Advanced Practice - Venous —
Training activity: 1

Details

Triage incoming referrals for:

• DVT
• Deep venous insufficiency
• Superficial venous insufficiency

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 experience
• Patient pathways for acute and chronic venous disease referrals
• Local and national guidelines
• Alternative imaging investigations

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 DVT, deep venous insufficiency, and superficial venous insufficiency.
• Consider how the learning outcomes apply, specifically in relation to accurately assessing urgency and appropriateness of the referral and appraising the impact of national guidelines.
• 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 DVT versus routine insufficiency).

What is your prior experience of this activity?

• Think about what you already know about referral triage processes or venous disease indicators.
• Consider possible challenges you might face during the activity, such as ambiguous clinical information, managing high referral volume, or prioritising DVT over insufficiency cases.
• 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 an urgent DVT referral lacks critical information or when unclear guidelines necessitate clarification.
• Acknowledge how you feel about the responsibility of triaging time-critical DVT cases.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as critical review of clinical data and application of national guidelines to triage decisions.
• Identify the specific insights you hope to gain into referral management pathways and the impact of initial triage on patient management (e.g., DVT treatment pathways).

What additional considerations do you need to make?

• Consult actions identified following previous experiences of referral handling or similar administrative/clinical review tasks.
• Identify important information you need to consider before embarking on the activity, such as current local protocols, criteria for DVT urgency, and the latest national guidelines for venous disease assessment.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst triaging incoming referrals for DVT, deep or superficial venous insufficiency?
• Are you encountering situations such as:
  • Conflicting information where the urgency marked on the referral (e.g., routine) contradicts the stated clinical symptoms (e.g., high suspicion of acute DVT)?
  • Key clinical data (e.g., symptom onset, VTE risk factors) 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 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 DVT urgency criteria
• 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 ambiguous clinical details 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 venous referrals?

On action

What happened?

• Begin by summarising the key steps you took when reviewing and triaging incoming referrals for DVT, deep venous insufficiency, and superficial venous insufficiency.
• Consider specific events, actions, or interactions which felt important, such as how you ensured the clinical symptoms matched the urgency rating or how you handled a referral with ambiguous clinical details.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately escalating the priority of a referral when the symptoms suggested acute DVT, 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 venous referrals?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in 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 complex 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 documentation 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 venous disease or key learning outcomes related to understanding specific referral criteria for DVT or venous insufficiencies?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of triaging incoming referrals for venous disease 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 DVT symptoms 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 venous urgency guidelines, clinical risk assessment, and national guidelines 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, demonstrating you have adapted improvements based on further learning.
• Has discussing complex referral cases or the impact of inappropriate triage on patient management 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 delayed DVT case refined your understanding of the critical nature of meticulous referral risk assessment during planning.

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 venous referrals, particularly in preparing for assessments like Case-Based Discussions (CBDs)? 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 Observed Communication Event (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 thrombectomy outside of routine scanning pathways, recognising this falls outside routine 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 objectives related to reviewing and triaging lower limb venous disease? 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 venous disease.
# 9	Outcome Appraise the impact of research evidence on national guidelines.