Hospital Medicine: Hospital Skills Program Curriculum ...€¦ · independently (eg, leading a Clinical Emergency Response System team in hospital wards or managing a normal delivery

HOSPITAL MEDICINEMay 2012, version 1.1HOSPITAL SKILLS PROGRAMHOSPITAL SKILLS PROGRAM

Health Education and Training Institute NSW Hospital Skills Program Hospital Medicine Module Version 1.1 Sydney: HETI 2012

This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated requires written permission from HETI.

© HETI 2012

ISBN 978-0-1936-3-6

For further copies of this document, please contact HETI, or download a digital copy from the HETI website: www.heti.nsw.gov.au

This document is the latest version of the Hospital Medicine Module prepared by the HSP Hospital Medicine Module Development Working Group, led by Dr Mary G T Webber.

Members of the Hospital Medicine Module Development Working Group:

Dr Mary G T Webber Hospitalist, Ryde Hospital

Dr Michael Boyd Hospitalist, Ryde Hospital

Dr Ross White Hospitalist, Ryde Hospital

Dr Simon Leslie Director of Emergency Department, Shellharbour Hospital

Dr Cathie Hull Workforce Development and Innovation, NSW Health

Dr Briege Hamill HSP Director of Training, HNE Local Health Network

Dr Ross Kerridge Director of Perioperative Service, John Hunter Hospital

Mr Peter Davy Curriculum Developer, HETI

www.heti.nsw.gov.au/hsp


MAY 2012 VERSION 1.1 PAGE 1

Hospital Skills Program Hospital medicine

P2 Section 1: Background and overviewP3 RationaleP4 Formative assessment and

entrustable professional activityP8 Summary of the module

P10 Section 2: Concurrent inpatient assessment, stabilisation and management

P12 Section 3: Common problems and conditions

P15 Section 4: Procedural entrustable professional activities

P17 Section 5: Responses to emergencies

P20 Section 6: System design and the characteristics of hospital practice

P24 References

P25 Appendix 1 Patient safety frameworkP26 Appendix 2 CANMEDs domainsP27 Appendix 3 Case study

Preamble The Hospital Skills Program vision

The Hospital Skills Program (HSP) provides a life-long pathway for self-directed medical education across three levels of agreed expertise, using a variety of traditional and non-traditional resources and methods appropriate to the working environment of the participant, resulting in the acquisition of a skills portfolio useful to an employer, and appropriate to the local patient community.

The HSP recognises the heterogeneous nature of the skills and circumstances of Career-Medical-Officer-equivalent medical practitioners, their continuing value in the delivery of health services to the population of NSW, and their right to meaningful educational opportunities in a mode appropriate to their working lives and geographic locations.

HSP recognises that self-directed education is the realm and property of the adult learner, and that accountability for learning remains with the individual. Therefore HSP exists firstly to identify, coordinate and facilitate the delivery of learning opportunities, and to assist the individual to evaluate their progress across the three levels of HSP and to plan for their own future needs.

Furthermore, the HSP provides a mechanism to align clinical learning activities with the goals of the health system and to deliver priority education to hospital generalist doctors when this need is identified by expert groups such as NSW Health and the NSW Clinical Excellence Commission.

Dr Mary G T Webber Hospitalist

Ryde Hospital, NSW

PAGE 2 HSP: HOSPITAL MEDICINE MODULE

Section 1: Background

The HSP Hospital Medicine module identifies the anticipated capabilities of doctors working in a hospital generalist role in NSW hospitals. Doctors participating in the HSP will have at least two years of clinical postgraduate experience and not be currently participating in a specialist vocational training program.

This module has been developed by HETI on behalf of NSW Health as part of the Hospital Skills Program for generalist doctors. It aims to guide doctors, their employers and educators with regard to learning and professional development needs, workplace responsibilities and clinical tasks.

This module is one of several that have been developed by HETI for the HSP. The other modules describe capabilities required for clinical work within a variety of medical contexts (including Mental Health, Aged Care, Paediatrics, Women’s Health, Drug and Alcohol Medicine, Rural Health and Aboriginal Health).

The HSP modules were developed with particular reference to the Australian Curriculum Framework for Junior Doctors (ACFJD), prepared by the Confederation of Postgraduate Medical

Education Councils. The HSP modules have a similar structure to the ACFJD, comprising the categories of clinical management, communication and professionalism. The modules also identify common illness problems and conditions for which HSP participants are likely to respond, and describe the procedures and clinical skills that are expected of HSP participants.

The presentation of the Hospital Medicine module is intended to recognise and reinforce a mode of practice within hospital medicine that focuses on the continuity and quality of clinical care, patient safety and patient flow.

Further curriculum work is underway to review module learning outcomes in terms of “entrustable professional activities” (Ten Cate 2006). These are broader capabilities that can be used to provide direction for professional development and to assess doctors as having the capacity to carry out particular clinical responsibilities, either under supervision, or independently (eg, leading a Clinical Emergency Response System team in hospital wards or managing a normal delivery in the Emergency Department).

Overview of the Hospital Medicine module

The HSP Hospital Medicine module identifies the capabilities of doctors working in the developing field of Hospital Medicine, with a particular focus on learning how to respond to clinical and system demands. These occur across many specialist teams without necessarily being the core business of that team or specialty.

Hospital medicine has recently emerged as a parallel rather than competitive stream of care, which supports inpatient specialist teams to focus safely on delivering their core skills, while reducing the transaction costs and variations of

care delivery across the hospital, and working to increase its safety and efficiency for patients.

It is anticipated that while the themes and concerns of this stream of medical practice will be widely applicable, their particular application will be site-specific and responsive to local conditions.


Rationale for a module in Hospital Medicine

The forces of population growth and ageing, social dislocation, ethnic diversification and altered systems of care that emphasise very short admissions and community-based models of service have combined over the last 30 years to alter the demographics of the inpatient population in irrevocable ways.

Patient characteristics have changed. It is widely recognised that today’s patients are older, sicker, have more interrelated co-morbidities, are more likely to suffer a complicating cognitive decline or mental illness and less likely to have a secure network of informal carers. Such patients require expert multi-disciplinary care delivered in systems responsive to the patient in context.

Less widely recognised are the effects of the way medicine is practised on this changing inpatient scenario. Doctors in hospitals are traditionally trained into specialities based upon discipline groupings (eg, cardiology, orthopaedic surgery) or defined hospital contexts (eg, the emergency department or the intensive care unit). Expertise and skills are developed to an extraordinary depth and detail within those fields as determined by specialist colleges, and as those fields advance. Specialisation inevitably narrows focus, and focus is assumed to be a good thing.

Innovation and training tend to increase specialisation, and specialisation is recognised, valued and rewarded, often by release from the confines of public hospital practice. Expert focus on system characteristics is the business of medical administrators who are often, though not always, separated from the realities of 24/7/365 clinical practice by their own process of specialisation.

Several characteristics of our current medical system, coupled with rising demand, predispose to patient risk. There is widespread dependence on specialist Visiting Medical Officers and specialist and super-specialist training and services are condensed into district-based networks. These networks are often dominated

by a few tertiary facilities offering advanced care in an environment of significant bed pressures and complex access issues. The rapid turnover of trainee junior medical staff creates challenges in providing adequate and consistent education, orientation and support.

It is difficult to manage clinical risk in an environment in which not even the most dedicated professional can have knowledge of everything that happens to a patient during their stay. Information loss is a pervasive hazard. Time-based performance targets for emergency departments place downward pressure on the ‘setting up and sorting out’ phase of the early admission process and bed pressures mean that patients must be discharged as soon as practicable – and sometimes before.

Outliers (eg, a medical patient in a surgical ward) are common and patients often suffer from several moves between specialised areas, such as from emergency department to emergency medical unit, and then to clinical decision units, between wards and beds, to off-site treatment units, between specialist teams, through transit lounges and surge beds, and to and from high acuity areas and rehabilitation units. Prevailing conditions and rising demand predispose to conditions of risk for the inpatient population.

The following data provide a context for the development of an HSP module in Hospital Medicine.

There were 1326 hospitals in Australia in the financial year 2009/10. The 753 public hospitals accounted for 67% of hospital beds (56,900) and the 573 private hospitals accounted for 33% (28,000), proportions remaining unchanged from 2008/09. There were 8.5 million separations for admitted patients in 2009/10, with 5.1 million occurring in public hospitals and almost 3.5 million in private hospitals.


This was an increase of 3.2% on average each year between 2005/06 and 2009/10 for public hospitals, and 5% for private hospitals. The proportion of admissions that were ‘same-day’ continued to increase, by 5% on average each year between 2005/06 and 2009/10, accounting for 58% of the total in 2009/10 (51% in public hospitals and 68% in private hospitals). For overnight separations, the average length of stay was 5.9 days in 2009/10, down from 6.2 days in 2005/06 (Australian Institute of Health and Welfare 2011).

The World Health Organization’s High 5’s program for patient safety articulates the top five challenges for patient safety that are generated by hospital admission (WHO, 2010):

1 concentrated injectable medicines

2 medication accuracy at transitions in care

3 correct procedure at the correct body site

4 communication failures during patient handovers

5 addressing health care associated infections.

These are complex problems and the need for a whole-of-hospital medical, multidisciplinary, and system engagement in patient safety is apparent.

Other risks of hospitalisation have been studied, especially through the deteriorating patient literature (eg, CEC, 2008), and a group of diagnoses can therefore be identified that are appropriate for the generalist hospital medicine practitioner to master. Innovative system design presents opportunities to influence the conditions that predispose to medical error and patient deterioration, avoiding situations like that described in Appendix 3.

Hospital generalists need to develop expertise in recognising, tolerating and managing risk. They also need to be familiar with the supporting legal framework of hospital practice, to act as reservoirs of information, support junior staff, and practise empirical decision making and

reflective practice. This requires self and system knowledge skills, such as recognising the point of need for speciality consultation. Properly managing this specialist interface requires a profound knowledge of local conditions and is a poorly recognised yet vital skill set for the coordination of patient access to care.

Hospital medicine responds to the characteristics of the inpatient population and provides a bridging function across discipline silos, seniorities, specialities and disciplines. The proper concerns of hospital medicine are the challenges, both clinical and systemic, that occur across many different teams, and which are not the core business of the team. Practitioners show maturity in understanding and promoting the management of the patient within their social and clinical context regardless of the location in the hospital in which they are employed. Such knowledge is built and held in a permanent continuous workforce.

Formative assessment and entrustable professional activities

The HSP provides a framework for workplace-based, competency-based formative assessment and the recognition of current competencies. The HSP framework for formative assessment is underpinned by core principles of authentic workplace based assessment. Assessment in the HSP is valid, reliable, feasible and fair.

A valid assessment task is one that accurately assesses the capability or competency as outlined in the HSP module. For example, a valid assessment of an emergency department tracheal intubation procedure would be the direct observation of a doctor performing this skill, but not a multiple choice test of how much a doctor knows about the anatomy and physiology of respiratory structure and function.

An assessment is reliable if it yields consistent and precise results and is free from bias or error.


A feasible assessment is one that is cost effective, allows sufficient time for the assessment tasks to be carried out by the doctor and can be administered using available relevant workplace equipment and other resources.

A fair assessment is one that allows for the recognition of current capabilities and achievement no matter how, where or when learning has occurred. A fair assessment also is one that does not disadvantage any particular individual on the basis of age, gender and other personal attributes.

Entrustable professional activities (EPAs) are sets of professional tasks that doctors perform in their clinical roles. These medical tasks are entrusted to doctors by health system employers and supervisors. Professor Olle ten Cate (2006) who first described EPAs, notes that this concept emphasises the notion of trust, formalising what medical managers and supervisors practise when they identify doctors who they trust to complete particular professional tasks on the ward or in other hospital contexts.

The EPAs described in this module have been identified by the Hospital Medicine Module Development Group through an analysis of clinical activities that are of central importance to the practice of hospital medicine.

Because the sum of what doctors do in hospital medicine practice is greater than the parts described by individual competencies, EPAs provide an approach that minimises the atomisation of professional competencies, which is an undesirable side-effect of some competency-based assessments (Van der Vleuten and Schuwirth, 2005).

Ten Cate (2006: 750) identifies the following criteria for EPAs:

• part of essential professional work

• require specific knowledge, skill and attitude

• generally acquired through training

• lead to recognised output of professional labour

• usually confined to qualified staff

• independently executable within a time frame

• observable and measurable in their process and their outcome

• lead to a conclusion (done well or not done well)

• reflect the competencies to be acquired.

Using the concept of EPAs and building formal entrustment decisions into the HSP has many advantages for the field of hospital medicine, including:

• providing guidance for professional development and progression

• supporting supervision and guiding workplace based assessment

• integrating professional competencies into broader capabilities reflecting real-world practice in hospital medicine

• fostering a developmental continuum of workplace-based learning, formative assessment and workplace progression.

Through involvement in the module’s educational experiences, including access to relevant resources, HSP participants will be able to engage in the entrustable professional activities relevant to their practice at the HSP level designated. This will support a career-long process of increasing depth of expertise and synthesis of clinical skills for doctors working in hospital medicine.


Levels of competence

Ten Cate and Scheele (2007: 543) argue that these EPAs “are the constituting elements of professional work” and applying this concept to postgraduate medical education involves considering multiple levels of professional activity.

An HSP level has been allocated for each EPA in the Hospital Medicine module. The three levels of the HSP reflect the developing knowledge and skills required of increasingly complex clinical management scenarios and increasing work role responsibility, entrustment and accountability. Each of the three levels broadly distinguishes doctors in terms of proficiency, experience and responsibility. The following is a summary of the criteria on which the HSP levels have been determined.

It is assumed that doctors will practise medicine with the degree of autonomy that is consistent with their level of experience (E), clinical proficiency (CP) and responsibility (R) to ensure patients receive care which is appropriate, effective and safe. The levels are cross referenced with levels described for the patient competencies in the National Patient Safety Education Framework (see Appendix 1).


Table 1: Defining levels of entrustable professional activity in the Hospital Skills Program

Key HSP 1 HSP 2 HSP 3

Level of experience (E)

Has limited workplace experience in this discipline.

Has moderate to large workplace experience in this discipline.

Has substantial workplace experience in this discipline.

Clinical proficiency (CP)

Reliably recognises familiar situations and key issues. Has a good working knowledge of the management of these. Decision-making is largely rule bound. Demonstrates effective clinical decision making and clinical proficiency in defined situations.

Recognises atypical presentations, recognises case specific nuances and their relational significance, thus reliably identifies key issues and risks. Decision making is increasingly intuitive. Fluent in most procedures and clinical management tasks.

Has an intuitive grasp of a situation as a means of linking his or her understanding of a situation to appropriate action. Able to provide an extensive repertoire of management options. Has a comprehensive understanding of thje hospital service, referral networks and links to community services.

Responsibility (R) Uses/applies integrated management approach for all cases; consults prior to disposition or definitive management; and arranges senior review of the patient in numerous instances, especially serious, complex, unclear or uncommon cases.. Observes family conference discussions about care and discharge planning if requested by senior clinician (and permitted by the family or carer/s)

Autonomously manages simple and common presentations and consults prior to disposition or definitive management for more complex cases. Conducts family conference discussions about care and discharge planning under supervision of senior clinician.

Works autonomously, consults as required for expert advice and refers to admitting team about patient who require admission. and other medical specialists as required. Independently conducts family conference discussions about care and discharge planning under supervision of senior clinician.

Patient safety (PS)

Level 2 Level 2 - 3 Level 3


Summary of the Hospital Medicine module

The rationale of hospital medicine is to understand the patient in context, and to use excellent clinical skills, a broad system view and expert local knowledge in making decisions.

The Hospital Medicine module aims to support the development of a doctor with a top-to-bottom, side-to-side perspective. It emphasises the following themes: continuity, quality, safety, flow and advocacy for hospital services and persons.

Continuity of hospital medicine care extends across hospital organisation and health discipline boundaries. Continuity of care also implies a relationship between clinician and patient that exists from admission to discharge and extends to supporting the patient through building relationships with general practitioners and other health professionals following discharge.

Haggerty et al (2003) in their review article on continuity of care argue that three types of continuity exist:

Informational continuity: The use of information on past events and personal circumstances to make current care appropriate for each individual.

Management continuity: A consistent and coherent approach to the management of a health condition that is responsive to a patient’s changing needs.

Relational continuity: An ongoing therapeutic relationship between a patient and one or more providers.

This module supports enhanced quality of care by hospital practitioners. Good hospital medicine practice leads to improved quality of care as measured by indicators such as length of stay and treatment costs.

Patient safety is focused on minimising risk of patient harm due to the experiences during their hospital stay. Approximately 10% of patients in hospitals experience actual harm as an

unintended consequence of care, such as a hospital acquired infection or medication error (Australian Patient Safety Foundation, 2010).

This module recognises the goal to expedite patient flow in a manner that ensures patients receive safe and timely care. This goal is not only to be achieved within the hospital, but it is expected that the hospital medicine practitioner will engage with the local health professional community to ensure appropriate patient care.

Hospital medicine practitioners routinely act as advocates for the effectiveness and efficiency of hospital services and the people providing hospital services.

Hospital generalists who participate in the Hospital Medicine module are expected to demonstrate the following personal characteristics: seniority in the health system, commitment to the health service, excellent situational awareness and confidence in their own skills, with the broad clinical experience to get things done for the patient.

The following topics covered in the Hospital Medicine module align closely with the Clinical Excellence Commission’s priority areas for clinical improvement (www.cec.health.nsw.gov.au):

Handover processes:

• Development and embedding at local level

• Using current resources

• Rolling audit and feedback

• Leadership and promulgation

• Team to team, term to term, day to night, week to weekend and return, across holidays, between clinical units, hand-back, building and supporting the hospital team.

Leading in system-wide responses to the deteriorating patient at ward level

• Participating in resuscitation teams

• Follow through and carriage of recurring issues


• Training in technical and non-technical topics

• Feedback loops to achieve prevention

• Mentorship and participation in multi-disciplinary teams

• Advocacy and trialling for equipment and training

• Performing audit

• Providing feedback and development

• Troubleshooting.

Transitions of care

• Admission negotiation skills

• Medical participation and leadership in multi-disciplinary teams

• Care and discharge planning meetings

• Standards in medical record keeping

• Promoting general practitioner liaison

• Discharge processes and their review

• Transfers between and inside institutions and levels of care

• Knowledge of local networks

• Retrieval services

• Escalation of failing systems and patient and community advocacy.

Medical education and support to junior staff

• Junior doctor and collegial support

• Cross-disciplinary professional development

• Medicolegal frameworks for practice

• Accessing and interpreting policies

• Recognition and assistance to the clinician in difficulty

• Conditions and requirements for supporting international medical graduates.

Organisational liaison and support

Medical error and clinical governance

• Open disclosure

• Ethical aspects of hospital practice

• Incident management and reporting

• Complaints management

• Clinical incident review

• Morbidity and mortality meetings

• Local quality systems

• The Coroner’s Court – purpose of

notification.

End of life processes

• Mentorship and participation in

multidisciplinary teams

• Development of local networks within the

hospitals and into the community

• Practical assistance and support to junior

staff

• Ethical issues and medicolegal requirements

• Processes of death certification and organ

donation.

Occupational health and safety

Public health

• Epidemiology of local environment

• Notification requirement of infections

• Multiresistant organism isolations and drug

reactions

• Health literacy - for example, health literacy

is defined in Health People 2010 as: “The

degree to which individuals have the capacity

to obtain, process and understand basic

health information and services needed

to make appropriate health decisions …

includes the ability to understand instructions

on prescription drug bottles, appointment

slips, medical education brochures, doctors

directions and consent forms, and the ability

to negotiate complex health care systems.”

Conditions that occur across the hospital and

across multiple specialist teams (but which

may not be the core business of that team)

and managing conditions of clinical risk are

considered to be the proper concerns of the

Hospital Medicine module.


Section 2: Concurrent inpatient assessment, stabilisation and management

Rationale

It is characteristic of providing hospital wide care to be called to assess a patient not on one’s ‘home’ team, or who has undergone a change of clinical status, or altered symptoms. This intervention has traditionally been provided by the most junior medical staff, working in overstretched roles, and confronted by patients whose complexity can be overwhelming (CEC, 2008). The hospital medicine role requires considerable experience and maturity, a tolerance of uncertainty and the capacity to act safely with incomplete information, and to understand and to balance risks.

Knowledge of local systems and capabilities across the 24/7/365 environment is required to provide efficient care and makes this a proper field of activity for Hospital Medicine. Furthermore, this skill involves understanding the patient in context — to make sense of disparate sources and levels of information — skills that are enhanced in the practitioner with seniority, with judgement, with corporate knowledge, and who functions in continuity roles across a single site.

Consideration of the inpatient environment reveals different skill and knowledge sets relevant to different groups of patients. While a deal of attention has been paid to the problems of acute patients, it is timely to separately consider and articulate the needs of chronic patients and periprocedural patients. Doing so results in a more satisfying and richer knowledge set, more reflective of the working realities of hospital medical staff and a better basis for planning education and training. Overlap between groups is inevitable. The specific requirements of the other main groups — pregnant women, children and adolescents, are beyond the scope of this module.

This section has been written to support hospital doctors by identifying some of the patient and environmental factors and skills involved in accurate patient assessment, initiation of correct investigations, and diligent follow-up of results. Articulating the differing requirements of patients in different care streams helps the practitioner to broaden their thinking, speed-up decision-making and response, reduce preventable errors, and improve system and patient outcomes.


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EPA

HM

2.4:

M

anag

e di

spos

ition

(HS

P2)

Iden

tify

need

for i

nter

depa

rtmen

t or

inte

rhos

pita

l tra

nsfe

r. A

cces

s re

triev

al

syst

ems.

App

ropr

iate

not

ifica

tions

and

be

d m

anag

emen

t sys

tem

s. P

repa

re fo

r re

triev

al.

Par

ticip

ate

in c

are

and

disc

harg

e pl

anni

ng p

roce

sses

. Ass

ess

pote

ntia

l fo

r reh

abili

tatio

n an

d id

entif

y ne

ed fo

r pa

lliat

ive

care

. Rec

ogni

se th

e ef

fect

s an

d tim

ing

of a

ltere

d w

eigh

t-be

arin

g.

Ant

icip

ate

the

effe

cts

of s

urge

ry (e

g, C

a++

af

ter t

hyro

id s

urge

ry).

Man

age

early

dis

char

ge

proc

esse

s, in

clud

ing

appr

opria

te a

nalg

esia

and

an

tibio

tics

for d

isch

arge

. Man

age

wou

nd fa

ilure

, id

entif

y su

rgic

al d

eter

iora

tion,

iden

tify

patie

nts

who

nee

d to

retu

rn to

occ

upat

iona

l the

rapy

, and

lia

ise

with

nur

sing

and

hos

pita

l man

agem

ent a

s ap

prop

riate

.


Rationale

The population at highest risk for acute hospital admissions and with the highest complex and chronic care needs are those aged 85 years and above. This age group has increased in numbers and as a proportion of the population over the period 2001–2011 and will continue to increase (GMCT, 2002), as Table 3.1 indicates.

In clinical practice, hospitalised patient populations show ‘herd characteristics’ determined by local demographics, patterns of referral, and the role delineation of the hospital. Patients admitted with disabling co-morbidities that are not ‘on the list’ of services provided under clinical services planning can face a difficult time obtaining access to care. Hospital doctors responsible for inpatients need to be cognisant of and adept in managing complex

overlapping health needs. Articulating these conditions and requirements for the differing but related groups (include acute patients, chronic patients and periprocedural patients) assists the doctor to work in a complex decision-making environment. These are problems or conditions that occur across many different teams without necessarily being the core business of the team, making this an appropriate field for hospital medicine activity.

Table 3.1: Population at highest risk for acute hospital admissions (from GMCT, 2002)

Hospital Medicine Module. NSW Hospital Skills Program. Version 1.2.

15

Section 3: Common Problems and Conditions Rationale The population at highest risk for acute hospital admissions and with the highest complex and chronic care needs, are those 85 years and above. This age group has increased progressively over the period 2001 - 2011 and will continue to increase (GMCT, 2002) as Table 1 indicates.

Table 1 Population at highest risk for acute hospital admissions (from GMCT, 2002)

In clinical practice hospitalised patient populations show ‘herd characteristics’ determined by local demographics, patterns of referral, and the role delineation of the hospital. Patients admitted with disabling co-morbidities that are not ‘on the list’ of services provided under clinical services planning, can face a difficult time obtaining access to care. Hospital doctors responsible for inpatients need to be cognisant of and adept in managing complex overlapping health needs. Articulating these conditions and requirements for the differing but related groups, which include acute patients, chronic patients and peri-procedural patients assists the doctor to work in a richer decision making environment. These are problems or conditions that occur across many different teams without necessarily being the core business of the team, making this an appropriate field for Hospital Medicine activity.

Section 3: Common problems and conditions


Tabl

e 3.

2: E

ntru

stab

le p

rofe

ssio

nal a

ctiv

ities

for

com

mon

pro

blem

s an

d co

nditi

ons

Acu

te p

atie

nts

Chr

onic

pat

ient

sPe

ripro

cedu

ral p

atie

nts

EPA

HM

3.1

Pro

vide

med

icat

ion

for b

lood

pre

ssur

e(H

SP

2)

Pro

vide

BP

sup

port

in th

e si

ck p

atie

nt.

Inte

rpre

t the

pla

ce o

f and

cho

ices

in

inot

rope

s.

Pro

vide

app

ropr

iate

ther

apeu

tic c

hoic

es in

re

nal f

ailu

re, a

nd a

djus

t ant

i-hyp

erte

nsio

n m

edic

atio

n w

ith a

ge.

Pre

scrib

e, in

itiat

e an

d w

ithho

ld a

nti-h

yper

tens

ive

med

icat

ions

. Im

plem

ent c

hoic

es in

nil

by m

outh

pa

tient

s.

EPA

HM

3.2

Man

age

card

iac

prob

lem

s(H

SP

2)

Man

age

new

ons

et s

hortn

ess

of b

reat

h an

d ch

est p

ain.

Inte

rpre

t the

alte

red

elec

troca

rdio

gram

. Ass

ess

pre-

sync

ope

and

sync

ope.

Pro

vide

app

ropr

iate

ther

apeu

tic c

hoic

es

in c

ardi

ac a

nd re

nal f

ailu

re, p

ostu

ral

hypo

tens

ion.

Man

age

new

atri

al a

rrhyt

hmia

s an

d sh

ortn

ess

of

brea

th in

the

perip

roce

dura

l per

iod.

EPA

HM

3.3

Pro

vide

end

of l

ife

care

(HS

P 2

)

Con

duct

end

of l

ife d

iscu

ssio

ns a

nd

impl

emen

t no

CP

R/ i

nter

vent

ion

orde

rs.

App

ly c

oron

er’s

requ

irem

ents

, cul

tura

l an

d lin

guis

tic d

iver

sity

requ

irem

ents

.

App

ly p

allia

tive

proc

esse

s an

d th

erap

eutic

s, re

ferra

l pat

tern

s an

d so

urce

s of

loca

l cap

acity

.

App

ly c

oron

er’s

lega

l req

uire

men

ts, c

onse

nt a

nd

guar

dian

ship

, dec

isio

ns to

ope

rate

, ope

n di

sclo

sure

an

d cu

ltura

l con

text

.

EPA

HM

3.4

Man

age

infe

ctio

us

cond

ition

s(H

SP

2)

Iden

tify

and

notif

y he

alth

aut

horit

ies

of a

n ou

tbre

ak o

f H1N

1, s

ever

e ac

ute

resp

irato

ry s

yndr

ome,

influ

enza

, no

rovi

rus,

her

pes

zost

er a

nd o

ther

no

tifia

ble

dise

ases

.

Iden

tify

and

notif

y he

alth

aut

horit

ies

of h

epat

itis,

tube

rcul

osis

, hum

an

imm

unod

efic

ienc

y vi

rus.

Pla

n fo

r MR

Os

- M

RS

A, E

SB

L, V

RE.

EPA

HM

3.5

Pro

vide

pai

n m

anag

emen

t(H

SP

2)

Inte

rpre

t the

phy

siol

ogy

and

phar

mac

olog

y of

acu

te p

ain

cons

ider

ing

alte

rnat

ives

in m

edic

atio

n an

d de

liver

y sy

stem

s, a

nd s

plin

ting.

Inte

rpre

t the

phy

siol

ogy

and

phar

mac

olog

y of

chr

onic

pai

n an

d al

tern

ativ

es, a

nd a

pply

ca

re s

yste

ms

for c

hron

ic p

ain.

Rec

ogni

se o

ptio

ns in

pha

rmac

olog

y of

pe

ripro

cedu

ral p

ain.

Man

age

deliv

ery

syst

em in

nil

by m

outh

pat

ient

s, p

lan

for s

urge

ry, a

nd p

resc

ribe

anal

gesi

a to

pro

mot

e m

obilis

atio

n.

EPA

HM

3.6

Man

age

thro

mbo

sis

and

DVT

pr

ophy

laxis

(HS

P 2

)

Rec

ogni

se th

e ap

prop

riate

ness

of

hep

arin

ver

sus

clex

ane.

App

ly

thro

mbo

sis

embo

lism

det

erre

nt. A

sses

s an

d m

anag

e he

art v

alve

pat

holo

gy,

thro

mbo

sis,

vas

cula

r occ

lusi

on a

nd

acut

e m

yoca

rdia

l inf

arct

ion.

Pro

vide

app

ropr

iate

ther

apeu

tic c

hoic

es in

re

nal f

ailu

re, I

nter

natio

nal N

orm

alis

ed R

atio

an

d m

edic

atio

n in

tera

ctio

ns.

App

ly c

urre

nt p

ract

ice

in w

ithho

ldin

g w

afar

in/

plav

ix/as

pirin

and

pro

vide

alte

rnat

ives

. App

ly a

nti-

coag

ulat

ion

reve

rsal

pro

cess

es a

nd in

terp

ret

deci

sion

tree

s. M

anag

e pe

ripro

cedu

ral,

acut

e m

yoca

rdia

l inf

arct

ion

and

com

plic

atio

ns.

EPA

HM

3.7

Pro

vide

dru

g an

d al

coho

l car

e(H

SP

2)

Pre

scrib

e m

etha

done

on

entry

to

hosp

ital,

asse

ss a

gita

tion.

Use

a d

rug

and

alco

hol s

ervi

ce, u

se a

m

enta

l hea

lth s

ervi

ce (e

g, fo

r rev

iew

of

trans

ferre

d in

patie

nts)

. Ass

ist p

atie

nts

to

rem

ain

sobe

r.

Writ

e up

and

inte

rpre

t an

alco

hol w

ithdr

awal

sca

le,

iden

tify

and

man

age

benz

odia

zapi

ne w

ithdr

awal

, m

anag

e po

st p

roce

dure

ana

lges

ic re

quire

men

ts a

nd

beha

viou

rs.

EPA

HM

3.8

Pro

vide

m

enta

l hea

lth /

psyc

hoso

cial

car

e(H

SP

2)

Res

pond

app

ropr

iate

ly to

dis

char

ge

agai

nst m

edic

al a

dvic

e, id

entif

y ps

ycho

sis,

lega

l fra

mew

orks

of r

estra

int,

acut

e m

ood

diso

rder

, and

man

age

treat

men

t pho

bia.

Sup

port

patie

nts

expe

rienc

ing

lone

lines

s,

soci

al is

olat

ion

and

loss

of i

ndep

ende

nce.

S

uppo

rt pa

tient

s ex

perie

ncin

g fu

nctio

nal

chan

ges

and

men

tal h

ealth

issu

es w

ith

prol

onge

d or

repe

ated

hos

pita

lisat

ion

Impl

emen

t gua

rdia

nshi

p re

quire

men

ts a

s ap

prop

riate

.

Man

age

patie

nt fe

ar a

nd p

ost-

diag

nosi

s di

stre

ss.


Tabl

e 3.

2 co

ntin

ued:

Ent

rust

able

pro

fess

iona

l act

iviti

es fo

r co

mm

on p

robl

ems

and

cond

ition

s

Acu

te p

atie

nts

Chr

onic

pat

ient

sPe

ripro

cedu

ral p

atie

nts

EPA

HM

3.9

Rec

ogni

se a

nd

man

age

delir

ium

, de

men

tia a

nd

depr

essi

on(H

SP

2)

Ass

ess

and

man

age

the

new

ly a

gita

ted,

co

nfus

ed o

r with

draw

n pa

tient

. Int

erpr

et

and

resp

ond

appr

opria

tely

to fl

uctu

atin

g at

tent

ion.

Ass

ess

and

man

age

the

post

-eve

nt

depr

esse

d pa

tient

, pos

t-st

roke

de

pres

sion

, the

effe

cts

of s

enso

ry lo

ss.

App

ly th

e S

AD

sco

re.

Ass

ess

and

man

age

perip

roce

dura

l del

irium

, DR

AT

scre

enin

g.

EPA

HM

3.10

Pro

vide

ear

ly

reco

gniti

on a

nd

prom

pt tr

eatm

ent

for s

epsi

s(H

SP

2)

Ass

ess

and

man

age

com

mon

in

fect

ions

— u

rinar

y tra

ct in

fect

ion,

co

mm

unity

acq

uire

d pn

eum

onia

, un

diffe

rent

iate

d se

psis

in th

e el

derly

, in

imm

unos

uppr

esse

d gr

oups

, fe

brile

neu

tropa

enia

, her

pes

sim

plex

en

ceph

aliti

s, a

spira

tion

pneu

mon

ia,

cellu

litis

, Pne

umon

ia S

ever

ity In

dex

and

seps

is e

scal

atio

n. R

ecog

nise

impe

ndin

g an

d se

vere

sep

sis

and

redu

ce ti

me

to

antib

iotic

s an

d co

rrect

ion

of s

hock

.

Ass

ess

and

man

age

mul

ti re

sist

ant

orga

nism

s, d

enta

l inf

ectio

n, re

curre

nt

infe

ctio

n, s

kin

ulce

rs.

Ass

ess

and

man

age

intra

-abd

omin

al in

fect

ion,

di

verti

culit

is, p

rost

hesi

s in

fect

ion,

wou

nd in

fect

ion.

EPA

HM

3.11

Man

age

nutri

tion

need

s(H

SP

2)

Man

age

subs

trate

repl

acem

ent a

nd

med

icat

ion

man

agem

ent i

n ni

l by

mou

th.

Man

age

mal

nutri

tion

and

tota

l par

ente

ral

nutri

tion

and

diffi

culti

es w

ith s

wal

low

ing.

Man

age

re-f

eedi

ng s

yndr

ome,

nas

ogas

tric

feed

ing,

det

erm

ine

the

indi

catio

ns fo

r an

d m

anag

e a

perc

utan

eous

end

osco

pic

gast

rost

omy,

man

age

med

icat

ion

choi

ces

via

tube

feed

ing.

Man

age

com

men

cem

ent a

nd c

essa

tion

of fo

od a

s ap

prop

riate

to th

e pa

tient

’s co

nditi

on, m

anag

e to

tal

pare

nter

al n

utrit

ion,

per

ipro

cedu

ral g

lyca

emic

con

trol,

ente

ral a

nd p

aren

tera

l nut

ritio

n.

EPA

HM

3.12

Mai

ntai

n gl

ycae

mic

co

ntro

l(H

SP

2)

Mon

itor f

or d

iabe

tic k

etoa

cido

sis,

hy

pero

smol

ar s

tate

s, h

ypog

lyca

emia

, st

abilis

ing

bloo

d gl

ucos

e an

d m

anag

e as

app

ropr

iate

.

Mod

ify o

ral h

ypog

lyca

emia

age

nts,

co

mm

enci

ng in

sulin

, con

verti

ng a

way

from

in

sulin

slid

ing

scal

es.

Impl

emen

t ope

ratin

g th

eatre

sch

edul

ing

requ

irem

ents

in d

iabe

tes

mel

litus

, adm

inis

ter

intra

veno

us fl

uids

and

pre

scrib

e in

sulin

in n

il by

m

outh

sta

tes,

sto

p/st

art a

n or

al h

ypog

lyca

emia

ag

ent.

EPA

HM

3.13

Man

age

derm

atol

ogic

al

prob

lem

s(H

SP

2)

Mon

itor a

llerg

ic re

actio

ns, i

nfec

tious

ag

ents

, sca

bies

, dru

g er

uptio

ns a

nd

man

age

as a

ppro

pria

te.

Man

age

pres

sure

are

as a

nd v

enou

s st

asis

.M

anag

e w

ound

man

agem

ent a

nd a

cute

deh

isce

nce.

EPA

HM

3.14

Res

pond

ap

prop

riate

ly to

ob

esity

(HS

P 2

)

Pro

vide

intra

veno

us a

cces

s,

med

icat

ion

dose

cal

cula

tions

, opt

ions

fo

r obs

truct

ive

slee

p ap

noea

, airw

ay

optio

ns, t

rans

port

and

man

ual h

andl

ing

optio

ns.

Mon

itor c

hron

ic c

ellu

litis

, con

tinen

ce,

men

tal h

ealth

, and

pro

vide

opt

ions

for

reha

bilit

atio

n (in

clud

ing

surg

ical

opt

ions

).

Impl

emen

t inv

estig

ativ

e an

d op

erat

ive

optio

ns fo

r po

st-o

pera

tive

resp

irato

ry d

epre

ssio

n, D

VT a

nd P

E

prop

hyla

xis.


Rationale

Unintended consequences have arisen from shortening admission length, less invasive approaches to surgery and subspecialisation. Interventions once commonly performed by the intern, such as inserting and maintaining a suprapubic catheter or changing a PEG tube, and even performing a lumbar puncture occur less frequently in general wards. Much initial patient stabilisation is being performed in the emergency department. In larger institutions the use of support staff such as surgical dressers is not uncommon. An increased number of interns rotating through and a newly recognised need for accreditation of procedural skills and consent requirements have resulted in challenges to acquiring and maintaining procedural skills and a gradual procedural deskilling of hospital medical staff outside specialist units.

The recognition of the realities of practice in a resource-poor environment can provide an impetus to develop and decentralise teaching materials to satisfy the minimum skill set required for a given location. Advances in communication technology offers significant opportunities in this area.

It is anticipated that consistent, skilled hospital medicine practitioners may function as the locus, not only of skill delivery, but of the provision of accreditation and teaching opportunities for junior staff. Knowledge of the indications for a procedure within a specific patient and resource context, and the ability to reach a reasoned decision and plan for intervention, distinguishes the advanced practitioner.

The increasingly aged and complex nature of the inpatient population, and the emerging need to integrate the efforts of many specialist and subspecialist, nursing and allied health systems, and then to function within a restricted resource base, dictates that a particularly broad set of

knowledge skills is required for the hospital medicine practitioner. This is a poorly articulated skill set worthy of additional study when implementing the Hospital Medicine module.

EPA HM4.1 Airway skills (HSP 3)Open the airway. Insert Guedel’s and nasopharyngeal airway. Perform bag valve mask ventilation. Insert laryngeal mask. Set up and monitor continuous positive airway pressure and bi-level positive airway pressure. Carry out decision making in support of, setting up for, and performing simple endotracheal tube airway management. Implement techniques to escalate care for difficult endotracheal tube patient (eg, can’t ventilate, can’t oxygenate). Perform surgical airway. Detect and respond appropriately to changing conditions.

EPA HM4.2 Vascular access (HSP 2)Provide normal and difficult venous access. Obtain arterial blood gases. Place central venous lines — ‘blind’ and under ultrasound. Attach monitoring and perform and confirm correct placement protocol for central vascular catheterisation. Implement best practice recommendations to avoid central catheter infection. Evaluate the need for and place an intra-osseous needle. Perform emergency venous cut down and place arterial lines — by touch and under ultrasound — and attach monitoring. Evaluate the need for and place peripherally inserted central catheter lines.

EPA HM4.3 Cardiovascular (HSP 3)Manage intravenous fluids. Evaluate the need for cardioversion, and if required, prepare for the conduct and performing of cardioversion. Initiate and monitor external pacemaking. Identify electrical and mechanical capture. Place temporary pacemaker in emergencies and interpret basic cardiac echo.

Section 4: Procedural entrustable professional activities


EPA HM4.4 Respiratory (HSP 2)Conduct emergency identification and drainage of tension pneumothorax. Insert intercostal catheter placement and maintain, monitor and remove underwater seal drainage. Conduct pleural drainage.

EPA HM4.5 Central Nervous System (HSP 2)Perform lumbar puncture under asepsis. Obtain and interpret cerebral spinal fluid pressures. Perform sip test to evaluate basic swallowing.

EPA HM4.6 Gastrointestinal (HSP 2)Initiate focused assessment with sonography for trauma scan. Provide peritoneal tap and drainage. Place nasogastic tube and provide confirmation of correct placement protocol. Provide for the care and removal of drains. Provide indications for the organisation and replacement of percutaneous endoscopic gastrostomy tubes.

EPA HM4.7 Urinary (HSP 2)Perform a bladder scan. Insert a simple male and female indwelling catheter, maintain aseptic technique, implement difficult catheter techniques, insert and replace suprapubic catheters as required.

EPA HM4.8 Management of Pain (HSP 2)Provide regional anaesthetic for pain control. Manage patient-controlled analgesia including writing up, setting up, and ceasing as appropriate. Adjust traction as required. Provide simple postoperative pain skills (eg, using Pain Buster). Provide opiate substitution as required.


Rationale

Knowledge and expertise in the common causes and presentations of deterioration is an appropriate skill and knowledge set for the hospital medicine practitioner to learn, maintain, and develop.

Knowledge of uncommon but serious conditions should also be developed and maintained. In this section a number of condition-specific knowledge and procedural skills are synthesised, building into an ‘emergency responses set’ appropriate to managing the undifferentiated patient whose condition deteriorates in hospital.

The most common presentations are respiratory distress, hypotension and neurological derangement.

The most common diagnoses for Medical Emergency Team/CERS scenarios are sepsis, pneumonia, atrial fibrillation and seizures (Calzavacca, Licari, Tee et al 2008).

Delay to activation of the MET/CERS team is known to be associated with worse outcomes (Quach, Downey, Haase et al 2008).

The hospital practitioner is cognisant of the many local determinants of willingness to activate the MET/CERS team, and actively supports the whole team to make the call.

Section 5: Responses to emergencies


Tabl

e 5.

1: E

ntru

stab

le p

rofe

ssio

nal a

ctiv

ities

for

res

pons

es t

o em

erge

ncie

s

Com

pone

nt c

ompe

tenc

ies

EPA

for

rel

ated

but

unc

omm

on

cond

ition

s (c

onte

xtua

l)E

PA H

M5.

1 Im

plem

ent B

LS/

ALS

/ DE

TEC

T/

AP

LS o

r eq

uiva

lent

(H

SP

2)

Hol

d cu

rren

t cer

tific

atio

n or

teac

hing

exp

erie

nce

with

in la

st 2

yea

rs, a

ppro

pria

te

to c

linic

al c

onte

xt –

eg,

with

pae

diat

rics

or w

ithou

t, fa

mili

ar w

ith m

ajor

topi

cs in

re

susc

itatio

n, a

ble

to le

ad a

med

ical

resp

onse

and

pro

vide

a m

inim

um o

f bas

ic

airw

ays

supp

ort.

Inst

itute

car

diov

ascu

lar s

uppo

rt in

ana

phyl

axis

.

EPA

HM

5.2

Man

age

airw

ays

obst

ruct

ion

(HS

P 3

)

Iden

tify

muc

ous

plug

ging

, ide

ntify

pre

sent

atio

ns o

f for

eign

bod

y, id

entif

y ne

ed fo

r and

pe

rform

suc

tion,

pos

ition

ing,

for d

iffic

ult i

ntub

atio

n to

mid

-leve

l ski

lls a

ccor

ding

to

anae

sthe

tic g

uide

lines

.

Man

age

trach

eost

omy

tube

car

e, id

entif

y an

d m

anag

e th

e ai

rway

in e

pigl

ottit

is, a

nd p

erfo

rm

emer

genc

y su

rgic

al a

irway

.

EPA

HM

5.3

Man

age

resp

irato

ry

failu

re

(HS

P 2

)

Iden

tify

type

1 a

nd ty

pe 2

resp

irato

ry fa

ilure

and

resp

ond

appr

opria

tely

to e

xace

rbat

ion

of c

hron

ic o

bstru

ctiv

e pu

lmon

ary

dise

ase.

Iden

tify

sign

s of

det

erio

ratio

n in

pat

ient

with

se

vere

ast

hma,

esc

alat

e br

onch

odila

tors

and

set

up

salb

utam

ol in

fusi

on a

ppro

pria

tely,

id

entif

y cl

inic

al c

riter

ia fo

r tra

nsfe

r to

Hig

h D

epen

denc

y U

nit.

Use

pne

umon

ia s

ever

ity

scor

e. Id

entif

y cr

iteria

for u

se o

f, se

t up

and

adju

st C

PAP

and

BIP

AP.

Iden

tify

pneu

mot

hora

x, d

ecom

pres

s an

d pl

ace

inte

rcos

tal d

rain

. Util

ise

appr

opria

te c

linic

al

and

labo

rato

ry in

vest

igat

ions

in ru

ling

in/o

ut a

pul

mon

ary

embo

lism

.

Est

ablis

h an

d ad

just

ven

tilat

or s

ettin

gs. I

dent

ify

Gui

llan-

Bar

re a

nd m

yast

heni

a gr

avis

and

inst

itute

th

erap

y. R

ecog

nise

whe

ther

to e

scal

ate

care

and

to

alte

r ven

tilat

or s

ettin

gs.

EPA

HM

5.4

Man

age

card

iova

scul

ar

cond

ition

s (H

SP

3)

Rec

ogni

se a

trial

fibr

illatio

n w

ith ra

pid

vent

ricul

ar re

spon

se, a

sses

s pr

ecip

itatin

g ca

uses

, us

e ap

prop

riate

dru

g th

erap

ies

and

follo

w-u

p. R

ecog

nise

and

app

ropr

iate

ly re

spon

d to

the

emer

genc

e of

acu

te p

ulm

onar

y oe

dem

a, u

sing

vas

cula

r dila

tors

, flu

id o

ff lo

ad if

re

quire

d, C

PAP

if n

eces

sary

. Rec

ogni

se a

nd c

an tr

eat b

rady

card

ia in

clin

ical

con

text

. R

ecog

nise

indi

catio

ns a

nd lo

cal p

roce

sses

for p

lace

men

t of t

empo

rary

pac

ing,

can

re

cogn

ise

clin

ical

ly s

igni

fican

t hyp

oten

sion

in a

var

iety

of c

linic

al c

onte

xts,

incl

udin

g oc

cult

gast

roin

test

inal

ble

edin

g an

d dr

ug re

actio

n, c

an p

lace

arte

rial l

ines

and

PIC

C a

nd

cent

ral l

ines

and

initi

ate

inot

ropi

c su

ppor

t, re

cogn

ises

the

EC

G, l

abor

ator

y an

d cl

inic

al

man

ifest

atio

ns o

f acu

te m

yoca

rdia

l inf

arct

ion,

fam

iliar w

ith a

nd a

ble

to in

itiat

e lo

cal

esca

latio

n pr

oces

ses

for i

nter

vent

iona

l car

diol

ogy.

Pla

ce a

tem

pora

ry p

acin

g w

ire. D

emon

stra

te

basi

c co

mpe

tenc

y in

ultr

asou

nd d

etec

tion

of

peric

ardi

al ta

mpo

nade

. Per

form

em

erge

ncy

peric

ardi

al d

rain

age.

Eva

luat

e an

d re

spon

d to

tra

nsfu

sion

reac

tion.

Loc

ate

and

follo

w m

assi

ve

trans

fusi

on g

uide

lines

.


Tabl

e 5.

1 co

ntin

ued:

Ent

rust

able

pro

fess

iona

l act

iviti

es f

or r

espo

nses

to

emer

genc

ies

Com

pone

nt c

ompe

tenc

ies

EPA

for

rel

ated

but

unc

omm

on

cond

ition

s (c

onte

xtua

l)E

PA H

M5.

5 M

anag

e ne

urol

ogic

al

cond

ition

s

(HS

P 2

)

Eva

luat

e th

e si

gnifi

canc

e of

a c

hang

e in

Gla

sgow

Com

a S

cale

in a

wid

e va

riety

of

clin

ical

sce

nario

s. R

ecog

nise

sei

zure

and

initi

ate

airw

ay s

uppo

rt an

d dr

ug tr

eatm

ent

and

inve

stig

atio

n. In

terp

ret t

he c

ereb

ral C

T in

age

-nor

mal

and

age

-abn

orm

al s

cans

. P

erfo

rm lu

mba

r pun

ctur

e. Id

entif

y de

liriu

m a

nd in

stitu

te a

ppro

pria

te p

harm

acol

ogic

an

d no

n-ph

arm

acol

ogic

man

agem

ent.

Rec

ogni

se p

hysi

olog

ical

sig

ns o

f inc

reas

ing

intra

cere

bral

pre

ssur

e an

d ac

tivat

e lo

cal r

esou

rces

to m

anag

e pr

essu

re.

Iden

tify

the

need

for a

nd p

erfo

rm e

mer

genc

y as

pira

tion

of a

blo

cked

ven

tricu

lo -

per

itone

al

shun

t.

EPA

HM

5.6

Man

age

seps

is

(HS

P 2

)

Rec

ogni

se p

hysi

olog

ical

cha

nges

of s

yste

mic

infla

mm

ator

y re

spon

se s

yndr

ome

and

seve

re s

epsi

s an

d im

plem

ent e

ffect

ive

and

appr

opria

te m

anag

emen

t. D

emon

stra

te

appr

opria

te u

se o

f ant

ibio

tics

in fe

brile

neu

tropa

enia

. Rec

ogni

se th

e ne

ed fo

r ino

tropi

c su

ppor

t and

man

age

trans

fer t

o hi

gher

leve

l car

e.

Rec

ogni

se s

epsi

s fro

m re

nal c

alcu

li, o

bstru

cted

ur

eter

and

resp

ond

appr

opria

tely.

Iden

tify

epid

ural

ab

sces

s an

d re

spon

d ap

prop

riate

ly.

EPA

HM

5.7

Man

age

rena

l di

sord

ers

(H

SP

2)

Per

form

bla

dder

sca

n, p

lace

urin

ary

cath

eter

s, m

odify

dru

g do

sage

s in

con

ditio

ns o

f re

nal f

ailu

re, r

ecog

nise

the

phys

iolo

gica

l and

ele

ctro

card

iogr

am m

anife

stat

ions

of l

ife

thre

aten

ing

elec

troly

te d

istu

rban

ces

of s

odiu

m, p

otas

sium

and

inst

itute

em

erge

ncy

treat

men

t.

EPA

HM

5.8

Oth

er –

ha

zard

ous

but

less

com

mon

(H

SP

2)

Rec

ogni

se d

iabe

tic k

etoa

cido

sis

and

hype

rosm

olar

sta

tes

in th

e in

patie

nt a

nd in

stitu

te

stab

ilisa

tion.

Iden

tify

acut

e m

arro

w fa

ilure

, Add

ison

ian

cris

is,

thyr

oid

cris

is, W

erni

ckes

enc

epha

lopa

thy,

B

erib

eri /

vita

min

def

icie

ncy,

incl

udin

g vi

tam

in D

.


Section 6: System design and the characteristics of hospital practice

Rationale

Experienced practitioners in hospital medicine bring additional dimensions to the culture and functioning of their hospitals. Translation of theory into practice, managing a difficult colleague, culture building, promoting cooperation, identifying an opportunity or a threat, responding to changing conditions over time are advanced cognitive and system skills that are under-recognised. Understanding these issues and achieving the hospital skills and knowledge sets listed below will demonstrate the advantages of a whole-of-hospital perspective.

System skills for hospital medicine practitioners:

• Understanding the health system, especially governance and accountability frameworks at local, network, state and federal levels.

• Identifying where knowledge about the local hospital system is stored. Who are the key personnel?

• Recognising the resource characteristics of overlapping clinical frameworks — retrieval, ambulance, disaster, public health, mental health, drug and alcohol, children’s health, trauma and burns networks, tissue donation and transplant, community services.

• Implementing successful systems to reduce avoidable readmission or failed discharge.

• Identifying and containing system failure — single events, multiple events, identifying emerging trends, and having a system-wide view.

• Improvising solutions and understanding the characteristics of high reliability organisations, with the purpose of building organisational resilience.

• Responding swiftly to the deteriorating patient (eg, through situational awareness, identifying and intervening when something goes wrong, knowing the importance of acute prevention, and implementing hazard reduction and reporting systems such as incident information management system [IIMS] and hazard registers).

• Adopting successful approaches to knowledge translation and the implementation of clinical guidelines, applying these to local conditions and understanding the possible constraints in health literacy in the local environment.

• Demonstrating good handovers and record keeping processes, including accessing and modifying electronic health records as required.

• Demonstrating good educational and presentation skills, planning and delivering good educational experiences for colleagues with differing levels of expertise. Understanding meta-cognition (ie, thinking about thinking) — for example, the use and shortcomings of mental heuristics, cognitive biases, clinical reasoning and knowing how doctors think.

• Demonstrating strong communication skills with staff, patients and carers.

• Implementing the overlapping roles of medical expert, health advocate, scholar, professional, communicator, collaborator and manager — for example, through consideration of the CANMED’s domains (see Appendix 2).

• Acting as an effective manager in assisting in shaping the attitude of hospital teams. (eg, understanding what the local clinical environment can offer), holding corporate


hospital knowledge, promoting alternative solutions, building and using trust relationships and social capital.

• Practising niche skills and understanding the local niche requirements (eg, the role of the dietician in total parenteral nutrition and re-feeding).

• Understanding the role of the doctor in the community, the epidemiology of the local area and the cultural mix and requirements of its communities.

• Predicting the nature of hospital work in 10 years (eg, the effect of increasing obesity, responding appropriately to the needs of culturally and linguistically diverse patients, the impact of rising rates of poor mobility, psychosocial stress, mental illness, social fragmentation and increasing numbers of very old patients).

• Recognising the ecology of the local area, being a health advocate for disadvantaged social groups and assisting the health literacy of patients (eg, preventing complications of age-related conditions).

• Developing planning and marketing skills — project management and continuity roles, change management, clinical redesign, research projects.

• Managing multiple roles in accreditation by HETI, the medical colleges, Quality Society of Australasia, Work Health and Safety, ACHS Evaluation and Quality Improvement Program (EQuIP) or equivalent, and providing a focus for medical quality improvement cycles.

The entrustable professional activities listed in Table 6.1 emerge from considering the holistic character of hospital practice, across the three broad categories of inpatients: acute, chronic and periprocedural. These topics and skills also contribute to identifying the requirements of system design.


Tabl

e 6.

1: S

yste

m d

esig

n an

d th

e ch

arac

teri

stic

s of

hos

pita

l pra

ctic

e

Acu

te p

atie

nts

Chr

onic

pat

ient

sP

erip

roce

dura

l pat

ient

sE

PA H

M6.

1 M

inim

ise

med

ical

err

ors/

so

urce

s an

d re

spon

ses

(H

SP

3)

Mon

itor e

arly

det

ectio

n sy

stem

s –

fla

ggin

g, p

reve

ntio

n, o

pen

disc

losu

re,

futil

e cl

inic

al c

ycle

s.

Impl

emen

t sys

tem

des

ign.

Cha

nge

care

pa

ths

as a

ppro

pria

te. M

anag

e or

phan

pa

tient

s, d

etec

t and

inte

rven

e in

faili

ng

care

.

Pla

n ca

re a

nd s

afe

syst

ems.

Man

age

diffi

cult

team

s an

d pl

an fo

r cha

ngin

g ca

re re

quire

men

ts.

EPA

HM

6.2

Res

pond

to

med

ical

em

erge

ncie

s (H

SP

3)

Coo

rdin

ate

CE

RS

team

s –

impl

emen

t tra

inin

g in

acu

te re

spon

seC

oord

inat

e C

ER

S te

ams

– im

plem

ent

train

ing

in E

OL

deci

sion

mak

ing.

Coo

rdin

ate

CE

RS

team

s –

impl

emen

t tra

inin

g in

co

mpl

ex te

am e

nviro

nmen

ts.

EPA

HM

6.3

Lead

han

dove

r pr

oces

ses

(H

SP

2)

Con

duct

han

dove

r pro

cess

es in

to a

nd

out o

f ED

, int

o an

d ou

t of I

CU

/ HD

U, o

ut

of h

ospi

tal.

Man

age

the

Wat

ch L

ist.

Impl

emen

t car

e an

d di

scha

rge

plan

ning

sy

stem

s.C

ondu

ct u

rgen

t tra

nsfe

rs a

nd h

and

offs

.

EPA

HM

6.4

Eng

age

in

adva

nced

cl

inic

al

reas

onin

g

(HS

P 3

)

Take

his

tory

for d

iffer

ent g

roup

s of

pa

tient

s.R

ecor

d m

anag

emen

t pla

ns a

nd a

pply

e-

reco

rds

and

prob

lem

list

s.C

ondu

ct re

ason

for a

dmis

sion

(RFA

) sur

veys

, car

e pa

thw

ays,

pre

-adm

issi

on c

linic

s an

d im

plem

ent

delir

ium

avo

idan

ce s

yste

ms.

EPA

HM

6.5

Faci

litat

e le

arni

ng a

nd

teac

hing

(H

SP

3)

Del

iver

Lea

rnin

g O

n Th

e R

un, T

each

ing

On

The

Run

and

dev

elop

car

e pa

thw

ays

for l

ess

expe

rienc

ed c

olle

ague

s.

Con

duct

pat

ient

car

er a

nd fa

mily

ed

ucat

ion

and

care

pla

nnin

g.Im

plem

ent p

roce

dura

l gui

delin

es a

nd d

isch

arge

ad

vice

as

appr

opria

te.

EPA

HM

6.6

Dem

onst

rate

an

d pr

omot

e le

ader

ship

(H

SP

3)

Pro

vide

app

ropr

iate

man

agem

ent f

or

clin

icia

n le

ader

s.W

ork

appr

opria

tely

with

mul

tidis

cipl

inar

y te

ams.

Lead

acr

oss

tradi

tiona

l bou

ndar

ies.


Tabl

e 6.

1 co

ntin

ued:

Sys

tem

des

ign

and

the

char

acte

rist

ics

of h

ospi

tal p

ract

ice

Acu

te p

atie

nts

Chr

onic

pat

ient

sP

erip

roce

dura

l pat

ient

sE

PA H

M6.

7 S

olve

pro

blem

s in

the

loca

l en

viro

nmen

t (H

SP

3)

Dep

loy

effe

ctiv

e cl

inic

al g

over

nanc

e st

ruct

ures

. Esc

alat

e ac

ute

care

issu

es a

s ap

prop

riate

. Con

duct

ope

n di

sclo

sure

an

d m

anag

e ris

k of

med

ical

err

or.

Adv

ocat

e w

hen

nece

ssar

y fo

r loc

al

serv

ices

and

pat

ient

pop

ulat

ions

.

Man

age

end

of li

fe p

athw

ays,

sys

tem

in

terfa

ce is

sues

aro

und

chan

ging

di

rect

ions

of c

are,

acc

omm

odat

ion

and

cont

ext.

Ass

ess

patie

nt c

ompe

tenc

y.

Esc

alat

e pr

oces

ses

for p

atie

nts

requ

iring

off-

site

se

rvic

es. N

egot

iate

with

the

Bed

Man

ager

as

requ

ired.

EPA

HM

6.8

Par

ticip

ate

in c

linic

al

gove

rnan

ce

(HS

P 3

)

Par

ticip

ate

in lo

cal s

afet

y co

mm

ittee

s,

drug

com

mitt

ees,

reco

gnis

e th

e A

PIN

CH

list

of h

igh

risk

med

icat

ions

(a

ntih

yper

tens

ives

, pot

assi

um, i

nsul

in,

narc

otic

s,ch

emot

hera

peut

ic a

gent

s,

hepa

rin).

Impl

emen

t ref

erra

l sys

tem

s fo

r tim

ely

allie

d he

alth

inte

rven

tion.

Dis

char

ge a

nd

adm

issi

on d

ocum

enta

tion

revi

ews.

Man

age

surg

ical

load

dur

ing

low

act

ivity

tim

es,

cond

uct r

evie

ws

of ti

mel

ines

s an

d ou

tcom

es o

f tra

nsfe

rs fo

r offs

ite c

are.

EPA

HM

6.9

Man

age

conf

lict

(HS

P 2

)

Effe

ctiv

ely

man

age

a di

scha

rge

agai

nst

med

ical

adv

ice.

Impl

emen

t gua

rdia

nshi

p re

quire

men

ts a

s ap

prop

riate

.M

anag

e di

ffere

nces

of p

rofe

ssio

nal o

pini

on.

EPA

HM

6.10

A

ssis

t the

pr

actit

ione

r in

diffi

culty

(H

SP

3)

Ass

ess

clin

ical

com

pete

nce

and

resp

ond

appr

opria

tely

to w

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References

Australian Institute of Health and Welfare (2011) Australian hospital statistics 2009–10: Health services series no. 40. Canberra: AIHW.

The Australian Patient Safety Foundation Annual Report 2009 -2010.

Calzavacca, Licari, Tee et al (2008) “A prospective study of factors influencing the outcome of patients after a Medical Emergency Team review” Intensive Care Medicine 34: 2112–2116.

Clinical Excellence Commission (2008) Recognition and management of the deteriorating patient.

Confederation of Postgraduate Medical Education Councils (Version 2.1) Australian Curriculum Framework for Junior Doctors.

Greater Metropolitan Transition Taskforce (2002) “Care of the acutely ill older person in greater metropolitan hospitals”.

Haggerty J, et al (2003) “Continuity of care: a multidisciplinary review” British Medical Journal 327: 1219–1221.

Miller G (1990) “The assessment of clinical skills, competence, and performance” Academic Medicine 65 (supplement): S63–S67.

Quach, Downey, Haase et al (2008) “Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension” Journal of Critical Care 23: 325–331.

RCA Team at RNSH (2011) RCA Summary.

Ten Cate O (2006) “Trust, competence, and the supervisor’s role in postgraduate training” British Medical Journal 333: 748-751.

Ten Cate O, Scheele F (2007) “Competency-based postgraduate training: can we bridge the gap between theory and clinical practice?” Academic Medicine 82 (6): 542–547.

US Department of Health and Human Services (2010) Healthy People 2010 <http://www.healthypeople.gov/Document/pdf/uih/2010uih.pdf>.

Van der Vleuten C, Schuwirth L (2005) “Assessing professional competence: from methods to programs” Medical Education 39: 309-317.

World Health Organization (2010) <http://www.who.int/patientsafety/implementation/solutions/high5s/ps_high5s_project_overview_fs_2010_en.pdf>.

http://www.healthypeople.gov/Document/pdf/uih/2010uih.pdf


Four levels of knowledge and performance elements have been defined in the patient safety framework. The level of knowledge and performance required by an individual is determined by their level of patient safety responsibility:

Level 1 Foundation knowledge and performance elements are required by all categories of health care workers (as defined below).

Level 2 Knowledge and performance elements are required by health care workers in categories 2 and 3.

Level 3 Knowledge and performance elements are required by health care workers in category 3.

Level 4 Organisational knowledge and performance elements are required by health care workers in category 4.

Some knowledge and performance elements in levels 2 and 3 may not be relevant for all non-clinical managers.

Four categories of health care workers have been defined in the patient safety framework.

Category 1 Health care workers who provide support services (eg, personal care workers, volunteers, transport, catering, cleaning and reception staff).

Category 2 Health care workers who provide direct clinical care to patients and work under supervision (eg, ambulance officers, nurses, interns, resident medical officers and allied health workers).

Category 3 Health care workers with managerial, team leader and/or advanced clinical responsibilities (eg, nurse unit managers, catering managers, department heads, registrars, allied health managers and senior clinicians).

Category 4 Clinical and administrative leaders with organisational responsibilities (eg, Chief Executive Officers, board members, directors of services and senior health department staff).

Health care workers can move to higher categories of the patient safety framework as they develop personally and professionally.

Source: Australian Council for Safety and Quality in Health Care (2005) National patient safety education framework. <www.health.gov.au/internet/safety/publishing.nsf/Content/ C06811AD746228E9CA2571C600835DBB/ $File/framework0705.pdf>.

Appendix 1: Patient safety framework

http://www.health.gov.au/internet/safety/publishing.nsf/Content/C06811AD746228E9CA2571C600835DBB/$File/framework0705.pdf


In 2001 the Royal College of Physicians and Surgeons of Canada developed a diagram that shows the seven CanMEDS roles and the relation between each.

Medical Expert:“As Medical Experts, physicians integrate all of the CanMEDS roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centered care. Medical Expert is the central physician role in the CanMEDS framework.”

Communicator:“As Communicators, physicians effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.”

Collaborator:“As Collaborators, physicians effectively work within a healthcare team to achieve optimal patient care.”

Manager:“As Managers, physicians are integral participants in healthcare organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the healthcare system.”

Health Advocate:“As Health Advocates, physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations.”

Scholar:“As Scholars, physicians demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge.”

Professional:“As Professionals, physicians are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour.”

Reference: Royal College of Physicians and Surgeons of Canada. CanMEDS 2005 Framework.

The Royal College of Physicians and Surgeons of Canada in 2001 developed a diagram that shows the seven CanMEDS roles and the relation between each.

Medical Expert:

“As Medical Experts, physicians integrate all of the CanMEDS roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient‐centered care. Medical Expert is the central physician role in the CanMEDS framework.”

Communicator:

“As Communicators, physicians effectively facilitate the doctor‐patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.”

Collaborator:

“As Collaborators, physicians effectively work within a healthcare team to achieve optimal patient care.”

Appendix 2: CANMEDs domains


This case study from a root cause analysis team at a large teaching hospital illustrates the importance of the hospital-wide perspective advocated by the Hospital Medicine module to avoid problems such as suboptimal communication within and between clinical teams about the deteriorating clinical picture of a patient.

A 52-year-old man with a history of gastric banding for obesity (2009), gastric ulcer (2009), low haemoglobin requiring iron infusions and unstable Type II diabetes mellitus presented to a large emergency department (ED) following referral from his general practitioner (GP). The patient had presented to his GP for review of swelling in his left calf. He also reported a two month history of increased shortness of breath on exertion, postural dizziness, increased heartburn, malaena, and occasional band-like chest pain. The previous day the patient had seen his gastroenterologist (who had performed the original gastric banding surgery) and at that appointment the gastric band was loosened to relieve symptoms of reflux. The GP documented that she suspected ‘severe reflux esophagitis from the gastric band, which is bleeding and causing symptomatic anaemia’.

On presentation to the ED the patient was appropriately triaged. His observations were within normal limits, although a postural drop in his blood pressure was noted. An ECG was preformed showing sinus tachycardia. A chest x-ray was unremarkable. The patient was admitted under the appropriate team with a provisional diagnosis of ‘shortness of breath secondary to anaemia’. Due to ward closures for the Christmas period he was not admitted to the treating team’s ward.

During the second night following admission, the patient had seven episodes of clinical deterioration falling within the Yellow zone and one episode falling within the Red zone of the standard adult general observations (SAGO) chart. These episodes were related to desaturation and tachycardia. These episodes were not escalated as per the ‘Between The

Flags’ guidelines. He also had two falls during his admission (no injury). ECG changes during his admission showed ST elevation and tachycardia, while his troponin levels were elevated and consistent with pulmonary emboli (PE). The patient also had an echocardiogram which suggested PE. He was reviewed daily by his treating team, but the staff specialist was not involved in ward rounds (this is standard for this procedural-based outpatient specialty). Medical review also included extensive review overnight which revealed a suspicion of PE, but evidence of clinical handover was limited.

Findings of a gastroscopy/endoscopy were consistent with the provisional diagnosis. During this procedure, the patient again desaturated and required anaesthetic reversal. While in the unit for these procedures, the staff specialist and patient discussed his discharge and, although the staff specialist would have preferred the patient to remain as an inpatient overnight, due to the patient’s insistence that he be discharged, it was agreed that he be discharged home later that afternoon. The staff specialist was unaware of any episodes of clinical deterioration of the patient, falls or echocardiogram results during the admission.

Before discharge, the patient was reviewed by the junior member of the medical team and in light of the patient’s clinical condition was again reviewed by the registrar. The patient’s saturation levels at this time fell within the Red zone of the SAGO chart. Despite this, he was discharged home.

Later that evening, the patient developed shortness of breath, chest tightness and epigastric pain and an ambulance was called. When it arrived, the patient complained of a sudden onset of chest pain and dyspnoea, and lost consciousness. He remained in asystole and was transported to the same ED where continued resuscitation attempts were unsuccessful. His death was referred to the Coroner.

Appendix 3: Case study for reflection


Notes page

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