RCEM Guidelines Flashcards
Name 4 examinations/procedures where “ co-operation with the procedure” amounts to valid implied consent?
Resource:
RCEM- consent in adults, adolescents and children in the
ED - Jan 2018
- physical examination
- ECG
- venepuncture
- small wound closure
In adults - who are the only people that can provide consent?
Resource:
RCEM- consent in adults, adolescents and children in the ED - Jan 2018
Consent may only be provided by:
- the patient (provided they have capacity)
- a person with Lasting Power of Atorney for welfare
- a court appointed deputy in England & Wales
In the setting of a clinical emergency and if it is NOT possible to find out a patients wishes - which 2 circumstances can you provide treatment without a patients consent?
Resource:
RCEM- consent in adults, adolescents and children in the ED - Jan 2018
- to save their life
2. or prevent a serious deterioration of their condition.
What should you do if a patient is not likely to regain capacity to give consent in a situation where a decision is time critical and a delay in initiating treatment would be detrimental to the patients well-being?
Resource:
RCEM- consent in adults, adolescents and children in the ED - Jan 2018
in this case: a best interest decision should be reached.
Where there is a choice of treatment, the treatment provided must be the least restrictive on the patients future choices.
What are the key features of valid consent?
Resource:
RCEM- consent in adults, adolescents and children in the ED - Jan 2018
Consent must be given:
- voluntarily and freely,
- without pressure being exerted on the patient to
accept or refuse treatment - and the person needs to understand the nature and
purpose of the procedure
Restraint may at times be considered a best interest intervention.
In which 3 circumstances can restraint be considered acceptable?
Resource:
RCEM- consent in adults, adolescents and children in the ED - Jan 2018
- the person using it reasonably BELIEVES IT IS NECESSARY to prevent harm to the person who lacks capacity
- the restraint used is a PROPORTIONATE RESPONSE to the likelihood and seriousness of harm
- This ACTION DOES NOT CONFLICT with a previous decision made by an attorney or deputy under their powers.
What would you do if a person withdraws consent to the procedure while you are carrying out the procedure?
Resource:
RCEM- consent in adults, adolescents and children in the ED - Jan 2018
- ascertain the problem
- ensure the patients capacity has not changed
- explain the consequences of abandoning the procedure
note: if stopping the procedure might endanger the life of the patient - the Dr is entitiled to continue untill that is no longer the case.
What should you do if a patient states that they do not wish to known in detail about their condition or the proposed treatment for which consent is being sought?
Resource:
RCEM- consent in adults, adolescents and children in the ED - Jan 2018
- their wishes should be requested as far as possible
- however if competent, they must still receive the basic information required in order to give valid consent
- such information is likely to include wether the procedure is invasive, what level of pain they might experience, what can be done to minimise this and if it involves any serious risks
- patient refusal to know in detail about the proposed treatment should be carefully documented in the patients notes.
Consent in children and adolescents:
- who can give consent?
- when can treatment be given without consent?
Resource:
RCEM- consent in adults, adolescents and children in the ED - Jan 2018
- who can give consent:
* the child or
* one parent or
* the court
Note: at 16, children can be presumed to have capacity to give consent. parents cannot override competent consent given by a child, but the reverse is legally complicated.
- regardless of age, emergency treatment to save a life or prevent deterioration can be given without consent
- When can police stations be used as a place of safety?
- when can police stations NEVER be used as a place of safety?
Resource:
RCEM- A brief guide to section 136 in the ED - Dec 2017
- a police station can only be used for an adult if the detaining officer is satisfied that :
a. the behaviour of the adult presents an imminent risk of serious injury/death to that adult/others
b. as a result, no other place of safety in the police area in which the adult is located can reasonable be expected to detain them; and
c. the use of police station is authorised by an inspector or higher rank.
- Never for under 18’s
Regarding police responsibility to stay in the ED with a patient brought in under section 136:
When can the ED take over the legal responsibility for a 136s detention?
if they have the staff and capacity to ensure
- the wellbeing of the patient and
- ensure they do not abscond
There will be cases when the detained person is not in a position to abscond ( if in a coma ) when it may be appropriate for ED to take over responsibility
What are the 5 key performance indicators for ED’s in the UK?
Resource:
RCEM guideline March 2019
Key performance indicators:
- time to initial assessment
- time to treatment
- total time in ED
- left without being seen
- re-attendance rate
Name 1 of the key quality indicators for ED’s ?
dont confuse performance indicators
Key Quality indicators:
- Proportion of patients with RCEM high
risk conditions who are seen by a Consultant or senior decision maker.
these are:
*Chest Pain in people over the age
of 30
* Abdominal pain in people age
over the age of 70 years
*Fever in children under six months
of age
*Unscheduled return visits within 72
hours
What factors cause crowding in the ED?
Crowding may be caused by a variety of factors:
1. Surges in demand
2. Inadequate staff or resources to meet demand
3. Inadequate physical capacity of the ED relative to the
demand faced
4. Constraints within internal processes
5. Exit block from the ED.
What are the markers of crowding in the ED?
Note : this is very similar to the measures of crowding.
- Prolonged Ambulance offload times (e.g. > 15 minutes).
- Long waits for patients to be assessed by Emergency
Department clinicians (e.g. > 1 hour). - Occupancy of available resuscitation and trolley spaces
greater than 100%. - Delays between request for a bed and that bed being
made available (e.g. > 1 hour). - High proportion of patients in the ED awaiting
placement on an inpatient ward.
Name a few measures that you can take to maintain safety in a crowded ED?
- Don’t compromise handovers. After handover walk the
department. - If you are overloaded think “STAR”:
Stop, Think, Act, Review.
This may require a team time-out to take stock and
make a plan. - If you have a specific check list, use it.
- Brief staff if specific actions required.
- Make a judgment on risk. Critical risk = harm to
patients likely OR no capacity
to accept and / or manage incoming sick patients. - If risk critical and resolution not immediately
expected:
o Contingency planning: what if a critically ill patient
arrives? - If exit block:
o Undertake a brief safety round every 2-4 hours to
ensure long stayers
are (1) stable (2) still needing to be in the ED.
o Ask clinicians to ensure next-step critical drugs and
fluids are written up:
attention to analgesia, antibiotics, diabetic regimes,
regular steroids.
o Ask clinicians to ensure investigations are followed
up and acted upon.
o Liaise with ambulance crews to mitigate risk in the
queue.
If your ED is crowded, what strategies can you employ to acutely decompress your ED?
- Stream to specialties and get the specialty doctors
down to see appropriate
patients if not already done - Any investigations you can get underway?
- Prioritise the CTs
- Ensure patients can get to X-ray (porters may be
deployed elsewhere) - Any patients you can get home quickly?
- Any patients who can be streamed to primary care or
walk in centres? - Does everyone in a cubicle, need to be in a cubicle
(can they go into a chair?) - Utilise internal professional standards if appropriate
and if it will help (e.g. direct admission). If there is exit
block this may be futile - Can you free up any space by streaming to
specialties which sometimes have space? (e.g.
paeds, gynae), or by using ambulatory care and
CDU? - Can any patients go to wards direct from CT?
- Anyone who can be discharged from, or sat-out from,
CDU?
What factors are associated with crowding?
Crowding is associated with:
- Negative effects for patients:
o Increased mortality amongst admitted patients
o Increased length of stay amongst admitted patients
o Failure in key quality standards
o Poor patient experience. - Negative effects on staff:
o Burnout
o Increased illness
o Difficulty with recruitment and retention. - Negative effects on organisations:
o Performance
o Reputational
Any assessment area needs to be safe for staff,
and conducive to valid mental health assessment.
What criteria should be met to achieve the standards of an assessment area for mental health patients?
- there should be no ligature points,
- and nothing that can be used as a weapon.
- The room should have an alarm system and
two doors (that open both ways)
What is the benefit of using AUDIT-C tool in the ED?
AUDIT-C identifies those who are drinking at
increasing/higher risk levels before their drinking becomes problematic or dependent.
A total score of > 5 indicates a high risk of alcohol drinking/dependency
You are discharging a patient who presented with alcohol intoxication.
What brief intervention can you offer?
- A sentence or two of feedback to the patient about his/her drinking based on the
screening tool and the person’s circumstances - A sentence or two of feedback plus an information leaflet.
- Five minutes of advice based on the FRAMES structure (i.e. Feedback, Responsibility,
Advice, Menu of options, Empathy, Self-efficacy).
Sepsis screening is done as a 2-part process.
what is this?
1stly confirming that sepsis risk stratification is required by asking 3 questions:
- is their a concern that sepsis is a possibility in this patient ( NEWS > 3 )
- Could this be due to an infection
- is full escalation of care appropriate for this patient
secondly ( in the population thus identified ) screening for the level of severity of sepsis ( sepsis risk stratification/ red flags for sepsis )
In Red flag sepsis - what does a high lactate indicate?
- highly predictive of death
- and poor outcomes
when initially elevated in a patient with confirmed sepsis
- What is cryptic shock?
2. What is septic shock ?
CRYPTIC SHOCK:
in a patient with sepsis , who have a normal blood pressure but elevated serum lactate ( a lactate above 2 is considered elevated )
SEPTIC SHOCK:
in a patient with sepsis, it is hypotension ( SBP < 90 )
OR serum lactate > 4mmol/L
In a patient with sepsis -what is the relationship of lactate to mortality?
Relationship of lactate level to mortality:
<2 = 15%
2-4 = 25%
> 4 = 38%
Contra-indications to transferring a patient with ruptured AAA?
- patient requiring RSI due to acute deterioration
- requiring ionotropic support
- cardiac arrest in the current admission
What are the risk factors for absconding in a patient that presents to the ED?
Verbalising wish to abscond High suicide risk Previously absconded Quiet / withdrawn Unaccompanied Not from locality Not willing to engage with staff Intoxication Agitated / angry / distressed Frustration in delay to assessment Psychotic symptoms Brought to ED against own wishes Lack of insight Has external commitments/ stressors Delirium / dementia Patient / family lack insight into condition Alcohol or drug dependence
The police bring in a patient under section 136 - what is the role of the nurse and senior doctor in charge?
Nurse in charge and senior medic to review patient on arrival with police and ambulance crew and
assess medical needs and RAVE risks
(of Resistance, Aggression, Violence and Escape. )
A patient absconds - In an emergency where there has been no chance to
assess the patient’s capacity - what can you do?
If there is a significant risk of harm, a patient may
be restrained or brought back by force effectively under common law (see separate MCA guidance).
You deem a patient does not have capacity and shortly after this he has absconded from your ED?
If a patient absconds who is felt not to have capacity, and is at risk either of selfharm or deterioration of their condition, then
- departments should activate a search of hospital premises
- Departments should have a policy for when to call security and what it is expected security will do to search for the patient.
- ED staff should try to contact the patient and relatives by phone.
What are the contra-indications to Bier’s block?
- Allergy to local anaesthetic
- Children – consider whether appropriate on individual
basis
3.Hypertension >200mm Hg - nfection in the limb
- Lymphoedema
- Methaemoglobinaemia
- Morbid obesity (as the cuff is unreliable on obese
arms) - Peripheral vascular disease
- Procedures needed in both arms
- Raynaud’s phenomenon
- Scleroderma
- Severe hypertension
- Sickle cell disease or trait
- Pagets Disease
- Uncooperative or confused patient
In a Bier’s block procedure - what anaesthetic drug and at what dose would you select?
What are the key principles to this procedure regarding the blood pressure cuff and inflation times
0.5% or 1 % prilocaine at a dose of 3mg/kg.
double pneumatic tourniquet cuff inflated to 100mmhg above the patients baseline BP or up to 300mmHG.
minimum cuff inflation 20 minutes maximum 45 minutes
In a case of suspected FGM - when does mandatory reporting duty apply?
In cases of a patient < 18 years old where
- either the child has told you that they have had FGM OR
- you have found evidence of FGM. in this instance - mandatory reporting duty applies. and you have to call 101 the police and report the case and then also contact local child safeguarding.
What to do when a patient discloses domestic abuse?
i.e. what is the role of the emergency physician?
The patient should be believed. Enquiry about the extent and severity of the abuse should
be made in a non-judgemental manner. An assessment should be made of the victim’s
immediate safety. Specific inquiry should identify whether there are any children living with
Management of Domestic Abuse (March 2015) 3
the victim or perpetrator. Injuries, if present, should be photographed. If an Independent
Domestic Violence Advocate (IDVA) is available immediately then they will make
adequate records, but if not, as much information as possible should be recorded at the
time of disclosure.
Contact with the police and outside agencies should be offered from the safety of the
emergency department. Information about local shelters and support agencies should
available in written form and handed to the patient.
Failure to involve outside help is common and may frustrate medical and nursing staff,
who may believe that there has to be immediate action to be effective. This is not true,
victims leave an abusive relationship when they feel ready, not when clinical staff feel
they should.
The risks to children growing up in an abusive household are greatly increased. Any
concerns about child welfare should lead to the prompt activation of local child
safeguarding procedures.
When might the principles of the MCA apply in the Emergency Department?
memory aid: RADIM
Patients who refuse treatment.
Patients who abscond.
Patients suffering from long term conditions that impair their ability to make
decisions such as dementia.
Patients suffering from temporary lack of capacity due to intoxication,
delirium, or reduced level of consciousness.
Some patients at end of life.
Patients whose mental health condition impairs their ability to make decisions
What are the key principles of the MCA?
- A presumption of capacity - Every adult (aged 16 or over) has the right to
make his or her own decisions and must be assumed to have capacity to
do so unless it is proved otherwise. - The right for individuals to be supported to make their own decisions - A
person is not to be treated as unable to make a decision unless all
practicable steps to help him to do so have been taken without success. - The right to make what might be seen as eccentric or unwise decisions- A
person is not to be treated as unable to make a decision merely because he
makes an unwise decision. It is important to acknowledge the difference
between unwise decisions, which a person has the right to make and
decisions based on a lack of understanding of risks or inability to weigh up the
information about a decision. - Best interests – A decision made, under this Act on behalf of a person who
lacks capacity must be made, in their best interests. - Less restrictive intervention -Before the act is done, or the decision is made, it
should be considered if the outcome is less restrictive of the person’s rights
and future freedom of action.
How to assess capacity using the two stage capacity test:?
Stage 1: Does the person have an impairment or disturbance of the functioning of their mind or brain?
Stage 2:
Does the impairment or disturbance of their mind or brain mean that the person is unable to make a particular decision?
What are the principles of restraint of a patient in the ED?
- The person taking action must reasonably believe that restraint is necessary to
prevent harm to the person who lacks capacity, and - The amount or type of restraint used and the amount of time it lasts must be
proportionate response to the likelihood and seriousness of harm.
When assessing a patients mental capacity - give examples of impairments to the functioning of the brain?
For example: Mental Disorder, Dementia, Learning Disability, Brain damage, Confusion, Delirium, Drug or alcohol intoxication.
What is DoLS and when does it apply in the ED?
Deprivation of Liberty Safeguards (DoLS) is the framework of safeguards under the
Mental Capacity Act 2005 (MCA), for people who need to be deprived of their
liberty in their best interests for care or treatment for which they lack the capacity
to consent
What are the contra-indications to Ketamine sedation in children?
Contraindications:
• Age less than 12 months due to an increased risk of laryngospasm and airway
complications. Children aged between 12 and 24 months should only receive ketamine
sedation from expert staff (usually a consultant)
• A high risk of laryngospasm (active respiratory infection, active asthma)
• Unstable or abnormal airway. Tracheal surgery or stenosis.
• Active upper or lower respiratory tract infection
• Proposed procedure within the mouth or pharynx
• Patients with severe psychological problems such as cognitive or motor delay or severe
behavioural problems.
• Significant cardiac disease (angina, heart failure, malignant hypertension)
• Recent significant head injury or reduced level of consciousness
• Intracranial hypertension with CSF obstruction.
• Intra-ocular pathology (glaucoma, penetrating injury)
• Previous psychotic illness
• Uncontrolled epilepsy
• Hyperthyroidism or Thyroid medication
• Porphyria
• Prior adverse reaction to Ketamine
YOu are about to sedate a child with ketamine. what will you advise the parents regarding the complications?
Risks/complications:
- agitation
- Nooisy breathing and rare - laryngospasm
- VOmiting ( usually in the recovery phase )
- Lacrimation & salivation
- transient rash
- Transient clonic movements
YOu are about to sedate a child with ketamine. what will you advise the parents regarding normal expected side effects of ketamine?
It is important to emphasise to the consenting adult that 1. nystagmus,
- purposeless movements and
- some degree of dissociation
are normal during ketamine sedation, so that these are expected.
In Ketamine sedation in a child, what indicates adequate sedation?
Adequate sedation is usually indicated by loss of response to verbal stimuli and
nystagmus: heart rate, blood pressure and respiration rate may all increase slightly.
Lacrimation or salivation may be observed. The effects of the drug are usually
apparent 1-2 minutes after an IV dose, and 5-8 minutes after an IM dose
What is an Advanced Decision and when is it valid?
An advance decision enables someone aged 18 and over, while still capable,
to refuse specified medical treatment when they may have lost the capacity to
consent to or refuse that treatment
For an advanced decision to refuse life sustaining treatment to be valid:
Patient has to be 18 or over and have capacity when the decision is made.
The decision should be in writing, signed and witnessed.
It should include a statement that advance decision is to apply “even if the
person’s life is at risk.”
What is the criteria for safe discharge after sedation of the adult in the ED?
➢ vital signs returned to normal levels
➢ the patient is awake with intact protective reflexes and no longer at risk of reduced
level of consciousness
➢ nausea, vomiting and pain have been adequately addressed.
Name 3 factors that contribute to sudden death in a patient presenting with acute behavioural disturbance?
- positional asphyxia secondary to restraint technique
- drug toxicity
- underlying cardiac disease associated with cardiac arrythmias
Name 4 complications of a patient presenting with ABD?
- hyperthermia
- acidosis
- rhabdomylisis
- DIC
What is SARC?and what can patients receive with they go there?
SARC is sexual assault referal centre.
patient will receive:
- forensic examination
- emergency COC
- PEP
- psychological councelling
- Legal advice
However SARC cannot deal with acute injuries
What is the role of the emergency physician in a patient that presents following a rape?
- take a careful accurate history
- when examining the patient - avoid DNA contamination. only perform a pelvic examination if ongoing active bleeding
- consider possibility of pregnancy and offer emergency contraception
- consider exposure to STD’s and take blood samples for HBV, HCV, HIV
- refer victim to social services, victim support or SARC
- activate local safeguarding procedures for adult and if concerns about a childs welfare
A victim of rape is concerned about contracting Hep B virus and if the perpetrator is not known to be hep B negative, what will you do?
then consider hepatitis vaccination immediately and then 1 month later and 2 months later ( given by the GP.
further follow up blood tests should be done 3 months after exposure at the GP or GUM clinic.
in a rape victim - which cases are high risk for HIV in which you would consider PEPSE?
- assailant is known HIV positive
- anal rape
- multiple asailants
- bleeding
in a rape victim - what regime of antibiotics will you offer if exposure to bacterial infections?
a common regime is CAM ( 400mg, 1g, 2g )
Cefixime - 400mg
azithromycin 1g
Metronidazole 2g
ALL AS A SINGLE STAT DOSE orally
When should a chaperone raise concerns about the doctor/clinician?
- A less than professional manner.
- Over-exposure of a patient’s body.
- Inappropriate comments or gestures.
- Inappropriate facial expressions
What is the seroconversion rate from exposure to blood infected with HIV, HCV and HBV ?
and HCV
and HBV
Resource:
https://patient.info/doctor/needlestick-injury-pro#nav-0
- 1% for mucocutaneous exposure to HIV-infected blood.
- 3% for percutaneous exposure to HIV-infected blood.
0.5-1.8% for percutaneous exposure to HCV-infected blood with detectable RNA.
30% for percutaneous exposure of a non-immune individual to an HBeAg positive source.
what are the minimum competencies for the sedating practitioner in the following instances:
- minimal sedation
- moderate sedation
- deep sedation
- GA
Resource- RCEM guidelines: safe sedation of adults in the ED - november 2012
- minimal sedation: current ILS/ALS certificate
- moderate sedation: current ILS/ALS certificate
and Local sign off for level 1 sedation training - deep sedation: RCOA Initial assessement of competencies and local sign off for level 2 sedation training
- GA: same as 3
You are planning a concious sedation for a painful procedure. you note that the patient has a high risk for aspiration. what steps would you take to mitigate this risk?
Resource:RCEM guidelines safe sedation of adults in the ED - november 2012
- delay the procedure if clinically appropriate
- Adopting an alternate technique
* RSI of anaesthesia & tracheal intubation is the gold standard where an increased risk of aspiration exists - Regional anaesthetic techniques
- reduce the depth and duration of sedation
Which insignificant cervical spinal injuries may lead to patients being discharged without further imaging?
Resource: best practice guideline - exclusion of significant cervical spine injuries in abults with blunt neck trauma - nov 2010
- isolated spinous process fracture not involving the lamina
- isolated osteophyte fracture
- isolated transverse process fracture not involving facet joint
- simple vertebral compression fracture ( < 25% loss of height )
Modified canadian C-spine rule recommends c-spine imaging for patients that have suspected blunt trauma with a mechanism that may have injured the neck in which patients?
Resource: best practice guideline - exclusion of significant cervical spine injuries in abults with blunt neck trauma - nov 2010
- Patients with neck pain AND NAY of the following high risk factors:
* age > 65years
* known vertebral disease
* injury > 48 hours earlier
* reattending with the same injury
* fall from a heigh > 1metre/5 stairs
* axial loading to the head ( diving )
* high-speed rtc ( combined speed > 60mph )
* ejection from motor vehicle
* rollover from motor vehicle - Patient with dangerous mechanism of injury AND visible injury above the clavicles even if no neck pain/tenderness
- Severe neck pain > 7/10 pain score
- Paralysis, focal neurological deficit or paraesthesia in extremities
- patient with abnormal vitals ( sbp < 90 mmhg )
- GCS < 15 on assessment in ED
Name to indications for performing a MRi of the cervical spine in a patient with neck pain following injury?
Resource: best practice guideline - exclusion of significant cervical spine injuries in abults with blunt neck trauma - nov 2010
- neurological signs and symptoms referable to the c-spine
2. suspicion of vertebral artery injury
What are the indications for a CT - C-spine ( dont confuse with indications for C-spine IMAGING as per canadian c-spine rules )
Resource: best practice guideline - exclusion of significant cervical spine injuries in abults with blunt neck trauma - nov 2010
- patient has dementia
- patient has known vertebral disease
- new neurological symptoms
- suspicion of abnormality on plain film series
- inadequate plain film
- GCS < 13 on initial assessment
- intubated patients
- patients being scanned for head injury or multi-region trauma
What is the clinical features of a scaphoid fracture?
- pain on longitudinal compression of the thumb
- tenderness in anatomical snuff box
- tenderness over scaphoid tubercle
certain ambulatory patients with lowe limb immobilisation and any 1 of 3 factors should be considered at increased risk of a VTE.
what are these3 factors?
- rigid immobilisation
- non-weight bearing status
- acute severe injury
