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Blacktown Hospital Emergency Department
Medical Officer
Orientation Information
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TABLE OF CONTENTS TABLE OF CONTENTS 1. GENERAL DESCRIPTION AND PHILOSOPHY 2. GOALS & OBJECTIVES OF TERM 3. SENIOR STAFFING 4. BLACKTOWN EMERGENCY FLOOR AREA 5. SUPERVISION 6. ROSTER 7. SICK CALLS 8. SHIFTS 9. COMMUNICATION 1 Between you and the Department 2 Within the Department and the Hospital 3 Between you, your patient and their family 10. ADMISSIONS 1 Who to Call 11. DISCHARGES 1 Discharge Letters 12. CASE PRESENTATION FOR ADMISSIONS AND DISCHARGES 13. HANDOVER 1 Handover Information 14. TRIAGE 15. BED AND AREA ALLOCATIONS 16. BAT CALLS TO RESUSCITATION AREA 17. ROLES AND SERVICES WITHIN THE DEPARTMENT 1 Fast Track 2 TCA (Treatment Commence Area) 3 PIT Area 4 Clinical Initiative Nurse 5 Nurse Practitioner 6 Physiotherapist 7 Social Worker 8 Care Navigation 9 Post Acute Community Care Program (PACC) 10 Aged Care Services Emergency Team (ASET) 11 Urgent Review Clinic 12 Drug and Alcohol 18. TEACHING AND EDUCATION RESOURCES .1 Registrar/CMO .2 Prevocational Teaching (SRMO) .3 JMO Teaching (RMO/Intern) .4 Library .5 On-Line .6 Term Assessment .7 Mentorship Program .8 Responsibility of Mentors .9 Research and Quality Assurance .10 UWS Medical School Rotation and Teaching 19. MEDICO-LEGAL ISSUES .1 Police Statements .2 Child Abuse .3 Needle Stick Injuries .4 Abnormal Radiology Results .5 Test Results .6 Media Inquiries .7 Police Requests .8 Blood Alcohol Sampling D: /Manuals/Medical Officer Orientation Information-Blacktown Updated February 2015
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.9 Rectal and Vaginal Examinations in Females .10 Duty of Care .11 Work Cover .12 Re-Presentations of Patients 20. GENERAL HOUSEKEEPING 21. COMPLAINTS AND DISPUTES 22. DISASTERS 23. ANCILLIARY SERVICES .1 Pharmacy .2 Pathology .3 Radiology .4 Interpreter Service 24. FORMS AND DOCUMENTATION 25. MANAGEMENT POLICY AND PROCEDURE 26. CONCLUSIONS
APPENDIX 1 URGENT REVIEW CLINIC BUSINESS RULES APPENDIX 2 EARLY PREGNANCY ASSESSMENT CLINIC APPENDIX 3 AGED CARE SERVICES EMERGENCY TEAM APPENDIX 4 MEDICAL EMERGENCY TEAM (M.E.T) APPENDIX 5 CASE PRESENTATION TEMPLATE APPENDIX 6 ADVANCED MEDICAL PLANNING FORM APPENDIX 7 SAMPLE OF DAILY FLOOR ROSTER APPENDIX 8 SOCIAL WORK REFERRALS APPENDIX 9 TRANSITIONAL NURSE PRACTITIONER SCOPE OF PRACTICE APPENDIX 10 SENSIBLE ORDERING PATHOLOGY APPENDIX 11 EMERGENCY DEPARTMENT SENIOR ASSESSMENT AND STREAMING
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1. GENERAL DESCRIPTION AND PHILOSOPHY
The Emergency Department at Blacktown Hospital offers emergency care for patients of all ages, 24 hours a day 7 days a week. The main purpose of the Department is the provision of initial assessment and acute management for patients presenting to the Department. Relevant subspecialty or the patient’s general practitioner carries out chronic or ongoing management.
The Emergency Department has a major role as a liaison between Blacktown Hospital and the community. To many, it symbolises the whole hospital, as it may be their first or only view of the hospital. The Department needs to be seen to be delivering a service to the community to help promote and maintain the hospital’s reputation.
The Department is a major area in the hospital that may witness patient frustration. It may present a stressful, confusing, or apparently hostile environment to patients and relatives and may therefore be a source of complaints and litigation. Staff members are requested to recognise the need for privacy, have a supportive and understanding attitude and to offer a word or explanation and counselling services, when appropriate.
The Emergency Department is a level 5 department, (with the hospital being a Level 2 trauma unit) providing treatment of major and minor trauma cases and medical emergencies. It provides a service that ensures the timely, skilled and appropriate management of all patients. Approximately 40,000 patients attend the department each year (about 115 patients per day). The number of admissions to inpatient beds averages 25 - 30 per day.
In addition, the Emergency Department provides primary care to non-acute ambulatory patients including treatment to minor wounds, abscesses, septic hands, eye injuries, ear, nose and throat complaints, minor fractures etc. Follow-up care for these patients is generally performed elsewhere.
The provision of services for the non-urgent patients should not interfere with the provision of emergency services.
The Emergency Department also provides a focus for teaching and research into the acute emergency care of patients and the health and well being of the community as a whole. The teaching is primarily for Hospital staff but also provides a service to others in the community.
An important role of the Emergency Department is its involvement in local and regional retrieval systems. Blacktown Campus sends half a disaster team (one doctor and two nurses) to the scene of a disaster as requested by the area response team.
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2. GOALS & OBJECTIVES OF TERM
To gain broad experience in the management of adult and paediatric emergencies
To develop and enhance resuscitation and procedural skills.
To further the ability to work in a multidisciplinary team
To develop a high standard of documentation in clinical recording
To participate in continuing education
To enhance communication skills with colleagues, patients and relatives
To develop skills in the efficient and appropriate use of investigations.
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3. SENIOR STAFFING
Director Emergency Medicine Blacktown and Mt Druitt Hospitals
A/Prof Reza Ali
Deputy Director Emergency Medicine Blacktown and Mt Druitt Hospitals
Dr David Melvin
Emergency Medicine Consultants
Dr Chamila De-Alwis Dr Harry Elizaga Dr Michael Hession Dr Karina Hochholzer Dr Shaila Islam Dr Dushan Jayaweera Dr Daya Jeganathan (DEMT and Head of BEST Network) Dr Ponnuthurai Jeyaruban (DEMT Mt Druitt Hospital) Dr Patricia Kijvanit Dr Catherine Kizana A/Prof James Kwan Dr Gopi Mann Dr Satish Mitter Dr Richard McNulty Dr Jannatun Nayim (DEMT Blacktown Hospital) Dr Fernando Pisani Dr Greg Robinson Dr Liaquat Sheriff Dr Kenny Yee
Emergency Medicine VMOs
Dr Richard Lennon Dr John Shirley Dr Vijay Manivel
Executive Assistant
Ms. Joan Brown
Nursing Unit Manager 3
Ms. Colleen Mullens
A/Clinical Nurse Educator
Mr Johnathon Hamilton
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Nurse Consultant
Ms Jo Scullion
A/Clinical Nurse Consultant
Ms Tracey Newton
Nurse Practitioner
Luke Strachan
4. BLACKTOWN EMERGENCY DEPARTMENT FLOOR AREA
The department is divided into different areas based on the model of cares provided. There is Acute, Sub-Acute, Fast Track, PIT (Early Senior Assessment) and Treatment Commence Area (TCA). There are 2 resus beds and 16 acute beds (4 – 19) in the Acute Area. There are 4 beds (21 – 24) in the sub-acute area. There are 6 recliner chairs in the fast track area and 7 recliners in the TCA. There are two consultation rooms plus an eye/suture room and plaster room, which may be used whenever appropriate. There is also a Short Stay ward in the department which comprises of 4 recliner chairs.
5. SUPERVISION
All JMO’s are supervised by the EDSS/Registrar/CMO/.They are expected to discuss ALL their cases with a senior medical officer in the Emergency Department as soon as possible, preferably even before starting to write their notes and definitely before all the results are back. This allows the department to reach the NEAT criteria by allowing early senior decision-making with regards to patient management and disposition
JMO’s are not expected to make admission or discharge decisions without the direct supervision of a senior physician.
Registrars/CMOs are expected to update and discuss with the consultant on the floor regarding the patients they are reviewing and directly managing and to escalate any deteriorating patient as soon as possible. The Staff Specialist directly supervises CMO/Registrars.
The Consultant on the floor will be in charge of the shift and decide on patient management plans and deal with any administrative or policy issues that might arise during the shift. In the absence of the consultant, the CMO or Registrar will fulfil this role.
When there is no ED Physician on the floor, there is a rostered on call ED Physician (please refer to the daily floor roster sheet). Any complex issues that the CMO/Registrar have difficulty with, needs to be discussed with the on-call ED Consultant. D: /Manuals/Medical Officer Orientation Information-Blacktown Updated February 2015
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Consultant on-call roster is published weekly and is clearly marked on the daily floor roster.
If an emergency physician is available, the ED handles its own cardiac arrest. At other times, call the Cardiac arrest team on 111. The MET (Medical Emergency Team) can also be called, on the same number, whenever further assistance is required in an unstable patient. The MET consists of the ED Senior as team leader, a medical registrar, an anaesthetic/ICU registrar, a resuscitation nurse and a wardsman. There is a nursing team leader, an airway nurse and a circulation nurse allocated for resuscitation in the ED for each shift.
The hospital’s Trauma Team should be called to assist in the management of any multi- trauma cases. See the guidelines in Appendix 5.
6. ROSTER
Blacktown and Mount-Druitt ED have their independent REG/CMO and JMO roster. The Executive Assistant of the Department is in charge of the JMO roster. Dr David Melvin is in charge of the REG/CMO roster.
The roster is arranged at least four weeks in advance. Thus any special requests must be made before this time.
The Department has a rotating roster and it is expected that everyone would do their shares of day, evening and night shifts.
Once the roster is finalised and published, JMO’s/REG/CMO must arrange their own swap/relief, if there is a specific shift they cannot work. The JMO/REG/CMO concerned in the swap must complete a “Shift Change Form” and inform the Executive Assistant. The shift change must be authorised by A/Prof Ali or his delegate when he is absent. All swaps must be within the same pay period. The change will also be noted on the master floor roster in the ED for pay purpose.
The number of hours worked per fortnight depends on the number of staff available for the shifts. The number of hours may range from 80 to 90 hrs per fortnight.
JMO/REG/CMO willing to work more shifts than usual should contact the Executive Assistant as early as possible for allocation to extra shifts.
Meal breaks are paid for after hours, and there is no need to claim for these. If you work an in-hours shift (Day Shift), and do not receive a meal break, you must write next to the shift “NMB”. The ED Director or staff specialist must countersign this.
If you are leaving the ED floor to go to a different part of the hospital, please notify Staff Specialist or Registrar of your whereabouts, so that you may be contacted if required.
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7. SICK CALLS
If you are sick, you must notify the Director A/Prof Reza Ali on his mobile via the switchboard and in his absence the Deputy Director Dr David Melvin on his mobile via the switchboard.
It is expected that the call is made early on (at least 6hrs prior to commencement of shift) and not just prior to commencement of the shift. This is particularly important for night shifts.
The person rostered on as night sick relief will need to work the shift. It is essential that you give as much warning as necessary so that relief staff can be organised.
Doctors taking sick leave two or more days consecutively will need a certificate from their LMO as to the cause. This certificate is to be given to the Executive Assistant.
8. SHIFTS
BLACKTOWN MT DRUITT
D/DB 0800 -1830 D/DM 0800 - 1830 MB 1200 – 2230 MM 1200 – 2230 E/EB 1400-2400 E/EM 1400 - 2400 N/NB 2230-0830 N/NB 2230 - 0830
On the REG/CMO and RMO/SRMO rosters there is an on-call night cover person clearly designated. The night cover person will be asked to cover any unexpected night sick call relevant to their roster.
9. COMMUNICATION
9.1 BETWEEN YOU AND THE DEPARTMENT
This will be via email. Please ensure that you have provided the ED Executive Assistant your CURRENT contact phone number, provider number and email address on commencing the term. Please notify her of any changes during the term.
All rosters and ED messages will be sent to you via email.
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9.2 WITHIN THE DEPARTMENT AND THE HOSPITAL
Available forms of communication include, telephone paging, electronic documentation, and writing legibly in the notes. However, the best way to communicate with other ED staff is by polite personal communication. Nursing staff need to be informed of management plans or changes to these, as they are often the personnel required to carry out these plans. There is also an overhead communication system in the ED department. The overhead system is for professional use only. It is not for personal communications/messages.
The paging system is used to contact the relevant in-patient Registrar/Resident. If the paged person is not answering his page, it is probably because the page number is wrong, he/she has gone home, has not picked it up from switch, has not turned it on, has left it in theatre, or most likely he/she is in theatre, etc etc. The variability’s are enormous. So in this circumstance,
a. Check that the paged number is correct.
b. Check with the Communication Clerk if they have any information. The theatre is a good place to start looking. With O&G registrars it is always worthwhile checking with the Delivery suite. A communication clerk is available during 06:30am and midnight to help with the paging.
9.2.1 To page someone via the telephone: Enter *2 and wait for tone Enter pager number then press * 3 beeps indicate message is sent Hang up
9.2.2 To page someone via the intranet: This link can be found by either: Via the Emergency Department home page – type in pager number and message - send Can be added to Firstnet as a link
The phones in ED have “group pick-up” and “search” facility.
9.2.3 Group pick-up: If one of the phones is ringing, you can pick-up this call by lifting the receiver of another phone in the area and dialling “1”.
9.2.4 Search facility: If one of the lines is engaged or unanswered for 5 rings, the call jumps to one of the other lines in the area.
All REFERRAL phone calls to the department by a LMO or VMO for admission should be referred to the Staff Specialist or CMO/Registrar in ED.
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Any communication with other teams or senior doctor in ED should be documented clearly in the patient’s notes, especially with regards to plans or advice given “If it hasn’t been documented it didn’t happen”
9.3 BETWEEN YOU AND YOUR PATIENT AND THEIR FAMILY
Introduce yourself politely to the patient, and listen to what they have to say. Keep the patient informed of your management plan and what to expect. If imaging or other tests are being organised inform them as to why they are being done. Again be polite and courteous.
By following these simple steps the complaints and dissatisfaction rate will be hugely reduced. Just think of yourself in the patient’s family’s situation and what you would have expected!
10. ADMISSIONS
ED medical staff assess and where indicated admit patients presenting to the department. Exceptions to this are:
Team admissions during office hours When workload demands assistance from ward staff.
After performing an assessment, organizing immediate management and investigations the ED JMO should discuss the case with the ED Staff Specialist/CMO/Registrar and agree on a differential diagnosis and management plan. If the plan is for admission then the JMO should contact the appropriate in patient team subspecialty registrar (please refer to “who to call” section), who should then review the patient as soon as possible following this notification. The time that the call was made should be documented in the patient’s notes.
Registrars should be called as early as possible about a possible admission, to prevent delays in management. Results of investigation are not always necessary before review by the registrar.
Surgical patients: Admitted under the consultant of the day unless specified otherwise by the Surg Registrar. (Except those who are private and make a special request)
Medical patients: If a patient is known to a consultant or his/her team from a previous admission for a similar issue, they are then usually admitted under the previous consultant. If the patient is not known to a consultant or his/her team for the specific presenting issue, then they are to be admitted under the on-call Physician of the relevant subspecialty.
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All renal, palliative care and haematology/oncology patients attending the ED must have their usual consultant notified while they are in the ED, regardless of whether or not they require admission.
O&G patients: Admitted under the consultant of the day unless specified otherwise by the O&G Registrar. (Except those who are private and make a special request)
Psychiatry patients: Admitted under the consultant of the day. (Except those who are private and make a special request)
Paediatric patients: Admitted under the consultant of the day. (Except those who are private and make a special request)
Orthopaedic patients: Admitted under the consultant of the day. (Except those who are private and make a special request)
Plastics patients: Need to be discussed with the plastics/hands surgeon on-call. These patients are managed in Auburn Hospital or a private hospital.
Urology cases: Admitted under the consultant of the day unless an Urologist on the hospital staff already knows the patient. (Except those who are private and make a special request)
10.1 WHO TO CALL
After hours: (Weekends/Public holidays and between 1700hrs to 0800 hrs week days)
Surgical Registrar for all surgical patients requiring admission. O&G Registrar for all O&G patients requiring admission. Paediatric Registrar for all Paediatric patients requiring admission. Acute Mental Health Team on 0429 390 579 between 0830-2230 hrs after which the on call Psychiatry Registrar for all psychiatry patients requiring assessment and or admission. Medical Registrar / On call VMO of particular subspecialty for all Medical patients requiring admission,
During Hours: (Weekdays 0800 hrs to 1700hrs)
The relevant team registrar needs to be contacted.
The pager numbers are available on the communication folder on the Communication Clerks desk in the acute area of the department. The VMO’s can be contacted via the switchboard. All phone calls to the department by a LMO or VMO for admission should be referred to the Staff Specialist or CMO/Registrar in ED.
Once admitted, the doctor doing the admission (this could be ED doctor or the in patient team doctor) should write up the medication and fluid charts as required.
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At this stage the CNUM should be informed of the admission.
Patients should not be transferred to the ward at any time until the appropriate registrar or VMO (night med reg after hours) has been notified.
11. DISCHARGE
After a THOROUGH ASSESSMENT and necessary investigation, if it is deemed that a patient does not require admission and may be managed in the out patient environment, then the patient may be discharged.
ALL PATIENTS BEING DISCHARGED MUST BE REVIEWED BY AN EMERGENCY MEDICINE STAFF SPECIALIST / CMO / REGISTRAR.
JMOs are not allowed to discharge patients without speaking to a senior physician.
An ED Registrar/CMO/Staff Specialist must review patients representing unexpectedly for the same problem within 7 days, whose conditions are not improving or whose diagnosis remains unclear. It could be worthwhile discussing these cases with the relevant subspecialty prior to discharge.
Elderly patients (65yrs and above) are NOT to be discharged home between 2200 and 0800, unless the patient and their family, and the medical and nursing staff, are satisfied that they can be well cared for in their home environment.
Please also refer to Appendix 4.
All patients being discharged home from the ED require a letter for their LMO to enable effective follow-up. This letter must NOT be cut and pasted from the patient’s medical or progress notes but a brief summary of their ED presentation with relevant discharge instructions.
Please make sure all cannulas are removed before discharging patients.
11.1 DISCHARGE LETTERS
All patients being discharged from the department must have a discharge letter to take to their LMO’s for review.
All letters are written on First Net.
It is accessed by Navigating to the Documentation section of the patient chart on First Net. Select ED Discharge Summary in Type Field Select and highlight Discharge Referral ED template from list on Catalogue tab D: /Manuals/Medical Officer Orientation Information-Blacktown Updated February 2015
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Click on OK
In Visit Information free text under summary of care:
The information given to the GP should include:
. Presenting complaint . Assessment - History and relevant positive examination findings. . Investigations of relevance done (print a copy of the results separately to accompany the letter) . Treatment . Follow up needed – when and what (Blood results, MCS results, CXR etc)
Please do not copy and paste the admission notes.
In the Health status tab: In Diagnosis - Enter the diagnosis – Essential In results review – include investigation results
In Discharge information – click relevant advice given to the patient. e.g. “to represent if symptoms worsen”, “Head injury advice”, “Advice regarding driving and swimming in patients with seizures” etc
Save or sign the discharge summary. – If you save it you can come back to make changes – e.g.: a doctor who gets handed over a patient can make changes to a discharge letter written by the first doctor.
Print a copy for the patient.
If you are writing a referral letter to a specialist, you must ensure that your Medical Provider Number is included on the letter.
12. CASE PRESENTATION FOR ADMISSION OR DISCHARGE
As a JMO you will be presenting / discussing all your patients with the REG/CMO/Staff Specialist.
As a Registrar/CMO you will be discussing your cases with the ED Staff Specialist and the In Patient team consultants regarding an admission or discharge.
The following template is to be used whenever you are presenting a case. All the ED Consultants have agreed on this template of presentation and would expect the presenter to follow it.
The following is an extension of the ISBAR / ISOBAR handover format
(Refer to Appendix 7 for detailed explanation of template)
Introduce yourself (when speaking to a VMO on the phone)
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Opening summary of the case History of presenting illness
Relevant past medical issues
Medication list
Important social/person history
On examination
Investigations results obtained thus far
Previous relevant investigation results on record
Issues on presentation
Diagnosis and possible differential
Management plan
13. HANDOVER
The Departmental Formal Hand Over round is conducted at the patients Bedside.
The timings for the hand over rounds are:
Morning shift handover at 0800hrs. Evening shift handover at 1715hrs Night shift handover at 2330 hrs.
The round will be announced on the department overhead paging system. The ED Consultant will conduct the round. In the absence of the Consultant, the CMO/Registrar will conduct the round. It is expected that the rounds would have a teaching focus for the participants. The JMO’s will be allocated work areas and patients during these rounds.
It is a multidisciplinary round and the staff expected to attend are:
Nursing: CNUM, Bedside Nurse CNE/CNC when available Social worker when available Care Navigation consultant when available. Medical Students.
13.1 INFORMATION YOU NEED TO GIVE WHEN HANDING OVER A PATIENT
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Name and age
Presenting problem
Working diagnosis and if admitted under which team
Brief History
Positive Examination findings
Relevant Investigation findings
Management PLAN
What needs to be followed up, i.e. Bloods, X-ray, CT, Urine ECG etc. etc.
If all necessary documentation have been completed.
If the patient is for discharge then it is the responsibility of the outgoing doctor to write the discharge summary before leaving the department and handing over his/her patient.
The incoming JMO should make an attempt to introduce him/herself to the patient.
It is expected that the outgoing doctor will have finished all relevant paperwork including progress notes, medication and fluid charts as well as “Safety to Transfer” forms. Handing these items over means that the incoming doctor has to review the patient again to ensure no information is missed, which is not acceptable and adds to the workload unnecessarily.
14. TRIAGE
All patients presenting to the department undergo a registration process followed by Triage.
A senior nurse trained in the process does the triage. It is based on the medical needs and acuity of the patient. Our department has to follow the guidelines by the Department of Health in achieving the triage targets. The guidelines of seeing patients are:
Triage 1: Immediate Triage 2: Within 10 min Triage 3: Within 30 min Triage 4: Within 60 min Triage 5: Within 120min
15. BED AND AREA ALLOCATION
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All JMO’s are allocated to a specific team in the department on the floor roster. The ED Consultant/CMO/Registrar of the particular shift can change this.
You will be responsible for all Cat 2 arriving to that specific area.
You will be expected to go and see the patient immediately, and organise immediate management / investigation / assessment. E.g. Patient with chest pain > organise immediate ECG/Analgesia and make sure your REG/CMO/Consultant has reviewed the ECG with you. Once that is done and the patient is stable you can go back to the task you were completing prior to the Cat 2 arriving.
(Please refer to the daily floor roster for your team allocation in the department during your shift.)
As a REG/CMO you will be assigned to a specific team or Fast Track on the floor rosters.
This allocation is not rigid, and all doctors are expected to help their colleagues as the workload requires.
16. BAT CALLS TO RESUSCITATION AREA
CDA has a direct phone link to the ED and will notify the department of imminent emergencies (eg cardiac arrests or multi-trauma). Information from such calls must be relayed immediately to the appropriate staff. (This phone is known as the “Bat Phone”)
17. ROLES AND SERVICES WITHIN THE DEPARTMENT
17.1 FAST TRACK
The principal objective of the fast track area is to see and promptly manage simple ED presentations (Category 4 and 5). The area is medically staffed by a REG/CMO or a competent SRMO as well as a Fast track nurse and usually does not need to be picked up by JMOs.
Patients designated for the Fast Track area will have a green arrow next to their names on “First Net patient list”
Please refer to the “FAST TRACK business rules” for a better understanding.
17.2 TCA (TREATMENT COMMENCE AREA)
This area is co-located with the Fast Track area. There are 6 recliners in TCA. Once a patient has been seen by a senior ED physician (EDSS/REG/CMO), and if space in the area is available, the patient can then be transferred to the TCA to receive ongoing management which might include IV analgesia, fluids, antibiotics etc. The TCA form must be completed prior to patient going into TCA with clear hand over to the TCA nurse.
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Please refer to the TCA business rules attached as well as protocols re management of patients on recliners.
17.3 PIT AREA
This is a designated space in the department where patients are seen by the “PIT TEAM C” on arrival to the department. Usually after a short triage the patients will be taken to the PIT area for immediate assessment by the PIT team. The PIT team will include, senior doctor (EDSS/CMO/REG), RMO, Nurse. Once the patient is seen in the PIT they can then be streamed into TCA/Acute/Fast Track etc as required. Rooms 26/27 or any other designated area can be used for PIT assessment by PIT team.
Please refer to the PIT business rules for better understanding.
The Safe-T notes are not to be taken as a proper history and the JMO needs to take a full History and examine the patient fully prior to making a disposition plan.
17.4 CLINICAL INITIATIVE NURSE (CIN)
C.I.N is a senior nursing staff member who has gone through specific learning objectives and can manage simple defined problems. CIN are allowed to treat patients under the supervision of the senior physician. Their role can include suturing, back slabs, organise bloods and other investigations as necessary under the direction of the senior physician. JMO’s from time to time may be asked to assist in this process by the REG/CMO/EDSS. Please refer to the “CIN role” document.
17.5 NURSE PRACTITIONER
The Nurse Practitioner is a senior nursing staff member who has gone through specific training to obtain the ability to assess, treat and diagnosis patients and discharge them home. Supervision will be provided by the Fast Track doctor and the Staff Specialist on duty. Please refer to “Transitional Nurse Practitioner Scope of Practice” appendix 11
17.6 PHYSIOTHERAPIST
The department has a Physiotherapist based in the unit. The role of this position is to manage acute musculoskeletal injuries in liaison with the orthopaedic team as well as the ED CMO/REG/Staff Specialist.
The Physiotherapist is available for assessment and advises regarding mobility issues in the elderly population and Acute on chronic back pain in the younger age group.
Monday to Friday: 0800 hrs - 1830 hrs (variable) 0830 hrs – 1900 hrs D: /Manuals/Medical Officer Orientation Information-Blacktown Updated February 2015
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0930 hrs – 1800 hrs 0930 hrs – 2000 hrs
Saturday and Sunday: 0930 hrs – 1800 hrs (variable) 0930 hrs – 2000 hrs
17.7 SOCIAL WORKER
The department has a part time social worker, being available from 0830hrs – 1700hrs on pager 7699 After hours the Hospital on call social worker can be contacted. The different issues the social worker would be able to assist with are: Accommodation, Centre Link payment, bereavement support for distressed families in the department Please see Appendix 9
17.8 CARE NAVIGATION
This service is based in the Emergency Department. Its main focus is to identify patients with Chronic and Complex co morbidities Organise early referrals for management of those conditions Case management of complex care needs in the acute care base as well as in the community. Out come is to avoid ED Presentation and reduce representations
Monday – Friday: 0800hrs – 1630 hrs Pager # 7529 Extension 48012
17.9 POST ACUTE COMMUNITY CARE PROGRAM (PACC)
This program attempts to reduce the number of inpatient admissions, as well as reducing length of stay for patients who do require admission to the hospital.
Common sub groups of patients managed under PACC are:
DVT, Cellulitis, Simple uncomplicated Pneumonia
Criteria for a patient to be included on the program are:
Reside in the WSLHD Treated at one of the WSLHD public hospitals Have access to a GP It is safe for the patient to be treated at home, with attendance by a nurse to a maximum of twice a day
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Patients MUST be accepted by an in-patient team for discharge under PACC and the accepting team must be clearly identified in the patient’s notes.
Service provided by the PACC program:
Up to twice daily visits by a registered nurse in the home, for up to 14 days Most types of illness can be catered for, provided it is likely that the patient will be recovered within 14 days Able to administer IV antibiotics up to twice per day, to patients with IV cannula in situ. However, these patients should have reasonable veins, in the event that the nurse requires resiting of the canula this could be done by the CIN or JMO Contact:
Page 8664 or Ext 46336
Mon – Fri 0800 - 1630 hrs Sat – Sun / Public Holidays 0800 – 1630 hrs
After Hours 7 days: 1630 -2130 hrs Ext 55555
17.10 AGED CARE SERVICES EMERGENCY TEAM (ASET)
ASET CNCs assess patients 70 years and over presenting to ED.
Aim
Assess the functional level of the patient on presentation to the department and recommend any referral or admission to prevent a further decline.
Prevent representation by early identification of at risk elderly patients in ED.
ASET aim to target patients with problems with any of the following: mobility or falls, personal care, cognition or behavior, caring or accommodation issues, and those living alone.
Exceptions: Patients from Nursing Homes or patients being admitted to Bungarribee House or Acute Stroke Unit.
Hours of business: 0700 – 2000 hrs Mon - Fri 0730 – 1600 hrs Sat Sun (Alternate weekends vacant at present)
Pager numbers: 7787 7709 7631 7789 or 7514 (weekends) D: /Manuals/Medical Officer Orientation Information-Blacktown Updated February 2015
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Referrals after hours: Firstnet by clicking on power orders and searching for ASET, then logging the referral. Liaise with the nursing team leader about this for the first few referrals you make.
All ASET appropriate patients discharged home will receive a phone assessment the following day or as early as possible.
17.11 URGENT REVIEW CLINIC
This is an out patient clinic where you can organize follow up of patients being discharged from the Emergency Department.
The follow up will occur within 7 days and can be accessed earlier if required.
Ensure that this has been organized after discussion with the relevant subspecialty team consultant/Reg.
To organize follow-up appointments please speak to one of the Clerical staff or the Communication Clerk in the acute area. The appointments are done through iPIMS.
Refer to Appendix 2 to view the Business rules of the clinic.
17.12 DRUG AND ALCOHOL
During hours the D&A CNC can be contacted for referrals.
0830 – 1700hrs Monday – Friday page 22857 or 22639 (Mobile 0434 327 540)
Voice mail messages can be left on the mobile number in order to follow up any admitted patients.
There are no in patient beds for D&A services in BMDH. If you have a patient who needs admission you can seek advice from the on call D&A Consultant (available via switch). Such a patient can be transferred to Nepean Hospital for a D&A admission.
18 TEACHING AND EDUCATIONAL RESOURCES
Blacktown and Mount Druitt Emergency Department is Accredited by the College for Emergency Medicine for Advanced training in Emergency Medicine.
Your time here will be counted towards Emergency Medicine training.
The following are the different teaching sessions. All the topics and dates are published well in advance. You are encouraged to read up on the topic in advance to get maximum benefit from the sessions. D: /Manuals/Medical Officer Orientation Information-Blacktown Updated February 2015
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Presenters go through a lot of work in preparing for the topics so attendance and participation is vital. This will be reflected on your term assessment.
18.1 REGISTRAR/CMO
Organised by the DEMT. Held every Thursday. 0830-1230. Paid and protected teaching time. (The names of attendee’s will be passed onto RSU for payment) Blacktown ED Tutorial room
18.2 PREVOCATIONAL TEACHING (SRMO)
Organised by Dr. Patricia Kijvanit Held every Tuesday and Thursday 1400hrs – 1500hrs. Blacktown ED Tutorial room
18.3 JMO TEACHING (RMO/Intern)
Organised by Dr. Patricia Kijvanit Held every Tuesday and Thursday , combined with SRMO teaching 1400 hrs – 1500 hrs ED Tutorial room
Interns and RMO’s are encouraged to attend when possible the General JRMO training sessions, which are held every Wednesdays and Thursdays 1300 to 1400hr in the LG Seminar Room in the Imaging Department.
18.4 LIBRARY
There is a small library in the Registrar Room of the Department. All the college recommended books for Emergency Medicine training are available in the Departmental library. The books are not to be removed from the Emergency Department. The key is available from the executive assistant.
The University library is a short walk from the Department.
There is an Eye Educational CD and Emergency Ultrasound DVD available for loan.
18.5 ON-LINE
On the intranet, The BMDH Emergency Department “Website”, provides a wide variety of information, both clinical and administrative, this includes paediatric and drug protocol. D: /Manuals/Medical Officer Orientation Information-Blacktown Updated February 2015
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They are constantly being updated and revised. Suggestions for improvement should be made to the Director of Emergency Medicine. http://wslhdintranet.wsahs.nsw.gov.au/Emergency-Medicine/Emergency-Medicine- BMDH/Emergency-Medicine-BMDH
Through the Clinical Information Access Project (CIAP) link you can also access Harrison on-line, Medline, Cochrane, MIMS, Poisindex and Antibiotic Guidelines.
18.6 TERM ASSESSMENT
You are assessed at mid-term and end of term. Feedback is received prior to the assessment from all Senior Medical and Nursing Staff. College trainee’s assessment is done by the DEMT.
18.7 MENTORSHIP PROGRAM
The department has an active mentorship program. All REG/CMO/JMO will be assigned a mentor. It is expected that you will meet your mentor formally at least three times during the term. The aim of the program is to give you a direct avenue to discuss any work or career related, personal or departmental issues with a Consultant in the department. Your mentor will also receive regular feedbacks from other senior staff in the department and will be passing that onto you in the meetings. Your Mentor will be responsible for completing your term assessment paperwork.
18.8 RESPONSIBILITY OF MENTOR
At least 3 contact meetings lasting 5min with the allocated resident during the term. To gather information from Registrars, Nurse, and Senior Ancillary staff regarding any “on the floor” concerns. All problem residents to be referred to the Director of the department early on so that appropriate measures to rectify the problems can be introduced. To be available to advise and guide the resident through the term.
18.9 RESEARCH AND QUALITY ASSURANCE
. Medical staffs are actively encouraged to take part in the process.
You will be required to carry out an audit project while in the department. Please see audit allocations as per appendix and contact your mentor within the first 2 weeks of your term.
Monthly M&M committee meetings are chaired by Dr Chamila de Alwis and education sessions on them will be carried out in the relevant teaching
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sessions for the different groups. A summary of recommendations are available on the intranet.
18.10 UWS MEDICAL STUDENT ROTATION and TEACHING
Medical students from the University of Western Sydney are rotated through the department as part of the critical care rotation.
If you would like to be involved in formal teaching of the Medical students please inform the Director of the department.
University conjoint appointment is a possibility.
During your work in the department a student might be assigned to you in order to “shadow” you.
19. MEDICO-LEGAL ISSUES
All notes and documentation have to be done on First Net. Medical notes must be legible and contain the following information:
Time seen and date (at every new entry.)Time stamp your documentation i.e. start writing as soon as you start seeing the patients and sign off once finished. You can always add on other things as an addendum: later reviews, more information etc. If you are unable to write for a long time, ensure that you write that you are writing in retrospect and document the time you saw the patient first, referred the patient etc. Ensure you document the name of the person you made the referral to. Presenting symptom Physical examination Differential diagnosis Management plan Tests performed Senior medical officers, or allied health staff contacted Time of discharge Doctor’s signature Entries should be in a “problem based medical record” format (see website).
19.1 POLICE STATEMENTS
Police statements may be required from time to time. If you receive a request for one, refer this in the first instance to the medical records department. You can only put in a police statement what YOU did for the patient. It is in your interest to complete the statement as soon as possible. The alternative may be a court subpoena.
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For clarification please discuss the statement with the Director of the department.
19.2 CHILD ABUSE
The paediatric registrar usually handles Child abuse cases. However, sometimes the ED RMO will be required to perform the assessment (at least the initial recognition of the problem). Coagulation studies, X-rays (indexed with the patient’s name, date and a 10cm reference marking) provide useful supportive documentation.
19.3 NEEDLE STICK INJURIES
Adequate precautions must be taken when there is a risk of contacting patient’s blood or other body fluids. Gloves must be worn when taking blood or inserting IV cannulas. Goggles should be worn as the situation indicates. The “Vaccutainer” system is generally used for the safe sampling of blood. A protocol exists for the management of needle stick injuries. All such injuries occurring in the hospital are managed through the ED.
19.4 ABNORMAL RADIOLOGY
Abnormal Radiology results from the ED are generally checked, and followed up on by the ED Staff Specialist on the day shift. See “Alert BT” folder, Picture Archiving System (Digital Radiology System). Patients are not requested to return merely for the follow-up of routine results.
19.5 TEST RESULTS
Test results are not given to patients over the telephone. They may however be given to the patient’s LMO, after checking the number and calling them back.
Information should not be given to family or friends without first checking with the patient.
19.6 MEDIA INQUIRIES
Inquiries from the media are referred to the hospital’s executive director. After-hours these should initially be referred to the executive on-call.
19.7 POLICE REQUESTS
Please co-operate with police requests, provided patient care is not compromised. Telephone inquiries should first be handled by obtaining the officer’s name, station and phone number. The number can then be independently checked, and the return call made.
19.8 BLOOD ALCOHOL SAMPLING
Patients requiring a forensic blood alcohol sample to be collected include: Any patient aged 15 years or above who presents to an emergency department for treatment within 12 hours of a vehicular accident, occurring on a public road. The test is
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There are special kits for this purpose. The samples must be collected in accordance with the enclosed instructions and the sample placed in the designated police container.
Consent is not required for the collection of this sample. It is a statutory requirement. If a patient refuses to allow the sample to be collected then the local police station needs to be contacted and this must be clearly noted in the patient’s record.
19.9 RECTAL AND VAGINAL EXAMINATIONS IN FEMALES
Rectal and/or vaginal examinations on any patient require a witness to be present. Please ensure a chaperone / Nurse is present.
When in doubt, SPEAK TO YOUR REG / CMO / CONSULTANT.
19.10 DUTY OF CARE
Remember your duty of care. Patients who are not lucid, or who are potentially not lucid (and children < 14 years), may be detained and treated, to protect them from themselves. Do not assume that confusion in the intoxicated head injured patient is purely due to intoxication. Beware of the “labelled” patient.
19.11 WORK COVER
A “Work Cover” certificate should be completed on the initial consultation for a patient who has been injured either on the way to or from work, or while at work. The form is given to the patient once a copy has been made for the patient’s notes. Additional certificates for the same condition may be supplied, but require only the standard medical certificate to be completed.
19.12 “RE-PRESENTATION” OF PATIENTS
Patients re-presenting to ED (from any Emergency Department) with in 1 week should be reviewed by a senior doctor.
20. GENERAL HOUSEKEEPING
Sharps Ensure that all sharps are disposed of properly in the YELLOW BINS
Blooded Instruments All blooded instruments are to be rinsed and placed in the blue box under the sink in the pan room, for sterilisation.
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Plaster All residual plaster should be placed in plastic bags in a bucket. It is not to be emptied into the sink.
IV Trolleys No blood is to be left on IV trolleys.
Faulty Equipment Report any equipment that is faulty or broken to Maintenance staff.
It is imperative that any equipment or surface used is cleaned after use.
Meal Breaks It is your responsibility to ensure you take your meal break at a timely fashion. The break is generally for 30min. It is encouraged that you have your meals in the tearoom of the Department. If leaving the department to go to the kiosk to buy something please ensure that the Consultant or REG/CMO is aware of you leaving.
Lockers Limited numbers of Lockers are available. Please contact Ms.Joan Brown (Executive Assistant) to organise one for yourself. If none are available it is safe to keep your bags under the desks in the acute area. If using this option please do not leave any valuables in bags, it might get lost.
Toilets Designated Staff toilets are located next to the tutorial room
Dress Please ensure that your appearance is neat, clean and tidy reflecting the demeanor of a physician.
All doctors should wear Green Scrubs. These can be ordered through the Executive Assistant.
Your ID badge must be worn and be clearly visible at all times.
Parking Please do not park outside the emergency department. This is to be kept clear for ambulances and other emergency vehicles. It is also reserved for emergency and disabled patient parking. There are designated staff parking areas and access to these is via your ID badge.
21. COMPLAINTS AND DISPUTES
Disputes between staff over any work or personal issues should NOT BE conducted in front of patients. If reasonable discussion does not resolve the problem, it should be referred to the Staff Specialist of the shift or the Director at an appropriate time.
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22. DISASTERS
The “Disaster Manual” indicates what to do in the case of fire, armed hold-up, bomb threat, external disaster, cardiac arrest, and evacuation. During your term at Blacktown Hospital, it is quite possible that you may be involved in one of these (mock or otherwise). Please read the manual, and become familiar with the equipment in the disaster packs. (Ask to be shown through these).
The Manual can be accessed from the Executive Assistant of the department
23. ANCILLIARY SERVICES
23.1 PHARMACY
0830 to 1700, on site 5 days per week. On call after hours.
Hospital Administration encourages patients to have their prescriptions filled externally.
23.2 PATHOLOGY
24 hours per day 7 days per week on site.
ABG’s are done within the department. Medical staff to organise training and access to this machine as soon as possible. There are staff in the department who can organise this training
Please notify biochemistry prior to sampling for ABG’s after hours.
Printed labels are used on all blood samples except the group and hold sample. Please hand write your employee number and date on each printed label prior to attaching onto tubes. Ensure you are aware of how to attach the label onto the tube. (Ask a staff member) Label blood specimens at the bedside, immediately after obtaining the sample.
Results should generally be accessed via FIRSTNET/Cerner Powerchart.
Specimens are sent via pneumatic tube in the ED. Please ask a staff member regarding how to use the tube.
23.3 RADIOLOGY
If a radiology service is not available at Blacktown Hospital, Westmead Hospital is to be contacted in the first instance. If the service is unavailable at Westmead Hospital, private
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In general, if a patient is discharged, further investigation should be organised by the patient’s LMO.
Out of hours investigations are expensive, and must be for genuine emergencies only.
The radiology department provides the following services: a) Plain Radiographs
24 hour service, with patients requiring a nurse escort after hours. b) Contrast Radiography
0800 to 1600 Monday to Friday, IV and oral contrast studies are available. You need to ring radiographer to book patient. c) Ultrasound
0800 to 1600 on site Monday to Friday Studies provided include abdominal, pelvic, transvaginal, testicular, venous, thyroid, foreign body location, and examination of limb fluid collections. Examination of joints is not available. After hours ultrasound is available in the Emergency Department, for emergency patients, during the following hours: Saturday & Sunday: 1200 – 2000 Monday – Friday : 1700 - 2300
NOTE: Transthoracic Echocardiography available through Cardiology team only
Obstetric ward has a portable ultrasound, which at times is available, including after hours. d) CT Scanning
Available 24/7 After 1700hrs the CT scan films are sent to an off site service “Tele Rad” for a formal report. The report should be available within 1 hr of the images been sent to “Tele Rad” Once completed the formal results are faxed back to the ED. To avoid delays please ensure that the films have been sent online to “Tele Rad” If you are not sure what type of CT the patient needs speak to the on call radiologist at Tele Rad for advice.
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0630 to 2400 on site Monday to Friday EDSS provider number can be used to access the service. . Patients can have this investigation as an out patient as well in which case they would need a formal request form with the EDSS provider number on the request.
23.4 INTERPRETER SERVICE
Health Care Interpreter Service (HCIS) should be called for all patients where it is ascertained that the patient requires assistance in understanding English. They are available 24 hrs a day, 7 days a week on 9840 3456. (This contact with the service should be done as soon as this situation is recognised. It is inappropriate for the notification to be delayed until the treating doctor sees the patient. While awaiting the interpreter, other resources such as family and friends may be used. However, regardless of this assistance, the information should be double checked with the patient once the interpreter arrives.
NOTE: A phone interpreter service is also available when the timely physical presence of an interpreter is not possible.
24. FORMS AND DOCUMENTATION
All clinical documentation is to be done on First Net electronically.
Formal orientation to Cerner and First Net will be provided prior to your commencing the term.
All relevant ordering of test and services are documented and done on Cerner.
Medical staff are required to enter certain data into FIRSTNET. This includes “Time and Date Seen”, “Diagnosis”, and “Departure Status”
This should be done accurately. We are monitoring closely the waiting time.
If the discharge summary is not completed correctly in Firstnet doctors will be requested by HIRS to complete all paperwork before the end of term.
The “ED PATIENT HANDOVER DOCUMENT” must be completed prior to patient going to the ward. This form is completed by the JMO/REG/CMO organising the admission and counter signed by the shift senior REG/CMO/EDSS
For patients who have a ceiling on their management and are not for Resuscitation, the “Advance Care Planning document” must be completed. Refer to Appendix …. For the form.
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All addendum to a medical record are documented in the initial clinical notes of the patient so that there is a definite chronological order to the patient’s assessment and documentation.
25. MANAGEMENT POLICY AND PROCEDURES
This is being constantly updated.
All finalized policies and procedures are available on the INTRANET web page of the Department.
http://swahsintranet.wsahs.nsw.gov.au/Emergency-Services-Blacktown-Mt-Druitt/default.aspx
Please ensure that you are familiar with the current policies.
Any changes to the existing documents will be notified to the Medical staff via email.
26. OUTPATIENT REFERRALS TO SPECIALITY CLINICS
Please see intranet regarding the paperwork required and processes involved
27. CONCLUSIONS
This orientation handout attempts to cover some of the common issues relating to the functioning of the Emergency Department. However, it cannot hope to cover all aspects of ED practice.
If there are other important points for medical officers, which should be included in the guide, please inform the Director of Emergency Medicine.
Protocols exist for guidance only. The rules they set down may be broken, provided the person breaking them knows why they are doing so, and can justify such actions.
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Appendix 1
Urgent Review Clinic – Business Rules
(Note, in previous drafts we used the name “Ambulatory Care Unit”, but URC has now been adopted to avoid confusion with other Ambulatory Care Services)
Purpose of URC
The Urgent Review Clinic is intended to provide an alternative to inpatient care for patients who have presented to Blacktown/Mt Druitt Hospitals with an acute management issue. It provides timely access to care by a specialist team for urgent management. URC care is for short‐ term management only and patients should be discharged or transferred to appropriate long‐ term follow within 2 weeks of the initial visit to URC. In the second phase of its operation URC will also provide a day procedure service.
Patient Selection
1. Patients recently discharged from Blacktown or Mt Druitt Hospitals (within 7 days) who require clinical review for issues pertaining to their admission problems
2. Patients referred from the Emergency Department of Blacktown or Mt Druitt Hospitals after an initial ED assessment, and after discussion with a relevant consultant medical officer.
3. Patients referred from Aged Care Facilities or the PACC Team, if their care has been discussed with and accepted by a Consultant Medical Officer.
Referral Process
1. Patients must be seen in the URC within 7 days of discharge from hospital or presentation to ED.
2. Planning for URC review must be documented in the patient medical record and must be agreed by the managing medical/surgical team (consultant or registrar). The specific purpose of URC review should be documented.
3. Appointments will be made using the iPIMS system and the clinician responsible for attending the appointment (e.g. Registrar) must be informed at the time the booking is made.
Communication and Discharge
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1. All episodes of care in URC must be recorded in the patient medical record. The clinician attending the patient should also consider appropriate communication (letter, electronic or telephone) with the patient’s General Practitioner.
2. Patients may be rebooked for attendance at URC, but plans should be made for discharge within 2 weeks (to appropriate long‐ term follow‐ up in consultant rooms, outpatient clinics or General Practice, as needed).
3. If a patient reviewed in URC is deemed to require admission a Request for Admission form should be completed and the Patient Flow Office informed urgently. If possible a ward bed will be allocated for direct admission. In an emergency situation the patient will be transferred to the Emergency Department.
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Appendix 2
Early Pregnancy Assessment Clinic for Blacktown Emergency Department Patient presents with a problem related to her early pregnancy Gestation < 18 weeks
Patient triaged as Category 1 or 2 Patient triaged as Category 3, 4 or 5
Referred to C.I.N. Nurse Patient placed in a bed in ED or Resuscitation Room
High Risk Low Risk
PV Bleeding > normal period PV Bleeding Contact O & G Registrar Patient chooses referral to Patient chooses to on pager 3911 and arrange direct EPAC-REAT nurse collects wait to be seen by transfer for gynaecologist ward. blood for BHCG and Group emergency doctor. and hold. Updated 24/01/17 34 36 Appendix 3 AGED CARE SERVICES EMERGENCY TEAM Hours of business: 0700 – 2000 Mon - Fri 0800 – 1630 Sat Sun Pager numbers: 7787 / 7709 / 7631 / 7789 (weekends) Referrals after hours can be left on phone 47602 with patient details. All ASET patients discharged home will receive a phone assessment as early as possible ASET staff: CNC, CNS, RN’s, Allied health, home physio service available ASET conduct a full aged care assessment of patients over the age of 70 years that present to the Emergency Department. This includes mobility, falls, functional, cognitive, nutritional, elimination, environmental, social, medications, carer issues, skin integrity and others as applicable Referrals can be made to internal departments as well as external service providers eg. Homecare, Compacks, Meals on Wheels, If a Care Navigation patient over the age of 70 requires an aged care assessment this occurs in consultation between the two services Patients are prioritised with those having potential for discharge being seen first. Residents from Aged Care Facilities can be reviewed if required by the Emergency Department team. Mental Health and Stroke patients are referred in the first instance to the respective staff but can be reviewed upon request. The aim of ASET according to the Department of Health, 2007, is to improve the clinical care and management of older people who present to Emergency Departments using the principles of dignity, respect, equity, participating in decision making, a multidisciplinary approach, all with an aged-care focus Aged Care Facilities have 3 levels of accommodation: 1. IDLU (Independent Living Unit): No nursing support or supervision. Clients must be independent in all care needs. Do not discharge patients after 2200hrs. 2. Hostel or Low Level Care: Clients should be independent with mobility and personal care and are assisted with cooking, cleaning etc. Minimal nursing support given during day, often no support after hours. Do not discharge patients after 2200hrs, call staff before discharge. 3. Nursing Home or High Level Care: 24 hour nursing and supervision with all cares and mobility. Patients may be discharged after 24 hours, call staff before discharge. Updated 24/01/17 36 37 Appendix 4 Medical Emergency Team (M.E.T.) For MET calls in the Emergency Department, the ED Registrar is the Team Leader. Other members of the MET team are: Mt Druitt Blacktown Day Night Day Night Team Leader ED Registrar ED Registrar ED Registrar ED Registrar M.O.2 ICU +/- MR ICU +/- ICU +/- Anaesth Reg Anaesth Reg Anaesth Reg M.O.3 Card Reg Ward RMO Card Reg / MR +/- Ward MR RMO A.L.S. RN Coordinates Coordinates Coordinates Coordinates Nursing Nursing Nursing Nursing Ward RN 1 “Airway” 2 “Procedure” 3 “Scribe” ADON Coordinates floor Wards Person Runs pathology Accesses lift Updated 24/01/17 37 38 MET’s are called (dial 111 and say “Code Blue”) for the following reasons – 1. Airway Threatened 2. Breathing Resp Arrests RR < 5 or > 36 3. Circulation Arrests PR < 40 or > 140 SBP < 90 4. Neuro Sudden fall in GCS > 2 points Repeated or prolonged seizures 5. Other Any patient about whom there is serious worry. The idea is clearly to encourage the early detection of deteriorating patients in a “no blame” culture. Updated 24/01/17 38 39 Appendix 5 CASE PRESENTATION TEMPLATE TO BE FOLLOWED WHEN JMO’s PRESENT CASES TO REG/CMO/EDSS/VMO or the REG/CMO PRESENTING TO EDSS/VMO 1. Introduce yourself: I am Dr……… an SRMO at Emergency 2. Opening Summery of the case : I need to discuss a 60 year old gentleman with possible community acquired pneumonia who needs admission for IV fluid, Antibiotics and Oxygen. 3. History of Presenting Illness: 4. Relevant Past medical issues: 5. Medication List: 6. Important social / personal history: 7. On Examination: General Appearance > SOB at rest or Comfortable Observation > HR, B/P, RR, Sat on Room Air or O2,Temp Spirometry /PEFR Chest exam finding Other systemic examinations if Relevant, Abdomen/Cardiac/Neuro 8.Investigation results obtained thus far: CXR ABG FBC,UEC,LFT 9. Previous relevant Investigation Results on Record Last Sputum MCS Last CXR finding 10. Issues on Presentation Hypoxia Acute Renal Impairment Sepsis (Hypotension, Tachycardia) 11. Diagnosis and Possible Differential 12. Management Plan IV Antibiotics Oxygen IV Fluid at 125ml/hr Ward Bed/HDU Bed Updated 24/01/17 39 40 Appendix 6 ADVANCED MEDICAL PLANNING FORM To be completed for any patient who is “Not for Resuscitation” or has a ceiling on treatment imposed Updated 24/01/17 40 41 Updated 24/01/17 41 42 APPENDIX 7- SAMPLE OF DAILY FLOOR ROSTER – Updated 24/01/17 42 43 BDH - ED MONDAY 14th December 2015 In Charge Day 0800 - TEAM A - 47130 TEAM B - 47987 TEAM C - 47988 1830 Staff Specialist Registrar/ CMO Fast Track Day In Charge Evening 1400 - TEAM A - 47130 TEAM B - 47987 TEAM C - 47988 2400 Staff Specialist Registrar/ CMO Fast Track Evening In Charge Night 2230 - TEAM A - 47130 TEAM B - 47987 TEAM C - 47988 0830 Registrar/ CMO Staff Specialist On Call Registrar On Call Night JMO on call night Nurse Practitioner Physiotherapist Updated 24/01/17 43 44 APPENDIX 8 SOCIAL WORK REFERRALS Referrals can be made to the Social Work Department on Pager 7699 Monday – Friday: 8:00am – 4.30pm Refer via E-consult to pager 7699. E-Consult request must contain the reason for referral, and a contact page or number for the referrer. The following issues need automatic referral to Social Work: . Sudden Death . Domestic Violence . Child at Risk or suspected of being at risk of harm (You are still a mandatory reporter,) however social workers can be involved in following up some cases) . An unwell patient who will be cleared for D/C but has no where to go/ stay upon D/C. . A patient who is a carer but has no- one to help care for their care recipient whilst they are in hospital. The following may be referred to Social Work if the issues are causing distress or are complicating discharge. . MVA/Trauma where Patient/family/friends are unusually distressed . MVA Trauma where other family members/ victims known to the patient have been injured or transferred to other hospitals. . Grief & Bereavement / Counseling . Homelessness / Accommodation Mental Health and Drug and Alcohol issues-refer to Mental Health and Drug and Alcohol teams. If you have trouble contacting SW, you can contact another Social Worker via the Social Work Crisis pager (7725). Please allow time for the ED Social Worker to reply to the page before paging a different number. Weekends: A Social Worker is available Saturdays and Sundays from 10am-4.30pm. Contact is via Blacktown Hospital Switch Updated 24/01/17 44 45 APPENDIX 9 NURSE PRACTITIONER SCOPE OF PRACTICE: All patients over 16 years of age presenting with the following conditions: � Upper and lower limb musculoskeletal Injuries not meeting the trauma criteria / open and closed fractures / underlying structure damage (open and closed) / sprains and strains � Lacerations and wounds including retained foreign body not meeting the trauma criteria / with no self-harm / may have underlying structure damage � Cellulitis - not systemically unwell / not bilateral � Bites and stings- not systemically unwell � Deep Vein Thrombosis- patients who have a definable cause related to travel, recent surgery, immobilisation etc… � Mild to moderate Asthma � Mild to moderate URT symptoms - not systemically unwell � Mild to moderate LRT symptoms - not systemically unwell � Vomiting in Early Pregnancy - not systemically unwell � Acute nausea and vomiting - not systemically unwell / <50 years � Acute diarrhea - not systemically unwell / <50 years � Mild corneal abrasions and conjunctival or corneal foreign bodies � Splash injuries to eye/s � Conjunctivitis � Mild head injury- no LOC / GCS 15 / <55 years / not intoxicated / no anticoagulant therapy � Acute sore throat � Acute earache Updated 24/01/17 45 46 � Acute foreign body in external auditory canal � Localised Soft Tissue Infections or Collections � Urinary symptoms- not systemically unwell � Symptoms suggestive of STI Updated 24/01/17 46 47 Updated 24/01/17 47 48 APPENDIX 11 Emergency Department Senior Assessment and Streaming The Emergency Department Front of House Model of Care EDSAS encompasses clinical assessment, clinical streaming and initiation of clinical treatment. Objectives of Streaming: Right patient to the right area of the Department 1. Patients seen on arrival. 2. Senior clinician input on arrival. 3. Waiting time should be less than 10 minutes. (Time taken for triage//registration//paperwork to be available) 4. Once seen and management plan commenced patient to be sent to different MOC in the department a. Acute area b. Fast Track c. Treatment Commenced Area d. Emergency Department Short Stay Unit The Front of House Staff includes: Triage Nurse: The Triage nurse is part of the Front of House Team. This role is a senior nursing position within the department and any staff member allocated into this position must have completed and be proficient in resuscitation nurse role, advanced life support (ALS), triage and undertaking of the Clinical Initiative (CIN) role is desirable. This roles criterion includes: 1. Assessing of patients presenting and allocating patients appropriate Triage category pertaining to their presenting problem 2. Triage as per the ATS Guidelines 3. Once patient flow through the department has improved ED will move to Quick triage system to optimise this model. Streaming Coordinator: The role of the Nurse Streaming Coordinator (SC) is an integral part of the flow of the EDSAS model of care and will work in unison with the CNUM for overall process and patient flow governance. Specifically this will involve coordination of care through the front end processes. The registered Nurse must have completed all ED pathways. This roles criterion includes: 1. Tracking the progress of patients care 2. Initiation of actions to address delays in the flow of patients 3. Streaming patients to the correct patient care areas Updated 24/01/17 48 49 4. Ensure no bottlenecks occur at Triage 5. Ensure streaming team maintain agreed timeframes 6. Support streaming team in times of high activity 7. Escalate changes in patients condition through regular rounds of streaming areas and waiting room 8. Liaise with key ED roles: Triage Streaming medical officer ED CNUM Rapid Emergency Assessment Team Nurse (REAT) The REAT nurse is part of the Front of House Team. This role is a senior nursing position within the department and any staff member allocated into this position must have completed and be proficient in resuscitation nurse role, advanced life support (ALS), triage and undertaking of the Clinical Initiative (CIN) role is desirable. This roles criterion includes: 1. The REAT nurse will assess patients unable to be allocated an acute bed due to overcapacity of department including patients who are on Ambulance stretchers. These patients may present with Chest Pain, Sepsis, Acute Asthma, Trauma etc. Assessment includes ECG, administration of medications/fluids, reassessment of vitals and trauma care. 2. Becoming the 2nd Triage Nurse during ambulance/walk-in presentation Surge times 3. Relieve Triage nurse, resuscitation nurse and Clinical Nursing Unit Manager (CNUM) if required 4. Carry resuscitation nurse role if 2nd resuscitation patients presents 5. Can carry the Medical Emergency Team (MET) Page – ALS trained and certified 6. Oversees Mental Health patients including over census admissions awaiting MH beds, patients awaiting reviews, “specials” allocated to MH patients and administration of medications. Clinical Initiative Nurse (CIN) The CIN role is part of the Front of House Team. The primary purpose of the CIN role is to provide nursing care to patients in ED waiting rooms. This role is a senior nursing position within the department and any staff member allocated into this position must have completed and be proficient in resuscitation nurse role, advanced life support (ALS), triage and CIN competencies. The role priorities are: 1 Clinically reviewing patients to determine if they require care escalation Updated 24/01/17 49 50 2 Communication with patients and carers regarding their waiting time and provision of relevant education on their health issues 3 Reassessment of patients following triage with a view to initiate diagnostics or treatment (with a set end point, which is defined by the CIN protocols) 4 Appropriate referral of patients to suitable services, which may be external to the ED (e.g. MAU, EPAS) PIT PIT is where the clinical streaming of patients commences. No Category 1 patients will be streamed through this model. Cannulation skills is not a requirement for the Enrolled Nurse allocated to this role however the EN must be medication endorsed. Objectives of the Team 1. Assessment of patients on arrival 2. Commence management plan 3. Continue to be the “primary provider” for the patient during their stay in ED 4. Follow up on any investigations sent. 5. Disposition plan 6. Minimal time wasting 7. Use of Emergency department Senior Assessment and Streaming (EDSAS) objectives Expected Role of the JMO in PIT 1. Assessment of the patient. 2. Carry out any procedures that might be required including cannulation and to obtain blood samples. 3. Order relevant investigations online including imaging tests. 4. Chart stat dose of medication (i.e. Antibiotics and Antiemetic’s) 5. Completing the PRN chart for analgesia if required so that this can be given in the Treatment Commenced Area (TCA). 6. Completing necessary documentation. 7. To continue looking after the patient while the patient is in the TCA. Expected Role of the Staff Specialist /SRMO in the Team 1. To asses patients in the pit area and provide guidance to the management plan of the patient. 2. Supervision of the JMO in the PIT area. Expected Role of the Nurse in PIT 1. To bring the next patient into the PIT from the waiting room or Triage room. 2. Carry out necessary tasks including obtaining a set of Observations Updated 24/01/17 50 51 3. Necessary procedures as requested including ECG, Spirometry, Urine sample for Dipstick, wound swabs, slings, bladder scan, Fluids, Antibiotics, Analgesia etc as charted by the medical officer. 4. To take patient from the PIT area to the TCA following completion of the designated tasks. 5. Brief hand over to the Registered Nurse in TCA regarding management plan. Treatment Commenced Area (TCA) TCA comprises of 6 recliners and is where the ongoing clinical management of the patients continues. Category 2 patients may be streamed through this clinical area post - acute review. The Registered Nurse allocated to this area must have completed the Transition to Emergency Nursing Practice and ED Resuscitation Training and have cannulation and venepuncture skills. Expected Role of the ED REG/CMO in the Team 1. Ensure that the circulation of patients in the TCA is maintained and patients are being admitted or discharged from the TCA. 2. Assist the JMO in documenting / charting / ordering. Expected Role of the Registered Nurse in TCA 1. Continuation of above treatment and management plans 2. Liaise with the medical team (as designated on Firstnet) regarding the management plan of each patient. 3. Co-ordinate with imaging regarding X-Ray, Ultrasound and CT’s pending. 4. Inform the medical team as soon as possible of the following a. Investigation results are obtained, b. In patient team have reviewed the patient and decided on a plan. 5. Prepare patients for theatre as required 6. Initiate referrals to appropriate services ie; Care Navigation, ASET, Occupational Therapy, Physiotherapy, Social Work 7. Escalate the deteriorating patient to the CNUM. 8. Enlist the assistance from the Fast Track nurse in busy periods. Fast Track (FT) Fast Track area refers to both the model of care and designated assessment and treatment space that will be utilized to manage a particular cohort of Emergency Department (ED) patients. Patients streamed into this model of care will be managed in a separate, designated area by a dedicated multidisciplinary team. This team will consist of medical, nursing and allied health staff capable of independently managing and discharging the majority of patients. The area consists of 6 recliner chairs. A fundamental goal of this model of care is to facilitate the safe and appropriate assessment, management and discharge of all patients within this model within 4-hours of arrival. In order to achieve this goal, it is imperative that only those patient that meet the inclusion criteria and none of the exclusion criteria are streamed to the FTMOC. Updated 24/01/17 51 52 The Fast Track Team Leader role is a senior nursing position within the department and any staff member allocated into this position must have completed and be proficient in resuscitation nurse role, advanced life support (ALS), triage and CIN competencies and or a Nurse Practitioner. Emergency Short Stay Unit This will be for patients who will require prolonged workup or extended observation in the Emergency Department. These patients should be recognized early and admitted to short stay unit. This will free up acute beds in the ED ensuring continuous flow and processing of patients leading to improved KPI’s for off-stretcher times, doctor seen times and NEAT targets. The EDSSU area comprises of 4 recliner chairs. Updated 24/01/17 52