QUESTION
Director of Casualty
I am writing to you because your department’s incompetence killed my husband Tony.
He was seen be a doctor (I don’t know his name but he was very rude and he had blond
hair) when he had pains in his chest. We had to wait in the department for 12 hours and
he was attached to a machine. All we was told was that he did not have a problem with
his heart but we did not know what caused his pain and that night it was back and
shocking. Two days later he’s dead and we got told that it was a blood clot on the lung
that did it.
My 5 children now don’t have a father, and your to blame. We want to know why this
happened and to make sure your hospital pays for what it did to him.
Yours sincerely,
Lynda Charles
As the director of a small country hospital, you receive this letter. Outline your actions in
response to this letter.
ANSWER
Actions
This is clearly a major issue for the family.
It is potentially a major problem for the hospital, department and doctor concerned as it
suggests that a pulmonary embolism may have been missed.
 I will therefore personally respond to the complaint
Ensure that the Complaints Liaison Officer or Medical Administrator is aware of the
complaint
Acknowledge the receipt of the complaint within 24 hours
Analyse the complaint letter and identify all the concerns of the author
Retrieve the history and examine all the evidence available thoroughly. Search for any
deviations from normal clinical practice, such as:
 Triage assessment
 Waiting time
 Assessment
 Seniority of resident – was he adequately advised by the senior doctor on for that
shift
 Etc.
Talk to concerned resident and nursing staff. Some form of counselling may be
necessary.
Draft an initial response to Ms Charles, expressing regret and sympathy for her situation.
 Thanks for complaining - a chance to improve systems
 Non-judgemental
 Attempt to address the individual issues raised by the complainant
o Missed diagnosis of pulmonary embolism
o Lack of appropriate follow-up advice
o Long waiting time
o Medical staff rudeness
 Expression of liability is not appropriate at this stage.
Have draft checked by CLO and / or hospital insurance solicitor
Attempt to answer the complaint within 72 hours
A meeting with the family may be required at a later stage (perhaps earlier). I would try
to arrange counselling for Ms Charles if not already done.
Further actions
o Education regarding undifferentiated chest pain / pulmonary embolism
o Counselling for resident re attitude towards patient
o Education of remainder of staff re patient interactions
o If there was a problem with triage, then an education session for the nursing staff
regarding the National Triage Scale may be worthwhile.
Admin SAQ
1. A famous footballer is brought to your department after sustaining injuries in a
local AFL football match. A large number of media journalists converge on your
hospital to cover the story. You are the duty ED Consultant.
How would you manage this situation?
2. You receive a phone call from the mother of a 6 year old boy who presented to
your ED the evening before. She wishes to lodge a formal complaint as she had
to wait 2 hours to be seen by a doctor. She says her son had a serious break of
his forearm bones after a sporting accident and was in excruciating pain whilst in
the waiting room. She has already called the Minister for Health who is a friend of
hers
Describe the actions you would take.
SAQ 001
A 45 year old man has a pre-hospital cardiac arrest and is dead on arrival in your ED. He
was sent home from your department six hours previously, after being referred by his GP
with central chest pain. His family are waiting for you in your office. Explain how you
would handle this difficult situation?
This is a complex situation with social/medicolegal qualities
Pre consultation
Patient chart ordered
Speak to Dr/nurse/LMO
SW notified
Timely balance of info vs keeping the relatives waiting
Doctor issues
Is this an isolated incident?
Documentation
MDU
Mentorship
Support
Policy and procedure (are they fully orientated and appropriate discharge ?did they ask)
Departmental process
Scenario
Appropriate
Quiet
No bleep
Private
Senior nurse
Safety aspects
Approach
ID yourself as most senior in dept and you who will be dealing with this
Blame
?accept blame
you are “pts advocate”
need to outline a plan
not role to admit liability
establish discharge facts ?self discharge
coroner/PM
nature of events
arrange FU post PM/ further Ix
Difficulty with IHD
Check CK, TnI and ECG
Departmental process and policy
who discharged
minimum documentation
reassess policy
SAQ 002
Your charge nurse approaches you to say that several of the nursing staff in your ED have
voiced concerns that one of your RMOs is stealing and using opiates from the ED. How do
you handle this situation? (or sexually harassing staff, abusing patients, doing
incompetent stuff; you pick the atrocity)
Introductory statement
This is a serious charge that may have significant implications in terms of the systems in place for
handling of opiates, the RMO involved, the team and the law. Management will need to
encompass all these aspects.
Investigate the allegations
Talk to the nurses making the allegations requesting specifics:
4where
4when
4how - narcotics taken from dangerous drugs cupboard Vs. taken from the pt for whom they were
intended
4action taken by nursing staff
4relationship to the RMO;
If @ drug cupboard:
4investigate the drug cupboard contents and the daily tally
4talk to those staff involved with drug counts on the affected days
If from patients intended to be given the drugs:
4Talk to the nurses caring for the patients re. amounts given, where stored between aliquots &
where remains disposed of
4Review patients charts
Suspicious behaviours
Undue drowsiness
Over-prescribing of opiates esp pethidine (eg; excessive doses)
Giving opiates to patients themselves rather than by nursing staff
Unexplained absences from ED
Review RMOs performance
4Request feedback from registrars & consultants re. RMO’s performance clinically & as member
of the team
4Look for “at risk” behaviour patterns
4Ask re performance in previous terms
4Chart review of patients treated by RMO
Advise from hospital legal team
4Legal obligations re:
4Reporting of opioid theft/ abuse to police services for investigation
4Reporting of potential opiate abuse to the medical board
Discuss with RMO
4Appointment time
4private room
4minimize disturbances
4ask re. Coping & whether any issues that RMO wishes to raise
4discuss allegations with RMO and ask for response to allegations
4non-judgemental approach
4Safety of RMO once allegations made (suicide risk greatest in first days after exposed)
If allegations correct:
4offer drug counselling information / confidential medical services for doctors
4suggest sick leave until counselling/ drug rehabilitation in place
4ensure confidentiality
4address any underlying stressors that may be contributing to drug use
If denies allegations that appear true:
4Gather evidence
4Will need external review eg; medical board
4Formal investigation instigated
Review the procedures in the ED re. handling of opiates
4QA review of the policies and procedures involved in handling of all S8 drugs
4compare handling policies and procedures with those in other similar emergency departments
4quality improvement
SAQ 003
Your medical superintendent sends you a memo saying that your junior medical staff
numbers are about to be reduced from 8 to 6. How do you respond? Detail your further
responses if you do not achieve the desired outcome. (The impending closure of your
observation ward would be an alternative problem to consider).
Immediate response:
Ask for an appointment in a few days time to discuss the issues involved
Gather information:
Potential Impact on Emergency Department Patient?
Current Clinical Indicators & Waiting times
Number and type of complaints
Critical Incidents/near misses and root cause analysis if done
Junior Doctor Issues…
Are junior doctors leaving? (And Why? Better training/opportunities elsewhere, poorly treated,
stress, fatigue, poorly supported)
Roster issues with less staff? More nights/increased stress
Gather data on number of patients seen vs years since graduation (SHOs tend to see more
patients so their loss has a much greater impact)
Policy and Procedure
Emergency is a mandatory term for interns (ie probably would lose staff at a JHO/SHO level,
increased supervision needed for interns)
College guidelines: Access Block, Waiting times vs Triage category
Safe working hours project AMA
Any reasons for decreased staff
Decreased junior doctors numbers across hospital
Apparent budget constraints
Other departments have a greater need
Investigate potential solutions for reduction in staff
1. Find an alternative workforce:
Locum junior staff or increase senior staff numbers
General Practitioners
Close non-essential or less-essential services to free up doctors
Paediatric registrar to see children directly
Nurses: Nurse practitioners to run minor injury clinic, early pregnancy assessment clinic,
community wound reviews, nurse initiated protocols (analgesia, bloods, x-ray)
2. Decrease number of patients
Improved discharge planning - TRACC nurse etc to decrease unplanned representations to ED
Only do core ED business
3. Measures to prevent blow-out in waiting times
Rapid Assessment Team
4. Improve junior doctor training and support
During Meeting…
Set out information in writing, clearly and concisely.
Approach to interview should be of honesty and collaboration. Demonstrate a clear willingness to
be part of the solution.
Further Action Needed?
If no resolution apparent, escalate the concerns to the next person up the management ladder
(district manager, state health minister)
If still no resolution apparent and reduction of junior doctors does eventuate…
Audit clinical indicators/waiting times/complaints/complications/overtime costs/critical incidents
/sick leave every 4 weeks
Formally document critical incidents and near misses
Increase support to junior staff - extend senior/reg cover, informal and formal debriefing, promote
healthy lifestyle, ensure appropriate meal breaks, pay overtime as needed if staff willing and able
to do it.
Notify other departments and junior doctors and ask for their support and understanding during
this time. Can they back up our claims and notify management of issues they encounter as they
arise
If patient outcomes become affected?
Report to Executive Director of Medical Services, District Manager, State Health minister, AMA,
Unions.
Whistle blowing and media to be used as a very last, extreme resort.
SAQ 004
Set up a protocol in your ED for the management of (insert one of the following here):
DKA
Thrombolysis
Chest pain
MI
Suspected epiglottitis
Suspected AAA
Thrombolysis Protocol
Be careful of the wording of the question re: “how to write” versus “write the protocol”
Template for “How to develop a policy or protocol”
1. Gather key stakeholders
a. ED staff
b. Other relevant departments
2. Gather information
a. Current evidence
b. Protocol from other hospitals (don’t reinvent the wheel)
c. Consider hospital infrastructure (eg access to cath lab)
3. Develop a Policy with the frame work..
a. Purpose and Scope (Who the policy is to be used by)
b. Content
c. Indications
d. Contraindications
e. Dose
f. Issues
g. Side Effects
h. Complications and their treatment
i. Date for review
4. Educate and Certify
5. Quality Assurance and Policy Review as evidence changes
THROMBOLYSIS POLICY
Purpose of this Policy:
To provide appropriate reperfusion therapy aiming for a door-to-needle time in thrombolysis of
less than 30 minutes
Use of this Policy:
This policy is for use in the Emergency Department as part of the Chest Pain Policy.
Background of Chest Pain Management:
Immediate management of chest pain or ischaemic symptoms should consist of:
1. Application of oxygen and administration of aspirin/GTN
2. Full set of vital signs
3. Treat any life threats (arrhythmia)
History is brief and should focus on 2 points:
1. Is this ischaemic chest pain?
2. Are their contraindications to lysis?
A ECG should be performed within 5 minutes of presentation shown to a senior doctor (training
registrar or consultant) for identification of ST elevation AMI which fulfil criteria for thrombolysis
A CXR is not vital prior to thrombolysis
Indications for Thrombolysis
1. ECG criteria for AMI fulfilled
a. New bundle branch block
b. 1mm ST elevation 2 or more of inferior leads
c. 2mm ST elevation in precordial leads
d. true posterior AMI (ST elevation V9, ST depression V1)
2. AMI with <12hours of chest pain
3. No contraindications for lysis
a. Allergy (if using Streptokinase
i. SK in past
ii. Documented strep throat in last month
iii. Aboriginal or Torres Straight islander
iv. Known allergy to SK
b. Bleeding Risk
i. Recent neurosurgery
ii. Recent surgery < 4 weeks
iii. Haemorrhagic CVA at any time
iv. Ischaemic CVA < 3 months
v. Recent Trauma < 4 weeks
vi. Medical condition that would be complicated by bleeding: suspected dissection or pericarditis
vii. Active internal bleeding: GIT bleeding, haematuria
4. Consider Relative Contraindications
a. PUD
b. Pregnancy or Post partum state
c. Prolonged CPR
d. Coagulopathy or Anti-coagulation
e. Diabetic Retinopathy
f. Severe uncontrolled HTN (consider nitrates or B-blockers then lysis)
Drugs
The Heart Foundation of Australia recommends second generation fibrin specific fibrinolytic
agents that are available as a bolus (ie tenectaplase) as the fibrinolytics of choice.
Tenecteplase provides a mortality benefit in patients age < 75 years with large infarcts who
present early, but at a higher cost, and higher risk of stroke in older patients. Streptokinase is
cheaper and may have a lower risk of stroke, but is more complex to administer and frequently
causes transient hypotension.
Dose
Streptokinase: 1.5 x 106 Units in 100 mL normal saline over 60 minutes
Adjunct to Thrombolysis
1. Heparin
2. Beta blockers
3. GTN infusion
4. Magnesium
5. Insulin
6. Hypokalemia
Referral to PAH for Angioplasty
1. Contraindications to thrombolysis
2. Failed thrombolysis after 90 minutes
3. <75 years old and presenting with cardiogenic shock
Side Effects: Bleeding
Manual pressure if external bleeding
Protamine 25-50 mg slow IVI (max 50 mg in 10 min) to neutralise 100 Units of heparin
6U of platelets IVI to raise platelet count by 50,000
Cease fibrinolytic and other anticoagulants
Treat effect of other agents (eg warfarin with Prothrombinex and FFP)
Cross match, FBC, aPTT, PT, fibrinogen level
Blood transfusion as required
Cryopreciptate 10 units IVI repeat until fibrinogen >100 mg/dL
If ongoing bleeding: FFP 2U IVI
If ongoing bleeding: tranexamic acid 10mg/kg q6-8 hrly
If ongoing bleeding: consider: rVIIa 30-100mcg/kg IVI or angiographic embolisation
Review
This policy should be reviewed by a multi-disciplinary team (cardiology, emergency and nursing)
in 48 months or sooner if significant evidence becomes available
SAQ 007
With regard to defibrillation:
Outline the principle underlying its action
List the complications
Outline the features you would look for when choosing a new defibrillator/monitor for your
ED.
Defibrillation action
Transient delivery of electrical current causes a momentary depolarization of most cardiac cells.
This allows the sinus node to resume normal pacemaker activity. In the presence of reentrantinduced dysrhythmia, such as paroxysmal supraventricular tachycardia (PSVT) and ventricular
tachycardia (VT), electrical cardioversion interrupts the self-perpetuating circuit and restores a
sinus rhythm. Electrical cardioversion is much less effective in treating arrhythmia caused by
increased automaticity
Complications
Failure to revert rhythm
Burns to skin and muscle
Pain
Dysrhythmia
Hypotension
Pulmonary oedema
Post cardioversion VF
Staff – accidental shock
Anaesthetic risks – hypoxia, hypotension
FEATURES
Specifications
Battery – SLA vs NiCD
Types – monophasic vs biphasic
Multifunction devices – integrated NIBP, IABP, PR, Sats, ETCO2 plus trends
Ability to pace
Pacing options
Pad options – paediatric vs adult
Weight
AC Power adapter and charge times
Dual battery capability
LCD display – channel option, able to be customised,
Ease of use in transfers – how it hangs of bed etc
Synchronisation
Ancillary Costs
Consumables
ECG dots
ECG paper
System issues
Hospital wide consistency
Integration with ambulance services
Integration with current technology
Education and support
Support – out of hours, maintenance
Eduction support and tools
Data Management
Ability to record events
Data transfer capabilities and cables
Price
Bulk purchase discount with other departments
Cost comparisons
Warranty – some only have 30day warranties
SAQ 314
As the Director of your Emergency Department, one of your emergency registrars
enquires of the possibility of purchasing an ultrasound scan machine for the department.
Outline the considerations that will need to be addressed in deciding on this acquisition
(100%)
• NEED – Is there a need? – Define a need / benefit.
o Reasons for acquiring it:
provided?
ternative / addition to existing practices?
o Specific clinical indications in question:
o What are the alternate options?
o Is it justifiable?
• RESEARCHING – Check it out.
o Types of machines
o Properties of each
ease of use, quality of images etc
o Other practical considerations – size, storage, portability, durability, electrical safety
• CONSULTING – asking and benchmarking.
o With other departments – ED’s, radiology, cardiology etc
o Own ED staff – ED consultants and nursing staff
• COSTING.
o Purchase costs v Leasing costs?
o Running costs?
o Maintenance costs?
o Cost-effectiveness?
o Predicted lives saved / decrease in morbidity?
o Funding sources?
o Staff training expenses?
• ADMINISTRATION.
o Quality assurance / auditing issues
o Medicolegal / accountability issues
o Protocols for use
• TRAINING.
o Who should be trained? Everyone v dedicated staff
o Who will use it?
o How will they be trained? By whom?
o Skill maintenance
o Ongoing education and certification
o Guidelines on training – minimal standards
• TRIALLING.
o Choose machine – set time period
o Audit and feedback
SAQ 311
Your hospital executive has decided to introduce a new patient database management
system. This will replace the current separate systems for clinical, administrative,
radiology and pathology data. It will include a completely paperless electronic medical
record.
(a) Outline the features that will be important for this system to possess in your
emergency department (50%)
(b) Describe the potential problems involved in implementing such a system (50%)
(a) Features of the system
• Reliability:
o Clinical and medico-legal implications of computing error.
o Need for minimal downtime for maintaining system.
o Reliable back-up provisions for system failure.
• Compatibility:
o With institution’s legacy systems (ie: existing IT systems).
o With existing hardware capabilities.
o With other hospitals / institutions – need for data sharing. Including capacity for networking
(local and wide area).
• Accessibility:
o Multiple hardware access points.
o Capacity for simultaneous access.
o Remote access by clinicians at home.
• Technical:
o Hypermedia capabilities ie: capable of supporting graphics, text, video, scanned data all in one
patient record.
o End-user friendliness – minimal time spent at terminal versus the bedside.
• Reporting capabilities:
o Need for analysis of data / generation of reports from queries.
o For – research, budgeting, audit, quality assurance processes.
• Security:
o Need to comply with provisions of Commonwealth Privacy Act.
o Ability to use password / firewalls to allow levels of access to parts of system.
o Security from viruses, criminal activity.
(b) Barriers to implementation
Recognise that these will be more organisational / managerial than technical.
• Cost of implementation:
• Research into most appropriate systems.
• Cost of actual hardware and software.
• Cost of reliable back-up systems.
• Cost of time required for hardware installation.
• Establishment of evaluation process:
• Initial costs will be large and up-front, whereas benefits likely to be intangible and delayed.
• Staff satisfaction.
• Consumer satisfaction.
• Staff training:
• Expensive.
• May lengthen period of orientation for all new staff.
• Will need to be ongoing.
• Organisational resistance to change:
• Need for informal and formal communication and information sharing.
• Consideration of employment of ‘change management consultants’.
• Power shifts as different groups are given different levels of access.
• Stakeholder consultation:
• Government, consumers, users.
• Especially with respect to access, privacy issues.
• Management decisions:
• IT support on contractual basis or full time hospital employment.
• Decisions regarding access to information by outside groups eg: clinicians from other hospitals
etc.
• Method of transition – overlapping systems in operation, introduction by department etc.
SAQ 097
List the features which would lead you to suspect a patient of being a drug-seeker. Outline
how you would deal with such a patient.
Signs that increase suspicion of drug seeking
Multiple allergies to non-narcotic medications
Stated diagnosis difficult to confirm (radio-opaque renal stones)
Vague pains - back, pelvis, headache, dental, abdominal - with minimal clinical signs
Carrying letter stating need for narcotics
Unknown in hospital/region
Presenting out of hours
Age >12
Using an alias
Asking for specific narcotic by name and dose
Requests specific doctor
Concurrent alcohol or drug abuse
Premature requests for refills
Reports lost/damaged/stolen medication
Third party requests
Therapeutic dependence with true chronic problems
Known to Medicare Prescription Shopping Information Service
Known to local drug management program
Management
1. Manage the Patient
* At the initial instance take claims at face value and offer complete assessment with physical
examination and investigations.
* Provide non-narcotic analgesia - NSAIDS, paracetamol, buscopan, hot packs, TCA, (ensure
alternatives are non-addictive)
* See further information - other hospital presentations, prescription shopping hotline, hospital
medical chart, GP, pharmacy
* Consider underlying social issues
* Consider undiagnosed organic cause
* If narcotic seeking cannot be confirmed give narcotics to alleviate distress with clear end-points
and limits on doses. A script for a limited supply (48 hours) until patient can return to normal GP.
If ongoing opiate need inpatient assessment should be offered.
* For multiple drug allergies consider drugs that don't release histamine: fentanyl, oxycodone
* For chronic pain ensure patient has had appropriate investigations have been done to exclude
organic causes of pain.
* If you are confident the patient is opiate seeking expect a loud outburst and threats when opiate
is denied. Avoid confrontation in public places (eg corridor, waiting room) and do this in a private
area. Have security staff near.
* Listen to concerns/threats and then give a calm explanation as to
- why you are concerned and refusing opiates
- department policy that supports the refusal
- offer alternative management
- offer admission/referral for further investigation
- offer support/referral for drug rehab, pain clinic
- offer withdrawal support
- Do not provide a script for opiates. Any scripts that are given should be tamper proof
- Notify GP of presentation.
* Document carefully in patients chart.
2. Management for Emergency Department doctors
* stay up to date in acute and chronic pain management techniques
* be aware of where to refer for chronic pain management clinics and drug rehab (inpt vs
outpatient)
3. Management of Emergency Department
* consider written guidelines re the use of opiates in migraines/chronic LBP,
* audit the 'frequent flyers' and develop individual pain management plans
* education sessions for staff
* clear protocols to contact security if patient becomes aggressive
4. Management of your community
* know where drug rehab is available and provide support/referral as needed
* notify to medical board if an individual community doctor seems to be over-prescribing opiates
SAQ 105
A woman presents to your Emergency Department with multiple injuries sustained in a
"fall" at home a week earlier. What features of the history and examination would lead you
to suspect domestic violence as the cause of her injuries ? She admits that she sustained
her injuries during a beating by her husband. What is your management ? Outline your
management of the social issues pertaining to this case.
Medical Mx
Life threats – strangulation, blunt injury, HI
Associated injuries – bruises, wound
Tetanus prophylaxis
Pregnant ?check fetus
Social
Accommodation - safe house
- offer hospital admission
Children ?safe, previous DOF involvement
Safety of patient and family
Mobilise support network – friends, family, religious
DV support groups
Support with notifying police
Support if returns to partner
Drug and alcohol abuse
Financial issues
Educate/provide information in writing
Follow-up phone call
Psychiatric illness - depression
- suicide risk
Pregnancy increased risk
Environment in ED
Same sex nurse
Try to interview alone
Support ++
Establish trust and show empathy
Social Work involvement
Ensure privacy
SAQ 226
Outline the ACEM clinical indicators used in measuring Emergency Department
performance. Also briefly outline strategies to maintain performance according to these
indicators (100%).
Clinical indicators are a measure of the clinical management and outcome of care within the
Emergency Department.
ED clinical indicators should be measurable, achievable, relevant to the clinical practice of
emergency medicine and acceptable to emergency physicians as a reasonable measure of
performance.
ED clinical indicators are a part of overall quality management in Emergency Medicine. Others
features of quality systems include risk management; consumer participation; complaint analysis
and resolution; clinical audit and review; occupational health and safety; and human resource
development.
Current ACEM recommended clinical indicators for Emergency Departments:
• Access:
o Indicators – waiting time; access block.
• Safety:
o Indicators – lost time to work related injury; body fluid exposures; patient falls.
• Acceptability:
o Indicators – patient satisfaction survey ratings; written complaint rate.
• Effectiveness:
o Indicator - admission rate by triage category; time to thrombolysis; unplanned representation
within 48hrs.
• Efficiency:
o Indicator – waiting time by Australasian Triage Scale.
• Continuity:
o Indicator – provision of written health information for sentinel conditions (eg: asthma, wound
care; provision of discharge summary.
Strategies to maintain performance:
Generally:
• Utilise clinical indicators as part of overall quality management within the ED.
• Strive for accurate data collection / performance measures.
• Education of staff as to what specific clinical indicators are.
Specifically:
• Waiting time: ensure adequate staffing levels; ensure accurate data collection; review of work
practices / time-management / triage practices.
• Access block: multi-faceted problem involving whole hospital systems; requires review of
systems within ED and whole of hospital regarding usage of in-patient beds.
• Safety indicators – staff education, ensure protocols regarding safe use and disposal of sharps
and adequate receptacles present, protocols for patient lifts, and protocols regarding use of rails
on beds and escorting mobilizing patients.
• Acceptability indicators – publicise to ED staff patient satisfaction survey results to highlight
good and bad aspects.
• Admission rate by triage category – ensure accurate data collection; protocols in place
regarding senior review prior to any discharge from ED; ED right of admission with in-patient
units.
• Time to thrombolysis – staff education regarding indications / contraindications for lysis; review
of work practices – ECG and ECG review by senior staff within 10min of arrival; ensure
availability of thrombolytics within the ED.
• Unplanned representations - protocols in place regarding senior review prior to any discharge
from ED; medical staff education programs esp.: commonly missed injuries.
• Waiting time – as previous.
• Provision of written information / discharge summaries – letter templates on computer terminals;
pre-formatted patient information sheets.
SAQ 313
You receive a letter from your hospital administration informing you that the Director of
Cardiology has made a complaint regarding times to thrombolysis for acute myocardial
infarction in your emergency department. They request a response.
(a) How would you approach this situation? (50%)
(b) What strategies could you implement to improve your times to thrombolysis? (50%)
Complaint from Cardiology to administration regarding ED ‘times to thrombolysis’
Response required back to the hospital administration.
(a) Approach:
• Express initial concern regarding lines of communication between ED and Cardiology. Given
that Director of Cardiology didn’t raise this matter directly with ED.
• Verify and validate the data being used to show that there are delays in time to thrombolysis –
esp: ensure that problems are not due to incorrect data entry.
• If data correct and delays are occurring –
• Analyse the three issues with this ED system – process, information and decision-making.
• Analyse the cases where delays have occurred looking for common issues that have lead to
delays eg:
• Process problems: appropriate triage of patients with chest pain, adequate nursing and medical
staff to manage case-mix / case-load (benchmark to ACEM standards), systems for early ECG,
adequate clinical areas (monitored) to manage the case-load of chest pain patients (benchmark
to ACEM standards), adequate equipment – enough ECG machines, thrombolytics within ED etc.
• Information problems – notification of chest pain patients into ED, is the information (ie: ECG)
getting to the appropriate medical staff.
• Decision making problems – information reaching the appropriate people who can make a
decision regarding lysis, educational issues regarding lysis – inability to make decisions, other
systems interfering / delaying lysis ie: PTCA access system, patient decision making regarding
consent to lysis
• Where problems identified – redesign system, with assistance of other stakeholders ie:
cardiology, hospital administration where appropriate
• Plan for audit of any new system / changes and report back – to close quality improvement loop
(b) Strategies to improve time to thrombolysis:
• Process:
• Ensure rapid, accurate and efficient triage process for chest pain patients eg: Category 2 NTC
• Chest pain patients triaged to dedicated monitored area for rapid processing
• ECG performed and sighted by senior medical staff member within 10 minutes of arrival
• Dedicated nursing and medical staff (with ability to make decisions on lysis) to manage all chest
pain patients
• Information:
• Relevant staff notified of arrival of chest pain patient
• ECG sighted by medical staff who can make decisions on lysis
• Thrombolysis indications / contraindications readily accessible in treating area for reference
• Decision-making:
• Education of nursing and medical staff of system (care-tracks) for managing chest pain patients
• Education of medical staff making decisions regarding lysis – regarding indications,
contraindications etc
• Simple to follow consent forms / procedure for patients
• Ensure care-track streamlines with any care-track for primary PTCA access
• Continual quality improvement – audit what you do
SAQ 312
You are a newly appointed consultant at a major referral hospital. The director asks you
work on a solution to the "access block" problem that exists in your department.
Outline your approach to this problem.
Definition: Access block has been defined by the ACHS and ACEM as the percentage of all
patients admitted, transferred or dying in the ED where their total ED time exceeds 8 hours.
Approach to working on a solution:
1. Gather information:
• From director - regarding what they see as the problem / any historical background local and
elsewhere / solutions already tried.
• Information from other hospitals / literature as to initiatives which have worked on this problem.
2. Determine immediate stakeholders:
• Inpatient medical teams, bed managers, nurses on wards, directors of nursing, medical
administrators
3. Determine potential fixers:
• divisional directors, medical administrators, district manager, health minister
4. Define the problem:
• Waiting times in all categories, number of admitted patients waiting for beds, time from patient
ready to bed ready, times of ward patient discharges, numbers of patients in ED corridors
• Document and graph - actual times, trends from previous years, seasonal variation
5. Make “fixers” aware there is a problem:
• Invite them to meet with you.
• Present your data including graphs, photos of trolleys in corridors etc
• Indicate that such a workplace is “unsafe” for patients, for staff liability, even as a fire hazard.
• Indicate that working under conditions of access block is undermining staff morale (sick leave
stats / resignations may support this) and impairing patient care (adverse events / critical
incidents occurring to patients with prolonged stays in ED)
• Make them aware that this is a hospital problem, not just an ED one, as evidenced by its
presence in many larger Australian hospitals, and all large US hospitals.
6. Suggest solutions:
• A commitment required from management that long term (eg: work practices) and short term
strategies (eg: beds reopened and staffed) will be needed, and met.
• That “root causes” in your hospital need to be addressed with the immediate stakeholders (from
admission process to discharge process).
• Other healthcare delivery systems (eg: medihotels, day of surgery admission, short stay wards,
chest pain units) will also need consideration to change ED work load.
• Develop a policy re: ambulance diversion and a system for going on “alert” prior to access
block.
7. Agree to a timetable of implementing changes.
8. Plan to measure the impact of any changes to processes.
• Follow up with statistics to show whether real changes have occurred and feedback to
administrators.
9. Consider raising profile of this issue
• Eg: via occupational health & safety, specialty colleges, AMA, media with director’s guidance /
consent.
SAQ 154
A 25 year old woman is brought to your Emergency Department after being raped
What is your management ?
Outline your history, examination and investigations
Outline your forensic examination
ALTERNATIVE QUESTION
A 22yo woman presents following an alleged assault. She is withdrawn and will not discuss the
details of the incident.
On examination, she has multiple bruises of varying appearance over her body and face. The
nursing staff report blood on her underpants while undressing.
Describe your assessment of this woman.
Exam Q
Also see SAQ 155, 175, 369, 442, 482
ISSUES
Extreme Sensitivity
Open support approach
Quiet and private room with no interruptions
Same sex nurse/SW (chaperone)
Support person to stay with patient throughout - never leave alone
Meticulous documentation
Don’t shower, change clothes or wash teeth
Mx
1. Life Threats
2. Assess physical injury
3. Assess genital injury
4. Psychological support
5. STD prophylaxis
6. Pregnancy prophylaxis
7. Tetanus prophylaxis
8. Gathering of forensic evidence
9. Support contacting Police
10. Ensure safety of patient and children on discharge
ASSESSMENT
Hx Event,
when/where/how/by whom,
nature of rape (vaginal/oral/anal),
other injuries (head/face/trunk extremeties),
alcohol or drug intoxication
Forensic hx – showering since ? Changed clothes since ? time of rape
O&G Hx – pregnancies, LNMP, last intercourse, contraception
PMHx, Meds, Allergies, ADT status ? hx – depression
Social hx – DV, dependents safe
Except for serious injury, be careful the Ex and Ix do not compromise forensic assessment.
Ex Life threats – strangulation, HI, haemoperitoneum, haemothorax
General exam – ass inj – defence wounds, bruises
O&G exam – injuries – vaginal/anal/oral (abrasions, lacerations, bruises, discharge)
Ix For trauma as indicated
Bedside
BSL, urinalysis (UTI, hematuria)
Lab
Bloods
FBE (Hb) if blood loss
Beta-HCG
LFT baseline
U&E, Cr
Coags, G&H if bleeding
Check blood type (?anti-D)
Serology Hep B&C, HIV, VDRL
Baseline, need to rpt inn 3 and 6/12
Swabs high vaginal, cervical (?STD)
Imaging as indicated
FORENSIC EXAMINATION
Should be done by government medical officer (GMO) or experienced forensic doctor
Objectives:
Proof of sexual contact
Consent vs use of foce
Identity of assailant
External
Collect all clothing as evidence
Skin any marks including evidence of restraints
Loose hair, nail trimmings, skin scrapings, dried blood
Comb pubic hair
Internal
Swabs (vaginal, cervical, +/- rectal, buccal)
For sperm: vaginal aspirate – wet mount within 72h Wood light for semen
PSA, acid phosphatase within 48h
Serology
Scrupulous documentation
MANAGEMENT
1. Resus/Stabilisation
ABC
Check obs
IV access if needed
Injuries: external, genital
2. Specific Treatment
Treat external injuries starting with life-threatening (external or internal hemorrhage)
IV antibiotics if indicated
ADT
a. Prevent pregnancy (risk 1%)
check beta-HCG (?already pregnant)
post-coital contraception
within 72h
levonogestrel 75mg q12h x 2tabs
SE – nausea, vomiting, dizziness, fatigue
Prophylactic metoclopramide
Advise: will get withdrawal bleed, next period will be late, check beta-HCG in 2/52
b. Prevent local STDs (risk 5%)
N. gonorrhea ceftriaxone im 250mg stat
Chlamydia doxycycline po 100mg bd 7d
Erythromycin if ?pregnant
c. Prevent blood-borne STDs
HIV discuss starter pack
2 x antiretroviral agents
SE – GI, hepatic, cutaneous, heatologic
2/52 course, then FU at ID clinic
weigh risk of infection vs risk of treatment
HBV if never immunised/sAb levels low:
Hep B Ig + commence course of Hep B s Ag x 3
HCV ?interferon (seek advice from ID)
3. Supportive care
Analgesia, antiemetic
Psychosocial input: social worker, rape counsellor, psyc service, legal services/police
Forensic assessment: GMO
Family support
4. Disposal
Depends on injuries – gynae, medical, surgical, ortho
If sent home, ensure tight follow up:
LMO – check test results, follow up tests
O&G – STDs, pregnancy
SW, counsellor
SAQ 285
Discuss the advantages and disadvantages of having a chest pain unit
Start with general concept
For risk stratification using Hx/ECG/pathology TNI and stress testing
Advantages
Decreased length of stay
Decrease in bed days
Discharge planning
Stress test
Managed care plan
PR aspect
Initiative
Disadvantages
Set up costs
Ownership
Poor pt selection
Undifferentiated pts being put through a differentiated system will result in
stuff-ups (Eg PEs or aneurysms)
Variation on question would be setting up a chest pain unit
OVERVIEW
Used for risk stratification
Danger of undifferentiated patient in differentiated system
NEEDS
Demographics
Numbers presenting, admissions, etc
LIAISON
With Cardiology, Physicians
PROTOCOLS
Use of TnI & ECG
EDUCATION
Medical staff
Nursing staff
STAFFING
After hours coverage
An 82 year old lady returns to your department 3 days after
a fall, comDlaining of ongoing shoulder Dam and bruising.
She was seen in your ED soon after the fall by p junior
resident. who diagnosed a soft tissue injury after viewing
this Xrav, and gave her a broad-arm sling.
a) Describe this Xray.
b?~ Outline your management.
~.)
R shoulder x-ray single view A-P
2 part SNOH fracture with impaction, 50% medial
displacement and
approx 30 degrees lateral angulation
Soft tissue swelling
No obvious dislocation on single view (needs nd to exclude
posterior).
2
bin) Manaaement issues
 Patient care and safe disposition
 Harm minimisation including potential
complaint
 Resident education and supervision
 Assess x-ray R/V process — missed fracture
not detected
 Documentation.
Patient care
Full reassessment including 2 view re-xray, extent of
bruising.
Analgesia. Paracetamol/codeine or morphine titrate
to response
Collar and cuff
u-slab for additional traction
patient/relative education reassurance and apology
(“miss” will not affect prognosis, broad arm sling
appropriate)
Discharge home only if safe:
“Non-pathological” cause of fall (eg. No syncope)
Pain controlled on oral medication
Able to cope at home with likely dominant arm in sling
Support including additional organised through ED
(multidisciplinary)
Patient/relatives happy for discharge
Follow-up home visit/GP and fracture clinic 1/52.
Falls/geriatric clinic as appropriate
Otherwise admit ortho/aged care team.
Missed fracture
Educate (sensitively) resident and
assess need for further ortho/ radiology
education for individual and group
Assess supervision levels and
address staffing levels and skill-mix as
appropriate
Clinical indicator: add to audit.
Assess reporting and recall
procedures (as 3/7 and patient selfpresented) with aid of radiologists.
Institute changes and reassess as
quality improvement program
Full documentation, including of
apologies, to anticipate potential
complaint/medico-legal.
Discuss your steps in introducing emergency department ultrasound to your
department.
General comments:
This question has a generic component and one specific to ultrasound. It asks what arc
thc gcneral principles into introducing and integrating any new technological skill into a
department and what that entails
As well as what you know about the role of ultrasound in the department.
Scoring: 1 point for each major point below. Depending on detail will establish mark out
of 10.
.,
General template of introducing new technology:
1. Establish need and scope- it is assumed that this has been addressed
2. Establish lead person
3. Canvass support from your department
4. Canvass support from other affected departments
5. Purchase of equipment
6. Credentialing and accreditation
7. Education and ongoing skill acquisition
g~ Quality assurance and appraisal
Specific to EDU (emergency department ultrasound)
Recognise that FACEM has policy statements on minimum standards and credentialing.
FACEM also has a subcommittee on US
Currently US knowledge on syllabus but not essential skill but highly recommended
1. Establish need and scope- it is assumed that this has been addressed
 Discuss scope of EDU eg FAST, AAA
 Brief comment on other EDU procedures that are currently not accredited
by FACEM eg. DVT, Pelvic, Renal, Biliary, Foreign body but have been
performed by United states ED physicians
 Assess your own department’s needs and whether it will be cost effective
i.e. improve length of stay, improve education, trainees satisfaction,
reduction in reliance on radiology
2. Establish lead person


credentialing
Delineate role
Adequate expertise and enthusiasm
3. Canvass support from your department
 Departmental heads
 Colleagues
 Nursing staff as they have to work around equipment
4.Canvass support from other affected departments
May need close liaison with radiology for further
Avoid turf battles and clearly delineate limited role of EDU
(not taking
over)
Support from surgical, o and g services. May share equipment
Hospital may have credentialing committee
5. Purchase of equipment
 Establish needs
 Address type of probes required, need for Doppler
 Peripherals eg printer, video
 Warranty and service agreements
 Costs and financing (may need to share or borrow
equipment initially)
 Compare companies and involve radiology in
examining equipment
6. Credentialing and accreditation
 Establish minimum requirements for people to use
machine
i. Often a system of levels /grades
 DOCUMENTATION of examinations
 Develop protocols for specific examinations
8.
7. Education and ongoing skill acquisition
 Establish programs that meet FACEM standards
 Integrate education component to trainees
 Establish minimum hours of US performed exams to
maintain skills
Quality assurance and appraisal

Require proctoring of examinations by radiology initially and then
accredited emergency physician

Address studies and audit program on cost effectiveness and
effects on
patient

Comparison of studies to gold standards eg operations, radiology
performed US, post mortems
SAQ 7.
You are asked to write guidelines to help fast —track the ED care of women in l~
trimester PV bleeding.
a) Outline these guidelines
b) How would you track the effectiveness of the new guidelines?
In general, this question was poorly answered as I think most ofyou ran out of time.
Firstly, afew general comments on writing guidelines.’
has to be simple, clear, concise... .for idiots
must have strict criteria to rule out certain conditions that are potentially fatal.. in this
case, ectopic pregnancy (previous ectopic, previous tubal ligation, shoulder tip pain,
unilateral abdo pain, JUD, PID) and cvical shock in incomplete aborts)
emphasise that it ‘s a guide to patient management and not a directive, does NOT
replace good clinical judgement (for e.g in my head injury guideline I have a waive out
clause at the end of the Hlform ~fyou want to go out of guideline)
No one mentioned patient advice for patients to return ~f symptoms got worse, or LMO
follow up, this should be standard in all patient discharge plans.
-
-
-
-
Tracking the effectiveness of the guideline really depends on why you created it in the
first place.
to decrease waiting times
to improve safety and reduce adverse events
to improve discharge plannng
to improve patient satisfaction
reduce pathology ordering
You monitor the outcomes of whatever you set out the guideline for.
Need some sort of comparison, so, have a historical control prior to guideline and a
prospective audit post guideline. Need to also measure compliance rate of guideline
i.e how many doctors and nurses are using it and ~f they are using it correctly.
-
-
-
-
-
a) Guideline for 1st trimester PV bleeding includes:
1. TRIAGE and GP REFERRALS
Confirm pregnancy if not already done with blood / urine test.
Normal triage procedure with assessment of vital signs and degree of pain and
bleeding.
Triage catergory assigned BUT should be highlighted as 1St trimester PV bleeding for
possible fast tracking if resources allow.
Relevant blood tests performed pHCG, blood group (fFBE I personally don ‘tfind this
useful, but it is in MMC ‘s guideline)
-
-
-
-
2. MEDICAL ASSESSMENT
Directed O&G history in particular past pregnancies, miscarriages, ectopics,
gynaecological procedures, contraception, ectopic risk factors (previous ectopic, PD,
IUID, tubal ligation, any unilateral pain)
has an intrauterine pregnancy been confirmed for this pregnancy on US?
assess severity of bleeding and or pain.
Examine patient, check vital signs, abdo and pelvic exam. Suspect ectopic if unilateral
pain, adnexal tenderness (or mass) and cervical motion tenderness.
Check for POC at os.
(assessing wheteher the os is opened or closed is useless)
-
-
-
-
3.
MANAGEMENT
(i) Unstable resuscitate,
(ii)
In pain: analgesia
(iii) Suspect ectopic : refer to O&G first then US if patient stable otherwise to
OR.
(iv) Ideally, all should have US to check viability of foetus,
retained products or missed abortion. This can be done
non-urgently and arranged for the next day and the
patient to be followed up in EPB (Early pregnancy
bleeding) clinic. If the patient needs admission for
pain, bleeding or surgery, then an urgent US may need
to be done.
(v)
Unstable patients : referred to O&G and admitted.
(vi) All discharged patients should be given advice and
follow up instructions on when to return if symptoms
worsen.
(vii) Anti-D in Rh (-)ve patients.
(viii) Counselling re miscarriages.
b) Tracking the effectiveness of the new guideline
1. Historical control / retrospective chart review of patients
pre guideline.
2. Prospective audit of guideline compliance rate and correct
use of guideline.
3. Monitor outcome measures of interest:
waiting times
adverse events or missed diagnosis
-patient satisfaction
amount of pathology ordered
time effectiveness of triage-treatment-discharge times
feedback from O&G, GP, radiology and ED doctors and
nurses
-
-
-
-
-
You are the director of a tertiary level ED. You receive a complaint from a patient who
states he is making legal enquiries regarding a bad experience he had in your department.
He states he heard a doctor informing other doctors about his condition. During the
conversation there was laughing and giggling at his expense. He felt embarrassed and
was ashamed to discuss his condition any further with anybody else.
Priorities
1.
2.
3.
4.
5.
6.
Ensure safety with possible incomplete assessment
apologise
investigate
discipline staff as necessary
inform hospital insurer and complaints department
take steps to prevent recurrence education re confidentiality/privacy department
layout cultural change
7. ensure that this process is agreed to by the patient and does not lead to further
embarrassing disclosure
(letter opened by wife.. .We apologise for the incident, it was just the buzzing sound that
set us all of)
Response to complaint
Recognise as serious legitimate complaint with privacy and confidentiality issues
Rapid initial contact.
Apologise without admitting guilt
Establish rapport
Non judgemental approach
Obtain more info regarding events
Ask for complaint in writing.
Document all conversations
Interview staff
Offer patient his own advocate/ access to complaints department.
State that you would like to properly investigate the matter and that you will make
contact with responce
After investigation take steps as indicated.
Inform hospital insurer
Discipline staff
Formal apology after liason with legal staff
Ask what steps the patient fells he would like taken (may or
may not be reasonable.
Steps to prevent recurrence
Consider a committee approach
Medical
Nursing
Legal or privacy officer
Administration
Define the problem eg. Breach of confidentiality in the ED
Investigate the causes and possible remedies
Literature search
Visit other departments
Hospital insurers max have resources
Enquire as to whether there is funding to tackle the problem
(eg. The insurer may be a sponser)
Collect data on confidentiality issues/breaches in the department
Note other areas of potential breaches eg. Pt information displayed on
“whiteboards”.
Look into underlying causes of problems
e.g. Cynicism or black humour reflecting poor morale!
burnout poor rostering, work load or supervision.
Institute changes
Eg. Department layout with tea rooms separate from patient areas
Hand-over areas
Screening of phone conversations.
You are a consultant in a tertiary hospital emergency
department. The director asks you to assess means by which
departmental investigation costs might be reduced.
Discuss your approach.
Answer provided by Graeme Thompson:
TEAM APPROACH
The first thing to do is to assemble a multi-disciplinary team.
Select team members who are:
Available to give some time,
Able to mtluence others
Include representatives from diagnostic imaging and laboratory
medicine
Have an interest in the problem
The team should be small enough to be cohesive and manageable. Set up
smaller teams with tasks.
Enquire if a budget is available (e.g. for external help)
MEETINGS
Arrange tbr regular meetings
Keep good records including attendance records
Set out clear goals
Ensure that minutes are circulated
Decide on a timeframe and try to adhere to it
APPROACH TO PROBLEM
Assemble information on current activity and costs, broken down in detail to
give an
accurate picture of individual test ordering
Try to ascertain who orders tests
Find out if current test ordering is protocol driven or left to individuals.
Ascertain ‘best practice’
Literature search
Visits, discussions with people from other hospitals where it is thought
that costs have been well contained.
Find money for site visits
Using a Delphi approach discuss the various aspects of best
practice that may be useful in your situation
-some aspects may be impractical
-using the same approach decide on the individual tests that
you will target. These may be the most common, or the
most expensive or the most
inappropriately ordered.
Decide if you want to reduce overall demand by having tests
ordered elsewhere. For example have woman needing non urgent
ultrasounds go back to GP’s to have them ordered or have many
of the tests ordered after patients are admitted, not from
ED
These approaches will need wider consultation and dissemination
of information to inpatient units andior GPts.
IMPLEMENTATION
Once your approach is decided upon, tell everyone concerned
what you are planning
to do
Use non-threatening ways including lunches, teaching sessions
and posters.
Implement changes and monitor compliance, progress and actual
savings
Gather feedback from staff and other users
Modify your approach based on progress and feedback
6.
In response to a high level of sick leave taken by medical staff in your ED,
consultant staff decide to look at strategies to reduce the level and impact of sick
leave. Describe the issues involved.
5)
The CEO of your tertiary ED states an intention to have ED consultants work night shifts
and requests your opinion. Outline your response.
2. What features would you want in a patient trolley (bed) for a resuscitation
area? Justify your answer.
1. Strong – up to 180kg patient, able to withstand CPR
2. Mobile – multidirectional wheels with unidirectional lock capability (+ all lock)
rubber fenders
3. Adjustable – patient sitting, 0-90O all positions
Trendelenburg and head up
Height of bed
Hydraulic assistance so easy to adjust, ergonomic issues to prevent staff injury
4. Compatible – with resusc, ICU, CT areas, easy to manoeuvre, light
Xray – space for film cartridges for trauma and other views
5. Attachments – drip pole at 4 corners
Equipment tray at foot end
Extendable for tall patients
Removable bed ends
O2 cylinders
Tray underneath for clothes, notes etc
6. Cost effective
1. Your department receives a series of complaints from relatives of patients who
die in the ED regarding the care and information offered to them. Outline the way
in which you would improve the standard of care offered to relatives of these
patients in your department.
‘
2.) You are appointed as a fellow with a non-clinical role in a large academic emergency
department. Outline methods by which you could increase the use of evidence in clinical
decision making within your department.
7.) Diseu.ss the role of emergency (lepartment short-stay wards.
i.
You wish to implement the use of bedside ultrasound by Emergency
staff in your department.
Outline the process of implementation.
2.) A 75 year old lady is brought in from home having fallen. An x-ray
ordered by the triage nurse shows a fractured neck of femur.
She refuses to be admitted saying that she just wants to go home
and that it will heal eventually.
2.) You are the director of a tertiary hospital Emergency Department. You receive
a complaint from a patient who states he is making legal enquiries regarding a bad
experience he had in your department. He states that he heard a doctor informing
other doctors about his condition. During the conversation there was laughing and
giggling at his expense. He felt embarrassed and was ashamed to discuss his
condition any further with anybody else.
Outline your response.
5.) You are the director of a rural department. Your registrar asks that the
department stock a new drug, B, in preference to the existing drug A, for the
treatment of myocardial infarction. She states that she has read an article in which
the use of drug B is associated with a statistically better outcome than A, and that
the p value is less than 0.05
The cost of drug A is $50 and that of B is $300.
SAQ1. Thomas Chan
Discuss your steps in introducing emergency department ultrasound to your
department.
General comments :
This question has a generic component and one specific to ultrasound.
It asks what are the general principles into introducing and integrating any new
technological skill into a department and what that entails
As well as what you know about the role of ultrasound in the department.
Scoring : 1 point for each major point below. Depending on detail , will establish mark
out of 10.
General template of introducing new technology:
1. Establish need and scope- it is assumed that this has been addressed
2. Establish lead person
3.
4.
5.
6.
7.
8.
Canvass support from your department
Canvass support from other affected departments
Purchase of equipment
Credentialing and accreditation
Education and ongoing skill acquisition
Quality assurance and appraisal
Specific to EDU (emergency department ultrasound)
Recognise that FACEM has policy statements on minimum standards and credentialing.
FACEM also has a subcommittee on US
Currently US knowledge on syllabus but not essential skill but highly recommended
1. Establish need and scope- it is assumed that this has been addressed
 Discuss scope of EDU eg FAST, AAA
 Brief comment on other EDU procedures that are currently not accredited
by FACEM eg. DVT, Pelvic, Renal, Biliary, Foreign body but have been
performed by United states ED physicians
 Assess your own department’s needs and whether it will be cost effective
i.e. improve length of stay, improve education, trainees satisfaction,
reduction in reliance on radiology
2. Establish lead person
 Delineate role
 Adequate expertise and enthusiasm
3. Canvass support from your department
 Departmental heads
 Colleagues
 Nursing staff as they have to work around equipment
4. Canvass support from other affected departments
 May need close liaison with radiology for further credentialing
 Avoid turf battles and clearly delineate limited role of EDU (not taking
over )
 Support from surgical, o and g services. May share equipment
 Hospital may have credentialing committee
5. Purchase of equipment
 Establish needs
 Address type of probes required, need for Doppler
 Peripherals eg printer, video



Warranty and service agreements
Costs and financing (may need to share or borrow equipment initially)
Compare companies and involve radiology in examining equipment
6. Credentialing and accreditation
 Establish minimum requirements for people to use machine
i. Often a system of levels /grades
 DOCUMENTATION of examinations
 Develop protocols for specific examinations
7. Education and ongoing skill acquisition
 Establish programs that meet FACEM standards
 Integrate education component to trainees
 Establish minimum hours of US performed exams to maintain skills
8. Quality assurance and appraisal
 Require proctoring of examinations by radiology initially and then
accredited emergency physician
 Address studies and audit program on cost effectiveness and effects on
patient
 Comparison of studies to gold standards eg operations, radiology
performed US, post mortems.