Core competencies for the care of acutely ill and injured children and young people May 2006
Contents Introduction 3 How the competencies can be used 6 Core competencies : Assessment domain 7 Core competencies : Treatment domain 11 Acronyms 14 Annex A Children s version NHS Education for Scotland, 2006 2
Introduction Within a healthcare system inevitably challenged by the demands of adult health needs, particularly in the context of an ageing population, specific and conscious attention needs to be given to ensure that the very different health needs of children and young people are prioritised and addressed. Emergency care of acutely ill or injured children and young people involves a wide range of unscheduled care services offered in hospitals and community. It includes not only specialist emergency services provided by accident and emergency departments in general and paediatric hospitals, but also those offered by minor injuries/illness units, out-of-hours care providers and GP services. The Child Health Support Group (CHSG) i was set up in 2000 with the remit of accessing professional expertise in driving forward improvements in child health and child health services across Scotland. The Group commissioned reports in several key areas, including emergency care. Emergency Care a Consultation on Emergency Care for Ill and Injured Young People in Scotland, prepared by a group chaired by Dr Tom Beattie of the Royal Hospital for Sick Children, Edinburgh, was published in 2004. The report sets out the basis for a national, co-ordinated process through which the care needs of acutely ill or injured children and young people can be identified and addressed. The report clearly recognises that services in Scotland must change to meet the ongoing needs of children and young people. Change must be based on a co-ordinated framework, and the framework should be supported by competency-based education. A tiered framework of education extending from foundation (or core ) level through intermediate to specialist is set out in the Emergency Care report, and an adaptation is illustrated in Figure 1. This document presents the competencies required by practitioners working in settings providing emergency care to acutely ill or injured children and young people at core level. i The CHSG was succeeded by the Children and Young People s Health Support Group (CYPHSG) in 2005 3
Specialist children s hospital Hospital with paediatric in-patient Unit on site Other hospitals with A & E departments Community Hospital Minor Injuries facilities Primary Care Out of Hours services NHS 24 Scottish Ambulance Service Specialist Intermediate Core Figure 1 Mapping of tiered emergency care service provision and education provision for staff The competency framework describes the key areas of assessment and treatment in which practitioners from a variety of health care professional backgrounds providing services to acutely ill or injured children and young people must demonstrate competence. It provides a structure with which: services, organisations, teams and individual practitioners can benchmark their current performance and identify future training needs education providers can design focused curricula practitioners competencies can be maintained and developed over time. Front-line clinical staff should be able to identify a need to achieve proficiency across all domains and competencies set out in the framework. 4
The competency framework has been developed through an inclusive and participative process under the aegis of NHS Education for Scotland. Over 40 professionals across a range of disciplines and specialties who contribute to the development and delivery of emergency care services for children and young people in Scotland attended a two-day workshop at which the domains, draft competency statements and indicators were formulated. A wider national consultation followed, resulting in refinement of the competencies and the framework contained in this document. Children s needs were uppermost in the attentions of the competency developers, and a representation of the key elements of the competencies specifically designed for children is included at Annex A. The illustrations were supplied by Graham Ogilvie. It also reflects and has been heavily influenced by the Skills for Health Emergency Care Competence Framework, particularly EC 7, Assess and Determine the Health Status and Needs of Children or Young People Presenting for Emergency Assistance (Version 5, April 2004). Competency statements from this framework have been instrumental in the development of the competencies set out in this document, which have been developed specifically to match the needs of the Scottish context. The competency framework reflects and complements the vision for paediatric services in Scotland set out in Delivering for Health, the Scottish Executive s policy for the NHS in Scotland. It takes its place as part of a raft of measures focused on making emergency care services for children and young people safer, more co-ordinated, and more clinically effective. 5
How the competencies can be used The competencies have three dimensions: domain the broad area under which relevant competencies are categorised competency the statement of competence to which individuals, teams and services should aspire indicators elements of behaviour and performance against which competency achievement can be benchmarked. The core competencies can be used by: practitioners, to benchmark progress and identify learning needs clinical teams, to identify current strengths and weaknesses service managers, to benchmark individual and team practice educators, to guide course design for the care of acutely ill and injured children and young people. Individuals using the competency documents should: review their experience and practice to date, identifying relevant skills and knowledge appraise themselves against relevant competency statements, identifying those that are not met agree with their manager or supervisor and education provider a programme that meets their learning needs to achieve all competencies relevant to their post and position set goals and an action plan to achieve the desired competencies collect documented evidence of achievement in meeting identified competencies. There will always be debate about the order that the indicators should appear under each competency. The appropriateness of order will be determined by each clinical situation, and as they are sequenced in this document will not necessarily be the order in which they will be executed in practice. 6
Core competencies for the care of acutely ill and injured children and young people Domain Competency Indicators A. Assessment A.1 Assess the child or young person presenting for explain the assessment process to the child or young person and those involved in their care and obtain the necessary agreement and consent ii emergency assistance enable the child or young person and those involved in their care to seek advice and express any concerns about the assessment process ii communicate with and actively listen to the child or young person and those involved in their care in a way that is appropriate to their age, understanding and preference take steps to ensure safety and minimise risks to yourself, the child or young person and others in the immediate environment obtain as much information as possible about the circumstances leading up to the child or young person requiring emergency assistance including any pre-existing conditions that may influence his or her health needs elicit an accurate clinical and social history from the child/young person and or parent/carer ii can differentiate normal and abnormal findings from the clinical examination use discretion and respect throughout the assessment, balancing the rights of the child or young person, their families and with those involved in their care minimise any unnecessary discomfort and encourage the child or young person, and any carer with them, to participate as fully as possible in the process ii While this standard is required to achieve competence it is recognised that there will be situations in which immediate intervention is required, and that this will affect the degree to which the indicator is met. 7
ensure those involved in their care to give appropriate support to the child or young person during the assessment comply with all the relevant legal, professional, and organisational requirements and guidelines maintain contemporaneous full, accurate and legible records of your assessment and make these available for future reference in line with organisational practices. A.2 Assess the clinical signs with regard to ABCD and recognise typical presenting symptoms for children and young people, appropriate to their age and gender Recognition of the seriously ill or injured child or young person Is able to assess: Airway patency Quality of breathing (rate, effort, efficacy) Circulation (pulse rate, peripheral markers of perfusion, skin colour) Disability (level of consciousness- AVPU/paediatric coma scalegeneral demeanour) Ensure life-saving definitive management is performed and appropriate assistance is accessed as soon as possible More general clinical assessment where appropriate measure temperature, blood glucose, blood pressure and perform urinalysis obtain data at appropriate intervals to: provide effective monitoring ensure accurate interpretation of the results enable prompt action to be taken Is able to recognise: pain fever monitor the child or young person s health status for a sufficient 8
A.3 Be aware of red flag iii presentations and initiate timely and appropriate consultation or referral with other health professionals as indicated by the child or young person s needs A.4 Form a judgment as to the health status and needs of the child or young person duration to be satisfied that their condition is safe and stable maintain contemporaneous full, accurate and legible records of your assessment and make these available for future reference in line with organisational practices. demonstrate awareness of limitations in own knowledge and recognise when to refer/consult with other staff is aware of red flag presentations which indicate special clinical risks and require particular clinical responses and/or referral make timely and appropriate referrals recognise promptly any life-threatening or high risk conditions make use of and interpret accurately all of the available information and data develop a judgment which is justifiable given the information and data available at the time with regard to: the health status of the child or young person the implications of any changes in the health status of the child or young person since you have been in attendance the nature, severity and extent of the child s or young person s health needs acknowledge any uncertainties and conflicts in your judgment recognise potential signs of abuse or neglect and report them promptly to the appropriate person, in line with national and organisational policy evaluate the risks to the child or young person based on your iii Red flag or alert presentations are those that should immediately prompt the health care staff to seek advice/consultation. These will be defined on a local, regional or national basis. 9
assessment make full and effective use of any protocols, guidelines and other sources of information and advice to inform your decision making arrive at a judgment as quickly as possible and refer the child or young person on to the appropriate pathway in line with your conclusions seek additional support and advice from other practitioners as necessary maintain contemporaneous full, accurate and legible records of your assessment and make these available for future reference in line with organisational practices. 10
Domain Competency Indicators B. Treatment B.1 Prioritise health problems demonstrate the ability to perform basic life support and intervene appropriately, including responding to initiate appropriate and effective first aid in accordance with recognised training standards unexpected and challenging initiate appropriate immediate management of urgent health problems situations use professional knowledge and skills and assessment tools appropriate to the child/young person s stage of development to facilitate recognition of injury, illness and pain in children and young people demonstrate ability to follow a logical sequence when initiating lifesaving measures alter management in response to changes in the child/young person s condition demonstrate awareness of limitations in own knowledge and recognise when to refer/consult with other staff recognise when further laboratory investigation may be required B.2 Act appropriately to stabilise child or young person following an acute illness or injury take measures to stabilise child or young person within the limits of competence, training and available equipment until appropriate transfer or discharge B.3 Demonstrate the ability to gain appropriate informed consent to treatment and/or investigation show an understanding of the legal definition of consent to treatment and/or investigation (especially in the 10 16 age groups) understand the difference between implied, verbal and written consent identify factors which modify consent in children and young people, such as competence, age and emergency situations understanding of the ethics concerning consent and confidentiality, and 11
B.4 Administer medicines/treatments appropriately and in line with legislation, local policy and professional guidance B.5 Evaluate results of interventions and initiate appropriate changes in the tensions which may exist between a child s or young person s rights, their parent/guardian s rights and the organisation s responsibility to the child or young person show awareness of legal procedures in cases where consent is problematic and has a working knowledge of the relevant mental health legislation demonstrate an ability to fully inform child/young person and parents/carers to meet the legal standard for consent act promptly to provide appropriate interventions, referring to colleagues as necessary and recording interventions given follow policies/protocols/guidance/algorithms/icps use information sources such as Toxbase and British National Formulary for Children as required undergo appropriate training/supervision to enhance practice in administering medicines/treatments accurately records administration of medicines/treatments in accordance with legislation, local policy and professional guidance ensure that any risk in clinical procedures is fully assessed and minimised as part of the decision-making process monitor responses to medicines/treatments and records observations and data appropriately respond promptly and appropriately to complications related to medicines/treatments administration show an awareness of the common types of medication errors and how to prevent them ensure that child/young person and parents/carers are informed of what to expect following an intervention and knows what to do if an adverse outcome occurs 12
treatment plan show awareness of the risks associated with any intervention and outlines actions to be taken to minimise those risks ensure that appropriate changes are instigated in treatment plan or an appropriate referral is made if the outcome deviates from the expected course ensure that appropriate follow-up is provided for child/young person after any intervention B.6 Appropriately delegate aspects of child/young demonstrate understanding of training and roles of practitioners who have different levels of knowledge, skills and competence person s treatment to colleagues ensure that any practitioner who carries out delegated treatment is competent and is authorised to perform such treatment and accepts accountability for his/her performance ensure that any request for delegated treatment is recorded and authorised in line with any local and national policies, and that the treatment given is also properly recorded give appropriate facilitation and supervision where that is part of B.7 Show proficiency in preparing a child or young person for transfer when required delegation role prepare child or young person for transfer physically, emotionally and psychologically, keeping him or her fully informed of developments monitor child or young person s condition pre-transfer and responds appropriately to changes communicate effectively and appropriately (both verbally and written) with the receiving unit about the child or young person s condition and needs keep family/carers fully informed on progress and developments regarding the transfer organise transport as appropriate and utilise proper documentation 13
ACRONYMS AVPU ICP Awake/alert Verbal Pain Unresponsive Integrated Care Pathways 14
ANNEXE A 15