Standard of Care for MTC inpatients The following document is intended to summarise the model of care for patients admitted under the care of the Leeds Major Trauma System. It will outline expected duties and responsibilities of the MTC on-call consultant teams delivering this care. It is important that the team/s working within the MTC familiarise themselves with this in order to ensure optimal utilisation of resources, time and personnel. Basic Principles: MTC inpatient care is run on model of shared MTC consultant responsibility MTC outpatient care is run on a model of a single MTC consultant responsibility Consultant led Daily Discussion and / or Review of all patients under the MTC service responsibility 1) The admitting MTC Consultant on call, on the day that the patient comes in, retains over-arching responsibility for that patient, and formulation of an overall management plan unless care is formally transferred (Consultant to Consultant agreement), or the patient has had surgical treatment under a different MTC Consultant, who agrees to take over (this should be clearly stated to the patient notes or operation sheet). 2) The transfer of responsibility should be clearly documented in the notes and conveyed to the team during the handover meeting. 3) Subsequently, the change of named MTC Consultant responsible for the patient should be reflected to the patient s administration system (notes, PAS, MTC ward Board, MTC ward handover sheets, etc.). 4) Day to day management decisions will be made via the MTC handover / MDT meeting and daily MDT ward round lead by the MTC consultant on call for that day. 5) The MTC consultant/s making these decisions will clearly be responsible for them. 6) Where there is a significant change in the clinical situation or there is proposed significant deviation from the initial management plan this is to be discussed and agreed with the MTC consultant with overall responsibility - this will be the responsibility of the MTC team on call that day. In case of inability to communicate, discuss the proposed changes of plan and reach a consensus, the on call MTC consultant should consider taking over the responsibility and care for this specific patient. Page 1 of 6
7) Where there is a divergence of opinion regarding on-going patient management the final decision will rest with the MTC consultant having the overall responsibility 8) Where a patient is stepped down from the MTC ward to a general trauma and orthopaedic ward (discharged from MTC care), the MTC consultant with overall responsibility will take full responsibility for the patient s care from that point onwards. 9) Where the patient is transferred elsewhere and discharged from the MTC ward round (step down to T&O bed base, or to another Department of LTHT, or a different hospital - TU) the MTC consultant providing follow up for the patient s orthopaedic injuries (either the initial admitting MTC consultant, or MTC consultant that has assumed responsibility following a surgical procedure, or for any other reason), will be responsible for that point onwards. 10) It is vital that when the patient is stepped down the MTC consultant who will be taking responsibility is contacted to inform them of this fact - this is the responsibility of the MTC consultant on call and the MTC team on-call on the day of transfer. (Preferred method would be an email or direct contact over the phone). 11) Where the MTC consultant assuming responsibility is on leave this should not occur and the patient either should remain under the care of the MTC ward round or the responsibility be temporarily assumed by the MTC on call consultant of that day. Clinical Duties of the MTC Consultant on Call A. HANDOVER BOARD ROUND MEETING 1) The post on call and the on call MTC consultant will attend the orthopaedic trauma meeting at 08:00 to receive hand over from the orthopaedic on call team. All new admissions will be discussed in this meeting and their imaging and overall management strategy discussed. 2) At 08:45 the post on call and the on call MTC consultant will lead an MTC board round / handover meeting on the MTC ward. This will transfer the immediate responsibility for this cohort of patients to the MTC and Vascular on call consultants of that day. 3) The MTC board round will be attended by; - The 2 MTC consultants Page 2 of 6
- The Vascular consultant on call for trauma - The senior nurse in charge on the MTC ward - The ward ANP and / or trust doctor - The MTC case manager - MTC physiotherapy - MTC occupational therapy - MTC ward pharmacist 4) Every patient under the care of the major trauma service will be discussed, this will include; - All patients on ward 22 (MTC ward) - All MTC patients on critical care (ICU / HDU) - Any outlying patients not stepped down to another service (not yet discharged from MTC ward round) - Any paediatric patients under the care of the MTC team - Patients discharged / stepped down on the previous day 5) On-going management of each patient should be discussed, this should include; - Clinical progress and any significant events - The patients injuries and overall management strategy - Discharge and step down planning - Repatriation processes 6) Patients who require review by other specialties including Vascular Surgery should be identified at this point and it should be ensured that a plan is in place for this to occur. 7) Patients that need to have an acute review, out of the specific order of the rest of the ward round (deterioration overnight, new admissions, stepped down from critical care bed base, etc.) will be also identified at this point and it should be ensured that an acute review will take place. B. MTC WARD ROUND On week days a consultant delivered ward round (MTC on call consultant of the day) will be carried out visiting every patient under the care of the major trauma service. An outline of ward round structure is suggested below. The multidisciplinary ward round will be attended by; Page 3 of 6
- The MTC T&O consultant on call - The MTC case manager - A senior member of ward staff - Physiotherapy - Occupational therapy - MTC core trainee doctor and / or advanced nurse practitioner - The Vascular consultant on call for trauma in relevant patients identified at the board round On weekends, due to time limitations (initiation of MTC list at 10:00 under the MTC on call consultant), all patients requiring review by the MTC on call consultant should be specifically identified at the board round / handover meeting. These patients should include always: - New admissions - Patients that have stepped down to L22 from Critical Care bed base over the last 24hrs - Patients at the Critical Care bed base - Patients that are reported as deteriorating overall state during the board round. Following the review of these priority patients and if time allows the MTC consultant on call or more likely the ANP or CT doctor will lead and complete a normal ward round to the rest of the MTC patients (L22, outliers). If any problems arise during this complete ward round the doctor or ANP leading should engage promptly the on call MTC consultant and/or other members of the on call team of the day as appropriate. A suggested standardised ward round format is detailed in a separate document (standardised ward round template). This is to address local and national guidelines regarding standards of inpatient care and note keeping and to ensure that important clinical and logistic issues are not missed. This template includes the following; 1) Review of observation chart and current physiology 2) Review of MRSA/VTE prophylaxis and documentation 3) Review of drug chart, check that all antibiotic prescriptions are appropriate 4) Check status and appropriateness of any catheters or IV lines 5) Review of patients injuries - check plan is in place and followed for each 6) Review if tertiary survey is completed Page 4 of 6
7) Check status of any traumatic or surgical wounds as appropriate 8) Check blood and other results and respond accordingly 9) For patients awaiting surgery check they are adequately prepared and paperwork complete (consented and marked). 10) Review the patients nutritional status 11) Review and document mobility status as appropriate 12) Review and document discharge and transfer plans and take any steps necessary to facilitate, check follow up plans are in place and appropriate 13) Review follow up plan and make sure that a named consultant of each specialty relevant to the clinical problems of each patient, is engaged and an appointment is booked as appropriate. Whilst it is not necessarily the case that all of these points are reviewed and documented in every patient every day they should be reviewed regularly. If the suggested documentation provided is not used, the team should ensure that they have their own mechanisms for reviewing these points. In order to ensure proper flow of the round it is vital that the team have this information readily available for each patient. Regular auditing of the duration of the Board round as well as the Ward round as well as of quality characteristics of both (take 5 audits of drug charts, tertiary surveys, mobilization plans, repatriation plans, etc) will be performed in order to improve the overall utilization of our resources and effectiveness. C. MTC LIST and SURGICAL PLANNING - Wherever possible the MTC consultant on call should attend the theatre bunker meeting at 16:00; - Prior to this the MTC list for the following day should have been planned with the consultant delivering that list, and this list then communicated to the trauma co-ordinators and theatre team. - The MTC on call consultant should ensure that the lists planned for the following day allow rapid availability of an acute theatre for trauma should the need arise (all lists are not planned to undertake lengthy procedures simultaneously) Page 5 of 6
- The MTC on call consultant may provide advice regarding the current status of theatre lists and planning for the remainder of the day. However it should be remembered that the twilight list remains the responsibility of the general T&O consultant on call and any changes must be communicated to them. D. EVENING WARD ROUND The consultant on call should return to the ward at a point following the bunker meeting (16:00 on weekdays) or the end of his MTC list (on weekends) and review the current status of inpatients with the rest of the MTC on call team. Any patients requiring further input should be identified at this point. It is usually most helpful to do this where possible before the end of the ANPs shift at 20:00. In the near future it is likely to be a national standard of care that new patients are reviewed within 18 hours of admission by a consultant and any patients in critical care are reviewed twice daily. It is therefore aspirational that these patients are seen wherever possible at this point. The MTC consultant will then be available for acute advice / clinical input regarding current and new MTC patients overnight until responsibility is handed to the incoming team the following day. Page 6 of 6