THE AFTER HOURS ROSTER 3 or 4 shifts per month TURN UP TO YOUR SHIFTS Check you have the latest version of the roster Shifts are confirmed via the JMO unit Read the job descriptions for more details
SHIFTS Shift Pager Hours Wards A1 MWI A2 SWI 293 1630-2230 6 South (Neurology) 6 West (Rehab) 7 South (Aged Care) 7 West (Aged Care) 036 1530-2230 3 South (Breast endocrine, ENT, surgical outliers) 3 West (Orthopaedics) 2 East (Vascular) 2 South (Cardiothoracics) 1 West (EDO: Non-O&G only) W1 293 0800-2230 As above for A1 W2 036 0800-2230 As above for A2
N1 N2 WOC OC Night shifts On-Call for sick relief ADO Annual Leave
STRUCTURE OF THE SHIFT 1. Pick up the pager before your shift starts 2. Receive handover from outgoing teams 3. Attend PACE Calls and perform clinical reviews 4. Complete the jobs on your allocated wards ( Clear the boards ) 5. Attend handover
ST GEORGE Pick up pagers from the windowsill on Level 4 common room (Door code CYZ480) Evening handover 2200 at the Level 4 common room Weekend morning handover 0800 at the Level 4 common room Weekday morning handover 0800 in the JMO Common room (Swipe card entry) Team: 2 interns (MWI, SWI), 2 x RMOs, MOIC, Surg Reg, CERS Nurse
SUTHERLAND Pick up the pager from switchboard at the hospital main entrance Evening handover in the JMO Common Room at 2200 Weekend Morning handover in JMO Common Room at 0800 Weekday Morning handover 0800 in the Handover Room (next to Southern Heart Clinic)
HANDOVER PACE calls Patients that you are concerned about Any reviews, repeat bloods, scans you want chased Give name, MRN and location, try to have short history and relevant meds
BLOOD TESTS You are responsible for checking the result of any tests you order/ take Handover pending results Can label as urgent or life threatening About 1 hour turnaround for urgent basic bloods Don t venepuncture on the same side as infusion
PURPLE TOP FBC BLUE TOP Coags: INR, APTT
GOLD TOP (serum) UEC CMP LFT Troponin Serology
PINK TOP Group and hold Crossmatch Hand written label (no stickers) Co-sign order form Time and date on tube and form must match
BLOOD CULTURES Temp 38.0 and above +/- Septic screen (urine, CXR, swabs) +/- Start or change antibiotics +/- Sepsis notification Peripheral cultures + lines (if applicable) If >3 sets taken, once/24hrs thereafter Look for instructions from the team
CANNULAS (?CANNULAE) 20g (pink) and 22g (blue) usually sufficient on wards May need 18g (green) CF if for CT with contrast Do not put off re-sites these must be done at 72hrs At least 2 attempts Out of hours IV access referral: 1. RMO or CERS 2. HDU (with ultrasound) 3. Anaesthetics
IV FLUIDS Indication Dehydration Maintenance Electrolyte disturbance Look at patient s fluid status and obs Renal function and electrolytes Intake (diet) and losses Caution in CCF, severe AS, ESRF, Geris No Saline in Cirrhosis
IV FLUIDS CONT Rate Bolus: 500mL stat, 1L q1h Fast: 1L q4-6h Maintenance: 1L q8-10h Slow: 1L q12h TKVO: 40mL/hr or less CHART 24 HOURS OF FLUIDS if you are the team CHART UNTIL NEXT MORNING if you are after hours
ELECTROLYTES ORAL INTRAVENOUS K+ Slow K (8mmol) Chlorvescent (14 mmol) Potassium Chloride 10mmol/100mL NS mini bag 30mmol/1000mL NS Potassium Dihydrogen Phosphate Mg Magmin Magnesium Sulfate 10mmol/100mL NS mini bag PO4 Sandoz Phosphate Ca++ Caltrate Potassium Dihydrogen Phosphate Sodium Dihydrogen Phosphate Calcium Chloride Calcium Gluconate
ANALGESIA Paracetamol, Ibuprofen Endone, Oxycontin, Targin Morphine PO or SC (not IV on the wards) Not in renal failure Hydromorphone if egfr <30 PO or SC - doses not equivalent! Anaesthetics available for phone/pca advice if needed (pager 999)
WARFARIN 4pm Look at: MAREVAN vs COUMADIN Indication for warfarin and target INR Current inpatient issues: bleeding, surgery Latest INR
HEPARIN INFUSION Usual APTT target is 45-90 Infusion as per protocol APTT every 6 hours with rate adjustment Once 3 consecutive APTTs are therapeutic, check APTT only once every 24 hours
INSULIN - Chart through to next morning, including the breakfast dose
BLOOD TRANSFUSION Group and Hold Crossmatch Consent IVC Fluid order chart or blood product order chart Rate (max 4hrs/unit) Fluid status r/v
IMAGING OUT OF HOURS Mobile CXR St George: Page #100 (before 8pm) or #1139 (after 8pm) Sutherland: Phone Ext 37644 or *8022 (24 hours) CT CT Brain: Call Radiology if urgent, no approval needed All other CT scans Need Radiologist approval You may be called to give contrast Reporting Sutherland Telerad
SEDATION AND RESTRAINT Sleeping tablets e.g. Temazepam 10mg Contraindications: Risk of delirium, falls, hypoventilation Sedation - discuss with MOIC e.g. Haloperidol 0.25mg 0.5mg PO or IM Restraint - discuss with MOIC
UNEXPECTED DISCHARGES Discharge against medical advice Talk to MOIC Assess capacity Careful documentation Absconded patient Mental Health Act- scheduled patients
DIRECT ADMISSIONS Sent in by specialist, or inter-hospital transfer Write an admission note Including HOPC, PMHx, examination, social Medication chart, fluid orders, etc Blood tests/ivc Investigations Initiate therapy if indicated discuss with team or MOIC
CERTIFYING DEATH 1 Clinical examination Unresponsive Fixed pupils Absent heart sounds, breathing, pulse (2 mins) Documentation Time of death
CERTIFYING DEATH 2 Condolences Offer your condolences to the family Nursing staff will offer bereavement package/ social worker. Notification If unexpected: MOIC will talk to consultant If expected: Evenings- you can call consultant Overnight- wait until morning Team to do the discharge summary and the death/cremation certificate
COMMON CLINICAL REVIEWS Chest pain Other pain Urinary retention Fall Change in mental state SOB Hypo/Hyperglycaemia Hypo/Hypertension Tachycardia
GENERAL TIPS Check your results or hand over to chase Be courteous to nursing staff Wear comfortable shoes Don t forget to eat/ drink/ bathroom Answer your pager promptly 744, 741 = outside call
TIME MANAGEMENT 1. Prioritize sick patients PACE and clinical reviews for sick patients first Routine jobs after that 2. Ward round approach 3. Focused review of patients 4. Efficiency - Set up all your IVCs at once - Get all your charts together and sit down in front of a computer to check results
WHEN TO ASK FOR HELP If you are worried or unsure: ASK SOMEBODY! RMO CERS Nurse MOIC / Surg Reg Always better to ask All PACE calls will be attended by MOIC or Surg Reg
WHEN TO SAY NO Decisions and discussions that should be made by the treating team Will he have an operation? Non-urgent paperwork Patient needs a discharge summary Can you fill out this certificate Non-urgent clinical questions Rash has been present for 4 weeks Pt wants to know his cholesterol Family just wants an update
FOR DAYTIME STAFF. Handover before you leave MOIC +/- JMO for sick patients JMO for routine jobs and results Do your own orders for warfarin, insulin, fluids (24 hours), medication charts Clear your boards before you go Clarify resuscitation status
USEFUL RESOURCES ALS1 or ALS2 course On Call book Online policies and procedures CIAP MIMS or AMH etg Injectable drugs handbook Uptodate, BMJ Best Practice etc
POLICIES AND BUSINESS RULES St George Intranet home page Hospitals/Facilities St George Policies, Procedures and Business rules J for JMO Folder
GOOD LUCK AND BE SAFE! ANY QUESTIONS?