CLINICAL PRACTICE MANUAL PRINCESS ALEXANDRA HOSPITAL DEPARTMENT OF EMERGENCY MEDICINE
PRINCESS ALEXANDRA HOSPITAL DEPARTMENT OF EMERGENCY MEDICINE CLINICAL PRACTICE MANUAL 2013 / 2014 1 Table of Contents: 1. 2. 3. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 2 PAH ED Clinical Areas 3 Safe Access for Emergency (SAFE) Patients in PAH ED 3 Clinical Teams 4 Assessment of patients 6 Documentation 6 Discussion of patients with ED senior staff 7 NEAT Procedures: Processing patients through the ED and Admissions 7 Ordering pathology tests 9 Ordering radiology (and vascular USS) 9 ED Clinical guidelines and procedures 10 Finding a nurse 10 Organising medications or intravenous fluids for a patient 11 Procedures – Procedural sedation, Suturing, Plastering 11 Telephones 12 Specialist Units and referring to an inpatient registrar 12 Referring to the medical registrars (and MAPU Medical and Cardiology Registrars) 13 Referring to a medical sub-specialty unit. 14 Referring to an inpatient consultant 14 Arranging a private / intermediate admission 14 Referring to ED Mental Health 14 Referring to OPD 15 Inter-hospital Transfers 15 Trauma 15 Persistent Pain Service 16 Referring to Fracture Clinic 16 Referring for outpatient investigations 16 Eye Clinic 17 Referring for Paediatric or Obstetric and Gynaecology services 17 Hospital in the Home 17 Pharmacy services 18 Social Work Services 18 Emergency accommodation 19 Referring to Allied Health 19 Referring to the CHIP Nurse (Community Hospital Interface Nurse) and ACEIM Team 20 Utilising Pastoral Care 20 Alcohol and Drug Assessment Unit (ADAU) 20 Referring to the Sexual Health Clinic 21 Security Unit 21 Discharging patients home 21 Admitting a patient to the ED Short Stay Unit 22 Admitting a patient to the ward 22 Finishing your shift 23 1. PAH ED Clinical Areas The PAH ED contains the following Clinical Areas: o Resuscitation Rooms – 5 (one of which is negative pressure isolation capable) o Acute Cubicles – 25 (designated ‘red’ and ‘yellow’ cubicles – all monitored; includes 4 isolation rooms (2 of which are negative pressure capable) o Ambulatory Care – mixture of 6 consult rooms and special assessment / treatment rooms for ambulating patients o Procedure Area – 1 main procedural room (anaesthetic / resuscitation capable for procedural sedation and minor operations) and 6 bays for minor procedures / plastering o Short Stay Unit – 14 bed short stay unit for ED patients (including 1 isolation room) o ED Mental Health Area – staffed by ED Mental Health Clinicians 2. Safe Access for Emergency (SAFE) Patients in PAH ED See also Hospital Procedures – Emergency Department Procedures (PAH Intranet) Purpose: To detail the process for safe access of patients to Princess Alexandra Hospital Emergency Department (PAH ED). To detail the procedure undertaken when an appropriate treatment space is not immediately available. Outcome of the Procedure: All non-ambulatory patients are triaged to an acute treatment cubicle or resuscitation room as soon as possible. All patients who are “ramped” are done so by the consultant based on clinical risk verses available resources. Authorised to Undertake the Procedure: Emergency Department Registered Nurses who have completed: o Emergency Triage Education Kit (ETEK), o The required number of preceptor shifts with a clinical facilitator, o Deemed competent by the Emergency Department’s Nurse Educator. Emergency Department Staff Specialists Indications: All non-ambulatory patients. Contraindications: Patients who meet the inclusion criteria for ambulatory care. Risks and Precautions: The below acknowledges that ideally all non-ambulant patients should have immediate access to an appropriate treatment space, and that any level of access block to the Emergency Department is associated with an increased clinical risk. At all times the Emergency Department will act to maintain availability of appropriate treatment spaces as much as possible within the limits of the resources available. 3 Procedure: All presenting patients are to be triaged and registered and placed on Emergency Department Information System (EDIS) on arrival as per triage procedure. Non-Ambulant Patients: All non-ambulatory patients are to be triaged into acute cubicles only. This is to allow history, examination and initial management to occur in an appropriate, safe environment. The only exceptions to this are patients whose clinical condition warrants management in a resuscitation room. No patient is to be accommodated in a corridor except in a declared disaster situation. Non-ambulatory patients presenting via Queensland Ambulance Service (QAS) who are unable to access an appropriate cubicle on arrival will be “ramped”. The decision to “ramp” is not a triage decision, but is one made by the Emergency Department Consultant in liaison with the Nursing Shift Coordinator. The Emergency Department consultant and the Nursing Shift Coordinator must be contacted by triage and notified of the patient and their clinical details. The Emergency Department consultant will decide whether it is clinically appropriate for the patient to be ramped given the resources available. It is acknowledged that overriding Princess Alexandra Hospital executive directives regarding capacity and redirection escalation procedures may impact on the resources available. In cases where the clinical decision regarding ramping is unclear, or clinical concerns are raised, the consultant or delegate may elect to review the patient prior to this decision being made. The triage Registered Nurse must ensure a clear passageway for critical patient movement through triage at all times. The patient is to be placed in the “Ramped Area / QAS_R” within the EDIS location map. ‘Ramped patients’ will be brought into the ED as soon as possible on the basis of triage category and / or time of arrival. If whilst ramped, the Queensland Ambulance Services paramedics have a clinical concern for their patient (e.g. change in patient condition or deterioration) this must be notified via the Triage Registered Nurse to the Emergency Department Consultant who will undertake the appropriate clinical action. The triage staff is not to suggest to the Queensland Ambulance Service crews to leave Princess Alexandra Hospital for another Emergency Department. When the Princess Alexandra Hospital Emergency Department is ‘ramping’ patients, Capacity Alert procedures may be undertaken as deemed appropriate. Non-Ambulatory Patients: Who self-present should receive priority into an appropriate area of the Emergency Department if they cannot be cared for safely at triage. The Shift Coordinator should be contacted by Triage to make arrangements to receive the patient. If ‘ramped’, the patient will be designated as ‘RFT’ – ‘Ramp Foot Traffic’ within EDIS. Resuscitation Rooms: Are to be kept available for any critical events that may present or occur (including deterioration of ‘ramped’ patients or for self-presenting patients requiring a cubicle when none are immediately available). Maintaining Patient Flow: Medical assessment of patients within acute cubicles will occur as safely and efficiently as resources allow. 3. Clinical Teams 4 Medical staff within the ED work within small clinical teams that cover geographical areas of the department. Each shift you will be assigned to a clinical team. Each team receives overall clinical oversight from an assigned ED consultant. This information is displayed in the medical write-up room each day. Each member of the clinical team should take a DECT phone at the start of every shift and record on the electronic rostering system their DECT phone extension. There are three clinical teams rostered during the day and evening, with one clinical team rostered overnight. Each team includes an ED registrar and 2-3 junior medical staff (residents and interns). A training SHO may also form part of the team. Within the Acute and Resuscitation Areas of the ED – there are two clinical teams for this area (Red Team and Yellow Team – with each team covering an area). Red Team – Resuscitation Rooms 1 and 2; Acute Cubicles 1 – 13. Yellow Team – Resuscitation Rooms 3, 4, and 5; Acute Cubicles 14 – 25. Each team is responsible for their area and the patients within it. Within the ‘Ambulatory Care’ area of the ED – there is one clinical team (Green Team) attending to the patients triaged to the waiting room and the ambulatory care area itself. This team also covers the Procedure Area – including patients triaged there with minor injuries and potentially for any procedures that are required to be conducted there. Within the Short Stay Unit there is an ED Consultant and a resident (Monday – Friday) or a Training SHO (Week-ends) from 08:00 – 18:00 responsible for the patients admitted there. 4. Picking up a patient Within the Acute and Resuscitation Areas of the ED – simply pick up the first triaged patient unseen by a doctor from the top of the screen from your area. Do not ‘select’ patients out of order or from outside your area unless instructed to do so by a senior staff member. Patients triaged to the ‘Acute Area’ will generally have been triaged to ATS Categories 1-3. Within the ‘Ambulatory Care’ area of the ED – Patients within this area will generally have been triaged to ATS Categories 3, 4 and 5 (majority being Cat 4 and 5); rather than picking these patients up in order of triage category they are to be picked up in order of time of arrival (though this may be subject to reprioritisation following a secondary nursing assessment within Ambulatory Care or at the discretion of the ED registrar or consultant). Patients are triaged (sorted) by nursing staff at the front desk. They are assigned a triage category based on their presenting complaint. The Australasian Triage Scale (ATS) categorises patients from Category 1 – 5 according to time needed to be seen by a doctor. o ATS Category 1 – immediate o ATS Category 2 – 10 minutes o ATS Category 3 – 30 minutes o ATS Category 4 – 60 minutes o ATS Category 5 – 120 minutes Although our goal is to see and manage all patients in a timely manner, our first priority is to the seriously ill or injured (i.e. Cat 1 and 2). Patients in the ED are on EDIS (Emergency Department Information System) which is displayed on all computer terminals. This is a windows based software system that assists in tracking patients in the ED, allows for electronic notes and serves as a database for audit purposes. Arrivals not yet seen by a doctor are at the top of the screen, whilst those already seen drop down the screen once a ‘treating doctor’ signs on. Within the list of patients in the ED, ‘seen’ and ‘unseen’ patients are placed in order of triage category, and then within each triage category by time of arrival. Fill in the details within EDIS of the patient you have picked up before seeing them. This involves double-clicking the patient’s name and completing the ‘treating doctor’ field and ‘time seen’ fields. Ensure the ‘time seen’ entered is accurate (please note the KPIs listed above regarding waiting times; in particular 5 note the 10 minutes for ATS Category 2). The department is assessed on waiting times for triage categories. Initially the patient will come into the department with a nursing assessment / observation sheet and patient labels. Charts for the patients will eventually be delivered by administration staff to the patient’s bedside within the resusctitation and acute areas. Charts for Ambulatory Care patients are delivered to the staff station in this area. The location of the patient within the department is on the EDIS screen. If the patient you are going to see turns out not to have waited (i.e. ‘DNW – Did Not Wait’) – inform the senior staff so they can determine whether any action is necessary in terms of contacting the patient. Please document the time/s the patient was called and any arrangements subsequently within your notes. 5. Assessment of patients Within the ED you have more direct senior supervision than in most other parts of the hospital. To facilitate effective and efficient assessment and management of patients you are required to consult senior staff (ED Consultants and Registrars) early and regularly. Different levels of experience and skill will dictate the level of trust afforded you. Generally, you should aim to perform a focused history and examination and consult a senior staff member (within the first 30 minutes) to discuss the case and enable a directed series of investigations. Many times you may find nursing staff have already arranged intravenous cannulation, routine bloods, certain x-rays and analgesia for your patients. However, this primarily becomes your responsibility once you start seeing the patient. Each shift you will be assigned to a clinical team with a registrar who will be responsible for you. This information is displayed in the medical write-up room each day. Meet your registrar and your team at the start of each shift. Discuss your cases with your assigned registrar or consultant – if you don’t seek them out, they will seek you. Remember that the ability to discuss any case with the consultants who are on the floor is a feature of clinical rotations to the ED. Once you have discussed a case with a senior staff member, continue to consult that person for that particular patient. Do not seek advice from multiple senior staff members for the one patient – it only confuses the process. Once you have discussed a patient with a senior staff member – fill in the details in EDIS with respect to the ‘senior doctor’ field. This allows others to see on the screen which registrar or consultant knows about the patient. 6. Documentation 6 All ED medical notes (other than when utilising the Trauma, Eye and Procedural Sedation Forms) will be undertaken electronically within EDIS in the ‘Medical Notes’ section. Your notes are a reflection of your and the department’s clinical practice; so please ensure they are accurate and reliably detail the patient’s journey in the ED. Document a thorough but focused history and examination. Document what investigations have been ordered. Document the results of all investigations you have ordered once they become available. Always finish with a diagnosis; or differential diagnosis; or a problem list. Always document a management plan that outlines treatment and management undertaken and other related issues (disposition etc). Document the name of the ED registrar or consultant you discuss the case with and accurately reflect their management plan in the chart. Document the name of the inpatient registrar you refer the patient to. Note the time they were contacted. Indicate the time of referral within the ‘Consultations’ screen in EDIS. When you are not using the patient’s chart ensure it stays with the patient in their cubicle / room or otherwise designated area. Once you have completed your notes, print them out and place them within the patient’s chart. 7. Discussion of patients with ED senior staff All patients you see should be discussed with an ED registrar or consultant. Early discussion (within the first 30 minutes of seeing the patient) enables more efficient and effective care of the patient. If you and the ED registrar / consultant determine that the patient is likely to be admitted, enter this into the patient’s clinical screen in EDIS – via ‘Departure Destination’ – ‘Admission likely’. If discharge home is likely, this can also be indicated via the ‘Departure Destination’ – ‘Discharge likely’. The ED senior staff focus on the seriously ill and those that are being sent home. Everyone else, by definition, will be admitted and have the safety net of a review by an inpatient registrar. However, these patients’ work-up should still be thorough. All patients being discharged from the ED should have been discussed with a registrar or consultant. All patients being referred for admission should be discussed with and seen by a registrar or consultant prior to the referral. Meet your registrar and your team at the start of each shift. Discuss your cases with your assigned registrar or consultant – if you don’t seek them out, they will seek you. Remember that the ability to discuss any case with the consultants who are on the floor is a feature of clinical rotations to the ED. Once you have discussed a case with a senior staff member, continue to consult that person for that particular patient. Do not seek advice from multiple senior staff members for the one patient – it only confuses the process. Once you have discussed a patient with a senior staff member – fill in the details in EDIS with respect to the ‘senior doctor’ field. This allows others to see on the screen what registrar or consultant knows about the patient other than you. 8. NEAT Procedures: Processing patients through the ED and Admissions NEAT (National Emergency Access Target) is the performance indicator for ED LOS for all our patients. The current benchmark is 77% (i.e. 77% of our patients need to be seen, assessed, managed and discharged or admitted (to an inpatient bed or to the SSU) within 4 hours of arrival to the ED). Meeting the 4 hour target requires a whole of hospital approach and each department / unit / individual needs to optimise their involvement in each patient. Discharged patients and those admitted to our SSU are primarily the ED’s responsibility with respect to meeting the 4 hour target. The ED aims to achieve 80-90% NEAT compliance for these groups of patients. Admitted patients require a shared / collaborative approach and as such, for clarity of understanding, the ED journey is divided into 2:(1):1 for these patients. 2:(1):1 divides the patient journey for admitted patients into three manageable time periods, each with a specific goal: 7 o 2 hours (from time of arrival to decision to admit; i.e. time of referral) – this includes completion of ED assessment / management o 1 hour (from time of referral to bed booking) - if required as part of ED management, for review by the admitting unit in the ED o 1 hour - from bed booking to departure of the patient to the inpatient ward o The underlying principal governing this policy is that patients should only stay in the ED for the minimum amount of time required to safely assess, manage and transfer care to the inpatient environment. What ED medical staff need to know and do: o The Emergency Department has responsibility for and right of admission. The majority of admissions through the ED are with the cooperation and input of the accepting inpatient team. o It is unusual for the ED to have to exercise its 'right of admission' to an inpatient bed. However, if required it should occur with the involvement of the ED Consultant (this does not apply to "closed" wards such as ICU, CCU, or Infectious Diseases.) o The ED is responsible for the ‘2’ hour time-frame of 2:(1):1 o Aim to complete the assessment / management / notification of admission to the admitting unit of all your patients as efficiently as possible. o Consult ED Consultants and Registrars early to assist with this. o Escalate to senior staff if your patients are experiencing delays (e.g. for imaging, inpatient unit review etc). o Determine with ED Consultants or Registrars as to whether the patient requires an inpatient review as part of their ED management; or are they suitable to progress to the ward for review there by the admitting unit (‘Direct admission from ED’). o Record the ‘time of referral’ to an inpatient team in the ‘Consultations’ field. Enter ‘Admission Likely’ (WAL) in ‘Departure Destination’ in the clinical screen. o When discussing any case with inpatient staff, state in order: Who you are What you want – advice, review for opinion, or admission Name of patient Diagnosis Other relevant history o If notifying an inpatient registrar of an admission: o Clarify acceptance of admission. o Ensure the inpatient registrar understands as to whether the patient will be progressing to the ward (‘Direct admission from ED’) or requires review prior to this in the ED by the admitting unit. o If the patient requires review in the ED by the inpatient registrar – determine the time-frame this will occur in. o Beds are only to be booked when the patient’s ED management is complete (+/- following review by the inpatient registrar in ED) (i.e. they are ready for the ward – this includes: ED notes completed and printed with a management plan, medication and fluids charted etc). o When ready, ensure your patient has a bed booking form (+/- a ‘Direct Admission to Ward’ form if applicable) completed either by yourself or by the inpatient registrar if they are reviewing the patient within the ED. DO NOT complete a bed booking form unless the patient is ready to be moved to the ward. Via the READI Process, the nursing staff undertakes a check of all the criteria to ensure suitability or ‘readiness’ for the ward with respect to completion of care and appropriate documentation. o 8 The review of admissions in ED by the accepting inpatient registrar is a privilege, not a right. Excessive delays (>1hr) for this review to take place and be completed (for any reason) will not be accommodated. Please notify ED senior staff if your patient is experiencing or likely to experience an excessive delay to inpatient review; they will decide on the clinical appropriateness of progressing the patient to the ward from where the inpatient registrar review can then take place. What ED Consultant and Registrar Staff also need to do: o Monitor and pro-actively manage 2:(1):1 times of the patients you are directly supervising for the residents – however quality and safety of care is also your priority. o Registrars, if required, discuss cases with ED Consultants early to assist with the above. o Aim to review all patients discussed with you by ED residents. o Give consideration to which patients requiring admission do not on a clinical basis need to stay in the ED for their review by the accepting inpatient registrar (NB. you need to see the patient yourself to make this decision correctly). If a decision is made that the patient can be admitted directly to a ward and thus bypasses inpatient review in the ED, then a ‘Direct Admission to Ward’ form needs to be completed along with a bed booking form. 9. Ordering pathology tests With respect to requesting pathology in the ED, only the pre-formatted pathology forms may be utilised and only those tests indicated on the form may be requested. Tests indicated on these forms include – FBS, UEG, LFT, Ca++, Lipase, BHCG, TNI, Blood Culture, Paracetamol level, INR (on warfarin), COAG for major bleed likely need for transfusion, COAG for end-stage liver disorder. Simply tick to indicate which tests you require. Group and Hold and Cross-Match requests have a unique form (purple in colour) that is to be utilised for these requests. Any other tests, not present on the forms, which are required by ED staff, need to be requested on a blank pathology request slip and signed off by an ED Consultant. Inpatient teams requesting additional tests must utilise blank pathology forms and indicate their consultant unit as the cost centre. Once bloods have been taken they should be labelled with the pathology stickers that accompany the patient ID labels. These pathology labels also need to be signed and dated. Please also ensure you name and DECT number is clearly PRINTED on the request form. The specimens and request slip is then placed in a plastic pathology bag and delivered via Lampson to the laboratory. The Lampson air-tube system and pathology bags are located within the Resuscitation area, Acute area and Ambulatory Care area. Turn around times for pathology results are on average 60 minutes – ED specimens have priority in the lab. Results can be accessed via AUSLAB/AUSCARE – found on all the computer terminals. Ensure that you review all the pathology results you request (+/- with your consultant or registrar) and document the findings in your notes. 10. Ordering radiology (and vascular USS) 9 The ED has its own satellite radiology unit with plain radiology, USS and CT rooms. On the radiology request form ensure you legibly PRINT your name as the referring / treating doctor, indicate the area the patient is in (i.e. Acute 3 - so the radiographer can find them) and whether or not they require oxygen and / or monitoring whilst they have their x-ray. Radiology request slips are to be faxed through to the radiographers’ work area or walked around there. The radiographers run an image alert system within the ED. If they identify an abnormality within a plain film they take they will insert the word ALERT on the film, such that it should be looked for when you are reviewing your films. If you have any queries about a film with an ALERT on it please see the radiographers. There is a radiology reporting room within the radiology area (across from the ED CT room). There is a radiology registrar present 24 / 7. The radiology consultant and / or registrar can be utilised to discuss imaging you have queries about. You must discuss any potential request for CT, USS, and MRI etc with an ED consultant or registrar. To organise a CT, USS or MRI you will need to go to the radiology reporting room. There you will find the radiology registrar and be able to discuss the case and organise the imaging. To organise USS you may be directed to the main radiology USS area. There you will find the radiology registrar for USS and be able to discuss the case and organise the imaging. An MRI request often needs to be discussed directly with the MRI Consultant. Radiology reports from CT, USS, MRI are generally available on PACS soon after completion of the imaging, or are phoned through by the reporting radiology consultant or registrar to the ED consultant. Otherwise, speak directly with the radiology registrar in the reporting room. Plain film reporting is also often complete whilst the patient is still in the ED. Ensure that you review all radiology films (and their reports) you request (+/- with your consultant or registrar) and document the findings in your notes. If you wish to arrange an outpatient radiological investigation for a patient – you can either fax a referral slip to the appropriate number (displayed on the x-ray forms) or ask the patient to proceed around to the hospital’s main radiology area to the appropriate radiology booking desk. Generally, if you are requesting a patient to attend an outpatient radiological investigation you should also ensure they have appropriate follow-up organised within the hospital to review the result with the patient. Vascular ultrasound Please note, the vascular lab (not radiology) performs all vascular USS within the hospital. They are available Mon-Fri 08:00 – 17:00 (last referrals at 16:30) If you require a vascular USS (e.g. investigating a potential DVT) – phone the vascular lab to arrange a time and fax up a request. After-hours – selective vascular scans can be performed by radiology if necessary. 11. ED Clinical guidelines and procedures There are numerous clinical guidelines for the management of certain conditions that present to the ED. ED senior staff will be aware of what is available. Important electronic clinical resources include: o CKN o ED Intranet webpage (includes access to clinical guidelines, policies and patient fact sheets) o ED internet webpage www.emergpa.net o Metro South Antimicrobial Guidelines 12. Finding a nurse 10 Nurses are assigned to areas within the department along similar lines to the allocation of medical staff. Introduce yourself to the nurses working within your area of the ED at the start of each shift. To determine which nurse is looking after your patient, refer to the nursing white board for each shift’s allocations or on the patient board in each cubicle. 13. Organising medications or intravenous fluids for a patient With any medication or fluid order, ensure that after it is written that you have also verbally informed the nurse looking after the patient of your request. This will ensure the patient receives the medication or fluid in a timely manner. There are numerous electronic resources (CKN, PAH Prescribing Guidelines, Metro South Antibiotic Guidelines) to enable correct prescribing of medications and fluids. Otherwise ask the senior staff if unsure. With respect to antibiotics, the ED aims to provide intravenous antibiotics to patients fulfiling SIRS, sepsis, septic shock criteria as early as possible (within 2 hours of arrival is the KPI). When prescribing Gram positive and Gram negative cover, the specific Gram negatve cover (e.g. gentamicin) should be delivered first to the patient. With respect to analgesia: o Relieving pain is a fundamental task in the ED. o There is a process for nurse-initiated analgesia within the ED. This enables effective pain relief for patients prior to a doctor’s assessment. o Within the ED, analgesia can be provided in a number of forms: o Simple splinting and immobilisation. o Oral analgesia – usually paracetamol and / or NSAIDs. o Oral opiates – oxycodone. o o o o IV opiates – generally morphine (or fentanyl for the renal patients). Use of regional local anaesthetic techniques (e.g. digital nerve blocks). Use of opiate PCAs. Please note S/C use of opiates does not have a role in the acute / immediate relief of pain within the ED; however it may do so later during their stay and on the wards. Document the order for analgesia in the ‘medication chart’ (either on the front page or in the PRN section at the back) and arrange with the nurse looking after the patient for it to be given to the patient. If charting intravenous opiates, allow for small titratable doses to achieve effective analgesia. Patients requiring opiate analgesia to be charted for their admission to the ward should have this prescribed via the s/c route. IV opiates are generally not given on the wards unless in the form of opiate PCAs. o o 14. Procedures – Procedural sedation, Suturing, Plastering 11 Most procedures will be undertaken within either the resuscitation rooms or in the procedure area. There are ED Clinical Guidelines concerning many common ED procedures to refer to. Procedural Sedation: o Any procedure requiring sedation / analgesia requires the involvement of senior staff. o Any procedure requiring sedation necessitates 2 doctors (one of which will be a registrar or consultant) – the senior doctor tending to the sedation and airway. o Generally, procedures requiring sedation / analgesia should not occur until written consent is obtained from the patient for the procedure (except in life-threatening conditions). Consent forms for most procedures conducted within the ED can be obtained from the hospital’s intranet web site. o Utilise the ED Procedural Sedation Form. Suturing: o Patients requiring wound closure are usually managed in the Procedure Area o Nursing staff should assist in the preparation and closure of the wound. o Prior to closure of any wounds a registrar or consultant should review the wound. o o o o Post-closure, a senior staff member should also assess the wound. Tendons ARE NOT to be repaired by ED staff in the ED. Patients should be provided with written instructions on wound management. Complex wounds can be brought back to the department for review, but generally patients should see their GP for ongoing wound management / ROS etc. A letter for the GP should accompany the patient for this purpose. Plastering: o Generally ED staff performs POP procedures on ED patients. o There are a number of enrolled nurses within the ED who are trained in plaster cast techniques. There will usually be at least one on each shift. o If required (e.g. for complex casts) there is a plaster technician in the Orthopaedic Department that can be utilised – page via switch. o Ideally, plastering is to occur only within the Procedure Area or the Resuscitation Rooms. There are mobile plaster trolleys for this purpose. o Ensure patients are provided with pamphlets on plaster care and, if applicable, use of crutches. o Clean up after yourself. o Plastering is a useful skill and one that should be acquired during your time in the ED. Utilise the senior staff and enrolled nurses to assist you in developing this skill. o All fractures that have required manipulation and placed in a cast require a post procedure x-ray to confirm adequacy of the position of the fracture. o A senior doctor should review all plasters performed and all post procedure x-rays if they haven’t been involved in putting them on. 15. Telephones Consultants, registrars, Training SHOs and residents have access to DECT phones to enable more ready access to each other within the ED and to the rest of the hospital. Ensure you collect one at the start of each shift and enter the number of the DECT against your name on the electronic medical allocation board in the ED write-up room. Answer the phones with “Emergency Department” or “PA Emergency Department”. Occasionally, outside calls from the public may be put through to the ED - DO NOT provide ‘over the phone’ medical advice to patient enquiries. This leads to bad medicine. Simply state to the caller that you are unable to provide advice or make a diagnosis over the phone and that if the caller is concerned about their health they should arrange for a medical review (either with a GP or at an ED). Alternatively they can be directed to call 13 Health. This is a QLD Health service that specialises in providing health advice to the public. All calls from other hospitals, GPs and QAS are to be taken by a registrar or consultant; and these are directed to the Consultant DECT Ex. 7215. There is also a phone dedicated for incoming urgent ambulance contacts. A consultant or registrar may be required to speak to ambulance officers on this phone. 16. Specialist Units and referring to an inpatient registrar On-call information can be obtained by phoning switch (dial ‘9’). Many specialty units are rightfully engaged in all aspects of their patients’ health care and as such appreciate to be informed / involved when their patients present to ED. Inpatient registrars can be contacted via the LAN Paging Network located on all computer terminals. Type in your name, location (ED) and return phone number. If registrars fail to answer their page – check with switch that they are indeed on- call (rosters do change without our knowledge); try a mobile phone if they don’t answer their page; if they are in OT – either leave a message to contact you when 12 they are finished (don’t forget to find out what time they are likely to be available), or ask to be put through to the theatre they are in to discuss more urgent cases. When referring cases to an inpatient registrar: o Introduce yourself and where you are from (ED) o State what you require of them (i.e. an admission; review and opinion; or advice). o Start by giving them a diagnosis and brief overview. If they require more detailed information they will ask you. (e.g. “I am John Smith a resident from ED. I have an admission for you. A 50yo gentleman with acute coronary syndrome. He has had 2 hrs of ischaemic sounding chest pain. His ECG shows ischaemia with lateral T-wave inversion. His initial troponin taken at 3 hours post onset of pain is elevated at 0.6. He is now pain free etc.). This will grab their attention, rather than reciting a history, examination and then a diagnosis at the end – by which time they will have lost interest. 17. Referring to the medical registrars (and MAPU Medical and Cardiology Registrars) The ‘Medical A or ‘New Case’ registrar is on-call for all ‘new’ admissions. A ‘new admission’ is one that hasn’t been seen at this hospital as an in-patient or in OPD for the last 12 months. Any ‘old’ patients (i.e. the patient has been seen as an inpatient or in OPD, with this or a related problem, within the last 12 months) are to be referred back to their treating unit (general medical or sub-specialty). Page that unit’s registrar. After hours and on weekends the ‘Medical B’ or ‘Old Case’ registrar is available to admit all ‘old’ patients. To summarise: The ‘Medical A’ or ‘ New Case’ registrar is responsible for: o All patients presenting to the hospital with a problem for which they have not been seen previously (either as an inpatient or in the OPD); or for which they were last seen (either as an inpatient or outpatient) more than 12 months ago (from the time of this presentation). o During hours (08:00-16:30) if it appears this ‘new’ presentation qualifies as a sub-specialty admission (there are guidelines in the medical registrar handbook, located on the PA intranet web-site, as to what type of patients the sub-specialty units take) contact the sub-specialty registrar for acceptance of the admission. If the sub-specialty unit declines the admission, the ‘Medical A’ or ‘New Case’ registrar accepts the patient to a general medical unit. o After-hours the ‘Medical A’ or ‘New case’ registrar is to admit all these ‘new’ patients regardless of whether it is felt they may be a sub-specialty admission. They will liaise with their consultant and/or the sub-specialty unit, if required, to determine whom the patient is admitted under. The ‘Medical B’ or ‘Old Case’ registrar is responsible after-hours for: o All patients presenting to the hospital with a problem (or related problem) for which they have been seen previously (either as an inpatient or in the OPD); and for which they were last seen (either as an inpatient or outpatient) less than 12 months ago (from the time of this presentation). They will admit the patient under the respective ‘old’ general medical or sub-specialty unit. o After-hours, any ‘new’ patients accepted by a sub-specialty unit from the community or another hospital will be admitted by the ‘Medical B’ or ‘Old Case’ registrar. 13 MAPU Medical and Cardiology Registrars: o The Medical Admission and Planning Unit is a 30 bed facility that sits adjacent to the ED. It is a ward generally for medical patients who have a planned length of stay of less than 48 – 72 hours. o There is a MAPU Medical Registrar (Mon – Sun 08:00 – 18:00) and MAPU Cardiology Registrar (Mon – Sun 08:00 – 18:00). Patients not requiring complex subspecialty care, without high care needs and with a predicted suitable length of stay, can be referred to these registrars who will assess their suitability for admission to MAPU and liaise with the admitting unit whom they will come in under. 18. Referring to a medical sub-specialty unit. There are guidelines in the medical registrar handbook (located on the PA intranet web-site) as to what type of patients the sub-specialty units take. Importantly, if you have an ‘old’ general medical or sub-specialty patient during the afternoon, be conscious of the time and attempt to expedite their referral to the relevant inpatient registrar before 16:30. This may involve notifying them before some investigations have been completed. Overall, they will be more familiar with admitting their ‘own’ patients than the ‘Medical B’ registrar and would prefer to do so at 15:30 rather than 16:30 if possible. 19. Referring to an inpatient consultant You may have reason to discuss a patient with the inpatient consultant (e.g. if they are a private patient). Prior to your discussion with them ensure you have discussed the patient with the ED registrar or consultant – so you know what you are talking about. Give consideration, especially overnight, to the ED registrar or consultant making the referral. It may allow for a more professional interaction. 20. Arranging a private / intermediate admission Patients occasionally present to the ED with private health insurance and wish to utilise this for a private / intermediate admission. Options: o You can liaise directly with the patient’s doctor of choice. o Or call the consultant on-call for the relevant discipline at PAH; they may also work privately and may be able to accept them for private admission in a private hospital or as an intermediate admission at PAH. 21. Referring to ED Mental Health There is a separate area within the ED where the ED Mental Health Service is located. They provide a 24 / 7 service. Mental Health patients are assessed at triage as to their suitability for the ED MH area. Agitated, aggressive patients or those with potential medical issues are seen first through the main ED area. Familiarise yourself with the elements of the Mental Health Act that pertain to examination orders and involuntary patients. All patients that present following a self-harm attempt or on an EEO should be discussed and assessed by the ED MH clinicians. Give careful consideration as to whether your patient should be ‘voluntary’ or ‘involuntary’ (i.e. by filling out a request and recommendation for assessment). Although patients should generally be first given the opportunity to remain ‘voluntary’, give consideration to making them ‘involuntary’ (in consultation with ED senior staff), prior to the mental health clinician review, if you would be concerned for the patient’s or others safety if they left the department prior to this review. 14 Any ‘involuntary’ patients within the ED should have a nurse ‘special’. This is arranged with the nurse in charge of the shift. Generally, only MH clinicians can discharge patients off an EEO. 22. Referring to OPD It is often reasonable to discuss your plans of referring a patient to a Specialist OPD with the appropriate specialty registrar. All outpatient referrals are to be electronically submitted via the PAH Intranet. Go to: o Projects ED blue slip referrals Provide as much information as possible on this referral – many OPD requests are triaged on the basis of what is on the referral form (not what is in the chart – however do indicate in your notes within the chart the purpose of the referral as well). Ensure the contact details for the patient are correct. Advise the patient an appointment will be sent out to them in the mail. Provide the patient with an OPD information slip – so they have a contact number if the appointment fails to arrive in the mail. If you require an urgent appointment, discuss the case with the relevant inpatient registrar and gain their approval for an early appointment and document this on the referral request. 23. Inter-hospital Transfers The aim of the PAH Inter-hospital Transfer Policy is to ensure safe and appropriately timed patient transfers to the PAH. The QEMS Central Clinical Coordinator is responsible for arranging the transfer of critically ill patients and patients from distant facilities. ICU determine whether patients from other facilities can be accepted into their units for further management. For local metropolitan transfers, the referring hospital liaises with the accepting inpatient unit and the PAH Bed Management Unit. These patients should ideally proceed to their booked bed upon arrival to the PAH. If the transferred patient does not have a bed ready upon their arrival to PAH, the accepting inpatient unit will be expected to ‘admit’ the patient in ED. ED staff will only become involved in their care if the patient is 'unstable' on arrival or in liaison with the accepting team. 24. Trauma There is a Professorial Trauma Service within PAH. The Acute Surgical Unit (ASU) undertakes assessing and managing all acute surgical and trauma patients that attend PAH. Monthly trauma audit meetings and weekly trauma case review meetings are coordinated by the ED, ASU and the Trauma Service. Management of trauma and resuscitations in the ED: o Trauma team activation – Via Switch (Dial 666 or 9) and state Trauma Alert or Trauma Respond Within the relevant clinical areas protocols for 'trauma notification' can be found. Please familiarise yourself with the levels of notification. There are two levels of response: Trauma alert – which is an ED internal response and includes notification to the Trauma CNC and Surgical Registrar. This response is for most traumas and is based on mechanism, specific injuries but essentially normal physiology re vital signs. 15 o Trauma teams: o Determined by the ‘trauma activation’. Traumas are generally coordinated by the ED consultant. Trauma management within the PAH is multidisciplinary and involves the cooperation and input of many specialties. Trauma Documentation: o Trauma Respond – this is for patients with abnormal physiology / vital signs, positive FAST and / or high likelihood of requiring OT or IR. Trauma assessment / management forms can be found in the resuscitation rooms. Utilising these allows improved auditing and research of our activities. PAH ED Trauma Clinical Indicators: CXR / Pelvic x-ray - within 10 minutes of arrival. Lateral C-spine within 15 minutes. OT within 30 minutes if unstable. CT Head within 30 minutes if stable. CT abdomen / pelvis (c-spine, chest etc) within 60 minutes if stable. 25. Persistent Pain Service The hospital has a Persistent Pain Service, however it only accepts referrals from GPs. If you believe your patient may benefit from this service they will need to arrange a referral from their GP. The service does not accept any referrals from ED. 26. Referring to Fracture Clinic All fractures that are seen through the ED should be referred for follow up to the Fracture Clinic run by the orthopaedic surgeons. The Orthopaedic Department has their own electronic OPD referral forms – again via the Intranet links: o Projects ED blue slip referrals To refer to the Fracture Clinic, indicate on the Orthopaedic referral form that you require a fracture clinic appointment, document the diagnosis (e.g. distal radius fracture), and when you would like them to be seen in the clinic (e.g. within 1 week). Ensure the contact details for the patient are correct. The fracture clinic staff will then send out an appointment to the patient. The fracture clinic is generally for orthopaedic injuries involving broken bones. However, it can also be utilised for follow up of dislocations and acute ligamentous injuries (e.g. acute knee injuries). 27. Referring for outpatient investigations 16 There may be situations where investigations can occur non-urgently after the patient is discharged from the ED. Such investigations may include EST, dobutamine stress echocardiography, Holter monitoring, EEG, imaging – USS / CT / MRI etc. This should occur either: o With the GP arranging the investigations privately and following up the results, or o With the ED arranging the investigations to occur within the hospital and the results to be followed up in a relevant OPD clinic. o Mixing of the above two pathways should ideally not occur - an investigative / management loop once started within the hospital system should preferably be completed within the hospital system. Avoid having GPs follow up results of investigations you are arranging to occur in the hospital as an outpatient. With respect to some investigations it may be more appropriate to discuss your investigative plan first with the relevant specialist registrar (e.g. cardiology, neurology etc). For example, to arrange radiological investigations, fill out a radiology request slip as appropriate. Ensure the patient’s contact details are correct. Indicate a time frame you would like the investigation performed. In particular, indicate if it needs to be performed prior to an accompanying request for an outpatient clinic appointment. Ensure to include as much information as possible on the form. Be sure to include the details of who will be following up the result. Generally this will be an inpatient unit in OPD. Radiology requests can be faxed to the relevant area (as detailed on the request slip itself) for an appointment to be sent out. Alternatively, during business hours patients may take the radiology request slip to the appropriate booking area in the main radiology department and arrange an appointment. 28. Eye Clinic The Eye Clinic is staffed with an Eye resident with access to Ophthalmology registrars. The hours of operation of the Eye Clinic are: Mon-Fri: 08:00 – 16:30 and Sat: 08:00 – 12:00. To avoid excess overtime for the clinic they cease taking new patients from 16:00 Mon-Fri and 11:30 on Saturdays. Eye patients going to the Eye Clinic from the ED triage desk do not appear on the EDIS screen. Outside operational times of the Eye Clinic, ED staff sees patients with eye complaints. Please utilise the ED Eye Forms (found in the Eye Room in Ambulatory Care) for documenting your assessment and management of eye cases. 29. Referring for Paediatric or Obstetric and Gynaecology services PAH attends to patients 16 years and older; the Mater Children’s ED attends to patients 15 years and younger. Patients younger than 15 years and younger normally present with their parents and should be triaged, briefly assessed, treated for pain or bleeding, then transferred (either by private vehicle or QAS) to the Mater Children's Hospital. PAH has no on-site obstetric and gynaecology service. We rely on accessing the services provided by the Mater hospital and QEII hospital. For obstetric issues (i.e. > 20 weeks) please contact the Mater Mothers Obstetric Registrar – they generally will be in the delivery ward. For gynaecological issues: o Urgent consultations – contact the QEII gynaecology registrar – 24hrs a day. The QEII registrar can attend PAH if the patient is too unstable for transfer; or can accept transfer of the patient to review / admit. o Non-urgent consultations - discuss an OPD appointment with the QEII gynaecology registrar and fax a referral to QEII. 30. Hospital in the Home 17 A HITH service is based in MAPU. HITH Clinical Nurses are available to review patients (Monday – Friday) within the ED or the SSU regarding suitability to be admitted to HITH. Potential patients for HITH can be admitted to MAPU or to the ED SSU to await HITH review the next day. 31. Pharmacy services Operational times of pharmacy: Mon-Fri: 08:00 – 18:00. Saturday: 08:30 –17:00. Outside of these hours discharge medications can be accessed from the ‘after- hours medication cupboard’ in the ACUTE drug room. A script for every medication dispensed from the cupboard is to be left on the paper spike in the room. The PBS scripts utilised within the hospital can also be used by patients in community pharmacies. The ED has its own pharmacist, available on the floor between 08:00 – 17:00 Monday to Friday. Pager 999. They will assist with: o Medication information and advice o Medication histories o Patient counselling and advice (e.g. Epipen education) o Community medication liaison (e.g. for Webster packs and nursing home patients) o Inpatient and discharge medication supply o PBS queries 32. Social Work Services A social worker is based in the ED: o Mon – Fri: 08:00 – 22:00 o Sat: 18:00 – 22:00 The social worker can be found in their office located in the MAPU offices opposite Mental Health They can also be contacted via pager 866 or 1434, or ext 3944 or 3949 Issues that can be referred to the social worker include: o Psycho-social assessment o Bereavement and coronial matters o Crisis intervention o Advocacy o Legal resources, legal aid police o Cross cultural referral and support o Referral to appropriate community resources / community health / ACAT o Financial difficulties o Discharge planning o Post trauma counselling o Sudden death counselling o Sexual assault o Information and support o Aged care assessment and respite referrals o Domestic or family violence After-hours crisis intervention (outside above operational hours) – the on-call social worker can be contacted through switch (dial ‘9’) for the following issues only: o Domestic violence o Trauma o Rape / Sexual assault o Sudden death o Child(ren) at risk o Donor family Any after hours referrals for Social Work intervention, not meeting the crisis intervention criteria above, should be recorded in the ‘yellow’ Allied Health book located behind the Nursing Shift Co-ordinator’s desk in the Acute area. The Social Worker will follow these referrals up the next working day. 18 33. Emergency accommodation The Homeless Liaison Officer is familiar with accommodation options – pager 5190. The ED Social Worker will be able to help in the absence of the Homeless Liaison Officer. 34. Referring to Allied Health There are designated allied health staff members covering the ED, they are located in the MAPU offices opposite Mental Health. All non-urgent after hours requests to Allied Health should be recorded in the ‘yellow’ AH book located behind the Nursing Shift Co-ordinator’s desk in the Acute area. The relevant allied health clinician will follow these referrals up on their next working day. Physiotherapy – o o o Occupational Therapy – o o o o o o o o 19 Mon – Fri: 07:30 – 18:00 Pagers 300 / 913 Musculoskeletal injuries of peripheral joints (Including a Primary Contact Physiotherapy Program – where physiotherapists will primarily assess patients and liaise with senior medical staff on management and disposition within Ambulaory Care). Acute and chronic neck or back pain De-conditioned elders and fallers: mobility assessment for discharge and MSK treatment Vestibular: assessment and early treatment as appropriate Neurological: balance, gait and co-ordination assessment and suitability for discharge Respiratory: early assessment and treatment Multi-trauma: early respiratory treatment as required Weekends: Mobility upgrades where the physiotherapist’s intervention is required to prevent admission (not routine education on the use of crutches). Acute respiratory patients waiting for an inpatient bed e.g. pneumonia, infective exacerbation of COPD, aspiration where the patient is having difficulty with sputum clearance and whose condition would otherwise deteriorate. Remote Call (after 18:00) Acute respiratory patients who will deteriorate overnight without physiotherapy intervention 08:00 – 16:30 Mon – Fri Pager 584 Review / assess functional performance for discharge planning (upper limb, vision, cognition, self cares) Referral to community OT for home visits (those who live alone, frail elderly, palliative, decreased function) Equipment prescription (shower chairs, grab rails, wheel-chairs) Cognitive assessment (confusion, closed head injuries or LOC) Neurological assessments Facilitate referral to upper limb orthopaedic hand team as appropriate Speech Pathology – o 07:30 – 16:00 Mon – Fri o o o 08:00 – 12:00 Sat, Sun Pager 5243 Referrals for: Acute stroke patients Suspected aspiration pneumonia New onset dysphagia or deterioration of pre-existing dysphagia New onset of communication impairment Laryngectomy patient with dislodged voice prosthesis Dietitian – o o o o 07:30 – 16:00 Mon – Fri Pager 5244 Weekends 09:00 – 17:00 via switch for urgent referrals Referrals for: Malnutrition New diagnosis for dietary education Nutrition support: enteral, parenteral and oral Chronic disease management and dietary compliance issues 35. Referring to the CHIP Nurse (Community Hospital Interface Nurse) and ACEIM Team CHIP Nurse: o The ED has a Community Hospital Interface Program (CHIP) co-ordinator available within the department 08:00 – 16:30 every day (Mon-Sun). o The community health nurse will review patients with respect to their needs at home. They can assist greatly with discharge planning and arranging appropriate community services and follow-up. Assessment and coordination of community services (e.g. domiciliary nurses, home care, wound care, social support) Liaising with community service providers Discharge planning Liaising with community education programs Patient advocacy Patient, family and carer education Chronic disease management Ongoing care / management of drains and catheters Aged Care Early Intervention and Management (ACEIM) team: o 08:00 – 16:30 every day (Mon – Sun) o Speed dial 4681 o Referrals: To facilitate right care right place model of care Implement avoidant strategies and where appropriate provide advice Liaise and follow up all presentations from Aged Care Facilities Facilitate rapid response to assessment Enhance the geriatric focus of nursing in ED Case management with teams to manage these patients focusing on continuity of care and optimal flow Co-ordination of referrals to external service providers 36. Utilising Pastoral Care Pastoral care workers are available within the ED between 18:30-22:30. They can be found via pager. They can assist with: o Spiritual counselling and guidance o Emotional support o Practical help o Liaison with social work and mental health o Patient advocacy 37. Alcohol and Drug Assessment Unit (ADAU) 20 PAH has a consultation Drug and Alcohol service that operates in business hours. Patients presenting to the ED may be referred to the ADAU for review in the ED. They will usually liaise with the patient regarding outpatient programs or refer to other agencies for certain services (inc. in-patient detoxification programs). ADAU can be contacted via Switch. Other agencies in Brisbane that patients can be referred to include: o RBH – Hospital Alcohol and Drug Service (HADS) o Biala – 24hr referral and counselling service o Moonyah – Salvation Army o Damascus Unit – Brisbane Private Hospital 38. Referring to the Sexual Health Clinic There are numerous sexual health clinics run within the Metro South Health District. The PA Sexual Health Clinic (PASH) has its details on the hospital intranet web site. Details of clinic sessions and referral procedures can also be found on their web page. 39. Security Unit The PAH has Queensland's only hospital jail. Only those people formally processed on a warrant can be placed there as a patient. Security is of prime importance to the unit. Dr Stuart McDonald and Dr Neville Henry are the SMOs who work in the unit Monday - Friday. Prisoners presenting with conditions necessitating an ATS Category 1 or 2 will be brought under guard to the ED for assessment. Prompt assessment by the ED staff and either discharge or transfer to the Security Unit is required. Other patients, ATS Category 3 – 5 will be taken to the Security Unit for their initial assessment by Dr McDonald. After-hours, patients brought for assessment from jail are to be seen by ED staff. Generally, a JHO or SHO from Ambulatory Care, who can work relatively independently, will be allocated to attend any patient in the unit. In general, the ED will have a low threshold for admission as the environment from which they have come is not conducive to ‘convalescence’. If the prisoner requires admission then the patient can be referred to an inpatient unit. Occasionally, there may be a need for the patient to stay for a 'SSU' style admission 'under the ED' in which case Dr McDonald or Henry will usually review and discharge the patient the next day. 40. Discharging patients home 21 Ensure you have discussed the case with an ED registrar or consultant. The patient must be safe for discharge. Consider the time of day in your deliberations and planning for discharge. Ensure your notes are complete and have been printed out and placed in the patient’s chart – they should include a diagnosis and a management / disposition plan. Enter a ‘diagnosis’ in the relevant field in the patient’s clinical screen in EDIS. You must communicate with the patient’s GP, nursing facility, Mental health facility, refering hospital etc. Ideally this should occur verbally and in a written format (with a discharge letter). All patients discharged from the ED must take with them a discharge letter. Ensure you complete a discharge letter with the level of detail you would expect yourself if receiving this patient. In particular describe the rationale of decisions made. This is particularly important if the GP has referred them in, or you require the GP to assist in the ongoing investigation or management of their presenting problem. EDIS has a letter writing function that makes this task very simple – simply follow the prompts. If the patient does not have a regular GP and GP follow up is required, please consider referring them to the UQ Health Service GP Practice in Cornwall Street (PACE Building). Communicate with the patient and their family/carers etc. such that they have a good understanding of their problem and any discharge instructions. There are numerous patient instruction sheets for conditions such as minor head injury, plaster care, wound care etc. that should be provided to the relevant patients. These can be found on the PAH ED intranet website and the QHEPS state wide ED website: Patient Fact Sheets Patients requiring discharge medications: o During hospital pharmacy hours (08:00-17:30) the patient can be provided with a hospital script to be filled out at the pharmacy (ground floor – near orange lifts). o After-hours a patient can be provided with a starter pack of commonly required medications from the drug cupboard in the ED. A hospital script should be left on the spike near the cupboard to allow replacement of stock. o A patient can be provided with a hospital script that can be utilised in community pharmacies. Once the patient has left the department place their chart in the discharged patient chart basket. If you were the last to see the patient leave the department, you are responsible for logging the patient off the EDIS system – this includes completing all the mandatory ‘yellow fields’ in the patient’s clinical screen. 41. Admitting a patient to the ED Short Stay Unit The 14 bed SSU forms an important part of the Emergency Department service. Patients with self-limiting conditions who are expected to be discharged within 24 hours are suitable candidates. Approval from an ED registrar or consultant is required before a patient is placed or admitted to the SSU. All patients admitted to the SSU must have an entry in their notes from an ED consultant or registrar. Patients are admitted under ED Consultants and there is a consultant designated to manage the SSU every day. Residents and registrars are expected to maintain knowledge of their SSU patients and ensure that documentation (especially of results) occurs. Decisions on discharge or ward admission will be made at consultant level. Ensure medication (in particular, regular analgesia if relevant) and fluid orders are written up. Ensure results of investigations are documented. Once in the Short Stay Unit the patient is primarily under the care of the senior staff but residents may be asked to assist in this. 42. Admitting a patient to the ward 22 Discuss the case with an ED registrar or consultant. Follow 2:(1):1 procedures for admitting patients: Record the ‘time of referral’ to an inpatient team in the ‘Consultations’ field. Enter ‘Admission Likely’ (WAL) in ‘Departure Destination’ in the clinical screen. When discussing any case with inpatient staff, state in order: o Who you are o What you want – advice, review for opinion, or admission o Name of patient o Diagnosis o Other relevant history If notifying an inpatient registrar of an admission: o Clarify acceptance of admission. o Ensure the inpatient registrar understands as to whether the patient will be progressing to the ward or requires review prior to this in the ED by the admitting unit. If the patient requires review in the ED by the inpatient registrar – determine the time-frame this will occur in. Beds are only to be booked when the patient’s ED management is complete (+/o following review by the inpatient registrar in ED) (i.e. they are ready for the ward – this includes: ED notes completed and printed with a management plan, medication and fluids charted etc). When ready, ensure your patient has a bed booking form completed either by yourself or by the inpatient registrar if they are reviewing the patient within the ED. DO NOT complete a bed booking form unless the patient is ready to be moved to the ward. Via the READI Process, the nursing staff undertakes a check of all the criteria to ensure suitability or ‘readiness’ for the ward with respect to completion of care and appropriate documentation. The review of admissions in ED by the accepting inpatient registrar is a privilege, not a right. Excessive delays (>1hr) for this review to take place and be completed (for any reason) will not be accommodated. Please notify ED senior staff if your patient is experiencing or likely to experience an excessive delay to inpatient review; they will decide on the clinical appropriateness of progressing the patient to the ward from where the inpatient registrar review can then take place. Most inpatient registrars will undertake the bed booking themselves after they have seen the patient (ideal) – others will not (i.e. you will have to do it). Regardless, please be vigilant and check back with your patients to ensure beds have been booked where and when appropriate. Bed booking is done by filling out a bed booking form (located on the desks in the various nursing stations). These forms can then be given to the nursing shift coordinator who will organise the rest of the booking procedure. Once the bed booking details are given to bed management, they will indicate on the EDIS tracking screen either WAA (ward - awaiting allocation until they can allocate an actual ward) or an actual ward (e.g. W2C). This allows for a more accurate overview of who in the ED is being admitted and is ready for transfer to the ward. Ensure your notes are complete – including investigation results, diagnosis and management plan on the ward, medication sheets and fluid orders. Print your notes out and place them within the patient’s chart. Until the patient leaves for the ward we continue to be responsible for their management. If the patient has been admitted by their inpatient team and remains in the ED, due to not being able to access a bed, their care is primarily via the inpatient unit – though ED staff will assist with any emergency. Generally, as the nursing staff hand over patients to the ward staff they will log them off the EDIS system. However, continue to be vigilant in ensuring your patients are logged off. 43. Finishing your shift 23 Check with your registrar or the consultant on duty that it is suitable for you to finish your shift – occasionally you may be asked to stay on due to excessive department activity. Ensure you hand over any patients you still have in the ED to another doctor within your geographical area: o Clinical handover should be in an SBAR style structure o Inform your patients and introduce the doctor receiving the handover to your patients. o Communicate a summary of their management thus far and their ongoing management plan. o Alter the name of the ‘treating doctor’ on the EDIS system. Your name should not appear on the screen when you depart. o Only hand over patients that have been essentially all ‘worked up’ (i.e. referred on for admission but not seen yet by the inpatient registrar; or awaiting CT – if normal can go home). If you haven’t got to this point you will need to stay on until you do. o 24 Include in your hand-over an action plan, dependent on what results are being waited on (e.g. if Hb normal – home; or if Hb low needs admission). Where possible, if the patient requires admission, or an inpatient registrar review, do this referral yourself before you go. You will know the patient better than the other doctor.
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