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Clinical Expectations

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)

ED Clincial Responsibility Principles 03062024[56] copyDownload

Consultant Expectations

The following are the agreed expectation of consultant roles in ED

Consultant expectationsDownload

Swallowed Foriegn Body

The ingestion of a foreign body or multiple foreign bodies (FB) is a common presenting complaint in paediatric surgery, with a peak incidence from 12-24 months however, can occur at any age. Ingested foreign bodies rarely cause problems; almost 80% of patients pass the foreign body without intervention – in seven days2 (only 1% require surgical removal). However, occasionally foreign bodies can cause significant morbidity (for example, oesophageal rupture) and 1% require surgical removal.

The presenting symptoms and outcomes of an ingested foreign body is highly dependent on the swallowed object, and for this reason, the guidance for hazardous and non-hazardous foreign body ingestion has been divided accordingly.

Using the Metal Detector

Non-Hazardous Objects

Button Battery

Ingestion of Button Battery = POTENTIAL EMERGENCY

See separate post for more resources and education if desired.

Magnets

 

Sharp Objects

PDF copy – HERE

Vascular Emergencies (Regional Pathways)

Intro

Vascular surgery has been reconfigured across etc region. The vascular oncall will be based at BRI 24/7.

Multiple pathways have been developed below to help guide appropriate use – full guide HERE

AAA (Symptomatic)
 
AAA (Incidental)
 
Ischaemic Limb (Acute)

Ischaemic Limb (Critical)

Ischaemic Limb (Intermittent Claudication)
 
Uncontrolled Haemorrhage (Interventional Radiology)

Some patients benefit from control of bleeding using embolization techniques, which is a procedure performed by an Interventional Radiologist.

Patients should be treated in their receiving hospital to the maximum of that hospital’s capability, where at all possible. When all local treatment options have been exhausted, the patient should be discussed with one of the Arterial Centres (BRI) with a view to transfer for ongoing management by IR techniques.

Isolated Vascular Trauma

Diabetic Foot

Emergency Transfer

Urgent Vascular Clinic

Access is very limited to this clinic. It is envisioned by WYVas that access to UVAC for ED patients will be arranged through direct (telephone) referral to either:

  • IN hours: Local (HRI) or ON-Call (BRI)Vascular Consultant
  • OUT of hours: ON-Call (BRI) Vascular Consultant

Brief Resolved Unexplained Event (BRUE)

Brief Resolved Unexplained Event (BRUE) is now the recommended term for ALTE (Apparent Life Threatening Event).

Definition:

BRUE is defined as an episode in an infant less than 12 months old characterized by: 

  • < 1 minute duration (typically 20-30s)
  • Followed by return to baseline state
  • Not explained by identifiable medical conditions

Includes one or more of the following:  

  • Central cyanosis/pallor
  • Absent, decreased or irregular breathing
  • Marked change in tone (hyper or hypotonia)
  • Altered level of consciousness

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