THE AFTER HOURS ROSTER

• 3 or 4 shifts per month

• TURN UP TO YOUR SHIFTS

•Check you have the latest version of the

roster

•Shifts are confirmed via the JMO unit

• Read the job descriptions for more details

SHIFTS

Shift Pager Hours Wards

A1

“MWI”

293 1630-2230 6 South (Neurology)

6 West (Rehab)

7 South (Aged Care)

7 West (Aged Care)

A2

“SWI”

036 1530-2230 3 South (Breast endocrine, ENT,

surgical outliers)

3 West (Orthopaedics)

2 East (Vascular)

2 South (Cardiothoracics)

1 West (EDO: Non-O&G only)

W1 293 0800-2230 As above for A1

W2 036 0800-2230 As above for A2

N1 Night shifts

N2

WOC On-Call for sick relief

OC

ADO

Annual Leave

STRUCTURE OF THE SHIFT

1. Pick up the pager before your shift starts

2. Receive handover from outgoing teams

3. Attend PACE Calls and perform clinical

reviews

4. Complete the jobs on your allocated wards

(“Clear the boards”)

5. Attend handover

ST GEORGE

• Pick up pagers from the windowsill on Level 4

common room (Door code CYZ480)

• Evening handover 2200 at the Level 4

common room

• Weekend morning handover 0800 at the Level

4 common room

• Weekday morning handover 0800 in the JMO

Common room (Swipe card entry)

• Team: 2 interns (MWI, SWI), 2 x RMOs, MOIC,

Surg Reg, CERS Nurse

SUTHERLAND

• Pick up the pager from switchboard at the

hospital main entrance

• Evening handover in the JMO Common Room at

2200

• Weekend Morning handover in JMO Common

Room at 0800

• Weekday Morning handover 0800 in the

Handover Room (next to Southern Heart Clinic)

HANDOVER

• PACE calls

• Patients that you are concerned about

• Any reviews, repeat bloods, scans you want

chased

• Give name, MRN and location, try to have

short history and relevant meds

BLOOD TESTS

You are responsible for checking the result

of any tests you order/ take

Handover pending results

Can label as “urgent” or “life threatening”

About 1 hour turnaround for urgent basic

bloods

Don’t venepuncture on the same side as

infusion

PURPLE TOP

• FBC

BLUE TOP

• Coags:

INR, APTT

GOLD TOP (serum)

• UEC

• CMP

• LFT

• Troponin

• Serology

PINK TOP

• Group and hold

• Crossmatch

Hand written label (no stickers)

Co-sign order form

Time and date on tube and form

must match

BLOOD CULTURES

Temp 38.0 and above

+/- Septic screen (urine, CXR, swabs)

+/- Start or change antibiotics

+/- Sepsis notification

Peripheral cultures + lines (if applicable)

If >3 sets taken, once/24hrs thereafter

Look for instructions from the team

CANNULAS (?CANNULAE)

• 20g (pink) and 22g (blue) usually sufficient on wards

• May need 18g (green) CF if for CT with contrast

• Do not put off re-sites – these must be done at 72hrs

• At least 2 attempts

Out of hours IV access referral:

1. RMO or CERS

2. HDU (with ultrasound)

3. Anaesthetics

IV FLUIDS • Indication

Dehydration

Maintenance

Electrolyte disturbance

• Look at

• patient’s fluid status and obs

• Renal function and electrolytes

• Intake (diet) and losses

• Caution in CCF, severe AS, ESRF, Geris

• No Saline in Cirrhosis

IV FLUIDS CONT

• Rate

•Bolus: 500mL stat, 1L q1h

• Fast: 1L q4-6h

•Maintenance: 1L q8-10h

• Slow: 1L q12h

• TKVO: 40mL/hr or less

• CHART 24 HOURS OF FLUIDS if you are the team

• CHART UNTIL NEXT MORNING if you are after hours

ELECTROLYTES

ORAL INTRAVENOUS

K+ Slow K (8mmol)

Chlorvescent (14 mmol)

Potassium Chloride • 10mmol/100mL NS “mini bag”

• 30mmol/1000mL NS

Potassium Dihydrogen Phosphate

Mg Magmin Magnesium Sulfate • 10mmol/100mL NS “mini bag”

PO4 Sandoz

Phosphate

Potassium Dihydrogen Phosphate

Sodium Dihydrogen Phosphate

Ca++ Caltrate Calcium Chloride

Calcium Gluconate

ANALGESIA

• Paracetamol, Ibuprofen

• Endone, Oxycontin, Targin

• Morphine

• PO or SC (not IV on the wards)

• Not in renal failure

• Hydromorphone

• if eGFR <30

• PO or SC - doses not equivalent!

• Anaesthetics available for phone/PCA advice if

needed (pager 999)

WARFARIN

• 4pm

• Look at:

MAREVAN vs COUMADIN

Indication for warfarin and target INR

Current inpatient issues: bleeding, surgery

Latest INR

HEPARIN INFUSION

• Usual APTT target is 45-90

• Infusion as per protocol

• APTT every 6 hours with rate adjustment

• Once 3 consecutive APTTs are therapeutic,

check APTT only once every 24 hours

INSULIN

- Chart through to next morning, including the

breakfast dose

BLOOD TRANSFUSION

• Group and Hold

• Crossmatch

• Consent

• IVC

• Fluid order chart or blood product order chart

Rate (max 4hrs/unit)

Fluid status r/v

IMAGING OUT OF HOURS

Mobile CXR

St George: Page #100 (before 8pm) or #1139 (after 8pm)

Sutherland: Phone Ext 37644 or *8022 (24 hours)

CT

CT Brain: Call Radiology if urgent, no approval needed

All other CT scans – Need Radiologist approval

You may be called to give contrast

Reporting

Sutherland “Telerad”

SEDATION AND RESTRAINT

Sleeping tablets

e.g. Temazepam 10mg

Contraindications: Risk of delirium, falls,

hypoventilation

Sedation - discuss with MOIC

e.g. Haloperidol 0.25mg – 0.5mg PO or IM

Restraint - discuss with MOIC

UNEXPECTED DISCHARGES

Discharge against medical advice

Talk to MOIC

Assess capacity

Careful documentation

Absconded patient

Mental Health Act- scheduled patients

DIRECT ADMISSIONS

Sent in by specialist, or inter-hospital transfer

Write an admission note

Including HOPC, PMHx, examination, social

Medication chart, fluid orders, etc

Blood tests/IVC

Investigations

Initiate therapy if indicated – discuss with team or MOIC

CERTIFYING DEATH 1

Clinical examination

Unresponsive

Fixed pupils

Absent heart sounds, breathing, pulse (2 mins)

Documentation

Time of death

CERTIFYING DEATH 2

Condolences Offer your condolences to the family Nursing staff will offer bereavement package/ social worker.

Notification If unexpected: MOIC will talk to consultant If expected: Evenings- you can call consultant Overnight- wait until morning

Team to do the discharge summary and the death/cremation certificate

COMMON CLINICAL REVIEWS

• Chest pain

• Other pain

• Urinary retention

• Fall

• Change in mental state

• SOB

• Hypo/Hyperglycaemia

• Hypo/Hypertension

• Tachycardia

GENERAL TIPS

• Check your results or hand over to chase

• Be courteous to nursing staff

• Wear comfortable shoes

• Don’t forget to eat/ drink/ bathroom

• Answer your pager promptly

• ‘744’, ‘741’= outside call

TIME MANAGEMENT

1. Prioritize sick patients PACE and clinical reviews for sick patients first Routine jobs after that 2. Ward round approach 3. Focused review of patients 4. Efficiency

- Set up all your IVCs at once - Get all your charts together and sit down in front of a computer to check results

WHEN TO ASK FOR HELP

If you are worried or unsure: ASK SOMEBODY!

RMO

CERS Nurse

MOIC / Surg Reg

Always better to ask

All PACE calls will be attended by MOIC or Surg Reg

WHEN TO SAY NO

• Decisions and discussions that should be made by the treating team

“Will he have an operation?”

• Non-urgent paperwork

“Patient needs a discharge summary”

“Can you fill out this certificate”

• Non-urgent clinical questions

“Rash has been present for 4 weeks”

“Pt wants to know his cholesterol”

“Family just wants an update”

FOR DAYTIME STAFF….

• Handover before you leave MOIC +/- JMO for sick patients

JMO for routine jobs and results

• Do your own orders for warfarin, insulin, fluids

(24 hours), medication charts

• Clear your boards before you go

• Clarify resuscitation status

USEFUL RESOURCES

• ALS1 or ALS2 course

• ‘On Call’ book

• Online policies and procedures

• CIAP MIMS or AMH eTG Injectable drugs handbook

• Uptodate, BMJ Best Practice etc

POLICIES AND BUSINESS RULES

• St George Intranet home page

•Hospitals/Facilities

•St George

• “Policies, Procedures and Business

rules”

• “J” for “JMO Folder”

GOOD LUCK AND BE SAFE!

ANY QUESTIONS?