Training activity information
Details
Review and identify the characteristic features of a pH-impedance investigation, including:
- Swallows (gas and liquid)
- Reflux events (gas, liquid, mixed, acid, weakly acid and non-acid)
- Baseline impedance (normal, low and nocturnal)
- Artefacts
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.
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 visually inspecting and accurately identifying characteristic features on a pH-impedance trace.
- Consider how the learning outcomes apply, specifically in relation to analysing and interpreting pH-impedance data and producing complete reports and recognising artefacts and the impact of pharmacological interactions.
- Discuss with your training officer to gain clarity of what is expected of you in relation to understanding reflux event classification (e.g., acid, weakly acid, non-acid) and interpreting baseline impedance (normal, low, nocturnal).
- What is your prior experience of this activity?
- Think about what you already know about the physiological basis of swallows and reflux events, and the typical appearance of normal and abnormal findings on a pH-impedance trace.
- Consider possible challenges you might face during the activity, such as differentiating artefacts from physiological occurrences, or understanding how different medications might affect pH and impedance measurements.
- 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 if unfamiliar artefacts or highly complex findings compromise accurate interpretation.
- Acknowledge how you feel about gaining confidence in identifying diverse features on complex traces.
- What do you anticipate you will learn from the experience?
- Consider the specific skills you want to develop, such as visually inspecting and identifying features on a pH-impedance trace, and improving your ability to differentiate between physiological occurrences, device error, and artefacts.
- Identify the specific insights you hope to gain into the variability of pH-impedance traces across different patients and conditions.
- What additional considerations do you need to make?
- Consult actions identified following previous experiences of reviewing example pH-impedance traces or analysis guidelines.
- Identify important information you need to consider before embarking on the activity, such as reviewing relevant pharmacology related to upper GI disorders that patients undergoing pH-impedance might be taking.
In action
- Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate whilst reviewing and identifying characteristic features on the pH-impedance trace?
- Are you encountering situations such as:
- A significant, persistent artefact (e.g., high impedance noise) appears to mimic true reflux events, challenging accurate classification?
- Baseline impedance is unexpectedly low across most channels, complicating the assessment of mucosal integrity?
- The trace suggests a clear physiological signature (e.g., supragastric belching pattern) that was not anticipated by the referral or clinical notes?
- 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 data analysis methodology or artefact differentiation?
- Consider the steps you are taking in the moment, such as:
- Immediately cross-referencing the ambiguous signal against raw data and different display filters/time scales to differentiate artefact from true physiological occurrence.
- Pausing the review to consult diagnostic criteria for identifying specific, unexpected patterns like supragastric belching.
- How are you feeling in that moment? For instance, are you finding it difficult to robustly classify the reflux events due to persistent noise? Is it affecting your confidence in accurately assessing mucosal integrity based on baseline impedance?
- What is the conclusion or outcome?
- Identify how you are working within your scope of practice. For example, are you successfully differentiating between a movement artefact and a genuine gas swallow by comparing channels? Or are you needing support because the trace quality is so poor that routine artefact differentiation techniques fail, compromising the diagnostic value of the entire study?
- What are you learning as a result of the unexpected development? For example, are you mastering a more effective technique for visually inspecting and identifying features on a pH-impedance trace? Or gaining insight into the technical limitations of the recording equipment?
On action
- What happened?
- Begin by summarising the key steps you took when reviewing the pH-impedance investigations, focusing on features like swallows, reflux events (acid, non-acid), baseline impedance, and artefacts.
- Consider specific events, actions, or interactions which felt important, such as how you attempted to differentiate a true reflux event from an artefact or how you interpreted the baseline impedance.
- Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately cross-referencing an ambiguous signal against different display filters to differentiate artefact from true physiological occurrence.
- How did you feel during this experience, e.g., did you feel focused on differentiating features or challenged by the variability of patterns across different investigations?
- How has this experience contributed to your developing practice?
- Identify what learning you can take from this experience regarding data analysis and interpretation.
- What strengths did you demonstrate, e.g., systematically reviewing all four key features?
- What skills and/or knowledge gaps were evident, e.g., difficulty in confidently identifying persistent, complex artefacts?
- Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved?
- Has your practice improved in understanding reflux event classification (e.g., acid, weakly acid, non-acid) and baseline impedance patterns?
- Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding interpretation when pharmacological interactions may have affected the pH measurements, and how you reacted to this.
- What will you take from the experience moving forward?
- Identify the actions you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving your proficiency in identifying characteristic features of pH-impedance traces.
- What will you do differently next time you approach reviewing a pH-impedance investigation, for instance, by proactively reviewing literature on technical artefacts that mimic true reflux events?
- Do you need to practise any aspect of the activity further, such as differentiating between liquid, gas, and mixed reflux events or key learning outcomes related to recognising factors affecting results?
Beyond action
- Have you revisited the experiences?
- How have your subsequent experiences of performing complex pH-impedance monitoring or producing reports since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, having difficulty interpreting non-acid reflux patterns in a subsequent complex case forced you to re-evaluate the diligence of initial classification of baseline impedance and reflux characteristics during your first attempt at this training activity.
- Considering what you understand about data quality, artefact differentiation, and physiological features 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 systematic review of pH-impedance traces based on further learning and experiences? For example, how you proactively reviewed and integrated criteria for differentiating complex noise artefacts from true physiological events (e.g., gas swallows or belching), demonstrating you have adapted improvements based on further learning.
- Has discussing challenging artefacts or the complexity of reflux event classification 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 case where artefact was misclassified as a non-acid reflux event refined your understanding of the critical nature of meticulous feature identification before proceeding to full analysis.
- How have these experiences impacted upon current practice?
- How has the learning from this initial training activity, in combination with subsequent analysis of complex and atypical studies, contributed to your overall confidence and competence in identifying characteristic features and mitigating artefacts, particularly in preparing for assessments like Direct Observations of Practical Skills (DOPS)? For example, how your accumulated ability in rapidly identifying and differentiating swallows, reflux events, and artefacts now enables you to confidently review symptom association with reflux for a pH-impedance study during a DOPS assessment.
- How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to pH-impedance interpretation?
- 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 technical support immediately when a persistent, complex artefact compromises the interpretation of baseline impedance across multiple channels, recognising this falls outside routine review scope.
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 2 |
Outcome
Perform combined oesophageal pH-impedance monitoring in adult patients presenting with a wide range of conditions. |
| # 3 |
Outcome
Analyse and interpret the data producing complete reports for both high-resolution oesophageal manometry and oesophageal pH-impedance monitoring, making recommendations for subsequent management/treatment. |
| # 8 |
Outcome
Identify situations where physiological measurements are affected by pharmacological interactions and the impact this may have on test results. |