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CESR Specialty Specific Guidance for Intensive Care

  • April 07, 2021

This Blog post aims to help Doctors who are applying for entry onto the Specialist Register via CESR in Intensive Care Medicine. Here we outline the types of evidence you can use and how to organize your evidence.

One of the most important things to acknowledge, if you’re considering CESR, is that the process is very lengthy and requires huge amounts of documentation/evidence. It is vital that you continually collect your documentation over time whilst you are working in your home country and/or overseas, in order to give yourself the best head-start at producing your portfolio when in the UK.
 

Organising your evidence: the 14 curriculum learning outcomes

The Intensive Care Medicine Curriculum is structured and divided into 14 ‘High Level Learning Outcomes’, commonly referred to as HiLLOs. The first four HiLLOs are generic and the remainder are specialty specific.

Within each HiLLO are a series of key capabilities describing the expected knowledge, skills, attitudes and behaviours of a practicing ICM specialist. Within your CESR submission you must be able to demonstrate that you have evidence of each key capability at the necessary level of ability.

In addition to each HiLLO, you will also need to incorporate examples of formal assessments, known as ‘Structured Learning Events’ (SLE’s). These are made up of mini-CEX, CBD, DOPS, ACAT and MSF. You should provide a balanced, equal mixture of SLEs across all HiLLOs (except for HiLLO 10). The minimum amount of SLE’s you can utilise within your CESR portfolio is 10. 

HiLLO 1:- Organisation, Management Systems and Frameworks

Within this section, you will need to demonstrate that you’re able to function successfully within NHS organisational and management systems whilst adhering to the appropriate legal and ethical framework

Within this section, the GMC recommend that you provide evidence of:

  • SLEs
  • Certificates of Good Standing
  • Completion of Data Protection/Information Governance Courses
  • CPD evidence
  • Postgraduate qualifications or other evidence of further study in management/leadership
  • Involvement in developing clinical or organisational policies and procedures (i.e Minutes of Meetings)
  • Evidence demonstrating an understanding of UK data protection issues and concepts of confidentiality (i.e Reflections on cases where maintaining confidentiality caused difficulty)
  • Supervisor Reports
  • Evidence/Letters demonstrating your role as an appraiser or assessor of others

The Key Capabilities that you must be able to reference through your evidence are as follows:

  • Understand, incorporate and implement national legislation (e.g. Health and Social Care Act 2012 and the Equality Act 2010 (Disability Discrimination Act 1995 in Northern Ireland)) into everyday practice
  • Successfully and ethically incorporate information technology and governance, according to national legislation, into patient care
  • Can communicate & document effectively, according to ethical and legal frameworks to promote the highest standards of healthcare
  • Know how to interpret, construct and apply ethical and legal frameworks into all areas of clinical governance
  • Demonstrate the highest professional behaviours, individually and corporately
  • Continually strive to enhance and integrate knowledge into clinical practice and the NHS organisation as a whole, whilst observing legal and ethical obligations
     

HiLLO 2:- Patient Safety and Quality Improvement

Within this section, you will need to demonstrate that you’re focused on patient safety and will deliver effective quality improvement, whilst practising within established legal and ethical frameworks

Within this section the GMC recommend that you provide evidence of:

  • SLEs
  • Portfolio of evidence of self-study
  • Minutes of Meetings demonstrating your participation, attendance and development
  • Case Reviews
  • Personal involvement
  • Personal involvement in Quality Improvement Projects

The Key Capabilities that you must be able to reference within this sector through your evidence are as follows:

  • Adhere to national legislation and guidelines relating to safeguarding children and other vulnerable groups of patients such as those with protected characteristics
  • Contribute towards quality improvement, communicate effectively and share good practice
  • Optimise care of critically unwell patients by the critical appraisal of recent medical literature and the application of evidence-based guidelines
  • Demonstrate a commitment to learn from critical incidents and adverse events as well as sharing the learning points from these experiences
  • Communicate effectively with patients, their families and professional colleagues whilst recognising and effectively managing any barriers to effective communication
  • Ensure patient safety is the key priority at all times in their clinical practice both within the intensive care unit and in the wider clinical environment of the hospital
     

HiLLO 3:- Research

Within this section, you will need to demonstrate that you know how to undertake medical research including the ethical considerations, methodology and how to manage and interpret data appropriately

Within this section the GMC recommend that you provide evidence of:

  • SLEs
  • Evidence or Qualifications involving undertaking research
  • Posters/Publications/Abstracts/Presentations
  • Minutes of Meetings
  • Involvement in Trials
  • Feedback from Presentations
  • Evidence of Involvement in Journal Clubs
  • CPD
  • Supervisor Reports

The Key Capabilities that you must be able to reference within this sector through your evidence are as follows:

  • Remain up to date in their reading of current research literature and best practice guidelines
  • An understanding of the processes and governance of clinical research, and will be able to communicate this to patients and their relatives where appropriate
  • Be able to critically appraise clinical literature, and to apply this, when appropriate, to their clinical practice
  • Using your knowledge of the ethical principles of practising medicine, and the legal framework associated with this in modern healthcare to benefit patients
     

HiLLO 4:- Teaching and Training

Within this section, you will need to demonstrate how you are an effective clinical teacher and will be able to provide educational and clinical supervision.

Within this section the GMC recommend that you provide evidence of:

  • SLEs
  • CPD record of educational activity from the last 5 years
  • Presentation slides of teaching you’ve delivered
  • Teaching timetables clearly identifying your sessions
  • Letters/emails from the Education Centre or Supervisor, confirming your regular teaching involvement
  • Letters from colleagues describing your role in supervising, mentoring and teaching
  • Evidence of teaching on ‘Life Support’ Courses
  • Feedback from pupils
  • Evidence or letters demonstrating your role as an appraiser, assessor or examiner
  • Supervisor reports

The Key Capabilities that you must be able to reference within this sector through your evidence are as follows:

  •     Deliver effective teaching and training to medical students, doctors in training, colleagues and members of the wider multidisciplinary team. This will include understanding the teaching, assessment and feedback needs of learners from all groups with protected characteristics and being able to adapt teaching and provide supportive techniques to ensure successful and equitable learning outcomes
  •     Competently assess the performance of learners objectively and deliver timely and constructive feedback on learning activities in accordance with current educational standards and best practice
  •     Meet any regulatory requirements of a trainer and will keep these current as well as participating in quality assurance processes to ensure excellent undergraduate and postgraduate training
  •     Endeavour to ensure patient involvement and feedback is integral to the delivery of education to doctors in their individual roles as well as their role as a member of the multidisciplinary team
     

HiLLO 5:- Treating Critically Ill Patients and Transfers

Within this section, you will need to demonstrate that you can identify, resuscitate and stabilise a critically ill patient, as well as undertake their safe intra-hospital or inter-hospital transfer to an appropriately staffed and equipped facility

Within this section the GMC recommend that you provide evidence of:

  • SLEs
  • Logbook of procedures
  • Attendance at a transfer course or Logbook evidence of patient transfers
  • Valid ALS/ATLS
  • Feedback from Colleagues
  • Reflective Notes
  • Supervisor Reports

The Key Capabilities that you must be able to reference within this sector through your evidence are as follows:

  • Identify an acutely ill patient or one at risk of significant deterioration by taking account of their medical history, clinical examination, vital signs and available investigations
  • Integrate clinical findings with timely and appropriate investigations to form a differential diagnosis and an initial treatment plan
  • Administer intravenous fluids and inotropic drugs as clinically indicated utilising central venous access where required and monitoring the effectiveness of these treatments with invasive monitoring techniques
  • Stabilise and initiate an initial treatment plan for a critically ill acute surgical, acute medical or peri-partum patient including those with sepsis or post-trauma and institute timely antimicrobial therapy
  • Provide definitive airway management and initiate and maintain advanced respiratory support
  • Undertake the transport of mechanically ventilated critically ill patients outside the Intensive Care Unit when required
  • Communicate effectively and in a timely manner, with fellow members of the multi-disciplinary team including those from other specialties and make an accurate, legible and contemporaneous entry in the patient’s medical record
  • Where escalation of care is required, be able to arrange this and provide a succinct structured handover to clinical colleagues
  • Recognise when a patient has the potential to deteriorate or requires future treatment escalation and be able to provide explicit instructions regarding an ongoing treatment plan and contact details should a further review be required
  • Have the ability to communicate with a patient's family, in terms they can understand, the patient's clinical condition, current and likely future treatment options and where possible, an indicative prognosis in an empathetic and understanding manner
  • Be mindful at all times that whilst assessing and treating patients they must maintain optimum safety for their patients by recognising any limitations of their current clinical environment, the available equipment and personnel and employing best practice guidelines where these exist
     

HiLLO 6:- Investigations and Monitoring Techniques

Within this section, you will need to demonstrate that you have the knowledge and skills to initiate, request and interpret appropriate investigations and advanced monitoring techniques, to aid the diagnosis and management of patients with organ systems failure. You will be able to provide and manage the subsequent advanced organ system support therapies. This will include both pharmacological and mechanical interventions

Within this section the GMC recommend that you provide evidence of:

  • SLEs
  • Case mix logbook showing echocardiography or ultrasound training
  • Letters discussing patient management and collaborating in patient care
  • Reflective Notes
  • Supervisor Reports

The Key Capabilities that you must be able to reference within this sector through your evidence are as follows:

  • Initiate, perform, interpret and integrate point-of-care testing, radiological and laboratory investigations with their patient’s clinical findings
  • Integrate knowledge, skills and investigations to treat a patient who is deteriorating and institute or escalate organ support therapies
  • Perform invasive procedures to aid the diagnosis and management of a critically ill patient, and provide advanced organ-support therapies as well as monitor the effectiveness of these therapies in improving the patient's overall condition
  • Use their knowledge, apply their skills, and interpret investigations and advanced therapeutic monitoring data to manage critically ill patients, including safe prescribing practices and advanced organ system support modalities, throughout the course of their critical illness
     

HiLLO 7:- Pre-Operative Resuscitation and Post-Operative Management

Within this section, you will need to demonstrate you can provide pre-operative resuscitation and optimisation of patients, deliver post-operative clinical care including optimising their physiological status, provide advanced organ system support and manage their pain relief.

Within this section the GMC recommend that you provide evidence of:

  • SLEs
  • Logbook of procedures
  • CPD record of educational activity from the last 5 years
  • Reflective notes

The Key Capabilities that you must be able to reference within this sector through your evidence are as follows:

  • Have the knowledge and understanding of the care of patients undergoing a wide range of operative procedures
  • Be expert in resuscitating and stabilising patients before and after a wide range of operative procedures including sold organ transplantation
  • Have an awareness of and be able to treat the common complications of a broad range of operative procedures including sold organ transplantation
  • Lead and contribute to the skill mix of a multidisciplinary team that will deliver the perioperative management of patients undergoing surgical procedures

HiLLO 8:- Physical and Psychosocial Consequences of Critical Illnesses

Within this section, you will need to demonstrate that you understand and manage the physical and psychosocial consequences of critical illness for patients and their families, including providing pain relief, treating delirium and arranging ongoing care and rehabilitation. You must also be able to manage the withholding or withdrawal of life-sustaining treatment, discussing end of life care with patients and their families and facilitating organ donation where appropriate.

Within this section the GMC recommend that you provide evidence of:

  • SLEs
  • Logbook of procedures and activities
  • Attendance at rehabilitation or ICU follow-up clinics, such as minutes, letters from clinics indicating applicants presence, referral letters
  • Letters or email correspondence to/from colleagues
  • CPD Record
  • Supervisor reports
  • Reflective notes

The Key Capabilities that you must be able to reference within this sector through your evidence are as follows:

  • Identifying and limiting the physical and psychosocial consequences of critical illness for patients and families paying attention to the assessment, prevention and treatment of pain and delirium
  • Communicating the continuing care requirements of patients at discharge from both ICU and hospital to healthcare professionals, patients and relatives. This will include the patient’s plan for ongoing care, medical follow up and rehabilitation
  • Facilitating discussions focused on how to manage end of life care with patients and their families. The process of withholding or withdrawing life sustaining treatments and providing palliative care whilst maintaining respect for cultural and religious beliefs will form an important element of this.
  • Diagnosing death using neurological criteria and diagnosing death using circulatory criteria in time sensitive scenarios (eg donation after circulatory death).
  • Identifying likely organ donors, working collaboratively with specialist nurses for organ donation and facilitating the process of organ donation, including providing appropriate physiological support to the organ donor
     

HiLLO 9:- Management

Within this section, you will need to demonstrate that you have the skillset and competence to lead and manage a critical care service, including the multidisciplinary clinical team and providing contemporaneous care to several critically ill patients.

Within this section the GMC recommend that you provide evidence of:

  • SLEs
  • Post graduate qualifications or evidence of further study involving leadership/management
  • Letters or email correspondence discussing patient management
  • Supervisor reports
  • Evidence of attendance at management or Hospital Board meetings
  • Indications of leadership and management capabilities
  • Organisation of MDT meetings

The Key Capabilities that you must be able to reference within this sector through your evidence are as follows:

  • Providing support to colleagues and contributing to the management of acutely unwell patients outside of the critical care unit when requested to do so
  • Having the leadership and communication skills to head a culturally diverse multidisciplinary team providing care to an equally diverse range of patients on the critical care unit
  • Involving patients and their relatives in as many treatment decisions as circumstances will allow whilst ensuring patients and relatives are kept abreast of the current treatment plan and options
  • Actively participating in the development and application of systems and processes designed to improve the delivery of safe care for critically ill patients
  • Understanding and being able to describe the special requirements of a mass casualty incident
     

HiLLO 10:- Anaesthesia, Airway Control and Understanding of Surgery

Within this section, you will need to demonstrate that you have developed the necessary skills of induction of anaesthesia, airway control, care of the unconscious patient and understanding of surgery and its physiological impact on the patient

Within this section the GMC recommend that you provide evidence of:

  • Logbook of more than 300 cases in total, showing development and progression of skills
  • Demonstrate performing emergency Anaesthesia for simple surface surgery in ASA 1 and 2 patients under local supervision
  • At least 12 SLEs for appropriate core anaesthesia procedures
  • Supervisor reports – demonstrating completion of the equivalent to a year in Anaesthesia training
  • Equivalent completion of two units of Core training
  • Anaesthesia records of charts

The Key Capabilities that you must be able to reference within this sector through your evidence are as follows:

  • Conduct comprehensive pre-anaesthetic and pre-operative checks
  • Demonstrate knowledge of anatomy, physiology, biochemistry and pharmacology relevant to anaesthetic practice
  •  Describe the functioning principles of standard equipment used within anaesthetic practice and understand the physical principles governing the operation of such equipment and the clinical measurements derived from them
  • Pre-operatively assess ASA 1-3 patients’ suitability for anaesthesia, prescribe suitable pre-medication and recognise when further investigation or optimisation is required prior to commencing surgery and adequately communicate this to the patient and their family
  • Safely induce anaesthesia in ASA 1-3 patients and recognise and deal with complications associated with the induction of anaesthesia
  • As a member of the multi-disciplinary theatre team, maintain anaesthesia for the relevant procedure, utilise appropriate monitoring and effectively interpret the information it provides to ensure the safety of the anaesthetised patient
  • Recognise anaesthetic critical incidents, understand their causes and how to manage them
  • Safely care for a patient recovering from anaesthesia and recognise and treat the common associated complications whilst providing appropriate post-operative analgesia (including that via regional and neuraxial blockade), anti-emesis and fluid therapies
  • Provide urgent or emergency anaesthesia to ASA 1E and 2E patients requiring non-complex emergency surgery
  • Identify patients with difficult airways, demonstrate management of the ‘cannot intubate cannot oxygenate’ scenario in simulation, and be familiar with difficult airway guidelines
     

HiLLO 11:- Management of Acutely ill Patients

Within this section, you will need to demonstrate you have the diagnostic, investigational and patient management skills required to care for ward-based patients whose condition commonly requires admission to the intensive care unit

Within this section the GMC recommend that you provide evidence of:

  • SLEs
  • CPD Record
  • Supervisor Reports
  • Letters or email correspondence discussing patient management and collaboration in patient care
  • Logbook of caseload and mix appropriate to a medical placement
  • Evidence to show you’re working in a General ICU which accepts medical patients
  • Evidence to show attendance of EM and ward referrals
  • ALS and other life support courses
  • Reflective Notes

The Key Capabilities that you must be able to reference within this sector through your evidence are as follows:

  • Be able to manage an acute unselected take
  • Manage an acute specialty-related take
  • Be capable of providing continuity of care to medical in-patients, including management of comorbidities and cognitive impairment
  • Know how to manage patients in an outpatient clinic, ambulatory or community setting (including management of long-term conditions)
  • Have the ability to assess and treat medical problems in patients in other specialties and special cases
  • Make an active contribution to the functioning of a multi-disciplinary clinical team including effective discharge planning
  • Deliver effective resuscitation and manage an acutely deteriorating patient
  • Care for patients who require end of life care as well as those who require palliative care
     

HiLLO 12:- Neurological Cases

Within this section, you will need to demonstrate that you understand the special needs of, and are competent to manage patients with neurological diseases, both medical and those requiring surgery, which will include the management of raised intracranial pressure, central nervous system infections and neuromuscular disorders

Within this section the GMC recommend that you provide evidence of:

  • SLEs
  • CPD record
  • Supervisor Reports
  • Logbook of caseload and mix appropriate to a 3 month placement
  • Evidence to show that you’re working in a nit which accepts referrals
  • Evidence of a short attachment to a specialist Neurosciences Unit
  • Reflective Notes

The Key Capabilities that you must be able to reference within this sector through your evidence are as follows:

  • Understanding and assessing the perioperative risks associated with patient comorbidities, emergency anaesthesia and surgery and the implications of concomitant drug therapies in these patients
  • Being competent in the postoperative care of common acute and chronic medical conditions commonly found in these patients
  • Being aware of the effects of major neurological surgery on these patients and the associated immediate postoperative management of these patients including the common complications and providing optimal analgesia
  • Knowing the factors which influence the intensity, levels of care and the clinical environments where the necessary care can be safely delivered to patients with neurological disease
  • Recognising and treating respiratory and cardiovascular dysfunction with their associated complications commonly encountered in these patients
  • Effectively assessing and managing other perioperative conditions and complications encountered by pre- and post-operative neurosurgical and neurological patient
  • Being able to competently assess a patient’s neurological status and provide appropriate support where necessary
  • Having a thorough understanding of the pathophysiology of raised intracranial pressure including the options for its operative and nonoperative management
  • Providing immediate treatment of perioperative emergencies in neurosurgical and neurological patients and knowing when to seek senior help and support
     

HiLLO 13:- Safeguarding and Paediatric Emergencies

Within this section, you will need to demonstrate that you are competent to recognise, provide initial stabilisation and manage common paediatric emergencies until expert advice or specialist assistance is available. You must also show that you are familiar with legislation regarding safeguarding children in the context of Intensive Care Medicine practice

Within this section the GMC recommend that you provide evidence of:

  • SLE
  • CPD Record
  • APLS or EPALS
  • Attendance at Child Safeguarding Courses
  • Appropriate Paediatric CPD
  • Logbook of Paediatric Emergencies
  • Logbook of caseload of 3-month Paediatric Placement
     

The Key Capabilities that you must be able to reference within this sector through your evidence are as follows:

  • Know and can effectively manage the major anatomical, physiological and psychological differences between adult and paediatric patients
  • Appreciate the pathophysiology of common paediatric emergencies, recognise their presentation and can provide initial management until expert help or specialist assistance is available
  • Ability to provide emergency and continuing cardiovascular support to a child until expert help or specialist assistance is available
  • Capable of resuscitating a child, know when to seek specialist help and support via their local paediatric retrieval team whose processes they are familiar with
  • Competent to provide elective and emergency airway management and mechanical ventilation to a child including induction of anaesthesia for intubation
  • Practice in accordance with national legislation and guidelines relating to safeguarding children in the context of critical care.
     

HiLLO 14:- Perioperative Care for Cardiothoracic Cases

Within this sector you will need to demonstrate that you’re competent to provide the perioperative care to patients who have undergone cardiothoracic surgery, including providing pain relief and advanced organ system support utilising specialised techniques available to support the cardiovascular system

Within this section the GMC recommend that you provide evidence of:

  • SLEs
  • CPD
  • Supervisor Reports
  • Logbook
  • Evidence of undertaking echocardiography or ultrasound training

The Key Capabilities that you must be able to reference within this sector through your evidence are as follows:

  • Assessing the perioperative risks associated with these patients’ comorbidities, emergency anaesthesia and surgery and the implications of their concomitant drug therapies
  • The postoperative care of common acute and chronic medical conditions commonly found in these patients
  • Assessing the implications of the type and site of surgery for these patients’ immediate postoperative management and the potential complications, which they can manage effectively whilst providing optimal analgesia
  • Considering the factors which influence the intensity, levels of care and the clinical environments where the necessary care can be safely delivered to these patients
  • Treating respiratory dysfunction and complications in these patients
  • Treat cardiovascular dysfunction and complications in these patients including understanding advanced monitoring techniques and provision of mechanical circulatory support
  • Assessing and managing other perioperative conditions and complications encountered by pre- and post-operative cardiothoracic surgery patients
  • Recognising and providing immediate treatment of perioperative emergencies and know when to seek senior help and support
     

References

Gmc-uk.org. 2021. [online] Available at: [Accessed 29 March 2021].

 
 

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