately 8:00am. Patients are assessed initially by nurses who will then review with you. Be sure to confirm any arrhythmia episodes or abnormal parameters. Any concerning findings or questions should be reviewed with staff; as you become more comfortable, you can utilize greater independence. If you have a tracing that is interesting but will not affect clinical management, allow the patient to leave and review the tracing with staff at a later time. If there is a backlog of nurses waiting to review, staff should be called in to help relieve the backlog (if they are not already present). These days are often busy, but if there is free time it can be used to read clinical guidelines/reviews or do research.

Clinic

At the discretion of the Cardiac Electrophysiology program, Fellows will participate in the ambulatory clinic at least 2 full day of clinic/month. Fellows will be assigned between 6-12 new consults and will be responsible for a thorough history, physical medication/lab review, developing a clinical plan and dictating the encounter. In addition, Fellows are also expected to attend a minimum of 6 Inherited Arrhythmia Clinics during the 2 years. These need to be identified by the Fellow and arranged as a clinical activity on the schedule by the Chief Fellow subject to approval by The EP Fellowship Program Director. 

Required clinic days will be assigned every 6 months with numbers varying depending on number of assigned service weeks.

Purple clinic counts as 0.5 day clinic. 

Every 5-6 consults is considered a half day of clinical work (30 mins per consult)

Non-Clinical Days

Non-clinical days should be spent 'onsite' at the UOHI pursuing academia such as research and self-directed learning. It is expected that the Fellow be readily available.

Rounds for the Cardiac Electrophysiology Fellows have been organized Monday 5:00pm and Friday 7:30am. These rounds are mandatory (exceptions will be allowed for mandatory clinical duties) in the Cardiac Electrophysiology Training Program. Individuals who do not participate/prepare for rounds may be assigned extra clinic days. Each quarter, all Fellows will be asked to present a progress update at Research Rounds (Monday 5:00pm).

Self-directed Learning

The goal for each trainee is to obtain a RCPSC Diploma in Adult Cardiac Electrophysiology. Self-directed learning should include core topics covered in the core curriculum, topics relevant to certification and the Fellow's research. Fellows are encouraged to review the RCPSC competency portfolio for candidates (http://www.royalcollege.ca).

The cardiac electrophysiology core lab has a library with donated textbooks for you to borrow. This cabinet is locked but books may be borrowed through The EP Fellowship Program Director’s office. Fellows will assume full responsibility for the textbook(s) borrowed. 

All Fellows are expected to participate in research. Preferably as a primary investigator but depending on the Fellow's academic goals other roles may be acceptable. It will be expected that the Fellow be an author/co-author on 1-2 manuscripts/year. All Fellows will present their research at quarterly Research Rounds to discuss research progress and identify limitations requiring resolution (i.e. identify ways we can improve/facilitate the research project (e.g. recruitment, etc.)) and at the annual UOHI research day.

Those Fellows with a major research focus will still be expected to attain the RCPSC Diploma in Adult Cardiac Electrophysiology, but may have a reduced clinical workload (protected time) to accomplish their goals during their 2-3 year Fellowship. However, protected time is dependent on individual clinical training/competence needs/requirements and service needs. The training track is to be determined by the Fellow and supervising Faculty prior to the Fellowship training.

All research projects should be reported to Dr Davis’ office. This is to ensure that there is an even distribution of research work and that Fellows' research time is being used appropriately. Dr Davis will meet with each fellow every second Monday afternoon between 1:00PM and 4:00PM to discuss progress. This can happen at scheduled times or between cases. Dr. Davis’ administrative assistant will provide a reminder email the Friday before the meeting and Fellows are expected to update their research progress table for review with Dr. Davis on Monday.

Mandatory training is required for all research involving human subjects and/or human subject data, as per the Ottawa Health Science Network Research Ethics Board (OHSN-REB) and the administration of UOHI. UOHI requires that all investigators comply with REB policies and the mandatory training requirements. All Fellows must complete a web-based tutorial on 'Ethics and Research' and provide the certificate to Dr. Davis. We strongly suggest that this be completed prior to July 1. Instructions for completion of the tutorial are located at http://www.pre.ethics.gc.ca/eng/education/tutorial-didacticiel/. If you have completed the TCPS 2 tutorial previously, please send a copy of your certificate to Lois Rae and to the OHSN-REB.

Once you are located on site you will have access to the internal Info Web. Please review the mandatory training requirements at http://info/Research%20Services/RS Mandatory.html, complete the required training, related checklist, sign and submit to Dr. Davis’ office.

All fellows are strongly encouraged to apply for Royal College AFC certification in Cardiac Electrophysiology. The Heart Institute will cover $500 of the application cost. It is recommended to review the Portfolio requirements and begin collecting documentation early in fellowship to facilitate the application process, as it is much more difficult to retroactively collect documentation.

Link to Procedure Logbook Template and Portfolio Folders Template here.

A duties schedule will be created monthly by The EP Fellowship Program Director’s office with the assistance of the Senior Fellows. We kindly request advance notice if you plan on being away. Once the schedule is distributed, it will be the Fellow's responsibility to make changes with their colleagues if needed. However, if changes are made to the schedule, please inform The EP Fellowship Program Director’s administrative assistant so it can be updated on a master schedule. ALL requests are to be discussed with and approved by The EP Fellowship Program Director. You are welcome to discuss options/switches with other Cardiac EP Staff and Fellows but all changes must be approved through The EP Fellowship Program Director’s office.

In the interest of 'fairness', every attempt will be made to develop an equitable schedule but recognize this does not always work. We will try to ensure that everyone has an equal share of 'clinical days' and work. It is recognized that individuals come from different backgrounds and have different goals. Certain Fellows are identified as primarily research Fellows for whom the clinical: research balance is adjusted to attain the research requirements of their funding agencies and their research goals. For those with a lower clinical load, the research expectations for such individuals are greater. Service and training standards need to be met by all.

The UOHI Cardiac Electrophysiology service provides 24 hour 7 day a week on call coverage. Cardiac Electrophysiology Fellows are first call with Cardiac Electrophysiology staff as back-up. Fellows are usually on call during the week of ward service but this is at the discretion of the Chief Fellow and The EP Fellowship Program Director. This is home call but Fellows are expected to provide advice and come into the hospital when needed. Only cardiology staff or residents can request EP consultations. If calls come from nurses or other services they should be directed towards the CCU resident or cardiology staff on call. Fellows are not expected to take consultations from external hospitals- these calls should be forwarded to the CCU resident or cardiology staff on call. Fellows carry a separate CARELINK pager that will notify the Fellow if adverse events (i.e., lead fracture, etc.) occur in the UOHI CARELINK population.

The Division of Cardiology requires all fellows, regardless of funding source, to contribute some general cardiology work during their fellowship. Every attempt will be made to provide some educational value to these commitments.

Firstly, several weekends, and possibly some stat days, on call (0800-1700) for general cardiology. This coverage may include some days on call over the festive period. The total number of days on call for the year will be prorated depending on the amount and onerousness of sub-specialty call. Typically, In addition to EP call, fellows should expect to have two weekend calls per year covering in-patient cardiology service. 

Secondly, a monthly general cardiology clinic consisting of a minimum of five new consults (or equivalent). This will be supervised by one of the cardiology staff in your subgroup. Every effort will be made to endeavor that the patients you see are somewhere related to your fellowship. This may not always be possible. The supervising staff will also do some teaching on the cases you see in the clinic.

Thirdly, as standby for coverage of daytime ward service, in situations of illness amongst the hospitalist staff. This is rarely required, as we have significant redundancy in the system, but occasionally may be necessary if several of the hospitalists are unavailable at the same time.

Over a 12 month period, you will have the opportunity to take 4 weeks holiday (20 working days). It is expected that all Fellows use their holidays within the year. Additional days may be allocated on an ad hoc basis but would be subject to The EP Fellowship Program Director and the training committee. A request may be made that 5 days of holiday be carried forward to another year however would be subject to approval by the training committee and Fellow coverage. Holiday requests should be made to The EP Fellowship Program Director and his administrative assistant. Requests must be made > 1 month in advance. Approvals for requests made < 1 month cannot be guaranteed. Christmas holidays are decided by the Hospital Administration and Directors of each department. We recognize that time with family and friends are of critical importance. Every effort will be made to honor requests made during this time, but it is expected that ALL Fellows work a portion of the Holidays.

Fellows are encouraged to participate in scientific meetings to further their education and to present their research. An additional 5 working days may be requested but subject to approval. The University of Ottawa Heart Institute provides a travel award, a maximum of $1000 stipend once per year, for trainees to attend a conference if they are presenting/speaking. Please refer to the internal Info Web for details: http://info/Research%20Services/RS_Trainee_Travel.html The Division of Cardiac Electrophysiology will supplement this to ensure that the cost to you is kept to a minimum. Additional conferences (within the 12 months) will NOT be routinely reimbursed however may be negotiated with your supervisor when an abstract is presented and manuscript is submitted to a peer-reviewed journal for publication. It is required that a budget be submitted prior to 'funding' of conference leave.

If Fellows are presenting at a conference, the presentation day + 2 travel days (subject to conference location) will be granted and may be taken in lieu of research days. Other conference leave will be considered vacation.

Maximum Funding for Conferences and Examination Fees

Given the limited resources, funding will be allocated on a '1st come, 1st served' basis and is contingent upon sufficient funds. Each full year (12 months, beginning 1st day of Fellowship training), a Fellow may request a maximum of $1500 CDN for conference.

Our Fellows are paid a fair and competitive wage. Often there are opportunities to supplement salaries within the City and abroad. Though we do not dissuade our Fellows from other professional sources of income, we remind the Fellows that their primary commitment is to the Cardiac Electrophysiology Program. Those unwilling to fulfill their clinical or research obligations will have their salary pro-rated.

Patient confidentiality is of the utmost importance and it is expected that all Fellows adhere to the policies/rules of the University of Ottawa Heart Institute, The Ottawa Hospital, the University of Ottawa as well as legislation of the Provincial (PHIPA) and Federal (PIPEDA) governments. Privacy training must be completed on arrival, and annually thereafter. See the Info Web for details: http://info/Privacy/privacy index.html

When it is necessary to collect patient data, information must be stored on the hospital server, ensuring security and regular back-ups. Records containing personal identifiers (name, initials, date of birth, postal code, MRN, OHIP number, etc.) should be password protected. Use of portable devices for patient information, even if de-identified, is limited to an encrypted 'Iron Key' USB supplied (on loan) by the University of Ottawa Heart Institute IT Department, through The EP Fellowship Program Director’s office. Files/devices containing patient identifiers may NOT leave hospital property. Personal laptops and regular memory sticks are not permitted for use of patient health information.

Though we endeavor to make everyone's training experience as fulfilling as possible, we recognize that personal/academic/workplace concerns may arise. We encourage you to speak freely to The EP Fellowship Program Director regarding concerns so that they may be addressed in a timely and equitable manner. The Chief EP Fellow will also function as a liaison between the Fellows and the cardiac EP Staff. Identified areas of concern related to the program can be discussed with The EP Fellowship Program Director or Dr Froeschl, Director of Postgraduate education for the Division of Cardiology at the UOHI.

Dr. Andres Klein (aklein@ottawaheart.ca) - wellness director

• the active pursuit of activities, choices and lifestyles that lead to a state of holistic health.

Residents and fellows must provide a medical note for a medical leave extending beyond seven (7) days to the Faculty Wellness Program, who are health information custodians at the Faculty of Medicine. Medical notes must be sent by email to fwpnotes@uottawa.ca. 

Trainees are expected to communicate with their program administrator that they will be away on medical leave and the anticipated duration of their leave.

The medical note/certificate is to be emailed to the Wellness Office instead of to the program.

Detailed information on the process is available on uottawa website.

FATIGUE Risk Management resources: Resident Fatigue toolkit 

Standard Catheter ablation
The rationale and mechanics of standard catheter ablation were reviewed with the patient (± power of attorney).
I cited a procedural success of 90-95% with a small risk for serious complications (i
ncluding death, stroke, heart attack, heart block requiring pacemaker insertion, puncture of the heart, DVT/PE, leg bruising and need for vascular repair).All questions were answered.
The patient (± power of attorney) understood, agreed and signed the consent.

Complex Catheter ablation
The rationale and mechanics of complex catheter ablation were reviewed with the patient (± power of attorney).
I outlined the prospects for procedural success and the possibility of needing multiple procedures.
I also elaborated upon the risks for serious complications (including death, stroke, heart attack, atria-esophageal fistula, puncture of the heart, DVT/PE (1/1000), pulmonary vein stenosis, leg bruising and need for vascular repair). All questions were answered.
The patient (± power of attorney) understood, agreed and signed the consent.

ICD implant
The rationale and mechanics of ICD implant were reviewed with the patient (± power of attorney).
I cited the risk for serious complications (including death, puncture of the heart, puncture of the lung, infection necessitating device removal, lead dislodgement and bleeding or major bruising).
All questions were answered.
The patient (± power of attorney) understood, agreed and signed the consent.

Pacemaker implant
The rationale and mechanics of pacemaker implant were reviewed with the patient (± power of attorney).
I cited a small risk for serious complications (including death, puncture of the heart, puncture of the lung, infection necessitating device removal, lead dislodgement, bleeding or major bruising).
All questions were answered.
The patient (± power of attorney) understood, agreed and signed the consent.

Note : % risks of procedure should be written on consent form (see UOHI EP group pt literature for % risks).

Clinical note
State the age, sex, relevant medical comorbidities, indication, relevant medications (i.e., anti-coagulants), ejection fraction and relevant lab results (i.e., platelet count, renal function).
If secondary prevention ICD, state the cycle length of the VT (if possible) and if syncopal.
Include the following statements:
“The patient presented in a fasted stated.”
“The mechanics and risks of the procedure were discussed.” “The patient understood and agreed to the procedure.”
“The consent was signed.”

Procedure note
Describe how the procedure was done.
State the make, model and serial numbers of the device/leads used. State the relevant pacing/sensing parameters.
Describe how the device/leads were secured in place.
State any complications.
State the device programming.
State the plan for follow-up (i.e., device clinic in 3-4 weeks).

Clinical note
State the age, sex, relevant medical comorbidities, indication, relevant medications (i.e., anti-coagulants), ejection fraction and relevant lab results (i.e., platelet count, renal function).
Include the following statements:
“The patient presented in a fasted stated.”
“The mechanics and risks of the procedure were discussed.”
“The patient understood and agreed to the procedure.”
“The consent was signed.”

Procedure note
Describe how the procedure was done.
Outline any relevant EP measurements.
State any complications.
State the plan for follow-up (i.e., clinic in 3-4 months).

Fellows will be evaluated using a standardized questionnaire sent to their supervisors. Performance will be evaluated formally by the Program Committee at least every 6 months