Guidance for new/locum staff starting in the Department of Medicine

Medical wards/staff:
Staples 30 beds level 5
Dr Dent (Cof E) and Drs Moran/Davis (gastro)

Glossop 30 beds level 5
Respiratory (Drs Hands/Moody) and Dr Lewin (Diabetes)

Victoria ward
Cardiology (Drs Gibbs/Roberts) and haematology

MAU 24 beds level 1
Admissions ward – run by Drs Watt/Tawil and the POD (physician of the day)

Alex 20 beds level 1
Rehab ward (Dr Harper)

Acute Stroke Unit level 1
(Dr Dent)

Other wards: occasionally outlier medical patients occur on other wards.

General Philosophy of Care for Medical patients

There are number of principles which help to improve the quality and efficiency of patient management:

1) if you know what to do go ahead and do it but if you do not know what to do, ask. We expect our juniors to make decisions and push on the management of patients. We will support you in making decisions away from consultant ward rounds even if you do not get those decisions perfectly right. It may be reasonable to delay a few questions to the main ward rounds, but most problems should be dealt with promptly to avoid delays in the care of the patient. So if in doubt ask one of the seniors on the firm, or find one of the consultants. If you are out of your depth with a sick patient and your seniors/consultant are not available then ask the oncall senior junior doctor/SpR or POD for help.

2) Our job is not just to diagnose and treat medial conditions, but also to organise the successful early discharge of the patient. This means enquiring about any problem which may require special arrangements for a successful discharge. So think about the social issues and problems of rehabilitation as well as mainstream medical problems. An estimated dated discharge is a useful tool in co-ordinating the different pieces of the jigsaw which need to be put in place in order to get a patient home. Aim to have an estimated date of discharge for the large majority of our patients within a day of their arrival on the ward.

3) Good communication within the ward teams is an essential part of good care. When doing a junior doctor ward round you cannot reasonably expect to have a staff nurse with you. However when you have finished seeing patients in the bay make a point of speaking to the staff nurse in charge of that bay and briefing them about the patients that you have seen, the diagnostic analysis, and the important outstanding problems.

4) Every time you see a patient always look at their TPR chart, other observation charts and the drug chart. Basic physiological data will help you identify patients who may be starting to deteriorate. The drug chart should be reviewed with a view to altering treatment (eg changing iv antibiotics to po) and avoiding drug errors.

Role of doctors on MAU

Most new and locum Drs will cover the MAU. MAU is a very busy ward where not only are there admissions and discharges but also multiple tests requested and procedures performed. To work well it requires efficiency and organisation. Everything on MAU should be done as quickly and efficiently as possible to ensure quick discharges and transfers to other wards.

Staff
– 6 F1s – usually 3 on an average day but can be 2 or 4
– 2 junior doctors (equivalents) – quite a lot of the time there will be only 1
– SpRs – acute medicine SpR is on MAU on Wed/Thurs (unless nights etc). The rest of the week depends on their on call days but there is also an ST2 on call on the days with no SpR who will come and help if busy.
– POD (physician of the day)

The junior doctor is the 502 bleep holder and takes referrals and coordinates the take. It is a team effort with everyone doing ward jobs and seeing patients. If it is busy and you are struggling let the SpR or Consultant know. They can co-opt other juniors into the ward to help.

Acute admissions
Admissions should be seen by the F1’s or junior doctor.
Where reasonably possible all F1 admissions should be reviewed by a more senior doctor .
When writing down the medications make a note of the source of the information e.g. repeat prescription. This makes it easier for the pharmacist to check accuracy.
A description of the ECG and CXR must be recorded in the clerking sheet (this may be altered on the PTWR).

Ward rounds

Starts at 08:30 and all the patients admitted by the night team are seen first followed by the rest of the ward (Bay by Bay)
Ward rounds need at least 1 F1 to attend plus 1 junior doctor if available. The F1s can swap during the round especially if they have patients to present.
A job list should be completed on the ward round as it progresses.
As many requests should be filled in during the round as possible (see requests).
During the round the other F1s should be completing TTAs as they are needed (see TTAs) and performing other tasks as they are requested. This requires constant communication between the ‘round F1’ and the other F1s to avoid duplication of tasks and missing important tasks.
At the end of the round the job list should be up to date. A brief meeting to make sure everyone knows what they are doing is important.

Documentation
All entries in the notes should be timed and dated. Signatures should be legible or should be followed by printed surname.
PTWR should be countersigned by the consultant (and amended as appropriate)
In the PTWR section there should be clearly documented:
Working diagnosis
Plan (including tests)
Any changes to medication should be documented and reasons stated
Outcome (3 options – discharge, stay overnight on MAU, admit to medical ward with ward specified if appropriate)
Challenge the consultant if you are not clear on any of these points – they don’t bite!!

Requests
Once it has been decided that a test needs doing then this should be recorded on the job list and in the notes using the ‘box method’ (unfilled, half-filled, filled)
All requests (unless urgent which may need discussion) should be attached to the clip behind the ward clerk and will be taken to the relevant departments by the porter
CT:
Do not discuss with radiology unless urgent
If you have requested a CT it is your responsibility to make sure it happens. Liaise with the coordinator. If CT hasn’t contacted the ward by 1pm ring to find out if it is happening.
Cardio-respiratory:
ETT can often be done before discharge so it is worth ringing them to check availability
If a test is to be done as an outpatient it is vital to make sure that the request has been sent, establish who is going to get the result (GP or consultant) and make sure that this is recorded in the Discharge Summary
Remember that results need chasing during the day so appropriate plans can be put in place.
If a patient moves off MAU after a test is done but before the result is available this must be discussed with the receiving team (see handover)

Consultant Referrals
All referrals to other specialities or medical consultants should be discussed with the SpR or Physician of the day
A written referral should be done for all patients and the blue copy stuck in the notes. The white copy goes on the ‘requests clip’.
If a patient is unwell the Physician of the Day or the SpR may ring the relevant consultant for early review
Cardiology referrals:
There is a cardiologist of the week. All cardiology referral should be put on the cardiology clip on MAU and not sent to CCU. When Dr. Gibbs is on then phone him about 12.30-1pm (unless he has already been) to let him know the number and nature of the referrals. Dr Roberts is happy to just turn up ~1pm to pick up any referrals present (although is happy to be phoned if necessary)

Discharge Summaries
The gold standard is that everyone is handed their discharge summary on leaving the hospital
If someone is due to go home the next day, do the summary the day before – plan ahead
All discharge summaries must be done within 24 hours of discharge including patients who have died or being transferred to other hospitals.

TTA’s – there are 3 options:
1) Normal discharge summary with drugs attached
2) For simple TTAs such as antibiotics or pain relief there are some TTA packs that the ward pharmacist can issue during the day or nurses out of hours – let the pharmacist know about these patients
3) For simple discharges not available in the TTA packs then it is possible to write an outpatient prescription (locked in CD cupboard). The patient has to be mobile enough to go to pharmacy themselves. Write “MAU patient” on the top and stick the pink copy in the notes so it is clear what has been written. Get all scripts checked with pharmacist (or consultant/SpR if not available)

Follow-up appointments
If a patient is known to a consultant and an existing appointment just needs to be brought forward then get the ward clerk to do this and record time of new appointment on the discharge summary
If it is a new referral then fill in a consultant referral form and send to relevant secretary. The consultant will then prioritise the outpatient appointment. Again record this action on the discharge summary
Do not write appointment booked ‘yes’ on the discharge summary if it hasn’t been done as this can lead to serious clinical incidents

Death of a patient

Please go to the bereavement office promptly to complete the death certificate. There is guidance available there on death certification. If in doubt, discuss with a senior member of the firm. We may need to report the death to the coroner or wish to ask for a hospital post-mortem. Another vitally important courtesy is that a member of the firm should ring the health centre on the next working day to inform the GP about the clinical events surrounding the death. A prompt discharge summary is a back up to this.

Last updated: October 3, 2017