University of Utah Health Sciences Campus Banner

Residency Standards of Performance

University of Utah Health Sciences Campus Banner

Residency Standards of Performance

University Health Care Hospitals and Clinics Graduate Medical Education Resident Policies and Procedures

Resident Standards of Performance and Academic Action Policy

STANDARDS OF PERFORMANCE


The Department has developed PGY specific standards of performance, which were established by consensus among Department members. These closely follow the ACGME milestones as the basis for objectives and evaluation and for advancement through the residency training program. The goals and objectives each year are cumulative.


To better comply with ACGME work hours guidelines; in 2010-2011 our program switched from monthly rotations to thirteen four-week blocks for our PGY2 and above residents. In 2014-2015 the PGY1s switched to this system as well.


Expectations of all residents

  1. Enter work hours into the electronic database in a timely manner.
  2. Complete semiannual faculty evaluations.
  3. Respond to departmental emails/calls in a timely manner.
  4. Answer all pages promptly.
  5. Attend teaching sessions:
    1. Grand Rounds (Wednesday mornings 7-8)
    2. Professor Rounds (Wednesday mornings 8-9)
    3. Chief Resident’s Conference (Wednesday morning 9-10)
    4. Morbidity and Mortality (M&M) Conference (1st Wednesday of each month)
    5. Subspecialty-specific conferences
    6. Periodic courses organized by faculty

THE DUTIES OF THE RESIDENTS IN EACH YEAR (Goals and Objectives)

PGY1


The PGY1 year is spent acquiring fundamental clinical skills. Residents learn the principles of diagnosis, management and treatment in a broad range of clinical areas. During this year the resident will participate in 6 blocks of clinical neurosurgery, 3 months in the NCCU under the direction of our neurocritical care intensivists, 3 Months of Neuroscience including 1 month of inpatient neurology plus 2 months from the following: additional NCCU, subspecialty outpatient clinics (neuro-ophthalmology, stroke, neuromuscular, epilepsy, movement disorders, or neuro-oncology).


Orientation to the PGY1 year is done by the University of Utah Graduate Medical Education department and includes education on sleep and sleep deprivation. The educational material on these topics is also accessible on the GME web site. In addition, the Department of Neurosurgery also has an orientation in which we review department specific policies, schedules and expectations.

PGY1 Goals and Objectives for Neurosurgery Rotations

Goal: learn the diagnosis and management of neurosurgical patients in the acute care setting (emergency room, neurological critical care unit, and in-patients) including the identification of neurosurgical emergencies.
 

Objectives:

  • Perform and document a comprehensive neurological history and physical examination [H&P]
  • Understand indications for and interpretation of laboratory and imaging studies
  • Learn to implement an effective patient management plan, including ICU care
  • Recognize postoperative complications
  • Perform the following procedures under appropriate supervision:
    • Insert central lines and arterial peripheral catheters
    • Perform lumbar punctures
    • Insert ICP monitors
    • Insert ventricular drains
    • Debride wounds
    • Place stereotactic frames
    • Position patients for intracranial and spinal surgery
    • Place patient in spinal traction; tongs and halo
    • Assist with craniotomy opening, lumbar discectomy, and shunt procedures
    • Assist with spine and peripheral nerve cases
  • Achieve level 1 on the ACGME milestones (see below)

PGY1 Goals and Objectives for Neuroscience Rotations:


Goal: Understand non-surgical neurological conditions that are relevant to neurosurgical management (stroke, MS, ALS and other things that enter the differential diagnosis in neurosurgical practice)


Objectives:

  • Learn to diagnose and manage acute neurologic conditions
  • Learn the diagnosis and management of ischemic and hemorrhagic stroke via the Brain Attack program.
  • Learn to manage stroke patients in the neurological critical care unit
  • Learn to differentiate operative from non-operative neurologic conditions
     

PGY1 Goals and Objectives for NCCU


Goals: Learn the practice of critical care medicine as it applies to neurosurgical patients. This includes but is not limited to management of cardiac, pulmonary, immunological, renal, gastrointestinal, nutritional, and hematological systems in the critically ill surgical patient. Emphasis is made on ventilator management, cardiac and pulmonary physiology.


Objectives:

  • Perform and document a comprehensive history and physical examination [H&P]
  • Understand indications for and interpret laboratory and imaging studies
  • Establish and implement an effective patient management plan for ICU patients
  • Recognize postoperative complications
  • Gain experience with management and care of surgical patients
  • Learn appropriate airway and ventilator management
  • Achieve level 1 on the ACGME Critical Care milestones (see below)

PGY2

Goal: build on PGY1 skills and add 1) the diagnosis and management of pediatric neurosurgical patients 2) out patient management 3) neurocritical care management.


Objectives:

  • Perform surgical procedure under direct supervision (such as lumbar discectomies, opening and closing of simple craniotomies, place ICP monitors and EVDs)
  • Assist in major surgical procedures that are appropriate for the level of training
  • Perform initial resuscitation of patients who are critically ill with neurosurgical problems (coma, raised intracranial pressure, intracranial hemorrhage, head injury, hydrocephalus)
  • Perform and document a comprehensive pediatric neurological history and physical examination [H&P]
  • Understand indications for and interpretation of laboratory and imaging studies in pediatrics
  • Learn to implement an effective patient management plan, for pediatrics
  • Recognize postoperative complications of pediatric neurosurgery
  • Diagnose and manage acute neurosurgical problems that occur after hours (night float)
  • Assess elective surgery patients pre-op to understand indications for surgery
  • Supervise PGY1s on their NCCU rotation
  • Achieve level 1.5 on the ACGME milestones (see below)


In addition to the PGY1 skill set, the PGY2 residents learn about patient selection for elective surgery by assessing patients coming through the outpatient surgery department for admission prior to surgery. In addition, they have in increased role assisting with surgery and providing pre- and postoperative care in the neurosurgical intensive care unit and on the hospital floor. They increase their knowledge about diseases affecting the nervous system by being exposed to a wide variety of problems, read independently,
perform daily rounds with the senior residents and the staff, and attend conferences regularly. In the operating room they learn how to set up cases and how to assist, progress to opening and closing a case, and then assume more responsibility as their skills grow. Assisting in the OR is rotated among the junior residents so that patient care out of the OR is neither neglected nor de-emphasized. Junior residents answer consultation requests from other services and the emergency room. They present these patients to the appropriate staff person. The morning after a night on call they go the OR, learning how to position patients, set up cases, and participate in the initial stages of the procedure and go home in accordance with the work hour regulations.


One or two blocks of the year are spent in the NCCU under the supervision of the NeuroCritical Care intensivists where they enhance skills in the care of critically ill neurological patients, managing acute stroke patients as well as nonsurgical neurological disorders. In addition, they support the PGY 1s in their first NCCU rotation. They also take 3-4 blocks of night-float call responsibilities in the NCCU where they are supervised by NeuroCritical Care faculty.


Junior residents also spend 3-4 blocks at Primary Children’s Hospital (PCH) as the junior resident, performing similar duties as the PGY2 resident at the UH. The junior PCH rotation is most commonly in the PGY2 year but occasionally occurs in the PGY3 year. During this rotation the residents learn to do an age-specific neuro exam, and the neurological/neurosurgical conditions unique to children. They have a one-in-three call rotation from home and obtain inpatient and outpatient, emergency department, and surgical experience.

PGY3

Goal: Broaden neurosurgical knowledge base and management skills in subspecialty areas of neurosurgery


Objectives

  • Learn patient selection, preoperative workup, clinical and operative management in functional, spine, neurosurgical oncology and peripheral nerve surgery
  • Learn the indications, dosimetry, complications and outcomes of patients treated with stereotactic radiosurgery (SRS)
  • Attend the multidisciplinary brain tumor clinic, participate in radiosurgery cases and formal didactic training with the radiation oncology residents
  • Learn interpretation of cerebral angiography, indications and complications of endovascular procedures and perform diagnostic cerebral angiograms on the Endovascular rotation
  • As mentioned above, occasionally the junior rotation on pediatric neurosurgery occurs in the PGY3 year (see objectives above)


Pass the ABNS written exam for credit. Time is allowed for intensive board preparation time and self-study prior to the exam date.


Achieve level 2 on the ACGME milestones (see below).


Identify a mentor and create a plan for research in the PGY4 year.

PGY4

Goal: formulate and carry out a research project that may involve basic science, translational research, or clinical research, working under the supervision of a research mentor. May participate in relevant course work at the University of Utah School of Graduate Medicine, and possibly earn a graduate degree. Limited clinical work: (two days per month of junior resident level call at UUHSC and telemedicine clinics ½ day twice monthly).
 

Objectives

  • Develop an appropriate research plan
  • Acquire an in-depth knowledge of the literature relevant to the research
  • Learn the necessary techniques for the research
  • Submit an IRB application
  • Adhere to ethical principles of research conduct
  • Submit a grant for peer reviewed funding
  • Present/describe the research at Department Grand Rounds
  • Publish results of the research in peer reviewed journal(s) as first author
  • Plan/suggest future experiments
  • Achieve level 2.5 on the relevant ACGME milestones
     

Many options for laboratory and/or clinical research in neuro-oncology, spine, skull base, endovascular, trauma, critical care, functional, pediatric neurosurgery, clinical trials and/or education are available during this year.

PGY5

Goal: To assume more senior clinical duties and begin a leadership role with the junior residents.


Objectives:

  • Teach a comprehensive neurosurgery history and physical examination
  • Teach the selection and interpretation of appropriate investigations (laboratory studies and imaging)
  • Describe treatment options and their pros and cons
  • Perform selected surgical procedures under direct supervision (for example, craniotomy for glioma, ACDF, craniotomy for trauma in an acutely ill patient, pterional craniotomy and exposure of ICA, split Sylvian fissure, closure of myelomeningocele, repair of sagittal synostosis, insertion of VNS, lumbar laminectomy, microdiscectomy, posterior cervical stabilization)
  • Assist in major surgical procedures that are appropriate for level of training
  • Begin to function more independently and direct in/outpatient care
  • Teach residents/interns/students simple surgical procedures appropriate to their level of training
  • Achieve a score of 3.0 on ACGME milestones
     

Rotations include

  • UUHSC: PGY 5s are part of the specialty specific teams gaining increased responsibility and surgical experience in all areas of neurosurgery (target is specialty specific ACGME milestones score of 3.0)
  • PCH: PGY5s work with a junior resident and a Pediatric Neurosurgery Fellow learning more advanced care and surgical treatment of pediatric neurosurgical patients (per ACGME milestones for pediatric neurosurgery, the target is a score of 3.0)
  • VA: PGY5s gain independence in decision making and surgery. The clinical load is largely spine and some cranial. The target is level 3.0 on ACGME milestones for spine surgery
  • Occasionally a resident may request a second year of research which would be the PGY5 year. Approval for this is assessed based on the research project and mentor and the year by year number of residents on service. If approved, the Chief year would automatically be PGY7.

Chief Resident Role

Goal: The department goal is to have residents in the Chief resident role in the PGY6 year. This allows them to do focused training in a subspecialty area as a PGY7 (enfolded fellowship). If a resident needs additional clinical time prior to a PGY6 Chief year, their Chief role will be deferred to the PGY7 year. This determination will be made by the PD with faculty input by Dec 1 of the PGY5 year. Waiting until PGY7 year to be a Chief is expected to be rare but may be necessary for a resident who is behind on their expected ACGME milestones. A PGY7 chief year may also be allowed if a resident chooses to do two years of research (PGY4 and 5), with PD approval.

PGY6

Goal: to lead the other residents, develop independence in decision making and operative skills, teach other residents and manage the team effectively.


Objectives:

  • Achieve a score of 3.5 – 4 on the subspecialty ACGME milestones (especially regarding the operative skills; perform a high volume of surgical cases of increasing complexity as skills allow)
  • Perform administrative duties of the service (call schedule, OR schedule)
  • Supervise the junior residents, coordinate the service, and run teaching rounds, work rounds, and conferences.
  • Achieve a score of 3.5 – 4 on all ACGME milestones


PGY7 (after PGY6 Chief year): Having completed Chief year, residents can do a focused clinical experience in the PGY7 year (“enfolded fellowship”). The Department offers enfolded fellowships in endovascular, neuro-oncology, spine, functional, peripheral nerve, skull base, and critical care. Each of these has a fellowship director and specific goals/objectives for the year. In general, the resident is
expected to function close to the level of a junior attending surgeon, learning the indications, surgical procedures, complications and their management specific to the subspecialty. Evaluation of the PGY7 remains the responsibility of the Clinical Competence Committee and the PD, in consultation with the fellowship director. The target is a score of 3.5- 4 on all relevant ACGME competencies.

PGY7

Goal: to lead the other residents, develop independence in decision making and operative skills, teach other residents and manage the team effectively.


Objectives:

  • Achieve a score of 3.5 – 4 on the subspecialty ACGME milestones (especially regarding the operative skills; perform a high volume of surgical cases of increasing complexity as skills allow)
  • Perform administrative duties of the service (call schedule, OR schedule)
  • Supervise the junior residents, coordinate the service, and run teaching rounds, work rounds, and conferences.
  • Achieve a score of 3.5 – 4 on all ACGME milestones


PGY6 (prior to PGY7 Chief year)
During this time, the resident is a senior member of the Neurosurgical housestaff. The goal is to complete preparation for the Chief year in PGY7. This time provides additional clinical experience tailored to the resident’s needs and career aspirations. The resident with the PD will identify areas in need of improvement in their clinical and/or surgical skills and use them to establish resident specific objectives for the year. The target is a score of 3.5 on all ACGME milestones.

METHODS OF RESIDENT EVALUATION

  1. Observations
    Personal observations by the Program Director, faculty and/or staff related to direct patient care activities. Performance/attendance/ punctuality at teaching conference are also considered in the overall evaluation of residents. Significant concern or patterns of concern of the Program Director related to unsatisfactory performance will be immediately communicated to the resident verbally and in writing.
  2. Semi-Annual Evaluations (Dec and June)
    1. Residents are evaluated at least semi-annually by the Clinical Competency Committee (CCC) using the following metrics.
      1. Faculty Evaluation (individual faculty assess residents on ACGME milestones and their scores are reviewed and summarized by the CCC for resident feedback)
      2. Multi-source evaluation (360 evals and unsolicited comments from other health professionals)
      3. Resident Self-Evaluation
      4. Examination performance
      5. Participation in QI and scholarly activity
  3. Annual Evaluation
    1. Summative evaluation of each resident that includes their readiness to progress to the next year of the program with the PD each June
  4. Final Evaluation
    1. Program Director will provide a final summative evaluation for each resident upon completion of the program.
      1. Verifies that resident has demonstrated the knowledge, skills, and behaviors necessary to enter autonomous practice.
  5. Mentor Evaluatios
    1. As residents develop specific areas of interest, they identify appropriate mentors. They then meet with mentors periodically for advice and feedback. Mentors are identified during PGY3.

COMMUNICATION OF PERFORMANCE WITH RESIDENTS

Residents have access to rotation evaluations in MedHub as soon as completed by faculty.
 

Residents meet at least semi-annually with the Program Director to discuss the following based on CCC input:

  • Review with each resident their documented semi-annual evaluation of performance, including above metrics and progress along the ACGME Milestones
  • Review work hour compliance
  • Review Case logs
  • Assist residents in developing individualized learning plans to capitalize on their strengths and identify areas for growth
  • Develop plans for resident that may need remediation or probation plans according to institutional policies and procedures.


UNSATISFACTORY PERFORMANCE


Any resident who receives an unsatisfactory semi-annual rating or who otherwise is not performing in a satisfactory fashion as determined by the faculty and program director will be reviewed for corrective action.
Specific recommendations from these reviews might include:

  • Suggesting specific corrective actions
  • Requiring repeating some time
  • Requiring special programs such as counseling
  • Placing an individual on academic probation
  • Terminating the individual if prior corrective action and/or probation have not been successful or immediately if behavior is especially egregious
     

The resident will be given an opportunity to remediate unsatisfactory performance. They will be advised as to the length of the probationary period and what must be accomplished in order to be removed from probation.


ACADEMIC ACTION AND DISPUTE RESOLUTION


The University of Utah Hospital and Clinics Academic Action, Dispute Resolution, and Hearing Procedures Policy detailed in Section 12.1 of University of Utah Graduate Medical Education Policies will be followed. This has been adopted to assure that all actions regarding resident disciplinary action or probation are enacted fairly.

OTHER RULES AND GUIDELINES

  1. General
    1. Residents are at all times expected to exhibit appropriate and professional behavior towards patients, staff and fellow residents.
    2. Residents are required to follow the procedures and meet the standards and requirements detailed in the University of Utah Graduate Medical Education Policies unless otherwise specified in this document.
  2. Medical Records
    1. Residents are expected to adhere to the medical record policy of the institution. This includes the timely preparation of both discharge summaries and operative dictations as well as timely correction of any oversights that have occurred.
    2. Every patient admitted to the hospital will have a history and physical recorded on the medical record. If this is done by a PGY1 resident or medical student it will be reviewed by the appropriate neurosurgery resident and any additions that are necessary appended to it.
    3. Every patient going to surgery will have their history reviewed and be examined by the most senior resident who is scrubbing on the procedure.
    4. The resident assigned to the case will be responsible for entering appropriate patient data into the electronic medical record (EMR) and completing the operative dictation. The residents involved in the case will also enter the operative data into the ACGME Case Log System according to their level of participation.
    5. Hospital policy requires orders to be rewritten after any procedure done in the operating room regardless of the anesthetic. For small procedures done outside the operating room under local anesthesia only, a "resume all previous orders" order can be written.
    6. Residents with an excessive number of incomplete charts will not be allowed to scrub in surgery until these charts are completed. Accumulation of undictated reports or summaries will result in suspension, with the need to make up suspended time to complete the residency.
  3. Professional Attire
    1. Neurosurgery has adopted the Graduate Medical Education Professional Attire Guidelines detailed in Section 9.1, (Reviewed January 2011) of their Policies.
  4. Special Consideration for Pregnant Residents Regarding Radiologic Exposure
    1. The Department of Radiation Safety has very reasonable guidelines of exposure during pregnancy and these guidelines will be the official policy of this department as well.
  5. Resident/Staff Communications
    1. The attending neurosurgeon should be notified as expeditiously as possible of any significant worsening in the patient's condition. Any major treatment decisions should be coordinated with the attending staff as well. All patients at University of Utah Health and Primary Children's Hospital are private patients and have an attending surgeon. The attending staff should be notified of any patient of theirs who is admitted to the hospital or transferred to or from the service. No patient will be taken to surgery unless the attending surgeon is either in house or immediately available except in the case of a life-threatening situation in which the most senior resident available may proceed while the support staff attempts to notify the attending surgeon or, if unable to contact him/her, contact any other staff surgeon.
  6. Drug Testing
    1. The Department of Neurosurgery has adopted the Graduate Medical Education Drug Testing Policy detailed in Section 1.7 (Reviewed January 2011) of their Policies.
  7. ABNS Primary Exam
    1. The American Board of Neurological Surgery (ABNS) Primary Examination is given each March. This examination is taken by the residents starting with the PGY1 year. The Department pays the exam fee. During the PGY1 and PGY2 years, the resident takes the exam for self-assessment. PGY3 and above residents will take it for credit only. All residents are required by the ABNS to satisfactorily pass this examination for credit. The Department goal is to have residents achieve a score of 25th percentile or
      higher.
  8. Additional Items
    1. Residents should notify the program director or department chair if at any time they feel they are not getting regularly scheduled time off or feel that their educational experience is suffering from a service load that has been given to them.
    2. The GME Wellness Office offers confidential individual and couples counseling services to housestaff. This service is free of charge, records are kept outside of EPIC, and insurance is not activated. In addition, wellness coaching, test anxiety treatment and learning assessments are provided. Our office also works with departmental wellness champions to provide workshops,
      consultation, resources and wellness improvements to trainee programs.
    3. The University of Utah Employee Assistance Program (EAP) is a confidential counseling service sponsored by the University to help trainees and their family members with a variety of personal concerns including family and relationship issues, stress, grief, depression, anxiety, alcohol/drugs, workplace issues, management consultation and more. The EAP can also provide advice and referrals to help resolve legal, financial, childcare and eldercare concerns. No fees or co-pays are required when using the EAP. The University has agreed to provide these services to benefit eligible employees and their dependents as part of their benefit package. See Policy 3.4 (Revised January 2018) of The GME Resident Policies and Procedures for more details.
    4. The Department of Neurosurgery at the University of Utah is committed to maintaining a drug-free workplace. When faced with the problem of an impaired physician, Utah Recovery Assistance Program (URAP) is available as a resource. This program’s purpose is to monitor chemically dependent licensed professionals in a manner that promotes confidentiality for the licensed
      professional while assuring the safety of his or her patients. The Utah Department of Commerce’s Division of Occupational and Professional Licensing has established the URAP as an alternative to formal disciplinary action.
      If a trainee has a problem with drugs or alcohol, has a patient with a professional license who needs help, or knows of another licensed professional who needs assistance, they can contact URAP at 801-530-6106. The programs’ benefits include protection for the safety of participants’ clients, protection for the livelihood and professional licensure of the participant, confidentiality – a private agreement instead of public action, and incentives and support to help participants remain substance free. Please see the GME Resident Policies and Procedures Substance Abuse Policy 9.3 (Reviewed October 2010) for more details.
  9. Resident Support
    1. University of Utah Hospital: At UH, there is a nurse specialist for every two attending surgeons and administrative assistant assigned for every three-four attending surgeons. The nurse specialists provide assistance in the care and management of inpatients and outpatients. They provide an especially valuable interface with patients and families. They take care of scheduling of imaging and follow up appointments and answer patient and family questions. They are also involved in clinical research
      studies for the appropriate attending. The clinical trial office provides help with IRB regulatory protocols, data collection, and study procedure management. There are nurse practitioners or physician assistants for disease specific teams including spine and neurosurgical oncology. They help with outpatient clinic visits and staple removal, education, and wound checks. There are also nurse practitioners that help with the inpatient service. They round with the team, arrange inpatient imaging, laboratories and perform minor procedures as needed. They do the patient discharge summaries and arrange for follow-up visits. Case managers take care of finding outside nursing facilities when needed, evaluating insurance and arranging transport as needed. Pharmacists reconcile home medications with in-patient orders. UH has all of the usual support services including phlebotomists and respiratory therapists. The retrieval of imaging studies for surgical procedures is facilitated by a digital imaging
      system. Hospital dictation is easily available from any telephone in the hospital. Outpatient clinical personnel are provided by both the hospital and department. In addition, the department provides full administrative support to the residents. A full-time medical editor, a medical illustrator and a computer/audiovisual specialist assist with preparation of presentations and scholarly manuscripts.
    2. Primary Children’s Hospital: At PCH, administrative support is provided. There are two nurse practitioners and several clinical specialists/MAs. The nurse practitioners assist with the care and management of inpatients. After morning rounds, a list of tasks for the inpatients is reviewed and the nurse practitioner performs drain removals, suture removals, patient education and discharge and arranges imaging tests and consults. She does not participate in surgery. The clinical specialists/MAs are in charge of the clinics and deals with calls from outside physicians and patients. They also perform surgical scheduling.
      Both hospitals have sleeping facilities adjacent to the clinical areas. Both hospitals provide a food allowance for residents on call. In addition, there is a neurosurgery library in the office area of the adult division at UH. Internet access is readily available and online journal search and ordering capabilities are provided to our residents for patient care and scholarly pursuits.
    3. Veterans Affairs Medical Center: At the VAMC the Neurosurgery service is staffed by one advanced practitioner covering weekdays between 8am to 5pm. The responsibility of the practitioner includes daily rounds, coordination of care seeing clinic patients and scheduling patients for surgery. The PA also takes calls from patients and outside physicians. Hospital dictation is available from any telephone in the hospital. The VA uses CPRS for its electronic medical records. The hospital has several services that help with patient care including the medicine team, MICU, and SICU. In the ward, there are pharmacists who assist with medication reconciling and case managers who assist with patient disposition after the hospital stay.
ACGME

NEUROLOGICAL SURGERY MILESTONES

The Milestones are designed for use only in the evaluation of residents in the context of their participation in ACGME-accredited residency programs. The Milestones provide a framework to assess resident development in key dimensions of physician competency in a specialty. They neither represent the entirety of the six domains of physician competency, nor are they designed to be relevant in any other context.

Chair: Nathan R. Selden, MD, PhD

Work Group

Aviva Abosch, MD
Nicholas Bambakidis, MD
Nicholas Barbaro, MD
Frederick A. Boop, MD
Charles Branch, MD
Richard W. Byrne, MD
Ennio Antonio Chiocca, MD
E.Sander Connolly Jr., MD
Laura Edgar, EdD, CAE
Steven L. Giannotta, MD
Michael Haglund, MD
Stanley Hamstra, PhD

Robert E. Harbaugh, MD
Griff Harsh, MD
Carl Heilman, MD
Nickalus R. Khan, MD
Jack Knightly, MD
Doug Kondziolka, MD
Timothy B. Mapstone, MD
Harry Rosenbluth, MBA
Oren Sagher, MD
Warren Selman, MD
Shelly Timmons, MD
Greg Zipfel, MD

MILESTONES REPORTING

This document presents the Milestones designed for programs to use in semi-annual review of resident performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME Core Competencies organized in a developmental framework from less to more advanced. They are descriptors and targets for resident performance as a resident moves from entry into residency through graduation. The Review Committee will examine Milestones reporting for each program’s residents as one element in the annual accreditation review process to determine whether residents overall are progressing.


For each period, review and reporting will involve selecting the milestone levels that best describe each resident’s current performance and attributes. Milestones are arranged into numbered levels. Tracking from Level 1 to Level 5 is synonymous with moving from novice to expert in the specialty. These levels do not correspond with post-graduate year of education.
Selection of a level implies that the resident substantially demonstrates the milestones in that level, as well as those in previous levels (see the diagram below).

  • Level 1: The resident demonstrates milestones expected of an incoming resident.
  • Level 2: The resident is advancing and demonstrates additional milestones, but is not yet performing at a mid-residency level.
  • Level 3: The resident continues to advance and demonstrate additional milestones, consistently including the majority of milestones targeted for residency.
  • Level 4: The resident has advanced and now substantially demonstrates the milestones targeted for residency. This level is the graduation target.
  • Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals that might describe the performance of someone who has been in practice for several years. Only a few exceptional residents are expected to reach this level.

Level 4 is the graduation target and does not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the residency program director. Study of Milestones performance data is required before the ACGME and its partners can determine whether milestones in the first four levels appropriately represent the developmental framework, and whether Milestones data are of sufficient quality to be used for high-stakes decisions.


Some milestone descriptions include statements about performing independently. These activities must occur in conformity to ACGME supervision guidelines, as well as to institutional and program policies. For example, a resident who performs a procedure independently must, at a minimum, be supervised through oversight.


At the end of this document is an appendix of procedures for each Patient Care subcompetency, including examples of procedures typically considered to be routine, complex, or expert. These lists are comprehensive but not exhaustive. Other resources are available on the Milestones page of each specialty section of the ACGME website. On www.acgme.org, choose the applicable specialty under the “Specialties” menu, then select the “Milestones” link in the lower navigation bar.

Neurological Surgery Milestones, ACGME Report Worksheets

Patient Care 1: Brain Tumor

Level 1 Level 2 Level 3 Level 4 Level 5
Performs a history and physical examination in patients with a brain tumor Explains the risks and benefits of craniotomy for brain tumor Formulates a diagnostic and treatment plan for a patient with a brain or spinal cord tumor Adapts standard treatment plans and techniques to special circumstances (e.g., recurrence, bone marrow suppression) Leads discussion at an interdisciplinary tumor board
Places an external ventricular drain; assists with set-up, opening, and closing for brain tumor craniotomies Assists with routine craniotomy for brain tumor Performs routine craniotomy for brain tumor; assists with complex craniotomy for brain tumor Performs complex craniotomy for brain tumor; assists with advanced craniotomy for brain tumor Performs advanced craniotomy for brain tumor
Provides routine perioperative care for brain tumor patients Recognizes and initiates work-up of routine complications (e.g., air, embolism, CSF fistula, hematoma) Manages routine complications and recognizes complex complications (e.g., refractory cerebral edema, major vascular injury) Manages complex complications Utilizes patient outcome data for quality improvement or the development of adjunctive therapy protocols

 

Patient Care 2: Surgical Treatment of Epilepsy and Movement Disorders

Level 1 Level 2 Level 3 Level 4 Level 5
Performs a history and physical examination in patients with epilepsy or movement disorders Explains the risks and benefits of functional neurosurgical procedures Formulates a diagnostic and treatment plan for a patient with epilepsy or a movement disorder Adapts standard treatment plans and techniques to special circumstances (e.g., Parkinson's plus, multifocal epilepsy) Leads discussion at an interdisciplinary epilepsy center patient management conference
Performs stereotactic frame placement or frameless navigation registration; assists with set-up, opening, and closing for functional neurosurgical procedures Assists with routine functional neurosurgical procedures Performs routine functional neurosurgical procedures; assists with complex functional neurosurgical procedures Performs complex functional neurosurgical procedures; assists with advanced functional neurosurgical procedures Performs advanced functional neurosurgical procedures, including interpretation of electrophysiological data
Provides routine perioperative care for movement disorder and epilepsy patients Recognizes and initiates work-up of routine complications (e.g., seizures, device infection) Manages routine complications and recognizes complex complications (e.g., status epilepticus, dystonia) Manages complex complications Utilizes patient outcome data for quality improvement; designs care pathways for epilepsy or movement disorder patients

 

Patient Care 3: Pain and Peripheral Nerve Disorders

Level 1 Level 2 Level 3 Level 4 Level 5
Performs a history and physical examination in patients with chronic pain or a peripheral nerve disorder Explains the risks and benefits of chronic pain and peripheral nerve procedures Formulates a diagnostic and treatment plan for patients with chronic pain or peripheral nerve disorders Adapts standard treatment plans and techniques to special circumstances (e.g., cancer pain, deafferentation pain) Leads discussion at an interdisciplinary case conference of specialty clinic for chronic pain or peripheral nerve disorder patients
Interrogates and programs implanted devices; assists with set-up, opening, and closing for chronic pain and peripheral nerve procedures Assists with routine chronic pain and peripheral nerve procedures Performs routine chronic pain and peripheral nerve procedures; assists with complex chronic pain and peripheral nerve procedures Performs complex chronic pain and peripheral nerve procedures; assists with advanced chronic pain and peripheral nerve procedures Performs advanced chronic pain and peripheral nerve procedures
Provides routine perioperative care for chronic pain or peripheral nerve disorder patients Recognizes and initiates work-up of routine complications (e.g., implanted device failure or infection) Manages routine complications and recognizes complex complications (e.g., intrathecal drug overdose or withdrawal) Manages complex complications Utilizes patient outcome data for quality improvement; designs care pathways for chronic pain or peripheral nerve disorder patients

 

Patient Care 4: Spinal Neurological Surgery

Level 1 Level 2 Level 3 Level 4 Level 5
Performs a history and physical examination in patients with degenerative, traumatic, or neoplastic spinal disorders Explains the risks and benefits of spinal surgery Formulates a diagnostic and treatment plan for a patient with degenerative, traumatic, or neoplastic spinal disorders Adapts standard treatment plans and techniques to special circumstances (e.g., spinal deformity, post-irradiated spine, or infection) Leads discussion at an interdisciplinary spine case conference or specialty clinic
Implements spinal bracing or traction; assists with set-up, opening, and closing for spinal surgery procedures Assists with routine spinal surgery procedures Performs routine spinal surgery procedures; assists with complex spinal surgery procedures Performs complex spinal surgery procedures; assists with advanced spinal surgery and reconstructive procedures Performs advanced spinal surgery and reconstructive procedures
Provides routine perioperative care for spinal surgery patients Recognizes and initiates work-up of routine complications (e.g., pain, surgical site infection) Manages routine complications and recognizes complex complications (e.g., myelopathy, cerebrospinal fluid (CSF) leak, instrument failure/malposition) Manages complex complications Utilizes patient outcome and registry data for quality improvement and treatment selection

 

Patient Care 5: Vascular Neurological Surgery

Level 1 Level 2 Level 3 Level 4 Level 5
Performs a history and physical examination in patients with ischemic or hemorrhagic stroke or vascular neurosurgical disorders Explains the risks and benefits of vascular neurosurgical and endovascular procedures Formulates a diagnostic and treatment plan for a patient with ischemic of hemorrhagic stroke or vascular neurosurgical disorders  Adapts standard treatment plans and techniques to special circumstances (e.g., vasculitis, ischemic heart disease) Leads discussion at an interdisciplinary vascular neurosurgical and endovascular surgery case conference or specialty clinic
Manages and obtains CSF samples from external ventricular drains; assists with set-up, opening, and closing for vascular neurosurgical and endovascular procedures Assists with routine vascular and endovascular neurosurgical procedures Performs routine vascular neurosurgical and endovascular procedures; assists with complex vascular neurosurgical and endovascular procedures Performs complex vascular neurosurgical and endovascular procedures; assists with advanced vascular neurosurgical and endovascular procedures Performs advanced vascular neurosurgical and endovascular procedures
Provides routine perioperative care for vascular neurosurgical and endovascular patients Recognizes and initiates work-up of routine complications (e.g., seizure, hydrocephalus) Manages routine complications and recognizes complex complications (e.g., cerebral vasospasm, herniation syndrome, intra-operative aneurysm rupture) Manages complex complications Utilizes patient outcome data for quality improvement; designs care pathways for vascular neurosurgical and endovascular patients

 

Patient Care 6: Pediatric Neurological Surgery

Level 1 Level 2 Level 3 Level 4 Level 5
Performs an age-appropriate history and physical examination with developmental assessment, including for non-accidental trauma Explains the risks and benefits of pediatric neurosurgical procedures; adapts diagnoses to age-related variations Formulates a diagnostic and treatment plan for a pediatric patient; determines prognosis in severe brain injury and/or diagnoses brain death in infants and children Adapts standard treatment plans and techniques to special circumstances (e.g., very young children and infants) Leads discussion at an interdisciplinary pediatric case conference or specialty clinic; counsels expectant parents regarding fetal anomalies
Performs CSF shunt tap and valve programming; assists with set-up, opening, and closing for pediatric neurosurgical procedures Assists with routine pediatric neurosurgical procedures Performs routine pediatric neurosurgical procedures; assists with complex pediatric neurosurgical procedures Performs complex pediatric neurosurgical procedures; assists with advanced pediatric neurosurgical procedures Performs advanced pediatric neurosurgical procedures
Provides routine perioperative care for pediatric neurosurgical patients Recognizes and initiates work-up of routine complications, including in pre-verbal children (e.g., CSF shunt failure, seizure) Manages routine complications and recognizes complex complications (e.g., hematoma, CSF leak) Manages complex complications Utilizes patient outcome data for quality improvement; designs care pathways for pediatric neurosurgical patients

 

Patient Care 7: Traumatic Brain Injury (TBI)

Level 1 Level 2 Level 3 Level 4 Level 5
Performs a history and physical examination in patients with severe TBI and assigns a Glasgow Coma Scale score Explains the risks and benefits of trauma neurosurgical procedures; evaluates patients with multiple trauma Selects patients for operative intervention; prioritizes the management of injuries in patients with multiple trauma Adapts standard treatment plans and techniques to special circumstances (e.g., medical comorbidity, coagulopathy) Leads discussion at interdisciplinary trauma unit rounds and/or conference
Places an intracranial pressure (ICP) monitor; assists with set-up, opening, and closing for neurotrauma procedures Assists with routine procedures for patients with TBI Performs routine procedures for patients with TBI; assists with complex procedures for patients with TBI Performs complex procedures for patients with TBI; assists with advanced procedures for patients with TBI Performs advanced procedures for patients with TBI
Provides routine perioperative care for patients with TBI Recognizes and initiates work-up of routine complications (e.g., sinus injury, air embolus) Manages routine complications and recognizes complex complications (e.g., cerebral herniation syndrome, persistent CSF fistula) Manages complex complications Utilizes patient outcome data for quality improvement; designs care pathways for neurotrauma patients

 

Patient Care 8: Critical Care

Level 1 Level 2 Level 3 Level 4 Level 5
Performs a history and physical examination in critically ill patients Manages transient intracranial hypertension (e.g., hyperosmolar agents, CSF drainage) Manages refractory intracranial hypertension (e.g., cerebral perfusion pressure directed therapy, advanced monitoring, decompressive craniectomy Diagnoses and initiates management of acute respiratory distress syndrome Leads a multidisciplinary neurocritical care team
Inserts arterial and central venous catheters Assists with routine neurocritical care unit procedures; manages airway and performs endotracheal intubation Performs routine and assists with complex neurocritical care unit procedures; manages difficult and emergency airways Performs complex and assists with advanced neurocritical care unit procedures; manages or initiates management of surgical airways Performs advanced neurocritical care unit procedures; performs bronchoscopy
Manages neurocritical care unit admissions and discharges Recognizes and initiates work-up of routine systemic complications (e.g., pneumonia, infection, pulmonary embolus, cardiac dysrhythmia, myocardial infarction) Manages routine systemic complications and prioritizes simultaneous critical clinical events Manages metabolic and nutritional support for critically ill patients Manages complex critically ill patients (e.g., septic shock, organ failure); designs care pathways for critically ill patients

 

Medical Knowledge 1: Information Gathering and Interpretation

Level 1 Level 2 Level 3 Level 4 Level 5
Correlates normal neuroanatomy and physiology with function Correlates pathological neuroanatomy and physiology with function Identifies anatomical and temporal patterns of disease occurence Interprets unusual variations in patterns of disease occurrence Effectively teaches anatomic-pathological correlation
Gathers, interprets, and reports basic diagnostic test results (e.g., serology, chest radiograph, brain and spine CT) Describes indications for standard diagnostic testing Prioritizes, orders, and interprets diagnostic tests appropriate to clinical urgency and complexity Prioritizes, orders, and interprets complex diagnostic studies (e.g., SPECT, cerebral perfusion, MR tractography) Utilizes complex diagnostic approaches in novel situations

 

Medical Knowledge 2: Critical Thinking for Diagnosis and Therapy

Level 1 Level 2 Level 3 Level 4 Level 5
Lists a differential diagnosis for common clinical presentations Provides a comprehensive differential diagnosis for a wide range of clinical presentations Provides a focused differential diagnosis based on individual patient presentation Interprets anomalous presentations and rare disorders Studies and reports challenging diagnostic presentations
Lists therapeutic options for common clinical presentations Explains advantages and drawbacks of standard therapeutic options Justifies optimal therapeutic option based on individual patient presentation Adapts therapeutic choice to anomalous or rare patient presentations Creates new or modifies existing therapeutic options

 

Systems-Based Practice 1: Patient Safety

Level 1 Level 2 Level 3 Level 4 Level 5
Describes principles of patient safety; performs safe and effective hand-offs and transitions of care in routine clinical situations Recognizes and reports patient safety events; performs safe and effective hand-offs and transitions of care in complex clinical situations Discloses patient safety events; supervises hand-offs and transitions of care Analyzes patient safety events and offers error prevention strategies; advocates for safe and effective transitions of care within and across health care systems Actively engages teams in process and system modification to prevent patient safety events; improves care transition practices within and across health care systems

 

Systems-Based Practice 2: Quality Improvement

Level 1 Level 2 Level 3 Level 4 Level 5
Describes basic quality improvement methods and metrics Participates in local quality improvement initiatives (e.g., surgical site infection (SSI) reduction, care pathway implementation) Identifies quality improvement opportunities and assists in the development, implementation, and analysis of a quality improvement project Advances multiple quality improvement initiatives through participation in a quality improvement working group or committee Creates, implements, and assesses quality improvement initiatives

 

Systems-Based Practice 3: Health Care Systems Awareness

Level 1 Level 2 Level 3 Level 4 Level 5
Describes principles of US health payment systems Analyzes how personal practice affects the health care system (e.g., test ordering, length of stay, readmissions) Seeks information about neurosurgical career options and identifies professional mentor(s) Prepares for transition to practice (e.g., information technology, risk management, billing and coding, financial personnel) Collaborates with nursing and administrative teams to promotes high value, quality care within a healthcare system

 

Practice-Based Learning and Improvement 1: Evidence-Based Practice

Level 1 Level 2 Level 3 Level 4 Level 5
Applies institutional treatment guidelines in basic patient care; identifies and reports complications Applies published treatment guidelines in standard patient care; tracks personal clinical care outcomes Critically adapts guideline recommendations to individual patient specifics and preferences; evaluates and applies available outcomes data to improve patient care Participates in the creation and implementation of institutional guidelines or evidence-base practice protocols; analyzes and reports outcomes data Promotes evidence-based practice by publishing clinical guidelines and teaching at local or national conferences; participates in clinical outcomes registry design or administration

 

Practice-Based Learning and Improvement 2: Research

Level 1 Level 2 Level 3 Level 4 Level 5
Formulates hypotheses and investigative approaches to clinical or basic scientific problems Participates effectively in clinical or basic scientific research Contributes to peer-reviewed clinical or basic scientific literature Leads a clinical or basic scientific research effort including application for funding Receives grant funding for clinical or basic scientific work and makes novel scientific contributions

 

Practice-Based Learning and Improvement 3: Mentorship and Teaching

Level 1 Level 2 Level 3 Level 4 Level 5
Demonstrates self-awareness and identifies gaps in knowledge, skills, and experience; incorporates feedback Teaches medical students, other residents, and patients in informal settings; develops faculty mentorship of self Teaches health professionals in formal settings (e.g., nursing in-service training, residency teaching conference); mentors medical students Organizes educational activities at the program level; mentors residents and other health care professionals Designs and implements clinical rotations, curricula, or learning and assessment tools; models and teaches mentoring to others

 

Professionalism 1: Ethical Behavior

Level 1 Level 2 Level 3 Level 4 Level 5
Behaves ethically and professionally and takes responsibility for personal conduct Employs ethical and legal principles (e.g., informed consent, advance directives, confidentiality, error disclosure, resource stewardship) and appropriately seeks advice Performs tasks in a thorough, timely, and respectful manner in complex or stressful situation and takes ownership of team outcomes Recognizes, reports, and helps rectify lapses in ethics or professionalism, including coaching others Promotes ethical and professional behavior by creating a teaching resources, addressing system-level problems, or serving on an ethics panel or Institutional REview Board

 

Professionalism 2: Well-Being

Level 1 Level 2 Level 3 Level 4 Level 5
Describes the importance of personal and professional well-being; manages sleep deprivation and fatigue Evaluates personal and professional well-being; seeks appropriate personal help and fatigue mitigation when needed Monitors and attempts to optimize professional well-being of the team; adjusts team assignments to mitigate fatigue and promote wellness Coaches and assists others in meeting professional expectations; recognizes and responds to physical impairment in self and others Develops a structured plan or team activity to optimize personal and professional well-being, resilience, and success; participates in a peer support program 

This subcompetency is not intended to evaluate a resident's well-being but to ensure each resident has the fundamental knowledge of factors that impact well-being, the mechanisms by which those factors impact well-being, and available resources and tools to improve well-being.

 

Patient Care 2: Surgical Treatment of Epilepsy and Movement Disorders

Level 1 Level 2 Level 3 Level 4 Level 5
Uses language and non-verbal behavior to exhibit respect, establish rapport, and demonstrate cultural competency Establishes therapeutic relationships in straightforward encounters using active listening and clear language Establishes therapeutic relationships, thoughtfully delivers information, and strives for consensus in challenging patient encounters Consistently models and mentors others in optimal patient and family communications Formally teaches communication skills to healthcare professionals

 

Interpersonal and Communication Skills 2: Communication in Coordination of Care

Level 1 Level 2 Level 3 Level 4 Level 5
Accurately records information in the patient record and safeguards protected health information; coordinates care within the neurosurgical service Communicates orally and in writing in a respectful, organized, clear, concise, and timely manner with all members of the interprofessional healthcare team; coordinates care with consulting service3s Effectively manages comples, team-based clinical care; coordinates care within a hospital system Models and mentors others in effective communication, including bidirectional feedback and conflict resolution; coordinates long-term care, including rehabilitation Develops of implements strategies for improving communication and teamwork within a healthcare system; creates care pathways at the healthcare system level

 

NEUROLOGICAL SURGERY MILESTONES APPENDIX:

Typical Procedures for Patient Care Milestones

Brain Tumor

ROUTINE COMPLEX ADVANCED
Resection of a convexity meningioma Resection of a central parasagittal meningioma Resection of a petroclival meningioma
Resection of a superficial cerebellar metastasis Resection of a fourth ventricular ependymoma Resection of a vestibular schwannoma
Resection of a polar glioma Resection of a central or eloquent glioma Resection of a central neurocytoma
Decompress chiasm from pituitary hemorrhage Resection of an endocrine active pituitary tumor Resection of a tuberculum sella meningioma
Stereotactic biopsy of a brain mass Stereotactic biopsy of a brainstem mass Resection of a third ventricular colloid cyst
Stereotactic radiosurgery of tumor in non-eloquent brain Stereotactic radiosurgery of a brainstem tumor Stereotactic radiosurgery of a parasellar tumor

 

Surgical Treatment of Epilepsy and Movement Disorders

ROUTINE COMPLEX ADVANCED
Vagal nerve stimulator implantation Vagal nerve stimulator lead revision Responsive neurostimulator (RNS) placement
Stereotactic electrode placement DBS electrode revision DBS or lesion placement for non-movement disorders
Subdural electrode placement for epilepsy monitoring Stereotactic EEG placement Multi-lobar resective epilepsy
Lesionectomy for epilepsy Lobectomy for epilepsy Amygdalohippocampectomy

 

Pain and Peripheral Nerve

ROUTINE COMPLEX ADVANCED
Spinal cord stimulator lead placement Microvascular decompression Redo microvascular decompression
Intrathecal catheter and pump placement Percutaneous trigeminal rhizolysis Cordotomy
Generator or pump replacement DREZ procedure Trigeminal tractotomy
Median or ulnar nerve decompression or transposition Brachial plexus exploration, neurolysis, or thoracic outlet decompression Adult or pediatric brachial plexus reconstruction (graft repair or nerve transfer)
Harvest of nerve graft or nerve biopsy (sural, medial antebrachial cutaneous, superficial sensory radial) Peroneal nerve decompression or ganglion cyst removal  

 

Spinal Neurological Surgery

ROUTINE COMPLEX ADVANCED
Open or MIS lumbar microdiscectomy Multi-level MIS decompression for stenosis  
1- to 2-level ACDF Corpectomy or 3 or 4 level ACDF  
Posterior cervical foraminotomy Posterior cervical laminectomy with lateral mass fixation  
Open single-level instrumented lumbar decompression minimally invasive single-level lumbar fusion Minimally invasive multiple-level lumbar fusion
  Ponte osteotomy and instrumentation for simple deformity correction Occipitocervical or thoraco-lumbar-sacral fusion for deformity correction
    Pedicle or vertebral subtraction osteotomy for complex deformity correction
Laminectomy for extradural lesion Laminectomy for intradural, extramedullary lesion Laminectomy for intradural, intramedullary lesion

 

Vascular Neurological Surgery

ROUTINE COMPLEX ADVANCED
Carotid and vertebral diagnostic angiography Super-selective cerebral angiography with or without infusion of agent Super-selective intravascular angiography with balloon dilation
  Cervical bifurcation carotid artery angioplasty and stenting Angioplasty and stenting of intracranial stenosis
Decompressive craniectomy for supratentorial malignant cerebral infarction syndrome with onlay dural graft Decompressive craniectomy for infratentorial malignant cerebral infarction syndrome with sewn dural graft Decompressive craniectomy for malignant cerebral infarction in the setting of incompletely reversed coagulopathy
  Endovascular thrombectomy (ICA, M1, BA) for ischemic stroke Endovascular thrombectomy (M2, P1) for ischemic stroke
Flow diverting stent placement for proximal ICA aneurysm without coils Coil embolization of aneurysm without balloon or stent assistance Coil embolization of aneurysm with balloon or stent assistance
Craniotomy for clipping of unruptured simple anterior circulation aneurysm Craniotomy for clipping of ruptured simple or un-ruptured complex anterior circulation aneurysm Craniotomy for clipping of posterior circulation aneurysm
  Craniotomy for resection of Grade I-II supratentorial arteriovenous malformation Craniotomy for resection of Grade I-II infratentorial or Grade III-V supratentorial arteriovenous malformation
Diagnostic STA biopsy Encephaloduroarteriosynangiosis (EDAS) STA-MCA bypass
Radiosurgical treatment of supratentorial arteriovenous malformation in a single stage Staged radiosurgical treatment of supratentorial arteriovenous malformation Radiosurgical treatment of brainstem or spinal arteriovenous malformation
  Endovascular embolization of a meningioma Endovascular embolization of a cerebral arteriovenous malformation
Craniotomy for evacuation of lobar intracerebral hemorrhage Craniotomy for minimally invasive evacuation of basal ganglia hemorrhage Craniotomy for emergent evacuation of lobar intracerebral hemorrhage with simultaneous treatment of a ruptured aneurysm or arteriovenous malformation
  Craniotomy or laminectomy for obliteration of simple dural arteriovenous fistula Craniotomy or laminectomy for obliteration of complex dural arteriovenous fistula
Craniotomy for resection of non-eloquent cavernous malformation Craniotomy for resection of eloquent non-brainstem cavernous malformation Craniotomy for resection of brainstem cavernous malformation
Carotied endarterectomy Resection of carotid body tumor Vertebral artery reimplantation

 

Pediatric Neurological Surgery

ROUTINE COMPLEX ADVANCED
EVD or ventriculoperitoneal shunt insertion Ventriculoperitoneal shunt insertion in a patient under 12 months of age Endoscopic third ventriculostomy and/or choroid plexus cauterization
Sagittal synostectomy Cranial vault reconstruction Fronto-orbital advancement
Small myelomeningocele closure Complex myelomeningocele closure or simple spinal cord untethering Complex untethering or lipomyelomeningocele repair
Atretic encephalocele repair Endephalocele repair Basal encephalocele repair
Supratentorial lobar tumor or simple posterior fossa tumor resection Complex posterior fossa tumor resection Craniopharyngioma, pineal tumor, or combined cerebello-pontine angle and 4th ventricular tumor resection
Chiari I decompression with or without duraplasty in a child over 12 months of age Chiari I decompression with or without duraplasty in a child less than 12 months of age Redo Chiari I decompression with duraplasty and lysis of arachnoid adhesions
Open depressed skull fracture repair with or without brain laceration Open depressed skull fracture repair with major sinus injury Spinal fracture repair or spinal deformity reconstruction
Vagus nerve stimulator implantation in a child Invasive EEG monitoring and resection in a child Functional hemispherotomy in a child
Surgical treatment of a child with traumatic brain injury    

 

Traumatic Brain Injury

ROUTINE COMPLEX ADVANCED
Parenchymal monitor placement (all types), ventriculostomy catheter lumbar drain Repair venous sinus laceration  
Craniotomy for evacuation of traumatic intracranial hematoma Decompressive craniotomy or craniectomy and duraplasty Complex cranial incision revision, including skull and scalp reconstruction
Simple or complex skull fracture repair Craniotomy for skull base reconstruction and repair of persistent CSF leak Craniotomy for complex craniofacial trauma including injuries of the orbit, zygoma, and frontal sinus
Burr hole drainage of chronic subdural hematoma Cranial surgery for penetrating injury  
Staged secondary bone flap replacement    

 

Critical Care

ROUTINE COMPLEX ADVANCED
Endotracheal intubation Tracheostomy Bronchoscopy
PICC line placement Vascular dialysis catheter placement Peritoneal dialysis catheter placement
Cervical traction Halo fixation Fluoroscopic reduction of cervical fracture-dislocation
Nasogastric tube placement   Gastrostomy
Pleuracentesis Chest tube placement Pericardiocentesis

 

Revised 7/25