Major Organs and Cancer —
Training activity: 3

Details

Identify cases that require urgent action and offer clinical advice on follow-up and further management

To include six of:

• DKA
• MI
• AKI
• Pancreatitis
• Hypo/hypernatraemia
• Hypo/hyperkalaemia
• Hypo/hypercalcaemia
• Refeeding

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Appropriate action for escalation
• Abnormal result
• Further tests
• Communication with the multidisciplinary team and service user

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to recognising urgent biochemical results (e.g., DKA, severe hypokalaemia, acute kidney injury) and offering appropriate clinical advice on follow-up and management.
• Consider how the learning outcomes apply, specifically in relation to interpreting data to identify urgency and applying knowledge of national guidelines to guide management
• Discuss with your training officer to gain clarity of what is expected of you in relation to the specific criteria for urgency and the acceptable scope and format for communicating clinical advice to clinicians.

What is your prior experience of this activity?

• Think about what you already know about urgent biochemical results, such as those related to acute electrolyte imbalances (hypo/hypernatraemia) or Diabetic Ketoacidosis (DKA).
• Consider possible challenges you might face during the activity, such as recognising subtle biochemical indicators of urgency, communicating effectively with clinical teams under pressure, or navigating complex management pathways (e.g., refeeding syndrome).
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example when the severity of a case (e.g., acute pancreatitis) requires immediate escalation to the duty biochemist rather than offering initial advice yourself.
• Acknowledge how you feel about undertaking this potentially high-pressure and critical patient safety activity.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as rapidly recognising urgent biochemical patterns (e.g., Myocardial Infarction markers) and communicating their clinical significance concisely.
• Identify the specific insights you hope to gain into the clinical management of the listed urgent conditions and applying relevant national guidelines in a real-time setting.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of managing urgent results or providing clinical communication.
• Identify important information you need to consider before embarking on the activity, such as clinical algorithms or protocols for identifying urgent cases, communication channels for contacting clinicians, and ensuring access to relevant national guidelines (e.g., for AKI or DKA).

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst screening incoming results for critical findings (e.g., DKA, MI, AKI, electrolyte imbalances)?
• Are you encountering situations such as:
  • A result is near a critical limit (e.g., borderline severe hypokalaemia) where urgency is unclear without further clinical context?
  • You identify a pattern (e.g., significant metabolic acidosis or hyperosmolarity) that requires urgent action for a condition (e.g., DKA) that was not explicitly suspected on the request form?
  • You are unsure of the appropriate immediate clinical advice to offer for a complex urgent case like refeeding syndrome or acute kidney injury (AKI)?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to prioritising communication or consulting urgent clinical guidelines?
• Consider the steps you are taking in the moment, such as:
  • Immediately contacting the clinical area to verify the patient’s condition (e.g., consciousness level) before escalating the result
  • Consulting the departmental critical result protocol or national guidelines (e.g., DKA, AKI) to formulate initial clinical advice
• How are you feeling in that moment? For instance, are you finding it difficult to formulate concise and actionable clinical advice? Is it affecting your confidence in assessing the true clinical urgency?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully identifying a critical result (e.g., severe hyperkalaemia) and escalating it according to protocol? Or are you needing support because the complexity of the advice required for a high-stakes case (e.g., acute pancreatitis) exceeds your current scope?
• What are you learning as a result of the unexpected development? For example, are you mastering the rapid recognition of myocardial Infarction markers or DKA patterns? Or gaining insight into the critical timing and judgment required for effective communication of urgent advice?

On action

What happened?

• Begin by summarising the key steps you took when reviewing results to identify urgent cases (e.g., DKA, MI, AKI, severe electrolyte imbalance) and formulating clinical advice.
• Consider specific events, actions, or interactions which felt important, such as the process used to confirm a suspected DKA case using critical thresholds or the communication steps you followed when escalating a critical electrolyte result.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately seeking senior review when uncertain about the appropriate advice for a complex urgent scenario like Refeeding Syndrome.
• How did you feel during this experience, e.g., did you feel calm and focused when handling the urgent case escalation or anxious when formulating initial clinical advice without immediate senior input?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding identifying urgency and applying national guidelines to management. What strengths did you demonstrate, e.g., rapid recognition of critical result patterns (e.g., MI markers or severe electrolyte imbalance)?
• What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the specific specifics of providing advice for rare or highly complex acute cases (e.g., acute pancreatitis)?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in adhering to critical result reporting protocols?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding whether the complexity of the case exceeded your delegated authority for offering clinical advice, and how you reacted to this.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving the efficiency and accuracy of urgent case escalation and advice provision.
• What will you do differently next time you approach managing a suspected urgent case, for instance, by proactively reviewing the relevant national guidelines (e.g., AKI staging) before communicating initial advice?
• Do you need to practise any aspect of the activity further, such as role-playing the communication of urgent advice to clinical teams or key learning outcomes related to applying knowledge of national guidelines to guide management?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of handling acute clinical liaison calls or attending urgent patient management clinics since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how a subsequent urgent case involving severe hypo/hyperkalaemia forced you to re-evaluate the speed and clarity of your critical result communication and the scope of advice offered during your first attempt at identifying and managing an urgent case.
• Considering what you understand about rapid clinical assessment, the pathophysiology of urgent conditions (e.g., DKA, MI, AKI), and effective communication under pressure now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your vigilance for critical results and protocol adherence based on further learning and experiences? For example, how you proactively reviewed and integrated national guidelines for refeeding syndrome management to inform the structure of clinical advice provided to ward staff.
• Has discussing specific urgent cases or the responsibilities of the duty biochemist role with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a delay in managing an acute pancreatitis case due to ambiguous initial advice refined your understanding of the critical nature of clear, actionable clinical liaison.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent urgent result management and clinical liaison experiences, contributed to your overall confidence and competence in rapid assessment and communication of critical findings, particularly in preparing for assessments like Observed Communication Events (OCEs)? For example, how your accumulated ability in rapidly identifying critical result patterns (e.g., DKA or severe hypokalaemia) and formulating immediate management advice now enables you to confidently and clearly escalate urgent findings during an OCE assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to identifying and advising on urgent biochemical cases? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the Training Officer or duty biochemist immediately when assessing the clinical urgency of a complex case (e.g., refeeding syndrome or acute pancreatitis), recognising this requires expert clinical consultation and falls outside routine critical result notification scope.
• Looking holistically at your training journey, how has this initial urgent case identification experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to analysing and interpreting biochemical data and applying knowledge of national guidelines to guide management? For example, how this foundational experience has supported your development in understanding the clinical impact of biochemical results and practicing effective communication with clinical staff, crucial for future advisory responsibilities.

Relevant learning outcomes

#	Outcome
# 2	Outcome Analyse and interpret biochemical data generated in the assessment of major organ function and cancer diagnosis and monitoring.
# 3	Outcome Evaluate the national guidelines for diagnosis and management of diseases associated with the major organ systems and cancer.