Emergency and non-emergency escalations during a remote supervision term
The remote supervisor must be made aware of all emergency situations as soon as practical, particularly as they are still medico-legally responsible for the registrar, as with traditional face-to-face supervision.
Initial management must be appropriate to the situation, and the registrar is expected to follow the local training site emergency and escalation policy. Collegial support in an emergency is different to supervision, and asking for the assistance of other health professionals is essential. Communication with the remote supervisor after an incident is required for debriefing and educational purposes.
In a serious but non-emergency situation, the registrar will discuss concerns with the remote supervisor, and together they can decide on further management. This may involve the onsite supervision team, the RACGP local medical educator or the RACGP regional team.
If at any point throughout the selection process or during the term there are serious safety or other concerns, the registrar will be supported to leave the placement and find alternative arrangements if necessary.
Preparing for emergencies
One of the main concerns of inexperienced doctors going to practise in areas where there is professional isolation is being required to treat a critically unwell patient on their own. The possibility of a poor outcome creates significant anxiety in all of us, but more so in a registrar with less experience. Anxiety can be mitigated, and patient safety improved, with appropriate preparation for such events. This begins during the application process and is reviewed carefully during orientation, involving the local supervision team. It is important that the registrar understands that they are part of a team in these events, and that clinic debriefing procedures are understood and followed.
There are three important aspects of preparing for an emergency clinical scenario:
1. Previous experience of the registrar
The registrar needs emergency training at a level appropriate for the placement, and the supervisor should be aware of gaps in the registrar’s experience from the CRSPP, and additional training organised before the placement begins if this is necessary. When asked to be involved during an initial assessment and management of an acutely unwell patient, the level of assistance required should already be in the supervisor’s mind. The available equipment should also be familiar to the supervisor, so that assistance can be specific to the context.
2. Emergency and escalation pathways
A clear pathway should be established with the onsite team and be documented in the orientation manual of what to do in an emergency or if escalation of a clinical situation is needed. When both doctors are in the clinic in the initial orientation period, there should be a run-through of cardiac, respiratory and trauma scenarios, involving adult and paediatric simulations, preferably with a local health professional who is part of the onsite supervision team also present. This scenario practise should involve a review of the onsite staff’s level of experience, allocation of roles and, in particular, decisions about who should be leading the team. Knowledge of the clinical management required is part of this, but mainly the run-through is about knowing the equipment, who to call, initiating a video link and contacting appropriate specialists for input, as well as contacting the supervisor if appropriate.
If such an incident occurs while the supervisor is offsite and the registrar requires supervision, the best oversight is obtained by having a view of the resuscitation space via a video link. How this is possible in the context should be established during the orientation period and should be one of the initial steps in the emergency and escalation pathway. If communication can also be established with another clinician, such as at the referring emergency department, clinical oversight can be transferred to the senior clinician in that facility.
It is likely that some emergencies will need direct support from the service that will transport the patient or receive the stabilised patient. In these situations, making contact with the supervisor simultaneously may be inappropriate. If this is the case, the supervisor should be contacted as soon as possible after patient stabilisation is achieved, and certainly for debriefing and discussion after the event.
Additional supports could include:
- the closest referral hospital or health service able to continue or escalate care, or able to give verbal advice
- Royal Flying Doctor Service/CareFlight/retrieval services
- district medical officer/remote medical practitioner
- visiting specialists
- a backup supervisor if the remote supervisor is not available
- IT support linked to the health service for the registrar and supervisor for communication issues, remote access and other software and hardware issues
- the regional primary health network or state rural workforce agency
- local HealthPathways web-based portal.
Normally the remote supervisor would not be involved in after hours work. The local referral pathways should be used for emergencies during this time. A clearly defined process will be required for the registrar.
Hospital work needs to be negotiated on a case by case basis.
3. Emergency procedures
There will be situations where a procedure is required as part of an emergency, such as insertion of a chest tube. If an emergency procedure is required as part of treating the acutely unwell patient, the risk assessment filter followed should include the following:
- Is completion essential NOW, before the arrival of an experienced retrieval doctor and additional equipment? Is there time to talk through the details prior to the procedure, or is it time critical requiring real-time teaching?
- What is the registrar’s experience with this procedure? (Do not neglect the experience of a nurse in the clinic. They may have assisted with several such procedures and can perform it or guide the process.)
- What is your experience and competence with the procedure? Are you able to talk through the steps required competently and confidently?
- What is the advice of the specialist or emergency physician who will be managing ongoing care?