BEST CARE BUNDLES BEST CARE for EVERYONE Prudence Cooke Prudence Cooke

WAITEMATA DHB BEST CARE BUNDLES BEST CARE FOR EVERYONE Prudence Cooke Prudence Cooke

Best Care Bundle elements

PATHWAY & CHECKLISTS NURSING EDUCATION

CLINICAL NOTES INTERDEPARTMENTAL AGREEMENT

PATIENT ADVICE STANDING ORDERS (PLACE PATIENT LABEL HERE) (PLACE PATIENT LABEL HERE) SURNAME: ______NHI: ______SURNAME: ______NHI: ______

FIRST NAMES: ______FIRST NAMES: ______

Date of Birth: ______/______/______SEX: ______Date of Birth: ______/______/______SEX: ______

BRONCHIOLITIS REHYDRATION

Indicate ﬁndings below by: ☑︎ Positive / given OR ☒ Negative / not given All boxes must be populated Indicate ﬁndings below by: ☑︎ Positive / given OR ☒ Negative / not given All boxes must be populated

Inclusion Criteria Inclusion Criteria

Date: Time: Name: Sign: Date: Time: Name: Sign:

➔ ▢ Upper Airway Obstruction ➔ STOP - NOT SUITABLE FOR THIS BEST CARE BUNDLE ▢ Under 6 w of age STOP - NOT SUITABLE FOR THIS CARE BUNDLE ↳ ED Senior Medical or Paediatric Registrar review without delay ↳ ED Senior Medical or Paediatric Registrar review without delay ▢ Wheeze present and < 1 year of age ➔ CONTINUE ▢ Diarrhoea with or without vomiting and > 6 w of age ➔ CONTINUE ↳ Initiate Best Care Bundle “Bronchiolitis” on Whiteboard ↳ Initiate Best Care Bundle “Rehydration” on Whiteboard ▢ Entered by Clinician request Initial Nursing assessment(PLACE PATIENT - LABEL Aim toHERE) complete by 30 minutes (PLACE PATIENT LABEL HERE) History, SURNAME:examination ______and vital signs recorded on the Nursing NHI: ______Assessment Sheet. InitialSURNAME: Nursing ______assessment - Aim to complete NHI: ______by 30 minutes FIRST NAMES: ______FIRST NAMES: ______Bronchiolitis Assessment Tool applied and appropriate pathway started. (see page 2) History, examination and vital signs recorded on the Nursing Assessment Sheet. ↳Date Initial of Birth: Pathway: ______/______▢ Mild /______▢ Moderate SEX: ______▢ Severe HydrationDate Assessmentof Birth: ______Tool /______applied /______and appropriate SEX: pathway ______started. (see page 2) Red Flags ➔ Senior Medical or Paediatric Registrar review without delay ↳ Initial Pathway: ▢ Not Dehydrated ▢ Dehydrated ▢ Severe with shock CROUP WHEEZE > 1YEAR OF AGE ▢ BAT “Severe” ➔ Move to Resus and inform Paediatric Team Red Flags ➔ Senior Medical or Paediatric Registrar review without delay Indicate ﬁndings below by: ☑︎ Positive / given OR ☒ Negative / not given All boxes must be populated Indicate ﬁndings below by: ☑︎ Positive / given OR ☒ Negative / not given All boxes must be populated ▢ Temp > 39°C or looks toxic ▢ Heart rate > 200 ▢ Previous PICU admit ▢ Severe dehydration with shock ➔ Move to Resus and inform Paediatric Team Known Cardiac or Airways issues History of Apnoeas Inclusion Criteria ▢ ▢ ▢ Pertussis contactInclusion Criteria ▢ Temp > 39°C or appears toxic ▢ Absent bowel sounds / suspected Ileus ▢ Chronic Lung Disease or on home oxygen ▢ Corrected gestation < 52 weeks or < 3m age post term Date: Time: Name: Sign: Date: Time: Name:▢ Known metabolic condition Sign: Designation:▢ Bloody bowel motions / Melaena ▢ Known cardiac issues ▢ Bile stained vomits ▢ Age < 6 months ➔ STOPPathway - NOT SUITABLE discontinued: FOR THIS Time: CARE BUNDLE Sign: 4 Paediatric Upper Airway ObstructionBCB's ➔ STOP - NOT SUITABLE FOR THIS CARE BUNDLE ▢ ↳ ED Senior Medical or Paediatric▢ Completed Registrar normally review without delay▢ Individualised management ▢ Alternative diagnosis ↳ ED Senior Medical or Paediatric Registrar review without delay Pathway discontinued: Time: Sign: Age > 6 months with stridor, barking cough and / or hoarse voice ➔ CONTINUE Wheeze present and older than 1 year of age ➔ CONTINUE

▢ ▢ ▢ Completed normally ▢ Individualised management ▢ Alternative diagnosis BEST CARE BUNDLE - PATHWAY - BUNDLE CARE BEST Admission Guidelines - When to refer for Paediatric review PATHWAY - BUNDLE CARE BEST ↳ Initiate Best Care Bundle “Croup” on Whiteboard ↳ Initiate Best Care Bundle “Wheeze over 1 year” on Whiteboard Include patients who have receivedIf history treatment of poor compliance en route who with are treatment currently after asymptomatic discharge in the past or suspicion that compliance is likely to be poor after discharge, discuss with Paediatric Team. Admission Guidelines - When to refer for Paediatric review

▢ Moderate symptoms persist ▢ Any other significant concerns or high risk of deteriorationInitial Nursing assessmentIf history - ofAim poor complianceto complete with treatment by 30 after minutes discharge in the past or suspicion that compliance is likely to be poor after discharge, discuss with Paediatric Team. Initial Nursing assessment▢ Oxygen - Aim requirement to complete or requiring byNG feeds30 minutes • Day 1 or 2 of illness with moderate signs History, examination and vital signs recorded Dehydrated on the despite Nursing treatment Assessment Sheet. Any other Initial concerns SS: or high risk of deterioration: History, examination and vital signs ▢recorded Apnoeas on or the history Nursing of Apnoeas Assessment Sheet. • Corrected gestation < 52w (or 3m of age post term) ▢ ▢ • If late at night and < 3 months old, consider admittingWheeze Severity Score recorded and Requiring appropriate ongoing pathway NG or IVstarted. treatment (see page 2) • Large volume ongoing losses ▢ Significant co-morbidities ▢ Croup Assessment Tool applied and appropriate pathway started. (see page 2) overnight rather than discharging at this time • Under 6 months of age ↳ Initial Pathway started: ▢▢ MildSignificant co-morbidities ▢ Moderate ▢ Severe ↳ Initial Pathway: ▢ Mild ▢ Moderate ▢ Severe Sample Signatures Red Flags ➔ Senior MedicalSample or Paediatric Signatures Registrar review without delay Red Flags ➔ Senior Medical or Paediatric Registrar review without delay Name Signature Initials Name Signature Initials Name Signature Initials Name Signature Initials ▢ SS = 6 or “Severe” ➔ Move to Resus and inform Paediatric Team ▢ CAT “Severe” or Hypoxia (Sats < 94%) ➔ Move to Resus and inform Paediatric Team ▢ Poor response to Salbutamol prior to arrival in ED ▢ Possible FB inhalation ▢ Stridor ▢ Sudden onset, no prodromal illness, history of choking (? Foreign body) ▢ Previous PICU admit ▢ Cardiac disease ▢ Other Respiratory disease (CF, Bronchiectasis) ▢ Urticarial rash (? Anaphylaxis) ▢ Allergies associated with Anaphylaxis in the past ▢ Allergies associated with anaphylaxis in past ▢ Urticarial rash ▢ Not immunised (? Epiglottitis) ▢ High fever and toxic appearance (? Bacterial Tracheitis / Epiglottitis)

▢ Known syndromes (e.g. Down IssueSyndrome) Date: Juneor airway 2015/EM issues (Laryngo-tracheoPage: malacia,1 of Haemangiomas)4 FILE IN PATIENT NOTES Trial Issue Date: June 2015/EM Page: 1 of 4 FILE IN PATIENT NOTES Trial Pathway discontinued: Time: Sign:

Pathway discontinued: Time: Sign: ▢ Completed normally ▢ Individualised management ▢ Alternative diagnosis BEST CARE BUNDLE - PATHWAY - BUNDLE CARE BEST ▢ Completed normally ▢ Individualised management ▢ Alternative diagnosis PATHWAY - BUNDLE CARE BEST Admission Guidelines - When to refer for Paediatric review Admission Guidelines - When to refer for Paediatric review If history of poor compliance with treatment after discharge in the past or suspicion that compliance is likely to be poor after If history of poor compliance with treatment after discharge in the past or suspicion that compliance is likely to be poor after discharge, discuss with Paediatric Team. discharge, discuss with Paediatric Team. ▢ Moderate symptoms persist ▢ Any other significant concerns or high risk of deterioration ▢ Moderate symptoms persist ▢ Any other significant concerns or high risk of deterioration ▢ Oxygen requirement • If late at night and transport issues, consider admitting overnight rather than discharging at this time ▢ Significant co-morbidities • Required 2 or more doses of Adrenaline Significant co-morbidities • Transport issues if needed to come back to ED ▢

Sample Signatures Sample Signatures Name Signature Initials Name Signature Initials Name Signature Initials Name Signature Initials

Issue Date: June 2015/EM Page: 1 of 4 FILE IN PATIENT NOTES Trial Issue Date: June 2015/EM Page: 1 of 4 FILE IN PATIENT NOTES Trial (PLACE PATIENT LABEL HERE) (PLACE PATIENT LABEL HERE) (PLACE PATIENT LABEL HERE) SURNAME: ______NHI: ______SURNAME: ______NHI: ______SURNAME: ______NHI: ______FIRST NAMES: ______FIRST NAMES: ______FIRST NAMES: ______✓ = YES ✗ = NO Date of Birth: ______/______/______SEX: ______Date of Birth: ______/______/______SEX: ______Date of Birth: ______/______/______SEX: ______✓ = YES ✗ = NO ☑ = YES ☒= NO

NURSING NURSING NURSING TRAUMATIC HIP PAIN - ADULTS ADULT ASTHMA MINOR HEAD INJURY: GCS ≥ 13 (Suspected # neck of femur)

Date: Time: Assessment nurse: Sign: Date: Time: Assessment nurse: Sign: Date: Time: Assessment nurse: Sign: INCLUSION CRITERIA EXCLUSION CRITERIA INCLUSION CRITERIA EXCLUSION CRITERIA INCLUSION CRITERIA EXCLUSION CRITERIA Any major injury or acute medical instability Known asthmatic Chronic lung disease other than asthma: Clinically suspected # NOF Neck of Femur ⬜ Age < 15 Previous # NOF or THJR on same side as injury e.g: COPD / Cystic ﬁbrosis / Bronchiectasis ⬜ Trauma to the head < 24 hrs Shortness of breath and / or wheeze Age > 65 History of heart failure ⬜ Multi-trauma requiring team response e.g. RTC

Initiate Treatment Pathway: BCB Suspected # NOF (PLACENot PATIENT suitable for LABEL this Best HERE) Care Bundle (PLACE PATIENT LABEL HERE) (PLACE PATIENT LABEL HERE) In TP column on the Electronic Whiteboard. This records the STOP! Select ‘BCB removed’ Treatment Pathway Initiate Treatment Pathway: # BCB Adult Asthma Not suitable for this Best Care Bundle ⬜ Initiate Treatment Pathway: Minor Head Injury Not suitable for this Best Care Bundle start of treatment time for audit purposes and informsSURNAME: the ______NHI: ______In TP column on the Electronic Whiteboard. This recordsSURNAME: the ______NHI: ______SURNAME: ______NHI: ______Continue usual nursing cares STOP! Select ‘BCB removed’ Treatment Pathway In TP column on the Electronic Whiteboard. This records STOP! Select ‘BCB removed’ Treatment Pathway medical staff start of treatment time for audit purposes and informs the the start of treatment time for audit purposes and informs FIRST NAMES: ______Continue usual nursing cares medical staff FIRST NAMES: ______the medical staff FIRST NAMES: ______Continue usual nursing cares ✓ = YES ✗ = NO Date of Birth: ______/______/______SEX: ______Date of Birth: ______/______/______SEX: ______Date of Birth: ______/______/______SEX: ______NURSING ASSESSMENT Aim < 15 minutes ✓ = YES ✗ = NO ✓ = YES ✗ = NO NURSING ASSESSMENT Aim < 30 minutes

NURSING ASSESSMENT Aim < 30 minutes NURSING History, examination, vital signs Document neurovascular observations on page 4 NURSING NURSING History, examination and vital signs Recorded on Nursing Assessment Record ⬜ History, examination & vital signs Document on Nursing Assessment Record URINARY SYMPTOMS IN ADULTS IV access and Bloods ✓ General panel, ✓G&H ✓Coagulation studies if: • Warfarin → INR only Calculate % Peak Flow ‘How to’ guide on page 2 Neuro observationsNAUSEA & VOMITING IN PREGNANCY (Suspected Urinary Tract Infection - UTI) LOWER BACK PAIN ⬜ Document on page 2 • Other anticoagulants → Coag studies ECG • Coagulation disorders → Coag studies Date: Consider C-spine injuryTime: PlaceAssessment in hard collar nurse: if any doubt. See page 4 for C-spine investigationSign: guide Date: Time: Assessment nurse: Sign: Measured Peak Flow ⬜ Pain score Date: (best ofTime: three) Assessment nurse: Sign: Administer analgesia Nurse initiated analgesia. Standing orders page 4 : X 100 = ______% Peak Flow INCLUSION⬜ CRITERIA EXCLUSION CRITERIA INCLUSION CRITERIA EXCLUSION CRITERIA INCLUSIONPatient’s CRITERIA ‘Best” or “Predicted” EXCLUSION CRITERIA At rest On movement Use 1-10 scale. Dementia / non verbal patients: RN impression: Symptoms suggestive of acute renal colic (see page 2) Pregnant ⩽ 12 weeks with nausea and vomiting PV bleeding ↳ No pain: 0 Mild:1-3 Moderate:4-7 Severe: 8-10 Age < 15 Upper back / neck pain Suspected UTI Lower back pain (likely mechanical) RED FLAGS All red flagor boxes must be populated /10 /10 Rectal or perineal pain Assess severity & assign pathway using the ‘Severity Assessment Abdominal Tool below pain Pathway instructions Chest pain on page 3 & 4 > 12 weeks with documented history of Hyperemesis Abdominal pain e.g. dysuria, frequency, urgency, Pain score > 5 any time ➞ Fascia Iliaca Block prior to X-ray < 6 weeks duration Acute flare up of chronic back ⬜ GCS < 13 at any time ⬜ GCS < 14 at 2 hrs post injury ⬜ Seizure New, either pre - or post injury Renal patient (especially transplant) supra-pubic discomfort, cloudy urine pain may be included Significant trauma e.g. fall > 1 m, RTC Anticoagulant Rx e.g. Warfarin, Clopidogrel, Dabigatran, Rivaroxaban etc. Renal failure Creatinine > 200 Minor trauma is not an exclusion ⬜ ⬜ Collapse Still needs investigation if cause unknown Administer analgesia See formulary on page 4. Arrange Fascia Iliaca block if pain moderate / severe Initiate Treatment Pathway: BCB Nausea & Vomiting Not suitable for this Best Care Bundle (PLACE PATIENT LABEL HERE) RED FLAGS in NO pregnancy RED FLAGS In TP column onRED the FLAGSElectronic PRESENT Whiteboard. (ANY) → Senior Dr review ASAP (SMO / Senior Registrar) (PLACE PATIENT LABEL HERE) ⬜ ⬜ STOP(PLACE! Select PATIENT ‘BCB LABEL removed’ HERE) Treatment Pathway Request Radiology ASAP Pelvis APSURNAME: and lateral. ______Specify ‘Fast track # NOF Best Care Bundle’NHI: ______Initiate Treatment Pathway: BCB Lower Back Pain(Asthma) Not suitable for this Best Care Bundle This records the start of treatment time for audit purposes and Chest pain Previous ICU admission Pregnant Hypotension < 100 systolic ⬜ Continue Best CareSURNAME: Bundle ______. Intervention if any: ______NHI: ______Initiate Treatment Pathway: BCB UTI Not suitable for this Best Care Bundle In TP column on the Electronic Whiteboard. This recordsSURNAME: the ______NHI: ______informs the medical staff Continue usual nursing cares STOP! Select ‘BCB removed’ Treatment Pathway CHECKIn TP column PAIN onPRIOR the Electronic TO RADIOLOGY Whiteboard. This Is there recordsFIRST any the pain NAMES: on flexionSTOP ______!of unaffectedSelect ‘BCB hip removed’to 90°? Treatment Pathway start Drowsy of treatment time for audit Known purposes brittle and Asthmatic informs the Hypoxia < 94% on air Current / recent oral steroids Continue BCB ⬜ Exit Care Bundle: Reason: ______FIRST NAMES: ______start of treatment time for audit purposes and informs the FIRST NAMES: ______Continue usual nursing cares Continue usual nursing cares PATHWAY - BUNDLE CARE BEST medical staff Nursing Pathway medical staff Date of Birth: ______/______/______SEX: ______↳ Select ‘BCB removed’ in TP column, Whiteboard.This signals the medical staff ✓ = YES ✗ = NO ↳ No → Continue to Radiology

NO RED FLAGS RED FLAGS PRESENT (ANY) → Senior Dr review ASAP (SMO / Senior Registrar) AY W H PAT - E L D N U B E R A C T S E B NURSING ASSESSMENT Aim < 30 minutes ✓ ✗ Date of Birth: ______/______/______SEX: ______✓ ✗ Date of Birth: ______/______/______SEX: ______= YES = NO = YES = NO Dr Name: ______Sign: ______↳ Yes → Fascia Iliaca Block prior to Radiology Continue Dr Name: ______Sign: ______NURSING ASSESSMENT Aim < 30 minutes History, examination and vital signs Document on Nursing Assessment Record NURSING ASSESSMENT Contact POD SMO to arrange FIB packs on procedure trolley & drug room NURSING Best Care Bundle - NURSING Continue Care Bundle. Move to monitored / Resus (yes / no) NURSING ACUTE URINARY RETENTION History,follow pathway examination and vital signs Document on Nursing Assessment Record IV access & bloods: ✓General panel ✓β-HCG ✓LFTs TFT’s only if clinical concern. Clinician decision History, examination and vital signs Document on Nursing Assessment Record instructions DIARRHOEA Exit Care Bundle: +/- Reason: VOMITING ______IN ADULTS INVESTIGATION INDICATIONS (includes the Canadian CT head rules) Urinalysis / Dipstix / Point of Care (POC) Please paste POC printout on page 2 Recordpage 3 pain& 4 score: ↳ Select ‘BCB removed’ in TP column, Electronic Whiteboard. This signals the medical staff TOTAL Calculate % weight HIP loss: JOINT REPLACEMENT DISLOCATION Date:RED FLAGS Time: All red flags Assessmentboxes must nurse:be populated ✓ = YES ✗ = NO Sign: ⬜ Age > 65 ⬜ Decreasing level of consciousness at any time ⬜ GCS < 15 at 2 hrs post injury Date:At rest Time:On movement Assessment nurse: Sign: Abnormal vital signs Shortness of breath (new) Seizure (pre / post fall) Other significant injuries Date: Time: Assessment nurse: Sign: Leucocyte Esterase or Nitrites positive → Send to the lab Only send MSU or CSU ⬜ SeizurePre-pregnancy weight⬜ Amnesia > 30 minutes before impact ⬜ Anticoagulant therapy INCLUSION CRITERIA EXCLUSION CRITERIA SEVERITY /10ASSESSMENT TOOL/10 Default to higher severity if any doubt - Current weight - Head injury Signs of CVA (new) GI bleeding Chest pain (active / recent) INCLUSION CRITERIA EXCLUSION CRITERIA (or last known weight) ⬜ ? Skull fracture: ? Open, depressed, or base of skull # (Racoon eyes, Battle’s sign) ⬜ Focal neurological signs Acute Collapse Urinary ? cause Retention suspected Decreased LOC (new)→ Ask the clinician Other Any majorconcerns injury noted or acute medical instability Mild Moderate Severe Life threatening : (PLACE PATIENTX 100 =LABEL______HERE) % Weight loss Leucocyte Esterase / Nitrites negative Administer analgesia Nurse initiated analgesia. Standing orders page 4 Severe pain / guarding INCLUSION CRITERIA EXCLUSION CRITERIA but any other Dipstix parameters positive Diarrhoea +/- vomiting suggestive of Gastroenteritis Vomiting only ⬜ Dangerous mechanismPre-pregnancy Pedestrian weight vs car, ejected from car, fall from height > 1m ⬜ Vomiting 2 or more times % Peak Flow > 75 % 50 - 75 % 33-50% < 33% (or last known weight) SURNAME: ______NHI: ______Providee.g. recent self onsetassessment of profuse sheet watery and pendiarrhoea, Known Crohns Coffee ground vomitus THJR dislocation suspected Any major injury or acute medical instability NO RED FLAGS RED FLAGS PRESENT (ANY) → Senior Dr review ASAP (SMO / Senior Registrar) Speaking Full Sentences Short sentences Words only Words or not speaking ⬜ NONE ⬜ Any of the above indications require bloods and probably a CT (senior doctor decision) Initiate Treatment Pathway: BCB Urinary Retention associated with nausea and / or vomiting. Melaena FIRST NAMES: ______Back pain / flankNot pain suitable present for this Best Care Bundle Known Ulcerative Colitis In TP column on the Electronic Whiteboard. This records→ the → Send to the lab Accessory muscles None / + ++ +++ +/- Urine ketones: ______Paste POC alysis in Nursing Assessment Record. Only send to lab if + Leuc esterase or + nitrites Dr Name: ______PretreatedSTOP! with SelectSign: Antibiotics ______‘BCB removed’ Treatment Pathway Immunocompromised ↳ Bloods sent ✓Date Trauma of Birth: panel ______bloods /______✓ β-HCG /______ 14-50y ✓ Coags SEX: ______start Dipstixof treatment all parameters time for audit negative purposes and informs the Only MSU or CSU RED RespiratoryFLAGS (URGENT rate REVIEW)< 18 FLAGS All 19-24red flags boxes must⩾ 25/min be populated ✓ Silent = YES chest ✗ = NO ✓ = YES ✗ = NO ⬜ Continue usual nursing cares No investigations medicalContinue staff Continue Best Care Bundle. Requested Intervention by clinician if any: ______Assess Initiate severity Treatment & assign Pathway: pathway BCB using THJR the dislocation ‘Severity Assessment Tool’ below Follow pathway instructions on page 2 & 3 Respiratory effort Normal ++ +++ Poor respiratory effort indicated Best Care Bundle HR < 50 or >120 Systolic BP < 90 Fever > 38.5°C Spinal surgery < 6 wks Known AAA In TP column on the Electronic Whiteboard. This records the Not suitable for this Best Care Bundle Exit Care Bundle: Reason: ______InitiateHeart Treatment rate Pathway:50 - 99 BCB /min Diarrhoea &100 - 130 bpm ⩾ 130 /min ⩾ 130 /min NURSING Not suitable for this Best Care Bundle start of treatment time for audit↳ purposes CT brain: and ⬜ informs Ordered the ⬜ Not ordered Discuss with Lead SMO or clinician if unsure → None of the above → Do NOT send NO RED FLAGS RED FLAGS PRESENT (ANY) → Senior Dr review ASAP (SMO / Senior Registrar) STOP! Select ‘BCB removed’ Treatment Pathway NURSING ASSESSMENT ↳ SelectAim < ‘BCB 30 minutesremoved’ in TP column, Electronic Whiteboard. This signals the medical staff vomiting InSPO2 TP column on 97the - Electronic100% Whiteboard. 95This - 96% STOP! 93Select - 94% ‘BCB removed’ Treatment< 92 %Pathway SEVERITYmedical staff ASSESSMENT TOOL Choose more severe pathway if any doubt records the start of treatment time for audit purposes and Continue usual nursing cares UrineHistory, Pregnancy examination test and All vital age signs 14 -Document 55 on Nursing Assessment Record Continue usual nursing cares PATHWAY - BUNDLE CARE BEST informsExhaustion the medical staff ContinueNone Best Care Bundle.Tired Intervention if any: +++______Exhaustion, altered LOC ALLOCATE DIRECTLY TO RESUSMild Moderate Severe BLEEDING / PAIN IN EARLY PREGNANCY AY W H PAT - E L D N U B E R A C T S E B Hospital↳ Not gown pregnant Start Pregnant fluid balance chart 1 4 Continue Exit Care Bundle: Reason: ______Time frame Recent onset Ongoing symptoms Severe intractable vomiting PATHWAY - BUNDLE CARE BEST Issued: 9/2016 Review period 2 yrs EM/Ortho/Gen Med Page: of FILE IN PATIENT NOTES Trial PATHWAY - BUNDLE CARE BEST 1 4 Trial IssueBest Date: Care July Bundle 2015/EM ↳ SelectPage: ‘BCB1 removed’ of 8 in TP column, ElectronicFILE IN PATIENT Whiteboard. NOTES This signals the medical staff Issued: Oct 2015 Reviewed: Feb 2016/EM Page: of FILE IN PATIENT NOTES NURSING ASSESSMENT Aim < 30 minutes Oral fluid tolerance Tolerating oral fluids Tolerating no or minimal fluids Not tolerating fluids Bloods + / - IV line indications: → ✓Abd pain panel, ✓βHCG. Blood cultures only if febrile NURSING ASSESSMENT Aim < 30 minutes RED FLAGS All red flag boxes must be populated Dr Name: ______Sign: ______Date: Time: Assessment nurse: Sign: Ketones 0 - 1+ 2 - 3+ ⩾ 4+ Haematuria Nausea / vomiting Flank / back pain Known renal impairment History, examination and vital signs Document on Nursing Assessment Record History, examination and vital signs Record on Nursing Assessment Record Signs of dehydration HR > 120 Systolic BP < 90 Clinical concern Change in mental state None or minimal Mild Severe Fever / rigors Any Red Flags Requested by Clinician: ______IV line and bloods for all patients in Acutes. In Waiting room use clinical judgement Hospital gown INVESTIGATION INDICATIONS (ACC Red Flags). X-ray indications in bold INCLUSIONWeight loss CRITERIA < 5% 5 -10%EXCLUSION CRITERIA > 10% NO RED FLAGS RED FLAGS PRESENT (ANY) → Senior Dr review ASAP (SMO / Senior Registrar) General profile, LFT’s , Lipase, Lactate (VBG) ECGBlood profile Normal Abnormal Fever︎ / rigors Age > 50 Unrelenting pain for > a few days Pregnant < 14/40 Not pregnant RED FLAGS All red flags Continue boxes mustBest Care be populatedBundle. Intervention ✓ = YES if any: ✗ ______= NO Blood cultures only if temp > 38 ° C or pregnant (? Listeria) Neurovascular Observations Document on page 4 Exit Care Bundle: Reason: ______IV drug use Worse pain supine or at night Significant trauma PV bleeding and / or pain > 14 weeks AgeContinue > 65 Immunosuppression Functional or anatomic abnormality of the urinary tract RED FLAGS All red flags boxes must be populated ✓ = YES ✗ = NO Steroids Stool culture → Do Loss not send bladder routinely / bowel. See function indications on page 2 Cancer history ✓General panel ✓Group & Hold ✓Coagulation studies if indicated: Best Care Bundle ↳ Select ‘BCB removed’ in TP column, Electronic Whiteboard. This signals the medical staff IVPregnancy access & not bloods confirmed → serum β-HCG ASAP HR >110 Change in mental state Recent urinary tract operation / instrumentation • Warfarin: INR only Diastolic BP > 90 Systolic BP < 80 or >130 Visual disturbance Headache / LOC Dr Name: ______Sign: ______IDDM / NIDDM Unintentional weight loss Not recovering as expected Full bladder needed for USS - push oral fluids • Other anticoagulants / coagulation disorders: Coag studies Systolic BP < 90 Clinical concern: ______HR < 50 or >120 Known high risk pregnancy Fever or diarrhoea Ataxia / Confusion RED Immunosupressed FLAGS All red flag Any boxes numbness must be/ weakness populated in legs Requested by Dr: ______NO RED FLAGS RED FLAGS PRESENT (ANY) → Senior Dr review ASAP (SMO / Senior Registrar) HR < 50 or > 120 Systolic BP < 90 mmHg Any signs of severe illness as per Assessment Tool NO Pain RED score FLAGS RED FLAGSNurse PRESENT initiated (ANY) analgesia. → Senior Formulary Dr review page ASAP 4 (SMO / Senior Registrar) URETHRAL CATHETER ASAP Check contraindications, flowchart & IDUC size guide page 2 /10 Dr Name: ______Sign: ______None present Any of the above indications require bloods and possibly X-Rays (X-ray indications in bold) Dr Name: ______Sign: ______Fever > 38.5° C Pain score > 5 / 10 Age > 65 Pregnancy consider Listeria InitiateContinue Treatment Pathway: Bleeding in pregnancy Not suitable for this Best Care Bundle In TP column on the Electronic Whiteboard. This records the URETHRALContinue CATHETER PLACEMENT Continue Best Care RECORD Bundle. InterventionKPI for this bundleif any: please______complete. Tachypnoea > 24 ↳ Blood Bloods in the stoolsent ✓General panel Nursing bloods, concern ✓ CRP, ✓β-HCG 14-50y Best Request Care Bundle Radiology Portable pelvis AP andSTOP lateral.! SpecifySelect ‘Fast ‘BCB track removed’ THJR Treatment pathway’ Pathway start of treatment time for audit Continue purposes Best and informsCare Bundle. the Intervention if any: ______follow pathway Best Care Bundle No bloods or Blood cultures if temperature ⩾ 38 ℃ medical staff Continue usual nursing cares Time: ______Exit PlacedCare Bundle: by: ______Reason: ______Sign: ______Designation: ______instructions Exit Care Bundle: Reason: ______X-Rays NO RED indicated FLAGS RED FLAGS PRESENT (ANY) → Senior Dr review ASAP (SMO / Senior Registrar) ↳ Select ‘BCB removed’ in TP column, Electronic Whiteboard. This signals the medical staff ↳ X-Rays: Ordered Not ordered Indications in bold REDpage FLAGS 2 & 3 ↳ Select ‘BCB removed’ in TP column, Electronic Whiteboard. This signals the medical staff Catheter size: ______Fg Size guide page 2 Balloon volume: _____ mL Continue Continue Best Care Bundle. Intervention Discuss if any: with______lead SMO or clinician if unsure PATHWAY - BUNDLE CARE BEST Abnormal vital signs Shortness of breath (new) Seizure (pre / post fall) Other significant injuries AY W H PAT - E L D N U B E R A C T S E B Best Care Bundle Exit Care Bundle: Reason: ______NURSING ASSESSMENT Issued: Insertion: July 2016 Review No perioddifficulty 2 years EM/Micro Minor difficultyPage: Unable1 of to insert4 FILE IN PATIENT NOTES follow pathway Trial Issued: July 2015/EM Reviewed June 2016 ↳ SelectPage: ‘BCB removed’1 of in4 TP column,FILE Electronic IN PATIENT Whiteboard. NOTES This signals the medical staff Issued: Head Sept 2016/EM/O&Ginjury Review due: Chest 2 years painDocument (active /Page: recent) on nursing1 of assessment Collapse4 ? causerecordFILE IN PATIENT DecreasedNOTES LOC (new) PATHWAY - BUNDLE CARE BEST instructions History, examination, vital signs Urine quality: Clear Cloudy Debris page 2 & 3 Dr Name: ______Sign: ______IV access and Bloods ✓ PV Bleed panel, ✓G&H ✓ β-HCG NO RED FLAGS RED FLAGS PRESENT (ANY) → Senior Dr review ASAP (SMO / Senior Registrar) Blood: No blood Rose Clots (few) Clots (heavy) Manual irrigation policy, CeDSS ↳ 2 large bore IV lines if signs of shock (i.e. cool, clammy, HR >110, BP < 90) Dr Name: ______Sign: ______Confirm: Sterile technique Specimen sent to lab only if + Leucocytes or Nitrites SEVERITY ASSESSMENT TOOL Choose more severe pathway if any doubt Administer analgesia See formulary on page 4 Continue Continue Best Care Bundle. Intervention if any: ______Foreskin replaced or Circumcised Push oral fluids Aim 2 full cups water immediately - full bladder preferable for USS Mild Moderate Severe Best Care Bundle Exit Care Bundle: Reason: ______IV fluids if NPO / concern about ? ectopic. Clinician decision General wellbeing Feels mildly unwell Feels unwell Looks and feels unwell ↳Select ‘BCB removed’ in TP column, Electronic Whiteboard. This signals the medical staff DOCUMENT VOLUME DRAINED Not distressed e.g. lethargic, tired, light headed e.g. Profound lethargy, restless Urine analysis not a priority - MSU only if ? UTI Volume Stat (30 mins) ______mL if > 1000 mL ➔ General panel bloods ✘ Do not send PSA Pulse rate 50 - 99 bpm 100 - 120 bpm > 120 bpm, weak radial pulse REDUCTION Aim < 1 hour drained: In 2 hours ______mL if > 1500 mL ➔ General panel bloods. Observe for post obstructive diuresis Blood pressure Normal Orthostatic hypotension Shock, systolic BP < 90 mmHg RED FLAGS All red flags boxes must be populated ✓ = YES ✗ = NO

Perfusion Peripherally warm Peripherally cool Cool and clammy Radiology completed: Contact clinician Lead EM SMO NSH 3366 / WTH 7799 PATHWAY - BUNDLE CARE BEST FURTHER TASKS To be done for all patients. DCT team, or nursing staff HR > 110 Heavy bleeding: e.g > 1pad / hr or clots Severe abdominal pain / guarding / rebound Mucous membranes Moist Dry Sunken eyes, ↓ skin turgor ↳ Reduction decision ASAP → ED or Theatre Catheter cares education Systolic BP < 90 Fever Collapse Discharge Coordinator: NSH 3861 Mon - Sun 8 am - 3 pm Urine output Normal or dark urine Decreased ↓ or no urine Move to resus as soon as possible if not already there Provide ‘Catheter pack‘ flight deck / staff base WTH 021 911 796 Mon - Sat 7 am - 5 pm Clinical concern Fluid tolerance Tolerating fluids Tolerating no or minimal fluids Tolerating no fluids Radiology delay > 30 mins: Expedite if possible. Inform ACCN or Lead EM SMO District Nurse referral for all patients. See TROC guide and timing information on page 3 Nr Diarrhoea episodes ⩽ 5 / 24 hrs ⩾ 6 / 24hrs ⩾ 10 / 24hrs NO RED FLAGS RED FLAGS PRESENT (ANY) → Senior Dr review ASAP (SMO / Senior Registrar) Issued: Oct 2014 Reviewed: Feb /2016/EM/Urol Page: 1 of 4 FILE IN PATIENT NOTES Trial Issued: July 2015/EM Reviewed: Feb 2016 Page: 1 of 4 FILE IN PATIENT NOTES Trial Issue Date: July 2015/EM Page: 1 of 4 FILE IN PATIENT NOTES Trial Dr Name: ______Sign: ______

Continue Continue Best Care Bundle. Intervention if any: ______Best Care Bundle Exit Care Bundle: Reason: ______↳ Select ‘BCB removed’ in TP column, Electronic Whiteboard. This signals the medical staff

Issued: 09/2016 Review period: 12 months EM/O&G Page: 1 of 4 FILE IN PATIENT NOTES Trial First Name:______Gender: ______Surname: ______(PLACE PATIENT LABEL HERE) AFFIX PATIENT✓ LABELSURNAME: HERE ______NHI: ______= YES SURNAME: ______NHI: ______Date of Birth: ______NHI#: ______✗ (PLACE PATIENT LABEL HERE) ✓ = YES FIRST = NAMES: NO ______Ward/Clinic:✗ = NO Consultant FIRST NAMES: ______Fluid Balance Record (24 hours) Date: Date of Birth: ______/______/______SEX: ______DIARRHOEA +/-Date VOMITING of Birth: ______/______IN /______ADULTS SEX: ______Time Fluid to be given and instructions Date: Prescribed Volume ml ml per hour Prescriber Signature of DIARRHOEAName and Signature + / - VOMITING 0.9%0.9% Sodium Saline Chloride + 5% Dextrose Administrators (Generated fromT ED) 1000 1000 INCLUSION CRITERIATime: Rate:0.9% Saline Date: / / 20 Time: Clinician: DISCHARGE15mL/kg/hr INFORMATION: OR ____1000 /____ DIARRHOEA /____ & VOMITING (ADULT) REFERRAL 500 Assessment nurse: 20mL/kg/hrDATE REC:HISTORY AND PRESENTING COMPLAINTDiarrhoea +/- vomiting suggestive of Gastroenteritis ______Consider: NoAdd of15mmol pages: KCLUnwell for : ______e.g. recent onset of profuse watery diarrhoea, associated with nausea and / or vomiting. ____ /____ /____ What%is%Gastroenteri-s%? CNS DATE SENT : Diarrhoea HS Reg NURSING ______Gastroenteri*s+('Gastro')*is+a+bowel+infec*on+that+causes+diarrhoea+ No (runny,*watery*stools)*and+it+may+also+ EXCLUSION CRITERIA SMO FAX NO : Clinician Name (print) Yes cause+vomi*ng,+abdominal+pain,+fever+and+lethargy+Nausea (extreme*4redness).*The+diarrhoea+may+last+longer+than+ Sign: No Yes Vomiting only WDHB UROLOGY CLINICthe+vomi*ng.+ Vomiting Initiate Treatment Pathway: BCB Diarrhoea & Code for output No Known Crohns REFERRED TO : Service / Ward Gastro+is+most+commonly+caused+by+a+virus+so+an*bio*cs+will+not+usually+work,+and+could+even+be+bad+for+you.+++Abdominal pain Yes vomiting A = Aspiration, B Clinician Name (print) Small volume diarrhoea - = Bile, BM = Bowel Motion, V=Vomit, No records the startIn TP of column treatment on thetime Electronic for audit purposesWhiteboard. and This Known Ulcerative Colitis Severe pain / guarding In+most+cases+the+infec*on+clears+over+a+few+days.+NG = Nasogastric, Yes BL - Blood Loss, consider alternative diagnosis Emergency Medicine informs the medical staff F = Fistula, S = Stoma Immunocompromised INTAKE Coffee ground vomitus REFERRED BY : Service / Ward Signiﬁcant Abdominal pain - Start OUTPUT Melaena How%is%Gastro%Treated?ext/locatorIntravenous Oral/Gastric high risk for other pathology time NURSING ASSESSMENTUrine Other In+most+cases+the+infec*on+clears+by+itself+over+a+few+days+Signature (Although*it*can*take*up*to*a*week*or*two)*.The+ Fluid given STOP Not suitable for this Best Care Bundle main+focus+is+to+take+in+plenty+of+ﬂuid+to+treat+and+prevent+dehydra*on.+ ! Clinician Designation History, examination and vital signs Select ‘BCB removed’ Treatment Pathway

check Site/ﬂuid Within 7 days Aim < 30 minutes

Start level IV line and bloods for

Volume Continue usual nursing cares URGENCY given Running total

Start level

Volume given

Running total

Time

Volume

Running total

Code

Volume

Running Within 24 hrs total Most+people+do+not+need+to+be+admiKed+to+the+hospital+or+treated+with+an*bio*cs all patients in Acutes.Document on Nursing Assessment Record Urgent - today Early Discharge ︎ General profile, Immediate - now Non-urgent Blood cultures LFT’s , In Waiting room use clinical judgement Risk factors for infectious diarrhoea Lipase, Lactate (VBG) Within 1 month Dehydra-on...ACTIVE ISSUES Stool culture only Contact unclean water if temp > 38 ° C or pregnant → Do not send routinely Recent Antibiotics RED FLAGS The+main+thing+to+worry+about+with+gastro+is+dehydra*on++ Recent(loss*of*too*much*fluid*from*the*body).** travel Review Red flags page 1 Best Older+people+or+those+with+lots+of+medical+problems+can+become+severely+dehydrated+and++this+can+happen+ HR < 50 or > 120All red flag boxes must be populated (? Listeria)Care Bundle pathway 1 Acute urinary retention precipitated by: > 14 days duration Infectious contacts Recent hospitilisation. See indications on page 2 quite+quickly. Fever > 38.5° C

RELEVANT PREVIOUS MEDICAL AND SURGICAL HISTORY Occupation: ______(including rest homes) 2 REFERRAL Tachypnoea > 24 Systolic BP < 90 mmHg 3 Pain score > 5 / 10 The%signs%of%dehydra-on... NO RED FLAGS 4 Blood in the stool • You+may+feel+thirsty+and+/+or+have+a+dry+mouth Any signs of severe illness as per Assessment Tool • Feel+lethargic+(sleepy)+or+irritableALERTS / ALLERGIESContinue Nil relevant 5 Best Care Bundle RED FLAGS PRESENT (ANY) Age > 65 • You+may+no*ce+you+make+a+lot+less+urine+than+usual MRSA / ESBL and other multiresistant drugs Immunosupression follow pathway Nursing concern ETHNICITY Maori Allergies instructions Continue Best Care Bundle. Intervention Pregnant if any: ______page 2 & 3 → (? Listeria) Pregnancy NZ European Oral%fluids%(oral%rehydra-on) Other: Exit Care Bundle: Reason: ______Senior Cook Island Maori Dr Neurosurgicalreview ASAP history consider Listeria ↳ Samoan • It+is+important+to+keep+up+with+taking+oral+fluids+G+even+if+you+s*ll+feel+nauseated.+You+ Select will+s*ll+absorb+ IDDM / NIDDM Niuean EMERGENCY MEDICINE Dr Name: ______‘BCB removed’ Sign: (SMO______/ Senior Registrar Tongan Indian some+of+the+fluid.++The+trick+is+to+take+smaller+drinks,+more+oHen.RELEVANT MEDICATIONSSEVERITY /ASSESSMENT ALLERGIES TOOL • Rehydra*on+drinks+such+as+‘Gastrolyte’%or+‘Pedialyte’%%provide+a+good+balance+of+water,+salts,+and+sugar.+ in TP column, Electronic Whiteboard. This signals the medical staff Chinese MOBILITY Chair ) The+small+amount+of+sugar+and+salt+helps+the+water+to+be+absorbed+beKer+from+the+bowel+(intes*ne)+into+ Other Walk Ambulance the+body.+ Choose more severe pathway if any doubt Trolley General wellbeing Nil regular medicinesPATIENT - BUNDLE CARE BEST INFORMATION • Oral%rehydra-on%fluids%do%not%stop%or%reduce%diarrhoea.% Mild BEST CARE BUNDLE - PATHWAY INTERPRETER REQUIRED: No Feels mildly unwell • Rehydra*on+drinks+(e.g.+Gastrolyte)+are+made+from+sachets+that+you+can+buy+from+pharmacies.+(The+ Not distressed Yes Pulse rate REASONsachets+are+also+available+on+prescrip*on.) FOR REFERRAL Blood pressure Moderate 50 - 99 bpm Feels unwell • Sports+drinks:+like+‘Powerade’+are+fine+as+long+as+they+are+diluted+50:50+with+water.+ Perfusion Normal e.g. lethargic, tired, light headed Mucousffi cultmembranes IDC placement Fluid Balance Record Thank you for follow up on this patient who presented with Di Acute Urinary Retention 100 - 120 bpm 24 HOUR TOTAL Peripherally warm Severe Do+not+use +homeGmade+rehydra*on+solu*ons+as+they+oHen+do+not+have+the+right+amount+of+salt+or+sugar+and+ Nil known allergies INTAKE Looks and feels unwell The indication for follow up in your Painless clinic retention is: Representation with clots OUT PUT can+be+dangerous. Urine output Moist Orthostatic hypotension FUNCTIONAL AND SOCIAL HXALLERGIES: e.g. Profound lethargy, restless Failed TROC Renal impairment Fluid tolerance Normal or dark urine Peripherally cool Independent Nr Diarrhoea episodes > 120 bpm, weak radial pulse The+secret+is+to+take+small+amounts+regularly+–+e.g.+taking+a+sip+or+two+(10G20+mL)+every+5+minutes.+That+way+if+ Dry New SPC Renal failure Yes Tolerating fluids Shock, systolic BP < 90 mmHg you+keep+on+doing+it+you+will+be+able+to+keep+the+fluid+down.+Drinking+a+lot+at+once+can+oHen+bring+on+Smoking Hx No HydronephrosisReview Date: June 2008 Issued: July 2015/EM Reviewed: Feb 2016 Decreased vomi*ng. Non smoker ⩽ 5 / 24 hrs Cool and clammy Smoker: Tolerating no or minimal fluids Recent lower urinary tract surgery <6 weeks 5.10.015 Sunken eyes, ⩾ 6 / 24hrs Issued: July 2015/EM Reviewed: Feb 2016 ↓ or no urine ↓ skin turgor 5.11.010 Page: Tolerating no fluids 1 Page: of 1 of 4 ⩾ 10 / 24hrs Issued: July 2015/EM Reviewed: Feb 2016 Page: 1 of 2 4 Trial FILE IN PATIENTFILE NOTES IN PATIENT NOTES

Trial Please see the detailed Electronic Discharge Summary for additional information Trial (PLACE PATIENT LABEL HERE) SURNAME: ______NHI: ______

FIRST NAMES: ______

✓ = YES ✗ = NO Date of Birth: ______/______/______SEX: ______

NURSING TRAUMATIC HIP PAIN - ADULTS (Suspected # neck of femur)

Date: Time: Assessment nurse: Sign:

INCLUSION CRITERIA EXCLUSION CRITERIA Any major injury or acute medical instability Clinically suspected # NOF Neck of Femur Previous # NOF or THJR on same side as injury

Initiate Treatment Pathway: BCB Suspected # NOF Not suitable for this Best Care Bundle In TP column on the Electronic Whiteboard. This records the STOP! Select ‘BCB removed’ Treatment Pathway start of treatment time for audit purposes and informs the medical staff Continue usual nursing cares

NURSING ASSESSMENT Aim < 15 minutes

History, examination, vital signs Document neurovascular observations on page 4

IV access and Bloods ✓ General panel, ✓G&H ✓Coagulation studies if: • Warfarin → INR only • Other anticoagulants → Coag studies ECG • Coagulation disorders → Coag studies Pain score

At rest On movement Use 1-10 scale. Dementia / non verbal patients: RN impression: ↳ No pain: 0 Mild:1-3 Moderate:4-7 Severe: 8-10 /10 /10 Pain score > 5 any time ➞ Fascia Iliaca Block prior to X-ray

Administer analgesia See formulary on page 4. Arrange Fascia Iliaca block if pain moderate / severe

Request Radiology ASAP Pelvis AP and lateral. Specify ‘Fast track # NOF Best Care Bundle’

CHECK PAIN PRIOR TO RADIOLOGY Is there any pain on ﬂexion of unaffected hip to 90°? BEST CARE BUNDLE - PATHWAY - BUNDLE CARE BEST ↳ No → Continue to Radiology ↳ Yes → Fascia Iliaca Block prior to Radiology Contact POD SMO to arrange - FIB packs on procedure trolley & drug room

RED FLAGS All red flags boxes must be populated ✓ = YES ✗ = NO

Abnormal vital signs Shortness of breath (new) Seizure (pre / post fall) Other signiﬁcant injuries Head injury Signs of CVA (new) GI bleeding Chest pain (active / recent) Collapse ? cause Decreased LOC (new) Other concerns noted

NO RED FLAGS RED FLAGS PRESENT (ANY) → Senior Dr review ASAP (SMO / Senior Registrar)

Dr Name: ______Sign: ______

Issued: 9/2016 Review period 2 yrs EM/Ortho/Gen Med Page: 1 of 4 FILE IN PATIENT NOTES (PLACE PATIENT LABEL HERE) SURNAME: ______NHI: ______

FIRST NAMES: ______

✓ = YES ✗ = NO Date of Birth: ______/______/______SEX: ______

NURSING TRAUMATIC HIP PAIN - ADULTS (Suspected # neck of femur)

Date: Time: Assessment nurse: Sign:

INCLUSION CRITERIA EXCLUSION CRITERIA Any major injury or acute medical instability Clinically suspected # NOF Neck of Femur ✓ Previous # NOF or THJR on same side as injury

✓ Initiate Treatment Pathway: BCB Suspected # NOF Not suitable for this Best Care Bundle In TP column on the Electronic Whiteboard. This records the STOP! Select ‘BCB removed’ Treatment Pathway start of treatment time for audit purposes and informs the medical staff Continue usual nursing cares

NURSING ASSESSMENT Aim < 15 minutes

History, examination, vital signs Document neurovascular observations on page 4

IV access and Bloods ✓ General panel, ✓G&H ✓Coagulation studies if: • Warfarin → INR only • Other anticoagulants → Coag studies ECG • Coagulation disorders → Coag studies Pain score

Administer analgesia See formulary on page 4. Arrange Fascia Iliaca block if pain moderate / severe

Request Radiology ASAP Pelvis AP and lateral. Specify ‘Fast track # NOF Best Care Bundle’

RED FLAGS All red flags boxes must be populated ✓ = YES ✗ = NO

NO RED FLAGS RED FLAGS PRESENT (ANY) → Senior Dr review ASAP (SMO / Senior Registrar)

Dr Name: ______Sign: ______

Issued: 9/2016 Review period 2 yrs EM/Ortho/Gen Med Page: 1 of 4 FILE IN PATIENT NOTES (PLACE PATIENT LABEL HERE) SURNAME: ______NHI: ______

FIRST NAMES: ______

✓ = YES ✗ = NO Date of Birth: ______/______/______SEX: ______

NURSING TRAUMATIC HIP PAIN - ADULTS (Suspected # neck of femur)

Date: Time: Assessment nurse: Sign:

INCLUSION CRITERIA EXCLUSION CRITERIA Any major injury or acute medical instability Clinically suspected # NOF Neck of Femur Previous # NOF or THJR on same side as injury

NURSING ASSESSMENT Aim < 15 minutes ✓ History, examination, vital signs Document neurovascular observations on page 4 IV access and Bloods ✓ General panel, ✓G&H ✓Coagulation studies if: ✓ • Warfarin → INR only • Other anticoagulants → Coag studies ECG ✓ • Coagulation disorders → Coag studies ✓ Pain score

At rest On movement Use 1-10 scale. Dementia / non verbal patients: RN impression: ↳ No pain: 0 Mild:1-3 Moderate:4-7 Severe: 8-10 /10 /10 6 9 Pain score > 5 any time ➞ Fascia Iliaca Block prior to X-ray ✓ Administer analgesia See formulary on page 4. Arrange Fascia Iliaca block if pain moderate / severe ✓ Request Radiology ASAP Pelvis AP and lateral. Specify ‘Fast track # NOF Best Care Bundle’ CHECK PAIN PRIOR TO RADIOLOGY Is there any pain on ﬂexion of unaffected hip to 90°? BEST CARE BUNDLE - PATHWAY - BUNDLE CARE BEST ↳ No → Continue to Radiology ↳ ✓ Yes → Fascia Iliaca Block prior to Radiology Contact POD SMO to arrange - FIB packs on procedure trolley & drug room

RED FLAGS All red flags boxes must be populated ✓ = YES ✗ = NO

NO RED FLAGS RED FLAGS PRESENT (ANY) → Senior Dr review ASAP (SMO / Senior Registrar)

Dr Name: ______Sign: ______

Issued: 9/2016 Review period 2 yrs EM/Ortho/Gen Med Page: 1 of 4 FILE IN PATIENT NOTES (PLACE PATIENT LABEL HERE) SURNAME: ______NHI: ______

FIRST NAMES: ______

✓ = YES ✗ = NO Date of Birth: ______/______/______SEX: ______

NURSING TRAUMATIC HIP PAIN - ADULTS (Suspected # neck of femur)

Date: Time: Assessment nurse: Sign:

INCLUSION CRITERIA EXCLUSION CRITERIA Any major injury or acute medical instability Clinically suspected # NOF Neck of Femur Previous # NOF or THJR on same side as injury

NURSING ASSESSMENT Aim < 15 minutes

History, examination, vital signs Document neurovascular observations on page 4

IV access and Bloods ✓ General panel, ✓G&H ✓Coagulation studies if: • Warfarin → INR only • Other anticoagulants → Coag studies ECG • Coagulation disorders → Coag studies Pain score

Administer analgesia See formulary on page 4. Arrange Fascia Iliaca block if pain moderate / severe

Request Radiology ASAP Pelvis AP and lateral. Specify ‘Fast track # NOF Best Care Bundle’ X CHECK PAIN PRIORX TO RADIOLOGY Is there any pain on✓ ﬂexion of unaffected hip to 90°? X BEST CARE BUNDLE - PATHWAY - BUNDLE CARE BEST X X ↳ No → ContinueX to Radiology X X ✓ ↳ Yes → FasciaX Iliaca Block prior to Radiology Contact POD SMO to arrange - FIB packs on procedure trolley & drug room ✓ RED FLAGS All red Rademeyerflags boxes must be populated ✓ = YES ✗ = NOCRrd Abnormal vital signs Shortness of breath (new) Seizure (pre / post fall) Other signiﬁcant injuries Head injury ✓ Signs of CVA (new) GI bleeding Move Chest painto (active monitored / recent) Collapse ? cause Decreased LOC (new) Other concerns noted

NO RED FLAGS RED FLAGS PRESENT (ANY) → Senior Dr review ASAP (SMO / Senior Registrar)

Dr Name: ______Sign: ______

Issued: 9/2016 Review period 2 yrs EM/Ortho/Gen Med Page: 1 of 4 FILE IN PATIENT NOTES (PLACE PATIENT LABEL HERE) SURNAME: ______NHI: ______

FIRST NAMES: ______

Date of Birth: ______/______/______SEX: ______✓ = YES ✗ = NO NURSING DIARRHOEA +/- VOMITING IN ADULTS

Date: Time: Assessment nurse: Sign:

INCLUSION CRITERIA EXCLUSION CRITERIA

Diarrhoea +/- vomiting suggestive of Gastroenteritis Vomiting only Severe pain / guarding e.g. recent onset of profuse watery diarrhoea, Known Crohns Coffee ground vomitus associated with nausea and / or vomiting. Known Ulcerative Colitis Melaena Immunocompromised

Initiate Treatment Pathway: BCB Diarrhoea & Not suitable for this Best Care Bundle vomiting In TP column on the Electronic Whiteboard. This STOP! Select ‘BCB removed’ Treatment Pathway records the start of treatment time for audit purposes and informs the medical staff Continue usual nursing cares

NURSING ASSESSMENT Aim < 30 minutes

History, examination and vital signs Document on Nursing Assessment Record IV line and bloods for all patients in Acutes. In Waiting room use clinical judgement

︎ General proﬁle, LFT’s , Lipase, Lactate (VBG) Blood cultures only if temp > 38 ° C or pregnant (? Listeria) Stool culture → Do not send routinely. See indications on page 2

RED FLAGS All red flag boxes must be populated HR < 50 or > 120 Systolic BP < 90 mmHg Any signs of severe illness as per Assessment Tool Fever > 38.5° C Pain score > 5 / 10 Age > 65 Pregnancy consider Listeria Tachypnoea > 24 Blood in the stool Nursing concern

NO RED FLAGS RED FLAGS PRESENT (ANY) → Senior Dr review ASAP (SMO / Senior Registrar)

Continue Continue Best Care Bundle. Intervention if any: ______PATHWAY - BUNDLE CARE BEST Best Care Bundle Exit Care Bundle: Reason: ______follow pathway ↳ Select ‘BCB removed’ in TP column, Electronic Whiteboard. This signals the medical staff instructions page 2 & 3 Dr Name: ______Sign: ______

SEVERITY ASSESSMENT TOOL Choose more severe pathway if any doubt

Mild Moderate Severe

General wellbeing Feels mildly unwell Feels unwell Looks and feels unwell Not distressed e.g. lethargic, tired, light headed e.g. Profound lethargy, restless Pulse rate 50 - 99 bpm 100 - 120 bpm > 120 bpm, weak radial pulse Blood pressure Normal Orthostatic hypotension Shock, systolic BP < 90 mmHg Perfusion Peripherally warm Peripherally cool Cool and clammy Mucous membranes Moist Dry Sunken eyes, ↓ skin turgor Urine output Normal or dark urine Decreased ↓ or no urine Fluid tolerance Tolerating fluids Tolerating no or minimal fluids Tolerating no fluids Nr Diarrhoea episodes ⩽ 5 / 24 hrs ⩾ 6 / 24hrs ⩾ 10 / 24hrs

Issued: July 2015/EM Reviewed: Feb 2016 Page: 1 of 4 FILE IN PATIENT NOTES Trial (PLACE PATIENT LABEL HERE) SURNAME: ______NHI: ______

FIRST NAMES: ______

Date of Birth: ______/______/______SEX: ______✓ = YES ✗ = NO NURSING DIARRHOEA +/- VOMITING IN ADULTS

Date: Time: Assessment nurse: Sign:

INCLUSION CRITERIA EXCLUSION CRITERIA

NURSING ASSESSMENT Aim < 30 minutes

History, examination and vital signs Document on Nursing Assessment Record IV line and bloods for all patients in Acutes. In Waiting room use clinical judgement

︎ General proﬁle, LFT’s , Lipase, Lactate (VBG) Blood cultures only if temp > 38 ° C or pregnant (? Listeria) Stool culture → Do not send routinely. See indications on page 2

NO RED FLAGS RED FLAGS PRESENT (ANY) → Senior Dr review ASAP (SMO / Senior Registrar)

SEVERITY ASSESSMENT TOOL Choose more severe pathway if any doubt

Mild Moderate Severe

Issued: July 2015/EM Reviewed: Feb 2016 Page: 1 of 4 FILE IN PATIENT NOTES Trial

CROUP Best Care Bundle

TIME TO TREATMENT 70

LENGTH OF STAY 264

0 mins 75 mins 150 mins 225 mins 300 mins PRE - BUNDLE

Jane Key, Stefan vd Walt CROUP Best Care Bundle ADMITTED

36%

64% DISCHARGED

PRE - BUNDLE CROUP Best Care Bundle ADMITTED

DISCHARGED 91%

POST - BUNDLE CROUP Best Care Bundle

Representations

0 % 2.5 % 5 % 7.5 % 10 % Pre-Bundle

(PLACE PATIENT LABEL HERE) SURNAME: ______NHI: ______

FIRST NAMES: ______

✓ = YES ✗ = NO Date of Birth: ______/______/______SEX: ______

LOWER BACK PAIN

Date: / / 20 Time: Clinician: CNS HS Reg SMO HISTORY AND PRESENTING COMPLAINT

Mechanism / onset: Ask about trauma

Location / duration:

24 hour pattern:

Aggravating factors: No aggravating / relieving factors: ? AAA or spinal Relieving factors: infections

Previous admissions or ED visits with back pain: MEDICAL HISTORY Nil relevant

Known AAA IDDM / NIDDM

Previous spinal surgery: Osteoporosis / previous osteoporotic fractures: EMERGENCY MEDICINE NOTES Herniated disk or chronic back pain due to: MEDICATION / ALLERGIES Nil regular medications

Warfarin Other anticoagulants: Steroids Immune modulators:

No known allergies! ALLERGIES:

PREMORBID FUNCTIONAL STATUS & SOCIAL HISTORY

Independent Yes No Details: Smoking history Non smoker Smoker:

IVDU Other recreational drugs: Epidural abscess risk Stairs at home: No Yes Occupation:

Issue Date: July 2015/EM Page: 1 of 4 FILE IN PATIENT NOTES Trial (PLACE PATIENT LABEL HERE) SURNAME: ______NHI: ______

FIRST NAMES: ______

✓ = YES ✗ = NO Date of Birth: ______/______/______SEX: ______ ☑✓ == YESYES ☒ == NONO

BLEEDINGMINORDIARRHOEALOWER HEAD / PAIN INJURY:INBACK + EARLY/ - VOMITING PAIN PREGNANCYGCS ≥ 13

Date:Date: / / / 20/ 20 Time: Time: Clinician: Clinician: ⬜ CNS CNS ⬜ HS HS ⬜ Reg Reg ⬜ SMO SMO Date:Date: / / / 20/ 20 Time: Time: Clinician: Clinician: CNS CNS HS HS Reg Reg SMO SMO HISTORY AND PRESENTING COMPLAINT HISTORYHISTORY ANDAND PRESENTINGPRESENTING COMPLAINTCOMPLAINT Mechanism MechanismGravida: ____: / onset: Para: ______M: ____ TOP: ____ E: _____ BewareAsk of injuries about trauma Unwell for : ______caused by weapon e.g. Currently: ____ /40 by Dates USS Unknown Baseball bat or hammer. Diarrhoea No Yes If no USS yet or assisted fertility: Unwell for : ______Small volumeHigh risk diarrhoea for skull #- Days Weeks ↑ risk for ectopic Nausea No Yes consider alternative diagnosis Assisted fertility: Yes No Vomiting No Yes Significant Abdominal pain - LMC: Yes No Name: Abdominal pain No Yes high risk for other pathology IUP confirmed by USS: Yes No Date: Abdominal pain: Yes No PV bleeding: Yes No Clots: Yes No Products of conception passed: Yes No NumberLocation of / duration:pads today: ______Pads per hour: ______Concern if > 1 pad/hr Loss24 ofhour consciousness pattern: ⬜ No ⬜ Yes: Aggravating factors:Amnesia ⬜ No ⬜ Yes: ⬜ Retrograde ⬜ Anterograde No aggravating / relieving Review Redfactors: flags ? pageAAA or 1 spinal Best RiskRelieving factors factors: Headachefor infectious ⬜ diarrhoeaNo ⬜ Yes: Care Bundle pathwayinfections Contact uncleanSeizure water⬜ No ⬜ Recent Yes: travel Recent hospitilisation (including rest homes) Previous RecentNausea admissions Antibiotics / vomiting or ED⬜ visits No with ⬜ back Infectious Yes :pain: contacts Occupation: ______Visual No Yes: Review red flags page 1 MEDICAL > 14 days HISTORYduration ⬜ ⬜ BestNil relevant Care Bundle pathway Previous ED visits for PV bleeding No Yes: Dizziness ⬜ No ⬜ Yes: RELEVANT PREVIOUS MEDICAL AND SURGICAL HISTORY Nil relevant Known AAA TinnitusInpatient (new) admissions No Yes No: Yes: ⬜ ⬜ Immunosupression RELEVANT PREVIOUS MEDICAL AND SURGICAL HISTORY IDDM / NIDDM MEDICAL HISTORY Nil relevant Nil relevant Pregnant (? Listeria) ⬜ Previous concussionPrevious / head PID injury No Yes: Neurosurgical history EMERGENCY MEDICINE Previous pelvic surgery / abnormalities No Yes: Previous spinal surgery: IDDM / NIDDM Endometriosis No Yes:

Osteoporosis / previous osteoporotic fractures: EMERGENCY MEDICINE NOTES EMERGENCY MEDICINE NOTES EMERGENCY MEDICINE NOTES EMERGENCY Herniated disk or chronic back pain due to: MEDICATION / ALLERGIES Nil regular medications RELEVANT MEDICATIONS / ALLERGIES Nil regular medicines RELEVANTMEDICATION Warfarin MEDICATIONS / ALLERGIES Other anticoagulants: / ALLERGIES Nil regular Nil medicines regular SteroidsWarfarin Immune Other modulators: anticoagulants: e.g. Clopidogrel, Dabigatran, Rivaroxaban. High risk of intracranial haemorrhage ⬜ Iodine Yes ⬜ No MOH requirement: All pregnant women should take Folic acid Yes No Folic acid & Iodine.* See link EM CeDSS site

No known allergies ALLERGIES: ⬜ No known allergies! ALLERGIES: Nil known allergies! ALLERGIES: FUNCTIONAL & SOCIAL HX SOCIALPREMORBID HISTORY FUNCTIONAL STATUS & SOCIAL HISTORY Independent ⬜ Yes ⬜ No Details: Independent Nil known allergies Yes No ALLERGIES: SmokingIndependent history ⬜ Non Yes smoker No Details: ⬜ Smoker: FUNCTIONALSmoking Hx AND Non SOCIAL Smoker HX Smoker: Provide smoking cessation advice Smoking history ⬜ ETOH Non smoker ⬜ Smoker: IVDU ⬜ Other recreational drugs: IndependentSFV Yes Completed No All pregnant patients must be screened Occupation IVDU Other recreational drugs: Epidural abscess risk SmokingStairsAlcohol at Hx home: Non smoker Smoker: Living situation No Yes To be discharged in the care of a responsible adult Home situation Completed Document on nursing assessment sheet Occupation: SVF ⬜

Trial Issued:Issue Date: JulySept NovJuly2015/EM 2016/EM/O&G 2015/EM Reviewed: Feb 2016 Page: 1 Page: of 4 1 of 4 FILE INFILE PATIENT IN PATIENT NOTES NOTES Trial (PLACE PATIENT LABEL HERE) SURNAME: ______NHI: ______

FIRST NAMES: ______

✓ = YES ✗ = NO Date of Birth: ______/______/______SEX: ______

LOWER BACK PAIN

Date: / / 20 Time: Clinician: CNS HS Reg SMO HISTORY AND PRESENTING COMPLAINT

Mechanism / onset: Ask about trauma

Location / duration:

24 hour pattern:

Aggravating factors: No aggravating / relieving factors: ? AAA or spinal Relieving factors: infections

Previous admissions or ED visits with back pain: MEDICAL HISTORY Nil relevant

Known AAA IDDM / NIDDM

Previous spinal surgery: Osteoporosis / previous osteoporotic fractures: EMERGENCY MEDICINE NOTES Herniated disk or chronic back pain due to: MEDICATION / ALLERGIES Nil regular medications

Warfarin Other anticoagulants: Steroids Immune modulators:

No known allergies! ALLERGIES:

PREMORBID FUNCTIONAL STATUS & SOCIAL HISTORY

Independent Yes No Details: Smoking history Non smoker Smoker:

IVDU Other recreational drugs: Epidural abscess risk Stairs at home: No Yes Occupation:

Issue Date: July 2015/EM Page: 1 of 4 FILE IN PATIENT NOTES Trial

DISCHARGE INFORMATION: DIARRHOEA & VOMITING (ADULT) Discharge Information What%is%Gastroenteri-s%? – Croup Gastroenteri*s+('Gastro')*is+a+bowel+infec*on+that+causes+diarrhoea+(runny,*watery*stools)*and+it+may+also+ cause+vomi*ng,+abdominal+pain,+fever+and+lethargy+(extreme*4redness).*The+diarrhoea+may+last+longer+than+ the+vomi*ng.+ What is Croup? Discharge Information Gastro+is+most+commonly+caused+by+a+virus+so+an*bio*cs+will+not+usually+work,+and+could+even+be+bad+for+you.+++ – MINORIn+most+cases+the+infec*on+clears+over+a+few+days.+ HEAD INJURY Your child has croup. This is a viral illness which affects young children and causes swelling and narrowing of the upper airways (voice box and windpipe). – Discharge Information How%is%Gastro%Treated? What causes wheeze in children? Wheeze/Bronchiolitis In+most+cases+the+infec*on+clears+by+itself+over+a+few+days+(Although*it*can*take*up*to*a*week*or*two)*.The+ What are the signs and symptoms of croup?In younger children, most wheezy episodes are caused by viral illnesses. The most common one is called You have had a minor head injury (sometimesmain+focus+is+to+take+in+plenty+of+ﬂuid+to+treat+and+prevent+dehydra*on.+ called concussion) Bronchiolitis. A dry ‘barking' cough which may be worse at night. but some problems can occur.for the next 24 hours to The doctors have seen you, and have found no serious injury. We now think it is safe for you to go Most+people+do+not+need+to+be+admiKed+to+the+hospital+or+treated+with+an*bio*cs Stridor, which is a harsh noise that is heard as your child home. better over the next 24 hours,someone should stay with you people get , but to be safe Most breathes in. Wheezing is a musical, whistling sound with breathing, usually as you breathe out. problems are rare wake you once the first night to check you. Serious you. should Dehydra-on... Friends or family watch and help How long will my child be sick? It comes from the chest It is safe to go to sleep. During a wheezy episode the smaller airways of the lungs The+main+thing+to+worry+about+with+gastro+is+dehydra*on++(loss*of*too*much*ﬂuid*from*the*body).** become narrowed. This can be due to: Older+people+or+those+with+lots+of+medical+problems+can+become+severely+dehydrated+and++this+can+happen+ – Return to hospital or call an ambulance if Your child may have stridor for a few days and the cough – not the nose or throat. Danger Signs quite+quickly. swelling of the airway wall may last for up to a week. an increase in mucous in the airway

you or your friends and family notice: tightening of the muscles in the airway wall The%signs%of%dehydra-on... What is the treatment? This causes wheezing and difficulty with breathing. You seem very sleepy or difficult to wake (Panadol). • You+may+feel+thirsty+and+/+or+have+a+dry+mouth Vomiting (being sick) more thanparacetamol 3 times. • Feel+lethargic+(sleepy)+or+irritable Croup is caused by viruses, so antibiotics do notBronchiolitis help. Bad headache not helpedusual. by • You+may+no*ce+you+make+a+lot+less+urine+than+usual with wheeze following. usually starts This with can amake runny it nosedifficult and for a coughyour Cannot see as well as Mild cases of croup can be managed at home and no medication is needed. ). child to breathe which affects sleeping, eating and drinking. Slurred speech. feet. (falling down and shaking on your Oral%fluids%(oral%rehydra-on) Your Doctor may prescribe a single dose of a steroid medicine which will reduce Fits/Seizures • It+is+important+to+keep+up+with+taking+oral+fluids+G+even+if+you+s*ll+feel+nauseated.+You+will+s*ll+absorb+ airway and help them to breathe more easily. Steroids improve the stridor but haveswelling little in effect your child'son the Have weak arms or legs, or are unsteady some+of+the+fluid.++The+trick+is+to+take+smaller+drinks,+more+oHen. cough. How long does Bronchiolitis last? Confusion (don’t know where you are or get things •mixedRehydra*on+drinks+such+as+ up) or unusual behaviour.‘Gastrolyte’%or+‘Pedialyte’%%provide+a+good+balance+of+water,+salts,+and+sugar.+

Dial 111 for anThe+small+amount+of+sugar+and+salt+helps+the+water+to+be+absorbed+beKer+from+the+bowel+(intes*ne)+into+ ambulance If you are concerned about the use of steroids,The pleasewheezing note and that difficulty a single breathing dose is safe lasts and for severalwill have days no and then gradually improves. The cough usually the+body.+ lasts 10 • Oral%rehydra-on%fluids%do%not%stop%or%reduce%diarrhoea.%harmful effects on your child. They work for up to -4814PATIENT - BUNDLE CARE BEST INFORMATION hours.days but may last as long as a month. So after discharge from hospital, do not worry if the cough helps. continues for that long. Milder problems • Rehydra*on+drinks+(e.g.+Gastrolyte)+are+made+from+sachets+that+you+can+buy+from+pharmacies.+(The+ sachets+are+also+available+on+prescrip*on.) How can I care for my child at home? How can it be treated? • Mild headache can occur, but paracetamol (Panadol)• Sports+drinks:+like+‘Powerade’+are+fine+as+long+as+they+are+diluted+50:50+with+water.+ usually dizzy, cannot remember things, or cannot concentrate for long. If your child becomes upset, remain calmBecause and comfort bronchiolitis your child is caused by a virus, there is no medicine that will “cure” it. • Feeling Do+not+use+homeGmade+rehydra*on+solu*ons+as+they+oHen+do+not+have+the+right+amount+of+salt+or+sugar+and+ stridor worse. – distress can make their breathing and Feeling tired, feeling easily annoyed or poor treatmentsleep. within a few weeks. • can+be+dangerous. Paracetamol can be given to help reduce a fever and/or to keep your child comfortable. see a GP (family doctor)doctor for amay check. want to Sips of cool fluid or ice blocks may be soothing if your child’s throat is sore. family weeks your These problems usually get better without anyThe+secret+is+to+take+small+amounts+regularly+–+e.g.+taking+a+sip+or+two+(10G20+mL)+every+5+minutes.+That+way+if+ You can give Paracetamol if your child Youngis miserable children with with a feverbronchiolitis or has a often sore getthroat. tired (Follow while feeding. the dosage If your child is getting tired or taking shorter are worried or your problems get worse, If you you+keep+on+doing+it+you+will+be+able+to+keep+the+fluid+down.+Drinking+a+lot+at+once+can+oHen+bring+on+instructions on the bottle feeds, try offering smaller feeds more often. vomi*ng. carefully) If the milder problems do not get better after two Although adding steam to the air used to be recommended, there is no evidence it actually helps. (There Antibiotics do not help. refer you to the Concussion Clinic. If your child is under 1 year of age some saline (salt water) nose drops may help to help clear have been several cases where children have been badly burned from the hot the nose. Give 0.2mls up each nostril as needed and 10 minutes before a recommend using steam for croup. water) WHAT YOU CAN DO TO HELP YOURSELF We do not DO NOT let anyone smoke near your child. Issued: July 2015/EM Reviewed: Feb 2016 Page: 1 of 2 BronchiolitisTrial spreads very easily. Keep your child away from other children during the first week

and drugs of the illness (e.g. your child should not attend day care). The virus is spread from person to Medication bottle/feed mucous • DO take paracetamol (Panadol) for headache. person by coughing and by contact with secretions from the nose.is due. from

• DO take your usual pills. take tablets containing aspirin for the next 4 days. • DO NOT you are better. take sleeping pills unless your doctor says you can. • DO NOT or use drugs until drink any alcohol • DO NOT

First Name:______Gender: ______Surname: ______AFFIX PATIENT LABEL HERE Date of Birth: ______NHI#: ______Ward/Clinic: Consultant Fluid Balance RecordREFERRAL (24 hours) (Generated from Date: ED)

Time Prescriber Signature of Fluid to be given and instructions Volume ml ml per hour PrescribedDATE SENT : ____ /____ /____ NameDATE and Signature REC: ____Administrators /____ /____ 0.9% Sodium Chloride + 5% Dextrose FAX0.9% NO Saline : ______T 1000 1000 No of pages: ______Rate:0.9% Saline 15mL/kg/hr OR 1000 500 REFERRED TO : WDHB20mL/kg/hr UROLOGY CLINIC Service / Ward Clinician Name (print) Consider: Add 15mmol KCL REFERRED BY : Emergency Medicine Service / Ward Clinician Name (print)

Code for output Clinician Designation Signature ext/locator A = Aspiration, B = Bile, BM = Bowel Motion, V=Vomit, NG = Nasogastric, BL - Blood Loss, F = Fistula, S = Stoma

INTAKE URGENCY OUTPUT Intravenous Oral/Gastric Start Immediate - now Urgent - today Within 24 hrs Urine WithinOther 7 days time Within 1 month Fluid given Non-urgent Early Discharge check Site/ﬂuid Site/ﬂuid

Start level ACTIVEVolume given Running ISSUEStotal Start level Volume given Running total Time Volume Running total Code Volume Running total 1 Acute urinary retention precipitated by: 2 3 4 5 REFERRAL ETHNICITY ALERTS / ALLERGIES NZ European Maori MRSA / ESBL and other multiresistant drugs Samoan Cook Island Maori Allergies Tongan Niuean Other: Chinese Indian Other MOBILITY INTERPRETER REQUIRED: Walk Chair Yes No Trolley Ambulance

REASON FOR REFERRAL Thank you for follow up on this patient who presented with Acute Urinary Retention The indication for follow up in your clinic is: Failed TROC Painless retention Diﬃcult IDC placement New SPC Renal impairment Representation with clots Hydronephrosis Renal failure

Recent lower urinary tract surgery <6 weeks Record Balance Fluid

24 HOUR TOTAL INTAKE OUT PUT

5.11.010 Review Date: JunePlease 2008 see the detailed Electronic Discharge Summary for additional information 5.10.015 ATUL GAWANDE ‘Good checklists are precise. The are efﬁcient, to the point, and easy to use, even in the most difﬁcult situations’

‘Good checklists are practical’

- Atul Gawande [email protected] https://vimeo.com/184951787