Patient Assessment in ED

• Get a detailed history of presenting complaint
• Your initial history and exam should be brief and focussed
• Get senior assistance immediately if patient has abnormal vital signs
• Time frame = under 20 minutes

• Consider “most likely” and “most serious”
• Commence symptomatic, supportive or specific therapy as indicated

Tailor further history and exam

• Decide the investigations required for rule in/out
• Talk to the ED team leader within 30 min to make sure you are on the right track
• ED team leader should review all interns’ patients at the bedside (remind us!)
• Arrange the investigations
• Then go back to complete any gaps in the full hx and exam.

• Obtain hx whilst cannulating and observing physical signs.
• Documentation whilst waiting on the results of investigations
• Documentation at the bedside using a Workstation on Wheels (WOW)

• Check for results regularly and enquire about delays over 1 hour
• Review the patient regularly
• Chase up inpatient reviews within an hour of referral

Oncology patients often have special or complex needs:

• They are at risk of serious complications
• Neutropenic sepsis requires antibiotics within 30 minutes
• Unfamiliar complications of chemotherapy, radiation or palliative procedures such as stenting need to be considered

  Always contact the patient’s treating oncology team early. However, depending on the nature of the patient’s presenting condition, another admitting team may be appropriate.   NB. There is a separate oncology electronic medical record (known also as ARIA, Varian or med onc manager) with notes from outpatient clinic appointments and useful information about patients' chemotherapy. You should access this record prior to calling the oncology AT or consultant. Access ARIA via Citrix. You will need your stafflink number and password.

• All infants under 12 months require senior review
• Interns must get senior review at the bedside for all patients aged under 16
• RMOs must discuss all patients under 16 with a senior

• Require a structured risk assessment including history, examination, VBG, ECG and paracetamol level.
• Consideration to decontamination and antidotes requires senior/specialist advice.
• Medical personnel should contact POW toxicology service for urgent advice 24/7 via POW switch

(Contact Poisinfo on 131126 for chemical exposures)

Radiology (Imaging) in ED

STOP radiology testing

Pathology testing in ED

STOP pathology testing

• ECGs are performed on the majority of acute patients
• ECGs must be sighted, signed & timed/ dated by an ED registrar or above within 10 minutes of completion
  • It is a requirement of NSW Health that chest pain patients have an ECG taken and reviewed within 10 minutes of arrival in order to detect STEMI requiring PCI
• ECGs may also show other abnormalities
  • Accredited ED registrars (and above) should look for evidence of arrhythmia, toxidromes, electrolyte disturbance and other cardiac or neurological pathology.
  • If a serious abnormality is detected, you should perform an urgent clinical review, even if you have not "picked up" the patient
  • JMOs should also carefully review the ECG in the clinical context

• Correct Patient
• Correct Site
• Correct Procedure

These three Cs must be performed:

• Whenever you order an investigation in eMR
• Whenever you are performing a procedure on a patient
• Whenever you administer medications/treatments to a patient

Blood taken from IVCs has higher rates of haemolysis compared to venepuncture specimens Especially if:

• small cannula (22g or less)
• difficult draw

Haemolysis can delay results and patient care Collect blood gently with a syringe, then use vacutainer transfer device to fill tubes (ask to be shown how to fill a blood gas syringe with the vacutainer Label tubes correctly

• Label at the bedside
• Position label correctly
• Check that labels match request form

  Extra care with Blood Bank specimens

• Zero tolerance policy
• Hand written labels for G&H or X-match tubes are compulsory
• Witness on forms for G&H or X-match is compulsory – best done by the patient

   

• Take on all pedestrians, drivers, cyclists, horse riders involved in an accident on a public road
• Uses a special kit, and is placed in a special secure box for collection by police
• Document the BAL sample number in the patient’s medical record and place the patient’s sticker in the book located at the secure sample box

First think: Do I really need to cannulate this patient?

• Half of IV lines inserted in the emergency department never get used
• Venepuncture is all that is needed for blood tests

Avoid the cubital fossa unless resuscitating via a large bore (14 or 16G) IVC

• start distal: dorsum of hand -> wrist -> forearm
• Use 20G or larger cannula in adults

Adhere to strict aseptic technique—have you done your NNTT module?

• Use the IV starter packs and disposable or single-patient use tourniquet

OH&S

• Clean your hands and wear gloves
• Clean up after yourself – especially sharps or blood

Difficult veins? • No more than 2 attempts, don’t ruin the last vein! • Ask someone more senior to help you • ED senior staff can use ultrasound to place IVCs • Rarely need to ring anaesthetics Secure the cannula carefully • Learn how to use the IV Tegaderm dressing for maximal effectiveness • Consider bandaging or splinting Date the cannula dressing and document insertion site in the notes.