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The RACGP Curriculum for Australian General Practice 2016

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Curriculum coverThe complete 2016 Curriculum consists of a number of units in addition to contextual units. All units will be available for download as a PDF shortly.

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Acute serious illness and trauma

Definition

Acute serious illness and traumatic injuries in general practice are conditions that require immediate care to relieve suffering and minimise morbidity and mortality risk. The core skills required for the competent general practice management of acute serious illness and trauma presentations are similar to those required to manage emergency department presentations, including major trauma.

Acute serious illness and trauma can occur in patients of any age. They may involve one or more body systems, and the context of the history may contribute to the required treatment response, for example, the collapsed patient or an accident site.

Acute serious illness can be classified by body systems including cardiovascular, respiratory, gastrointestinal, musculoskeletal, neurological, the immune system, and dermatological and metabolic conditions.

Presentations can also be classed into groups such as paediatric, obstetric, gynaecological, orthopaedic, surgical, general medical, psychiatric, ophthalmologic, eye and ear, and nose.

Traumatic conditions, such as accidents and injury to self and others, can generally be divided according to cause, for example, road trauma, environmental, toxicological, envenomation, assault and occupational injury.

Curriculum in practice

Typical cases that illustrate how the acute serious illness and trauma curriculum applies to general practice include:

  • A friend of Betty, one of your elderly patients with asthma, telephoned saying that 'Betty is having breathing troubles and could you come and see her'. Betty's asthma is usually well controlled and she is up-to-date with her vaccinations, but you know there is a nasty viral respiratory tract infection going around. Her house is only a block away and you have just finished for the morning, so you are able to go straight there. When you arrive, Betty is sitting up in bed, cyanosed and too breathless to speak. Both women are highly anxious. The local ambulance is on another call and a replacement will not arrive for half an hour. You have not brought resuscitation equipment with you, but your doctor's bag is in the car.
  • You are late home from work after a full day and looking forward to dinner and a good night's rest. As you drive past the football oval you see a car has taken the corner too fast and hit a power pole. The left front tyre appears to have run into a ditch, running the car off the road with the car momentarily flipping up against the pole, crushing the cabin area. You pull up behind it with your hazard lights and headlights on to illuminate the scene. You see a terrified primary school-aged child struggling to get out the smashed passenger window. Her mother is unconscious with her head hanging half out the driver's window, resting on the doorsill. There is barely an inch between the side of her head and the crushed roof and it is apparent that at the time of impact she sustained a head injury. She is cyanosed and has an obstructed airway.

Rationale and general practice context

Emergency life-threatening presentations in general practice are uncommon and the presentation of traumatic injuries to general practice has declined with hospital emergency departments being used as the first line of management for physical injuries.1 This creates a professional development challenge because general practitioners need to maintain skill levels for the management of rare life-threatening conditions, as well as for the more common conditions that present to general practice.

General practitioners are more likely to see acute serious illness in the early stages when early recognition of warning signs, early investigation and referral may be life saving. Early treatment and patient education may help prevent disease exacerbations and avoid conditions deteriorating into more serious and potentially life-threatening conditions.

The diagnosis of acute serious illness may be clearer in patients presenting later in the natural history of the condition, but these patients may bypass general practice and go directly to an emergency department.

Trauma due to injury may vary in severity of presentation. Minor trauma such as musculoskeletal injuries and lacerations can be managed in general practice.

As with serious acute illness, patients with major trauma are less likely to present to general practice. They may go straight to an emergency department, although these may be staffed by GPs, especially in smaller or more remote rural hospitals.

General practitioners in rural and remote areas require a higher level of emergency care skills due to lower numbers of GPs, reduced access to specialist services, and the logistic and geographic difficulties of evacuating seriously ill patients. There is also a higher incidence of farming, mining, industrial and motor vehicle accidents, as well as greater access to firearms in isolated areas.

General practitioners may also be required to treat acute conditions outside of the practice or hospital setting, such as a collapse on a street or an accident site.

Acutely ill patients require stabilisation and transfer and admission to an acute care setting. This may involve advocating for the admission of the patient.

Continuity of care for seriously ill patients requires the use of handover skills.

Emergency situations may require GPs to provide clear instructions to staff, take control of situations and demonstrate the ability to lead the general practice or another team. This may occur outside the general practice setting, such as at an accident site, where leadership skills in sometimes chaotic and dangerous settings are critical to effective emergency management.

Personal safety issues for the GP and practice staff are of more concern in emergency situations, such as the management of acute psychiatric conditions, or at the scene of an accident.

General practitioners need to be prepared to manage complex medicolegal and ethical decisions in the acute care setting. These could include the management of the unconscious patient; the patient with impaired ability to give informed consent when ill; next-of-kin issues; and being sensitive to patient and next-of-kin choices, which may not accord with best possible treatment outcomes.

General practices also need to be able to prioritise patients according to treatment urgency. Within the context of regular general practice appointment systems, this will require the time management and organisational skills of both the GP and the general practice systems.

Acute serious illness may occur outside of usual practice hours. General practitioners require skills in after hours care, including telephone triage, to ensure that patients have access to appropriate levels of care.

The management of acute serious conditions has the potential to cause fear, fatigue and stress, and may be a significant risk to the doctor's own health. It may also impair clinical performance.

General practitioners need to ensure they have self care strategies in place to prevent and manage work related stress. They may also need to provide care for practice staff and others affected by emergency and acute care settings.

Related Curriculum areas

Acute serious illness and trauma can occur in any medical specialty area, although there is a common set of management skills required in managing any emergency situation.

For specific areas consult other curriculum statements including:

Training Outcome of the five domains of general practice

1. Communication skills and the patient-doctor relationship

ACUT1.1

Communicate clearly with patients and their carers when managing acute illness and trauma.

ACUT1.2

Communicate sensitively with distressed patients and carers to allay anxiety during times of crises, especially in potentially life-threatening situations.

ACUT1.3

Manage unconscious or severely ill patients when they have an impaired ability to provide informed consent.

ACUT1.4

Communicate sensitively and with empathy when breaking bad news to patients and carers in times of bereavement, for issues around certifying death, and coroner and police involvement.

ACUT1.5

Use appropriate telephone triage communication skills when providing emergency care including out-of-hours care.

2. Applied professional knowledge and skills

ACUT2.1

Diagnose and immediately manage the range of life-threatening and emergency medical, surgical and psychiatric conditions occurring in the general practice setting.

ACUT2.2

Recognise and evaluate acutely ill adults and children, and identify those patients who require immediate resuscitation and transfer to acute care settings.

ACUT2.3

Provide the appropriate level of care when transferring severely ill patients from the general practice to the acute care setting.

ACUT2.4

Identify which patients are more likely to become progressively ill, and provide management advice, including 'safety netting' and how to access care if their condition deteriorates.

ACUT2.5

Use time management skills to prioritise patients according to the seriousness of the patient's condition.

ACUT2.6

Maintain skill levels for the management of acute serious illness and trauma in the general practice setting, including those that are not common.

ACUT2.7

Have the necessary skills to provide out-of-hours management of acute serious illness and trauma, which may occur when the practice is closed.

ACUT2.8

Have an appropriate higher level of emergency general practice skills in particular settings, such as rural and remote areas.

ACUT2.9

Diagnose cause of and certify death in a patient.

ACUT2.10

Manage manipulative patients who request inappropriate emergency treatment.

3. Population health and the context of general practice

ACUT3.1

Understand the range of presentations necessary to be able to identify and manage acute illness and identify potentially life-threatening situations including acute illness and trauma, which are not common in the general practice setting.

ACUT3.2

Incorporate knowledge of cultural, occupational or other factors that may affect management of acute illness and trauma in the general practice setting.

ACUT3.3

Educate patients and carers to help prevent disease exacerbations and the frequency of preventable emergency presentations (eg. the use of asthma medications to prevent asthma attacks, the use of seat belts in cars and not drink-driving).

ACUT3.4

Be aware of the role of carers who may be involved at the time of the acutely ill person's presentation to the general practice, and the potential for conflict between patients and their relatives.

4. Professional and ethical role

ACUT4.1

Respect patient choices and wishes when involved in complex ethical decisions that often occur during the management of acute illness and trauma.

ACUT4.2

Initiate and make decisions regarding acute and emergency care in consultation with colleagues, when necessary.

ACUT4.3

Demonstrate the leadership necessary in times of crises, such as the management of acute illness, including being able to provide clear direction and instruction to general practice staff in the management of acute illness, trauma and crisis situations.

ACUT4.4

Advocate for patients who require admission to referral centres but who have been refused admission and have not yet been assessed by the centre.

ACUT4.5

Ensure that self care strategies are in place to reduce the potential adverse health effects of caring for acutely ill patients and to prevent stress related performance impairment.

ACUT4.6

Intervene and support colleagues who are affected by caring for acutely ill patients, when appropriate.

ACUT4.7

Recognise ethical obligations in assisting in the management of acute illness and trauma, which may take place outside the general practice setting, such as at accident sites or in a patient's home.

5. Organisational and legal dimensions

ACUT5.1

Prioritise patient consultation times according to the severity of the presenting illness, as acute serious conditions and trauma may present at unexpected times.

ACUT5.2

Ensure that triage procedures are in place to ensure that seriously ill patients are seen first, and then managed accordingly in a timely manner.

ACUT5.3

Ensure that clear communication occurs between the GP and other health workers within and outside the practice, for seriously ill patients needing referral and transfer from general practice to the acute care setting and during patient handover.

ACUT5.4

Maintain the appropriate level of care during the transport of a patient from the general practice to the acute care setting.

ACUT5.5

Ensure that acutely ill patients can access appropriate out-of-hours general practice care.

ACUT5.6

Understand the resources required to be able to manage acute illness and trauma that may take place outside the general practice setting (eg. at accident sites or in a patient's home).

ACUT5.7

Assess the potential of serious conditions that present significant personal security risks to self, staff, patients and others (eg. in an acutely disturbed psychiatric patient or at an accident site).

ACUT5.8

Follow patients up after referral to the acute care setting to ensure continuity of care.

ACUT5.9

Ensure appropriate handover procedures occur to ensure continuity of care for acutely ill patients.

ACUT5.10

Exercise legal responsibilities such as using mental health regulations, certifying death or contacting the police and coroner.

ACUT5.11

Exercise appropriate legal responsibilities for sick adults with an impaired ability to give informed consent and the special measures required when obtaining informed consent for treating an ill child.

Learning objectives across the GP professional life

Medical student

1. Communication skills and patient-doctor relationship

ACULM1.1

Describe why a patient centred approach is used in the management of acutely ill patients with diminished capacity for autonomous treatment decisions.

ACULM1.2

Describe how communication in acutely ill patients may be influenced by age and other factors such as gender, ethnicity.

ACULM1.3

Describe the principles involved in breaking bad news to patients and carers.

2. Applied professional knowledge and skills

ACULM2.1

Describe the abnormal physiology and manifestations of critical illness.

ACULM2.2

Identify how an acute illness may be an acute exacerbation of a chronic disease.

ACULM2.3

Discuss the principles of medical triage.

ACULM2.4

Describe why resuscitation may need to precede full assessment.

ACULM2.5

Demonstrate the basic principles of airway management and ventilatory and circulatory support.

ACULM2.6

Describe contemporary practices in basic and advanced life support.

ACULM2.7

Demonstrate cardiopulmonary resuscitation.

ACULM2.8

Describe how to assess patient vital signs.

ACULM2.9

Describe the general clinical presentations of important acute serious illness and trauma.

ACULM2.10

Describe the diagnosis and management of common and important acute serious illness and traumatic conditions including eye problems, chest pain, the collapsed patient, acute abdominal pain, respiratory problems (eg. asthma), major trauma (eg. face and spine), and common fractures (eg. hip fractures in older people, wrist fractures in the young).

ACULM2.11

Demonstrate the safe practice of common clinical skills such as intramuscular injections, blood taking (including blood cultures, preparation of intravenous fluids), use of nebulisers, simple suture and current tetanus recommendations.

3. Population health and the context of general practice

ACULM3.1

Describe the role of general practice in the management of acute illness and traumatic injury.

ACULM3.2

Describe the patterns of presentation and care of acute serious illness and traumatic injury in the Australian healthcare setting.

ACULM3.3

Describe the epidemiology of common presentations of acute serious illness and traumatic injury listed in the previous section: Applied professional knowledge and skills.

4. Professional and ethical role

ACULM4.1

Discuss the impact of clinician fear, fatigue and stress associated with the treatment of seriously ill patients.

ACULM4.2

Describe the personal health risks to doctors providing acute healthcare including personal safety, fatigue and stress, and the potential impact of practitioner impairment on patient health.

ACULM4.3

Describe the professional obligations related to infection control in the acute healthcare setting.

ACULM4.4

Describe the leadership role of clinicians and teamwork in the emergency and acute care setting.

5. Organisational and legal dimensions

ACULM5.1

Discuss the role of informed consent in the treatment of acutely ill patients.

ACULM5.2

Describe processes for obtaining informed consent in acutely ill minors.

ACULM5.3

Describe potential threats to personal safety in the treatment of acutely ill patients.

ACULM5.4

Describe the application of mental health legislation to patients with severe mental illness.

ACULM5.5

Describe the laws that relate to certifying death.

ACULM5.6

Describe mandatory reporting requirements, including when the coroner and police need to be notified in cases of death.

Prevocational doctor

1. Communication skills and patient-doctor relationship

ACULP1.1

Integrate a patient centred approach into the management of acutely ill patients who may have a decreased ability to make autonomous treatment decisions because of their illness.

ACULP1.2

Integrate clear, culturally appropriate communication into the management of patients with acute illness and trauma.

ACULP1.3

Demonstrate how to discuss serious illness and bereavement with patients and their carer, including breaking bad news.

2. Applied professional knowledge and skills

ACULP2.1

Recognise and evaluate acutely ill patients.

ACULP2.2

Identify which acutely ill patients require immediate resuscitation and when to call for assistance.

ACULP2.3

Identify the clinical presentations of important acute serious illness and trauma.

ACULP2.4

Demonstrate the assessment of a sick child.

ACULP2.5

Accurately and efficiently diagnose and manage common and important acute serious illness and traumatic conditions, including eye problems, chest pain and respiratory problems (eg. asthma).

ACULP2.6

Perform and interpret an electrocardiogram.

ACULP2.7

Demonstrate cardiopulmonary resuscitation of children and adults, including the use of a defibrillator.

ACULP2.8

Demonstrate how to control haemorrhage.

ACULP2.9

Demonstrate how to suture a wound.

ACULP2.10

Demonstrate how to use a nebuliser.

ACULP2.11

Demonstrate male and female catheterisation.

ACULP2.12

Demonstrate basic airway management and ventilatory and circulatory support.

ACULP2.13

Diagnose cause of death and write death certificates.

3. Population health and the context of general practice

ACULP3.1

Describe how cultural, occupational or other factors may affect patient management in the acute care setting.

ACULP3.2

Demonstrate the ability to identify conflicts that may exist between patients and their carers, and act in the best interests of the patient.

4. Professional and ethical role

ACULP4.1

Describe ethical complexities of caring for acutely ill patients.

ACULP4.2

Describe the impact of acute illness and trauma on the ability to give informed consent.

ACULP4.3

Participate in decision making and debriefing when ceasing resuscitation.

ACULP4.4

Describe the leadership role that may be required of a doctor in emergency situations.

ACULP4.5

Show an ability to work well within medical teams during emergencies.

ACULP4.6

Outline measures that can be taken to promote clinician self care.

ACULP4.7

Demonstrate how to recognise a clinician in difficulty.

ACULP4.8

Describe how to consult colleagues about ethical concerns.

5. Organisational and legal dimensions

ACULP5.1

Demonstrate accurate note taking and recording in emergency situations.

ACULP5.2

Demonstrate how to give high priority to acutely ill patients.

ACULP5.3

Demonstrate handover procedures for acutely ill patients.

ACULP5.4

Demonstrate the ability to liaise patient care between hospitals and emergency services.

ACULP5.5

Describe the management of the aggressive patient.

ACULP5.6

Outline legal responsibilities regarding death certification, including when to involve the police.

ACULP5.7

Describe how to apply mental health regulations for detaining acutely mentally ill patients.

ACULP5.8

Describe the importance of maintaining or increasing the level of care while transferring the patient to the acute care setting.

Vocational registrar

1. Communication skills and patient-doctor relationship

ACULV1.1

Demonstrate consultation skills appropriate to the management of acute illness and trauma in the general practice setting.

ACULV1.2

Demonstrate clear communication with the patient and their family in the general practice setting during times of crisis.

ACULV1.3

Demonstrate how to triage patients by telephone and decide whether to give telephone advice, arrange to see the patient at an appropriate time, or arrange emergency transfer.

ACULV1.4

Describe how to sensitively communicate to patients and carers in life-threatening situations or at times of bereavement, including issues around certifying death and coroner and police involvement.

2. Applied professional knowledge and skills

ACULV2.1

Demonstrate a range of essential procedures and skills for the management of acute illness and trauma presentations.

ACULV2.2

Demonstrate decision making skills in the effective management of acute illness and trauma presentations.

ACULV2.3

Identify which patients may become acutely ill and give management advice including how to access care if the patient's condition deteriorates.

ACULV2.4

Demonstrate the management of common medical, surgical and psychiatric emergencies in the out-of-hours setting.

ACULV2.5

Describe when resuscitation or intensive care may be inappropriate.

ACULV2.6

Demonstrate the appropriate level of resuscitation and stabilisation required to transfer severely ill patients from the general practice setting to the acute care setting.

ACULV2.7

Demonstrate essential advanced life support skills.

ACULV2.8

Describe procedures for managing manipulative patients to prevent the inappropriate use of healthcare resources.

3. Population health and the context of general practice

ACULV3.1

Demonstrate how to use patient education to help reduce the number and frequency of preventable presentations.

ACULV3.2

Describe the needs of carers involved at the time of the acutely ill person's presentation in the general practice setting.

4. Professional and ethical role

ACULV4.1

Demonstrate an ability to make complex ethical decisions in accordance with a patient's wishes.

ACULV4.2

Demonstrate how to use a team based approach in the management of acute illness in the general practice setting, including how to provide leadership and how to follow instructions.

ACULV4.3

Describe how to act as an advocate for patients who require admission to referral centres but who have been refused admission and have not yet been assessed.

ACULV4.4

Describe the strategies in place to reduce the potential impact of providing acute care on the health of the GP, and how to help prevent stress related performance impairment.

5. Organisational and legal dimensions

ACULV5.1

Demonstrate how to prioritise patient consultation times according to the severity of the presenting illness.

ACULV5.2

Describe procedures for the appropriate referral and transfer of acutely ill patients from general practice to the acute care setting, including the role of effective communication with other health workers.

ACULV5.3

Describe how acutely ill patients can access out-of-hours care in the general practice setting.

ACULV5.4

Evaluate the awareness and management of the personal security risks to self, staff, patients and others (eg. at an accident site).

ACULV5.5

Outline geographical and logistical transport issues for acutely unwell patients from rural and remote areas to tertiary centres.

ACULV5.6

Describe how patients are followed up after transfer to the acute care setting.

ACULV5.7

Describe the rehabilitation services available for patients who have suffered acute serious illness or trauma.

Continuing professional development

1. Communication skills and patient-doctor relationship

ACULC1.1

Review special communication needs of practice populations (eg. the use of interpreters).

ACULC1.2

Review educational needs to maintain communication skills.

2. Applied professional knowledge and skills

ACULC2.1

Maintain competency in advanced life support skills and management of other acute serious illness, including through structured courses and professional development.

ACULC2.2

Consider developing further advanced life support skills, especially in rural and remote areas.

3. Population health and the context of general practice

ACULC3.1

Consider the use of patient education to prevent acute exacerbations of chronic conditions.

ACULC3.2

Consider the need for differing or increased general practice in provisions of local emergency health services (eg. in rural and remote areas).

ACULC3.3

Consider the role of the practice in the event of bioterrorism or other emergency.

4. Professional and ethical role

ACULC4.1

Review skill levels in emergency medicine to ensure ongoing skill level maintenance.

ACULC4.2

Review self care strategies.

5. Organisational and legal dimensions

ACULC5.1

Review practice staff safety procedures and measures.

ACULC5.2

Review practice staff capacity for dealing with acute situations.

References

  1. Britt H, Charles J, Henderson J, et al. General practice activity in Australia 2000–01 to 2009–10 10 year data tables. Canberra: Australian Institute of Health and Welfare; 2010.

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