SLO 3 – Resuscitate and stabilise patients in the ED, knowing when it is appropriate to stop

EM clinicians need to be expert in the resuscitation and stabilisation of critically ill adults. This outcome outlines what is needed to be able to deliver that role. It includes the leadership of resuscitation teams, communication with patients and their loved ones and the support of the whole resuscitation team. It also includes knowing when not to resuscitate and when to stop. The care of those at the end of their life is also represented in this Speciality Learning Outcome.

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

At completion of ACCS a trainee will:

  • Recognise and manage the initial phases of any acute life threatening presentation including cardiac arrest and peri-arrest situations and know when to seek help.
  • Be able to provide definitive airway, respiratory and circulatory support to critically ill patients with support.
  • Be able to establish the most appropriate level of care for critically unwell patients – including end-of life decisions – and support their needs as well as those of their loved ones.

On completion of training an EM specialist will:

  • Be able to provide airway management & ventilatory support to critically ill patients
  • Be expert in fluid management and circulatory support in critically ill patients
  • Manage all life-threatening conditions including peri-arrest & arrest situations in the ED
  • Be expert in caring for ED patients and their relatives and loved ones at the end of the patient’s life
  • Be able to effectively lead and support resuscitation teams

An EM specialist is / can:

  • Identify an acutely ill patient by taking account of their medical history, clinical examination, vital signs and available investigations
  • Integrate clinical findings with timely and appropriate investigations to form a differential diagnosis and an initial treatment plan
  • Institute definitive airway management and initiate and maintain advanced respiratory support
  • Utilise intravenous fluids and inotropic drugs as clinically indicated, utilising central venous access where required and monitored by invasive monitoring techniques
  • Manage life-threatening cardiac & respiratory conditions including peri-arrest & cardio-respiratory arrest situations
  • Formulate and initiate ongoing treatment plan for a critically ill acute surgical or acute medical patient post resuscitation, including those with sepsis and institute timely antimicrobial therapy with an aim for ongoing stabilisation
  • Communicate effectively and in a timely manner with fellow members of the multi-disciplinary team including those from other specialties and completing accurate legible and contemporaneous entries in the medical record
  • Arrange escalation of care when required and provides a succinct structured handover of the relevant patient details including treatment to that point
  • Recognise a patient is in danger of deterioration or who requires further treatment and provides explicit instructions regarding an ongoing treatment plan and contact details should a further review be required
  • Decide when it is appropriate to end resuscitation, and is cognisant of the specific care needs of patients and their loved ones when this decision has been made
  • Respect patient autonomy and understands when and how they should use advance directives & living wills
  • Recognise the potential for organ donation in certain end of life situations and is aware of associated best practice guidelines and legislation
  • Demonstrate effective consultation skills in challenging circumstances
  • Demonstrate compassionate professional behaviour and clinical judgement

Simulated Practice: progressing from identification & initial treatment of critically ill patient to being a team leader of a multi-disciplinary resuscitation team

Supervised practice: progressing from defined time in resus, being first attender to leading a complex resuscitation case to definite endpoint & carrying out team debrief afterwards to being senior doctor in charge of the resuscitation area (e.g. EPIC resuscitation)

RCEM-learning modules: life & limb threatening conditions, resuscitation, organ donation, end-of life care, debrief

ALS/ APLS/ EPLS/ NLS/ ATLS / ETC courses

Airway management skills including endotracheal intubation will continue through intermediate and higher specialty training. This will include experiential learning that will include continuing experience of RSI. This will include maintaining a log book, undertaking RSI in the ED under direct supervision, and may include time in theatre. The requirement for skill retention following IAC is under development.

Skill retention in circulatory management is required. This will include continued experience of central vein cannulation. The requirement for skill retention following ACCS sign off is under development.

Airway management & ventilatory support

Demonstrate ability to recognise patients with airway & ventilatory difficulties, and provide appropriate support to these patients. Recognise situations where there is potential for airway & ventilatory problems & act appropriately to minimise complications. Demonstrate ability to work within a multi-disciplinary team to provide airway management & ventilatory support.

  • Mini-Cex, CBD; DOPS inc simulated patients

Attainment of competence in airway management & ventilatory support as per ACCS criteria

  • IAC
  • IBTCM Basic Level Training Document

Fluid management and circulatory support in critically ill patients

Demonstrate ability to recognise patients with circulatory difficulties, and provide appropriate support to these patients. Recognise situations where there is potential for development of circulatory problems & act appropriately to minimise complications. Demonstrate ability to work within a multi-disciplinary team to provide fluid management & circulatory support.

  • Mini-Cex, CBD, RCEM assessment app
  • DOPS inc simulated patients

Attainment of competence in fluid management & circulatory support as per ACCS criteria

  • IAC
  • IBTCM Basic Level Training Document

Management of all life-threatening conditions including peri-arrest & arrest situations

Demonstrate ability to identify sick patients among those they are directly providing care for, commence resuscitation and participate in a/ the multi-disciplinary resuscitation team as a team member. Demonstrate ability to formulate and initiate ongoing treatment plan for a critically ill acute surgical or acute medical patient post resuscitation.

  • Mini-Cex, CBD
  • DOPS inc simulated patients

Attainment of competence in management of life-threatening conditions as per ACCS criteria

  • IAC
  • IBTCM Basic Level Training Document

Transfer of resuscitated patient to definitive care

  • Mini-Cex; CBD; DOPS inc simulated patients
  • ALS course (Certification or instructor status)
  • IAC
  • IBTCM Basic Level Training Document

Care for ED patients and their relatives and loved ones at the end of life

Determine when it is appropriate to withhold, limit or withdraw resuscitation treatment, cognisant of the specific care needs of patients and their loved ones when this decision has been made

  • Mini-Cex;  CBD; DOPS inc simulated patients
  • ALS course (Certification or instructor status)
  • IAC
  • IBTCM Basic Level Training Document

Lead and support resuscitation teams

  • Mini-Cex, CBD; DOPS inc simulated patients; RCEM leadership tool
  • ALS course (Certification or instructor status)
  • IAC
  • IBTCM Basic Level Training Document

Airway management & ventilatory support

Demonstrate ability to recognise the need for & deploy the key initial interventions in airway management & ventilatory support consistently. Demonstrate development of skills in leadership of others in provision of airway management & ventilatory support within a multi-disciplinary team.

  • Mini-Cex, CBD, ELSE, RCEM assessment app (including specific assessments of team leading abilities)
  • DOPS inc simulated patients

Fluid management and circulatory support in critically ill patients

Demonstrate ability to recognise the need for & deploy the key initial interventions in fluid management & circulatory support consistently. Demonstrate development of skills in leadership of others in provision of fluid management & circulatory support within a multi-disciplinary team.

  • Mini-Cex, CBD, ESLE (including specific assessments of team leading abilities)
  • DOPS inc simulated patients

Management of all life-threatening conditions including peri-arrest & arrest situations

Demonstrate ability to identify sick patients among those they are directly providing care for & commence resuscitation consistently. Demonstrate ability to formulate and initiate ongoing treatment plan for a critically ill acute surgical or acute medical patient post resuscitation consistently.

Demonstrate development of skills & knowledge to formulate and initiate ongoing treatment plan for a critically ill acute surgical or acute medical patient post resuscitation. They will be developed in the skills to liaise with multi-disciplinary and other specialty teams to ensure best patient care.

Demonstrate an awareness of the limits of their capability, know when to seek help for complex cases and can do so in a timely manner. 

  • Mini-Cex, CBD, ESLE (including specific assessments of team leading abilities)
  • DOPS inc simulated patients
  • ALS/ APLS/ EPLS/ ATLS (Certification or instructor status)

Transfer of resuscitated patient to definitive care

  • Mini-Cex, CBD, ESLE (including specific assessments of team leading abilities)
  • DOPS inc simulated patients; RCEM leadership tool
  • ALS/ APLS/ EPLS/ ATLS (Certification or instructor status)

Care for ED patients and their relatives and loved ones at the end of life

  • Mini-Cex, CBD, ESLE (including specific assessments of team leading abilities)
  • DOPS inc simulated patients
  • ALS/ APLS/ EPLS/ ATLS (Certification or instructor status)

Lead and support resuscitation teams

  • Mini-Cex, CBD, ESLE (including specific assessments of team leading abilities)
  • DOPS inc simulated patients; RCEM leadership tool
  • ALS/ APLS/ EPLS/ ATLS (Certification or instructor status)
  • FRCEM Intermediate Certificate

Suitable WPBAs include RCEM assessment App; Mini-cex; CBD; ESLE.

Airway management & ventilatory support

Demonstration of application of skills & knowledge attained to patients with airway & ventilatory problems. Provide guidance & leadership to others in provision of airway management & ventilatory support as leader of a multi-disciplinary team.

  • Mini-Cex, CBD, ELSE, RCEM assessment app (must demonstrate ability to lead the multi-disciplinary team in both adult and paediatric cases)
  • DOPS inc simulated patients; RCEM leadership tool
  • ALS/ APLS/ EPLS/ ATLS (Certification or instructor status)
  • ETC certification
  • ESLE (must demonstrate ability to lead the resuscitation area as a whole, involving overview of a number of cases. As well as leading a multi-disciplinary team in any adult and paediatric cases)

 Fluid management and circulatory support in critically ill patients

Demonstration of application of skills & knowledge attained to patients with circulatory problems. Provide guidance & leadership to others in provision of circulatory support as leader of a multi-disciplinary team.

  • Mini-Cex, CBD, ELSE (must demonstrate ability to lead the multi-disciplinary team in both adult and paediatric cases)
  • DOPS inc simulated patients; RCEM leadership tool
  • ALS/ APLS/ EPLS/ ATLS (Certification or instructor status)
  • ETC certification
  • ESLE (must demonstrate ability to lead the resuscitation area as a whole, involving overview of an number of cases. As well as leading a multi-disciplinary team in any adult and paediatric cases)

Management of all life-threatening conditions including peri-arrest & arrest situations

Demonstration of application of skills & knowledge attained to patients with life-threatening conditions. Provide guidance & leadership to others in provision of circulatory support as leader of a multi-disciplinary team.

  • Mini-Cex, CBD, ELSE (must demonstrate ability to lead the multi-disciplinary team in both adult and paediatric cases)
  • DOPS inc simulated patients; RCEM leadership tool
  • ALS/ APLS/ EPLS/ ATLS (Certification or instructor status)
  • ETC certification
  • ESLE (must demonstrate ability to lead the resuscitation area as a whole, involving overview of a number of cases. As well as leading a multi-disciplinary team in any adult and paediatric cases)

 Transfer of resuscitated patient to definitive care

  • Mini-Cex, CBD, ESLE (must demonstrate ability to lead the multi-disciplinary team in both adult and paediatric cases)
  • DOPS inc simulated patients; RCEM leadership tool
  • ALS/ APLS/ EPLS/ ATLS (Certification or instructor status)
  • ETC certification

Care for ED patients and their relatives and loved ones at the end of life

  • Mini-Cex, CBD, ESLE (must demonstrate ability to lead the multi-disciplinary team in both adult and paediatric cases)
  • DOPS inc simulated patients; RCEM leadership tool
  • ALS/ APLS/ EPLS/ ATLS (Certification or instructor status)
  • ETC certification

Lead and support resuscitation teams

  • Mini-Cex, CBD, ELSE (must demonstrate ability to lead the multi-disciplinary team in both adult and paediatric cases)
  • DOPS inc simulated patients; RCEM leadership tool
  • ALS/ APLS/ EPLS/ ATLS (Certification or instructor status)
  • ETC certification

Entrustment decisions

End of ACCS level 2b:

  • Trainees at the end of core training will be entrusted to identify sick patients among those they are directly providing care for, commence resuscitation and participate in multi-disciplinary resuscitation as a team member.
  • They will also be able entrusted to formulate and initiate an ongoing treatment plan for a critically ill acute surgical or acute medical patient post initial  resuscitation, including those with sepsis.

End of intermediate training level 3:

  •  At the end of intermediate training a trainee will be entrusted to recognise the need for & deploy the key initial interventions consistently..
  • They should have developed skills to be able to lead the multi-disciplinary team in typical resuscitation cases to disposal in adult and paediatric care aware of the limits of their capability and  know when to seek help for complex cases and can do so in a timely manner.
  • They should have an awareness of resuscitation status and withholding or withdrawing treatment. They should have a knowledge of procedure for organ donation.

Higher Specialist training Level 4:

Early in HST Level 3:

  • In early HST EM trainees should have further developed their leadership skills & both their procedural skills in continuing patient care.
  • They should be able to effectively lead with authority the multi-disciplinary team in resuscitation through to disposal regardless of complexity in all but exceptional circumstances.
  • They should be developing skills in debriefing after resuscitations to enable others to learn & also in supervision of junior trainees to provide expert feedback on their progress.

At the end of HST Level 4:

  • At the end of training an EM specialist will be entrusted to lead the multi-disciplinary team in any complex resuscitation through to disposal.
  • They should be able to assume a full role in making and implementing decisions about resuscitation status and withholding or withdrawing treatment.
  • They should be able to debrief after resuscitations to enable others to learn, supervise junior trainees and provide expert feedback on their progress.
  • They should be able to hold the position of EPIC for the resuscitation area as a whole, involving overview of multiple cases.
  • Excellence might be demonstrated by highly effective leadership skills, the ability to rapidly and insightfully work out the key step in a time critical resuscitation or the maintenance of a highly professional demeanour in challenging resuscitation scenarios, acting as a role model for team members.

RCEM examinations

MRCEM 
SBA
OSCE
FRCEM
SBA
MSO

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