Procedures

Curriculum overview Learning outcome Key capabilities Level 1   Learning outcome Key capabilities Level 1 Adapts clinical examinations to meet the needs of the child and family or carers, undertaking basic paediatric clinical procedures. Recognises emergency situations, knowing when and how to escalate appropriately; initiates basic life support and carries out advanced life support with guidance. Performs appropriate clinical examinations of a baby, child and young person. Demonstrates that they have achieved both basic and advanced life support skills. Undertakes key procedures including the following: Peripheral venous cannula Lumbar puncture Advanced airway support, including tracheal intubation Umbilical venous cannulation Level 2 Supervises and assesses junior staff when undertaking clinical procedures; responds to and leads emergency situations, and performs advanced life support. Ensures the correct placement of arterial and venous access. Supervises and assess junior staff undertaking clinical procedures. Responds to and leads emergency situations, and performs advanced life support. Level 3 Demonstrates competence in the full range of clinical skills relevant within paediatrics and either general paediatrics or their chosen sub-speciality. Utilises the skills of other health professionals when required. Maintains skills at the level of competency.

Underpinning knowledge Procedures Frameworks and legality of consent. Communications Using medical devices and equipment safely Infection control History taking, diagnosis and medical management

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 Advance planning Copes with multiple activities/information Formulates Routines Competent Limited situational awareness Individual steps given equal importance Advanced Beginner Strict adherence to rules Little situational awareness/discretionary judgment Novice As the student becomes more skilled, they depend less on abstract principles and more on concrete experience 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

Example – Advanced Airway Management Revise the relevant clinical knowledge Paediatric airway anatomy, watch some videos to understand clinical anatomy – before you pick up a laryngoscope! Understand the steps of the procedure and be able to safely use the relevant equipment.

Pre-patient training Before you do your first intubation get someone to supervise you using a mannequin and give you feedback on positioning and laryngoscopy technique. A great way to practice basic airway management is on resuscitation courses when you get lots of real time feedback.

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 Sometimes you are in the right place at the right time but to maximise your opportunities to practice procedural skills make sure you identify yourself to the clinical lead/co-ordinator for the day and request to do any procedures that are available.

Teaching procedural skills Peyton’s 4 Stage Approach Stage 4 - Execution The student performs the skill narrating each step. Stage 3 - Comprehension The student describes the steps of the skill and prompts the instructor to perform each stage. Stage 2 – Deconstruct The teacher performs each step, with added explanation and detail for each sub-section Stage 1 - Demonstrate The teacher demonstrates the skill in real time e.g. Umbilical line Insertion Adapted from Peyton 1998

Teaching Procedural Skills Kolb’s Experiential Learning Concrete Experience e.g. Long Insertion Reflective Observation What went well, what could be improved Abstract Conceptualization How can I apply what I have learned for next time? Active Experimentation Did new technique improve success? Honing skills 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

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/TeachingResources/Radiology/HUSS/NeonatalHUSSViews.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://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)