Clinical Quality FAQs

Frequently Asked Questions (FAQs) from doctors and other healthcare workers:


Can the College offer advice to individual doctors on specific cases of clinical care and medico-legal issues?

The College cannot advise individual doctors on specific episodes of clinical care or medico-legal issues.  To be thorough and fair we would have to conduct a full investigation of all the surrounding circumstances, including taking statements from involved parties, which the College has no authority to request. 

Furthermore, as an independent professional organisation, we are often called on to offer advice to employers, and possibly to attend and comment on the investigation of a particular event; for this reason we cannot offer advice to an individual that may place us in a conflicted position if/when invited to present a neutral opinion to an employer or regulator. 

Support for individual practitioners is in the domain of the medical defence organisations and it would be inappropriate for the College to offer any form of individual or specific guidance that may conflict with what they may offer in defending an individual, should that become necessary.

The College strongly advises anaesthetists and related medical professionals to obtain appropriate independent insurance cover and membership of a medical defence organisation. 

Does a wrong site block carried out perioperatively count as a never event according to the Never Events list 2015–2016?

Since the publication of the latest NHS England Never Events List (2015-16), we have received a number of enquiries asking for clarification on whether surgical wrong site blocks should be considered as never events, as the statement in the list would seem to exclude blocks undertaken as a pain control procedure, which technically speaking would apply to all anaesthetic blocks.

The supporting information provided by NHS England (Revised Never Events Policy and Framework – Frequently Asked Questions) further explains that the exclusion only applies to wrong site blocks undertaken as a pain control procedure relating to a long term medical condition. Therefore wrong site blocks that have taken place during the perioperative period should be treated as never events. Please see the NHS England website for more information.

What advice can the College provide if I am expected to regularly work long shifts to cover complex lists and cases?

The RCoA supports the statement in the guideline by the AAGBI Fatigue and Anaesthetists (2014) that:

“A 12-hour working day is not acceptable working practice for an individual anaesthetist of any grade”.

This pattern of work should not be a routine occurrence, but only a last resort in rare and exceptional circumstances where the patient cannot be left by the anaesthetist. The department and hospital management have a responsibility to put in place safe systems to provide adequate cover for complex and prolonged cases/lists, avoiding situations where a single anaesthetist is expected to work extended shifts on a regular basis. In cases when it becomes unavoidable for a single anaesthetist (of any grade) to cover a long and complex list, we would expect anaesthesia departments to set up arrangements to allow  the anaesthetist to be relieved by a colleague or PA(A) for meal and comfort breaks. We fully support the UK Government’s position on rest breaks as defined in employment law and suggest that only in extreme and rare circumstances should these be breached.

What grades of staff should assist the anaesthetist and what specific qualifications do they require?

On this issue the RCoA endorses the AAGBI document The Anaesthesia Team (3rd edition 2010), and specifically the statement:

Anaesthetists must have dedicated qualified assistance wherever anaesthesia is administered, whether in the operating department, the obstetric unit or any other area.

Trained assistance should come from an Operating Department Practitioner (ODP), Anaesthetic Nurse or (College recognised) Physicians’ Assistant Anaesthesia (PA(A)). ODPs are all now qualified to the same national standard and registered with the Health and Care Professions Council. A nurse's 'qualification' is not so clear as, since the loss of English National Board (ENB) courses, there is no UK standard; however, locally recognised, appropriate and specific training should have been completed. In Scotland a national standard has been developed, but elsewhere in the UK the individual hospital's clinical governance committee will assess and endorse the training of anaesthetic nurses and indemnify their enhanced practice accordingly.

The PA(A) is a new role and provides a qualified assistant when working alongside the anaesthetist. However, when the qualified (non-training) PA(A) is maintaining the anaesthetised patient in accordance with his/her scope of practice and without the anaesthetist in theatre, they too should have assistance by an ODP or anaesthetic nurse as indicated above.

For the safety of patients and the protection of those in the assistant role, neither an anaesthetist nor PA(A) should work without appropriate qualified assistance in the team. 
Updated: October 2011

Does the RCoA consider that the CCT in anaesthesia and specialist register status indicate that a consultant anaesthetist has undertaken appropriate Advanced Life Support (ALS) training, or does this have to be supplemented by a commercial (UK Resuscitation Council) ALS course?

The College requirements are deliberately flexible in this area, as anaesthetists may be able to demonstrate their continuing skills in their daily practice, and many are involved in teaching resuscitation skills to others. In our Guidelines for the Provision of Anaesthetic Services document  we recommend that all clinicians dealing with patients should be 'appropriately trained' in resuscitation skills. Anaesthetists should be 'appropriately trained and assessed' in advanced life support. The reference level is that of the ALS courses or equivalent. The 'equivalence' aspect is one for local agreement; there are simply too many organisations providing these courses to be prescriptive.

That said, some Trusts simply accept the CCT qualification, ongoing clinical experience and the maintenance of CPD with in-house assessment in this area – others may demand specific certification confirming the doctor attended their requisite course recently. 
Updated: October 2011

Is there a minimum number of anaesthetic sessions I should undertake in order to retain clinical skills and remain competent, thus allowing me to revalidate?

The College does not provide a list of recommended case numbers or lists per week to undertake in order to retain competency levels. This is because the requirements will vary from anaesthetist to anaesthetist depending on their scope of practice and the environment in which they work. Even if an anaesthetist manages a fixed list with a predictable case profile he or she must be able to competently manage the range of perioperative emergencies that can arise.

Issues of clinical skills and competency are however key areas of discussion for the annual appraisal. Appraisers will need to handle these areas robustly. Only an appraiser can make judgements as to clinical skills and competency knowing the scope and context of the anaesthetist’s practice and having reviewed the quality of the supporting information (including evidence of CPD) in the appraisal and revalidation portfolio. The test will be if the anaesthetist has a serious untoward incident or death and needs to demonstrate that his or her management of the situation was not adversely affected by limited ongoing clinical experience.

Some principles that may be useful for the appraisal discussion:

  • The amount of practice should be sufficient to allow the anaesthetist to maintain the core anaesthetic skills to practise safely, e.g. airway management, vascular access.
  • The appraiser needs to be confident that the appraisee has adequate experience to manage the range of perioperative emergencies that may arise.
  • The anaesthetist must be able to present an adequate portfolio of CPD to support the full range of his or her practice including the management of critical incidents.

What advice can the College provide if I am returning to work after a period of absence of more than one year?

The return to work (RTW) process is your employer’s responsibility and should not just be driven by yourself. Your clinical director/lead (i.e. the employer) should be involved in drawing up an agreed plan for managing your return to clinical practice in a manner which meets patient safety concerns. This plan should identify how your learning needs are to be met, how progression is to be demonstrated, and a timeline with review meetings. You and your employer may wish to refer to the checklist of questions and guidance on Return to Practice developed by the Academy of Medical Royal Colleges to help with the identification of issues and facilitate support planning – available here

The RCoA has also issued guidance on Returning to Work containing signposts to educational activities which are aimed at supporting anaesthetists, such as the AAGBI return to work days which are about refreshing knowledge, and simulation RTW sessions as delivered by the GAS (Giving Anaesthesia Safely) Again group, which are more around confidence and competence, reinforcing team skills and decision making.  Useful guidance on Returning to Clinical Practice has also been issued by the BMA.

In relation to revalidation the dates of your 5-year revalidation cycle remains unaffected by the time you spent away from work. However, if your RTW falls around the time of your revalidation date the Responsible Officer may agree to defer the revalidation recommendation decision made to the GMC, giving you time to compile the required supporting information and participate in appraisal. If you are returning to work, an important item of supporting information for your appraisal and revalidation portfolio is evidence that you have successfully participated in a robust RTW programme supported by your employer. The College recommends that anaesthetists returning to work after a period of absence of more than three years should anticipate a significant supervised period with a robust assessment of progress. Particular attention should be paid to how patient safety concerns are met in a RTW programme. This is because revalidation is very much about demonstrating that you are fit to practise with no concerns about patient safety issues.

What advice can you provide on allowance for supporting professional activities (SPAs) in a career grade anaesthetist’s job plan?

The issue of adequate SPA time is a difficult one and needs to take into consideration all your commitments, including whether you have any teaching, service development, management and other non-clinical duties.

The Academy document on consultant job planning and supporting professional activities proposes that the minimum number of SPAs allowed for a consultant to keep up to date should be 1.5 per week not including annual study leave. This is something the RCoA concurs with for all career grade doctors including those working as locums.

In addition to the 1.5 SPA, adequate time should also be made available if the doctor has any other SPA work, e.g. teaching, research, service development, clinical governance, etc. Depending on the extent of this work an additional 1.0 SPA (in total 2.5 SPAs) seems reasonable. Consideration of an adequate number of SPAs is therefore not just about meeting the formal process of revalidation but also about contributing to service development, management, training, quality improvement and patient safety initiatives in the department. Should you be involved in these initiatives it should be an area when discussing your SPA time with your Clinical Director or Lead. In the case of locums their contribution to non-clinical work might well be limited because of their job plans. Their jobs might  be tailored in that way. However this is not universally the case, and some locums are very active in clinical service development, teaching, etc. If this is the case for you, adequate documentation of time spent on specific duties should be kept to inform on the job planning discussion with your clinical lead.  

We must point out that the RCoA and the Academy are not regulatory bodies. The advice we offer is an opinion based on good professional practice but is not a contractual right or enforceable. It would be disappointing, however,  if our advice was wilfully  disregarded by employers and we believe that doctors should demand a clear explanation of why such advice is considered not appropriate. The necessity of SPA time for a range of activities is furthered explored in an RCoA Bulletin article on SPAs published in July 2012. The article is focussed towards the standard consultant role but the main principles holds true for all career grade doctors including those in locum posts.

Can the College advise on future changes to capacity requirements for operating theatres and where can I find this information?

These are difficult predictions to make as local requirements and regional variation are highly significant factors in this matter.  Whatever is happening or developing on a national or UK front may not be replicated in a region or local area where significant reconfiguration, change in service provision or even local politics need to be taken into account.

Generally, the demand for theatre staff is likely to increase in the future, due to many factors, such as plans by DH to extend hospital services to a 24/7 provision, increase in ageing population and the complications of operations on patients with co-morbidities, to name a few. Estimates from healthcare economists vary from a 20% to 100% expected increase in healthcare/theatre support requirements.

A standard increase in population allowance is built in by workforce estimators and rolls on to recruitment figures; however, as above, the ageing population will be more demanding and projections for longer life offer some indicators in accordance with National Census data from the Office of National Statistics.

Another useful source of information is the website of the Centre for Workforce Intelligence.

As the national picture fluctuates and remains uncertain, there is probably a need to focus principally on the local support requirement, noting the demographic and day-case issues above.  The College will run another workforce census in 2015 and we are engaging with the national workforce bodies to influence training numbers.  Progress on this area will be published on the College website and in the Bulletins over the coming 12-18 months.

Does the College have any guidance on the use of sedation by non-anaesthetists?

The College is aware of the increasing use of sedation by non-anaesthetists for a wide variety of procedures. In 2013, the Academy of Medical Royal Colleges established a working group, under the leadership of the RCoA, to revise the previous guidelines published in 2001. The new guidelines can be found here.

Sedation and clinical procedures have evolved in the past decade whilst the population of patients for sedation has aged and become frailer with more co-morbidities. Individual specialties have developed guidance on sedation and there has been improvement in training and practice. This report defines Fundamental Standards and Development Standards in safe sedation practice and recommends competency-based formal training for all healthcare professionals involved in sedation.

Does the College have any guidance on conscious sedation for dentistry?

Yes, the RCoA and the dental faculties of the surgical Royal Colleges of the UK published the report of the Intercollegiate Advisory Committee on Sedation in Dentistry (IACSD) on 22 April 2015 entitled Standards for Conscious Sedation in the Provision of Dental Care. This document will be subject to review no later than April 2018.

The IACSD has produced comprehensive FAQs to complement the standards; these can be found here.

I am a sedationist working in dental practice, but I am not formally qualified to use sedation techniques; how can I make sure I can continue to practise sedation in light of the new guidelines ‘Standards for Conscious Sedation in the Provision of Dental Care’ (2015)?

The new guidelines clearly state that “from the time of the publication of the report (April 2015), no healthcare professional should commence the provision of conscious sedation for dental patients without the training described in the report having been satisfactorily completed.”  The report does acknowledge that there are “experienced practitioners currently providing conscious sedation for dentistry who have not received the formal postgraduate training as described in the report”.

However, in the interests of patient safety, it is an expectation of the College that those anaesthetists already engaged in the provision of conscious sedation working as independent/autonomous practitioners (without supervision by a consultant) be able to demonstrate, through means of the appraisal and revalidation process, that they possess the necessary competencies for safe independent sedation practice.

Formal appraisal/revalidation for this activity would include demonstration of:

  1. possession of appropriate adult and/or paediatric anaesthetic training, and maintenance of adult and/or paediatric anaesthetic competencies
  2. possession of the necessary adult and/or paediatric dental sedation competencies.
  3. ongoing experience (logbook of sedation activity)
  4. evidence of appropriate continuing professional development
  5. participation in audit of practice and outcomes
  6. documentation of any complaints

Does the College have a standard anaesthetic chart/consent form?

The College does not have a standard anaesthetic chart with a specific section on consent.  The content of NHS Consent Form 1 is still considered suitable for this need, in particular where it states before signature:

This procedure will involve:

general and/or regional anaesthesia local anaesthesia sedation

Guidelines on anaesthetic records can be found in chapter 7 of the document Good Practice - A guide for departments of anaesthesia, critical care and pain management, a joint publication by the Royal College of Anaesthetists and The Association of Anaesthetists of Great Britain and Ireland.

Guidelines on consent have been produced by the Association of Anaesthetists of Great Britain and Ireland. Formal, signed, written consent for anaesthesia is not currently mandatory, and verbal consent may be sufficient. The guidance says “In many cases, verbal consent for anaesthesia is acceptable”. However, for significant planned procedures, e.g. those that are invasive or which carry significant risks, it is essential for health professionals to document clearly both a patient’s agreement to the intervention and the discussions which led up to that agreement. This can be done on a standard consent form, on the anaesthetic record or separately in the patient’s notes. Departments of Anaesthesia may wish to design anaesthetic records to document the discussions and agreement to specific modes of anaesthesia and interventions."

Can general anaesthetists treat and monitor postoperative patients they have anaesthetised, if the patients are then transferred to HDU?

The agreed arrangement, through the recently published Guidelines for the Provision of Intensive Care Services, is that level 1+ post-operative patients can be looked after by the anaesthetist who administered the anaesthetic, provided that the anaesthetist has received training in intensive care medicine. Level 2 patients need to be looked after by clinicians who have regular direct clinical care PAs in intensive care.

Anaesthetists and Intensivists need to reach local agreement about the interpretation of these guidelines, especially in small or medium size hospitals where there are not enough intensivists to fully cover rotas. The primary consideration must be the optimal care of patients, bearing in mind local circumstances.

Distribution of surveys

There are a considerable amount of requests received by the College to forward surveys to College representatives, mainly Regional Advisers and College Tutors. The College values highly the commitment of its representatives and their hard work and considers it unfair to burden them with additional business that does not directly involve the College. The College is unable to forward surveys to its representatives or post links in the secure area of the website that are not formally sponsored by a member of College Council and agreed at a President’s meeting.

Can an Operating Department Practitioner, Anaesthetic Nurse or Physicians’ Assistant (Anaesthesia) draw up drugs for the anaesthetist in the operating theatre?

The Royal College of Anaesthetist advises against this practice as per guidance issued by the College of Operating Department Practitioners in their Scope of Practice document (2009), which states:

“In accordance with other professional groups, the drawing up of drugs by anyone other than the person who is to administer it is not acceptable practice.

Exceptions:
Pair of hands activity’ this is where the medical practitioner (surgeon or anaesthetist) requires you to draw up a drug at their request if they are unable to, due to them needing to tend directly to the patient. In this case:

  • the drug must be checked with the medical practitioner before opening
  • drawn up in the presence of the medical practitioner – checking prior to administration, drug; dose and expiry date.”

Further information on the management and handling of controlled drugs in theatre can be found in the Safer Management of Controlled Drugs - A guide to good practice in secondary care (England) October 2007 by the Department of Health.

 

When is it safe to drive after anaesthesia?

Patients wishing to drive after surgery should discuss when it would be safe to do so with the healthcare professionals looking after them. Any decision about returning to driving must take into account issues that include:
  • Recovery from the effects of sedative and anaesthetic drugs.
  • Recovery from the effects of the procedure itself.
  • Any distracting effects of the pain resulting from the procedure.
  • Impairment resulting from taking analgesic drugs.
  • Other restrictions caused by the procedure, the underlying condition or other comorbidities.
Common guidance is that fit patients undergoing minor surgical procedures should not drive for a period of at least 24 hours after a general anaesthetic. The RCoA supports this guidance, with the proviso that this is a minimum period, not a set period for all patients, all procedures and all anaesthetic techniques.
 
Patients themselves have a legal responsibility to remain in control of their vehicles at all times, and should not attempt to drive if they feel impaired by any of the above factors. Patients must ensure that they are covered by insurance to drive after surgery. Further information can be found on the DVLA website.
 
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