SURVIVING AFTERHOURS WOC On-Call for sick relief OC ADO Annual Leave . STRUCTURE OF THE SHIFT 1....

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Transcript of SURVIVING AFTERHOURS WOC On-Call for sick relief OC ADO Annual Leave . STRUCTURE OF THE SHIFT 1....

  • 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

  • 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 fil