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MEDICAL OFFICER ORIENTATION MANUAL
DEPARTMENT OF EMERGENCY MEDICINE
BMDH Last updated: January 2020
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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 10. ADMISSIONS 11. DISCHARGES 12. CASE PRESENTATION 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 18. TEACHING AND EDUCATION RESOURCES 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 .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
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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 BMDH 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, stabilisation and acute management for patients presenting to the Department. Relevant subspecialty or the patient’s general practitioner carries out 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 service provided by the unit has to be of world standard.
The Emergency Department is a level 5 department, (with the hospital being a Level 2 trauma unit) providing treatment for major and minor trauma and medical emergencies. It provides a service that ensures the timely, skilled and appropriate management of all patients. Approximately 60,000 patients attend the department each year (about 170 patients per day). The number of admissions to inpatient beds averages 30%.
The Emergency Department also provides a focus for teaching and research. The unit is actively involved in many research projects. Being accredited for Emergency medicine training by the Australasian College for Emergency Medicine (ACEM) the unit provides structured teaching programmes in Fellowship, Diploma and Certificate training programme of the ACEM.
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.
2. GOALS AND OBJECTIVES DURING YOUR TERM
To gain broad experience in the management of adult and paediatric emergencies. To develop and enhance your resuscitation and procedural skills. You are encouraged to keep your on log book (Electronic Log Book). To further the ability to work in a multidisciplinary team and enhance your leadership skills. To develop a high standard of documentation in clinical recording. To participate in continuing education within and exterior to the unit. 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 (Co-DEMT BMDH) Dr Shaila Islam Dr Dushan Jayaweera Dr Daya Jeganathan Dr Ponnuthurai Jeyaruban (Co-DEMT MDH) Dr Gopi Mann Dr Richard McNulty Dr Satish Mitter (Network Co Director of Training) Dr Jannatun Nayim (Co-DEMT BDH) Dr Fernando Pisani
Dr Greg Robinson Dr Liaquat Sheriff Dr Kenny Yee Dr Anj Amarasekera Dr Peter Preisz Dr Susie Stapledon
Emergency Medicine VMOs :
Dr Irshath Abdul Raheem Dr Richard Lennon Dr Vijay Manivel Dr John Shirley Dr Jana Usenko Dr Behzad Vasfi Dr Payam Yahyavi Dr Nina Dhaliwal Dr Rasel Ahmed Dr Ravindar Jassal Dr Waseem Hassan
Executive Assistant: Ms. Joan Brown
Nursing Unit Manager Blacktown ED: Ms. Camille Dooley Nursing Unit Manager Mount Druitt ED: Mr. David Glastonbury Clinical Nurse Consultant (BMDH) (Acting): Mr Aaron De Los Santos
Clinical Nurse Educator (BDH): Miss Catherine Priestley Clinical Nurse Educator (BDH) (Acting): Jonathamiel Abarquez Clinical Nurse Educator (MDH): Mr. Jonathon Hamilton
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4. BLACKTOWN EMERGENCY DEPARTMENT FLOOR AREA
The department is divided into different areas based on the model of care provided. There is Resuscitation, Acute, Urgent care, Front of House (Early Senior Assessment/ Team C) area.
Resus area: 4 beds Acute area: 24 monitored beds Urgent care area: 8 recliner chairs and 2 beds, Eye ENT room Front of house area: 5 consultation rooms Short stay unit: 14 beds
5. SUPERVISION
All JMO’s (Interns, RMOs and SRMOs) are supervised by the ED Consultant /Registrar/CMO. All JMOs 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.
It is our departmental policy that ALL patients seen by an Intern, RMO or SRMO will be seen briefly by the senior doctor (ED Consultant/ Registrar/ CMO) of the shift. This is to ensure clinical safety as well as allowing the department to achieve ETP (Emergency Treatment Performance set by Ministry) following on 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.
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 Consultant on the floor, there is an ED Consultant rostered on call. Any complex issues that the CMO/Registrar have difficulty with, needs to be discussed with the on-call ED Consultant who is contactable via switchboard.
If an emergency consultant is available, the ED staff handles management of all emergencies including cardiac arrests. At other times, call a code BLUE on 2222 for the hospital MET call team. The ED senior doctor will remain the team leader for all MET calls in ED. You are expected to assist with the resuscitation. You are expected to alert the ED senior doctor of any critically ill patient for immediate review in order to prevent further deterioration.
You are expected to attend and notify ED seniors if a CERS call is activated in ED until team Doctors or ED seniors are available.
The hospital’s surgical Team should be called to assist in the management of any multi- trauma cases. See the guidelines in Appendix 5.
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6. ROSTER
Blacktown and Mount-Druitt ED have their independent REG/CMO and JMO (Intern, RMO, SRMO) roster. The Executive Assistant of the Department is in charge of the Intern/ RMO/ SRMO 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, Intern/RMO/SRMO/Reg/CMO must arrange their own swap/relief, if there is a specific shift they cannot work. The Intern/ RMO/SRMO/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 (Staff Specialist). 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.
During your shift 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.
You will be rostered to a team in ED. Team A and Team B consists mostly of 2 or 3 JMOs attached to an ED senior (ED SS or Reg/CMO).Team C consists of an ED senior (ED SS or Reg/CMO) with 1 JMO and 1 JMO in ESSU (short stay unit.). There is no Team C at night, hence the work load will be shared between teams A & B.
You are expected to see patients BASED on team allocation and utilise any clinical space that might be available depending on how busy the unit is.
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. It is essential that you give as much warning as necessary so that relief staff can be organised.
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The person rostered on as night sick relief will be required to work the shift.
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.
Medical Certificates are also required to be provided when sick leave is taken for ONE or more days on the following occasions:
Immediately before or after annual leave Immediately before or after a public holiday Immediately before or after a ADO For a rostered weekend shift
8. SHIFTS
BLACKTOWN MT DRUITT
D/DB 0800 -1830 D/DM 0800 - 1830
E/EB 1400 - 2400 E/EM 1400 - 2400
N/NB 2230 - 0830 N/NM 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.
ON ARRIVAL TO YOUR SHIFT:
Check floor roster to see which team you are allocated to. Inform your team leader and commence seeing patients allocated to your team on FirstNet. Click on the Medical Officer column and allocate yourself to the patient prior to going to meet the patient. If you have not clicked your name on the patient on FirstNet before seeing the patient, PLEASE CHANGE THE CLOCK TO THE ACTUAL TIME YOU SAW THE PATIENT. When on a particular shift continue picking up patients till the last 20 min of the end of your shift. That will assist your colleague in continuing to manage the floor. YOU CAN HAND OVER ANY PATIENT THAT HAS HAD SOME DEGREE OF WORK UP DONE. Once you arrive for your Evening or Night shift, inform your Team leader and start seeing patients allocated to your team immediately (Do not wait for handover call)
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9. COMMUNICATION
9.1 BETWEEN YOU AND THE DEPARTMENT
This will be via health 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 health email.
9.2 WITHIN THE DEPARTMENT AND THE HOSPITAL
Mode of communication include, telephone paging and electronic documentation on eMR. However, the best way to communicate with other ED and hospital staff is by polite personal communication. Nursing staff need to be informed of management plans or changes to these, so that the management plans can be updated and carried out. There is also an overhead communication system in the ED department which should be used to page someone or announce any major issue. The overhead paging system should be used professionally. It is not for personal communications/messages.
All in patient team contact during hours is via paging system. If not answered try calling via switch and notify your ED senior ASAP.
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 * Message is sent Hang up
9.2.2 To page someone via the intranet: (PREFFERED PROCESS) This link via ED home page on the intranet. Type in pager number Message (your name, and which patient you are calling about) - send
The phones in ED have “group pick-up” and “search” facility. 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”. 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/GP or VMO for admission should be referred to the Staff Specialist or CMO/Registrar in ED (Team A In Charge).
Use the ISBAR format when communicating with teams.
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
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advice given. Please do remember that “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 INVESTIGATIONS and management 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 Surgical 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. Some specialities may differ. Consult your senior.
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)
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Paediatric patients: Admitted under the consultant of the day. (Except those who are private and make a special request.) All admissions to Mt Druitt Hospital.
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 patients: 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. On-call Consultant of the 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 On Call Consultant can be contacted via the switchboard. All phone calls to the department by a LMO or VMO for admission should be referred to the Consultant or CMO/Registrar in ED.
Once admitted, the doctor doing the admission (this could be ED doctor or the in-patient team doctor) should chart the medication and fluid as required on emeds (electronic medication and fluid chart).
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 Consultant (night med reg after hours) has been notified.
11. DISCHARGE
After ASSESSMENT, if it is deemed that a patient does not require admission and may be managed in the outpatient environment, then the patient may be discharged.
ALL PATIENTS BEING DISCHARGED MUST BE REVIEWED BY AN EMERGENCY MEDICINE CONSULTANT / CMO / REGISTRAR.
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JMOs are not allowed to discharge patients without speaking to a senior physician.
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 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 a “cut and paste” from the patient’s medical or progress notes but a brief summary of their ED presentation with relevant discharge instructions. A “Cut and Paste” scenario allows unwanted confusing information given to the patient
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.
Please remember your patient WILL READ THE LETTER YOU HAVE WRITTEN!!! Avoid putting in any confusing and unsubstantiated information.
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 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.
If you are writing a referral letter to a specialist, you must ensure that your Medical Provider Number is included on the letter.
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REPRESENTATION:
Patients re-presenting to ED (from any Emergency Department) with in 1 week should be reviewed by a senior doctor (Consultant/Registrar/CMO).
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
12. CASE PRESENTATION
As a JMO you will be presenting / discussing all your patients with the REG/CMO/Staff Specialist. You will also be discussing with inpatient teams.
The following template is to be used whenever you are presenting a case. 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) Opening summary of the case history of presenting illness Relevant past medical issues Medication list Important social/personal 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 patient’s Bedside.
The timings for the hand over rounds are:
Morning shift handover at 0800hrs. Evening shift handover at 1700hrs Night shift handover at 2300 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. Individual ED Teams will take hand over of their respective Teams It is expected that the rounds would have a teaching focus for the participants. The JMO’s will be allocated patients during these rounds.
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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
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 (Transfer to ward document i.e. MAPS forms).
If the patient is for discharge then it is the responsibility of the outgoing doctor to write the DRAFT discharge summary which can be completed by the incoming JMO who the patient is being handed over to for completion.
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
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15. BED AND AREA ALLOCATION
All JMO’s are allocated to a specific team (A, B or C) in the department on the floor roster. The ED Consultant/CMO/Registrar of the particular shift can change this. Teams A and B will be allocated to acute care. Team C JMO will be working with the senior in the Front of House area or in ESSU (short stay unit.)
You will be responsible for all Cat 2 arriving AND allocated to your Team 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.
This allocation is not rigid, and all doctors are expected to help their colleagues as the workload requires.
Cat 2 are allocated alternating between Team A and Team B by the Triage nurse. All other patients are allocated ideally by the FOH Consultant (Team C leader)
16. BAT CALLS TO RESUSCITATION AREA
CDA has a direct phone link “Bat phone” to the ED and will notify the department of imminent emergencies (e.g. cardiac arrests or multi-trauma). Information from such calls must be relayed immediately to the appropriate senior staff.
17. ROLES AND SERVICES WITHIN THE DEPARTMENT
17.1 URGENT CARE
The principal objective of the Urgent care 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 Urgent Care nurse and usually does not need to be picked up by JMOs.
Patients designated for the Urgent Care area will have a “U” next to their names and will be found under the UCC tab in First net.
17.2 FRONT OF HOUSE AREA
Front of House area is a designated space in the department where patients are seen by TEAM C on arrival to the department. Team C will include, senior doctor (ED Consultant/CMO/REG), RMO. Once the patient is seen by Team C they can then be streamed into Acute/ESSU/ Discharge etc. as required.
17.3 ED SHORT STAY UNIT (ESSU)
Blacktown ED operates a 14 bed short stay unit. This unit is under the governance of the ED. Any patient that we think would require some further degree of work up prior to being discharged will be admitted to the ESSU. (Please refer to the Business rules).
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There is a JMO allocated on the floor roster to work in ESSU. The role of the JMO is to,
1. Meet the TEAM C consultant at the start of your shift. 2. Take hand over of all patients being transferred to ESSU. If the JMO has not received a call from the admitting ED Team they should proactively speak to the ED Team looking after the patient and find out what the management plan for the particular patient is. 3. Liaise closely with the Team C consultant to ensure that ALL management plans are followed through. 4. Carry the EDSSU JMO allocated DECT phone so that everyone can contact you. 5. The evening shift EDSSU JMO will commence work at 1700hrs (Between 1400 and 1700 hrs they are to work with the Team C leader on the floor) 6. You are expected to hand over to Team B night senior staff at 23:00.
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 back slabs for MSK injury, 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 0930 hrs – 1800 hrs 0930 hrs – 2000 hrs
Saturday and Sunday: 0930 hrs – 1800 hrs (Variable) 0930 hrs – 2000 hrs
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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. Outcome is to avoid ED Presentation and reduce representations
Monday – Friday: 0800hrs – 1630 hrs Pager # 7529 Extension 48012
17.9 HOSPITAL IN THE HOME (HITH)
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 HITH 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 Patients MUST be accepted by an in-patient team consultant or an ED consultant for discharge under HITH and the accepting team must be clearly identified in the patient’s notes.
Service provided by the HITH 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
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17.10 AGED CARE SERVICES EMERGENCY TEAM (ASET)
ASET CNCs assess patients 70 years and over presenting to ED.
Role: 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)
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.
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There are limited in patient beds for D&A services in BMDH. 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.
17 TEACHING AND EDUCATIONAL RESOURCES
Blacktown and Mount Druitt Emergency Department is accredited by the College for Emergency Medicine for Advanced Training in Emergency Medicine. Blacktown is accredited for 18 months whilst Mt Druitt is accredited for 6 months of advanced 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. 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.
17.1 REGISTRAR
Organised by the DEMT. Held alternate Thursday (see teaching roster for venue). 0830-1830. Paid and protected teaching time. (The names of attendee’s will be passed onto MWU for payment)
17.2 INTERN/RMO/SRMO TEACHING
Organised by Dr Harry Elizaga for BDH and Dr Shaila Islam for MDH BDH Tuesday and alternate Wednesday/Thursday & MDH Monday and Thursday 1400 hrs – 1500 hrs ED Tutorial room
17.3 CMO TEACHING
Organised by Dr Fernando Pisani Once every month 0830 - 1830
17.4 ACEM PRIMARY EXAM PREPARATION
o Organised by DEMTs o Trial Viva sessions o Network 5 trial Exam
17.5 ACEM DIPLOMA AND CERTIFICATE PROGRAMME
o Dr Chamila DeAlwis is the coordinator for this program.
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o All Emergency Specialist are approved providers of ACEM for certificate and Diploma. It is anticipated that ALL SRMO’s and CMO’s will actively participate in this programme by joining the college (ACEM).
17.6 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.
17.7 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. 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, Poisionindex and Antibiotic Guidelines.
17.8 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. SRMO coordinator: Dr Shaila Islam for BDH and MDH JMO coordinator: Dr Susie Stapledon for BDH and Dr Shaila Islam for MDH College trainee’s assessment is done by the DEMT. DEMT for BDH: Dr Karina Hochholzer and Dr Jannatun Nayim DEMT for MDH: Dr Karina Hochholzer and Dr Ponnuthurai Jeyaruban
17.9 MENTORSHIP PROGRAM
The department has an active mentorship program. Dr Chamila De Alwis is the coordinator for the 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.
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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.
17.10 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.
17.11 RESEARCH AND QUALITY ASSURANCE
. Medical staffs are actively encouraged to take part in the process. . Dr.Richard McNulty is the coordinator for ALL research happening in the ED.
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 A/Prof Reza Ali in BDH and Dr. David Melvin in MDH.
17.12 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.
18 MEDICO-LEGAL ISSUES
All documentation including medications have to be done on First Net. Medical documentation should include the following: Time stamp your documentation i.e. start typing 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.
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Presenting symptom Physical examination Differential diagnosis Management plan Tests performed Senior medical officers, or allied health staff contacted Time of discharge
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.
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
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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 required for any patient who was the driver of a vehicle (includes cars, cycles – motor or pedal), was in control of an animal, eg a horse, or a pedestrian.
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.
20 GENERAL HOUSEKEEPING
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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.
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 “Time Lock” Lockers are available for your use and can be found opposite the tea room at the end of the corridor. Please contact Ms.Brown if you are unable to locate or operate the lockers.
Toilets Designated staff toilets are located in the A2 Hub area
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
The Emergency Department has an In House Pharmacist and can be contacted during working hrs for Advise/Reconciliation and dispensing. Week days 0830 to 1700 – ED pharmacist available. For any Emergency medication after hours - CNUM
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.
Please notify lab of any urgent Joint aspirate/CSF that is being sent so that its processing can be prioritised and sent to Westmead lab if required.
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 to the Lab via pneumatic tube in the ED. Please ask a staff member regarding how to use the tube.
All crossed matched and Urgent blood or blood products are now dispatched from the lab to ED via the pneumatic shute. If you have ordered such blood/products please keep an eye on the arrival shute (alarm should ring to warn arrival of such a product)
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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 imaging centres or another public hospital may be contacted. (A list of private centres is available in the ED).
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
24 hours service - IV and oral contrast studies are available. You need to ring radiographer to book patient.
You need to chart the contrast on eMED. c) Ultrasound
On site Weekdays 0800 to 2400 and weekends 0800 to 2400 Studies provided include abdominal, pelvic, transvaginal, testicular, venous, thyroid, foreign body location, and examination of limb fluid collections.
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. You need to inform the CT radiographer (by calling the CT room) of the online request. 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 result is available on First net system. 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. e) MRI
0630 to 2300 on site Monday to Friday.
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Emergency MRI with radiologist approval on weekends 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.
WHEN TO CALL THE ON CALL I TELERAD RADIOLOGIST:
Urgent reporting on CT/MRI scan 24/7 Urgent opinion on plain imaging that would require an intervention (Pneumothorax) in the middle of the night. Urgent opinion on modality of imaging that would best suit the patient
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 Firstnet, eMR, eMED and eFLUIDS will be provided prior to your commencing the term.
All relevant ordering of test and services are documented and done on Firstnet.
Medical staff are required to enter certain data into FIRSTNET. This includes “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
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).
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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 06/02/20 31 32 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 06/02/20 32 33 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 Anaesthetic ED RMO ICU +/- ICU +/- Reg Anaesth Reg Anaesth Reg M.O.3 ED RMO ED RMO ED RMO MR +/- Ward 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 06/02/20 33 34 MET’s are called (dial 2222 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 06/02/20 34 35 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 06/02/20 35 36 Appendix 6 ADVANCED MEDICAL PLAN To be completed for any patient who is “Not for Resuscitation” or has a ceiling on treatment imposed. It needs to be documented on line in FirstNet. Resuscitation form can be found under the adhoc to document the advanced care plan. APPENDIX 7- SAMPLE OF DAILY FLOOR ROSTER – BDH - ED MONDAY 4th February 2019 In Charge Day 0800 - 1830 TEAM A - 47130 TEAM B - 40909 TEAM C / EDSSU Staff Specialist Registrar/CMO EDSSU Jnr ED SSU TEAM C - Consultant In Charge Evening 1400 - 2400 TEAM A - 47130 TEAM B - 40909 TEAM C / EDSSU Staff Specialist Registrar/CMO EDSSU Jnr ED SSU TEAM C - Consultant In Charge Night 2230 - 0830 TEAM A - 47130 TEAM B - 40909 Registrar/CMO In Charge EDSSU ED SSU TEAM B Registrar Staff Specialist On Call Registrar On Call Night JMO on call night Nurse Practitioner Physiotherapist Updated 06/02/20 36 37 Bed Allocation EMERGENCY DEPARTMENT ROSTER MT DRUITT MONDAY 4th February 2019 Staff Specialist (Day) Registrar Day 0800 - 1800 Ambulatory Care D2 Zone A D3 Zone C D4 Zone B D3/4 Zone D Paediatrics Physiotherapist Staff Specialist (Evening) 1400 - 2400 Registrar Evening Ambulatory Care E2 Zone A E3 Zone C E4 Zone B E5 Zone D E5 Zone D Paediatrics Registrar Night 2230 - 0830 N2 Zone A + C + D N3 Zone B + C + D N4 Zone B + D ED MED REG 1700 - 2230 MOIC 2230 - 0830 Staff Specialist On Call Registrar On Call Night JMO on call night Zone A Resus 1, Isolation Bed 1, Acute Beds 1,2,3,4 Zone B Resus 2, Acute Beds 5,6,7,8,9 Zone C Paediatric Beds 1,2,3,4,5 Zone D To be allocated beds by SS Updated 06/02/20 37 38 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 nowhere 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 06/02/20 38 39 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 � Acute foreign body in external auditory canal � Localised Soft Tissue Infections or Collections � Urinary symptoms- not systemically unwell Updated 06/02/20 39 40 � Symptoms suggestive of STI Updated 06/02/20 40 41 APPENDIX 11 Updated 06/02/20 41 42 Emergency Department Senior Assessment and Streaming The Emergency Department Front of House Model of Care 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. Urgent care c. 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 4. Ensure no bottlenecks occur at Triage 5. Ensure streaming team maintain agreed timeframes 6. Support streaming team in times of high activity Updated 06/02/20 42 43 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 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) Updated 06/02/20 43 44 FRONT OF HOUSE MODEL (Team C) Front of House is where the clinical streaming of patients commences. No Category 1 patients will be streamed through this model. Objectives of the Team 1. Assessment of low acuity 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 Team C 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. 6. Completing necessary documentation. 7. To continue looking after the patient. Expected Role of the Consultant /Reg/CMO in the Team 1. To asses patients in the front of House area and provide guidance to the management plan of the patient. 2. Supervision of the Team C JMO in the front of house area. URGENT CARE CENTER (UCC) Urgent care center 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 2 beds and 8 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 UCCMOC. Updated 06/02/20 44 45 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 06/02/20 45