Entrustable Professional Activities

EPA 6: Acute care

EPA 6

Acute care

Manage the early care of acutely unwell patients

This activity requires the ability to:

  • assess seriously unwell or injured patients and initiate management
  • assess patients for delirium and delirium risk
  • identify possible causes of delirium
  • recognise clinical deterioration and respond by following the local process for escalation of care
  • recognise and manage acutely unwell patients who require resuscitation
  • lead the resuscitation team initially, and involve other necessary services
  • liaise with transport services and medical teams
  • perform this activity primarily in inpatient settings, and be able to perform in community settings

Professional practice framework domain

Medical expertise

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • effectively assess, diagnose, and manage acute clinical presentations, including atypical and undifferentiated presentations and/or course of delirium
  • recognise immediate life-threatening conditions, deteriorating and critically unwell patients, and respond appropriately with reference to patient and family and/or carer wishes, including when not to escalate care
  • perform advanced life support according to resuscitation council guidelines, to a high level of advanced resuscitation skills
  • demonstrate knowledge of potential risks and complications of resuscitation
  • recognise the diagnostic criteria for delirium
  • identify and manage precipitating or perpetuating factors of delirium
  • manage the behavioural symptoms of delirium
  • determine if the cognitive impairment is likely to be short-term, long-term, or progressive
  • manage delirium with non-pharmacological and pharmacological strategies
  • identify frailty and risk factors for poor outcomes
  • recognise function-limiting interventions which may impact patient function while in hospital, e.g. prolonged telemetry, IV drips, high beds, catheter
  • implement strategies to prevent hospital acquired complications common to older people in an acute care setting, e.g. pressure sores, falls, deconditioning, and infections
  • select investigations that ensure maximum patient safety through excluding or diagnosing critical patient issues
  • systematically identify causes of acute deterioration in health status and levels of physical and cognitive functioning
  • manage escalations or transitions of care in a proactive and timely manner
  • develop plans of multidisciplinary treatment, rehabilitation, and secondary prevention following acute events
  • provide clear and effective discharge summaries with recommendations for ongoing care

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • recognise seriously unwell patients requiring immediate care
  • apply basic life support as indicated
  • understand general medical principles to caring for patients with undifferentiated and undiagnosed conditions
  • identify potential causes of current deterioration, and comply with escalation protocols
  • facilitate initial tests to assist in the diagnosis, and develop management plans for immediate treatment
  • document information to outline the rationale for clinical decisions and action plans
  • be unable to synthesise the risk factors that may have contributed to delirium

Communication

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • communicate clearly with other team members, and co-ordinate efforts of multidisciplinary team members
  • use closed-loop and clear communication with other health care team members during resuscitation
  • facilitate early communication with patients, families, and healthcare team members to allow shared decision making
  • negotiate realistic treatment goals, and determine and explain the expected prognosis and outcomes
  • employ communication strategies appropriate for younger patients or those with cognitive difficulties
  • explain the situation to patients in a sensitive and supportive manner, avoiding jargon and confirming their understanding
  • determine the level of health literacy of individual patients and level of understanding of agreed care decisions
  • explain delirium to a distressed family member or carer

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • demonstrate communication skills to sufficiently support the function of multidisciplinary teams
  • determine patients’ understanding of their diseases and what they perceive as the most desirable goals of care

Quality and safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • maintain up-to-date certification in advanced life support
  • use clinical information technology systems for conducting retrospective and prospective clinical audits
  • evaluate and explain the benefits and risks of clinical interventions based on individual patients’ circumstances
  • analyse adverse incidents and sentinel events to identify system failures and contributing factors
  • identify evidence-based practice gaps using clinical indicators, and implement changes to improve patients’ outcomes
  • coordinate and encourage innovation, and objectively evaluate improvement initiatives for outcomes and sustainability

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • evaluate the quality of processes through well-designed audits
  • recognise the risks and benefits of operative interventions
  • raise appropriate issues for review at morbidity and mortality meetings
  • evaluate the quality and safety processes implemented within the workplace, and identify gaps in their structure

Teaching and learning

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • educate colleagues on best practice guidelines for working with older people in the hospital setting
  • demonstrate effective supervision skills and teaching methods which are adapted to the context of the training
  • encourage questioning among junior colleagues and students in response to unanswered clinical questions
  • seek guidance and feedback from health care teams to reflect on the encounter and improve future patients’ care

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • mentor and train others to enhance team effectiveness
  • provide constructive feedback to junior colleagues to contribute to improvements in individuals’ skills
  • coordinate and supervise junior colleagues from the emergency department and the wards

Research

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • select studies based on optimal trial design, freedom from bias, and precision of measurement Research
  • evaluate the value of treatments in terms of relative and absolute benefits, cost, potential patient harm, and feasibility
  • evaluate the applicability of results of clinical studies to the circumstances of individual patients, especially those with multiple comorbidities
  • evaluate the applicability of evidence-based guidelines and protocols to older people
  • specify research evidence to the needs of individual patients

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • demonstrate efficient searching of literature databases to retrieve evidence
  • use information from credible sources to aid in decision making
  • refer to evidence-based clinical guidelines and protocols on acutely unwell patients
  • demonstrate an understanding of the limitations of the evidence and the challenges of applying research in daily practice

Cultural safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • negotiate healthcare decisions in a culturally appropriate way by considering variation in family structures, cultures, religion, or belief systems
  • integrate culturally appropriate care of Aboriginal and Torres Strait Islander and Māori peoples into patients’ management
  • consider cultural, ethical, and religious values and beliefs in leading multidisciplinary teams

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • practise cultural competency appropriate for the community serviced
  • proactively identify barriers to access to health care

Ethics and professional behaviour

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • develop management plans that are based on medical assessments of the clinical conditions and multidisciplinary assessments of functional capacity
  • advise patients of their rights to refuse medical therapy, including life-sustaining treatment
  • consider the consequences of delivering treatment that is deemed futile, directing to other care as appropriate
  • facilitate interactions within multidisciplinary teams, respecting values, encouraging involvement, and engaging all participants in decision making
  • demonstrate critical reflection on personal beliefs and attitudes, including how these may affect patient care and health care policy

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • communicate medical management plans as part of the multidisciplinary plans
  • establish, where possible, patients’ wishes and preferences about care
  • contribute to building a productive culture within teams

Judgement and decision making

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • evaluate and determine the balance of intensity of treatment options in collaboration with patients’ families and decision makers
  • recognise the need for escalation of care, and escalate to appropriate staff or service
  • integrate evidence related to questions of diagnosis, therapy, prognosis, risks, and causes into clinical decision making
  • reconcile conflicting advice from other specialties, applying judgement in making clinical decisions in the presence of uncertainty
  • use care pathways effectively, including identifying reasons for variations in care
  • participate in shared decision making and medical management before, during, and after operations

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • involve additional staff to assist in a timely fashion when required
  • recognise situations in which to ask for help

Leadership, management, and teamwork

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • work collaboratively with staff in the emergency department, intensive care, and other subspecialty inpatient units
  • manage the transition of acute medical patients through their hospital journey
  • lead a team by providing engagement while maintaining a focus on outcomes

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • collaborate with and use other team members, based on their roles and skills
  • ensure appropriate multidisciplinary assessment and management
  • encourage an environment of openness and respect to lead effective teams

Health policy, systems, and advocacy

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • use a considered and rational approach to the responsible use of resources, balancing costs against outcomes
  • prioritise patient care based on needs, considering available health care resources
  • collaborate with emergency medicine staff and other colleagues to develop policies and protocols for the investigation and management of common acute medical problems

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • understand the systems for the escalation of care for deteriorating patients
  • understand the role of clinician leadership and advocacy in appraising and redesigning systems of care that lead to better patient outcomes