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