Orange Health Service

Emergency Department

Registrar Orientation

Page 1 of 32 Welcome

Welcome to Orange! This orientation booklet intends to provide information that can be quite useful during your term as an ED registrar in this .

Orange Health Service opened in March 2011 and is part of the Western NSW Local Health District. It is a major rural referral health service and the regional trauma service for the central west. The

Page 2 of 32 hospital provides a wide range of clinical services including emergency services, ICU, coronary care, general and specialist medical and surgical services. In addition, interventional cardiology, maternity, paediatric and neonatal services, aged care and rehabilitation, cancer services including radiotherapy, oral health, renal dialysis, psychiatric services and advanced imaging and are also provided.

Apart from being the primary in-patient care facility for the nearly 40,000 people in Orange, it is a referral centre for a number of specialist services from adjacent towns in the central west region, including Bathurst, Canowindra, Condobolin, Cowra, Molong, Forbes, Parkes and for select services from Dubbo region.

The OHS Emergency Eepartment places a strong emphasis on team work at all levels of staff and you are seen as a significant part of the team. With that in mind everyone in the department is there to help you and provide guidance to you in your daily work as well as your career.

The consists of 19 beds comprising of:

• 2 resuscitation/trauma bays • 12 monitored beds (including a monitored negative/positive pressure room) • 4 unmonitored beds • 1 secure assessment room • 2 fast track rooms • 5 consultation rooms (including ENT/Eye and plaster rooms)

The Department provides care to over 27,000 patients per annum, 25% of which are Paediatric, with an overall admission rate of 31%. The department manages all the trauma patients for the region and deals with a wide variety of clinical presentations unique to rural medicine.

Page 3 of 32 Page 4 of 32 Contacts

Emergency Department phone number: 6369 3156

Emergency Department in-charge 6369 3862

Emergency Department fax number: 6360 2010

Director of Emergency Medicine – Greg Button: ext 3861

Acting Nursing Unit Manager – Meg O’Brien: ext 2202

Duty Emergency Officer / Admitting Officer phone: ext 3862

Clinical NUM: ext 3860

Trauma CNC – Vicki Conyers: ext 3904

Other Useful Numbers:

Orange Base Hospital main switchboard: 6369 3000 / ext 9

Payroll Service Desk: 1800 428 283

Barb Pollinelli (JMO manager) 6369 3536

Medical Administration ext 3826

Westmead Hospital 9845 5555

Page 5 of 32 Staffing

Emergency Physicians (FACEM / VMO / senior CMO) provide direct clinical cover during day and evening shifts, with on call cover being provided for most 24 hour periods by a senior emergency physician. In addition there are 4-5 junior staff / locum / CMO staffed between 8:00am to 23:00pm and 1 senior doctor / 1 junior doctor overnight. The on-call Emergency Physician overnight is rostered on the master roster in the doctor’s office. He/ she can be contacted by mobile phone on the number provided on the roster.

Medical staff

Emergency Director – Dr Greg Button (FACEM)

DEMT - Dr Ruby Hsu (FACEM)

Emergency Consultants Staff Specialists/VMO’s:

- Dr Colin Dibble (FACEM) - Dr Nikki Grant (FACEM) - Dr Sally Clunas (FACEM) - Dr Fergal McCourt (FACEM) - Dr Brien Burns (FACEM)

Emergency CMO:

- Dr Louise Treloar - Dr Mike Sobotta (GP) - Dr Tove Riphagen (GP)

Daily Schedule

SHIFT ALLOCATIONS

Day Shift: 08:00 – 18:00

(Bridging Shift: 10:00 - 20:00)

Evening Shift: 13:00 – 23:00

Page 6 of 32 Night Shift: 22:00 – 08:00 (registrar) / 22:00 – 08:00 (JMO)

## Currently there is no specific rostered sick relief JMO on the roster. ED would call in the JMO rostered for ‘Overtime theatre cover as a backup if staffing level is low due to sick leave.

WARD ROUNDS

Ward rounds will be carried out on a daily schedule.

· 0800 – morning ward round will be conducted with the senior ED physician and all medical staff. This allows appropriate handover of patients from the night to the day medical staff.

· 1600 - afternoon ward round will be conducted with all medical staff and the NUM.

· 2200 – evening ward round with senior night doctor and all medical staff. Allows appropriate handover of patients from the day to the night medical staff.

Page 7 of 32 Pre-requisites for ED Registrars at Orange Health Service:

An interesting case mix coupled with guidance from the friendly FACEMs provides ample learning opportunities for ED registrars rotating through Orange Health Service. It also provides a clinical challenge with a steep learning curve for entrants into Emergency Medicine training. Registrars are expected to have some pre-requisites which would enable them to function effectively. These include:

1. Knowledge and experience in Advanced Life Support (a brief review session on the topic will be done by the Intensivist as part of orientation package) 2. Theoretical and practical knowledge in Emergency Medicine at level of PGY3 or above 3. Clinical and people skills to deliver supervised and semi-independent medical care to patients 4. Ability to prioritize work 5. Leadership qualities to organize and supervise residents, interns and medical students in providing effective patient care 6. Ability to participate in team work and excel in communication – ability to liaise with ED consultants, other consultants, general practitioners and doctors in other to provide optimal patient care 7. Insight into environmental and individual limitations with keen ability to source resources to achieve optimal patient care 8. Enthusiasm to learn Emergency Medicine 9. Knowledge and readiness to teach medical students, interns and RMOs 10.Professional pleasant attitude and committed work ethics.

Page 8 of 32 Role of ED Registrar

· Responsible for initial assessment of patients presenting to ED

· Establishing initial management plan and clear documentation of clinical notes on eMR/firstnet

· Referral to the relevant admitting team and documentation of time of referral

· Taking responsibility for the ongoing management of the patient whilst they are in the Emergency Department

· Following up investigation results and ensure that admitted patient’s clinical condition and planning of further investigations or therapy (e.g. IV fluid, analgesia, DVT prophylaxis) are satisfactory when transferred to ward

· Taking the team lead role (if necessary) or being a part of trauma and resuscitation teams

· Taking an active role in managing critically ill patients in ED in close liaison with the intensive care team

· Assisting ED consultant in managing the department and facilitating good team work

· Taking the role of “ED senior-in-charge” in managing the department and taking referrals when there is no FACEM on duty

· Maintaining and improving your knowledge and skills through attending and contributing to formal education and handover sessions

· Actively participate in the teaching and supervision of JMOs and medical students

Page 9 of 32 OHS Rapid Response Calls (Medical Emergency Team)

The emergency department is not primarily involved in Rapid Response calls.

If there are 2 medical emergencies at the same time, then the Emergency Department will be responsible for attending the 2nd medical emergency.

The emergency department rapid response team should consist of a senior emergency doctor and nurse. They should take the resuscitation pack with them which consists of airway / breathing and circulation equipment and resuscitation drugs.

To make a Rapid Response Call dial # 888

Trauma Calls

Trauma calls will be initiated according to the established “Trauma Call Criteria” in ED, which can be ‘Adult Trauma Call’ or ‘Paediatric Trauma Call’.

The aim of trauma calls is to provide critical care interventions to acutely injured patients caused by major trauma. This can only be achieved by all members working as a cohesive multidisciplinary ‘trauma team’.

An ED senior will be the designated ‘team leader’ responsible for coordinating the patient’s care and monitoring progress. He/she should assign every individual team member to a different role with specific tasks. (Please refer to the chart of ‘trauma team members: roles & responsibility)

ED registrars are encouraged to participate as the team leader when necessary or as a team member in managing major trauma patients. This will be beneficial for developing clinical/ resuscitative skills in any specific trauma team role and skills of team work.

Page 10 of 32 Clinical Business Rules - Orange Base Hospital Admission Acceptance

PROCEDURE FOR ADMISSION OF PATIENTS

General – “one way referral”. After ED assessment, discussion with ED consultants and formulating a management plan for a patient who requires admission, the decision should be determined as to which specialty is the most appropriate for this patient to be admitted under. Once ED referral for admission is made to a specialist team, it will be the specialist team who decides one of these three paths: 1) admit; 2) discharge; 3) refer to a second specialist team if it is decided that the admission under the first specialist team is not appropriate.

GWAHS Responsibility of the ED doctor who has made the referral to the admitting team: Jul 18, '13, 12:17 PM Added: Space • Document clearly the time and the member of the admitting team whom the patient was referred to. GWAHS Jul 18, '13, 12:19 PM Added Text • Outline clearly the ED management plan for the patient. Ensure the planned investigations have been in progress and ED-initiated treatment/therapy has been charted and carried out. Patient’s GWAHS Jul 18, '13, 12:20 PM appropriate regular medications should be documented/charted. Added Text

GWAHS Jul 18, '13, 12:16 PM • Ensure the patient’s clinical condition continues to be satisfactory. Detect and manage any Added: Paragraph Break deterioration promptly while the patient is still in ED.

• If there is undue delay in review for admission by the admitting team, a stable patient should be admitted to the ward directly after completing the ‘medical checklist for ward transfer’ (see appendix) and informing the admitting team.

Page 11 of 32 Emergency Department Management and NEAT project

It is part of the ED registrars’ responsibility to manage ED and facilitate patient flow in the department, by working closely with ED clinical NUMs, especially when there is no FACEM on the floor. The NSW Health policy on National Emergency Access Targets (NEAT) mandates a Four-Hour time frame from ED presentation to Disposition, for both discharge from ED and admission.

This should not impact on proper patient care and management, and it should serve as a framework to facilitate timely investigations, clinical reviews and decision-making.

Please bear in mind that team work is crucial and inquiry about your clinical decision making is part of the process.

Page 12 of 32 Policy for accepting Admissions/Referrals to the Emergency Department.

Referrals to OHS ED are usually made by other health professionals who have had a certain level of involvement in patients’ clinical care. These referrals can be local but the majority of them are from a varying distance within our catchment area.

The referrals to ED can be clinically complicated and patients can be quite unstable, or they can be simply for a specialist’s opinion. Therefore, the duty of accepting these admissions/referrals should belong to ED seniors, who are more equipped to give clinical advice, allocate resources and link up to specialist’s care.

More information on your role in accepting patients is contained below under “Practical Tips”. Also please refer to the OHS ED referral/admission policy.

Page 13 of 32 Onsite Support

There is 24 hour on site registrar cover for the following services:

· General Medicine · ICU/HDU * registrar/resident cover. · Anaesthetics

There are off-site subspecialty registrars on call outside normal working hours for:

· General surgery (who also covers ENT/urology/vascular after hours) · Orthopaedics · Paediatrics · Obstetrics and Gynaecology

PATHOLOGY services are available 24 hours

RADIOLOGY services are available till midnight. On call radiology cover from midnight till 8am. Reporting of radiology will be done routinely during working hours and verbal reports are accessed via the MERLIN system located in the doctor’s office in ED. After hours reports done off-site will be faxed to ED (expected reporting time: 60 minutes for a single system, e.g. CT head, 90 minutes for more than one system). If an urgent report is required, the on-call radiologist should be contacted by phone. There is a separate radiographer and ultrasonographer on call after hours. After midnight, the radiographer should be called back for urgent imaging which will impact on patient’s clinical management. After hours ultrasound imaging should be discussed and approved by the on-call radiologist before the ultrasonographer is called. Patients who are seen after midnight and need non- urgent imaging may be discharged and advised to return in the morning for imaging. Westmead hospital is able to access our radiology images. Instructions for doing this are posted above the MERLIN system computer in the doctors’ office.

NOTE: ORANGE HEALTH SERVICE HAS NO NEUROSURGICAL COVER, CARDIOTHORACIC COVER or PLASTICS / BURNS COVER. See subspeciality section.

Copies of the daily ‘On-Call List’ are available in the Doctors’ writing room. The list is also available on the intranet.

Page 14 of 32 Internal medicine services at Orange:

A number of specialties provide in-patient services at OHS. These include:

Cardiology (Dr. David Amos, Dr. Ruth Arnold, Dr. Andrew French) (Dr. Geoff Chu, Dr. Darryl Mackender) Nephrology (Dr. Lisa Phipps, Dr Thulasi Jegatheesan, Dr. Gabriel Shannon) Neurology (Dr. Jamie Gordon, Dr. Simon Hammond, Dr. Simon Hawke) Rehabilitation/Aged Care (Dr Fran Gearon, Dr Sumitha Gounden)

A number of specialties provide visiting outpatient services in the Orange region and are often available for telephone advice for patients. This includes:

Dermatology (Dr. Derek Davies) Endocrinology (Dr. Rob Cole, Dr Channa Perera) Haematology (Dr. Scott Dunkley) Immunology (------) Infectious disease (Michael Guinness) Memory clinic (Dr Catriona Ireland) (Prof. Rodney Allen) Oncology (Dr. Stephen Cooper, Dr. John Grygiel) Psychogeriatrics (Dr Catherine Jones) Rheumatology (Dr. Mark Toh @ Dudley, for private patients only) Sleep medicine (Dr. Michael Dodd, @ Dudley, for private patients only).

In-patient Medical Teams: SIBR (Structured Interdisciplinary Bedside Rounding) ward - one general physician does on-call for a week (Wed-Wed) with two teams composed of one medical registrar each and JMOs. This newly designed approach for medical admissions is to promote multidisciplinary management, shortening the length of stay and optimal patient care by prompt decision making by senior physicians. Medical admissions when cardiac monitoring is not required will be to the SIBR ward unless patients are under the palliative care team. Cardiovascular Medicine - there is a separate on-call cardiologist roster from Monday to Friday for admitted patients who require continuous cardiac monitoring (IHD or Stroke). CCU will be covered by the on-call general physician over the weekend. OHS is set for primary PCI on weekdays, and STEMI patients should be discussed with the on-call cardiologist as soon as they are identified. On weekends, STEMI should be thrombolysed after discussion with the on-call physician.

Surgical services at Orange

A number of general surgeons (some with a special area of interest) provide in-patient service at OHS. These include:

Dr Henry Hook (upper GI) Dr Raj Kapadia (lower GI) Dr Stephen Hayes (breast) Dr Michael King (trauma)

Page 15 of 32 Dr Hugh Lukins (vascular) Dr William Mackie

Acute Surgical Unit (ASU) One general surgeon is on-call for a week (hand-over on Friday) and trauma patients are admitted under General Surgery.

ENT ENT surgeons who provide in-patient services:

Dr Peter Bryan Dr David Houghton

During working hours (0800-1700) there is an ENT registrar on call for providing assistance with patients in ED and for referral for admissions. Call 7405. After hours cover is provided by the general surgical registrar.

On some occasions, there will be no ENT specialist cover within OHS (the on-call list will state ‘NO COVER’). Patients should be managed in ED with consultation by the general surgical registrar, then further referral can be arranged accordingly.

Urology Urologists who provide in-patient services:

Dr Tim Nicholson Dr Claire Whelan Dr Jimmy Yuhico

During working hours (0800-1700) there is a urology registrar on call for providing assistance with patients in ED and for referral for admissions. Call 7412. After hours cover is provided by the general surgical registrar.

Maxillofacial Maxillofacial injures should be referred to Westmead Hospital plastics team.

Dr Arthur Mills is the only Maxillofacial surgeon in our area, and he can be phoned for advice if available. Out-patient follow-up or possible admission in OHS can be arranged when he is available.

Subspecialty cover and referrals at Orange

Orthopaedics

Orthopaedic surgeons who provide in-patient service:

Dr Andrew Ashton Dr Evan Jones Dr Sam Kwa

Page 16 of 32 Dr Ben Milne Dr Geoff Mutton

Hand injuries at OHS are covered by orthopaedic surgeons. Fracture Clinic is run three days a week, and out-patient referrals to Fracture Clinic should be arranged prior to discharge.

Paediactics

Paediatricians:

Dr Paul Bloomfield Dr Stuart Crisp Dr Alan Kerrigan Dr Des Mulcahy Dr Jo Rainbow

There is a paediatric registrar on site during working hours and on call after hours. All patients that are admitted – including out of working hours must be discussed with the paediatric registrar prior to transfer to the ward. If patients are being admitted to the paediatric ward under a subspeciality team (eg surgery) the paediatric registrar does not need to be called overnight, unless specific paediatric input is required. Paediatric teams also cover the Special Care Nursery. Interns should discuss all paediatric patients with a senior emergency doctor. JMO’s should discuss all infants < 3/12 of age with a senior emergency doctor.

· PACS unit and referrals There is a paediatric short stay ward, which may be used for children requiring short periods of observation / management i.e head injury / gastroenteritis etc. Patients that are suitable for PACS need to be referred to the paediatric registrar and a PACS referral form filled out (forms are in the doctor’s room). This ward operates only during working hours. Discharged patients may also be referred for review by the paediatric team in the PACS unit. You should call the paediatric ward for an appointment time, or if after hours – fax a referral form and ask the patient to call for an appointment time the following day.

· Paediatric guidelines are available on the desktop located in the emergency department for certain paediatric conditions.

Obstetrics and Gynaecology

Obstetricians/Gynaecologists:

Dr David Knox Dr Ron Vaughan

There is an O & G registrar on site during working hours (0800-1700) and he/she is on-call off-site after hours. All admissions including after hours must be referred to the O & G registrar. Overnight patients may be admitted to the ward after discussion with the O & G registrar if they are stable and have been reviewed by the senior ED doctor.

Page 17 of 32 · EPAS: Early Pregnancy Assessment Service is available for CLINICALLY STABLE emergency patient referrals only on Monday / Wednesday / Friday – for 3 appointments 0800 / 0840 / 0920. o Patients with 1st trimester PV bleeding or < 16 weeks with pregnancy related issues may be referred to EPAS. During working hours the patient should be discussed with the O & G registrar and EPAS contacted for an appointment time on 3270. o After hours referrals may be made with or without calling the O & G registrar. Call the maternity ward after hours on 3261 – and they will arrange an appointment time.

ERCP

OHS is the regional referral centre for ERCP, which can be performed by:

Dr Geoff Chu Dr Henry Hook

There is a separate on-call roster for ERCP with Dr Chu and Dr Hook on alternative weeks when they are available.

Psychiatry Mental Health CNC on call for psychiatric referrals during working hours, Chris Reiss/Ext 7453

If MH CNC is not available, Mental Health Hotline (1800 011 511) provides 24-hour on call support for ED patients with psychiatric concerns after medical clearance. If required, admission to Bloomfield Hospital will be arranged by Mental Health workers. Referrals for admission to Bloomfield Hospital from outlying areas should not present to ED unless there are urgent medical concerns, as these patients should have been seen and scheduled by health professionals.

CAMHS (Children & Adolescent Mental Health Service) - Psychiatrist Dr Susan Blinkhorn

A Psychiatry Registrar works closely with MH CNC and reviews in-patients who have psychiatric issues within OHS.

Ophthalmology

There is no ophthalmology registrar or eye clinic at OBH. Options for eye emergencies:

1. Orange Ophthalmologists:

· Dr Crayford: (Kite Street Specialist Centre) 126-130 Kite St, Orange. Phone number: 6361 2960

· Dr Tang: 109 Sale St, Orange: Phone number 6361 0188

2. Westmead Hospital Opthalmology Registrar – call Westmead Hospital.

Dental

Page 18 of 32 There is a dental clinic located at OBH which is open during working hours, but the care is only accessible to patients who are on pensions or hold ‘Health Benefit Cards’.

If they are unable to see the patient, referral to a private dentist in Orange is required.

Plastic surgery

There is no Plastics cover in Orange. Most patients will have injuries which require admission under the general surgical team. Referrals to Plastic Surgery are usually delayed and done by the surgical team.

Primary referral centre is Westmead Hospital for plastics service.

Neurosurgery

Neurosurgical patients – with ICH / skull # etc if not suitable for admission to OHS – will need to be referred to Sydney for neurosurgical management. Westmead Hospital is our primary referral centre. If they are unable to accept a patient due to bed shortages, then another hospital may need to be contacted. Note: trauma patients with neurosurgical injuries should be transferred to either Westmead or Royal North Shore (for spinal injuries).

Burns

Burns patients should be reviewed by the surgical registrar. If the patient needs admission with minor burns, they should be admitted under the general surgical team at OHS. If patient is not suitable for admission to OHS, they will need to be transferred to Sydney for ongoing burns management. Concord Hospital is our primary referral centre. You should contact the Burns Registrar on call at Concord Hospital to discuss referral and transfer. Concord switchboard: 9767 5000. Children’s Hospital at Westmead is the referral centre for paediatric patients with burns. CHW switchboard: 98450000.

Page 19 of 32 Support Services

CLINICAL INITIATIVES NURSE (CIN NURSE)

The CIN nurse works to monitor waiting room patients and is there to initiate basic investigations and treatment of patients presenting after triage. The CIN nurse is also available to carry out basic procedures such as an ECG, cannulation, drug administration etc. that you may require.

NURSE PRACTITIONER – Kate Hain

The department has a nurse practitioner who is an independent practitioner and will see Fast Track patients. If a number of low acuity and fast track patients are present please go and assist the NP in getting through these patients.

PHYSIOTHERAPIST – Jason Taylor

We are lucky to have a department physio whose prime role is to: see patients who present with musculoskeletal injuries; perform mobility assessments; provide physiotherapy advice and apply casting and strapping. Jason is a great resource to assist you in the management of your patients with musculoskeletal injuries.

ASET NURSE - Vanessa Kelly/Jacqueline Grey

There is an ASET nurse available during working hours and weekends. The ASET nurse provides comprehensive geriatric assessment of any elderly patient that presents to the emergency department. This assists in determining need for admission, suitability for discharge and the need of adequate home supports. They provide home support services and access to relevant aged care services – such as respite / community aged care packages / residential care accommodation / memory clinics / DVA services and aged care assessment teams.

SOCIAL WORKER and SPEECH PATHOLOGIST

There is a social worker and speech pathologist available during working hours by contacting Ext 3300. Special permission can be obtained from the executives for after-hour cover if the circumstances are deemed necessary.

Page 20 of 32 HOUSEKEEPING

Roster / Swapping shifts

· Registrar roster: is generally a rolling roster that has been devised to try and ensure fairness in work patterns for all. It is set out in advance of your term taking into account leave requests that have already been submitted. From time to time the roster may need to be changed and updated. The latest copy of the roster is displayed in the doctor’s work office. Whilst every effort will be made to notify you of changes that will affect you, you still need to check the displayed roster regularly. The DEMT is responsible for running the registrars’ roster and the DEM for JMO’s roster.

· Leave requests: such as annual leave and study leave need to be submitted to the Director of Emergency Medicine or the DEMT, as soon as you are aware of your plans. Requests should ideally be submitted prior to starting your term and every effort will be made to accommodate your requests. Unfortunately due to a number of circumstances leave cannot always be guaranteed as requested.

· Shift Swaps are permitted within the limitation of adequate rest periods, and the Director or DEMT must be notified of these changes.

Safety and Security

· Security access cards are issued to all ED staff and should be carried at all times. Please see Barb Pollinelli for the form that needs to be signed and given to security for you to obtain your own personal ID and security card.

· Valuables and Belongings: the nature of the Emergency Department is that of an open area that multiple members of hospital staff and the general public have access to. It is important to ensure that all your valuables and belongings are kept in the lockers provided or at least in the doctor’s workstation. We also rely on you to keep an eye out for any suspicious behaviour or persons that you feel do not belong in the department and to raise it with senior ED staff or security.

· Zero tolerance policy towards abuse both verbal and physical towards any staff member. If you feel your safety is being threatened remove yourself from the situation and bring it to the attention of senior staff.

· Psychotic or drug affected patients - ensure you are not alone with those patients if their behaviour is violent or unpredictable. Hospital Security staff should be able to provide assistance if required.

Page 21 of 32 Teaching

There will be regular formal ED registrar teaching provided fortnightly on Tuesday. Attendance is compulsory and as such you will be paid for the period of time.

This is aimed at providing you with education on emergency medicine and critical care that is required at your level. The consultant team is open to suggestions to tailor this teaching to your learning needs.

Teaching is one of the best ways of learning and ED registrars are encouraged to make use of teaching opportunities during their rotation. Apart from the opportunity for informal teaching of JMOs and medical students during ward rounds, ED registrars may be used in formal medical student teaching for PBLs, tutorials and bed-side teaching.

Learning opportunities: A significant portion of ED registrar education takes place by learning through work. There are streamlined teaching sessions which ED registrars can access and these include:

Daily-Weekdays: 8:00am and 16:00pm - Handover rounds in ED

Wednesday 10:00–11:00am Cardiology sessions (x6 sessions for every medical registrar term provided by Dr Andrew French. Cardiology teaching schedules are available in the CCU orientation booklet) Monday 12:00-12:30pm Radiology teaching in ICU

Tuesday 07:30 – 0830am Anaesthetic teaching or monthly Trauma M&M Tuesday 08:30am – 12:30pm every other week ED Registrar teaching Tuesday13:00pm Grand Rounds @ Lecture Theatre (1st floor) Tuesday 13:30-13:40pm Trauma 10 minutes

Wednesday 14:30 – 16:00pm every other week Rapid Response Team Meeting, all welcome

Thursday 12:00 – 12:30pm Radiology teaching in ICU Thursday 13:30 – 13:40pm Trauma 10 minutes Thursday 13:00 – 14:00pm RPA ICU video-link

Friday 08:00-09:00am Physician Journal Club @ Meeting Room 1 (ICU area - J). The journal club is presented by mainly medical registrars / physicians based on a roster maintained by the Journal Club coordinator. VMO/SS will moderate the session. Any contemporary article can be chosen by the presenter and forwarded electronically to the coordinator on Wednesday for mail out on Thursdays. The coordinator will organize paper copies to be available at the meeting.

Educational resources – ED poloicies and guidelines available on www.orangeed.net or ‘T’ Drive on desktops in doctor’s wirte-up area.

Monthly ED/ICU M&M meeting and Trauma M&M meeting - scheduled 1-2 months ahead, please check emails and flyers. GWAHS Jul 18, '13, 12:24 PM Added Text

Page 22 of 32 ED M&M meeting – every two months, please check emails and flyers.

UpToDate access is provided free inside hospital. This can be accessed from any computer terminal using http://gwahs  web based application link  UpToDate A number of learning resources are available through CIAP and also through terminals in the Library.

Library Opening hours are 0900AM - 1530PM, and the Library is accessible 24-7 with your ID card.

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Research – There is always opportunity to get involved in a research project during your term in the ED, including completion of the 4:10 requirement for the College.

PRACTICAL TIPS

Role in ED patient care:

When patients are admitted, the ED documentation (by ED Staff or admitting team registrars) should clearly state three key points in the admission instruction. The consultant under whom the patient is to be admitted, the destination location (ward bed, stroke bed, CCU, HDU, ICU etc) and whether patients need a monitored bed or not.

Admission to CCU is based on Physician’s assessment of the patient’s need. Patients with a predominant cardiac condition should be admitted to CCU. Patients with multiple organ involvement eg respiratory failure/ sepsis generally require HDU/ICU referral.

If the ED registrar feels a patient requires HDU/ICU admission, this must be discussed with the on call intensivist to request review, making sure that detailed clinical information is available (i.e. functional status, acuity requiring HDU or ICU care, outcome of discussion of end of life decisions in appropriate patients and results of current investigations including blood gas, ECG and imaging). After such discussions have taken place, until the ICU/HDU team has physically taken over the care of the patient, the ED registrar is responsible for resuscitating the patient and must call the ED Consultant for advice or for urgent back up if needed.

Derangement of vital observations are a frequent reason for Medical Review (Yellow and Red flag calls) response. In some patients (e.g. palliative patients) modification of medical review criteria may be needed. After due consideration and, if necessary, discussion with the admitting consultant, the altered Medical Review criteria should be documented on the SAGO chart. This should be reviewed daily based on change in condition of the patient.

Particular attention should be given to prophylactic Heparin or Clexane and anticoagulation with Warfarin, as well as timing and compliance with antibiotic administration. Missing anti-coagulation can lead to serious thrombotic events. Antibiotics should be administered in a timely fashion in accordance with the Surviving Sepsis Campaign

Page 23 of 32 Any medication error related to administration should be brought to the attention of the ED Clinical NUM and rectified. Potentially dangerous medication errors especially with a likelihood of recurrence should be reported in the IIMS.

End of life issues should be discussed with patients or responsible carers (in case of institutionalized patients and/ or those with cognitive impairment) when looking after: all elderly patients (>80years); those with terminal disease; irreversible organ failure with no prospects of effective treatment or extremely poor baseline functional status. Results of such a discussion should be documented in the file. If the patient is not for life support measures this should be clearly documented with all the relevant entries on the prescribed form.

Infection control: hand-washing is mandatory before and after all patient contact. Compliance with isolation precautions or patients with multi-drug resistant and other communicable organisms is essential. Please ensure cannulae for patients under your care are dated. Injudicious use of antibiotics is a recurring problem in Orange Health Service as in any other hospital. To curb this, an ‘Antibiotic control form” should be filled out when prescribing certain restricted antibiotics. Nurses can refuse to administer the antibiotic if this form is not filled out. When prescribing empirical antibiotics please refer to the Therapeutic guidelines or other reputed resources like Sepsis Guideline or UpToDate. When antibiotics are prescribed against standard recommendations, the reasons for violating standard practice should be documented. When in doubt please contact Dr. Michael Guinness over telephone.

Role in providing telephone advice to GPs:

GPs working in nearby towns and more remote locations in the area often require help in diagnosis and treatment of sick patients under their care. Patients may need to be transferred to Orange for further treatment, but some patients can be treated locally with expert advice. Orange is a major referral hospital for regional GPs and is expected to provide such advice. Some GPs call the consultants directly, but for most GPs the first point of contact is the ‘Patient Flow Unit’ (PFU) who often pass the request to ED senior/admitting doctor. Patient Flow should conference you in with the referring doctor and the relevant specialty Registrar.

The clinical capability of these locations varies considerably and there is limited medical coverage in some centres. Some of these centres have other limitations like absence of on-site , imaging etc, which makes handling of sick patients extremely risky. Patients with low levels of acuity can be managed locally if the specialty registrar and GP are able to reach an appropriate management plan. If a GP does not feel they have the resources or expertise to manage the patient, it is best to accept transfer of the patient. When in doubt, the ED registrar should involve the consultant on call early in the discussion about an off-site patient.

It is important to keep a record of the patients about whom telephone advice is given, so that these patients can be later followed up if needed. A pre-arrival note should be made in FirstNet. All patients for whom telephone advice was given have to be discussed with the consultant on call at the earliest opportunity.

Assessing a patient’s acuity over the telephone may at times be challenging. The important information to collect and record in such a telephone case evaluation is: 1. Name of the GP 2. Name and age of the patient 3. Time of the call 4. Exact presenting complaint and time of presentation to the centre,

Page 24 of 32 5. Background medical history, 6. Vital observations including oxygen saturation, level of consciousness (GSC), systemic examination findings, 7. Results of basic investigations including routine bloods, BSL, ECG and X-ray where available. 8. ECGs can be faxed for viewing. Often bloods and imaging from local hospitals can be viewed in the Orange hospital computer database.

The important issues to be considered in providing telephone advice are

1. What is the diagnosis – how accurate is the diagnosis? 2. What is the optimal treatment of this condition? 3. Can this patient be treated locally? 4. If the patient needs to come to Orange, what is the best means of transport – a road ambulance or is medical retrieval needed? 5. Does any treatment need to be administered while awaiting transfer?

More complicated therapies eg anti-arrhythmic agents should not be advised without consulting with physician on call. In case of any doubt always contact the consultant (ED or physician). ECGs can often be faxed or sent as e-mail to the on-call cardiologist who can view it off-site and provide input.

A knowledge of the geography of the region would be useful in assessing the approximate travel time needed from the centre to Orange should transfer become necessary. .

Approximate transfer times from common locations by road include: Bathurst (45 mins), Canowindra (45 mins), Condobolin (3hrs), Cowra (90mins), Forbes (90mins), Kandos (90mins), Molong (30mins), Mudgee (3hrs), Parkes (90mins).

It is important to ensure there is availability of beds in the required area before accepting a patient in a peripheral location. This is best done by involving the PFU in the process. If GPs directly call the

Page 25 of 32 ED -in-charge phone and you end up deciding on accepting the patient, please call the Campus Nurse Manager (3222) to ensure there is availability of beds in the hospital. Availability of monitored beds may often be scarce.

Critical Care Advisory Service (CCAS): this service is available every day 8:00am to 8:00pm including weekends and is run by district Intensivists on a roster. An unstable patient in a peripheral location with complicated problems obtains maximum benefit from this service. Often such patients require transfer to ICU/HDU at Orange or medical retrieval. When GPs contact ED or a specialty registrar for such unstable patients, PFU should be advised to contact the CCAS, who in turn can conference call the CCAS in to minimize inconvenience for referring GPs.

A number of hospitals in the network have dedicated areas where IP cameras are fitted. Once CCAS calls are logged, the patients are transferred to the IP camera field areas and the patients can be seen by the Intensivist on call. The Intensivist can evaluate the patient including monitors, ECG etc and provide advice to facilitate focused evaluation and administration of appropriate therapy.

After 8:00pm unstable patients for ambulance transport should be referred to the medical retrieval team on 1800 650 004. The ED registrar may have to make a calculated decision about the safety of transfer by road ambulance and when in doubt always involve the consultant on call. If CCAS is inaccessible between 8:00am and 8:00pm for any reason, please contact the consultant urgently to ensure appropriate advice is given to treat the unstable patient and arrangements are made for the retrieval.

Whenever in doubt please feel free to call the consultant on call. If the consultant on call is inaccessible for prolonged periods of time in wake of a crisis, the escalation pathway involves the Director of ED followed by the Director of Medical Service.

Role in transferring patients out of the area:

1. Referral to a tertiary care hospital: If patients require subspecialty interventions which are not available at OHS, referrals to a higher level of care should be made and appropriate transfers arranged. Patients with major trauma should be referred to Westmead Hospital via theSurgical registrar - as our trauma referral centre, there should be NO need to make separate phone call to ICU/Bed manager to ensure bed availability. For medical patients, the referrals are usually made by the admitting teams and the accepting hospitals might vary. The ED team’s responsibility is to ensure a patient’s clinical condition is stable, ongoing management is established and appropriate transfer arranged. If the patient’s condition warrants medical escort, the Medical Retrieval Unit (MRU 1800 650 004) should be contacted to request a medical team for transfer of the patient.

2. For return to primary care facilities: patients with NO ongoing diagnostic challenges or need for active treatments can often be transferred back to the primary hospitals from where the patients came. This includes stable patients with a clear diagnosis and treatment plan established, when the ongoing management can take place in the primary care facilities or nursing homes. It is important to speak with the doctor at the primary care facility to ensure they are happy to accept the patient and once you have identified the doctor, speak with the Campus Nurse Manager about the potential transfer.

(some of these positions might not exist even, could you provide any detail you may have on these or add any other services that might be existing)

Page 26 of 32 Aboriginal liaison worker ACAT COPD nurse Delirium CNC Discharge facilitator – Ms Margaret Davis Drug and Alcohol care coordinator Heart failure community clinic / Nurse Occupational therapist Physiotherapist Speech pathology Stoma Nurse Stroke coordinator Wound care Nurse

Page 27 of 32 OHS ED Registrar Orientation Package

BLS Algorithm (based on AHA 2010 guidelines) OHS ED Registrar Orientation Package

Adult ACLS algorithm (based on AHA 2010 guidelines) OHS ED Registrar Orientation Package

Adult Bradycardia Algorithm (based on AHA 2010 guidelines)

For specific management of arrhythmias, refer to CCU orientation booklet or contact cardiologist. OHS ED Registrar Orientation Package

Adult Tachyacardia Algorithm (based on AHA 2010 guidelines) OHS ED Registrar Orientation Package Appendix:

SURNAME: MRN: Orange Health Service OTHER NAMES: Western NSW Local Health District DOB: SEX: AMO: EMERGENCY DEPARTMENT AFFIX PATIENT ID LABEL HERE WARD ADMISSION CHECKLIST Initial MEDICAL OFFICER CHECKLIST Boxes

1. Admitting Specialty: ..…………………………. Admitting Consultant: . ……………………………….

2. Admission Diagnosis: …. …………………………………………………………………………………. 3. Any outstanding investigation results (yes/no) …………………………………………………………. [If yes and urgent result, ward resident or NMR must be notified to chase results on ward]

Name of resident/NMR to chase urgent results …………………………………………………………………………………………..

4. Dietary requirements charted as appropriate:

Diet: Full Diabetic Clear Fluids Nil By Mouth Other ……………………………….

5. Fluids (if required) and Analgesia has been charted IV Fluids Analgesia

6. Medications which will impact on the next 8 hours of care have been charted. (Consider DVT prophylaxis if appropriate)

7. Observations on SAGO chart are within normal limits for the past two hours, or “Modification of MET Call Criteria” Form completed (if applicable). Yes No N/A 8. “End-of-life Directive” discussed and documented. Yes No N/A (IF YES, A SIGNED FORM SHOULD BE INCLUDED.)

9. Patient has been discussed with ED Senior- DR ……………………………………………….

10. ED Doctor completing form ………………………………………… ED Doctor’s signature………………………………. Date:.…/……/…… Time: ……………..

11. Admitting AMO or delegate contacted and are aware of admission and plan Name of AMO/ team delegate……………………………………………………………………………………………… Contacting doctor name………………………………………Position ……………………………………………………. Contacting doctor signature …………………………………………………… Date ……………………………………… Time…………………………………………………………………………….