Severn Deanery OOH Workbook For GPSTs  

This workbook draws on the workbooks of the KSS and Welsh Deaneries with additional material on expansion of the COGPED traffic light system from the work of the Cheltenham Trainers Group. (Jan 2011) It's aim is to provide guidance to trainees on the acquisition of the competencies associated with OOH GP work and to outline the Deanery Policy for OOH work and training. This workbook should be read in conjunction with:

The Workbook 

Learning Outcomes 

Primary care management

  • Recognise and evaluate acutely ill patients.
  • Describe how the presentation may be changed by age and other factors such as gender, ethnicity, pregnancy and previous health.
  • Be aware of the presentation of common severe illnesses and where symptoms may be confused with less severe illnesses
  • Be able to recognise those illnesses where immediate action is needed to reduce death and significant morbidity
    • Recognise death.
    • Demonstrate an ability to make complex ethical decisions demonstrating sensitivity to a patient’s wishes in the planning of care.
    • Provide clear leadership, demonstrating an understanding of the team approach to care of the acutely ill and the roles of the practice staff in managing patients and relatives.
    • Coordinate care with other professionals in primary care and with other specialists.
    • Take responsibility for a decision to admit an acutely ill person and not be unduly influenced by others, such as secondary care doctors who have not assessed the patient.

The GP must be competent to provide out of hours care by demonstrating:

  • Ability to manage common medical, surgical and psychiatric emergencies in the out-of-hours setting
  • Understanding of the organisational aspects of NHS out-of-hours care
  • Ability to make appropriate referrals to hospitals and other professionals in the out-of-hours setting
  • Appropriate communication skills required for out-of-hours care
  • Individual personal time and stress management
  • Maintenance of personal security and awareness and management of the security risks to others.

Person-centred care

  • Describe ways in which the acute illness itself and the anxiety caused by it can impair communication between doctor and patient, and make the patient’s safety a priority.
  • Demonstrate a person-centred approach, respecting patients’ autonomy whilst recognising that acutely ill patients often have a diminished capacity for autonomy.
  • Describe the challenges of maintaining continuity of care in acute illness and taking steps to minimise this by making suitable handover and follow-up arrangements.
  • Describe the needs of carers involved at the time of the acutely ill person’s presentation.
  • Demonstrate an awareness of any conflict regarding management that may exist between patients and their relatives, and act in the best interests of the patient.
  • Understand the way in which different individuals place emphasis on different symptoms
  • Understand how patients from different cultures and social backgrounds may interpret and report symptoms.

 Specific problem-solving skills

  • Describe differential diagnoses for each presenting symptom.
  • Decide whether urgent action is necessary, thus protecting patients with non-urgent and self-limiting problems from the potentially detrimental consequences of being over-investigated, over-treated or deprived of their liberty.
  • Demonstrate an ability to deal sensitively and in line with professional codes of practice with people who may have a serious diagnosis and refuse admission.
  • Demonstrate an ability to use telephone triage:
    • to decide to use ambulance where speed of referral to secondary care or paramedic intervention is paramount
    • to make appropriate arrangements to see the patient
    • to give advice where appropriate.
    • Demonstrate the use of time as a tool and to use iterative review and safety-netting as appropriate.
      • Be able to undertake an appropriate evaluation of a patient’s presentation without access to their medical records
      • Understanding the different context of communication in an OOH presentation and how to modify your own communication skills to accommodate this
      • Understanding of the different communication skills required in talking to patients or their representatives on the telephone and effectively assessing the presented situation in order to deliver appropriate patient care
      • Know how, when and why to involve other professionals

A comprehensive approach

  • Recognise that an acute illness may be an acute exacerbation of a chronic disease.
  • Describe the increased risk of acute events in patients with chronic and co-morbid disease.
  • Identify co-morbid diseases.
  • Describe the modifying effect of chronic or co-morbid disease and its treatment on the presentation of acute illness.
  • Recognise patients who are likely to need acute care and offer them advice on prevention, effective self-management and when and who to call for help.

Community orientation

  • Demonstrate an ability to use knowledge of patient and family, and the availability of specialist community resources, to decide whether a patient should be referred for acute care or less acute assessment or rehabilitation, thus using resources appropriately.
  • Deal with situational crises and manipulative patients, avoiding the inappropriate use of healthcare resources.
  • Understand the wider community of the population of patients presenting to the out of hours service
  • Understand the other sources of help that they may access for urgent and unscheduled care.
    • Describe approaches to improving access to services for hard-to-reach groups.

A holistic approach

  • Demonstrate an awareness of the important technical and pastoral support that a GP needs to provide to patients and carers at times of crisis or bereavement including certification of illness or death.
  • Demonstrate an awareness of cultural and other factors that might affect patient management.
    • Be aware of how different communities respond to and manage episodes of acute illness
    • Be aware of the varying beliefs that patients have about the need to ask for medical help with regard to similar symptoms

Contextual aspects

  • Demonstrate an awareness of legal frameworks affecting acute healthcare provision especially regarding compulsory admission and treatment.
  • Demonstrate an awareness of the tensions between acute and routine care and impact of workload on the care given to the individual patients.
  • Demonstrate an awareness of the impact of the doctor’s working environment and resources on the care provided.
  • Demonstrate an understanding of the local arrangements for the provision of out-of-hours care.
  • Understanding your ability to work in a busy and time pressured environment
  • Being aware of how you respond to stress
  • Managing adequate rest and relaxation
  • Understanding the organisational aspects of the OOH provider organisation
  • Ensuring you are informed about the administrative and communication processes of the OOH provider, including handover to the patient’s GP, familiarity with the IT and patient recording processes
  • Awareness and use of the COGPED guidance for OOH training guidance

Attitudinal aspects

  • Demonstrate an awareness of their personal values and attitudes to ensure that they do not influence their professional decisions or the equality of patients’ access to acute care.
  • Identify patients for whom resuscitation or intensive care might be inappropriate and take advice from carers and colleagues.
  • Demonstrate a balanced view of benefits and harms of medical treatment.
  • Demonstrate an awareness of the emotional and stressful aspects of providing acute care and an awareness that they need to have strategies for dealing with personal stress to ensure that it does not impair the provision of care to patients.
    • Understanding the value of effective team work in the OOH situation and the roles and responsibilities of all staff both administrative and clinical
    • Recognising your personal attitudes to patients who may request unscheduled care inappropriately as part of an unorganised lifestyle
    • Demonstrating good practice in the recording of learning areas encountered in the OOH session in order to consolidate learning goals that may need to be addressed at a later time and dat

Scientific aspects

  • Describe how to use decision support to make their interventions evidence-based, e.g. Cochrane, PRODIGY, etc.
  • Demonstrate an understanding of written protocols that are available from national bodies and how these may be adapted to unusual circumstances.
  • Evaluate their performance in regard to the care of the acutely ill person; including an ability to conduct significant event analyses and take appropriate action.
    • Understanding the factors that affect the demand for OOH and unscheduled primary care in different communities
    • Understanding the information that OOH providers use to audit and map the service that they provide.

Psychomotor skills

  • Performing and interpreting an electrocardiogram.
  • Cardiopulmonary resuscitation of children and adults including use of a defibrillator.
  • Controlling a haemorrhage and suturing a wound.
  • Passing a urinary catheter.
  • Using a nebuliser.

The Knowledge base 

Symptoms

  • Cardiovascular – chest pain, haemorrhage, shock.
  • Respiratory – wheeze, breathlessness, stridor, choking.
  • Central nervous system – convulsions, reduced conscious level, confusion.
  • Mental health – threatened self-harm, delusional states, violent patients.
  • Severe pain.

Common and/or important conditions

  • Shock (including no cardiac output), acute coronary syndromes, haemorrhage (revealed or concealed), ischaemia, pulmonary embolus, asthma.
  • Dangerous diagnoses.
  • Common problems that may be expected with certain practice activities: anaphylaxis after immunisation, local anaesthetic toxicity and vaso-vagal attacks with, for example, minor surgery or intra-uterine contraceptive device insertion.
  • Parasuicide and suicide attempts.
  • Carbon monoxide poisoning
    • Meningococcal and other bacterial septicaemia

Investigation

  • Blood glucose.
  • Other investigations are rare in primary care because acutely ill patients needing investigation are usually referred to secondary care.

Treatment

  • Pre-hospital management of convulsions and acute dyspnoea.

Emergency care

  • The ‘ABC’ principles in initial management.
  • Appreciate the response time required in order to optimise the outcome.
  • Understand the organisational aspects of NHS out-of-hours care.
  • Understand the importance of maintaining personal security and awareness and management of the security risks to others.

Resources

  • Appropriate use of emergency services, including logistics of how to obtain an ambulance/paramedic crew.
  • Familiarity with available equipment in own car/bag and that carried by emergency services.
  • Selection and maintenance of appropriate equipment and un-expired drugs that should be carried by GPs.
  • Being able to organise and lead a response when required, which may include participation by staff, members of the public or qualified responders.
  • Knowledge of training required for practice staff and others as a team in the appropriate responses to an acutely ill person.

Prevention

  • Advice to patients on prevention, e.g. with a patient with known heart disease, advice on how to manage ischaemic pain

Recommendations for Recording Sessions and Level of Supervision to Inform Clinical Supervisors 

While the ideal would be to have all recording electronic in the e-portfolio the reality is that OOH clinical supervisors do not currently have access to a trainee’s e-portfolio so a practical system to allow clinical supervisors to be able to quickly review a trainee’s previous OOH experience and current level of OOH supervision needs to be in place. It is suggested that trainees keep a file/folder containing a summary log of their OOH sessions to date (Appendix G); the record of their progression through the traffic light system (Appendix F) and the hard copies of their individual session log sheets (Appendix E). This file can then be reviewed by the clinical supervisor at the start of a session. The individual session log sheets are the vehicle for communication between clinical supervisors and educational supervisors. The self assessment tool (Appendix A) and identification of learning needs sheets (Appendices B, C and D) could also be included in this file. When all OOH sessions have been completed these records could be scanned into the e-portfolio to contribute towards the evidence for attainment of OOH competencies.

 

Appendix A:  GPST OOH Competencies Self-Assessment Tool  

To help you identify your learning needs in relation to the GP Curriculum we have attached a list of learning outcomes and the knowledge base taken from section 3 Care of Acutely Ill People, in the form of a confidence rating scale. You will then be able to use it to help you identify areas that require development.

 Care of Acutely Ill People - Knowledge Base                                                                        

Please rate your confidence in your knowledge of the following area

 Not Confident    Slightly Confident     Confident      Very Confident

Symptoms

 

Cardiovascular – chest pain, haemorrhage, shock.

 

Respiratory – wheeze, breathlessness, stridor, choking.

 

Central nervous system – convulsions, reduced conscious level, confusion.

 

Mental health – threatened self-harm, delusional states, violent patients.

 

Severe pain

 

Common and/or Important conditions

 

Shock (including no cardiac output), acute coronary syndromes, haemorrhage (revealed or concealed), ischaemia, pulmonary embolus, asthma.

 

Dangerous diagnoses: e.g. MI, PE, SAH, appendicitis, limb ischaemia, intestinal obstruction, meningitis, AAA, ectopic pregnancy, acute psychosis, visual problems that can lead to blindness.

 

Common problems that may be expected with certain practice activities: anaphylaxis after immunisation, local anaesthetic toxicity and vaso-vagal attacks with, for example, minor surgery or intra-uterine contraceptive device insertion.

 

Parasuicide and suicide attempts.

 

Treatment

 

Pre-hospital management of convulsions and acute dyspnoea.

 

Investigation

 

Blood glucose.

 

Other investigations are rare in primary care because acutely ill patients needing investigation are usually referred to secondary care.

 

Emergency Care

 

The ‘ABC’ principles in initial management. 

 

Appreciate the response time required in order to optimise the outcome.

 

Understand the organisational aspects of NHS out-of-hours care.

 

Understand the importance of maintaining personal security and awareness and management of the security risks to others.

 

Resources

 

Appropriate use of emergency services, including logistics of how to obtain an ambulance/paramedic crew.

 

Familiarity with available equipment in own car/bag and that carried by emergency services.

 

Selection and maintenance of appropriate equipment and un-expired drugs that should be carried by GPs.

 

 

Please rate your confidence against the following statements taken from learning outcomes of the GP Curriculum

Strongly disagree             Disagree              Agree          Strongly Agree

Being able to organise and lead a response when required, which may include participation by staff, members of the public or qualified responders.

 

Knowledge of training required for practice staff and others as a team in the appropriate responses to an acutely ill person.

 

Prevention

 

 Advice to patients on prevention, e.g. with a patient with known heart disease, advice on how to manage ischaemic pain including use of glyceryl trinitrate (GTN), aspirin and appropriate first-line use of paramedic ambulance.

 

Primary Care management

 

I can recognise and evaluate acutely ill patients

 

I can describe how the presentation may be changed by age and other factors such as gender, ethnicity, pregnancy and previous health

 

I can recognise death

 

I can demonstrate an ability to make complex ethical decisions demonstrating sensitivity to a patient’s wishes in the planning of care

 

I can provide clear leadership, demonstrating an understanding of the team approach to care of the acutely ill and the roles of the practice staff in managing patients and relatives

 

I can take responsibility for a decision to admit an acutely ill person and not be unduly influenced by others, such as secondary care doctors who have not assessed the patient

 

I can coordinate care with other professionals in primary care and with other specialists.

 

Person-centred care

 

I can describe ways in which the acute illness itself and the anxiety caused by it can impair communication between doctor and patient, and make the patient’s safety a priority.

 

I can demonstrate a person-centred approach, respecting patients’ autonomy whilst recognising that acutely ill patients often have a diminished capacity for autonomy.

 

I can describe the challenges of maintaining continuity of care in acute illness and taking steps to minimise this by making suitable handover and follow-up arrangements.

 

I can describe the needs of carers involved at the time of the acutely ill person’s presentation.

 

 I can demonstrate an awareness of any conflict regarding management that may exist between patients and their relatives, and act in the best interests of the patient.

 

Specific problem-solving skills

 

I can describe differential diagnoses for each presenting symptom.

 

I can decide whether urgent action is necessary, thus protecting patients with non-urgent and self-limiting problems from the potentially detrimental consequences of being over-investigated, over-treated or deprived of their liberty.

 

I can demonstrate an ability to deal sensitively and in line with professional codes of practice with people who may have a serious diagnosis and refuse admission

 

I can demonstrate an ability to use telephone triage

 

I can demonstrate the use of time as a tool and to use iterative review and safety-netting as appropriate

 

A comprehensive approach

 

 I can recognise that an acute illness may be an acute exacerbation of a chronic disease.

 

I can describe the increased risk of acute events in patients with chronic and co-morbid disease.

 

I can identify co-morbid diseases.

 

I can describe the modifying effect of chronic or co-morbid disease and its treatment on the presentation of acute illness

 
 

I can recognise patients who are likely to need acute care and offer them advice on prevention, effective self-management and when and who to call for help

 

 Community orientation

I can demonstrate an ability to use knowledge of patient and family, and the availability of specialist community resources, to decide whether a patient should be referred for acute care or less acute assessment or rehabilitation. Thus using resources appropriately.

 

I can deal with situational crises and manipulative patients, avoiding the inappropriate use of healthcare resources.

 

 A holistic approach

I can demonstrate an awareness of the important technical and pastoral support that a GP needs to provide to patients and carers at times of crisis or bereavement including certification of illness or death.

 

I can demonstrate an awareness of cultural and other factors that might affect management of an acutely ill patient.

 

Contextual aspects

I can demonstrate an awareness of legal frameworks affecting acute healthcare provision especially regarding compulsory admission and treatment.

 

I can demonstrate an awareness of the tensions between acute and routine care and impact of workload on the care given to the individual patients.

 

I can demonstrate an understanding of the local arrangements for the provision of out-of-hours care.

 

Attitudinal aspects

I can demonstrate an awareness of my personal values and attitudes to ensure that they do not influence my professional decisions or the equality of patients’ access to acute care.

 

I can identify patients for whom resuscitation or intensive care might be inappropriate and take advice from carers and colleagues.

 

I can demonstrate a balanced view of benefits and harms of medical treatment.

 

I can demonstrate an awareness of the emotional and stressful aspects of providing acute care and an awareness that I need to have strategies for dealing with personal stress to ensure that it does not impair the provision of care to patients.

 

Scientific aspects

 

I can describe how to use decision support to make their emergency interventions evidence-based, e.g. Cochrane, Clinical Knowledge Summaries (PRODIGY), etc..

 

I can demonstrate an understanding of written protocols that are available from national bodies and how these may be adapted to unusual circumstances.

 

I can evaluate my performance in regard to the care of the acutely ill person; including an ability to conduct significant event analyses and take appropriate action.

 

Psychomotor skills

I can perform and interpret an electrocardiogram.

 

I can perform cardiopulmonary resuscitation of children and adults including use of a defibrillator.

 

I can control a haemorrhage and suture a wound.

 

I can pass a urinary catheter.

 

I can use a nebuliser

 

Care of Acutely Ill People – Learning Outcomes

Please rate your confidence against the following statements taken from learning outcomes of the GP Curriculum

Strongly disagree        Disagree          Agree        Strongly Agree

Primary care management

 

I know of the epidemiology of major cancers along with risk factors and unhealthy behaviours.

 

I know of the principles of palliative care and how it applies to non-cancer illnesses such as cardiovascular, neurological, respiratory and infectious diseases.

 

Person-centred care

I have the ability to attend to the full range of physical, social and spiritual needs of the patient and carer(s).

 

I have the ability to communicate effectively with the patient and carer(s) regarding difficult information about the disease, its treatment or its prognosis.

 

I know about how to provide and manage 24-hour continuity of care through various clinical systems.

 

Specific problem-solving skills

I know of the appropriate investigations of patients with cancer and of how they fit in with national guidelines.

 

I have the ability to manage pain.

 

I have knowledge about and skill in using a syringe driver:

  • suitable drugs
  • conversion of drugs from oral dosage to syringe drive, either, IV or subcutaneous
 

I have knowledge of various palliative care emergencies and their appropriate management:

  • major haemorrhage
  • hypercalcaemia
  • superior vena caval obstruction
  • spinal cord compression
  • bone fractures
  • anxiety/panic
  • use of emergency drugs.
 

A comprehensive approach

I have the ability to manage cancer and non-cancer symptomatology in the same patient.

 

I have the ability to counsel and explain:

  • risk of disease
  • behaviour change
  • treatment options
  • symptom control
 

Community orientation

I have knowledge of the social benefits and services available to patients and carer(s).

 

I understand the current population trends in the prevalence of risk factors and cancer in the community.

 

I appreciate the importance of the social and psychological impact of cancer on the patient’s family, friends, dependants and employers.

 

A holistic approach

I have the ability to offer spiritual care for the patient and carer(s).

 

I have knowledge of normal and abnormal grieving, and its impact upon symptomatology.

 

Contextual aspects

I understand the key health service policy documents that influence healthcare provision for cancer and palliative care

 

I recognise how geographical factors influence the prevalence and treatment of cancers

 

Attitudinal aspects

I have knowledge of the ethical dimensions of treatment and investigation choices, palliative and terminal care, and advanced directives.

 

I have knowledge of the ethical principles and how they apply to cancer care and control.

 

I have knowledge of their own personal attitudes and experiences that can affect their attitude towards patients with cancer or who are dying.

 

Scientific aspects

I have the ability to define and apply evidence-based care in patients with cancer.

 

I have the ability to learn from the clinical experience.

 

I have knowledge of cancer treatment trials and how to inform patients about their participation.

 

 

Appendix B: Trainer statement on OOH Training Learning Needs of GPST 

The following is a list of learning needs we have identified for this GPST, specific to unscheduled care:

Need

Date identified

Trainer’s name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Areas identified as needs in the OOH setting that may be addressed in hours:

Need

Date identified

Trainer’s name

 

 

 

 

 

 

 

 

 

 

 

 


Appendix C: Supervisor Statement on Learning Needs of GPST Identified During OOH experience 

The following is a list of learning needs we have identified for this GPST, as a result of experience in OOH:

Need

Date identified

Supervisor’s name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specific skills that need further development/experience are:

Skill

Date identified

Supervisor’s name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Appendix D: Self Statement on Learning Needs of GPST identified during OOH experience 

The following is a list of learning needs I have identified for myself, as a result of experience in OOH:

Need

Date identified

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specific skills that need further development/experience are:

Skill

Date identified

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix E: OOH Session Log Sheet 

Type of session: base doctor, telephone triage, mobile doctor, other-describe

Level of Supervision: Red; Amber; Green

Trainee:

Clinical Supervisor:

 Date of session:

Time of session and length (hours):

Type of cases seen and significant events

Competencies demonstrated (please relate to OOH assessment scale)

Learning areas and needs identified (to be discussed with trainer)

Debriefing notes from Clinical Supervisor

Signature of Clinical Supervisor       

Signature of GP Registrar:

Appendix G: Summary Log of OOH Sessions 

Date

Session Type

Supervision Level

Supervisor

Hours

Total Hours