Emergencies in general practice: could checklists support teams in stressful situations?

Paul Greig; Anne Maloney; Helen Higham

doi:10.3399/bjgp20X709373

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Emergencies in geneal practice
John Sharvill

Published on: 03 September 2025
Where are GP residents learning to manage emergencies?
Emer Forde, Emily Lyness and Clare Wedderburn

Published on: 06 August 2025
The practical management of emergencies in primary care: Brief simulation-based training can help
Emer Forde, Emily Lyness and Clare Wedderburn

Published on: 06 August 2025
Emergencies in general practice: could checklists support teams in stressful situations?
Dr Sarah O’Hare, Professor Gerard Gormley and Dr Richard Conn

Published on: 04 August 2020
Properly funded services required to enact checklists in GP emergencies
Olivia J. Baker

Published on: 21 June 2020

Published on: (3 September 2025)
Page navigation anchor for Emergencies in geneal practice
Emergencies in geneal practice
John Sharvill, Nearly retired GP, NHS
I personally was involved last week (as a neighbour, not primarily as a doctor) when there was a 30-minute wait for an immediate ambulance. The use of a nebuliser as opposed to a spacer in one of the scenarios (setting up a nebuliser), especially as few GPs in isolated areas do not carry oxygen or defibs nowadays, so knowing the open number for local community defibs in their area may also be useful. How many nights (red eyes) do registrars have to do as part of their training, may I ask?

Competing Interests: None declared.
Published on: (6 August 2025)
Page navigation anchor for Where are GP residents learning to manage emergencies?
Where are GP residents learning to manage emergencies?
Emer Forde, GP Programme Director, NHSE South East (Dorset)
Other Contributors:
Emily Lyness, GP Programme Director, NHSE South East (Dorset)

Clare Wedderburn, Associate Dean, GP Training, NHSE South East (Dorset)
The first competency in the RCGP Curriculum for urgent and unscheduled care¹ is that GPs must qualify with the skills to ‘Recognise patients with urgent needs and act promptly to ensure correct and timely treatment and reduce the risk of death or morbidity.’

But where are UK GP residents learning these skills?

One might assume that GP residents have adequate time during their foundation training (or equivalent), and NHS ST12 hospital rotations, to acquire the required knowledge and skills to manage emergencies - but data we collected suggests this may not be the case.

All final year GP resident doctors on the Dorset Vocational Training Scheme in November 2024 were asked which emergencies they had experience of managing in a hospital and primary care setting.

100% GP residents reported managing sepsis in secondary care, but fewer had managed acute coronary syndrome (84%), severe asthma (84%), cardiac arrest (80%), hypoglycaemia (80%) or seizures (72%), and less than a quarter had managed anaphylaxis (24%) or meningitis (24%) in a hospital setting.

Their experience in general practice was even more limited. 63% reported managing sepsis in primary care, but fewer had managed acute coronary syndrome (47%), severe asthma (32%), hypoglycaemia (11%) or anaphylaxis (5%). None of the final year GP residents had experience of managing cardiac arrest, meningitis or seizures in primary care.

With an ambition...
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The first competency in the RCGP Curriculum for urgent and unscheduled care¹ is that GPs must qualify with the skills to ‘Recognise patients with urgent needs and act promptly to ensure correct and timely treatment and reduce the risk of death or morbidity.’

But where are UK GP residents learning these skills?

One might assume that GP residents have adequate time during their foundation training (or equivalent), and NHS ST12 hospital rotations, to acquire the required knowledge and skills to manage emergencies - but data we collected suggests this may not be the case.

All final year GP resident doctors on the Dorset Vocational Training Scheme in November 2024 were asked which emergencies they had experience of managing in a hospital and primary care setting.

100% GP residents reported managing sepsis in secondary care, but fewer had managed acute coronary syndrome (84%), severe asthma (84%), cardiac arrest (80%), hypoglycaemia (80%) or seizures (72%), and less than a quarter had managed anaphylaxis (24%) or meningitis (24%) in a hospital setting.

Their experience in general practice was even more limited. 63% reported managing sepsis in primary care, but fewer had managed acute coronary syndrome (47%), severe asthma (32%), hypoglycaemia (11%) or anaphylaxis (5%). None of the final year GP residents had experience of managing cardiac arrest, meningitis or seizures in primary care.

With an ambition for GP residents to spend all three years of their specialist training in general practice, there is an urgent need for more comprehensive training in emergencies. Grieg et al.² highlight that, whilst medical emergencies are increasing in primary care, individual clinicians may go ‘months or even years without having to manage one personally’. There is no requirement and few opportunities to receive regular training, over and above BLS, which does not equip adequately for peri-arrest, time critical emergencies.^3,4.

Checklists may be helpful, but doctors also need training. In Dorset, simulation-based workshops, focussing on the practicalities of managing emergencies, are now an integral part of our GP Vocational Training Scheme.

References

1. RCGP Curriculum for Urgent and Unscheduled Care. www.rcgp.org.uk/mrcgp-exams/gp-curriculum/urgent-unscheduled-care (accessed 12 August 2025).
2. Greig P, Maloney A, Higham H. Emergencies in general practice: could checklists support teams in stressful situations? Br J Gen Pract 2020; 70(695): 304-305.
3. Forde E, Bromilow J, Wedderburn C. The practical management of emergencies in primary care: Taking simulation out of the classroom and into real-life environments. BMJ Simul Technol Enhanc Learn 2017;9; 4(1): 43-44.
4. Forde E, Bromilow J, Wedderburn C. Managing emergencies in primary care: Does real-world simulation based training have any lasting impact? BMJ Simul Technol Enhanc Learn 2018; 29;5(1): 57-58.

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Competing Interests: None declared.
Published on: (6 August 2025)
Page navigation anchor for The practical management of emergencies in primary care: Brief simulation-based training can help
The practical management of emergencies in primary care: Brief simulation-based training can help
Emer Forde, GP Programme Director, NHSE South East (Dorset), NHSE South East (Dorset)
Other Contributors:
Emily Lyness, GP Programme Director, NHSE South East (Dorset)

Clare Wedderburn, Associate Dean, GP Training
General Practitioners need to be equipped to initiate time critical care for patients presenting with medical emergencies. This is part of the RCGP curriculum and, although patients are increasingly presenting to general practice with a medical emergency, they still are relatively infrequent. Many GPs feel underconfident and want more training.^1-2 In view of this, we provided simulation-based training for all final year GP residents in Dorset. Simulation based education is widely used in secondary care because it allows the amplification of real-life situations with guided experience³ but, in comparison, relatively underutilised in primary care.

A three-hour workshop was designed to cover emergencies such as severe asthma, meningitis, hypoglycaemia and anaphylaxis. Participants rotated around scenarios in small groups. Each scenario was 25 minutes (including debrief) and our focus was on the practicalities. For example, if a participant said, “I would give salbutamol”, they were asked to demonstrate how to set up a nebuliser.

Participants were asked to rate their confidence (1= not confident at all, 9 = very confident) on two questions:

In theory, how confident are you about what is required to manage …

How confident are you in the practical management of … in primary care.

Our results show that, prior to the workshop, GP residents...
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General Practitioners need to be equipped to initiate time critical care for patients presenting with medical emergencies. This is part of the RCGP curriculum and, although patients are increasingly presenting to general practice with a medical emergency, they still are relatively infrequent. Many GPs feel underconfident and want more training.^1-2 In view of this, we provided simulation-based training for all final year GP residents in Dorset. Simulation based education is widely used in secondary care because it allows the amplification of real-life situations with guided experience³ but, in comparison, relatively underutilised in primary care.

A three-hour workshop was designed to cover emergencies such as severe asthma, meningitis, hypoglycaemia and anaphylaxis. Participants rotated around scenarios in small groups. Each scenario was 25 minutes (including debrief) and our focus was on the practicalities. For example, if a participant said, “I would give salbutamol”, they were asked to demonstrate how to set up a nebuliser.

Participants were asked to rate their confidence (1= not confident at all, 9 = very confident) on two questions:

In theory, how confident are you about what is required to manage …

How confident are you in the practical management of … in primary care.

Our results show that, prior to the workshop, GP residents were more confident in theory, rather than the practicalities (mean confidence ratings 6.1 and 4.9, respectively), but this gap narrowed after the simulation workshop (mean confidence ratings 7.6 and 7.2, for theory and practical management, respectively). Participants were also asked for qualitative feedback and Perplexity AI asked to summarise their responses:

‘In summary, students found the session highly practical and confidence-boosting, with a strong emphasis on hands-on skills, teamwork, and preparedness for emergencies in primary care. They learned not just the ‘what’ but also the ‘how’ and ‘where’ - how to manage acute situations, where to find vital information, and the importance of regular practice and teamwork.’

We agree that checklists have value, but doctors also need regular opportunities to practice the practical aspects of providing emergency care and short simulation-based training can help.

References

1. Forde E, Bromilow J, Wedderburn C. The practical management of emergencies in primary care: Taking simulation out of the classroom and into real-life environments. British Medical Journal, Simulation & Technology Enhanced Learning. 2017;9; 4(1): 43-44.
2. Forde E, Bromilow J, Wedderburn C. Managing emergencies in primary care: Does real-world simulation based training have any lasting impact? British Medical Journal, Simulation & Technology Enhanced Learning, 2018; 29;5(1): 57-58.
3. Gaba D. The future vision of simulation in health care. British Medical Journal, Quality & Safety 2004;13:2-10.
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Competing Interests: None declared.
Published on: (4 August 2020)
Page navigation anchor for Emergencies in general practice: could checklists support teams in stressful situations?
Emergencies in general practice: could checklists support teams in stressful situations?
Dr Sarah O’Hare, GP Academic Research Trainee, Queens University Belfast
Other Contributors:
Professor Gerard Gormley, Clinical Professor, School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast

Dr Richard Conn, Academic Clinical Lecturer, Queens University Belfast
We welcome Grieg et al.'s debate article about checklists.¹Any activity that supports general practitioners in delivering safe, effective care in time-critical situations is greatly welcomed. However, we would like to take the opportunity to encourage practitioners to adopt a more critical approach when considering the use of checklists.

As Greig et al. suggest, the rise of checklists in healthcare has largely followed their use in the aviation industry, where they provide a safety layer that protects against classic human failings like forgetting, particularly when working under pressurised conditions. But differences between healthcare and aviation present a challenge for this cognitivist way of understanding checklists.²For example, patient complexity makes healthcare delivery much less amenable to standard operating procedures than aviation. Managing healthcare emergencies relies on seamless functioning of multiple staff members across a wide range of roles - from GPs to practice nurses to receptionists – rather than just pilots and cabin crew. Practice treatment rooms and equipment vary from place to place much more than standardised aeroplane cockpits do. This means that checklists may not always be effective, may not transfer well between contexts, or may work in different ways than expected.³

We remain convinced about t...
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We welcome Grieg et al.'s debate article about checklists.¹Any activity that supports general practitioners in delivering safe, effective care in time-critical situations is greatly welcomed. However, we would like to take the opportunity to encourage practitioners to adopt a more critical approach when considering the use of checklists.

As Greig et al. suggest, the rise of checklists in healthcare has largely followed their use in the aviation industry, where they provide a safety layer that protects against classic human failings like forgetting, particularly when working under pressurised conditions. But differences between healthcare and aviation present a challenge for this cognitivist way of understanding checklists.²For example, patient complexity makes healthcare delivery much less amenable to standard operating procedures than aviation. Managing healthcare emergencies relies on seamless functioning of multiple staff members across a wide range of roles - from GPs to practice nurses to receptionists – rather than just pilots and cabin crew. Practice treatment rooms and equipment vary from place to place much more than standardised aeroplane cockpits do. This means that checklists may not always be effective, may not transfer well between contexts, or may work in different ways than expected.³

We remain convinced about the potential usefulness of checklists, particularly in pressurised, infrequently occurring situations such as emergencies. However, faced with the complex, contextualised nature of healthcare, we recommend qualitative, sociocultural research to develop a deeper understanding of how they can be made to work effectively and in what contexts. We also recommend road testing of checklists – a process that may be supported by the emerging field of in-situ simulation⁴ to ensure that they work within the realities of real-world general practice.

References

1. Greig P, Maloney A, Higham H. Emergencies in general practice: could checklists support teams in stressful situations? Br J Gen Pract 2020; 70(695): 304 305.

2. Clay-Williams R, Colligan L. Back to basics: Checklists in aviation and healthcare. BMJ Qual Saf 2015; 24(7):428-431. doi:10.1136/bmjqs-2015-003957.

3. Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Introduction of Surgical Safety Checklists in Ontario, Canada. N Engl J Med 2014; 370(11):1029-1038. doi:10.1056/nejmsa1308261.

4. Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf 2013; 22(6):468-77.

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Competing Interests: None declared.
Published on: (21 June 2020)
Page navigation anchor for Properly funded services required to enact checklists in GP emergencies
Properly funded services required to enact checklists in GP emergencies
Olivia J. Baker, Foundation Doctor, Royal Papworth Hospital
The feature “Emergencies in general practice: could checklists support teams in stressful situations?”¹argues aptly the need for concise, well-designed checklists to guide primary care teams to deliver best practice amid increasingly common emergencies. The authors briefly mention delays in emergency services in response to such emergencies, reporting that 91% of GPs audited experienced delays in ambulance arrivals,¹ an issue I have witnessed first-hand.

I recall one case quite vividly as a fifth-year medical student during a primary care placement. A patient came for an emergency GP appointment, reporting intense suicidal ideations and plans to commit suicide. The patient, visibly distressed and becoming increasingly agitated in the waiting room, was moved to a side room to protect the welfare of other patients and the patient them self. Soon afterward they threatened to leave the practice and attempt suicide that same morning, at which point the decision to call an ambulance, with consent, was made, to ensure safe delivery to secondary care. We were informed the ambulance crew could not arrive for approximately 6 hours. Whilst a checklist would certainly have proven beneficial guidance for initiating escalation, a lack of one was not the rate limiting factor in this case.

The National Audit Office report between 2011 and 2016 funding for ambulance emergency services increased by 16%, yet demand increased...
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The feature “Emergencies in general practice: could checklists support teams in stressful situations?”¹argues aptly the need for concise, well-designed checklists to guide primary care teams to deliver best practice amid increasingly common emergencies. The authors briefly mention delays in emergency services in response to such emergencies, reporting that 91% of GPs audited experienced delays in ambulance arrivals,¹ an issue I have witnessed first-hand.

I recall one case quite vividly as a fifth-year medical student during a primary care placement. A patient came for an emergency GP appointment, reporting intense suicidal ideations and plans to commit suicide. The patient, visibly distressed and becoming increasingly agitated in the waiting room, was moved to a side room to protect the welfare of other patients and the patient them self. Soon afterward they threatened to leave the practice and attempt suicide that same morning, at which point the decision to call an ambulance, with consent, was made, to ensure safe delivery to secondary care. We were informed the ambulance crew could not arrive for approximately 6 hours. Whilst a checklist would certainly have proven beneficial guidance for initiating escalation, a lack of one was not the rate limiting factor in this case.

The National Audit Office report between 2011 and 2016 funding for ambulance emergency services increased by 16%, yet demand increased by almost double (30%).² The number of ambulance trusts meeting response-time targets has also fallen steadily over the same period.² The situation I experienced as a medical student was not an isolated event and will become increasingly common as GPs encounter more emergencies.¹

I often think about this case; how frightened the patient appeared, the sense of desperation within the medical team trying to co-ordinate patient safety, and the overwhelming sense of defeat knowing we could not provide the best immediate care for this patient. If we continue along the trajectory of underfunding emergency services, there will be dire consequences.

References
1. Greig P, Maloney A, Higham H. Emergencies in general practice: could checklists support teams in stressful situations? Br J Gen Pract 2020; 70(695): 304 305.
2. Report by the Comptroller and Auditor General. NHS Ambulance Services, NHS England. National Audit Office. January 2017. www.nao.org.uk/wp-content/uploads/2017/01/NHS-Ambulance-Services.pdf [Accessed 21 June 2020].

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Competing Interests: None declared.