CLINICAL PRACTICE MANUAL
CPM
2012
1
PRINCESS ALEXANDRA HOSPITAL
DEPARTMENT OF EMERGENCY MEDICINE
CLINICAL PRACTICE MANUAL
CONTENTS:
1.
2.
3.
4.
5.
PAH ED Clinical Areas
Safe Access for Emergency Patients in PAH ED
Clinical teams
Picking up a patient
Assessment of patients
6. Documentation
7. Discussion of patients with ED senior staff
8. 3:1 Procedures – Processing patients through the ED
9. Ordering pathology tests
10. Ordering radiology (and vascular USS)
11. ED Clinical Guidelines and Procedures
12. Finding a nurse
13. Organise analgesia or intravenous fluids for a patient
14. Procedures – Procedural sedation, suturing, plastering
15. Answering the telephone
16. Referring to an in-patient registrar
17. Referring to the medical registrars (and MAPU medical and cardiology
registrars)
18. Referring to a medical sub-specialty unit
19. Referring to an in-patient consultant
20. Arranging a private / intermediate admission
21. Referring to ED Mental Health
22. Referring to OPD
23. Referring to Fracture Clinic
24. Referring for outpatient investigations
25. Eye Clinic
26. Referring for Obstetric and Gynaecology Services
27. Pharmacy services
28. Social Worker services
29. Emergency accommodation
30. Referring to Allied Health
31. Referring to Community Health Nurse
32. Utilising Pastoral Care
33. Alcohol and Drug Services (ADAU)
34. Referring to Sexual Health Clinic
35. Discharging patients home
36. Admitting a patient to the ED Short Stay Ward
37. Admitting a patient to the Ward
38. Finishing you shift
(Last update: MAR 2012)
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1. PAH ED Clinical Areas
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 patients
o 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
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.
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.
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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.
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 Coordinator.
o The Emergency Department consultant (ext. 7215) and the Nursing Shift Coordinator (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.
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3. Clinical Teams
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o
o
o
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.
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.
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.
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.
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
o
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.
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 reprioritisation following a secondary nursing assessment within Ambulatory Care or
at the discretion of the ED registrar or consultant).
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
o
o
o
o
o
o
o
o
o
ATS
ATS
ATS
ATS
ATS
Category
Category
Category
Category
Category
1
2
3
4
5
–
–
–
–
–
immediate
10 minutes
30 minutes
60 minutes
120 minutes
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).
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.
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.
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.
Initially the patient will come into the department with a nursing assessment /
observation sheet and patient ‘sticky’ labels.
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o
o
o
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.
Charts for Ambulatory Care patients are delivered to the staff station in this area.
The location of the patient within the department is on the EDIS screen.
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
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o
o
o
o
o
Within the ED you have more direct senior supervision than in most other parts of
the hospital.
To facilitate effective and efficient assessment and management of patients you
are required to consult senior staff (ED Consultants and Registrars) early and
regularly.
Different levels of experience and skill will dictate the level of trust afforded you.
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.
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.
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.
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
o
o
o
o
o
o
o
o
o
o
All ED medical notes (other than when utilising the Trauma Forms) will be
undertaken electronically within EDIS.
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.
Document a thorough but focused history and examination.
Document what investigations have been ordered.
Document the results of all investigations you have ordered once they become
available.
Always finish with a diagnosis; or differential diagnosis; or a problem list.
Always document a management plan that outlines treatment and management
undertaken and other related issues (disposition etc).
Document the name of the ED registrar or consultant you discuss the case with
and accurately reflect their management plan in the chart.
Document the name of the inpatient registrar you refer the patient to. Note the
time they were contacted.
When you are not using the patient’s chart ensure it stays with the patient in their
cubicle / room or otherwise designated area.
Once you have completed your notes, print them out and place them
within the patient’s chart.
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7. Discussion of patients with ED senior staff
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All patients you see should be discussed with an ED registrar or consultant.
Early discussion (within the first 30 minutes of seeing the patient) enables more
efficient and effective care of the patient.
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’.
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.
All patients being discharged from the ED should have been discussed with a
registrar or consultant.
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).
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.
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.
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
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.
What ED medical staff need to know and do:
o The ED is responsible for the ‘3’ hour time-frame of 3:1
o
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.
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o
o
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
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.
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
o
o
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.
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.
Simply tick to indicate which tests you require.
Group and Hold and Cross-Match requests have a unique form (purple in colour)
that is to be utilised for these requests.
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o
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o
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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.
Inpatient teams requesting additional tests must utilise blank pathology forms and
indicate their consultant unit as the cost centre.
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.
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.
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)
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The ED has its own satellite radiology unit with plain radiology, USS and CT rooms.
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.
Radiology request slips are to be faxed through to the radiographers’ work area.
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.
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.
You must discuss any potential request for CT, USS, and MRI etc with an ED
consultant or registrar.
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.
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.
An MRI request often needs to be discussed directly with the MRI Consultant.
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.
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 ultrasound
o
o
o
o
Please note, the vascular lab (not radiology) performs all vascular USS within the
hospital.
They are available Mon-Fri 08:00 – 17:00 (last referrals at 16:30)
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.
After-hours – selective vascular scans can be performed by radiology if necessary.
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11. ED Clinical guidelines and procedures
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o
o
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.
These have been developed by the ED or in conjunction with inpatient units.
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.
They may also be found on the department’s webpage within the hospital’s
intranet.
12. Finding a nurse
o
o
o
Nurses are assigned to areas within the department along similar lines as to the
allocation of medical staff.
Introduce yourself to the nurses working within your area of the ED at the start of
each shift.
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
o
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.
There are numerous electronic resources (CKN) to enable correct prescribing of
medications and fluids. Otherwise ask the senior staff if unsure.
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
o
Most procedures will be undertaken within either the resuscitation rooms or in the
procedure area.
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
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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 Room
o Nursing staff should assist in the preparation and closure of the wound.
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
o
o
Answer the phones with “Emergency Department” or “PA Emergency Department”.
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).
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
o
o
o
On-call information can be obtained by phoning switch (dial ‘9’).
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.
If registrars fail to answer their page – check with switch that they are indeed oncall (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.
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.
11
17. Referring to the medical registrars (and MAPU Medical and Cardiology
Registrars)
o
o
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.
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.
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 subspecialty 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
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.
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
12
‘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
o
o
o
You may have reason to discuss a patient with the inpatient consultant (e.g. if they
are a private patient).
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.
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
o
Patients occasionally present to the ED with private health insurance and wish to
utilise this for a private / intermediate admission.
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
o
o
o
o
o
o
There is a separate area within the ED where the ED Mental Health Service is
located. They provide a 24 / 7 service.
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.
Familiarise yourself with the elements of the Mental Health Act that pertain to
examination orders and involuntary patients.
All patients that present following a self-harm attempt or on an EEO should be
discussed and assessed by the ED MH clinicians.
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.
Any ‘involuntary’ patients within the ED should have a nurse ‘special’. This is
arranged with the nurse in charge of the shift.
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).
Ensure the contact details for the patient are correct.
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
o
13
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 Clinic
o
o
o
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.
Appointments can be made via an electronic OPD request addressed to ‘Urology
OPD – Acute Stone Clinic’
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
o
o
o
o
o
All fractures that are seen through the ED should be referred for follow up to the
Fracture Clinic run by the orthopaedic surgeons.
The Orthopaedic Department has their own electronic OPD referral forms – again
via the Intranet links:
o Projects

ED blue slip referrals
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).
Ensure the contact details for the patient are correct.
The fracture clinic staff will then send out an appointment to the patient.
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
o
o
o
o
o
o
There may be situations where investigations can occur non-urgently after the
patient is discharged from the ED.
Such investigations may include EST, dobutamine stress echocardiography, Holter
monitoring, EEG, imaging – USS / CT / MRI etc.
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).
To arrange investigations, fill out a radiology request slip as appropriate. Ensure
the patient’s contact details / address is correct.
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.
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.
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.
14
25. Eye Clinic
o
o
o
o
o
The Eye Clinic is staffed with an Eye resident with access to Ophthalmology
registrars.
The hours of operation of the Eye Clinic are: Mon-Fri: 08:00 – 16:30 and Sat.
08:00 – 12:00.
To avoid excess overtime for the clinic they cease taking new patients from 16:00
Mon-Fri and 11:30 on Saturdays.
Eye patients going to the Eye Clinic from the ED triage desk do not appear on the
EDIS screen.
Outside operational times of the Eye Clinic, ED staff sees patients with eye
complaints.
26. Referring for Obstetric and Gynaecology services
o
o
o
PAH has no on-site obstetric and gynaecology service. We rely on accessing the
services provided by the Mater hospital and QEII hospital.
For obstetric issues (i.e. > 20 weeks) please contact the Mater Mothers Obstetric
Registrar – they generally will be in the delivery ward.
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
o
o
o
o
Operational times of pharmacy:
o Mon-Fri: 08:00 – 18:00.
o Saturday: 08:30 –17:00.
Outside of these hours discharge medications can be accessed from the ‘afterhours 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.
The PBS scripts utilised within the hospital can also be used by patients in
community pharmacies.
The ED has its own pharmacist, available on the floor between 08:00 – 17:00
Monday to Friday. Pager 999.
They will assist with:
o Medication information and advice
o Medication histories
o Patient counselling and advice
o Community medication liaison (e.g. for Webster packs and nursing home
patients)
o Inpatient and discharge medication supply
o PBS queries
28. Social Work Services
o
o
o
o
A social worker is based in the ED:
o Mon – Fri:
08:00 – 22:00
o Sat:
18:00 – 22:00
The social worker can be found in their office located in the MAPU offices opposite
Mental Health
They can also be contacted via pager 866 or 1434, or ext 3944 or 3949
Issues that can be referred to the social worker include:
o Psycho-social assessment
o Bereavement and coronial matters
o Crisis intervention
o Advocacy
o Legal resources, legal aid police
15
o
o
o Cross cultural referral and support
o Referral to appropriate community resources / community health / ACAT
o Financial difficulties
o Discharge planning
o Post trauma counselling
o Sudden death counselling
o Sexual assault
o Information and support
o Aged care assessment and respite referrals
o Domestic or family violence
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 violence
o Trauma
o Rape / Sexual assault
o Sudden death
o Child(ren) at risk
o Donor family
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
o
The Homeless Liaison Officer is familiar with accommodation options – pager 5190.
The ED Social Worker will be able to help in the absence of the Homeless Liaison
Officer.
30. Referring to Allied Health
o
o
There are designated allied health staff members covering the ED, they are located
in the MAPU offices opposite Mental Health.
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 – Fri
o Pagers 300 / 913
o 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 pain
o De-conditioned elders and fallers: mobility assessment for discharge and
MSK treatment
o Vestibular: assessment and early treatment as appropriate
o Neurological: balance, gait and co-ordination assessment and suitability for
discharge
o Respiratory: early assessment and treatment
o Multi-trauma: early respiratory treatment as required
o 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.
16
o
Remote Call (after 18:00)

Acute respiratory patients who will deteriorate overnight without
physiotherapy intervention
Occupational Therapy –
o 08:00 – 16:30 Mon – Fri
o Pager 584
o Review / assess functional performance for discharge planning (upper limb, vision,
cognition, self cares)
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 assessments
o Facilitate referral to upper limb orthopaedic hand team as appropriate
Speech Pathology –
o 07:30 – 16:00 Mon – Fri
o 08:00 – 12:00 Sat, Sun
o Pager 5243
o Referrals for:
o Acute stroke patients
o Suspected aspiration pneumonia
o New onset dysphagia or deterioration of pre-existing dysphagia
o New onset of communication impairment
o Laryngectomy patient with dislodged voice prosthesis
Dietitian –
o 07:30 – 16:00 Mon – Fri
o Pager 5244
o Weekends 09:00 – 17:00 via switch for urgent referrals
o Referrals for:
o Malnutrition
o New diagnosis for dietary education
o Nutrition support: enteral, parenteral and oral
o Chronic disease management and dietary compliance issues
Aged Care Early Intervention and Management (ACEIM) team
o 08:00 – 16:30 every day (Mon – Sun)
o Speed dial 4681
o Referrals
o To facilitate right care right place model of care
o Implement avoidant strategies and where appropriate provide
advice
o Liaise and follow up all presentations from Aged Care Facilities
o Facilitate rapid response to assessment
o Enhance the geriatric focus of nursing in ED
o Case management with teams to manage these patients
focusing on continuity of care and optimal flow
o Co-ordination of referrals to external service providers
31. Referring to the Community Hospital Interface Nurse (CHIP Nurse)
o
o
The ED has a Community Hospital Interface Program (CHIP) co-ordinator available
within the department 08:00 – 16:30 every day (Mon-Sun).
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)
17







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
32. Utilising Pastoral Care
o
o
o
Pastoral care workers are available within the ED between 18:30-22:30.
They can be found via pager.
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
o
o
o
PAH has a consultation Drug and Alcohol service that operates in business hours.
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).
ADAU can be contacted via Switch.
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
o
o
There are numerous sexual health clinics run within the Metro South Health
District.
The PA Sexual Health Clinic (PASH) has its details on the hospital intranet web site.
Details of clinic sessions and referral procedures can also be found on their web
page.
35. Discharging patients home
o
o
o
o
o
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.
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.
Enter a ‘diagnosis’ in the relevant field in the patient’s clinical screen in EDIS.
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).
Communicate with the patient and their family/carers etc. such that they have a
good understanding of their problem and any discharge instructions.
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
18
o
o
o
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.htm
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
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.
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.
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
o
o
o
o
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.
Criteria for admission to the Short Stay Ward can be found in the ‘Clinical
Guidelines and Procedures’ folder.
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.
Ensure medication (in particular, regular analgesia if relevant) and fluid orders are
written up.
Ensure results of investigations are documented.
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
o
Discuss the case with an ED registrar or consultant.
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
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
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.
19
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
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.
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.
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.
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.
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.
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.
o
o
o
o
o
38. Finishing your shift
o
o
o
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.
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.
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.
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.
20