DRAFT - RCEM Specialty learning outcomes: Describing the scope … Draft Specialty... · 2018-10-17 · Be able to lead a multidisciplinary paediatric resuscitation including trauma

Last update 19/04/2018

DRAFT - RCEM Specialty learning outcomes:

Describing the scope of practice

The RCEM curriculum sub-committee have identified 13 specialty learning outcomes

that we believe describe independent practice as an Emergency Medicine

Specialist. These range from the skills and knowledge of an expert diagnostician and

resuscitationist, through shop floor leadership to key administrative activities. These

represent a range of what we believe to be relatively discrete activities. They are

not, however, intended to be equal in size and scope. The development of the

clinical skills required for expert emergency care delivery will remain the primary

focus of learning and assessment. We include the wider skill set required to support,

guide, administer, teach and lead to ensure fundamentals are in place to cope with

the huge array of challenges that leading a shift in the ED can pose. This current

document outlines the starting point for development.

The specialty learning outcomes we outline ensure that Generic Professional

Capabilities (fig1.), required by the GMC, are covered. We are also required to

describe levels of entrustment for supervision (Fig 2.). We have included these

below to indicate our initial thoughts on how a clinician might develop in each

aspect. In this way we give an indication of what an independent EM clinician might

be expected to be able to do. These are activities and so the title of each speciality

learning outcome follows on from the following statement;

A fully trained EM specialist will be able to…

The assessment schedule through which progress will be reflected and fed back will

be the minimum that is required for reliable estimates of performance. The FRCEM

exam will remain a key summative step to ensure professional knowledge remains

ensured.

The decision about whether a trainee is ready to progress at key points, usually

where this means a change in responsibility, will be framed as an ‘entrustment

decision’ that the training faculty will be expected to make. These decisions will be

informed by assessment in the work place and will take into account the trainees’

own views and concerns about readiness. Decisions about unreadiness are not

punitive, but a realistic reflection of the wide ranging and challenging nature of EM

care and that differences exist between trainees and are to be expected.

We will highlight indicators of excellence in the specialty learning outcomes as we

further refine. In this way, we aim to have an approach that reflects accurately,

fairly and transparently the range of performance across the varying domains that

people must cover in work. We will use exception reporting to remove the need for

blanket coverage of every element of training, we will allow very clear statements

about whether a trainee is ready to progress and aim to encourage the pursuit of excellence in our plan.

Figure 1. Generic Professional Capabilities

Domain 1: Professional values and behaviours

Domain 2: Professional skills

Domain 3: Professional knowledge

Domain 4: Capabilities in health promotion and illness prevention

Domain 5: Capabilities in leadership and team working

Domain 6: Capabilities in patient safety and quality improvement

Domain 7: Capabilities in safeguarding vulnerable groups

Domain 8: Capabilities in education and training

Domain 9: Capabilities in research and scholarship

Figure 2. Levels of Entrustment for Supervision

1. Observing the activity

2. Acting with direct supervision in the room

3. Acting with supervision available within minutes

4. Acting unsupervised (i.e. under clinical oversight)

5. Providing supervision to others

In drafting our specialty learning outcomes we need to be able to say clearly and

decisively to trainees, the public and ourselves that someone who finishes training

would be fit to look after one of our own.

The following are outlines of the speciality learning outcomes we have developed.

They are presented to give an overview of the approach we propose. They will be

further developed with stakeholder feedback. We seek feedback on the broad

approach we have taken.

Specialty learning outcome 1


care for low acuity, high complexity,

stable patients

Specifications & Limitations

Patients with multiple complaints requiring a focussed workup around the most

concerning complaint;

Patients with uncommon or unusual complaints; patients unable to provide much

history; those with cognitive impairment, intoxication; patients with complex co-

morbidity or frailty needs.

Relevant GPC domains

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Required experience / skills / attitudes / behaviours / knowledge

History

Examination

Differential diagnosis generation

Presentation skills to individuals or ‘board round’

Use of secondary sources

Able to communicate effectively in challenging encounters

Communicating effectively with clinical colleagues

Effective handover



answer clinical questions on the

shop-floor


Supporting the clinical team in answering clinical questions about individual patient

care.

Includes an understanding of key pitfalls in diagnostic reasoning, awareness of

when it is appropriate to review patients directly, able to teach these principles to

others as the trainee nears reaches independence.


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ECG interpretation

Cognitive psychology of decision making

Bayesian analysis

Diagnostic test methodology

Decision rule design

Use of guidelines

Communicating ideas



resuscitate anyone and know not to


Caring for Patients with likely and less common serious/life-threatening

conditions

Resus team membership

Resus team leadership

Post-resuscitation care of patients

End of life decisions, including withdrawing and withholding limiting

resuscitation treatment, consideration of advanced directives and living wills.

Organ donation


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Specialty learning outcome 3 continued…


Can identify likely and less common but serious/life-threatening complaints

Can initiate, lead and complete resuscitation

Can clinically manage patient that has been successfully resuscitated

Can discuss with colleagues and relatives in a professional and empathic

manner, the initiation or possible discontinuation of active interventions when

this is considered to be medically appropriate

Respects patient autonomy and understands when and how they should use

advanced directives such as Do Not Attempt to Resuscitate (DNAR) orders,

living wills and durable powers of attorney

Recognition of futility in pursuing resuscitation in certain cases and the

subsequent ability to manage issues associated with end of life care

Can approach the issue of organ donation sensitively, and is aware of the

associated legislation

Can offer constructive, useful feedback in this domain

The ability to rapidly assimilate the strengths of individual team members to

allow allocation of tasks as necessary

The recognition of the need to perform specific resuscitation tasks by individual

team members

The ability to perform an immediate or delayed team debrief

Communicating ideas



care for the injured patient


Able to assess and manage patients with isolated non-life-threatening injuries

Able to manage patients with multiple and/or life-threatening injuries

Have the skills to lead (and be a member of) a multi-disciplinary trauma team


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Skills

Ability to perform primary/secondary survey

Examination skills required to identify/diagnose injury including vascular and

neurological consequences

Appropriate use of investigations including XR/CT/US/MRI to confirm

presence/consequences of injury

Management of wounds, soft tissue injuries, fractures and dislocations including

local anaesthetic techniques

Safe use of range of local anaesthetic techniques (field block, ring block,

common regional nerve blocks).

Range of techniques for wound closure (simple dressing, suturing, skin

adhesive, steri-strips).

Management of fractures and dislocations (slings, splints, basic plastering,

manipulation as appropriate)

Removal of foreign bodies from the eye and ear.

Manage a patient with burns

Attitudes & Behaviours

Provide calm and effective leadership in major trauma or Major Incident

scenarios

Participation in local/national audit and research into trauma care

Supervision of a multi-disciplinary team in caring for injured patients, including

Nurse Practitioners/ACPs

Acceptance that all patients presenting to ED are entitled to assessment and a

safe management plan, which may include signposting to other services

and/or education on self-care.

Provide opportunistic advice on accident prevention.

Knowledge

Likely injury patterns dependent upon mechanism of injury

Pathophysiology and management of injury (including specific populations

e.g. elderly, paediatric and pregnancy

Local/regional/national trauma protocols and guidelines

Human factors/non-technical skills that affect performance of team caring for

trauma patient

Major Incident Plans and how they will affect the ED/hospital

Ability to predict likely prognosis/recovery time of injuries including potential

complications

Able to assess burns, wounds and injuries including vulnerable anatomic

structures.

Understanding of social/economic consequences of injury upon individual and

society including specific knowledge of the implications of violent crime (e.g.

gun or knife)

Ability to estimate a timeline of healing and give general and specific safety

net advice on concerning features of potential complications.



care for the paediatric patient


Caring for children of all ages from 0-16 years at all stages of development and

children with complex needs and their families.


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Be able to interact with children of different stages of development and their

families to elicit the history

Be able to undertake a careful, sensitive and flexible examination of children of

all ages, at different stages of development and with complex needs

Be aware of the different developmental stages of children and their

assessment and how injury and illness can affect this

Acquire the special skills needed to resuscitate children of all ages and know

that this may differ dependent on developmental age and know how this

differs from adult resuscitation

Be aware that paediatric life-threatening emergencies are infrequent and

therefore prior preparation is essential i.e. successful completion of APLS or

equivalent is needed


Be able to lead a multidisciplinary paediatric resuscitation including trauma

Be able to lead a team debrief following a paediatric resuscitation/trauma

Acquire the special skills needed to manage the paediatric patient– e.g.

airway management, vascular access

Know that the interpretation of vital signs and tests is age dependant e.g. ECG,

radiology, bloods

Be able to prescribe safely for children

Know when to utilize distraction techniques and play therapists to manage

children in the ED

Be able to identify the sick child and initiate appropriate management steps

Know that paediatric trauma is different to adult trauma

Assess paediatric patients with concerning presentations and know that some

of the presenting symptoms could be manifestations of non- accidental injury

(NAI)

Be able to talk with parents and inform them that a social services referral is

being made

Be able to identify those patients needing urgent specialist attention and know

when and how to refer

Have an understanding of which patients can be safely discharged home and

what follow-up they may need

Know the immunisation schedules

Know and respect the legal framework and ethical issues relating to children in

the ED including consent and confidentiality

Know the local procedure for sudden unexpected death in infants and

children (SUDIC)



deliver ‘Pinnacle’ Emergency Care

Skills


The EM Physician should be able to perform key emergency skills that are time

critical and/or life/limb saving.


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Has the clinical knowledge to identify when key practical emergency skills are

indicated.

Has the clinical knowledge of how to safely conduct the skill.

Has the clinical knowledge to identify when a practical procedure should be

deferred to an in-patient specialist for definitive management.

Has the manual dexterity to perform the skill safely and in a timely fashion.


Can supervise another team member to complete the skill safely and make

judgements about junior colleagues’ competence in this domain.

Appropriately uses the National Safety Standards for Invasive Procedures

(NatSSIPs) checklist.

Maintains skills for rare procedures that are life-saving and time critical. An

Emergency Physician who has completed their training and is working in an ED

without the in-patient services to provide the skills for rare, life-threatening

conditions (e.g. resuscitative thoracotomy, peri-mortem caesarean section)

should acquire and ensure maintenance of skills via simulation courses, local

training, etc.



deal with shop floor curve balls


Individual shop-floor occurrences, situations or circumstances that do not pertain

directly to clinical evaluation, but that need managing effectively.


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Understand adult safeguarding issue; capacity assessment;

Dealing with police/FME enquiries on the shop floor

Knowledge of the medical/legal interface on the shop floor

Supporting clinical staff in a shop floor ‘melt down’

Ability to deal with hospital colleagues when accepting clinical handover

appears troublesome

Liaising with primary care colleagues on clinical shop floor matters

Know how to deal with violent or threatening situations



lead the ED shift as ‘Emergency

Physician in Charge’ (EPIC)


Provide support to ED staff of all levels and disciplines.

Liaise with the rest of the acute / urgent care team.

Lead the shift!


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Knowledge:

Patient flow management & escalation

Risk management across the ED

Understanding of major incident plan


Skills:

Management of workload

Task prioritisation

Management of staff & allocation of resources including staff

Leadership

Situational awareness

Communication

Management of conflict

Able to conduct a ‘board round’

Providing support & feedback to other staff members

Able to liaise with the rest of the hospital w.r.t safety and performance

Attitude & Behaviour:

Remains calm and professional at all times

Demonstrates assertiveness whilst maintaining professionalism

Provides an acceptable role model to others



supervise and appraise junior

colleagues


Supervise the clinical practice of junior colleagues and provide feedback following

this supervision.

Observe clinical practice of a doctor in training in the work place or in a simulated

work environment and debrief the doctor with good judgement in order to support

their learning and development as a clinician.

Support colleagues after a significant event in clinical practice by facilitating a

debrief and taking forward learning opportunities.

Appraise junior doctors.


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Identifies that a junior colleague has gaps in their knowledge, competence or

performance.

Understands the different aspects of non-technical skills relevant to

performance in an emergency physician.

Ability to monitor and observe non-technical skills in clinical practice and in

simulated teaching sessions.

Consistently applies effective techniques to feedback on performance to

colleagues.

Ability to facilitate a debrief after a clinical event to ensure learning is shared

with all members of the team and the wider clinical community as appropriate.

Understands the difference between feedback and debrief and is able to use

both techniques appropriately to support development of junior colleagues.

Respects the process of appraisal in professional practice and supports this

both in junior colleagues, peers and personal practice.



educate the team


Set educational objectives and deliver an effective session on any EM topic


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Proficient in bedside teaching, small group facilitation and presentation skills

Able to organise local and regional teaching programmes using the RCEM

Curriculum as a blueprint

Able to instruct learners on procedural skills

Able to facilitate a basic simulation session Understanding that not all learners

are the same and different teaching techniques may enhance teaching

dependant on group

Able to tailor teaching content and style dependant on learner’s prior

knowledge

Understands the importance of having clearly defined achievable learning

outcomes

Understand different modes of delivering feedback and knows which is most

appropriate for each learning event

Can re-direct learners to appropriate resources to consolidate learning

Can communicate with other teacher’s appropriately to create a teaching

day relevant to learners need

Can teach in real life scenario’s, engaging the learner whist maintaining quality

patient care.

Able to peer-review others teaching sessions, giving appropriate feedback to

enhance their teaching sessions in the future

Understand key principles of teaching delivery

be able to use a variety of teaching techniques appropriate for topic

be able to use questions as teaching opportunities

be able to use effective constructive feedback

be able to communicate effectively to engage the learner

be able to teach practical skills

be able to organise a regional teaching day or educational course

be able to complete constructive WBPA’s for juniors with guidance for

improvement



understand, apply and contribute to

research


Be able to participate in research, take consent and recruit patients (GCP training)

interpret and synthesise research findings.


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GCP training- to allow involvement with departmental research

Able to construct PICO questions

Able to search the medical literature for evidence to answer PICO questions

Able to appraise studies of therapy and diagnosis and meta-analyses of the

same

Able to synthesise the findings of studies of therapy and diagnosis to deliver a

‘clinical bottom line’

Able to collate research, audit or QIP findings to present to a meeting as a

poster or oral presentation



lead an Emergency Medicine Quality

Improvement project to completion


The Quality Improvement Project must be directed to improve patient care in the

ED.

Projects that aim to save money or meet performance targets are important, but

not necessarily quality improvement, though a QIP might lead to savings.


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l kn

ow

led

ge

Ca

pa

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s in h

ea

lth

pro

mo

tion

an

d illn

ess

pre

ve

ntio

n

Ca

pa

bilitie

s in le

ad

ersh

ip

an

d te

am

wo

rkin

g

Ca

pa

bilitie

s in p

atie

nt

safe

ty a

nd

qu

ality

imp

rov

em

en

t

Ca

pa

bilitie

s in

safe

gu

ard

ing

vu

lne

rab

le

gro

up

s

Ca

pa

bilitie

s in e

du

ca

tion

an

d tra

inin

g

Ca

pa

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s in re

sea

rch

an

d sc

ho

larsh

ip


Knowledge

Understands and can compare and contrast improvement tools and

methodology.

Understands and can compare and contrast the principles of measurement for

improvement, judgement, and research.

Can describe types of measures and methods of assessing variation.

Understands principles of change management.

Skills

Proactively identifies opportunities for Quality Improvement and can lead

multidisciplinary Quality Improvement project teams.

Can supervise a Quality Improvement project involving junior trainees and

other members of the multidisciplinary team using improvement methodology.

Leads and facilitates team-based reflective evaluation of a project.

Organise and prioritise a departmental quality improvement project.

Behaviour

Demonstrates advocacy for clinical quality improvement.

Encourages and supports trainees and other clinicians who want to start

clinical quality improvement.

Engages staff outside the emergency department in quality improvement.



undertake key administrative tasks


Medico-legal - handling complaints, reports for coroner or legal services

Risk management – Investigation of a serious incident, participation in ED clinical

governance

Human resources – rota management, recruitment

Management training (Local) – Committee work

Management training (National) – the evolving NHS landscape

Relevant Domains of Competence 1 Professional values and behaviours


1 2 3 4 5 6 7 8 9

Pro

fessio

na

l va

lue

s an

d

be

ha

vio

urs

Pro

fessio

na

l skills

Pro

fessio

na

l kn

ow

led

ge

Ca

pa

bilitie

s in h

ea

lth

pro

mo

tion

an

d illn

ess

pre

ve

ntio

n

Ca

pa

bilitie

s in le

ad

ersh

ip

an

d te

am

wo

rkin

g

Ca

pa

bilitie

s in p

atie

nt

safe

ty a

nd

qu

ality

imp

rov

em

en

t

Ca

pa

bilitie

s in

safe

gu

ard

ing

vu

lne

rab

le

gro

up

s

Ca

pa

bilitie

s in e

du

ca

tion

an

d tra

inin

g

Ca

pa

bilitie

s in re

sea

rch

an

d sc

ho

larsh

ip


Can respond to complaints in a variety of formats including verbal response,

written response and face to face meetings

Can construct a report for the coroner and legal services using information

available from clinical notes

Can assist in leading a SI investigation and be familiar with the tools involved

such as RCA/ 5 Whys/Fishbone

Participate in ED CG meetings

Represent the ED on a Hospital Committee (such as resuscitation committee,

transfusion committee, trauma committee etc.) and feedback to the ED team

meeting

Participate in the daily rota management ensuring adequate skill mix and

cover

Participate in recruitment for the ED

Awareness of the interplay of various agencies in the NHS and how they

interrelate in the evolving NHS Landscape

Documents

DRAFT - RCEM Specialty learning outcomes: Describing the scope … Draft Specialty... · 2018-10-17 · Be able to lead a multidisciplinary paediatric resuscitation including trauma