A GUIDE TO THE EMERGENCY CARE ADVANCED ... Guide to the Emergency...EMERGENCY CARE ADVANCED CLNICAL PRACTITIONER PILOT CREDENTIALING PROJECT November 2016 2 v2 updated 28 November

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v2 updated 28 November 2016

A GUIDE TO THE

EMERGENCY CARE ADVANCED

CLNICAL PRACTITIONER

PILOT CREDENTIALING PROJECT

November 2016

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Preface

This edition of “A Guide for Emergency Care Advanced Clinical Practitioner Pilot Credentialing

Project” provides guidance to trainee Advanced Clinical Practitioners (ACPs), assessors and

other stakeholders on the arrangements for the pilot for Emergency Care ACP credentialing.

This edition is a consolidation of all earlier versions of the Reference Guide and is applicable

to all trainee ACPs undertaking the pilot credentialing process in June 2016. This edition

replaces all previous editions with immediate effect.

The standards and requirements for the advanced clinical practitioner are set out in the

Emergency Care ACP Curriculum, which is available on the Royal College of Emergency

Medicine website and Health Education England website. The curriculum has been endorsed

by the Royal College of Nursing and the College of Paramedics.

The development of this Reference Guide has been through an iterative process of feedback

from Health Education England, Royal College of Emergency Medicine (as co-producers of

the Emergency Care ACP Curriculum) and other key stakeholders.

The Guide is published in electronic format and will be available via the Royal College of

Emergency Medicine website.

It is noted that the June 2016 and April 2017 credentialing process is a pilot. Evaluation of the

pilot will assist in developing the process and a further edition of this guide

The purpose of the Reference Guide is to assist stakeholders in understanding the pilot

process and documentation to be used. The Reference Guide is as the title states, a Guide,

and as such practices, processes and paperwork may be altered at the discretion of Health

Education England, Royal College of Emergency Medicine and credentialing panel assessors.

To access the curriculum and other information, please visit:

http://www.rcem.ac.uk/Training-Exams/Emergency%20Care%20ACP


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Contents

Preface .................................................................................................................................... 2

Section 1: Introduction and Background .................................................................................. 4

Section 2: Employer Support and Evidence Collation .............................................................. 5

Section 3: The Pilot Credentialing Process .............................................................................. 6

Appendix One: Checklist of Evidence ...................................................................................... 7

Adult Emergency Care ACP ................................................................................................. 9

Paediatric Competences if the ACP is Adult and Paediatric ................................................12

Paediatric Emergency Care ACP ........................................................................................13

Appendix Two: Assessment Descriptors and Assessment Forms for Emergency Care

Advanced Clinical Practitioners ..............................................................................................15

Consultant-Led Mini-Clinical Evaluation Exercise - Mini- CEX ................................................16

Mini-CEX Descriptors .............................................................................................................17

Emergency Care ACP Mini-CEX Summative Descriptors for Major Presentations ..............19

Mini-CEX Summative Descriptors for Acute Presentations ..................................................25

Consultant-Led Case based Discussion CbD .........................................................................30

CbD Descriptors ..................................................................................................................31

Direct Observation of Procedural Skills – DOPs ......................................................................32

Practical Procedures DOPs Descriptors ..................................................................................33

ACAT-EM Descriptors ............................................................................................................37

Instructions for Use of ACAT-EM ........................................................................................37

The Acute Care Assessment Tool (ACAT-EM) Form ...............................................................38

Multi-Source Feedback (MSF) Form .......................................................................................39

Patient Survey Tool .................................................................................................................40

Mini-CEX Summative Descriptors for PEM ACP .....................................................................41

Acute Presentations ................................................................................................................41

Paediatric Practical Procedures DOPs Descriptors .................................................................45

Structured Training Report for ACP ........................................................................................48

Appendix Three: Self-Declaration Form ..................................................................................50

Appendix Four: Credentialing Outcome Form .........................................................................54

Appendix Five: Credentialing Feedback Form ........................................................................56

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Section 1: Introduction and Background

1.1. This Guide sets out the arrangements for the pilot Emergency Care Advanced Clinical

Practitioner (ACP) credentialing process, as agreed by Health Education England (HEE) and

Royal College of Emergency Medicine (RCEM).

1.2 The pilot credentialing process is a mechanism whereby trainee ACPs in Emergency Care

will present evidence of their achievements and competences to be evaluated against the

Emergency Care ACP curriculum.

1.3 Trainee ACPs will be required to collect evidence, as per the curriculum, through use of

the RCEM e-portfolio for ACPs.

1.4 To access the curriculum, information about e-portfolio access and other information

relating to Emergency Care ACP developments, please visit: http://www.rcem.ac.uk/Training-

Exams/Emergency%20Care%20ACP.

1.5 ACPs who successfully credential against the curriculum will be awarded a certificate and

their details will be held on a new register of successfully credentialed ACPs held by RCEM.

1.6 The Emergency Care ACP credentialing process is a pilot in June 2016 and April 2017, as

such the paperwork and processes are likely to change at any stage after the first or second

pilot is completed.

1.7 Individuals interested in applying for the credentialing process, or wishing to join the

‘Emergency Care ACP mailing list’ should contact [email protected]; likewise any questions

may be sent to this email address.

1.8 All time periods referred to within this document (and other Emergency Care ACP

paperwork) are full-time equivalent.



mailto:[email protected]

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Section 2: Employer Support and Evidence Collation

2.1. Evidence should be collected as per the pilot process and curriculum requirements; this

should be saved on the RCEM e-portfolio.

2.2 For RCEM e-portfolio technical support, please contact: [email protected].

2.3 Individuals considering undertaking ACP credentialing should have support from their

employers.

2.4 At least one individual involved in assessing trainee ACPs at the local department should

have completed the appropriate Emergency Care ACP mandatory assessor training. The local

individual who has had the mandatory assessor training will be responsible for ensuring other

colleagues involved in assessing the trainee ACP understand the requirements. Where

relevant, the WBA must be a consultant in Emergency Medicine who has undertaken training

for workplace based assessment and is accredited by the General Medical council as an

educational supervisor or named clinical supervisor.

2.5 Trainee ACPs and those assessing ACPs should review the curriculum and checklist

regularly to ensure they understand the requirements, processes and paperwork. Any queries

should be directed to [email protected].

2.6 Trainee ACPs and those assessing ACPs should pay particular attention to

Appendix 1, which is a checklist of assessments provided as evidence required for pilot

credentialing process.

2.7 Trainee ACPs and those assessing ACPs should pay particular attention to

Appendix 2, which extracts details of assessment descriptors and forms.



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Section 3: The Pilot Credentialing Process

3.1. All credentialing panel members will be appointed and trained by the Royal College of

Emergency Medicine.

3.2 The credentialing panel will be responsible for reviewing the e-portfolio and agreeing an

outcome.

3.3 For the pilot, the panel will consist of up to 6 assessors. For the ACP feedback session,

the panel will nominate 2 representatives of which one must be a Fellow in good standing of

the RCEM.

3.4 For the pilot, Trainee ACPs will be required to submit their evidence 8 weeks prior to the

credentialing panel date. This allows the credentialing panel to review evidence remotely well

in advance prior to the credentialing panel meeting. This means that evidence submitted within

8 weeks of the panel date will not be considered (with the exception of evidence as detailed in

Section 3.5)

3.5 Trainee ACPs will be required to submit their Self-Declaration form (Appendix Three) to

[email protected] at least one week prior to the credential panel meeting.

3.6 There are two possible outcomes at the credentialing panel: Successful – credential OR

Further evidence required (see Appendix Four – Credentialing Outcome Form).

3.7 Outcomes will be recorded on a Credentialing Outcome Form (Appendix Four). Those who

have successfully met the curriculum requirements will receive a certificate and will be added

to the register of credentialed Emergency Care ACPs.

3.8 The credentialing panel members will provide feedback to trainee ACPs via the

Credentialing Feedback Form (Appendix Five). For those who have not met the requirements,

detailed feedback, including potential timescales for re-submission, will be provided.

3.9 In the pilot, there is no mechanism for appeal against the credentialing panel’s decision.

Candidates who have not met the credentialing requirements may re-submit the evidence in

future to be considered in subsequent processes.


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Appendix One: Checklist of Evidence

Emergency Care Advanced Clinical Practitioner

Curriculum and Assessment

Checklist of assessments provided as evidence required for pilot credentialing process

The ACP is required to present evidence that demonstrates the competences developed over

their training and experience. This evidence should be mapped to the ACP curriculum so that

every competence in the curriculum is associated with appropriate evidence of attainment.

Evidence required

There are two types of evidence:

1. Formal assessments: these will be a mixture of assessments by a consultant and those undertaken by senior ACPs and consultant nurses, and senior EM trainees. There are a minimum number of assessments that MUST be completed by a consultant on a summative assessment form. An assessment should take the form of formal observation of clinical activity with feedback from the supervisor/assessor and reflection. We would suggest consultants should usually use summative assessment forms as these clearly identify whether satisfactory performance is displayed. The other formative forms can be used by consultants and other assessors and these are useful to indicate where any weaknesses are or suggestions for further development. ACPs are also required to complete at least 1 ACAT–EM where they are observed over a period of time with a number of patients – we recommend up to three ACAT–EMs may be useful as demonstrating multi-tasking with multiple patients. Additional assessments that are required include successful completion of life support courses, satisfactory multisource feedback.

2. Other evidence. Not every presentation or competence in the curriculum must have a formal assessment/evaluation by other clinicians to demonstration competence. Other evidence that can be presented includes case reflections, evidence of attendance at courses (with reflection), teaching others or e-learning. In addition the ACP will be expected to have evidence of successful completion and conduct of an audit with reflection on the impact their role in the audit.

ACPs should read the guidance on reflection available from their regulatory body, as evidence

of appropriate reflection on the role and attributes would be important to demonstrate the ACP

is performing at the expected level and standard.

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Summary of formal assessment required -

Adult ACP:

1. 20 minimum consultant assessments 2. Minimum of 1 x ACAT-EM assessment 3. 19 DOPS (or CBD equivalents) 4. 1 MSF 5. ALS, APLS and a Trauma Course 6. 1 Audit

Paediatric ACP:

1. 24 minimum consultant assessments 2. Minimum of 1 x ACAT-EM assessments 3. 5 x paediatric-specific DOPs and the 19 x generic DOPs (or CBD equivalents) 4. 1 MSF 5. ALS, APLS and a Trauma Course 6. 1 audit

Other evidence required including reflection, elearning, teaching, etc

Adult ACP:

1. The remaining 23 common competencies 2. The remaining 33 acute presentations 3. The remaining 5 additional acute presentations 4. Optional anaesthetic competencies (O3 and O4) are not mandatory for credentialing.

Paediatric ACP:

1. The remaining 23 common competencies 2. The remaining 26 acute presentations 3. The remaining 4 additional acute presentations 4. Optional anaesthetic competencies (O3) are not mandatory for credentialing.

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Adult Emergency Care ACP

Area of curriculum Evidence required In library or

certificates? Date, type of assessment and name of assessor

Logbook output All competences/presentations/procedures evaluated by supervisor

Not Applicablei wonder if we should specifcy the supervisor should comment as well as confirm competence

All curriculum elements have evidence linked to them

Not Applicable I wonder if we should specify that the ACP should self evaluate here as well as confirm the competence level

Common competences

Level 2 for all CCs – self and supervisor assessment CbD or MiniCEX led by consultant for: CC4 - time management and decision making CC8 - team working and patient safety

Major presentations

Consultant assessment for: Anaphylaxis Cardiac arrest (or ALS) Major Trauma Sepsis Shocked patient Unconscious patient

Acute presentations

Consultant assessment for: Chest pain Abdominal pain Breathlessness Mental health Head injury

Alternatively an ACAT (by a consultant) may be utilised which covers 3 or more presentations of which these may be 1 or 2.

Additional Major Presentation

Consultant assessments for (or ATLS/ATNC/ETC with reflection): Major trauma chest Major trauma abdominal injury Major trauma spine Major trauma maxfax Major trauma burns (one patient – two injuries may be appropriate)

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Area of curriculum Evidence required In library or certificates?

Date, type of assessment and name of assessor

Additional acute presentations

Consultant assessments for: Traumatic limb/joint injuries Interpretation of abnormal blood gas Abnormal blood glucose Alternatively an ACAT may be utilised which covers 3 or more presentations of which these may be 1 or 2.

Airway management

Consultant assessment for A5B

Multisource feedback

1 MSF per year with at least 15 respondents

Life support courses

Adult: ALS Paediatric: APLS or EPLS Trauma: ETC or ATNC or ATLS (as a full candidate, not observer)

Audit Evidence of leadership and implementation of actions from audit or quality improvement project with reflection

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Area of curriculum Evidence required In library or certificates?


Practical procedures

Where the department or work environment does not offer the opportunity for the ACP to personally undertake or practice procedures, a CbD with a consultant is sufficient (one per procedure). At least 10 procedures in total must be directly observed as a procedure.

1. Arterial cannulation (CBD) 2. Peripheral venous cannulation 3. Central venous cannulation (CBD) 4. Arterial blood gas sampling 5. Lumbar puncture (CBD) 6. Pleural tap and aspiration (CBD) 7. Intercostal drain – Seldinger (CBD) 8. Intercostal drain – Open (CBD) 9. Airway protection* 10. Basic and advanced life support 11. DC cardioversion 12. Knee aspiration 13. Temporary pacing (external) 14. Reduction of dislocation/fracture* 15. Large joint examination 16. Wound management* 17. Trauma primary survey* 18. Initial assessment of the acutely unwell 19. Secondary assessment of the acutely unwell

*For these procedures RCEM have developed specific descriptors which are available in this guide.

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Paediatric Competences if the ACP is Adult and Paediatric

Area of curriculum Evidence required In library or

certificates? Date, type of assessment and name of assessor

Paediatric Major presentations

Consultant assessment (or APLS) for all presentations: Anaphylaxis Apnoea stridor and airway obstruction Cardiorespiratory arrest (or APLS) Major trauma Shocked child Unconscious child

Paediatric Acute presentations

Consultant assessment for: Abdominal pain Breathing difficulties Acute life threatening event Concerning presentation Head injury Mental health ACAT may be utilised which covers 3 or more presentations.

Paediatric procedures

Consultant assessment for: Venous access in children* Airway assessment and maintenance Safe sedation in children Paediatric equipment and guidelines in the resuscitation room* Primary survey in a child*

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Paediatric Emergency Care ACP

Area of curriculum Evidence required Number of consultant

assessments (number of other assessments)


Common competences Level 2 for all CCs – self and supervisor assessment CbD or MiniCEX led by consultant for: CC4 - time management and decision making CC8 - team working and patient safety

Paediatric Major Presentations

Consultant assessment for: All 6 presentations Cardiac arrest may be assessed by successful completion of APLS/EPLS

Paediatric Acute presentations

6 consultant summative assessments for: Abdominal pain Breathing difficulties Acute life threatening event Concerning presentation Head injury Mental health

Alternatively an ACAT (by a consultant) may be utilised which covers 3 or more presentations.

Additional Major Presentations

Consultant assessments for: All 5 major trauma competences. One patient may cover up to two competences if appropriate. Or ATLS, ATNC or ETC with reflection.

Additional acute presentations

Consultant assessments for: Traumatic limb/joint injuries Interpretation of abnormal blood gas Abnormal blood glucose

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Area of curriculum Evidence required Number of consultant assessments (number of other assessments)


Airway management Consultant assessment for A5B

Practical procedures 5 *DOPs required for: Venous Access in children Airway assessment and maintenance Safe sedation in children Paediatric equipment and guidelines in the resuscitation room Primary survey in a child

Plus up to 19 further procedures as appropriate in the paediatric setting. Where the

department or work environment does not offer the opportunity for the ACP to personally undertake or practice procedures, a CbD with a consultant is sufficient (one per procedure). *For these procedures RCEM have developed specific descriptors which are available in this guide.

Multisource feedback 1 MSF per year with at least 15 respondents

Life support courses Paediatric: APLS or EPLS Trauma: ETC or ATNC or ATLS (as a full candidate, not observer)

Audit Evidence of leadership and implementation of actions from audit or quality improvement project

Other presentations All remaining presentations have evidence against them

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Appendix Two: Assessment Descriptors and Assessment Forms for Emergency Care Advanced Clinical Practitioners

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Royal College of Emergency Medicine

Consultant-Led Mini-Clinical Evaluation Exercise - Mini- CEX

Name of trainee:

Year of Training:

Assessor: GMC/NMC/HCPC No:

Grade of assessor:

Date / /

Case discussed (brief description) Diagnosis

Focus of assessment –

Examination

Diagnosis

Management

Communication History

Please TICK to indicate the standard of the

trainee’s performance in each area

Not observed

Further core

learning needed

Demonstrates good practice Demonstrates

excellent practice

Must address learning points

highlighted below

Should address learning points

highlighted below

Initial approach

History and information gathering

Examination

Investigation

Clinical decision making and judgment

Communication with patient, relatives, staff

Overall plan

Professionalism

For summative Mini-CEX

Unsuccessful

Successful

Things done particularly well

Learning points

Action points

Assessor Signature: Trainee Signature:

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Mini-CEX Descriptors

This table of satisfactory and unsatisfactory indicators is provided to support feedback and

development. It can be contextualized for most presentations and not all descriptors are expected to

be demonstrated for every presentation.

Dimension Descriptor of satisfactory performance Descriptor of unsatisfactory

performance

History taking Engages with the patient

Clear and focused history taking

Recognises the critical symptoms/symptom patterns

Obtained all the important information

from the patient, not missing

important points

Elicits the history in difficult circumstances, copes with the challenge of noise, distractions, high workload

History taking was not focused

Did not recognise the critical symptoms, symptom patterns

Failed to gather all the

important information from the

patient, missing important

points

Did not engage with the patient

Was unable to elicit the history in difficult circumstances- busy, noisy, multiple demands

Physical examination Detects /elicits and interprets

important physical signs.

Maintains dignity and privacy

Failed to detect /elicit and interpret important physical signs

Did not maintain dignity and privacy

Communication Communication skills with colleagues

1. Listens to other views

2. Involves the whole team in discussions

3. Respected the lead of others when appropriate

4. Considerate and polite to colleagues

5. Able to give clear and timely instructions

6. Clear referral discussion- whether for opinion, advice, or admission Communication with patients

7. Responsive to the concerns of the patient, their understanding of their illness and what they expect

8. Sensitive and responsive to patients unarticulated fears

9. Ensured carers/patients informed and given adequate information and education

10. Encourages patient involvement/ partnership in decision making

Communication skills with colleagues

1. Did not listen to other views 2. Did not discuss issues with

the team 3. Failed to follow the lead of

others when appropriate 4. Rude to colleagues 5. Did not give clear and timely

instructions 6. Inconsiderate of the rest of

the team 7. Was not clear in referral

process- was it for opinion, advice, or admission

8. Communication with patients 9. Did not elicit the concerns

of the patient, their understanding of their illness and what they expect

10. Did not inform and educate patients/carers

11. Did not encourage patient involvement/ partnership in decision making

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Dimension Descriptor of satisfactory performance Descriptor of unsatisfactory

performance

Clinical judgement-clinical decision making

Identifies the most likely diagnosis in a given situation

Appropriately judicial in the use of diagnostic tests

Able to construct a comprehensive and likely differential diagnosis

Able to correctly identify those who

need admission and those who can be

safely discharged.

Recognised atypical presentation

Able to recognise the urgency of the case

Able to select the most effective treatments

Made decisions in a timely fashion

Decisions reflected clear understanding of underlying principles

Reassessed the patient

Anticipated interventions and responded with alacrity

Reviewed the effect of interventions and took appropriate action

Did not identify the most likely diagnosis in a given situation

Was not discriminatory in the use of diagnostic tests

Did not construct a comprehensive and likely differential diagnosis

Did not correctly identify those

who need admission and those

who can be safely discharged.

Did not recognise atypical presentation

Did not recognise the urgency of the case

Did not select the most effective treatments

Did not make decisions in a timely fashion

Decisions did not reflect clear understanding of underlying principles

Did not reassess the patient

Did not anticipate interventions and slow to respond

Did not review effect of interventions

Professionalism Respected confidentiality

Protect the patients dignity

Sensitive and respectful of patients opinions/hopes/fears

Explained plan and risks in a way

the patient could understand

Did not respect confidentiality

Did not protect the patients dignity

Insensitive to patients opinions/hopes/fears

Did not explain plan and risks in

a way the patient could

understand

Organisation and efficiency

Demonstrated efficiency in progressing the case

Was slow to progress the case

Overall care Ensure patient was in a safe monitored environment

Anticipated or recognised complications

Focused sufficiently on safe practice

Was aware of and followed published standards guidelines or protocols

Follow infection control measures

Safe Prescription and provision of therapeutics

Did not ensure patient was in a safe monitored environment

Did not anticipate or recognise complications

Did not focus sufficiently on safe practice

Did not follow published standards guidelines or protocols

Did not follow infection control measures

Did not safely prescribe/provide therapeutics

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Emergency Care ACP Mini-CEX Summative Descriptors for Major Presentations

Anaphylaxis

Unconscious/Altered Mental State

Shock

Trauma

Sepsis

1 Anaphylaxis

Expected behaviours

Initial approach ABCD approach, including GCS

Asks for vital signs including SPaO2, blood sugar

Requests monitoring

Recognises physiological abnormalities

Looks for obvious cause of shock (e.g. bleeding)

Secures iv access

History Obtains targeted history from patient

Obtains collateral history form friends, family, paramedics- cover PMH

Recognises the importance of treatment before necessarily getting all information

Obtains previous notes

Examination Detailed physical examination which must include physical signs that would differentiate between haemorrhagic, hypovolaemic , cardiogenic and septic causes for shock

Investigation Asks for appropriate tests-

arterial blood gas or venous gas and lactate

FBC,

U&Es,

clotting studies,

LFTs, toxicology,

Cross match as indicated

blood and urine culture,

CK and troponin,

ECG,

CXR,

Familiar with use of US to look for IVC compression and cardiac tamponade

Clinical decision making and judgement

Forms diagnosis and differential diagnosis including:

Trauma-haemorrhagic, blood loss control form direct pressure, pelvic splintage, emergency surgery or interventional radiology

Gastrointestinal - upper and lower GI bleed, or fluid loss form D&V

Cardiogenic - STEMI, tachy and brady dysrhythmia

Infection- sepsis, knows sepsis bundle

Endocrine - Addison’s disease, DKA

Neurological - neurogenic shock

Poisoning - TCAs, cardio toxic drugs

Communication Effectively communicates with both patient and colleagues

Organisation and efficiency

Manages time well – does not appear rushed but completes critical tasks in a timely way.

Uses staff and delegates appropriately

Overall plan Identifies immediate life threats and readily reversible causes

Stabilises and prepares for further investigation, treatment and admission

Professionalism Behaves in a professional manner

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2 Unconscious/altered Mental Status

Expected behaviour

Initial approach

ABCD approach, including GCS


Secures iv access

Looks for lateralising signs, pin point pupils, signs of trauma, considers neck injury

Considers opiate OD, alcoholism, anticoagulation

History Obtains history- friends, family, paramedics- cover PMH, previous ODs etc


Examination Detailed physical examination including fundoscopy

Investigation Asks for appropriate tests

arterial blood gas

FBC

U&Es

clotting studies

LFTs, toxicology

blood and urine culture

CK and troponin

HbCO

ECG

CXR

CT



Trauma- SAH, Epidural and subdural

Neurovascular- stroke, hypertensive encephalopathy

Cardiovascular- dysrhythmia, hypotension

Neuro- seizure or post ictal

Infection- meningitis, encephalitis, sepsis

Organ failure- pulmonary, renal, hepatic

Metabolic- glucose, sodium, thyroid disease, temperature

Poisoning

Psychogenic


Overall plan Identifies immediate life threats and readily reversible causes Stabilises and prepares for further investigation, treatment and admission


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3 Shock

Expected behaviour



Requests monitoring

Recognises physiological abnormalities

Looks for obvious cause of shock e.g. bleeding

Secures iv access

History Obtains targeted history from patient

Obtains collateral history form friends, family, paramedics- cover PMH

Recognises the importance of treatment before necessarily getting all information


Examination Detailed physical examination which must include physical signs that would different between haemorragic, hypovolaemic , cardiogenic and septic causes for shock


Arterial blood gas or venous gas and lactate

FBC

U&Es

clotting studies

LFTs, toxicology

Cross match as indicated


CK and troponin

ECG

CXR

Familiar with use of US to look for IVC compression and cardiac tamponade



Trauma-haemorrhagic, blood loss control form direct pressure, pelvic splintage, emergency surgery or interventional radiology

Gastrointestinal - upper and lower GI bleed, or fluid loss form D&V

Cardiogenic - STEMI, tachy and brady dysrhythmia,

Infection- sepsis, knows sepsis bundle

Endocrine - Addison’s disease, DKA

Neurological - neurogenic shock

Poisoning - TCAs, cardio toxic drugs


Overall plan Identifies immediate life threats and readily reversible causes Stabilises and prepares for further investigation, treatment and admission


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4 Major Trauma

Expected behaviour

Initial approach Knows when to activate the trauma team (based on local guidelines)

Able to perform a rapid primary survey, including care of the c spine and oxygen delivery

Can safely log roll patient off spinal board

Able to assess disability, using AVPU or GCS

Asks for vital signs

Able to request imaging at end of primary survey

Knows when to request specialty opinion and/or further imaging

History Obtains history of mechanism of injury from paramedics

Able to use AMPLE history

Examination After completing a primary survey is able to perform detailed secondary survey


Primary survey films

CT imaging

arterial blood gas

FBC

U&Es

clotting studies

PT

toxicology

ECG

FAST

UO by catheterisation

Appropriate use of NG


Forms differential diagnosis and management plan based on:

Able to identify and mange life threatening injuries as part of primary survey

Able to identify the airway that may be at risk

Can identify shock, know it classification and treatment

Safely prescribes fluids, blood products and drugs.

Can identify those patients who need urgent interventions or surgery before imaging or secondary survey

Can safely interpret imaging and test results

Demonstrates safe disposition of trauma patient after secondary survey

Able to identify those patients that be safely discharged home

Communication Effectively communicates with both patient and other members of the trauma team

Overall plan Identifies immediate life threats and readily reversible causes. Stabilises and prepares for further investigation, treatment and admission


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5 Sepsis

Expected behaviour

Initial approach Initial approach based on ABCD system- ensuring early monitoring of vital signs including temperature,SPaO2, blood sugar

Can interpret early warning medical score as indicators of sepsis (EMEWS or similar)

Aware of systemic inflammatory response criteria (SIRS), and that 2 or more may indicate sepsis o T>38 or < 36

o HR > 90 o RR > 20 o WCC > 12 or < 4

History Obtains history of symptoms leading up to illness

Able to take a collateral history, form paramedics, friends and family

Able to use AMPLE history

Looks specifically for conditions causing immunocompromise

Examination Able to perform a competent examination looking for 1. Possible source of infection 2. Secondary organ failure


FBC

U&Es

clotting studies

ABGs or VBGs

Lactate, ScVo2

Blood cultures

ECG

CXR

Urinalysis +/- catheterisation

Other interventions which may help find source of sepsis o Swabs o PCR o Pus

Considers need for further imaging

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Form a management plan with initial interventions being:

Oxygen therapy

Fluid bolus, starting with 20 mls/Kg

IV Antibiotics, based on likely source of infection

Documentation of a physiological score, which can be repeated

Be able to reassess Recognises and is able to support physiological markers of organ dysfunction, such as:-

Systolic BP < 90 mm Hg

PaO2 < 8 Kpa

Lactate > 5

Reduced GCS

Urine output < 30 mls/hr Demonstrates when to use invasive monitoring, specifically

CVP line

Arterial line

Demonstrates when to start inotropes, Noradrenaline v dopamine Demonstrates how to set up an inotrope infusion

Communication Effectively communicates with both patient and other members of the acute care team

Overall plan Identifies sepsis Implements sepsis bundle Stabilises patient, reassesses and able to inform and/or hand over to critical care team


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Mini-CEX Summative Descriptors for Acute Presentations Chest pain

Abdominal pain

Breathlessness

Mental Health

Head Injury

1 Chest Pain

Expected behaviours

Initial approach Ensures monitoring, i.v. access and defibrillator nearby.

Ensures vital signs are measured including SpO2

History Takes focused history (having established conscious with patent airway) of chest pain including

o site o severity o onset o nature o radiation o duration o frequency o precipitating and relieving factors o Previous similar pains and associated symptoms

Systematically explores for symptoms of life threatening chest pain

Assesses ACS risk factors

Specifically asks about previous medication and past medical history

Seeks information from paramedics, relatives and past medical notes including previous ECGs

Examination On examination has ABCD approach with detailed cardiovascular and respiratory examination including detection of peripheral pulses, blood pressure measurement in both arms, elevated JVP, palpation of apex beat, auscultation e.g. for aortic stenosis and incompetence, pericardial rub, signs of cardiac failure, and pleural rubs

Investigation Ensures appropriate investigation

ECG (serial)

ABG

FBC, U&Es

troponin and d dimer if indicated

Chest x-ray


Prescribing Able to relieve pain by appropriate prescription


Able to formulate a full differential diagnosis and the most likely cause in this case.

Overall plan Stabilises and safely prepares the patient for further treatment and investigation


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2 Abdominal Pain

Expected behaviours

Initial approach Ensures appropriate monitoring in place and iv access

Establishes that vital signs measured

History Takes focused history of abdominal pain including o site o severity o onset o nature o radiation o duration o frequency o precipitating and relieving factors o previous similar pains and associated symptoms

Systematically explores for symptoms of life threatening abdominal pain

Specifically asks about previous abdominal operations

Considers non abdominal causes- MI, pneumonia, DKA, hypercalcaemia, sickle, porphyria

Seeks information from paramedics, relatives and past medical notes

Examination Able to undertake detailed examination for abdominal pain (ensuring adequate exposure and examining for the respiratory causes of abdominal pain) including 1. Inspection, palpation, auscultation and percussion of the abdomen 2. Looks for herniae and scars 3. Examines loins, genitalia and back 4. Undertakes appropriate rectal examination

Investigation Ensures appropriate investigation-

ECG

ABG

FBC

U&Es

LFTs

amylase

erect chest x-ray

and abdominal x-rays if obstruction or perforation suspected


Able to formulate a full differential diagnosis and the most likely cause in this case


Prescribing Able to relieve pain by appropriate prescription

Overall plan Stabilises (if appropriate)and safely prepares the patient for further treatment and investigation


27

3 Breathlessness

Expected behaviours

Initial approach Ensures monitoring, iv access gained, O2 therapy

Ensures vital signs are measured including Spa O2

History If patient able, trainee takes focused history of breathlessness including onset,

o severity o duration o frequency o precipitating and relieving factors o previous similar episodes o associated symptoms

Systematically explores for symptoms of life threatening causes of breathlessness

Takes detailed respiratory history

Specifically asks about medication and past medical history

Seeks information from paramedics, relatives and past medical notes including previous chest x-rays and blood gases

Examination On examination has ABCD approach with detailed cardiovascular and

respiratory examination including, work of breathing, signs of

respiratory distress

detection of wheeze

crepitations

effusions

areas of consolidation

Investigation Ensures appropriate investigation

ECG

ABG

FBC

U&Es

troponin and d dimer if indicated

Chest x-ray

Able to interpret chest x-ray correctly


Able to formulate a full differential diagnosis and the most likely cause in this case Knows BTS guidelines for treatment of Asthma and PE


Prescribing Able to prescribe appropriate medication including oxygen therapy, bronchodilators, GTN, diuretics

Able to identify which patients would benefit from NIV

Overall plan Stabilises and safely prepares the patient for further treatment and investigation


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4 Mental Health

Mental health issues are a common problem within the ED (typically combinations of overdose, DSH, suicidal ideation but also psychotic patients). Selection of patients suitable for min-CEX assessment must be undertaken thoughtfully.

Expected behaviours

Initial approach Ensures assessment takes place in a safe environment.

History History taking covers

presenting complaint,

past psychiatric history,

family history,

work history,

sexual/marital history,

substance misuse,

forensic history,

social circumstances,

personality.

Undertakes mental state examination covering:

appearance and behaviour

speech

mood

thought abnormalities

hallucinations

cognitive function using the mini mental state examination

insight Elicits history sympathetically, is unhurried Searches for collateral history- friends and relatives, general practitioner, past medical notes, mental health workers

Examination Ensures vital signs are measured Undertakes physical examination looks for physical causes of psychiatric symptoms- head injury, substance withdrawal, thyroid disease, intoxication, and hypoglycaemia

Investigation Ensures appropriate tests

U&E

FBC

CXR

CT

toxicology


Ensures no organic cause for symptoms Forms working diagnosis and assessment of risk- specifically of suicide and toxicological risk in those with overdoses


Prescribing Knows safe indications, routes of administration of common drugs for chemical sedation

Overall plan Identifies appropriately those who will need further help as an inpatient and who can be followed up as an out patient Is able to assess capacity Have strategies for those who refuse assessment or treatment or who abscond


29

5 Head Injury

Expected behaviours

Initial approach Ensures ABC is adequate and that neck is immobilised in the unconscious patient and those with neck pain. Ensures BM done

History Establishes history- o mechanism of injury o any loss of consciousness and duration o duration of any amnesia o headache o vomiting o associated injuries especially facial and ocular

Establishes if condition is worsening

Gains collateral history from paramedics, witnesses, friends/relatives and medical notes

Establishes if taking anticoagulants, is epileptic

Examination After ABC undertakes systematic neuro examination including

GCS

papillary reactions and size

cranial nerve and peripheral neurological examination

and seeks any cerebellar signs

Looks for signs of basal skull fracture

Examines scalp

Looks for associated injuries- neck, facial bones including jaw

Actively seeks injuries elsewhere

Investigation Is able to identify the correct imaging protocol for those with potentially significant injury -specifically the NICE guidelines


Is able to refer appropriately with comprehensive and succinct summary Knows which patients should be referred to N/surgery Is able to identify those patients suitable for discharge and ensures safe discharge.


Prescribing Able to safely relieve pain in the head injured patient

Overall plan Stabilises and safely prepares the patient for further treatment and investigation or safely discharges patient


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Consultant-Led Case based Discussion CbD

Name of trainee:

Regulatory Body and Registration Number:

Assessor:

Case discussed (brief description) Diagnosis

Date of Discussion

Please TICK to indicate

the standard of the trainee’s performance in

each area

Not observed

Further core

learning needed

Demonstrates good practice

Demonstrates excellent practice


highlighted below


highlighted below

Record keeping

Review of investigations

Diagnosis

Treatment

Planning for subsequent care (in patient or discharged patients)

Clinical reasoning

Patient safety issues

Overall clinical care


Learning points

Action points

Assessor’s Signature: Trainee’s Signature:

31

CbD Descriptors

Domain Descriptor

Record keeping Records should be legible and signed. Should be structured and include provisional and differential diagnoses and initial investigation & management plan. Should record results and treatments given.

Review of investigations Undertook appropriate investigations. Results are recorded and correctly interpreted. Any Imaging should be reviewed in the light of the trainees interpretation

Diagnosis The correct diagnosis was achieved with an appropriate differential diagnosis. Were any important conditions omitted?

Treatment Emergency treatment was correct and response recorded. Subsequent treatments appropriate and comprehensive

Planning for subsequent care (in patient or discharged patients)

Clear plan demonstrating expected clinical course, recognition of and planning for possible complications and instructions to patient (if appropriate)

Clinical reasoning Able to integrate the history, examination and investigative data to arrive at a logical diagnosis and appropriate treatment plan taking into account the patients co morbidities and social circumstances

Patient safety issues Able to recognise effects of systems, process, environment and staffing on patient safety issues

Overall clinical care The case records and the trainees discussion should demonstrate that this episode of clinical care was conducted in accordance with good clinical practice and to a good overall standard

32

Direct Observation of Procedural Skills – DOPs

Name of trainee:


Assessor:

Procedure observed (including indications)

Date of Assessment

Please TICK to indicate the standard of the trainee’s performance in each area

Not observed

Further

core learning needed


Demonstrates excellent practice


highlighted below


highlighted below

Indication for procedure discussed with assessor

Obtaining informed consent

Appropriate preparation including monitoring, analgesia and sedation

Technical skills and aseptic technique

Situation awareness and clinical judgement

Safety, including prevention and management of complications

Care /investigations immediately post procedure

Professionalism, communication and consideration for patient, relatives and staff

Documentation in the notes

Completed task appropriately


Learning points

Action points


33

Practical Procedures DOPs Descriptors • Basic airway • Trauma - primary survey • Wound management • Fracture manipulation and joint reduction

1 Basic airway management including adjuncts e.g. BVM, oxygen delivery

Observed behaviour Task Completed

1. Is able to assess the adult airway and in the obstructed patient provide a patent airway by simple manoeuvres and the use of adjuncts and suction.

2. Undertakes this in a timely and systematic way.

3. Assesses depth of respiration and need for BVM.

4. Can successfully BVM.

5. Knows and can show how to deliver high flow 02

6. Knows other O2 delivery systems typically in ED- fixed concentration masks, nasal specs, Mapleson C circuits.

7. Consents the patient

2 Perform a primary survey of a potentially multiple injured trauma patient


1. Ensures safe transfer of patient onto ED trolley

2. Assesses airway, establishes if obstructed, corrects and ensures delivery of 100%O2

3. Concurrently ensures cervical spine immobilisation (using collar, sandbags and tape)

4. Exposes chest identified raised respiratory rate, chest asymmetry, chest wall bruising, air entry (anteriorly and laterally) and percussion (laterally). Identifies life threatening problems and correctly carries out associated procedures

5. Examines for signs of shock, ensures monitoring established and has gained iv accessX2

6. If shocked looks for potential sites of blood loss- abdomen, pelvis and limbs.

7. Can formulate differential for shocked patient

8. Establishes level of consciousness and seeks lateralising signs

9. Examines limbs, spine and rectum ensuring safe log roll.

34

10. Will have identified and searched for potential life threatening problems in a systematic and prioritised way

11. Reassesses if any deterioration with repeat of ABCD

12. Elicits full relevant history from pre-hospital care providers

13. Ensured appropriate monitoring

14. Will have placed lines, catheter and NG tubes as appropriate

15. Ensured appropriate blood testing (including cross match).

16. Plain radiology trauma series undertaken

17. Ensures adequate and safe pain relief

18. Directs team appropriately

19. Notes of primary survey are clear and legible

3 Wound Management


1. Wound assessment- takes history of mechanism of injury, likely extent and nature of damage, and possibility of foreign bodies. Establishes tetanus status and drug allergies.

2. Assesses the wound- location, length, depth, contamination, and structures likely to be damaged

3. Establishes distal neurovascular and tendon status with systematic physical examination

4. Consents the patient

5. Provides wound anaesthesia (local infiltration, nerve or regional block).

6. Explores wound – identifies underlying structures and if damaged or not.

7. Ensures good mechanical cleansing of wound and irrigation.

8. Clear understanding of which wounds should not be closed

9. Closure of wound, if indicated, without tension, with good suture technique. Can place and tie sutures accurately.

10. Provides clear instructions to patient regarding follow up and suture removal and when to seek help.

35

4a Fracture Manipulation (e.g. Colles fracture)


1. Confirms correct patient, taken relevant history, and consented the patient. Explains to patient procedure and anticipated course

2. Interprets the x-ray correctly and looks for associated injuries

3. Ensures appropriate monitoring and resuscitation equipment available and another clinician to assist.

4. Typically reduction will involve the use of a Biers block (but could use haematoma block)

5. Patient weighed. Contraindications to Biers known and considered

6. Biers machine and resuscitation equipment checked

7. IV access gained both arms, affected side distal to fracture

8. Correct volume and concentration of local anaesthetic drawn up

9. Arm raised, padding applied to arm, brachial artery occluded

10. Cuff inflation to 100mmhg greater than patients systolic BP

11. Clock started, anaesthetic given slowly.

12. Ensure anaesthesia of fracture site.

13. Remove cannula from affected side.

14. Ensure counter-traction and traction

15. Reduce fracture, maintaining reduction and POP applied.

16. Knows how to size and apply POP

17. Check x-ray

18. Release of cuff slowly at 20 minutes post inflation

19. Continued observation of patient for signs of toxicity- peri oral paraesthesia, hypotension, and seizures.

20. Check circulation to limb.

21. Ensures well one hour post procedure, ensures post procedure analgesia and indicates when patient to return and predicted course.

36

4b Reduction of a dislocated joint (e.g. shoulder, ankle)


1. Confirms correct patient, takes focused history and consents the patient.

2. Takes focused history and examination to establish that sedation is safe.

3. Undertakes examination to confirm dislocation and assesses distal neurovascular function

4. Interprets the x-ray correctly and looks for associated injuries

5. Ensures appropriate monitoring and resuscitation equipment available and another clinician to assist.

6. Gains IV access, and has correct volume of opiate, benzodiazepine or other

agent e.g. Ketamine, in correctly labelled syringes.

7. Knows the pharmacology of these drugs and their antagonists

8. Explains to patient procedure and anticipated course.

9. Ensures another clinician present

10. Gives drugs in controlled way in monitored environment with patient receiving oxygen.

11. Establishes sedated- still responsive to verbal commands.

12. Undertakes reduction in gentle and controlled manner.

13. Confirms reduction by physical examination and checks distal neurovascular function

14. Immobilises - sling, pop correct patient, taken relevant history, and consented the patient. Explains to patient procedure and anticipated course

15. Gets check x-ray- checks reduced and no additional fractures detected.

16. Ensures observed and monitored until fully recovered.

17. Rechecks neurovascular function

18. Ensures well one hour post procedure, ensures post procedure analgesia and indicates when patient to return and predicted course.

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ACAT-EM Descriptors

ACAT –EM

Assessment Domains Description

Clinical assessment and clinical topics covered

Quality of history and examination to arrive at appropriate diagnosis- made by direct observation in different areas especially in the resuscitation room.

No more than 5 AP should be covered in each ACAT and this should involve a review of the notes and management plan of the patient.

Medical record keeping

Quality of recording of patient encounters including drug and fluid prescriptions

Investigations and referrals

Quality of trainees choice of investigations and referrals

Management of patients

Quality of treatment given (assessment, investigation, urgent treatment given involvement of seniors)

Time management Prioritisation of cases

Management of take/team working

Appropriate relationship with and involvement of other health professionals

Clinical leadership Appropriate delegation and supervision of junior staff

Handover Quality of handover of care of patients between EM and in patient teams and in house handover including obs/CDU ward

Patient safety Able to recognise effects of systems, process, environment and

staffing on patient safety issues

Overall clinical judgement

Quality of trainees integrated thinking based on clinical assessment, investigations and referrals. safe and appropriate management, use of resources sensibly

Instructions for Use of ACAT-EM This tool works best if:

1. The assessment is best conducted over more than one shift (typically 2-3) as not all the domains may be observed by the assessor in one shift. The assessor should ensure that as many domains are covered as possible 2. The assessor should seek the views of other members of the ED team when judging performance 3. The clinical notes and drug prescriptions should be reviewed especially relating to patients cared for in the resuscitation room. 4. The ACAT can be used to confirm knowledge, skills and attitudes for the cases reviewed by the assessor 5. The ACAT can be used in a variety of setting within the ED- cdu ward rounds, clinics as well as major/minor/resuscitation and paediatric areas

38

The Acute Care Assessment Tool (ACAT-EM) Form

Name of Trainee:


Assessor

Setting, ED, CDU, Clinic, other

Date

Timing, duration and level of responsibility

Acute presentations covered (5 max for EM)

Please TICK to indicate the standard of the trainee’s performance in each area

Not observed

Further core

learning needed


Demonstrates excellent practice Must

address learning points

highlighted below

Should address

learning points highlighted

below Clinical Assessment

Medical record keeping

Time management

Management of the team

Clinical leadership

Patient safety

Handover

Overall Clinical Judgement

Which aspects were done well Learning points

Unsatisfactory AP? Plan for further AP assessment, specify WPBA tool and review date

Trainees Comments Action points


39

Multi-Source Feedback (MSF) Form

Thank you very much for completing this form, which will help me to improve my strengths and

weaknesses. This form is completely anonymous.

Name of ACP:

Grade of Assessor:

Date / /

UNKNOWN 1 2 3 4 5

Not Observed

Performance Does Not Meet

Expectations

Performance Partially Meets

Expectations

Performance Meets Expectations

Performance

Exceeds

Expectations

Performance Consistently

Exceeds Expectations

Good Clinical Care 1-5 or UK

Comments 1 Medical knowledge and clinical skills 2 Problem-solving skills 3 Note-keeping – clarity; legibility and

completeness

4 Emergency Care skills

Relationships with Patients 1-5 or UK

1 Empathy and sensitivity 2 Communicates well with all patient groups 3 Treats patients and relatives with respect 4 Appreciates the pyscho-social aspects of

patient care

5 Offers explanations

Relationships with Colleagues 1-5 or UK

1 Is a team-player 2 Asks for others’ point of view and advice

3 Encourages discussion Empathy and sensitivity

4 Is clear and precise with instructions 5 Treats colleagues with respect 6 Communicates well (incl. non-verbal

communication)

7 Is reliable 8 Can lead a team well 9 Takes responsibility

10 “I like working with this practitioner”

Teaching and Training 1-5 or UK

1 Teaching is structured 2 Is enthusiastic about teaching 3 This clinician’s teaching sessions are

beneficial

4 Teaching is presented well 5 Uses varied teaching skills

Global ratings and concerns 1-5 or UK

1 Overall how do you rate this practitioner

compared to other comparable clinicians

2 How would you rate this ACP’s performance at this stage of training

3 Do you have any concerns over this clinician’s probity or health?

40

Patient Survey Tool

Communication with patients is a very important part of quality medical care. We would like to know how you feel about the way your practitioner communicated with you. Your answers are completely confidential, so please be as open and as honest as you can. Thank you very much for your help and co-operation.

The Clinician Poor Fair Good Very Good

Excellent

Greeted me in a way that made me feel comfortable

1 2 3 4 5

Treated me with respect 1 2 3 4 5

Showed interest in my ideas about my health

1 2 3 4 5

Understood my main health concerns 1 2 3 4 5

Paid attention to me (looked at me and listened carefully)

1 2 3 4 5

Let me talk without interruptions 1 2 3 4 5

Gave as much information as I wanted 1 2 3 4 5

Talked in terms I could understand 1 2 3 4 5

Checked to be sure I understood everything 1 2 3 4 5

Encouraged me to ask questions 1 2 3 4 5

Involved me in decisions as much as I wanted

1 2 3 4 5

Discussed next steps including any follow up plans

1 2 3 4 5

Showed care and concern 1 2 3 4 5

Spent the right amount of time with me 1 2 3 4 5

Clinician’s Name:

Validated by:

41

Mini-CEX Summative Descriptors for PEM ACP

Acute Presentations 1. Abdominal pain 2. Fever 3. Breathlessness 4. Pain

1 Abdominal pain

Expected behaviour

Initial approach ABCD approach

Asks for vital signs

History Obtains history-patient, friends, family, paramedics- cover PMH


Examination General appearance – listlessness, features of dehydration and shock

Detailed physical examination including assessment of dehydration

Abdominal examination for guarding and distention

Inguinal and testicular examination


FBC,

U&Es,

LFTs,


Abdominal x-ray for those with? obstruction


Forms diagnosis and differential diagnosis for D&V including:

Intussusception

Bacterial and viral gastroenteritis

Food poisoning

Pyelonephritiss for abdominal pain

hernia,

intussusception,

pyloric stenosis,

appendicitis,

UTI,

viral URTI,

lower lobe pneumonia


Overall plan identifies immediate life threats and readily reversible causes

Able to classify degree of dehydration and prescribe appropriately

Stabilises and prepares for further investigation, treatment and admission.

Identifies which patients can be safely discharged


42

2 Assessment of the febrile child

Expected behaviour


Asks for vital signs including o SPaO2, o temperature, o blood sugar.

Identifies patient that needs resuscitation

History Obtains history- parents, friends, paramedics- cover PMH,


Identifies if immune deficient/ high risk-sickle, DM, CSF shunts, cardiac patients

Examination General appearance

Detailed physical examination focus on looking for causes of fever- o ENT, o neck stiffness, o chest for resp and cardiac causes, o abdomen, o CNS, o joints, o Skin/rash


arterial blood gas

FBC,U&Es, o clotting studies, o LFTs, o toxicology, o blood and urine culture

Appropriate imaging including Chest x-ray


Forms diagnosis and differential diagnosis including: Infection Bacterial

otitis media,

UTI,

pneumonia,

meningitis,

cellulitis,

joint infection,

appendicitis Viral

chickenpox,

gastroenteritis Others

neoplastic,

salicylates,

hyperthyroidism Demonstrates knowledge of NICE guidelines for management of febrile child

Communication Effectively communicates with both child, parents and colleagues

Overall plan Stabilizes and prepares for further investigation, treatment and admission


43

3 Assessment of the breathless child

Expected behaviour

Initial approach ABCD approach focusing on o airway patency, o effort and efficacy of breathing, o effects of inadequate respiration o and cardiovascular status.

Ensures patent airway and high flow oxygen. Ensures monitoring

History Obtains history- parents, paramedics

Examination General appearance

Detailed physical examination with detection of stridor & wheeze,

Signs of heart failure

Investigation Asks for appropriate tests- o arterial blood as, o FBC, o U&Es, o clotting studies, o blood and urine culture, o blood sugar

Appropriate imaging Cxray



Stridor: croup/epiglottitis

Wheeze: asthma/bronchiolitis

Fever :pneumonia Demonstrates knowledge of guidelines e.g. NICE for management of asthma. Knows of croup scoring system

Communication Effectively communicates with both child, parents and colleagues

Overall plan Stabilises and prepares for further investigation, treatment and admission. Seeks senior help early and appropriately


44

4 Assessment of the child in pain

Expected behaviour

Initial approach Recognises child in pain including behavioural and physiological changes

History Obtains history of the condition causing pain

Elicits past history of painful experiences and successful relieving measures

Examination Able to determine the cause of pain

Able to undertake pain assessment including the use of pain ladder and faces scale

Investigation Appropriate to the presentation


Ensures parent involvement

Selects most appropriate analgesic and route of administration

Demonstrates comprehensive knowledge of drugs and dosages

Calculates dosage correctly

Considers use of distractive techniques

Communication Communicates effectively to both the child and parents. Sensitive and reassuring

Overall plan Ensures effective analgesia by repeated assessment and additional treatment if needed


45

Paediatric Practical Procedures DOPs Descriptors 1. Venous access 2. Airway assessment and maintenance 3. Paediatric equipment and guidelines in the resuscitation room 4. Primary survey in a child

1 Venous access in children

Trainee should identify suitable sites for cannulation in a child- specifically

the dorsum of the hand and foot,

cubital fossae,

external jugular,

scalp veins,

femoral vein,

IO. S/he should select appropriate route depending on the clinical case

For the fully conscious patient:

Should ensure adequate pain relief if appropriate- using topical anaesthetic

Should ensure clean site and use aseptic technique

Prepares equipment- cannulae, connections, steristrips, flush and blood collection bottles

Immobilisation of limb using other members of staff

Gains access, takes samples, connects, secures and flushes to ensure correct position

Splints limb

Writes up fluid to be administered (if any).

For those undergoing resuscitation (this DOPs will be unplanned but should not stop this valuable learning opportunity from being missed) a. femoral vein cannulation

Demonstrates correct anatomy and proposed site of puncture


Prepares equipment- cannulae, connections, steristrips, flush and blood collection bottles

Immobilisation of limb using other members of staff

Gains access, takes samples, connects, secures and flushes to ensure correct position

b. Intraosseous insertion using either IO needle or EZ drill

Demonstrates correct anatomy and proposed site of insertion over the medial tibia.


Prepares equipment- IO needle, connections, flush and syringe for collection of marrow blood

Successfully inserts, confirms secure and patent. Connects to giving set and three way tap, and gives fluid bolus

Knows complications of IO insertion If trainees cannot do IO needle insertion on real patient then they must demonstrate to their trainer they can do so using a mannequin

46

2 Basic airway manoevers in children

Preparation- can size nasophrayngeal and oral airways

Can select appropriate BVM

On arrival assesses airway for patency

Established if obstructed or not.

Uses suction, adjuncts and positioning appropriately

Ensures patent airway

Administers high flow oxygen with appropriate mask

Supports ventilation with BVM

Ensures concurrent monitoring including SpAO2, ECG

Correctly identifies those that will need intubation

Works effectively with medical and nursing colleagues to deliver effective care

3 Equipment and guidelines in the resuscitation room.

This is designed to ensure the trainee is familiar with and can access important paediatric resuscitation information and equipment

The trainee must demonstrate that:

Can calculate the child’s weight, defibrillation energy, ETT size, fluid bolus, dose of adrenaline, dose of 10% dextrose to correct hypoglycaemia

Can attach paediatric defibrillation paddles to adult paddles

Can size and use o/p, n/p airways and use BVM

They can find IO needle set

That they know/ can find the normal range of physiological variables

Can immediately access and know the common paediatric protocols- for cardiac arrest, seizures and anaphylaxis

They can interpret limb x-rays- specifically recognise epiphyses, joint effusions.

That they can interpret lat cspine (age <10)

That they recognise the normal paediatric ECG and how it changes

47

4 Perform a primary survey in a child

Expected behaviour

Preparation phase

Has calculated weight – prepared – defibrillation charge, ETT, fluid bolus, and dextrose (10%)

Has Broselow tape and knows how to use it

Transfer Ensures safe transfer of patient onto ED trolley

Examination Assesses airway, establishes if obstructed, corrects and ensures delivery of 100%O2. Appropriate use and correct sizing of airway adjuncts

Concurrently ensures cervical spine immoblisation (using collar, sandbags and tape)- able to select and apply correct collar

Exposes chest identified raised respiratory rate, chest asymmetry, chest wall bruising, air entry (anteriorly and laterally) and percussion (laterally). Identifies life threatening problems and correctly carries out associated procedures

Examines for signs of shock, ensures monitoring established and has gained iv accessX2

If shocked looks for potential sites of blood loss- abdomen, pelvis and limbs.

Can formulate differential for shocked patient

Knows protocol for fluid administration for the shocked child

Establishes level of consciousness and seeks lateralising signs

Uses paediatric GCS scale

Examines limbs, spine and rectum (if unconscious or spinal injury suspected) ensuring safe log roll.

BM done for those with altered level of consciousness

Will have identified and searched for potential life threatening problems in a systematic and prioritised way

Ensured child is kept warm

Reassesses if any deterioration with repeat of ABCD

Elicits full relevant history from prehospital care providers, witnesses and parents

Monitoring and interventions

Ensured appropriate monitoring

Will have placed lines, catheter and NG tubes as appropriate

Investigations Ensured appropriate blood testing (including cross match).

Plain radiology trauma series undertaken

Prescribing Ensures adequate and safe pain relief


Directs team appropriately

Liaises with and involves parents

Overall plan Notes of primary survey are clear and legible


48

Structured Training Report for ACP

The Educational Supervisor must complete this ACP, having reviewed the Trainee ACP’s

e-portfolio

Trainees Name and NMC/HCPC Number

Educational Supervisor name and GMC

Number

Region

Training Unit

Date of assessment

Period covered in this assessment (start and end date)

Assessments and number required No. completed

Comments

Common Competences

All to level 2- 2 mandatory CCs assessed

Core Major Presentations Adult (CMP1-6)

Core Acute Presentations CAP Adults 1-38 5 assessed by Consultant Remaining covered and linked in curriculum All self and supervisor assessed

ACP Additional Emergency Presentations

Adult Practical Procedures = 19

Paediatric Major Presentations PMP 1-6

5 Paediatric Acute Presentations assessed

Remaining covered by other means

Practical procedures in children – 5 + 19

Audit and reflection

Multi-source Feedback (MSF)

All other curriculum items covered with reflection, courses etc

49

Other outcome to be considered

Activity Date Outcome Comments

Educational achievements

Evidence of reflective practice

Critical incidents

Complaints

Strengths of ACP

Development needs of ACP

Preparedness for independent practice – view of the local faculty

Names of faculty consulted:

Comments:

Supervisor’s Name and Signature Trainee ACP’s Name and Signature

Date: Date:

50

Appendix Three: Self-Declaration Form

Self-Declaration Form for Emergency Care Advanced Clinical

Practitioners

Section 1: Personal details

Forename: Surname:

Home Address:

Employer Address:

Telephone: Primary contact email address:

Current Deanery/LETB:

Section 2: Probity and Health Declaration

Convictions, finding against you and disciplinary action

In the last 12 months have you been convicted of a criminal offence? Yes No If yes, please give details:

Do you have any criminal proceedings pending against you inside or outside the UK? Yes No If yes, please give details:

Have you had any cases considered, heard and concluded against you by any of the following:

o The Nursing and Midwifery Council o The Health and Care Professions Council o Any other professional regulatory or other professional licensing body within the

UK o A professional regulatory or other professional licensing body outside the UK

Yes No If yes, please give details:

51

Health Declaration: Your own health Regulatory bodies acknowledge that nurses and paramedics who become ill deserve health and support. Advanced Clinical Practitioners (ACPs) also have to recognise that illness can impair their judgment and performance and thus put patients and colleagues at risk. The NMC and HCPC therefore encourages ACPs to reflect in their own health, seek professional advice if necessary and consider whether, for health related reasons, they should modify their professional activities in accordance with fitness to practice requirements. It is the ACP’s responsibility to report any sickness absence to their employer and they must be aware of employer policy. Sickness absence could also be recorded in the ePortfolio.

Do you have any illness or physical condition that has, in the last 12 months, resulted in your restricting or changing your professional activities?

Yes No If yes, please give details of the changes in your professional activities, which it is (or was) necessary for you to make:

Are you currently or in the last 12 months, been subject to supervision, voluntary or otherwise, and/or any restrictions voluntary or otherwise, imposed by your employer or contractor resulting from any illness or physical condition within the UK or abroad?


Regulatory and voluntary proceedings

1) Are you, or have you been in the last 12 months, the subject of any proceedings with any of the following organisations:

a. The Nursing and Midwifery Council b. The Health and Care Professions Council c. Any other professional regulatory or other professional licensing body within the UK d. A professional regulatory or other professional licensing body outside the UK Yes No If yes, please give details:

2) In the last 12 months, have there been any disciplinary actions taken again you by your employer or your contractor (either inside the UK or outside) that have been upheld?


52

3) In in last 12 months, has your employment contract ever been terminated or suspended (in the UK or abroad) on grounds relating to your fitness to practice (conduct, performance or health)?


Section 3: Involvement in significant events, complaints or other investigations:

Significant Event: A significant event (also known as an untoward or critical incident) is any unintended or unexpected event, which could or did lead to harm of one or more patients. This includes incidents which did not cause harm but could have done, or where the event should have been prevented. You are required to record and reflect on Significant events with the focus on what you have learnt as a result of the event/s. Use non-identifiable patient data only.

Complaints: A complaint is a formal expression of dissatisfaction or grievance. It can be about an individual, the team or about the care of patients where you could be expected to have had influence or responsibility. As a matter of honesty & integrity you are obliged to include all complaints, even when you are the only person aware of them. You should reflect on how complaints influence your practice. Use non-identifiable patient data only.

Other investigations: In this section you should declare any on-going investigations, such as honesty, integrity, conduct, or any other matters that you feel the panel should be made aware of. Use non-identifiable patient data only.

**REMINDER: DO NOT INCLUDE ANY PATIENT-IDENTIFIABLE INFORMATION ON THIS FORM

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Please tick/cross ONE of the following only: I do NOT have anything to declare I HAVE been involved in significant events/complaints/other investigations

If you know of any significant events/complaints/other investigations, you are required to have written a reflection on these in your ePortfolio. Please identify where in your ePortfolio the reflection(s) can be found.

Significant event: Complaint: Other investigation:

Date of entry in ePortfolio ____________ Title/Topic of Reflection/Event _________________________________

Location of entry in ePortfolio __________________________________________________________________

** Significant event: Complaint: Other investigation:



** Significant event: Complaint: Other investigation:



Section 4: Declaration

I confirm this form is a true and accurate declaration at this point in time and will immediately notify the panel and my employer if I am aware of any changes to the information provided in this form. I give permission for my past and present portfolios and / or appraisal documentation to be viewed by the panel and any appropriate person nominated.

Trainee’s Signature :

Date:

Chair of the Panel’s

Signature:

Date:

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Appendix Four: Credentialing Outcome Form

Emergency Care Advanced Clinical Practitioner Credentialing Outcome Form

Forename: Surname: Regulatory Body and

Membership Number:

Primary Qualification (Institution and year awarded):

Master’s Degree (Institution and year awarded):

Date of Credentialing Assessment:

List all panel

members

1. 2.

3. 4.

5. 6.

Location of training/working From: (insert

dates)

To: (insert

dates)

Evidence considered by the panel and known to the trainee

1. ePortfolio 2. Structured Training Report

3. Checklist of evidence 4.

5. 6.

Panel Outcome

Successful - Credential

Achievement of all curriculum requirements

Further evidence required

Further evidence is required, see additional feedback form.

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If further evidence is required:

Recommended time required to achieve outstanding objectives (whole time equivalent) following

discussion:

________________________________________________________________________________

Chair of Panel’s

signature: Date:

Trainee ACP’s

signature: Date

By signing this form the Chair of the panel is confirming that fitness to any practice issues have been considered. This

document should be scanned and saved in the trainee ACP’s ePortfolio. This information will also be recorded at the

Royal College of Emergency Medicine. By signing the form, the ACP is indicating that they understand and agree that

the information will be shared with other parties involved in their training as outlined above. The ACP signature on the

form indicates that they understand the recommendations arising from the credentialing assessment. It does not imply

they accept or agree with the outcome.

56

Appendix Five: Credentialing Feedback Form

Emergency Care Advanced Clinical Practitioner Credentialing Feedback Form

Forename: Surname: Regulatory Body:

Date of Credentialing Assessment:

List panel

members 1. 2.

Feedback from Credentialing Panel – Evidence Presented

ePortfolio

Structured Training Report

Checklist of evidence

57

Chair of Panel’s signature:

Date:

Trainee ACP’s signature:

Date

Feedback from Credentialing Panel – Post-Assessment

Overall Quality of Evidence

Comments on areas of ACP Progression/Developments In Role

Feedback on the Pilot

Recommended Actions (for those in who require further evidence):

A GUIDE TO THE EMERGENCY CARE ADVANCED ... Guide to the Emergency...EMERGENCY CARE ADVANCED CLNICAL PRACTITIONER PILOT CREDENTIALING PROJECT November 2016 2 v2 updated 28 November

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