ACCS training in
UniversityHospitalSouthampton
An introductory guide to the rotations through Acute Medicine, Intensive Care,Anaesthetics and Emergency Medicine.
Acute Medicine in Southampton
Introduction
The ACCS acute medical block in Southampton comprises 6 months, separated into two 3 months blocks. These will be spent in AMU and respiratory medicine.
The intention is to expose trainees to a combination of acute and chronic disease management which is necessary to fulfil the requirements of the ACCS curriculum. The AMU block will enable trainees to obtain experience in the initial management of medical and elderly care patients during the first few days of their hospital stay. During the respiratory attachment, trainees will also be involved in the initial management of respiratory patients in the AMU and for the ongoing care of patients being managed by the respiratory team.
All trainees will be allocated an educational supervisor at the start of their 6 month block which will be one of the Acute Medicine consultants based on AMU; this consultant will also act as clinical supervisor during the AMU block. During the respiratory block one of the respiratory consultants will act as Clinical Supervisor.
The Clinical Lead for the ACCS Acute Medicine programme in Southampton is Dr Beata Brown; she will ensure you are allocated an educational supervisor at the start of your attachment. Divisional induction is undertaken at the start of your 6 month attachment and a local ‘mini-induction’ meeting will be arranged at the time of changeover after 3 months. It is important that you arrange to meet with your allocated educational supervisor as soon as possible after starting your post and after the changeover. If you have any concerns or questions about the posts please discuss these initially with your educational supervisor or contact Dr Brown (ext 4716 or email:
The Acute Medical Unit
Introduction
During your medicine attachment you will undertake a 3 month block of time working on the Acute Medical Unit (AMU). During this time you will be under the supervision of the Acute Medical Consultants:
Dr Chris Roseveare
Dr Jas Dulay
Dr Beata Brown
Dr Mayank Patel
Dr Ben Chadwick
The consultants work a combination of early and late shifts, providing senior cover on AMU between 08.00 and 21.00, Monday to Friday.
At weekends and overnight a larger number of consultants take part in an on-call rota, which also encompasses the morning Post Take ward round. (PTWR)
Layout and operation of AMU
AMU is made up of 4 clinical areas:
Ambulatory Care (AMA) – 6 trolleys / 2 chairs
AMU1 (green) – 10 beds- mixed acute admissions bay
AMU 2 (purple) – 18 beds- male bay
AMU 3 (pink) – 18 beds- female bay
Most patients admitted as emergencies to the medical / elderly care ‘take’ will start their in-patient stay in the AMU. GP referred patients are usually brought directly to AMA, where they undergo immediate senior assessment (STAT), when a decision is made on further investigation and need for admission. Patients who self present to hospital or who are acutely unwell will be assessed initially in the Emergency Department (ED) prior to referral to the medical team.
Ambulatory Care (AMA) also functions as a trolley based area for daytime assessment of patients where overnight stay is deemed un-necessary. This area also encompasses the nurse-led DVT service and an area where patients requiring once-daily IV antibiotics for cellulitis can be assessed on a daily basis. AMA should close overnight (from 9pm).
When all beds are full it is sometimes necessary for AMA to be used overnight for patients on beds.
Referral System
GP Referrals
If a General Practitioner deems that hospital admission to medicine / elderly care is required he / she will contact the Admissions Dept (ADT). They bleep the receiving Dr (bleep 9189) who will determine whether the patient requires admission.
If the patient is accepted for admission, ADT then telephone the nurse co-ordinator on AMU to inform them of the admission.
Between 8am-9pm Mon-Fri the GP calls are usually answered by the acute medicine consultant.
Overnight and at weekends the calls are taken by the on-call SpR.
Emergency Department Referrals
Patients are initially assessed by the ED Triage nurse and medical staff. If medical / elderly care referral is deemed necessary, the ED Doctor will contact the acute medicine SpR during weekdays or on-call SpR overnight and at weekends.
The nurse in charge in the ED will inform ADT and liaise with the nurse co-ordinator on AMU.
The ‘Take’ Lists
When a patient is accepted for admission the accepting Dr will type their name on the Take List.
The list comprises a table with columns indicating the source of referral, whether they are to be seen by the medical / elderly care consultant, the problem described by the referrer and the name of the junior doctor who has assessed them. This list is kept on a daily basis on the computer in the Multiprofessional Office on AMU.A new list should be created each day and is stored under AMU-list icon.
Currently a new electronic, hospital wide, Doctors' Worklist is being developed and soon will replace the current system.
Following referral of a patient to AMU…..
When a patient arrives on AMU the nurse co-ordinator will write their name on the white board on the door of the Multiprofessional Room (MPR) along with their destination bed. GP referred patients are initially assessed via STAT system in AMA and wait there for junior clerking and a bed to be allocated or directly discharged if admission is not needed
ED referred patients will be transferred to the AMU as soon as possible; if a bed is not immediately available medical juniors may require to undertake their initial assessment in the ED (see below), rather than waiting for transfer to AMU.
The priority with which a patient needs to be seen is indicated by a number on the board next to the patient’s name (1 is highest priority; 5 is lowest). Please write your name on the board & the computer list to make it clear who has seen the patient.
Senior Review of Medical / Elderly Care Patients on AMU
All patients admitted as part of the acute medical take are seen within 12 hours of admission by a consultant on a Post Take Ward Round (PTWR)
a)Patients aged <80 are the responsibility of the Acute Medicine consultant of the day.
During weekdays the acute medical consultants operate a system of continuous senior review; following initial assessment by a junior doctor the acute medical consultant will review the patient and a clear management plan will be documented on the ‘Post Take Ward Round’ page
Patients admitted overnight will be reviewed on the morning PTWR (starting 8am) by the consultant who has been on-call the previous night; in some cases this will be the acute medicine consultant for the following day. (Consultant rota is displayed in the Multidisciplinary Office)
b)Patients aged >=80 are the responsibility of the on-call elderly care consultant.
The elderly care consultant will usually arrive on the ward at around 4pm and undertake a ward round of all patients seen before that time; wherever possible the junior doctor who has clerked the patient should be available to present the patient to the consultant.
Elderly care patients not clerked will be seen on the following morning elderly care PTWR, which usually starts at 9am.
Speciality review of patients on AMU
Each morning a respiratory and gastroenterology team will come to AMU and take over care of patients whose problem is deemed to be more appropriate for their care.
Patients who are deemed to have a respiratory or GI problem should be indicated in the ‘speciality’ column of the take list. The speciality team will review these patients; if it’s deemed appropriate they will indicate in the notes that they have taken over the care of the patient. Although the junior doctors on AMU remain responsible for the day-to-day management of these patients, daily senior review will be undertaken by the speciality team. Once transferred off AMU the speciality team takes full responsibility for their care.
All patients should be admitted using the Medical Unit Admission Sheet. This includes a page for the post-take consultant ward round. It is essential that this part of the document be completed in its entirety, including differential diagnosis, clear management plan, and documentation of x-ray and ECG findings.
The estimated length of stay and proposed ward localisation area should be documented in ALL cases; where possible, patients whose length of stay is predicted to be <48 hours will remain within the AMU to ensure rapid discharge.
Patients with a GI haemorrhage should be discussed with the on call Endoscopist; emergency endoscopy is usually available before the start of the morning list (8am-9am), between morning and afternoon lists (12.30-1.30) and after the afternoon list. Patients admitted after 5pm should be discussed with the on-call Endoscopist (available via switchboard) in time to be endoscoped before 9am (e.g. before midnight or approx. 7am if the patient is haemodynamically stable).
Patients referred following an episode of deliberate self-harm are usually seen by the psychiatric crisis team in A&E. If admission is required for medical reasons (e.g. cardiac monitoring, treatment with Parvolex, etc), or the patient is too drowsy to be assessed in A&E the patient will be referred to the medical team. A psychosocial assessment form should be completed by the admitting medical team and faxed to the Department of Psychiatry (under 65 years of age) or Moorgreen (over 65 years of age) as early as possible
Handover
Good patient care depends on adequate handover of all patients with active medical problems. It is good practice to ensure that the following are clearly indicated in the notes:
a)Working diagnosis
b)The next proposed stage of medical management
c)The appropriateness of investigations
d)CPR/ITU/DNAR decisions
e)Information given to the patient
To assist handover there is
-space at the end of the admission document
-Weekend handover label
-Weekend handover list/file on each ward
Formal daily handover meetings for Medicine and Elderly Care are conducted Monday to Friday in WF11 Seminar Room on F Level West Wing starting at 08:30 hours. An SHO representative from D level and G level will attend the meeting, and are then responsible for passing on the information to the relevant inpatient team. There is a separate rota for handover meetings issued by Zena Sadler in the Junior Doctor’s office X4734.
There is a formal handover on Medical HDU from 16:45 to 17:15 daily. This involves the medical HDU team, and the evening on call team. Any patients from the medical wards who require it can be handed over at this meeting.
There is also a formal handover from the evening on call team to the night team from 21:00 until 21:30 in the F level seminar room WF11. Here jobs and patients are handed over to the night team. Representatives from the Hospital at Night team and Outreach are present at the meeting.
The weekend handover form in each patient’s notes must be completed on Friday morning.Please state clearly the patient’s resuscitation status where this has been discussed.
In addition a weekend handover list (green file) should be completed on each ward, this should include any patient who needs clinical review or may be suitable for discharge over the weekend. The cover team on a Saturday and Sunday morning ward round will review these patients.
Discharge
All patients must have an estimated date of discharge (EDD) on admission which will need to be continually monitored and updated if necessary.EDD must be set for the date you think the patient will be medically fit.When the patient is medically fit you will need to sign a section 5 form if they require any further ongoing services.
Discharge summaries (HMR) are produced electronically on the e-docs system. The discharge summary should be a full account of both the admitting episode and any co-morbidities that the patient suffers from (e.g. diabetes), whether or not they are directly related to the admission episode.
Patients are expected to go home before 11.00hrs on the day of discharge in accordance with pre-11am trust targets. Therefore, ideally, all HMRs need to be commenced on admission to the ward, updated regularly and completed the day before discharge to ensure timely arrival of TTOs.
Junior Doctors Roles / Responsibilities while on AMU
The working arrangements on AMU are complex and subject to change on a regular basis. On the first day of you AMU block you should make contact with the AMU SpR / Acute medicine consultant who will give you a brief introduction to the current working practice. If you are ever unsure about your role please ASK any of the resident AMU medical staff.
Weekdays
A weekly rota is posted on the door of the multiprofessional office; this indicates which area each junior doctor is allocated to on a daily basis. Punctuality is extremely important – if you are likely to be late please bleep the on-call SpR (9061) to inform them.
AMU 2 and AMU 3
During weekdays two junior doctors (one FY1 and one FY2 or SHO) are allocated to each of AMU 2 and AMU 3. One of these juniors will be allocated to work 8am-6pm; the other will work from 9am to 7pm. The 8am-6pm junior should go to their respective area and join the morning PTWRs when they enter their area. A handover folder is kept in each area in which the junior should document jobs to be done following the PTWR.
Patients who are not seen as part of the morning PTWR will usually be seen by the acute medicine consultant or SpR for the day. Once the morning PTWR has been completed the junior doctors in this area should start to review the remaining patients, maintaining a list of jobs to be done using the handover folder.
Junior doctors allocated to the areas are responsible for ensuring that the jobs relating to their patients are all completed.
When new patients arrive in the area they should be clerked in a timely fashion by the team in each AMU (supported by the ‘take’ SHOs – see below). Junior doctors should always be prepared to cross boundaries – if another area is struggling due to junior doctor absence, patient dependency or the need to undertake procedures requiring supervision.The 8am FY1 is also responsible for the 2111 crash bleep and for dealing with any investigation cards placed in the folder in the Multiprofessional Office.
AMU 1 and AMA
These areas are covered by FY2 and more senior grades doctors supported by one of the Acute medicine SpRs.
Due to sickness or other leave it may be necessary for one of the AMU2 or 3 juniors to provide support to these areas during some weekdays.
Warfarin prescriptions for ambulatory patients with DVT need to be completed between 5pm-7pm; the AMA junior will usually complete this before leaving; on occasions it may be necessary for the on-call SHO to compete this.
‘TAKE TEAM’
TAKE SHO 1(CARDIAC ARREST BLEEP 2011) 1100-2100
Pick up bleep from 8am SHO and obtain handover of any patients waiting to be seen. If no patients waiting to be seen, go to AMU 1 / AMA and support the juniors in those areas.
You are responsible for ensuring that all patients are clerked in a timely fashion – if patients referred by the ED are not moved to AMU immediately due to lack of bed availability you should start assessing them in the ED.
Keep a close eye on the take list / patient list on the door of the multiprofessional room.Present patients to the relevant consultant (medicine / elderly care) once results are available.
Please ensure that you go to ED to see referrals as soon as possible, rather than waiting for them to come to AMU. Once results of investigations are back, patients can be reviewed promptly by the duty AMU consultant. GP referrals are admitted via AMA STAT or straight to all areas of AMU and you may need to visit each area to be aware of their admission. Please ensure that any unwell patients/outstanding results/jobs or investigations are handed over to the night team.
TAKE SHO 2 (BLEEP 2993)1300-2200
10001
Pick up bleep from multiprofessional room. Contact Take SHO 1 on arrival and start undertaking review of any new patients waiting to be seen. If no patients waiting to be seen support team on AMU1 / AMA or any other area of AMU which is under pressure.
As above, please ensure that you go to ED to see referrals as soon as possible, rather than waiting for them to come to AMU. Please be available at 4pm to direct the EC consultant PTWR (mon-fri).
LATE SHIFT FY1 (CARDIAC ARREST BLEEP 2012 held 1700-2200)1300-2200
On arrival bleep the take SpR 1 on 9061 and identify whether there are patients waiting to be seen.If no patients waiting to be seen, support medical staff on AMU / AMA.
Main role is to clerk acutely admitted patients anywhere in AMU, either from ED or from GP referrals, then present to consultants when results are back. In general FY1 should prioritise GP-referred patients, as ED referred patients will usually have seen an SHO / SpR already.