An Introduction to CDU for F1 Doctors

An introduction to CDU for F1 Doctors

CDU is Clinical Decision Unit – Patients who are stable and who should be fit for discharge home after a period of observation, treatment or rapid access to investigations are admitted under various proformas (pathways).

Entry to CDU is determined by meeting criteria on the proforma and discussion with a Middle grade/Consultants.

The current specific pathways are [1] anaphylaxis, [2] asthma, [3] back pain, [4] Low risk ACS, [5] DVT, [6] elderly patients, [7] head injury, [8] renal colic, [9] deliberate self harm, [10] upper GI bleed, [11] acute urinary retention, [12] trauma (post +/-pre) procedures, [13] cellulitis, [14] PE and TIA.

There are formal proformas for anaphylaxis, asthma, back pain, Low risk ACS, DVT, elderly patients, head injury, renal colic, TIA, DSH and PE. There is a generic proforma for pathways without proformas and for miscellaneous admitted at the discretion of the ED Consultant.

The role of the F1 is to facilitate assessment, investigation and discharge/referral to an appropriate specialty.

Typical Day

Arrive early to read all the admitted patients notes, print off bloods, do out standing charts and order investigations

0800 ward round with consultant

Jobs- Imaging (if CT/MRI/USS need to go round to the dept to request), bloods, medication, collateral histories, referrals (RSO/RMO has to come to CDU- they can’t go up to AMU/SAU as in A&E, unless they have only been sitting in the waiting room)etc etc.

Getting patients home – each needs TTO on blue paper, GP written letter, Advice sheet for patient, CDU data collection form (nurses and doctors can do this) and need an entry in the GPs information section on the electronic clinical records on MSS. The patient needs to know what the plan is, especially if they are coming back for an ETT, USS, CTKUB, where they should come to CDU for the results. All discharges should be cleared with the consultant/Middle Grade

New patients will come in through the day, and these should be handed over to you – it may not happen so read the notes – they may have come round for imaging where the form is filled but the scan has not been requested yet.

Waiting room – patients may be there waiting for transport, (or blood results…) waiting for the results of an USS or ETT (in which case they will have appeared with a brown envelope with the reports in for you to see.) they may be waiting to go for a CTKUB, and when they get back you need to chase up the results – which can take a couple of hours – any longer then go round to CT.

Where to put notes when patient leaves, 1. Green tray – if patient returning for tests/ review 2. Red tray- patient discharged not returning

CDU CTKUB diary – put CTKUB request forms to be collected by radiology if CTKUB for next day

CDU diary – enter in diary if patient is coming back for USS/Scans/clexane or review

1600 – hand-over to the Middle grade coming on at 4pm (check rota) with a written sheet and anything they need to do.

Proformas All patients should be under a proforma before they can come to CDU, unless they are, waiting for transport or waiting for a bed in another speciality.

If they do not meet criteria for a specific proforma they will come under a generic proforma and all patients over the age of 65 years should come under the elderly care proforma.

Elderly care proforma  All patients over the age of 65 years should be under this proforma.  They should have ECG, urine dipstick, lying and standing BP and blood tests done before they come to CDU.  Most patients may require intermediate care assessment for care packages and assessment of mobility. Their office is next to CDU and they usually come in the mornings to see if there are any patients for them or the nursing staff can inform them

 Check if they need to be referred to a falls clinic if recurrent falls (form found with elderly care proforma).

 If ICT are not happy, they will usually be admitted to the elderly care ward – call 40221 and ask for Maggie – who allocates beds, if there is a bed available then the ECAU doctors will come down and clerk the patient, (before 3pm) if not, they go to AMU and the RMO comes down to clerk the patient.

ACS  To be admitted to CDU they need to be pain free with no ECG changes, TIMI score <=1  Check they have had a cholesterol and glucose ordered.  ECGs 4 hrly (from when their cas card says they came in)  TnT before admission and at time of 4th ECG (12 hours since admission to A and E)  Learn how to use the D dimer machines

 ANY chest pain or ECG changes (seek out the ECGs to look at them!!) – they leave the proforma and are referred to medics.

 Before discharge, o ETT - Fax ETT form (found in proforma); or call the dept and see if they can have it this day. o Prescribe Aspirin 75mg OD (to take until ETT); GTN and statin if cholesterol >5  Advice patient – ETT appointment in 1-2 weeks time; continue Aspirin till ETT; return to CDU after ETT to discuss result; Take GTN if further chest pain and if pain not relieved with GTN to return to A and E.  Letter to GP (found in proforma) need to check LFTs and CK in 3 months from starting the statin  Notes in green tray

When the patient come back, with the ETT, check it over, ask about any symptoms since the ETT and if they have used the GTN or taking statin etc. get a MG/cons to review and then they can go home (if ETT has changes the techs don’t send them back down) – either on the aspirin and statin, or the aspirin may not be needed.

Asthma  Patients are usually observed for 2 to 4 hours with ½ hrly obs, and pre and post neb PEFRs – use salbutamol and ipratropium nebs  Discharge if asymptomatic, PEF >75%, vital signs stable and discuss with senior, home  If PEFR not improving refer to RMO.  When going home, Prescribe salbutamol PRN (if patient does not have any) and Predisolone 40 mg 5 days.  Check inhaler technique, need for spacer  Advice to see GP in 2 days  Give letter to take to GP

Renal colic  Put CTKUB requests for next day in CDU diary (Small blue diary) – in filing cabinet, radiographers will come and collect forms around 8.30-9 am; if they do not come, hand in forms to new CT in radiology department.  Patients who come in during the day, hand in CT form to radiology department- may need discussing with the radiologist.  Check blood results  Refer to urology or discharge patient according to CT results/ blood results/ pain status (details can be found in proforma)  If discharging patient, prescribe regular analgesia if needed, send GP letter, fax referral form for urology out patients clinic for follow up even if no stone found. WHEN FAXING, ALWAYS INCLUDE THE CONFIRMATION FORM IN THE NOTES

Anaphylaxis  Patients observed for 6 hours  Need mast cell tryptase in ED and one in CDU about 6hrs.  Meds in CDU – piriton, pred and ranitidine  Before discharge, asymptomatic or symptoms improved; -discuss with senior, Prescribe chlopheniramine, ranitidine and prednisolone, refer to immunology (fax referral form), check if patient has an epi-pen, need to be educated how to use them, and needs 2 preferably, send GP letter and give patient information sheet.

Back pain  Patients with back pain usually come to CDU for analgesia and mobilization with a diagnosis of simple back pain.  You need to examine them neurologically, look for red flags and do a PR if not already done so in A and E.  Any neurological abnormality needs to be discussed with a senior.

 If simple back pain, prescribe regular analgesia. PR diclofenac 100mg is very effective (maximum 18hrly) with 3-5mg Diazepam TDS, Tramadol 100 mg TDS.

 Get the patients mobilizing as soon as they can. If difficulty mobilizing Intermediate care team may need to assess them (especially if elderly)

 Good regular analgesia is needed.

Once mobilizing, consult senior, discharge patient with advice sheet on back pain management, regular analgesia on TTO and GP letter.

DVT  Patients with suspected DVT (high pretest probability score or positive D dimers) will have an US Doppler scan. You need to take the form around to x- ray reception to book the appointment. (Book online EPR) If a scan can not been done on the same day, give the patients phone number to them and they will contact the patient when an appointment is available.

 The patient will have to have daily Clexane 1.5mg/kg SC until the USS appointment, which should be within 24hrs. Patients can either come to CDU daily for injections or you can phone the GP or ask district nurses to give the injections.

 Advice the patient to report any SOB or chest pain and to come back to A&E.  When they come after the results if it is positive, you will have to liaise with the anticoagulation nurses to start warfarin. This can be done by bleeping the anticoagulation nurses and faxing a referral form (can be found in AMU if not available on A and E)

 If the result is negative and alternative diagnosis should be sought and if the pre test probability score is >2 the patient is advised to return to CDU in 1 week for assessment by a senior.

First seizure  Patients will be observed for about 6 hours.  Blood results should be checked before discharge.  Arrange for inpatient CT head scan (hand in form to radiology department), fax EEG request form (found in proforma)  Write a referral letter for Neurology out patients at Heartlands, this and the notes need to be handed to A&E secretaries for photocopying and for referral.  Give patient information leaflet  Explain to patient management plan and explain information on advice sheet (avoid driving, supervision when swimming and discuss the job etc)

Head injury  Patients have neuro observationshalf hourly, then hourly then 2 hourly for at least 12 hours – see proforma for details.  CT head scans may have been requested – consutl the nice guidelines on internet and the proforma for guidance too. Make sure the form is handed over to the radiology department. It may need to be discussed with the radiologist, out of hours the oncall service should be used.

 Lots of these patients have alcohol history, if this is suggested, prescribe regular chlordiazepoxide and Pabrinex, on discharge give advice re alcohol and AA/Aquarius and consider Vit B&Thiamine medication.

 Before discharge, give patient information sheet and explain the information on the sheet, avoid contact sports 1 month, advice re post head injury concentration and fatigue, prescribe analgesia if required and send GP letter.