Table 5 EPA – Managing elderly patients following a fall

Justification

Fall injuries are a common and potentially complex presentation in the emergency department. Appropriate management may be particularly critical with elderly patients. Therefore, the ability to conduct an accurate initial assessment of an elderly patient admitted following a fall is important in order to manage patients with potentially complex conditions.

In the emergency department, initial assessment of elderly patients admitted following a fall requires the integration of multiple competencies and the ability to execute these in a busy clinical environment with multiple distractions.

Description

PGY1s must be able to assess, synthesise and prioritise key steps required in managing care of an elderly patient (aged 65 and older) presenting after a fall.

They must have the ability to conduct a patient medical and social history in a timely manner to establish the cause/s of fall, the injuries sustained in fall and the functional and social implications of the fall. They must undertake an appropriate trauma examination, and be able to select, justify and interpret appropriate investigations, and synthesise findings to formulate a working diagnosis. PGY1s must be able to commence initial therapeutic steps within guidelines applicable to the setting where they work.

They must have knowledge of trauma investigations and treatment options relevant to falls generally and to those specific to caring for elderly patients. Their knowledge must incorporate physiology in the context of elderly patients.

Interns must also have the ability to recognise the signs and symptoms of a critically ill patient, and seek supervisory assistance with appropriate urgency.

Link with ACFJD competencies

Clinical management – Safe patient care (Systems); Patient assessment (History and examination; Problem formulation; Investigations; Referral and consultation); Emergencies (Assessment; Prioritisation); Patient management (Management options; Therapeutics; Pain management; Discharge planning)

Communication – Patient interaction (Context; Respect; Meetings with families or carers); Working in teams (Team structure; Case presentation)

Professionalism – Doctor and society (Access to health care; Culture, society and health care; Professional standards); Professional behaviour (Professional responsibility; Time management; Personal well-being)

Skills and procedures – General (Measurement; Interpretation of results); Trauma

Clinical problems and conditions – Neurological; Critical care/Emergency

Required knowledge, skills and attitudes

Knowledge

Demonstrates knowledge of trauma symptoms and management procedures

Demonstrates knowledge of effects of trauma in the elderly patient

Demonstrates knowledge of normal functioning, vital signs, and hemodynamic responses in the elderly patient

Demonstrates knowledge of reasons for relevant investigations and treatment options for elderly patients admitted following a fall

Demonstrates knowledge of interactions between trauma, co-morbidities and pre-morbid conditions

Skills

Recognises signs of critical illness and can ask for help when needed with appropriate urgency

Takes a focused, relevant and succinct patient history (medical and social) in a timely manner

Ascertains cause/s of fall

Performs a relevant and focused trauma assessment

Synthesises information to formulate provisional diagnosis

Performs basic procedural skills (for example, suturing)

Selects, requests and can justify relevant investigations (CT, x-ray)

Interprets relevant investigations (x-ray)

Recognises abnormal results from investigations

Simple pain management within appropriate guidelines for the setting

Formulates and can justify initial management plan, within the context of the patient’s unique social circumstances and co-morbidities/pre-morbid conditions

Presents case clearly and succinctly to senior doctors and other staff

Attitudes

Adheres to professional standards

Aware of own limitations and asks for help appropriately

Respects patient privacy and confidentiality

Treats patients and patients’ family members courteously and respectfully

Respects other health professional team members

Behaves in ways to mitigate the personal health risks of emergency medicine, such as fatigue and stress

Sources of information to assess progress

This EPA is continuously assessed during clinical supervision of PGY1s using direct observation, structured interviewing, case presentation, and multi-source feedback.

Entrustment and supervision scale

Supervision of PGY1s is required with the supervisor present in the emergency department. However, the intensity of supervision varies according to the individual PGY1’s ability to perform the EPA. The 3 levels of decreasing intensity of supervision reflect the levels of entrustment.

Level 1: Direct active – Full supervision at bedside. After the supervisor’s initial assessment of the patient, the PGY1 assesses the patient with regular prompting and feedback from the supervisor.

Level 2: Indirect active – Partial supervision within line of sight. Supervisor pre-prompts PGY1 to assess the patient. The PGY1 reports back his or her assessment of the patient to the supervisor.

Level 3: Passive – Full entrustment with the supervisor present in the emergency department. The supervisor entrusts the PGY1 to initiate assessment of the patient and report back his or her findings with minimal prompting and feedback.

Estimated stage of training when level 3 (Passive) is to be reached

End of the emergency medicine rotation in the first year of GME training

Basis for formal entrustment decisions

The following activity will be entrusted at Level 3 when the supervisor is confident that the PGY1 has the knowledge skills and attitudes to perform the activity at an acceptable standard and that the intern knows when to ask for help in a timely manner.