Explainer document on how to achieve ACCS Learning outcome: Provide safe basic anaesthetic care including sedation

 

ACCS Learning outcome: Provide safe basic anaesthetic care including sedation

Mastering Safe Basic Anaesthetic Care and Procedural Sedation

Executive Summary

This briefing document provides a comprehensive guide for Acute Care Common Stem (ACCS) trainees in Emergency Medicine to achieve excellence in the learning outcome of providing safe basic anaesthetic care and procedural sedation. Mastery extends beyond pharmacology to encompass meticulous preparation, environmental optimization, airway stewardship, and human factors. Excellence is defined by proactive preparation, creating a safe environment before the patient is present.

Key principles for safe practice include a profound understanding of sedative agents (Propofol, Ketamine, Midazolam, Fentanyl), their physiological profiles, and potential complications. Adherence to national guidelines, such as those from the Royal College of Emergency Medicine (RCEM) and the Academy of Medical Royal Colleges (AoMRC), is fundamental, treating procedural sedation with the same vigilance as general anaesthesia. The procedural framework is structured into five phases: Knowledge Foundation, Preparation, Execution, RSI Assistance, and Recovery.

Essential steps for every procedure involve a formal airway assessment using the LEMON mnemonic, a thorough equipment check using the SOAP-ME checklist, and a structured team brief. Capnography is mandatory for breath-by-breath ventilation analysis, as pulse oximetry has a significant lag time. Pre-oxygenation via high-flow nasal cannulae (apnoeic oxygenation) is the most critical step to prevent desaturation. Post-procedure, vigilant 1:1 monitoring must continue until the patient returns to their baseline, as a significant number of airway complications occur during recovery. Evidence for this competency is gathered through Direct Observation of Procedural Skills (DOPS), Case-Based Discussions (CbD), simulation, and a comprehensive logbook.

ACCS Learning Outcome: Provide Safe Basic Anaesthetic Care Including Sedation

The objective is to progress from a 'competent' to an 'excellent' practitioner in procedural sedation and basic airway management within the emergency department setting. This outcome requires a deep understanding of risks, pre-operative patient assessment, safe induction and maintenance of anaesthesia or sedation for ASA 1/1E and 2/2E patients, and effective management of recovery and complications [1, 2]. The entrustment decisions by the end of ACCS training include the ability to pre-operatively assess patients, provide urgent anaesthesia and perioperative care, and deliver safe procedural sedation.

Clinically Relevant Anatomy: The Pre-Sedation Airway Assessment

A formal, documented airway assessment is mandatory before every sedation procedure to anticipate and plan for potential difficulty. The assessment focuses on anatomical features that predict challenges with bag-valve-mask ventilation, supraglottic airway insertion, or laryngoscopy.

• LEMON Law Mnemonic: A structured approach to assess the airway [5]:
• L - Look Externally: Identify any external features associated with a difficult airway (e.g., small mandible, large tongue, facial trauma).
• E - Evaluate (3-3-2 Rule):
• 3 fingers: Inter-incisor distance should be at least 3 fingers wide.
• 3 fingers: The distance from the hyoid bone to the chin should be at least 3 fingers wide.
• 2 fingers: The distance from the thyroid notch to the floor of the mouth should be at least 2 fingers wide.
• M - Mallampati Score: Assess the visibility of pharyngeal structures.
• O - Obstruction: Identify any signs of airway obstruction (e.g., stridor, muffled voice, swelling).
• N - Neck Mobility: Assess the range of motion of the cervical spine.
• Dentition: A thorough check for any loose teeth, caps, or crowns is essential to prevent dislodgement and potential aspiration during airway manipulation.

Clinical Assessment: Pre-Procedural Evaluation

The pre-sedation assessment evaluates the patient's suitability for the procedure and identifies physiological risks. This is structured using the A, B, C, D, E framework.

• Airway:
• History: Ask about previous difficulties with anaesthesia, snoring, or obstructive sleep apnoea.
• Examination: Perform and document the LEMON assessment and check dentition as detailed above.
• Breathing:
• History: Inquire about respiratory conditions (e.g., asthma, COPD) and smoking history.
• Examination: Assess respiratory rate, oxygen saturation (SpO2), and auscultate for any abnormalities. Note baseline work of breathing.
• Circulation:
• History: Identify any cardiovascular comorbidities, including ischaemic heart disease, heart failure, or arrhythmias. Note any history of hypo- or hypertension.
• Examination: Measure heart rate and blood pressure. Assess peripheral perfusion. Consider the patient's fluid status, particularly in cases of sepsis where haemodynamic instability is a risk.
• Disability:
• History: Note any neurological conditions, previous stroke, or substance use.
• Examination: Assess baseline neurological status, including GCS or AVPU score.
• Exposure:
• History & Examination: Conduct a full secondary survey to ensure no other injuries or conditions are missed. Note patient weight for accurate drug dosing. Assign an ASA (American Society of Anesthesiologists) physical status classification. This LO focuses on ASA 1/1E and 2/2E patients.

Key Investigations and Monitoring

Continuous, vigilant monitoring is a cornerstone of safe sedation and is equivalent to the standard required for general anaesthesia [4].

• Mandatory Monitoring Suite:
• Capnography: Provides real-time, breath-by-breath analysis of ventilation and is the earliest indicator of apnoea or airway obstruction [6]. It is considered mandatory.
• Pulse Oximetry (SpO2): Measures oxygen saturation but has a significant lag time compared to capnography.
• Electrocardiogram (ECG): For continuous monitoring of heart rate and rhythm.
• Non-Invasive Blood Pressure (NIBP): Must be cycled every 3-5 minutes to monitor for haemodynamic changes.
• Capnography Interpretation [6]:
• Normal Square Wave: Indicates effective ventilation.
• Loss of Waveform: Signifies apnoea or complete airway obstruction.
• Damped/Shark-Fin Waveform: Suggests partial airway obstruction (e.g., snoring, laryngospasm) or a poor monitoring seal.

Treatment: A Phased Approach to Safe Sedation

Excellence is achieved through a structured, multi-phase process that prioritises safety and preparation.

Phase 1: The Knowledge Foundation

A deep understanding of pharmacology and guidelines is a prerequisite for safe practice. The practitioner must understand the physiological profile of each drug beyond simple dose recall [3].

Drug	Primary Use	Pros	Cons/Risks
Propofol	Deep Sedation / RSI	Rapid onset/offset, anti-emetic properties.	Hypotension (>15% drop common), apnoea, pain on injection.
Ketamine	Dissociative Sedation	Preserves respiratory drive/airway reflexes, haemodynamically stable.	Laryngospasm (0.3% risk), emergence phenomenon, hypersalivation.
Midazolam	Anxiolysis / Amnesia	Reversible (Flumazenil), excellent amnesia.	Respiratory depression, variable duration, accumulation in renal failure.
Fentanyl	Analgesia	Rapid onset, cardio-stable.	Chest wall rigidity (rare/high dose), respiratory depression synergism with sedatives.

Furthermore, practitioners must be familiar with the RCEM & AoMRC Safe Sedation Guidelines, which state that the depth of sedation is a continuum, and one must always be prepared to rescue a patient who enters a deeper level of sedation than intended [4].

Phase 2: Preparation and Environment (The "Setup")

This phase defines the expert practitioner. The environment must be optimized for safety before the procedure begins.

• Step 1: Equipment Check (SOAP-ME Mnemonic)
• Suction: Turned on, working, with a rigid yankauer catheter placed under the patient's pillow.
• Oxygen: High-flow source available, Bag-Valve-Mask (BVM) connected, and nasal cannulae ready for apnoeic oxygenation.
• Airway: Oropharyngeal (OPA) and Nasopharyngeal (NPA) airways of appropriate sizes, a correctly sized supraglottic airway (e.g., i-gel/LMA), and a checked laryngoscope with blades.
• Pharmacy: All sedation and analgesic drugs drawn up and clearly labelled. A flush must be available. Emergency drugs (e.g., Ephedrine/Metaraminol for hypotension, Atropine for bradycardia) must be immediately to hand.
• Monitoring: All mandatory monitoring (Capnography, ECG, SpO2, NIBP) applied and functioning.
• Equipment: A defibrillator with pads applied to the patient if they are at high risk.
• Step 2: The Team Brief
• Conduct a formal "Time Out" or use a local safety checklist (LocSSIPs).
• Assign Roles: Clearly designate the airway doctor, the proceduralist, and the monitoring nurse.
• Verbalize Plan B: Explicitly state the contingency plan. For example: "If the patient desaturates, we will stop the procedure, perform a jaw thrust, and use the BVM."

Phase 3: The Procedure (Execution)

• 1. Pre-oxygenation: This is the single most important step to increase the patient's reserve and delay desaturation.
• Apply nasal cannulae at 15L/min before starting sedation and leave them on throughout. This provides apnoeic oxygenation (also known as NODESAT - Nasal Oxygenation During Efforts at Securing a Tube) [7].
• Aim for denitrogenation, evidenced by an end-tidal O2 concentration >85% if available.
• 2. Drug Administration:
• Start low, go slow. Titrate drugs to effect.
• Be mindful that arm-to-brain circulation time can be prolonged in shocked or elderly patients.
• Flush the IV line between boluses to ensure the full dose is delivered and to avoid "dead space" stacking.
• 3. Airway Maintenance:
• Be proactive with simple manoeuvres. Snoring indicates obstruction and requires immediate intervention.
• Chin Lift / Jaw Thrust: Apply aggressively at the first sign of obstruction.
• Oropharyngeal Airway (OPA): Insert only if the patient tolerates it without gagging.
• Nasopharyngeal Airway (NPA): Often better tolerated at lighter levels of sedation.

Phase 4: Assisting in Rapid Sequence Induction (RSI)

ACCS trainees must be competent assistants during an RSI.

• Cricoid Pressure: Understand correct application (10N when awake, 30N when asleep) and when to release (during active vomiting or if it obstructs the intubator's view) [8].
• Passing Equipment: Know the ergonomics of passing the endotracheal tube and other equipment to the intubator.
• Failed Intubation Drills: Be intimately familiar with the Difficult Airway Society (DAS) guidelines [9]:
• Plan A: Laryngoscopy and intubation.
• Plan B: Insertion of a Supraglottic Airway Device (SAD).
• Plan C: Facemask ventilation.
• Plan D: CICO (Cannot Intubate, Cannot Oxygenate) - Front of Neck Access.
• Excellence Tip: Enhance team situational awareness by vocalizing time and vital signs during the procedure (e.g., "Sats are 94% and dropping, BP is 100 systolic").

Phase 5: Post-Procedure and Recovery

Safe care does not end until the patient has fully returned to their baseline physiological and cognitive state. The Fourth National Audit Project (NAP4) highlighted that a significant number of airway disasters occur in the recovery phase [10].

• Monitoring: Continue 1:1 dedicated monitoring until the patient is awake, responsive, and verbalizing.
• Discharge Criteria: Use a formal scoring system (e.g., Aldrete Score) to ensure clear criteria are met before the patient is discharged from the recovery area to a ward or home.

Complications: Recognition and Management

Anticipating and managing complications is a critical component of safe sedation.

Complication	Timeframe	Key Signs	Management
Hypotension	Immediate	>15% drop in BP (common with Propofol).	Have vasopressors (Ephedrine/Metaraminol) ready. Consider fluid bolus.
Respiratory Depression/Apnoea	Immediate	Loss of capnography waveform, decreased respiratory rate, desaturation.	Stop sedation, provide jaw thrust/chin lift, assist ventilation with BVM. Consider reversal agents (Flumazenil for Midazolam).
Airway Obstruction	Immediate	Snoring, stridor, damped capnography waveform.	Aggressive jaw thrust/chin lift. Insert OPA or NPA. Stop procedure if unresolved.
Laryngospasm (0.3% with Ketamine)	Immediate	Stridor, tracheal tug, paradoxical chest movement, desaturation.	Deepen sedation, apply positive pressure with BVM.
Emergence Phenomenon (Ketamine)	Recovery	Agitation, hallucinations.	Provide reassurance in a quiet environment. Consider small doses of Midazolam if severe.
Chest Wall Rigidity (Fentanyl)	Immediate	Inability to ventilate patient with BVM despite patent airway.	Requires neuromuscular blockade for management. Rare, associated with high doses.
Recovery Phase Complications	Delayed	Airway obstruction, desaturation, aspiration.	Maintain 1:1 monitoring until patient meets formal discharge criteria. Never leave a recovering patient unattended [10].

Evidencing Competence for Portfolio

To demonstrate progression and achievement of this learning outcome, trainees should gather a variety of evidence.

• Workplace-Based Assessments:
• Direct Observation of Procedural Skills (DOPS): Aim for at least 3-5 logged cases of procedural sedation. Also, seek assessment in BVM ventilation and insertion of an LMA/i-gel.
• Case Based Discussions (CbD): Discuss complex cases, such as the sedation of a physiologically compromised (e.g., septic) patient.
• HALO (Hobbs, Holroyd, and Langford Observation) in Sedation
• IAC (Initial Assessment of Competence)
• MCR (Multi-Consultant Report)
• MSF (Multi-Source Feedback)
• Logbook: Maintain a detailed logbook of all sedation and airway management cases.
• Simulation: Actively participate in simulation training. Attending a dedicated "Safe Sedation" course or running local scenarios on managing sedation complications like laryngospasm is highly valuable.
• CPD and Reflection:
• Utilize RCEM Learning modules, SBAs, and SAQs relevant to the LO. These automatically generate a certificate of completion in the CPD Diary.
• Reflection on all learning activities is highly valued and demonstrates a commitment to professional development.

References

1. Intercollegiate Committee for Acute Care Common Stem Training. ACCS Curriculum 2021. London: ICACCST; 2021.
2. Royal College of Emergency Medicine. RCEM Curriculum 2021. London: RCEM; 2021.
3. Brown TB, Lovato LM, Parker D. Procedural sedation in the acute care setting. Am Fam Physician. 2005;71(1):85-90.
4. Academy of Medical Royal Colleges. Safe Sedation Practice for Healthcare Procedures: Standards and Guidance. London: AoMRC; 2013.
5. Reed MJ, Dunn MJ, McKeown DW. Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J. 2005;22(2):99-102.
6. Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency department. Br J Anaesth. 2011;106(5):632-642.
7. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59(3):165-175.
8. Vanner RG. Cricoid pressure. Int J Obstet Anesth. 2009;18(4):103-105.
9. Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827-848.
Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005;103(1):33-39.

A structured script designed for an ACCS trainee leading an RSI. This script follows the DAS (Difficult Airway Society) logic and is designed to be read out loud during the "Time Out" phase, just before drugs are pushed.

It is divided into The Situation, The Strategy (Plans A-D), and Role Assignment.

---

The "Time Out" Script

Lead (Intubator): "Okay everyone, stop for a moment. Let's confirm the plan. My name is [Name] and I am leading the airway."

1. The Situation

Lead: "We are performing a Rapid Sequence Induction on this [Age] year old patient for [Indication: e.g., reduced GCS/respiratory failure]. We anticipate a [Standard / Difficult] airway."

2. The Strategy (The DAS Approach)

This is the most critical part. You must verbalize the failure plan so the team is mentally prepared.

Lead: "Here is the airway plan:"

• "Plan A (Primary Plan): I will intubate using a Video Laryngoscope (Mac 4 blade) and a Bougie. I will use [Drug X] and [Drug Y]. We will use 30 degrees head-up positioning."
• "Plan B (Rescue Oxygenation): If I fail to intubate after a maximum of 2 attempts—or if the saturations drop below 90%—I will stop. We will insert a size [4] i-gel to re-oxygenate."
• "Plan C (Facemask): If the i-gel fails to ventilate, we will move to two-person Bag-Valve-Mask ventilation with an oral airway."
• "Plan D (Emergency): If we cannot intubate and cannot oxygenate via i-gel or facemask, this is a CICO (Can't Intubate, Can't Oxygenate) scenario. I will declare 'CICO' and perform a Front of Neck Access (FONA) using the scalpel-bougie-tube technique."

3. Role Assignment

Point to specific people. Do not shout into the void.

Lead: "Let's confirm roles:"

• "[Name], you are on Drugs. Please confirm you have [Drug doses] drawn up and flushed. Push only when I say."
• "[Name], you are my Airway Assistant. You will provide Cricoid pressure (if used) and pass me the equipment."
• "[Name], you are the Team Leader/Scribe. Please watch the monitor. Call out clearly if Sats drop below 93% or Hypotension occurs."

4. Final Check

Lead: "Does anyone have any questions or concerns before we start? ... Okay, let's pre-oxygenate."

---

Key Phrases for During the Procedure

Even with a perfect brief, communication can break down during the stress of the procedure. Use these standardized phrases to maintain control:

1. To Standardize the Handoff:

"I have a view. Grade 2. Passing the bougie... Bougie is in. Railroading the tube... Tube is in. Cuff up."

2. To Optimize a Failed First Attempt:

"Attempt one failed. Saturations are stable. I am going to optimize: Change my blade / Adjust head position / Apply external laryngeal manipulation. Going for attempt two."

3. To Declare Failure (Crucial for safety):

"Attempt two failed. I am moving to Plan B. Pass me the i-gel."

4. To Declare CICO:

"Failed oxygenation. This is a CICO situation. Open the FONA pack. I am proceeding to front of neck access."

---

Why this script works

1. Shared Mental Model: The nurse knows exactly when to hand you the i-gel without you having to scream for it.
2. Cognitive Offloading: By stating "Max 2 attempts" out loud, you prevent yourself from getting "task fixated" and trying a third or fourth time while the patient becomes hypoxic.
3. Empowerment: Explicitly telling the Scribe to "call out if sats drop" gives them permission to interrupt you, which is a vital safety barrier.

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Briefing on Invasive Procedures and Procedural Skills in the Emergency Department

 

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:

1. Consent: Obtain verbal or written consent. If clinical circumstances make this impossible, the procedure must be considered in the patient’s best interests.
2. 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.
3. 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)

1. Consent and verification of site
2. Team Brief
3. Sign In
4. Time Out
5. Reconciliation of items (e.g., guide wires, suture needles)
6. Sign Out
7. 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.

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References

1. The Royal College of Emergency Medicine. Best Practice Guideline: Invasive Procedures in the Emergency Department. London: RCEM; 2023.
2. The Royal College of Emergency Medicine. Procedural Sedation in the Emergency Department. London: RCEM; 2022.
3. The Royal College of Emergency Medicine. Consent in Adults, Adolescents and Children in Emergency Departments. London: RCEM; 2018.

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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]

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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.

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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].

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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.]

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