ED Shift Survival Guide

Please ensure you are well rested and nourished, as work in the ED, though it should be enjoyable, is tiring and cognitively demanding. Avoid alcohol or late nights prior to shifts. Please ensure that you have adequate time to get to work so that doctors on the previous shift can go home.

Your standard of dress and presentation should be professional and clean, and you should bear in mind the risks of body fluid or sharps exposure. Closed toe footwear is expected for this reason. Clothes should bear in mind procedural requirements, so sleeves should be able to be pushed up, and shirts/ skirts should provide adequate coverage. ED scrubs are available but not mandatory and may be ordered for the ED term only using the link at the end of this booklet.

Use of surgical scrubs is not unreasonable, but has been the subject of complaint when worn without an over-gown outside of operating theatres. Jeans or other casual wear are not regarded as satisfactory.

Shift times are: Day 0800-1800, Evening 1400-2400 and Night 2230 to 0830 (2300 to 0900 for registrars). Staff will be designated to Acute, Fast Track and EDSSU.

Assignment to a particular work area is rostered, however during the shift, this may change at the discretion of the senior medical staff, in accordance with workflow. You may be allocated ongoing responsibility for existing patients in the department. Please ensure that you allocate yourself to these patients in FirstNet, and document the handover round in the patients’ notes.

Handover rounds will commence in Acute and Fast-Track at 0800, 1700 and 2300. It is expected that most detailed discussion and planning regarding patients will occur prior to handover taking place. For the departing night-team, it is expected that the registrar will have sufficient knowledge of each patient to conduct the acute handover while night JMOs hand over their patients in Fast-Track. For the evening shift, incoming staff should promptly attend their designated areas, and commence seeing patients, whilst also facilitating cover for any day staff who has not yet had an adequate break to do so. If a meal break is not taken, this should be recorded on the time sheet and the usual mealtime will not be deducted.

Each area will have a nursing team leader or coordinator, and you should identify yourself to him or her early in your shift.

Likewise each area/ team will have a registrar and/or consultant assigned, and you should identify yourself to them.

Name badges, displaying your full name and role, should be clearly visible at all times. Both your hospital I.D. and your chest ‘Garling’ Badge should be worn. Please contact the administrative team if you need a new badge.

Patients are seen according to triage category, and, within triage category, are ordinarily seen in order of arrival. This is occasionally subject to specific variation under guidance from senior medical and/or nursing staff.

Triage Categories:

• immediate resuscitation
• 2: life-threatening: treatment should be initiated within 10 minutes
• 3: treatment should be initiated within 30 minutes
• 4: treatment should be initiated within 60 minutes
• 5: generally reserved for (rare) clearly non-urgent presentations or for review clinic patients.

Please do not rely on the presence or position of paper notes for a patient as the best indicator of who is to be seen next, rather use the EMR to confirm that you are picking up the correct patient.

Please assign yourself on FirstNet to your patient as soon as you intend to pick them up, then either see the patient in the allocated treatment space, or if no space has been allocated, you should assign a space with agreement of the Nursing Team Leader for that area.

Identification:

• Please ensure you are seeing the correct patient, that an identification wrist-band has been attached at registration/ triage, and verify that the notes you are using corresponds with the correct patient. The minimum standard identification data before initiating treatment for any patient are full name, date of birth and address. You should ask using open-ended questions: ‘what is your name?’ and ‘what is your date of birth’. The ED is a high risk area for mistakes, particularly where factors apply such as crowding, high-acuity, confused or intoxicated patients, 2 or more patients with similar names, and patients with limited ability to communicate in English.
• Such mistakes have the potential to be catastrophic, so please do not assume that someone else has identified your patient for you.

Ideally, your patient will have a treatment space that provides adequate monitoring, privacy, comfort and easy access to a PC to record your assessment. Unfortunately this will not always be the case, but we should take any steps we can to give our patients the best treatment space possible. If your patient has had a long wait, or conditions are crowded, please consider how you would feel in the patient’s position and apologise on behalf of the ED.

Even if a patient presents with what seems to us to be a minor complaint, we must take our patients’ concerns seriously and advocate for them from their point of view.

Pain management and addressing immediate stability (particularly taking note of abnormal vital signs) are your first tasks, as these issues will not always be recognised prior to you seeing the patient. (For example, patients initially assigned to Fast track may subsequently need a higher level of care).

Communication- both verbal and non-verbal, and providing regular updates to patients and their families, is the most important thing we provide for almost every patient we see.
Providing comfort, warmth, food and drink to patients, are also essential to good care, and assist good medical care enormously. 

If a patient experiences a cardiorespiratory arrest or you need urgent assistance for any reason there are red buttons at the end of every bed which, when pushed, will cause an alarm to ring. Consoles hanging from the ceiling will alert staff as to where the emergency is. All available staff should respond in the initial stages.

It is not uncommon for a new patient to appear well, and be assigned a relatively less urgent triage category, but subsequently deteriorate rapidly. You have a significant role in picking up cues from these patients and bringing them to the attention of senior medical and nursing staff immediately.

The ED provides ‘consultant-led’ care, whereby each patient is ultimately under the care of a consultant Emergency Physician (EP). EPs are Fellows of the Australasian College for Emergency Medicine, with expertise in acute and resuscitative care, hospital and health systems, and in teaching and supervision.

Where the responsibility for decision-making is extended to non-specialist staff, the expectations are as follows:

• Registrars are doctors with at least 3 complete full-time postgraduate years of experience, who have been authorised by the consultant group to make disposition decisions and supervise junior staff independently, but to escalate risk to the consultant present or on call, or, when appropriate, to an inpatient service. Registrars are the most senior doctor in the ED from 2400 to 0800. Most registrars will be in Emergency Medicine training.

• Senior Resident Officers are doctors with at least 2 postgraduate years of experience, who are expected to manage most elements of assessment and disposition independently, but to have a lower threshold for discussion regarding any elements of risk. They may assist but should not supervise more junior staff.

• Junior Medical Officers.

• • PGY2 doctors must discuss every patient prior to admission or discharge, and if any change in patient condition occurs, with a registrar or consultant. Senior staff will consider whether direct review of patients is required based on risk, and will lead admission calls.
  •  PGY1 doctors must similarly discuss every patient. Senior staff should provide at least brief assessment of every patient, and will conduct admission calls.

• Other ‘Independent practitioners’ such as nurse practitioners or physiotherapists also work within this model, and are expected to escalate issues of risk or problems outside their scope to the consultant on duty.

• Where decision-making has been shared with a supervisor (and/ or inpatient team), the names and contribution to care must be clearly documented, including when elements of supervision pass from one doctor to another.

The interpreter service should be used for all non-English-speaking patients. In an emergency a member of staff may be used, however use of friends or family members is discouraged and should be reserved for lower-risk (or urgent) circumstances.

Please take note of referrals, past notes, and any indicators that your patient may be at higher risk for a poor outcome than you would otherwise expect. Please do not ignore your own judgement and experience- you may well have obtained details or concerns that a more senior doctor has missed. A good suggestion is to consider the ‘clinical bottom line’ for each patient, which may vary depending on what the patient’s particular concerns are, what you feel the patient needs, and also on what other people such as relatives or other doctors have suggested the patient needs.

Please consider social safety: this includes risk of fall or other misadventure, risk of assault or neglect of the patient, and occasionally risk to others. Always consider whether your patient has dependents (children, disabled partners, even animals) and their safety and welfare both while the patient is in hospital and on discharge. If there are children at risk you will need to consider and obtain advice on Community Services notification.  Consider if there are any activities that would pose a particular risk to the patient or others, e.g. driving, flying, safety at work, even risk of assault. Particular rules or legislation may mandate notification to third parties.

Beware the possibility of an atypical presentation of a serious diagnosis. Unexpected deaths after ED discharge have been associated with 3 main factors:

• Atypical presentation of a serious diagnosis, such as sepsis, cardiac disease, pulmonary embolism, early neurological emergency.
• Decompensation of chronic disease.
• Impaired ability to return to the ED if deterioration occurs. This group includes the elderly living alone, mentally ill patients, patients with substance dependence, and patients with other constraints on their choice on return such as correctional inmates.

Some particular note needs to be made of risk management prior to discharge.

• Abdominal Pain: we expect registrar or consultant involvement, especially if morphine has been given or in the elderly. All females of reproductive age with abdominal pain should have serum HCG as ectopic pregnancy can be insidious. An Abdominal and Loin Pain Guideline is available on the ED SharePoint.

• Chest pain: all ECGs are assessed and electronically signed by a registrar or consultant, principally to screen for ST elevation syndromes. If you see an unsigned ECG, please bring it to senior attention immediately. Once you have commenced an assessment, please discuss, ideally with the same senior doctor, to allow clinical correlation.

• Headache: all patients with undifferentiated and unresolved headache require consultant (generally ED or neurology) assessment. It is not safe to diagnose a primary or self-limiting headache syndrome unless your patient has had similar headaches before. There are a number of important rare but important diagnoses which require risk-assessment prior to discharge. A Headache Guideline is available on the ED Sharepoint.

• Pulmonary Embolus: this is a differential diagnosis for a wide range of patients with shortness of breath, syncope, and/ or chest pain. Consider whether your patient reaches threshold for structured investigation.

• Acute testicular pain: consider torsion until a clear alternative diagnosis has been identified. Notify a senior doctor immediately.

• Complex infections:
  • Diabetic foot infections: are always discussed with Infectious Diseases prior to contemplating discharge. Admission is usually required, normally jointly with a surgical team- this cycles between vascular and orthopaedic surgery and switch have this roster
  • Infected joints/ orthopaedic hardware: are always discussed with the relevant surgical team prior to antibiotics. 

• Spinal patients: the spinal (medicine) team is to be informed of all long-term spinal patients who require admission (so that an appropriate bed can be arranged) or who have a spinal medicine-related presentation.

• Renal/ dialysis patients: the renal team is to be informed of all dialysis patients who present to the ED.

Some work tips:

• Try to structure your consult to maximise efficiency and front-loaded decision making. If a patient clearly needs admission then many investigations can be deferred to the admitting team; ED senior staff should be involved to get that patient admitted. If a patient is likely to need a particular investigation to decide ongoing care, then efforts to organise that test earlier rather than later will be very worthwhile.
• The number of patients a doctor will see in a shift will vary depending on the patient, seniority and experience of the doctor, and the overall environment in the ED that day. If you feel you are having difficulty progressing though sufficient patients, or progressing to the point where you can comfortably pick up a new patient while other patients are still in process, please discuss with a senior colleague. Many of us will have tips that could work for you.
• Junior Medical Staff in Fast-track/ Subacute: if an NP or Physiotherapy practitioner is on duty, please check with them before picking up a patient within their scope. They may be overloaded and welcome your assistance, or you may be better placed to pick up a different patient. 

Clinical notes, both by ED and non-ED staff, should be typed into FirstNet, as contemporaneously as possible. Handwritten notes are only to be used in the event of EMR outage. All notes should be signed at the first possible opportunity to avoid them being reassigned to another staff-member. Where notes are the product of joint assessment this should be made clear.

The recommended Clinical documentation formats for medical staff are ‘Adult Exam ED’ and ‘Discharge Referral ED’, with the particular pre-completed title ‘POW ED- Medical’. A Discharge Referral is required for patients going home, and will be faxed electronically to your patient’s nominated GP. Please ensure you have been shown how to use these formats at the start of your term. ‘Progress note’ is not recommended for initial medical assessment.

Many patients do not need investigations. History and examination are often sufficient to guide care, and many investigations can safely and wisely be deferred to the patient’s own GP.

Investigations/ imaging

The ED should only investigate testing if it will genuinely change what we do. There is a role for commencing some investigations on behalf of admitting teams, but if a patient needs admission on clinical grounds, the results of these should not delay admission.

If a positive blood culture or clearly unexpected imaging abnormality is noted on an ED patient who is subsequently discharged, the ED will generally receive a call from the lab/ reporting room advising us to follow that patient up. For other results (generally urine cultures and serology testing) the ED may not receive this result for some time, and follow-up systems are currently very unreliable.

Please specify in your letter which antibiotic has been prescribed, as resistant organisms are common. In the ED we expect all doctors to endorse all results in their EMR Message Centre regularly. The Review Clinic is also very useful and highly recommended whenever a patient is discharged without all results available.

A difficult or unexpected result should be discussed with a senior doctor prior to endorsement, as there is no means of recovering a result from the system. JMOs will normally be asked to focus on their own Message Centre, but may be asked to help work from the ED ‘pool’ under senior supervision.

On day shift please speak to the consultant on duty for EDSSU, otherwise the consultant on duty can be contacted for any complex or unresolved issues.

If you perform active follow-up for a patient (i.e. phone, call back to ED, call GP, fax, mail or email copies etc.) please open the discharge referral in ‘documentation’ tab, and make an addendum detailing your actions and instructions. This will prevent subsequent doctors seeing the same report and making the same attempts to follow-up.
Follow-up on abnormal or unexpected results remains our responsibility until we know that our duty of care has been discharged.

Biopsies, serology testing, endocrine testing, autoimmune testing and similar tests can generate not only cost to the ED but also significant clinical and medico-legal risk. In our ED, if you are considering or have been advised by a non-ED team to do a test that would fall under such a category, you must discuss it with a registrar or consultant and make a clear record regarding approval and follow-up in EMR. Such tests should generally be ordered only if a requesting team is unambiguously taking on responsibility for follow-up. If entrusting follow-up to a GP, then merely advising a patient, even in a letter, may not be enough. A call, documented in EMR, specifically noting GP acceptance of that responsibility, may be needed.

Imaging reports in particular are subject to change, and the EMR does not itself keep a version history, so please bear in mind that you could be sending a patient home with a normal report that could change to an abnormal one. The default instruction should be that all patients should seek the final report via their GP. If you are not 100% certain the X-ray showed no fracture, splint the injured part, provide analgesia, and send the patient to the next fracture clinic.

Imaging can be ordered on FirstNet, with most plain radiology available in the ED X-ray suite 24 hours a day (mobile CXRs can be done in resuscitation bays and beds 8-12), and CT (x20333)/ ultrasound (x20353)/ MRI available in the radiology department nearby.

Clinical information is very important for subsequent evaluation and is best entered in the ‘reason for exam’ section of the FirstNet order screen.

Nuclear medicine is available on level 2- not suitable if your patient is unstable. Venous Doppler is performed at the Ultrasound department (x20353) within POW Medical Imaging. Gynaecological ultrasound is available at RHW (x26080) and can be ordered by any ED doctor, after discussion with senior ED staff to ensure it is required, without the need for prior consultation with the on-call gynaecology registrar. Imaging outside the ED generally needs a phone call (or page after hours) to confirm/ discuss after ordering on FirstNet.

Transfusion is a particularly important area to get right, as it has significant resource (both blood bank and ED workload) and safety issues.

Group and Save requests need to be printed and signed (by the collector), and sent with the correct hand-printed tube to Blood bank. Clerical errors are unfortunately very common in our ED and each one is logged as an incident by Blood Bank, requiring full sample re-collection. Please take a ‘time-out’, ideally with your patient, to check every detail: spelling, dates, identity. ‘Wrong blood in tube’ incidents are potentially fatal, and all steps to avoid them should be taken. Always maintain sight of blood from point of exit from your patient to completion of tube details. Recollect if it has left your sight. Never handle more than one blood-bank tube at a time and never hold on to blood bank tubes ‘just in case’. The sample should be collected and sent at the time it is to be ordered or sent.

Cross match requests should only be sent when cross-matched products are required. When blood is ready a pink requisition should be sent. The same pink form should also be sent for other blood products (plasma, platelets, anti-D etc). Type O blood (O negative for females of childbearing age) is available as a ‘Trauma pack’ is required super-urgently. Guidelines for transfusion and blood product replacement are available on the Sharedrive and Hospital Intranet. Administration of blood products requires specific consent and administration forms, including a specific for Anti-D administration (250 iU for first trimester, 625 iU for 12 weeks onward).

NB current unit availability can be found in the ‘Patient Product Enquiry’ link from Firstnet, not on the EMR Flowsheet. Mandatory training includes ‘Blood Safe’: please ensure you have completed the current module.

Please minimise transfusions in the ED, bearing in mind appropriate indications and haemoglobin levels and deferring them whenever possible to inpatient teams in hours. All consent requirements must be adhered to, with forms available around the department- both the general blood product form and the specific one for Anti-D. Single unit transfusions are recommended when appropriate for symptom management- and admission under the appropriate team is required if larger transfusions are planned. Iron infusions may be an alternative or additional option. Admission under an inpatient team is expected if more than one unit is planned. The POWH Ambulatory Care Unit can take referrals for non-urgent outpatient transfusions and infusions.

Once your initial assessment is complete, you will need to make a plan, under supervision, for further management and disposition. All referrals external to ED should be discussed and approved by senior ED staff before they are made.

Under the Emergency Treatment Performance (ETP) target, all EDs are required to keep time from arrival to departure within four hours, so efficient decision-making and communication at this point is vital.

• 2:1:1 means that key disposition decisions should be made within 2 hours, an appropriate admitting team arranged by 3 hours and transfer to ward should be complete by 4 hours.

Most contact with an inpatient consultant or team regarding a patient will constitute a ‘decision to admit’ which should be recorded on ‘events’ in FirstNet.

You should communicate with the patient throughout, not only regarding diagnosis and treatment, but also regarding where he or she is in the ED process.

Medications

Medications (both regular and PRN) should be sufficiently reconciled and charted on eMeds, to ensure adequate care until team review. Please follow the steps ‘Document medications by history’ and then ‘Admission Reconciliation’ for all patients who take or who will be commenced on regular medications.

Please check ‘First Dose’ timing carefully to ensure appropriateness. ‘Add order’ may be used for stat/ single dose medications only. Pay particular care when interpreting lists on transfer letters, which may be incomplete or contain superseded medications. Checking medications, dosage, interval and compliance with at least 2 sources, one of which should be directly with patient or carer, is the standard expected. Please be aware of high-risk medications (e.g. methotrexate) and combinations (e.g. beta-blockers plus calcium channel blockers, NSAID plus ACE inhibitors).

Check and chart insulin carefully; all insulin-dependent patients need at least long-acting insulin, even when fasting. Guidelines are available on the Sharepoint for fasting patients. Consult endocrinology if in doubt. Please ensure that any order to start or stop a specific medication is reflected in the chart. Please use the charting stage to double-check that any medication charted is appropriate- e.g. suspend metformin if IV contrast is to be administered or in acute kidney injury, suspend potassium if hyperkalaemic, suspend antihypertensives if at risk of hypotension, ensure methotrexate is charted WEEKLY not daily, ensure that transdermal patches are correctly prescribed including date of next patch change, ensure methadone paperwork is completed and dosing history obtained from provider.

Please ensure that discharge documentation reflects medications being taken on discharge.

Antibiotics

In order to reduce inappropriate prescribing of antimicrobials (and consequent rates of multiresistant organisms) the hospital has a system of antimicrobial stewardship. ‘Orange’ antimicrobials should have appropriate approval numbers obtained via the ‘MS Guidance’ tab from FirstNet and entered on eMeds. “Red” antimicrobials should have approval from the Infectious Diseases team.  

Our antimicrobial choices overall should closely follow current recommendations in eTGs, except where a more specific hospital guideline (e.g. Initial Management of Febrile Neutropaenia) is available.

If your patient is to be admitted, then one or more of the following will happen:

• Default, and currently expected in hours: ED senior (see below) to admitting consultant or delegate. Medications sufficient for immediate needs should be charted.
• The admission principle is ‘Call equals disposition’. Disposition decisions may include consideration of EDSSU (+/- team review there) if otherwise appropriate, discharge with an appropriate follow-up plan, or admission under an alternative team. While the ED may assist with a call to an alternative team, patients requiring admission are allocated under the first team referred, which carries primary responsibility for arranging transfer of care.
• ED senior means consultant, registrar, or after discussion with a more senior doctor, ED SRMO call to consultant. On occasion an intern or PGY2 doctor may wish to participate in an admission call, but you must ensure that their patient has also been seen by a more senior doctor who is able to take over the call if needed.
• Registrars are first call for surgical specialties, gastroenterology and dermatology (24 hours), and during normal working hours for most medical specialties. A detailed call sheet is available in the clinical areas. If any delay or difficulty is encountered the on-call consultant should be contacted.
• Medical registrar review:
  • In-hours, the team registrar is the approved AMO delegate.
  • The call to any registrar should be as for admitting calls above. Transfer to an inpatient bed should not be delayed.
  • Out of hours we page the ward medical registrar either for assistance with the admission process or if requested by the AMO.

The JMO role in these situations is to ensure EMR documentation is correct and complete, that any medications needed are charted (please check to make sure your charts are consistent with senior plan) and that all ongoing treatment (fluids, transfusion etc.) is correctly written up. Outstanding results or tasks are handed over either to the admitting team in hours or to after-hours ward-cover.

Please also be aware that if a patient appears to deteriorate while awaiting either inpatient team review or transfer to a ward, that you need to notify senior ED medical staff. Patient care remain the responsibility of the ED until they have left the department.

If your patient is to be discharged, a number of general requirements should be met.

• No patient should be discharged unless they are reasonably expected to get to and manage in their home environment, either alone or with available assistance.
• Patients should have a clear understanding of their diagnosis, treatment recommended, prompts for return and plan for follow-up.
• If you are advised to discharge a patient and you are not convinced that it is appropriate, discuss it with the ED consultant, particularly if the decision has been made without the advising doctor (whether ED or inpatient specialty) seeing the patient. EDSSU may be an appropriate option, especially after hours.
• A patient who has visited the ED more than once for the same or related problems should be discussed carefully with senior staff, with this discussion documented, with a very low threshold for personal senior review. There may be complex reasons for failure of a single ED visit to deal with such patients’ problems, and potential for senior review to have a significant impact. There may also be significant clinical and departmental risk associated with discharge without such review.

A default rule, which can be tailored to individual circumstances, is that all patients should see their GP after an ED visit. The patient should have a safe means of getting home, preferably with a carer to assist them. A number of options for transport can be arranged if needed- please discuss with senior staff or, in elderly patients, with ASET. Elderly patients should not generally be sent home without capable care after dark.

A similar handover of care to that given to inpatient teams is needed for the patient’s GP. If the discharge decision is contrary to the expectations in the GP referral letter, then a phone call to the GP is usually a good idea to discuss options or to explain the outcome of attendance.

A letter should be provided for every patient unless specific reasons exist for not doing so. It should contain, at minimum3:

• Your name and the names of any other doctors who had significant involvement. It should name any inpatient team representative consulted.
• History and examination. In many cases this may be your clinical notes.
• Investigations performed and results, and if applicable, details of outstanding results. Please note that EMR-generated documentation may be incomplete in this regard.
• Assessment / problem list including Differential Diagnoses considered.
• Plan of management

If bloods have been taken these should be loaded into the letter via FirstNet (or at least printed out separately if this has not been possible), and if other investigations such as ECG are relevant to care, they should be copied and enclosed.

Your letter may also be structured as a referral to outpatient clinic or specialist, in which case it should contain a valid Medicare Provider Number

Both of these groups of patients represent a failure of service. The most common feature associated with either group is long waiting times, either to be seen or for definitive care once seen. Such delays are not always preventable, but should be actively monitored.

Patients should feel free to leave if they wish, but the following basic requirements need to be met:

• The patient must have general capacity to understand their choice, and must have any specific information relevant to them about their likely diagnosis to assess their own risk of coming to harm. This is obviously difficult if a patient has not been seen, and places significant onus on us, for example if intoxication or head injury is suspected or if an investigation (bloods or x-ray) has been ordered at triage.
• There must not be a legal obligation to detain or treat a patient involuntarily, either under the Mental Health Act, or under ‘Duty of Care’ provisions to prevent significant harm to a patient lacking capacity. Please again beware intoxicated or possibly head-injured patients, as well as those who are dependent on others to decide their own best interest.

If in any doubt, please ask for support from senior staff.

Variations in advice

One thing you will notice in ED, as in the rest of medicine, is that advice may vary depending on which senior doctor you speak to. The ED sees patients at their most dynamic and least differentiated, and it is hardly surprising that there may be more than one valid way to treat a patient. Emergency care is not about finding the one best way to treat a patient, but about finding a good, effective and efficient way to negotiate care between ourselves, community providers, inpatient resources and the patient (ethically balanced with the needs of other patients). Seeing different styles and approaches in this light is an important part of training.

Some general rules of thumb:

• Management advice will be much more consistent and effective if the senior doctor giving advice has also seen your patient. You should have a low threshold for asking for this review.
• For one patient, seek advice from one consultant or registrar. Please try not to ‘doctor shop’, as it can create mistrust and undermine patient confidence. If you are uncertain or concerned about advice you have received, in the first instance discuss those concerns with the senior doctor involved. If that fails to resolve the problem, you may wish to seek guidance from another trusted senior member of staff.
• If the initial doctor is not available when something has changed or a new question arises, please let the second doctor know what advice was received from the first.
• Always discuss with the ED senior before referring to inpatient teams. We have responsibility for patients while they are in the ED, as well as priorities based on our patients’ presence in ED rather than in that team’s clinic or ward. While we value expertise and support from others, it is up to us when to seek and what to do with that advice.  
• If a plan changes, for example on the handover round, do not take it as a personal reflection. It is simply the nature of ED.

The Mental Health team is available 24 hours. The Mental Health CNC team is generally your first point of referral, and subsequent disposition can then be managed with mental health registrar and consultant.

No patient who has an acute psychiatric illness should leave the ED until they have been discussed with psychiatry.
All patients expressing or who have evidence of recent suicidal ideation are to be seen by psychiatry. They should receive a psychosocial assessment by attending medical staff, as well as care for any physical/medical concerns, and referral to the Mental Health Team.

If there is any doubt about such referral, if the patient wishes to leave and there is any doubt as to whether the risk of harm justifies involuntary assessment, or the team is not available to discuss the patient, please seek senior advice urgently.

Consider the need for a medical coassessment to ensure that there is no intercurrent organic illness that would make admission to a mental health unit unsafe. Important acute diagnoses include delirium, specific neurological illness such as encephalitis, or medical problems which may have been neglected in the context of poor mental health or social supports. Such a screen does not equate to an extended psychosis screen, nor does it guarantee that there is no organic illness present. If vital signs are normal and no physical symptoms are expressed, it may not require any tests at all. It does not routinely include urine drug testing- this has complex ethical ramifications and is only ordered by ED staff in very specific circumstances. If in doubt about any aspect please discuss with senior ED medical staff.

Please consider the need for schedule under the Mental Health Act. At the ED level this is a safety assessment about whether a patient could foreseeably come to or cause harm if he or she left without being seen by Mental Health. Please consult if in any doubt. If a patient absconds while under schedule we need to notify police and security immediately with a description.

If you are caring for a patient whom you anticipate will need mental health admission but who has not been admitted or is awaiting second or subsequent review, please ensure senior ED medical staff are aware so that any elements of risk and delay are managed.

The Mental Health team should be aware of any patient being considered for emergency sedation.

The EDSSU is used for patients admitted under the Emergency Consultant, who are expected to be discharged within 24 hours. Examples of suitable patient include patients with mild head injury undergoing neurological observation, renal colic awaiting scan and/ or response to analgesia, patients accepted for care at other hospitals awaiting trasnsport, and elderly patients not safe for discharge at night.

Admission needs to be approved by senior ED medical staff, with a plan documented and medications charted. Other teams may not admit to the EDSSU, with the exception of toxicology. Admission to EDSSU for team review will be considered for patients who are likely to be discharged, and subject to other demands on the unit. The key EDSSU exclusion criteria are: likely subsequent inpatient admission, and involuntary status under the Mental Health Act (unless specifically agreed to after appropriate risk-assessment).

An EDSSU Draft business Rule is located on the ED SharePoint.

Communications Clerk

We have a Communications Clerk, with duty hours 0800 to 2300 7 days a week, to assist with paging, putting through calls, finding staff and updating patient details.

The daily on-call sheet is a useful guide to who is carrying call for the various specialties.

Phone Calls

Admission or advice calls should not be taken by JMOs but handed on to the admitting doctor for the day, usually the EDSSU consultant. If you receive a call relating to a patient you know or have discharged, seek supervision as you would were the patient present.

Ambulance notification ‘Bat-Calls’ are received on a dedicated phone on the bridge. Answer immediately, write down the information given including time of call and estimated time of arrival, and tell senior staff immediately.

Whenever possible please discuss your patients with and make your referrals before each shift handover.

Consultant-supervised handover is a very important process in ED, as many patients will require care from many staff across shift transitions and thing can change rapidly. The acute round is at the bedside and, where appropriate, will involve patients or their representative by clarifying what is happening and who will be taking continued care.

Our handover processes, particularly at shift transition, emphasise succinct but effective and predictable transfer of responsibility and care4. Learning to summarise a patient’s presenting complaint, diagnosis, differentials, plan and outstanding items efficiently is an important and satisfying skill. ISBAR, adapted slightly to an ED environment, is the expected standard across NSW Hospitals and is a good structure for remaining focussed on those issues and helping the receiving doctor take on care safely:

• Introduction- patient name and location (if unclear)
• Situation: Presenting symptom- e.g. chest pain
• Background: Only as relevant to current care- e.g. Known IHD, renal impairment with creatinine baseline 150.
• Assessment: Diagnosis, stability, any serious differentials under consideration.
• Recommendation: Disposition, tasks pending- e.g. admitted cardiology, 2nd troponin at 8 pm, has bed on CCU.

Patients should be assigned to and handovers documented by the incoming JMO4, ideally as an addendum on EMR documentation.

The other occasions of handover include receiving care from ambulance or other external staff, and handing care on to ward staff once admitted. Although the formalities are different, the principles should be the same. Patients leaving the ED should have plans clearly documented in the electronic notes, and if outstanding tasks or potential instability exist, then the onus is on us inform covering medical officer(s), particularly after hours.

Handover to wards:

Please consider carefully whether your patient has decisions pending or is at risk of deterioration on transfer to the wards where monitoring and staffing may not be as intensive as in the ED, in particular after-hours. Be particularly mindful of concerns expressed by nursing staff. Escalate any evolving issues to senior medical staff.

Use the ‘ED to ward handover’ form for patients who may need after-hours attention and tick the ‘Add to Census Task List’ option. This list will be used at the 16.30 and 22.30 inpatient handover meetings. When placing a patient on this list you will be reminded to call the relevant staff-member (usually the Medical Officer in Charge- ‘MOIC’) to ensure that your handover is received and to give the opportunity for check-back of information.

Following handover, it should ordinarily be possible to depart by the end of shift. Tasks that were identified at handover but are yet incomplete can usually be tasked to doctors on the next shift. On some occasions, usually related to finalising care for a particular patient, it is recognised that this is not possible, and unrostered overtime should be claimed. The main proviso for this is that the senior doctor on duty for the ED needs to be aware and approve of this before the time is worked. Overtime can then be claimed for signing by athe ED Director prior to the next timesheet.

You can expect to be rostered for approximately 2 ADOs over a 10-week term, and if you have several ADOs accrued and need to claim a 3rd please let us know. ADOs can also be claimed during periods of planned leave—check with the JMO office if in doubt. The ED will endeavour to keep overtime to a minimum, both for fatigue management and to help the hospital control costs, but reasonable overtime (generally up to 1 full shift over a fortnight) can be rostered. Please let us know if difficulties arise.

Night Shifts

Ensure you are well rested prior to and between night shifts by developing a routine that works for you. Some tips include:

• Avoid caffeine or alcohol before sleep
• Plan meals and try to eat healthy, enjoyable food
• Try to darken the room/ damp out external noise. Routines like a shower or something simple that prompts your body that it is sleep time can be useful.
• Go to bed when you have wound down and are ready for sleep, try to avoid distractions once in bed (such as TV etc).
• Exercise after waking rather than before sleep
• Plan a time of day when you can interact with friends or loved ones, and plan something special to look forward to after nights.
• A final ‘power nap’ prior to the shift can really help!

Avoiding complaints

Treat patients and their relatives, as you would want yourself or your family to be treated. This includes limiting waiting times as much as possible for patients waiting to be seen, maintaining confidentiality of patients you treat, and involving them respectfully in discussions and plans regarding their care.

Most of the complaints received by the ED result from problems in communication. Talk to your patients frequently. Explain what is happening to them; what you think is wrong with them and what they are waiting for. Reassure them that you are doing everything you can but some things are outside your control. Apologise for delays if necessary, even though you may not personally be responsible: remember, you are a spokesperson for the whole department. Involve your patients in decisions relating to their care, including triggers to return, areas of uncertainty relating to diagnosis, or where 2 or more valid treatment options might be considered.

Another area of complaint revolves around pain - do everything you can to relieve your patient’s pain. Carefully titrated narcotics, despite a traditional concern that this might be a risk, do not mask peritonitis. If the patient turns out to be a drug seeker, don’t worry about it - you’ll recognise them the next time. Patients with opiate tolerance require special care and early senior review to ensure adequate analgesia. Splint fractures - don’t leave them waving in the breeze.

Give early, effective pain relief, preferably via fast acting, titratable routes (IV or inhalational) for severe pain; don’t forget paracetamol for mild pain. Check with the patient that the pain has resolved; if not, more analgesia may be required. A guideline to pain management is on the department share drive.

You will be interrupted on occasions to prescribe pain relief for patients waiting to be seen: make a quick assessment, site an IV (if required), prescribe analgesia, order an X-ray/ splint etc. record a brief note and the time you assessed the patient, then put the patient’s folder back in the box for the patient to be seen by next available medical officer.

ED is a tiring term, even though overtime is generally minimal, both because of the nature of the work we do and because of the disturbance shift-work causes to our natural daily pattern. All the senior staff in the ED have experience of this stress and fatigue over many years, and will try to support you.

The up-sides are days off when otherwise we would be on ward duties, and also the rapid development of personal and clinical skills that comes from learning to make decisions on behalf of acute, undifferentiated patients.

If a shift or patient encounter has been particularly stressful, try to take a trusted senior or supervising colleague aside to debrief. ‘Operational debrief’ addresses the main questions that trouble us all, i.e. ‘What was done well?’ ‘What was done less well? And ‘What would I do next time?’ and in the ED is added a particular mentoring and supportive element, because the senior doctor has either shared the experience and can reflect on it, or has been through similar experiences before.

If the term overall has been stressful, again approach a trusted colleague, but also seek out the term supervisor for a confidential discussion. Remember that your colleagues (including senior colleagues) also find work stressful at times. A common cause for the stress felt in ED is the high standards we all set for ourselves. These standards are important, but in ED we need to moderate our expectations by the awareness that we share care within a very complex system, and that no such system can be perfect. Try to get away on time and not take too much of the shift’s difficulty home. Try to allocate time each week to things outside work that you enjoy and can look forward to. Try to get sufficient sleep.

We do our best to provide encouragement and support, and to be flexible regarding compassionate leave, study leave (in liaison with the JMO office for rotating JMOs), or shuffling shifts if significant issues arise.

• Sklar P et al. Unanticipated Death After Discharge Home From the Emergency Department. Ann Emerg Med. 2007; 49: 737-745.
• Australasian College for Emergency Medicine. S18: Statement on Responsibility for Care in Emergency Departments. 2005
• POW ED Clinical Documentation Policy, 2008
• Australasian College for Emergency Medicine. G21: Guideline on clinical handover in the emergency department. 2010.

The campus parking is run by Metro parking and not by the hospital. Once you commence work at Prince of Wales you will need to visit the car park office on level B1 to put your name on the car park waiting list. The waiting list can be very long so in the meantime if you still wish to park in the Metro car park the cost for casual parking for a whole day is approx. $24. They also have a 5 day staff pass that can be used for out of hour shifts, the rules for the out of hours pass are as follows:

• You must enter the car park after 4pm and leave before 8am the next day, otherwise casual rates will apply.
• Weekends – any time
• The cost is $17.30 and can be used over a three-month period.
• The pass needs to be purchased within 24 hours of entering the main car park.

Another parking option is Early bird parking at Ezipark next to Randwick Ritz cinema on St Pauls street. This is a $6 all day flat rate, you must be in between 5.30am and 11am and out between 2pm and 7pm

Scrubs are not mandatory and discretionary funding is not currently allocated to the ED to provide them. They may be used in accordance with the SESLHDPR/281. The approved colour for Junior Medical Staff is green/ emerald.

https://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Nursing_and_Midwifery/Documents/UniformsProvisionDressCodeandappearanceforClinicalandCorporate.pdf .

Resources for purchasing/ choosing scrubs include:

• https://www.infectious.com.au/
• http://www.healthshare.nsw.gov.au/__data/assets/pdf_file/0009/296244/Uniform-Catalogue.pdf

• Choosing a Scrub Style to Suit Your Body Shape ( 106.7 KB)

• Measurement Guide - Male Version 4 ( 1.1 MB)
• Measurement Guide - Female Version 3 ( 1.2 MB)