1. Procedures

2. 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.

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

4. 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.

5. 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

6. 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.

7. 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

8. 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

9. 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.

10. 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.

11. 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.

12. 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.

13. 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

14. 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

15. Useful training and resources
RCPCH Progressing Paediatrics course: Paediatric Emergency Medicine
RCPCH How to Manage courses - a sample of forthcoming events shown below

16. Useful Websites Resuscitation Council https://www.resus.org.uk
Spotting the Sick Child
Paediatric Emergencies – Great resource with lots of resources and videos for intubation
The Difficult Airway Society -

17. Useful Websites
Paediatric FOAM website – useful resources for ventilation management Cranial Ultrasound Standard Views MRCPCH Clinical Examination Website

18. Useful Videos
Great videos and lectures for intubation and management of the sick child
Percutaneous Long line insertion from Evelina Children's Hospital
Central Line insertion from PICU at GOSH
Neonatal Procedures from MPROve
Paediatric Anaestheisa and Airway Management

19. Useful Apps
Neomate – useful measurements for Endotracheal tube size and length and Umbilical lines

20. 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; Teaching in the Theatre; p. 171–180.
Kolb D. Experiential education: Experience as the source of learning and development. Englewood Cliffs, NJ
Harden RM, Laidlaw JM. Essential skills for a medical teacher: an introduction to teaching and learning in medicine: Elsevier Health Sciences; 2016.(3)