Systematic Training in Acute Illness Recognition and Treatment (START)
Faculty Handbook
Third edition
Systematic Training in Acute Illness Recognition and Treatment (START)
Faculty Handbook
Third edition
Edited by Steve Cavanagh, Kim Chandler, Louise Cousins, Ben Lindsey and Mark O’Donnell
Systemic Training in Acute Illness Recognition and Treatment (START)
©2022 The Royal College of Surgeons of England. All rights reserved.
First edition printed 2014 in the United Kingdom.
Published by the Royal College of Surgeons of England, Registered Charity no. 212808
The Royal College of Surgeons of England
38–43 Lincoln’s Inn Fields London WC2A 3PE
www.rcseng.ac.uk
No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the Royal College of Surgeons of England.
While every effort has been made to ensure the accuracy of the information contained in this publication, no guarantee can be given that all errors and omissions have been excluded. No responsibility for loss occasioned to any person acting or refraining from action as a result of the material in this publication can be accepted by the Royal College of Surgeons of England or the contributors.
Foreword
Thank you for agreeing to teach on the Systematic Training in Illness Recognition and Treatment (START) course, which was first developed by the Royal College of Surgeons of England in 2006. The course has been updated and relaunched as the Third Edition in 2021. The new edition consists of reading and reflection activities followed by a 1-day, face-to-face interactive session.
This course is primarily aimed at Foundation Year 1 (FY1) doctors completing their preregistration year, no matter what discipline of medicine they plan to go on to practise. It may also be beneficial to other members of the medical and surgical teams, such as advanced care practitioners, physician associates and surgical care practitioners. Cases have been provided across a whole range of both medical and surgical conditions, with learning objectives relevant to all doctors. This is a major change for this edition, which moves away from a surgical focus and emphasises that all FY1 doctors and clinical staff working at a similar level can benefit from the START course.
The new edition of the Participant Handbook has been rewritten and updated with advances in medical practice. New chapters have been added to reflect the increasing importance of human factors. Participants are expected to read the Participant Handbook before the face-to-face day. This ensures that they come to the face-to-face day with a base level of knowledge and are therefore bestplaced to use the interactive components of the course to develop their understanding.
The face-to-face day has been completely revised, removing most of the lectures. Interactive cases, a series of hands-on patient assessments and an exciting virtual ward round session have been added, allowing participants to problem-solve, triage and work in teams.
START aims to provide instruction in the practical management of critically ill and potentially ill inpatients in any hospital setting and provides participants with a common-sense, consensual and safe approach to patients.
The course is deliberately designed to be formative, rather than summative, with no formal assessment or pass/fail rubric. It recognises the enormous leap between medical school and the challenges and responsibilities of real clinical practice. As well as the course teaching a systematic approach to the assessment and management of patients and their problems, it builds confidence and introduces ideas about human factors and responsibility.
The course has been designed to be delivered to FY1 doctors at any point in their foundation year. The faculty can be flexible in their approach, depending on the experience and confidence of the participants.
Course ethos
The course is much more than another ‘ABC’-type course, with the aim of not only emphasising the threestage assessment system to participants, but also to help them realise how vital their role is in providing care to patients. This will empower them to think of themselves as doctors and not just as technical members of the ward or team. In general, the FY1 role in current practice is busy and hectic; each team of junior doctors has a large number of patients to look after, some of whom will be very sick and some of whom will be at risk for becoming very sick. We need to help them create order from this chaos.
FY1 doctors are generally the first responders when a track and trigger system indicates a potential problem with a patient and this course aims to emphasise that their actions at that stage can have a major influence in final patient outcomes and empower them to act appropriately. Clearly, FY1 doctors do not need to escalate everything to a specialist registrar or consultant level and the aim of the START threestage system of assessment is to give them the confidence and skills to make the right decisions about which patients to escalate care on and act in an assertive manner when making that request for escalation.
Additionally, it is expected that the same assessment system will also help them to understand their role in the general running of the ward or team and in the management of more stable patients, and their smooth journey through their hospital stay. The aim, as ever, is to improve patient outcomes and their experience of care while in hospital.
Contributors to the third edition
Editors
Stephen Cavanagh
MD, FRCS (General Surgery), PGCHPE; Consultant Vascular Surgeon, York Hospital; Programme Clinical Lead for the Royal College of Surgeons of England CCrISP® and START courses
Kim Chandler
MBCHN, BSc (Hons); Associate Specialist, Gastroenterology and General Medicine, York Hospital
Louise Cousins
MB, BCh, BAO, MRCS; General Surgery Registrar Trainee ST5, Craigavon Area Hospital, County Armagh, Northern Ireland
Ben Lindsey
FRCS; Consultant General Vascular and Renal Transplant Surgeon, Barts Health NHS Trust
Mark O’Donnell
Dip SEM (GB&I), MF SEM (UK), MF SEM (RCSI & RCPI), MFSTEd, MMedSc (Dist), MD, RPVI (ArDMS), FCPhleb, FRCSEd (General and Vascular Surgery), FEBVS (Hons); Consultant Vascular and Endovascular Surgeon, Royal Victoria Hospital, Belfast
Contributors
Ian Maheswaran
FRCS(Gen Surg) MA MSc MEd FHEA FFSTEd, Consultant UGI & Bariatric Surgeon, Chief of Surgery, TPD HE KSS Core Surgery, Clinical Lead RCS Eng for CCrISP & START courses
Dibyendu Bandyopadhyay
MBBS, MS (General Surgery), FRCS, PG Cert in Medical Education; Consultant Colorectal Surgeon, York Hospital
Prashanth Chowdary
MBBS MS (General Surgery) MRCS (Eng), Barts Health NHS Trust
Andy Kordowicz
MA, MEd, FRCS; Consultant Vascular Surgeon, York Hospital
Ben Lindsey
FRCS; Consultant General Vascular and Renal Transplant Surgeon, Barts Health NHS Trust
Jeffrey Lordan
FRCS, PhD, MRCS, MBBS, BSc; Consultant HPB and Sarcoma Surgeon, Royal Free Hospital, London; Senior Lecturer, University College London Medical School
Sudhakar Mangam
MS, FRCS, FEBS-C; Consultant General and Colorectal Surgeon, The Queen Elizabeth The Queen Mother Hospital, Margate
Kalyan Raman
MD, FRCA; Consultant in Anaesthesia and Critical Care, York Hospital
Jonathan Redman
MBChB, FRCA, FFICM; Consultant in Anaesthesia and Intensive Care Medicine, York Hospital
Donald Richardson
MBChB, BSc, FRCP; Consultant Renal Physician, Deputy Medical Director and Chief Clinical Information Officer, York Hospital
Clare Scott
RGN, BSc (Hons); Lead Sister, Critical Care Outreach Team, York Hospital
Shraddha Shetty
MBBS MS (General Surgery), MRCS (Eng), Barts Health NHS Trust
Olivia Smith
MBBS (Hons), BSc (Hons), MSc (Dist); Foundation Year Doctor, York Hospital
Michael Stone
MBChB, FRCA; Consultant Anaesthetist, York Hospital
David Yates
MBChB, FRCA, FFICM; Consultant in Anaesthesia and Intensive Care Medicine, York Hospital
Contributors to previous editions
Editors
Daniele Bryden
MB CHB, FRCA, FFICM, LLB (Hons), MML
John S Jameson
MA (Cantab), MBBS, FRCS, MD
Contributors
Will Carr FRCS
Kiron Chakrabrati FRCA
Giuseppe Garcea MB ChB FRCS MD
Mary Herns PhD
Robert Insall FRCS
Ben Lindsey FRCS
Andrew Moir FRCS
Junia Rahman FRCSEd FRCA
Roderick Skelly FRCS
Andrew Temple MRCP FRCA FFICM
Acknowledgements
We thank our surgical, anaesthetic and intensive care medicine colleagues up and down the country, who work hard to deliver the best care possible to patients and frequently give up their free time to train and inspire the next generation of doctors.
We thank all the contributors to the Care of the Critically Ill Surgical Patient ® course, from which this course is built.
We also thank the Royal College of Surgeons of Edinburgh for the definitions in the Non-Technical Skills for Surgeons System Handbook (v 2.0, 2019), which have been used in the chapter on Human Factors in this Handbook.
The Royal College of Surgeons of England acknowledges the generous support of
About the editors
Steve Cavanagh
Mr Steve Cavanagh has been a consultant vascular surgeon in the York and North Yorkshire Vascular Unit since 2004. He has a wide-ranging vascular practice, covering all aspects of vascular surgery, with particular interests in aortic and carotid disease. He is actively involved in undergraduate and postgraduate teaching and is an honorary senior lecturer in the Hull York Medical School. He is also interested in patient safety, having been involved in introducing safety briefings and checklists into York Hospital.
Mr Cavanagh qualified in Leeds in 1991 and undertook his surgical training and MD thesis in Yorkshire. He became involved in the Care of the Critically Ill Surgical Patient® (CCrISP®) course in the 1990s, while a surgical registrar, and taught regularly on provider courses in Leeds. In 2007, he initiated and directed the CCrISP® course in York and later Scarborough, which he enjoys running every year. He also regularly teaches internationally for both the CCrISP® provider and instructor courses. Mr Cavanagh was appointed as Programme Clinical Lead for CCrISP® and START in January 2017.
Kim Chandler
Dr Kim Chandler is an associate specialist in gastroenterology and hepatology and graduated from the University of St Andrews in 2007 (BSc Medicine) and then Manchester University in 2010 (MBChB). She has served in the Royal Air Force and Army. On leaving the military and unable to apply for core medical training, she designed her own general medical and gastroenterology specialist training.
Dr Chandler has a diverse inpatient and outpatient gastroenterology practice, with a key interest in the management of gastrointestinal bleeds, particularly the pre- and post-endoscopic management of variceal bleeds.
Dr Chandler has vast acute and general medicine experience, pioneering the role of ‘acute physician in charge’ as a way of managing the ever-increasing demand of the acute medical take in district general hospitals. She sits on the local ‘Deteriorating Patient’ and ‘Surviving Sepsis’ steering groups. More recently, she was appointed as the COVID-19 lead for York and Scarborough Teaching Hospitals NHS Foundation Trust and Principal Investigator for RECOVERY in York. She has lectured nationally and internationally on the management of COVID-19 and has advised on national treatment protocols. She is also part of the local clinical commissioning group’s clinical ethics committee during the pandemic.
Dr Chandler is passionate about the recruitment and retention of doctors within hospital medicine, particularly women and single parents, and has worked tirelessly to design and actively recruit locally into new ‘trust grade’ and ‘specialty doctor’ roles, supporting career progression for those for whom it has been previously difficult.
Louise Cousins
Ms Louise Cousins is a general surgery specialty trainee working in Northern Ireland with a special interest in breast surgery. She graduated from Queen’s University Belfast in 2010 receiving the Sir Thomas Houston prize for first place in microbiology. She completed the Erasmus Programme in Switzerland during her undergraduate studies. After Foundation and Core training, Louise completed a year as a specialty doctor in breast surgery before entering specialty training.
Ms Cousins is an enthusiastic educator, embracing teaching roles throughout her career. She has worked as an anatomy clinical demonstrator with Queen’s University Belfast and has completed two teaching fellowships as a specialty trainee. She completed a master’s in medical education with distinction based on research evaluating social media vascular educational resources. This research culminated in first-place prizes at the Joint Irish Vascular Societies’ Annual Meeting in 2018 and 2019. She is actively involved with the Royal College of Surgeons of England (RCS England) and teaches regularly on RCS England courses. She continues to develop her interest in human factors and medical education.
Ben Lindsey
Mr Ben Lindsey was appointed as a renal transplant and vascular surgeon in London in 2008. He teaches laparoscopic donor nephrectomy and complex open vascular surgery, sometimes to facilitate transplantation. He is supporting the physician’s associate course at Queen Mary University of London and Barts Health NHS Trust because he feels that integration of all allied health professionals is crucial. He delivers change management by constantly questioning dogma.
Mr Lindsey qualified at University College London in 1993 and trained in the UK and Cape Town, South Africa. He left the NHS for a year to work as a hyperbaric medicine physician. After specialist registration, he worked single-handed as a general surgeon in South Africa. Already experienced in the CCrISP® course, he encountered the START course in 2010. He recognised the broader potential of START and developed the model to roll it out to all newly qualified doctors at the Royal Free Hospital in 2014. Since then, it has been delivered annually in-house as part of the Foundation Year 1 curriculum. He regularly teaches internationally on both the CCrISP® provider and instructor courses.
Mark O’Donnell
Professor Mark O’Donnell graduated from Queen’s University Belfast in 1999 with distinction. After higher surgical training in Northern Ireland, he completed a vascular surgery fellowship at the Mayo Clinic where he attained the academic rank of assistant professor. After receiving first-place honours in the Fellow of the European Board of Vascular Surgery Examination, he was appointed as consultant vascular and endovascular surgeon in East Lancashire in 2015 before moving to the Belfast Vascular Centre in 2017.
Professor O’Donnell has completed both a master’s in medical science and a medical doctorate. His research has yielded over 100 PubMed publications and many prestigious awards, including the Society of Vascular Surgery International Scholar Award, Society of Academic Research Prize and Belfast City Hospital Young Investigator of the Year. He is a strong advocate of the principles of the ‘Getting it Right First Time’ programme, effective patient communication and promoting human factors in surgical training. He continues to maintain an active interest in trauma surgery along with his academic practice based at Ulster University’s Sport and Exercise Sciences Research Institute in Northern Ireland. He is a regular faculty member and course director of the Intercollegiate Basic Surgical Skills course and RCS England’s START course.
Course overview
Aim
Participants learn how to manage the critically ill or potentially unwell patients on the wards or high-dependency unit.
Target audience
This course is most suitable for FY1 doctors. It may also be beneficial to other members of medical and surgical teams, such as advanced care practitioners, physician associates and surgical care practitioners.
Duration
1 day
Resources
Faculty
A faculty to participant ratio of 1:5, plus the course director, is required. If necessary the morning sessions can be delivered by just two members of faculty.
Electronic USB stick containing:
• PowerPoint presentations for each session;
• START algorithm videos.
Online learning site for faculty and coordinators containing:
• copies of the presentations and handouts;
• START algorithm videos (streaming only, not downloadable);
• programme template;
• joining instructions template.
Hard copy
• Faculty Handbook
• Participant Handbook
• Participant handouts
• Flip chart
• START algorithm poster
Clinical The Practical Assessment session requires mannequins, skills beds and a variety of equipment for managing patients, such as airways, masks, BP cuffs and cannulas. Further details are available in the Course Delivery Guide.
Course delivery
This course is about the practical application of knowledge, rather than an exercise in knowledge transfer. It is our job to improve participants’ confidence and encourage them to use their knowledge in a logical way when they come across unfamiliar situations. The START system of assessment helps them make a logical and safe start to almost any clinical situation; frequent reference to it will help get participants into the habit of using it.
It is very important that this course is taught in a reproducible fashion and to a common standard, ensuring consistency in training wherever participants study. Away from the course, participants have to satisfy many senior colleagues and examiners at work and in examinations. Consequently, they need accepted middle ground approaches that they can use under a range of circumstances. All experienced doctors have their own clinical preferences, but faculty must put our personal preferences aside to give participants the advantage of a unified message.
CCrISP® faculty will note that the START algorithm is the same as the CCrISP® algorithm. However, participants will mostly be in their foundation year so the level of knowledge, skills and confidence may be lower than expected on CCrISP®. Faculty will need to bear this in mind when facilitating discussions and simulations.
Pre-course learning: a copy of the participant handbook is made available at least four weeks before the course.
Face-to-face day: after a general introduction to the course and the START algorithm, participants work in groups to critique cases where decision-making was poor. They then do interactive sessions focusing on the START algorithm and human factors. After lunch, they are split into groups again for simulated patient scenarios, followed by a virtual handover, where they practise prioritisation and triage skills in teams. The day ends with a summary and feedback on the course.
Assessment: the course is assessed formatively; there is no pass/fail element.
Learning outcomes
By the end of the course, participants will be able to:
• recognise an unwell patient;
• perform a systematic patient assessment;
• commence appropriate treatment;
• escalate care to an appropriate senior doctor;
• recognise the importance of human factors in the workplace;
• harness team resources available to them.
Each session has learning outcomes that map to one or more of the course-level learning outcomes. The session-level learning outcomes can be found in the session plans.
Course programme
Time
Content
8:30am – 9:00am Registration and refreshments/faculty meeting/ complete sticky notes
9:00am – 9:15am Welcome and introduction
9:15am – 10:15am Patient consequences Case critiques – group work
10:15am – 10:30am Refreshments
10:30am – 11:30am START algorithm
How to use the START system of patient assessment
11:30am – 12:15pm Human factors
Non-technical skills: teamwork, situational awareness, decision-making, task management, communication
12:15pm – 12:50pm Lunch
12:50pm – 3:05pm Practical assessment of a patient Simulated patient scenarios
3:05pm – 3:20pm Refreshments
3:20pm – 4:35pm Virtual handover challenge
Formulating management plans and prioritising patients – group work
4:35pm – 5:00pm Course summary, questions and feedback
5:00pm Finish/faculty meeting
Roles and responsibilities
Course director
Course directors are responsible for the overall running of the course. There are a few vital things to take care of.
Before the course:
• Identify a codirector who can cover for you in the event that you are suddenly unable to attend (eligibility requirements apply – see Faculty requirements).
• Make sure you know exactly which sessions are running in which rooms and what technical and administrative support is needed for each session (see the Course Delivery Guide).
• Assign teaching sessions to faculty in advance so that they have time to prepare.
During the course:
• Ensure the course runs to time.
• Conduct a faculty meeting immediately before the course covering:
o the ethos of the course;
o how the course is organised;
o what is expected of faculty;
o how assessment will be done and faculty responsibilities during assessment.
Remember to:
o start and finish on time;
o structure the meeting to avoid rushing;
o introduce everyone and make new faculty welcome;
o allow time for faculty to ask questions.
• Troubleshoot problems, working with technicians and coordinators to get matters resolved as quickly as possible, so that participants have a good experience despite any issues.
After the course:
• Hold a faculty meeting at the end of the course to gather feedback on what went well and what could be improved. Encourage faculty to complete the online evaluation and give their feedback directly to RCS England.
Supporting new faculty
New faculty must meet the eligibility requirements. See the Course Delivery Guide for details. The first time they teach on the course, they must be a supernumerary instructor candidate (IC). You or your codirector will observe them and sign them off as suitable, or not suitable, to be faculty:
• Familiarise yourself with the IC observation form so you know what to look out for.
• Have a chat with the IC beforehand to understand why they want to become faculty, what their goals are and what their perceived areas of challenge are.
• Set your expectations of them during the course and assign them to specific groups/activities if appropriate, so that they can prepare. Ensure they have sufficient opportunities to demonstrate their teaching skills.
• Monitor their performance, offering encouragement and guidance as appropriate. Draw their attention to any behaviour that requires improvement as soon as you can, so that they have time to correct it before the end of the course.
• Ensure that all participant assessments are carried out in conjunction with an experienced member of faculty.
• Complete the IC form and go through your observations with the IC.
Supporting a new codirector
The aim of being a codirector is to prepare to take on the additional responsibilities involved in directing a course:
• Take time to discuss the overall organisation of the course, such as:
o technical requirements and working with technicians;
o timekeeping;
o faculty requirements;
o working with the course coordinator;
o working with RCS England.
• Discuss common problems in running the course and suggest solutions.
• Encourage them to attend any development days organised by RCS England.
• If you want them to assess new ICs, make sure they have read this guidance.
Faculty
Faculty can make or break a course. Participants will look to you for advice and guidance, and your behaviour and attitude may continue to influence participants long after the course has finished. The following are important on all courses:
• Represent the ethos of the course: while techniques may vary, participants should receive a consistent overall message from all faculty.
• Familiarise yourself with the course content and materials: participants look to you as the expert.
• Be a good role model: exemplify safe practice and professional values at all times.
• Provide a welcoming and supportive environment by:
o arriving in advance to welcome participants;
o talking to participants during break times – they really value hearing about your experiences and sharing theirs with you;
o giving feedback in a supportive way, even if it is negative (see Giving feedback): some participants find criticism difficult to take, so help them see it as a way to learn and improve;
o highlighting any serious concerns about a participant’s abilities to the course director early, so that remedial steps can be taken.
• Use the course materials provided. If you supplement them, ensure you have copyright permission to use them on an RCS course.
Teaching tips
Using teaching materials prepared by someone else is challenging. The faculty teaching notes in this document are intended to help you understand the author’s intentions.
Each session has designated learning outcomes. It is essential that these are covered and that participants know what they are so they can focus on them.
Consideration of some basic principles may help you deliver the course:
• Do not underestimate the importance of peer-to-peer learning. Significant learning takes place when participants discuss things among themselves with the faculty member acting as a facilitator.
• Be mindful of the concept of levels of knowledge and try to explore whether participants just know a fact or can use that knowledge appropriately, and whether or not they can evaluate how useful the knowledge is.
• Participants usually remember a relatively modest amount of content. Consequently, reinforcing key points at the close of the session is vital and a common error is to drop this when time is short. Always leave time for questions and then give your closing points so that participants leave thinking about the key points of the session.
Giving an interactive lecture
Making a session interactive usually makes it memorable and fun. Posing appropriate questions takes a bit of practice but it is well worth the effort:
• Explain how you want the participants to be involved and set ground rules, eg not talking at the same time as another participant.
• Ask questions (use Bloom’s taxonomy).
• Give participants time to think. When you present a question, do not answer it yourself or try to reformulate it. Count to ten silently before speaking again. When you have something you could say (which could be most of the time), count to ten again.
• Look around the group both when you are speaking and when a student is speaking. That way, students will quickly recognise that they are addressing the group rather than just you.
• If a participant has asked a question or made a comment, it is good practice to repeat what they have said to ensure that the entire group has heard.
• Summarise at the end. What have they learnt?
Managing small group work
• If it is not specified in the faculty handbook, decide beforehand how you will organise the groups:
o Group size. Pairs? Fours?
o Similar levels of experience or mixed senior/junior?
o Where will they work? Move into different corners of the room or just turn their chairs towards each other?
• Give a clear task and time limit. It may help to have these on the screen or flip chart.
• Will you have a member of faculty with each group or leave them alone?
o If they are working alone, circulate between groups: observe but do not get involved unless they are stuck.
o If you have faculty with each group, try to facilitate not teach. Ask questions if they get stuck but do not feel you need to be talking.
• Do not be worried if it gets noisy and seems chaotic – this is normal. You may need to raise your voice to get their attention at the end of the activity.
• Decide beforehand how you will conclude the session. Will you summarise the things you heard as you circulated or will you ask one group to report back?
Running a demo
• Have a clear focus and structure.
• Ensure that faculty taking part know what they are supposed to do. If possible, do a rehearsal or at least talk it through.
• Check that all resources are ready beforehand and that you have enough space.
• Make sure all participants can see and hear:
o If standing around a ‘patient’, be aware that your body may block someone’s view.
o If you have your back to the audience, try to turn slightly to face them when speaking. Do you need microphones?
o If streaming the demo to a screen, make sure the camera is angled correctly so that the procedure is shown clearly.
• Summarise at the end. What have they learnt?
Case scenarios
Many elements of the course use case scenarios. You need to be familiar with the scenario you are delivering and, where details are not included in the case material, be prepared to provide further information that helps the emerging clinical picture go in the direction intended. This can be challenging since the intention is to avoid participants jumping to conclusions and guessing what the point of the particular case presentation is.
Using someone else’s scenarios can be difficult if you do not quite ‘tune in’ to the author’s way of thinking. If this happens, ask the course director or another faculty member how they would approach it. It can be tempting to modify the scenarios provided or make up your own scenarios for the course, but this is discouraged. START scenarios have been rehearsed extensively so that areas of confusion are minimised.
Allow participants to do all the evaluation of data and clinical information. When trying to get through a lot of material, it is easy to do the analysis for the participants and then ask them what they would do. Often it is working out what is wrong that is difficult for trainees: once they know the diagnosis, they know the treatment.
Asking questions
By asking the right question, you can make sure learning is happening and also promote high-order thinking and reasoning. Refer to Bloom’s taxonomy and vary and adapt the level of questioning to your outcomes and participants.
What can you plan? What can you create? How could you innovate?
How could/can you? How would/do you?
What if? What would happen?
What could happen? How could that happen?
How is it used? How does it work?
Why? How?
Where? When? Who? What?
Giving feedback
Use Pendleton’s Model to give feedback:
• First check that the learner is ready to receive feedback.
• Ask the learner what went well.
• Discuss with the learner what went well.
• Ask the learner what they think could have been done differently.
• Discuss with the learner what could have been done differently.
• Agree a SMART action plan: specific, measurable, achievable, relevant, time-bound.
By using this model, you help participants focus on the positive aspects first, so they can maintain and build on what they do well. Next, you encourage participants to reflect and identify their zones of improvement. Finally, you help participants create an action plan with the necessary steps to improve on specific skills.
Session plans
Welcome and introduction
9:00am – 9:15am
Session summary A general introduction to the course and each other
Duration 15 minutes
Session objectives
The session aims to:
• ensure that all housekeeping is covered;
• set the tone for the day;
• outline the structure and aims of the course, and why the course is important;
• ascertain participant expectations.
Faculty Two faculty members
Electronic resources
Hard copy resources
Clinical resources
After this session
Teaching notes
PowerPoint: Session 1 Welcome and introduction
Sticky notes, flip chart
None
Patient consequences session
This session sets the tone for the day and should not be rushed or skimmed over. It should be impressed on the participants that this will be a safe but challenging environment to practise applying their knowledge.
This session is best led by the course director with other members of the faculty present.
Start with housekeeping and introduce faculty and course coordinators. If participants are in a mixed group from different hospitals, ask them to give their name and place of work.
During registration, participants should have written their expectations of the course on sticky notes. Summarise these for the group and then go over the course learning outcomes. Then spend a few minutes emphasising why the course is important.
Allow questions and finish with a brief summary of how participants can get the most out of the course.
Slides: Welcome and introduction
Welcome and introduction START
Housekeeping
Fire escapes, toilet facilities, breaks and geography of the venue to be covered. Let them know who to approach if they have problems.
Welcome and introductions
Introductions
Faculty & Administrators (more faculty joining after lunch). Candidates. Interactive day. Formative- there’s no pass/fail.
Welcome and introductions
Expectations
Sticky notes exercise (participants should have put up sticky notes with their expectations during registration).
Introduce faculty and administrators (more faculty joining after lunch). Introduce participants (if they don’t already know each other).
Interactive day.
Formative- there’s no pass/fail.
Should have read the participant handbook!
By the end of the course you should be able to:
• recognise an unwell patient
• perform a systematic patient assessment
• commence appropriate treatment
• escalate care to an appropriate senior
• recognise the importance of human factors in the workplace
• harness team resources available to you
Learning outcomes Programme
Time Activity
08.30– 09.00 Arrival and registration / faculty meeting / sticky notes
09.00 – 09.15
Programme
Time Activity
12.50 – 13.00 Practical assessment of a patient (introduction)
13.00 – 15.05 Practical assessment of a patient (5 x 25-minute rotations)
15.05 – 15.20 Break
15.20 – 16.35 Virtual handover challenge
16.35 – 17.00 Course summary, questions and feedback
Knowledge
• Most candidates have a comprehensive knowledge base
• Gaps in your knowledge?
• Self-directed learning
• This course is about application of knowledge!
Opening to the future.
You should have all read the participant handbook and most of it should have been revision. If you did identify gaps in your knowledge, as part of your professional development, you should address this using self-directed learning.
Why do we need this course?
• NEWS 2
• Sepsis 6
• Correlation between time of admission to ICU and survival
• Correlation between number of organ failures and mortality on ICU
• NCEPOD recurring themes
• Adverse incidents
• Medical examiner review
• Coroner’s reports
• Medical/legal and negligence cases
Why do we need this course?
• A structured assessment and management of the critically ill patient in a timely fashion improves patient outcomes
• This doesn’t always happen!
• Therefore…
Why do we need this course?
The START course will enable you to:
• recognise an unwell patient
• perform a systematic patient assessment
• commence appropriate treatment
• escalate care to an appropriate senior
• recognise the importance of human factors in the workplace
• harness team resources available to you
Why do we need this course?
• A systematic approach optimises patient care and minimises error.
• Prompt simple actions initiated early can prevent complications and reduce mortality.
• Patient reassessment evaluates clinical response and provides an opportunity to further optimise treatment.
• Predict and prevent rather than react and respond.
Please emphasise that all candidates in the room have the knowledge and ability to commence basic treatment at ward level, eg Oxygen, nebulisers, intravenous fluids and antibiotics. They do not have to wait until the evening ward-round or senior review to implement these clinical actions. These simple early actions can make dramatic differences in patient outcome. (This is also emphasised in the START algorithm lecture).
Welcome and introduction
Questions?
And finally…
• Enjoy it!
• The course is fun and challenging but not pass/fail.
• Use your faculty ask the questions you’ve always wanted to ask. There are no stupid questions!
• Stick to the system you are about to be taught.
• If you’re going to get it wrong, get it wrong today.
Summary: emphasise things they learn today they will still use towards the end of their career Opening to the future.
Patient consequences
9:15am – 10:15am
Session summary
Through interactive discussion and small group working, this session explores the consequences of a variety of real-life management decisions on a patient’s outcomes. By means of critique and reflection, it stimulates the candidates towards highlighting the importance of a systematic approach to all patient assessment.
Duration 60 minutes
Learning outcomes By the end of this session, participants should be able to:
• explain the need for a systematic approach to assessing patients;
• explain that variation in clinical decisions undertaken early in the patient’s assessment dramatically affects the final patient outcome;
• explain that to construct a successful management plan, a systematic appraisal of all available patient data is vital.
Faculty All faculty
Electronic resources PowerPoint: Session 2A Patient consequences group exercise and 2B Patient consequences presentation of handouts
Hard copy resources Handouts for cases 1–5
After this session Refreshments
Teaching notes
The session lasts 60 minutes in total, broken down as follows:
• Deliver the introduction (10 minutes).
• Divide into groups; each group discusses and critiques one case (8 minutes).
• Each group spends 8 minutes presenting their case to the whole class (40 minutes).
• Questions and summary (2 minutes).
Use presentation 2A to introduce the session by explaining the learning outcomes, introducing the scenario used in the handouts and explaining how the group work is conducted.
Separate participants into groups of five and give each group a handout with one of the cases from A to E (the handouts are not included in this book but are essentially the slides from presentation 2B). Emphasise that although the cases in the handouts reflect situations that participants could find themselves in, this exercise is not suggesting that they or their group would have made the decision described.
Each group spends eight minutes discussing and critiquing their case. Suggestions for factors for each group to consider are included in their handouts.
Each group is then given a further eight minutes to present their case to the wider group and justify their decisions. Show presentation 2B to help each group summarise their case for everyone.
The following consequences result from each of the cases:
• Decision A results in the patient’s son dialling 999 from home because the patient (Mr Jones) has worsening abdominal pain. The system assumes he has a leaking AAA, so he gets a contrast CT before being catheterised and put on the ward for his own team to pick up in the morning.
• Decision B results in Mr Jones getting a suprapubic catheter by the urology/transplant registrar overnight. This potentially compromises the sterility of the hernia mesh repair and additionally results in him being given a second dose of gentamicin and penicillin containing an antibiotic to which he is allergic.
• Decision C results in clinician C being embarrassingly asked to review their own patient in A&E at 2:00am, having failed to review them earlier on the day case unit. A superficial and inadequate attempt to overcompensate for their earlier poor decision results in the medical registrar being called. Mr Jones has an opiate-induced respiratory arrest. He also has a falling blood glucose. He is still in retention.
• Decision D represents an inappropriate attempt to seek advice from the care of the elderly team and examines when and how to call for help. Honesty and probity is also covered. Mr Jones remains in retention.
• Decision E results in Mr Jones being readmitted with urinary retention wrongly diagnosed as bowel perforation and resuscitated for an emergency laparotomy.
Application of the START algorithm would result in urinary catheterisation, admission overnight, a trial without his catheter in the morning and safe discharge home. This will be covered in the next session on the START algorithm.
Return to presentation 2A to summarise the exercise, offer an opportunity for questions from the whole group and review the learning outcomes. There is an opportunity here to discuss human factor elements relevant to these scenarios, eg in scenario A the doctor is pressured down a route to discharge the patient.
Patient Consequences
Group Exercise
START
Learning outcomes
By the end of this session you should be able to:
• Explain the need for a systematic approach to assessing patients.
• Explain that variation in clinical decisions undertaken early in the patient’s assessment dramatically affects the final patient outcome.
• Explain that in order to construct a successful management plan, a systematic appraisal of all available patient data is vital.
Learning Objectives.
Ideal outcomes
A large ‘open’ question can cause a clinician in training to panic. We are all ‘clinicians in training’. Application of a structured system will reduce being overwhelmed by breaking the problem into small steps. Slides: patient consequences – group exercise
How do you manage… …anything?
History Examination
Differential diagnosis
Special Investigations Treatment Follow Up
Ideal outcomes
How do you manage…
… an outpatient GP referral for a man with a left inguinal hernia?
In this example the same structure can be applied.
A healthy degree of scepticism as well as having a sense of purpose to give a patient the most appropriate treatment has given rise to the advice:
Trust No-one and Do it Yourself.
Is this history consistent with a hernia or is there something else going on?
Do the clinical findings support this being a hernia – what is the differential diagnosis?
Is there a role for an ultrasound or even a CT scan?
Does it really need treating?
Do you know your own outcomes? Can your healthcare system afford follow-up for all interventions?
Ideal outcomes
This scenario follows a man undergoing an elective surgical inguinal hernia repair.
Unexpected clinical events or complications are common and range from minor to catastrophic.
This exercise is designed to demonstrate how easily complications can occur and the importance of a systematic approach when assessing a patient.
Who has seen or managed a general surgical case? Whose fault is it that a colonic anastomosis fails by leaking?
An anastomosis needs to be tension free (the surgeon’s technical ability) and adequately perfused with oxygen.
Whose responsibility is it to maintain adequate visceral perfusion postoperatively?
Scenario
A nurse calls the ward cover foundation doctor to come and review a patient.
The cover doctor tells the nurse that they are handing over to the evening cover foundation doctor, who will come and see the patient ASAP.
Has anybody had an operation? Was it as you expected?
How do you know if what you are experiencing is normal or abnormal?
Scenario
An elderly man underwent an elective inguinal hernia repair in the day case unit. It is 17:30 hrs and he tells the nurse that he thinks that he has too much pain to go home.
Information
• The evening cover foundation doctor arrives to find that the patient, Mr Jones, is distressed. He is unhappy with the care that he has experienced in the day case unit.
• Mr Jones arrived at 07:30 hrs this morning having had nothing to eat or drink from midnight and yet didn’t have his surgery until 14:00 hrs.
• All the nurses have left the day case unit with the exception of a healthcare assistant who is also keen to go home.
• A porter is waiting with a trolley to take Mr Jones to the ward.
Is this a plausible or common scenario?
What do you think about the significance of the word ‘experience’: in the context of perception? in the context of ‘the friends and family test?’ What do you think about his starvation management? What are the rules for fluids and diet?
Extension - 1
What should patients do with their routine medicines before an operation?
Extension – 2
How are most inguinal hernias repaired in the UK?
LA or GA?
Open or laparoscopic?
Consequences Exercise
You will be assigned to a group and given details of Mr Jones’s management and outcome
Task1 – You have eight minutes to discuss and critique the case, including :
• Is the outcome acceptable?
• The factors leading to the outcome
• An estimate of how many days Mr Jones will need to stay in hospital
• An estimate of how well Mr Jones is on a scale of 1–10
• How you may have managed this case differently
Task 2 – Each group has a further eight minutes to present the case and debate the outcome
Consequences Exercise
• We will now split into groups and carry out the exercise
• Each group will have the information provided on handouts
• When each group presents, this information will be available on a PowerPoint to present to the whole group (Session-2B)
Consequences
The previous exercise shows how unexpected clinical events or complications are common and range from minor to catastrophic. It also demonstrates how easily complications can occur.
In the next session you will explore how the START system can be applied to Mr Jones’s care. As you become more familiar with Mr Jones’s case, it will become more and more clear how and why the poor outcomes described in this session were allowed to happen.
Summary
You should now be able to:
• Explain the need for a systematic approach to assessing patients.
• Explain that variation in clinical decisions undertaken early in a patient’s assessment dramatically affects the final patient outcome.
• Explain that in order to construct a successful management plan, a systematic appraisal of all available patient data is vital.
Learning objectives.
Slides: patient consequences – presentation of handouts
Patient Consequences Presentation of Handouts
Decision ‘A’ made between 17:45 – 18:00 hrs
• An elderly man underwent an elective inguinal hernia repair in the day case unit. It is 17:30 hrs and he tells the nurse that he thinks that he has too much pain to go home.
• The nurse calls the ward cover foundation doctor. He tells the nurse that he is handing over to the evening cover foundation doctor, who will come and see the patient ASAP.
• Clinician A decides to send Mr Jones home having had a long discussion about how it is felt that he will be fine and able to cope.
• After talking for fifteen minutes Clinician A finally gets through to Mr Jones that this is a very routine procedure and that it is safe for him to go home. His slightly unkempt looking son is in reception waiting for him.
• Having spent time speaking about his complicated infections and unreasonably frequent blood tests he now seems reassured.
• Mr Jones walks slowly to the patient reception area. He says goodbye, and asks Clinician A to pass on his best wishes to his nephew who he thinks works somewhere in the hospital.
Information – Decision A – Monday 18:05 Hrs Slide 2 of 7
Information – Decision A - Tuesday 08:35 hrs
Ward round with registrar – Tuesday 08:35 hrs
• Clinician A is leading the morning ward round with his registrar. Halfway round, Clinician A and their quite tired looking registrar are surprised to see Mr Jones, on an insulin sliding scale, catheterised and confused.
• The registrar says ‘I am not sure why this man is in one of our beds. There doesn’t seem to be anything surgical going on with him so I think we should give the medics a call, what do you think?’
Slide 3 of 7
Information – Decision A - Tuesday 08:35 hrs
Clinician A and the registrar read the notes together to understand the sequence of events
Vascular registrar 03:20Hrs …. Written in retrospect
PC Bought in by ambulance - Blue light to Resus - ? Leaking AAA ….
HPC Patient’s son rang 999 c/o severe back and abdominal pain following a day case LIH repair under GA …..
OE Unable to exclude ruptured AAA – BP 150/100mmHg HR 130 CT angio STAT
Slide 4 of 7
Information – Decision A - CTA – 03:20 Hrs
Information – Situation A - Tuesday 08:45 hrs
Clinician A and the registrar read the notes together to understand the sequence of events
Vascular registrar 03:20Hrs …. Written in retrospect
PC Bought in by ambulance - Blue light to Resus - ? Leaking AAA ….
HPC Patient’s son rang 999 c/o severe back and abdominal pain following a day case LIH repair under GA …..
OE Unable to exclude ruptured AAA – BP 150/100mmHg HR 130 CT angio STAT – no AAA. Large bladder.
Catheterised 1.8 litre residual. Admit Gen Surg
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• Is the outcome acceptable?
• The factors leading to the outcome
• An estimate of how many days Mr Jones will need to stay in hospital
• An estimate of how well Mr Jones is on a scale of 1–10
• How you may have managed this case differently
Slide 5 of 7
Slide
Slide
Decision ‘B’ made between 17:45 – 18:00 hrs
• An elderly man underwent an elective inguinal hernia repair in the day case unit. It is 17:30 hrs and he tells the nurse that he thinks that he has too much pain to go home.
• The nurse calls the ward cover foundation doctor. He tells the nurse that he is handing over to the evening cover foundation doctor, who will come and see the patient ASAP.
Information – Decision B – Monday 18:05 hrs
• Clinician B decides to rapidly admit Mr Jones for an overnight stay with the intention of discharging him in the morning.
• Clinician B takes care to transfer the analgesia prescribed on the day-case treatment chart to an inpatient prescription chart.
• Clinician B is pleased with themselves for not prescribing low molecular weight heparin. Mr Jones does technically require DVT prophylaxis if he was a planned inpatient following a GA hernia repair. Clinician B feels that this is a slightly different situation because this is really a convenience ‘hotel’ type admission.
Slide 2 of 7
Information – Decision B - Tuesday 07:45 hrs
Ward round with registrar – Tuesday 07:45 hrs
• During a swift pre-ward round preparation, Clinician B reviews Mr Jones.
• He is confused, covered in a blotchy rash and tachycardic with a systolic blood pressure of 70 mmHg. He has an insulin sliding scale and a suprapubic catheter in place.
• The registrar has been doing exactly the same pre-ward round checks as Clinician B, but a bit earlier, and is walking towards Clinician B with Mr Jones’s notes in his hands.
Slide 3 of 7
Slide 1 of 7
Information – Situation B – Tuesday 07:50 hrs
Clinician B and the registrar go through the notes together in order to find out the sequence of events
Urology/Transplant Reg 05:10Hrs …. Written in retrospect…
Called by the hospital at night team. The clinical nurse specialist has diagnosed retention of urine post elective hernia repair. They are unable to catheterise
Multiple failed attempts at urethral catheterisation (with gentamicin cover)
Information – Situation B – Tuesday 07:50 hrs
Clinician B and the registrar go through the notes together in order to find out the sequence of events
Urology/Transplant 05:10Hrs Written in retrospect
No cystoscopes available from sterile supplies dept
Aseptic technique – supra-pubic catheter placement – difficult ? because hernia repair incision across midline – resistant fascia ?? Multiple skin punctures before bladder decompressed – immediate symptomatic relief….
Estimated residual 1.5 litres plus two soaked incontinence pads.…
Information – Situation B – Tuesday 07:50 hrs
Clinician B and the registrar go through the notes together in order to find out the sequence of events
Urology/Transplant 05:10Hrs Written in retrospect
Estimated residual 1.5 litres plus two soaked incontinence pads.
Additional stat dose 1.2 Grams Co-amoxiclav in view of procedure difficulty.
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Slide 4 of 7
Slide
Slide
Decision B – considerations
• Is the outcome acceptable?
• The factors leading to the outcome
• An estimate of how many days Mr Jones will need to stay in hospital
• An estimate of how well Mr Jones is on a scale of 1–10
• How you may have managed this case differently
Decision ‘C’ made between 17:45 – 18:00 hrs
• An elderly man underwent an elective inguinal hernia repair in the day case unit. It is 17:30 hrs and he tells the nurse that he thinks that he has too much pain to go home.
• The nurse calls the ward cover foundation doctor. They tell the nurse that they are handing over to the evening cover foundation doctor, who will come and see the patient ASAP.
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Slide 1 of 8
The ward staff decided to send Mr Jones to A&E for assessment as no doctor arrived on the day unit to review him.
• Clinician C’s consultant contacts them at 02:00 hrs from home. The senior A&E nurse has called Clinician C’s consultant directly because the on-call surgical registrar is not responding to their bleeps.
• Clinician C’s consultant asks them to review a patient in A&E who is distressed and in pain following a day case inguinal hernia repair. They apologise for calling Clinician C but are confident that they can sort the patient out.
• Clinician C arrives feeling a bit uncomfortable about not reviewing Mr Jones on the day case unit.
Information – Situation C – 02:00 hrs Slide 2 of 8
Slide
Information – Situation C – 02:00 hrs
Review in A&E
• Mr Jones is uncomfortable too. He is hungry and thirsty because the triage nurse made him nil by mouth as per the acute A&E pathway.
• He is complaining of back pain – he blames this on having been laying on nothing but hospital trollies for the last 12 hours.
• He also has lower abdominal pain – he assumes because of his operation – he hasn’t had any pain relief since leaving the day case unit.
Slide 3 of 8
Information – Situation C – 02:00 hrs
Review in A&E
• Clinician C apologises for how the system has let him down, gives an immediate dose of iv morphine and prescribe Mr Jones regular oral/iv paracetamol and tramadol with PO oromorph for breakthrough pain.
• Clinician C immediately requests a bed on the general surgical ward.
• They also take care to ensure that Mr Jones has a jug of water within reach and hand over to the nurses that he can eat and drink. Clinician C promises that they will review Mr Jones in the morning on the ward round at 08:30.
Slide 4 of 8
Decision C – Tuesday 08:35 hrs
Ward round with registrar – Tuesday 08:35 hrs
• Clinician C is doing the morning ward round with their registrar. Halfway round, the quite tired looking registrar is surprised to see Mr Jones in a bed with a small bleeding cannula, a sliding scale for insulin delivery, urinary catheter, sleepy and confused.
• Clinician C’s registrar says, ‘I am not sure why this man is in one of our beds. There doesn’t seem to be anything surgical going on with him so I think we should give the medics a call, what do you think?’
Slide 5 of 8
Decision C – Tuesday 08:35 hrs
Clinician C and the registrar review the medical notes together to find out the sequence of events
Medical registrar 06:10hrs …. Written in retrospect…
2222 Arrest call - unresponsive following elective hernia repair.…
A not maintained – Chin lift/Jaw thrust – Guedel airway tolerated
B No respiratory effort – bag/mask/o2 Ventilating easily
C HR 130, BP 100/50 mmHg – 250 ml saline fluid challenge stat. Urinary Catheter – 1000 mls – clamped to prevent circulatory collapse….
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Decision C – Tuesday 08:35 hrs
Clinician C and the registrar review the medical notes together to find out the sequence of events
Medical registrar 06:10hrs …. Written in retrospect…
2222 Arrest call - unresponsive following elective hernia repair…
D U of AVPU….Blood Glucose 1.0 Pupils 1 mm Dextrose Stat Plus 400mcg Naloxone IV
E NAD
Post script – further 1000mls drained from bladder catheter – some haematuria…
Decision C – considerations
• Is the outcome acceptable?
• The factors leading to the outcome
• An estimate of how many days Mr Jones will need to stay in hospital
• An estimate of how well Mr Jones is on a scale of 1–10
• How you may have managed this case differently
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Slide
Slide
Slide
Decision ‘D’ made between 17:45 – 18:00 hrs
• An elderly man underwent an elective inguinal hernia repair in the day case unit. It is 17:30 hrs and he tells the nurse that he thinks that he has too much pain to go home.
• The nurse calls the ward cover foundation doctor. He tells the nurse that he is handing over to the evening cover foundation doctor, who will come and see the patient ASAP.
Information – Situation D – Monday 18:05 hrs
• Clinician D tries to get some advice from the care of the elderly team.
• The care of the elderly registrar has not turned up for their on call shift.
• The consultant is taking the calls and Clinician D can phone them at home if they need urgent help.
• Clinician D calls the care of the elderly consultant.
Information – Situation D – Monday 18:05 hrs
• Clinician D explains to the care of the elderly consultant that they have an elderly man who is too frail to go home after his GA elective inguinal hernia repair.
• The consultant asks for some medical history starting with his age – he needs to be 80 years or over to be considered by her service.
• Clinician D tells the care of the elderly consultant that Mr Jones is older than 80 years old.
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Slide 1 of 5
Slide
Slide
Information – Situation D – Monday 18:05 hrs
• Clinician D explains that they have an 85-ish year old man called Mr Jones who is stranded in a rapidly closing day case unit.
• Clinician D states that Mr Jones is normally fit and well but lives alone and that there are concerns about whether Mr Jones will cope on his own because he has a lot of post operative midline pain.
• The care of the elderly consultant asks what level of social services support he has. Clinician D admits that they don’t know.
• The consultant is kind to clinician D and suggests they call back when they know more about the patient.
Decision D – considerations
• Is the outcome acceptable?
• The factors leading to the outcome
• An estimate of how many days Mr Jones will need to stay in hospital
• An estimate of how well Mr Jones is on a scale of 1–10
• How you may have managed this case differently
Decision ‘E’ made between 17:45 – 18:00 hrs
• An elderly man underwent an elective inguinal hernia repair in the day case unit. It is 17:30hrs and he tells the nurse that he thinks that he has too much pain to go home.
• The nurse calls the ward cover foundation doctor. He tells the nurse that he is handing over to the evening cover foundation doctor, who will come and see the patient ASAP.
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Slide 4 of 5
Slide 5 of 5
Slide
Decision E made between 17:45 – 18:00hrs
• Clinician E decides to contact the pain management team for advice.
• The pain management team does not answer their bleep.
• Since Mr Jones continues to be in pain, clinician E prescribes him oral cocodamol, which helps him a little bit.
• Clinician E gives him some more to take home and assures him that the pain will eventually go away.
Information – Situation E – Tuesday 09:05 hrs
Ward round with registrar – Tuesday 09:05 hrs
• Clinician E is leading the morning ward round with their registrar. During the round, their registrar’s phone rings. Since the registrar is in conversation with a patient clinician E answers the registrar’s phone.
• It is the Anaesthesia Core Trainee who says that they are sending for the patient admitted last night, Mr Jones, who requires a laparotomy for bowel perforation.
• When clinician E informs their registrar that Mr Jones needs surgery, they suggest that clinician E reviews Mr Jones in the anaesthetic room before he is anaesthetised. The registrar will catch up once they have finished dealing with the current patient.
Slide 3 of 7
Information – Situation E – Tuesday 09:15 hrs
Clinician E is reviewing Mr. Jones in the anaesthetic room when the registrar arrives.
• Together they rapidly review his notes and see that he was admitted with lower abdominal pain last night.
• He had an abdominal X-ray following which he was asked to remain Nil by Mouth for an urgent laparotomy.
• He has received about 600 ml of IV fluids since admission.
Slide 4 of 7
Slide 2 of 7
Information – Situation E – Tuesday 09:15 hrs
Information – Situation E – Tuesday 09:15 hrs
• Mr Jones continues to be in severe abdominal pain. The registrar asks clinician E to check if the lab results are back while she evaluates Mr Jones.
• Clinician E comes come back to let her know that the results will take another 10 minutes, only to find her catheterising Mr Jones.
• The urine bag immediately fills to capacity and Mr. Jones feels relief almost instantaneously. He thanks the Registrar profusely. The team unanimously agree a laparotomy is no longer needed.
• Is the outcome acceptable?
• The factors leading to the outcome
• An estimate of how many days Mr Jones will need to stay in hospital
• An estimate of how well Mr Jones is on a scale of 1–10
• How you may have managed this case differently
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Slide 5 of 7
Slide 6 of 7
Slide
START algorithm
10:30am – 11:30am
Session summary An interactive lecture that exposes participants to the START algorithm for the first time as a tool for the systemic assessment of their patient.
Duration 60 minutes
Learning outcomes By the end of this session, participants should be able to:
• recognise a sick patient;
• adopt a system for full patient assessment;
• initiate a management plan;
• know their limits and when to escalate care appropriately;
• communicate effectively to other members of the team.
Faculty
Electronic resources
Two faculty members
PowerPoint: Session 3 START Algorithm Videos: RCS START Algorithm videos 1–3
Hard copy resources The START Algorithm poster
After this session Human factors session
Teaching notes
The session lasts 60 minutes in total, broken down as follows:
• Introduction and general principles (slides 1–7) (2 minutes).
• Body content (55 minutes):
o Mr Clark: A–E management (slides 8–12, Video 1).
o Mr Clark: full patient assessment (slides 13–16, Video 2).
o Mr Clark: decide and plan (slides 17–21, Video 3).
o Mr Jones (slides 22–43).
• Summary and questions (slides 44–45) (3 minutes).
This session works best when delivered by two faculty members: the first covers slides 1–21 (including the videos), which introduce a new patient, Mr Clark; the second leads on slides 22–46 with the START algorithm now applied to Mr Jones, who we met in the Patient consequences session
To engage participants, encourage them to review the performance of the candidate in the videos and suggest at least one area the candidate performed well in and one area where they could have performed more effectively.
The faculty members demonstrate progress through the assessment of a patient, with the initial aspects of basic assessment and management providing a revision opportunity for participants. The tutorial then explores the different pathways for assessment and management of the stable and unstable patient. The key message for faculty is to instil confidence that all participants have the ability to use this algorithm and start treatment early for their patients.
Slides: the START algorithm
START algorithm START
Learning outcomes
By the end of this session you should be able to:
• recognise a sick patient;
• adopt a system for patient assessment;
• initiate a management plan for both stable and unstable patients;
• know your limits and when to escalate appropriately;
• communicate effectively with other members of the team.
This slide explains and emphasises the course ethos for the candidates.
The
Mr Jones
The slides start with an example of a trainee applying the START algorithm in a simulation (like participants will do later in the day) and then re-examines the management of Mr Jones, applying his case to the framework of the algorithm.
It is recommended that the faculty member that delivered the Consequences session is in the room for this session and that the person delivering this session in turn attended the Consequences session.
There are a lot of details in the slides that will help you illustrate points but please do not dwell on the details otherwise the session will likely overrun.
START algorithm
Briefly highlight the contents of the START algorithm, but do not labour on specific sections on this slide, as they will be explored in subsequent slides.
General principles
• A systematic approach optimises patient care and minimises error.
• Prompt simple actions initiated early can prevent complications and reduce mortality.
• Patient reassessment evaluates clinical response and provides an opportunity to further optimise treatment.
• Predict and prevent rather than react and respond.
Please emphasise that all candidates in the room have the knowledge and ability to commence basic treatment at ward level, eg oxygen, nebulisers, intravenous fluids and antibiotics. They do not have to wait until the evening ward-round or senior review to implement these clinical actions. These simple early actions can make dramatic differences in patient outcome.
START algorithm
Briefly highlight the contents of the START algorithm, but do not labour on specific sections on this slide, as they will be explored in subsequent slides.
Patient assessment demonstration part 1 – Mr Clark
The video:
• shows a simulated patient assessment, similar to the exercise you will undertake this afternoon.
• introduces a new patient – Mr Clark
• demonstrates an example of real-time A-E management
Task:
• Watch the video, put yourself in the position of the candidate and critique their approach
Instructions for video: brief the group, run the video without interruption and facilitate the group critiquing the candidate’s performance.
The video looks at the case of ‘Mr Clark’ (not to be confused with Mr Jones, who we’ll look at later).
Patient assessment demonstration part 1 – Mr Clark
START Algorithm video, part 1 – play video
This is the immediate management section of the algorithm.
Brief the group, run the video without interruption and facilitate the group critiquing the candidate’s performance.
The video shows a simulated patient assessment, similar to the exercise you will undertake this afternoon.
Introduces a new patient – Mr Clark.
Demonstrates an example of real-time A-E management.
Patient assessment demonstration part 1 summary
What did the trainee do well?
• A comprehensive, systematic A-E assessment and treatment
• Recognition and treatment of airway and breathing problem
• Prompt recognition of shock with appropriate treatment
• Excellent disability assessment
• Picked up melaena on exposure
• Reassessment following interventions
What could they have done differently?
• Begin with simple airway manoeuvres – chin lift before guedel
• Make better use of the full team and put monitoring on early
• Use the START algorithm without prompting to move beyond A-E management.
This should be interactive. Please just don’t just list off the points one-by-one. The list is not comprehensive, so participants may come up with answers not presented on the slides.
Emphasise the trainee in the video performs quite well at the A-E management, but in real life trainees often struggle to move beyond that.
START algorithm
This slide is self-explanatory and encourages candidates to move on from ‘initial management’ to ‘full patient assessment’. Faculty should not dwell here, as ‘full patient assessment’ is discussed in the subsequent slides.
Full patient assessment
People
• patient
• ward nursing and other allied healthcare professionals
• medical team – colleagues and / or senior staff
• relatives / next of kin
Bedside
• clinical examination
• observation charts / Early Warning Score (NEWS)
• fluid balance and fluid prescription charts
• drug chart
Clinical documents
• patient notes file including operation notes / anaesthetic chart
• advanced directives – End-of-Life pathway, DNAR orders
• available results
This is one of the most important slides, so rather than listing information that may be gleaned, faculty should encourage candidate interaction. Go through each section asking what information should be obtained. Emphasise the importance of other members within the clinical team. Faculty should advise participants to always double-check any clinical documents to ensure correct patient and time periods listed. Explore with the candidates what information can be gleaned from an operative note. Ask whether attendees review operative notes when a patient returns from theatre. What results for a ward patient are expected to be reviewed? (Urinalysis, bed-side blood gas, laboratory (haematology, biochemistry, microbiology), radiology (plain x-ray, ultrasound, cross-sectional)).
Summarise this slide at the end of interaction. After immediate management, perform an information gathering process with the patient (if able), ward staff, medical colleagues or seniors. Complement this with bedside clinical assessment to evaluate underlying pathologies, surgical wounds, as well as stomas and drains. Be careful when reviewing observation charts and drug kardexes, which may not be up to date. Have a low threshold at all times to remeasure patient haemodynamics: look for evidence of acute deterioration, or more gradual downward spiralling trends, and monitor for clinical response to initial treatment strategies.
Patient assessment demonstration part 2 – Mr Clark
This is the full patient assessment section of the START algorithm
Task:
• Watch the video, put yourself in the position of the candidate and critique their approach
Instructions for video: brief the group, run the video without interruption and facilitate the group critiquing the candidate’s performance.
Patient assessment demonstration part 2 – Mr Clark
START Algorithm video, part 2 – play video
Instructions for video: brief the group, run the video without interruption and facilitate the group critiquing the candidate’s performance.
Patient assessment demonstration part 2 summary
What did the trainee do well?
• Excellent full patient assessment
• Asked for and analysed the relevant charts
• Verbalised their logical thoughts
What could they have done differently?
• Ask for the full medical notes –remember, patients often have a complex pre-existing history which may influence their current presentation
Again, this should be interactive. Please just don’t just list off the points one-by-one. The list is not comprehensive, so participants may come up with answers not presented on the slides.
START algorithm
The full patient assessment is only meaningful if you unite and use the information that you have collected in order to decide if the patient is
or unstable.
Patient assessment demonstration part 3 – Mr Clark
This is the decide and plan section of the START algorithm
Task:
• Watch the video, put yourself in the position of the candidate and critique their approach
Instructions for video: brief the group, run the video without interruption and facilitate the group critiquing the candidate’s performance.
Patient assessment demonstration part 3 – Mr. Clark
START Algorithm video, part 3 – play video
Instructions for video: brief the group, run the video without interruption and facilitate the group critiquing the candidate’s performance.
Patient assessment demonstration part 3 summary
What did the trainee do well?
• Recognised the patient was unstable
• Made a diagnosis and implemented definitive treatment
• Used SBAR to communicate concerns to the Medical Registrar
What could they have done differently?
• Be aware of appropriate escalation to the Medical Registrar – make things happen
Again, this should be interactive. Please just don’t just list off the points one-by-one. The list is not comprehensive, so participants may come up with answers not presented on the slides.
Faculty should stress the importance of SBAR in day to day communication, which will be covered in more detail in the Human Factors session.
START algorithm
The full patient assessment is only meaningful if you unite and use the information that you have collected in order to decide if the patient is stable or unstable.
Is the patient stable?
Stable patient
• Physiology improving
• Levels of support needed decreasing
• Following the expected clinical course, eg expected recovery from right hemicolectomy or total knee replacement
• Improving following medical diagnosis of community acquired pneumonia
Unstable/unsure
• It’s OK to be unsure!
• Err on the side of caution: if unsure, go down this pathway
In most cases, patient stability is easily identifiable; e.g. the mobile patient awaiting hospital discharge. However, if any concerns are present, re-evaluate your patient’s clinical assessment and compare with previous assessments to re-assure that the patient is indeed stable. Such actions will provide objective clinical evidence of stability, and, as your experience increases, such assessments may be performed very succinctly.
By the nature of the course, we tend to focus on the dramatic A-E problems, but most patients will be stable, but equally need a complex package of care; hence the daily management plan is important.
Stable patient: daily management
Baseline observations
• Chart review – haemodynamic / temperature trends
• Oxygen requirements / physiotherapy
Input / output
• Oral intake – fluids / nutrition
• Fluid balance – accuracy / daily prescription
Clinical Assessment
• Systematic examination
• Sutures / drain removal
Medication
• Therapeutic (eg analgesia, antibiotics)
• Prophylactic (eg VTE)
• For comorbid diseases (eg cardiac)
Investigations
• Haematological
• Radiological
• Consultations
Forward Planning
• Level of care – escalation
• Continuity of Care – communication with patient and clinical team
• Weekend / discharge planning – checklist / documentation
Have a system in place that addresses all key aspects of daily management, often starting with basic observations and optimise accordingly: FiO2 levels, input/output for blood pressure and kardex review, particularly for cardiovascular medications. Advise participants that there are other mechanisms or systems of assessment, eg systematic (cardiac, respiratory, GI, renal, neurological, etc). It is important that whatever system is used is inclusive of all key aspects for daily patient management planning.
Knowing what you know now… back to Mr Jones
How would you manage Mr Jones, having seen the demonstration in the videos?
The faculty member who delivered the patient consequences session should ideally also deliver this section.
History
• An elderly man underwent an elective inguinal hernia repair in the day case unit. It is 1730 hrs and he tells the nurse that he thinks that he has too much pain to go home.
• The nurse calls the ward cover foundation doctor. He tells the nurse that he is handing over to the evening cover foundation doctor (you!) and that you will come and see the patient ASAP.
Recap.
History
• You arrive to find that the patient, Mr Jones, is distressed. He is unhappy with the care that he has experienced in the day case unit.
• Mr Jones arrived at 07:30 hrs this morning having had nothing to eat or drink from midnight and yet didn’t have his surgery until 14:00 hrs.
• All of the nurses have left the day case unit with the exception of a healthcare assistant who is also keen to go home.
• A porter is waiting with a trolley to take Mr Jones to the ward.
At this point, get the group to say what should be done next (ie, the START algorithm).
Faculty should reference the Patient Consequences section, which the participants will have talked through earlier, and ask them to apply the algorithm to Mr. Jones.
START
You’re going to assess Mr Jones properly now.
In the Patient Consequences session, all groups should have identified that a lack of detailed physiological information made the assessment unreliable.
Immediate assessment – Mr Jones
Prioritise, diagnose and treat immediate threats to life:
• A Spontaneously talking
• B RR 18 and shallow; O2 sats 93% on room air; chest clear
• C HR 100 - BP 150/80 mmHg CRT<1s
• D A from ACVPU, PERLA
• E temp. 37; cannula in situ; dry dressing over open LIH repair
Immediate management – Mr Jones
A airway patent, sats >92%, therefore in target range and no extra oxygen required
B no immediate management required
C large-bore cannula and bloods; fluid bolus, thinking about subsequent maintenance fluids
D alert, consider blood glucose assessment
E normothermic, wound ok
Use this slide to discus common controversies, ie high-flow oxygen, but titrating to need.
Get the candidates to describe how they would perform the management. They should start by saying they would introduce themselves to Mr Jones, and his responding would assess his airway and in part his circulation. Use the animations to provide the data as they ask for it. Facilitate a discussion from the group around the different points of the assessment. START
What are you going to do next?
Full Patient Assessment – History (Mr Jones)
PMH
• Insulin dependent diabetes – 30 years
• Hypertension
• CKD stage 4 – has a radio-cephalic fistula
SH
• Lives with youngest son (etoh excess)
• Wife lives in a nursing home
• Nephew (Michael) sits on this Trust Board
Don’t just read these items out; get the group to interpret and comment on them to make it interactive.
Patient is pre-dialysis, but has had a fistula made in anticipation of the impending need for future dialysis.
Full Patient Assessment – Chart Review
DH
• Alfacalcidol 2mcgs 3xweek PO on HD
• Amlodipine 5mg OD
• Atorvastatin 20mgs ON
• Bisoprolol 5mgs OD
• Lansoprazole 30mgs OD
• Sucroferric Oxyhydroxide 500mgs 3XDAY
• Erythropoietin - Darbepoetin(syringe)
• Aranesp 50mcg x 1/week Venofer as per protocol
• Renavit 1/d
Don’t just read these items out; get the group to interpret and comment on them to make it interactive.
Don’t get bogged down in the details of the drug history: the main point is that it’s a complex patient with polypharmacy, which is common in elderly patients and needs to be considered carefully.
Full Patient Assessment – Chart Review
DH
• Fortisip Compact protein 125mls 1-2/d
• Metoclopromide 10 mg tds
• Novorapid 4 units bd & 6 units at nocte
• Levemir (Insulin) 20 units bd
• Sertraline 50 mg od
• Pregabalin 25 mg at nocte
• Allergic to Penicillin
Full Patient Assessment – Operation notes
The patient has been operated on under the care of Mr Rigby but the actual person that did the case was Ms Smith.
Operation note: ‘Routine LA Left inguinal hernia repair with mesh. Poorly tolerated. 50 mls 1% plain lidocaine, sliding hernia therefore very difficult. subcut vicryl to skin. Home when safe, GP follow-up only.
Don’t just read these items out; get the group to interpret and comment on them to make it interactive.
Points for faculty: How might “poorly tolerated” be interpreted? It’s likely the operation was either difficult or the operator was inexperienced.
Dose of lidocaine; maximum dose should be 3mg/kg. 1% lidocaine means 1g of lidocaine in 100ml solutionTherefore, the concentration of lidocaine is 10mg/ml. Therefore, the maximum dose for a 70kg man is 3mg x 70kg = 210 mg21ml of 1% lidocaine solution contains 210mg of lidocaineFaculty should reassure the group that they are not expected to know the detailed doses at this stage of their career, but as they become more senior and start to perform invasive procedures, they will need to know this information. At this stage they should be able to pick up that this seems like a high dose.
START algorithm
The full patient assessment requires as much information from each of the three sources listed.
Full
Patient Assessment – Systematic Examination
Inspection – ? slightly distended. Obvious old appendicectomy scar. Clean and dry left inguinal hernia repair wound closed with subcuticular sutures.
Palpation – upper abdomen non-tender, easily palpable aorta? Transmitted pulsation? Tender lower abdomen with an impression of fullness.
Percussion – dull to percuss lower abdomen. Upper abdomen resonant.
Auscultation – quiet but present bowel sounds.
What are the differential diagnoses from this abdominal examination?
• Query AAA, retention of urine, bowel injury during hernia repair, infection, bleeding
The group should say they would take a full history and perform an examination; the history doesn’t give any information beyond what they already know and the overall examination is consistent with what they already know with the addition of the findings on this slide.
Challenge the participants: what else could they investigate?
START algorithm
The full patient assessment requires as much information from each of the three sources listed. FBC from pre-op assessment 2/52 ago, Hb 97, Plts 350, WCC 5.6
U&E from pre-op assessment 2/52 ago, Cr 400, Urea 13, Na 136, K 5.8
ECG from pre-op assessment, HR 78 Sinus Rhythm
START algorithm
The full patient assessment is only meaningful if you unite and use the information that you have collected in order to decide if the patient is stable or unstable.
Decide and plan
Stable or unstable? Unstable
Diagnosis?
Retention of urine following inguinal hernia repair
Definitive treatment? Catheterisation
Don’t get distracted with the specifics of renal function and acid-base balance.
Catheterise
• You pass a 14 Fr Foley catheter and drain 1.2 litres of urine.
• Within the first few hundred millilitres of urine being drained, Mr Jones feels much more comfortable and is very grateful to you for helping him.
Sorted! Would you do anything else?
• Urgently chase the bloods you took in your A-E management, particularly for the creatinine and potassium. Consider blood gas to obtain immediate potassium level and gather information about acid-base status.
Don’t get distracted with the specifics of renal function and acid-base balance.
You’re a great doctor, but… have you really finished here?
Faculty could draw attention to the fact that you are more likely to succeed with catheterization during daylight hours with a relaxed patient, than in the scenario when catheterization failed.
What would you do next?
Escalate
Escalate to your senior with an effective SBAR conversation
S: ‘I’m with Mr Jones, he’s 78 and has urinary retention following an elective inguinal hernia repair.’
B: ‘He was a day case, but has substantial comorbidities with diabetes, CKD stage four and polypharmacy.’
A: ‘I’ve done a full START assessment. I’m correcting his physiology and have catheterised him for his urinary retention. He’s now improving. However, I don’t have upto-date blood results yet.’
R: ‘I think he needs to be admitted, probably under the renal team. I’m happy to ring them and sort that out if you agree.’
If time allows, it is possible to try to get the participants to talk through the SBAR; however, if time is tight you can do this yourself.
treatment
Admitted and reviewed urgently by nephrology team who helped you to manage Mr Jones’s fluid balance, acidaemia, glucose and potassium overnight.
He passed his trial without catheter in the morning and was discharged for GP follow-up.
Mr Jones is very grateful to you and you go home feeling like you’ve made a real difference.
START algorithm
Emphasise that using the algorithm results in a good outcome even for a complex patient.
START algorithm
Questions?
• A systematic approach using the START algorithm reduces omissions and improves patient care.
• At the decide and plan stage, make an active decision whether the patient is stable or unstable
• Constantly evaluate and re-assess the effect of your management.
• At any stage, consider the need for help if your patient remains unstable.
• Inform and involve senior colleagues and members of the clinical team appropriately.
Advise candidates that the START Algorithm can be a useful adjunct for answering clinically based questions in interviews.
Human factors
Session summary This session is designed to give participants a flavour of human factors and how they affect us in the workplace. It is not comprehensive and further reading is available in the Handbook. Other resources are available online (links provided).
Duration 45 minutes
Learning outcomes By the end of this session, participants should be able to:
• define non-technical skills;
• describe the implications of human error in healthcare;
• discuss the importance of non-technical skills in relation to clinical practice;
• recognise the impact of stress and fatigue;
• evaluate their own coping strategies.
Faculty All faculty
Electronic resources PowerPoint: Session 4 Human factors
Hard copy resources Handout: Human factors scenario
After this session Lunch 11:30am – 12:15pm
Teaching notes
This session lasts 45 minutes in total, broken down as follows:
• Introduction and discussion of the 5 domains of human factors (15 minutes).
• Scenario and discussion (15 minutes).
• Resilience (13 minutes).
• Questions and summary (2 minutes).
Introduction
The content of this session has been adapted from RCS Edinburgh Non-Technical Skills for Surgeons course, with permission.
Teamwork
Situational awareness
Decision-making
Task management
Communication
Teams
Should
Decide
Things
Collaboratively
Go through the slides. The mnemonic ‘Teams Should Decide Things Collaboratively’ may help participants remember the five domains. This is given in the Participant Handbook but it is not included in the slides.
For slides 6–10, ask participants what they understand each domain to involve before showing the bullets and illustrating with appropriate examples (see the notes on each slide).
Slides: human factors
Split cohort into small groups.
Human factors START
Learning outcomes
By the end of this session you should be able to:
• describe the implications of human error in health care;
• define non-technical skills and human factors;
• discuss the importance of human factors in relation to clinical practice;
• recognise stress and fatigue;
• evaluate your own coping strategies.
This session aims to provide participants with an overview of this large topic. Emphasise that these skills are essential for junior doctors, for professional development, their curriculum and foundation year competences.
© The Royal College of Surgeons of England 2021. All rights reserved
1.
2.
Background
• At least 10% of hospital inpatients will suffer from an adverse event.
• Research in high-risk industries, such as aviation, have found that up to 80% of adverse events are the result of human factors and lack of non-technical skills rather than technical issues.
• This suggests that clinical knowledge and technical skill alone are not enough to keep patients safe and an additional skill set is required.
• Non-technical skills mitigate these risks and provide personal / professional problem-solving processes.
The importance of human factors and non-technical skills should be emphasised. Evidence has shown that human factors have been central to major adverse events and errors within the hospital setting. Clinical knowledge and skills alone are not enough to provide safe and effective care for patients; an extra skill set is required. Teaching of non–technical skills is important to mitigate the risk of human factors, improve patient safety and provide junior doctors with skills to improve their performance along with personal and professional development.
For example: ask the audience to think of the last take they were on call for and imagine that 10% of those patients had or will have an adverse event.
Human factors and non-technical skills
Human factors
‘Environmental, organisational and job factors, as well as human and individual characteristics, which influence behaviour at work in a way that can affect health and safety.’ – HSE (https://www.hse.gov.uk/humanfactors/introduction.htm)
Non-technical skills
Behaviours in the working environment not directly related to the use of medical expertise, drugs or equipment.
Provide definitions.
Highlight the fact that learning non-technical skills is an important additional skillset required to mitigate mistakes caused by human factors. The latter is an inevitable error owing to human fallibility.
6.
What are non-technical skills?
The five key domains:
These non-technical skills include 5 domains of cognitive behaviors and interpersonal skills. These domains are all interlinked and complement each other. The domains have all been covered within the participants handbook.
Over the next few slides, ask participants for their understanding of each domain before revealing the ‘answers’ and discussing further.
Encourage participants to review the information in the handbook at a later stage.
Teamwork
• Shared goal and aim
• Awareness of role and responsibility
• Respecting and valuing team members
Faculty should emphasise the key skills for good teamwork:
Shared goal and aim: all team members are on the same page (we all want to do the best for the patient but need to realise others might have competing demands, eg your SPR might have a sick patient in A&E or theatre that means their response isn’t what you want).
Being aware of your role and responsibility within the team ensures tasks are covered and completed.
Mutual respect of team members ensures good morale and creates a positive work environment. Knowing other team members’ skills and limitations is important.
Support and encouragement is an important part of respecting and valuing team members.
Situational awareness
• Information gathering
• Evaluation of information
• Advance planning
Situational awareness may be a new concept for junior doctors. Situational awareness encourages junior doctors to ensure they have all the relevant information, act on this information and anticipate problems, ie take a minute to work out what is happening before moving on to making a decision.
Emphasise the three key points:
Information gathering - know your patient; know your environment; know your role.
Evaluation of information - understand and act on information.
Advance planning - prepare for ‘what if?’ scenarios: predict and prevent rather than react and respond.
If you have time, you may like to refer back to Mr Jones, eg:
Information gathering - not attempting to do a systematic evaluation of Mr Jones had serious consequences for him.
Evaluation of information - if we had performed a systematic evaluation of Mr Jones, we would have had to analyse the information obtained, which all groups acknowledged were lacking in the patient consequences section.
Advance planning - in Mr Jones’ case, planning for unforeseen circumstances that may require an overnight stay.
Decision making
Good decisions depend on good situational awareness:
• Recognise the problem
• Anticipate the consequences
• Make a decision
• Review the outcome
The ability to make good decisions relies on having good situational awareness and using the skills of the team around you.
In order to make good decisions you need to be able to;
1. recognise a problem or potential problem;
2. predict and anticipate the consequences of the problem;
3. make a decision and institute your plan;
4. review the outcome.
Task management – ward round example
• Preparation
• Prioritisation
• Organisation – resource management
You could use the example of a ward round to illustrate this slide, eg
• Preparation
o Know your rota;
o Turn up at the right ward at the right time;
o Log on and get a patient list;
o Prep the notes.
• Prioritisation
o Make a list: identify who needs to be seen first.
• Organisation – resource management
o Delegate – who should do what? who is taking bloods? Who is writing the discharge summary;
o Escalate – within the team and outside the team;
o Use your team – it’s larger than you think (eg other doctors, nurses, pharmacists, physiotherapists).
Communication failures are often contributors to medical errors. Communication can be done well or it can be done badly.
Communication involves interaction within the wider multidisciplinary team, patients, relatives and general public.
Highlight that many tasks within a regular day for a junior doctor require the ability to communicate well – handovers, ward rounds, patient discharge planning, referrals, outpatients and theatre interaction.
Tips: Think before you speak. Transfer all important information clearly and concisely.
Ask: What communication tool is most commonly used in hospitals? SBAR.
Communication SBAR
S Situation ‘I am … and I am calling because…’
B Background
‘Patient history is… Progress has been… Patient condition has changed…’
A Assessment ‘I think the problem is… I don’t know that the problem is… They are stable/unstable.’
Faculty should briefly highlight the SBAR tool and emphasise its importance. This is something junior doctors are likely to be familiar with therefore doesn’t need to be labored too much.
You don’t need to read out the slide. Instead, ask participants which bits they find most difficult and address those, eg the difference between S and B.
Common pitfalls you may wish to draw out include:
• to prevent the blurring of S and B, participants should consider the situation as the headline of why you are calling, with the more detailed information coming in the B section.
• in the R section, the person calling should make an attempt to come up with a plan.
(Originally designed by the US Navy to improve communication on Nuclear Submarines)
Interactive task
• Clinical case scenario
• You will be split into 5 groups
• Consider what went wrong and what could have been done better
Faculty will now facilitate an interactive task: a clinical case scenario where there has been an error.
Using the five domains of non-technical skills, participants will discuss what went wrong and what could have been done better.
Split into small groups.
Scenario and discussion
After the slides, move on to the scenario and discussion. Split participants into groups of four or five, each with a member of the faculty. The small groups talk through the scenario (available on a handout for participants) and discuss what went wrong and what could have been done better in terms of each domain.
You can use the following suggestions to prompt participants. Although it is a simple case, there is plenty of detail to pick up on.
Teamwork
What went wrong?
• No team huddle or handover.
• No acknowledgement of each other’s priorities.
• No clear leader of the team. Where is the medical/surgical registrar?
• No communication between ward nurses and doctor. Remember, the nursing staff are part of your team.
What could have been done better?
• Strong handover identifying leadership and individual roles.
• Task allocation and prioritisation.
• Empowering the team to speak up and contact each other.
Situational awareness
What went wrong?
• Information was gathered and the appropriate conclusion was drawn.
• However, there was no advanced planning.
What could have been done better?
• Understand the big picture. Which departments are busy?
• You cannot do two jobs at once: collect the information on one patient, evaluate it and move on to the next.
• Take time to ensure the nursing staff understand your plan.
Decision-making
What went wrong?
• There was recognition of the patient’s presenting complaints and appropriate decisions were made.
• However, error in the implementation of treatment resulted in a dangerous outcome.
What could have been done better?
• Take time to review the patient and communicate the plan to the nursing staff.
Task management
What went wrong?
• There was lack of early preparation and prioritisation by the on-call team.
• It is unclear if the team’s resources have been used effectively.
• Two patients needed to be managed as two separate tasks.
What could have been done better?
• Individual cases require accurate assessments.
• Both patients need an equal amount of thinking and implementation time.
Communication
What went wrong?
• Poor communication across the board (among the on-call team, from doctor to patient, between ward staff).
• Thus, all elements of the human factors matrix have been negatively impacted.
What could have been done better?
• Communicate!
• Verbal, face-to-face, telephone, email, WhatsApp, medical notes.
Handout: human factors
Clinical scenario
• It is 1:00am on an on-call shift.
• The FY1 is busy and has not seen the core trainee (CT) or specialty trainee (ST) since the handover.
• The ward call the FY1 about two unwell patients needing review.
• Following the ABCDE assessment:
o patient A is in pulmonary oedema;
o patient B is hypotensive and oliguric.
• While prescribing, the FY1 gets a call from a busy CT2 demanding to know why they aren’t helping in the emergency department.
• The FY1 prescribes intravenous (IV) furosemide and IV fluids and quickly leaves the ward without speaking to the nurse.
• The patient with pulmonary oedema receives IV fluids.
• The patient with hypotension and oliguria receives IV furosemide.
In relation to the five domains… What went wrong?
Resilience
The resilience section is an important part of the session and you should encourage participants to discuss their experience. Principles of safety and confidentiality are key to effective facilitation of this session. You can use the following notes to help you facilitate the discussion.
Stress and fatigue
Why does it occur?
• excessive workload;
• long working hours;
• difficult patients;
• difficult colleagues;
• difficult situations;
• errors;
• bad outcomes.
It is effective for faculty to share their own personal examples of recognising when they are experiencing stress and fatigue.
Ask the group for their own examples of things they find stressful.
Reassure participants that in a medical career, stress and fatigue are common and are caused by many different situations in and out of the working environment. Stress and fatigue are not signs of weakness.
What are the warning signs?
As doctors, it is important to understand how stress and fatigue manifest within each individual. Examples might include headaches, irritable bowel, irritability, poor sleep, muscle tension. Essentially these signs and symptoms are warning signs from your body to indicate periods of stress and fatigue.
What could be the consequences of ignoring your warning signs?
If, as individuals, we fail to recognise these signs or ignore them, there could be further consequences, eg sickness, time off work, relationship problems, anxiety, low mood, depression, addiction, burnout.
Coping strategies
Within the workplace, negative or ineffective strategies include ‘just keep going’ and ‘soldier on’. However, these lead to further burnout and emotional and physical exhaustion.
What strategies could you use to cope?
• Work smarter, not harder (ie learn how to prepare, delegate, manage your time and prioritise effectively).
• Talk to a friend or family member.
• Take time out or a holiday.
• Spend time on a hobby.
• Exercise.
• Consider counselling.
Doctors need to look after themselves to look after their patients. Remind participants that there are links to resources for supporting junior doctors’ well-being in their Handbook.
Summary
• Non-technical skills help mitigate the risk caused by human factors.
• Therefore, non-technical skills are of significance in your medical career.
• Stress and fatigue are not signs of weakness but are common occurrences within the hospital environment.
• Look after yourselves as well as your patients.
• Use the Handbook to find support services.
Practical assessment of a patient
12:50pm – 3:05pm
Session summary This session consists of five scenarios assessing airway, breathing, circulation, neurological dysfunction and acute kidney injury. Each participant leads a scenario and undertakes a supervised assessment of a patient who needs critical intervention.
Duration 2 hours 15 minutes
Learning outcomes By the end of this session, participants should be able to:
• implement the START assessment algorithm;
• discuss key clinical topics relevant to junior doctors;
• reflect on the verbal feedback received from peers and faculty.
Faculty Five faculty members, one per participant group
Electronic resources PowerPoint: Session 5 Practical assessment of a patient overview Video: RCS START Algorithm (video 4)
Hard copy resources PA Handouts cases 1–5
Clinical resources Variety of equipment for conducting A–E assessment, such as face masks, stethoscope and BP cuff. (See case faculty notes and Appendix 1 for a detailed equipment list.)
After this session Refreshments
Teaching notes
This session lasts 2 hours 15 minutes in total, broken down as follows:
• Introduction and participant briefing (10 minutes).
• Five 25-minute scenarios organised as:
o lead participant performs the scenario (15 minutes).
o feedback, discussion and questions (8 minutes).
o move to the next station (2 minutes).
After the introduction, divide participants into five groups: each group rotates through the five breakout rooms, doing each scenario in turn. For each scenario, a different participant takes the lead.
Faculty members are assigned to each room and do not rotate: each faculty member delivers the same case scenario five times during the session.
You should review the scenario beforehand and ensure that the appropriate equipment is available. In the initial scenarios, it may be necessary to prompt the participants and offer assistance. You may also need to encourage them to role-play and use the equipment. It is important to encourage participants to follow the START algorithm, which should be displayed nearby. As they proceed through the scenarios, they will become more confident and are likely to need less help.
For each case, this Handbook includes a table showing case information for immediate management. When you start, give each participant the first handout with the patient photograph and scenario. Feed participants relevant information when they tell you which item they are assessing, along with test result handouts when appropriate. Incorporate the ‘Faculty interactions’ at an appropriate point. Participants must then decide which actions they would take; you can inform them of the outcome, allowing them to move on to the next section.
Remember that the aim of the course is for participants to progress beyond A–E, so try to keep the immediate management section moving and allow participants to experience the later stages of the algorithm.
Time management is vital for this session. Stronger participants will get further along in the algorithm, while weaker participants will progress more slowly and not get as far in the time allowed. However, it is important that all participants receive their allotted time for feedback, regardless of how quickly or how much of the algorithm they have covered.
The course coordinator should assist with timekeeping and ensure smooth transitions between rooms.
Slides: practical assessment of a patient
Learning outcomes
By the end of this session you should be able to:
• implement the START assessment algorithm
• discuss key clinical topics relevant to junior doctors
• reflect on verbal feedback received from peers and faculty
• This session consists of five scenarios.
• Each scenario will demonstrated in one of the breakout rooms.
• You will be divided into five groups rotating through each scenario (25 minutes per station – 15 minutes for the exercise and 10 for feedback/discussion).
• Each participant will have the opportunity to lead a scenario and undertake a supervised assessment of a patient in need of critical intervention.
• Each participant will then be given constructive verbal feedback.
• Remember, this course is formative.
Feedback video
START Algorithm video, part 4 – play video
This lecture aims to provide participants with an overview of this large topic. Emphasise that these are skills that are essential for junior doctors, for professional development, their curriculum and foundation year competences.
Practical assessment of a patient 6.
Questions?
Case 1 (Airway) faculty notes
Printed resources
• Case scenario with patient photograph.
• Charts: NEWS 2, drug, patient-controlled analgesia (PCA), fluid balance.
• Results: arterial blood gases at time of deterioration.
Equipment
• A – Guedel airway (red, orange, green), nasopharyngeal airway (5, 6, 7), O2 mask, non-rebreather mask, nasal cannula, bag valve mask.
• B – Pulse oximeter, stethoscope.
• C – BP cuff, cannulas, blood gas syringe, blood collection tubes, IV fluid (1 litre Hartmann’s solution).
Scenario for participants
You are the night FY1 covering the elective colorectal ward. You have been asked to review a 72-year-old man with increasing drowsiness and reduced responsiveness. Mr George is currently day 1 post-open right hemicolectomy. He is currently prescribed a PCA for analgesia.
He has a background of asthma, hypertension and peripheral vascular disease. His medications include aspirin, atorvastatin, budesonide, lisinopril and salbutamol. The staff nurse is concerned about Mr George, due to a climbing NEWS score (4 to 9). They advise you that Mr George has received a number of morphine bolus doses.
Background for faculty
This 72-year-old man is day 1 post-surgery. He is obviously narcotised because he has selfadministered 40mg morphine since midnight. He shows signs of airway obstruction and hypoventilation. He responds to naloxone but needs ongoing critical care support because he is at risk of further deterioration.
Full patient assessment
• The observation chart demonstrates an increasing NEWS combined with a reduced respiratory rate and corresponding oxygen saturations.
• The drug and PCA charts show over 40mg of morphine administered since midnight.
• The blood gas test shows hypoxia with elevated PaCO2.
Decide and plan
• The participant should recognise that the patient is at risk of further deterioration and seek help.
• Escalation of care to level 2 – critical care?
Discussion points
• Dose of naloxone – issues with pain if administered in excess.
• Risk of further deterioration when naloxone wears off.
• Discuss blood gas test results.
• Does the patient need ventilator support?
• Is anaesthetic help required?
Case 1 Immediate management information
Airway
Check: airway
Faculty interaction
Action
Airway partially obstructed.
Patient unresponsive, not speaking, making snoring noises.
Simple airway manoeuvre – head tilt and jaw thrust needed. Airway adjuncts – Guedel not tolerated, needs nasopharyngeal help.
Outcome Secure airway patency. Proceed to B.
Check: rate
depth/symmetry/pattern
Breathing
RR 6 breaths/min.
Equal chest movement. chest percussion
Resonant bilaterally. use of accessory muscles
Not using accessory muscles. auscultation
Normal breath sounds.
oxygen saturation 88% on room air.
Faculty interaction
Pinpoint pupils identified by nursing staff.
Action Apply high-flow oxygen. Use bag mask ventilation. Consider intravenous naloxone.
Outcome
Check: pulse
BP
temperature
heart sounds
cardiac resynchronization therapy (CRT)
urine output/fluid balance
Faculty interaction
Action
Outcome
Check: ACVPU (Alert, Confusion, Voice, Pain, Unresponsive)
Patient is more responsive.
Respiratory rate increases to RR 12 breaths/min. Oxygen saturation increases to 96%. Proceed to C.
Circulation
57, regular.
110/55mmHg (note that the patient has a past history of hypertension).
36.5°C.
1 + 2.
2 seconds, warm peripheries.
Unknown.
No real concerns.
Vascular access.
Arterial blood gases (ABGs). Consider fluid replacement.
Patient haemodynamically stable.
Disability
U but becomes responsive after naloxone (to voice).
blood glucose level 5.2.
pupil size and reaction
Faculty interaction
Action
Pinpoint before naloxone.
Currently stable.
Administer naloxone if not yet given.
Outcome Improved responsiveness.
Exposure
Head-to-toe examination
Abdominal examination. Review wound.
Case 1 Handouts
Scenario
You are the night FY1 covering the elective colorectal ward. You have been asked to review a 72-year-old man with increasing drowsiness and reduced responsiveness. Mr George is currently day 1 post-open right hemicolectomy. He is currently prescribed a PCA for analgesia.
He has a background of asthma, hypertension and peripheral vascular disease. His medications include aspirin, atorvastatin, budesonide, lisinopril and salbutamol.
The staff nurse is concerned about Mr George, due to a climbing NEWS score (4 to 9). They advise you that Mr George has received several morphine bolus doses.
Case 1: NEWS chart
Case 1: drug chart (page 1)
Case 1: drug chart (page 2)
Case 1: drug chart (page 3)
Case 1: drug chart (page 4)
Case 1: drug chart (page 5)
Case 1: PCA chart (page 1)
Case 1: PCA chart (page 2)
Case 1: fluid balance chart
Case 1: ABG results
Case 2 (Breathing) faculty notes
Printed resources
• Case scenario with patient photograph.
• Charts: NEWS 2, drug.
• Results: blood tests, ABGs on admission and at time of deterioration.
• Chest x-ray (CXR).
Equipment
• A – Venturi mask, non-rebreather mask, nasal cannula, bag valve mask.
• B – Pulse oximeter, stethoscope, nebuliser kit.
• C – BP cuff, cannulas, blood gas syringe, blood collection tubes, blood culture bottles, IV fluid (1 litre Hartmann’s solution).
Scenario for participants
You are the FY1 covering the medical ward. You have been called urgently to see Ms Cousins by the nursing staff because she is increasingly short of breath.
Ms Cousins is a frail 77-year-old woman recovering from a recent fall. She has a history of severe COPD. Her medications are aspirin, beclometasone dipropionate, lisinopril and fluticasone with salmeterol.
Background for faculty
This frail woman, who has been admitted after a fall at home, has a history of severe COPD. Over the last 12 hours, she has deteriorated and has likely developed an infective exacerbation of her airways disease. She is tachypnoeic with worsening ABGs. Standard bronchodilator therapy should be instituted and carefully targeted oxygen therapy is indicated. The participant should recognise that the patient needs non-invasive ventilation (NIV) and should be escalated to critical care.
Full patient assessment
• The observation chart shows an increasing NEWS 2 score, especially the respiratory rate.
• The drug chart has her admission medication with inhalers only.
• ABGs have deteriorated with hypoxia on room air and an elevated PaCO2
• Electrolytes are normal but her C-reactive protein (CRP) and white cell count (WCC) are elevated.
• CXR shows hyperinflation but no obvious consolidation.
Decide and plan
The participant should recognise that the patient has type 2 respiratory failure and needs NIV.
Discussion points
• Compare and discuss the significance between the two ABG tests.
• The treatment options available include oxygen flow rate, nebuliser types and steroids (oral/IV).
• Does the patient have sepsis? Note the raised WCC and CRP.
• Discuss the indications for antibiotics.
• Discuss the indications for escalation to critical care.
• Discuss the indications for NIV.
Case 2 Immediate management information
Airway
Check: airway
Speaking single words.
Faculty interaction Sit patient upright.
Action Proceed to B.
Outcome
Airway patent but still speaking single words.
Breathing
Check: rate RR 35 breaths/min. depth/symmetry/pattern Reduced expansion. chest percussion Resonant bilaterally. use of accessory muscles Using accessory muscles (splinting diaphragm-tripodding). auscultation
Quiet air entry with scattered wheeze. oxygen saturation 80% on room air.
Faculty interaction
Ensure that oxygen therapy is commenced + nebulisers.
Target oxygen saturation – 88–92%. Discuss investigations at this stage. ABG baseline.
ABG at the time of current deterioration. CXR.
Action
Commence oxygen. Commence nebulisers. Monitor patient’s progress. Escalate care to senior colleagues and critical care.
Outcome Patient remains distressed despite ward-based treatment. Escalation is warranted. Proceed to C.
Check: pulse
Circulation
110 bounding.
BP 140/75mmHg.
temperature 35.9°C.
heart sounds 1 + 2.
CRT 2 seconds, warm peripheries.
urine output/fluid balance Unknown.
Faculty interaction No immediate concerns. Note: temperature.
Action Obtain vascular access. Carry out full blood panel. Consider fluid replacement.
Outcome Haemodynamics are unchanged.
Disability
Check: ACVPU A. blood glucose level 5.6. pupil size and reaction Normal.
Faculty Interaction No intervention required.
Action No action required.
Outcome
Patient remains in respiratory distress.
Exposure
Head-to-toe examination Cachectic female. Nicotine staining.
Case 2 Handouts
Scenario
You are the FY1 covering the medical ward. You have been called urgently to see Ms Cousins by the nursing staff because she is increasingly short of breath.
Ms Cousins is a frail 77-year-old woman recovering from a recent fall. She has a history of severe COPD. Her medications are aspirin, beclomethasone dipropionate, lisinopril and fluticasone with salmeterol.
Case 2: NEWS chart
Case 2: drug chart (page 1)
Case 2: drug chart (page 2)
Case 2: drug chart (page 3)
Case 2: ABG results
On admission
Test
At the time of deterioration
Test
Case 2: Blood tests
Test
Case 2: CXR
Case 3 (Circulation) faculty notes
Printed resources
• Case scenario with patient photograph.
• Charts: NEWS 2, fluid balance.
• Results: blood tests, ABGs.
• ECG.
Equipment
• A – Non-rebreather mask, Venturi mask.
• B – Pulse oximeter, stethoscope.
• C – BP cuff, cannulas (blue/pink/green/grey), blood gas syringe, blood collection tubes, IV fluid (1 litre Hartmann’s solution).
Scenario for participants
Ms Olivia is a 70-year-old woman with a 2-day history of increasing epigastric pain awaiting assessment. She has a background of atrial fibrillation and fibroids. Her regular medications include digoxin, lansoprazole, naproxen and warfarin.
You are called urgently by the nursing staff on the medical assessment unit to review Ms Olivia, who feels faint. The nursing staff have noticed blood-stained vomitus on her clothes.
Background for faculty
A 70-year-old woman with atrial fibrillation, taking warfarin, has presented with a significant upper gastrointestinal bleed. Her airway and breathing are stable. The participant must appreciate that this is a significant bleed. Initial resuscitation should take place but further help is needed. Anticoagulation should be discussed and reversed. The patient is unstable-hypotensive and definitive intervention is warranted.
Full patient assessment
• The observation chart shows hypotension and tachycardia.
• The ABGs show a metabolic acidosis secondary to an elevated lactate.
• Routine bloods show significant anaemia with acute kidney injury and elevated international normalised ratio (INR).
• The ECG shows fast atrial fibrillation (AF).
Decide and plan
• The participant should realise that the patient is unstable despite ward-based management; therefore, they need help with further intervention to stop the bleeding.
Discussion points
• Fluid resuscitation – crystalloids versus blood.
• Reversing warfarin.
• IV proton pump inhibitor – hold off until endoscopy.
• Urgent gastroenterology referral.
• Definitive management endoscopy versus surgery.
• Differential diagnosis.
• Escalation of care – will depend on the type of intervention.
• Significance of ECG – fast AF.
Case 3 Immediate management information
Airway
Check: airway Airway is patent.
Faculty interaction No action is required.
Action Proceed to B.
Outcome
Airway is patent.
Breathing
Check: rate RR 25 breaths/min.
depth/symmetry/pattern Equal chest movement.
chest percussion Resonant bilaterally. use of accessory muscles Not using accessory muscles. auscultation
Normal breath sounds.
oxygen saturation 93% on room air.
Faculty interaction
Basic respiratory interventions are warranted.
Action Administer oxygen.
Outcome
Breathing is stable – proceed to C.
Circulation
Check: pulse 120, irregular, thready.
BP 85/40mmHg.
temperature 35°C.
heart sounds 1 + 2.
CRT
5 seconds, cool, pale peripheries.
urine output/fluid balance No catheter – not passed urine today?
Faculty interaction
Immediate resuscitation is warranted. Call for help.
Action Vascular access – choice/number. Fluid replacement – choice/volume/speed. Bloods tests – routine, coagulation and blood bank. ABGs.
Urinary catheter – hourly urometer. ECG.
Reassessment.
Outcome
Patient remains hypotensive after 1 litre of crystalloid. Escalate. Call for help.
Check: ACVPU A.
blood glucose level 4.9.
pupil size and reaction Normal.
Faculty interaction
Disability
No intervention required.
Action No action required.
Outcome
Head-to-toe examination
The patient remains hypotensive.
Exposure
Full exposure – look for any bleeding source. Rectal examination.
Case 3 Handouts
Scenario
Ms Olivia is a 70-year-old woman with a 2-day history of increasing epigastric pain awaiting assessment. She has a background AF and fibroids. Her regular medications include digoxin, lansoprazole, naproxen and warfarin.
You are called urgently by the nursing staff on the medical assessment unit to review Ms Olivia, who feels faint. The nursing staff have noticed blood-stained vomitus on her clothes.
Case 3: NEWS chart
Case 3: drug chart (page 1)
Case 3: drug chart (page 2)
Case 3: drug chart (page 3)
Case 3: fluid balance chart
Case 3: ABG results
Case 3: blood tests
Case 3: ECG
Case 4 (Neurological dysfunction) faculty notes
Printed resources
• Case scenario with patient photograph.
• Charts: NEWS 2.
• Results: ABGs (metabolic acidosis), blood tests (septic full blood count (FBC), mild acute kidney injury (AKI)).
• ECG.
• CXR.
Equipment
• A – Venturi mask, non-rebreather mask, nasal cannula.
• B – Pulse oximeter, stethoscope.
• C – BP cuff, cannulas, blood gas syringe, blood collection tubes, blood culture bottles, IV fluid (1 litre Hartmann’s solution), urinary catheter bag.
Scenario for participants
Mr Basri is an 84-year-old man admitted from his nursing home with suprapubic pain and dysuria. He transfers with a hoist and has not been mobile for 3 years. You are called to see him urgently on the elderly ward because the nursing staff tell you that he has become drowsy.
Background for faculty
The patient is a frail 84-year-old man who is a nursing home resident with significant comorbidities. He is fully dependent and needs hoisting. He has urosepsis (likely from his long-term in situ catheter), which is causing confusion, hypotension and AKI. Treatment should be based around resuscitation and the Sepsis Six. His blood pressure remains low after fluids, which should prompt discussion about escalation and ceilings of care.
Full patient assessment
• The observation chart shows hypotension, tachycardia and pyrexia.
• Routine bloods show elevated CRP/WCC with AKI.
• Blood gases show significant metabolic acidosis with elevated lactate.
• The ECG shows sinus tachycardia.
• CXR is normal.
• Fluid balance chart is required.
Decide and plan
• The patient remains unstable with resilient hypotension.
• Conversations should take place around ceilings of care and the appropriateness of escalation to critical care.
Discussion points
• Fluid resuscitation.
• Consider the likely diagnosis – urosepsis and possible other sources (lines, chest, sores).
• Sepsis Six.
• Metabolic acidosis and underlying renal dysfunction.
• Review medications with regard to AKI. What should be stopped?
• Indication for critical care (ongoing hypotension) versus ceiling of care.
Case 4 Immediate management information
Airway
Check: airway Airway is patent.
Faculty interaction No action is required.
Action Proceed to B.
Outcome Airway is patent.
Breathing
Check: rate RR 28 breaths/min.
depth/symmetry/pattern Equal chest movement, shallow. chest percussion Resonant bilaterally. use of accessory muscles Not using accessory muscles. auscultation
Normal breath sounds.
oxygen saturation 93% on room air.
Faculty interaction Basic respiratory interventions are warranted.
Action Administer oxygen.
Outcome
Breathing stable – proceed to C.
Circulation
Check: pulse 110, regular.
BP 85/40mmHg.
temperature 39.1°C.
heart sounds 1 + 2.
CRT
urine output/fluid balance
3 seconds, warm peripheries.
35 ml in the last 3 hours; urinalysis nitrate +++, WCC ++, blood +.
Faculty interaction Fluid resuscitation. Sepsis screening.
Action
Outcome
Vascular access. Bloods (FBC/renal function/CRP/cultures). ABGs.
Fluid replacement. Sepsis Six. CXR. ECG.
Patient remains unstable. Escalation.
Ceiling of care discussions with patient ie do not attempt cardiopulmonary resuscitation (DNACPR).
Check: ACVPU C.
blood glucose level 11.6.
pupil size and reaction
Disability
Pupils equal and reactive to light and accommodation (PERLA).
Faculty Interaction Is this new confusion versus baseline status? Collaborative history – information gathering.
Action Discussion with family/nursing home/general practitioner.
Outcome Proceed to E.
Exposure
Head-to-toe examination
Full exposure.
Sources of potential sepsis – cellulitis, pressure sore, lines, abdominal examination. Calves soft? Deep vein thrombosis (DVT).
Urine dip. Catheter in situ.
Case 4 Handouts
Scenario
Mr Basri is an 84-year-old man admitted from his nursing home with suprapubic pain and dysuria. He transfers with a hoist and has not been mobile for 3 years. You are called to see him urgently on the elderly ward because the nursing staff tell you that he has become drowsy.
Case 4: NEWS chart
Chart 4: drug chart (page 1)
Chart 4: drug chart (page 2)
Case 4: drug chart (page 3)
Case 4: fluid balance chart
Case 4: ABG results
Test
Case 4: Blood tests
Case 4: ECG
Case 4: CXR
Case 5 (AKI) faculty notes
Printed resources
• Case scenario with patient photograph.
• Charts: NEWS 2, drug (including nephrotoxins angiotensin-converting enzyme (ACE) inhibitors, non-steroidal anti-inflammatory drugs (NSAIDs)).
• Results: blood tests (FBC, urea and electrolytes, CRP, consider coagulation screen), ABGs.
• Hyperkalaemic pathway.
• Two ECGs – previous outpatient ECG normal; second ECG on this admission – peaked T waves.
Equipment
• A – Venturi mask, non-rebreather mask, nasal cannula.
• B – Pulse oximeter, stethoscope.
• C – BP cuff, cannulas, blood gas syringe, blood collection tubes, IV fluid (1 litre Hartmann’s solution).
Scenario for participants
You are the surgical FY1 and have been asked to review Ms Jones, a 76-year-old woman who underwent an elective total right knee replacement yesterday. She has a past history of myocardial infarction (2010), hypertension, heart failure and asthma. She weighs 52kg and the nurses have informed you that she has not passed urine today.
Background for faculty
This 76-year-old woman, who is postoperative from a knee replacement, has developed an AKI with life-threatening hyperkalaemia. She has many risk factors for AKI that should be identified. Fluid resuscitation, strict fluid balance and hyperkalaemia treatment need to be instituted. The participant should seek senior help and escalate the patient to critical care.
Full patient assessment
• The observation chart shows dipping BP in the last 24 hours postoperatively.
• The drug chart includes NSAIDS and ACE inhibitors.
• The blood results show significant AKI with hyperkalaemia.
• The blood gases show metabolic acidosis.
• Preoperative ECG 1 in sinus rhythm.
• ECG 2 shows peaked T waves.
• Hyperkalaemia management pathway is available to consult.
Decide and plan
• The patient remains unstable with a significant AKI and needs to be escalated to critical care with potential renal team involvement.
Discussion points
• Recognition of AKI causes (prerenal/renal/postrenal).
• Multimodal AKI treatment options (fluids/nephrotoxins/scan/BP).
• Hyperkalaemia treatment options (and implications).
• Implications of deteriorating AKI (acidosis/potassium/fluid overload/uraemia).
• Indications for dialysis.
Case
5 Immediate management information
Airway
Check: airway Airway is patent.
Faculty interaction No action is required.
Action Proceed to B.
Outcome Airway is patent.
Breathing
Check: rate RR 21 breaths/min.
depth/symmetry/pattern Equal chest movement, shallow. chest percussion Resonant bilaterally. use of accessory muscles Not using accessory muscles. auscultation Reduced bibasal air entry. oxygen saturation 96% on room air.
Faculty interaction None.
Action
Outcome
No action is required.
Breathing stable – proceed to C.
Circulation
Check: pulse 78, regular. BP 99/50mmHg.
temperature 36.1°C.
heart sounds 1 + 2.
CRT 2 seconds, cool peripheries.
urine output/fluid balance
No urine for 12 hours (not catheterised).
Faculty interaction Instigate fluid resuscitation and perform information gathering for potential renal insults.
Action Fluid resuscitation. Catheterise/bladder scan. Stop nephrotoxins. Bloods. ABGs.
Treat hyperkalaemia. Escalation.
Outcome
Ongoing renal dysfunction with life-threatening electrolyte derangement.
Check: ACVPU A.
blood glucose level 6.6.
pupil size and reaction PERLA.
Faculty interaction None.
Disability
Action No action is required.
Outcome Proceed to E.
Exposure
Head-to-toe examination
Full exposure.
Case 5 Handouts
Scenario
You are the surgical FY1 and have been asked to review Ms Jones, a 76-year-old woman who underwent an elective total right knee replacement yesterday. She has a past history of myocardial infarction (2010), hypertension, heart failure and asthma. She weighs 52kg and the nurses have informed you that she has not passed urine today.
Case 5: NEWS chart
Case 5: drug chart (page 1)
Case 5: drug chart (page 2)
Case 5: drug chart (page 3)
Case 5: ABG results
Test
Case 5: Blood tests
Test
Case 5: ECG
Previous outpatient
On current admission
Case 5: protocol for hyperkalaemia
Virtual handover challenge
3:20pm – 4:35pm
Session summary The virtual handover challenge is the culmination of the course. Participants analyse a case using the START algorithm, formulate a plan and work in a group to triage cases.
Duration 75 minutes
Learning outcomes
By the end of this session, participants should be able to:
• demonstrate the ability to gather information about a variety of patients and use that information to formulate appropriate management plans;
• discuss management plans with peers and prioritise patients according to their clinical needs;
• present management plans to peers and faculty, and justify the decisions they have made.
Faculty
Electronic resources
Hard copy resources
Two faculty members
PowerPoint: Session 6 VHC Overview
Handouts: START VHC handouts for eight cases
Two flip charts
After this session Course summary
Teaching notes
The session lasts 75 minutes in total, broken down as follows:
• Introduction (5 minutes).
• Small groups review clinical information (15 minutes).
• Group presentations and prioritisation (25 minutes).
• Whole-group discussion and comparison of priorities (30 minutes).
We have provided 16 cases of varying difficulty, from which faculty select 4. The details of each case are listed here, with additional notes. Bear in mind that participants will be prioritising these cases, so choose cases that will provoke debate as to which is most important.
We have made 16 cases available primarily because it allows faculty a range of difficulties to choose from, depending on the strength of the group, which faculty should be able to gauge by this stage of the course day. Previous feedback has suggested that some elements of the START course are too easy for FY1s nearing the end of the foundation year. We suggest that faculty select more difficult cases to challenge these participants further.
Use the PowerPoint presentation to introduce the session and explain the exercise to participants. The exercise runs as follows:
1. Split the participants into two large groups, A and B. Each group is given four printed case studies, along with accompanying clinical information. You may want to ask groups to work in separate rooms (5 minutes).
2. Divide each large group further into four subgroups (usually of three or four participants). Each subgroup examines one case and formulates an initial plan. Faculty should oversee the discussions (15 minutes).
3. Subgroups present a summary of their case to their respective larger groups. Collectively, the group then prioritises the four cases from most to least urgent and forms a final management plan for each. A summary of their decisions and management plans should be written on a flip chart. It is important to recognise that there may be no ‘correct’ order of cases. Faculty will need to facilitate the discussion (25 minutes).
4. Groups A and B come together to compare how the two groups have prioritised the tasks, using the flip charts as prompts. Again, faculty will need to facilitate the discussion (30 minutes).
Some of the case information includes lots of details for potential discussion: you can use as much as you see fit, depending on the level of the participants, and prompt discussions of greater depth where appropriate. You may like to ask participants to complete some of the case tasks, for example, writing ward round notes (case 2) or holding an SBAR (situation, background, assessment, recommendation) conversation (case 6).
Case difficulty
The 16 case studies are grouped into two levels of difficulty:
• Early FY1 year: cases 1, 2, 4, 6, 7, 8, 14
• Late FY1 year: cases 3, 5, 9, 10, 11, 12, 13, 15,16
• Case 1: Incomplete electronic discharge notification (EDN)
• Case 2: Getting patient with appendicitis ready for theatre
• Case 3: Patient expecting to go home but develops acute retention
• Case 4: Confused orthopaedic patient
• Case 5: Postrenal AKI with hyperkalaemia
• Case 6: Bleeding risks on anticoagulation medication
• Case 7: Deteriorating patient with pneumonia needing escalation
• Case 8: Patient with COPD needing ceiling of care discussion
• Case 9: Patient needing palliative care
• Case 10: IV drug user needing access
• Case 11: Patient with pulmonary embolism
• Case 12: Acutely unwell patient with tension pneumothorax
• Case 13: Patient with diabetes with chronic kidney disease needing a colonoscopy
• Case 14: Patient with acute pulmonary oedema
• Case 15: Inadvertent paracetamol overdose in a patient with low body weight
• Case 16: Patient with obstructive jaundice
Learning outcomes
By the end of this session you should be able to:
• demonstrate the ability to gather information about a variety of patients and use that information to formulate appropriate management plans;
• discuss management plans with peers and prioritise patients according to their clinical needs;
• present management plans to peers and faculty, and justify the decisions you have made.
Handover exercise – stage 1 (5 mins)
You will be split into two large groups.
Each group will have four scenario handouts, along with accompanying clinical information.
Handover exercise – stage 2 (15 mins)
You will be further divided into sub-groups of 3 or 4
Each sub-group examines one case.
You will have 15 minutes to formulate a plan.
Group
Group A
Group B
Each large group prioritises the cases from most to least urgent, and forms a management plan for each. Handover exercise – stage 3 (25 mins)
Sub-groups present a summary of their case to their respective larger groups.
Handover exercise – stage 4 (30 mins)
All participants come together to discuss how each group has prioritised their cases.
Learning outcomes
By the end of this session you should be able to:
• demonstrate the ability to gather information about a variety of patients and use that information to formulate appropriate management plans;
• discuss management plans with peers and prioritise patients according to their clinical needs;
• present management plans to peers and faculty, and justify the decisions you have made.
Participant resources
The following pages detail the case descriptions and accompanying resources for each case study. Faculty members allocated to this session should preselect 4 of the 16 scenarios in advance of the session. In reality, this should be done by lunchtime and you should allow 5 minutes to review and select the cases.
Case 1 (EDN) faculty notes
Printed resources
• Case scenario with patient photograph.
Discussion points
• This case challenges the candidate to think about the prioritisation of tasks. Although clinically this would be of low priority in terms of patient flow, patient journey and potential conflict, EDN/ discharge is an important knowledge point.
• This case will encourage participants to think about whether this task could be delegated to someone else, such as a specialist nurse or physician assistant. Stronger participants may think about feeding back to the day team regarding how they prioritise tasks from the morning ward round.
Case tasks
• Complete the full START assessment.
• Where possible, delegate to a colleague or specialist nurse.
• Feedback to surgical team.
Case 1 Handouts
Case details
• Staff nurse on diagnostic unit rings at 4pm, unable to get a hold of the surgical team.
• List finished early.
• The patient had local anaesthetic endothermal ablation of varicose veins.
• EDN incomplete.
• Nurse requests you come to the diagnostic unit straightaway to complete the EDN since the patient cannot be discharged.
What would you do?
Case 2 (Appendicitis) faculty notes
Printed resources
• Case scenario with patient photograph.
• NEWS chart.
• Plain paper for writing ward round entry/plan.
Discussion points
• Participants should recognise that this is an organisation, documentation and verbal communication task.
• Participants should prioritise the various tasks in a sensible, coherent way.
• They need to accept responsibility for the patient getting to theatre.
• Common errors on the ward include:
o poor documentation of ward round;
o group and screen/bloods not taken;
o pregnancy test not taken;
o nurses not aware of plan, causing delays;
o miscommunication, such as not specifying which team member is responsible for each task.
Case tasks
• Complete the full START assessment.
• Complete the ward round notes.
• Liaise with senior (probably registrar or consultant) to determine who is going to consent and book the patient into theatre.
• Arrange the appropriate bloods, including group and screen.
• Ensure that a pregnancy test has been taken.
• Monitor the patient’s fasting status.
• Maintain documentation of plan in notes, using the ward round checklist (pen and paper will be required).
• Communicate the plan to the nursing staff and the patient and their relatives.
Case 2 Handouts
Case details
• The patient is a 19-year-old woman, who is accompanied by her anxious mother.
• She was seen on the 6:00pm consultant general surgeon ward round.
• 3-day history of anorexia, nausea and central abdominal pain moving to right iliac fossa (RIF).
• Patient is flushed with no gynaecological or urinary symptoms.
• Tender RIF with guarding/rebound.
• Consultant speaks to patient and family, probably diagnosis of appendicitis.
• The plan is to send the patient to the operating theatre tonight for laparoscopy.
• FY1 is asked to document and ‘sort out theatre and patient’.
What would you do?
Case 2: NEWS chart
Case 3 (Safe discharge and urinary retention) faculty notes
Printed resources
• Case scenario with patient photograph.
• EDN.
Discussion points
• Safe discharge criteria.
• Worsening admission pathology versus new problem versus correct initial diagnosis.
• Pressure on discharge due to hospital acuity.
• Make own assessment based on changing clinical picture.
Case tasks
• Complete the full START assessment.
• Take dipstick +/− midstream urine specimen of urine.
• May require urinary catheter if unable to pass urine.
• Enact Sepsis Six if sepsis is worsening.
• Consider AKI and electrolyte disturbance.
• Consider CXR and repeat gas if respiratory deterioration.
• Admit for catheter and observation versus discharge with catheter for trial without catheter clinic.
• Urology advice and follow-up.
• Consider escalation, where appropriate.
• Communicate with patient and family about plan.
• Document appropriately.
Case 3 Handouts
Case details
• The patient is an 82-year-old man, who has recovered from community-acquired pneumonia, awaiting discharge.
• Nurse calls FY1 at 6:00pm, because patient now has suprapubic pain.
• Bladder scan shows distended bladder.
• Nurse tells you that his family have arrived to take him home and asks you to review but you are in another ward cannulating a patient.
What other information do you need and what would you do?
EDN
This 82-year-old man was admitted with productive cough, reduced exercise tolerance and shortness of breath. He was pyrexial on admission, with bloods demonstrating neutrophilia and raised CRP.
CXR confirmed right basal consolidation. He was treated with 48 hours of IV benzylpenicillin and clarithromycin, and has been switched to oral amoxicillin (to complete a further 4-day course). Reviewed by physiotherapist and occupational therapist before discharge and is back to baseline.
The patient is fit for discharge.
Case 4 (Delirium) faculty notes
Printed resources
• Case scenario with patient photograph.
• Dipstick urine result.
• NEWS chart.
Discussion points
• Brief and inadequate orthopaedic clerking (no social/drug history/allergies/alcohol history/next of kin).
• Likely urosepsis but could be alcohol withdrawal.
Case tasks
• Complete the full START assessment.
• Determine alcohol history.
• Take dipstick +/− midstream specimen of urine.
• Enact Sepsis Six protocol.
• Check blood sugar.
• Take medication review.
• Consider escalation, where appropriate.
• Communicate with the patient and their family.
• Document appropriately.
The seven Cs for postoperative pyrexia
• Chest.
• Catheter/urinary tract infection (UTI).
• Cut.
• Collection.
• Calf (DVT).
• Cannula.
• Central line.
Case 4 Handouts
Case details
• The patient is a confused and agitated elderly man on an orthopaedic ward.
• 1 week post-open reduction and internal fixation (ORIF) (neck of femur).
• Nurse says he is on antibiotics for a UTI.
• The patient is demanding to go home.
What other information do you need and what would you do?
Case 4: NEWS chart
Case 4: clerking notes
Case 4: dipstick urine result
Case 5 (Acute urinary retention with AKI) faculty notes
Printed resources
• Case scenario with patient photograph.
• Fluid balance chart.
• Drug chart.
Discussion points
• Postrenal AKI (retention likely secondary to bladder outlet obstruction due to enlarged prostate, possibly prerenal dehydration, renal due to NSAID).
Case tasks
• Complete the full START assessment.
• Manage AKI (fluids without potassium, catheter, input/output, drug review).
• Stop NSAID, provide alternative.
• Stop apixaban.
• Start enoxaparin sodium.
• Manage potassium. Check that the patient is not continuing to receive potassium supplements and provide 50ml 50% dextrose and 6 units human insulin stat; 10ml 10% calcium gluconate, 5mg salbutamol nebuliser PRN-hyperkalaemia protocol.
• Make urgent renal referral stat.
• Take renal tract ultrasound scan (hydronephrosis).
Case 5 Handouts
Case details
• The patient is an 80-year-old man recovering from neck-of-femur fracture (ORIF), experiencing suprapubic pain.
• The staff nurse on the orthopaedics ward calls at 6:00pm saying patient is in retention according to bladder scan.
• Assessment: NEWS 1 (temperature: 37.5°C).
• The nurse thinks that the patient requires a catheter, but there are no available nurses are able to do it.
• Bloods show raised urea and creatinine; increased from 2 days previous; potassium: 6.0.
• The fluid balance chart shows poor oral intake; no output charted.
• The notes show that the patient was previously fit and well; he tripped and fell in the garden; x-ray satisfactory; scheduled for discharge post-physiotherapy review.
What would you do?
Case 5: drug chart
Case 5: fluid balance chart
Case 6 (Bleeding risk on anticoagulation medication) faculty notes
Printed resources
• Laminated sheet with photograph and case details.
• Yellow warfarin chart (showing stable INR on reasonable doses of warfarin indicating AF; INR from 2 days OK (2.5)).
• Drug chart.
Discussion points
• Indications for warfarin – AF.
• Risk of thrombosis/embolisation versus bleeding (CHADS2-VASC score).
• Considerations:
o The patient’s mental state/capacity and perspective.
o Compliance.
o How has warfarin treatment been going with, for example, INRs.
o Comorbidities.
o Other drug interactions, eg clarithromycin.
o Pros and cons of novel oral anticoagulant versus warfarin.
o Medical team need to make decision with patient/family.
Case tasks
• Complete the full START assessment (bruised but otherwise fine).
• Gather the complete range of information.
• Determine the CHADS2 score.
• Determine whether AF medication is safe to give or safe to omit.
• Ask for help.
• Communicate (SBAR) with medical registrar after full group discussion (60s to prepare).
• Member of faculty to role-play as medical registrar (professional but busy and irritated).
Case 6 Handouts
Case details
• The patient is an 89-year-old woman brought to the emergency department (ED) after a fall.
• Social admission because the patient lives alone and felt unable to cope.
• The patient has been on warfarin for 10 years.
• Extensive bruising sustained to face.
• Max-Fax shows no facial fracture; CT scan of head appears normal (all conducted in ED).
• On the Care of the Elderly Ward at 6:00pm, ward pharmacist calls to say warfarin has been withheld in the ED; asks: ‘Should it be given tonight? Would she be better off on something else? Should it be stopped altogether? Why don’t you speak to the medical registrar?’
What would you do?
Case 6: drug chart
Case 6: warfarin chart
Case 7 (Pneumonia/sepsis) faculty notes
Printed resources
• Case scenario with patient photograph.
• NEWS chart.
• Fluid balance chart.
• Drug chart.
• ECG showing AF (rhythm strip).
• CXR showing consolidation.
Case tasks
• Complete the full START assessment (B confirms findings).
• Measure for AF.
• Determine what is normal BP for the patient in the context of being partially decompensated with relative hypotension.
• Determine causes (ie sepsis or dehydration).
• Take fluid challenge, bloods, electrolyte disturbances, Sepsis Six and determine hourly urine output.
• Escalate antibiotics to trust guidelines.
• Consider AKI (withhold ACE inhibitor for both BP and AKI).
• Communicate with outreach with regard to documentation, parameters, escalation, ceiling of care (this patient should be escalated).
Case 7 Handouts
Case details
• The patient is a 75-year-old woman being treated for community-acquired pneumonia (CAP); on CAP protocol antibiotics (benzylpenicillin and clarithromycin).
• NEWS 2 changes from 0 to 3.
• You receive a call from a nurse at 6:00pm, informing you of NEWS 2 deterioration due to tachycardia at 120bpm; asks you to review.
• Bloods raised (WCC and CRP): urea 10, creatinine 140, eGFR 55, potassium 3.2.
What would you do?
Case 7: CXR
Case 7: ECG
Case 7: drug chart
Case 7: fluid balance chart
Case 7: NEWS chart
Case 8 (Ceiling of care) faculty notes
Printed resources
• Case scenario with patient photograph.
Discussion points
• Communication with patient, family, nursing staff, seniors, and critical care team/outreach.
• Ceiling of care is based on comorbidities, age, patient perspective, likelihood of escalation working or being appropriate.
• Is the DNACPR form appropriate? Would an FY1 decide on their own or more likely discuss with senior?
• Assessment of patient capacity, based on four tenets:
o ability to understand the information relevant to the decision;
o ability to retain that information;
o ability to weigh that information as a part of the process of making a decision;
o ability to communicate their decision (whether by talking, using sign language or any other means).
Case tasks
• Complete the full START assessment.
• Gather information and review notes.
• Discuss openly with the patient. (Has anyone talked to you about this before?)
• Consider the appropriateness of DNACPR form and determine who should complete the relevant forms and when they should be done.
Case 8 Handouts
Case details
• The patient is a 78-year-old woman admitted with COPD, who you are reviewing on the ward round with an ST4.
• Patient is responding to ward-based care and has received supplemental O2, antibiotics, nebulisers, steroids and physiotherapy.
• The ST4 rushes off to a cardiac arrest, so the nurse asks you to come back and speak to the patient. The nurse was told at handover that the ceiling of care has not been completed, so asks you to finish it.
What would you do?
Case 9 (Palliative care and pain management) faculty notes
Printed resources
• Case scenario with patient photograph.
Discussion points
• Showing empathy.
• Pain issue.
• Ladder of pain relief.
• Palliative care referral.
• Notes review/patient understanding/perspective/documentation.
• Trying to ensure a good death.
Case tasks
• Complete the full START assessment.
• Gather information and review the notes.
• Acute pain management.
• Palliative care involvement/pain team for long-term pain relief plan.
• Ceilings of care in discussion with the patient.
• Check that the DNACPR is in place and if not then consider the appropriateness of the DNACPR form and determine who should complete the relevant forms and when they should be done.
• Consider hospice/radiotherapy to spine metastasis/end-of-life pathway.
• Consider escalation where appropriate.
• Communicate with patient and relatives clearly.
• Document appropriately.
Case 9 Handouts
Case details
• The patient is a frail 89-year-old woman in palliative care with metastatic breast cancer (spreading to bone and liver).
• The patient is complaining of back pain and wants to die: ‘Can’t you just give me something so I can go to sleep and never wake up?’
• Sister on breast ward rings you for help and pain relief.
What would you do?
Case 10 (IV drug user needing access) faculty notes
Printed resources
• Case scenario with patient photograph.
Discussion points
• Timing and urgency of cannula for computed tomography angiography (CTA) in this case.
• Importance of ruling out a false aneurysm before surgical intervention.
• How many attempts at cannulation before calling for help?
• Universal precautions due to increased risk of blood-borne viruses.
Case tasks
• Complete the full START assessment.
• Attempt cannulation once (full PPE).
• Communicate with senior, central line (anaesthetics), midline/peripherally inserted central catheter line under ultrasound control.
• 3–4 needs: bloods, antibiotics and access for contrast +/− fluids.
Case 10 Handouts
Case details
• The patient is a 42-year-old man (IV drug user), whom the experienced ward nurse has failed to cannulate.
• The porter is waiting to take the patient for urgent CTA for swollen groin (false aneurysm).
• The nurse rings you to cannulate.
What would you do?
Case 11 (Pulmonary embolism) faculty notes
Printed resources
• Case scenario with patient photograph.
• CXR: normal.
Discussion points
• How do they present?
• What are the initial investigations (initial/urgent and to confirm diagnosis)?
• Test for D-dimer?
• Initial versus longer-term management.
• Determining when to thrombolyse.
Medical notes
• ABG type 1 respiratory failure, PO2 7, PCO2 3.0, no acidosis.
• ‘Classic presentation’, eg pleuritic chest pain – usually how the patient will present to ED; as an inpatient, often the presentation is more subtle and can be confused with other conditions.
• More subtle presentations include postural dizziness, syncope, new tachycardia, observations seeing desaturation.
• History is important (think risk factors, all surgical/medical inpatients are at risk).
• Causes: DVT, fat emboli, sepsis, neoplasm, recent surgery, foreign materials, ischaemic heart disease – myocardial infarction.
• Massive pulmonary embolism (PE): often presents as cardiac arrest.
• Consider PE for all newly breathless inpatients.
• Signs: tachycardia, tachypnoea, look for postural hypotension, raised right heart pressure, raised jugular venous pressure, tricuspid regurgitation, S3, pulmonary regurgitation, cyanosis. All suggest massive PE, pleural rub or effusion.
• Examine lower limbs, look for DVT.
• Poor prognosis: hypotension, hypoxia, ECG changes.
• Role of D-dimer: only really looking for it to be negative (almost no role in an inpatient since it is highly sensitive but non-specific).
• ABGs: low PaO2, mild responsiveness, alkalosis and low PaCO2 due to hyperventilation; metabolic acidosis, if shocked.
• ECG: sinus tachycardia most common; non-specific ST/T changes; acute cor pulmonale, S1Q3T3, right axis deviation, right bundle branch block , new AF.
• CXR: may be normal but helps exclude other causes; may see wedge-shaped shadows, effusion, dilated proximal pulmonary arteries.
• Check appropriate blood tests.
• ECHO: bedside, again to exclude other causes and assess the degree of heart strain; may be useful if considering thrombolysis.
• CTPA and V/q scan: normal V/q will rule out a large/significant PE .
• Later: Doppler ultrasound of lower limbs, look for malignancy and procoagulant disorders (factor V, protein C, S, antiphospholipid), autoimmune screen.
• Assess risk: low versus medium/high, all inpatients latter so start low-molecular-weight heparin (LMWH) (unless significant thrombocytopenia or PT++).
Case tasks
• Complete the full START assessment.
• Monitor continuously.
• Give IV access and take bloods and gas.
• Consider fluids (crystalloid).
• Give oxygen.
• Start LMWH medication.
• Initiate thrombolysis (when?), considering severe hypotension, age, risk of arrest.
• Perform 1h 30min of chest compressions along with thrombolysis if patient in arrest (discuss considerations with this – chest compression systems).
• Consider inotropic support if hypotension is present (hypotension).
Case 11 Handouts
Case details
• The patient is a 64-year-old woman, normally fit and well, recovering from elective bilateral total knee replacement.
• The ward nurse rings to tell you the patient was walking to the bathroom and became very short of breath, saying she felt like passing out; then taken back to bed.
• Obs taken, O2 sats 92%, RR 24, HR 130bpm.
• The nurse asks you to review the patient.
What other information do you need and what would you do?
Case 11: CXR
Case 12 (Tension pneumothorax) faculty notes
Printed resources
• Case scenario with patient photograph.
• NEWS chart.
• CXR showing tension pneumothorax on the same side as internal jugular central line.
Discussion points
• Tension pneumothorax can be confused and present similar to bleeding.
• Full assessment prevents jumping to conclusions and errors.
• Tension pneumothorax on CXR: consider sepsis or bleeding (but actually B problem).
Case tasks
• Complete the full START assessment.
• Give oxygen.
• Monitor continuously.
• Needle decompression of tension pneumothorax – correct side.
• Establish IV access and take bloods and gas.
• Consider fluids (crystalloid).
• CXR.
• Formal chest drain insertion.
• Notes and charts review.
• Escalate to seniors and higher level of care.
• Communicate with patient and family.
• Document appropriately.
Case 12 Handouts
Case details
• The patient is a 56-year-old man with no past medical history following elective laparoscopic nephrectomy.
• NEWS 2 score on ward deteriorated.
• Call received from ST5 worried about bleeding. Asks if you can review and book for operating theatre if you think they are bleeding.
What would you do?
Case 12: CXR
Case 12: NEWS chart
Case 13 (Young patient with diabetes) faculty notes
Printed resources
• Case scenario with patient photograph.
• Drug chart.
• Insulin chart.
Discussion points
• Consider which drugs to give, whether insulin should be given and whether IV fluids are required.
Case tasks
• Complete the full START assessment.
• Recognise patient will be dehydrated on background of chronic kidney disease (CKD) (anticipate problem).
• For diabetic control, do not give normal insulin as fasted; either reduce dose or change to sliding scale.
• Seek help from CT1 because access will be difficult in patients with obesity.
• Potassium raised artefact – repeat bloods urgently and action.
• Prescribe IV fluids.
• Stop ACE inhibitor.
• Refer to diabetic team next day (poor control with end-organ damage).
• Plan verbally with nurse for 4-hourly blood glucose monitoring and document in notes.
Case 13 Handouts
Case details
• The patient is a 38-year-old woman with type 2 diabetes (T2D) and a BMI of 36; admitted via the ED with diarrhoea.
• Plan is for inpatient colonoscopy tomorrow at 9:00am; bowel prep started at 9:00am today.
• Staff nurse on drug round rings you at 6:00pm.
• Glucose chart consistently shows 10–15mmol/l.
• Obs chart normal; past medical history shows T2D, hypertension, chronic kidney disease (CKD) and retinopathy.
• HbA1C 65, creatinine 140, potassium 5.2, taken at 9:00am today.
• Bowel prep instructions: start 24h before colonoscopy, free fluids until midnight, no solids from 9:00am (24h prior), start 2 doses of 2 sachets of Moviprep at 9:00am (24h prior).
What other information do you need and what would you do?
Case 13: drug chart
Case 13: insulin chart
Case 14 (Pulmonary oedema) faculty notes
Printed resources
• Case scenario with patient photograph.
• CXR.
• ECG (sinus tachycardia).
Discussion points
• Obs – oxygen saturation 92% (recognise this is hypoxia).
• O/E – bibasal crepitations, distressed.
• RR 35.
• ABGs – hypoxic, hypercapnic, acidotic – type 2 respiratory failure.
• ABGs – PaO2 low, pCO2 may be low (hyperventilation) or start to increase with severity – type 2 respiratory failure. Pulse oximetry may not be accurate if peripherally shut down.
• CXR – bedside. Look for interstitial shadowing, pleural effusion, Kerley B, prominent hila, upper lobe vessel dilatation +/− cardiomegaly.
• ECG – sinus tachy most common,? any arrhythmias (supraventricular tachycardia, AF, ventricular fibrillation)? evidence of acute ST changes (STEMI, NSTEMI)? underlying strain (left ventricular hypertrophy).
• Urea and electrolytes? any pre-existing renal failure.
Principles of management
• Stabilise the patient, relieve distress and begin definitive treatment.
• Address respiratory and haemodynamic compromise.
• Look for the underlying cause.
• Optimise and introduce long-term therapy.
Case tasks
• Complete the full START assessment.
• Sit patient up and give O2 – 60–100%.
• If severely distressed – get ITU/critical care outreach team (CCOT)/anaesthetist at this stage (if dyspnoea cannot be improved with above – early consideration of CPAP (associated with better outcomes) or ventilation).
• IV access (decent cannula – not blue!) and send bloods.
• Diuresis – furosemide 40–120mg IV (bolus versus slow IV).
• If systolic >90mmHg, give nitrates-GTN infusion 1–10mg/hr, increasing infusion rate every 15–20min, titrating to BP (this should be done on consultation with medical registrar/cardio on call/ITU on call – ie senior input early.
• Consider morphine/diamorphine (2.5–5mg) and metoclopramide (10mg IV).
• Catheterise! Urine output monitoring is essential.
• Continuous monitoring and repeat ABGs after initial therapy.
• Diuretics, vasodilators +/− inotropes.
• Shocked (BP <100mmHg) versus haemodynamically stable.
• Unstable. In refractory shock seniors/ITU should be involved – inotropes will be needed.
• Stable – continue diuretics and nitrates.
• Where should the patient be managed – ward, critical care unit, high-dependency unit/ITU (other factors to consider – comorbidities/DNACPR, other reversible causes).
• Longer-term management – initiation of ACE inhibitor (significant prognostic benefit in the context of left ventricle impairment). If patient is already on ACE inhibitor and diuretics consider initiation of spironolactone.
• Ensure all arrhythmias are treated – role of betablockade/digoxin (again mortality benefit).
Addressing the causes
• Increased pulmonary capillary pressure (hydrostatic).
• Increased left atrial pressure (mitral valve (MV), arrhythmia, eg AF with pre-existing MV disease).
• Increased left ventricular end-diastolic pressure – ischaemia, arrhythmia, atrial valve (AV) disease, cardiomyopathy, uncontrolled hypertension, fluid overload, pericardial constriction, renovascular disease, high output states (anaemia, thyrotoxicosis, AV fistula).
• Increased pulmonary venous pressure – L-R shunt (ventricular septal defect) veno-occlusive disease.
• Neurogenic – cerebral oedema, big immune checkpoint blockade.
• Increased pulmonary capillary permeability.
• Acute lung injury, eg acute respiratory distress syndrome.
• Decreased intravascular oncotic pressure.
• Hypoalbunaemia, eg increased losses – liver failure, nephrotic syndrome, decreased production – sepsis, dilutional −/++ crystalloids (or combination).
• Inevitably there will be crossover between the above causes.
Case 14 Handouts
Case details
• The patient is a 74-year-old man with acute shortness of breath.
• Recent observations show desaturation.
What other information do you need and what would you do?
Case 14: CXR
Case 14: ECG
Case 15 (Paracetamol overdose – low-weight patient given ‘normal’ dose) faculty notes
Printed resources
• Case scenario with patient photograph.
Discussion points
• Importance of drug dose adjustment.
• Daily review of drug chart.
• Malnourished or underweight patients are at risk of inadvertent drug overdose and fulminant liver failure.
• Staggered inadvertent drug toxicity is common and frequently missed.
• Early advice from liver unit impacts outcomes since severe cases may be considered for transplant.
• Renal function considerations with drug excretion.
• Drug interactions/clearance/monitoring.
• Pharmacy input if unsure.
• Reporting drug errors – incident reporting.
• Education, shared learning from error, duty of candour.
Case tasks
• Complete the full START assessment.
• Stop paracetamol (paracetamol levels are irrelevant).
• Start N -acetylcysteine .
• Request urea and electrolyte levels.
• Take venous blood gas (for lactate and pH).
• Take blood glucose test.
• Involve seniors/CCOT/ITU/hepatology on call.
• Give IV fluids and K+.
• Ischaemia/paracetamol/viral – alanine transaminase (ALTD) >1,000.
Case 15 Handouts
Case details
• The patient is a 52-year-old woman with no past medical history, weighing 49kg.
• Two weeks post-potentially curative resection for bowel cancer and anastomotic leak; taken back to theatre.
• On surgical ward, requiring IV analgesia (2 weeks of IV 1g 1 every 6h paracetamol).
• Normal obs.
• Biochemistry abnormal; blood results: ALT = 1,200, alkaline phosphatase = 450, prothrombin time = 16, bilirubin = 42.
What would you do?
Case 16 (Obstructive jaundice and coagulopathy) faculty notes
Printed resources
• Case scenario with patient photograph.
Discussion points
• Participants should use the START assessment to recognise:
o jaundice;
o coagulopathy;
o sepsis.
• Participants should consider sepsis because the patient has an obstructed biliary tree, is likely to be immunosuppressed and is also at risk of ascending cholangitis.
• If participants are strong, faculty can add to the case: ‘The nurse asks about venous thromboembolism prophylaxis’ (LMWH? Compression stockings (TEDS)? inferior vena cava filter?).
Case tasks
• Complete the full START assessment.
• Check clotting.
• Consider the role of vitamin K.
• Inform senior and escalate.
• Handover to night staff.
• Document the plan and set parameters if the patient deteriorates.
• Communicate with the patient (reassurance).
Case 16 Handouts
Case details
• At 6:00pm, you are asked by nursing staff to review a jaundiced patient because the NEWS score has deteriorated.
• The patient was admitted admitted 2/7 ago with a 6-day history of progressive painless jaundice and pale stools and dark urine.
• Bloods show obstructive picture.
• The ultrasound scan shows dilated biliary system and no stones.
• The patient had a nosebleed, which has since stopped; has green cannula with no fluids; on 30ml orally only.
What would you do?
Course summary, questions and feedback
4:35pm – 5:00pm
Session summary
This short session is an opportunity to take stock of the course in a concise, informal manner.
Duration 15 minutes
Session aims
• Summarise the experience of the course.
• Identify future steps.
Faculty One faculty member leading but all present
Electronic resources PowerPoint: Session 7 Course summary
Hard copy resources Sticky notes (from session 1), flip chart
After this session Close/faculty meeting
Teaching notes
After a reminder of the learning outcomes, which they have hopefully achieved, go through the sticky notes and address any expectations that have not been met.
Allow time for participants to ask questions.
Ask participants which areas of the course they found most useful and challenging, then provide suggestions for areas that can be built on and developed further.
Finish with a few concluding remarks and any housekeeping, eg need to do the evaluation to receive their certificates.
Course summary START
By the end of this course you should be able to:
• Recognise an unwell patient
• Perform a systematic patient assessment
• Commence appropriate treatment
• Escalate care to an appropriate senior
• Harness team resources available to you Review of learning outcomes Slides: course summary
• Recognise the importance of humans factors in the work place
Course summary
Course summary
Sticky notes
Course summary
Questions?
• You will be sent a link to an evaluation.
• Please ensure that you complete the survey within 30 days of receiving the link so that you can be download your course certificate from the website. Evaluation
You should now be able to:
• Recognise an unwell patient
• Perform a systematic patient assessment
• Commence appropriate treatment
• Escalate care to an appropriate senior
• Recognise the importance of humans factors in the work place
• Harness team resources available to you Summary
Policies
Course directors at regional and international centres should read the RCS Centre Handbook, which contains a full set of policies for running RCS courses. The following policies may be useful to all faculty.
Standards and consistency
Participants should receive broadly the same experience, no matter where they take the course. While there will be differences in teaching style, the fundamental content of the course must remain the same. Faculty must:
• Follow the programme timings. It is acceptable to change the overall start and finish times, and length of breaks, to fit local needs. However, sessions must have their full duration as stated in the session plans.
• Use the course materials supplied by RCS.
Faculty requirements and pathway
Faculty must:
• be CT2 and above, and locally employed or specialty and associate specialist doctors with at least 3 years’ postgraduate clinical experience.
• be a surgeon, anaesthetist, intensive care specialist or physician.
We also accept members of the wider surgical care and nursing teams who can meet the requirements set out in the faculty application form.
New faculty teaching for the first time are known as ICs. The course director or co-director must observe the IC teaching and complete an IC form. The form has two objectives: first, to provide constructive feedback to the IC on the standard of their teaching; second, to provide quality assurance by recommending the IC as suitable or unsuitable as faculty.
Unless otherwise stated in the session plans, a faculty to participant ratio of 1:5 must be maintained throughout the course. Course directors and ICs are supernumerary.
Participant attendance
Latecomers should be admitted at a convenient point. Failure to attend most of the day should be considered non-attendance for the purposes of certification.
Health and safety
House rules for the venue must be observed at all times in addition to standard health and safety protocols.
Evaluations and certificates
The RCS will send a link to the online evaluation to participants and faculty after the course. Participants who complete the evaluation within 30 days of receiving the notification will be able to print their certificate from the RCS website. Faculty will also be able to print a certificate.
Expenses
Faculty are volunteers and should not be paid for their teaching time; however, the organising centre should reimburse reasonable expenses. Before booking any travel or accommodation, please check your centre’s expenses policy for details on what you can claim.
Feedback on the course
If you have any suggestions on the course content or materials, or you have spotted any errors, you can:
• complete the online evaluation (anonymous);
• send us an email.
All comments submitted via the online evaluation are logged and considered for action; however, due to the anonymous nature of the evaluations, we are unable to respond to individuals. If you require a response, please email edufaculty@rcseng.ac.uk
Appendix 1: equipment for practical assessment of a patient session
Each breakout room should be set up with a resus manikin on a bed. The following equipment should be placed on a table within easy reach of the bed.
Case 1: airway
Guedel airway (red, orange, green)
Nasopharyngeal airway (5, 6, 7)
of each size
Case 2: breathing