ORIENTATION DOCUMENT QUICK SUMMARY
Welcome to Shoalhaven Emergency Department!
Please feel free to ask for the in-charge MO or RN to give you an orientation to the department on your arrival to your shift.This manual is to guide you in the general workings of the department.Please try to familiarise yourself with it as much as you can but don’t hesitate to ask staff at any time if there are any questions.
The Department
a)Contact phone numbers -
Main Desk (Communications Clerk) - 0244239262
Triage Clerk0244239365
Nurse in Charge0244239312
NUM0244239328
Director 0244239400
b) Dept map – amenities – tea room, toilet etc.(2017 is a year of reconstruction)
c) Who’s who?
Medical Director -Dr. Jacqui Irvine
Director Emergency Medicine Training – Prof Andrew Bezzina
EMET Staff Specialist Dr Peter Llewellin
Staff Specialist – Dr. John Slater
Staff Specialist – Dr. Mark Newcombe
MMO (Clinical Coordinator) – Dr. James Swinton
VMO – Dr. Glenn
NUM -Ms. Wendy Fetchet
Clinical Nurse Educator – Ms. Sharyn Balzer
– Ms. Katherine Riley
Clerical Co ordinator – Ms. Lee
Executive Support/PA to Director – Ms. Robyn Bartlett
d) Who to see for…..
eMR access - JMO Unit 02 42534845 will arrange access and four hours of training before commencement where possible. If any problems refer to Lee Lloyd or in-charge RN.
Roster problems – JMO Unit 02 42534845 (as above) in hours.
- After hours Nursing Manager on duty 44239738.
Accommodation issues – JMO Unit 02 42534845 will contact Lee Lloyd
to arrange.
-Any problems see Lee on arrival or speak to Wendy Fetchet in hours.
-If after hours contact Nursing Manager on duty. DECT phone 9738
Medical Records
- All documentation is carried out within the electronic medical record.
- All pathology and imaging results can be accessed through the eMR.
- Be very careful when accessing imaging results. If you wish to access all results in order to compare previous images then you must open the entire folder not just the image you are interested in.
1.1Emergency Department Medical Officers Ward Duties out of Hours 10pm – 8am 7 days a week.
Out of hours there is limited MO cover on the wards. ICU and Medical Registrar 24 hours. Surgical Registrar is on call after 10.30 pm.
PACE 1 calls at any time must be attended by one of the ED MOs.
The SMO2 is the allocated person for that role. Team meetings are held
at 08:30 and 17:30 with the other PACE team members at which role
allocation will be agreed.
1.2Ward Rounds and Clinical Handovers
- 0800 hours - Hand over from Night EDMOs to Day EDMOs (including NUM and RN in-charge) at computer in main write up area OR preferably using the computer on wheels at the bedside
- 1700 hours – NUM, EDMOs, Pharmacist if available, in-charge RN, NP and any RN available, attend walk around ward round( may use computer on wheels)
- 22:30 hours – Hand over from Day EDMOs to Night EDMOs (including in-charge RN) at computer in main write up area or using the computer on wheels at the bedside
- At the end of each shift- each clinician( medical and nursing) is responsible for handing over care to the oncoming staff. Handover is to include information per ISBAR guidelines(Introduction, situation/diagnosis, background/history, assessment findings, recommendation/plan)
- A handover tool as a laminated sheet is present with the computer on wheels. (See Appendix 2)
1.3Team Responses
At the commencement of each shift the ED senior Medical Officer should allocate roles of Team Leader, Airway, Procedures and Circulation. When the internal alert bell sounds these medical officers should attend the indicated area immediately and remain until the Team Leader releases them.
Trauma Call (9222) – for trauma presentations fitting trauma call (MIST) criteria the following should attend ED in support
- Surgical Registrar (+/or consultant)
- ICU registrar (+/or consultant)
- Anaesthetics registrar (+/or consultant)
The ED SMO2 or night shift senior will be the team leader and should allocate tasks along traditional lines - ABC. If the Emergency Department senior doctor deems themselves inadequately skilled to function as team leader they may delegate that role to an attending consultant (surgery/ICU/Anaesthetics) if present.
There is a trauma hotline for connection with the Trauma centre at St George Hospital - (02) 9113 4500.
Critical Care Response
For non trauma critical care responses e.g. cardiac arrest, unconscious patient, unstable arrhythmia the ED SMO2 is again the team leader and at least 2 ED Medical Officers (resource allowing) should attend to these cases initially.
Of paramount importance- if you have an unwell patient with deteriorating vital signs then involve the senior MO and ICU early!
1.5 Rostering
Medical Officers must comply with the roster provided. They must be punctual and available at all times during shift and must attend immediately when required by the Emergency Department nursing staff.
If you intend to leave the department (even briefly to get lunch etc) you MUST let the other medical staff/in-charge RN know that you are going.
NO ROSTER CHANGES ARE TO BE MADE without notifying the Medical Director and completing the appropriate “Shift Swap” form (available via the clerks). If swaps occur without notification and a “no show” occurs the person originally on the roster will be held responsible for that shift.
Procedure to follow if Medical Officer does not arrive (when scheduled to work): -
–check current roster
–try to phone MO if phone number is available.
–During business hours Monday to Friday 8am – 4 p.m. call JMO unit Wollongong Hospital ph 42534845.
–Out of business hours contact after hours Nursing Manager.44239738
–
1.6Important Department Policies
1.6.1Disposition decisions (Admit/ Transfer or Discharge must be documented in eMR including times and conveyed to the In Charge Nurse or Navigator.
1.6.2No patient should be admitted to ANY ward without documentation, and having been discussed with the admitting VMO/ staff specialist or their registrar.
1.6.3If there is a delay beyond 1 hour for a registrar to review a patient then direct contact with the admitting MO should be made and the ward transfer expedited.
1.6.4Where conflict difficulties arise in relation to admissions under inpatient teams then this should be escalated to the admitting SMO1 or SMO2 and the admitting VMO. Failure to achieve resolution at that point requires escalation to the Director of Clinical Services in hours or to the Executive on call out of hours.
1.6.5Transfers to higher level care are arranged according to the ISLHD Emergency Department Admission Process.
1.6.6No patient should be transferred to ANY other hospital without documentation(in eMR), discussion and acceptance with the registrar or VMO for that specialty
1.6.7All patients requiring significant alteration in management before discharge (e.g. changes to usual medication) or follow up should be discharged with a letter to the GP
1.6.8If you perform investigations on a patient then arrange if possible for copies of reports to go to the GP. The results can be incorporated in the discharge letter in eMR or they can be printed off separately from eMR results.
1.6.9Emergency Department Medical Officers will check pathology/x-ray reports and follow up as appropriate. Pathology results will be on eMR and are best authorised as you check them on the day. MO’s are responsible for the appropriate follow up of these results
1.6.10Discharge requires that it be safe for the patient to go home. Consideration of capacity for self care, availability of supervision and ease of access to review where appropriate should be considered. Night time discharges are most prone to risk and between 12 am and 6 am should only occur provided the patient is capable and safe by these criteria.
1.6.11In NSW all pedestrians, bicycle riders, horse riders, motor bike riders or drivers over the age of 14 who present as the result of a motor vehicle accident on a public road within 12 hours require a blood alcohol by law. This vial number must be documented in the notes. Failure to do this will lead to fines to the MO
1.6.12Transfers to Nowra Community Hospital for surgical procedures MUST have a review by anaesthesia BEFORE confirming transfer. (The private facility has no after-hours medical cover).
1.7General Info
ID cards are required to access the hospital. Please see Lee Lloyd or the clerks to obtain an access form. Security will process your ID card.
Lockers are available for use in the tea room and any locker with a key in the door is available for the shift you are working. The cafeteria is open from 8am to 2pm for meals. The main entrance Coffee Cart has meals and coffee, hours are 8am to 2pm.
The cafeteria is open from 8am to 2pm for meals. The main entrance Coffee Cart has meals and coffee, hours are 8am to 4pm.
Hospital in the Home (Community based IV care)
there is a strict referral process.
- ring the HITH office 9362 or mobile 0401 140 587
to check service availability.
- ring Dr Pratt 0405 313 185 and hand over patient to tact service. if busy dr pratt will accept message on mobile phone.
- complete referral form, obtain consent and give information sheet to patient
- leave file and med chart completed in tact box in ed.
2.0ADMISSIONS
2.1Classification of Patients
Emergency Department Medical Officers should be aware of whether patient is “chargeable” when contacting Admitting Medical Officer for admission. Clerical staff should be contacted to clarify this and document this on the patient file.
2.1.1 Insured (chargeable) patients have the right to select the doctor of their choice (except where this is inappropriate for the condition). The Emergency Department Medical Officer will contact the selected practitioner. If admission to Nowra Community Hospital (NCH the local private hospital) is arranged, copies of the admission documentation by Medical Officer accompanies patient. There is also a separate drug chart to be written out.
2.1.2 Uninsured (non-chargeable) patients – Admission is under the Duty Doctor of the day.
2.1.3 Veterans’ Affairs (Repatriation) – Vet Affairs are admitted to SDMH if a bed is available, admitted under the doctor of their own choice (if available) or maybe transferred to NCH from Emergency Department. Emergency Department in-charge RN is to advise Nursing Administration to arrange approval with Vet Affairs.
2.2Notifying Attending Medical Officer
Duty Roster – The first point of contact for admission is the registrar for the admitting team. If they are not contactable or if they fail to attend within 2 hours then notify VMO/Staff Specialist according to duty doctor rosters for SDMH and TWH kept in Emergency Department. If VMO/SS uncontactable for any reason, contact Medical Administration.
Stroke unit admissions should be notified directly to the admitting consultant and the patient transferred to the stroke unit expeditiously.
VMO/SS– Once the VMO/Staff Specialist has been informed of the admission their admitting team is responsible for the ongoing management issues. In hours, this team should be informed so they can attend to the patient that day.
Whilst the patient remains in the ED however the ED staff are responsible for any acute medical issues arising.
2.3Admission Policy
All “admissions” must have documented:
-Date
-Reason for admission
-Relevant history
-List of medications
-Allergies
-Relevant and general physical examination
-Working diagnosis
-Plan of management and /or investigation:
-tests done and results needing to be checked
-tests to be ordered
-Instructions to nursing staff re diet, positioning, ambulation, observations, etc
-Whether VMO, GP notified.
2.4Non-urgent Admissions
Admissions direct to ward – when a VMO decides that a patient needs admission and will be managing the patient in hospital, that doctor has the responsibility of organising the admission.
Patient will be admitted directly to the ward if bed available when their registrar is on duty.
GP admissions – Occasionally GPs will ring ED to discuss admission. These patients should be seen in ED and admissions performed if appropriate. If patient is not to be admitted the GP must be contacted personally.
2.5 ADMISSION PROCEDURES AND PARTICULAR SPECIALITIES
The SMO1 or SMO2 medical Officer should be notified of cases before contact with inpatient teams is made.
Anaesthetist – Duty Anaesthetists are rostered on for 24 hours from 8am to 8am. Calls to the duty Anaesthetist from ED should be made by a Medical Officer, personally wherever possible. Calls to the duty Anaesthetist should not be initiated by non-medical staff except if directed by medical staff. Nursing staff can provide experienced advice to the Medical Officer regarding the contact with an anaesthetist.
Paediatrics –
Paediatrics –
-This flowchart following indicates when a child should be referred to, or discussed with, a paediatrician
-It is designed to assist doctors in the Emergency Department and to minimise the medico legal risk to the hospital
Attachment 1: Referral Process to Paediatric Services from Emergency.
Paediatric Consultation Guidelines
Under the Age of 16 Years
Paediatric Registrar/RMO: 0800-1700 Monday – Sunday
On call Paediatrician After Hours: 1700-0800 Monday – Sunday(Call to be made by Senior ED MO)
PAEDIATRIC ACUTE RESPONSE CALL:
- Any CAT 1/2 patient (eg Cardiorespiratory Arrest, Major Trauma)
- SEPSIS of any sourcemeeting Sepsis Pathway Criteria
- Paediatric Team to be notified as per above via pager or phone activated by Triage
CONSULT PAEDIATRIC MEDICINE TEAM:
-Fever > 38C in Child < 3 Months
-Any child requiring admission or Paediatric advice or follow up
-Any non-orthopaedic patient requiring transfer to a tertiary centre, including NETS retrievals, the paediatrician on call must be called directly, prior to transfer being arranged.
-Concerns about possible Non-Accidental Injury
-Chronic Disease / Oncology Presentation:
- that already has Paediatric involvement
- or requires Medical or Surgical Intervention
-Surgical admission Age <5yo to be referred to Paediatrics by Surgical team
GP REFERRALS TO PAEDS
GP calls Paeds Paeds inform ED
UTI’S IN PTS < 4 YRS
- If child is UNWELL: admit-
Otherwise advise F/U with GP to confirm Urine MCS
- If positive, GP to arrange Renal US + referral to Paeds
Attachment 2: Escalation to Emergency Senior Medical Officer for Review of Paediatric Patients in the Emergency Department.
RED FLAGS: ESCALATION TO ED SENIOR MO
Any Child with Observations NOT Between The Flags
Any Child Requiring Referral / Admission
Fever > 38C in Child < 3 Months
Any child possibly requiring CT
Abnormal Blood Results
Representation with same or similar Complaint
Bilious Vomiting
Blood in Stools
Headache and Vomiting
Petechial Rash with Fever
Head Injury with LOC
Head Injury with Persistent Vomiting
Parental Concern / Request for Paediatric/Senior MO Review
Unexplained Injury / Injury not consistent with History / Delay to Seek Review
Orthopaedics – There are 2 orthopaedic surgeons with admitting rights to SDMH andthere are 2 other privately available Orthopaedic surgeons in the Shoalhaven. Only Dr Jarman and the 2 privately available orthopaedic surgeons have admitting rights Nowra Community Hospital (the local private hospital).
All can be contacted regarding privately insured patients (at a reasonable hour). Dr Jarman who has admitting rights to Shoalhaven Hospital has allocated days on call as does Dr. Thornton Bott. See on call roster.
All other admissions for orthopaedic issues phone TWH switch 42225000 and discuss with the on-call Orthopaedic Registrar (paged).
For patients not requiring admission or immediate advice but where they have fractures or other orthopaedic issues requiring follow up there are several possible pathways -
a)Privately insured patients – these should have initial care arranged e.g. backslab etc and then advised to call and arrange appointment at a private orthopods rooms (Dr. Jarman will accept these even if he is not on call for a particular day).If a patient is given a referral to an Orthopaedic VMO they should be informed that there would be an upfront fee.
b)If there is concern regarding ensuring early follow up e.g. hand injuries, fractures involving joints then EDMO contacts the orthopaedic registrar at Shoalhaven if either of the 2 hospital appointed orthopaedic surgeons is on call OR the orthopaedic registrar at Wollongong Hospital if not to arrange consultation or fracture clinic appointment at SDMH OR TWH.
c)If the patient has suffered a relatively minor injury e.g. undisplaced, uncomplicated clavicular fracture, minor torus(buckle) fracture of forearm, and the patient has a GP they can access, then they may be referred to their GP for follow up.
All fractures requiring plaster immobilisation must initially be given POP Back slab and referral to LMO/ Physio /Orthopaedic surgeon for application of full plaster.
Vascular Surgeon: There are no vascular surgeons at SDMH. Contact TWH for Vascular Surgeon Registrar (business hours) or General Surgical Registrar on –call (all other hours) In the event of an emergency (e.g. ruptured AAA) the General Surgeon may be contacted for advice
ENT–Available for rooms consults from ED only (Dr Serefli). Rooms consults via referral. ENT Reg at TWH on call for more urgent cases.
Urology–
Patients presenting to the Emergency Department of Shoalhaven Emergency Department with isolated urological problems will like other groups fall into three broad categories: -
a)Simple problems that can be dealt with in the Emergency Department by medical staff on site – e.g. urinary retention requiring insertion of indwelling catheter, haematuria without evidence of haemodynamic compromise or clot retention.
b)Relatively simple problems that require admission but not urgent urological intervention – e.g. ureteric colic with uncontrolled pain, haematuria with clot retention requiring 3 way IDC and irrigation.
c)Seriously unwell patients requiring urgent surgical or procedural intervention to avoid loss of life or appendage. e.g. obstructed kidney with urinary sepsis, renal laceration, testicular torsion.
Disposition options –
Presuming appropriate resuscitation and stabilisationthe disposition options are –
Patient group a) will be simple and generally ambulatory and can be discharged home for outpatient follow up.
Patient group b)
- 3 days per week and one weekend in three Dr. Spencer Murray provides on call cover.
- Outside those hours discuss the case with the senior doctor in ED who may then contact the urologist on duty at Wollongong.
Patient Group c)- These should be stabilised and resuscitated as appropriate to their presentation. If Doctor Murray is on call for the day the contact the surgical registrar at SDMH. Otherwise their early transfer to the urology service at Wollongong should be arranged ASAP in tandem with the resuscitation process. The exception is the case of testicular torsion which can be managed by the local general surgeon on duty whose registrar should be contacted ASAP and if any delay in that contact then the consultant contacted directly.