SAQ 001
A 45 year old man has a pre-hospital cardiac arrest and is dead on arrival in your ED. He was sent home from your department six hours previously, after being referred by his GP with central chest pain. His family are waiting for you in your office. Explain how you would handle this difficult situation?
This is a complex situation with social/medicolegal qualities
Pre consultation
Patient chart ordered
Speak to Dr/nurse/LMO
SW notified
Timely balance of info vs keeping the relatives waiting
Doctor issues
Is this an isolated incident?
Documentation
MDU
Mentorship
Support
Policy and procedure (are they fully orientated and appropriate discharge ?did they ask)
Departmental process
Scenario
Appropriate
Quiet
No bleep
Private
Senior nurse
Safety aspects
Approach
ID yourself as most senior in dept and you who will be dealing with this
Blame
?accept blame
you are “pts advocate”
need to outline a plan
not role to admit liability
establish discharge facts ?self discharge
coroner/PM
nature of events
arrange FU post PM/ further Ix
Difficulty with IHD
Check CK, TnI and ECG
Departmental process and policy
who discharged
minimum documentation
reassess policy
SAQ 002
Your charge nurse approaches you to say that several of the nursing staff in your ED have voiced concerns that one of your RMOs is stealing and using opiates from the ED. How do you handle this situation? (or sexually harassing staff, abusing patients, doing incompetent stuff; you pick the atrocity)
Introductory statement
This is a serious charge that may have significant implications in terms of the systems in place for handling of opiates, the RMO involved, the team and the law. Management will need to encompass all these aspects.
Investigate the allegations
Talk to the nurses making the allegations requesting specifics:
4where
4when
4how - narcotics taken from dangerous drugs cupboard Vs. taken from the pt for whom they were intended
4action taken by nursing staff
4relationship to the RMO;
If @ drug cupboard:
4investigate the drug cupboard contents and the daily tally
4talk to those staff involved with drug counts on the affected days
If from patients intended to be given the drugs:
4Talk to the nurses caring for the patients re. amounts given, where stored between aliquots & where remains disposed of
4Review patients charts
Suspicious behaviours
Undue drowsiness
Over-prescribing of opiates esp pethidine (eg; excessive doses)
Giving opiates to patients themselves rather than by nursing staff
Unexplained absences from ED
Review RMOs performance
4Request feedback from registrars & consultants re. RMO’s performance clinically & as member of the team
4Look for “at risk” behaviour patterns
4Ask re performance in previous terms
4Chart review of patients treated by RMO
Advise from hospital legal team
4Legal obligations re:
4Reporting of opioid theft/ abuse to police services for investigation
4Reporting of potential opiate abuse to the medical board
Discuss with RMO
4Appointment time
4private room
4minimize disturbances
4ask re. Coping & whether any issues that RMO wishes to raise
4discuss allegations with RMO and ask for response to allegations
4non-judgemental approach
4Safety of RMO once allegations made (suicide risk greatest in first days after exposed)
If allegations correct:
4offer drug counselling information / confidential medical services for doctors
4suggest sick leave until counselling/ drug rehabilitation in place
4ensure confidentiality
4address any underlying stressors that may be contributing to drug use
If denies allegations that appear true:
4Gather evidence
4Will need external review eg; medical board
4Formal investigation instigated
Review the procedures in the ED re. handling of opiates
4QA review of the policies and procedures involved in handling of all S8 drugs
4compare handling policies and procedures with those in other similar emergency departments
4quality improvement
SAQ 003
Your medical superintendent sends you a memo saying that your junior medical staff numbers are about to be reduced from 8 to 6. How do you respond? Detail your further responses if you do not achieve the desired outcome. (The impending closure of your observation ward would be an alternative problem to consider).
Immediate response:
Ask for an appointment in a few days time to discuss the issues involved
Gather information:
Potential Impact on Emergency Department Patient?
Current Clinical Indicators & Waiting times
Number and type of complaints
Critical Incidents/near misses and root cause analysis if done
Junior Doctor Issues…
Are junior doctors leaving? (And Why? Better training/opportunities elsewhere, poorly treated, stress, fatigue, poorly supported)
Roster issues with less staff? More nights/increased stress
Gather data on number of patients seen vs years since graduation (SHOs tend to see more patients so their loss has a much greater impact)
Policy and Procedure
Emergency is a mandatory term for interns (ie probably would lose staff at a JHO/SHO level, increased supervision needed for interns)
College guidelines: Access Block, Waiting times vs Triage category
Safe working hours project AMA
Any reasons for decreased staff
Decreased junior doctors numbers across hospital
Apparent budget constraints
Other departments have a greater need
Investigate potential solutions for reduction in staff
1. Find an alternative workforce:
Locum junior staff or increase senior staff numbers
General Practitioners
Close non-essential or less-essential services to free up doctors
Paediatric registrar to see children directly
Nurses: Nurse practitioners to run minor injury clinic, early pregnancy assessment clinic, community wound reviews, nurse initiated protocols (analgesia, bloods, x-ray)
2. Decrease number of patients
Improved discharge planning - TRACC nurse etc to decrease unplanned representations to ED
Only do core ED business
3. Measures to prevent blow-out in waiting times
Rapid Assessment Team
4. Improve junior doctor training and support
During Meeting…
Set out information in writing, clearly and concisely.
Approach to interview should be of honesty and collaboration. Demonstrate a clear willingness to be part of the solution.
Further Action Needed?
If no resolution apparent, escalate the concerns to the next person up the management ladder (district manager, state health minister)
If still no resolution apparent and reduction of junior doctors does eventuate…
Audit clinical indicators/waiting times/complaints/complications/overtime costs/critical incidents /sick leave every 4 weeks
Formally document critical incidents and near misses
Increase support to junior staff - extend senior/reg cover, informal and formal debriefing, promote healthy lifestyle, ensure appropriate meal breaks, pay overtime as needed if staff willing and able to do it.
Notify other departments and junior doctors and ask for their support and understanding during this time. Can they back up our claims and notify management of issues they encounter as they arise
If patient outcomes become affected?
Report to Executive Director of Medical Services, District Manager, State Health minister, AMA, Unions.
Whistle blowing and media to be used as a very last, extreme resort.
SAQ 004
Set up a protocol in your ED for the management of (insert one of the following here):
- DKA
- Thrombolysis
- Chest pain
- MI
- Suspected epiglottitis
- Suspected AAA
Thrombolysis Protocol
Be careful of the wording of the question re: “how to write” versus “write the protocol”
Template for “How to develop a policy or protocol”
1. Gather key stakeholders
a. ED staff
b. Other relevant departments
2. Gather information
a. Current evidence
b. Protocol from other hospitals (don’t reinvent the wheel)
c. Consider hospital infrastructure (eg access to cath lab)
3. Develop a Policy with the frame work..
a. Purpose and Scope (Who the policy is to be used by)
b. Content
c. Indications
d. Contraindications
e. Dose
f. Issues
g. Side Effects
h. Complications and their treatment
i. Date for review
4. Educate and Certify
5. Quality Assurance and Policy Review as evidence changes
THROMBOLYSIS POLICY
Purpose of this Policy:
To provide appropriate reperfusion therapy aiming for a door-to-needle time in thrombolysis of less than 30 minutes
Use of this Policy:
This policy is for use in the Emergency Department as part of the Chest Pain Policy.
Background of Chest Pain Management:
Immediate management of chest pain or ischaemic symptoms should consist of:
1. Application of oxygen and administration of aspirin/GTN
2. Full set of vital signs
3. Treat any life threats (arrhythmia)
History is brief and should focus on 2 points:
1. Is this ischaemic chest pain?
2. Are their contraindications to lysis?
A ECG should be performed within 5 minutes of presentation shown to a senior doctor (training registrar or consultant) for identification of ST elevation AMI which fulfil criteria for thrombolysis
A CXR is not vital prior to thrombolysis
Indications for Thrombolysis
1. ECG criteria for AMI fulfilled
a. New bundle branch block
b. 1mm ST elevation 2 or more of inferior leads
c. 2mm ST elevation in precordial leads
d. true posterior AMI (ST elevation V9, ST depression V1)
2. AMI with <12hours of chest pain
3. No contraindications for lysis
a. Allergy (if using Streptokinase
i. SK in past
ii. Documented strep throat in last month
iii. Aboriginal or Torres Straight islander
iv. Known allergy to SK
b. Bleeding Risk
i. Recent neurosurgery
ii. Recent surgery < 4 weeks
iii. Haemorrhagic CVA at any time
iv. Ischaemic CVA < 3 months
v. Recent Trauma < 4 weeks
vi. Medical condition that would be complicated by bleeding: suspected dissection or pericarditis
vii. Active internal bleeding: GIT bleeding, haematuria
4. Consider Relative Contraindications
a. PUD
b. Pregnancy or Post partum state
c. Prolonged CPR
d. Coagulopathy or Anti-coagulation
e. Diabetic Retinopathy
f. Severe uncontrolled HTN (consider nitrates or B-blockers then lysis)
Drugs
The Heart Foundation of Australia recommends second generation fibrin specific fibrinolytic agents that are available as a bolus (ie tenectaplase) as the fibrinolytics of choice.
Tenecteplase provides a mortality benefit in patients age < 75 years with large infarcts who present early, but at a higher cost, and higher risk of stroke in older patients. Streptokinase is cheaper and may have a lower risk of stroke, but is more complex to administer and frequently causes transient hypotension.
Dose
Streptokinase: 1.5 x 106 Units in 100 mL normal saline over 60 minutes
Adjunct to Thrombolysis
1. Heparin
2. Beta blockers
3. GTN infusion
4. Magnesium
5. Insulin
6. Hypokalemia
Referral to PAH for Angioplasty
1. Contraindications to thrombolysis
2. Failed thrombolysis after 90 minutes
3. <75 years old and presenting with cardiogenic shock
Side Effects: Bleeding
Manual pressure if external bleeding
Protamine 25-50 mg slow IVI (max 50 mg in 10 min) to neutralise 100 Units of heparin
6U of platelets IVI to raise platelet count by 50,000
Cease fibrinolytic and other anticoagulants
Treat effect of other agents (eg warfarin with Prothrombinex and FFP)
Cross match, FBC, aPTT, PT, fibrinogen level
Blood transfusion as required
Cryopreciptate 10 units IVI repeat until fibrinogen >100 mg/dL
If ongoing bleeding: FFP 2U IVI
If ongoing bleeding: tranexamic acid 10mg/kg q6-8 hrly
If ongoing bleeding: consider: rVIIa 30-100mcg/kg IVI or angiographic embolisation
Review
This policy should be reviewed by a multi-disciplinary team (cardiology, emergency and nursing) in 48 months or sooner if significant evidence becomes available
SAQ 007
With regard to defibrillation:
Outline the principle underlying its action
List the complications
Outline the features you would look for when choosing a new defibrillator/monitor for your ED.
Defibrillation action
Transient delivery of electrical current causes a momentary depolarization of most cardiac cells. This allows the sinus node to resume normal pacemaker activity. In the presence of reentrant-induced dysrhythmia, such as paroxysmal supraventricular tachycardia (PSVT) and ventricular tachycardia (VT), electrical cardioversion interrupts the self-perpetuating circuit and restores a sinus rhythm. Electrical cardioversion is much less effective in treating arrhythmia caused by increased automaticity
Complications
Failure to revert rhythm
Burns to skin and muscle
Pain
Dysrhythmia
Hypotension
Pulmonary oedema
Post cardioversion VF
Staff – accidental shock
Anaesthetic risks – hypoxia, hypotension
FEATURES
Specifications
Battery – SLA vs NiCD
Types – monophasic vs biphasic
Multifunction devices – integrated NIBP, IABP, PR, Sats, ETCO2 plus trends
Ability to pace
Pacing options
Pad options – paediatric vs adult
Weight
AC Power adapter and charge times
Dual battery capability
LCD display – channel option, able to be customised,
Ease of use in transfers – how it hangs of bed etc
Synchronisation
Ancillary Costs
Consumables
ECG dots
ECG paper
System issues
Hospital wide consistency
Integration with ambulance services
Integration with current technology
Education and support
Support – out of hours, maintenance
Eduction support and tools
Data Management
Ability to record events
Data transfer capabilities and cables
Price
Bulk purchase discount with other departments
Cost comparisons
Warranty – some only have 30day warranties
SAQ 314
As the Director of your Emergency Department, one of your emergency registrars enquires of the possibility of purchasing an ultrasound scan machine for the department.
Outline the considerations that will need to be addressed in deciding on this acquisition (100%)
• NEED – Is there a need? – Define a need / benefit.
o Reasons for acquiring it:
Why now?
Have there been specific critical incidents?
Is there a deficiency identified in the current imaging modalities / services / systems already provided?
Are there new developments to suggest its added usefulness?
Will it replace / be an alternative / addition to existing practices?
What are the expected / predicted advantages?
Do these equate to improvements in patient care?
o Specific clinical indications in question:
What are the actual clinical uses envisaged? (eg: FAST, AAA etc)
o What are the alternate options?
What is the current availability of USS?
Can the existing service be improved?
What are the alternatives that exist at present?
o Is it justifiable?
Does the ED / hospital casemix justify it?
• RESEARCHING – Check it out.
o Types of machines
o Properties of each
Costs, warranties, servicing, technical support, compatibility issues, spare parts availability, ease of use, quality of images etc
o Other practical considerations – size, storage, portability, durability, electrical safety
• CONSULTING – asking and benchmarking.
o With other departments – ED’s, radiology, cardiology etc
o Own ED staff – ED consultants and nursing staff
• COSTING.
o Purchase costs v Leasing costs?
o Running costs?
o Maintenance costs?
o Cost-effectiveness?
o Predicted lives saved / decrease in morbidity?
o Funding sources?
o Staff training expenses?
• ADMINISTRATION.
o Quality assurance / auditing issues
o Medicolegal / accountability issues
o Protocols for use
• TRAINING.
o Who should be trained? Everyone v dedicated staff
o Who will use it?
o How will they be trained? By whom?
o Skill maintenance
o Ongoing education and certification
o Guidelines on training – minimal standards
• TRIALLING.
o Choose machine – set time period
o Audit and feedback
SAQ 311
Your hospital executive has decided to introduce a new patient database management system. This will replace the current separate systems for clinical, administrative, radiology and pathology data. It will include a completely paperless electronic medical record.
(a) Outline the features that will be important for this system to possess in your emergency department (50%)
(b) Describe the potential problems involved in implementing such a system (50%)
(a) Features of the system
• Reliability:
o Clinical and medico-legal implications of computing error.
o Need for minimal downtime for maintaining system.
o Reliable back-up provisions for system failure.
• Compatibility:
o With institution’s legacy systems (ie: existing IT systems).
o With existing hardware capabilities.
o With other hospitals / institutions – need for data sharing. Including capacity for networking (local and wide area).
• Accessibility:
o Multiple hardware access points.
o Capacity for simultaneous access.
o Remote access by clinicians at home.
• Technical:
o Hypermedia capabilities ie: capable of supporting graphics, text, video, scanned data all in one patient record.
o End-user friendliness – minimal time spent at terminal versus the bedside.
• Reporting capabilities:
o Need for analysis of data / generation of reports from queries.
o For – research, budgeting, audit, quality assurance processes.
• Security:
o Need to comply with provisions of Commonwealth Privacy Act.
o Ability to use password / firewalls to allow levels of access to parts of system.
o Security from viruses, criminal activity.
(b) Barriers to implementation
Recognise that these will be more organisational / managerial than technical.
• Cost of implementation:
• Research into most appropriate systems.
• Cost of actual hardware and software.
• Cost of reliable back-up systems.
• Cost of time required for hardware installation.
• Establishment of evaluation process:
• Initial costs will be large and up-front, whereas benefits likely to be intangible and delayed.
• Staff satisfaction.
• Consumer satisfaction.
• Staff training:
• Expensive.
• May lengthen period of orientation for all new staff.
• Will need to be ongoing.
• Organisational resistance to change:
• Need for informal and formal communication and information sharing.
• Consideration of employment of ‘change management consultants’.
• Power shifts as different groups are given different levels of access.
• Stakeholder consultation:
• Government, consumers, users.
• Especially with respect to access, privacy issues.
• Management decisions:
• IT support on contractual basis or full time hospital employment.
• Decisions regarding access to information by outside groups eg: clinicians from other hospitals etc.
• Method of transition – overlapping systems in operation, introduction by department etc.
SAQ 097
List the features which would lead you to suspect a patient of being a drug-seeker. Outline how you would deal with such a patient.
Signs that increase suspicion of drug seeking
Multiple allergies to non-narcotic medications
Stated diagnosis difficult to confirm (radio-opaque renal stones)
Vague pains - back, pelvis, headache, dental, abdominal - with minimal clinical signs
Carrying letter stating need for narcotics
Unknown in hospital/region
Presenting out of hours
Age >12
Using an alias
Asking for specific narcotic by name and dose
Requests specific doctor
Concurrent alcohol or drug abuse
Premature requests for refills
Reports lost/damaged/stolen medication
Third party requests
Therapeutic dependence with true chronic problems
Known to Medicare Prescription Shopping Information Service
Known to local drug management program
Management
1. Manage the Patient
* At the initial instance take claims at face value and offer complete assessment with physical examination and investigations.
* Provide non-narcotic analgesia - NSAIDS, paracetamol, buscopan, hot packs, TCA, (ensure alternatives are non-addictive)
* See further information - other hospital presentations, prescription shopping hotline, hospital medical chart, GP, pharmacy
* Consider underlying social issues
* Consider undiagnosed organic cause
* If narcotic seeking cannot be confirmed give narcotics to alleviate distress with clear end-points and limits on doses. A script for a limited supply (48 hours) until patient can return to normal GP. If ongoing opiate need inpatient assessment should be offered.
* For multiple drug allergies consider drugs that don't release histamine: fentanyl, oxycodone
* For chronic pain ensure patient has had appropriate investigations have been done to exclude organic causes of pain.
* If you are confident the patient is opiate seeking expect a loud outburst and threats when opiate is denied. Avoid confrontation in public places (eg corridor, waiting room) and do this in a private area. Have security staff near.
* Listen to concerns/threats and then give a calm explanation as to
- why you are concerned and refusing opiates
- department policy that supports the refusal
- offer alternative management
- offer admission/referral for further investigation
- offer support/referral for drug rehab, pain clinic
- offer withdrawal support
- Do not provide a script for opiates. Any scripts that are given should be tamper proof
- Notify GP of presentation.
* Document carefully in patients chart.
2. Management for Emergency Department doctors
* stay up to date in acute and chronic pain management techniques
* be aware of where to refer for chronic pain management clinics and drug rehab (inpt vs outpatient)
3. Management of Emergency Department
* consider written guidelines re the use of opiates in migraines/chronic LBP,
* audit the 'frequent flyers' and develop individual pain management plans
* education sessions for staff
* clear protocols to contact security if patient becomes aggressive
4. Management of your community
* know where drug rehab is available and provide support/referral as needed
* notify to medical board if an individual community doctor seems to be over-prescribing opiates