Promoting Excellence in Emergency Medicine Training 2025 Update: A Briefing for Clinicians

Executive Summary

This briefing synthesises the 2025 Royal College of Emergency Medicine (RCEM) standards for education and training, which aim to address significant challenges within the specialty, including high rates of burnout and attrition among trainees and trainers (1). The standards establish a framework for excellence, emphasising that high-quality patient care is inseparable from a positive learning environment that values and supports both learners and educators (1).

Key takeaways for clinicians and educational leaders include:

• Shared Responsibility: Quality in Emergency Medicine (EM) training is a shared responsibility across training sites, postgraduate EM schools, and individual trainees. Training sites must provide a safe, well-resourced environment, while schools manage programme quality and trainees engage as adult learners (1).
• Supervision is Paramount: High-quality supervision is fundamental to patient safety and trainee development. The standards mandate specific consultant-to-trainee ratios, require trainers to have protected time (0.25 PA per trainee) in their job plans, and recommend that trainees receive direct consultant supervision on a minimum of 50% of shifts (1).
• Protected Learning Time: Trainees must be allocated Educational Development Time (EDT) within their work schedules. The minimum recommendations are: 3 hours/week for ACCS, 4 hours/week for ST3, and 8 hours/week for Higher Specialty Trainees (ST4-6) (1).
• Environment and Culture: A positive safety culture is non-negotiable. Departments must have robust systems for raising concerns without fear of reprisal, learning from incidents, and ensuring adequate staffing and resources, including 24-hour on-site access to key supporting specialties like Anaesthetics, Intensive Care, and Acute General Surgery (1).
• Structured Training Experience: Rotations must be balanced to provide exposure to the full breadth of the curriculum, including paediatrics, trauma (with at least six months in a Major Trauma Centre or accredited Trauma Unit for HST), and a variety of departmental settings. Trainees must not be placed in isolation (1).
• Quality Governance: Both local and regional quality management processes are essential. Departments must have a Local Faculty Group (LFG) to monitor training, and postgraduate schools are responsible for ensuring all standards are met, with RCEM providing national oversight through mechanisms like ARCP externality (1).

Introduction

The RCEM's "Promoting Excellence in Emergency Medicine Training" document sets the standards for medical education and training within the specialty, updating the 2021 edition for 2025 (1). It operates within the quality assurance frameworks of the General Medical Council (GMC) and NHS England, aiming to standardise and improve the quality of EM training across the UK (1).

The document acknowledges the immense pressures on Emergency Departments (EDs), driven by escalating demand and increasing patient complexity. These pressures contribute to the high rates of burnout and dissatisfaction reported by EM trainees and consultants in GMC surveys, leading to significant attrition from training programmes. The standards are designed to counteract the erosion of educational opportunities and address national variations in training quality. They are intended to support regional postgraduate teams in setting clear goals for improvement where standards fall short, aligning with the NHS England Quality Framework and Intensive Support Framework (1).

The Learning Environment: Foundations for Quality Training

A safe and supportive learning environment is the bedrock of effective training and is inextricably linked to patient safety (1).

Workload, Staffing, and Resources

• Balance: There must be a balance between service provision and educational opportunities. While patient needs are the priority, work undertaken by trainees must support learning and not be dominated by routine tasks with little educational value (1).
• Staffing Levels: Medical staffing should work towards the standards set by RCEM's Guidelines for the Provision of Emergency Medical Services (GPEMS). There must be enough suitably qualified staff to ensure safe patient care, appropriate supervision, and manageable working patterns (1).
• Rota Design: Rotas must be designed to provide appropriate supervision, support professional development, minimise fatigue, and give trainees access to their educational supervisors. The use of self-rostering and resources like "EM-POWER: A practical guide to flexible working and good EM rota design" is encouraged. Trainees' hours must comply with the Junior Doctor Contract (1).
• Rest: Departments are expected to support trainee wellbeing by providing appropriate sleep and rest facilities, in line with the #RestEM campaign (1).

Physical Environment and Equipment

EDs must be adequately equipped to provide high-standard care and training. This includes:

• A dedicated and fully equipped resuscitation area.
• Adequate space and equipment for patients with less serious conditions.
• A room and trained staff for bereaved relatives (1).
• Specialist Facilities: Where applicable, facilities must comply with national standards for the care of children ("Facing the Future" standards), and for patients with mental health needs ("Mental Health in Emergency Departments toolkit") (1).

Essential Supporting Specialties

To ensure patient safety and provide a comprehensive training experience, the following specialties are expected to be available on-site 24 hours a day:

• Anaesthetics
• Intensive Care
• Acute General Medicine
• Obstetrics
• Coronary Care
• Acute General Surgery (with a consultant-led operating theatre available 24/7)
• Orthopaedic Trauma
• Paediatrics (if children are seen)
• 24-hour Radiology
• Haematology, Chemical Pathology, and Blood Transfusion services (1).

The absence of these on-site services increases clinical risk for trainees. Robust and reliable transfer systems and clinical support protocols must be demonstrable. An altered case mix due to ambulance diversion may restrict training opportunities, potentially limiting the time a trainee can spend in that unit (1).

Departmental Safety Culture

A positive safety culture is mandatory. The department must demonstrate:

• An environment where learners and educators can raise concerns about patient safety, care standards, or training quality without fear of adverse consequences.
• Immediate and effective responses to any safety concerns.
• A culture of learning from mistakes through effective incident reporting, reflection, and clinical governance.
• Support for the development of communication skills aligned with the duty of candour.
• Active seeking and responding to feedback from learners and educators (1).

Educational Structure and Opportunities

A structured approach to education ensures trainees can meet all curriculum requirements (1).

Induction, Handover, and Teamwork

• Induction: All learners must receive a formal induction covering their duties, supervision arrangements, their role in the team, how to access support, key policies, and how to raise concerns (1).
• Handover: Handovers must be organised to ensure continuity of patient care while maximising learning opportunities, without placing undue pressure on clinicians at the end of a shift (1).
• Teamwork: A culture of learning and collaboration between specialties and professions is essential. The educational needs of trainees must be recognised as a priority by hospital management (1).

Protected Learning Time and Resources

Trainees must have protected time for learning and development.

Trainee Level	Minimum Recommended Educational Development Time (EDT)
ACCS	3 hours per week (or 60 hours per 6-month block)
ST3	4 hours per week (or 160 hours per annum)
HST (ST4-6)	8 hours per week (or 320 hours per annum)
Pro-rata for Less Than Full Time (LTFT) trainees.

In addition to EDT, departments must:

• Release specialty trainees for formal regional teaching.
• Provide adequate time and resources for workplace-based assessments, in line with CEED (Valuing Assessment) principles.
• Ensure ST3-6 trainees have allocated office space with computer and telephone access.
• Provide access to funding and study leave in line with regional policy (1).

Specialised Training Opportunities

Departments are expected to provide structured opportunities for trainees to develop skills in key areas as required by the curriculum:

• Teaching & Supervision: Gaining experience in teaching junior colleagues and medical students.
• Procedural Sedation: Achieving confidence and competence in a range of sedation skills.
• Ultrasound (POCUS): Gaining skills as per the RCEM curriculum, with departments following RCEM POCUS governance guidance.
• Leadership & Management: Engaging with the EMLeaders framework and gaining supervised experience in leadership.
• Quality Improvement (QI): Active involvement in departmental QI and audit programmes, including leading a project during higher training.
• Research: Access to advice and support for research projects within the region (1).

Supervision and Educational Capacity

Effective supervision is central to the RCEM standards, directly impacting patient safety, trainee development, and workforce retention (1).

Defining Educational Capacity and Trainer Ratios

Training capacity is determined by the ability to provide high-quality supervision.

• Trainer Job Planning: Named trainers must have 0.25 PA per trainee allocated in their job plans for educational responsibilities (1).
• Consultant Staffing:
  • General EDs must have at least two substantive FRCEM consultants on the specialty register to be recognised for EM training.
  • For Higher Specialty Trainees (ST4+), there should be at least one consultant per trainee and one FRCEM Educational Supervisor for every two trainees at ST4 level or above (1).
• Direct Supervision: RCEM recommends a minimum of 50% of shifts have direct clinical supervision by an EM consultant for all trainees (1).
• Other Trainees: Specific ratios also apply to Advanced Clinical Practitioner (ACP) and CESR trainees, who require one consultant per trainee and specific trainer accreditation (1).

The Core Functions of Supervision

Good supervision serves three main functions, which can be remembered with the mnemonic Q.L.W.

• Normative (Quality): Ensuring the supervisee provides high-quality and safe patient care.
• Formative (Learning): Facilitating workplace learning through high-quality, timely feedback.
• Restorative (Wellbeing): Enhancing the wellbeing of the supervisee (1).

Supervisor Roles, Responsibilities, and Support

Every trainee must have an allocated Educational Supervisor (ES) and a Named Clinical Supervisor (NCS).

• Eligibility: An ES or NCS must be a substantive EM consultant for over one year, be GMC-recognised as an appropriately trained supervisor, undergo annual educational appraisal, and have relevant equality and diversity training (1).
• Local Faculty Group (LFG): Departments should have an LFG (or Specialty Training Committee) with trainee representation that meets regularly to discuss the training environment and trainee progress. This group provides regular feedback via Faculty Educational Governance Statements (FEGS) (1).
• Examiner Presence: Departments training ST4+ level trainees should have at least one FRCEM Examiner (1).

Workplace Supervision Standards

Clear and reliable supervision and escalation pathways are essential at all times, including out of hours.

• ST1-3 Trainees: Must be able to contact a trainee or trainer of ST4 level or above for immediate attendance if required (1).
• ST4+ Trainees: Must be able to contact their appropriately qualified clinical supervisor (usually an EM consultant) for advice or attendance at all times (1).

Programme Management and Trainee Responsibilities

The successful delivery of training requires effective programme management by the EM School and active engagement from the trainee (1).

Training Programme Structure and Progression

• ACCS: The first two years comprise 6-month placements in EM, Acute Medicine, Anaesthetics, and Intensive Care Medicine (1).
• Intermediate Training (CT3/ST3): A 12-month period covering paediatric EM and general EM competencies (1).
• Progression: To progress from ST3 to ST4, trainees must have successfully passed MRCEM and have an Outcome 1 ARCP for ST3 (1).
• Sub-specialty Training: Nationally competitive training is available in Paediatric EM (PEM) and Pre-Hospital EM (PHEM). Dual accreditation with Intensive Care Medicine is also an option (1).

Designing Balanced and Supportive Rotations

It is the responsibility of the EM School to coordinate rotations that allow trainees to meet all curricular competencies.

• Balanced Exposure: Rotations must account for variations in case mix and ensure adequate training in the care of children and trauma management.
• Paediatrics: No Higher Specialty Trainee (ST4-6) should spend all three years in an adult-only department (1).
• Trauma: During ST4-6, trainees should spend at least six months in a Major Trauma Centre (MTC) or an accredited Trauma Unit with ring-fenced trauma experience (1).
• Peer Support: Trainees should not be placed in training sites in isolation. A minimum of two ACCS and/or two ST3-7 trainees should be placed in any one site to provide peer support (1).

The Trainee's Role in Their Own Development

As adult learners, doctors in training are responsible for:

• Familiarising themselves with the RCEM curriculum and assessment requirements.
• Keeping an up-to-date e-portfolio, including a diary of their EDT.
• Actively participating in workplace-based assessments and appraisal.
• Managing their own learning requirements and awareness of CCT timelines (1).

Pastoral Support, Wellbeing, and Inclusivity

Training programmes must ensure learners have access to educational and pastoral support.

• Resources: This includes confidential counselling services, careers advice, and occupational health services (1).
• Culture: Learners must not be subjected to behaviour that undermines their professional confidence, performance, or self-esteem (1).
• Adjustments & Flexibility: Reasonable adjustments must be made for learners with additional needs. Access to less than full-time training (LTFT) and supported return to training after a break must be available (1).

Quality Governance and Assurance

Robust governance at local, regional, and national levels is required to monitor and maintain training standards (1).

Responsibilities of the Training Site

EDs and their parent organisations are responsible for:

• Having effective and transparent educational governance systems.
• Ensuring those in educational leadership roles have demonstrable credibility.
• Collecting and acting on feedback from learners and educators.
• Sharing information about quality management with other responsible bodies.
• Escalating any safety, wellbeing, or fitness-to-practice concerns about a learner to the postgraduate school or Director of Medical Education (DME) (1).

The Role of the Regional Postgraduate School

The postgraduate school is responsible for:

• Ensuring the quality of educators through proper training, appraisal, and support.
• Monitoring local training quality via trainee feedback, ARCP outcomes, examination results, and differential attainment data.
• Providing support for trainees and ensuring equality, diversity, and inclusion.
• Overseeing opportunities for LTFT and supported return to training (1).

National Oversight and Review Mechanisms

Quality assurance is a national process involving:

• Annual Surveys: All trainees and trainers are expected to complete the GMC National Training Survey annually (1).
• RCEM Training Standards Committee (TSC): The TSC works with EM Schools to quality assure training, provides externality for ARCPs, and collates national data to support workforce planning and quality improvement (1).
• ARCP Externality: RCEM provides external representatives for a sample of ARCPs to ensure national standards are applied consistently. Reports are fed back to the Head of School and Postgraduate Dean to drive learning and improvement (1).

References

1. Royal College of Emergency Medicine Training Standards Committee. Promoting Excellence in Emergency Medicine Training. London: RCEM; 2025.

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Clinical Debate: Clinical Decisions Rules - Helping or Harming Emergency Medicine?

 

Clinical Decision Rules in Emergency Medicine: A Briefing on Evidence, Application, and Controversy

Executive Summary

Clinical Decision Rules (CDRs), also known as Clinical Decision Instruments (CDIs), are ubiquitous tools designed to standardise care, reduce low-value testing, and mitigate the effects of cognitive bias in the high-pressure environment of the Emergency Department (ED). Their value, however, is the subject of considerable debate among emergency medicine professionals.

Proponents argue that CDRs are essential for addressing significant practice variation and promoting evidence-based, high-value care. They highlight evidence showing that well-validated rules, such as the Pulmonary Embolism Rule-Out Criteria (PERC) and the Pregnancy-Adapted YEARS algorithm, can safely reduce unnecessary imaging and hospital admissions, aligning with the principles of Choosing Wisely. They posit that CDRs serve as vital supplements to clinical reasoning, which alone has led to decades of excessive testing.

Conversely, critics contend that the widespread adoption of CDRs has been deleterious to clinical decision-making. They argue that most CDRs are never proven to be superior to, or even as effective as, a trained physician's clinical judgment. A common pitfall is an emphasis on high sensitivity at the expense of specificity, which can paradoxically increase overall testing. Furthermore, the evidence base is often weak; very few CDRs have undergone rigorous impact analysis in randomised controlled trials to prove they improve patient-oriented outcomes in real-world settings.

The practical application of CDRs is also fraught with risk. Clinicians frequently misapply them by ignoring crucial inclusion and exclusion criteria ("indication creep") or by misinterpreting one-way "rule-out" tools as being directive for further testing. This can lead to unintended consequences, such as the widespread belief that any patient over 65 with a head injury requires a CT scan, a misapplication of the Canadian CT Head Rule.

Ultimately, CDRs are not a replacement for the honed expertise of an emergency physician. Their judicious use requires a deep understanding of each rule's derivation, validation, performance characteristics, and intended population. Effective implementation is not a passive process but requires a structured, department-wide approach involving education, stakeholder buy-in, and continuous monitoring. This briefing document synthesises the arguments for and against CDRs, providing a framework for their critical appraisal and responsible application in clinical practice.

Introduction: The Role of CDRs in Modern Emergency Medicine

The typical emergency physician undergoes 11 to 13 years of post-secondary training, developing a clinical mind shaped by over 80 billion neurons (1). Yet, in the face of complex decisions about serious illness and injury, there is an increasing reliance on distilling data into a handful of questions to yield a score that dictates action (1). These tools—Clinical Decision Rules (CDRs)—aim to enhance diagnostic, prognostic, or therapeutic accuracy by estimating the probability of a clinical condition or future outcome from a small number of predictors (2, 3).

Their proliferation is a response to the realities of the ED: a time-limited environment with a low tolerance for missed diagnoses, which fosters a culture of liberal testing and admissions to mitigate uncertainty and liability (1). CDRs are appealing because they offer a structured, consistent approach that can potentially standardise practice, reduce unnecessary interventions, and serve as a learning aid (1, 4). This has led to their widespread adoption, with over two thousand potential CDRs identified in the literature (4).

However, this ubiquity raises critical questions: Do these rules oversimplify complex decision-making? Do they neglect individual patient variability and undermine the nuanced art of medicine? This briefing document will explore the central debate surrounding CDRs, synthesising the evidence for their use as valuable aids and the counterarguments that they may hinder, rather than help, clinical practice (1).

The Case for Clinical Decision Rules: Standardising Care and Reducing Harm

Advocates for CDRs argue they are indispensable tools for improving the quality and efficiency of care in the modern ED. They contend that CDRs can standardise practice, reduce harmful and unnecessary testing, and serve as a bulwark against the cognitive biases inherent in a high-stress environment (1).

Mitigating Bias and Practice Variation

A significant challenge in emergency medicine is the wide variation in practice patterns. A patient presenting with chest pain may receive a vastly different evaluation depending on which ED they attend, which is both ethically and financially problematic (1). CDRs offer a method to standardise care, ensuring patients receive consistent, evidence-based evaluations (1). Furthermore, they can help mitigate the impact of cognitive biases and external factors such as stress, fatigue, and a hectic environment, which are known to impair clinical judgment (1).

Reducing Low-Value Care

In line with the "Choosing Wisely" philosophy, CDRs are a key strategy to identify and eliminate low-value care that does not improve patient-oriented outcomes (1). By accurately identifying low-risk patients, CDRs can help avoid overdiagnosis and the cascade of downstream harm that results from unnecessary testing and treatment (1).

Evidence of Benefit

While many CDRs lack robust implementation data, several high-quality studies have demonstrated their real-world value:

• The PERC Rule: An international, multi-centre, cluster-randomised trial found that using the PERC rule in patients at very low risk for pulmonary embolism resulted in a 9.7% absolute reduction in imaging and a 3.3% reduction in hospital admissions, with no significant difference in missed thromboembolic events (1, 5).
• Pregnancy-Adapted YEARS Algorithm: In a prospective multi-centre study, this algorithm safely avoided radiation-associated imaging in 39% of pregnant patients being evaluated for pulmonary embolism (1, 6).
• The HEART Pathway: This pathway, which combines the HEART score with serial troponin testing, has been shown to safely identify low-risk chest pain patients for early discharge. A prospective randomised trial found it increased early discharges by 21.3% and reduced the median length of stay by 12 hours, with no missed major adverse cardiac events (MACE) in the discharged group (7, 8).
• The Canadian CT Head Rule: One study of 13 EDs in California found that clinician education on the rule, combined with clinical decision support in the electronic health record (EHR), was associated with a 5.3% reduction in CT use and a corresponding 2.3% increase in the diagnostic yield of intracranial injuries (1, 9).

A Counterpoint to Unstructured "Gestalt"

Proponents of CDRs argue that while clinician "gestalt" or judgment can be accurate, it does not always translate into action that reduces low-value care (1). Several studies have shown that even when clinicians accurately identify patients as low-risk, a significant proportion still undergo unnecessary imaging or admission (1).

• In a study comparing physician gestalt to a CDR for paediatric appendicitis, clinicians’ gestalt was highly accurate for low-risk patients. Despite this, 22.8% of these low-risk patients still underwent imaging, whereas the CDR recommended observation (1, 10).
• Similarly, an external validation of the Canadian Syncope Risk Score found that while clinician gestalt had a similar predictive ability, 25% of patients in the "very-low-risk" group were still admitted to the hospital (1, 11).

In these instances, CDRs provide an explicit, evidence-based justification to forgo further testing, helping to recalibrate a risk-intolerant culture that drives overuse (1).

Critique and Caution: The Potential Pitfalls of Algorithmic Medicine

Despite their potential benefits, a compelling case exists that CDRs, as currently developed and used, may be "ruining medicine" (12). Critics point to a flawed evidence base, a lack of superiority over clinical judgment, significant risks of misapplication, and a negative impact on the culture of medicine (1, 12).

Lack of Superiority over Clinical Judgment

The core assumption that CDRs improve upon physician decision-making is largely unproven. Most rules are never directly compared to the gold standard of clinical judgment in the same patient population (12).

• A 2017 review in Annals of Emergency Medicine found that only 11% of 131 studies on clinical decision aids compared them to physician judgment. In the few that did, the decision aid outperformed judgment in only 10% of the papers (two trials in total) (12, 13).
• PECARN Head Injury Rule: A prospective cohort study in Australia and New Zealand found the PECARN rule did not improve upon clinician judgment. While it had similar sensitivity for clinically important traumatic brain injuries, its specificity was diminished, suggesting its use could increase CT utilisation without a corresponding benefit (1, 14).
• Alvarado Score: For suspected appendicitis in adults, this score has been shown to be less sensitive (72%) than unstructured clinical judgment (93%) (12, 15).

Many rules are derived by simply codifying the factors that experienced clinicians already use, making it difficult for a subset of clinical judgment to outperform total clinical judgment (12).

The Problem of Low Specificity and Over-testing

To avoid missing diagnoses, many CDRs are designed to have very high sensitivity. This almost invariably comes at the cost of low specificity, meaning the rule generates many false positives. This has led critics to label CDRs as the "lab-free version of a D-dimer"—a test that, if used indiscriminately, can trigger a cascade of further investigations (12). The Canadian CT Head Rule, for example, has been criticised for fuelling an increase in CT usage due to its low specificity, particularly in older adults (1, 12).

Flawed Evidence Base and Limited Generalisability

The scientific foundation for many widely used CDRs is weak. The ideal development pathway requires derivation, multiple external validations, and finally, an impact analysis to prove the rule changes behaviour and improves outcomes (3, 16).

• Lack of Validation: Many CDRs are used without sufficient external validation in diverse settings. Rules derived in one population (e.g., a US trauma centre) may not perform well in another (e.g., a UK district general hospital) and can risk exporting a culture of overuse (1, 12).
• Absence of Impact Analysis: This crucial final step is rarely performed. As a result, for the vast majority of CDRs, we do not know if they improve practice (12). Commonly used rules lacking controlled trials demonstrating patient benefit include NEXUS, Wells score for PE, PECARN head and abdominal trauma rules, and the Canadian Syncope Risk Score (12).
• Negative Impact Studies: In the rare cases where impact analysis is done, the results are not always positive. A prospective cluster-randomised trial to implement the Canadian CT Head Rule failed to show a benefit and suggested a trend towards increased CT use after implementation (1, 17).

Risks of Misapplication in Practice

In real-world clinical practice, CDRs are frequently misunderstood and misapplied, leading to patient harm.

Risk of Misapplication	Description and Example
Indication Creep	Applying a rule to a patient population for which it was not intended or validated. A classic example is the application of the Canadian CT Head Rule—designed for patients with witnessed loss of consciousness, amnesia, or disorientation—to patients with any "minimal" or trivial head injury. This has led to the widespread but incorrect belief that every patient over 65 needs a CT after any fall (1, 12, 18).
One-Way vs. Two-Way Rule Confusion	Many CDRs, like PERC, are "one-way" rules designed only to rule out a diagnosis in low-risk patients. A negative result can stop a workup. However, clinicians often misinterpret them as "two-way" rules, believing a positive result mandates further testing. This is a critical error, as these rules have poor positive likelihood ratios and should not be used to "rule in" a diagnosis or initiate a workup (1, 19, 20).
"Franken-rules"	Accidentally or intentionally mixing and matching components from different rules, such as combining parts of the Canadian C-Spine Rule and NEXUS. This creates a new, unvalidated rule that is likely to be less specific and lead to more imaging (12).
Ignoring Inclusion/Exclusion Criteria	This is a fundamental and common error. The Canadian CT Head Rule, for instance, only applies to patients who have had a witnessed loss of consciousness, definite amnesia, or witnessed disorientation. Applying it outside these criteria is invalid (12, 21).

Cultural and Cognitive Impact

The proliferation of CDRs has a broader, more subtle impact on medical culture and cognition.

• Automation Bias: Over-reliance on CDRs, especially when embedded in EHRs, can lead to "heuristic replacement for vigilant information seeking" and cause decision errors (1, 22).
• Superficial Objectivity: Rules provide a score that appears objective but often relies on subjective inputs (e.g., "suspicious history" in the HEART score). Inter-rater reliability for these components can be poor. This false objectivity creates an artificial standard of care that can be used against clinicians in medico-legal settings (12).
• Erosion of Expertise: An over-emphasis on rules can foster a "zero miss" culture and devalue nuanced clinical reasoning. Trainees may mimic a pattern based on rule features rather than developing a wider base of clinical knowledge, and experienced clinicians may find their own "gestalt" fundamentally altered by repeated rule use (1, 12).

Best Practice: The Judicious Application of Clinical Decision Rules

Navigating the controversy surrounding CDRs requires a framework for critical appraisal and thoughtful application. Clinicians should view themselves not as passive users of algorithms, but as skilled interpreters who can leverage these tools appropriately to augment—not replace—their judgment.

A Framework for Evaluating a CDR

Before incorporating a CDR into practice, it should be assessed against a set of quality criteria. The development process itself provides a useful mnemonic: D-V-I-A: Derivation, Validation, Impact Analysis (3, 4, 16).

1. Derivation: How was the rule created? A strong CDR is derived from a prospective, multi-centre cohort study that is representative of the target population. It should use appropriate multivariable statistical analysis and undergo internal validation (e.g., bootstrapping) to correct for overfitting (3).
2. Validation: Has the rule been externally validated? It is essential to test the rule's performance in new and different patient populations. Look for "broad validation" across multiple varied settings, not just "narrow validation" in a similar setting (3, 4).
3. Impact Analysis: Is there evidence the rule actually helps patients? This is the highest level of evidence and the most crucial step. The ideal impact study is a cluster-randomised controlled trial that demonstrates the rule's use improves patient outcomes, changes clinician behaviour for the better, or reduces costs without causing harm (3, 16).
4. Applicability and Usability: Is the rule right for your practice?
   • Does it address a common and relevant clinical problem? (4)
   • Is it applicable to your specific patient population? (4)
   • Is it easy to remember and use at the bedside? Complex rules are less likely to be adopted (4, 19).

Integrating CDRs with Clinical Judgment and Shared Decision Making

CDRs should be used as supplements to, not replacements for, clinical reasoning (1).

• The Primacy of Gestalt: Clinical judgment should always have a place and may override a rule's recommendation. If a rule is consistently overridden for specific reasons, it may highlight a limitation of the rule itself (19). However, it is also important to recognise that gestalt is subject to bias and can be unreliable, especially when clinicians are fatigued or stressed (23).
• Embracing Probability: A core skill is understanding that medicine is probabilistic, not deterministic (24). A test with 98% sensitivity means that 2% of patients with the disease will be missed (1 in 50) (24). This must be contextualised by the pre-test probability (prevalence). In a low-prevalence population, the absolute number of missed cases per patient investigated is very low, which is why rule-out strategies can be safe (24).
• Communicating Risk: Discussing risk in terms of natural frequencies ("We expect to miss one case for every 500 patients we investigate with this strategy") can be more intuitive for both clinicians and patients than using percentages (24).
• Supporting Shared Decision-Making: The binary output of many CDRs ("image" or "do not image") can hinder shared decision-making. However, rules that provide a numerical risk estimate (like the PECARN head injury rules) can be powerful tools to frame a discussion with patients and their families about the risks and benefits of further testing (12). The HEART Pathway is a model that explicitly incorporates a shared decision-making model into its framework (7, 8).

Implementing a CDR in the ED: A Practical Guide

Successful implementation is an active process that requires a systematic, department-wide effort (19).

Implementation Step	Key Actions
1. Assess Need and Select a Rule	Target common, high-volume, or high-risk conditions where a CDR can make a tangible impact. Systematically review the literature to ensure the chosen rule is well-validated and applicable to the local patient population (3, 19).
2. Identify Roadblocks	Anticipate potential barriers. These can be from individual providers (resistance to change, belief that gestalt is superior) or the institution ( medico-legal culture, lack of consultant support) (19).
3. Gain Departmental Buy-In	A CDR cannot be implemented by decree. Hold departmental meetings to discuss the literature and rationale. Involve all staff—physicians, nurses, technicians—as well as consulting services like cardiology and radiology to ensure the pathway is understood and supported. Nominate a clinical "champion" to lead the project (19).
4. Educate and Simplify	Provide clear, concise education. Create simple summaries, pocket cards, or posters. Crucially, train staff on the proper use of the rule, including its inclusion/exclusion criteria and the distinction between one-way (rule-out) and two-way rules (19).
5. Integrate and Monitor	Integrate the CDR into the clinical workflow, for example through the EHR or as part of a formal clinical pathway. Set up a process to monitor adherence, track key outcomes (e.g., imaging rates, miss rates), gather feedback from staff, and refine the pathway as needed (19).

Conclusion: A Call for Critical Application

Clinical Decision Rules are powerful but imperfect instruments. Their rapid proliferation, often without a complete and rigorous evidence base, presents a significant challenge to the practice of emergency medicine. While they offer the promise of standardised, efficient, and safer care, they also carry the risk of de-skilling clinicians, promoting over-testing through low specificity, and causing harm when misapplied.

The path forward is not to blindly accept or reject all CDRs, but to engage with them critically. Emergency physicians must become discerning consumers of these tools, equipped to evaluate the evidence behind each rule and understand its specific strengths and limitations. The goal is not to replace the mind of the clinician—a product of immense training and experience (1)—but to support it. The focus must be on using well-validated rules judiciously as aids to enhance, rather than dictate, clinical judgment and to facilitate meaningful shared decision-making with patients. At the same time, the emergency medicine community must continue to advocate for and conduct the high-quality implementation research needed to prove the true value of these ubiquitous tools.

References

1. Morgenstern J, Radecki R, Westafer L, Niforatos JD, Atkinson P. CJEM debate: clinical decision rules–thinking beyond the algorithm. Can J Emerg Med. 2025;27:165–9.
2. Adams ST, Leveson SH. Clinical prediction rules. BMJ. 2012;344:d8312.
3. Cowley LE, Farewell DM, Maguire S, Kemp AM. Methodological standards for the development and evaluation of clinical prediction rules: a review of the literature. Diagn Progn Res. 2019;3:10.
4. Long B, Sheridan B. The Clinical Decision Rules Series (Part 1). emDocs; 2016 Jul 7.
5. Freund Y, Cachanado M, Aubry A, et al. Effect of the pulmonary embolism rule-out criteria on subsequent thromboembolic events among low-risk emergency department patients: the Proper randomized clinical trial. JAMA. 2018;319(6):559–66.
6. van der Pol LM, Tromeur C, Bistervels IM, et al. Pregnancy-adapted years algorithm for diagnosis of suspected pulmonary embolism. N Engl J Med. 2019;380(12):1139–49.
7. Long B, Sheridan B. The Clinical Decision Rules Series (Part 3): Clinical Pathway Use. emDocs; 2016 Jul 14.
8. Mahler SA, Riley RF, Hiestand BC, Russell GB, Hoekstra JW, Lefebvre CW. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015 Mar;8(2):195–203.
9. Sharp AL, Huang BZ, Tang T, et al. Implementation of the Canadian CT head rule and its association with use of computed tomography among patients with head injury. Ann Emerg Med. 2018;71(1):54-63.e2.
10. Simon LE, Kene MV, Warton EM, et al. Diagnostic performance of emergency physician gestalt for predicting acute appendicitis in patients age 5 to 20 years. Acad Emerg Med. 2020;27(9):821–31.
11. Zimmermann T, du Fay J, de Lavallaz NT, et al. International validation of the canadian syncope risk score : a cohort study. Ann Intern Med. 2022;175(6):783–94.
12. Morgenstern J. Clinical decision rules are ruining medicine. First10EM; 2023 Feb 2.
13. Schriger DL, Elder JW, Cooper RJ. Structured clinical decision aids are seldom compared with subjective physician judgment, and are seldom superior. Ann Emerg Med. 2017;70(3):338-344.e3.
14. Babl FE, Oakley E, Dalziel SR, et al. Accuracy of clinician practice compared with three head injury decision rules in children: a prospective cohort study. Ann Emerg Med. 2018;71(6):703–10.
15. Meltzer AC, Baumann BM, Chen EH, Shofer FS, Mills AM. Poor sensitivity of a modified Alvarado score in adults with suspected appendicitis. Ann Emerg Med. 2013;62(2):126-31.
16. Stiell I, Wells G. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med. 1999;33(4):437–47.
17. Stiell IG, Clement CM, Grimshaw JM, et al. A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments. CMAJ. 2010;182(14):1527–32.
18. Davey K, Saul T, Russel G, Wassermann J, Quaas J. Application of the Canadian computed tomography head rule to patients with minimal head injury. Ann Emerg Med. 2018;72(4):342–50.
19. Sheridan B, Long B. Clinical Decision Rules Series Part 2: CDR Implementation. emDocs; 2016 Jul 8.
20. Green SM, Schriger DL, Yealy DM. The case for 1-way clinical decision rules in emergency medicine reply. Ann Emerg Med. 2015;66(6):690.
21. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391–6.
22. Lyell D, Coiera E. Automation bias and verification complexity: a systematic review. J Am Med Inform Assoc. 2017;24(2):423–31.
23. Carley SD, Beardsell I, Body R, Carden R, May N, Gray C. Risk, probability and decisions in emergency medicine v2. St.Emlyn’s; 2017 Nov.
24. Carley SD, May N, editors. Risk, probability and decisions in emergency medicine. St.Emlyn’s; 2017.

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MEM-EM PODCAST 

3.2 Clinical Decision Rules: Helping or Harming EM?

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Achieving RCEM SLO 2: Support the ED team by answering clinical questions & making safe decisions

 

Achieving RCEM Specialty Learning Outcome (SLO) 2: Support the ED team by answering clinical questions and making safe decisions

Executive Summary

This briefing document outlines the core principles and practical strategies for achieving the Royal College of Emergency Medicine (RCEM) Specialty Learning Outcome 2 (SLO 2): "Support the ED team by answering clinical questions and making safe decisions" (1). SLO 2 is a cornerstone of emergency medicine practice, demanding expert decision-making, a profound understanding of diagnostic reasoning, and an unwavering commitment to patient safety in a high-stakes environment.

Achieving this outcome involves a clear progression through training: from asking sound, evidence-based questions at the Core level, to practising without direct supervision in Intermediate training, and ultimately to a deep, communicable understanding of diagnostic reasoning by the end of Higher Specialty Training (HST). The Emergency Department (ED) is described as a "perfect storm for diagnostic error" due to its hectic pace, frequent interruptions, high cognitive load, and the inherent uncertainty of managing undifferentiated patients (2).

Effective clinical decision-making requires a paradigm shift from the traditional, diagnosis-focused "bottom-up" approach taught in medical school to a "top-down" methodology suited for the ED. This expert approach prioritises resuscitating the unstable and identifying dangerous conditions in others, asking "What does this patient need from us right now?" rather than "What does this patient have?" (3).

Mastery of SLO 2 hinges on understanding the cognitive science behind decision-making. This includes an appreciation of dual-process theory (fast, intuitive System 1 thinking vs. slow, analytical System 2), the numerous cognitive biases that can lead to error, and the limitations of simply trying to "be more mindful" (4, 5). While individual metacognition is valuable, evidence suggests that systemic improvements, the use of cognitive aids like checklists, and strategies to build expertise and manage cognitive load are more effective at mitigating error (6, 7). This document synthesises these concepts, providing practical frameworks, mnemonics, and evidence-based strategies to develop and demonstrate competence in SLO 2.

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1. Understanding RCEM SLO 2

SLO 2 is designed to ensure clinicians develop into expert decision-makers who can navigate clinical uncertainty, apply evidence-based principles, mitigate cognitive errors, and formulate safe management and disposition plans (1).

1.1. Progression Through Training

The capabilities required for SLO 2 develop incrementally throughout training, with specific entrustment decisions made at key stages.

Training Stage	Key Capabilities & Entrustment Decisions
End of Core Training (Level 2b)	- Not yet entrusted to answer clinical questions independently.<br>- Must be entrusted to ask questions based on sound principles of diagnostic methodology, cognitive bias, and the application of decision rules and guidelines.
End of Intermediate Training (Level 3)	- Must be able to practice without direct supervision in this activity.<br>- Support is available from a consultant by phone.<br>- Must demonstrate awareness of limitations, with a faculty entrustment statement attesting to readiness.
End of HST (Level 4)	- Must demonstrate a profound understanding of diagnostic reasoning and its application in the ED.<br>- Must be able to communicate and teach key principles to others.<br>- Markers of excellence include a readiness to adapt and develop these skills.

1.2. Demonstrating Competency

Competency in SLO 2 is demonstrated through a combination of formative workplace-based assessments (WPBAs) and summative examinations. Reflection on clinical encounters where decision-making was challenging is highly valued (2).

• Formative Evidence: CbD, ESLE, FEG, RCEM App, ACAT, MCR (AM), Mini-CEX, MSF.
• Summative Assessment:
  • MRCEM: SBA, OSCE
  • FRCEM: SBA, MSO

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2. The Emergency Medicine Mindset: A Paradigm Shift

The fundamental role of the Emergency Physician is not to provide a definitive diagnosis for every patient. Many patients will leave the ED without one, as the primary focus is on resuscitation, identifying dangerous conditions, and appropriate resource management (2). This requires a shift in thinking from the traditional medical model.

2.1. From "Bottom-Up" to "Top-Down" Thinking

Dr. Reuben Strayer contrasts the traditional medical school approach with the expert emergency medicine approach (3):

• Bottom-Up Approach (Medical School): This method involves a comprehensive history, a thorough head-to-toe exam, generation of a lengthy differential diagnosis, and sequential testing to arrive at a final diagnosis. This is often inefficient and inappropriate for the time-sensitive and unstable nature of ED patients.
• Top-Down Approach (Emergency Medicine): This expert approach is driven by the question: "What does this patient need from us right now?". It focuses on a limited menu of relevant interventions and dangerous differential diagnoses applicable to the patient at hand. Your job is to resuscitate patients who need it and identify dangerous conditions in the rest (3).

2.2. The Top-Down Toolkit

This model is built on two core concepts that focus attention on what is most critical in the ED (3):

1. The Wheel of Dangerous Conditions: This represents all conditions that can cause harm in the near term. For any given presentation (e.g., headache, chest pain), the clinician’s task is to use a focused, "knife-like" history and physical exam to sequentially cut away the slices of this "cake," ruling out the relevant dangerous conditions until only benign possibilities remain.
2. The Interventions Wheel: This encompasses every test, procedure, and medication routinely used in the ED. For the sickest patients, such as those in cardiac arrest, care is driven primarily by this wheel (e.g., chest compressions, electricity, epinephrine) before the "dangerous conditions" wheel (the H's and T's) is fully considered.

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3. The Science of Clinical Reasoning and Diagnostic Error

The ED environment—with its high decision density, frequent interruptions, and cognitive overload—is a "natural laboratory of error" (8). Understanding the cognitive processes that underpin decision-making is essential to mitigating this risk.

3.1. Dual-Process Theory: System 1 vs. System 2

The dominant theory of cognition posits two distinct systems of thinking (9):

• System 1 (Thinking Fast): This is an intuitive, unconscious, and rapid process that relies on heuristics (mental shortcuts) and pattern recognition. It is the default mode of thinking and accounts for approximately 95% of decisions (10). While essential for efficiency, it is prone to cognitive biases and errors.
• System 2 (Thinking Slow): This is a conscious, analytical, and deliberate process. It is slow, requires significant effort, and is generally considered less prone to error.

Expert practice involves a fluid interplay between these systems. Heuristics and pattern recognition are vital for expert resuscitationists, but an over-reliance on System 1 without checks from System 2 can lead to diagnostic failure, particularly in cases with atypical presentations or confounding data (5).

3.2. Cognitive Biases in the ED

Cognitive biases are predictable, systematic errors in cognition. The ED is a "perfect storm" for these biases to manifest (2). Being aware of them is the first step toward mitigation, but simply knowing about them does not confer immunity (the Blind-spot bias) (11).

Common Cognitive Bias	Description & ED Example
Anchoring	Prematurely settling on a diagnosis based on initial information and failing to adjust as new data emerges. E.g., A triage note of "anxiety" leads the clinician to discount new signs of hypoxia.
Availability Heuristic	Judging the likelihood of a disease by how easily examples come to mind (e.g., recent cases, emotionally charged cases). E.g., After missing a pulmonary embolism (PE), a clinician over-investigates low-risk patients for PE (12).
Confirmation Bias	Seeking or interpreting evidence in ways that confirm pre-existing beliefs, while ignoring contradictory evidence. E.g., Focusing on pleuritic pain to confirm costochondritis while discounting a new tachycardia.
Premature Closure	Accepting a diagnosis before it has been fully verified. "When the diagnosis is made, the thinking stops." E.g., Finding pneumonia on a chest X-ray and failing to consider a concurrent PE.
Diagnosis Momentum	Once a diagnostic label is applied by others (e.g., triage, EMS), it becomes difficult to remove. E.g., A patient labelled "drunk" is not assessed for a head injury.
Search Satisfaction	The tendency to stop searching once something has been found. E.g., Identifying a distal radius fracture and missing a concurrent scaphoid fracture on the same X-ray.
Base Rate Neglect	Ignoring the true prevalence of a disease when making a diagnosis. E.g., Routinely investigating for rare "zebra" diagnoses in low-risk populations.
Zebra Retreat	Backing away from a rare diagnosis only because it is rare, even when it fits the clinical picture. The opposite of base rate neglect.

3.3. Implicit Bias

Implicit biases are unconscious attitudes or stereotypes that affect our understanding, actions, and decisions. They are a product of our genetics, environment, and experiences, creating "blindspots" we are often unaware of (13).

• Impact on Care: Healthcare providers demonstrate the same levels of implicit bias as the general population, which can influence diagnosis and treatment, leading to disparities in care for marginalised populations (e.g., non-white patients receiving fewer pain medications) (13).
• Recognition: Identifying one's own biases is difficult but critical. A useful exercise is to reflect on one's "in-group" (close non-family members) and note how similar they are across categories like age, race, and socioeconomic status. Gaps may reveal potential blindspots. Another strategy is to listen to one's own emotional reactions (e.g., frustration with a language barrier) as a cue to apply a "second filter" to decision-making (13).

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4. Strategies for Improving Decision-Making and Mitigating Error

While cognitive science offers a framework for understanding error, the evidence for many "de-biasing" techniques is limited or mixed (7, 14). Research suggests that strategies focusing on systemic improvements, building expertise, and managing cognitive load are more effective than simply trying to consciously override bias (6).

4.1. Individual Strategies: Metacognition and Practical Tools

Metacognition, or "thinking about your thinking," involves actively examining and reflecting on the decision-making process. While mindfulness alone is an insufficient solution (6), structured cognitive tools can be helpful.

• Cognitive Forcing Strategies: These are deliberate checks designed to trigger System 2 thinking.
  • SPOT Dx Method (2): A structured approach for refining the ED workup.
    • Serious: Must-not-miss diagnoses requiring immediate consideration.
    • Probable: The most likely diagnoses.
    • Outliers: What fits? What doesn't? What else could it be?
    • Time out: A cognitive pause to consider biases (e.g., HALT - Hungry, Angry, Late, Tired) and sources of error.
  • SPIT Differential Diagnosis (4): Expands the differential to avoid premature closure.
    • Serious
    • Probable
    • Interesting
    • Treatable
• Routine Questions: Incorporate a simple checklist into every encounter: "What else can this be? Is there anything that doesn't fit? Do I need to slow down?" (4).
• Cognitive Stop Points: Develop a routine of pausing to reflect at critical junctures, such as before ordering major investigations, before disposition, and during patient handovers (4).

4.2. Systemic and Expertise-Based Strategies

The most effective interventions are often systemic changes that make it easier for clinicians to do the right thing (6).

• Cognitive Aids: These are external tools that reduce cognitive load and prompt memory recall. They emerged from high-reliability organisations like aviation (15).
  • Checklists: Prevent errors of omission (e.g., Surgical Safety Checklist, intubation checklist). They should be designed with minimalist principles, containing only essential information (15).
  • Emergency Manuals: Contain guideline-based protocols for crises. They are designed to be used in real-time by a delegated "reader," offloading the team leader and improving team performance (15).
• Managing Cognitive Load: The ED is an environment of high decision density and frequent interruptions, which overloads working memory and increases error rates (14). Strategies to manage this include:
  • Offloading Tasks: Write things down ("write more, remember less"), use lists, and delegate appropriately (14, 16).
  • Avoiding Task Switching: Complete tasks sequentially ("one patient at a time") where possible (14, 16).
  • Planning for Negatives: At the initial encounter, anticipate the plan for negative test results. This is when you are thinking most clearly about the patient (3, 16).
• Improving Expertise and Feedback: Diagnostic error is often linked to a lack of readily accessible knowledge or experience (14).
  • Routine Feedback: The key to improving judgement is regular, routine feedback on "normal flight," not just on "crashes" (adverse events) (17). Trainees should actively seek this by reviewing discharge summaries and lab results for their patients 4-6 weeks after the ED visit (18).
  • Peer Review: Working alongside colleagues provides an opportunity for direct observation and feedback (17).
  • The Vigilance Pendulum: A poor outcome increases vigilance and testing for a specific diagnosis. After many negative tests, vigilance wanes. With experience, the magnitude of these swings diminishes as practice becomes better calibrated (18).

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5. Practical Application: Documentation, Disposition, and Planning

Applying these principles culminates in safe and effective patient management plans.

5.1. Formulating and Documenting the Plan

Documentation should serve communication and risk management, not just billing. The primary goal is to "buff your brain, not the chart" by using documentation as a tool to clarify thinking (18).

• Real-time Documentation: Document immediately after seeing a patient to improve accuracy and as part of the workflow. Deferring documentation until the end of a shift is a bad practice (3, 16).
• Documenting Rationale: Explicitly state the reasoning for pursuing or not pursuing specific pathways. Be careful with assigning specific benign diagnoses (e.g., costochondritis, migraine); do not convey more certainty than you have (3, 18).
• DdAVIDds Mnemonic (2): A mnemonic to structure a comprehensive plan.
  • Drugs
  • diet
  • Activity
  • Vitals
  • Investigations/Interventions
  • Disposition
  • dNACPR/TEP
  • social/Safeguarding

5.2. Safe Disposition Planning

Decisions to admit or discharge are a core responsibility and a major source of risk.

• HOME Safe? Mnemonic (2): A checklist for safe discharge.
  • Health literacy (does the patient understand?)
  • Organise follow-up
  • Medications
  • Explanation & Advice/Red flags understood
  • Safe: Social/Safeguarding issues considered
• Frameworks for Uncertainty:
  • The 2-10% Rule: For a dangerous condition, if the pre-test probability is <2%, the harms of testing likely outweigh the benefits. If it is >10%, the test should be ordered. The 2-10% "plaintiff's gap" is where shared decision-making is key (18).
  • Preferred Error: Consider which potential error—overtreatment versus undertreatment—would result in less harm to the patient. Choose the course of action that "fails better" (18).

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6. Resources for Ongoing Learning

Continuous learning is required to develop and maintain the skills for SLO 2.

• RCEMLearning: The RCEM provides numerous learning sessions, SBAs, SAQs, and clinical cases directly mapped to SLO 2 and its descriptors (19).
• Further Resources:
  • Blogs/Podcasts: St. Emlyn's, First10EM, LITFL, EM Cases, EMOttawa Blog, The Clinical Problem Solvers.
  • Checklists/Schemas: Resources are available from institutions such as the University of Toronto (pie.med.utoronto.ca) and the University of Calgary (blackbook.ucalgary.ca) (2).
  • Local Resources: Familiarity with local guidelines (e.g., ExED) and referral pathways (e.g., HUB) is essential for efficient and safe patient management (2).

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References

1. Royal College of Emergency Medicine. SLO 2 – Support the ED team by answering clinical questions and making safe decisions - RCEMCurriculum [Internet]. 2019 [cited 2024 Jul 15]. Available from: https://rcemcurriculum.co.uk/slo-2/
2. Excerpts from "Achieving RCEM Specialty Learning Outcome 2.pdf".
3. Strayer R. Dr. Reuben Strayer - Emergency Thinking [Internet]. Emergency Medicine London; 2015. Available from: YouTube.
4. Morgenstern J. Cognitive errors in medicine: Mitigation of cognitive errors. First10EM [Internet]. 2015 Sep 21 [cited 2024 Jul 15]; Available from: https://first10em.com/2015/09/21/mitigation-of-errors/
5. Morgenstern J. Cognitive theory in medicine: A brief overview. First10EM [Internet]. 2015 Sep 14 [cited 2024 Jul 15]; Available from: https://doi.org/10.51684/FIRS.736
6. Douros G. The trouble with mindfulness [Internet]. LITFL • Life in the Fast Lane Medical Blog. 2020 [cited 2024 Jul 15]. Available from: https://litfl.com/the-trouble-with-mindfulness/
7. Morgenstern J. Cognitive theory in medicine: Some problems. First10EM [Internet]. 2015 Sep 22 [cited 2024 Jul 15]; Available from: https://doi.org/10.51684/FIRS.742
8. Croskerry P. ED cognition: Any decision by anyone at any time. CJEM. 2014;16(1):13–9.
9. Kahneman D. Thinking, Fast and Slow. New York: Farrar, Straus and Giroux; 2011.
10. May N. When is a Door Not a Door? Bias, Heuristics & Metacognition [Internet]. St.Emlyn’s. 2017 [cited 2024 Jul 15]. Available from: https://www.stemlynsblog.org/when-is-a-door-not-a-door/
11. Morgenstern J. Cognitive errors in medicine: The common errors. First10EM [Internet]. 2015 Sep 15 [cited 2024 Jul 15]; Available from: https://doi.org/10.51684/FIRS.726
12. Morgenstern J. Decision Making in Emergency Medicine: Availability Bias. First10EM [Internet]. 2022 Mar 7 [cited 2024 Jul 15]; Available from: https://doi.org/10.51684/FIRS.125778
13. Syed S. Healthcare’s Implicit Bias Problem [Internet]. EMOttawa Blog. 2022 [cited 2024 Jul 15]. Available from: https://emottawablog.com/2022/03/healthcares-implicit-bias-problem/
14. McKinney M, Malette J. Reducing Diagnostic Errors: Using Cognitive Science [Internet]. EMOttawa Blog. 2021 [cited 2024 Jul 15]. Available from: https://emottawablog.com/2021/05/diagnostic-errors-what-cognitive-science-has-to-say/
15. Borshoff D. Cognitive Aids in Healthcare [Internet]. LITFL • Life in the Fast Lane Medical Blog. 2021 [cited 2024 Jul 15]. Available from: https://litfl.com/cognitive-aids-in-healthcare/
16. Helman A, Weingart S, Betzner M, Strayer R. Ep 200 How EM Experts Think: Strategies for Pre-Shift, Arrival Ritual, Staying Focused, Managing Interruptions, Cognitive Load & Negative Emotions, Resuscitation Mindset, Post-Resuscitation Recovery [Internet]. Emergency Medicine Cases. 2024 [cited 2024 Jul 15]. Available from: https://emergencymedicinecases.com/how-the-em-experts-think-part-1/
17. Carley S. Making good decisions in the ED. #RCEM15 #EuSEM15 [Internet]. St.Emlyn’s. 2015 [cited 2024 Jul 15]. Available from: https://www.stemlynsblog.org/making-good-decisions-in-the-ed-rcem15/
18. Helman A, Weingart S, Betzner M, Strayer R. Ep 201 How EM Experts Think Part 2: Data Gathering, Diagnostic and Treatment Decision Making, Test Ordering and Interpretation, Documentation, Emotional Resilience [Internet]. Emergency Medicine Cases. 2025 [cited 2024 Jul 15]. Available from: https://emergencymedicinecases.com/how-em-experts-think-part-2/
19. RCEMLearning. SLO2 Archives - RCEMLearning [Internet]. [cited 2024 Jul 15]. Available from: https://www.rcemlearning.co.uk/curriculum/slo2/

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MEM-EM PODCAST 

2.2 RCEM SLO 2: Probabilitician Not Diagnostician 

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Practice Update: A Proposed Emergency Department Protocol For The Rapid Exclusion of Acute MI

 

Practice Update: A Proposed Emergency Department Protocol For The Rapid Exclusion of Acute MI 

1.0 Introduction and Scope

This protocol provides a systematic, evidence-based framework for the assessment, diagnosis, and initial management of adult patients presenting to the Emergency Department (ED) with symptoms suggestive of Acute Coronary Syndrome (ACS). It is intended for use by all emergency department clinicians within this NHS Trust to ensure a standardised, timely, and effective approach to a common and high-risk clinical presentation.

WARNING: Exclusion of Other Life-Threatening Conditions is Mandatory

Chest pain is a symptom of numerous critical conditions. Before applying this ACS-specific pathway, clinicians must first actively consider and take steps to rule out other life-threatening causes of chest pain. These include, but are not limited to:

• Aortic Dissection
• Pulmonary Embolus
• Pneumothorax
• Oesophageal Rupture
• Significant Pneumonia
• Referred pain from intra-abdominal pathology

This protocol should only be initiated once ACS is deemed a probable diagnosis after careful consideration of alternative pathologies.

The protocol begins with the foundational step of a focused clinical assessment to identify patients who warrant further investigation.

2.0 Step 1: Initial Clinical Assessment (History and Examination)

A focused history and physical examination is the foundational step in identifying patients for whom ACS is a probable diagnosis. The presence of specific clinical features should significantly raise the index of suspicion and trigger progression along this diagnostic pathway.

Key Clinical Indicators Suggestive of ACS

The following features, identified during the initial clinical assessment, warrant the consideration of ACS as a potential cause:

• Chest pain (or pain in the arms, back, or jaw) lasting for longer than 15 minutes.
• Chest pain associated with nausea and vomiting, marked sweating, or breathlessness, particularly when these symptoms occur in combination.
• Chest pain occurring in the context of haemodynamic instability.
• New onset chest pain, or an abrupt deterioration in previously stable angina, with recurrent episodes occurring frequently with minimal or no exertion and lasting longer than 15 minutes.

(National Institute for Health and Care Excellence, 2016)

A strong clinical suspicion of ACS based on these findings mandates immediate diagnostic testing, beginning with a 12-lead electrocardiogram (ECG).

3.0 Step 2: ECG Interpretation and Immediate Actions

The 12-lead ECG is the primary diagnostic tool for rapidly identifying patients with ST-elevation myocardial infarction (STEMI) or significant ongoing ischaemia. These findings require immediate, time-sensitive intervention to restore myocardial perfusion and preserve cardiac function.

Actions must be taken immediately based on the specific ECG findings outlined in the table below.

ECG Finding	Mandatory Action
STEMI or STEMI Equivalent (See Appendix 1)	Immediately call the Coronary Care Unit (CCU) on extension **** to activate the cardiac catheterisation lab for primary Percutaneous Coronary Intervention (PCI).
Ongoing Ischemic Chest Pain with ischaemic changes (Territorial ST depression)	Initiate full ACS treatment and consider a Glyceryl Trinitrate (GTN) infusion for ongoing pain. Serial ECGs must be performed if the patient experiences ongoing or recurrent episodes of chest pain to detect evolving changes.

Following the initial ECG, the diagnostic process proceeds to the use of biochemical markers to detect myocardial injury.

4.0 Step 3: High-Sensitivity Troponin Pathway

A positive test is considered to be a second troponin >120% of the original value.

After the initial troponin the patient will be either Green, Amber or Red (coloured boxes on algorithm)

The high-sensitivity troponin assay is a critical component of the diagnostic algorithm, used to risk-stratify patients and guide subsequent management or discharge decisions. For the purposes of this pathway, a positive test indicating significant myocardial injury is defined as a second troponin level greater than 120% of the initial value.

Patients will be stratified into one of three pathways (Green, Amber, or Red) based on their initial troponin result.

4.1 Green Pathway

This pathway is for patients with a very low likelihood of ACS.

• Initial Troponin: <5 ng/L
  • CAVEAT: If the initial Troponin is <5 ng/L but the chest pain onset was <3 hours from the time of the test, the patient must be managed via the AMBER Pathway.

For patients meeting the Green Pathway criteria, safe discharge from the ED is appropriate if all conditions in Section 4.4 are met.

4.2 Amber Pathway

This pathway is for patients who require further observation and a repeat troponin measurement to rule out ACS.

• Initial Troponin: 5-11 ng/L (or <5 ng/L if pain onset was <3 hours prior to the test).

The mandatory next step is to: Repeat troponin at 1 hour.

• If the change in troponin at 1 hour is >3 ng/L: The patient has "ruled in" for ACS. Refer to Acute Medicine for further assessment and initiate ACS treatment.
• If the change in troponin at 1 hour is <3 ng/L: The patient may be suitable for discharge. This is appropriate only if all conditions in Section 4.4 are met.

4.3 Red Pathway

This pathway is for patients with an elevated initial troponin, indicating a high probability of ACS.

• Initial Troponin: >11 ng/L

The mandatory next step is to: Repeat troponin at 3 hours.

Disposition is determined by the patient's clinical state and ECG findings.

Refer to Acute Medicine (SDEC Suitable)

A referral to the Same Day Emergency Care (SDEC) unit may be appropriate if the patient meets all of the following criteria:

• The ECG is normal or shows only non-specific changes, with no dynamic evolution.
• The patient's pain has fully resolved.
• The initial troponin level is between 12 and 42 ng/L.

Refer to Acute Medicine & Strongly Consider Immediate ACS Treatment

An urgent inpatient referral to the acute medical team is required, and ACS treatment should be strongly considered immediately (before the repeat troponin result is available) if the patient exhibits any of the following high-risk features:

• ECG changes consistent with ischaemia.
• A concerning initial troponin level (e.g., >42 ng/L, >3 times the upper limit of normal, or a >20% rise from a known baseline level).
• Ongoing ischemic chest pain.

4.4 Criteria for Safe ED Discharge

For patients stratified to the Green or Amber pathways who meet the biochemical rule-out criteria, safe discharge from the Emergency Department is appropriate only if all of the following conditions are also met:

1. The patient has no other criteria warranting a referral to acute medicine (see Section 5.0).
2. The ECG is not concerning for ACS and shows no dynamic ischaemic changes.
3. An alternative, non-cardiac cause for the chest pain has been considered and appropriately investigated.

Even with a negative biochemical result, certain clinical presentations require further senior assessment and potential admission.

5.0 Overarching Referral and Disposition Criteria

Clinical judgment remains paramount throughout the patient's journey. A patient may warrant referral to acute medicine irrespective of their position on the troponin algorithm if certain high-risk clinical features are present.

The following scenarios mandate discussion and potential referral to the acute medical team:

• There is a persistent clinical concern regarding unstable angina, following a direct discussion with a senior ED clinician (RED Dr or above).
• The patient has a presentation concerning for crescendo angina (angina pain occurring more frequently with less exertion and/or lasting longer than usual), even if the serial troponin results are negative as per the algorithm.

This document serves as a clinical guideline to standardize care. It does not replace the critical application of sound clinical judgment in the management of individual patients.

6.0 Appendices and References

6.1 Appendix 1: STEMI Equivalents

This appendix contains detailed information on specific ECG patterns of occlusion myocardial infarction that do not meet classic STEMI criteria but carry a similar prognosis and should be managed with the same urgency (i.e., immediate referral for PCI).

Ricci, F., et al. (2025). ECG patterns of occlusion myocardial infarction: A narrative review. Annals of Emergency Medicine, 85(4), 330–340. https://doi.org/10.1016/j.annemergmed.2024.11.019

6.2 References

1. National Institute for Health and Care Excellence. (2016). Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis (NICE Clinical Guideline CG95).
2. Ricci, F., et al. (2025). ECG patterns of occlusion myocardial infarction: A narrative review. Annals of Emergency Medicine, 85(4), 330–340. https://doi.org/10.1016/j.annemergmed.2024.11.019

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GreenED Initiative

 

GreenED Initiative: A Briefing for Emergency Department Professionals

Executive Summary

Climate change presents an existential threat to public health and a direct challenge to the delivery of healthcare services in the UK. The NHS, which contributes 4% of the UK's carbon footprint (1), is responding with a world-leading commitment to become the first net-zero national health service, an ambition enshrined in the Health and Care Act (2022). For Emergency Departments (EDs), this national mandate coincides with the compounding crisis of rising demand, creating both a significant challenge and a unique opportunity.

The Royal College of Emergency Medicine (RCEM) has established the GreenED initiative to guide departments in this transition. This briefing synthesises the core principles and practical guidance for implementing environmentally sustainable practices within the emergency care setting.

Key Takeaways:

• Sustainability as Quality Improvement: The core principle is that sustainable healthcare is high-quality healthcare. By improving efficiency, optimising patient pathways, and reducing waste, EDs can enhance patient care, improve staff well-being, generate cost savings, and reduce their environmental impact simultaneously.
• Leadership is Crucial: A key finding from the GreenED pilot project is that lasting change is exceptionally difficult without senior buy-in. Engaging clinical leads, senior nurses, and managers by aligning green initiatives with trust-level strategic goals (e.g., cost savings, patient experience) is essential for success.
• A Whole-Team Approach: Effective change requires the engagement of all staff, from consultants and nurses to porters, administrative staff, and managers. Establishing a multidisciplinary "Green ED" group is a foundational first step.
• The "Reduce, Reuse, Recycle" Hierarchy: The greatest environmental and financial benefits come from reducing consumption in the first place (e.g., rationalising blood tests, avoiding unnecessary cannulation). This is a more impactful strategy than reuse, which in turn is more effective than recycling.
• Actionable Framework: This document provides a practical framework covering strategic context, RCEM's official recommendations, and a detailed guide to implementation, including forming a green group, identifying carbon hotspots, and motivating an already exhausted workforce with tangible, data-driven benefits.

1. The Strategic Context: Climate Change and the NHS

Emergency Medicine is at the forefront of two compounding crises: the immediate pressures on the emergency care system and the escalating health consequences of climate change. Extreme weather events, such as the 2022 UK heatwaves, are already increasing demand on EDs (2). The Lancet has described the climate emergency as "the greatest threat to human health of the 21st Century" (2).

In response, the NHS has embarked on a transformative journey.

• National Mandate: In October 2020, the NHS became the world's first health service to commit to reaching carbon net-zero. The "Delivering a Net Zero Health Service" report outlines the evidence-based targets for this ambition (3).
• Legislative Backing: In England, these net-zero targets are enshrined in the Health and Care Act (2022), with the responsibility for implementation delegated to Integrated Care Boards (ICBs) (2).
• Demonstrable Progress: As of 2025, five years into the initiative, the NHS has reduced direct emissions by 68% since 1990 and by 14% since 2020 (3).

The RCEM's position is that embracing environmental sustainability is not an additional burden but an opportunity to innovate and improve care. By creating more efficient patient pathways and minimising unnecessary interventions, EDs can improve patient flow, reduce harm, and maximise resources, thereby tackling both the emergency care crisis and the climate crisis (2).

2. RCEM Recommendations for a Sustainable ED

The RCEM has issued a formal position statement outlining five core recommendations for improving the environmental sustainability of emergency medicine (2).

1. Understand and Reduce Impact: ED staff should actively work to comprehend and minimise their environmental impact. This includes developing tools to measure carbon emissions of services and care pathways, in partnership with suppliers, and using 'green' or sustainable Quality Improvement (QI) methodologies to implement change.
2. Leadership Engagement and Structure: ED leadership teams must engage with the environmental agenda as part of their core business. The ideal structure includes a dedicated 'Green ED' group and a nominated environmental sustainability lead to drive cultural and systemic change.
3. Promote Efficient, Low-Carbon Care: EDs can contribute significantly by optimising resource use to ensure the right patient receives the right care at the right time. Initiatives like the Getting It Right First Time (GIRFT) programme, which saw a 30% reduction in surgical admissions in one example, not only improve patient flow but also cut the significant carbon footprint of inpatient stays (estimated at 37-85 KgCO2e per 24 hours) (2, 4).
4. Champion Public Health and Prevention: The most sustainable healthcare is healthcare that is no longer needed. Emergency care professionals can play a vital role in public health by promoting active transport, physical activity, and social prescribing initiatives. They can also use their trusted voices to advocate for wider societal decarbonisation to protect health systems (2, 5).
5. Develop the Evidence Base: There is not yet a consensus on what a net-zero health service looks like in practice (6). Dedicated research funding is required to evaluate best practices and ensure that net-zero goals are achieved while maintaining excellent standards of patient care.

3. Implementing GreenED: A Practical Framework

Translating strategic goals into departmental action requires a structured approach focused on engagement, prioritisation, and communication.

3.1 Building the Foundation: Engagement and Senior Support

Lasting change is built on the engagement of the entire departmental team, critically underpinned by senior support.

Forming a Green Group:

• Start the Conversation: Talk to a wide range of colleagues—clinical and non-clinical—to identify interest. A 2017-2019 survey found 98% of NHS staff believe it is important to be environmentally responsible (7).
• Identify Champions: Form a multidisciplinary group of "green champions," ensuring representation from junior and senior staff across medical, nursing, domestic, and administrative roles.
• Ensure Longevity: Involve permanent, long-term staff members to maintain momentum beyond junior doctor rotations.
• Define a Purpose: Once formed, the group should agree on a clear set of aims and objectives to keep activities focused.

Securing Senior Buy-in: The 2022 GreenED pilot identified a lack of senior buy-in as a primary barrier to success (8). To secure support from clinical leads and managers, it is crucial to align sustainability projects with their priorities. The FRAME mnemonic can guide this approach:

Letter	Driver	Description
F	Financials	Demonstrate clear cost savings from reducing waste and consumption. This is a powerful motivator for management.
R	Reputation	Frame initiatives as an opportunity for positive publicity and to position the Trust as a regional leader in sustainability.
A	Alignment	Show how GreenED projects directly support the strategic objectives of the Trust, the ICB, and NHS England.
M	Mandates	Highlight that sustainability targets may become mandatory, and some trusts are already including them in consultant appraisals.
E	Efficiency	Emphasise improvements to patient care, quality, and staff workload. Frame sustainability as a core pillar of quality.

3.2 Prioritising Action: The Sustainability Hierarchy

Efforts should be prioritised according to the "reduce, reuse, recycle" hierarchy, as reduction has the greatest carbon impact.

1. REDUCE (Highest Impact): This involves systematically eliminating wasteful practices.

• Clinical Interventions: Rationalise blood tests on admission and reduce unnecessary cannulation. Switch to lower-carbon alternatives, such as providing paracetamol in tablet form instead of intravenously.
• Procurement: Challenge historical ordering practices. One Trust stopped an annual order of 87,000 water bottles with just two emails.
• Energy and Travel: Reduce the carbon impact of staff presence by promoting virtual meetings and teaching sessions where appropriate.

2. REUSE (Medium Impact): This focuses on challenging the disposability culture prevalent in healthcare.

• Staff Amenities: Incentivise staff to bring reusable cups for drinks. This can be supported with funds from a hospital staff charity.
• Equipment: Investigate and establish mechanisms for cleaning and testing returned equipment, such as crutches, that are often needlessly thrown away.

3. RECYCLE (Lowest Impact of the Three): While important, recycling should be seen as the final step after reduction and reuse have been maximised.

• Start with Easy Wins: Focus first on recycling and single-use plastics in catering.
• Conduct a "Waste Walk": Physically trace the waste process to understand segregation and identify opportunities. Ensure bins are plentiful and signage is clear (e.g., "no masks or gloves").
• Collaborate: Speak to the Trust waste team to discover what can be recycled. In some Trusts, this includes plastic wrappers from syringes and IV fluid bags.

3.3 Identifying and Tackling Carbon Hotspots

A carbon hotspot is a specific activity or resource with a disproportionately high carbon footprint. Identifying and targeting these can yield significant results.

• Common ED Hotspots:
  • Nitrous Oxide: This can be reduced by switching off manifolds that supply the ED.
  • Metered-Dose Inhalers (MDIs): Switching to Dry-Powder Inhalers (DPIs) where clinically appropriate offers a dramatic carbon saving.
  • Waste Streams: Diverting clean packaging from clinical waste into recycling streams.
• Measuring Impact: Learning to "carbon count" allows a team to measure the impact of changes. The Centre for Sustainable Healthcare runs courses on this topic. Converting savings into relatable formats is a powerful communication tool.

Item Comparison	Carbon Footprint Equivalent
Ventolin MDI	175 miles in an average petrol car
Salbutamol DPI	4 miles in an average petrol car
One Trust's Annual IV Paracetamol Use	Seven return flights to Perth, Australia

4. Overcoming Challenges and Maintaining Momentum

Implementing change in a high-pressure environment requires persistence and savvy communication.

• Motivating an Exhausted Workforce: Acknowledge that saving the planet may not be front-of-mind during a busy shift.
  • Highlight Hidden Benefits: Frame projects as workload reducers (e.g., less cannulation, oral meds).
  • Make it Easy: Recycling must be convenient, and staff should be incentivised (e.g., free reusable mugs).
  • Communicate Effectively: Use direct "shop floor" engagement, handovers, and WhatsApp groups, which are more effective than emails. Regularly explain the reasons for change to embed new habits.
• Expect a Drop-off: Initial enthusiasm may wane due to departmental pressures or staff rotations. Plan for this by integrating GreenED updates as a standing item on governance agendas and in staff inductions.
• Self-Promote: Use the Trust communications team to publicise successes. Share regular updates with the entire ED and key managers. As one consultant noted, framing initiatives as a way to save money and gain good publicity almost always gets a quick, positive response.

Ultimately, turning an ED green is a rewarding journey that offers insights into hospital-wide operations and the satisfaction of seeing positive, tangible change take root.

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References

1. Source for 4% UK healthcare carbon footprint not fully cited in context material (cited as [1] in RCEM position statement).
2. Royal College of Emergency Medicine. RCEM position statement on environmentally sustainable emergency healthcare. May 2023.
3. NHS England. Greener NHS. [Website]. Accessed from source context.
4. Sustainable Healthcare Coalition. Sustainable Care Pathways Guidance: Inpatient Bed Day Module. Oct 2015. Available from: https://shcoalition.org/wp-content/uploads/2019/10/Sustainable-Care-Pathways-Guidance-Inpatient-Bed-Day-Module-Oct-2015.pdf
5. Source cited as: BMJ 2023;380:p378.
6. Source cited as: EMJ 2022;38(4):315. Available from: https://emj.bmj.com/content/38/4/315
7. NHS Sustainable Development Unit. Staff and sustainability survey 2017-2019. (As described in source context).
8. GreenED Pilot Report March 2023. Available from: https://rcem.ac.uk/wp-content/uploads/2023/04/GreenED-Pilot-Report-March_2023.pdf

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1.10 Net Zero Emergency Care can Improve Flow!

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