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
  • RCEM learning modules, podcasts and blogs, mapped to the key EM capabilities and to the EM syllabus.
  • Local teaching will also be mapped to the Key capabilities and underpinning syllabus.
  • RCEM learning modules, podcasts and blogs, mapped to the key EM capabilities and to the EM syllabus.
  • Local teaching will also be mapped to the Key capabilities and underpinning syllabus.
  • Simulation will be used to provide feedback to enable development in dealing with distressed patients and relatives

The focus of learning in this outcome in HST will include:

  • The care of patient with complex co-morbidity; developing expertise in supporting patients with frailty needs; learning how to work effectively with other agencies to provide best care for such patients; developing expertise in caring for highly distressed patients with psychological illness. This may be delivered in local teaching.
  • A programme of learning in observational medicine will be delivered and include experience of work in such units in at least one rotation in training

Experience of caring for a physiologically stable but potentially complex patient will be a key feature of the Emergency Medicine and Acute Medicine components of ACCS. In this time these key skills will be honed by experience, receiving focussed feedback, discussion, reflection and following patients through the early part of hospital admission. In core training, development in this learning outcome is of fundamental importance.

It is therefore expected that in ACCS EM a trainee would seek feedback on their care of such patients on most shifts. These may the take the form of brief educational episodes captured using the RCEM assessment app.

Evidence to inform decisions include:

  • ACAT
  • CbD
  • ESLE
  • Logbook of cases
  • Mini-CEX
  • MSF
  • RCEM App
  • MCR (AM)

Learners will be expected to seek feedback across the full breadth of EM patients. This must include patients attending with mental health problems, frailty issues and complex co-morbidity.

Challenging case where there are barriers to history or examination or where there is uncertainty are of particular value, to chart progress in this aspect. It is expected that assessment would begin in the first week or two of each post.

In intermediate training the programme of learning will focus on more challenging cases. This might include distressed patients, those with acute mental illness, more complex co-morbidities, and ensuring that learners have a clear and robust approach to defining a worst case scenario in all circumstances in preparation for HST work.

Evidence to inform decisions include:

  • ACAT
  • CbD
  • ESLE
  • Logbook of cases
  • Mini-CEX
  • MSF
  • RCEM App
  • MCR (AM)

In HST learners will be expected to be able to provide safe care in all but the most challenging cases, and learners will be role modelling good care and supporting others in this learning outcome. The most complex or challenging cases will be sought out. In particular those with where there is clinical or organisational complexity- including when a number of agencies are required to deliver the optimum outcome for the patient, or when there is uncertainty or patient or relatives are distressed.

Learners will also receive feedback about their handling of risk in the care of patients on CDU/ observational medicine unit. This feedback will inform reflection about the learners’ diagnostic approach and approach to managing risk as a decision maker.

Evidence to inform decisions include:

  • ACAT
  • CbD
  • ESLE
  • Logbook of cases
  • Mini-CEX
  • MSF
  • RCEM App
  • MCR (AM)

Entrustment Decisions

End of core training level 2b :

At the end of ACCS a trainee will be entrusted to evaluate a physiologically stable patient by taking a history and examining the patient, formulate a differential diagnosis that includes a realistic worst case scenario and articulate a plan for investigation and management. They will also able to interpret key investigations, including ECG and plain radiography.  They will be entrusted to know their limitations and when to seek help.

End of intermediate training level 3: 

At the end of intermediate training a trainee will be entrusted to evaluate any physiologically stable patient attending the Emergency Department and be able to formulate an appropriate and safe management plan in all but the most complex cases with senior support only available remotely

End of HST Level 4:

At the end of HST a trainee will be entrusted to evaluate any physiologically stable patient attending the Emergency Department and be able to formulate an expert management plan independently. They will be able to support others in this domain and be a role model for this element of EM work

RCEM examinations

MRCEM 
SBA
OSCE
FRCEM
SBA
MSO

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