Executive Summary

This briefing document provides a comprehensive guide for Acute Care Common Stem (ACCS) trainees in Emergency Medicine to achieve excellence in the learning outcome of providing safe basic anaesthetic care and procedural sedation. Mastery extends beyond pharmacology to encompass meticulous preparation, environmental optimization, airway stewardship, and human factors. Excellence is defined by proactive preparation, creating a safe environment before the patient is present.

Key principles for safe practice include a profound understanding of sedative agents (Propofol, Ketamine, Midazolam, Fentanyl), their physiological profiles, and potential complications. Adherence to national guidelines, such as those from the Royal College of Emergency Medicine (RCEM) and the Academy of Medical Royal Colleges (AoMRC), is fundamental, treating procedural sedation with the same vigilance as general anaesthesia. The procedural framework is structured into five phases: Knowledge Foundation, Preparation, Execution, RSI Assistance, and Recovery.

Essential steps for every procedure involve a formal airway assessment using the LEMON mnemonic, a thorough equipment check using the SOAP-ME checklist, and a structured team brief. Capnography is mandatory for breath-by-breath ventilation analysis, as pulse oximetry has a significant lag time. Pre-oxygenation via high-flow nasal cannulae (apnoeic oxygenation) is the most critical step to prevent desaturation. Post-procedure, vigilant 1:1 monitoring must continue until the patient returns to their baseline, as a significant number of airway complications occur during recovery. Evidence for this competency is gathered through Direct Observation of Procedural Skills (DOPS), Case-Based Discussions (CbD), simulation, and a comprehensive logbook.

This briefing synthesizes key guidance and curriculum requirements for performing invasive and high-risk procedures within the Emergency Department (ED). The Royal College of Emergency Medicine (RCEM) has issued a Best Practice Guideline (October 2023) to provide pragmatic recommendations for ED clinicians, adapting the national NatSSIPs 2 standards for the unique, time-critical environment of emergency medicine (1).

The core principles for all invasive procedures revolve around a triad of safety checks: obtaining patient consent (or acting in their best interest), independent verification of the procedure site by two practitioners (one of whom must be ST4 or above), and conducting a team brief to ensure all members understand the plan. The use of checklists, such as the modified 'NatSSIPs Eight', is strongly encouraged to ensure auditable compliance and account for significant risks. In time-critical emergencies where full compliance is not possible, clinicians must document their rationale.

In parallel, the RCEM curriculum's Specialty Learning Outcome 6 (SLO6) defines the skillset required for EM physicians to proficiently deliver key life- and limb-saving procedural skills. It outlines a structured progression of learning and entrustment from ACCS to Intermediate and Higher training. Proficiency is developed through a combination of eLearning, simulated practice, and observed clinical performance, with assessment via tools like DOPS and logbooks. This ensures clinicians are prepared for both common and rarely performed critical procedures.

Executive Summary: Transitioning from Exposure to Entrustment

This report details a best-practice, longitudinal roadmap designed for Emergency Medicine (EM) doctors in training to achieve Specialty Learning Outcome (SLO) 6: Deliver Key Procedural Skills, adhering rigorously to the RCEM 2021 curriculum and its assessment frameworks. The foundational strategic shift articulated within the 2021 curriculum is the elevation of assessed quality—measured by the RCEM Universal Entrustment Scale—over mere quantity or procedural volume.[1, 2]The methodology emphasizes the critical need for Simulation-Based Mastery Learning (SBML), formalized through adoption of a systematic progression model such as the OASIS framework, to ensure structured, deliberate practice, the attainment of proficiency milestones, and the integration of crucial non-technical skills.[3, 4] A specific focus is placed on Point of Care Ultrasound (PoCUS), where the curriculum mandates explicit modality sign-offs and clarifies that verified clinical competence (Entrustment Level) is the primary determinant of progression, taking precedence over indicative scan volume.[2] Successful implementation of this roadmap requires strict adherence to assessment protocols, including the correct delineation between technical assessment (Direct Observation of Procedural Skills, DOPS, filed in SLO 6) and cognitive/contextual assessment (Case-based Discussions, CbDs, or Acute Care Assessment Tools, ACATs, filed in SLO 1).[5, 6]