Trainee Manual

2012

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Princess Alexandra Hospital

Department of Emergency Medicine

Trainee Manual - 2012

INTRODUCTION TO PAH

The Princess Alexandra Hospital is one of three tertiary level facilities in Queensland, providing care in all major adult specialties, with the exception of obstetrics and gynaecology, and one of Australia’s leading teaching and research hospitals. The Hospital provides Acute Medical, Surgical, Mental Health, Rehabilitation, and Allied Health Services as well as state-wide services - Acquired Brain Injury Outreach Service, Queensland Amputee Limb Service, Spinal Outreach Team, and a Transitional Rehabilitation Program.

The Hospital is nationally recognised for its expertise in spinal injury management and is a major transplantation centre for livers, kidneys, bone cartilage, and corneas. The District houses the Queensland Liver Transplant Service, Queensland Eye Bank, the Queensland Bone Bank, and one of the major Queensland Health Pathology Services.

PAH is the major referral hospital for the Southern Area Health Service within QLD Health.

The Princess Alexandra Hospital Emergency Department (PAH ED) is a major referral department. It is responsible for the triage, assessment, immediate treatment, and disposition of acutely ill patients presenting to the hospital. The ED has approximately 55,000 attendances per year with an admission rate of 37%.

The Emergency Department has 3 main areas of focus: service delivery, education and research. Emergency trainees play an integral role in all these areas.

This manual aims to provide an overview of the department and how it functions along with an understanding of the training program for emergency medicine trainees.

Our mission is to partner trainees in attaining the aims of the PAH Emergency Medicine Training Program:

Our aim is to develop: Trainees with the ability to be:

o Higher order thinkerso Effective communicators

Trainees with the self-belief to be:o Independento Decision makerso Resilient

Trainees with the capacity to:o Show empathyo Link actions to outcomeso Be discerning and ethical decision makers

Trainees with the courage and commitment to:o Aspire to excellenceo Be tolerant and inclusiveo Be patient advocates

The principles by which the entire PAH Emergency Department work by:

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In order to allow patients presenting to the PAH Emergency Department (ED) to have their rights under the Queensland Health Patient Charter (2002) preserved, specifically their rights to be treated with respect and dignity and to be treated on the basis of their clinical condition, the following applies:

All PAH ED staff will continually work to optimise the efficiency of our healthcare delivery, thus maximising the number of patients that we can provide quality care to.

The PAH ED recognises that within its health area the PAH is responsible for maintaining access to health services that cannot be accessed elsewhere.

Each patient has a right to be assessed and managed in an individual cubicle, affording them privacy during history, examination and management.

The clinical condition of a patient will dictate their right to an emergency bed and

to the degree of observation and monitoring they require.

Contents of this manual:

Pages 4 – 8: PAH DEM – Staff, Security and Safety, Facilities, Patient Population

Pages 9 – 24: PAH Emergency Medicine Training Program

Pages 25 – 29: PAH Operations and Service Delivery

Pages 30 – 49: PAH Clinical Practice Manual

Pages 50 – 53: PAH Trainee Manifesto (includes trainee clinical expectations – the specifics)

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PAH DEPARTMENT OF EMERGENCY MEDICINESTAFF

Medical

Consultants:

There are 17.5 full-time equivalent Staff Specialist positions within the PAH ED. These positions are currently filled with a mixture of full-time and part-time staff.

The current personnel are:

Director: Dr Phil Kay Co-Director: Dr James Collier

Deputy Director: Dr Andrew Staib

Director of Emergency Medicine Training: Dr James Collier / Dr Darren Powrie

Staff Specialists:

o Dr Michael Sinnott

o Dr Bevan Lowe

o Dr Colin Page

o Dr Marianne Cannon

o Dr Ellen Burkett

o Dr Andrew Parkin

o Dr Sean Lawrence

o Dr Roy Mulcahy

o Dr Peter McSweeney

o Dr Jonathon Isoardi

o Dr Hector Fuentes

o Dr Iain McNeill

o Dr Tina Bazianas

o Dr Jonathon Isoardi

o Dr Glenn Ryan

o Dr Kim Nicholls

o Dr Katherine Isoardi

o Dr Ogilvie Thom

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Consultant Roles and Management Portfolios:

Michael Sinnott – Head of Research

Andrew Staib – Residents

Jonathon Isoardi – Department Education Supervisor

Marianne Cannon, Hector Fuentes – Medical Students

Sean Lawrence - Simulation

Glenn Ryan / Katherine Isoardi – Trauma

Katherine Isoardi – Clinical Guidelines and Procedures; USS

Ellen Burkett – Quality

Darren Powrie – Mental Health

Bevan Lowe, Hector Fuentes - Equipment

Colin Page – Toxicology, Drugs and Therapeutics, Rostering

Please see these consultants directly if you have any particular concern within these areas, otherwise contact either of the DEMTs or the ED Executive (Phil Kay, James Collier, Andrew Staib and Darren Clark (ADON)). The above describes some of the main management portfolios; a more extensive list covering all consultant responsibilities is displayed on the noticeboard and on www.emergpa.net

Consultant ACEM Roles:

Various consultants hold college appointments and as such may be a useful resource for trainees:

James Collier – Regional Censor, QLD; Board of Education; Chair of Accreditation; Court of Examiners; TRC – Senior Adjudicator

Sean Lawrence – Court of Examiners; FEC subcommittee – VAQ Committee; CPD – ACME Monitoring Subcommittee

Bevan Lowe – FEC subcommittee – VAQ

Hector Fuentes – PEC – Pathology Subcommittee

Ogilvie Thom – TRC – Adjudicator

Michael Sinnott – TRC - Adjudicator

Marianne Cannon – Public Health Committee

Andrew Staib – Standards Committee – ED Ultrasound

Registrars:

There are 17.5 full-time equivalent registrar positions in the ED. The PAH ED is accredited for 24 months of advanced emergency medicine training by the Australasian College for Emergency Medicine. The registrar positions are only filled by advanced trainees.

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Each year a Registrar Liaison is appointed to chair monthly trainee meetings and liaise with the consultant group about trainee issues.

Training Senior House Officers:

There are 10 Training SHO positions available within the training program, generally for provisional trainees. They undertake a 12-month program involving - 9 months in ED and 3 months in ICU (8 trainees); or 6 months in ED and 6 months in the Acute Surgical Unit (2 trainees). At any point in time there are 7 Training SHOs working on the ED roster.

Resident Medical Staff:

There are 29 Resident Medical Officers assigned each term to the ED. This consists of 17 Junior House Officers / Senior House Officers and 12 Interns.

Nursing

Assistant Director of Nursing- Darren Clark

Nurse Manager – Jan Gehrke

There is also a small group of Clinical Nurse Consultants who supervise the ED floor from a nursing perspective.

Administration Staff

The ED Office Manager, Jillian Vernon and Administration Officers are the main points of contact for medical staff administrative issues.

Mr Pete Fugelli is the ED’s Database Manager and is responsible for organising your access and orientation to the Emergency Department Information System (EDIS).

Upon commencing at the hospital you should have been given passwords and orientation to PACS (radiology) and AUSLAB (pathology). If you have any problems please see Jillian Vernon, ED Office Manager.

Radiography Staff

The ED has dedicated plain x-ray facilities and radiography staff. Mr John Lucjan is the head radiographer within the ED. There is also a radiology registrar within ED Radiology 24/7 for CT, USS and plain film requests and reporting.

Wardpersons

The ED has dedicated wardpersons to assist in patient transport, patient lifting, and general cleaning.

Allied Health Staff

There are dedicated physiotherapists, occupational therapists and speech pathologists for the ED. Contact details and criteria for referral can be found in the PAH ED Clinical Practice Manual (CPM).

Community Health Nursing Coordinator

There is a Community Health Nursing Coordinator (CHIP nurse) based in the ED. There is also an ‘Aged Care Early Intervention and Management’ program coordinator. Contact details and criteria for referral can be found in the PAH ED CPM. They are also the initial point of contact for the ‘Hospital in the Home’ and ‘Hospital in the Nursing Home’ programs.

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Social Work

A social worker is based in the ED; contact details and criteria for referral can be found in the PAH ED CPM.

Pastoral Care

There are a number of Pastoral Carers who provide support to patients and their families every evening shift.

EMERGENCY DEPARTMENT SECURITY AND SAFETY

The Emergency Department has secured entry and exit points. To access or leave the ED you are required to use your hospital ID badge on the infrared scanners to release the doors. These measures are to ensure safety of staff and patients from outside threats. They also ensure the safety of patients within the ED who shouldn’t leave for their own safety due to medical or mental illness.

Emergency Alarms :

These alarms are situated in all the cubicles and at the nurses’ station for your protection.

Emergency / Arrest - Blue Security Alert - Red

Nurses - Handheld button

Wardpersons - Yellow

Fire exits/Alarms/Extinguishers :

Look around on your first shift for the fire exits and position of alarms and extinguishers. Follow the fire exit signs in the event of a fire or other emergency. The hospital provides fire safety lectures each year for all employees.

Hospital Identification Badges :

You are expected to wear your ID badge where it can be easily seen. The ID badges allow you access through the secured doors to and within the ED. They ensure you are recognised by security staff as a hospital employee, whilst patients and other staff can more readily identify you as well.

Safety/Security :

Please guard your valuables. Do not leave or store your bags in the medical write-up room. You will be given a key to the trainee office where valuables can be kept. Otherwise, there are lockers in each of the male and female toilets for storage of personal and valuable

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items. If you wish to make use of these, please see the ED Office Manager / ED Administration Officer. A $5 refundable deposit is required for a locker key.

EMERGENCY DEPARTMENT FACILITIES

Staff Tea Room :

The ED staff tea room has refrigeration, microwave, tea and coffee facilities. There is also a TV and general reading material. Pigeon holes for staff mail are located here. It is everyone’s responsibility to keep the tea room clean.

Toilet facilities:

Within the male and female toilets there are lockers that can be utilised for storage of personal and valuable items. Locker keys can be obtained from the ED Office Manager / ED Administration Officer (a $5 refundable deposit is required for a key).

There are also shower facilities within the toilets.

Trainee Office:

A dedicated office for trainees is located within the ED Administration area. Within this room are individual trays for trainee mail and correspondence; fridge for drinks, 2 computers (one of which has a large widescreen monitor that can be utilised for small group teaching within the room); resources for education (electronic and paper resources; a text book library, an EMRAP CD library, anatomy models, filing cabinet with other primary exam resources); and noticeboards for communication of education and training programs being run in the ED.

The room also serves as a ‘sanctuary’ from the floor to have meal or drink breaks and is lockable such that you may wish to keep personal items there.

Conference Room:

The ED shares a conference room with radiology. It contains all the necessary audiovisual equipment and is utilised for the weekly CME program and other larger clinical meetings.

EMERGENCY DEPARTMENT PATIENT POPULATION

PAH ED has a relatively high acuity workload with complex medical cases and multi-system trauma being a feature. An expansive knowledge and skill set is required with particular emphasis on acute resuscitative skills.

PAH ED sees approximately 55 000 presentations per year, with a 37% admission rate. A high proportion arrives by QAS (47%) which underlines the high acuity of the presentations the ED manages.

Being one of the 3 major trauma centres for QLD PAH ED attends to a high number of trauma cases.

The presence of a Professorial led Trauma Unit; interventional cardiologists and 3 catheter labs; a stroke unit that offers lysis to suitable patients; a respiratory HDU that allows for NIV in the ED through to the HDU; neurosurgical services; cardiothoracic services; cancer services; renal unit; transplant unit (renal and liver); spinal injuries services from acute surgical care to the rehabilitation unit; and the full spectrum of radiology services including interventional services, provides for a challenging but very interesting patient population that is managed through the ED.

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Mental health patients (8% of PAH ED’s presentations) are catered for by a dedicated ED Mental Health Service which operates 24/7.

PAH ED has its own 8 bed Short Stay Ward for ED patients and access to Hospital in the Home and Nursing Home programs.

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PAH EMERGENCY MEDICINE TRAINING PROGRAMThe PAH ED offers a high quality, comprehensive training program for emergency medicine trainees. It includes specific programs to suit the needs of trainees at all stages of their training.

An overview of the training requirements for fellowship with the college, and how these requirements can be met within the PAH ED training program, is as follows:

o Basic Training – 2 years – usually but not necessarily, the intern and second postgraduate years.

o Obviously this can be undertaken anywhere; if you are at PAH for the first 2 post graduate years, we would advise that in PGY 2 you seek to undertake some rotations from the following selection: anaesthetics, cardiology, ENT, orthopaedics, renal medicine, ophthalmology, plastic surgery.

o Provisional Training – 12 months (minimum):o 6 months training in a single approved ED

o 6 months other approved training (this may be ED or non-ED)

PAH ED, through the Training SHO positions, provides an ideal 12-month program for provisional training, ideally suited to PGY 3 or 4 trainees.

o Completion of the Primary Exam (this may be completed at any time during basic or provisional training)

PAH ED provides a Primary Exam Preparation Program prior to each exam. It is expected that provisional trainees undertaking the Training SHO role will complete all their provisional training requirements, including the primary exam, within this year.

o Extended training time requirements (if required) – whilst completing primary exam requirements beyond the initial 12 months of provisional training.

Depending on the needs and skill set of the trainee, additional provisional training time may be undertaken within a registrar position in PAH ED or more commonly it will be arranged to occur in one of the non-tertiary ED’s in SEQ.

o Advanced Training – 48 months:o 30 months training in approved ED posts (minimum of 6mths in a tertiary

and 6mth in a non-tertiary ED)

PAH ED is accredited for 24 months of advanced emergency medicine training (being a major referral ED this satisfies the ‘minimum 6 month tertiary ED’ requirement).

Non-tertiary ED time requirements (minimum 6 months) are generally provided by rotations to nearby Mater Adults, Logan, Redlands, Greenslopes, QEII or Ipswich ED (however PAH ED has links to all accredited EDs in QLD and a non-tertiary rotation can generally be arranged to wherever the trainee wishes). As PAH ED

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does not receive paediatric or obstetric presentations these rotations offer the opportunity to see these patient populations.

o 18 months training in approved non-ED posts.

Non-ED rotations currently available to trainees at PAH include: PAH ICU (either at a junior or senior registrar level); PAH Psychiatry; PAH Internal Medicine; Anaesthetics (QEII) and Retrieval Medicine with Careflight Medical Services. Many other rotations are available via the DEMT on negotiation with the unit in question.

o Minimum paediatric requirement – accredited via a logbook system or completion of 6 months in a JTC accredited paediatric ED.

Most trainees will satisfy the minimum paediatric requirement via a 6 month rotation from PAH ED to the Mater Children’s ED (accredited by JTC for 12 months training).

Otherwise Paediatric Logbook requirements can generally be completed during non-tertiary ED rotations.

o Research requirement – to be eligible to sit the Fellowship Exam trainees must have completed their Trainee Research Project (TRP):

We strongly recommend that trainees within our program satisfy their research requirement by undertaking the necessary TRC approved university subjects.

The UQ - PAH ED Research Unit will help instigate, oversee and support trainees that wish to undertake a research project – preferably after they have completed their university subjects.

o Fellowship Exam – may be undertaken after completing 36 months of advanced training and completion of the Trainee Research Project:

o A highly regarded Fellowship Exam Preparation Program is run from PAH ED prior to each exam. This program is often accessed by trainees from all over SEQ.

PAH ED Trainees:

The PAH ED currently has positions for:

17.5 FTE Registrars. The registrar positions within the ED are generally reserved for advanced training registrars.

10.0 FTE Training SHOs. These positions are generally reserved for those commencing their training (i.e. provisional trainees).

Trainees are placed into Trainee Groups for the purposes of mentoring and allowing for small group teaching amongst similarly experienced trainees. The Trainee Group Structure template (including the coordinators and mentors) can be seen below.

Directors of Emergency Medicine Training:

James Collier and Darren Powrie are the Co-DEMTs. They are responsible for ensuring the provision of a training program commensurate with the accreditation status of the ED. The DEMT takes responsibility for all training issues within the ED and coordinates the delivery of trainee education programs and in-training assessment.

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Jonathon Isoardi is the department’s ‘Education Supervisor’ and has oversight of all education programs running within the department, from medical students to consultant CME. In particular, he is heavily involved with delivery of education to the trainee group.

Other general training issues concerning QLD based trainees can be taken up with either:

QLD Censor – James Collier; Deputy Censor – Philip Richardson ACEM Trainee Representative, QLD

Or the relevant contact at the college (see ACEM Website – Contact Us)

Trainee Assessment:

James Collier coordinates the assessment process for all trainees. All ED consultants provide feedback on trainees with emphasis on strengths and weaknesses. Mid-term and end-of-term assessments are conducted primarily by James Collier with the trainee and where possible their mentor. Aims and objectives for the coming training period are set and action plans implemented where necessary.

With respect to the On-line Training Assessment (OTA) process it is expected all trainees familiarise themselves with the relevant rules and procedures. With respect to entering a DEMT within the system when undertaking an ED term at PAH, trainees should select ‘James Collier’.

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TRAINEE GROUPS TEMPLATETRAINEE GROUPS TEMPLATE

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ADVANCED TRAINEES - REGISTRAR POSITIONS:

The program for advanced trainees at the PAH ED can be thought of as one that covers the duration of their 48 months of advanced training with the college.

The DEMT(s) will liaise with you to map out an individually tailored program that covers your training needs and rotations over the 48 months. This will be reviewed regularly with you to ensure its currency in light of any training or personal changes. The DEMT will take responsibility for arranging your rotations outside of PAH ED.

Advanced training registrars can be expected to spend 18-24 months in the PAH ED during the course of their training. We generally recommend that a continuous 12 months be undertaken in the PAH ED leading into and including the time of the Fellowship Exam, in order to readily access the exam preparation program and other resources we have to offer.

As a result the first 2 years of advanced training will generally involve proportionally more non-ED time and include your non-tertiary ED time. The last 2 years will include more PAH ED time as you prepare and sit your Fellowship Exam.

Supervisors / Mentors:

For the purposes of mentoring and small group teaching within the weekly CME program, trainees are divided into the following groups with the following consultant supervisors / mentors:

Trainee Group 1 – Training SHOs – Provisional Trainees; Supervisors / Mentors – Andrew Staib (Coordinator), Hector Fuentes, James Collier, Kim Nicholls and Katherine Isoardi

Trainee Group 2 – Registrars – Advanced Trainees – Pre-Exam; Supervisors / Mentors – Michael Sinnott (Coordinator), Marianne Cannon, Tina Stathakis, Ellen Burkett and Glenn Ryan

Trainee Group 3 – Registrars – Advanced Trainees - Exam; Supervisors / Mentors – Darren Powrie (Coordinator), Bevan Lowe, Sean Lawrence, Iain McNeill and Jonathon Isoardi

Trainee Group 4 – Registrars / Senior Registrars – Post Fellowship Exam; Supervisor / Mentor – James Collier

The aim of having these groups is to recognise that trainees have different educational, psychological and emotional needs at various stages of their training and as such these groups allow for more directed education and mentoring. By having a number of consultants assigned to each group allows for ‘group mentoring’ in that a trainee may be more comfortable having a small selection of consultants from which to choose to discuss issues. This also allows for access to someone from your group in the event of a consultant being on leave etc.

Each group has its own educational objectives and a detailed curriculum which will be provided to you within the group. An overview of the program is outlined in the ‘Trainee Education’ section of this manual.

Registrar Duties:

The clinical duties of registrars within the ED primarily involve patient care and supervision of junior staff. The balance can be difficult at times, but guidance from consultants is always close at hand.

The role on the floor at PAH ED is weighted towards the ED registrars taking on a more supervisory role of their resident team. The registrars will have less of their own patients to manage independently, but will be intimately involved with the patients the residents

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within their team are seeing, with particular emphasis on the ATS Category 2 patients. With respect to ATS Category 1 and 2 patients within the ED Resuscitation Rooms, the consultants and registrars take primary responsibility whilst utilising the assistance of the junior staff.

The senior medical staff, in conjunction with the senior nursing staff, should also take responsibility for the flow of patients through the department. This entails:

knowledge of all patients in the department guidance of the resident staff in efficient work practices 

timely clinical decisions regarding patient assessment, management and disposition

Within PAH ED there is a high level of consultant supervision of the registrars. This is not intended to be intimidating but offers an opportunity to have frequent clinical discussions and receive ‘teaching on the run’.

Please see Appendix 2 ‘Trainee Manifesto’ for more specific details on the role of a registrar within the department.

Resident Supervision:

Medical staff work within clinical teams consisting of a registrar and 2-3 residents (this will often include a Training SHO); the teams are responsible for geographic areas of the department. The registrar is expected to manage their team and coordinate the delivery of patient care by their team. It is the registrar’s responsibility to know what their residents are doing. The residents are told to seek their registrar out early in their deliberations with patients. Early guidance in their management of patients can save appreciable time later.

Department Management:

The registrars on the floor also need to be aware of 'patient flow' in the ED. Registrars need to be proactive in assisting the consultants in ensuring the timely processing of patients through the ED. Staff and space are limited within the ED, thus good time-management skills and efficient use of resources is essential. However, above all, the consultants rely on the registrars to focus on the delivery of quality care for their patients.

In particular, registrars must familiarise themselves with the patient flow procedures that have been designed to assist with the safe and efficient movement of patients through the ED. Please see the PAH ED Clinical Practice Manual (CPM) for further details.

Procedural logbook:

It is suggested / expected that all trainees keep a logbook of their procedural experiences. This logbook will be reviewed at mid and end of term assessments.

Registrar on-call commitments:

Each day the roster indicates one of the evening registrars to be on-call for the department in case of ICU transfers, multi-casualty incidents etc that may occur overnight; though it should be noted that the call-in rate is extremely low.

Short Stay Ward:

A consultant and registrar are assigned each day to the SSW. Together they will review and manage those patients in the SSW of a morning.

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Intern, Resident Teaching:

The majority of intern and resident teaching occurs 'at the coal face'. The ED offers a unique opportunity for resident staff to easily access consultant / registrar teaching whilst discussing cases throughout their shift.

Interns have their own educational program – More Learning for Interns in ED (MoLIE) - that is delivered every Tuesday and Wednesday by the consultant group. This program is resourced such that interns are provided with 8 hours of teaching per week.

There is also a program for resident teaching each morning. A 30-40 minute session for residents in the ED occurs Mon-Fri at 08:00 (except Thursday). This is run by a consultant. There are weekly educational themes with topics covering common ED presentations or practical skills. The use of simulation training and multidisciplinary teaching is emphasised within this program.

Resident Assessment:

Registrars are required to provide feedback on the performance of the interns and residents working within the ED. Interns and residents receive a mid and end of term assessment interview with a consultant. Access to Survey Monkey is sent to all consultants and registrars at these times to provide feedback prior to these interviews.

Problems on the floor:

Occasionally you will confront problems whilst undertaking your clinical duties. The consultants have a presence on the floor from 08:00 – 24:00 every day and would encourage you to bring any query, concern or problem to them.

Consultant Supervision:

The consultants provide clinical coverage from 08:00 – 24:00 every day. They expect to be notified at all times about critically ill or injured patients and anything 'political' in the ED. Overnight they are on-call and will readily return to the ED if requested by the registrar. The consultants are also required to approve any after-hours CT / USS in the ED (after 22:00).

Major trauma overnight is an automatic call in for the consultants.

Clinical issues, problems with inpatient teams etc should be escalated to the consultants at all times.

The consultants will conduct hand-over rounds at 08:00, 13:00, 17:00 and 22:00. Between these times they will often undertake frequent rounding of the ED with the senior nursing staff and the registrar and their clinical team.

Registrar Education:

The programs and resources available for registrars are described in detail in the Trainee Education section of this manual.

Another important aspect of education is that which occurs on the floor. The consultant group will always attempt to take advantage of ‘learning opportunities’ on the floor; either in hand-over rounds or simply in discussing a case one-on-one.

Rostering:

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Colin Page coordinates the registrar roster.

It is a rolling roster with requests added in as required. If you want any time off on a particular day / weekend / morning / evening etc you can request this when requests are sought for the compilation of the following roster period. When the roster is written, every effort will be made to accommodate your requests. However, there can never be a 100% guarantee of fulfilling all requests.

Usual shift times –

DAY shift: 08:00 – 18:30 EVENING shift: 14:00 – 00:30

NIGHT shift: 22:00 – 08:00

Punctuality for the commencement of shifts is expected.

Principles of the roster:

There are 3 day (0800-1830), 3 evening (1400-0030) and 2 night registrars (2200-0830) each day. This may change if staffing is stretched due to leave and exams etc. With respect to the Training SHOs there is at least one SHO per shift, seven days per week. Trainees work 4-5 out of 8-10 weekends on average.

One of the evening registrars is on call-back for the night shift if the department is overloaded with category 1 patients (e.g. multi-traumas). However, the call-back rate is extremely low.

There will always be a 10 hour break between rostered shifts.

The roster is based on an 8 X 10 hours per fortnight. The standard week therefore is 40 hours. Occasionally, to balance leave requirements in particular, rosters may be 30 hours one week and 50 hours the next.

Nights are broken into 2 periods and follow each other. Mon –Thur one week; and Fri-Sun the following week.

Process of writing the roster:

Each roster will be written for approximately 3 months i.e. Jan-Apr, April-July, July-Oct, and Oct-Jan.

All requests must be in writing, usually by email. Verbal requests do not count.

If you want any time off on a particular day/weekend/evening/morning you can request it when requests are called for the next roster period. There can never be a 100% guarantee that you will get all your requests; however every effort is made to accommodate everyone’s requests. Please note that after the roster is written, late requests will almost never be met.

A notice for roster requests will be distributed approximately 5 weeks before the end of the last published roster. You will have 1-2 weeks to submit your requests. You will be emailed to confirm that your requests have been received. It is also advisable that you also put down any holidays to be taken in that period in addition to entering them on the leave roster. Requests are taken only for the dates the roster is being written. Please do not send requests for dates outside of the roster. Requests must be received by the due date. Late requests will normally not be accepted.

A final roster will be published approximately 1 week after all requests are received. It will be labelled ‘final roster’. Thereafter, any changes to the roster are made amongst

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yourselves (i.e. you can swap with your colleagues providing that the department coverage remains unaltered and follows the rules below).

For those sitting exams, whether primary or fellowship, if possible you will not be rostered for nights in the 3 weeks before the exam.

Principles of swaps on the roster:

A swap with your colleagues once the final roster is completed is allowed. Colin does not require notification of your swaps; however notification of all swaps must go to Jillian Vernon (ED Office Manager) who will change the master copy.

Though the swap must still comply with the following:

o Coverage of the department should remain the same as the original rostero Minimum of 3 days off after 4 nights and 2 days off after 3 nights

o No evening shift after finishing a night that morning

o No more than 6 days worked straight

o For pay office reasons swaps must be in the same pay fortnight and the total hours rostered after the swap cannot be less then 80 hours in that fortnight

o Any problems regarding swaps, then please see Colin Page or Jillian Vernon

Holidays and exam time:

Holiday requests are made in writing via email to Jillian Vernon who enters them on the leave roster.

A central official registrar holiday register is kept. It is located on the “G” drive of the hospital computer system (G drive – Emerg – Share – Rosters – Consultant and Registrar Leave) for reference. If it isn’t on the leave roster then the request doesn’t exist. Request early and if time off is to be taken in the next roster request period ensure the holidays are recorded before the final date for roster requests elapses.

First in gets the holidays, except in the month before exam times when people sitting exams are given priority - unless extenuating circumstance prevail (e.g. getting married, having a baby etc).

Only two people off at any one time (obviously exam leave for attendance at the exam is the exception).

If more than two people want time off to study for an exam, a ‘job share arrangement’ can be undertaken whereby 2 people each work 20 hours/week. The details can be worked out with Colin Page.

If you want the weekend off before the holiday, then let Colin Page know at roster request time. In general this will be factored in on the roster anyway but it cannot always be guaranteed.

Unless there are extreme circumstances you can only take your annual entitlement (6 weeks annual leave, plus 1 week professional development leave) of leave each calendar year. This rule is so everyone can freely take their entitlement. Carrying forward leave from other hospitals etc impacts on your colleague’s ability to take their leave. For those of you who are with us for only 6 months then you are only entitled to half of the above.

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Unexpected emergency leave e.g. sick leave/compassionate leave, maternity/paternity leave:

Please discuss this with Phil Kay, James Collier, or Andrew Staib. All reasonable requests will be accommodated even at very short notice.

If you need to take sick leave, as much notice as possible would be appreciated on the day e.g. 8 am call before an evening shift, night shift etc. This will enable changes to be made to cover your shift. You need to notify the consultant who is on at the time that you ring (If ringing at night, then notify the night registrar).

Any problems:

Contact Colin Page. Email colin_page@health.qld.gov.au or cpage@bigpond.net.au Mobile: 0404 044 732. If all else fails – contact Jillian Vernon by phone (3176 7513) and leave a message or contact by email Jillian_Vernon@health.qld.gov.au

Tasks for you:

It is strongly advised that you notify Colin and Jillian of your personal email address if you want rosters etc via this route. Colin will be doing the roster notifications by email.

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PROVISIONAL TRAINEES – TRAINING SHO POSITIONS:

There are 10.0 FTE Training SHO positions for appointment each year. The position is designed for provisional trainees, in particular those in PGY 3 and 4. The expectation is that trainees are only in this position for 12 months.

The 12-month Training SHO position involves either:

9 months in PAH ED and 3 months in PAH ICU (working as the ICU Junior Registrar) (8 trainees), OR

6 months in PAH ED and 6 months in PAH Acute Surgical Unit (2 trainees)

The objectives of the 12-month program are:

To further develop a trainee’s interest in emergency medicine To develop a trainee’s emergency medicine and critical care knowledge and skills

beyond those of other senior residents

To provide an environment conducive to successfully completing the ACEM Primary Exam

To produce at the end of 12 months a trainee who has completed all requirements for provisional training and has the knowledge and skills to undertake a registrar role as an advanced trainee.

Supervisors:

Andrew Staib, Hector Fuentes, Kim Nicholls, Katherine Isoardi and James Collier are the consultant supervisors for the program and act as mentors for all Training SHOs. Andrew Staib coordinates and writes the Training SHO roster.

Details of the 12 month Program:

(a) 3 months ICU:

The 3 month rotation to ICU is ideal for immersion in critically ill patients. PAH ICU is a C24, high volume unit with a patient acuity and complexity reflective of the tertiary status of the hospital. The ICU junior registrar position is a supported one, with more senior staff supervising and in attendance for high level decision making and procedures.

Trainees will gain experience in many aspects of caring for the critically ill but in particular management of the ventilated patient, patient transfer and vascular access.

(b) 6 months Acute Surgical Unit

This 6-month rotation seeks to expose trainees to acute surgical problems with a focus on trauma. The surgical personnel within the Acute Surgical Unit also run the Trauma Services within the hospital.

(c) 6 or 9 months ED:

The Training SHOs’ primary goal when working in the ED is to ‘see patients’, in order to achieve the clinical exposure we believe the trainee needs at this stage of their training. The main difference from the registrars working in the ED is that Training SHOs do not have formal responsibilities for supervising the resident staff in the ED. The main differences from the resident staff working in the ED is that the Training SHOs are supervised (mainly by consultants, but also by the registrars) and educated on the floor within the context of their emergency medicine training (i.e. they are prompted and questioned from the point of view of what they need to learn to function as a registrar one day); they are more closely involved with the management of patients in the resuscitation

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rooms; and they have access to the resources and education programs available to the registrars.

Training SHO Duties and Rostering:

The ED Training SHOs work a 24/7 roster, separate from the registrar and resident rosters. The shifts are designed to cover times of need for the department as well as provide maximal clinical exposure to the trainee.

There are several patient groups, and thus areas within the ED, to which we would like you to gain as much experience as possible:

1) Urgent, acute care and resuscitation-type patients2) Non-urgent, complex patients (e.g. ATS Category 3 medical patients)3) Non-urgent, ambulatory patients

Each is as important as the other and it is vital to spread your exposure across all these areas. We expect you to eventually achieve a junior registrar level of skill (with respect to knowledge, practical skills and decision making abilities) in dealing with all these types of patients.

You will usually be working within a team with a supervising registrar, and whilst the consultants are also closely involved with supervising your work you will need to keep the registrars informed of your patients.

It is expected all trainees keep a logbook of their procedural experiences. This logbook will be reviewed at mid and end of term assessments.

Roster Swaps / Holidays / Leave:The roster is a rolling roster which covers 24/7, but with plenty of time off. This benefit is lost if we try to accommodate lots of individual daily requests. However there are multiple opportunities to swap. Andrew Staib coordinates and writes the Training SHO roster.

As three quarters of your leave is funded by ED and one quarter by ICU, you should attempt to spread it between the terms in a similar ratio if possible. The roster easily sustains one person away at a time, but becomes very onerous on the remaining people if 2 or more are away. As such, the rule is one away at any one time except for special circumstances such as exams. Unlike the resident leave roster at PAH you do not have to take all your leave at once.

Jillian Vernon, Office Manager, administers a spreadsheet that records everyone’s leave. When you know what leave you want, notify Jillian in writing via email. If it is not on the spreadsheet it doesn’t count. If there is already someone away on the dates you want, the rule is first in, first served, unless negotiated otherwise. The roster is written three months in advance and we will try to accommodate all reasonable requests.

Training SHO Education:

PAH ED CME program run on Thursdays (0830-1200):

Trainee Group Sessions (Group 1 – Training SHOs; 08:30 – 09:30): EM Foundation Knowledge and Skills. This is based around case discussions, data interpretation, equipment review, and small group simulation. Whilst a program of facilitators, presenters and topics is provided, it is still a very flexible session, so feel free to bring questions or cases along to discuss. As with the whole CME program run on Thursday mornings, all trainees are expected to attend if reasonably possible (i.e. not away or on nights) to make up a 75% attendance requirement over the course of a term. There will be no trainee group sessions when the Thursday CME session is simulation (as this is required to start at 08:30).

Large Group Session (all trainees and consultants) 0930-1200. All trainees and consultants come together for this component of the morning in the ED Conference Room.

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Primary Examination Preparation Program: Sessions are held on Thursday afternoons 1600 - 1800. If rostered on, you are able to attend and you will be covered on the floor.

The section on ‘Trainee Education Program’ outlines these programs in detail.

PAH ED TRAINEE EDUCATION PROGRAM:

PAH ED provides a comprehensive education program to guide trainees through their emergency training.

There are many opportunities to be involved in teaching in numerous environments. A great deal of effort is made by all the consultants to ensure you receive high quality education. Your attendance is expected.

Ultimately, you are responsible for your own learning. If you would like more sessions, or missed out on something you feel to be important, please approach Jon Isoardi, Darren Powrie or James Collier. Alternative arrangements can always be made.

Please note that all education sessions are programmed and rostered, you will need to keep abreast of the program, and your involvement within it, via the calendar on www.emergpa.net.

OVERVIEW:

Departmental CME: Thursday 0830 – 1200

Simulation training:Airway simulation Tuesday 1400 - 1500Weekly team simulation Thursday 0800 - 0900Trauma simulations any time on the floor

EMCET (Emergency Medicine Clinical Evaluation and Teaching)

Fellowship Exam Teaching Tuesday 0930 – 1200

Primary Study Group Thursday 1600 – 1800Tuesday 1600 (before viva)

Online Education Modules www.emergpa.net

DMEDED (DAY - MEDICAL EDUCATION) Your day to deliver medical education to the junior doctors under consultant supervision

DANAES (Airway Management Program) Selected trainees undertake an 8-week airway management program involving one day a week in theatre

Airway Management Module SHOs and selected advanced trainees to participate in airway management module

Continuing Medical Education (CME): Weekly ED Education Sessions:

The weekly training sessions for the consultant and registrar group are held on Thursday mornings from 0830 - 1200.

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Within the CME program exists small and large group teaching sessions. The template for the education sessions is attached below; with details of general content and trainee requirements for each term.

In summary, the trainees split into their small Trainee Groups 1-4 from 0830 until 0930. At 0930, all trainees and consultants rejoin in the conference room for the large group session (0930 – 1200).

Rosters for both the Trainee Group Sessions and the main sessions are provided well in advance to allow you sufficient preparation time. Please note that a consultant is generally assigned to facilitate each session and they will assist trainees in the preparation of their presentations.

To further assist in your development of being able to deliver an effective presentation, your presentations are informally assessed and feedback is provided one-on-one at the conclusion of the morning session.

Whilst the ED does not provide for paid attendance to all these sessions, we do attempt to provide non-clinical days for trainees throughout the term. These DE (Day Education) are generally rostered to occur on Thursdays. There is an expectation that trainees will attend 75% of the Thursday sessions throughout a term (an attendance record is kept). Night shifts and annual leave etc is not taken into consideration as there is no expectation that you will attend. You will manage most of this with day shifts and DE days, but it does mean there will be days you attend when you are on evening shifts or a day off. It is hoped the morning’s program is of enough interest and benefit to make this an easy chore anyway.

Simulation Training:

Simulation training accounts for a considerable proportion of the CME program and the training program as a whole. It allows for multidisciplinary teaching, communication and team work training and is well regarded by all levels of staff.

Weekly team simulation sessions involving trainees, junior medical staff and nursing staff occurs weekly on Thursdays 08:00 – 09:00.

Small group multi-disciplinary simulation training also occurs on a fortnightly basis on Tuesday afternoons, with a focus on airway management simulation. A selection of Registrars and Training SHOs on a DE day or from a DAY shift will be rostered to attend.

Sean Lawrence and Jonathon Isoardi are the coordinators of simulation training within the ED.

EMCET (Emergency Medicine Clinical Evaluation and Teaching)

EMCETs are one-on-one interactions between a consultant and a trainee; they are an ‘education’ interaction not an ‘assessment’ interaction. They are based on the mini-CEX format. Essentially consultants observe the trainee undertake a specific component of their clinical practice and then provide immediate feedback and have a debriefing discussion. A written record is kept of the EMCET for both the trainee and the DEMTs to refer to.

The EMCETs will ideally aid with the following domains:

Short case skills

1) Examination2) Synthesis of examination findings3) Presentation of examination findings

Long case skills

4) History taking5) Problem lists

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6) Investigations - use and interpretation7) Management options

Communication

8) Breaking bad news9) Counselling skills – e.g. discharge advice or treatment explanation10) Referrals and notes

Management

11) Supervision of junior staff12) Management of multiple patients13) Education of junior staff

Procedural skills

14) Direct supervision of any procedural skill, including ultrasound

Guidelines for Trainees and Consultants

• You will need to be proactive in seeking each other out during a shift• Discuss first with your consultant what will be observed• Aim to have 10 minutes for observation and 10 minutes for discussion / feedback• Feedback must be immediate• Finish with discussion about areas done well and requiring improvement• Written feedback will be provided but this IS NOT A RATING or MARK• Use your logbook to keep a record of EMCETs completed• Keep your feedback sheets for discussion with the DEMT at mid + end of term

meetings

Suggestions for EMCETs (but not limits)

Do a short caseThis will cover domains 1,2,3

Listen to a history and formulate a problem listThis will cover domains 4 and 5

Discuss investigation and management of a problem listDomains 6 and 7

Identify then observe difficult patient/family communicationDomains 8 or 9

Listen to a referralDomain 10

Observe and discuss "floor management" (this may occur over the length of a shift)Domains 11 and 12

Observe a teaching interactionDomain 13

Supervise a procedural skillDomain 14

ACEM Primary Exam Preparation:

Primary Exam Training - This is coordinated by the DEMTs with the assistance of other consultants. These sessions occur on Thursdays 1600 - 1800. A 22 week preparation

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program is conducted prior to each exam. However the focus of the program is one of support rather than ‘teaching content’. The facilitators ensure resources and advice are readily available to guide and assist you in your preparation. The sessions held resemble a study group with a consultant facilitator. There are 4 subject heads that coordinate the teaching.

Anatomy – Andrew Parkin / Tina Bazianas

Pathology – James Collier / Glenn Ryan

Physiology – Hector Fuentes / Jonathon Isoardi

Pharmacology – Colin Page / Darren Powrie

Following the MCQ exam, twice weekly viva practice sessions are held on Tuesdays and Thursdays (from 16:00) until the viva exam.

Within the Trainee Room a filing cabinet with resources for all four subjects can be found. The ED also has all the anatomical models that are utilised in the exam to assist you in your viva practice.

Please see the DEMTs with respect to commencing your preparation.

ACEM Fellowship Exam Preparation:

Fellowship Exam Training - this is coordinated by Dr Darren Powrie with the assistance of other consultants. A formal 9-10 month program is conducted prior to each exam sitting for candidates.

The program involves sessions at PAH ED every Tuesday 0930 -1200. The program is highly regarded, with trainees outside of PAH frequently accessing it, and is associated with a high degree of success at the exam.

Please see Darren Powrie with respect to commencing your preparation.

Online Education Modules

Various consultants have collated resources and provided specific education modules on important emergency medicine topics. These modules combine latest evidence with PAH specific clinical practice guidelines to provide a comprehensive overview of topics with local applicability.

We would recommend all trainees work through theses modules during the course of their term in the ED.

DAY – Medical Education (DMEDED)

A large part of your future role as an Emergency Physician will be in the education of emergency medicine trainees and junior medical staff. As a result we aim to provide

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education on “how to teach” via rostering registrars to ‘Medical Education Days’ (appearing as DMEDED on the roster). These days consist of:

1) Involvement in morning resident tutorials (08:00 – 08:30)

Each weekday morning, except Thursday, at 0800 the A3 consultant delivers a tutorial for the residents. There is a theme for each week. The DMEDED registrar will be expected to deliver some of this tutorial, with a consultant mentor (A3 consultant). You will need to liaise with the A3 consultant rostered for that day to work out your preparation. The session outline can be found on the USB stick on the noticeboard in the EM office area.

2) Involvement in MoLIE teaching (13:00 - 17:00)

The intern cohort from both PA and QE2 hospitals are rostered for one non-clinical day per week. This day is for MoLIE teaching (MOre Learning for Interns in Emergency). The day consists of two modules: 0830 – 1230 and 1300-1700. Registrars will be helping to facilitate the afternoon session. Each module has a theme and is structured around cases. There is a variable amount of practical teaching depending on the module. Most of the teaching takes the form of group discussion.

Each registrar will be expected to facilitate some of these modules, under the mentoring of a consultant. You can expect to be given feedback on your teaching skills.

Please liaise with your mentor prior to the session. The “MoLIE B” consultant will be the person to approach. You will need some time to become familiar with the module prior to its delivery; do not turn up unprepared. The actual modules can be accessed from the USB stick on the noticeboard on the EM office area.

Airway Management Program - DANAES

In order to address the difficulties in acquiring and maintaining airway management skills we have developed a specific airway management module in conjunction with the Department of Anaesthetics. It is an 8-week program undertaken by one trainee at a time. The program involves one day per week being assigned to theatre to acquire and develop skills in airway management. They will also be expected to complete certain reading requirements (airway management manual), attend the airway simulation sessions on Tuesdays (as the roster enables), complete the Airway Education Module (on-line and within the small group training sessions on Thursday mornings) and have EMCETs completed with respect to airway management within the ED. More specific details will be provided to those trainees selected to undertake the program.

Airway Management Module

This is an online module but also delivered over the course of 10 weeks within the small group training sessions on Thursday mornings. It is run twice a year and is for the Training SHOs and selected registrars who are undertaking the airway management program.

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08:30 – 09:15

TRAINEE GROUPS SESSION (Groups 1-4)

Location: ED

09:15 – 09:30

Coffee Break

09:30 – 10:30 – Session 1

ALL TRAINEES

Location: Conference Room

10:30 – 11:00

Morning Tea

Administration

11:00 – 12:00 – Session 2

ALL TRAINEES

Location: Conference Room

Details: Trainees divide into trainee groups for individual sessions with coordinator and mentors from their group.

Sessions are not held on Thursdays that involve Simulation Training (as the Simulation Sessions must commence at 08:30.

Aim of Trainee Groups Session: Focus on issues / topics / needs specific for that trainee group.

Thursdays that involve Radiology Sessions will not have a 09:15 coffee break (the Radiology Sessions will commence at this time).

Radiology Sessions will be followed at 10:00 by Morning Tea & Administration for 30min

General Content of Sessions 1 / 2: Orientation Sessions at start of

term Critical Care Sessions

(involves 2-3 trainees - Audit / Cases / Evidence)

Morbidity and Mortality Sessions (involves 2-3 trainees - Audit / Cases / Evidence)

Simulation – 3-4 simulation training sessions per term

Monthly Radiology Sessions (last Thurs of the month)

Quality Assurance – Clinical Audit

Toxicology Sessions Trauma Review Data Interpretation Critical Appraisal of the

Literature

Administration Session involves feedback from consultant management meetings; discussion of operational issues arising in the week; notification of residents requiring assistance.

On a monthly basis (the first Thursday of the month) this 30 minute session will allocated to the registrars for their own registrar meeting.

Research Sessions Professional Development

Sessions Disease Module Sessions

(involves 2-3 trainees per module - evidence and clinical audit based)

Inpatient Unit Sessions Case Discussion Forums

All sessions / topics will have a coordinating consultant who will facilitate the preparation of the session with the trainees involved.

Trainees will be provided details of their topics and involvement in the sessions as each 3 month roster is produced.

Princess Alexandra Hospital – Department of Emergency MedicineEmergency Medicine Education Sessions – CME – Consultants and Trainees

Session Template

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PAH ED RESEARCH:

The consultant staff actively encourages research initiatives within the ED. The UQ - PAH ED Research Unit overseas all research within the department.

Dr Michael Sinnott is the current Head of Research. Rob Eley is the Academic Manager of the Research Unit. Drs Ellen Burkett, Iain McNeill, Colin Page and Ogilvie Thom are the other consultants with significant research expertise.

The DEMTs strongly advise trainees to complete their trainee research requirement via undertaking TRC approved university subjects. All trainees should have completed their trainee research requirement requirements prior to commencing their preparation for the fellowship exam. Thus, these subjects should ideally be completed during advanced training years 1 and 2.

If a trainee has an interest in research, then they are actively encouraged to undertake research through the department’s research unit after having first satisfied their training research requirement via the university subjects.

If a trainee wants to utilise a Trainee Research Project (TRP) to satisfy the research requirement, then they MUST gain prior ‘approval’ from the DEMTs, before commencing their project with a TRP supervisor.

Research Resources:

PAH ED has compiled an electronic resource titled “Research Resources and EBM”. Within it is a catalogued array of resources that will assist you with research projects and critical appraisal of the literature. This can be found on the desktop of the computer in the Trainee Office.

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PAH ED OPERATIONS / SERVICE DELIVERYThe processes by which ED staff see patients and manage patient flow are detailed in the PAH ED Clinical Practice Manual (CPM). This can be found within the appendix of this manual.

The ED CPM is a practical manual for all medical staff working in the ED and can be found on the desktop of all computers in the ED.

Importantly PAH ED runs a comprehensive orientation program for its trainees at the start of each term. It is here that we attempt to explain not only ‘what to do’ but ‘why we do it’ in order that you gain an understanding of the model of care we aim to deliver.

Other aspects that trainees should note are:

ED Scrubs:

Consultants and trainees have the option of purchasing PAH ED scrubs to wear on duty. Please see Jillian Vernon, Office Manager, for details and ordering.

Scrubs can be ordered and purchased from Hunter Scrubs:

www.scrubs.com.au

Order NAVY. Landau unisex tops and pants are favoured by most – though there are also many other styles. Embroidery – the PAH ED logo should be purchased and placed on the left pocket of the scrubs top.

Communication and Information Distribution in the ED:

The primary method of communication in the ED (other than face-to-face in meetings etc) is via email. Ensure you set up your GroupWise email accounts upon arrival (see Jillian Vernon, Office Manager, for details). Please also provide Jillian with your home email.

The G-drive of the computer system also contains a Trainee Folder with useful information (previous PowerPoint presentations, Clinical Guidelines and Procedures, Research and EBM Resources etc). This is accessed via G-drive...Emerg...Share...Trainee Folder. These electronic resources, covering ED operations, education and research, can be uploaded onto your USB drive if you wish. This will allow ready access to information both on the floor and at home and includes an electronic logbook to record procedures and interesting cases etc.

Otherwise information will also appear in your pigeonholes (in the trainee room) or on the notice board in the Trainee Room and in the corridor of the office area.

On the floor, consultants, registrars, Training SHOs and residents have access to DECT phones to enable more ready access to each other within the ED and to the rest of the hospital. Ensure you collect one at the start of each shift and write the number of the DECT against your name on the medical / nursing allocation whiteboard in the ED write-up room.

Trainees are also provided with laminated cards to be carried on their person; these contain information on: important phone numbers, traffic light system of pathology and radiology requests and principles of critical care patient management.

PAH ED runs an intranet website (as part of the hospital’s web site) where important orientation documents may be found. The hospital’s intranet website (accessed from all computer desktops) contains useful information as to what is occurring within the hospital and provides access to the Clinicians Knowledge Network and Up to Date. It also contains information from various clinical units regarding their own guidelines and protocols.

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A state wide ED intranet site is also available on QHEPS and has other useful information including QH approved patient information sheets.

Finally, the ED operates its own internet sit www.emergpa.net – it contains orientation resources, educational resources, calendar of events and many useful links to emergency medicine websites and blogs. It is edited by Iain McNeill. This website is the primary site for informing trainees and consultants of education and training sessions – you must make it a habit to check the calendar on it regularly.

Telephones:

In general all incoming medical calls (from other hospitals, GPs etc) are directed to the Consultant DECT Ex. 7215. Otherwise, if these calls come through to other phones it is expected only consultants or registrars are to take these calls. As a general rule medical advice is not provided to the public over the phone – these calls can be directed to 1300 HEALTH.

There are also a few other distinctive telephones in the department:

There is a phone dedicated for incoming urgent ambulance contacts. A consultant or registrar may be required to speak to ambulance officers on this phone.

There is also another phone in the staff station area that is sometimes utilised by general practitioners and peripheral hospitals as a help line for seriously ill patients. Registrars should answer or be willing to speak on this phone if necessary; and to obtain the consultant if requested. 

QAS UHF radio - for communication with ambulance officers in the field

Clinical Guidelines and Procedures:

A collection of formal and informal clinical guidelines and procedures have been collated for easy reference. These can be accessed from a desktop icon on most computers in the ED. There is also a copy of these guidelines and procedures in the Trainee Folder on the G-Drive of the computer system.

There are flip folders on the desks in the write up room providing an overview of the more important guidelines and procedures and advice as to where to find important information within the ED.

PAH Tertiary Services:

It is important to be aware of the numerous specialist tertiary services the PAH offers. Being aware of these units will ensure you consider them when managing patients in the ED.

These clinical units in many cases offer services that are not found elsewhere in Queensland. Many of these units like (or expect) to be consulted if their patients present to ED.

Examples of specialist tertiary services at PAH are:

- Spinal Injuries Unit

- Spinal Surgery

- Renal Unit 

- Transplant Unit - hepatic and renal

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- Cardiothoracic Unit / Interventional Cardiology

- Interventional Radiology

The PA Hospital Orientation Manual (found on the hospital intranet site) provides a full description of all clinical services offered.

Admissions:

The Emergency Department has responsibility for and right of admission. The majority of admissions through the ED are with the cooperation and input of the accepting inpatient team.

Please see the ED CPM and the PAH 3:1 procedures regarding admission practices.

It is unusual for the ED to have to exercise its 'right of admission' to an inpatient bed. However if required it should occur with the involvement of the ED Consultant (this does not apply to "closed" wards such as ICU, CCU, or Infectious Diseases.)

Short Stay Ward Admissions:

The 8 bed SSW forms an important part of the Emergency Department service. Patients with self-limiting conditions who are expected to be discharged within 24 hours are suitable candidates.

All patients admitted to the SSW must have an entry in their notes from an ED consultant or registrar.

Patients are admitted under ED Consultants who undertake 3 ward rounds daily (2 on weekends).

Residents and registrars are expected to maintain knowledge of their SSW patients and ensure that documentation (especially of results) occurs. Decisions on discharge or ward admission will be made at consultant level.

The SSW is also used for the care of non-admitted patients (e.g. ED patients awaiting transport, tests, or other factors) and inpatients awaiting ward bed availability.

Inter-hospital Transfer Policy:

The aim of the PAH Inter-hospital Transfer Policy is to ensure safe and appropriately timed patient transfers to the PAH.

The QEMS Central Clinical Coordinator will continue to be responsible for arranging the transfer of critically ill patients and patients from distant facilities. ICU and CCU will continue to determine whether patients from other facilities can be accepted into their units for further management.

For local metropolitan transfers, the referring hospital liaises with the accepting inpatient unit and the PAH Bed Management Unit. These patients should ideally proceed to their booked bed upon arrival to the PAH. If the transferred patient does not have a bed ready upon their arrival to PAH, the accepting inpatient unit will be expected to ‘admit’ the patient in ED. ED staff will only become involved in their care if the patient is 'unstable' on arrival or in liaison with the accepting team.

Trauma Care:

There is a Professor of Trauma and Trauma Surgical Fellows within PAH. A 4 bed Trauma HDU exists within the orthopaedic ward. The trauma fellows when available back up the

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surgical registrars. Monthly trauma audit meetings and weekly trauma case review meetings are coordinated by the ED, Trauma Unit and the Trauma Registry.

Management of trauma and resuscitations in the ED:

Trauma notification:

Within the relevant clinical areas protocols for 'trauma notification' can be found. Please familiarise yourself with the levels of notification.

Trauma teams:

Determined by the ‘trauma notification’. Traumas are generally coordinated by the ED consultant. Trauma management within the PAH is multidisciplinary and involves the cooperation and input of many specialties.

Trauma Documentation:

Trauma assessment / management forms can be found in the resuscitation rooms. Utilising these allows improved auditing and research of our activities.

PAH ED Trauma Clinical Indicators:

CXR / Pelvic x-ray - within 10 minutes of arrival. Lateral C-spine within 15 minutes.

OT within 30 minutes if unstable.

CT Head within 30 minutes if stable.

CT abdomen / pelvis (c-spine, chest etc) within 60 minutes if stable.

 Security Unit:

The PAH has Queensland's only hospital jail. Only those people formally processed on a warrant can be placed there as a patient. Security is of prime importance to the unit.

Dr Stuart McDonald and Dr Neville Henry are the SMOs who work in the unit Monday - Friday. Prisoners presenting with conditions necessitating an ATS Category 1 or 2 will be brought under guard to the ED for assessment. Prompt assessment by the ED staff and either discharge or transfer to the Security Unit is required. Other patients ATS Category 3 – 5 will be taken to the Security Unit for their initial assessment by Dr McDonald.

After-hours, patients brought for assessment from jail are to be seen by ED staff. Generally, a JHO or SHO who can work relatively independently should be allocated to attend any patient in the unit. In general, have a low threshold for admission as the environment from which they have come is not conducive to ‘convalescence’. If the prisoner requires admission then the patient can simply be referred to an inpatient unit. Occasionally, there may be a need for the patient to stay for an 'SSW' style admission 'under the ED' in which case Dr McDonald or Henry will usually review and discharge the patient the next day.

Paediatrics and Gynaecology:

The PAH ED will see patients 16 years of age and over (The Mater Children's Hospital sees patients 15 years and younger).

Patients younger than 16 years normally present with their parents and should be triaged, briefly assessed, treated for pain or bleeding, then transferred (either by private vehicle or QAS) to the Mater Children's Hospital.

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There is no on-site obstetric or gynaecology services at the PAH. Obstetric cases (greater than 20 weeks) are to be discussed with the Mater Obstetric Registrar. Gynaecology staff at the QEII Hospital provides a consultation service. Patients that present here with gynaecology problems may be assessed and discussed with the QEII on-call gynaecology registrar. If admission is required, the patient can be transferred to QEII Hospital (Please see the ED CPM for details).

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PRINCESS ALEXANDRA HOSPITAL

DEPARTMENT OF EMERGENCY MEDICINE

CLINICAL PRACTICE MANUALCONTENTS:

1. PAH ED Clinical Areas2. Safe Access for Emergency Patients in PAH ED3. Clinical teams4. Picking up a patient5. Assessment of patients

6. Documentation7. Discussion of patients with ED senior staff8. 3:1 Procedures – Processing patients through the ED9. Ordering pathology tests10. Ordering radiology (and vascular USS)

11. ED Clinical Guidelines and Procedures12. Finding a nurse13. Organise analgesia or intravenous fluids for a patient14. Procedures – Procedural sedation, suturing, plastering15. Answering the telephone

16. Referring to an in-patient registrar17. Referring to the medical registrars (and MAPU medical and cardiology

registrars)18. Referring to a medical sub-specialty unit19. Referring to an in-patient consultant20. Arranging a private / intermediate admission

21. Referring to ED Mental Health22. Referring to OPD23. Referring to Fracture Clinic24. Referring for outpatient investigations25. Eye Clinic

26. Referring for Obstetric and Gynaecology Services27. Pharmacy services28. Social Worker services29. Emergency accommodation30. Referring to Allied Health

31. Referring to Community Health Nurse32. Utilising Pastoral Care 33. Alcohol and Drug Services (ADAU)34. Referring to Sexual Health Clinic35. Discharging patients home

36. Admitting a patient to the ED Short Stay Ward37. Admitting a patient to the Ward38. Finishing you shift

(Last update: MAR 2012)

1. PAH ED Clinical Areas

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o The PAH ED contains the following Clinical Areas:o Resuscitation Rooms – 5 (one of which is negative pressure isolation

capable)o Acute Cubicles – 25 (designated ‘red’ and ‘yellow’ cubicles – all monitored;

includes 4 isolation rooms (2 of which are negative pressure capable)o Ambulatory Care – mixture of 6 consult rooms and special assessment /

treatment rooms for ambulating patientso Procedure Area – 1 main procedural room (anaesthetic / resuscitation

capable for procedural sedation and minor operations) and 6 bays for minor procedures / plastering

o Short Stay Ward – 8 bed short stay ward for ED patients (including 1 isolation room)

o ED Mental Health Area – staffed by ED Mental Health Clinicians

2. Safe Access for Emergency Patients in PAH ED

See also Hospital Procedures – Emergency Department Procedures (PAH Intranet)

Purpose: o To detail the process for safe access of patients to Princess Alexandra Hospital

Emergency Department (PAH ED). o To detail the procedure undertaken when an appropriate treatment space is

not immediately available.

Outcome of the Procedure: o All non-ambulatory patients are triaged to an acute treatment cubicle or

resuscitation room as soon as possible. o All patients who are “ramped” are done so by the consultant based on clinical

risk verses available resources.

Authorised to Undertake the Procedure: o Emergency Department Registered Nurses who have completed:

o Emergency Triage Education Kit (ETEK), o The required number of preceptor shifts with a clinical facilitator, o Deemed competent by the Emergency Department’s Nurse Educator.

o Emergency Department Staff Specialists

Indications: o All non-ambulatory patients.

Contraindications: o Patients who meet the inclusion criteria for ambulatory care.

Risks and Precautions: o The below acknowledges that ideally all non-ambulant patients should have

immediate access to an appropriate treatment space, and that any level of access block to the Emergency Department is associated with an increased clinical risk. At all times the Emergency Department will act to maintain availability of appropriate treatment spaces as much as possible within the limits of the resources available.

Procedure: o All presenting patients are to be triaged and registered and placed on

Emergency Department Information System (EDIS) on arrival as per triage procedure.

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Non-Ambulant Patients: o All non-ambulatory patients are to be triaged into acute cubicles only. This is to

allow history, examination and initial management to occur in an appropriate, safe environment. The only exceptions to this are patients whose clinical condition warrants management in a resuscitation room.

o No patient is to be accommodated in a corridor except in a declared disaster situation.

o Non-ambulatory patients presenting via Queensland Ambulance Service (QAS) who are unable to access an appropriate cubicle on arrival will be “ramped”. The decision to “ramp” is not a triage decision, but is one made by the Emergency Department Consultant in liaison with the Nursing Shift Co-ordinator.

o The Emergency Department consultant (ext. 7215) and the Nursing Shift Co-ordinator (ext. 7566) must be contacted by triage and notified of the patient and their clinical details. The Emergency Department consultant will decide whether it is clinically appropriate for the patient to be ramped given the resources available. It is acknowledged that overriding Princess Alexandra Hospital executive directives regarding capacity and redirection escalation procedures may impact on the resources available.

o In cases where the clinical decision regarding ramping is unclear, or clinical concerns are raised, the consultant or delegate may elect to review the patient prior to this decision being made.

o The triage Registered Nurse must ensure a clear passageway for critical patient movement through triage at all times.

o The Queensland Ambulance Services paramedics will return to the ambulance with their patient following registration and triage. The rationale for this is that the Queensland Ambulance Services vehicle is a safer clinical space (with access to oxygen suction and monitoring) than any internal corridor or foyer.

o The patient is to be placed in the “Ramped Area” within the EDIS location map.o ‘Ramped patients’ will be brought into the ED as soon as possible on the basis

of triage category and / or time of arrival. o If whilst ramped, the Queensland Ambulance Services paramedics have a

clinical concern for their patient (e.g. change in patient condition or deterioration) this must be notified via the Triage Registered Nurse to the Emergency Department Consultant (ext. 7215) who will undertake the appropriate clinical action.

o The triage staff is not to suggest to the Queensland Ambulance Service crews to leave Princess Alexandra Hospital for another Emergency Department.

o When the Princess Alexandra Hospital Emergency Department is ‘ramping’ patients, notification to Bed Management should be made by the Nursing Shift Coordinator or Emergency Department Consultant; and Capacity Alert procedures may be undertaken as deemed appropriate.

Non-Ambulatory Patients: o Who self-present should receive priority into an appropriate area of the

Emergency Department if they cannot be cared for safely at triage. The Shift Co-ordinator (Ex. 7566) should be contacted by Triage to make arrangements to receive the patient.

Resuscitation Rooms: o Are to be kept available for any critical events that may present or occur

(including deterioration of ‘ramped’ patients or for self-presenting patients requiring a cubicle when none are immediately available).

Maintaining Patient Flow: o Medical assessment of patients within acute cubicles will occur as safely and

efficiently as resources allow.

3. Clinical Teams

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o Medical staff within the ED work within small clinical teams that cover geographical areas of the department. Each shift you will be assigned to a clinical team. These teams receive clinical oversight from the ED consultants. This information is displayed in the medical write-up room each day.

o Each member of the clinical team should take a DECT phone at the start of every shift and record on the electronic rostering system their DECT phone extension.

o There are three clinical teams rostered during the day and evening, with one clinical team rostered overnight. Each team is lead by an ED registrar and includes 2-3 residents. A training SHO may also form part of the team.

o Within the Acute and Resuscitation Areas of the ED – there are two clinical teams for this area (Red Team and Yellow Team – with each team covering an area). Red Team – Resuscitation Rooms 1 and 2; Acute Cubicles 1 – 13. Yellow Team – Resuscitation Rooms 3, 4, and 5; Acute Cubicles 14 – 25. Each team is responsible for their area and the patients within it.

o Within the ‘Ambulatory Care’ area of the ED – there is one clinical team (Green Team) attending to the patients triaged to the waiting room and the ambulatory care area itself. This team also covers the Procedure Area – including patients triaged there with minor injuries and any procedures that are required to be conducted there.

4. Picking up a patient

o Within the Acute and Resuscitation Areas of the ED – simply pick up the first triaged patient unseen by a doctor from the top of the screen from your area. Do not ‘select’ patients out of order or from outside your area unless instructed to do so by a senior staff member. Patients triaged to the ‘Acute Area’ will generally have been triaged to ATS Categories 1-3.

o Within the ‘Ambulatory Care’ area of the ED – Patients within this area will generally have been triaged to ATS Categories 3, 4 and 5 (majority being Cat 4 and 5); rather than picking these patients up in order of triage category they are to be picked up in order of time of arrival (though this may be subject to re-prioritisation following a secondary nursing assessment within Ambulatory Care or at the discretion of the ED registrar or consultant).

o Patients are triaged (sorted) by nursing staff at the front desk. They are assigned a triage category based on their presenting complaint. The Australasian Triage Scale (ATS) categorises patients from Category 1 – 5 according to time needed to be seen by a doctor.

o ATS Category 1 – immediateo ATS Category 2 – 10 minuteso ATS Category 3 – 30 minuteso ATS Category 4 – 60 minuteso ATS Category 5 – 120 minutes

o Although our goal is to see and manage all patients in a timely manner, our first priority is to the seriously ill or injured (i.e. Cat 1 and 2).

o Patients in the ED are on the EDIS (Emergency Department Information System) displayed on all computer terminals. This is a windows based software system that assists in tracking patients in the ED, whilst also serving as a database for audit purposes.

o Arrivals not yet seen by a doctor are at the top of the screen, whilst those already seen drop down the screen once a ‘treating doctor’ signs on. Within the list of patients in the ED, ‘seen’ and ‘unseen’ patients are placed in order of triage category, and then within each triage category by time of arrival.

o Fill in the details within EDIS of the patient you have picked up before seeing them. This involves double-clicking the patient’s name and completing the ‘treating doctor’ field and ‘time seen’ fields. Ensure the ‘time seen’ entered is accurate (please note the KPIs listed above regarding waiting times; in particular note the 10 minutes for ATS Category 2). The department is assessed on waiting times for triage categories.

o Initially the patient will come into the department with a nursing assessment / observation sheet and patient ‘sticky’ labels.

o Charts for the patients will eventually be delivered by administration staff to the patient’s bedside or to a basket at the main nursing station of the acute area.

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o Charts for Ambulatory Care patients are delivered to the staff station in this area.o The location of the patient within the department is on the EDIS screen.o If the patient you are going to see turns out not to have waited (i.e. ‘DNW – Did

Not Wait’) – inform the senior staff so they can determine whether any action is necessary in terms of contacting the patient. Please document the time/s the patient was called and any arrangements subsequently within your notes.

5. Assessment of patients

o Within the ED you have more direct senior supervision than in most other parts of the hospital.

o To facilitate effective and efficient assessment and management of patients you are required to consult senior staff (ED Consultants and Registrars) early and regularly.

o Different levels of experience and skill will dictate the level of trust afforded you.o Generally, you should aim to perform a focused history and examination and

consult a senior staff member (within the first 30 minutes) to discuss the case and enable a directed series of investigations. Many times you may find nursing staff have already arranged intravenous cannulation, routine bloods, certain x-rays and analgesia for your patients. However, this primarily becomes your responsibility once you start seeing the patient.

o Each shift you will be assigned to a clinical team with a registrar who will be responsible for you. This information is displayed in the medical write-up room each day. Meet your registrar and your team at the start of each shift. Discuss your cases with your assigned registrar or consultant – if you don’t seek them out, they will seek you. Remember that the ability to discuss any case with the consultants who are on the floor is a feature of clinical rotations to the ED.

o Once you have discussed a case with a senior staff member, continue to consult that person for that particular patient. Do not seek advice from multiple senior staff members for the one patient – it only confuses the process.

o Once you have discussed a patient with a senior staff member – fill in the details in EDIS with respect to the ‘senior doctor’ field. This allows others to see on the screen which registrar or consultant knows about the patient.

6. Documentation

o All ED medical notes (other than when utilising the Trauma Forms) will be undertaken electronically within EDIS.

o Your notes are a reflection of your, and the department’s, clinical practice; so please ensure they are accurate and reliably detail the patient’s journey in the ED.

o Document a thorough but focused history and examination.o Document what investigations have been ordered.o Document the results of all investigations you have ordered once they become

available.o Always finish with a diagnosis; or differential diagnosis; or a problem list.o Always document a management plan that outlines treatment and management

undertaken and other related issues (disposition etc).o Document the name of the ED registrar or consultant you discuss the case with and

accurately reflect their management plan in the chart.o Document the name of the inpatient registrar you refer the patient to. Note the

time they were contacted.o When you are not using the patient’s chart ensure it stays with the patient in their

cubicle / room or otherwise designated area. o Once you have completed your notes, print them out and place them

within the patient’s chart.

7. Discussion of patients with ED senior staff

o All patients you see should be discussed with an ED registrar or consultant.

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o Early discussion (within the first 30 minutes of seeing the patient) enables more efficient and effective care of the patient.

o If you and the ED registrar / consultant determine that the patient is likely to be admitted, enter this into the patient’s clinical screen in EDIS – via ‘Departure Destination’ – ‘Admission likely’. If discharge home is likely, this can also be indicated via the ‘Departure Destination’ – ‘Discharge likely’.

o The ED senior staff focus on the seriously ill and those that are being sent home. Everyone else, by definition, will be admitted and have the safety net of a review by an inpatient registrar. However, these patients’ work-up should still be thorough.

o All patients being discharged from the ED should have been discussed with a registrar or consultant.

o All patients being referred for admission should be discussed with and seen by a registrar or consultant prior to the referral (see 3:1 procedures).

o Meet your registrar and your team at the start of each shift. Discuss your cases with your assigned registrar or consultant – if you don’t seek them out, they will seek you. Remember that the ability to discuss any case with the consultants who are on the floor is a feature of clinical rotations to the ED.

o Once you have discussed a case with a senior staff member, continue to consult that person for that particular patient. Do not seek advice from multiple senior staff members for the one patient – it only confuses the process.

o Once you have discussed a patient with a senior staff member – fill in the details in EDIS with respect to the ‘senior doctor’ field. This allows others to see on the screen what registrar or consultant knows about the patient other than you.

8. 3:1 Procedures: Processing patients through the ED

o 3:1 is a variation of the 3:2:1 management system that has been applied at PAH with respect to the processing of Emergency Department (ED) patients who require admission to hospital.

o 3:1 divides the patient journey for admitted patients into three manageable time periods, each with a specific goal:

o 3 hours (from time of arrival to bed booking) – this includes completion of ED assessment / management and review in the ED (if required as part of ED management) by the admitting unit

o 1 hour - from bed booking to departure of the patient to the inpatient ward

o The underlying principal governing this policy is that patients should only stay in the ED for the minimum amount of time required to safely assess, manage and transfer care to the inpatient environment.

o What ED medical staff need to know and do:o The ED is responsible for the ‘3’ hour time-frame of 3:1o Aim to complete the assessment / management / notification of

admission to the admitting unit of all your patients as efficiently as possible.

o Consult ED Consultants and Registrars early to assist with this.o Escalate to senior staff if your patients are experiencing delays (e.g. for

imaging, inpatient unit review etc).o Determine with ED Consultants or Registrars as to whether the patient

requires an inpatient review as part of their ED management; or are they suitable to progress to the ward for review there by the admitting unit.

o Record the ‘time of referral’ to an inpatient team in the ‘Consultations’ field. Enter ‘Admission Likely’ (WAL) in ‘Departure Destination’ in the clinical screen.

o When discussing any case with inpatient staff, state in order: Who you are

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What you want – advice, review for opinion, or admission Name of patient Diagnosis Other relevant history

o If notifying an inpatient registrar of an admission: Clarify acceptance of admission. Ensure the inpatient registrar understands as to whether the

patient will be progressing to the ward or requires review prior to this in the ED by the admitting unit.

If the patient requires review in the ED by the inpatient registrar – determine the time-frame this will occur in.

o Beds are only to be booked when the patient’s ED management is complete (+/- following review by the inpatient registrar in ED) (i.e. they are ready for the ward – this includes: ED notes completed and printed with a management plan, medication and fluids charted etc).

o When ready, ensure your patient has a bed booking form completed either by yourself or by the inpatient registrar if they are reviewing the patient within the ED. DO NOT complete a bed booking form unless the patient is ready to be moved to the ward. Via the READI Process, the nursing staff undertakes a check of all the criteria to ensure suitability or ‘readiness’ for the ward with respect to completion of care and appropriate documentation.

o The review of admissions in ED by the accepting inpatient registrar is a privilege, not a right. Excessive delays (>1hr) for this review to take place and be completed (for any reason) will not be accommodated. Please notify ED senior staff if your patient is experiencing or likely to experience an excessive delay to inpatient review; they will decide on the clinical appropriateness of progressing the patient to the ward from where the inpatient registrar review can then take place.

o What ED Consultant and Registrar Staff also need to do:o Monitor and pro-actively manage 3:1 times of the patients you are

directly supervising for the residents.o Registrars, if required, discuss cases with ED Consultants early to assist

with the above.o Aim to review all patients discussed with you by ED residents.o Give consideration to which patients requiring admission do not on a

clinical basis need to stay in the ED for their review by the accepting inpatient registrar (NB. you need to see the patient yourself to make this decision correctly).

9. Ordering pathology tests

o With respect to requesting pathology in the ED, only the pre-formatted pathology forms may be utilised and only those tests indicated on the form may be requested.

o Tests indicated on these forms include – FBS, UEG, LFT, Ca++, Lipase, BHCG, TNI, Blood Culture, Paracetamol level, INR (on warfarin), COAG for major bleed likely need for transfusion, COAG for end-stage liver disorder.

o Simply tick to indicate which tests you require.o Group and Hold and Cross-Match requests have a unique form (purple in colour)

that is to be utilised for these requests.o Any other tests, not present on the forms, which are required by ED staff, need to

be requested on a blank pathology request slip and signed off by an ED Consultant.o Inpatient teams requesting additional tests must utilise blank pathology forms and

indicate their consultant unit as the cost centre.

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o Once bloods have been taken they should be labelled with the pathology stickers that accompany the patient ID labels. These pathology labels also need to be signed and dated. The only specimen that cannot be labelled with the stickers is a G+H or cross-match – these tubes must be entirely hand-written.

o The specimens and request slip is then placed in a plastic pathology bag and delivered via Lampson to the laboratory. The Lampson air-tube system and pathology bags are located within the Resuscitation area, Acute area and Ambulatory Care area.

o Turn around times for pathology results are on average 60 minutes – ED specimens have priority in the lab. Results can be accessed via AUSLAB/AUSCARE – found on all the computer terminals.

10. Ordering radiology (and vascular USS)

o The ED has its own satellite radiology unit with plain radiology, USS and CT rooms.o On the radiology request form please indicate the area the patient is in (i.e. Acute 3

- so the radiographer can find them) and whether or not they require oxygen and / or monitoring whilst they have their x-ray.

o Radiology request slips are to be faxed through to the radiographers’ work area.o The radiographers run an image alert system within the ED. If they identify an

abnormality within a plain film they take they will insert the word ALERT on the film, such that it should be looked for when you are reviewing your films. If you have any queries about a film with an ALERT on it please see the radiographers.

o There is a radiology reporting room within the radiology area (across from the ED CT room). There is a radiology registrar present 24 / 7. The radiology consultant and / or registrar can be utilised to discuss imaging you have queries about.

o You must discuss any potential request for CT, USS, and MRI etc with an ED consultant or registrar.

o To organise a CT, USS or MRI you will need to go to the radiology reporting room. There you will find the radiology registrar and be able to discuss the case and organise the imaging.

o To organise USS you may be directed to the main radiology USS area. There you will find the radiology registrar for USS and be able to discuss the case and organise the imaging.

o An MRI request often needs to be discussed directly with the MRI Consultant.o Radiology reports from CT, USS, MRI are generally available on PACS soon after

completion of the imaging, or are phoned through by the reporting radiology consultant or registrar to the ED consultant. Otherwise, speak directly with the radiology registrar in the reporting room.

o If you wish to arrange an outpatient radiological investigation for a patient – you can either fax a referral slip to the appropriate number (displayed on the x-ray forms) or ask the patient to proceed around to the hospital’s main radiology area to the appropriate radiology booking desk. Generally, if you are requesting a patient to attend an outpatient radiological investigation you should also ensure they have appropriate follow-up organised within the hospital to review the result with the patient.

Vascular ultrasoundo Please note, the vascular lab (not radiology) performs all vascular USS within the

hospital.o They are available Mon-Fri 08:00 – 17:00 (last referrals at 16:30)o If you require a vascular USS (e.g. investigating a potential DVT) – phone the

vascular lab to arrange a time and fax up a request.o After-hours – selective vascular scans can be performed by radiology if necessary.

11. ED Clinical guidelines and procedures

o There are numerous clinical guidelines for the management of certain conditions that present to the ED. ED senior staff will be aware of what is available.

o These have been developed by the ED or in conjunction with inpatient units.o They may be found in the ‘Clinical Guidelines and Procedures’ folder on the

desktop of most computers in the write up areas of the ED.

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o They may also be found on the department’s webpage within the hospital’s intranet.

12. Finding a nurse

o Nurses are assigned to areas within the department along similar lines as to the allocation of medical staff.

o Introduce yourself to the nurses working within your area of the ED at the start of each shift.

o To determine which nurse is looking after your patient, refer to the nursing white board for each shift’s allocations.

13. Organising medications or intravenous fluids for a patient

o With any medication or fluid order, ensure that after it is written that you have also verbally informed the nurse looking after the patient of your request. This will ensure the patient receives the medication or fluid in a timely manner.

o There are numerous electronic resources (CKN) to enable correct prescribing of medications and fluids. Otherwise ask the senior staff if unsure.

o With respect to analgesia:o Relieving pain is a fundamental task in the ED.o There is a process for nurse-initiated analgesia within the ED. This enables

effective pain relief for patients prior to a doctor’s assessment.o Within the ED, analgesia can be provided in a number of forms:

o Simple splinting and immobilisation.o Oral analgesia – usually combinations of paracetamol and codeine.o Oral NSAIDS.o IV opiates – generally morphine (or fentanyl for the renal patients).o Use of regional local anaesthetic techniques (e.g. digital nerve blocks).

o Please note IM use of opiates does not have a role in the acute relief of pain within the ED.

o Document the order for analgesia in the ‘medication chart’ (either on the front page or in the PRN section at the back) and arrange with the nurse looking after the patient for it to be given to the patient. If charting intravenous opiates, allow for small titratable doses to achieve effective analgesia.

o Patients requiring opiate analgesia to be charted for their admission to the ward should have this prescribed via the s/c route. IV opiates are generally not given on the wards unless in the form of opiate PCAs.

14. Procedures – Procedural sedation, Suturing, Plastering

o Most procedures will be undertaken within either the resuscitation rooms or in the procedure area.

o There are ED Clinical Guidelines concerning many common ED procedures to refer to.

Procedural Sedation:o Any procedure requiring sedation / analgesia requires the involvement of senior

staff.o Any procedure requiring sedation necessitates 2 doctors (one of which will be a

registrar or consultant) – the senior doctor tending to the sedation and airway.o Generally, procedures requiring sedation / analgesia should not occur until written

consent is obtained from the patient for the procedure (except in life-threatening conditions). Consent forms for most procedures conducted within the ED can be obtained from the hospital’s intranet web site.

Suturing:o Patients requiring wound closure are usually managed in the Procedure Area or

Resuscitation Roomo Nursing staff should assist in the preparation and closure of the wound.

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o Prior to closure of any wounds a registrar or consultant should review the wound.o Post-closure, a senior staff member should also assess the wound.o Tendons ARE NOT to be repaired by ED staff in the ED.o Patients should be provided with written instructions on wound management.o Complex wounds can be brought back to the department for review, but generally

patients should see their GP for ongoing wound management / ROS etc. A letter for the GP should accompany the patient for this purpose.

Plastering:o Generally ED staff performs POP procedures on ED patients.o There are a number of enrolled nurses within the ED who are trained in plaster cast

techniques. There will usually be at least one on each shift.o If required (e.g. for complex casts) there is a plaster technician in the Orthopaedic

Department that can be utilised – page via switch.o Ideally, plastering is to occur only within the Procedure Area or the Resuscitation

Rooms. There are mobile plaster trolleys for this purpose.o Ensure patients are provided with pamphlets on plaster care and, if applicable, use

of crutches.o Clean up after yourself.o Plastering is a useful skill and one that should be acquired during your time in the

ED. Utilise the senior staff and enrolled nurses to assist you in developing this skill.

15. Answering the telephone

o Answer the phones with “Emergency Department” or “PA Emergency Department”.o Occasionally, outside calls from the public may be put through to the ED - DO NOT

provide ‘over the phone’ medical advice to patient enquiries. This leads to bad medicine. Simply state to the caller that you are unable to provide advice or make a diagnosis over the phone and that if the caller is concerned about their health they should arrange for a medical review (either with a GP or at an ED).

o All calls from other hospitals, GPs and QAS are to be taken by a registrar or consultant; and these are directed to the Consultant DECT Ex. 7215.

16. Referring to an inpatient registrar

o On-call information can be obtained by phoning switch (dial ‘9’).o Inpatient registrars can be contacted via the LAN Paging Network located on all

computer terminals. Type in your name, location (ED) and return phone number.

o If registrars fail to answer their page – check with switch that they are indeed on-call (rosters do change without our knowledge); try a mobile phone if they don’t answer their page; if they are in OT – either leave a message to contact you when they are finished (don’t forget to find out what time they are likely to be available), or ask to be put through to the theatre they are in to discuss more urgent cases.

o When referring cases to an inpatient registrar state what you require of them (i.e. an admission; review and opinion; or advice). Start by giving them a diagnosis and brief overview. If they require more detailed information they will ask you. (e.g.: “I have a 50yo gentleman with acute coronary syndrome who requires admission. He has had 2 hrs of ischaemic sounding chest pain. His ECG shows lateral T-wave inversion. He is now pain free etc.). This will grab their attention, rather than reciting a history, examination and then a diagnosis at the end – by which time they will have lost interest.

17. Referring to the medical registrars (and MAPU Medical and Cardiology Registrars)

o The ‘Medical A or ‘New Case’ registrar is on-call for all ‘new’ admissions. A ‘new admission’ is one that hasn’t been seen at this hospital as an in-patient or in OPD for the last 12 months.

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o Any ‘old’ patients (i.e. the patient has been seen as an inpatient or in OPD, with this or a related problem, within the last 12 months) are to be referred back to their treating unit (general medical or sub-specialty). Page that unit’s registrar. After hours and on weekends the ‘Medical B’ or ‘Old Case’ registrar is available to admit all ‘old’ patients.

o To summarise:o The ‘Medical A’ or ‘ New Case’ registrar is responsible for:

All patients presenting to the hospital with a problem for which they have not been seen previously (either as an inpatient or in the OPD); or for which they were last seen (either as an inpatient or outpatient) more than 12 months ago (from the time of this presentation).

During hours (08:00-16:30) if it appears this ‘new’ presentation qualifies as a sub-specialty admission (there are guidelines in the medical registrar handbook, located on the PA intranet web-site, as to what type of patients the sub-specialty units take) contact the sub-specialty registrar for acceptance of the admission. If the sub-specialty unit declines the admission, the ‘Medical A’ or ‘New Case’ registrar accepts the patient to a general medical unit.

After-hours the ‘Medical A’ or ‘New case’ registrar is to admit all these ‘new’ patients regardless of whether it is felt they may be a sub-specialty admission. They will liaise with their consultant and/or the sub-specialty unit, if required, to determine whom the patient is admitted under.

o The ‘Medical B’ or ‘Old Case’ registrar is responsible for: All patients presenting to the hospital with a problem (or related

problem) for which they have been seen previously (either as an inpatient or in the OPD); and for which they were last seen (either as an inpatient or outpatient) less than 12 months ago (from the time of this presentation). They will admit the patient under the respective ‘old’ general medical or sub-specialty unit.

After-hours, any ‘new’ patients accepted by a sub-specialty unit from the community or another hospital will be admitted by the ‘Medical B’ or ‘Old Case’ registrar.

MAPU Medical and Cardiology Registrars:o The Medical Admission and Planning Unit is a 30 bed facility that sits

adjacent to the ED. It is a ward generally for medical patients who have a planned length of stay of less than 48 – 72 hours.

o There is a MAPU Medical Registrar (Mon – Sun 08:00 – 18:00) and MAPU Cardiology Registrar (Mon – Fri 08:00 – 18:00). Patients not requiring complex subspecialty care, without high care needs and with a predicted suitable length of stay, can be referred to these registrars who will assess their suitability for admission to MAPU and liaise with the admitting unit whom they will come in under.

18. Referring to a medical sub-specialty unit.

o There are guidelines in the medical registrar handbook (located on the PA intranet web-site) as to what type of patients the sub-specialty units take.

o Importantly, if you have an ‘old’ general medical or sub-specialty patient during the afternoon, be conscious of the time and attempt to expedite their referral to the relevant inpatient registrar before 16:30. This may involve notifying them before some investigations have been completed. They will often be familiar with the patient if they are ‘old’. Overall, they will be more familiar with admitting their ‘own’ patients than the ‘Medical B’ registrar (who starts at 16:30) and would prefer to do so at 15:30 rather than 16:30 if possible.

19. Referring to an inpatient consultant

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o You may have reason to discuss a patient with the inpatient consultant (e.g. if they are a private patient).

o Prior to your discussion with them ensure you have discussed the patient with the ED registrar or consultant – so you know what you are talking about.

o Give consideration, especially overnight, to the ED registrar or consultant making the referral. It may allow for a more professional interaction.

20. Arranging a private / intermediate admission

o Patients occasionally present to the ED with private health insurance and wish to utilise this for a private / intermediate admission.

o Options:o You can liaise directly with the patient’s doctor of choice. o Or often the consultant on-call for their discipline at PAH will also work

privately and may be able to accept them for private admission in a private hospital or as an intermediate admission at PAH.

21. Referring to ED Mental Health

o There is a separate area within the ED where the ED Mental Health Service is located. They provide a 24 / 7 service.

o Mental Health patients are assessed at triage as to their suitability for the ED MH area. Agitated, aggressive patients or those with potential medical issues are seen first through the main ED area.

o Familiarise yourself with the elements of the Mental Health Act that pertain to examination orders and involuntary patients.

o All patients that present following a self-harm attempt or on an EEO should be discussed and assessed by the ED MH clinicians.

o Give careful consideration as to whether your patient should be ‘involuntary’ (i.e. by filling out a request and recommendation for assessment). Although patients should generally be first given the opportunity to remain ‘voluntary’; give consideration to making them ‘involuntary’ (in consultation with ED senior staff), prior to the mental health clinician review, if you would be concerned for the patient’s or others safety if they left the department prior to this review.

o Any ‘involuntary’ patients within the ED should have a nurse ‘special’. This is arranged with the nurse in charge of the shift.

o Generally, only MH clinicians can discharge patients off an EEO.

22. Referring to OPD

o All outpatient referrals are to be electronically submitted via the Intranet via the links:

o Projects ED blue slip referrals

o Provide as much information as possible on this referral – most OPD requests are triaged on the basis of what is on the referral form (not what is in the chart – however do indicate in your notes within the chart the purpose of the referral as well).

o Ensure the contact details for the patient are correct.o Advise the patient an appointment will be sent out to them in the mail. Provide the

patient with an OPD information slip – so they have a contact number if the appointment fails to arrive in the mail.

o If you require an urgent appointment, discuss the case with the relevant inpatient registrar and gain their approval for an early appointment and document this on the referral request

Acute Stone Clinico For patients seen in the ED with proven urolithiasis (via some form of imaging),

outpatient follow-up can be arranged with the Urology Ambulatory Care Unit.

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o Appointments can be made via an electronic OPD request addressed to ‘Urology OPD – Acute Stone Clinic’

o If you believe the patient requires to be seen urgently then the case should be discussed with the urology registrar and noted on the referral.

23. Referring to Fracture Clinic

o All fractures that are seen through the ED should be referred for follow up to the Fracture Clinic run by the orthopaedic surgeons.

o The Orthopaedic Department has their own electronic OPD referral forms – again via the Intranet links:

o Projects ED blue slip referrals

o To refer to the Fracture Clinic, indicate on the Orthopaedic referral form that you

require a fracture clinic appointment, document the diagnosis (e.g. distal radius fracture), and when you would like them to be seen in the clinic (e.g. within 1 week).

o Ensure the contact details for the patient are correct.o The fracture clinic staff will then send out an appointment to the patient. o The fracture clinic is generally for orthopaedic injuries involving broken bones.

However, it can also be utilised for follow up of dislocations and acute ligamentous injuries (e.g. acute knee injuries).

24. Referring for outpatient investigations

o There may be situations where investigations can occur non-urgently after the patient is discharged from the ED.

o Such investigations may include EST, dobutamine stress echocardiography, Holter monitoring, EEG, imaging – USS / CT / MRI etc.

o With respect to some investigations it may be more appropriate to discuss your investigative plan first with the relevant inpatient unit registrar (e.g. cardiology, neurology etc).

o To arrange investigations, fill out a radiology request slip as appropriate. Ensure the patient’s contact details / address is correct.

o Indicate a time frame you would like the investigation performed. In particular, indicate if it needs to be performed prior to an accompanying request for an outpatient clinic appointment.

o Ensure to include as much information as possible on the form. Be sure to include the details of who will be following up the result. Generally this will be an inpatient unit in OPD. Avoid where possible arranging for investigations to be followed up by the GP – the investigative / management loop once started within the hospital system should preferably be completed within the hospital system.

o Radiology requests can be faxed to the relevant area (as detailed on the request slip itself) for an appointment to be sent out. Alternatively, during business hours patients may take the radiology request slip to the appropriate booking area in the main radiology department and arrange an appointment.

25. Eye Clinic

o The Eye Clinic is staffed with an Eye resident with access to Ophthalmology registrars.

o The hours of operation of the Eye Clinic are: Mon-Fri: 08:00 – 16:30 and Sat. 08:00 – 12:00.

o To avoid excess overtime for the clinic they cease taking new patients from 16:00 Mon-Fri and 11:30 on Saturdays.

o Eye patients going to the Eye Clinic from the ED triage desk do not appear on the EDIS screen.

o Outside operational times of the Eye Clinic, ED staff sees patients with eye complaints.

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26. Referring for Obstetric and Gynaecology services

o PAH has no on-site obstetric and gynaecology service. We rely on accessing the services provided by the Mater hospital and QEII hospital.

o For obstetric issues (i.e. > 20 weeks) please contact the Mater Mothers Obstetric Registrar – they generally will be in the delivery ward.

o For gynaecological issues: Urgent consultations – contact the QEII gynaecology registrar – 24hrs a

day. The QEII registrar can attend PAH if the patient is too unstable for transfer; or can accept transfer of the patient to review / admit.

Non-urgent consultations - discuss an OPD appointment with the QEII gynaecology registrar and fax a referral to QEII.

27. Pharmacy services

o Operational times of pharmacy:o Mon-Fri: 08:00 – 18:00.o Saturday: 08:30 –17:00.

o Outside of these hours discharge medications can be accessed from the ‘after-hours medication cupboard’ in the ACUTE drug room. A script for every medication dispensed from the cupboard is to be left on the paper spike in the room.

o The PBS scripts utilised within the hospital can also be used by patients in community pharmacies.

o The ED has its own pharmacist, available on the floor between 08:00 – 17:00 Monday to Friday. Pager 999.

o They will assist with:o Medication information and adviceo Medication historieso Patient counselling and adviceo Community medication liaison (e.g. for Webster packs and nursing home

patients)o Inpatient and discharge medication supplyo PBS queries

28. Social Work Services

o A social worker is based in the ED:o Mon – Fri: 08:00 – 22:00o Sat: 18:00 – 22:00

o The social worker can be found in their office located in the MAPU offices opposite Mental Health

o They can also be contacted via pager 866 or 1434, or ext 3944 or 3949o Issues that can be referred to the social worker include:

o Psycho-social assessmento Bereavement and coronial matterso Crisis interventiono Advocacyo Legal resources, legal aid policeo Cross cultural referral and supporto Referral to appropriate community resources / community health / ACATo Financial difficultieso Discharge planningo Post trauma counsellingo Sudden death counsellingo Sexual assaulto Information and supporto Aged care assessment and respite referralso Domestic or family violence

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o After-hours crisis intervention (outside above operational hours) – the on-call social worker can be contacted through switch (dial ‘9’) for the following issues only:

o Domestic violenceo Traumao Rape / Sexual assaulto Sudden deatho Child(ren) at risko Donor family

o Any after hours referrals for Social Work intervention, not meeting the crisis intervention criteria above, should be recorded in the ‘yellow’ Allied Health book located behind the Nursing Shift Co-ordinator’s desk in the Acute ‘Hot’ area. The Social Worker will follow these referrals up the next working day.

29. Emergency accommodation

o The Homeless Liaison Officer is familiar with accommodation options – pager 5190.o The ED Social Worker will be able to help in the absence of the Homeless Liaison

Officer.

30. Referring to Allied Health

o There are designated allied health staff members covering the ED, they are located in the MAPU offices opposite Mental Health.

o All non-urgent after hours requests to Allied Health should be recorded in the ‘yellow’ AH book located behind the Nursing Shift Co-ordinator’s desk in the Acute ‘Hot’ area. The relevant allied health clinician will follow these referrals up on their next working day.

Physiotherapy – o 07:30 – 18:00 Mon – Frio Pagers 300 / 913o Musculoskeletal injuries of peripheral joints (Including a Primary Contact

Physiotherapy Program – where physiotherapists will primarily assess patients and liaise with senior medical staff on management and disposition).

o Acute and chronic neck or back paino De-conditioned elders and fallers: mobility assessment for discharge and

MSK treatmento Vestibular: assessment and early treatment as appropriateo Neurological: balance, gait and co-ordination assessment and suitability for

dischargeo Respiratory: early assessment and treatmento Multi-trauma: early respiratory treatment as requiredo Weekends:-

Mobility upgrades where the physiotherapist’s intervention is required to prevent admission (not routine education on the use of crutches).

Acute respiratory patients waiting for an inpatient bed e.g. pneumonia, infective exacerbation of COPD, aspiration where the patient is having difficulty with sputum clearance and whose condition would otherwise deteriorate.

o Remote Call (after 18:00) Acute respiratory patients who will deteriorate overnight without

physiotherapy intervention

Occupational Therapy – o 08:00 – 16:30 Mon – Frio Pager 584o Review / assess functional performance for discharge planning (upper limb, vision,

cognition, self cares)

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o Referral to community OT for home visits (those who live alone, frail elderly, palliative, decreased function)

o Equipment prescription (shower chairs, grab rails, wheel-chairs)o Cognitive assessment (confusion, closed head injuries or LOC)o Neurological assessmentso Facilitate referral to upper limb orthopaedic hand team as appropriate

Speech Pathology – o 07:30 – 16:00 Mon – Frio 08:00 – 12:00 Sat, Suno Pager 5243o Referrals for:

o Acute stroke patientso Suspected aspiration pneumoniao New onset dysphagia or deterioration of pre-existing dysphagiao New onset of communication impairmento Laryngectomy patient with dislodged voice prosthesis

Dietitian –o 07:30 – 16:00 Mon – Frio Pager 5244o Weekends 09:00 – 17:00 via switch for urgent referralso Referrals for:

o Malnutritiono New diagnosis for dietary educationo Nutrition support: enteral, parenteral and oralo Chronic disease management and dietary compliance issues

Aged Care Early Intervention and Management (ACEIM) teamo 08:00 – 16:30 every day (Mon – Sun)o Speed dial 4681o Referrals

o To facilitate right care right place model of careo Implement avoidant strategies and where appropriate provide

adviceo Liaise and follow up all presentations from Aged Care Facilitieso Facilitate rapid response to assessmento Enhance the geriatric focus of nursing in EDo Case management with teams to manage these patients

focusing on continuity of care and optimal flowo Co-ordination of referrals to external service providers

31. Referring to the Community Hospital Interface Nurse (CHIP Nurse)

o The ED has a Community Hospital Interface Program (CHIP) co-ordinator available within the department 08:00 – 16:30 every day (Mon-Sun).

o The community health nurse will review patients with respect to their needs at home. They can assist greatly with discharge planning and arranging appropriate community services and follow-up.

Assessment and coordination of community services (e.g. domiciliary nurses, home care, wound care, social support)

Liaising with community service providers Discharge planning Liaising with community education programs Patient advocacy Patient, family and carer education Chronic disease management Ongoing care / management of drains and catheters

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32. Utilising Pastoral Care

o Pastoral care workers are available within the ED between 18:30-22:30.o They can be found via pager.o They can assist with:

Spiritual counselling and guidance Emotional support Practical help Liaison with social work and mental health Patient advocacy

33. Alcohol and Drug Assessment Unit (ADAU)

o PAH has a consultation Drug and Alcohol service that operates in business hours. o Patients presenting to the ED may be referred to the ADAU for review in the ED.

They will usually liaise with the patient regarding outpatient programs or refer to other agencies for certain services (inc. in-patient detoxification programs).

o ADAU can be contacted via Switch.o Other agencies in Brisbane that patients can be referred to include:

o RBH – Hospital Alcohol and Drug Service (HADS) o Biala – 24hr referral and counselling service o Moonyah – Salvation Army o Damascus Unit – Brisbane Private Hospital

34. Referring to the Sexual Health Clinic

o There are numerous sexual health clinics run within the Metro South Health District.

o The PA Sexual Health Clinic (PASH) has its details on the hospital intranet web site.o Details of clinic sessions and referral procedures can also be found on their web

page.

35. Discharging patients home

o Ensure you have discussed the case with an ED registrar or consultant. The patient must be safe for discharge. Consider the time of day in your deliberations and planning for discharge.

o Ensure your notes are complete and have been printed out and placed in the patient’s chart – they should include a diagnosis and a management / disposition plan.

o Enter a ‘diagnosis’ in the relevant field in the patient’s clinical screen in EDIS.o Communicate with the patient’s GP. All patients discharged from the ED

must take with them a discharge letter. This is particularly important if the GP has referred them in, or you require the GP to assist in the ongoing investigation or management of their presenting problem. EDIS has a letter writing function that makes this task very simple – simply follow the prompts. If the patient does not have a regular GP and GP follow up is required, please consider referring them to the UQ Health Service GP Practice in Cornwall Street (PACE Building).

o Communicate with the patient and their family/carers etc. such that they have a good understanding of their problem and any discharge instructions.

o There are numerous patient instruction sheets for conditions such as minor head injury, plaster care, wound care etc. that should be provided to the relevant patients. These can be found on the PAH ED intranet website and the QHEPS state wide ED website:

o http://qheps.health.qld.gov.au/ed/home.htmo Patients requiring discharge medications:

o During hospital pharmacy hours (08:00-17:30) the patient can be provided with a hospital script to be filled out at the pharmacy (ground floor – near orange lifts).

o After-hours a patient can be provided with a starter pack of commonly required medications from the drug cupboard in the ED. A hospital script

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should be left on the spike near the cupboard to allow replacement of stock.

o A patient can be provided with a hospital script that can be utilised in community pharmacies.

o Once the patient has left the department place their chart in the discharged patient chart basket on the desk in the acute ‘hot’ area nursing station.

o If you were the last to see the patient leave the department, you are responsible for logging the patient off the EDIS system – this includes completing all the mandatory ‘yellow fields’ in the patient’s clinical screen.

36. Admitting a patient to the ED Short Stay Ward

o The ED Short Stay Ward is an 8 bed unit for short stay patients with easily correctable ailments. Planned lengths of stay should be less than 24 hours.

o Criteria for admission to the Short Stay Ward can be found in the ‘Clinical Guidelines and Procedures’ folder.

o Approval from an ED registrar or consultant is required before a patient is placed or admitted to the SSW. All SSW admissions are required to be reviewed by the registrar or consultant and this review and a plan is to be documented in their medical notes.

o Ensure medication (in particular, regular analgesia if relevant) and fluid orders are written up.

o Ensure results of investigations are documented.o Once in the Short Stay Ward the patient is primarily under the care of the senior

staff but residents may be asked to assist in this.

37. Admitting a patient to the ward

o Discuss the case with an ED registrar or consultant.o Follow 3:1 procedures for admitting patients:

o Record the ‘time of referral’ to an inpatient team in the ‘Consultations’ field. Enter ‘Admission Likely’ (WAL) in ‘Departure Destination’ in the clinical screen.

o When discussing any case with inpatient staff, state in order: Who you are What you want – advice, review for opinion, or admission Name of patient Diagnosis Other relevant history

o If notifying an inpatient registrar of an admission: Clarify acceptance of admission. Ensure the inpatient registrar understands as to whether the

patient will be progressing to the ward or requires review prior to this in the ED by the admitting unit.

If the patient requires review in the ED by the inpatient registrar – determine the time-frame this will occur in.

o Beds are only to be booked when the patient’s ED management is complete (+/- following review by the inpatient registrar in ED) (i.e. they are ready for the ward – this includes: ED notes completed and printed with a management plan, medication and fluids charted etc).

o When ready, ensure your patient has a bed booking form completed either by yourself or by the inpatient registrar if they are reviewing the patient within the ED. DO NOT complete a bed booking form unless the patient is ready to be moved to the ward. Via the READI Process, the nursing staff

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undertakes a check of all the criteria to ensure suitability or ‘readiness’ for the ward with respect to completion of care and appropriate documentation.

o The review of admissions in ED by the accepting inpatient registrar is a privilege, not a right. Excessive delays (>1hr) for this review to take place and be completed (for any reason) will not be accommodated. Please notify ED senior staff if your patient is experiencing or likely to experience an excessive delay to inpatient review; they will decide on the clinical appropriateness of progressing the patient to the ward from where the inpatient registrar review can then take place.

o Most inpatient registrars will undertake the bed booking themselves after they have seen the patient (ideal) – others will not (i.e. you will have to do it). Regardless, please be vigilant and check back with your patients to ensure beds have been booked where and when appropriate.

o Bed booking is done by filling out a bed booking form (located on the desks in the various nursing stations). These forms can then be given to the nursing shift coordinator who will organise the rest of the booking procedure.

o Once the bed booking details are given to bed management, they will indicate on the EDIS tracking screen either WAA (ward - awaiting allocation until they can allocate an actual ward) or an actual ward (e.g. W2C). This allows for a more accurate overview of who in the ED is being admitted and is ready for transfer to the ward.

o Ensure your notes are complete – including investigation results, diagnosis and management plan on the ward, medication sheets and fluid orders. Print your notes out and place them within the patient’s chart.

o Until the patient leaves for the ward we continue to be responsible for their management. If the patient has been admitted by their inpatient team and remains in the ED (often the Short Stay Ward) due to not being able to access a bed, their care is primarily via the inpatient unit – though ED staff will assist with any emergency.

o Generally, as the nursing staff hand over patients to the ward staff they will log them off the EDIS system. However, continue to be vigilant in ensuring your patients are logged off.

38. Finishing your shift

o Check with your registrar or the consultant on duty that it is suitable for you to finish your shift – occasionally you may be asked to stay on due to excessive department activity.

o Ensure you hand over any patients you still have in the ED to another doctor (you need to take them to these patients for introductions and to communicate a summary of their management thus far and their ongoing management plan); you will also need to alter the name of the ‘treating doctor’ on the EDIS system. Your name should not appear on the screen when you depart.

o Only hand over patients that have been essentially all ‘worked up’ (i.e. referred on for admission but not seen yet by the inpatient registrar; or awaiting CT – if normal can go home). If you haven’t got to this point you will need to stay on until you do.

o Include in your hand-over an action plan, dependent on what results are being waited on (e.g. if Hb normal – home; or if Hb low needs admission). Where possible, if the patient requires admission, or an inpatient registrar review, do this referral yourself before you go. You will know the patient better than the other doctor.

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THE PAH EMERGENCY MEDICINE TRAINEE MANIFESTO

Our mission is to partner trainees in attaining the aims of the PAH Emergency Medicine Training Program:

Our aim is to develop: Trainees with the ability to be:

o Higher order thinkerso Effective communicators

Trainees with the self-belief to be:o Independento Decision makerso Resilient

Trainees with the capacity to:o Show empathyo Link actions to outcomeso Be discerning and ethical decision makers

Trainees with the courage and commitment to:o Aspire to excellenceo Be tolerant and inclusiveo Be patient advocates

The principles by which the entire PAH Emergency Department work by:

In order to allow patients presenting to the PAH Emergency Department (ED) to have their rights under the Queensland Health Patient Charter (2002) preserved, specifically their rights to be treated with respect and dignity and to be treated on the basis of their clinical condition, the following applies:

All PAH ED staff will continually work to optimise the efficiency of our healthcare delivery, thus maximising the number of patients that we can provide quality care to.

The PAH ED recognises that within its health area the PAH is responsible for maintaining access to health services that cannot be accessed elsewhere.

Each patient has a right to be assessed and managed in an individual cubicle, affording them privacy during history, examination and management.

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The clinical condition of a patient will dictate their right to an emergency bed and to the degree of observation and monitoring they require.

Trainee Clinical Practice Expectations – the specifics:

Enjoy yourselfo You are training in your chosen specialty, being exposed to new

experiences each day and gaining knowledge and skills that will shape the rest of your professional career – what is not to enjoy!

Clinical expectationso Expectations for the standard of clinical care in this department are high;

as a result you can expect to be closely supervised; and with this comes support for the challenges you will face and many ‘teachable moments’. We would hope this provides an overall rewarding experience.

o Be responsible for the delivery of patient care in your clinical area: The registrars largely dictate the quality of care in the department.

Your role in “quality control” cannot be understated. If anyone, including a consultant, makes a decision that you think undermines good quality care, please bring this to light at the time. In this situation, it is likely that you have more accurate, detailed or timely information. Raise your concern such that a discussion can take place; apart from being good medical practice, it is a good opportunity for teaching!

Discuss any concerns with your consultant, at any time; these concerns may relate to direct patient care, supervision of junior doctors, or relevant personal concerns.

Always discuss the care of critically unwell patients with the consultant.

Clinical guidelines and protocols do exist for some conditions – be aware of them. However this is a highly consultant supervised department affording you the ability to learn from multiple consultants. Use these opportunities to learn and formulate your own safe approach.

Ensure your residents are delivering high quality patient care. Do not refuse the transfer of critically unwell or trauma patients to

our ED. Always write good clinical notes (or ensure good notes are written

by your residents) – once the patient leaves the ED, your notes are the only thing that reflects your quality of care. Good notes are accurate, thorough yet focused, include results of all investigations ordered, contain a diagnosis / differential diagnosis list / or a problem list, and a management plan. Be sure that your clinical notes are always printed out and placed in the patient’s chart.

Always use the ‘Trauma Form’ for all trauma patients seen in the resuscitation area. All areas of the form need to be completed accurately and thoroughly. Use additional ‘Progress notes’ if necessary.

You should always aim to ‘finish’ your patients to an ‘admission level’. That is, to a level where they can go to the ward without seeing an inpatient team. This includes clinical notes with management plans, medication charts, fluid orders and nursing orders.

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Professional expectationso Do not leave your clinical area with excessive work for your colleague on

the following shifto Be punctualo Be courteous to all patients, visitors and work colleagueso Strive to effectively communicate with all clinical staff and especially your

patients and their families – when patients are in our ED it is not just another day at work for them; communication and compassion goes a long way.

o Complete your administrative paperwork, including medico-legal documents, in a timely fashion

o Check your emails frequently

Education and Training expectationso Be responsible for your involvement in the PAH EM Training Program and in

your own self-directed learning program. We aim to ensure that teaching opportunities are numerous, however you will not be ‘dragged’ in to becoming involved in your own education.

o Rostering is undertaken to ensure as much as possible your availability to attend the various education sessions in ‘clinical support time’ (i.e. DE or education days). When this is not possible strategies are in place to ensure you can be ‘relieved’ of your clinical duties to attend. This is guaranteed on Thursday mornings (CME program) and depending on workload and staffing generally possible on Tuesday mornings (Fellowship Exam Program) and Thursday afternoons (Primary Program).

o The 3 registrars and Training SHO rostered for a ‘DAY’ shift on a Thursday need to present first to the floor at 08:00 and aim to take a quick hand-over of SSW patients. They should then collectively sort these patients out prior to presenting to teaching at 08:30. Most patients can be seen and a plan made in this time.

o Ensure that you remain ‘on-site’ within the hospital for your DE days.o Rostering and other allowances are given to those sitting the Fellowship

Exam; it is expected that the wider trainee group also supports them at this time and will see that these allowances will one day be theirs when they sit.

Specifics of the clinical shiftso Ideally, you will be the first point of call for residents in your area. If you are

struggling with your patient load, let the consultant know (this does happen and will happen to everyone). Remember to redirect residents to discuss their cases with a consultant if you are busy – this is not a sign of ‘failure’.

o The model of care for registrars is balanced more to the supervision of residents and early focused input into patients within the ‘acute’ area and more direct patient care with respect to patients in the resuscitation area.

o Aim to discuss patients with residents at the bedside so you can clarify history and exam findings.

o Whilst patient flow is the concern of the consultants and quality of care is the concern of trainees; do be aware of potential patient movements that may aid the running of the department.

o You and your team must aim to ‘finish’ your patients as soon as time allows; ‘finish’ means completed notes, fluid charts, medication charts, and orders to an admission level. For many patients this allows for their movement to the ward prior to being seen by the accepting inpatient team.

o Notify the consultant of any procedure you are going to undertake.o All patients being discharged should have been discussed and usually seen

by a registrar or consultant.o The overlapping of shifts in the afternoon coincides with the department’s

peak activity. Ensuring new patients are seen and ‘finishing’ off patients from the morning is vital. Working as a team with your evening registrar counterpart on your side is crucial to this.

o The evening shift teams should ensure they do not leave excessive work for the night shift. The on-call registrar is the person nominated to stay back and assist with excessive activity if required (this is not uncommon).

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This person would also be the one to return to undertake any inter-hospital transfers overnight (though this is infrequent).

o If you are in ambulatory care: You and your team will be attending to patients triaged to that

area, the waiting room and the procedural area. Some of these patients will be ‘acute’ and some will be ‘complex’ – however they should all be able to sit and generally will be ambulatory (except for some fractures / dislocations etc).

Generally see patients by time of arrival rather than triage category – however be aware to scan the screen and liaise with nursing staff to ensure the priority of who will be seen next is appropriate.

Look to identify patients who will be uncomplicated and quick and ensure at least one resident continues to work their way through these. The other resident(s) can then continue to work their way through the complicated patients who may take some time to sort out.

Ensure you still discuss patients you are unsure about with the consultant and alert them to any issues.

All patients being discharged should have been discussed with or seen by a registrar or consultant.

You (or your team) will often be the first point of call for performing procedures on patients (including many on patients from the acute area) in the procedural area, reviewing paediatric presentations at triage, seeing patients in the Security Unit or undertaking medical reviews of psychiatric patients in ED Mental Health.

Do not leave excessive numbers of patients in the waiting room left unseen at the end of the evening shift.

o If you are on the night shift: This is recognised as a difficult shift – it is expected that sometimes

the department may be ‘unsorted’ in the morning. Aim to at least have a plan for each patient rather than just ‘touch

base’ with every patient and have no decisions made or plan enacted.

If you are concerned or worried about any patient ring the consultant.

If you have a critically unwell patient ring the consultant. You will have to manage general patient flow to some extent on

this shift – however, if you have a problem with the overall running of the department ring the consultant – the nursing shift coordinator has been given the same instructions, so do not feel aggrieved if they ring the consultant.

Look to nominate one resident to continue to see patients in the waiting room through the night shift.

You will be the point of contact for incoming medical calls - do not refuse the transfer of critically unwell or injured patients to our ED

o On every shift: Ensure you and your team communicate to the nursing staff Ensure you and your team communicate with your patients Manage yourself and your residents - such that everyone gets their

breaks Aim for you and your team to leave on time and enjoy your shift

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