IMAGING

X-RAY

- mention specific views

- call 56621 to expedite when urgent

- Mobile Xray (generally for PACE/ALS): e-Order, then:

1. Page #9032 (mobile radiographer) from hospital phone

2. Fill out physical request form and put at patient bedside (this sometimes prints)

MRI

- needs approval from MRI fellow (can only call @ 9-9.30am, 2-2.30pm, 3.30-3.45pm)

- complete MRI safety form and fax it to radiology (fax number on form)

- if previous surgeries with metal work (including stents), may need to get operation reports

- if not on system or done at another hospital, call medical records

CT

- mention Creatinine/eGFR and non-con vs contrast

- page and get scan approved by CT reg on #22778 (get advice on how the scan should be protocol-ed)

- call 57606 to expedite scan when urgent once approved

- IV contrast: needs 20G PIVC, preferably in cubital fossa (18G PIVC in cub fossa for CTPA)

- consider pre and post hydration!

- withhold metformin for 48hrs post contrast load especially in renal impairment

General rule for e-Orders: describe exactly what you are looking for with relevant symptoms/background

US

- no need for approval in hours (Mon-Fri 8am-5pm)

- if scan needs to be done after hours and is urgent, then you need to speak to the US/Nuc Med consultant on call to justify the request as they will need to come in with a sonographer

- reported quickly

How to check if a scan is already scheduled

INTERVENTIONAL RADIOLOGY - Speak to Ruby first (for a potential booking slot)

- 3 forms ◦ 1. Medical Imaging request form ◦ 2. IR safety checklist with recent Coags + Plt count ◦ 3. +/- Pathology form (for biopsies, fluid...)

- Review by IR fellow/consultant

- If urgent, go to angiography/IR suite (in Radiology) and speak to IR fellow/consultant directly

- If the patient is NESB, inform Ruby as an interpreter may need to be organised for the IR procedure so that consent may be obtained.

MEDICATION CHARTS Medication charts are your responsibility! Review each morning during rounds. Re-charting is a team job.* VTE prophylaxis Check with registrar before charting. Check patient is not on therapeutic anticoagulation already (NOACs are often missed!). If contraindicated, mark appropriate box and cross section out! Options: heparin subcut 5000units BD (or TDS) OR Enoxaparin subcut 40mg OR 20mg daily Fluid chart Ensure sufficient fluids for overnight (e.g. maintenance, TKVO). PICC lines need TKVO fluids (chart as: indication = TKVO PICC; rate = 10 or 20mL/hr) PCA chart Initially filled out by Acute Pain Service (APS). You may be asked to re-chart when order runs out. Check the last APS entry in notes for ongoing plan. If PCA is to continue, copy EXACTLY what APS has written.

MEDICATION SCRIPTS

5

Inpatient • 5-7 day supply of medications that are NEW OR CHANGED. Common

exceptions are anti-platelets (28 days supplied for new stents) and few weeks of antibiotics.

• Works for both S4 and S8 (written properly).

• Write these out early in the morning or even day before if it is an anticipated discharge!

Outpatient • Two types – S4 and S8.

• Locked up in medication room – ask nurses for these scripts.

• Needs prescriber number.

• S4 – max 3 meds on same script. If unsure of tablets per box, just write max and circle it.

PIVC NURSE AND CVAD CNC SERVICE - Hospital policy dictates that PIVCs should be changed every 72 hours

- Always document date of insertion in Powerchart (otherwise PIVC may be pulled out early)

- PIVC nurse available 1400 – 2200, 7 days/week ◦ eOrder – “PIVC Nurse” (#8319) – nurses can also e-order this ◦ Good for difficult access (they have ultrasound) ◦ Can insert midlines

- CVAD CNC SERVICE (e.g. PICC lines, tunneled vascath, midlines…) ◦ eOrder – “Central Venous Access Team” (#9248) ◦ Specify how many lumens ◦ If for long term IV Abx, need to have plan from ID team ◦ Need recent platelets/INR and written consent (Risks: pain, infection, bruising, bleeding, thrombus,

kinking/blockage, malposition, line migration, accidental removal, arrhythmias, nerve damage) ◦ Don’t need CXR afterwards unless you suspect a complication

DISCHARGE SUMMARIES - Some teams have their own templates (e.g. Respiratory) - Surgical discharges are generally shorter than medical discharges - It is crucial to include an Issues list – the hospital runs on activity-based funding! You will learn all about the importance of coding! - Update the Background / Past Medical History on discharge! – it is hard to find time to do this in ED, you and your colleagues will be thankful

for this! - If you want the GP to chase any investigations, include the number they should contact!

- General Structure: 1. Opening statement 2. HPI 3. PMHx 4. SHx 5. Issues during admission

◦ List/number issues, describe reason for issue, relevant consults, investigations, management, results or outcomes, any follow-up plans 6. Investigations

◦ If no report, make sure to highlight **PRELIMINARY REPORT** or **REPORT NOT AVAILABLE ON DISCHARGE** 7. Medications on discharge

◦ Should be divided into 4 sections: New, Pre-existing BUT CHANGED, Pre-existing AND SAME, Stopped; give reasons for medication changes! 8. Plan

For University Clinic Follow-ups: - Fax discharge to 8890 8333, with type of clinic written clearly on top of first page - Clinic will contact patients with appointment details closer towards the date

FREE TEXT DISCHARGES • Discharge prepared in a Word document

• Clinical Notes Add Note e-Discharge

• Delete most of the template and replace with prepared discharge

• Once signed, you won’t be able to make any changes to the document itself, but can add modifications at the bottom.

FORM BROWSER DISCHARGES • AdHoc Common forms eDischarge

• BIG advantage: multiple interns on same OR different team can see prepared discharges before they’re signed, and continue to update them until time of discharge!

ICU DISCHARGE SUMMARIES - Patients discharged from ICU will have a separate discharge summary for their ICU stay (generally printed and kept in patient’s file). ◦ This is useful to review when prepping the

patient’s hospital discharge summary.

- Ensure your discharge summaries for all your patients are prepped prior to ending your term rotation or prior to a patient’s care being transferred to another team (it’s common courtesy and it makes it easier for the incoming JMO on the next term).

BOOKING PROCEDURES RFAs and Op Lists

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RFA – “recommendation for admission” • When you want an outpatient to come in for a procedure. • Need to be given in to bookings. Specific admin staff for each

specialty. • These make up your boss’s waiting list. • Admin staff will book patients in to Pre-admissions clinic if

required. • Admin staff will also call patients up to notify them of clinic

appointments and/or procedure dates.

Operation list • Senior registrar sets the OT list order. • Need to be given in to the Anaesthetic department 10am the

day before at the latest. • Blank forms found in Anaesthetic department. • Can also get department secretary or bookings to print list.

BOOKING PROCEDURES GREENSHEETING

• Specialties are allocated specific theatre space throughout the week – elective list (RFAs).

• Patients admitted through ED who need operations are put on emergency list.

• When you want to:

1) Book a case under the Emergency theatre list

2) Book a case on elective list, but it’s past 10am the day before already

• Powerchart AdHoc Fill out the “Emergency Theatre Operation List / Booking Form”

• Page #8460 discuss case with the Duty Anaesthetist

• Make sure you know urgency and reason for procedure, equipment required and patient’s co-morbidities.

PRE-ADMISSIONS CLINIC (PAC) • Pre-op assessment, optimization of medications, pre-op investigations.

• Patients are assessed by a nurse, JMO and Anaesthetic consultant/registrar.

• Have a template for your Powerchart entry.

• Dr Farheen Ali (Pre-admissions CMO) may contact you with abnormal test results.

• Dr Ali also runs the high risk clinic.

• Important info, especially which medications should be withheld + how long before day of operation.

• Refer to specialty-specific pre-op protocols in PAC and/or UptoDate.

• May need to arrange a post-op:

• HDU bed call Patient Flow (55547, 55548).

• ICU bed fill out ICU bed booking form in E3b.

TIPS

1) Booking in patients last minute – speak to Janice (Pre-admissions NUM) or Dr Ali. (Chocolate helps)

2) Don’t ask if Anaesthetics has seen patient first.

3) If in doubt, refer to your specialty’s pre-op protocols (folders in PAC).

3) When you’re finished with patient files, hand them back to nurses.

PAC NOTE TEMPLATE •Planned Surgery •Surgeon •Date of surgery

• Indication for surgery •PMHx •Medications •Allergies •SHx

•O/E •Relevant test results

•Plan • Fasting (6h solids, 2h clear liquids) • Medication changes • Pre-op investigations required (i.e. FBC, EUC, Coags, G&H, MCS) • Post-op destination (ICU, HDU, ward, discharge)

ENDING YOUR DAY - Ensure you have documented for everyone!

- Review all entries (e.g. consulting teams, allied health staff)

- Order bloods for the next day / weekend

- Update cheat sheets (if applicable)

- Prep the following day’s discharge summaries and scripts for expected discharges

- Hand over to the after-hours MO about out-of-hours jobs or patients to be aware of (remember to e-Order a JMO Job List order when relevant)

GOLDEN TID-BITS! o There is always someone you can ask for help / advice / guidance.

o Resources are abundant – Intranet, JMO app, each other…

o Make it a daily habit to check through patient’s entire investigations since admission to ensure no abnormal tests are missed.

o Chart medications + fluids / electrolytes judiciously and legibly.

o How to earn yourself a good reputation: don’t be lazy (regardless of term); be organised & prepared; always be honest; keep your cool!

o Look after your peers & colleagues!

o If you’re having issues, please seek help from: your GP, DPET (Dr Baker), RSU, JMO Support Line (NSW): 1300 566 321, beyondblue, Lifeline 13 11 14…

QUESTIONS???

EXTRAS – REVIEW AT OWN LEISURE CONSULTS

ALLIED HEALTH

SPECIAL ORDERS – MEDS & FLUIDS

PATHOLOGY

OTHER IMAGING

MORE TIPS FOR DISCHARGES

HOW TO CONSULT ANOTHER TEAM Step 1: WHY are you getting a consult? If you’re not sure, please ask. Specific clinical question, phone advice/formal review/TOC? Step 2: Work out WHO you need to call. Go to the ED Rosters Intranet page. A. Refer to the Team Allocations roster. If there is a dedicated consults pager, page this number. This is the case for

most SURGICAL specialties. OR B. Refer to the Consultant on call roster to work out which boss is on for that day. Then, refer to the Team Allocations roster to

work out who their registrar is. Page this registrar. (e.g. Cardiology problem, but not known to Westmead boss already) OR C. If a patient is already known to a boss (e.g. Cardiology), page this team’s registrar. Step 3: Be PREPARED (e.g. chase previous correspondence). Have the patient’s file opened on PowerChart, meds/BSL/fluid charts

handy. Write down question/key points. Step 4: CALL; use ISBAR! Introduction: Your name, position and (in ED) which hospital Situation: What’s your question/reason for calling Background: name/age/MRN/reason for admission/PMH Assessment: what’s the current clinical picture, what’s been done so far Recommendation/response: make a suggestion for how problem could be handled/ask for their advice Step 5: Document word for word – e.g.: Vascular JMO: XYZ Cardiology Phone Advice: Discussed case with Dr XYZ (Specialty Registrar/SRMO for Dr Boss on call) who kindly advised XYZ. Will review patient – with

many thanks.

CONSULTS - FAQs HOT TIPS Refer to the Consults

Handbook: http://www.wslhd.health.nsw.gov.au/Ed

ucation-Portal/Medical/Junior-Medical-Officer-Resources/The-Westmead-Hospital-Consults-Handbook/Westmead-Medical-Officers--Consult-Handbook

Don’t get a consult for PR bleeding

without doing a PR Don’t get a Cardiology consult without

reviewing the ECG Don’t get an Ophthal consult without

doing a VA And so on…

They haven’t responded to my page; What do I do? 1. Wait 5-10 minutes and page again 2. Still no response, do something else and try again later (the inherent benefit of paging

from your phone is that you can continue to do jobs on the go) 3. If you’ve paged x3, ring through to mobile via Switch 4. Page the team JMO and find out if all the regs are in theatre/that you’ve got the right

number/person you’re supposed to contact is away – don’t consult the JMO! 5. If none of the above works, document your attempts + escalate to your regs. I don’t know the answer to a question the consulting reg has asked me? What do I do? Say “Sorry – I don’t know”; Don’t lie! How late can I make a consult? Convention says before midday Before 1400 if you’re desperate Any later - you’ll be met with extreme levels of resistance Phone advice any time during working hours Bottom line: if the consulting team comes to review your patient, you’ve succeeded. Yay!

ALLIED HEALTH REVIEWS How to consult Physiotherapy/Occupational Therapy/Social

Work/Speech Pathology/Dietitian: Step 1: Make sure you’re involving the right allied health practitioner (different wards have different AH practitioners). Step 2: Find pager number. Look at ward whiteboard. Ask ward clerk. Step 3: eOrder via PowerChart; reason for involving them should be

clear in the notes/plan. Step 4: If the review is urgent/complicated, page/talk to them as well Pharmacists: saving JMOs (and patients) from themselves (JMOs) Step 1: Find your ward pharmacist and make friends with them. Step 2: Find pager number. Use pager number when you have a

question/ have written a discharge prescription. Step 3: Write discharge scripts early. This is often the rate limiting step

to discharge.

HOT TIPS Refer EARLY PT/OT are blanket referrals in Geriatrics (all

patients will be seen, no need for eOrder)

PT = mobility OT = function SW = counseling and support/family issues/

accommodation issues/ financial issues SP = swallowing/speech Dietitian = nutrition Pharmacist = DRUGS

SPECIAL ORDERS – meds & fluids Heparin infusion (fluid chart) 25,000 units of heparin in 45mL of 0.9% sodium chloride

◦ Rate: APP (as per protocol) and specify protocol (e.g. ACS, AF) Insulin/dextrose infusion (fluid chart) Order 1: 50 units of Actrapid in 50mL of 0.9% sodium chloride

◦ Rate: APP (as per protocol) Order 2: The sugar

◦ No fluid restriction: 5% dextrose 1000mL @ 80mL/hr ◦ Fluid restriction: 10% dextrose 500mL@ 40mL/hr

PPI infusion (fluid chart) 80mg pantoprazole in 100mL 0.9% sodium chloride @ 12mL/hr (for 72 hours) Blood transfusion (fluid chart) PRBC (packed red blood cells)

◦ Volume = 1 unit ; Rate: generally over 2-3 hours (Q4hr = max) ◦ Needs valid Group and Screen (pink tube); i.e. taken within last 72 hours ◦ Needs informed written consent ◦ Order unit(s) from blood bank on 56744 ◦ If risk of circulatory overloading, transfuse slower (q4hr), check fluid

status post (+/- between transfusions) and consider diuretic

HOT TIPS Go to the ED Drug Protocols page For Consent information, Google

‘Queensland Health Consent [insert procedure/product]’

Potassium PO: Order on medication chart

◦ Slow K (2 tabs STAT/BD) OR Chlorvescent (TT STAT/BD) IV: Order on fluid chart

◦ 30mmol potassium chloride in 1000mL 0.9% sodium chloride (maintenance) ◦ 10mmol potassium chloride in 100mL 0.29% sodium chloride ◦ Maximum rate PIVC = 10mmol/hour

Magnesium PO: magnesium aspartate (1g BD) IV: magnesium sulphate 10mmol in 100mL of 0.9% sodium chloride over 1-2 hours OR magnesium sulphate 20mmol in 250mL of 0.9% sodium chloride over 2 hours

Phosphate:

Iron infusion:

HOW IT SHOULD LOOK ON THE CHART

Heparin infusion

Insulin/Dextrose infusion

PPI infusion

Blood transfusion

Electrolyte replacement

PATIENT STICKER

WRITE PATIENT’S NAME

COMPLETE THIS

PATHOLOGY TUBES Purple – FBC

Green – EUC, CMP, LFT, lipase, CRP, troponin, lipids, vancomycin level

Blue – Coags (do NOT underfill, NEED to fill up to the line) • If using butterfly and vacutainer, take an extra tube to prime the line

Gold – TFTs

Pink – Group & Hold • Need to write patient details on tube • Need to include group & hold form (either printed off as e-Order or written

out on pink form) • Make sure date/time and collector signature on form is the same as on tube

Blood gas – VBG, ABG

If unsure, call ICPMR on 57552 or 55099!

PATHOLOGY – PNEUMATIC TUBES GETTING BLOODS TO ICPMR VIA:

A3A E3C

AB lifts Level 3 C5A

AB lifts Level 5 Op Suite

A6a OR walk to ICPMR… Level 2 near CD lifts

ED (closest to G block / Women’s Health)

N.B. All ABGs and urgent VBGs need to be taken to a blood gas machine!

PACE/ALS Patient sticker + FiO2 B5b (medical HDU), ICU, ICPMR, ED (has Creatinine)

Otherwise if non-urgent, walk it to ICPMR

OTHER IMAGING – all are e-Orders for inpatients! Nuclear medicine

- Bone scan, PET, V/Q, MIBI

- No need for approvals

Clinical measurements TTE, EST, Holter monitors

- note that the order needs to be copy-pasted into the “Clinical Indications” box

- Call 55479 to expedite

TOE

- Need cardiology consult first +/- TTE beforehand

- Speak to Cardio TOE AT to organise time

DISCHARGES

NEAT PATHOLOGY RESULTS

HOW TO MAKE PATHOLOGY RESULTS LOOK NEAT!

DISCHARGE SERVICES Non-medical services – COMPACKs, ACAT assessment • Refer patient to social work who assesses patient’s needs and then contacts specific services. • Services will send someone to review. • They don’t always document in Powerchart – check in patient’s folder for written note. Private rehab facility • Ask nurses to refer patient. Rehab facility will send someone to review. • They don’t always document in Powerchart – check in patient’s folder for written note.

Silverchain • Complete e-Document then e-Fax this.

Community nursing – for dressing changes • Ask nurses to refer patient. Will need to provide specific plan for dressing changes (i.e. what dressing, how often).

HITH/PACC – for antibiotics, anticoagulation • e-Order “HITH” then call 46333 to discuss patient’s case. • They will come and assess patient on the ward (patient needs to meet inclusion criteria before acceptance). • If for IV Abx - will need ID input for dose and duration. • Write out 2 medication charts – 1 for pharmacy, 1 for PACC team to administer.