Dr Orane Richards, MD

V1 – Patients’ ChartsDocumentation is paramount

Medico-legal documentlegibility and completenessName, time, signature, position of personnelChronological sequence of events in departmentDocumentation not to be removed from recordChart to be completed before end of shift and

before leaving department

V1 – Patients’ ChartsGeneral format

Time and dateCCHxPhysical examProvisional DxInvestigationsTx and OutcomesFinal DxDisposition

V1 – Patients’ ChartsTrauma

Alleged cause of injurySize, location, type of injury

ProceduresType, indication, details of procedureMaterial left inside (e.g. sutures, drains etc) and

removal plan

ReferralsClear documentation of person case discussed

with, time and date

V2 – Reception of Patients and Visitors

ReceptionPrompt and courteousInvolves all personnel (from orderly to ED

physician)Ongoing training and orientation of staff

Visitors/RelativesONE relative per patient at any given timeRelative not allowed to stay indefinitely unless

patient a minor or requested by Dr or Nurse

V3 – Initial Assessment of Patients and Triage

Priority based on severity of illnessCODE RED

Life-threatening Seen immediately (within 5 minutes)

CODE YELLOW Seriously ill Seen ASAP (within 30 minutes)

CODE GREEN Non-urgent Seen when possible

Triage officer = experienced doctor/nurse on each shiftTriage officer in mass casualty = Senior Doctor

V3 – Initial Assessment of Patients and Triage

Triage formVital signsComprehensive initial assessment of patient’s

complaints and likely working diagnoses Should provide sufficient information to effectively orient

medical personnel during subsequent patient contact Guides further management Facilitates greater expedience

Important initial investigations/procedures/medsIf patient accepted for direct admission by a specialist

service, call accepting resident to obtain clear instructions

Patient subsequently registered and record made available

V4 – Initial Assessment of Patients and Triage

Triage formVital signsComprehensive initial assessment of patient’s

complaints and likely working diagnoses Should provide sufficient information to effectively orient

medical personnel during subsequent patient contact Guides further management Facilitates greater expedience

Important initial investigations/procedures/medsIf patient accepted for direct admission by a specialist

service, call accepting resident to obtain clear instructions

Patient subsequently registered and record made available

V5 – Life-threatening CasesCode RED

Pt taken directly to ERREGISTRATION SHOULD NOT TAKE

PRECEDENCEExamined by most senior Dr All A & E team to respond immediately if called

(avoid time-consuming cross-questioning Resuscitation

ABCDEVital signsLow threshold for suspecting cervical spine injuryIVA with large bore line(s) + blood investigations

Pt stable -> head-to-toe exam, quick hx

V6 - Seriously Ill PatientsCode Yellow

Seen ASAP (within 30 minutes)Disposal

Should not be kept in ED awaiting obviously abnormal results of investigations

Admit promptly for definitive managementDocument time, date, name of consulted

physician

V7- Seriously Ill PatientsCode Green

Accommodated in waiting area away from active treatment areas

Team member to supervise areaPromotes order with respect to contact with

medical teamObserve for possible complications

V7 – Examination of PatientsTo arrive at WORKING DIAGNOSIS(ES)

Guides subsequent investigations and treatmentAvoid routine, non-contributory investigationsChaperone for physical examinationsMinimum level of investigations that should be

available to ED:Blood tests

CBC, U&E, RBG, GXM, Ca2+, Amylase, PT/PTT, Cardiac enzymes

Urine Urinalysis, Microscopy, Beta-hcg

ABGAvoid non-urgent investigations at this pointRemember UNIVERSAL PRECAUTIONS!!

V7 – Examination of PatientsIf patient requests that a doctor of a particular

gender assesses them???????grant wish if possibleNo subsequent victimization or sub-standard

treatment

V8 – Care of the Psychiatric PatientUse of restraints?

Last resortWhat about involuntary admission and treatment?

Imminent danger to self or othersDemonstrates deteriorating status

Informed consentPatient if in appropriate state of mindNearest relative or person accompanying to ED if

patient has AMSTreat and dispose of promptly to avoid

deteriorationMental Health Clinic referral PRN

V8 – Care of the Psychiatric PatientUnbiased treatment + Respect + Dignity + BUT

SAFETY for allWhat about involuntary admission and treatment?

Imminent danger to self or othersDemonstrates deteriorating status

Informed consentPatient if in appropriate state of mindNearest relative or accompanying person if patient

has AMSTreat and dispose of promptly to avoid

deteriorationMental Health Clinic referral PRN

V8 – Evaluation of the Psychiatric Patient

Detailed hxPrevious illnessFamHxDrug Hx (Rx, Licit, Illicit)Current meds and previous responseSuicidal or homicidal ideation

Idea, Plan, Intent to activate planPhysical examMSEInvestigationsAssociated features

V8 – Involuntary treatment of the Psychiatric Patient

Last resort Voluntary or consent when possible

Indicated when patient is imminent danger to self or others

V8 – ED treatment of the Acutely Disturbed Patient

Step 1Talk downTime out

Step 2 – If patient will take meds:Oral meds

Lorazepam 2-4 mg Diazepam 5-10 mg Chlorpromazine 50-200mg Haloperidol 5-20mg Risperidal 3mg

V8 – ED treatment of the Acutely Disturbed Patient

Step 3 – if patient refuses oral meds:Parenteral meds

IM Lorazepam 2-4mg + IM Haloperidal 2-10mg (rept q4-6 hrly PRN)

IM Zyprexa up to 10mg (rept q2-4 hrly with max. 30mg in 24 hrs)

Clopixol Acuphase 50-100mg in 24-72 hrs

Step 4 – if patient is aggressive or uncooperativeImmediate sedation

Diazepam up to 10mg IV (slow titration, monitor respiration) + Haloperidal 5-10 mg IM

V8 – ED treatment of the Acutely Disturbed Patient

ReferralsStabilization before transfer

If in doubt, CONAULT PSYCHIATRIC RESIDENT/CONSULTANT!!!!

V8 – Use of Physical Restraint in Psychiatric Patient

Last resortTry gaining consent and cooperation first5 point restraint by trained staffMonitor for patient safety post restraintRestraint released when meds take effect

V9 – ConsultationsED senior resdent or consultant in charge of

patient until patient admitted or dischargedSpecialist team takes over manadement once

admitted to a ServiceMain purpose of consultation = Assistance in

decision-makingIf ED Senior resident disagrees with suggestions

via consultation?ED Senior’s decision takes precedence (patient in

his/her care)Consult consultant of Service or ED consultant if

significant disagreement

V9 – ConsultationsIf after reviewing patient a Service, after accepting

consultation, deems case is best fit for another firmBest course of action agreed on by both ED resident

+ consulting doctor Prompt consultation by Service after referral

Max. 1 hourContact consultant of firm, ED consultant or SMO

hereafter

THE END!!