Welcome

Welcome to the Acute Medicine team at the Countess of Chester Hospital. Acute Medicine is a very busy specialty and is well supported by consultants. We hope you enjoy your time here and learn lots of acute and general medicine.

Contributions and acknowledgements

Dr Chakraborty,Dr Barker, Dr Shingles

The Department

Dr Ruth McEwen (Clinical Lead) Acute Medicine and Infectious Diseases Consultant Bleep: 2908

Email: Ruth.mcewen@nhs.net

Dr Priti Rath Acute Medicine Consultant Bleep: 2544

Email: pritirath@nhs.net

Dr Leon Barker Acute Medicine Consultant with a special interest in medical education Bleep: 2908

Email: leon.barker@nhs.net

Dr Adedayo Adelodun Acute Medicine Consultant special interest in respiratory medicine Bleep: 2446

Email:adedayo.adelodun@nhs.net

Dr Anu Jayachandran Acute Medicine Consultant special interest in medical ultrasound and healthcare informatics Bleep: 2994

Email:anu.jayachandran1@nhs.net

Dr Craig Davies Acute Medicine and Infectious Diseases Consultant Bleep: 2415

Email: craig.davies7@nhs.net

Dr Satyanarayana Vanga Locum Acute Medicine Consultant special interest in renal medicine Bleep: 2844

Email: s.vanga@nhs.net

Dr Karpagam Ramaiyan Locum Acute Medicine Consultant special interest in renal medicine Bleep: 2459

Email: karpagam.ramaiyan1@nhs.net

Secretaries

Mon - Fri: Joanne Sadler, extension: 3780

Alison Patterson (Support Secretary) 4481

Office located off main A&E corridor opposite entrance to minors ward

The Wards

AMU (Ward 47 + 46)

Structure of the day:

1. Ward round

The AMU is for assessment and stabilisation of patients prior to moving to a ward or being discharged. There are 51 (14 cardiac monitored) beds in total with 3 ward rounds:

· A, B – Acute side – Ward round 8am

· C, D – Acute side – Ward round 8am

· E,F,G – Short stay side – Ward round 9am

There are AMU daily review sheets, which should be used to document for each patient on the ward round.

2. Huddle

There is a huddle between 11.30 and 12.00 that teams covering the acute side attend with the sister in charge. Each patient is briefly discussed and allocated a medical specialty.

Trolley/afternoon review round

A trolley round occurs around 14.45 to 15.00 with the consultant covering AB and CD and their team to discuss any outstanding issues, unwell patients and update on expedited plans.

If all ward jobs are not able to be done before the end of the shift or if there are jobs outstanding, hand these over to the on call AMU F1 unless they require someone more senior in which case contact the ward cover F2/CMT/ACCS/GPST (‘second on’) on bleep 2787 or the on call registrar on bleep 2603.

Staff available:

1. Ward clerks:

The ward clerks are extremely helpful, if you need letters from other hospitals or need appointments making in the acute medicine clinic they will be more than happy to help with these.

2. AMU based pharmacists (Usually one for A+B, one for C+D, and one for E,F+G)

3. Physiotherapists/Occupational therapist

4. Advanced nurse practitioners (usually join the AMU medical team)

5. Medical staff on 47:

a. Two consultants

b. Two “SHO”’s (1 CMT and 1 ACCS/trust grade)

c. Two FY1 (long day and short day)

d. ST3+

e. +/-Physician’s associate

6. Medical staff on 46

a. One consultant

b. One “SHO”

c. One ST3+ equivolent

Specialty in-reach

Specialties providing in-reach service to AMU:

· Cardiology (Cardiologist of the Week – COW)

· Gastroenterology (Gastroenterologist of the Week – GOW – now need to put in meditech refferal)

· Care of the Elderly

If a patient is identified on ward round their names must be added to the board opposite the cardiac monitor screens. You must call the COW or GOW if it is determined then need a review after 12:00pm.

Follow up options

· Acute medicine clinic – in outpatients, ask ward clerk to book. Ensure it specifies whether virtual follow up or face to face follow up.

o Acute Medicine Clinic held Monday afternoon between 2pm and 5pm in Outpatients 1. Up to ten patients are seen during each session.

· Ambulatory clinic (‘ACU’) – in GPU. For review of patients as an alternative to keeping them in hospital. Meditech referral – ensure it is clear on the referral why the patient is attending. Ensure it specifies whether virtual follow up or face to face follow up.

· Specialty clinics – specific referral is required. Please ensure you provide all relevant clinical details. For ‘seizure clinic’ there is a paper referral found on the intranet which is faxed to Walton Hospital. Other outpatient specialty referrals can be made on meditech.

· Pleural clinic – email referral form available on intranet.

· When requesting a planned follow up investigation (e.g. repeat CXR following pneumonia) then please request as ‘P’ in the ‘Type of Request’ box on meditech request. Give a date to the patient to attend for a CXR as radiology do not send out appointment letters for CXRs.

Documentation

The ward clerk can print you a list of patients. Please dispose of these in confidential waste at the end of the day.

Document date, time, location, who is present (doctors and relatives).

Document everything the patient says.

Document investigations results – double check radiology reports as these can be updated following consultant radiologist review.

Document diagnosis, working diagnosis or problem list. Do not write the diagnosis as impression: it will not get coded but “Treat as” is acceptable.

Document management plan, tick an item to show that it has been requested.

Request in real time, the consultants should wait or release you from ward round.

Have a post-ward round debrief at the end to ensure everyone understands the plan.

All patients need a daily review of – antibiotics, cannulas, hydration/IV fluids, VTE prophylaxis, nutrition, catheter care etc.

Antibiotics

Use the trusts antibiotic guidelines (see link below).

Always write a stat dose and then a regular dose, inform the nurse that you would like them to give the stat dose.

Ensure antibiotic prescriptions do not auto-stop over the weekend/holidays.

Complete the Antibiotic review section of the daily review sheet particularly between 24-72 hours in patients diagnosed with sepsis.

e-Discharge

It is a recognised Quality Standard that patients should be given a copy of their discharge summary to take home. It is also a trust requirement that all e-Discharges are completed within 24 hours. Please encourage your colleagues to perform e-Discharges at the time of discharge particularly when on call.

Tips for jobs

Do jobs in real time on the ward round - Batching jobs toward the end of ward round is inefficient and introduces bottle necks

Don’t divide jobs by bays - Ensures more senior doctors are able to support and supervise more junior doctors. Both doctors will be aware of patients if problems arise.

Document results and action taken on investigations - If it’s not documented then it didn’t happen.

Handover jobs to ward doctor if patient moves before jobs are finished - Ward transfers and handovers are notoriously risky for patient safety.

Do TTOs on the ward round if possible

Do e-Discharge on the day of discharge - AMU quality standard – patient should be given copy of summary to take home.

Use PTWR + daily review safety checklists

• VTE
• IV fluid prescription
• Medication review
• IV cannula required
• EDD
• Ceiling of care/ CPR status
• Ward requested

Help each other out. If you find you are not busy please ask AMU/SSU/GPU whether any help is required otherwise help out with the e-Discharges.

GP Unit (Opposite EAU)

Opening hours: 09:00-22:00

This is an ambulatory care and assessment area with ambulatory clinic.

It is comprised of the waiting area, 2 clinic rooms and 8 trolleys.

E-discharges are required for patients discharged from this area.

Aim to turn around patients within 4 hours.

ACU

ACU is a ‘virtual extension’ of GPU and is located in UTC.

F1 doctor information

Long day F1

Monday to Thursday: 09.00 to 21.00

Friday 09.00 to 16.30 followed by the weekend long day FY1 from 16.30 to 21.30

Short Day F1

Monday to Friday: 08.00-16.00

Working on AMU

A lot of the nursing staff and health care assistants on AMU are able to do bloods, cannulas, ABGs and ECGs if you ask politely they may help you. However it is still your responsibility to ensure they are performed in a timely manner.

Patient turnover is high in the AMU, and sometime patients move beds within the AMU. If there are outstanding jobs for patients transferred out of the AMU, ensure that you do the ones that can be done remotely and handover the rest. Remember it is much easier to do the jobs in real time.

If a patient needs a review on their new ward you should contact the ward doctor to handover. If a patient need review over the weekend ensure that you complete the MEDITECH weekend review referral.

Clerking

It is important that you get the opportunity to clerk while on placement in AMU. The AMU Registrar will timetable you in clerk taking into account overall staffing numbers.

It is very important that the patient you clerk has a NEWS < 5 and is suitable for an F1 to clerk. Make sure that the ‘SHO’ does not give you such patients. Ensure the patients are fully clerked, with VTE form completed and medicines prescribed. The patients you clerk should be senior reviewed asap.

IMT information

The IMTs rotate weekly between AMU, ACU, Acute take and EMU.

AMU week 8am - 4pm or 5pm

· AMU consultant ward round at 8am

· Participation in handover meeting at 9am and ward handover at approx. 11:45am

· Completion of jobs relating to ward round

· Opportunity to do any procedures on AMU

· Participate in teaching any medical students attached to the ward

· Completion of e-discharges for the ward

· Participation in AMU teaching, morbidity & mortality meeting, radiology MDT

· Attendance at medical meeting, Grand Round and Rolling Half Days

· Support acute medical take if AMU ward work complete and take busy

‘Front Door’ Geriatrics - Emergency Multidisciplinary Unit Week 9am-5pm Mon-Fri

· Daily consultant ward rounds starting on EAU at 9am with pharmacist

· Patients who can be turned around in 24 hours are seen

· Rapid response team consisting of physiotherapists and occupational therapists are usually available to discuss feasibility of discharging frail patients

· Attendance at medical meeting, Radiology MDT, Grand Round and Rolling Half Days

· EMU clinics – clerking new patients and discussing complex cases with Consultant Community Geriatrician with particular emphasis of Comprehensive Geriatric Assessments

· Observe multidisciplinary holistic assessments with other health professionals and Wellbeing Co-coordinator (Age UK representative)

· Opportunity to attend home visits (domiciliary and care home) with Community Geriatrician

Ambulatory Care Week 9am-5pm

· ACU clinic (mixture of follow-up patients from ACU and referrals from ED/AMU/Wards returning for tests and results) based in urgent treatment centre

· Seeing and arranging diagnostic tests for Ambulatory Care Clinic patients

· ACU clinic is supported by a GP and Consultant – please discus every patient you see.

· Completion of letters from ACU

· Clerk patients in GPU if no ambulatory care patients waiting and do GPU e-discharges

· Participation in AMU teaching, morbidity & mortality meeting, radiology MDT

· Attendance at medical meeting, Grand Round and Rolling Half Days

Acute Take Week 2pm-12am Mon-Fri

· Clerking admissions in ED, EAU, AMU and GPU, arranging diagnostics and initiating appropriate management along with on-call team

· Participation in AMU teaching, morbidity & mortality meeting, radiology MDT where possible

· Attendance at medical meeting, Grand Round and Rolling Half Days where possible

· Carry the Tier-2 cardiac arrest bleep from 21:00-0:00 (or from 14:00 if Tier 2 person not interested in attending cardiac arrests). Bleep kept behind AMU reception.

Weekend 9am-5pm (or 8-4 -> negotiate with consultant doing the round)

· The IMT covers ward 46 (short stay side) at the weekend

· Consultant ward round in the morning, then jobs including e-discharges

· Once jobs complete should join on call team to help clerk patients or review deteriorating patients.

Registrar information

Duties of ST3+ in Weekdays:

To take part in Ward round.

To lead Ward Rounds supervised by consultant

Attend Acute Medicine Clinic.

Manage departmental junior doctors rota.

Teaching medical students/Junior doctors.

To run departmental teaching rota.

Seeing patients in ambulatory care/GPU is a good way of increasing your clinic numbers.

Education

Presentation/classroom based teaching:

· Acute Medicine Teaching – peer teaching 13:00 Monday Handover Room

· Medical Unit Meeting – Consultant led teaching 13:00 Tuesday Boardroom (usually)

· Grand Round – 12:30 Friday Education Center

· Rolling half day – twice a month – variable times

Other educational opportunities:

· Radiology Meeting – 13:00 Thursday Radiology Seminar Room

· Acute Medicine Mortality & Morbidity Meeting held every third Thursday of the month

· Handovers

· Ward rounds

Regional and Local IMT Teaching

It should be possible for all but the person on Acute Take week to attend IMT teaching (providing it is in afternoon only), but please let AIM rota coordinator know well in advance of your teaching dates so that cover may be arranged. If one individual is down for Acute Take for more than one IMT teaching session, please swap between yourselves to make sure you all get the opportunity to attend teaching sessions.

Annual and study leave guidance

IMT: Leave is permitted in the AMU week.

The Registrar manages the Acute Medicine rota, please let him/her know of any changes to your rota and they will also sign off any leave as rota co-ordinator. You will then need Dr McEwan to sign the annual leave form before taking it to medical staffing. Please ensure you give 6 weeks notice.

LDF1: This is your on-call week therefore you need to swap this with your colleagues if you wish to take leave. The SD F1 is not contractually obliged to swap however we kindly request that you help out by trying to swap (leave will not be denied if you do not find a swap) – please ensure you let the Ellen Medical Rota Co-ordinator well in advance.

Guidelines/Pathways/Care bundles

All the guidelines at the COCH can be found at:

http://doclib.xcoch.nhs.uk/Pages/specialty.aspx

Please make sure you use the guidelines and pathways/care bundles available to you. In particular:

· Sepsis screening and action tool

· AKI bundle

· DKA pathway

· NIV pathway

· Decompensated liver disease care bundle

Registrar information

Duties of ST3+ in Weekdays:

· To take part in Ward round

· To lead Ward Rounds supervised by consultant

· Attend Acute Medicine Clinic.

· Manage departmental junior doctor’s rota.

· Teaching medical students/Junior doctors. To run departmental teaching rota.

· Seeing patients in ambulatory care/GPU is a good way of increasing your clinic numbers.

Education

Mortality & Morbidity Meeting held every third Thursday of the month in the Consultants’ office (located off main A&E corridor opposite DVT nurse office).

Annual and study leave guidance

CMT/ACCS: Leave is permitted in the community geriatrics and frailty week. If there is enough staff on AMU, leave can be taken in the afternoon.

The acute medicine registrar runs the master rota for those allocated to AMU, please let him/her know of any changes to your rota and they will also sign off any leave as rota co-ordinator.

If the registrar is unavailable to deal with leave requests Dr Chakraborty or Dr Rath may be asked.

FY1: This is your on-call week therefore you need to swap this with your colleagues if you wish to take leave.

Medical students

Some learning points medical students should aim to see are listed below, be proactive and don’t be afraid to ask questions. This is a valuable opportunity to learn.

1. Sepsis

2. AKI

3. Acute coronary syndromes

4. Pneumonia

5. Pulmonary embolism

6. Arrhythmias e.g. AF

7. Upper GI bleed

8. Decompensated chronic liver disease

9. Diabetic emergencies

10. Overdoses

11. Respiratory failures (e.g. asthma, pulmonary oedema, ex COPD)

12. ABG – Performing and interpreting: there will also be teaching provided.

13. ECG – Performing and interpreting: there will also be teaching provided.