Emergency Medicine Trainees

Orientation and Policy Guidelines

October 2019

Index

Section 1 Organisation

Section 2 Medical Staffing Arrangements

Section 3 ACEM related information

Section 4 Education

Section 5 BMDH General Information

Section 6 Role of the ED registrar

Section 7 Allied services

Section 8 Trauma / AMI / Stroke/PE etc

Section 9 Outpatient’s clinics

Section 10 Paediatrics

Section 11 ED ward Transfer form (T- form)

Section 12 Other policies

Section 13 Investigations

Section 14 Radiology

Section 15 Emergency Short Stay Unit

Section 16 Policy for Accepting referrals to the ED

Section 17 Deaths in the ED

Section 18 BMDH Stroke Thrombolysis Protocol

Section 19 Sepsis pathway

Section 20 Contacting the ON-CALL ED CONSULTANT

Section 21: Commonly used phone numbers at Blacktown ED

Section 1: ORGANISATION Senior Medical Staff

Director of Emergency A/Prof Reza Ali Deputy Director of Emergency Dr David Melvin

Directors of ED Training (DEMT) Dr Karina Hochholzer Dr Ponnuthurai Jeyaruban Dr Jannatun Nayim

JMO coordinator Blacktown – Dr David Melvin Mt Druitt – Dr Shaila Islam

Staff Specialist / Toxicologist A/Prof Naren Gunja Dr Dushan Jayaweera Dr Gopi Mann Dr Satish Mitter Dr Richard McNulty

Ultrasound coordinators Staff Specialist Dr Michael Hession VMO Dr John Shirley Staff Specialist Dr Kenny Yee

WBA coordinator Dr Chamila De Alwis

Staff Specialist Dr Anj Amarasekera Dr Harry Elizaga Dr Daya Jeganathan Dr Susie Stapledon Dr Fernando Pisani Dr Greg Robinson Dr Liaquat Sheriff

VMO Dr Irshath Abdul Raheem Dr Rasel Ahmed Dr Nina Dhaliwal Dr Waseem Hassan Dr Ravinder Jassal Dr Richard Lennon Dr Vijay Manivel Dr Janina Usenko Dr Behzad Vasfi Dr Faryal Waqar Dr Payam Yahyavi

Nursing Unit Manager Blacktown ED Ms Camille Dooley A/Mt Druitt ED Ms Tahlia Strickland Clinical Nurse Consultant Ms Helen Zaouk Clinical Nurse Educator Ms Zoe Clarkin Clinical Nurse Educator Mr Jonathon Hamilton

Administration Staff Executive Assistant Ms Joan Brown ED Clerical Manager Ms Di Lyons ED Data Manager Marty Bodsworth

Trauma Service

Australasian College for Emergency Medicine (ACEM) affiliations Dr Jannatun Nayim - ACEM Primary exam VIVA working party Dr Kenny Yee - ACEM Examiner - ACEM Fellowship exam committee (OSCE subcommittee)

Coordinators of ACEM Emergency Medicine Certificate / Diploma Dr Chamila De Alwis

ANY QUESTIONS OR CONCERNS?

Section 2: MEDICAL STAFFING ARRANGEMENTS JMO total per shift (i.e. Intern / RMO / SRMO): Weekdays and Weekends Day: 6 – 7 Evening: 6 – 9 Night: 3 - 4 Registrar total per shift: Day: 3 Evening 3 Night 2 - 3

The registrar numbers on Day / Evening may vary during times of increased leave due to exams.

Emergency Physicians provide direct clinical cover from 8:00am to midnight seven days a week, every day of the year. There are 2 ED consultants on call overnight.

Staff Specialist/VMO total per shift: Day (Mon – Sun): 2 - 3 Evening (Mon – Sun): 2 – 3 On Call nights (Mon-Sun): 2

Rostering The registrar roster is written by the ED Deputy Director.

The SRMO roster is written by the ED Executive Assistant.

The registrar roster is usually written in 13-week blocks. The roster process has flexibility to accommodate requests. You will be asked for your next terms roster request in the middle of the preceding term (this will allow you to request leave dates and specific rostering shift dates if required).

We pride ourselves on being very flexible with our rostering and try to accommodate most requests.

In general terms, registrars and SRMO’s are usually rostered for 80 hours per fortnight (eight 10-hr shifts). Unless you request that you want to save your ADOs (Accrued Day Off), an ADO will be rostered in once per month.

All rosters are made available on Google Sheets which can be viewed via a smartphone or computer

There are five shift types:

Day (D) 0800 – 1800 (Registrar) / 0800 - 1800(JMO, SRMO) Evening (E) 1400 – 2400 (Registrar) / 1400 - 2400 (JMO, SRMO) Night (N) 2230 – 0830 (Registrar) / 2230 – 0830 (JMO, SRMO)

Sick relief(S) for night shift ONLY

The load of night shifts for each registrar over a 13-week term is approximately:

- Full time (12 - 15); pro- rated for part timers

The number of nights can vary during periods of excessive exam leave. The number of night shifts per term is the same no matter the amount of leave taken in a term.

Weekly Roster

The weekly roster is generated from the most recent JMO/Registrar and Consultant rosters. The ED director, A/Prof Reza Ali, and the ED executive assistant are responsible for allocating your location for each shift. Every attempt will be made to ensure you get an equitable distribution of shift locations during your term. If you find you are getting a disproportionate number of shifts in one particular area, please speak with the ED secretary and politely ask her to even up the count. On the roster, medical personnel will be allocated to one of the following teams:

Team A = Acute A (includes resus) Team B = Acute B (includes resus) Team UCC= Urgent Care Centre Team EDSSO = Emergency Short Stay unit (for JMO’s)

SRMO’s will be rostered to these areas.

Shift Swaps

- Shift swaps can only be made with a Registrar of equal / greater seniority for night shifts – Any shift swaps need to be approved by Dr Melvin and a notification sent to the Executive Assistant to make sure floor rosters are up to date.

Leave

If you have accumulated leave and you wish to take it, the ED management will try its best to approve this leave. Most requests are in fact approved; however, the following must be borne in mind when planning your leave.

Plan your leave well ahead, preferably at the start of the year. All other things being equal, leave will be granted on a first come first serve basis. As the roster is written up to 13 weeks in advance, it is not possible to process requests for annual leave for the period when the roster has already been written. This does not obviously apply for urgent leave required for sickness or other calamitous events.

In the periods leading up to the College exams (primary and fellowship), preference will be given to those sitting for the exam.

Sick Leave

If you are unable to work a shift due to an illness or other reason, then the following procedure needs to be followed.

1. Please call Prof Ali or Dr Melvin via the switch and notify the in-charge on the floor. Leaving messages with the secretary/nursing staff/JMO’s is not acceptable. When ringing the in-charge please ask them to make adjustments on the floor roster.

It is the responsibility of the trainee to provide the ED with sufficient notice. This is especially important for the evening and night shifts.

A medical certificate needs to be produced if you are sick for more than one consecutive day or for more than two days per term. The certificate can only be written by a non- hospital MO, preferably your own LMO and not a relative or close associate.

Emergency Department on-call Consultant

The ED has a 24 hour on call roster for Consultants. The on-call Consultant should be contacted by the senior doctor rostered on duty in the ED or the nursing Team Coordinator under the following circumstances:

The following Criteria is a guide to calling the Emergency Consultant on call. This list is not exhaustive and the emergency consultant on call is always available to answer questions and give advice and support as required.

Clinical: 1. Any clinical decision that requires consultant to consultant discussion 2. Expected difficult resuscitations (eg. pregnant OHCA or neonatal resuscitation, potential difficult airway) 3. Clinical advice on patient management or disposition 4. Significant adverse event or unexpected outcome (eg. unexpected death/SAC 1)

Departmental: 5. Any major incident with multiple casualties/patient presentations expected, issues with staff safety, overwhelmed department with overwhelmed resources 6. HR, performance or staffing matter unable to be resolved by duty staff

Attire

- Trainees are expected to wear appropriate clothing and footwear - green scrubs - Medical staff wear green scrubs and nursing staff wear dark blue scrubs .Footwear needs to be sensible and comply with OH and S requirements - No sandals or non-protective footwear are to be worn. - No jeans - Remember use your common sense!!

Emails

From mid 2017, NSW Health policy requires ALL employees to communicate using their health email for all work-related emails. You are automatically given a health email if you previously worked with NSW health. If you are new to NSW Health, then you will be given a health email when you start. Instructions on how to access your email can be found below.

1. Health email All correspondence regarding patients and work-related discussions must be on Health email. Do NOT use personal email for work purposes. Health email is available on any device at https://webmail.health.nsw.gov.au (login with Stafflink credentials) Health email is also available on your smartphone/tablet native email app or Outlook app – this needs to be activated.

2. Wifi All medical staff have Wifi access across the 4 acute hospitals (Westmead, Blacktown, Auburn, Mt. Druitt) on the “Clinical” network. To apply for Wifi access please complete an eForm on the ITS intranet. Setup instructions and username/password will be sent to your Health email.

Section 3: ACEM related information

Any feedback or questions regarding your contract or training should be directed to the Directors of ED training. There is usually at least one of us available on most weekdays.

Terms

Rotations for each year are organized by the DEMT’s. When organising secondments, the department takes into consideration each trainees’ preferences, training requirements and availability

Available rotations for Advanced trainees include: - Emergency Medicine . Westmead Adult Hospital (Tertiary ED) . Westmead Children’s Hospital (Tertiary Paediatric ED) ▪ Nepean ED (tertiary ED) - Intensive Care Medicine (Blacktown) - Anaesthetics (Blacktown & Mount Druitt) - Paediatrics (Mount Druitt) - Psychiatry - Medicine - Toxicology - Simulation - ED Ultrasound - Other rotations may be arranged through the DEMT for interested trainees

Available rotations for Provisional trainees include: - Anaesthetics - Intensive Care Medicine Assessments The DEMT’s are responsible for completing your ACEM in training assessments (ITA’s). These need to be completed every term, regardless of your FTE. Your assessments are based on your performance during your term and feedback is obtained from all ED staff (medical staff, nursing, clerical, allied health).

Workplace Based Assessments (WBA’s) WBA’s are required to be completed as per ACEM requirements for all advanced trainees during their ED term. The WBA roster is completed by the WBA coordinator (Dr Chamilla De Alwis). This roster outlines the consultant responsible for completing your WBA. Please follow this roster to ensure you meet the minimum ACEM requirements.

Learning Needs Analysis (LNA’s) As part of the review of the ACEM curriculum, in 2015, broad changes were introduced to the ACEM assessments. Part of this change involved the implementation of the ‘Learning Needs Analysis’. The LNA is a trainee-led process. A direct quote from the ACEM site “This structured online form enables trainees to map out their learning and development goals for a specified period. All trainees are encouraged to create a learning plan for each placement.”

Section 4: Education

The ED is a major source of both formal and informal teaching. ED trainees play an important role in the ongoing education of JMO’s and should act as a resource person for junior staff in a non-threatening, non- judgmental and constructive manner.

For our trainees, there are a number of education opportunities. You will be granted access to the Blacktown Master ED teaching program which is kept updated via a ‘Google Sheets’ link. This link will publish all the education sessions listed below:

1. Fortnightly ED trainee teaching Day (Thursday 0800-1800) These sessions are compulsory and each trainee is expected to meet ACEM’s requirements of attendance to 70% of available sessions (equates to at least 9 / 13 sessions per term). This is an important requirement for ACEM accreditation of the Emergency Department and a requirement of your training. A record of attendance is kept which is available for ACEM to view if required. During the teaching sessions, registrars are freed of their clinical duties in the ED to allow you to attend. Teaching time is paid for by the Department, you are rostered to attend the teaching. This is usually included in your 8 shifts in a fortnight and marked in the roster as DT (Teaching Day). Topics included in these sessions are: Simulation sessions, teaching on Trauma / ED Ultrasound / Airways and ALS, Journal Club, Case presentations, Topic reviews, Mortality / Morbidity, Policies and Procedures as well as ED consultant talks and guest lecturers on relevant topics. The topics are based upon the ACEM Fellowship Curriculum. There is also a trainee feedback session once per term where we discuss issues which are relevant to you over coffee This is dedicated teaching time for those on the ED roster but those on rotation to other areas are encouraged to attend the meeting also.

2. Primary Examination Preparation Course

This course is run by the senior ED staff as well as candidates who have recently passed the primary exam. The aim of the course it to provide structure to the candidates own study program. There is a didactic teaching program with lecture notes, lectures / tutorials and well as practice MCQ’s. There are also intensive viva sessions in the lead up to the Integrated Vivas. Theses session all require an organised preparation on the part of each candidate.

3. SRMO Teaching

There are twice weekly teaching program for ED SRMO’s. Teaching is focused on topics designed to assist in the transition from SRMO to registrar level. It runs twice every week, on Tuesday and Thursday from 2-3pm (all SRMO’s on both day and evening shifts should attend and those on non-ED terms will also be encouraged to attend). The sessions cover the ‘bread and butter’ core areas necessary to function competently as a registrar – these include radiology, ECG interpretation, blood gases, airway management, team leadership etc.

There are also regular SRMO workshops run by the Department 2 - 3 times every year focusing on Trauma, ALS and procedure skills.

There are separate workshops run by the Network (trainee skills Day) 3-4 times every year. All BMDH SRMO and Registrar have access to attend those sessions.

4. Fellowship Examination Preparation Course

An intensive course is run twice a year by the Consultants in the lead up to the exam. This is based around both the written and OSCE component of the exam.

There is a separate written exam (SAQ) course run by the Network 5 for all trainees in Network 5 Hospitals, BMDH trainees have access to attend the course.

5. NSW Fellowship Course

This program is run for 6 months every Thursday morning at various hospitals around Sydney for candidates immediately before their fellowship written and OSCE exam.

6. FEAST (Fives Education Assessment, and Skills training day for trainees)

This is a quarterly education day which is run either at Westmead Children’s, Westmead Adults or Blacktown Hospitals on a Wednesday. It is based on a different ED topic and involves all Network 5 hospitals.

7. Informal Teaching

The consultant staff in the ED provide extensive supervision and teaching to all ED staff but are particularly interested in supporting trainees in developing their skills in Emergency Medicine. Bedside teaching, viva practice, “cases” practice are just some of the other opportunities for teaching provided in our department.

8. ED trainees’ room

This contains a number of books and other ED references. There is also free access to the EM reports journal. All trainees also have access to all other resources for primary and fellowship exam preparation.

9. Intranet and internet.

Each computer has access to the intranet. On most computers the homepage is the BMDH Emergency Medicine page. This has links to inpatient team rosters, NETS calculator, CIAP, webmail, MIMS, eTG and ECI.

Hospital Clinical Guidelines are located under the ‘Emergency Medicine BMDH, Clinical Information’ tab. There is large amount of information which is of practical use, including clinical pathways and policy guidelines. Topics are listed from A to Z.

We also have our own website for trainees, where you will find clinical nuggets, links to podcasts and procedure videos, clinical resources and rosters. There is also a link to our fantastic ultrasound site, POCUS West.

www.bmdhed.com

https://pocuswest.wordpress.com/

Emergency Medicine Research Unit

Blacktown ED has a strong history of producing quality research for publication. We are currently conducting a number of research and Audit projects and we encourage all doctors who have an interest in research and wish to participate in any projects to contact Dr Richard McNulty.

Emergency Medicine Disaster Unit

The ED trainees have the opportunity to involve in several mass participation events such as City to Surf and disaster exercises. If you are interested in becoming involved, then please contact Dr Fernando Pisani, our Disaster Coordinator.

Section 5: BMDH Emergency Department General information

Blacktown and Mount Druitt Hospital (BMDH) is a single hospital operating across two campuses – one at Blacktown and one at Mount Druitt. . Blacktown has an annual census of nearly 55,000 and Mount Druitt nearly 35,000 patients per year.

Blacktown Hospital provides a 24-hour emergency service, intensive and high dependency care, subspecialty acute medical and surgical care, obstetrics and newborn care and sub-acute rehabilitation. Inpatient acute mental health and community mental health services are delivered from Bungarribee House.

Mount Druitt Hospital offers 24-hour emergency care, inpatient Paediatric care, and a district-wide role in the provision of elective surgery, with a high proportion of general, orthopaedic and breast surgery.

Adult emergency admissions from Mount Druitt are transferred to Blacktown hospital, including patients needing acute surgical assessment.

Paediatric patients who present to Blacktown ED go to Mt Druitt, after review in BLK ED by the onsite Paediatric registrar.

Staffing

Both departments are staffed by fully qualified Fellows of the Australasian College of Emergency Medicine (FACEMs). They may be permanently employed as Emergency Staff Specialist or as Visiting Medical officers. They comprise the senior medical officer (SMO) group. Junior Medical Officers (JMOs) are composed of Interns, Resident Medical Officers (RMOs), Senior Resident Medical Officer (SRMO), Registrars (Advanced or provisional trainees of ACEM). We also have Career Medical Officers (CMOs) in our group.

Role and Philosophy of the Department

The Emergency Department (ED) is responsible for initial assessment and initial stabilisation and management of all patients presenting to the hospital (with the exception of elective admissions, team admissions, patients with routine outpatient appointments or patients coming for specialised investigations organised by their LMO).

The ED is not an endpoint in itself in the delivery of health care to its patients. We mainly act in the assessment and management of acute conditions and after performing this function, pass the patient’s ongoing care over to the appropriate inpatient unit or to the patient’s LMO or other practitioner (e.g. outpatients clinic or consultants rooms) in the case of non-admitted patients. Good communication is

14 therefore vital for good quality ongoing care. Please note the requirement to use the Interpreter service and not friends or relatives of patients who are from a non-English speaking background.

The ED strives to deliver high quality service to our patients and other customers. To do this, care needs to be timely, appropriate and delivered with understanding and empathy. Most patients are in crisis and have arrived in the Emergency Department, often for the first time, and usually expecting the worst. They, their friends and relatives are not always going to be rational. This is occasionally compounded by the fact that patients may have waited a significant amount of time to be seen and to undergo investigations. It is therefore important to recognise these problems, be supportive and understanding of your patient’s situation and communicate effectively with them.

Acute Care

All patients except those who are suitable to be triaged to URGENT CARE are triaged to Acute Care. Acute Care consists of 28 beds or treatment spaces. This includes four resuscitation beds and 24 other beds (including 2 single rooms). All of the 24 beds have full monitoring capacity.

Urgent Care Centre

Urgent Care Centre includes 10 treatment spaces including two bed spaces. There are separate plaster room, procedure/suture room, eye/ENT room. All treatment spaces have full monitoring capacity. Urgent Care Centre is used for the assessment of patients with single system problems unlikely to require admission but may require a period of treatment such as: – IV fluids for gastroenteritis or hyperemesis gravidarum , - IV antibiotic and steroids for tonsillitis – Injuries not fulfilling trauma criteria – Threatened miscarriage – Mild to moderate abdominal pain in patients < 50 with normal vital signs and no co-morbidities – Rashes – Other conditions as determined by the senior doctor

The use of pathology, ultrasound or CT should be selective. The Urgent care is staffed by a Registrar or SRMO, Physiotherapist and a JMO. Discuss the patient with a senior medical officer before contacting inpatient team Registrars. If transferred to Acute Care, the Urgent care doctor will need to hand over all care to the relevant JMO.

Front of House Area

Front of House area includes 5 consult rooms. These areas are staffed by 1 JMO and a Consultant during the day and a Consultant /Registrar and JMO on the evening. In Front of House, a senior (consultant or registrar) have 10 minutes to do a brief assessment of the patient, order investigations and commence interventions if required (fluids/analgesia etc.). Following your assessment, the senior decides where the patient is streamed to (e.g. an acute bed, ESSU, UCC, waiting room or home). The idea is that patients don’t wait for prolonged periods prior to being seen and having their investigations / management commenced.

Clinical Guidelines

There are over 100 clinical guidelines in place in the ED. These are available on the ED Intranet. These provide direction for junior medical staff and allow nursing staff to utilise standing orders for instituting investigations and initiate standard management. If deviated from, management should be discussed with a senior medical officer.

Consultation with Senior Staff

Senior staff (ED Registrars or Staff Specialists/VMO) must be consulted about all patients in Acute Care before they are admitted or discharged. In particular, all patients must be discussed with an ED Registrar or Staff Specialist/VMO before contact is made with a potential inpatient team. External referrals need to be planned to minimise any delays to decision making. In the majority of cases, admission decisions will be made by the senior ED doctors and not by the inpatient teams. All JMOs must have all their patients reviewed by an ED Registrar or Staff Specialist (Senior Medical Officer: SMO). They cannot discharge patients without that patient being seen by a senior staff member. If you have consulted a particular ED SMO about a patient, do not refer to another SMO for follow-up, unless that responsibility has been handed over or when a Staff Specialist reviews a particular case.

Early Consultation

It is a common misconception that investigation results need to be back before a diagnosis can be made, a referral to an inpatient team can be made or a decision on disposition can be made. This is usually not the case. JMOs should consult with one of the ED Registrars or Staff Specialists after initial review of the patient, rather than waiting for all results to be available. Frequently, important decisions can be made (and time saved) by making a clinical diagnosis based on careful history and examination and selected investigations that can be done within the Department. Blood tests are usually unnecessary to make initial decisions. For instance, in less than 6% of patients, they can be predicted to influence admission decisions. JMOs are expected to have made an assessment of the presenting problems and reached diagnoses that need to be excluded as part of the initial investigations

Formulation and Implementation of a Management Plan

This includes particularly resuscitation and urgent treatment, a decision about patient disposition (i.e. admit or discharge, referral to which sub-specialty, etc.) charting of fluids and medications.

Consent

Emergency Department medical staff cannot consent patients for a procedure that is not undertaken by Emergency Department staff except on approval by an Emergency Department Consultant. Note that the Guardianship Act allows for emergency procedures to be undertaken without consent if required to save life or prevent serious illness.

Chaperone

All male staff must be chaperoned by a female staff member when performing an internal examination on a female patient. Relatives are not sufficient for this purpose.

Discharge

All patients for discharge after being treated by a JMO should be discussed with a Registrar/Staff Specialist prior to discharge. All patients who are discharged should have the following:

S L Information on management and follow- Certificate: Medical or Work Cover if required (file Emergency: what to do if condition deteriorates

All the above should be documented along with details about the resolution of symptoms and that they are able to be discharged to the environment planned and have appropriate support.

Overnight stays are only for patients with mitigating social circumstances in whom it is not safe to discharge them home alone. It is not as a replacement for full evaluation and admission. The senior ED doctor on duty must approve this. Note that Social Worker is available, on call 24 hours a day.

Discharge Letters

All patients leave the Department with a Discharge Letter generated by FirstNet. Should this not happen, post the letter to the patient with a brief note attached as to whom it is intended. Do not use patient labels to address the envelope; this contains confidential information and is not for use external to the hospital.

The Discharge Letter is a free text field and the subheadings need not all be used. If the letter is a referral to a Specialist, it must be addressed to them and have your name and provider number. An extensive history and examination is not necessary. If more information is required, a photocopy of the clinical record may be appropriate.

Please note: 1. Letters written in all capital letters or with misplaced commas, spaces and periods make legibility difficult..

2. Avoid excessive or obscure abbreviations and acronyms.

3. Do not ask GPs to refer patient with acute problems or if the GP has referred that patient to the ED because of a problem that requires specialty review. If in doubt about the appropriateness of a referral, discuss with an ED SMO. Where possible, patients should be given the option of attending Outpatient Clinic or a Consultant’s private rooms. Remember, the Discharge Letter must be addressed to the doctor they are being referred to by a doctor with a Provider Number. If you have forgotten your Provider Number contact the HIC on 13 2150 and quote your Medical Registration Number. If you do not have a Provider Number, use the supervising doctor’s name and Provider Number. If so, the responsible SMO should view and sign the letter.

Discharge of Elderly Patients After Hours

Do not discharge Elderly Patients after hours unless the patient is going back to a nursing home and they have been contacted, and the family notified and all concerned are happy with the arrangements, OR

The patient is being taken home by a family member, who is happy to take the patient back at that time and who will be staying with the patient that night (or some other responsible adult will take responsibility for the patient).

Clarify the level of care if the patient comes from an Aged Care Facility. Unlike nursing homes, Other Residential Facility do not have sufficient staff to provide any additional assistance to residents.

Patients who are intoxicated should not be discharged until they are sober/safe and able to care for themselves. Once sober, they should preferably be discharged to the care of a responsible adult.

If a patient requires planned follow-up in the Emergency Department:

In general, this is to be avoided but, after discussion with a senior ED doctor, it may be appropriate to bring a patient back to the ED for follow-up. If so: 1. Confirm this is an appropriate option with a senior ED doctor. 2. Identify a doctor who will be present when the patient is going to return and notify them of the details asking them to see the patient and fast track their management. 3. Ensure the patient has a discharge letter, which identifies that they are returning to the ED and the doctor who is to be contacted, when the patient arrives.

Discharge against Medical Advice The following must be undertaken and documented: 1. The patient is mentally capable of a rational decision 2. The patient understands the risks involved 3. The patient’s understanding of the pros and cons of treatment, including none at all 4. Provision of a management plan and follow-up that is acceptable to the patient

5. When to return and an assurance that they will receive treatment without prejudice 6. A completed Discharge Summary 7. Contact with the GP

A patient not mentally capable of rational decision should not be allowed to leave the hospital. The patient should be urgently considered for Schedule under the Mental Health Act and urgently referred to Psychiatry. Otherwise the patient may be treated under a DUTY OF CARE if considered too unwell to give consent.

Absconding Patients

If absent from the hospital for greater than four (4) hours, consider to be discharged. GP to be contacted. If concerns regarding the patient’s mental capability, refer to senior ED doctor and NUM.

Mailing information to Patients

If this is required, hand write the patient’s name and address on a hospital envelope (do not use a patient medical record label) and hand to the clerical staff at the front desk.

Private patients

If a patient is a private patient of a particular consultant, it is advisable to contact the consultant directly early on. This will facilitate early decision making and significantly reduce the LOS.

Documentation

All ED medical records are documented online via FirstNet.

This should include relevant history, medications (using generic names for oral and parenteral drugs), allergies, vital signs, relevant physical examination, diagnosis and differential diagnosis and an initial management plan. The depth and detail of the documentation may not necessarily be to that required for a full hospital admission. The detail of the record should focus on findings that are relevant to the acute problem. Excellence in medical record keeping is important, as medico-legal issues are common in the ED. Sign, print your name, date and time all entries.

Old medical records are not automatically ordered for all patients – only for admitted patients. On arrival, they will be placed in the bed slots that hold the current record. All medical records (current and old) should be placed in that bed slot when not in use.

Telephone Calls

No medical advice can be given out over the telephone. Advise callers that if they are concerned, they should visit their local GP or attend the nearest Emergency Department. Patients in genuine emergencies should be assisted to get an ambulance. Estimation of waiting times cannot be given, as the patient will need to be triaged in person.

Refer all admitting calls or calls about incoming patients to a Staff Specialist or ED Registrar, to be added to FirstNet as an expected patient.

Hand-over to Ward

Before patients are transferred to an ICU /HDU bed, the team or the after-hours ward cover should be notified. This must be documented in the medical records before the patient leaves the Emergency Department. An “ED Ward Patient Transfer Online Form (T- form)” has been developed as a checklist to assist in readying patients for the ward. This form is online and when complete is signed by a Registrar or Staff Specialist. Please use this form to document up to date plans and any results that need to be chased.

Prescriptions

Medication Chart

We use electronic Medication and Fluid chart (e MEDS and Fluids) in First net to prescribe medication, Intravenous Fluid and most infusions. Blood products are prescribed manually in NSW Health IVF chart.

Adverse Drug Reactions

Adverse drug reactions must be documented online in the medical records. Include the nature of the adverse drug reaction as this may influence the decision to prescribe this or a related drug.

External Prescriptions

Only prescribe from the Schedule of Pharmaceutical Benefits: Unrestricted and Restricted Drugs.

Authority prescriptions cannot be issued from public hospital Emergency Departments. It is rare to require a patient to be discharged on such a medication. If required, and Pharmacy is closed, a small selection of medications is available in the Medical Officers Drug Cupboard in Pharmacy store in the Emergency Department. If not available, review the choice of agent with senior medical staff and contact the on-call pharmacist.

The prescription of benzodiazepines and S8 drugs (narcotics other than Panadeine Forte) should be discussed with a senior medical staff; they are only prescribed in exceptional circumstances and can not be written by an Intern.

If after discussion with senior staff member it is decided to prescribe one of these drugs, they cannot be prescribed on the standard script pads marked with:

“Do Not Dispense if Controlled Drugs or Benzodiazepines are prescribed.” You need to obtain a prescription pad without this warning stamped on the pad. These pads are locked in the S8 drug cupboard. Methadone cannot be prescribed to any patient for the purposes of treating withdrawal unless they are admitted. Refer to guidelines in the RMO’s Handbook.

Admissions Policy and Matrix

Blacktown and Mt Druitt Emergency Departments follow NSW Health Admission Decision Framework. As such the senior Emergency doctor (consultant or registrar) who has seen the patient makes the admission decision. Once the inpatient consultant or registrar has been notified if they are unwilling to accept the patient they may elect to see the patient and then arrange admission under another consultant.

There is an admission matrix on the BMDH Emergency intranet to simplify admission decisions.

Patient Flow

All staff have a role in ensuring that patients move through the ED in a timely fashion. Important factors to keep in mind are seeking early senior input to facilitate decision making, carefully considering that all diagnostic tests ordered are appropriate and necessary, and not waiting for results that are not going to change decision making. We aim to have the ED assessment, disposition decision, management plan and referral completed with 2 hours.

Multicultural Health

Western Sydney is a culturally diverse community, with 47% of people born overseas, and half speaking a language other than English at home. India is the most common country of origin and Arabic is the most common non-English language. About 4% of the western Sydney population identify as Aboriginal, and reside largely in Blacktown. People from culturally and linguistically diverse (CALD) backgrounds may have a higher rate of some chronic diseases such as diabetes, and may face language barriers, problems with health literacy and absence of family support.

You can contact the Aboriginal Liason Officer on p7533.

Interpreter services pH 9912 3803.

ACEM has an online course on Indigenous Health and Cultural Competency.

HETI have a 2 hour elearning course called Aboriginal Culture: Respecting the Difference.

The NSW Government has a great site for multicultural resources, including multilingual information sheets. http://www.mhcs.health.nsw.gov.au/

Section 6: Role of the ED Registrar

The Emergency Medicine registrar is clinically responsible to the Director of the Emergency Department, the Directors of ED training and the Emergency Medicine staff specialist on duty.

Overall Summary of Duties The registrar in Emergency Medicine is responsible, either directly or indirectly for supervision of junior medical officers, for the initial assessment and management of patients presenting to the Emergency Department, under the direction of the appropriate Emergency Medicine duty staff specialist. Responsibilities also exist in the areas of teaching junior medical officers and medical students and taking part in research where appropriate.

Routine Patient Responsibilities The registrar is responsible for: - Ensuring the smooth overall functioning of the Emergency Department - Ensure the Emergency Treatment Performance targets (ETP) are met - Supervision of work of junior medical staff - Ensuring that patients receive adequate and appropriate assessment and emergency medical care, either directly or through supervision of JMO’s - Ensure that there is adequate consultation and communication of such assessment and management decisions to the appropriate subspecialty registrar or consultant - Overseeing the organisation of appropriate diagnostic and therapeutic procedures, with consultation with duty staff specialist as is appropriate - Ensuring adequate communication with the patient and immediate family where appropriate - Ensuring that accurate and relevant documentation exists - Communicating with and coordinating other health professionals - Review of patient progress as appropriate - Ensuring effective referral and disposition of the patient after they leave the ED - Is aware of and complies with the Emergency Department’s policies and procedures - Participates in teaching of junior doctors and medical students and in the Emergency Medicine teaching program - Participates in the prescribed ED teaching program which is compulsory - Participates where appropriate in research being undertaken in the ED

Any other duties at the direction of the Emergency Department Medical Director or Director of Emergency Medicine Training (or their representatives, duty staff specialist or duty registrar in Emergency Medicine)

When no Staff Specialist is on duty, the Registrar needs to be in touch with all activity within the department during their shift. The best way to achieve this is by regular rounds of the department with the senior nurse and regular review of each patient’s progress with the JMO involved in their case.

On Site Support

At Blacktown, There is after hours Registrar cover for the following services: Medical registrar p7509 m:0400940578 p7551 p7511 Intensive Care p7571 and mobile via switch registrar p7538 mobile via switch Psychiatry mobile via switch

Mandatory Registrar Review

The JMO’s are instructed that they must seek registrar review of the following patients:

When you are discussing care with the JMO’s, it is important to establish whether they fulfil any of the above criteria and if so you (or another registrar) must review the patient and document this. All admitted patients are to have a Transfer (T) form filled in by a registrar or SRMO prior to transfer to the ward. This is to ensure safe transfer to the ward.

Supervision

One of the most important aspects of the above is supervision of junior medical staff. ALL patients seen by interns should be physically seen by either a staff specialist or registrar. It is also strongly recommended that patients seen by residents be also reviewed, particularly if the patient is to be discharged.

In general, when junior doctors discuss patients with registrars, it is preferable that patients should be reviewed by that registrar rather than making decisions based on the junior doctor’s assessment alone.

All X-rays interpreted by a junior doctor (resident or intern) should also be interpreted by a registrar or staff specialist.

WORKFLOW (for Registrars)

Registrars are allocated to Acute team A, Acute team B, Acute Team C (FOH/ Urgent Care Centre).

BMDH ED averages more than 150 patients per day. Peak periods see up to 150 patients presenting per hour. The majority of our patients present between 11 am to 9 pm.

In order to avoid long patient waiting times, our ED treatment or TAT (turnaround time) needs to be short enough to ensure that patients are not occupying bed or treatment spaces longer than necessary.

Our work practices need to ensure that we do not order unnecessary investigations or that we write excessively long medical notes on patients. This would especially be the case for Urgent Care Centre patients. For Urgent Care Centre patients, documentation can be brief.

Equally in Acute Care, we need to ensure that the patients that require admission may be sent to the ward as quickly as it is safe to do so. Early review by a Registrar is mandatory as this facilitates early decision making.

The morning shift for the registrars commences at 8am.

There is a brief ED team meeting/huddle in acute area every morning at 8:00 am (involving all ED medical, nursing, clerical staff).

Morning handover starts immediately after the huddle in your allocated team. Handover occurs in your rostered area with staff allocated there for the day.

The evening shift commences at 1400. There is no JMO handover round at this time. JMOs are expected to make themselves known to the senior and commence seeing waiting patients or work under the direction of the Registrar or Consultant.

At 2pm a computer round in your allocated area occurs with morning/evening registrars/ consultants.

Evening handover round commences at 1700.

Following handover round, JMOs are to ensure that all outstanding tasks and management issues are completed or handed over to the evening staff.

Night shift commences at 2230. The night handover round commences approximately 2230. It is imperative that the Night JMO/Registrar is aware of any outstanding diagnostic and management issues.

During the ward round, JMO’s will be assigned several patients to oversee during the shift. These will be in addition to the patients that they workup during the shift.

The next patient to be seen (TBS) in FirstNet will be prioritized according to:

1. Triage category

2. Length of Stay (LOS) in the department.

TBS patients that are given a category 1 or 2 will be announced via an overhead.

Section 7: Allied Services

Social Work

There is an on-site social worker from 8.30am to 5pm, 5 days per week. A social worker is on call outside these hours and can be contacted via switchboard. The social worker is a valuable resource to assist in communication with relatives of acutely ill or recently deceased patients. The social worker is also available for suspected domestic violence, suspected child at risk and acute accommodation or social crises.

Physiotherapy

The in-hospital physiotherapy department provides limited support to the ED in working hours. Overall, there are 3 ED physios. An ED physio available from 10 to 8pm 7 days per week. They base themselves in the Urgent Care Centre and are able to see appropriate patients independently.

Speech Therapy

Available during working hours 5 days a week from Monday to Friday to review patients in the ED.

PACC (Post-Acute Community Care service)

The PACC service is available during business hours and provides intensive outpatient therapy for selected patients including IV antibiotics DVT/PE management.

They are closely affiliated with the Hospital in The Home Service.

Sexual Assault

There is a sexual assault unit (Forensic Medical Unit) for the Sydney West Area Health Service. Where possible, these patients are fast tracked through the Emergency Department. If there are no injuries that require urgent management (these should be picked up at triage) the sexual assault team are to be contacted. They will then screen them as to whether or not they require a forensic examination. The on- call Forensic Medical Officer or Sexual Assault Nurse Examiner (SANE) is then contacted to assess and perform the forensic examination. Further information on this topic is in the policies and procedures manual on the Intranet site.

Dental

Any patient presenting with a Dental Emergency can be referred to the on-call dentist at Westmead via switchboard.

Hospital in the Home

Contactable via switchboard during weekdays

Section 8: Trauma, AMI, Stroke, PE, Torsion, NIV

Trauma team response

Trauma activations are divided into Stable and Major. This distinction is made on clinical and mechanism criteria which can be found on the intranet. A Major trauma at Blacktown is called via pH 111 “Major Trauma” or “Paediatric Major Trauma”. Usually the nursing staff puts out the trauma call that contact switch. The medical staff do have a responsibility to ensure that there is appropriate liaison with the nursing staff so that the correct call is put out, particularly in borderline cases. A Stable trauma call elicits a purely Emergency Department response, and can usually be managed at Blacktown (or Mt Druitt if admission needed for a Paediatric patient). Should it become obvious that the patient is unstable, the patient can be upgraded to a major trauma by the treating doctor or Nurse. A Major trauma call is attended by a surgical registrar, anaesthetic registrar and ICU registrar. These patients should be stabilised at Blacktown Hospital prior to rapid transfer to the Trauma specialist at Westmead Hospital or Children’s Hospital Westmead.

You should at least be familiar with clinical policies relating to the following areas: cervical spine imaging and clearance, shocked trauma patient, major pelvic injuries with significant blood loss, massive transfusion protocol and others. These are all available on the Intranet site in the hospital trauma manual. Westmead Trauma has an App which you can download on your smartphone which lists some of their clinical pathways (‘Westmead trauma’ app).

Acute Myocardial Infarction

Primary Percutaneous Transluminal Coronary Angioplasty is the revascularisation procedure of choice at BMDH for all patients who have the requisite ECG criteria. Once again, there is a fast track procedure aimed at getting these patients to the cardiac catheterisation laboratory as quickly as possible. In hours Monday to Friday call the Cardiology Advanced Trainee 0409 582 774. After hours speak to the cardiologist on call at Blacktown to liaison with the interventional Cardiologist at Westmead.

During business hours 0800-1630 the patient can be managed at Blacktown Hospital’s cath lab. Outside business hours, the patient should be transferred by ambulance with lights and sirens directly to the Westmead hospital cath lab.

While awaiting transfer, but not delaying transfer, commence treatment as per Chest Pain Pathway with routine bloods, GTN, morphine, CXR, iv cannula x2 (avoid right hand/wrist), aspirin, second anti-platelet (prasugrel or ticagrelor), heparin iv bolus. Inform Westmead ED admitting Officer on Extension 58222 regarding transfer.

Massive/ Sub-massive Pulmonary Embolism

Catheter-directed thrombolysis is indicated on selected patients and available 24/7 at Westmead Hospital. Call on call Respiratory Physician at Blacktown and involve ICU team to decide on Thrombolysis. Guideline for PE thrombolysis is available on intranet.

Stroke thrombolysis

See Section 18.

Urological Emergencies

Patients with an acute scrotal or testicular issue should be referred ASAP to the on-call Urology/Surgical registrar. An Ultrasound should NOT be ordered until first discussing with the team registrar.

See Section 10 for detail information.

Acute Respiratory Unit Admissions for Non Invasive Ventilation

The ARU will accept patients who require acute treatment with CPAP, BiPAP/NIV, or high flow from Blacktown HDU/ICU only. ARU will only accept ICU/HDU referred patients between the hours of 08:00 and 15:00 Monday to Friday (excluding public holidays). Referrals for those patients outside those hours will not be accepted. After hours admission to the ARU will be at the discretion of the on call respiratory physician only.

Clinical criteria appropriate admission to the ARU include:

> 45mmHg. Appropriate clinical conditions associated with T2RF include obstructive lung diseases (COPD, bronchiectasis) and restrictive lung diseases (obesity hypoventilation syndrome, neuromuscular disease or severe chest wall abnormalities). fy the criteria above, but have increased work of breathing, may be suitable for CPAP or BiPAP le for CPAP, ideally managed in CCU

ne for those patients with a baseline <12

ptable to the patient, or where CPAP/BIPAP/NIV is the limitation of therapy. This must have been clearly discussed and documented on the Advanced Care Plan form in eMR.

Section 9: Outpatients Clinics

When you are referring a patient to the Outpatient Clinic, it is important to know approximately how long the waiting time is for that clinic and if the patient requires review before then, how to organise a timelier appointment. The clerical staff can look up the waiting times for clinics via PIMS. There are also some services that do not provide an outpatient service.

Currently, most clinic referrals are performed via E-referrals via Firstnet. These include:

Referrals to these clinics (from ED) should NOT be faxed.

Note: referrals to either Outpatient Clinic or a Consultant’s rooms require the discharge letter (generated from FirstNet) to include:

1. The name of the Consultant

2. A provider number

Further details about the Outpatient Clinics are detailed on the ED Intranet.

Section 10: Paediatric Patients

Paediatric patients with surgical presentations at Blacktown/Mt Druitt Hospital - Early review by senior Emergency doctor - Referral to surgical registrar, and review within 1 hour - Decision whether child (>6 yo) is to be admitted and treated at BMDH, or transferred to the SCHN - One parent or a designated primary carer must be enabled to remain with them throughout their hospital admission. - Always consider non-accidental injury, and manage this according to NSW Health Guidelines

Paediatric patients with suspected testicular torsion - Under 6 yrs old call the General Surgery Registrar on call at the Children’s Hospital Westmead to inform that patient is enroute (permission not required). Ambulance transfer lights and sirens to Children’s Hospital Westmead. - 6 yrs and over notify the General Surgical Registrar at Blacktown Hospital through switchboard. From Mt Druitt transfer via ambulance lights and sirens, permission not required. - Over 16 yrs notify the Urology registrar at Blacktown Hospital via switchboard. From Mt Druitt transfer via ambulance lights and sirens, permission not required. After Hours adult Urology service is at Westmead Hospital via switchboard.

Paediatric patients with non-surgical presentations - Life threatening or acute problem likely to require ICU call NETS 1300 36 2500, and inform Paediatric registrar - Referrals for admission should be made to the Paediatric registrar, who will arrange admission to Mt Druitt paeds ward

Neonatal Emergencies

For any neonatal emergency please contact the general emergency number (111). This will contact the Neonatal ICU registrar located in our hospital in additional to other critical care doctors who may be able to assist.

Section 11: ED Transfer (T) form

GUIDELINES

All admissions to an inpatient unit require a T-form to be completed prior to patient transfer.

The JMO is to open the T-form (safe transfer form on FIRSTNET) soon after the decision to admit the patient is made and the team informed of the admission. The JMO is to complete the sections of the form that are able to be completed. Ideally the patient’s imaging and bloods tests are complete, medication, MMP and fluid chart would have of been completed. The JMO then ticks the TICK icon on the T-form. This triggers an RED T symbol on the tracking board. Make sure that a diagnosis is entered, that is the main diagnosis responsible for the admission.

RED T-symbol will indicate to the senior that a T-form has been completed by the JMO. The ED senior is to complete and sign-off the T form when a bed has been allocated and it is determined that the patient can be safely transferred to the allocated ward. The ED senior ensures that the information in the JMO completed T-form is correct and complete any additional mandatory fields. The ED senior ensures that a set of Observations are performed within an hour of transfer to a non HDU ward and prior to transfer to a HDU bed. The ED senior will then tick T-form complete. It will appear in the patient’s patient care column that T-form is completed and it will then equate with a senior medical authorisation for transfer. The ED NUM may complete the T-form on behalf of the ED senior on occasions when the MO is unable to promptly attend to its “sign-off” due to clinical overload.

Any patients whose observations are unstable (as per Adult Observation chart) are to be reviewed by a senior prior to transfer. These transfers are only to occur once the patient is handed over to the HDU SRMO/reg. If it is necessary to alter PACE calling criteria, you need approval from the Admitting Physician. Unstable patients can only be transferred to appropriate wards. (ICU, HDU)

Section 12: Other Policies

There are multiple policy documents currently listed on the Blacktown ED intranet Page.

It is impossible to place these in this manual, so we would encourage you to familiarise yourselves with these policies during your stay with us. Below you will find a few PEARLS of information i) ADMISSION AND DISCHARGE POLICY – Please see intranet (we will include this policy with your orientation pack) ii) MEDICAL ADMISSIONS ON NIGHT SHIFT – Unwell or unstable patients should be reviewed by the ED registrar who should make the phone call to the admitting consultant. For stable patients, notification can be made by the registrar/RMO to the consultant at 0600, however if the patient goes to the ward prior to this then the Medical registrar needs to be notified. Interns can call the consultant after being reviewed by the ED registrar. iii) NOTIFICATION OF WARD STAFF WHEN TRANSFERRING UNWELL OR UNSTABLE PATIENTS TO THE WARD – Notify relevant team or registrar in regards to the patient prior to transfer of the patient from the ED. iv) NURSING STANDING ORDERS – When an ED nurse enacts one of the accepted standing orders on a patient, the ED medical officer is required to officially sign off on this, in the once only drug administration chart. v) ANTIRETROVIRAL POST EXPOSURE PROPHYLAXIS (PEP) – Risk assessment of patient needs to be made as soon as possible. Discuss with the ID team. vi) BLOOD GAS ANALYSER The ABG analyzer may be utilized for urgent ABG, Lactate, Carboxy Hb, or Creatinine results. All results obtained via a POCT ABG analyser appear on the power chart results. Ensure correct patient details are entered on the machine. Each doctor will require a user specific log on. vii) GUIDELINES FOR PATIENTS IN A METHADONE MAINTENANCE PROGRAM PRESENTING TO ED – Need to confirm from the patient’s methadone provider that the patient is a registered participant, their current dose and when it was last administered and details of any “take away doses”. The provider needs to fax a copy of the patient’s current methadone prescription. The patient must be admitted before dosing. Please inform Drug and Alcohol of the patient. viii) FEBRILE NEUTROPAENIA DRUG REGIMEN – Tazocin and gentamicin are the recommended first line antibiotics of choice. Early antibiotics are the key. ix) ANAPHYLAXIS

After Hours Epipens can be dispensed from the ED stock for patients who have presented with

31 anaphylaxis, after discussion with the on-call immunologist. Thereafter your discharge letter should request the GP to write an authority script.

In hours, an Epipen can be dispensed from our hospital pharmacy – a hospital pharmacy script needs to be completed to obtain it, patients need to be shown how to use the pen prior to discharge. viii) LOW RISK CHEST PAIN – AS per the chest pain pathway, low risk patients who are safe for discharge can be referred online for an outpatient exercise stress test if there are no contraindications, or a CTCA (must be discussed with cardiologist) within 2 weeks.

Intermediate risk patients should be discussed with the cardiologist on call to arrange an outpatient CTCA (instructions on Chest Pain pathway) or EST within 1 week, if considered suitable for discharge. viii) FIRST SEIZURE – As per the First Seizure Guide in the Clinical Information page online, discuss with neurology team, if medically cleared then arrange an out patient EEG at Westmead, and book an out pt follow up with the Urgent Review Clinic at Blacktown.

Counsel the patient that they should not drive for at least 6 months, irrespective of the EEG result. Also to avoid situations in which a seizure would be dangerous such as bathing alone, unsupervised swimming, operating machinery.

Section 13: Investigations Organisation and Performance of Investigations

FirstNet can now order most investigations and you should understand the procedure for doing this.

Investigations that do not impact on the immediate management of the patient may be done from the ward or as an outpatient (should the patient be discharged). The patient’s progress through the Emergency Department should not be held up by tests, particularly complex imaging when the result does not affect the immediate management.

We have 4 dedicated pathology tube system (located in Acute Care, Resus area, UCC and the resus area) which minimises the transport time of specimens. CSF samples should not be sent via this tube; call the porters instead.

It is also important that if you perform an investigation that you check the result and act appropriately on any abnormality. If the result of a particular investigation will not immediately affect the patient's management, then they can be discharged for the LMO to obtain the result. Note that all X-rays and all positive blood cultures are followed up by the ED; it is not necessary to ask GPs to follow these up. All drivers, pedestrians or bike riders involved in an accident on a public road, who are 15 years or older, must have a police blood alcohol level taken if they arrive within 12 hours of the accident. Record the number on the police blood alcohol seal in the medical records.

Section 14: Radiology a) Plain Radiographs - 24 hour service. Mobile xray 48641. b) Ultrasound

NOTE: Transthoracic Echocardiography available through Cardiology team only c) CT Scanning le 24/7 You need to inform the CT radiographer when ordering a CT, ext 48244. service “Tele Rad” for a formal report. The report should be available within 1 hr of the images been sent to “Tele Rad” results appear on the power chart result. You will need to chart the oral and iv contrast for relevant scans in the medication chart You can speak to the on call reg p7659, or radiologist at Tele Rad, pH 1800 009 945. e) MRI

t approval on weekends

We recommend using the Western Australia Imaging Guidelines, http://www.imagingpathways.health.wa.gov.au/ for evidence based guidance of diagnostic imaging.

Section 15: Emergency Department Short Stay Unit (EDSSU)

BUSINESS RULES

The Emergency Short Stay Unit (EDSSU) is a 13 -treatment space (including one single room) unit located adjacent to the main ED. All treatment spaces have monitoring capabilities.

The role of the EDSSU is to provide an alternative treatment pathway for patients requiring a short-term admission (2- 24 hours)

Patients are admitted to the EDSSU via

1. FOH (Team C)

2. Acute Care after a brief workup and commencement of treatment.

3. UCC due to need for further work-up, management or observation.

The decision to admit to the EDSSU needs to be made early in the patients work up with all transfers into the EDSSU made < 4 hours. Admissions are decided by the senior ED doctor. Inpatient teams which require patients to be admitted for treatment, observation, or further investigation, cannot admit to the SSU.

Section 16: Policy for accepting referrals to the ED

 AMO Directed Admissions The current policy with regards to patients assessed by an AMO or Registrar outside the Emergency Department (ED) as requiring acute hospital admission is that the referring doctor must contact the relevant Clinical Support Manager regarding bed availability. The patient will ideally be admitted to a ward bed if available, bypassing ED if stable.

 Interhospital Transfer: Unstable patients at Mount Druitt ED require transfer to Blacktown ED for further investigation and management. Stable patients from Mount Druitt ED are transferred directly to the ward for admission to Blacktown Hospital.

 GP Referrals Similarly, local General Practitioners contacting AMO’s or Registrars directly about patients they wish to send to hospital, should be referred back to us BEFORE sending the patient, to confirm that we are able to accept the patient.

 Unstable patients from non-acute areas in the Hospital (Dialysis unit, outpatient clinic) may be referred to ED for management.

Section 17: Deaths in the ED Patients who die in the ED are either a coroner’s case or can have a death certificate completed. The criteria for a coroner’s case can be found on the Intranet. It can also be accessed via the link below. This will take you to the ‘NSW Coroners Act 2009’ which details the criteria if a death is reportable to the Coroner http://www0.health.nsw.gov.au/policies/pd/2010/PD2010_054.html

Death Certificates Patients who do not fulfil the criteria for a coroner’s case may have a death certificate issued provided you have seen the patient whilst alive. All patients who have a death certificate issued should also have a cremation certificate completed. Patients seen alive by the inpatient team who subsequently die should have paperwork completed by that team not ED staff.

Death certificates are a legal document and should be completed accurately. Please refer to the cause of death booklet which should be available on each ward. The most immediate cause of death should be written in Part 1 of the death certificate followed by the cause of that and ante ceding causes continued down the death certificate. Part 2 of the death certificate should contain any diseases which contributed to, but were not directly the cause of death.

Cremation Certificates It is the policy of this hospital that a cremation certificate be completed at the time a death certificate is completed. Approximately 90% of deceased patients will be cremated and it will save everyone time if both certificates are done at the same time.

Section 18: Blacktown Mt Druitt Stroke Thrombolysis Protocol During a stroke, 1.9 million brain cells die every minute. Intravenous thrombolysis within 4.5 hours saves lives and reduces disability - the earlier we intervene, the more we save.

In patients with persisting symptoms or signs suggestive of stroke, the time of symptom onset should be sought. Where time of onset is initially unknown, urgent attempts must be made to establish the onset time via collateral history.

Patients presenting with persisting symptoms and/or signs within 6 hours of onset, even if improving or fluctuating, must be considered potential candidates for reperfusion therapies (thrombolysis and/or endovascular clot retrieval). These patients must be triaged as category 1 or 2, a stroke call activated, the patient allocated a monitored bed, and brought to the attention of ED senior medical staff for rapid assessment (within 10 minutes). An ED Senior (registrar or consultant) determines if a Code Thrombolysis is to be activated by ringing switchboard on 2222.

If there is no response from the Stroke team or consultant within 5-10 minutes of the stroke page, a call must be made to the Stroke Consultant on call to ensure that he or she is aware of the patient.

For patients under 70 years the Neurologist is the Stroke consultant, and it is the Geriatrics Medicine consultant for patients 70 years and over.

A DWI-only MRI protocol is available for patients presenting to Blacktown and Mount Druitt Hospitals, can be done rapidly, and is the most sensitive imaging modality for excluding acute (< 1-2 weeks) ischaemic stroke. It is not required for confirmation of stroke in patients presenting with clinically probable acute stroke who are candidates for reperfusion therapies. It should be done prior to any decisions regarding disposition in patients with acute neurological presentations in whom ischaemic stroke needs exclusion. CT is not adequate to exclude acute ischaemic stroke.

All patients with suspected TIA or stroke who may be candidates for endovascular clot retrieval (up to 24 hours after symptom onset in selected patients) should have non contrast CT followed by CT angiography or MRA from the aortic arch to cerebral vertex.

Patients with suspected stroke suitable for thrombolysis at Mt Druitt Hospital

All patients at Mt Druitt in whom the differential diagnosis includes stroke, with onset within 3 hours, with no obvious contraindications to thrombolysis, should be transferred (lights and sirens) as soon as possible to Blacktown Hospital Emergency. They should not be offloaded from the ambulance trolley at Mt Druitt.

Thrombolysis for acute stroke with Alteplase at Blacktown Hospital

Procedure: - promptly assess Inclusion / Exclusion criteria ; - Perform NIHSS; suggested score ≥ 3 for treatment eligibility but may be varied at the discretion of the Stroke Consultant; - Assess BP – Parameters for thrombolysis ≤ 185/110mmHg; - Insert 2 cannulas (size 18) ; take full blood count, coagulation studies and BSL; - If patient is unable to consent, contact next of kin; If NOK not available, treatment may be given as emergency procedure without consent. - All cases MUST be discussed with Stroke Consultant prior to thrombolysis.

Suitable patients for transfer for endovascular thrombectomy: - Independent premorbid function (modified Rankin Scale 0 – 2) - NIH stroke scale 5 or more - Acute ischaemic stroke with proven large vessel occlusion on CTA  Internal Carotid Artery (ICA)  Proximal Middle Cerebral Artery (MCA) M1 or proximal M2  Basilar artery - Ability to perform procedure within 6 – 24 hours (for selected strokes) - Intravenous rtPA within 4.5 hours of onset should still be given to eligible patients

Referral for endovascular clot retrieval: Telephone (central number): 1800 738 764 (“1800 SEVSNI” = 1800 Specialist Endo Vascular Services Neuro Intervention)

Procedure for referral: Step 1: Telephone call to 1800 SEVSNI Step 2: Fax referral form to 02 8088 6509 Find the form online at http://www.snis.com.au/stroke-referral/ Step 3: ED AMO and Stroke registrar of receiving hospital must be contacted.

Mon-Fri 0800-1500h patient will be transferred to either RNSH or WH.

Outside these hours they will be transferred to Liverpool Hospital (recommended) or RPA or POW depending on availability of Interventionalist.

Section 19: Sepsis pathway

Antibiotic Prescribing

• Obtain two/three sets of blood cultures before administering antibiotics • Obtain other clinical specimens as appropriate but do not delay administration of antibiotics or wait for results of investigations Refer to eTG Antibiotic Guidelines for appropriate antibiotic prescribing. Higher doses of antibiotics are given to patients with severe sepsis. • Contact the ID Physician/Microbiologist on call via switchboard to seek advice as needed • You will be provided with a lanyard outlining the Westmead Antibiotic prescribing guidelines upon the commencement of your ED placement.

Section 20: Guidelines on when to contact the ON-CALL ED CONSULTANT

Section 21: Commonly Used Numbers at Blacktown

ICU Referrals: Senior Registrar 7571

STEMI Referrals, and Other Cardiology Referrals After Hours: Advanced Trainee via Mobile

Cardiology, Gastroenterology and Haematology: BPT for on call team takes in hours consults, AT takes after hours referrals.

Anaesthetics After Hours: p7511

Surgical Registrar: p7577

Orthopaedics: p7822

Urology: registrar via switch

AMU: sRMO p7854 in hours, consultant via switch after hours

PECC CNC for MH referrals: 0429 390 579

NETS: 1300 362 500

Medical Retrieval: 1800 650 004

CT orders: 48244

CT Reporting: 1800 009 945

Mobile xray: 48641

Radiology reg: p7659

Pathology: 48001/48419

ED Clinical NUM: 47558

ED Fax in Acute: 9881 8212