SLO 1 – Care for physiologically stable adult patients presenting to acute care across the full range of complexity

This Specialty Learning Outcome is the basic building block for patient care within the ED.  It outlines the development of expertise in history taking, examination, decision making and management of individual adult patients presenting to the ED.

It includes the care of all physiologically stable adult patients, the knowledge, skills, behaviours and attitudes are applied across the range of presentations and conditions outlined in the syllabus. At completion of training an EM specialist will be expert in this SLO however complex.

Being expert in this SLO includes an understanding and aptitude in caring for patients with mental health problems, those with complex co-morbidities and those with frailty needs. These are outlined in more detail.

Relevant GPC domains

Domain 1: Professional values and behaviours
Domain 2: Professional skills

• practical skills
• communication and interpersonal skills
• dealing with complexity and uncertainty
• clinical skills (history taking, diagnosis and medical management; consent; humane interventions; prescribing medicines safely; using medical devices safely; infection control and communicable disease)

Domain 3: Professional knowledge

• professional requirements
• national legislation
• the health service and healthcare systems in the four countries

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

• patient safety
• quality improvement

Key ACCS capabilities

At completion of ACCS a trainee will be able to:

• gather appropriate information, perform a relevant clinical examination and be able to formulate and communicate a management plan that prioritises patient’s choices and is in their best interests, knowing when to seek help
• assess and formulate a management plan for patients who present with complex medical and social needs

These capabilities will apply to patients attending with physical and psychological ill health

Key EM capabilities

At completion of Intermediate training a trainee will be able to:

• assess and manage all adult patients attending the ED. These capabilities will apply to patients attending with both physical and psychological ill health
• assess and formulate a management plan for patients who present with complex medical and social needs or who manifest as one of the frailty syndromes

with Supervisor ‘on call’ from home for queries, able to provide directions via phone and able to attend the bedside if required to provide direct supervision

At completion of higher training a trainee will:

• Be expert in assessing and managing all adult patients attending the ED. These capabilities will apply to patients attending with both physical and psychological ill health

and would be able to manage with no supervisor involvement

ACCS descriptors

• Demonstrate professional behaviour with regard to patients, carers, colleagues and others
• Deliver patient centred care including shared decision making
• Take a relevant patient history including patient symptoms, concerns, priorities and preferences
• Perform accurate clinical examinations
• Show appropriate clinical reasoning by analysing physical and psychological findings
• Formulate an appropriate differential diagnosis
• Formulate an appropriate diagnostic test and management plan, taking into account patient preferences, and the urgency required
• Explain clinical reasoning behind diagnostic and clinical management decisions to patients/carers/guardians and other colleagues
• Appropriately select, manage and interpret investigations
• Recognise need to liaise with specialty services and refers where appropriate
• Demonstrate awareness of the needs of vulnerable adults attending the acute care sector
• Demonstrate professional behaviour with regard to patients, carers, colleagues and others

Intermediate & Higher Descriptors

General

• Recognise when care would be more appropriately delivered by other healthcare professionals

Mental Health

• Assess and initially manage patients of all ages presenting with features consistent with mental illness by taking account of their psychiatric and medical history, mental state examination, vital signs and available investigations
• Make a competent assessment of a patient’s suicide risk, taking into account circumstances and known risk factors
• Professionally and compassionately assesses a patient in crisis
• Safely manage acutely disturbed behaviour
• Manage the patient threatening to abscond
• Work collaboratively with Psychiatry Liaison staff and other agencies (including the Police) where necessary when caring for patients with mental health problems
• Contribute effectively to multidisciplinary care for frequently attending patients with mental illness
• Identify risk factors for suicide and/or absconsion and mitigates these by appropriate nursing/security observation
• Competently manages the physical/wound care and toxicological consequences of self-harm
• Understand safeguarding responsibilities
• Safely manages aggressive or disturbed behaviour via de-escalation techniques as well as assisting with physical and chemical restraint (rapid tranquilisation) by providing clinical oversight
• Communicate effectively with psychiatry liaison colleagues, nursing staff, security and the police when necessary
• Understand the legal frameworks underpinning the care of the psychiatric patient, as relevant to the ED and ED observation areas
• Respect patient autonomy but understand when a patient lacking capacity should have investigations or treatment made in their best interests

Older patients with complex co-morbidity in the ED

• Able to interact with frail older people especially those with cognitive impairment and their carers and families
• Able to assess for frailty syndromes: falls and fragility fractures, immobility, incontinence, polypharmacy, end of life care, delirium and “non-specific presentations”
• Aware of physiological pitfalls in assessment and management of frail older people including in trauma and resuscitation
• Aware of the evidence base underpinning the utility of investigations and interventions in frail older people
• Aware of safeguarding issues in older people
• Aware of mental health presentations in older people and liaison services
• Aware of pharmacokinetics and pharmacodynamics in frail older people and its interaction with existing polypharmacy
• Aware of medicolegal framework and associations for managing older people with cognitive impairment
• Aware of various models of care delivery for improving quality of care for frail older people including frailty decision units, ambulatory frailty pathways, role of multidisciplinary teams in the ED
• Aware of design principle for EDs to improve person-centred outcomes for older people including structure, resources and processes

Observational medicine

• Able to evaluate patients in a CDU/ observational medicine setting, be able to estimate risk and utilise diagnostic tests appropriately and make safe discharge plans, liaising with other services effectively when needed
• Able to communicate effectively with patients in the CDU/observational medicine setting