General Surgery

Consultant Surgeon of the Week (CSOW) – The CSOW begins a week of on-call from midday on a Friday. The CSOW is on-call over the weekend and then in-hospital from 8am-8pm during the week with a different consultant covering the on-call on week nights. During the week the CSOW is responsible for all patients admitted as an emergency under General Surgery, all patients seen in SAU Review clinic, and all patients requiring Emergency Surgery.

Surgical Registrar (Bleep 3217) – The SPR. is on-call from 8am-8pm Monday-Thursday or Friday-Sunday and oversees new admissions & ward referrals as well performing the majority of emergency operating. Together with the Surgical Surgical F2/CST, the SPR will also review patients brought back to SAU clinic.

Surgical Surgical F2/CST (Bleep 3218) – Like the SPR, the Surgical F2/CST is on-call from 8am-8pm Monday-Thursday or Friday-Saturday and takes all new referrals from A&E, reviews patients brought back to SAU clinic, and assists the SPR/CSOW in Emergency Theatre.

Surgical F1 (Bleep 3216) – Unlike the rest of the team, the F1 On-call does not normally attend the PTWR each morning (unless he/she belongs the CSOW’s firm). The F1 On-call receives GP referrals via Bed Bureau and clerks in SAU. After 5pm the F1 provides ward cover for General Surgery/Urology/Vascular & Breast Patients.

From 8pm until 8am the On-call team comprises a Registrar and Surgical F2/CST with a consultant on-call from home. Between them they take referrals from A&E, cover the surgical wards and operate when necessary out of hours.

Handover occurs at 8am usually in the Board Room or the Surgical Secretaries’ office (both located off the T-block corridor). Present at handover are the Night Team, CSOW and On-Call Team, other juniors working the Consultant’s firm who look after the ward patients, and often medical students on placement.

At Handover the new patients admitted are discussed, any critically unwell patients on the ward should be highlighted to the On-call team, and any patients scheduled for surgery should be discussed. The CSOW and SPR then lead the Post-take ward round of all take patients, often liasing with Emergency Theatre staff & Anaesthetists to agree in what order operations should be performed.

The Take List is kept in the Handover folder on the Ward 44 Desktop.

Username: ward44

Password:XXXXX

It is the responsibility of the On-call F1 and Surgical F2/CST to add new patients to the Take List (in Bold). The Colorectal/UGI F1s update the list with relevant blood results and imaging in time for the list to be printed at the 8am and 8pm handovers.

Patients are referred to the On-call Surgical Team in one of 3 ways:

1. A&E Doctor/ANP referring a patient to the Surgical Surgical F2/CST.
2. GP referring a patient via SPA/Bed Bureau to the Surgical F1.
3. A Doctor from another specialty referring a ward/HDU patient the Surgical Surgical F2/CST /Reg

All new patients seen in A&E or SAU should be clerked using the General Surgery Pro Forma recently introduced. History & Examination findings as well as blood results and investigations, Senior review (by SPR/CSOW) and Post-take Ward Round should be all documented.

Note that the VTE Assessment forms have been incorporated into the new Pro Forma, which requires that it be documented whether the patient requires IV fluids and whether the patient can be fed.

The Surgical Assessment Unit (SAU) is located on Ward 46 opposite MAU. The SAU is run by Lorraine and Michael – 2 experienced nurse practitioners. It comprises a seated waiting area, 2 patient couches for clerking patients and a 4-bed assessment area. It serves 3 main functions:

1. Patients referred in by the GP who are ambulatory can be assessed and clerked by the F1.
2. Patients who have been referred by A&E and are clinically well awaiting either assessment or a ward bed can wait. (*There are only 4 beds in SAU and any referrals to SAU from A&E must be discussed with the Surgical Reg and SAU Nurse – there are agreed criteria).
3. Patients who have been brought back by the On-call team for imaging/repeat bloods and will be seen by the Surgical F2/CST /Registrar. To bring a patient back to SAU review clinic – the investigation and referral to SAU must be booked via Meditech with the necessary clinical information supplied. The patient can then be discharged with the advice that they will be telephoned by SAU the following day with a time for their scan. When bringing a patient back to SAU please consider what investigation you are requesting – for example an Ultrasound can be obtained at relatively short notice but an MRCP can take up to several days.

With a high turnover of patients throughout the week, an important part of the team’s workload involves keeping up with discharge paperwork. All patients who are either admitted to hospital or discharged from A&E or SAU require an E-discharge form to be completed. Patients seen by the Surgical F2/CST /SPR in the SAU review clinic being discharged require an SAU Review Letter to be completed.

Completion of e-discharges is vital to ensure that the patient has the appropriate follow-up arranged and so that GPs are kept informed about what investigations & treatment the patient has received. If a patient is discharged and an e-discharged is not completed, the Department will eventually be fined for every outstanding e-discharge and the Consultants will be informed. Therefore to make your life easier try to ensure that e-discharges are completed prior to the patient leaving hospital, and if not then a list of outstanding e-discharges can be accessed from Meditech in order that you can clear any that have been missed.

Note although it is often the House Officers that complete the majority of e-discharges, all members of the team are expected to pitch In and help complete e-discharges especially if the patient has been discharges from Daycase Theatre or SAU and the F1 has not been involved in said patient’s care.

Regarding Follow-up for patients being discharged if there is any doubt then check with a senior colleague. But generally the following will apply:

• Any patient that has had a Bowel Resection to treat Bowel Cancer (Emergency/Elective) should be seen in clinic by the named Consultant, by which time the histology from the resected specimen should be available.
• Patients presenting acutely that are found to have a new diagnosis of Bowel Cancer will be discussed either in the Upper GI or Lower GI MDT – both of which take place on a Monday morning. To add a patient to the MDT, the MDT coordinator must be contacted and given the patient’s details usually by Thursday at the latest.
• Patients that have presented with PR bleeding that has settled but not been investigated will require either endoscopic investigation (Flexible sigmoidoscopy/Colonoscopy) or CT-colon.
• Patients who have undergone common surgical procedures such as appendicectomy, hernia repair, cholecystectomy, or drainage of abscess do not usually require follow-up in clinic, unless specified by the Consultant. (Note – if an abscess has been drained and the cavity packed then this patient will require District Nurse Follow-up for change of packing).
• Patients referred to the on-call team who are well enough to be discharged but require prompt investigation may be referred to SAU review clinic. If you are the referring doctor then any imaging must be requested and a SAU referral form must be completed electronically via Meditech. You may then discharge the patient and advise them that they will be contacted the next day with a time to attend for scan/review. Note A&E doctors should not be bringing patients back to SAU directly without consulting with the Surgical On-call team.

Theatre 5 is the Emergency Theatre for all Emergency Surgery, bar Vascular Surgery, and is located opposite Theatre Assessment Lounge.

Any patient requiring emergency surgery must be booked on Meditech under “Emergency Theatre Bookings”, which will then instruct you to contact the Theatre Coordinator on #2750. The 1^st On-Anaesthetist should also be contacted on #2605.

For any patient going to theatre the following must be completed:

• The appropriate consent form must be completed and signed by the patient.
• A VTE form has been completed (VTE forms have now been incorporated into the new Surgical Pro Form).
• VTE prophylaxis is prescribed on Meditech.
• The patient has 2 Group & Save samples on Meditech – one may be historic but the other must be <3 days old.
• In the cases of Abscess/Hernia the area should be marked with pen.
• The patient should be nil-by-mouth and have IV fluids prescribed if needed.

The On-call team is also responsible for Urology referrals from A&E or GP. Urology patients are clerked and managed by the On-call team then added to the Urology Take List which is picked up by the Urology Team on ward round the following morning. In the case of Urology emergencies, the commonest being suspected torsions requiring exploration in theatre, there is a Consultant Urologist on-call for 24hours contactable through Switchboard.

On weekends/bank holidays the Consultant Urologist will do a ward round of the Urology patients usually in the afternoon with the F1 or Surgical F2/CST on-call.

The Surgical F2/CST & Registrar On-call respond to Trauma Calls in A&E Resus. An A&E Consultant or Registrar usually acts as Team Leader with the Surgical team assisting with the Primary Survey or obtaining IV Access. All Major Trauma should be discussed with the Trauma Centre at Aintree.

Patients that have sustained Head, Chest or Abdominal trauma who do not require transfer to either Aintree or Walton will be admitted under the Surgical Team.

ATLS qualification is not mandatory for junior Surgical F2/CST’s but is obviously helpful when working as part of the Trauma Team, and the course is run at the Countess of Chester Hospital once a year but does tend to book up very quickly.