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Shellharbour ED Orientation July 2022- expectations and aspirations overview
This was an Orientation talk for new doctors doctors working in Shellharbour ED - expectations and a framework for practice. Shellharbour is a lovely peripheral hospital ED situated in the coastal region of Illawarra NSW. We see >30,000 patients per year, with a broad and interesting range of acuity. Our staff is made up of an interesting mix of local and international doctors who embrace a small hospital team spirit, tackling large hospital problems. Our ED is a mixed adult and paediatric ED that is located 30 mins away from a fully serviced Tertiary hospital. We support ACEM Advanced training with a FACEM led department, supported by ACRRM and Senior CMOs in the medical leadership. The department is host to UOW Clinical Medical students, and subspecialty training term or ED Ultrasound. Our hospital is in the process of an upgrade to include short stay an ICU. The work is challenging but rewarding , and embraces the full mix of what a coast peripheral ED can hope to offer.
Shellharbour ED Orientation July 2022- expectations and aspirations overview
- 1. Shellharbour ED Orientation Expectations anda Framework for working in our ED Dr Bishan Rajapakse (FACEM, PhD, MBChB) Staff Specialist Emergency Medicine Update 11-7-22
- 2. Introductions and “Knowingthy team…” Learning works best when you know what your goals are, and knowing your team ; 1. What do you hope to gain from your SHH ED term? • How do you plan to add value? 2. What interests and background do you bring to this job? 3. What are your communication and learning styles –what are the Teaching / Supervision styles of your Seniors and colleagues? Emergency Medicine=TEAM
- 3. Goals : Whatdo you hope to get out of your term/time in our Peripheral hospital ED TEAM? • Learning/ Experience? • Medical Expertise / Team work / Leadership • EM Specialty training ? • Other General or Sub-speciaity Medical ? • Sub-specialty interests with EM? • Ultrasound • Geriatric EM • Global EM care / International Medicine (SHH has diverse international mixed of doctors and nurse) • Research Exposure
- 4. Our SHH ED ConsultantTEAM (and interests) • Simon Keane – ED Director (Leadership/ Retrieval/ Innovation) • Angelo Abeywickrema – (DEMT / Ultrasound/ Retrieval ) • Phil Manczac – (Co-DEMT / Paeds / Med ED) • Bish Rajapakse – (Well-being / Research & Med ED / International EM) • Kham Saysana - (Clinical Governance/ Policy / Toxicology) • Ayman Elattar – (Education & Training/ Simulation • Brona Geary – (Peripheral Hospital Training / Med ED / Simulation) • Kris Yuen – ED / Med ED • Tom Carrigan– Medical leadership/ Research
- 5. Professional Behaviour Expectations Be on time Dressthe part Bring your “A Game” Be polite, Be Kind (to self and others)
- 6. EM Approach -a framework Risk Management 5 Questions (to ask yourself about every patient) 1) RESUS or Not 2) IN or OUT 3) Stream (Med/surg/Paeds/OBG) 4) Sub-spec 5) Specific Dx and DDx Bio-Psycho-Social approach • Biological • Psychological • Sociological
- 7. Shellharbour Hospital: Peripheral HospitalED Emergency Department - 2 resus beds - 12 Acute Adults+ 2 Acute Paeds - 5 Subacute treatment spaces Inpatient Service - 87 Medical, Surgical and specialty beds - Close observation Unit (9 beds) - General Medicine - Geriatric Medicine - Surgical (8 Bed day care) - 69 Mental Health beds - NO Paeds /OBGYN Presentations >30,000 presentations/year 6000 Paediatric presentations
- 8. Team Interactions ED Psych Gen Med SSH GenSurg O&G Paeds ICU SHH TWH AMAU – acute medical assessment unit
- 9. Department Spaces – Types of patients ACUTE •MED/Surg • Paeds, Psych • Spaces • Resus (2 beds) 1 Paeds equip (NETS cam) • Acute Bed (Iso or Non-Iso) • Paeds Bed (2, Isolation capable) • Coridoor 2 spaces – bed and Chair • Acute Waiting Room patients • Iso Waiting room (up to 4) • Rapid Assessment Room (RAT room) 1 bed, 2 chairs Sub-Acute • Fast track waiting room • Plaster Room • Procedure Room (Nitrous capable) • Consult Rooms x2 • RAT (room)
- 10. Medical Roles in SHHED & On site Services ED Staff • ED Senior /Shift Lead • FACEM • CMO / MMO • Registrars (ACEM AT) • SRMO • Varying Seniority • JMO • Resident • Intern Services Gen Med Reg - 24 hour cover Acute Surg Reg - M-F (8-4pm) elective surgery TWH ICU Reg General Surgery Reg (24 hours) - All Surgical Subspecialties GEN Med Sub specialties PAEDs and O&G
- 11. Nursing Roles in ED NurseUnit Manger (Frank Testa) - Daily Huddle 9:45 M-F Acute Area • Num1 (Nurse Shift Leaders) / Nursing Shift in Charge • Resus Nurse (R1-2 + Quiet Room) • Paeds Nurse (P1-2) • Acute Bed nurses (A1-11, Iso) Triage • Triage Nurse • CIN nurse (looks after Acute waiting room patients – high load) Fast Track • Nurse Practitioner • FT Nurse • Physio Practitioners
- 12. Acute Waiting Room Patients • Patient’s whoneed acute work up but do not warrant a bed (or no beds available) • Challenges and Pitfalls • Get Missed • Often don’t get picked up due to not being in bed • Decreased care • High patient to Nurse(CIN) ratio • Observations (less frequent) • Haven’t had medications/analgesia • Strategies • SAS (senior assessment • Investigations ordered at triage • JMOs and SMOs • To pick up acute patients by ”Length waiting” not convenience (ie patients in bed) • Ensure investigations are taken and medications given • Support nurses where possible • Escalate concerns; Medical Shift lead & NUM1
- 13. Allied Health & Other Services •PACE Nurse (Amy Purkiss, Jenny Larson) • Clinical Nurse specialist • Part of Emergency Response team • Nurse Educator (Ryan Klogger) • ASET • Aged care nurse • Social Worker • M-F 8-5pm • On Call from TWH • LAB • 8am - 8pm, onsite (leave at 9pm) • TWH lab overnight >9pm – regular collections & Courier • Radiology (Xrays and CT) • 8am-11pm on Site • >11pm Radiographer Call back • Ultrasound • 8am-4:30pm • >4:30pm on call Radiographer (check with Shift lead before making call back)
- 14. Team vision/ expectations (every shift) Safeand efficient patient care Communicate and collaborate Look after yourself (take meal breaks), Learn & have some fun on your shift Feedback/Debrief at the end of shift to improve for the next one
- 15. Expectation: Safe andEfficient patient Care •SAFE = Life and limb threats, Risk Management , Escalation, safe disposition •To “Care” for the patient ie advocate as one of our own friends or family SAFETY •You may see less than this when taking to account complexity, other factures (eg elderly, language issues, health literacy) •KEY to efficiency Early discussion with Shift Lead to refine/formulate plan; •Early decisions on INVx, Speciality consults, rough disposition decisions •Check with Shift lead for picking up next patient – Generally in order of time waiting Efficiency : (Rough goal – seeing 1 patient per hour) •Always have an “Impression” (Dx & DDx) and a ”Plan” (what must be done now) •Even with limited time – can formulate a DDx (Most Serious Dx, most likely/working Dx, and DDx ‘s) •Document IMP and Plan frequently & Update (also discuss plan with Nurse in Charge) •Frequent Re-assessments of patients; EM is 4 dimensional (ie responsive to time) RISK Management & Acute CARE & Timely ACTION
- 16. Communication and Collaboration •Communication with your patient is KEY • Collaboration & supervision: Every patient gets discussed with the supervising doctor • Update your patient Frequently & be honest (Don’t promise what you can’t deliver • Difficult interactions with patients: Listen and acknowledge always. Explain. Be Polite but firm and/or Get help
- 17. Department Behaviour Expectations •We are an ED Team - There is no job that is “beneath” you or I • Don’t get into arguments with the nursing staff (any staff) • Discuss conflict with Seniors (Shift Lead or FACEM mentor) • Maintain patient confidentiality
- 18. Documentation & EMR Expectations • Pickingpatients • Check with ED consultant/shift lead • Usual order of waiting time rather than category • Don’t skip Acute Waiting Room patient • NOTES • PCx, HPCx, PMHx, Meds/Allergies, SHx, Exam, INV, IMP, Plan • D/w (Surname & Role & Time) • Buttons • Med / Surg Consult ICON • Advanced Care Directive • Medications • Work certificate / D/c summary
- 19. Choosing Wisely – Investigationordering Shift in Charge/Lead - Black ; need to be notified of callback (on call radiographer RED –independent ordering Yellow – Discuss ordering Green – No D-dimer
- 20. SHIFT STRUCTURE MAIN SHIFTS FOR DOCTORS Dayshift 0800 – 1830hrs Mid shift 1000 - 2030hrs PM shift 1400 - 2400hrs Night shift 2000 (2200) – 0800hrs
- 21. ED Handovers • Dangeroustime for gaps in communication between patient • Ideally don’t pick up a patient at end of shift if not able to clearly manage • Have clear working diagnosis • Also clear management plan (what as been done so far) • Clear disposition plan • Document discussions • Eg with ED seniors and Specialty teams (Initial Surname, role) • Chart Meds for Admitted patients
- 22. SHH ED Education Program • Usu9-10am Simulation Education every Wed Morning • Either Thu or Frid • 2:30 – 3:30 SHH ED Teaching - FACEM led / SRMO run ED Training :DEMTs – Dr Angelo Abeywickrema / Dr Phil Manczac SRMO Teaching program : Dr Ayman Elattar M&M : Dr Kham Saysana Research – Dr Bish Rajapakse Make sure you get added to the Education Whats app group
- 23. Mentorship program You willbe allocated a mentor at the beginning of term Mentorship is not supervision, it’s a 2-way street and the relationship can be developed - Recommendation is that you make contact with your mentor every 4-6 weeks - Goal is to have a platform to talk about the human side of Medicine, and develop a relationship with a senior for support - You many have one formal allocated mentor but many mentors in the department - Participation is voluntary – will email you for your preferences • I aim to provide support for the mentorship arrangement • Bishan.Rajapakse@health.nsw.gov.au • Your feedback on the program is welcome!
- 24. SAFETY First Sick Calls Occ health Always wear Gloves COVID PPE Testing Being Illyourself Calling Sick Let Senior Doctor/Shift lead know As EARLY as possible (any time of day )
- 25. Leave, Rostering and Overtime Our aimis for Rostering and Leave that satisfies staff needs Must be equitable & Safe Department Discuss Early/ Put requests in early - Roster Manager & Department Director
- 26. Department Values and Dealing with Conflict Department Values (CORE) Collaboration Openness Respect Empowerment • In Conflict –step away, and always “Talk” to someone • Director • Supervisor • Mentor • Friend
- 27. In Summary Welcome toour TEAM! • Get to know your team members, the space, and the services Shift Goals • Safe and efficient patient care • Communicate and collaborate • Look after yourselves, learn and grow