Clinical Skills and Procedures in Paediatrics Training
In the Royal College of Paediatrics and Child Health's curriculum, trainees must develop expertise in clinical skills and procedures, adapting to patient needs and emergencies. Key capabilities include assessing patients, performing procedures like venous cannulation and lumbar puncture, and managing airway support. The curriculum emphasizes flexibility, mentoring, and continuous skill development at both core and specialty levels.
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Presentation Transcript
Domain 3: Clinical Procedures The Royal College of Paediatrics and Child Health is a registered charity in England and Wales (1057744) and in Scotland (SCO38299).
Curriculum overview Structural changes Reduction in the overall indicative length of training from eight to seven years. Change to two training levels 1. Core Level Paediatrics (Year 1-4) 2. Specialty Level Paediatrics (year 5-7) Changes with a view to improving flexibility: Embedding capability rather than time-based training Removal of the requirement to do six-month blocks (e.g., neonates, community child health). Mapping of similarities between sub-specialties so trainees can change pathway and count capabilities already achieved. Promotion of OOP (out of programme) opportunities
Core Level Curriculum Learning Outcome 3 Doctors at all training levels must develop expertise in clinical skills and procedures, including examinations, while respecting the dignity of babies, children, and young people. Trainees should adapt their approach to meet the needs of patients and their families. They must perform basic paediatric procedures, recognize emergencies, and initiate or escalate life support as needed. By the end of core training, trainees will be proficient in required skills and play a role in mentoring junior staff while maintaining their own competence. Core Learning outcome Key capabilities Performs appropriate clinical assessments of a baby, child and young person. Undertakes key paediatric clinical procedures both elective and emergency, including responding to and leading emergency situations and performing advanced life support, recognising when and how to escalate and adapting clinical assessments to meet the needs of babies, children, young people and families/carers. Demonstrates achievement of both basic and advanced life support skills. Undertakes key procedures, including the following: Peripheral venous cannula, Neonatal umbilical venous catheterisation (UVC), Lumbar puncture, Intraosseous needle insertion for emergency venous access. Confirms the correct placement of arterial and venous lines. Performs advanced paediatric airway support, including airway opening manoeuvres and the use of airway adjuncts to the point of intubation.* * - see notes Demonstrates neonatal Airway maintenance: Airway opening manoeuvres and the use of airway adjuncts (including supraglottic airway) to maintain the airway of a term or preterm baby to the point of intubation.*
Specialty Level Curriculum Learning Outcome 3 The trainee performs all clinical skills that are required in paediatrics with babies, children and young people and confidently teaches these to junior staff. Specialty Learning outcome Key capabilities Teaches, supervises and assesses junior staff undertaking clinical procedures. Manages and co-ordinates the response to an emergency situation. Where defined in the GENERAL PAEDIATRICS/ SUB SPECIALITY syllabus, performs the procedures relevant to that syllabus.* Demonstrates capability in taking consent for genetic and genomic testing applicable to GENERAL PAEDIATRICS / SUB SPECIALITY and discusses the results with children, young people and their families. Capable in the full range of clinical skills relevant within GENERAL PAEDIATRICS/ SUB SPECIALITY, including appropriately co- ordinating the skills of other health professionals, when required. * - see notes
Underpinning knowledge Frameworks and legality of consent. Communications Using medical devices and equipment safely History taking, diagnosis and medical management Procedures Infection control
Procedures Learning to competently and compassionately perform procedures is one of the hardest skills in paediatrics. Acquisition of skills is a continuum from novice to expert. Developing the skills to competently teach as well as perform procedural skills is an important part of training.
Dreyfus Model of Skill Acquisition Adaptability transcends reliance on rules Deep understanding and intuitive grasp of skill Expert/Master Holistic view/perception of goals Prioritization of important aspects Perceives deviations from normal pattern/adapts situation Proficient Advanced planning Copes with multiple activities/information Formulates Routines Competent Advanced Beginner Limited situational awareness Individual steps given equal importance Strict adherence to rules Little situational awareness/discretionary judgment Novice Adapted from Dreyfus and Dreyfus,1980
Things to consider for every procedure Right procedure, place, time and patient. Right people Supervision, Senior help if required, play specialist, assistant. Consent is it needed? Have you informed the parents / patient of the procedure. Check equipment Analgesia/Distraction aids Important blood results e.g. LP check platelets.
How to evidence Directly observed procedures Best done at the time with contemporaneous feedback Skills log Keep a contemporaneous log of skills competence including supervising others Reflective log Part-task simulation and Resuscitation courses Mini-CEX Demonstrating clinical examination of a baby, child or young person or basic resuscitation skills ACAT Observed leading resuscitation in ED/Labour Ward Mini-CEX/CBD For the senior supervising or teaching the procedure
Steps for learning a new procedure Revise relevant clinical knowledge Safe use of equipment Learn the procedural steps Practice outside clinical environment e.g. part task simulation/mannequins Perform supervised procedures with feedback Practice in a variety of different contexts/ situations/age groups Maintain capability
Further practice Preparation, preparation, preparation if your department has an intubation checklist use it. Another great way to get experience is to arrange to shadow an anesthetic colleague. For more advanced airway management you can attend a difficult airway course in your region.
Procedural top-tips Identify what you need to practice - Put yourself forward for procedures to the clinical team coordinator and the procedures you would like to gain competence in Be proactive with learning opportunities e.g. organizing anesthetic room experience for airway management Ask for feedback when leading resuscitation scenarios in ED
Teaching procedural skills Peyton s 4 Stage Approach Stage 1 - Demonstrate The teacher demonstrates the skill in real time e.g. Umbilical line Insertion Stage 2 Deconstruct The teacher performs each step, with added explanation and detail for each sub-section Stage 3 - Comprehension The student describes the steps of the skill and prompts the instructor to perform each stage. Stage 4 - Execution The student performs the skill narrating each step. Adapted from Peyton 1998
Teaching Procedural Skills Kolb s Experiential Learning Concrete Experience e.g. Long Insertion Active Reflective Observation What went well, what could be improved Experimentation Did new technique improve success? Honing skills Abstract Conceptualization How can I apply what I have learned for next time? Adapted from Kolb 1984
Useful training and resources RCPCH Progressing Paediatrics course: Paediatric Emergency Medicine RCPCH How to Manage courses - a sample of forthcoming events shown below: https://www.rcpch.ac.uk/education- careers/courses/rcpch- course?keywords=how+to+manage RCPCH Learning gives you access to quality- assured courses to support your professional development and clinical practice, see link below: https://learning.rcpch.ac.uk/
Useful Websites Resuscitation Council https://www.resus.org.uk Spotting the Sick Child https://spottingthesickchild.com Paediatric Emergencies Great resource with lots of resources and videos for intubation https://www.paediatricemergencies.com The Difficult Airway Society - https://das.uk.com
Useful Websites Paediatric FOAM website useful resources for ventilation management https://www.paediatricfoam.com Cranial Ultrasound Standard Views http://www.adhb.govt.nz/newborn/Teachin gResources/Radiology/HUSS/NeonatalHUSS Views.htm MRCPCH Clinical Examination Website https://mrcpch.paediatrics.co.uk
Useful Videos Great videos and lectures for intubation and management of the sick child https://www.youtube.com/channel/UCULr4Ved30fymSHoxeweJHg Percutaneous Long line insertion from Evelina Children's Hospital Central Line insertion from PICU at GOSH https://www.youtube.com/watch?v=7KjjJVFdbC0 Neonatal Procedures from MPROve https://www.youtube.com/channel/UC22LMIG5Bwqhreic_DFHATw Paediatric Anaestheisa and Airway Management https://www.youtube.com/channel/UC4B28Tt4K6hc4tJ239CLS_Q
Useful Apps Neomate - useful measurements for Endotracheal tube size and length and Umbilical lines: https://www.neomate.co.uk/ https://itunes.apple.com/us/app/neomate- for-nicu-staff/id944319462?mt=8
References Dreyfus SE, Dreyfus HL. A five-stage model of the mental activities involved in directed skill acquisition. California Univ Berkeley Operations Research Center; 1980. Walker M, Peyton JW. Teaching and Learning in Medical Practice. Heronsgate Rickmansworth, Herts: Manticore Europe Ltd; 1998. Teaching in the Theatre; p. 171 180. Kolb D. Experiential education: Experience as the source of learning and development. Englewood Cliffs, NJ. 1984. Harden RM, Laidlaw JM. Essential skills for a medical teacher: an introduction to teaching and learning in medicine: Elsevier Health Sciences; 2016.(3)
