Advanced Practice - Arterial —
Training activity: 1

Details

Triage incoming referrals

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

• Prioritisation and escalation
• Managing inappropriate referrals
• Patient pathways
• Clinical presentation
• Patient experience
• Alternative imaging investigations
• Record keeping and documentation
• Local and national guidelines

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 effectively reviewing and triaging referrals for lower limb arterial disease.
• Consider how the learning outcomes apply, specifically in relation to accurately assessing the urgency and appropriateness of the referral based on clinical information.
• Discuss with your training officer to gain clarity of what is expected of you in relation to expected turnaround times and criteria for different triage categories (e.g., urgent vs. routine) for lower limb arterial disease.

What is your prior experience of this activity?

• Think about what you already know about referral triaging or common signs and symptoms of lower limb arterial disease.
• Consider possible challenges you might face during the activity, such as incomplete referral information, ambiguous clinical details, or conflicting priorities.
• 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 you need to escalate a referral or seek clarification from referrers.
• Acknowledge how you feel about the responsibility of triaging referrals, given its impact on patient pathways.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as improving your ability to critically evaluate expected underlying haemodynamics and pathology.
• Identify the specific insights you hope to gain into referral pathways and how initial triage influences patient management and outcomes.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of similar administrative or patient management tasks related to information gathering or decision-making.
• Identify important information you need to consider before embarking on the activity, such as reviewing specific departmental guidelines on referral management or common arterial disease presentations.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst triaging incoming referrals?
• Are you encountering situations such as:
  • The urgency indicated on the referral form (e.g., marked as routine) contradicts the stated clinical symptoms (e.g., high-risk critical limb ischaemia symptoms)?
  • Key clinical information, such as the onset date of symptoms or previous interventional history, is missing or ambiguous, complicating the assessment of clinical priority?

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 verifying the clinical details or assigning the triage category?
• Consider the steps you are taking in the moment, such as:
  • Immediately documenting the ambiguous clinical priority and contacting the referrer to obtain clarification on the urgency status
  • Halting the triage process for that patient to cross-reference departmental guidelines regarding critical limb ischaemia definitions
• How are you feeling in that moment? For instance, are you finding it difficult to remain objective when presented with confusing or conflicting information? Is it affecting your confidence in assigning the correct priority?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully re-prioritising the patient’s appointment time based on verbal clinical clarification? Or are you needing support because the clinical details are ambiguous and require senior sign-off before a high-risk triage category can be assigned?
• What are you learning as a result of the unexpected development? For example, are you mastering a more efficient technique for vetting the completeness of a referral form? Or gaining insight into the critical factors that define urgent vs. routine lower limb arterial disease referrals?

On action

What happened?

• Begin by summarising the key steps you took when reviewing and triaging incoming referrals for lower limb arterial disease.
• Consider specific events, actions, or interactions which felt important, such as how you ensured the clinical details matched the urgency rating or how you initiated contact with the referrer to clarify ambiguous information.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately elevating the priority of a routine referral when the clinical symptoms suggested acute limb ischaemia, complicating the initial triage decision.
• How did you feel during this experience, e.g., did you feel stressed by the logistical challenge or confident in your knowledge of triage guidelines?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding referral triage. What strengths did you demonstrate, e.g., meticulous attention to detail in cross-referencing clinical symptoms against procedural expectations?
• What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the specific departmental criteria for escalating critical limb ischaemia referrals?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in accurately assessing the urgency and appropriateness of the referral?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding escalating a referral due to ambiguous clinical details, 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 your triage decisions.
• What will you do differently next time you approach referral triage, for instance, by proactively structuring a template for documenting conversations with referrers to clarify conflicting information?
• Do you need to practise any aspect of the activity further, such as reviewing the common presentations of lower limb arterial disease or key learning outcomes related to accurately assessing the urgency and appropriateness of the referral?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of triaging incoming referrals since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where a subsequent urgent referral required immediate escalation due to critical limb ischaemia forced you to re-evaluate the initial quick prioritisation methodology you applied during your first attempt at this training activity.
• Considering what you understand about referral urgency criteria, patient pathways, and clinical risk assessment 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 referral triage process based on further learning and experiences? For example, how you proactively implemented a mandatory secondary check of clinical symptoms against the urgency categorisation to minimise errors in patient priority.
• Has discussing challenging referral cases or the impact of inappropriate triage on patient waiting lists 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 time when a delayed referral led to a critical patient outcome refined your understanding of the critical nature of meticulous referral risk assessment.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent triage experiences, contributed to your overall confidence and competence in accurately assessing and prioritising vascular referrals, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated ability in assessing referral urgency now enables you to confidently communicate with a referrer to gather more information regarding a referral 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 triage incoming referrals? 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 immediately when clinical details suggest pathology requiring immediate surgical intervention outside of routine scanning pathways, recognising this falls outside routine referral triage scope.
• Looking holistically at your training journey, how has this initial triage incoming referrals experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to communicating effectively with a range of patients and other professionals? For example, how this foundational experience has supported your development in recognising and communicating clinical urgency.

Relevant learning outcomes

#	Outcome
# 1	Outcome Review and triage referrals for lower limb arterial disease.