The Medical School Clinical Skills Assessment Criteria and Guidance Notes for Completion of the elogbook September 2014
Contents Skill Page Guidance for clinical skills assessments and completion of the 3 elogbook Abridged guidance notes for assessors in clinical practice 8 Clinical Skills Assessment Criteria: 9 1 Assessing vital signs - measuring body temperature 9 2 Assessing vital signs - measuring blood pressure, pulse rate and respiratory 9 rate 3 Transcutaneous monitoring of oxygen saturation 9 4 Venepuncture 10 5 Managing blood samples correctly 10 6 Taking blood cultures 11 7 Measuring blood glucose 12 8 Managing an electrocardiograph (ECG) monitor 13 9 Performing a 12 lead electrocardiograph 14 10 Basic respiratory function tests 15 11 Urinalysis using Multistix 16 12 Advising patients on how to collect a mid stream urine specimen 17 13 Taking nose, throat and skin swabs 18 14 Nutritional assessment 19 15 Pregnancy testing 20 16 Administering oxygen 21 17a Establishing peripheral intravenous access 22 17b Setting up an infusion 23 18 Making up drugs for parenteral administration 24 19 Dosage and administration of insulin and use of sliding scales 25 20 Subcutaneous and intramuscular injection 26 21 Administering a blood transfusion 27 22 Male and female urethral catheterisation 29 23 Instructing patients in the use of devices for inhaled medication 31 24 Use of local anaesthetics 33 25 Skin suturing 34 26 Wound care and basic wound dressing 35 27 Correct technique for moving and handling including patients 36 28 Obtaining informed consent 37 29 Hand washing (including surgical scrubbing up) 38 30 Use of personal protective equipment (gloves, gowns, masks) 40 31 Infection control in relation to procedures 40 32 Safe disposal of clinical waste, needles and other sharps 40 33 Arterial blood gas sampling 41 Appendix A: Schedule of teaching and assessment 42 Appendix B: Categorisation of clinical skills according to risk 49 Appendix C: Levels of supervision required for practice of clinical 51 skills in the clinical environment 2
Guidance for Clinical Skills Assessments and Completion of the elogbook In Tomorrow s Doctors (2009), the General Medical Council (GMC) have specified thirty-two diagnostic/procedural skills that all medical students must be able to perform competently in order to graduate with a medical degree (General Medical Council. Tomorrow s Doctors 2009; 77-81). In consultation with specialists in each subject area, the Academic Unit of Medical Education, University of Sheffield developed a Clinical Skills Logbook that will act as a record of the training received and assessments undertaken by students in relation to these clinical skills. Teaching and assessment of clinical skills will take place throughout all Phases of the course and the format this will take varies according to the clinical skill. For example, some skills have a large theoretical element to them and this may be taught in a mandatory lecture or small group tutorial and be followed by an online assessment of knowledge, accessed by the student via Minerva and marked electronically. For many of the practical skills, however, there will be small group teaching in simulation at the clinical skills centre, followed by an assessment in simulation under examination conditions. In the clinical phases of the course (Phase 2b onwards), and only following satisfactory completion of the relevant assessments in simulation, students will then be allowed to undertake these skills with patients under strict supervision in the clinical environment. This will be followed by one or more assessments of a student s competence in performing each skill in clinical practice. For some skills, students will be required to undergo a further assessment in clinical practice during Phase 4, in order to demonstrate sustained competence at the point of graduation from Medical School. These assessments are Mastery assessments i.e. students are required to achieve a competent standard of performance in all of the skills prior to graduation. Whilst students will not be permitted to graduate with the MBChB until all skills have been signed-off, there is no pre-determined limit to the number of assessments that a student may undergo. Remedial teaching will be provided where needed to help students achieve the required standard of performance and further assessments will be arranged. It should be noted, however, that students failing to achieve competence in all of the skills, despite remedial teaching, will not be permitted to graduate. These clinical skills assessments are not summative assessments and do not contribute to ranking criteria for Foundation Programme applications. Arterial blood gas sampling is considered by the Medical School to be an important skill for graduating students and will be taught and formally assessed in addition to the 32 skills specified by the GMC. There are also many other clinical skills which students may encounter during their clinical training and be expected to acquire, but these are currently not subject to assessment within the logbook. 3
Teaching and assessment in simulation The schedule of teaching and assessment during the MBChB course is attached as Appendix A. Please note that this may be subject to alteration by the School and students should ensure that they consult Minerva for up to date information. Attendance at all teaching is mandatory and a register of attendance will be taken. For clinical skills teaching and assessments organised by the Medical School, a timetable will be provided on Minerva listing the date, time and venue. Teaching and assessments will also be arranged during clinical placements within Sheffield Teaching Hospitals (STH) and the Associate Teaching Hospitals (ATHs) and students will be notified of these by the hospital s Undergraduate Co-coordinator, either directly or via Minerva. Students should access Minerva once daily to determine whether any teaching or assessment schedules have been added. Assessments in simulation will be carried out by clinical skills educators from the Medical School, STH and the ATHs and by clinical and academic members of staff from the Medical School, STH and ATHs. Students must make every effort to attend assessments on the dates and times given. If a student is unable to attend, they must notify the appropriate person immediately (e.g. The Academic Lead, Clinical Skills Centre Manager, Undergraduate Co-ordinator) so that an alternative assessment date can be arranged. Students must also notify the relevant Phase Administrator and submit a special circumstances form explaining their absence together with appropriate medical evidence (e.g. doctor s letter). Supervised practice and assessment in the clinical environment Prior to performing any skill in clinical practice, a student must have received the necessary training. For those skills requiring an assessment in simulation, a student must have been signed off as having performed the skill competently in simulation, before being permitted to perform the skill under supervision in the clinical environment. The level of supervision required for each skill in clinical practice is determined by the level of risk that the performance of that skill may pose to the patient, staff and/or student if performed incorrectly. Appendix B categorises clinical skills according to the level of risk and Appendix C details the level of supervision that medical students performing each clinical skill must have. Students must never carry out any clinical procedures with patients without appropriate supervision. Assessments in clinical practice will take place during clinical placements from Phase 2b onwards. The suggested timing of these assessments in relation to the course is detailed in Appendix A, and it is anticipated that the majority of students will complete their assessments within this time frame. However, some students will take longer to achieve competence and the time frame for assessments in some skills will need to be lengthened accordingly. The suggested timings of assessments in clinical practice (Appendix A) indicate where the opportunities are most likely to exist for you to carry out a clinical skill in practice and to be assessed following adequate supervised practice. 4
Some hospital trusts will provide students with lists of approved assessors for each skill, and in other trusts, students will be required to identify and approach suitable assessors themselves. Assessors must be able to competently perform the procedure themselves. Hospital doctors from Foundation Year 2 through to Consultant, General Practitioners, Specialist Nurses, Allied Healthcare Professionals, Nurse Practitioners and Nursing Staff/Health Care Assistants with specialised skills (e.g. HCA s working in the vascular access team) may assess students. F1 doctors should not perform these assessments as they are not fully-registered practitioners. During clinical practice, if multiple assessments of a skill are required, students should be assessed by different persons for each episode wherever practicable. The Clinical Skills Assessment Criteria are contained within this handbook. They are also available for students to download via the Clinical Skills elogbook link on Minerva. The assessment criteria are not intended to be used as a teaching manual. Instead, the contents are intended to support and complement current clinical skills teaching and to provide students and assessors with criteria on which to base their assessments. The assessment procedure When performing a procedure, students should not provide a running commentary, but should interact with the simulated or real patient as they would during day-to-day clinical practice. Assessors should not interrupt or prompt, unless patient or student safety is at risk. The student should indicate when they have completed the procedure and the assessor should then state if the student has carried out the procedure competently. The judgement of the assessor is final and should not be challenged by the student. Verbal and/or written feedback will be provided as required. Students who do not meet the required standard will need to undergo further assessment. Students who fail a second assessment in simulation will receive remedial teaching. Formative feedback and opportunities to practice will be provided during the remedial sessions. Following the remediation process, the student will be re-assessed. Repeated failures will result in an Academic Interview, further remediation and an additional opportunity to demonstrate competency. The information listing the venue, time and date of the remedial sessions and re-assessments will be provided on Minerva. Students who fail to demonstrate competency in clinical practice will be offered further teaching and assessment in the clinical environment. However, at the discretion of the assessor, and especially where unsafe practice is observed, students may be referred back to the Clinical Skills Centre for further teaching and assessment in simulation before being permitted to resume supervised practice or undergo further assessment in the clinical environment. 5
Completion of the logbook The Clinical Skills Logbook is an electronic document, accessed via Minerva. Each entry into the logbook will automatically be date-stamped. All assessments should be recorded in the elogbook, including those with unsatisfactory outcomes. Clinical Skills Educators and Phase Administrators will have the facility to sign-off large numbers of students as having attended teaching or having passed assessments. This facility will be used for the majority of teaching and assessment in simulation. Following completion of an assessment in clinical practice, the student will need to make an entry in their elogbook via Minerva and should access this using their own login and password. The student and assessor may choose to log the assessment together or, if internet access is limited, the student may need to obtain the assessor s details and log the entry later themselves. It is mandatory that all sections are completed correctly. Only the professional email address of an assessor will be accepted (e.g. joe.bloggs@sth.nhs.uk or j.bloggs@sheffield.ac.uk). An automated e-mail will be generated to notify the assessor that the assessment has been inserted into the student s elogbook. All assessments in clinical practice should be logged within three days of completion so that assessors will still be able to recall the outcome of the assessment at the time that they receive the automated e- mail. If the assessor receives notice of an assessment that they do not believe to be correct, they will notify either the Phase Administrator in the Medical School or their own hospital s Undergraduate Co-ordinator (who will then notify the Phase Administrator and Academic Lead for Clinical Skills) immediately. If a student encounters any difficulty whilst completing the elogbook they should get in touch with their Phase Administrator or the Academic Lead for Clinical Skills as soon as possible. End of the year review of all Clinical Skills e-logbooks will be conducted and on rare occasions, the logbook contents may need to be verified and assessors may be contacted by the Medical School to verify the information provided. Competence For the purposes of these assessments, a competent student is one who approaches the task in a professional manner, and performs it safely and effectively, in accordance with the assessment criteria, demonstrating good understanding of the task and good decision-making skills. (Adapted from Harden RM, Crosby JR & Davis MH (1999). An introduction to outcome-based education, Medical Teacher 21(1): 7-14). It is recognised that there are variations in how clinical skills are performed, both regionally and interprofessionally, and therefore minor deviations from the assessment criteria may be accepted at the discretion of the assessor, where they are deemed not to interfere with the safe and effective performance of the skill. It should be noted that the assessor is only required to indicate that the student performed the procedure competently at the time of the assessment. In doing so, they are not making any prediction of future performance. For high-risk skills 6
(Appendix B), multiple assessments are required, and all carry equal weight in the assessment procedure. Evidence of continued practice Completion of the logbook is not a substitute for students own self-directed learning and safe practice. It is essential that students refer to the recommended literature regarding clinical skills and continue to develop their skills in clinical practice. Even after successful completion of assessments in clinical practice, students must provide evidence of continued practice, electronically logging each time they perform a skill in the clinical environment. These logs will be periodically accessed by the students Personal Academic Tutor as part of the student s academic review to ensure that students are engaging in continued practice. Some skills will be assessed in clinical practice relatively early in the course (i.e. in Phase 2b or 3a), and if the skills are not considered to be high-risk, there will be no requirement for a further assessment of competence in Phase 3b or 4 (see Appendix A). In these cases, evidence of continued practice is particularly important and the student s eportfolio log will be formally reviewed and signed-off by a member of the Clinical Skills staff at the end of Phase 3b. A similar procedure will be followed for those skills where the structure and delivery of an assessment in simulation would be essentially identical to that of an assessment in clinical practice (e.g. urinalysis using multistix). In such cases, to reduce the number of assessments required, the assessment will only be conducted in simulation but the student will be required to demonstrate evidence of continued practice via their eportfolio log (see Appendix A). This will be formally reviewed and signed-off by a member of the Clinical Skills staff at the end of Phase 3b. There will also be a final review of all Clinical Skills elogbooks during Phase 4 (prior to the Student Assistantship) to ensure that any clinical skills requiring additional competency sign off have been undertaken successfully and the logbooks are complete prior to graduation. Contact details For all general enquires related to the clinical skills, please contact the Clinical Skills Centre at the Medical School via the following email address clinicalskills@sheffield.ac.uk For all academic matters related to the clinical skills elogbook please contact: Dr. Amir Burney a.burney@sheffield.ac.uk Mr. Martin Hague m.g.hague@sheffield.ac.uk 7
Abridged guidance notes for assessors in clinical practice Students should present this page for assessors to read prior to being assessed in clinical practice. They should also direct the assessor to the page of the handbook containing the relevant assessment criteria. Thank you for agreeing to act as an assessor. The following abridged guidance notes are intended to inform you of the standard of performance required, the conduct of the assessment and the method of completion of the electronic logbook (elogbook). Assessors must be able to competently perform the procedure themselves. Suitable assessors will include doctors from Foundation Year 2 to Consultant, General Practitioners, Allied Healthcare Professionals, Nurse Practitioners, nursing staff/health Care Assistants with specialised skills (e.g. vascular access teams) and suitably-qualified and experienced staff from within the Medical School (e.g. clinical skills tutors). These assessments are Mastery Assessments. You are required to make a judgement of the student s competence when performing this clinical skill. For the purposes of these assessments, a competent student is one who approaches the task in a professional manner, and performs it safely and effectively, in accordance with the assessment criteria, demonstrating good understanding of the task and good decision-making skills. Please note that you are only required to indicate whether the student performed the procedure competently at the time of the assessment. In doing so, you are not making any prediction of future performance. Students will be required to undergo between 1 and 3 assessments of their competence in performing each clinical skill with patients in clinical practice (Appendix A). The number of assessments required is determined by the level of risk that the skill carries to patients if performed incorrectly (Appendix B), with high risk skills requiring multiple assessments, performed by different assessors wherever possible. In such cases, all assessments carry equal weight in the assessment procedure. The assessment criteria you need to apply for each skill are detailed within this handbook. Please refer to the relevant page when conducting your assessment. During the assessment, students should not provide a running commentary when performing the procedure. You should not interrupt or prompt the student, unless patient or student safety is at risk. Once the student has finished, you should indicate if the procedure was carried out competently and provide verbal feedback as appropriate. Following completion of an assessment (satisfactory or otherwise), the student will need to complete the relevant sections of the Clinical Skills elogbook on Minerva, the School s Managed Learning Environment. They will need your full name, job title and NHS/University e-mail address. An automated e-mail will be sent to you stating the student s name, and the date and outcome of the assessment. If you receive an email containing details that you believe to be incorrect, you should contact your hospital s Undergraduate Co-ordinator as soon as possible. If you have concerns about a student s performance in clinical practice, and especially where unsafe practice is observed, you may refer the student back to the Clinical Skills Centre for further teaching and assessment in simulation, prior to them being permitted to undergo further supervised practice and assessment in the clinical environment. 8
Clinical skills (1), (2) and (3): Measuring body temperature, blood pressure, pulse, respiratory rate and oxygen saturation using manual techniques and automated electronic devices a) Gathers relevant equipment b) Introduces self c) Identifies the patient d) Explanation and rationale e) Gains consent Preparation of equipment/patient to include a) Demonstrates correct technique for hand washing b) Asks a series of pre-assessment questions c) Asks the patient to roll up their sleeve d) Supports the arm so that the upper arm is at the level of the heart Performance of Blood Pressure to include: a) Places the cuff 2cm above the antecubital fossa b) Inflates the cuff and obtains an estimated systolic pressure whilst palpating the radial pulse. Then deflates the cuff c) Correctly places the stethoscope over the brachial artery d) Re-inflates the cuff between 10 30 above the estimated systolic then, whilst auscultating the brachial artery, deflates the cuff at a rate of 2mm/Hg/second to obtain the systolic and diastolic pressure readings Performance of radial pulse to include: a) Locates the radial artery b) Palpates the radial artery for a minimum of 15 seconds Performance of respiratory rate a) Whilst appearing to the patient to be palpating the radial pulse, counts the respiratory rate for a minimum of 15 seconds Performance of body temperature to include: a) Places a disposable cover on the thermometer probe b) Inserts the probe gently into the ear canal at the correct angle for accurate measurement c) Activates and waits for signal before removing the thermometer and reading the result Performance of blood pressure using a Dynamap to include: a) Collects the relevant equipment b) Places the cuff in the correct position on the arm c) Operates the equipment as per guidelines d) Obtains the blood pressure reading Oxygen saturation measurement to include a) Correctly attaches the saturation probe on patient s finger b) Observes and notes the correct oxygen saturation Completes relevant documentation correctly, accurately recording findings 9
Clinical skills (4) and (5): Venepuncture and managing blood samples a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent Preparation of equipment/patient to include a) Demonstrates good hand washing technique b) Dons gloves and apron c) Positions patient comfortably with elbow extended and supported d) Assesses arm and checks for any local contraindications e) Applies tourniquet approximately 5cm above the antecubital fossa f) Identifies suitable site by inspection and palpation Performance of task to include: a) Cleans the site as per local policy b) Attaches needle to needle holder c) Inserts needle confidently, in-line with vein, bevel up, and at an angle no greater than 45 degrees. Adjusts position of needle until sited intravenously d) Secures and maintains position of needle whilst inserting blood tube and waits sufficient time for the blood tube to fill fully, then removes blood tube e) Releases tourniquet before removing the needle. Removes needle in a single smooth movement, immediately applies pressure with cotton wool and disposes of sharps into a sharps bin f) Labels the blood sample correctly g) Completes laboratory request forms correctly h) Checks patient s welfare and applies a suitable dressing, checking for any known allergies i) Removes gloves and apron and washes hands Documents the procedure in the patient s medical notes 10
Clinical skill (6): Taking blood cultures a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent Preparation of equipment/patient to include: a) Demonstrates good hand washing technique b) Dons gloves and apron c) Positions patient comfortably with elbow extended and supported with a pillow d) Assesses arm and checks for any local contraindications e) Applies tourniquet approximately 5cm above the antecubital fossa f) Identifies suitable site by inspection and palpation Performance of task to include: a) Cleans the site as per local policy b) Assembles equipment appropriately c) Inserts needle confidently, in-line with vein, bevel up, and at an angle no greater than 45 degrees. Adjusts position of needle until sited intravenously. d) Secures and maintains position of needle whilst filling the blood culture bottles in the right order e) Releases tourniquet before removing the needle. Removes needle in a single smooth movement, immediately applies pressure with cotton wool and disposes of sharps into a sharps bin f) Labels the blood sample bottles correctly g) Completes the laboratory request form correctly h) Checks patient s welfare and applies a suitable dressing, checking for any known allergies i) Removes gloves and apron and washes hands Documents the procedure in the patient s medical notes 11
Clinical skill (7): Blood glucose testing a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent Preparation of equipment/patient to include a) Demonstrates correct technique for hand washing b) Dons gloves and apron c) Positions patient s hand in a comfortable position d) Indentifies suitable puncture site on either 3 rd, 4 th or 5 th finger Collection of the sample: a) Holds side of finger firmly, releases needle from sheath, punctures previously identified site b) Applies gentle pressure to digit to obtain sufficient size drop of blood and applies to the test strip c) Inserts the test strip in to the machine and waits for reading d) Disposes of needle/lancet into the sharps bin e) Reads the result on the display screen and passes the information onto the patient. f) Removes gloves and apron and washes hands g) Checks patient s welfare Documents the procedure and results in the patient s medical notes 12
Clinical skill (8): Managing an Electrocardiograph (ECG) Monitor a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent Preparation of equipment/patient to include a) Demonstrates correct technique for hand washing b) Prepares the patient appropriately, including shaving electrode sites on male patients chest if necessary c) Applies electrodes to the correct areas of the chest d) Correctly attaches the cardiac monitor leads to the electrodes e) Switches on the cardiac monitor and sets the alarms within the parameters f) Checks patient s welfare Documents the procedure in the patient s medical notes 13
Clinical skill (9a): Performing a 12 lead electrocardiograph (ECG) a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent Preparation of equipment/patient to include a) Demonstrates the correct hand washing procedure b) Prepares and positions the patient appropriately, adequately exposing chest, arms and lower legs and offering to clean/shave electrode sites as required c) Correctly attaches limb electrodes and ensures good skin contact: Green = left leg; Yellow = left arm; Red = right arm; Black = right leg d) Correctly attaches chest electrodes and ensures good skin contact: V1 = 4 th intercostal space, right sternal border V2 = 4 th intercostal space, left sternal border V3 = half-way between V2 and V4 V4 = 5 th intercostal space, mid-clavicular line V5 = anterior axillary line at the same horizontal level as V4 V6 = mid-axillary line at the same horizontal level as V4+ V5 e) Asks the patient to lie still without talking f) Ensures that the machine is calibrated to the correct settings g) Records the ECG and checks for artifact. Repeats recording if needed. h) Removes leads and electrodes carefully i) Correctly labels ECG with patient details and time and date j) Checks patient s welfare Documents the procedure in the patient s medical notes Please Note: Clinical Skill (9b): Interpreting a 12 Lead ECG You will need to complete an online questionnaire on Interpreting a 12 Lead ECG by the end of Phase 2a. The online questionnaire is available on the Clinical Skills home page which can be accessed via MINERVA. 14
Clinical skill (10): Basic respiratory function tests - PEAK EXPIRATORY FLOW a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent Performance of the task - to include a) Demonstrates technique correctly to the patient, including: setting the pointer to zero, sitting upright, holding the meter horizontally without impeding the movement of the pointer, taking a deep breath, forming a tight seal around mouthpiece and producing a short, sharp expiration of air b) Checks patient s technique c) Instructs the patient to repeat twice more and records the highest value d) Records the results on an appropriate chart Documents the procedure and result in the patient s medical notes SPIROMETRY a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent Performance of the task to include: a) Demonstrates technique correctly to the patient, including: Sitting upright, taking a deep breath, forming a tight seal around the mouthpiece, blowing out as hard and fast as possible for at least 6 seconds b) Checks patient s technique c) Instructs the patient to repeat twice more, resting for at least 30 seconds between each attempt d) Correctly records highest values obtained from 3 attempts Checks patient s welfare Documents the procedure and result in the patient s medical notes 15
Clinical skill (11): Urinalysis using Multistix a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent Performance of the task - to include: a) Demonstrates correct hand washing technique b) Dons a pair of non-sterile gloves c) Asks the patient to provide a fresh urine sample d) Dips the reagent strip in the urine and removes immediately e) Waits the required time interval before reading the strip against the test chart f) Correctly disposes of the urine and sample bottle Documents the procedure and result in the patient s medical notes 16
Clinical skill (12): Advising patients on how to collect a mid stream urine specimen a) Introduces self b) Identifies patient c) Explanation and rationale d) Gains consent Performance of the task - to include informing the patient that they should: a) wear non-sterile gloves b) clean their urethral meatus with soap and water (but not disinfectant) c) pass the first and last part of the urine stream into the toilet and catch the middle part of the stream in a sterile container d) not touch the inside of the container Documents the procedure in the patient s medical notes 17
Clinical skill (13): Taking nose, throat and skin swabs a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent f) Demonstrates correct hand washing technique g) Dons a pair of non sterile gloves Nose swab to include: a) Moistens the swab with sterile water b) Rotates the swab on the mucosa of the anterior nares (nostril), moving in a direction toward the tip of the nose c) Places the swab into the specimen tube and completes the documentation on the tube Throat swab to include: a) Positions the patient facing a strong light source b) Depresses the tongue with a spatula c) Rubs the swab over the tonsillar fossa and any other area with a lesion or visible exudate d) Places the swab into the specimen tube and completes the documentation on the tube Wound swab to include: a) Gently rotates the swab on the wound area before cleaning b) Places the swab in its specimen tube and completes the documentation on the tube Skin swab for MRSA Screening to include: a) Without cleaning the area and using the same swab for both sides of the groin area, gently rotates the swab in relevant area b) Places the swab in its specimen tube and completes the documentation on the tube Checks patient s welfare Documents the procedure in the patient s medical notes 18
Clinical skill (14): Nutritional assessment The MUST (Malnutrition Universal Screening Tool) chart, BMI chart and weight loss table are required for this particular assessment. These can be accessed via the link below: http://www.bapen.org.uk/must_tool.html a) Introduces self b) Identifies patient c) Explanation and rationale d) Gains consent e) Makes sure that they have the MUST chart. BMI chart and weight loss table Performance of the task a) Obtains the patient s height and weight (either by direct measurement or from patient s notes) and calculates patient s body mass index (BMI) using the appropriate BMI chart b) Asks the patient a series of questions regarding unplanned weight loss during the past 3-6 months Loose fitting clothes and/or jewellery? Reduction in appetite? Problems eating, drinking or swallowing? c) Asks the patient about any relevant medical condition that may cause weight loss d) Notes the percentage weight loss and identifies the correct score using the appropriate weight loss chart e) Establishes if the patient is acutely ill f) Establishes if there has been no nutritional intake for >5 days or if it is likely that there will be no nutritional intake for >5 days g) Calculates the overall risk of malnutrition using the MUST chart h) Indentifies the appropriate care plan and documents the findings in the patient s medical notes Documents the procedure in the patient s medical notes Please Note Nutritional Assessment can be performed with any patient who is admitted to the hospital. You can be assessed by a dietician or any other suitably experienced and qualified staff member on the ward, for example a ward sister, staff nurse, Foundation doctor (F2), etc. The MUST (Malnutrition Universal Screening Tool) chart, BMI chart and weight loss table are required for this particular assessment and can be accessed via the link mentioned above. Print a copy of the MUST tool as you will need it during the assessment. 19
Clinical skill (15): Pregnancy testing a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent Performance of task a) Demonstrates correct hand washing technique b) Dons a pair of non-sterile gloves c) Obtains a specimen of fresh urine from patient d) Dips the absorbent tip of the cassette test into the sample of urine OR uses the pipette to obtain a measured amount of urine and adds to the specified test window of the palette e) Checks that the control window indicates a control line and waits for the required time interval before reading the results/test window f) Reads and interprets result accurately g) Checks patient s welfare Documents the procedure in the patient s medical notes 20
Clinical skill (16): Administering oxygen This assessment will test the student s ability to identify the most appropriate oxygen therapy for a clinical scenario / patient, select and assemble the relevant equipment, prescribe oxygen correctly and commence the prescribed oxygen therapy. a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent Performance of task a) Demonstrates correct hand washing technique b) Identifies the most appropriate mask, oxygen percentage and oxygen flow c) Prescribes the oxygen correctly as per local guidelines d) Assembles the equipment correctly e) Switches the oxygen on prior to applying the mask then applies the mask correctly to the patient f) Checks patient s welfare Documents the procedure in the patient s medical notes Gives clear instructions for monitoring the patient s response Target saturation range Monitoring with pulse oximetry Obtain arterial blood gas sample within the hour 21
Clinical skill (17a): Establishing peripheral intravenous access a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent Performance of task a) Positions and exposes the arm b) Assesses the arm, checking for any local contraindications and identifies a suitable vein (avoiding the antecubital fossa and wrist, if possible) c) Demonstrates correct hand washing technique d) Dons a pair of non-sterile gloves e) Applies tourniquet and rechecks the vein f) Cleans the site g) Ensures the patient is ready to proceed and explains to them what they might feel (slight scratch) h) Removes the equipment from the packaging using a no touch technique i) Stretches the skin and inserts the needle, bevel upwards, in line with the vein at an angle of no more than 45 degrees j) Advances needle until a flashback of blood appears in the hub of the cannula k) Following initial flashback lowers the angle, slightly withdraws the needle from the cannula and advances the cannula into the vein l) Releases tourniquet m) Elevates the arm and applies proximal pressure then removes the needle from the cannula n) Discards the needle into a sharps bin o) Replaces the end of the cannula with a suitable bung p) Secures the cannula with a suitable dressing q) Flushes the cannula with saline r) Checks patient s welfare Documents the procedure in the patient s medical notes 22
Clinical skill (17b): Setting up an infusion a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent Performance of task a) Asks the patient if they have any known drug allergies b) Checks the patient s drug chart to establish the fluid to be infused, volume, rate, time and date, validity of chart c) Collects the fluid and checks it against the prescription chart d) Checks the expiry date of the fluid e) Demonstrates correct handwashing technique f) Dons gloves (as per local policy) g) Removes the seal of the infusion bag entry port aseptically h) Opens the iv administration set ( giving set ) aseptically, closes the roller clamp and spikes the infusion bag entry port aseptically i) Half-fills the drip chamber with fluid j) Opens the roller clamp and aseptically primes the line, expelling any air bubbles k) Replaces the cover on the distal end of the giving set to maintain asepsis until connection to the cannula l) Cleans bung and ensures patency of the cannula using a flush m) Cleans bung,connects giving set to the cannula and commences infusion at correct rate n) Checks patient s welfare Completes the relevant documentation Clinical skills (17c) and (17d): Use of infusion devices and choice of infusion fluids Knowledge and understanding of the principles involved will be assessed as part of a discussion with an anaesthetist or relevant specialist e.g. specialist nurse on ITU/critical care etc. You will need to organise a mutually convenient time and date with an anaesthetist or relevant specialist to discuss your understanding on use of infusion devices and choice of infusion fluids. 23
Clinical skill (18): Making up drugs for parenteral administration a) Introduces self b) Identifies patient c) Explanation and rationale d) Gains consent e) Gathers relevant equipment Performance of task a) Asks the patient if they have any known drug allergies b) Checks the patient s drug chart to establish the drug, dosage, time and date, route, diluents and validity of chart c) Collects the drug and checks it against the prescription chart d) Checks the expiry date of the drug e) Demonstrates correct handwashing technique f) Dons gloves (as per local policy) g) Opens the equipment (as per local policy) h) Using an appropriately-sized syringe and needle, draws up the diluent i) Removes the protective cap from the vial and cleans the injectable bung with appropriate swab (as per local policy) j) Injects the diluent into the vial k) Whilst keeping the needle in the vial, and the syringe attached, releases the plunger to allow the syringe to fill with air from the vial and equalize the pressure between the vial and syringe l) Gently mixes the powder and diluent m) Once the powder has dissolved, injects all of the air in the syringe back into the vial to increase the pressure n) Inverts the syringe, needle and vial so that the vial is uppermost o) Releases the plunger, keeping the bevel of the needle within the solution p) Allows the syringe to fill and ensures that all of the solution has been drawn up into the syringe q) Removes the syringe and needle from the vial and caps off the syringe (as per local policy) r) Discards sharps safely Completes the relevant documentation 24
Clinical skill (19): Dosage and administration of insulin and use of sliding scales Knowledge will be assessed using an online assessment which can be accessed via Minerva. The online assessment is available on the Clinical Skills home page. Please Note The online assessment should be completed by the end of Phase 3b. Prior to starting the online assessment you will need to ensure that you are connected to a printer. Once you have successfully completed the assessment you will need to print out two copies of the completion certificate. Kindly submit one copy at the Medical School with the Phase 3b administrators and keep one copy for your record. You won t be able to save a copy on your desktop/laptop. Please inform the Academic Lead for Clinical Skills once you have completed the online assessment at the following email address: clinicalskills@sheffield.ac.uk The assessment will then be uploaded by the clinical skills team in your respective clinical skills elogbooks. 25
Clinical skill (20) Subcutaneous and intramuscular injection a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent Performance of task a) Asks the patient if they have any known drug allergies b) Checks the patient s drug chart to establish the drug, dosage, time and date, route and validity of chart c) Collects the drug and checks it against the prescription chart d) Checks the expiry date of the drug e) Draws up the drug correctly f) Demonstrates the correct handwashing technique g) Dons a pair of non-sterile gloves h) Correctly positions the patient i) Identifies a suitable site j) Cleans the area as per local policy and allows the area to dry SUBCUTANEOUS INJECTION a) Pinches the skin around the chosen site with thumb and forefinger b) Holds needle and syringe at 45 to the skin surface (insulin injection 90 ) c) Informs patient what they may feel (sharp scratch) d) Inserts needle into the subcuticular layer and releases grasped skin e) Gives medication slowly but continuously f) Once all of the medication is administered, removes the needle and syringe and disposes of it safely into a sharps bin g) Checks puncture site ensuring there is no bleeding h) Checks patient s welfare INTRAMUSCULAR INJECTION a) Stretches the skin around the chosen site b) Holds needle and syringe at 90 to the skin surface c) Informs patient what they may feel (sharp scratch) d) Inserts needle into the muscle, leaving a third of the needle exposed e) Pulls back the plunger to ensure the needle is not within a vessel f) Gives medication slowly but continuously g) Once all of the medication is injected, removes the needle and syringe and disposes of it safely into a sharps bin h) Applies pressure to puncture site with cotton wool until haemostasis occurs. i) Checks patient s welfare Completes the relevant documentation 26
Clinical skill (21) Administering a blood transfusion Initiating the procedure (pre-collection checks) - to include: a) Introduces self b) Identifies patient c) Explanation and rationale d) Gains consent e) Records patient s blood pressure, pulse, respiratory rate, temperature, oxygen saturation f) Checks venous access is available and patent g) Checks blood prescription chart: Date the blood component is to be administered Type of blood component to be administered Any accompanying medication to be administered (e.g. furosemide) Checks that the blood prescription chart is completed correctly h) Requests appropriately trained staff to collect the blood unit Performance of task to include: Bedside Checks (to be carried out together with a second qualified member of staff) a) Patient: Asks the patient to state their name and date of birth. Checks name, date of birth and hospital number on wristband, blood prescription chart and Trust s compatibility label (attached to transfusion bag). b) Blood component: Checks that the blood component matches that prescribed on the blood prescription chart Inspects the bag and its contents visually for leaks, clumping, discolouration, clots, evidence of haemolysis in the plasma or at the red cell-plasma interface c) Compatibility: Checks the patient s blood group on the Trust s compatibility label against the donor s blood group on the compatibility label and against the National Blood Service (NBS) label on the front of the bag Checks that the donation number on the Trust s compatibility label matches the donation number on the NBS blood bag label d) Checks expiry date and time of the unit on the NBS blood bag label Administering the transfusion to include: a) Carries out infection control procedures as per local policy b) Correctly assembles the blood giving set and primes the line c) Connects and secures the giving set and cannula as per local policy d) Administers the transfusion at the rate prescribed Monitoring the patient to include: a) Informs the patient to report any change in their condition to a member of staff. In particular, asks the patient to observe for and report chest or loin pain, feeling unwell, shortness of breath, rash, a restless or anxious feeling, abdominal discomfort, or blood in their urine b) States that the patient should be closely observed for 15 minutes after the start of the transfusion and pulse, respiratory rate, blood pressure and temperature should be recorded 15 minutes after each unit is started and thereafter according to local trust policy. 27
Completes all documentation as per trust policy to include: a) Recording the blood unit number, date and time of transfusion on blood prescription chart b) Signing the prescription chart c) Filing the compatibility report in the patient s notes d) Completing the transfusion label return slip (on the back of the compatibility label) and stating that this will be returned to the blood bank 28
Clinical skill (22a): Urethral Catheterisation (male) a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent f) Checks for any known allergies Performance of task a) Correctly positions the patient b) Demonstrates the correct hand washing technique c) Cleans the trolley and aseptically opens the catheter pack and other equipment. Pours relevant cleaning agent into the receiver d) Dons a pair of sterile gloves e) Drapes a sterile sheet around the penis f) Cleans the penis and pulls back the foreskin to clean around the meatus g) Inserts the nozzle of the anesthetic gel into the urethral opening and squeezes gel into the urethra h) Allows time for the gel to take effect whilst putting on a new pair of sterile gloves i) Uses a piece of gauze to hold the penis in an upright position. j) Advances the catheter tip into the urethra using a no-touch technique until the bifurcation of the catheter reaches the meatus, allowing time to overcome prostatic resistance. k) Inflates balloon with appropriate amount of water (as per the manufacturer s instructions) l) Attaches catheter bag and gently withdraws catheter until the balloon stops further progress m) Ensures that the catheter bag is supported on a stand or is suspended from the side of the bed. n) Repositions the foreskin o) Checks for urine drainage and volume and completes fluid balance chart p) Clears away equipment q) Checks the patient s welfare Documents the procedure in the patient s medical notes 29
Clinical skill (22b): Urethral Catheterisation (female) a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent f) Checks for any known allergies Performance of task a) Correctly positions the patient b) Demonstrates the correct hand washing technique c) Cleans the trolley and aseptically opens the catheter pack and other equipment. Pours relevant cleaning agent into the receiver d) Dons a pair of sterile gloves e) Exposes the patient correctly f) Drapes a sterile sheet across the thighs g) Parts the patient s labia and cleans the vulva h) Inserts the nozzle of the anesthetic gel into the urethra and squeezes gel into the urethra. i) Allows time for the gel to take effect j) Washes hands and dons a new pair of sterile gloves k) Advances the catheter into the urethra, up to the bifurcation using a notouch technique l) Inflates the balloon with an appropriate volume of water (as per the manufacturer s instructions) m) Attaches catheter bag and gently withdraws catheter until the balloon stops further progress n) Ensures that the catheter bag is supported on a stand or is suspended from the side of the bed. o) Checks for urine drainage and volume and completes fluid balance chart p) Clears away equipment q) Checks the patient s welfare Documents the procedure in the patient s medical notes 30
Clinical skill (23a): Instructing patients on the use of inhalers a) Gathers relevant equipment b) Introduces self c) Identifies patient d) Explanation and rationale e) Gains consent Performance of task a) Checks the medication and expiry date against the patient s prescription chart b) Asks the patient if they have any known allergies c) Asks the patient to sit upright d) Instructs the patient to shake the inhaler and remove the cap, then place the correct end into their mouth whilst forming a tight seal around it with their lips e) Instructs the patient to take a deep breath in and simultaneously depress the end of the inhaler to release the medication, then hold their breath for 15 seconds (or as long as they comfortably can) f) Advise the patient that they should wait at least 30 seconds before repeating the process g) Checks patient s welfare Documents the procedure in the patient s medical notes 31