ED Tiers.

Tier [Examples]	Expectation
1. [FY1]	– Require direct supervision – At a minimum patient being admitted should be discussed with a more senior clinician (ideally Tier 3+), and reviewed in person by a senior clinician if being discharged (Tier 3+)
2. [FY2-ST2]	– Require reduced supervision compared to tier 1 – Require access to on-site supervision but able to see some patients independently within a limited and agreed scope of practice – RCEM senior sign-off guidance appliesProgression of increasing responsibility and experience as per RCEM curriculum
3. [ST3/SAS/ACP]	-Senior doctors able to lead a department with remote supervision from a tier 5 doctor.Possess some extended skills that can be practiced independently. Full scope ofpractice – Progression of increasing responsibility and experience as per RCEM curriculum
4. [ST4+, SAS]	– Senior doctors able to lead a department with remote supervision from a tier 5 doctor. – Possess some extended skills that can be practiced independently. – Full scope of practice – Progression of increasing responsibility and experience as per RCEM curriculum
5. [Consultant]	– Senior doctors with a full set of extended skills and who have demonstrated their ability to take independent clinical responsibility for an ED – Reference point: RCEM curriculum

Senior Reviews.

The following require Consultant/Tier 4/PEM T3+ – Sign off

• NEWS2 > 5
• Atraumatic chest pain in patients aged 30 years and over
• Fever in children under 1 year of age
• Patients making an unscheduled return to the ED with the same condition within 72 hours of discharge
• Abdominal pain in patients aged 70 years and over

The review should be recorded in the patient’s clinical notes and should ideally include the patient being seen and reviewed in person by the EM Senior.

Responsibility in ED – Trust Agreed

The following principles have been agree by ALL: CD’s, DD’s and Medical Director, (as per GIRFT guidance)

Consultant Expectations

The following are the agreed expectation of consultant roles in ED