DRAFT. Curriculum for training in respiratory paediatrics in the UK. April 2007

Transcription

1 Page 1 of 45 Draft competencies 21/06/2007 DRAFT Curriculum for training in respiratory paediatrics in the UK April 2007 Members of the College Specialist Advisory Committee have drawn up this curriculum. It is intended as a guideline for trainees and trainers and is summarised in the RCPCH document Framework of Competencies for Respiratory Paediatrics.

2 Page 2 of 45 Draft competencies 21/06/2007 DRAFT FOR PILOTING CURRICULUM AND COMPETENCY-BASED ASSESSMENT FOR RESPIRATORY GRID TRAINEES APRIL 2007 The 2002 curriculum for Respiratory trainees specifies obligatory and desirable modules. This curriculum has been updated by the respiratory CSAC (2006). This new curriculum is more specific about the training that is required and the evidence of training and competence that the trainee should provide. Although trainers will be not be fully conversant in competency assessment (CA), CA will eventually become standard in all specialties at all grades Peer appraisal (360 appraisal) has already begun. The CA methods enclosed with this curriculum are, at this stage, suggestions. It is important to pilot these. CBD Case Based Discussion Mini-CEX Mini-Clinical Evaluation Exercise DOP Directly observed Procedures SAIL Sheffield Assessment Instrument for Letters Trainees are already expected to keep a portfolio which documents their training. Some trainees portfolios have become large and unwieldy. Perhaps now is the time for trainees to 1) keep most of their records electronically, 2) to manage references in a recognised database eg Reference Manager and 3) to keep electronic downloads of papers, guidelines, Cochrane reviews and other learning materials, properly indexed for review by assessors. Each year the trainee should complete the assessment enclosed with the curriculum. It is important to know what is expected at the start of training and so as part of the goal-setting the trainee should read the curriculum and the assessment document. knowledge of each topic and competencies will be acquired over a three year period. Trainers in the future will need to be trained in competency assessment. They should also become comfortable with reviewing electronic records of training portfolios. It is hoped that this approach to training is suitable for life-long learning and revalidation. It is intended that this curriculum be issued to 2006 grid trainees as a pilot. All trainees and their trainers will be asked for feedback after the first year. The RCPCH is preparing curricula for all sub-specialties which are summaries of competencies required. This more specific document spells out what is required in more detail.

3 Page 3 of 45 Draft competencies 21/06/2007 Obligatory modules A A General competencies and skills A1. In-patient Management A2. Out-patient management B Specific competencies and skills B1. Lung function measurements in schoolchildren B2. Flexible bronchoscopy B3. Imaging of the lung B4. Aerosol Therapy C Diagnosis and management of specific disorders C1. Allergy and respiratory disorders C2. Congenital malformations C3. Asthma and the other wheezing disorders of childhood C4. Chronic lung disease of prematurity C5. Cystic fibrosis C6. Acute and chronic infection C7 Tuberculosis C8 Management of technology dependent children C9 Sleep medicine in children D Management and teaching skills D1 Management and Leadership D2. Teaching D3 Evidence-based Medicine E Research Desirable modules 1. Lung Function Measurements in Infants 2. Management of children with Immune deficiency 3. Lung transplantation 4. Exercise testing awaited 5. Chest physiotherapy for paediatric respiratory diseases and their complications No competency assessments Sheila McKenzie, Chair Respiratory CSAC April 2007

4 Page 4 of 45 Draft competencies 21/06/2007 DRAFT Competencies for accreditation in respiratory paediatrics UK sub-specialty advisory committee A General competencies and skills Obligatory Modules A1. In-patient Management, including A&E and ambulatory care and respiratory care of children in high dependency units Resources: Must spend at least 12 months at an accredited centre with at least two respiratory trainers. It is recognised that with shift systems and the need to cover general paediatrics the trainee will have other commitments and training opportunities during this attachment. Competencies: 1. Determine the need for admission when assessing those referred, including psychosocial impact on need as well as medical need. CBD 2. Determine, plan and explain to families the appropriate investigations and treatment. CBD, Mini-CEX 3. Recognise and manage severe and/or deteriorating respiratory problems including the need for and implementation of invasive and non-invasive ventilatory support CBD, Mini- CEX. 4. Liaise with the multidisciplinary team caring for the patients Give discharge advice to families with acute or chronic respiratory problems and arrange follow up as necessary. 360, CBD 6. Communicate with the primary care team about the patient s future management. Review of SAIL letters Assessment: 1. Portfolio of at least 50 cases of which 5 should be reflective notes should be available. These should demonstrate evidence based practice eg management of bronchiolitis, pneumonia, acute asthma, stridor, upper airway obstruction, pneumothorax. 2. At least 5 observed episodes of interaction with families eg on explaining tests, explaining diagnosis / differential or giving discharge advice. Satisfactory completion certified by tutors.

5 Page 5 of 45 Draft competencies 21/06/2007 A2. Out-patient management Resources Training should be in 2 specialised respiratory outpatient clinics each week seeing both new referrals and follow-up visits. DOP Competencies 1. The trainee should have an up-to-date understanding of respiratory symptoms and noises including: snoring, congestion/rattles, stridor, wheeze, grunting and problem coughing. 2. Organise investigations to aid diagnosis or to measure disease severity. 3. Understand the diagnostic accuracy of investigations 4. Recommend and institute age related disease-specific treatments. 5. Follow-up monitoring of disease progress and for adherence to and side-effects of treatment 6. Identify factors, complications and co-existent conditions that make the management of a disorder difficult (.e.g asthma) 7. Communicate effectively with primary care and multi-disciplinary team 360 and reflective notes and SAIL letters 8. Identify and manage where appropriate unrelated conditions Teach the topic and CBD Assessment: 1. Portfolio of 50 cases managed (log book) together with SAIL clinic letters 2. Prepare and deliver a treatise or presentation on each of the specific conditions that are investigated and followed up at the Outpatients 3. Signed off when supervisor considers that the trainee is able (on his/her own) to: a. safely see new respiratory referrals (make diagnosis, order investigations, institute treatments and communicate findings and plans to children/parents), b. provide follow up monitoring related to the specific problem. c. know when to discharge back to primary care. Specific conditions which should all be represented in the portfolio (see following sections) 1. Asthma (including infant and pre-school wheezing) 2. Problem coughing 3. Cystic Fibrosis 4. Chronic suppurative lung disease ( non-cf bronchiectasis) 5. Rarer chronic lung disease (pulmonary haemosiderosis, ILD pulmonary hypertension) 6. Congenital thoracic malformations 7. Neuromuscular disorders 8. Children with immunodeficiencies 9. TB 10. Sleep disordered respiration (OSAS) 11. The child with recurrent lung infections or pulmonary infiltrates

6 Page 6 of 45 Draft competencies 21/06/2007 B Specific competencies and skills B1. Lung function measurements in schoolchildren: Before making measurements in children trainees should consider attending an adult lung function laboratory where they can gain experience. Where there is a busy children s lung function laboratory this may not be necessary. They should then make measurements under the supervision of a lung function technician or clinical physiologist. 1. Should demonstrate an understanding of the underlying physiology - flow-volume curves, measurement of lung volumes, the principles of bronchial lability, and ventilation, perfusion and gas exchange 2. Understand the correct use of reference data 3. Understand within and between occasion repeatability and how these are expressed 4. Understand the diagnostic accuracy for common disorders and limitations of the test Laboratory skills 1. Undertaking spirometric testing, measurement of bronchodilator responsiveness,measurement of lung volumes, bronchial responsiveness (by any one method) and assessing fitness to fly. 2. Knowing which reference data are available 3. Knowing when tests are acceptable 4. Knowing how to calibrate equipment 5. Knowing risk management issues for laboratories 6. Knowing maintainence costs and estimates of cost of each test Portfolio Assessment : The trainee should be considered competent when they can teach the respiratory physiology underlying the tests, and their accuracy, to peers The trainee should be considered competent when the laboratory technician and educational supervisor consider they are proficient and knowledgeable in laboratory skills, can report studies and can teach basic lung function to junior doctors. The trainee is not expected to be as proficient as a lung function technician but should know enough to set standards in their own laboratory. Assessment of knowledge Questions 1 and 2

7 Page 7 of 45 Draft competencies 21/06/2007 B2. Flexible bronchoscopy 1. The trainee should be familiar with the indications, contraindications, risks and complications of bronchoscopy in children and be able to explain these to parents. CBD 2. He/she should be familiar with the indications for rigid bronchoscopy and nonbronchoscopic lavage and have seen these procedures performed on at least one occasion. CBD 3. He/she should be familiar with different procedures performed during bronchoscopy such as BAL, mucosal and TBBs, bronchography etc. Written evidence/portfolio 4. The trainee should be familiar with the maintenance and cleansing of equipment. He/she should be aware of risks of cross infection and how to minimise these. Written evidence/cbd 5. He/she should have some knowledge of processing techniques used in the laboratories and ideally witness these being performed on at least one occasion. Portfolio Clinical skills 1. He/she should have witnessed 50 bronchoscopies in children and visualised all of the common abnormalities encountered in routine clinical practice. 2. He/she should have performed at least 25 bronchoscopies under supervision and in the opinion of the supervisor to be competent to perform procedures without further supervision. DOP Assessment of knowledge Question 2

8 Page 8 of 45 Draft competencies 21/06/2007 B3. Imaging of the lung 1. The trainee should understand the value of a chest radiograph in the diagnosis and management of common conditions such as chest infection and wheezing disorders and be conversant with opinions expressed in evidence-based guidelines 2. The trainee should know the comparative radiation burdens of the different chest imaging procedures. There should be written evidence in the trainee s portfolio Clinical skills 1. The trainee should attend radiology rounds, and evaluate chest radiographs under supervision. 2. Additional experience in evaluating CT scans of the lung and MR images of the mediastinum is mandatory. 3. The trainee will be competent to select the appropriate imaging investigation for different clinical scenarios. 4. He/she will be able to evaluate chest radiographs and CT scans of the chest. Assessment: The trainee will regularly evaluate radiographs at a respiratory X ray meeting, under supervision of the module leader(s) who will assess competence at interpreting chest radiographs and CT scans of the chest. The trainee will be able to choose imaging investigations, and will be familiar with the appropriate use of ultrasound, isotope scanning and MRI scanning of the chest, as well as various CT scanning modalities. CBD, Mini-CEX

9 Page 9 of 45 Draft competencies 21/06/2007 B4. Aerosol Therapy 1. An understanding of the science of aerosol delivery and its limitations in children 2. An understanding of the differences the difference between dry powder treatment, nebuliser treatment and aerosol treatment Clinical skills 1. The delivery of therapy to children of different ages 2. Instruction of children, parents, nurses and doctors in the use of inhalers and devices. Assessment: The trainee will be observed in a clinic setting and also in a teaching session giving advice and information. The portfolio will contain copies of scientific papers on drug delivery detailing the science. CBD, Portfolio

10 Page 10 of 45 Draft competencies 21/06/2007 C Diagnosis and management of specific disorders C1. Allergy and respiratory disorders The training will focus on children with asthma and allergic disease of the upper airways, but should also include non-respiratory allergic disorders. 1. Atopic and non-atopic asthma 2. Allergic inflammation 3. The genetics of allergy 4. The epidemiology of allergy 5. The allergic march 6. The allergic history and when to refer for challenge testing 7. The meaning and validity of test positivity Written evidence/portfolio/cbd Clinical Skills 1. Undertaking skin prick testing and the proper care of allergens 2. The place of specific IgE testing 3. The cost of tests Written evidence/cbd/portfolio 4. The use of corticosteroids in asthma, hay fever and eczema 5. The place of antihistamines in seasonal and chronic rhinitis 6. Basic management of eczema 7. Avoidance measures 8. Be able to discuss the role of immunotherapy with families 9. Alternative therapies and allergy CBD Assessment: 1.The trainee should be considered competent when they can teach basic allergy and its relationship to respiratory disease to peers. 2.The trainee should be considered competent when the laboratory technician considers they can undertake and properly report these tests

11 Page 11 of 45 Draft competencies 21/06/2007 C2. Congenital malformations 1. The trainee should understand the aetiology and genetics of the congenital malformations of the lung and chest wall 2. They should know how the congenital malformations effect lung function Clinical skills 1. The trainee should be familiar with the diagnosis of all the major congenital upper and lower respiratory tract abnormalities including laryngomalacia, Pierre-Robin sequence, large airway malacias, congenital lobar emphysema, cystic adenomatoid malformation and pulmonary sequestration and the malformations which cause stridor. Mini-CEX CBD 2. He/she should be familiar with the use of relevant diagnostic techniques including CT, angiography and bronchoscopy and the principles of microlaryngoscopy. CBD 3. He/she should be familiar with the principles underlying medical and surgical management Written evidence 4. He/she should have had practical experience in the initial assessment and follow up of the major congenital abnormalities to the satisfaction of his/her supervisor. Portfolio

12 Page 12 of 45 Draft competencies 21/06/2007 C3. Asthma and the other wheezing disorders of childhood The trainee should 1. understand the difficulties in the diagnosis and know how and when to investigate for alternative diagnoses 2. understand the underlying abnormalities in lung function 3. recognise the asthma phenotypes, their different pathologies and long term outcome 4. know the epidemiology of the wheezing disorders of childhood 5. know the pharmacology of both common and unusual asthma medication Clinical skills 1. understand the management of infants and older children with acute wheezing disorders, including bronchiolitis and acute severe asthma Mini-CEX 2. To manage chronic infant wheezing/asthma in a clinic setting Mini-CEX/CBD 3. To evaluate difficult asthma, arrange investigations and understand potential further treatments. Mini-CEX/CBD 4. To know the evidence basis for asthma treatments at different ages Written evidence in posrtfolio Assessment 1. See Module 2 2. Consultant respiratory paediatrician should be satisfied with outpatient management of 20 cases of chronic asthma/infant wheezing. 3. Trainee should prepare presentation of one case of difficult asthma and be able to discuss investigations and treatment. All recorded in portfolio

13 Page 13 of 45 Draft competencies 21/06/2007 C4. Chronic Lung Disease (CLD) of Prematurity The trainee should know 1. the aetiology and pathogenesis of CLD. 2. current stategies and therapies used in Neonatal intensive Care Units to try a prevent CLD occurring and the evidence base underpinning this. Written evidence in portfolio Clinical skills 1. The trainee should have managed the respiratory and nutritional care of babies baby with CLD. This should include managing the discharge and home care planning process (including ventilatory support, home oxygen therapy, pharmacological treatments and outpatient monitoring of progress) and follow-up. The trainee should have visited at least two homes of children on oxygen therapy. Mini-CEX/CBD 2. The trainee should have an understanding of the problems (including investigations and treatments) or complications and co-morbidities that slow the resolution of CLD. These include airways disorders, recurrent pulmonary aspiration, infections and pulmonary hypertension. Assessment: 1. Presentation to peer audience at SpRs/Consultant level. 2. The trainee should be considered competent when the accredited supervisor considers that the trainee is competent to manage babies with CLD of prematurity unsupervised. (Supervisor may be a neonatologist or respiratory paediatrician). Portfolio with reflective notes

14 Page 14 of 45 Draft competencies 21/06/2007 C5. Cystic fibrosis Training will be in a Regional Cystic Fibrosis Centre with a minimum of 50 patients. Must spend at least 12 months with a major input into CF unit. The trainee should understand 1. the genetics and pathophysiology of CF 2. the reasons for the long-term complications and the strategies of how to prevent them. 3. the pharmacology and side-effects of drugs used in CF Clinical Skills The trainee should 1. Know how to counsel parents expecting child with CF. 2. Be able to Interpret newborn screening information. 3. Know how to counsel parents of newly diagnosed child. 4. Be able to initiate treatment plan for a child newly diagnosed. 5. Be able to complete annual comprehensive assessment. 6. Be able to assessment of child with respiratory exacerbation. 7. Be able to use imaging investigations for children with CF properly 8. Know how to initiate discussion re:transplant 9. Know how to deliver terminal care. 10. Be able to manage psychosocial issues and specifically issues affecting teenagers. 11. Have been involved in handover clinics with Adult Physicians. 12. Be able to manage needle phobia. 13. Be able to discuss risks/benefits of access devices. 14. Be abel to manage portacaths. 15. Be able to insert long lines 16. Be able to assess and treat CF related bowel obstruction, liver disease, diabetes mellitus and bone disease. 17. Develop knowledge and understanding of the cost of care. Mini-CEX, CBD and written evidence in portfolio Assessment: Portfolio with reflective notes and copies of clinic notes and inpatient assessments to cover the above competencies. 360 appraisals with cf team, teach the topic and satisfactory completion certified by tutors.

15 Page 15 of 45 Draft competencies 21/06/2007 C6. Acute and chronic infection The trainee 1. Should demonstrate an understanding of the epidemiology of common respiratory infections, including TB 2. Should have knowledge of methods of microbiological diagnosis and the range of pathogens causing respiratory illness in children 3. Should have a knowledge of the pharmacology of antibiotic and antiviral therapy used for respiratory infections in children 4. Have a working knowledge of methods of transmission or respiratory illness and the risks and prevention of cross-infection Written evidence in portfolio/demonstration of understanding at department meeting Clinical Skills The trainee should be familiar with the diagnosis and management of common respiratory infections including: 1. upper respiratory tract respiratory illness 2. croup 3. viral bronchiolitis 4. all forms of pneumonitis, including lung abscess 5. empyema 6. bronchiectasis 7. the diagnosis and management of respiratory infections in high risk situations especially the child with CF and the immunosuppressed child risk CBD/mini-CEX Practical skills 1. Performing naso-pharyngeal aspirate and washings 2. Taking a cough and a pernasal swab 3. Performing a diagnostic pleural tap and inserting a chest drain 4. Bronchoscopic bronchoalveolar lavage DOP by supervisor or by nursing, paramedical and radiology staff. Assessment The trainee should be considered competent when they can teach about respiratory information to their peers, i.e. other respiratory trainees, or MRCPCH candidates, drawing on a library of interactive teaching slides, where appropriate. This should be confirmed by their supervisor and recorded in the log book.

16 Page 16 of 45 Draft competencies 21/06/2007 C7 Tuberculosis The trainee should 1. Know the epidemiology of TB 2. Understand the differences between primary and post-primary TB and their infectivity 3. Understand the development of tuberculin sensitivity 4. Understand the limitations of current diagnostic methods Clinical skills 1. Practical experience of contact tracing in children exposed to tuberculosis by spending time with a TB liaison nurse 2. Ability to perform and interpret tuberculin skin testing 3. Ability to perform BCG vaccination 4. IP and OP management of children with TB infection and disease including knowledge of relevant diagnostic strategies and recommended current management DOP/miniCEX Assessment: The trainee should be considered competent when they have satisfactorily completed the following objectives: 1. Completion of 10 Tuberculin skin tests confirmed by senior clinician involved in regularly performing skin tests 2. Satisfactory administration of 5BCG vaccinations confirmed by senior nurse regularly performing BCG 3. Management of 5 cases of latent TB and 2 cases of paediatric tuberculosis confirmed in portfolio of cases by clinic documentation

17 Page 17 of 45 Draft competencies 21/06/2007 C8 Management of technology dependent children For this module, the trainee should be in a paediatric respiratory centre that is regularly involved in the initiation and review of chronic ventilatory children requiring chronic ventilatory support. The trainee should 1. Understand the pathophysiology of chronic respiratory failure in children. 2. Know the developmental changes in respiratory physiology and how these impact on vulnerability to chronic respiratory failure during childhood. 3. Understand the methods used in the diagnosis and monitoring of ventilation in children, and their limitations. 4. Understand the principles and working of the commonly used ventilatory modalities including CPAP, BiPAP, and pressure and volume support 5. Know about the interfaces used in non-invasive ventilation in children 6. Understand the place of long term oxygen therapy in children with chronic respiratory failure Written evidence in portfolio/demonstration of understanding Clinical skills The trainee should develop: 1. Sound knowledge and practical experience of the diagnosis, assessment and management of children with chronic respiratory failure including specifically children with: neuromuscular disorders ventilatory control disorders severe chronic lung disease severe obstructive sleep apnoea and/or craniofacial anomalies unresponsive to adenotonsillectomy Mini-CEX/CBD 2. Practical experience of long-term ventilatory support in children including the choice and set up of equipment, discharge planning, and follow-up and troubleshooting Mini- CEX/CBD 3. Practical experience in the prescription, initiation, and supervision of children who require home oxygen therapy. Mini-CEX/CBD 4. Knowledge of principles and practice of tracheostomy care in children DOP/CBD Assessment: The trainee should complete 3 detailed case histories of children which the trainee has been involved in: 1. The care of a child who is diagnosed as having chronic respiratory failure and is started on long term ventilation 2. A clinical problem in a child on long term ventilation 3. A child who requires to be established on long term oxygen therapy Mini-CEX/CBD

18 Page 18 of 45 Draft competencies 21/06/2007 C9 Sleep medicine in children The trainee should 1. Know the physiology of sleep at different ages, sleep stages, their effects on cardiorespiratory status and changes with age. 2. Know what clinical conditions disturb sleep and in particular those which result in airway obstruction and central apnoea 3. Know which medical conditions are likely to give the different clinical pictures 4. be familiar with the advantages and disadvantages of polysomnography, abbreviated montage and oxygen downloads Written evidence in portfolio Clinical skills The trainee should be able to 1. take a sleep history 2. set up a sleep study 3. score respiratory events 4. report sleep studies 5. assess clinical status for intervention DOP/CBD Assessment: The trainee will be observed sleep histories mini-cex 2. 5 sleep studies undertaken by the trainee (including measures of airflow, effort, oximetry, ECG, capnography and movement), to include description of set up, results, scoring and reporting. These studies may be supervised. DOP

19 Page 19 of 45 Draft competencies 21/06/2007 D Management and teaching skills D1 Management and Leadership Tertiary respiratory centres are part of the whole NHS network and as such need to be managed and need to be accountable. Delivery of health care The trainee should know 1. The purpose of a business case, a) how to work with managers to develop a business case for development of a tertiary respiratory centre b) the steps through to approval of the business case 2. How to set up care pathways particularly for children with chronic respiratory disease 3. The importance of clinical networks a) Clinical Trial networks. b) Neonatal networks. c) BPSU respiratory issues Evidence in portfolio of training and experience in these competencies Database competences Competencies in relation to audit a) How to set up a database for specific patient details. b) Keeping a personal database of references and learning materials c) Understanding and participating in the Dundee/National CF database. Evidence in portfolio of training and experience in these competencies The trainee needs to understand how to work with the hospital audit department to develop specific audits relating to respiratory paediatric diseases. a) Show development of audit. b) Present locally. (At least 1 audit completed and presented per year.) c) Involvement in regional/national respiratory audit (e.g. asthma admission) General competencies a) How to manage critical incidents b) How to chair meetings c) How to resolve conflict a) the handling of complaints, b) difficult patients c) difficult trainees d) trainees in difficulty

20 Page 20 of 45 Draft competencies 21/06/2007 D2. Teaching The trainee should 1. Attend a Teaching the Teacher course 2. Develop competencies to draw up plans for a) Bedside tuition. b) Small group/tutorial discussions. c) More formal lectures. 3. Show how preparation and delivery of the teaching would vary dependent on the audience. (medical student, nurse, post-medical, etc.) a) Ten sessions taught in at least 2 different respiratory modules. b) Teaching in both undergraduate and graduate settings 4. Appraising and assessing junior doctors 5. Case-based discuaaion 6. Mini-Cex 7. DOP 8. Open appraisal Evidence in portfolio of training and experience in these competencies D3 Evidence-based Medicine The trainee should 1. Know the evidence base for the investigation and management of respiratory diseases. 2. How to access and use different evidence databases eg the Cochrane Database. 3. Keep up-to date electronic copies of EBG 4. These should be easily accessible and organised Written evidence in portfolio E Research It is hoped that a trainee is able to take out-of-programme experience in order to undertake a higher degree. Rules about the time that this can be done may change. The trainee should 1. Attend a basic research course to give competencies on understanding a) The process b) Basic statistics c) Protocol development d) Research governance 2. Demonstrate involvement in research undertaken in training centre. \Portfol a) Present data at a national or international conference. b) Submission and acceptance by medical journal of original research with trainee as main/first author. (At least two, preferably more papers).

21 Page 21 of 45 Draft competencies 21/06/ Lung Function Measurements in Infants Desirable modules It would be helpful if trainees had already completed the module on lung function measurements in schoolchildren prior to that relating to infancy. Some neonatal experience would also be helpful but not essential. Few centres in the UK have a laboratory where infant lung function testing takes place. The time taken for the trainee to learn, apply and become skilled in some of the more complex techniques is such that it should not be mandatory for them to achieve a high level of practical expertise. The trainee should nevertheless have observed the preparation, execution, analysis and reporting of such complex investigations and have some practical experience of tests that are less demanding to perform. Tests of infant lung function can usually be classed according to whether they are assessing: Lung volume plethysmography gas dilution multibreath washout Compliance of lungs/respiratory system Airway function squeeze plethysmography Rint Gas mixing Trainees should have experience of measurements in at least 3 of these 4 areas, including practical experience of at least 2 areas of investigation. Experience would involve observing the measurement on a minimum of 5 patients, writing a summary of the rationale for the investigation and the findings, and presenting the same at an appropriate in-house clinical meeting. Practical experience would involve performing measurements under the direct instruction and observation of a skilled operator. Such practical experience would include the setting-up and calibration of the equipment and the trainee should also be familiar with the cleaning and maintenance requirements of the equipment. An important aspect of many infant lung function tests is the requirement for sedation. Trainees should be familiar with the sedatives used routinely, including the appropriate doses for different infants and investigations, and any contraindications for sedation. Theoretical Basis of Infant Lung Function Tests The trainee should be able to (i) describe the nature and purpose of each test to the parents; (ii) explain the theoretical basis of each test to a trainee of similar experience; (iii) interpret the findings of each test in relation to predicted measurements (where available and appropriate); (iv) discuss the usefulness of lung function tests in specific clinical scenarios and in a research setting.

22 Page 22 of 45 Draft competencies 21/06/2007 Assessment of competence The trainee should be considered competent when the laboratory technician or manager and the educational supervisor consider that they are proficient and knowledgeable in the areas in which they have worked or studied. A suitable test of the theoretical background would be to deliver a teaching seminar to their peer group. A record of their proficiency should be made in their log book and signed by the educational supervisor. 2. Management of children with Immune deficiency Objectives The trainee will be competent to: Recognise indications for investigation of immune system in respiratory patients Prioritise investigations, and order those appropriate for the clinical scenarios. Interpret the significance of abnormalities in immune tests. Take appropriate preventive action to minimise risk of infections in immune deficient patients. Assessment: Portfolio of at least 10 cases of immunodeficiency seen by trainee. Should include examples of deficiencies in humoral and cell-mediated immunity, as well as pulmonary complications of HIV, and notes on diagnosis and management Portfolio of immune investigations ordered in a further 20 patients, with reflective notes on the indications for investigation, and the outcome. CBD, portfolio review. 3. Lung transplant The trainee should be familiar with the indications, contra-indications complications and risks of lung and heart-lung transplant in children. He/she should be familiar with the pre-operative assessment process and have been involved in the assessment of 5 patients including attendance at relevant multidisciplinary meetings. He/she should be aware of principles of perioperative and post-operative care. He/she should be familiar with the principles of long term management of transplant recipients. He/she should have witnessed at least one transbronchial biopsy procedure 4. Exercise testing - awaited 5. Chest physiotherapy for paediatric respiratory diseases and their complications The trainee acquires an understanding of the principles of specialised chest physiotherapy and learns to prescribe and monitor such treatment. completion of training certified by tutor Required minimum: not specified Resources: Physiotherapists on the respiratory ward, in out patients and on home visits.

23 Page 23 of 45 Draft competencies 21/06/2007 Module Leaders: Respiratory trainer and specialist physiotherapist. Objectives The trainee will be competent to: 1. Determine the need for a specialist physiotherapist s input for acute and chronic in-patient cases as well as for out-patient problems 2. Recognise the different forms of chest physiotherapy and when they are appropriately used. 3. Understand the underlying rationale / physiological principles of different methods. 4. Liaise with the physiotherapist as part of the multidisciplinary team. Assessment: Portfolio of at least 10 cases seen by the trainee with a specialist physiotherapist including reflection on why one form of physiotherapy was used and how effectiveness was assessed. At least 2 physiotherapist observed explanations of a physiotherapy technique to a patient/family. At least 2 physiotherapist observed explanations of why a certain physiotherapy technique is appropriate in a particular patient to a trainee (medical or physiotherapy). Satisfactory completion certified by tutors.

24 Page 24 of 45 Draft competencies 21/06/2007 Training record Trainee s name NTN Grid reference This training record refers to Year 1, 2 or 3? This record should be completed with your assessor. However, before you take it to your assessor please read it through and make sure you have the information to hand which will allow him/her to complete it. You will need to fill in the tables and have your electronic portfolio ready for your assessor to review. This should all be done electronically but the signatures should be added by hand after a final printing April 2007 There will be an assessment of knowledge details after log book during years 3 and 4. The trainees will prepare 3 topics for a minute presentation to external assessors and peers. One topic will be chosen at random for presentation and judged as satisfactory or not.

25 Page 25 of 45 Draft competencies 21/06/2007 Module A1 In-patient management of acute respiratory illness 1. Record of a total of 50 cases in months to reflect competencies outlined in curriculum Bronchiolitis requiring ventilatory support Noninvasive Competency assessment CBD Mini-CEX (number (number) of cases) Reflective notes (number) Presentation of topic to peers Acute severe asthma Community-acquired pneumonia (CAP) Empyema requiring drainage Stridor Severe upper airway obstruction (UAO) Inhaled foreign body Pneumothorax Invasive Acute Sub-glottic stenosis Tonsillar hypertrophy Other 2. Most recent EB guidelines/reviews down-loaded the trainee is working to. The trinee should store these electronically and index these Bronchiolitis Acute severe asthma CAP Empyema Stridor UAO Inhaled foreign body Pneumothorax Name of EB Not yet Please append trainee s index of references relating to acute respiratory illness 3. How many observed interactions with families of acutely ill children ( 5)? 4. At the end of this year, what else does this trainee need to do to become competent in this module?

26 Page 26 of 45 Draft competencies 21/06/2007 Module A2 Outpatient management 1. Record of a total of 50 cases in months to reflect competencies 1 7 outlined in this section of the curriculum. Number of patients Year 1 Wheezing disorders Problem coughing Recurrent lung infections Cystic fibrosis Chronic & suppurative lung disease Rare chronic lung disease Congenital thoracic malformations Neuromuscular disease Chronic lung disease of prematurity Immunodeficiency TB Tracheostomies OSA <1 year 1-5 years 5-10 years Adolescents Tertiary Shared Non-CF bronchiectasis Chronic aspiration Intrathoracic Thoracic cage Outpatient Seen in home Outpatient Seen in home Assessment Needing CPAP CBD Mini- CEX SAIL letters Presentation to peers of topic 2. Does the trainee have recent EB guidelines/reviews or an index of references? Index of references Yes Not yet appended? Asthma and wheezing disorders Problem coughing Recurrent lung infections Cystic fibrosis Chronic & suppurative lung disease Rare chronic lung disease Congenital thoracic malformations Neuromuscular disease Chronic lung disease of prematurity Immunodeficiency TB Tracheostomy managment OSA At the end of this year, what else does this trainee need to do to become competent and in what areas?

27 Page 27 of 45 Draft competencies 21/06/2007 Module B1 lung function measurements 1. Has the trainee undertaken tests in an adult lung function laboratory, if this is necessary? 2. What progress has been made in learning about and understanding the physiology and accuracy underlying pulmonary function testing? Pulmonary physiology Understanding reference data Understanding repeatability Diagnostic accuracy of tests Please provide an index of relevant publications and learning materials (eg examples of acceptable and unacceptable tests) from the trainee s collection Has the trainee been on any pulmonary function course? 3. Laboratory skills 1. What progress has been made in undertaking lung function testing? 2. Knowledge of reference data 3. Acceptability of tests how many lung function tests has the trainee reported under supervision? 4. Has the trainee learnt to calibrate laboratory equipment? 5. Does the trainee understand risk managemnt issues for the laboratory? Do they have a copy of the relevant guidelines? 6. Do they know how to judge maintenance costs and test costs? 4. At the end of this year, what else does the trainee need to do to become competent in this module at the end of training?

28 Page 28 of 45 Draft competencies 21/06/2007 Module B2 Flexible bronchoscopy What evidence of progress is there in the following? Indications, contraindications and complications of bronchoscopy Use of bronchoscope Knowedge of procedures undertaken at bronchoscopy Maintenance of bronchoscope Processing techniques used on tissue in laboratories What written materials are in the trainee s collection to support satisfactory understanding of the background knowledge of bronchoscopy and the procedures undertaken at bronchoscopy? Please attach an index Bronchoscopy skills details of each case undertaken should be in portfolio Observed Age of adult/ child Indication Present when explanation and consent obtained? Attendance from induction to recovery? Outcome Undertaken Are there any notes, images etc in the portfolio which enlarge on any of these? At the end of this year, what else does the trainee need to do to become competent in this module at the end of training?

29 Page 29 of 45 Draft competencies 21/06/2007 Module B3 Imaging of the lung 1. Can the trainee fully explain the value of a chest radiograph in common conditions such as chest infection and wheezing disorders? Does the trainee know what the relevant guidelines suggest? 2. Does the trainee know the radiation cost of the different chest imaging procedures? What written material is in the trainee s portfolio to support this? Evaluation of chest radiographs 1. What progress has the trainee made in the evaluation of chest radiographs? 2. Number of patients Identification of lobar and sub-segmental atelectasis Consolidation Airleaks Pleural fluid Mediastinal shift Tuberculosis Mediastinal abnormalities Cardiac failure Congenital abnormalities CBD Mini-Cex Please include an index of images which the trainee has collected 3. How many times has the trainee attended ultrasound examination of the chest? 4. How many lateral neck radiographs has the trainee evaluated? Record of chest scans ordered and evaluated Type of scan Age Indication Name of supervisor of evaluation Radiology diagnosis At the end of Year 3, what else does the trainee need to achieve to be considered competent in this module?

30 Page 30 of 45 Draft competencies 21/06/2007 Module B4 Aerosol therapy 1. What progress has the trainee made in the understanding of the science of aerosol delivery and its limitations in children? 2. Does the trainee understand the difference between dry powder treatment, nebuliser treatment and aerosol treatment? Please append an index of the trainee s references and other learning materials Clinical skills 1. How many times have you or a children s respiratory nurse observed the trainee teach patients and their families? a. How to use the treatment properly b. How to care for the delivery system At the end of this year, what else does the trainee need to do to become competent at the end of training?

31 Page 31 of 45 Draft competencies 21/06/2007 Module C1. Allergy diagnosis and treatment 1. What progress has been made in items 1-6 in this section? 2. Has the trainee taught the basics of allergy as it is related to respiratory illness to their peers? Please append an index of the trainee s references and other learning materials Clinical skills 1. How many skin prick tests has the trainee undertaken satisfactorily? 2. Does the trainee know the place of specific IgE testing? 3. Do they know the costs of the tests? 4. What evidence does the trainee have reflecting their competence in the management of simple eczema and rhinitis? 5. Does the trainee know current recommendations and controversies in the role of allergen avoidence and immunotherapy? 6. Has the trainer witnessed discussions with the family about treatment including controversial treatments, such as alternative medicine? 7. Has the trainee taught peers about the treatment of allergic disorders? Please append an index of the trainee s references and other learning materials At the end of this year, what else does the trainee need to do to become competent at the end of training?

32 Page 32 of 45 Draft competencies 21/06/2007 Module C2 Congenital malformations What evidence does the trainee have that he/she understands the origins and anatomy of the commoner congenital malformations? Do they understand the effect on lung function? Please append an index of the trainee s references and other learning materials Clincial skills Malformations assessed and/or managed (see curriculum) Malformation Age of patient Relevant Investigations Trainee s involvement in management Prognosis Please append an index of the trainee s references and other learning materials and reflective notes about cases

33 Page 33 of 45 Draft competencies 21/06/2007 C3 Asthma and wheezing disorders of childhood 1. What evidence is there of progress in items 1-5 of the curriculum? 2. Has the trainee taught or presented these topic to peers? Clinical skills Please append an index of the trainee s references and learning materials 1. Please document the management of acute severe asthma and wheezing disorders under Module 2. Chronic asthma (Step 3 and above) SAIL letter reviewed CBD with supervisor Mini-CEX Presentation of topic to peers - dates Chronic wheezing in infants Difficult asthma Please append an index of the trainee s references and other learning materials

34 Page 34 of 45 Draft competencies 21/06/2007 Module C4 Chronic lung disease of prematurity (CLD) 1. What evidence is there of progress in the understanding of the pathophysiology of CLD? 2. Does the trainee know the strategies used in perinatal and neonatal medicine to minimize the risk of CLD? 3. Has he trainee presented this topic to their peers? Please append an index of the trainee s references and learning materials Clinical skills 1. How many discharge planning meetings for infants with CLD has the trainee run and who has observed these? 2. Has the trainee visited at least 2 babies with CLD on oxygen at home? 3. How many follow-up clinics has the trainee attended and over what period? 4. Has the trainee documented reflective notes about how families mange looking after infants with CLD needing oxygen? Family CBD Mini-CEX Chaired discharge planning meeting? Supervisor in attendance? Date of followup clinic attended and number of patients seen Please attach a list of the trainees references and learning materials

35 Page 35 of 45 Draft competencies 21/06/2007 Module C5 Cystic fibrosis 1. What evidence is there of progress in items 1-3 of the curriculum? 2. Has the trainee made a presentation to peers about the genetics, pathophysiology and complications of CF? 3. Do they understand the pharmacology and side-effects of drugs used in CF Please append an index of the trainee s references and other learning materials Clinical skills Items 1-4 Clinical skills around diagnosis Age of patient SAIL letter CBD Mimi-CEX Presentation of topic to peers Annual review Care of adolescent Respiratory assessment Transplant and terminal care Management of access devices Non-pulmonary complications Cost of care Please append an index of the trainee s references and other learning materials

36 Page 36 of 45 Draft competencies 21/06/2007 Module C6 Acute and chronic infection 1. What evidence does the trainee have of knowledge of iem s 1-4 in the curriculum 2. Which topics has the trainee presented to their peers? Please append an index of the trainee s references and other learning materials Clinical skills See competencies listed under section A1 and A2. 5. Performing naso-pharyngeal aspirate and washings 6. Taking a cough and a pernasal swab 7. Performing a diagnostic pleural tap and inserting a chest drain NP aspirate Cough swab Pernasal swab Pleural tap Insertion of pleural drain DOP (date) Signature of observer Please include and index of the trainee s references and teaching materials

37 Page 37 of 45 Draft competencies 21/06/2007 Module C7 Tuberculosis What evidence is there that the trainee has the background knowledge listed in this section in the curriculum? Has the trainee taught this to peers? Please include a list of the trainee s references, guidelines and learning materials Tuberculin tests (N=10) BCG (N=5) Home visits with TB nurse DOP (Date) Date Observed by Management of cases CBD Mini CEX Describe case Reflective notes Reflective notes should be in portfolio

38 Page 38 of 45 Draft competencies 21/06/2007 Module C8 Management of technology dependent children 1. What evidence is there of progress in Items 1-6 in the curriculum? 2. Have they presented this topic to their peers? Please include a list of the trainee s references and learning materials Clinical skills (see this section of curriculum) Age of patient & problem CBD Mini-CEX Discharge planning Home visit The trainee should be considered competent when the supervisor is content that they can mange the aspects of the care of technologically dependent children outlined in the curriculum. Has the trainee taught this topic to his peers? Please include a list of the trainee s references and learning materials

39 Page 39 of 45 Draft competencies 21/06/2007 Module C9 Sleep medicine 1. Is the trainee conversant with sleep physiology as outlined in the curriculum? 2. Does the trainee understand the different methods for undertaking sleep studies? 3. Has the trainee presented these topics to their peers? Please include a list of the trainee s references, guidelines and learning materials Clinical skills Sleep histories Problem CBD Mini-CEX Sleep studies set up and analysed Problem Equipment CBD Please include an index of examples from trainee s portfolio Please include a list of the trainee s references, guidelines and learning materials

40 Page 40 of 45 Draft competencies 21/06/2007 Module D1 Management and Leadership Delivery of health care Has the trainee attended a course which covers the competencies in this section? What learning materials and other references does the trainee have in their portfolio? Database competences What evidence is there that the trainee has a) set up a database? b) kept a reference database? c) entered data in the national databases? Competencies in relation to audit a) What audit did the trainee present this year? b) Has the trainee participated in national audits? General competencies a) How many critical incident meetings has the trainee attended? b) Which meetings has the trainee chaired regularly? c) How does the trainee manage conflict? Please include a list of the trainee s references, guidelines and learning materials for each competency