General Medicine

Welcome to the General Medicine team at the Countess of Chester, we hope you enjoy your time with us.

Contributions and acknowledgements

Dr Leon Barker

Dr Nicholas Wreglesworth

Accessing the on call rota

You can access the medical on call rota using the shared drive (s drive)> Public > Medical staff rota> Medicine on-call rotas.

Cardiac arrest

To put out a cardiac arrest call dial ‘2222’

Members of the cardiac arrest team:

Medical Registrar
2^nd on
Medical F1
Anaesthetics junior doctor
ODP
Critical Care Outreach

It is reasonable for any member of staff to summon the cardiac arrest team for peri-arrest situations

Minimum clerking standards

Prior to PTWR the following should be completed for all medical take patients

Full clerking and examination
All sections of clerking proforma completed
EMAR completed + IV fluids/ insulin/ anticoagulation charts completed as necessary
Basic investigations i.e Bloods, ECG, Radiology ordered
Immediate treatment started
VTE assessment
Oxygen target saturations prescribed, whether on oxygen therapy or not
Utilisation of appropriate pathways

Handover

Handover is at 09:00 and 21:00 in the handover room on ward 46.

Each member of the team should introduce themselves and their role
Handover sick patients
Handover patients waiting to be clerked/ to come in
Handover outstanding tasks; delegate specific tasks to specific doctors
Any staffing/ capacity concerns i.e. bed status of CCU/ ITU etc.

When handing over use SBAR, handover will be documented by the consultant leading it, using a standardised proforma.

Learning while on call

Ask the consultant/ SpR who is on shift with you for CBD’s/ACAT's etc.
Read up on interesting cases you see whilst you are on call
If you are unsure of something don’t be afraid to ask

F1 Twilights

16:00 – 00:00

7 Twilight shifts in a row - followed by Monday off and 11am start Tuesday.

Bleep 2601 to collect the crash bleep; 2601 is the crash bleep, you hold this until 00:00 and then return it to AMU at the end of your shift.

You will get bleeped from different wards with jobs, it is good to be organised and keep a list by ward to prioritise incoming jobs.

When you collect the bleep from the ward cover F1 at the weekend it is good to discuss outstanding jobs and divide them between yourselves.

Top Tips

DVT patients– Refer to vascular,

Dialysis patients – Inpatient dialysis must be discussed with Arrowe Park and will remain under A&E until being transferred as there are no IP dialysis beds unless they need ITU

Hemodynamically unstable Upper GI Bleeds need to be discussed with surgeons

Stroke patients will normally be seen by the stroke co-ordinator and sent to Ward 33 these patients still require clerking and eMAR prescribing

Interprofessional Standards

The Medical Director has sent a Memo to all doctors regarding taking referrals which is reproduced below:

11^th January 2019

Dear all,

Professional standards in specialty referrals

I understand how challenging it is to work in an ED environment. We all know that the effectiveness of clinical referrals to specialties following ED assessment is a crucial element of safe care. I want to support you in being able to make any appropriate referral to a specialty colleague in a professional, constructive manner. I likewise want to know about any situation where that hasn’t occurred so I can look into the reasons why and improve things for all concerned.

Referrals to specialty clinical colleagues

If you are making a referral to a colleague for specialty assessment, I expect that both clinicians in the call will conduct a professional conversation. The referral must include both people clarifying who they are, what grade they are and what the intended outcome of the call will be (“Hi, it’s Dr X here calling from ED, who am I speaking to? I am referring a patient to you who requires assessment for possible admission / who requires an urgent clinic appointment / who I want advice please regarding their management”).

Where referrals have been made, and transfer to an assessment area is to occur, it is imperative that the patient has appropriate analgesia and fluids prescribed before they leave the ED area and that the clinical handover to the specialty team confirms that this has been done.

Of course, no patient should be transferred whose physiological scoring renders this unsafe.

We will not tolerate argument, rudeness or any other non-constructive conduct in any referral calls. If this is the case then the relevant consultant on call for that specialty must be contacted immediately, day or night, to facilitate resolution and I would like please to be notified by email of the staff concerned and the details of what went wrong.

Hand-backs to ED following a specialty assessment

Wherever a patient has been referred for specialty assessment, and that specialty then decides they are not the appropriate specialty to manage that patient, it is the responsibility of that specialty to refer the patient onwards – patients must not be ‘referred back’ to ED. I need please to be alerted by email to any scenario in which this is a problem so I can act appropriately to support the ED referrals process.

Seeking an opinion from a specialty

I do not support us asking F2-level clinical staff for a specialty opinion on the management of any patient under the care of ED. If ED staff require specialty clinical opinions from inpatient teams then this is for the Middle Grade or Consultant in that specialty team to provide, so please do not ask our F2 doctors to do this. We have on-call cover from senior doctors in all specialties so there should not be any circumstance in which a senior opinion cannot be obtained. If senior staff are in theatre, for instance, then escalation to the consultant can be made. There will always be occasions when all the senior team are occupied with a clinically urgent case, in which scenario the patient can be transferred to an assessment area pending specialty review.

I hope these comments and expectations are clear. I am open to all feedback on this, but we must move forwards on these aspects alongside many others, and I will do all I can to support you.

Darren A Kilroy M.Ed. MBA PhD

Acting Medical Director

Divisional Medical Director (Planned Care and Clinical Variation)

Countess of Chester NHS Foundation Trust

Specialty acceptance and transfer

Please see ‘guideline for specialty acceptance and transfer’ for full guidance, see common conditions below:

Who may want to contact you?

As the person overseeing the take, you will get bleeped by different people throughout the hospital, these include:

Accident + Emergency (Referring medical patients or nurses with a query)
Primary Care Unit (Either asking for advice or referring a patient) 09:00-18:00 Voip 3478, OOH to medical registrar
Clinics (Patients may be admitted from clinic) – Medical SpR

GP Referrals

Medical patients that are referred by GPs need to go through Single Point of Access (See Flowchart), as far as SHO 1 is concerned, these patients will appear on the A3 Board at the AMU reception and it is their responsibility to ensure that these patients are clerked by the medical team. This board of patients is populated by The Bed Bureau Team (between the hours of 0800 – 2000) and the Clinical Site Co-Ordinators

Tip: It is a good idea to check this board periodically to see how many GP referrals there are and copy these names onto your ‘list’.

GPU

GPU has ambulatory care and a trolley area, it is for medical patients who do not require require ED treatment/monitoring in Majors or Resus.

Both ANPs, AMU doctors and on call team clerk patients on this unit. There is a GPU exclusion criteria displayed on the wall of GPU behind ward clerk. The Acute Medicine Consultant for GPU is on VoIP 2001 for any advice/post-takes.

Patients may be admitted via our ‘Ambulatory Care Unit’ which runs weekdays from the UTC near the main hospital entrance. These patients will also need to be post-taked and will usually be transferred to GPU.

How to keep ‘the list’ up to date?

Keeping the list up to date is very important so patients are not lost in the system. Check on Meditech with the patient’s CC number, to see if the patient has registered for their care episode on a particular day. Occasionally, you may get a bleep from ED, AMU or GPU to let you know that a patient has arrived and needs clerking.

Where to find patients?

Unfortunately, patients can be spread out through the hospital meaning you need a reliable way to find where they are, you can search for them on Meditech (See Previous Section) which will tell you their current location. You can also use option 2 (PCI) on meditech to find patients in ED using the ED screen.

Post-Take Ward Round (PTWR)

After you have seen a patient and have a working diagnosis, you should order any relevant investigations and start any treatment for your patient, you should also prescribe their regular medications on eMAR. Once these things have been done you should contact the on-call consultant to have your patient reviewed, they may change your management plan and create some more jobs, which it would be your responsibility to do.

The PTWR is an excellent learning opportunity, if you need ACATs or CBDs it would be worth letting them know beforehand so these assessments can be carried out.

At around 19:00, the night consultant takes over and will continue to post take patients until handover at 21:00. Patients seen during the night shift will have their post-take ward round in the morning.

Jobs to be completed for each patient prior to PTWR

Clerked

Order basic investigations

VTE

eMAR

You will be given the consultant bleep at handover, when you are ready to post take bleep the consultant. As first on, it helps to liaise closely with the consultant throughout the day to ensure the PTWR runs smoothly.

Weekend Working

If you are covering the medical wards, there is normally a weekend handover list which the MAU ward clerk will print out and leave by the reception. Essentially, it is a list of the patients the day team feel need a weekend review; this could include anything from checking blood tests, reviewing patients or reviewing them prior to discharge. Again, there is no particular way to do this; some SHOs like to go around with the FY1 and some like to split up, it helps to be systematic in the way you cover the jobs on the weekend review list as you will you invariably be bleeped to review patients on the wards. The ward cover FY1 will hold the 2601bleep until 1600 when the twilight FY1 starts (so between 1600 – 1900 there are three doctors allocated to the wards.).

Working at Night

There is a useful RCP publication on working night shifts The Royal College of physicians have produced a useful guide to working the night shift, follow the link below:

http://www.agamfec.com/pdf/MIR/Guardias_Supervivencia.pdf

The system at nights is slightly different in that each shift is only 10 hours, as a result you will be holding both bleeps for two hours during each shift.

SHO 1 (2300 – 0930) Holding the List
SHO 2 (2100 – 0600) Covering Wards and/or clerking
Med SpR (2100 – 0930)

As Second on, it is useful at the start of the shift that you have an up to date list of all the patients waiting to be clerked, so go to the board and make sure all the names are on your list. During the first two hours, there is also the Twilight House Officer, so any jobs handed over could possibly be delegated to them e.g. if a patient who has been clerked is awaiting the bloods/CXR.

As First on, you will be finishing later, so at 0600, SHO 2 will hand over any jobs/concerns from the wards. This is particularly important during weekend nights when they won’t be routinely reviewed by their day team and it will be looked after by the weekend on call team.

The 8am OGD Slot

The gastroenterologists have agreed to provide an urgent GI bleed endoscopy slot at 8AM. A GI bleed endoscopy coordinator has been identified and should be contactable on VOIP 3872. A GI bleed nurse rota has also been agreed to facilitate the 8AM GI bleed slot.

Practicalities of utilising the 8am OGD Slot

It is crucial that the patient be in the endoscopy department and ready to be scoped by 8am, to minimize impact on the endoscopy unit and the gastroenterologist. This service is being provided in addition to existing clinical activity for the endoscopy unit and the gastroenterologist. The patient needs to be cannulated, consented and stabilized with a view to starting the procedure at 8AM in the endoscopy unit.

It is key that the on-call medical SPR liaise with the endoscopy GI bleed coordinator before 7:30AM about patients admitted with a GI bleed. The endoscopy GI bleed coordinator should also bleep the on-call medical SPR at 7:30AM, so that every effort is made for potential GI bleeds to use that slot. At the night medical handover meeting, potential GI bleeds should be flagged. The site coordinator should also handover any potential GI bleeds to the on-call medical SPR before 7:30AM.

If no patients are identified, then the 8AM slot should not be filled with diagnostic OGDs, to prevent unnecessary delays to starting service lists at 8:30AM.

Only one patient can be physically scoped in that 8AM slot, be it in the endoscopy department or in theatres. All referrals will need to be coordinated by the GI bleed coordinator so that two bleeds are not organised simultaneously, in theatres and in the endoscopy unit. Also, to ensure an endoscopy nurse is available to assist with the scope.

If the patient needs endoscopy in theatre:

Patients with fresh haematemesis or who are unstable will be scoped in theatre. The anaesthetists have agreed to support this, provided their involvement is restricted to patients that require intubation. All other patients should be scoped in the endoscopy unit.

Useful guidelines

You can access the intranet using the link below or via the homepage on internet explorer from any trust computer and clicking on the link to the document library. (These links will only work if this page is accessed on a hospital networked computer)

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

Guidelines you will commonly use whilst on call include:

Sepsis

http://doclib.xcoch.nhs.uk/Documents/Sepsis%20Pathway%20updated%202015.docx

http://doclib.xcoch.nhs.uk/Documents/Sepsis%20Care%20Bundle.docx

Antibiotics

http://doclib.xcoch.nhs.uk/Documents/Antibiotic%20Guidelines%20for%20the%20Countess%20of%20Chester%20Hospital.doc

AKI

http://doclib.xcoch.nhs.uk/Documents/AKI%20(Acute%20Kidney%20Injury)Network%20Manual.pdf#search=AKI

ACS

http://doclib.xcoch.nhs.uk/Documents/Cat_1_Chest_pain_primary_PCI%202016.pdf#search=ACS

http://doclib.xcoch.nhs.uk/Documents/LHCH%20ACS%20Referral%20Form.doc