Briefing on Invasive Procedures and Procedural Skills in the Emergency Department
Executive Summary
This briefing synthesizes key guidance and curriculum requirements for performing invasive and high-risk procedures within the Emergency Department (ED). The Royal College of Emergency Medicine (RCEM) has issued a Best Practice Guideline (October 2023) to provide pragmatic recommendations for ED clinicians, adapting the national NatSSIPs 2 standards for the unique, time-critical environment of emergency medicine (1).
The core principles for all invasive procedures revolve around a triad of safety checks: obtaining patient consent (or acting in their best interest), independent verification of the procedure site by two practitioners (one of whom must be ST4 or above), and conducting a team brief to ensure all members understand the plan. The use of checklists, such as the modified 'NatSSIPs Eight', is strongly encouraged to ensure auditable compliance and account for significant risks. In time-critical emergencies where full compliance is not possible, clinicians must document their rationale.
In parallel, the RCEM curriculum's Specialty Learning Outcome 6 (SLO6) defines the skillset required for EM physicians to proficiently deliver key life- and limb-saving procedural skills. It outlines a structured progression of learning and entrustment from ACCS to Intermediate and Higher training. Proficiency is developed through a combination of eLearning, simulated practice, and observed clinical performance, with assessment via tools like DOPS and logbooks. This ensures clinicians are prepared for both common and rarely performed critical procedures.
1. RCEM Best Practice Guideline for Invasive Procedures (October 2023)
1.1 Rationale and Context
The 2023 RCEM guideline was developed in response to the revised National Safety Standards for Invasive Procedures (NatSSIPs 2), which specifically referenced the ED and applied to 'minor procedures' (1). The RCEM noted that while NatSSIPs 2 has significant applicability in theatre environments, strict adherence to all its principles in the ED is unlikely to yield significant safety benefits and may introduce unforeseen risks or overburden services.
The ED environment differs significantly from operating theatres. Many procedures are performed by a single clinician, making a full team approach unnecessary or an inefficient use of resources. Furthermore, the emergent nature of many conditions requires specialists to act rapidly, sometimes without explicit consent, in the patient's best interest. This guideline aims to provide pragmatic recommendations that uphold the key NatSSIPs 2 principles of Standardisation, Harmonisation, and Education while being tailored to the ED context.
1.2 Scope and Definitions
The guideline applies to all EM clinicians undertaking invasive procedures in adults and children. An invasive procedure is defined by a comprehensive list of examples, while noting that certain non-invasive procedures are considered high-risk and should comply with the same safety requirements where applicable.
Examples of Invasive Procedures in the ED (1) |
Fascia-iliaca block / Femoral nerve block |
Vascular access (internal jugular vein, subclavian vein, femoral vein) |
Chest drain (Seldinger technique or open technique) |
Pleural aspiration of air |
Resuscitative thoracotomy |
Lateral canthotomy |
Resuscitative hysterotomy |
Ascitic fluid drainage |
Lumbar Puncture |
High-Risk Non-Invasive Procedures: Procedural Sedation, Bier's Block |
The NatSSIPs 2 document categorises procedures performed in ED treatment rooms under local anaesthesia as 'minor', but this fails to include major interventions like open thoracostomy or resuscitative thoracotomy which are also performed in the ED (1).
1.3 Core Safety Recommendations
Clinicians should aim to comply with the following three key requirements for any invasive procedure:
- Consent: Obtain verbal or written consent. If clinical circumstances make this impossible, the procedure must be considered in the patient’s best interests.
- Site Verification: Two healthcare practitioners must independently agree on the site (and side) of the procedure. One of these practitioners must be ST4 grade or above.
- Team Brief: The responsible clinician must ensure all assistants and team members are aware of the proposed procedure, the planned approach, any 'plan B' for complications, and the requirements for post-procedure monitoring.
1.4 The Role of Checklists and Safety Briefs
The use of checklists is strongly encouraged to ensure auditable compliance with the core recommendations and to verify that contraindications and significant risks have been addressed. The guideline provides a modified version of the 'NatSSIPs Eight' checklist for ED use.
Modified 'NatSSIPs Eight' Checklist for the ED (1)
- Consent and verification of site
- Team Brief
- Sign In
- Time Out
- Reconciliation of items (e.g., guide wires, suture needles)
- Sign Out
- Handover/Debrief
Key modifications from the original NatSSIPs checklist include:
- Removal of 'Verification of Implant': This step generally does not apply in the ED.
- Removal of 'Site Marking': This requires organisational-level agreement. The guideline highlights a specific risk: marking a hip for a fascia-iliaca block could be confused by theatre teams as consent for the definitive surgical procedure.
For procedural sedation, a specific Safety Brief is recommended before the procedure commences (2):
- Roles of team members.
- Intended plan (depth/length of sedation, start trigger).
- Confirmation of correct side (where applicable).
- Confirmation of equipment checks (e.g., suction).
- Confirmation of location of rescue devices and drugs.
- Anticipated problems.
A 'hot' debrief is also encouraged after emergency cases or when complications occur to provide feedback and drive future improvement.
1.5 Guidance for Special Circumstances
- Time-Critical Procedures: If the patient's acuity prevents adherence to some recommendations, clinicians must document their rationale for non-compliance in the patient record.
- Patients Lacking Capacity: For patients with cognitive impairment, clinicians must act in their best interests. Where time and practicality allow, they should consult with family or those with Lasting Power of Attorney for health. Note that legislation in Scotland differs from the rest of the UK for adults who lack capacity.
- Children and Young People: Clinicians should refer to separate RCEM guidance for consent in this patient group (3).
- Minor Procedures: For procedures like fracture manipulation, suturing, or incision and drainage, patient consent is mandatory. Other safety elements may be applicable on a case-by-case basis.
1.6 Departmental and Team Responsibilities
Departments have a responsibility to address safety issues related to invasive procedures in their induction programmes and procedure-specific training. It is crucial that the ED nursing team is aware of what constitutes a high-risk or invasive procedure, understands the relevant guidance, and is empowered to challenge any clinician who proceeds without the required safety checks.
1.7 Audit and Compliance Standards
The following audit standards are recommended for invasive procedures:
- 100% should have documented site verification.
- 100% should have some form of consent documented, or a statement explaining why consent was not possible.
- 100% of cases involving procedural sedation should have a sedation proforma completed.
2. Specialty Learning Outcome 6 (SLO6): Procedural Skills Proficiency
SLO6 defines the skillset required for an EM Physician to proficiently deliver time-critical and life/limb-saving procedures, including those that are rarely used.
2.1 Training Progression and Capabilities
Training Stage | Key Capabilities | Level of Supervision |
ACCS | - Identifies when key ACCS practical skills are indicated.<br>- Performs ACCS procedural skills safely and in a timely fashion. | Direct Supervision |
Intermediate | - Identifies when key EM procedural skills are indicated.<br>- Performs ACCS procedural skills safely and in a timely fashion. | Supervisor ‘on call’ from home for queries, able to provide directions via phone and attend if required. |
Higher | - Identifies when key EM practical skills are indicated.<br>- Performs EM procedural skills safely and in a timely fashion.<br>- Supervises and guides colleagues in delivering procedural skills. | Able to manage with no supervisor involvement. |
2.2 Required Procedural Skills by Training Level
ACCS Procedural Skills:
- Pleural aspiration of air
- Chest drain: Seldinger and open technique
- Establish invasive monitoring (CVP and Art line)
- Vascular access in emergency (IO, femoral vein)
- Fracture/dislocation manipulation
- External pacing
- DC Cardioversion
- Point of care ultrasound: Vascular access and Fascia iliaca block
- Lumbar puncture
Intermediate & Higher Training Procedural Skills:
- Procedural sedation in adults & children
- Advanced airway management
- Non-invasive ventilation
- Open chest drain
- Resuscitative thoracotomy
- Lateral Canthotomy
- DC cardioversion
- External pacing
- Pericardiocentesis
- ED management of life-threatening haemorrhage
- Emergency delivery
- Resuscitative Hysterotomy
- Fracture/dislocation manipulation
- Large joint aspiration
- Point of Care Ultrasound (expanded scope)
2.3 Detailed Learning and Assessment Requirements (Intermediate & Higher Training)
The table below outlines the specific learning pathways and assessment methods for key procedures to achieve Level 3 entrustment by the end of Intermediate training and Level 4 by the end of Higher training.
Procedure | Programme of Learning | Programme of Assessment |
Paediatric Sedation | - RCEM eLearning module<br>- Paediatric sedation simulation session<br>- Observed procedural sedation under direct supervision | - Certificates of completion/attendance<br>- DOPS (simulation for Int., observed practice for Higher)<br>- Logbook record |
Advanced Airway (RSI, Surgical) | - IAC training (ACCS)<br>- Ongoing observed/simulated practice<br>- ATLS or similar trauma course | - IAC certificate<br>- DOPS assessment<br>- Logbook record |
Non-invasive Ventilation | - eLearning module<br>- Observed or simulated practice of NIV initiation | - Certificate of completion<br>- DOPS assessment<br>- Logbook record (for Higher) |
Open Chest Drain | - Understand NatSSIPs checklist<br>- Observed or simulated practice<br>- Observed instruction of technique (Higher) | - DOPS assessment<br>- Logbook record |
Resuscitative Thoracotomy | - eLearning module<br>- Simulated practice | - Certificate of completion<br>- DOPS assessment (for Higher) |
Lateral Canthotomy | - eLearning module<br>- Simulated practice | - Certificate of completion<br>- DOPS assessment (for Higher) |
DC Cardioversion | - eLearning or ALS course<br>- Observed or simulated practice<br>- Observed instruction of tachydysrhythmia management (Higher) | - DOPS assessment<br>- Logbook record |
External Pacing | - eLearning or ALS course<br>- Observed or simulated practice<br>- Observed instruction of bradydysrhythmia management (Higher) | - Certificate of completion or ALS cert<br>- DOPS assessment<br>- Logbook record |
Pericardiocentesis | - eLearning module<br>- Simulated practice | - Certificate of completion<br>- DOPS assessment (for Higher) |
Life-Threatening Haemorrhage | - eLearning modules<br>- Observed/simulated practice (Nasal packing, splints, tourniquet, haemostatic agents) | - Certificates of completion<br>- DOPS assessments<br>- Logbook record |
Emergency Delivery | - eLearning module<br>- Simulated practice | - DOPS assessment<br>- Logbook record |
Resuscitative Hysterotomy | - eLearning module<br>- Simulated practice | - Certificate of completion<br>- DOPS assessment (for Higher) |
Fracture/Dislocation Manipulation | - Supervised practice of various techniques<br>- Observed practice and instruction (Higher) | - DOPS assessments<br>- Logbook record |
Large Joint Aspiration | - eLearning module<br>- Observed or simulated practice | - DOPS assessment<br>- Logbook record |
Point of Care Ultrasound | - eLearning resources<br>- Observed/simulated practice (ELS, AAA, eFAST, Shock assessment, etc.) | - Logbook record<br>- DOPS assessments<br>- Supervisor review and sign-off |
3. Suggested Mnemonic for Pre-Procedure Safety Checks
To aid retention of the core safety principles from the RCEM guideline, the following mnemonic is proposed:
C.S.T.
- Consent: Confirm valid consent has been obtained or the procedure is in the patient's best interest.
- Site: Independently verify the correct procedure site and side with a second practitioner (one ST4+).
- Team Brief: Brief all involved staff on the plan, potential issues, and post-procedure care.
--------------------------------------------------------------------------------
References
- The Royal College of Emergency Medicine. Best Practice Guideline: Invasive Procedures in the Emergency Department. London: RCEM; 2023.
- The Royal College of Emergency Medicine. Procedural Sedation in the Emergency Department. London: RCEM; 2022.
- The Royal College of Emergency Medicine. Consent in Adults, Adolescents and Children in Emergency Departments. London: RCEM; 2018.
--------------------------------------------------------------------------------
Appendix: Example EHR Documentation Structure (EPIC)
This template can be adapted for use in an electronic health record system like EPIC to ensure key safety elements are documented for invasive procedures.
Procedure Note: [Name of Procedure]
Indication for Procedure: [Free text: e.g., Spontaneous pneumothorax with respiratory distress]
--------------------------------------------------------------------------------
Pre-Procedure Safety Checklist:
- [ ] Consent:
- [ ] Verbal consent obtained from patient with capacity.
- [ ] Written consent form completed and signed.
- [ ] Patient lacks capacity; procedure performed in best interests.
- [ ] LPA/family consulted where practical.
- [ ] Consent not obtainable due to time-critical emergency; rationale documented in MDM.
- [ ] Site Verification:
- Procedure site/side: [Right / Left / Midline / Not Applicable]
- [ ] Site independently verified by two practitioners.
- Verifier 1 (Operator): [Name, Grade]
- Verifier 2: [Name, Grade - must be ST4 or above]
- [ ] Team Brief / Time Out Conducted:
- [ ] Patient identity confirmed.
- [ ] Procedure and site confirmed.
- [ ] Key procedural steps, potential complications, and 'plan B' discussed.
- [ ] Post-procedure monitoring plan confirmed.
- [ ] Procedural Sedation Safety Brief (if applicable):
- [ ] Roles assigned and understood.
- [ ] Intended depth/duration of sedation confirmed.
- [ ] Equipment checks (incl. suction) complete.
- [ ] Rescue devices/drugs available.
- [ ] Anticipated problems discussed.
--------------------------------------------------------------------------------
Medical Decision Making (MDM):
Summary: This [age] year old patient with a history of [PMH] presented with [symptoms]. The decision was made to perform a [procedure] for [indication].
Rationale: The procedure is necessary to [e.g., relieve tension pneumothorax, drain septic joint, obtain CSF for analysis].
Risks & Benefits: The benefits of the procedure, including [e.g., improved oxygenation, diagnosis of meningitis, pain relief], were felt to outweigh the risks. The primary risks discussed with the patient/family (or considered) include: bleeding, infection, pain, damage to adjacent structures, [procedure-specific risks], and failure of the procedure.
Alternatives: Alternative management options considered included [e.g., conservative management, alternative diagnostic imaging, transfer for specialist intervention]. These were deemed less appropriate because [e.g., patient instability, time-critical nature of the condition].
--------------------------------------------------------------------------------
Procedure Details: [Free text description of the procedure performed, equipment used, any complications, and outcome.]
Post-Procedure Plan: [Free text: e.g., Post-procedure chest x-ray, neurovascular observations, admission under specialty team, handover to nursing staff.]
============================
MEM-EM PODCAST
5.1 Invasive Procedures and Procedural Skills in the ED
.png)
No comments:
Post a Comment