An Introduction – RCEM Induction

Author: Charlotte Davies / Codes: / Published: 31/07/2018 / Updated: 29/07/2020

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Welcome to the ED induction modules. We first started creating induction specific content in 2018 when we released our first induction iBook . This was really well received, and we added more content with our second induction iBook, and our PEM induction pack. 2020 has brought further innovation, and here is our induction package. We’ve refreshed our blogs, and written some focused and specific questions to test your knowledge, and make you emergency ready. This may not be face to face, but we’re with you every step of the way – you can contact the RCEMLearning team by email, or twitter and we will do our best to help as much as possible.

How to use this e-learning

Read the blog, and when you’re ready complete the MCQs found at the bottom of each blog. Your learning needn’t stop there – if you’re interested, read further links, see the patient, discuss your local adaptations, then reflect and document how your hospital management varies. You can put this straight on your e-portfolio and curriculum map it. Sorted! You’ll find loads of resources online that are there to help you. Be careful about trying to read everything all at once. If there’s anything you want to know more about, RCEMLearning is a great place to start. The blogs, podcasts, cases and reference section are all free to anyone to access. If you like those, you could join RCEM to get access to all of the online modules! There are some emergency medicine modules on eLFH. Twitter can also give you lots of support.

The ED Environment

The ED will throw you in the deep end, testing your practical, diagnostic and risk juggling skills, whilst being the most supported environment you’re likely to work in. We work closely with most other specialties, and we are the specialty that provides the barometer for the rest of the trust. If the ED provides poor care or compassion, the rest of the patient’s journey will be affected. Never underestimate the importance of excellent communication.

Communication might be the difference between a patient complaining or not complaining.
Communication can make the difference between a patient with non epileptic seizures being admitted or going home.

Communication can make the difference to patient experience.

Communication can make the difference between a patient with new onset atrial fibrillation returning home or being referred.

Communication can make the difference between a lonely patient admitting their loneliness or fabricating a medical presentation. Communication is the difference between life and death and will be one of the important, yet underrated, achievements of your emergency department placement.

The ED Mindset

The mindset in ED is very different to what you may have encountered elsewhere. We want to know the salient points that will change our management. Do we care that they’ve got a budgie called Bob? Not if they’ve come in with a broken leg. Only ask the questions you want to know the answers to. Other doctors dwell on the questions: what does this patient have? What’s the diagnosis? We’re constantly thinking what does this patient need? In the ED you must focus on the patient in front of you, but also be aware of those in the queue. There are lots of distractions and a chronic cacophony of noises. Only order the tests that will change what you do. Ordering a magnesium level in the fitting patient may make you look clever, but will the results change what you do? No, and it’s not evidence-based either. Will bowel sounds change whether your patient is going home or to the surgeons? No. Challenge the dogma and perform evidence-based medicine. You will become an expert in communicating diagnostic uncertainty. This can sometimes cause difficult interactions with other specialties. Stand your ground, and remember, you are the patient’s advocate. Rudeness is always a hinderance, and just like specialties don’t always understand how the ED works, we often don’t understand their specific challenges. ED has created a “RespectED” campaign, in conjunction with civility saves. Be nice and advocate for your patient and speak to your seniors sooner rather than later. They are used to navigating these pitfalls.

This short video from RCEM talks about how in emergency medicine we make decisions with minimal information.

The Four Hour target

You’ve all heard of the four hour target. Before the target, emergency care was terrible. Patients would wait on the corridors of the hospital for significant amounts of time as there was no incentive to see them. Broken arms might wait eight hours or more. Then the target came along, and suddenly, there was an incentive to see and discharge patients within four hours. It’s evolved, and has its own problems, but generally, the four hour target is considered to be a good thing. It provides a surrogate marker for how the rest of the hospital is working and is really important. If your patient breaches the four hour target because there’s no inpatient bed, that’s a hospital failing. If your patient breaches because there weren’t enough clinicians to see them promptly, that’s a staffing failing. If your patient breaches because you didn’t make a decision on what to do with them, that’s a departmental failing. All of these breach reasons will be investigated, as it’s important for patient safety and patient flow. Be aware of it – it is not just a target for managers.

Because of national breach reporting processes, most trusts have broken the four hour target down into mini targets, although this is not a mandated definition:
0 15min Triage
0 60min First seen by Doctor
0 – 120min Referral to specialty, if needed
0 – 180min Seen by specialty
0 240min Transferred to ward

How to Cope With Crowding (and generally be a good ED doc)

Last Winter was bad. There were no beds anywhere, and patients were waiting long times to be seen in corridors. Different departments have different strategies for managing this, but everyone agrees, it makes ED a difficult place to work. Many staff feel powerless. Many Clinicians are dreading the potential for COVID + Winter. There are a few things we think you can do:

  • Address the elephant.
    Yes, your patient is cross they’ve waited a long time. Yes, they don’t think you should see them in a corridor. Start by saying “thank you for your patience in waiting so long. I’m sorry we’re seeing you in a corridor – as you can see we’re all doing the best we can in these difficult circumstances.”
  • Treat aggressively and early
    Don’t start with paracetamol in a patient with back pain. Hit them hard and early with appropriate treatment.
  • Discuss early. This means your plans can be adjusted, and your patient can go home. This is really important. Think about an elderly patient who fell at home. Your plan is await x-rays and hopefully get them home. You discuss, and the plan changes to analgesia, x-ray and admission avoidance. This means you manage to refer the patient to admission avoidance team before they go home, preventing an overnight stay on your observation ward.
  • Use your observation ward / clinical decisions unit.
    Most departments now have one of these. Use it for your ED patients as much as possible, but stick to your department’s policies to prevent your CDU becoming blocked with referred patients. Your low risk chest pain who needs a repeat troponin but you think will go home? Most departments would be happy for that patient to go to CDU. Your patient with chest pain that occurred at rest, and you think it’s unstable angina… not suitable for CDU. Your patient you’re not sure what to do with, and don’t have a plan for? Not suitable for CDU!
  • Escalate and deescalate early
    If your patient is in the waiting room, but should be in resus let your seniors know. This might be a verbal update, or a computer annotation, but they need to know. Likewise, if your patient is in resus but doesn’t need to be, let someone know. Space is always a premium.
  • Anticipate the course
    If your patient is going to be in hospital for 24 hours, consider writing up their next dose of antibiotics. Yes, it’s probably the medical team’s job, but it’s in the patient’s best interests. Was your patient admitted for pain control reasons? Write up their next dose of “as needed” analgesia to stop you being chased to find it.
  • Utilise your management team
    If you can never get hold of the ambulatory care consultant, ask your seniors if the site manager needs to go and check they’re alive. If mental health won’t come and see your patient on a s136 for ten hours, do your seniors want you to escalate to the management team.
  • It’s always your job
    You didn’t train to push trolleys, but sometimes, that’s what is needed. To meet the sepsis targets, you might need to hang the IV fluids yourself. If you don’t know how to do these things always ask.
  • Reporting Crowding
    The impact of crowding will vary from hospital to hospital. If bad things happen, incident report it. Speak to your bosses to see what they want you to do.
  • Ensure you have your breaks, and rest.
  • Beware handovers!
    The Oxford Handbook of Emergency Medicine says so, and you really should. Always accept handovers but check that a plan has been documented. Treat the patient as “my patient” and not a “handover patient”. The discharge summary will have your name on it and not your colleague’s. Check the investigations results yourself, ask/do a set of obs and briefly re-examine the patient (in regards to the presenting complaint) prior to discharge. On the flip side, do handover patients when it is time to go home, teaching etc. As above, ensure you’ve documented a plan. It is nice to let your patient know that you will be handing them over to another doctor and if you can introduce them to your patient. It takes an 10 extra seconds after the handover to do that but patients really appreciate it.
  • Aim to see one majors patient an hour.
    This is likely to be what your Consultants are expecting. Yes, some people are fast, some are slow but it’s good to have a target!
  • It’s the 21st century.
    Most EDs have comprehensive electronic systems. You wouldn’t copy the notes by hand twice, so why copy them from paper to the computer? Choose which one you prefer but check with your department. If you do go the paper way, write a brief summary in the electronic system. If you go the electronic way, it helps to print the notes and attach to the physical notes if you are handing over the patient or going on a break (remember crash teams look through physical notes in the first instance).
  • Clinical Knowledge
    It will be a steep learning curve in the ED and this induction booklet can’t teach you everything. Identify your resources early. Most departments would rather you discuss with an ED senior, rather than the specialty registrar. Most departments would rather you discuss with an ED senior than spend hours ploughing through uptodate or another resource. Most departments would rather you use their own departmental policies, rather than googling for others. Find out what your department prefers and whilst you wait for the ED registrar to be free, you can always use RCEM Reference!
  • Never forget that what ever is happening, you are still a clinician and still able to be compassionate, provide analgesia and communicate with your patient.
  • Trust your instincts but never take any risks. If you feel your patient looks unwell but the bloods/investigations are normal, dont be afraid to ask for a review by a senior. Same goes for those with abnormal bloods/investigations but otherwise look very well.

Other Clinical Tips

These induction modules take you through some of the key presentations to ED. They won’t cover everything. The rest of RCEMLearning will be there to provide further information – the reference section, FOAMEd blogs, podcasts and iBooks, clinical cases, and research sections are all open access.

In addition, there are several resources that have been created to support those working and training within the ED around leadership, which can be found on the RCEM website and several eLearning modules (EMLeaders) on e-LfH.

We haven’t covered much paediatrics, or mental health, and you are likely to see children, and mental health presentations (and children with mental health problems) in your ED. Have a look at our paediatric starter iBook. We especially recommend reading the sections about fever in children, and non accidental injury, and mental health in the ED.

Enjoy your ED placement – there’s no where quite like it!

Contributors
This induction package wouldn’t have been possible without a fantastic team of people. All these people have given up their time to share their cumulative wisdom. Their trusts are obviously fantastic supportive places to work!

Links and downloads:
induction ibook 2
PDF Version RCEM Learning Induction Book 2 
RCEMLearning Induction Book One

Other Induction Resources:
St Emlyns Induction Resources
DFTB (paediatric) induction resources
EM3 induction

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