Executive Summary
This document provides a comprehensive synthesis of the core principles, strategic frameworks, and practical requirements for mastering the Royal College of Emergency Medicine (RCEM) Speciality Learning Outcome (SLO) 8, "Lead the ED Shift." Achievement of SLO 8 signifies the critical transition of a technically proficient clinician into a strategic system operator, capable of ensuring departmental safety, efficiency, and quality of care.
Key Takeaways:
Executive Summary
Emergency Department (ED) crowding is not an operational inconvenience but a persistent, state of active patient harm and a marker of systemic failure in health policy and leadership. It represents a significant threat to the timely and safe delivery of emergency care within the UK's National Health Service (NHS). This document synthesizes evidence and expert guidance to provide NHS Emergency Medicine clinicians with practical, evidence-based strategies for managing crowded environments, articulating clinical risk, and escalating effectively to restore patient safety.
The primary driver of ED crowding is exit block—the inability to move admitted patients from the ED to inpatient beds due to a lack of hospital capacity. This systemic failure, rooted in a severe mismatch between demand and available staffed beds and social care, creates a dangerous "vicious circle" where delays lead to patient deterioration, further increasing admissions and exacerbating crowding.
The consequences are severe and quantifiable. Studies demonstrate a direct, linear relationship between delays to admission and patient mortality. Data from the Getting it Right First Time (GIRFT) report shows that for every 67-82 patients delayed in the ED for 6-12 hours, there is one excess death. This harm extends to delayed critical treatments, increased medication errors, and profound moral injury and burnout among staff, threatening the sustainability of the Emergency Medicine workforce.
Effective management requires a shift in mindset and language: from describing "risk" to declaring "harm," and from viewing crowding as an "ED problem" to articulating it as a "corporate safety failure." This guide provides clinicians with the necessary tools, including specific escalation scripts, in-department safety protocols, and whole-system flow strategies like the Full Capacity Protocol (FCP) and Continuous Flow Models. By mastering these strategies, clinicians can move from passively absorbing systemic risk to actively and professionally compelling a hospital-wide response to regain safety for both patients and staff.
Executive Summary
The effective management of organ dysfunction and failure is a cornerstone of Emergency and Critical Care Medicine. This briefing document outlines the essential knowledge and procedural steps for ACCS trainees to achieve competence and excel in this critical domain, corresponding to RCEM curriculum code ACCS LO 3 / SLO 1.
Key takeaways include the imperative to recognize impending organ failure before physiological decompensation by looking beyond vital signs and utilizing tools like NEWS2 and lactate trends. A structured, critical-care-focused Airway, Breathing, Circulation, Disability, Exposure (A-E) assessment is paramount. This involves anticipating the need for advanced airway management, differentiating respiratory failure types, defining shock states with the aid of Point of Care Ultrasound (POCUS), and initiating neuroprotective measures.
Initial management focuses on timely organ support. Cardiovascular support requires judicious fluid challenges with balanced crystalloids, followed by the early initiation of peripheral vasopressors to maintain a Mean Arterial Pressure (MAP) > 65mmHg. Respiratory support involves escalating from standard oxygen to High-Flow Nasal Oxygen (HFNO) or Non-Invasive Ventilation (NIV) where appropriate, with a low threshold for recognizing treatment failure. Renal protection is achieved through strict fluid balance, maintaining perfusion, and ceasing nephrotoxic medications.
Excellence in this area transcends basic management; it involves advanced physiological reasoning, such as understanding fluid responsiveness versus tolerance and calculating the Shock Index. Furthermore, superior performance is demonstrated through strong team leadership, employing closed-loop communication, developing a shared mental model, and making timely, appropriate decisions regarding escalation to Critical Care or establishing a ceiling of care.
Specialty Learning Outcome 7 (SLO 7), "Deal with complex and challenging situations in the workplace," is a continuous and mandatory component of Royal College of Emergency Medicine (RCEM) training, representing the pinnacle of professional competence for an Emergency Physician [1, 2]. Mastery of this outcome signifies a transition from a clinical proceduralist to an autonomous leader capable of managing the multifaceted challenges inherent to the Emergency Department (ED). This requires a demonstrable integration of clinical excellence with robust professionalism, advanced communication, ethical acumen, and systemic leadership [2, 3].
The core requirement for mastery, particularly at Higher Training levels (Entrustment Levels 3 and 4), is the ability to manage complex clinical, interpersonal, and systemic challenges with no supervisor involvement [4]. This autonomy must be evidenced through consistent, high-quality performance in four key domains:
Demonstrating mastery for the Annual Review of Competence Progression (ARCP) requires strategic evidence generation. High-quality reflections on critical incidents using models like "What? So What? Now What?", detailed Extended Supervised Learning Episodes (ESLEs) capturing autonomous leadership, and Multi-Source Feedback (MSF) from external colleagues are essential [4, 6, 26]. Engagement in structured debriefing, both hot (e.g., STOP5) and cold (e.g., TRiM), provides further evidence of a commitment to team resilience and institutional learning [31].
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.
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.
Executive Summary: Transitioning from Exposure to Entrustment
This report details a best-practice, longitudinal roadmap designed for Emergency Medicine (EM) doctors in training to achieve Specialty Learning Outcome (SLO) 6: Deliver Key Procedural Skills, adhering rigorously to the RCEM 2021 curriculum and its assessment frameworks. The foundational strategic shift articulated within the 2021 curriculum is the elevation of assessed quality—measured by the RCEM Universal Entrustment Scale—over mere quantity or procedural volume.[1, 2]The methodology emphasizes the critical need for Simulation-Based Mastery Learning (SBML), formalized through adoption of a systematic progression model such as the OASIS framework, to ensure structured, deliberate practice, the attainment of proficiency milestones, and the integration of crucial non-technical skills.[3, 4] A specific focus is placed on Point of Care Ultrasound (PoCUS), where the curriculum mandates explicit modality sign-offs and clarifies that verified clinical competence (Entrustment Level) is the primary determinant of progression, taking precedence over indicative scan volume.[2] Successful implementation of this roadmap requires strict adherence to assessment protocols, including the correct delineation between technical assessment (Direct Observation of Procedural Skills, DOPS, filed in SLO 6) and cognitive/contextual assessment (Case-based Discussions, CbDs, or Acute Care Assessment Tools, ACATs, filed in SLO 1).[5, 6]
Executive Summary: The Strategic Imperative of PEM Sub-Specialty Accreditation
Paediatric Emergency Medicine (PEM) is formally recognised as a sub-specialty of both Emergency Medicine (EM) and Paediatrics in the United Kingdom.[1, 2] For Emergency Medicine trainees, pursuing PEM sub-specialty accreditation represents a critical professional choice that significantly enhances clinical capability and career marketability. The successful completion of the stipulated training programme culminates in the Royal College of Emergency Medicine (RCEM) recommending the doctor to the General Medical Council (GMC) for inclusion on the Specialist Register, noting PEM as a sub-specialty alongside EM.[1]
Hand injuries account for approximately 20% of all Emergency Department (ED) attendances in the UK. The complexity of hand anatomy means that seemingly minor surface wounds can mask debilitating injuries to tendons, nerves, or joints.
Critical Takeaways:
Position of Injury: Wounds must be explored through the full range of motion (ROM) to detect retracted tendon injuries.
Fight Bites: Any laceration over the metacarpal head (knuckle) is a human bite until proven otherwise. These require aggressive washout and antibiotics due to high risk of septic arthritis.
Rotational Deformity: Scissoring of fingers on flexion is the hallmark of malrotated metacarpal/phalangeal fractures and requires reduction/fixation.
Kanavel’s Signs: Recognition of these four signs is vital for diagnosing flexor tenosynovitis, a surgical emergency.
The Royal College of Emergency Medicine (RCEM) Specialty Learning Outcome 5 (SLO 5) defines the required competence for Emergency Medicine trainees in Paediatric Emergency Medicine (PEM). This outcome is comprehensive, demanding expertise in the care of children of all ages, across all stages of development, and explicitly including those with complex medical and social needs.[1] Achieving SLO 5 is not simply about clinical proficiency but requires integration across professional domains: evaluation, investigation, decision-making, safeguarding, resuscitation, and empathetic care for families and loved ones attending the Emergency Department (ED) [1].
Effective teamwork within high-acuity environments, such as the Emergency Department (ED) caring for critically unwell patients, necessitates a paradigm shift away from traditional, hierarchical models of interaction. While leadership is often lauded, organizational reliability critically depends on the quality of followership. The common societal perception often portrays followers as passive, weak, or unmotivated individuals. In the healthcare context, this stereotype is not only misleading but poses a significant safety threat. A comprehensive strategy for improving teamwork requires the professional rebranding of followership from a subordinate role to that of an "Engaged Sentinel"—an essential, proactive safety layer.
Executive Summary
This document provides a comprehensive briefing on the assessment and management of "Silver Trauma"—significant injury in patients aged 65 and over. This patient demographic now constitutes the majority of major trauma cases in the UK, frequently presenting after low-energy falls (<2 metres). The core challenge lies in their diminished physiological reserve, multiple comorbidities, and polypharmacy, which blunt the typical signs of severe injury, leading to systemic under-triage, delayed diagnosis, and disproportionately high morbidity and mortality.
The fundamental principle of care is a shift from an injury-centric to a patient-centric, holistic model. Key best practices include mandatory triage modification with early senior clinician involvement, universal screening for frailty (Clinical Frailty Score) and delirium (4AT test), and the adoption of modified physiological thresholds for shock. A Systolic Blood Pressure < 110 mmHg, a Heart Rate > 90 bpm, or a venous lactate > 2.5 mmol/L are critical indicators of occult hypoperfusion requiring aggressive intervention.
Management requires a multidisciplinary team (MDT) approach initiated in the Emergency Department, incorporating geriatric principles into the standard trauma survey. This includes proactive management of geriatric syndromes (summarised by the PINCHME mnemonic: Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment), optimised analgesia with a focus on regional blocks, and a low threshold for comprehensive CT imaging. The use of structured screening tools, such as the 'Shake, Rattle, Rock and Roll' assessment, is advocated to detect occult truncal and head injuries. This integrated pathway aims to address the patient's intrinsic vulnerability concurrently with their acute injuries, thereby improving outcomes and ensuring they receive safe, high-quality, and dignified care.
The Royal College of Emergency Medicine (RCEM) Specialty Learning Outcome (SLO) 4 mandates the capability to provide "Care for acutely injured patients across the full range of complexity." This outcome represents the fundamental role of the Emergency Physician in trauma care, demanding competence across the entire spectrum, from minor soft tissue injuries to complex, life-threatening polytrauma.[1] Achieving entrustment in SLO 4 requires not merely technical skill but sophisticated leadership, adherence to systematic protocols, and demonstrated engagement with quality improvement initiatives.
Functional Friday = A guided mental workout for your mind
This episode focuses on the crisis resource management and human factors a trauma team leader needs to master for coordinated effective patient care of sick patients. The principles can be applied to team leading in all resus situations.
Effective team leadership in the high-stakes environment of an emergency department (ED) resuscitation bay is defined less by technical prowess and more by the mastery of non-technical skills. Crisis Resource Management (CRM), a discipline originating from the aviation industry, provides a robust framework of behavioural and cognitive skills designed to optimise team performance and mitigate human error. Evidence indicates that communication failures are the primary root cause in over 70% of sentinel events, and human factors contribute to 60-70% of all clinical errors [1,2]. This document synthesises core principles of CRM and human factors, providing a practical blueprint for the ED team leader.
The most critical takeaways are the necessity of proactive preparation, structured communication, and continuous situational awareness. The Zero Point Survey—a framework for preparing Self, Team, and Environment before patient contact—is a foundational tool for shifting from a reactive to a proactive stance. Mastery of communication techniques, particularly Closed-Loop Communication, is non-negotiable for ensuring clarity and reducing errors; its use has been shown to accelerate task completion by a factor of 3.6 [3].
Effective leaders maintain strategic oversight, or "drone vision," fostering a shared mental model through techniques like "flying by voice" and regular team updates. They must also actively manage their own and their team's cognitive load, implementing strategies to mitigate common cognitive biases such as search satisficing and confirmation bias. This requires creating a culture of psychological safety where all team members feel empowered to speak up using tools like graded assertiveness. Ultimately, these skills are not innate; they are cultivated through deliberate practice in simulation, structured feedback using models like Advocacy-Inquiry, and a commitment to continuous system improvement.
Specialty Learning Outcome 3 (SLO 3) is a pre-eminent component of the Royal College of Emergency Medicine (RCEM) 2021/2025 curriculum, defined as the ability to "Identify sick adult patients, resuscitate and stabilise, and know when it is appropriate to stop" . It represents the core clinical identity of an emergency physician, encompassing the management of the most time-critical and life-threatening conditions.
Achieving entrustment in SLO 3 requires the successful integration of three key elements:
Progression is measured across training levels, shifting from direct patient care in core training (ACCS) to expert leadership and systems management in higher specialty training (HST) [6]. Assessment is a triangulated process involving formal examinations, a portfolio of Workplace-Based Assessments (WPBAs), and panel-based judgments [3]. Trainees must strategically use WPBAs, high-fidelity simulation (formally documented via ELSEC), and external courses (where instructor status is highly valued) to build a robust evidence base for entrustment.
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:
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.
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.
This document outlines the framework and practical strategies for achieving the Royal College of Emergency Medicine (RCEM) Specialty Learning Outcome (SLO) 2: Support the ED team by answering clinical questions and making safe decisions. SLO 2 requires Emergency Medicine (EM) clinicians to become expert decision-makers, proficient in diagnostic reasoning, the mitigation of cognitive error, and the application of evidence-based medicine to formulate safe patient management and disposition plans.