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.

1. Shellharbour ED
Orientation
Expectations and a Framework
for working in our ED
Dr Bishan Rajapakse
(FACEM, PhD, MBChB)
Staff Specialist
Emergency Medicine
Update 11-7-22

2. Introductions and “Knowing thy 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 : What do 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
Consultant TEAM
(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
Dress the 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 Hospital ED
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
Gen Surg
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 SHH ED &
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
Nurse Unit 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 who need 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)
Safe and 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 and Efficient 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
• Picking patients
• 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 –
Investigation ordering
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
Day shift 0800 –
1830hrs
Mid shift 1000 -
2030hrs
PM shift 1400 -
2400hrs
Night shift 2000
(2200) – 0800hrs

21. ED Handovers
• Dangerous time 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
• Usu 9-10am
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 will be 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 Ill yourself
Calling Sick
Let Senior Doctor/Shift lead know
As EARLY as possible (any time of day )

25. Leave,
Rostering and
Overtime
Our aim is 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 to our 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