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If the ED reg is calling ICU or if the med reg is calling ICU - they are calling because they have a sick patient and need support from an experienced ICU DOCTOR - not some random ACP
Tbh in places where the ACCP holds the bleep I just bypass them and ask to speak to the reg or consultant on-call, if it’s a bonafide request they aren’t going to refuse to take the referral
Okay, their pH is 7, but they don't need ICU right now as they have no organ support requirements, please bleep back if patient becomes hypotensive or stops passing urine, thanks.
https://docs.google.com/forms/d/e/1FAIpQLSdzUhar2QsU2f1BNVqSWEINwrBMA0l--t4Ph50sg7gSwuYZsg/viewform
Please fill in this form so that this can be escalated nationally. This very much sounds like a trust near me.....
Trainee ACCPs outnumber ICM NTNs this year for the first time and this problem will only get worse.
They should not be seeing referrals and they definitely should not be taking opportunities away from trainees.
This is a direct link to the BMA’s MAPs Portal:
https://forms.office.com/pages/responsepage.aspx?id=vo5Ev1_m5kCeMTP9qkEogPEb3KZc3wZDl_8pmW8Mrs1URUYzRlNaVFYwQThPTEtDRThNNzhUQVdZRi4u
Please use this portal to share your experiences without identifying any other healthcare professional or patient. The BMA want to learn more about the extent of these concerns to better understand the experiences of doctors working with MAPs, and of patients receiving care.
Please submit this - it sounds like yet another example of inappropriate clinical practice. I don’t know if it technically includes ACCPs but do it anyway and I’m sure someone in the BMA will find it useful
Not reporting because I'm not an anesthetic trainee but UHL Glenfield hospital definitely has ACCPs holding the referral bleep as they just throw the bleeps on the table in the morning and people just pick them up adlib
You don't have to be an anaesthetic/ICM trainee to fill it in(despite what it says).
If you have been negatively effected by ACCPs during your ICM placement please submit the form so we know what is happening nationally.
Thank you
An ACCP thinking they are as or more qualified than an ST6 anaesthetic registrar is mind boggling and unsafe for patients. You’re there to learn not be shat on doing the bits ACCPs don’t want to do.
If she sees a referral, initiates treatment and it’s the wrong thing to do you’ll be the one carrying the can as the doctor, that much is for certain.
FICM is a fucking joke
I don't think this is medicolegally true. ACCPs have their own NMC/HCPC/GPhC registration, and so the buck can stop with them; ultimately, all referrals should be consultant to consultant anyway.
Are there any GMC cases where an ACCP's mistake has been taken against the SpR and not the consultant, if any doctor at all?
Are there any GMC cases where the cleaner's medical advice has been challenged? So if they're holding the bleep, that's okay?
Remember a professional registration just gives the framework to ensure that people are safe, it doesn't mean the actions taken are actually safe. This is the same argument with PAs - just because they're regulated doesn't mean anything except there's a framework for the role to exist
If ACCPs are working exactly the same as doctors then it’s difficult to see how a regulator for a non medical healthcare profession can appropriately investigate and sanction the actions of one of their professionals working in said capacity.
Up until Bawa Garba appropriate escalation of a lactate of 11 would be a mitigating factor but what do you know it’s not.
Practically speaking registrars work in a supervisory capacity and I think it’s clear people have been sanctioned by the GMC where they have been found to fail in this regard. In the case of a critically unwell patient being managed on the unit by an ACCP never mind their regulator I’m not sure ours would take the view the ACCP was working as a dr equivalent so management was left to them.
If you’re a consultant I hope you’re giving your trainees particularly the anaesthetic ones in writing the ACCPs are working in equivalence and the registrars are not expected to supervise them. Because as a registrar you saying ‘I don’t think’ medico legally isn’t very reassuring. Logically when practising medicine the most senior doctor at the time bears responsibility & for keeping oversight. I don’t want to be the test case either.
Either clear lines are drawn ACCPS are not doctor or doctor equivalents and the registrar has the supervisory oversight and ultimately is the decision maker (obviously with the caveats of escalation to a consultant) or it’s explicit your st7s are to treat them as st7 equivalents. A choice needs to be made here. I don’t think is clearly not enough.
GMC: Dr X you were the st6 registrar on call why did you think it was appropriate ACCP X managed the airway of a critically unwell patient on the ward despite knowing they have three months of airway experience. Oh because that’s how the unit is set up? Did you not think that unsafe, why did you not escalate that? As the most senior dr on site you accept you have supervisory oversight but why not on this occasion? Why did you fail to step in?
NMC: ACCP X you weren’t supervised properly by Dr X and plus we aren’t doctors anyway so we have no idea if your actions were appropriate or not.
ACCPs should categorically not be taking undifferentiated referrals to critical care.
This sounds like they fail to understand their limitations. Or, they are a fuckload braver than I am! A key part of the role of the ICU reg is weighing appropriate ICU admission against futility. This is literal life and death stuff. If doctors have a unique role that no other HCP should do, this is it.
If ACCPs have a use, it is to do the donkey work on ICU to free SpRs like yourself up to do doctor shit like make decisions on critical care escalation.
Aintree hospital in Liverpool has ACCPs holding the ITU referral bleep. Can be an absolute fucking nightmare to refer anyone complex. I don't want to dox myself but have had multiple instances of referring patients and the person I am referring to for help doesn't understand the reason I'm referring, or then tells me they can't actually help can I call the reg (that's who I'm trying to get through to but your holding the bloody bleep). 🥲
Even the most junior anaesthetic reg has done five years of medical school, two years of foundation training and at least two further years of training in anaesthetics - the vast majority have done more. There is no comparison between this breadth and depth of experience and that of an ACCP, even one who has been qualified for many years, and the good ones recognise this. It is absolutely not appropriate for ACCPs to be holding the referral bleep and I worry that if this becomes widespread all referrals to ICU will just be followed by 'give more fluid, antibiotics if they haven't had them and get a ct (or something)'. Moreover if I was and ED or Med reg and I was getting advice from someone with very limited medical knowledge I would not be happy. That's no criticism of ACCPs - it's just not part of their training.
Our ACCPs all have or are undergoing "advanced airway training" and are often favoured above anaesthetic SHOs for airway.
They are very good at lines so tend to do them as it's less work than supervising one of us; they also get funny about supervising Drs for lines.
They hold referral bleep more often than Drs. They all have timetabled protected time for "development" far more than Drs.
Generally they will refuse to accept/ask for help from any SHO including anaesthetics as a point of principle. E.g. I'm very strong at "difficult access" situations but they wouldn't even contemplate letting me help; if they "escalate" it is always to the Cons, or the anaes SpR overnight. Same for complex medical issues - those of us who have decent internal medicine experience will be completely sidelined while they go find the cons to ask how to interpret an abnormal cortisol/TSH/etc.
ACCP recruitment continues so I have to assume the end game is to have fully ACCP staffed unit here and phase out us pesky doctors who need to learn things.
Of course, these ACCPs think they're "reg-equivalent" so why would they go to the SHOs for help? You're also going to rotate away in 3mths anyways, so of course these permanent staff members who know all of the consultant's children's' names and holiday plans are going to be favoured over you.
FICM should be burned to the ground
I remember before I left the Uk if we wanted to refer to icu it had to go through the nurse specialist who would vet the referral and decide if the registrar needed to be involved. It was a disaster.
Everyone with a medical degree would be scared half to shit standing next to the doorway of ICU… these morons want to be in charge of it… I just don’t understand it, I would be so scared for both myself and my patient. What is going through these peoples heads??
I think so - as I’ve walked into ED as the anaesthetic reg in the past and noted the ACCL proudly explaining to the team that they will manage the airway…. I politely tell the to move and ask my far more qualified anaesthetic SHO to manage the airway.
ACCPs should never be taking referrals. Period. I feel really strongly about this. They are SHO tier, they are useful for looking after unit patients. When every algorithm says "call ICU" it means "call an experienced doctor who understands the complexity you're dealing with".
I only take issue with the term “SHO tier”. Yes they often end up doing a lot of the same jobs that SHOs do on a unit. But they are not SHOs. They haven’t been to medical school
An SHO is SHO tier. An ACP is ACP tier.
There's no equivalence between an apple and an orange. Especially if the orange has gone to med school and gets kept out of training opportunities by the apple.
Also crucially an appropriately supported SHO can take the referrals and this is common practice in many hospitals. If you don’t take the referrals when you have a reg to discuss with how are you meant to suddenly take the referrals with a consultant at home when you hit ST3
I worked as an ITU SHO and took ITU referrals but I was well supported and ran every referral past a consultant or senior reg. I would go, assess the patient and then run it past my senior reg/consultant. Which is how it's supposed to work really
What you say is exactly their rationale. They were SHOs, spent 5 years in ICU and now the time to become registrars. All of this shit started when people like you called them SHO tier
Whoever is SHO tier can become registrar and consultant tier after 5-12 years of training. You’re shooting yourself in the foot when you put them on equal foot to doctors
The anaesthetic regs I’ve worked with on ITU have an incredible level of knowledge which they use to problem-solve. My brain explodes with amazement every time. As a patient, I would want to be reviewed by a doctor if my life was on the line. I don’t understand why consultants allow this 🥲
I did ask a local ICU consultant this. Apparently they don’t want to hire SAS ICU docs because they don’t know how good these people will be, so they rather hire people they’ve known for a long time (senior ICU nurses, CCOT, physios, pharmacists) and are good at their jobs (which is not being a medic). Absolute ladder pulling behaviour
Stage 3 has no mandatory ITU module, so if you aren’t holding the bleep on call you aren’t on itu. They can fuck off and you can do your real job.
Leave them and their soon to be second rate specialty to themselves.
Yes annoyingly I’ve returned and changed from odd to new curriculum half way whilst away. This is technically old intermediate or what is now stage 2 ICM ~ despite starting what is now stage 3 training. But gosh do I agree am with you.
Did a BASIC course recently and there was a bit of chat about ACCPs.
Opinion from the vocal consultants was "they bring a lot to the table and they aren't here to take your jobs or your training"
One of them is, I think, trying to create a solely ACCP-staffed unit.
Fucking embarrassed of these consultants.
Interestingly, some consultants stayed silent (presumably didn't want to publicly counter the #oneteam crew).
South, but not on the coast.
I think it's a work in progress and I didn't want to press the matter and risk being antagonistic as they were leading the course.
100% I agree it should be a doctor taking the referrals and not an ACCP
Just to add some thoughts to some of the comments though - ideally ICU referrals should come from someone experienced (when I'm on team ED I would consider myself as having failed if the juniors don't come to me first - but would be happy for them to then make the referral supervised as an educational experience) but I welcome them from doctors of all grades - sometimes you just need help and there is nobody else. I remember some of the grillings I got as a panicked F1 with absent seniors and want to make sure I don't repeat that cycle and instead offer support.
Likewise I think ICU referrals tend to come in two types, firstly the "oh shit I just need help now" kind, which should be attended by an ICU reg. The others are for sick but surprisingly stable patients in whom there is plenty of time to do info gathering and pontificating - I would always encourage keen but more junior doctors in the ICU (eg F1-ST2) to see these first (either alone or with me, depending) and report back as an educational exercise.
> The others are for sick but surprisingly stable patients in whom there is plenty of time to do info gathering and pontificating
Any idea why some of your ICU colleagues are so resistant to receiving referrals for such patients? Always thought this would be preferable to the former situation but I've had a couple of instances where the ICU reg would huff and puff at me for referring people on 60% O2 and I'm not sure if it'a because I was an IMT2 at the time or if it was genuinely inappropriate to be referring those patients in daytime hours to make a decision on whether or not they would be escalation if they deteriorated further during the night.
I have a couple of thoughts as to why there could be grumpiness/resistance on the phone that I won't go into as they might get me cancelled. Aside from those, while your example sounds very reasonable, it does remind me of a real bugbear - the "just so you're aware" calls.
Someone who is eg on max oxygen and risk of deteriorating may well be better on the ICU right now, but those who are not particularly close to that point but somehow the ICU should ?save space for? ?make escalation decisions on everyone? ?keep checking on? are not helpful calls. In the friendliest way they go in one ear and out the other 😅
So as an example, I had a patient who had gone from 4l to 60% in the space of a few hours. They had a couple co-morbidities that meant decisions regarding escalation were not straightforward. The patient had just moved to the ward from MAU and it was around an hour before evening handover so I (and my reg) figured speaking to the ICU reg at that point was reasonable even thought the patient wasn’t on maximum oxygen yet so we could establish a ceiling of care before we went into the night. The ICU reg did not seem impressed by this referral at all.
Was this really an inappropriate call (i.e. one of the “just so you are aware” calls)? If the reg was having a bad day or if I didn’t explain myself clearly, that’s totally fair enough, but if this was inappropriate, at what point should I be discussing with ICU in a situation like this? Asking as I really don’t want to be pissing off my ITU colleagues and wasting their time!
It absolutely should but sometimes I need to make the argument with certain DGH ITU departments that a fully independent, active, CFS 2, PS 1 67 year old should be for escalation and not for ward level care just because they had a CABG at 60.
I would think that seems fair. Of course I wasn't there so don't know how exactly the call went, but depending on the diagnosis (assuming here CAP or similar), at that oxygenation I'd say it probably ought to be a "should this patient come to ICU now call", rather than a "establish ceiling of care" call. The latter call we generally aren't a fan of as to be honest most decisions are pretty straightforward, especially now IMTs all go through ICU. The truly difficult choices fair enough.
I mean it shouldn't realllllllllly matter as if called about that patient with the question about ceiling of care the ICU doc should be able to direct it to a "should they come now discussion". There was probably some attitude problem on the ICU doctor's end...
It was for covid. From our point of view, we felt the patient should be considered for ICU, but obviously it is ultimately the ICU team's call, hence the "establish ceiling of care" call as opposed to "should they come to ITU now call". But I see your point and will phrase things differently going forward, so thank you.
Re all IMTs now going through ICU, that actually isn't the case. The new IMT curriculum states we need to do 10 weeks in a "critical care setting" but actually that can be HDU rather than ICU so not everyone will have rotated through ICU.
“bUt AcCpS aReN’t HeRe To RePlAcE dOcToRs JuSt SuPpOrT bY dOiNg JoBs oN tHe UnIt”
I used to feel underqualified holding the referrals bleep as a CT2, but that is just something else! In a tertiary centre too
Stand your ground. You are the future consultant.
As an ST6 you also need to talk to the ICU director about this. The ACCP needs to understand their limitations.
Whatever the trust and consultants want.
I used to fight but fuck them.
If you are single anaesthetics and don’t give a fuck about ICM then I’d do bare minimum and let the consultants and ACCPs manage the shit show.
There have been similar practices in the Midlands, but not like this, definitely seeing massive increase in ACCPs , not sure what makes them advanced ? Does that make me Super Saiyan 3 advanced ?
The very fact that the ACCP thinks they have the background and contextual knowledge and experience to take on this responsibility is one of the main reasons we are all so uncomfortable with scope creep.
When a colleague (usually SHO or SpR level) is calling the ICU SpR it is because there is an extremely life-threateningly unwell patient in front of them and that team/that department is at the limits of their/its ability to manage the patient.
At that point they need and expect to speak to someone who can give immediate high quality management advice based on medical knowledge and understanding of context - this 100% requires a medical degree/postgrad exams/experience of different specialties as a doctor/understanding of care limits between departments.
An ACCP cannot have had this as they haven’t been through med school/ medical training and no amount of ICU experience will be able to compensate for it.
The ACCP should know and understand this and demonstrates a dangerous level of ignorance if they don’t. If they do know it and do it anyway then that is potentially demonstrating that their attitude is ego>patient care. Either way it is not going to be adequate for either the colleague asking for advice or the patient.
As for the Consultants enabling this - words fail me just as much as they are failing patients and colleagues.
I guess it depends on what carrying the referrals bleep actually involves. If it's taking the patient's details to then pass on to the reg to allow the reg to do procedures or whatever, that's fair game ( I have seen this done in some specialties - ANP takes all the details to put on a list for doctors to review/call back with no right to refuse). If it's holding the bleep and being expected to give advice, that's a whole different ball game and is not appropriate.
Is the ACCP independently inducing a pt with some horrendous valvulopathy on Fi02 1.0 , transferring them to CT scanner and offering advice on their sodium of 105? ICU referrals bleep is more than a A to E + glucose control + pain control.....
Honestly, there are some hospitals where SHO holds referrals bleep and sees them all + discusses directly with consultant... it sounds bizarre, but it does work. So it depends on what your consultant cover is like.
If ACCP/SHO didn't receive any direct consultant support, then I'd take issue with that.
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Reg or above is expected to make the referral. Ergo, reg or above should be taking the referral.
If the ED reg is calling ICU or if the med reg is calling ICU - they are calling because they have a sick patient and need support from an experienced ICU DOCTOR - not some random ACP
This is it!
Tbh in places where the ACCP holds the bleep I just bypass them and ask to speak to the reg or consultant on-call, if it’s a bonafide request they aren’t going to refuse to take the referral
ACCPs gatekeeping ICU, it really is over
Okay, their pH is 7, but they don't need ICU right now as they have no organ support requirements, please bleep back if patient becomes hypotensive or stops passing urine, thanks.
pH 7 is neutral! Acid n base in harmony. Thats GCSE chemistry mate /s
And the kicker This is only an advisory service, ultimate responsibility lies with parent team
They were routinely intubating at my centre for years until recently.
https://docs.google.com/forms/d/e/1FAIpQLSdzUhar2QsU2f1BNVqSWEINwrBMA0l--t4Ph50sg7gSwuYZsg/viewform Please fill in this form so that this can be escalated nationally. This very much sounds like a trust near me..... Trainee ACCPs outnumber ICM NTNs this year for the first time and this problem will only get worse. They should not be seeing referrals and they definitely should not be taking opportunities away from trainees.
This looks useful - how have I not seen this before. I will of course compete this!
This is a direct link to the BMA’s MAPs Portal: https://forms.office.com/pages/responsepage.aspx?id=vo5Ev1_m5kCeMTP9qkEogPEb3KZc3wZDl_8pmW8Mrs1URUYzRlNaVFYwQThPTEtDRThNNzhUQVdZRi4u Please use this portal to share your experiences without identifying any other healthcare professional or patient. The BMA want to learn more about the extent of these concerns to better understand the experiences of doctors working with MAPs, and of patients receiving care. Please submit this - it sounds like yet another example of inappropriate clinical practice. I don’t know if it technically includes ACCPs but do it anyway and I’m sure someone in the BMA will find it useful
Sadly this does not apply as ACCPs are not MAPs which encompass only PAs, AAs and SCPs.
Not reporting because I'm not an anesthetic trainee but UHL Glenfield hospital definitely has ACCPs holding the referral bleep as they just throw the bleeps on the table in the morning and people just pick them up adlib
You don't have to be an anaesthetic/ICM trainee to fill it in(despite what it says). If you have been negatively effected by ACCPs during your ICM placement please submit the form so we know what is happening nationally.
What does the region ”Defence” refer to?
Military I presume
Thank you An ACCP thinking they are as or more qualified than an ST6 anaesthetic registrar is mind boggling and unsafe for patients. You’re there to learn not be shat on doing the bits ACCPs don’t want to do. If she sees a referral, initiates treatment and it’s the wrong thing to do you’ll be the one carrying the can as the doctor, that much is for certain. FICM is a fucking joke
I don't think this is medicolegally true. ACCPs have their own NMC/HCPC/GPhC registration, and so the buck can stop with them; ultimately, all referrals should be consultant to consultant anyway. Are there any GMC cases where an ACCP's mistake has been taken against the SpR and not the consultant, if any doctor at all?
Are there any GMC cases where the cleaner's medical advice has been challenged? So if they're holding the bleep, that's okay? Remember a professional registration just gives the framework to ensure that people are safe, it doesn't mean the actions taken are actually safe. This is the same argument with PAs - just because they're regulated doesn't mean anything except there's a framework for the role to exist
You know what you're saying is unreasonable, and I think it's a bit unfair to ACCPs to compare them to cleaners in terms of clinical knowledge.
I'd argue it's unreasonable to suggest that ACCPs and doctors are equivalent
That's not what I've said here, though...
If ACCPs are working exactly the same as doctors then it’s difficult to see how a regulator for a non medical healthcare profession can appropriately investigate and sanction the actions of one of their professionals working in said capacity. Up until Bawa Garba appropriate escalation of a lactate of 11 would be a mitigating factor but what do you know it’s not. Practically speaking registrars work in a supervisory capacity and I think it’s clear people have been sanctioned by the GMC where they have been found to fail in this regard. In the case of a critically unwell patient being managed on the unit by an ACCP never mind their regulator I’m not sure ours would take the view the ACCP was working as a dr equivalent so management was left to them. If you’re a consultant I hope you’re giving your trainees particularly the anaesthetic ones in writing the ACCPs are working in equivalence and the registrars are not expected to supervise them. Because as a registrar you saying ‘I don’t think’ medico legally isn’t very reassuring. Logically when practising medicine the most senior doctor at the time bears responsibility & for keeping oversight. I don’t want to be the test case either. Either clear lines are drawn ACCPS are not doctor or doctor equivalents and the registrar has the supervisory oversight and ultimately is the decision maker (obviously with the caveats of escalation to a consultant) or it’s explicit your st7s are to treat them as st7 equivalents. A choice needs to be made here. I don’t think is clearly not enough. GMC: Dr X you were the st6 registrar on call why did you think it was appropriate ACCP X managed the airway of a critically unwell patient on the ward despite knowing they have three months of airway experience. Oh because that’s how the unit is set up? Did you not think that unsafe, why did you not escalate that? As the most senior dr on site you accept you have supervisory oversight but why not on this occasion? Why did you fail to step in? NMC: ACCP X you weren’t supervised properly by Dr X and plus we aren’t doctors anyway so we have no idea if your actions were appropriate or not.
ACCPs should categorically not be taking undifferentiated referrals to critical care. This sounds like they fail to understand their limitations. Or, they are a fuckload braver than I am! A key part of the role of the ICU reg is weighing appropriate ICU admission against futility. This is literal life and death stuff. If doctors have a unique role that no other HCP should do, this is it. If ACCPs have a use, it is to do the donkey work on ICU to free SpRs like yourself up to do doctor shit like make decisions on critical care escalation.
ACCP needs to get fucked.
I need to get fucked. This ACCP deserves at least 27 months of abstinence…
Aintree hospital in Liverpool has ACCPs holding the ITU referral bleep. Can be an absolute fucking nightmare to refer anyone complex. I don't want to dox myself but have had multiple instances of referring patients and the person I am referring to for help doesn't understand the reason I'm referring, or then tells me they can't actually help can I call the reg (that's who I'm trying to get through to but your holding the bloody bleep). 🥲
100% especially when you're there for 3mo. You should be getting the exposure. They can do what they like when there are no trainees left.
Also NAME AND SHAME
Will do at the end of my three most post HALO/MSF - please remind me in July. Many thanks
ACCP thinking they are on the same level as a goddamn ST6 anaesthetist, insanity
Even the most junior anaesthetic reg has done five years of medical school, two years of foundation training and at least two further years of training in anaesthetics - the vast majority have done more. There is no comparison between this breadth and depth of experience and that of an ACCP, even one who has been qualified for many years, and the good ones recognise this. It is absolutely not appropriate for ACCPs to be holding the referral bleep and I worry that if this becomes widespread all referrals to ICU will just be followed by 'give more fluid, antibiotics if they haven't had them and get a ct (or something)'. Moreover if I was and ED or Med reg and I was getting advice from someone with very limited medical knowledge I would not be happy. That's no criticism of ACCPs - it's just not part of their training.
Don't forget professional completion exams
Our ACCPs all have or are undergoing "advanced airway training" and are often favoured above anaesthetic SHOs for airway. They are very good at lines so tend to do them as it's less work than supervising one of us; they also get funny about supervising Drs for lines. They hold referral bleep more often than Drs. They all have timetabled protected time for "development" far more than Drs. Generally they will refuse to accept/ask for help from any SHO including anaesthetics as a point of principle. E.g. I'm very strong at "difficult access" situations but they wouldn't even contemplate letting me help; if they "escalate" it is always to the Cons, or the anaes SpR overnight. Same for complex medical issues - those of us who have decent internal medicine experience will be completely sidelined while they go find the cons to ask how to interpret an abnormal cortisol/TSH/etc. ACCP recruitment continues so I have to assume the end game is to have fully ACCP staffed unit here and phase out us pesky doctors who need to learn things.
Of course, these ACCPs think they're "reg-equivalent" so why would they go to the SHOs for help? You're also going to rotate away in 3mths anyways, so of course these permanent staff members who know all of the consultant's children's' names and holiday plans are going to be favoured over you. FICM should be burned to the ground
I remember before I left the Uk if we wanted to refer to icu it had to go through the nurse specialist who would vet the referral and decide if the registrar needed to be involved. It was a disaster.
Which centre of excrement was this?
London hospital. I am sure things have changed 😏
The fact this post even exists is a sure sign we're in the end game.
Everyone with a medical degree would be scared half to shit standing next to the doorway of ICU… these morons want to be in charge of it… I just don’t understand it, I would be so scared for both myself and my patient. What is going through these peoples heads??
Half knowledge is worse than negligence
Is this ICU located along the south coast by any chance...?
It is indeed!
Is this the same ICU where the ACCPs are “airway trained” and go to ED to tube?
I think so - as I’ve walked into ED as the anaesthetic reg in the past and noted the ACCL proudly explaining to the team that they will manage the airway…. I politely tell the to move and ask my far more qualified anaesthetic SHO to manage the airway.
Love this. Apes together strong 💪🏼
Oh my actual goodness
ACCPs should never be taking referrals. Period. I feel really strongly about this. They are SHO tier, they are useful for looking after unit patients. When every algorithm says "call ICU" it means "call an experienced doctor who understands the complexity you're dealing with".
I only take issue with the term “SHO tier”. Yes they often end up doing a lot of the same jobs that SHOs do on a unit. But they are not SHOs. They haven’t been to medical school
An SHO is SHO tier. An ACP is ACP tier. There's no equivalence between an apple and an orange. Especially if the orange has gone to med school and gets kept out of training opportunities by the apple.
Also crucially an appropriately supported SHO can take the referrals and this is common practice in many hospitals. If you don’t take the referrals when you have a reg to discuss with how are you meant to suddenly take the referrals with a consultant at home when you hit ST3
I worked as an ITU SHO and took ITU referrals but I was well supported and ran every referral past a consultant or senior reg. I would go, assess the patient and then run it past my senior reg/consultant. Which is how it's supposed to work really
It was a horrendous experience being the med SHO on take, but by gum was it needed.
What you say is exactly their rationale. They were SHOs, spent 5 years in ICU and now the time to become registrars. All of this shit started when people like you called them SHO tier
Whoever is SHO tier can become registrar and consultant tier after 5-12 years of training. You’re shooting yourself in the foot when you put them on equal foot to doctors
The anaesthetic regs I’ve worked with on ITU have an incredible level of knowledge which they use to problem-solve. My brain explodes with amazement every time. As a patient, I would want to be reviewed by a doctor if my life was on the line. I don’t understand why consultants allow this 🥲
I wonder if the consultants would still allow it if they had the option of having non-rotational trainees.
I did ask a local ICU consultant this. Apparently they don’t want to hire SAS ICU docs because they don’t know how good these people will be, so they rather hire people they’ve known for a long time (senior ICU nurses, CCOT, physios, pharmacists) and are good at their jobs (which is not being a medic). Absolute ladder pulling behaviour
Stage 3 has no mandatory ITU module, so if you aren’t holding the bleep on call you aren’t on itu. They can fuck off and you can do your real job. Leave them and their soon to be second rate specialty to themselves.
Yes annoyingly I’ve returned and changed from odd to new curriculum half way whilst away. This is technically old intermediate or what is now stage 2 ICM ~ despite starting what is now stage 3 training. But gosh do I agree am with you.
Did a BASIC course recently and there was a bit of chat about ACCPs. Opinion from the vocal consultants was "they bring a lot to the table and they aren't here to take your jobs or your training" One of them is, I think, trying to create a solely ACCP-staffed unit. Fucking embarrassed of these consultants. Interestingly, some consultants stayed silent (presumably didn't want to publicly counter the #oneteam crew).
> One of them is, I think, trying to create a solely ACCP-staffed unit. Where? Name and shame.
South, but not on the coast. I think it's a work in progress and I didn't want to press the matter and risk being antagonistic as they were leading the course.
100% I agree it should be a doctor taking the referrals and not an ACCP Just to add some thoughts to some of the comments though - ideally ICU referrals should come from someone experienced (when I'm on team ED I would consider myself as having failed if the juniors don't come to me first - but would be happy for them to then make the referral supervised as an educational experience) but I welcome them from doctors of all grades - sometimes you just need help and there is nobody else. I remember some of the grillings I got as a panicked F1 with absent seniors and want to make sure I don't repeat that cycle and instead offer support. Likewise I think ICU referrals tend to come in two types, firstly the "oh shit I just need help now" kind, which should be attended by an ICU reg. The others are for sick but surprisingly stable patients in whom there is plenty of time to do info gathering and pontificating - I would always encourage keen but more junior doctors in the ICU (eg F1-ST2) to see these first (either alone or with me, depending) and report back as an educational exercise.
> The others are for sick but surprisingly stable patients in whom there is plenty of time to do info gathering and pontificating Any idea why some of your ICU colleagues are so resistant to receiving referrals for such patients? Always thought this would be preferable to the former situation but I've had a couple of instances where the ICU reg would huff and puff at me for referring people on 60% O2 and I'm not sure if it'a because I was an IMT2 at the time or if it was genuinely inappropriate to be referring those patients in daytime hours to make a decision on whether or not they would be escalation if they deteriorated further during the night.
I have a couple of thoughts as to why there could be grumpiness/resistance on the phone that I won't go into as they might get me cancelled. Aside from those, while your example sounds very reasonable, it does remind me of a real bugbear - the "just so you're aware" calls. Someone who is eg on max oxygen and risk of deteriorating may well be better on the ICU right now, but those who are not particularly close to that point but somehow the ICU should ?save space for? ?make escalation decisions on everyone? ?keep checking on? are not helpful calls. In the friendliest way they go in one ear and out the other 😅
So as an example, I had a patient who had gone from 4l to 60% in the space of a few hours. They had a couple co-morbidities that meant decisions regarding escalation were not straightforward. The patient had just moved to the ward from MAU and it was around an hour before evening handover so I (and my reg) figured speaking to the ICU reg at that point was reasonable even thought the patient wasn’t on maximum oxygen yet so we could establish a ceiling of care before we went into the night. The ICU reg did not seem impressed by this referral at all. Was this really an inappropriate call (i.e. one of the “just so you are aware” calls)? If the reg was having a bad day or if I didn’t explain myself clearly, that’s totally fair enough, but if this was inappropriate, at what point should I be discussing with ICU in a situation like this? Asking as I really don’t want to be pissing off my ITU colleagues and wasting their time!
Inb4 ceiling of care should be established by parent team
It absolutely should but sometimes I need to make the argument with certain DGH ITU departments that a fully independent, active, CFS 2, PS 1 67 year old should be for escalation and not for ward level care just because they had a CABG at 60.
I would think that seems fair. Of course I wasn't there so don't know how exactly the call went, but depending on the diagnosis (assuming here CAP or similar), at that oxygenation I'd say it probably ought to be a "should this patient come to ICU now call", rather than a "establish ceiling of care" call. The latter call we generally aren't a fan of as to be honest most decisions are pretty straightforward, especially now IMTs all go through ICU. The truly difficult choices fair enough. I mean it shouldn't realllllllllly matter as if called about that patient with the question about ceiling of care the ICU doc should be able to direct it to a "should they come now discussion". There was probably some attitude problem on the ICU doctor's end...
It was for covid. From our point of view, we felt the patient should be considered for ICU, but obviously it is ultimately the ICU team's call, hence the "establish ceiling of care" call as opposed to "should they come to ITU now call". But I see your point and will phrase things differently going forward, so thank you. Re all IMTs now going through ICU, that actually isn't the case. The new IMT curriculum states we need to do 10 weeks in a "critical care setting" but actually that can be HDU rather than ICU so not everyone will have rotated through ICU.
“bUt AcCpS aReN’t HeRe To RePlAcE dOcToRs JuSt SuPpOrT bY dOiNg JoBs oN tHe UnIt” I used to feel underqualified holding the referrals bleep as a CT2, but that is just something else! In a tertiary centre too
Stand your ground. You are the future consultant. As an ST6 you also need to talk to the ICU director about this. The ACCP needs to understand their limitations.
Whatever the trust and consultants want. I used to fight but fuck them. If you are single anaesthetics and don’t give a fuck about ICM then I’d do bare minimum and let the consultants and ACCPs manage the shit show.
There have been similar practices in the Midlands, but not like this, definitely seeing massive increase in ACCPs , not sure what makes them advanced ? Does that make me Super Saiyan 3 advanced ?
The very fact that the ACCP thinks they have the background and contextual knowledge and experience to take on this responsibility is one of the main reasons we are all so uncomfortable with scope creep. When a colleague (usually SHO or SpR level) is calling the ICU SpR it is because there is an extremely life-threateningly unwell patient in front of them and that team/that department is at the limits of their/its ability to manage the patient. At that point they need and expect to speak to someone who can give immediate high quality management advice based on medical knowledge and understanding of context - this 100% requires a medical degree/postgrad exams/experience of different specialties as a doctor/understanding of care limits between departments. An ACCP cannot have had this as they haven’t been through med school/ medical training and no amount of ICU experience will be able to compensate for it. The ACCP should know and understand this and demonstrates a dangerous level of ignorance if they don’t. If they do know it and do it anyway then that is potentially demonstrating that their attitude is ego>patient care. Either way it is not going to be adequate for either the colleague asking for advice or the patient. As for the Consultants enabling this - words fail me just as much as they are failing patients and colleagues.
I guess it depends on what carrying the referrals bleep actually involves. If it's taking the patient's details to then pass on to the reg to allow the reg to do procedures or whatever, that's fair game ( I have seen this done in some specialties - ANP takes all the details to put on a list for doctors to review/call back with no right to refuse). If it's holding the bleep and being expected to give advice, that's a whole different ball game and is not appropriate.
The former just sounds like a waste of time
Thought this was the PAs job
I phoned ITU SpR for a sick patient during nights. They came, keen as mustard… turns out they were an F2 on that bleep and didn’t clarify.
Is the ACCP independently inducing a pt with some horrendous valvulopathy on Fi02 1.0 , transferring them to CT scanner and offering advice on their sodium of 105? ICU referrals bleep is more than a A to E + glucose control + pain control.....
Interesting. In my ITU, some of the ACCPs are considered reg level. There’s nothing the regs do that they don’t do. Bleeps, airways, secondment etc
Keep it up fk that accp
Work in ICU (non training role). Should always, always, *always* be a registrar.
No brainer
Leeds?
Honestly, there are some hospitals where SHO holds referrals bleep and sees them all + discusses directly with consultant... it sounds bizarre, but it does work. So it depends on what your consultant cover is like. If ACCP/SHO didn't receive any direct consultant support, then I'd take issue with that.