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TotheRMO Thishandbookhasbeendesignedtoactasaquickreferencetoassistyouinyour dailyactivities,particularlyinrelationtoafterhoursandwardcalls.Itisnotmeantto beamedicalcompendium,andifyouareeverunsureaboutanythingalwaysaskyour registrar,theseniornurse,anotherresident,ortheconsultant.Additionallyyouwill finddetailedclinicalinformationaswellaspoliciesandproceduresavailable electronicallyviatheQHwebsite. Itisrecognisedthatthechallengesofworkingintheearlyyearspostgraduationare many.Youareencouragedtoaccessallavailablesupportandtoseekguidancewhen necessary.Neverdeferaskingforhelpduetofearofanycriticismfordoingso.This approachwillcontributetohighqualitypatientcareaswellascontributetothe enhancementofyourownpersonaltraininganddevelopment. Acknowledgements ThishandbookhasbeenadaptedfromanumberofsourcesincludingtheIpswich HospitalInternSurvivalPocketbookwrittenbyDrIanScott,thePrincessAlexandra HospitalHandbook,andanumberofotherfacilitymanuals. Version:2.0 (LastupdatedOctober2011)
ForfeedbackandcorrectionspleaseEmail:ClinEdQ_QMET@health.qld.gov.au

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TABLEOFCONTENTS SectionAEmergencies WhentocallaMET ........................................................................... 3 Pathology:SpecimenCollectionTubeRecognition ......................... 5 MedicalEmergencyFlowcharts ........................................................ 6 SectionBLookingAfterYourself .............................................................. 11 SectionCWardWorkandPreadmissions GeneralDailyWardWork ................................................................. 12 Pathology .......................................................................................... 18 PharmacyPrescribing.................................................................... 20 InfectionControl ............................................................................... 23 PreadmissionClinics ....................................................................... 26 SectionDWardCall DosandDonts................................................................................. 27 WardCall........................................................................................... 27 RingingtheRegistrar........................................................................ 29 ClinicalHandover .............................................................................. 29 SimultaneousCriticalCalls ................................................................ 30 Phoneorders..................................................................................... 30 SBARCommunicationTool ............................................................... 32 InformationforCommonCalls: Referenceforclinicalproblems ....................................................... 33 (CKNeBOOKSOnCall,Marshall&Ruedy,Cadogan1sted)
https://wwwmdconsultcom.cknservices.dotsec.com/books/page.do?eid=4u1.0B9780729538039..X5001 5&isbn=9780729538039&uniqId=2875984952#4u1.0B9780729538039..X50015TOP

Anticoagulation..................................................................... 34 CardiacArrest........................................................................ 34 ChestPain.............................................................................. 35 DripsandPeripheralIVCannulation..................................... 35 Endocrinology ...................................................................... 35 Falls ...................................................................................... 36 HypoglycaemiaseeEndocrinology ................................... 35 HyperglycaemiaseeEndocrinology ................................... 35 MentalHealthBasics ............................................................ 37 SectionEReportingandMedicoLegalRequirements WithholdingandWithdrawingLifeSustainingMeasures ................ 40 InformedConsent ............................................................................. 44 CertifyingandReportingDeath ....................................................... 46 PRIME(ClinicalIncidentManagementSystem)................................ 48 2 QMETRMOHandbook
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WhentocallaMedicalEmergencyTeam(MET)
TheMETprovideanearlyandrapidresponsetoseriouslyillpatientswithlife threateningconditions,ortopatientswhoareatriskofacardiopulmonaryarrest. Thegoalistoidentifyandtreatpatientsatriskofcardiacarrest,unplannedICU admissionorunexpecteddeath.

AMETcallcanbeinitiatedbyanyhospitalstaffmember.

Dial<Insertlocaldata> StateMETcallanddestination

Whentogethelp

Emergencies: Consultaseniorstaffmemberaboutanypatientrequiringmorethannormal wardcare. Acuityofillness,aetiology,comorbidity,responsivenesstointervention, predicteddurationofillnessandinterventionalmonitoringneeddetermine individualpriorityforcriticalcaremanagement. Formoredetailedinformationagoodreferenceis: AnaestheticIntensiveCare1995;23:183186TheMedicalEmergencyTeam,ALee etal CallaMETforallcardiacandrespiratoryarrestsandallconditionslistedbelow: AdultCriteria

ACUTECHANGESIN: AIRWAY

PHYSIOLOGY Threatened Allrespiratoryarrests Respiratoryrate<5 Respiratoryrate>36 Allcardiacarrests Pulserate<40 Pulserage>140 SystolicBloodPressure<90mmHG Suddenfallinlevelofconsciousness (fallinGCSof>=2points) Repeatedorprolongedseizures Anypatientyouareseriouslyworried aboutthatdoesnotfittheabovecriteria 3 QMETRMOHandbook
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BREATHING

CIRCULATION

NEUROLOGY

OTHER

PaediatricCriteria

ACUTECHANGESIN: AIRWAY

PHYSIOLOGY Threatened Allrespiratoryarrests Severerespiratorydistress Hypoxaemia:SpO2<90%inanyamountof oxygen;SpO2<60%inanyamountof oxygen(cyanotichearddisease) Cyanosis Apnoea Tachypnoea: Term3mths>60bpm 412mth>50 14years>40 512years>30 12+years>30 Allcardiacarrests Bradycardia/Tachycardia: Term3mths<100bpm,>180bpm 412mth<100bpm,>180bpm 14years<90bpm,>160bpm 512years<80bpm,>140bpm 12+years<60bpm,>130bpm SystolicBloodPressure Term3mths<50mmHg 412mth<60mmHg 14years<70mmHg 512years<80mmHg 12+years<90mmHg Suddenfallinlevelofconsciousness (fallinGCSof>2points) Repeatedorprolongedseizures Anypatientyouareseriouslyworried aboutthatdoesnotfittheabovecriteria

BREATHING

CIRCULATION

NEUROLOGY

OTHER
Paediatric Crit Care Med 2009 Vol. 10, No. 3p308

TocallaMET:<insertlocaldata> StateMETCALLandthelocationofthepatient

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 LookingAfterYourself Theinternyearisademandingtransitionfromstudenttoprofessional.Manypeople commencingworkinaclinicalsettingfindtheenvironmentandresponsibilities bewilderingandexhausting,andexperienceatypeofcultureshock.Someinterns reactwithfrustration,angerandresentmenttotheorganization;othersfeelunhappy orlosetheirconfidenceandbegintodoubttheirabilities. Theworkyouwillbedoingmayattimesbedistressing.Lookingaftercriticallyunwell anddyingpatientscanbeverychallenging.Youmaysometimesfeelunsupported, especiallyinthesettingofshiftwork,sleepdeprivationandaheavyworkload. Allowseveralmonthstofamiliarizeandsocializeyourselfintothenewwork environment,andaccepttherewillbedisappointmentswhenyouconfrontyour knowledgegapsandrecognizeyourperformanceweaknessesdontbetootoughon yourself.Askforhelpfromyourcolleaguesandknowthatthereisplentyofsupport foryourdifficultnewrole. Itcanbeeasytogivealowprioritytofood,sleep,friendships,breaksfromwork; somepeopledontevenstopatworktodrinkwaterorgotothetoilet.Yourpersonal healthisvitaltoyoursuccessasadoctorandyourhappiness.Carrysnacksandtryto stopeveryfewhoursforabreak.Mostofthestaffyouworkwithwillrespectthese requirements.Veryfewthingscantbedeferredfor15minuteswhileyougrab somethingtoeatanddrink. HavingyourownGPisimportant,bothforyourpreventativehealthandincasesof acuteillness.Youwillneedmedicalcertificatesfromtimetotime,andhavingyour owndoctorratherthanhavingtopresenttoyourownemergencydepartmentisa goodidea!Researchshows2030%ofinternsexperiencedepression.PLEASEseek helpearly. Ifyouhaveaconcernaboutacolleague,orifyoufeelyouarentreallycoping,oryou feelmiserableandwanttotalktosomeone,anumberofoptionsareavailableto you: TalktotheDCTorMEOs(theyarestrongadvocatesforyourwellbeing) ContactDoctorsHealthAdvisoryService(DHAS)aconfidentialservicesupported byRoyalCollegesandAMA,andstaffedbyexperiencedGPssupportedbyapanel ofConsultantswithexpertiseindealingwithmedicalconditionsofcolleagues. DHASisavailable24hoursadaybyphoning(07)38334352. ContactQueenslandHealthEmployeeAssistanceScheme(EAS)PH:1300361008. Theycanassistyouwithinformationaboutconfidential,freeappointmentswitha privatecounselor.

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SectionCWARDWORKandPreadmissions

WorkinginaWard
1.GENERALISSUES Duringtheweekbeforestartinganewterm,organisetomeetwiththeoutgoing internandbebriefedaboutwardroutineregardingyournewunit. Eachunitwillhaveanorientationprocedure;ensureyouobtainacopyoftheunit inductionmanual(preferablypriortocommencement)andareprovidedwithan adequateorientationtotheunit. Onfirstarrivinginyourunitintroduceyourselftothestaffandfamiliariseyourself withtimesforwardrounds,unitandclinicalmeetingsand,ifrelevant,operating sessions.EnsureyoucomprehensivelyunderstandtherolesofAlliedHealthstaff MakeanappointmenttomeetyourTermSupervisorifthishasnotalreadybeen arrangedforyou. Introduceyourselftothenurseinchargeofyourunit.Heorshewillwanttospeak withyouandwillprovideyouwithawealthofinformationandguidanceabout howyoushouldorganiseyourworkwithinthedaytodayfunctioningoftheunit. Understandassoonaspossiblethefunctioningoftheward,itslayoutand equipment,particularlytheresuscitationtrolleyandotheremergencyequipment. Askyourregistrartoshowyouhowtoworkanyequipmentassoonaspossible. Donotassumeyouknow. Askregistrar/nursingstaffaboutanyparticularrequirementsyourconsultants mayhave,eglyingandstandingbloodpressure,syphilisserology,etc. Ensureyouunderstandimportantadministrationprocesses(egifrequiredtotake leaveofabsence;timesheetrequirements) 2.ADMISSIONS Introduceyourselftothepatient(establishrapport),stateyourroleinthehealth team,orientatethepatientalittlemoretotheward/unitifrequired. Takehistoryandperformexamination.Youmayneedtospeaktorelativesor witnessestoconfirmthehistory. Writeupfindingsinchart(blackpen).Alwayssign,date,timeandstamporprint yournamebesideyoursignature. Beconciseandasaccurateaspossibleindocumentingthepatientsclinical details. Documentdifferentialdiagnosisorproblemlist. Lookupanytestresultsavailable. Decidewhatothertestsmaybenecessary;checkconsultantrequirementsor clinicalpathwayifavailable;liaisewithregistrar;resistthetemptationtoover order. Takeorarrangeforbloodtobetakenifindicated. ArrangeorperformanECGifindicated. Organisefurtherinvestigationandliaisewithvariousdepartments/hospitalsand registrarsre:CTScans,nuclearmedicine,endoscopies,etc. Anticipateandbegindischargeplanningfromfirstdayofadmissionensuringyou seekadvicefromrelevantAlliedHealthprofessionals. 12 QMETRMOHandbook
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LiaisewithGP/NursingHome/Hospitaletc.repasthistory,medications,drug allergies(includingreactionstocontrastdye/iodine),andpastfunctionalcapacity. Communicatetothepatient/relativesthenatureoftheproblemandtheexpected durationoftheadmissionwithsensitivity.Ensureyouhavethepatientsconsent todiscusstheirconditionwithrelativesandothers. Inquireastopatientspreviouslevelofindependentfunctioning,socialsupport, andpsychosocialriskfactors. Decideaboutongoingtreatment,iemedications,fluidsandwriteitup. Ensurethattheregistrarknowsabouttheadmission.Iftheregistrarisverybusy ortiredremembertoremindthemofthepatientbeforeyougooffdutyifthey havenotyetseenthepatient. Discusscasewithregistrarbeforeinstigationoftreatment. AnticipatebaselineinvestigationsmorningofarrivalieBaselinebloodtests,CXR, ECGformscanbeleftonwardtobecompletedwithpatientonarrival. 3.ONGOINGPATIENTCARE PATIENTMANAGEMENT Eachdayuponarrivalobtainalistofpatientsinyourunitforthatdayanddiscuss withnursingstaffanychangesinpatientconditions.Enquireaboutpatients reviewedbyafterhourswardcallduetosignificantclinicalissues.Thenprioritise tasks.(seeClinicalHandoversection) Liaisewithalliedhealthstaff. Rememberthat"medical"patientsgetsurgicalproblemsandviceversa. Seeandexamineeachpatientatleastoncedaily,maybemoreifillreport changestoregistrar,andwriteanoteinchart. Dealwithanypatientdifficultiesthatarise,egchestpain,SOB,urineoutput, headache. Dailyreviewofmedicationsandfluids:Ensuremedicationswhichrequirevariable dailydosing(egwarfarin,heparin,insulin)arewrittenupforthenextshift. Explaintopatientandrelativestheirprogressandprocedureresults. Reviewpathologyandradiologyresultsdaily.Donotgohomeunlessyouhave organisedsomeonetochaseupanyoutstandingresultsfortheday. Organisefurtherinvestigationsasneeded.Donotreordersimplebloodtests(eg FBC,LFTs,Urea&Electrolytes/Creatinine)merelytomonitorclinicalconditionif patientisclinicallystable. Collectbloodasnecessaryforurgenttests. DoECGandIVresitesasindicated. CompleteNursingHomeForms,HostelForms,InterimCare. Providedetailofpatientsconditiontowardcallresidentespeciallyifitis considerednecessarytoreviewpatientafterhours.Qualityeffectivehandoveris essentialtoensureinformationissharedandensurespatientsafety.(SeeClinical Handoversection)

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4.WARDROUNDS Prioritiseandorganiseyourtimetodealwithbothpressingclinicalproblemsand yourattendanceatrounds. Comewellpreparedwiththeresultsofkeyinvestigationsandanyother importantinformationaboutyourpatientsincludingdetailprovidedduring handoverfromafterhoursrosteredstaff.(Writingimportantresultsinchartie keyresultswhicharebeingcloselymonitoredorhaveundergonesignificant changeisagoodpractice,butdonotwastetimeenteringallabnormalresultsif theseareinconsequentialtofurthermanagement). Havereadilyavailablethepatientsgeneralclinicalconditionandotherrelevant detailsandbereadytopresenttotheConsultant. Itismostimportantthatstatementsmadebytheconsultantsconcerningtheir patientsduringroundsbeclearlyrecorded.Itissuggestedthattheregistrarenter notesfromthewardroundintotheclinicalrecord.Thispreventsmisinterpretation oftheplanformulatedbytheteam. Thefollowingfacts,atleast,shouldalwaysbeobtainedfromtheconsultant concernedandrecordedinthenotes: Whetherhe/sheagreesordisagreeswiththephysicalsignsassetoutinthe chart His/heropinionconcerningallrelevantinvestigations His/herprovisionaldiagnosis Plannedinvestigationalprocedures Treatmentproposed TheFINALDIAGNOSIS,futuretreatmentandfollowuparrangements. Attempttotakeactionabouttheseimmediatelyaftertheround. Donotunderestimatewardroundsasanopportunitytolearn,andtoimpress. 5.ORGANISATIONOFDISCHARGES Dischargeplanningbeginsfromthetimethepatientisadmittedandisa multidisciplinaryapproachonmostwards.Alwaysreferearlytoalliedhealthstaff(eg OccupationalTherapisthomeenvironmentandequipmentorganisedfordischarge; Physioremobilityandifsafefordischargeetc)sothatdischargeisnotunnecessarily delayed. Assessfitnessfordischargeandconfirmwithregistrar.Theregistrar,inturn,should ensurethattheconsultantresponsibleforthecareofthepatientissimilarlyadvised. Patientsshouldbedischargedasearlyinthedayaspossible,inordertomaximisethe useoftheavailableaccommodationandpreventpatientswaitingforlongperiodsto beadmitted.Ifdischargeisdelayedforwhateverreason,thepatientmaybeableto waitelsewhereratherthancontinuetooccupyabed.Discussthiswiththenursein charge.Notifynursingstaffofdischargeplan&documentclearlyinnotes.Itis unreasonableforhospitalbedstobeoccupiedbypatientsfromcountrycentreswho arewellenoughtotravelhomebypublictransportbutareawaitinganambulance fromthatcentre.Thiscanoftentake23days.Usetaxivouchers(withinreason)or othermeansfordischargingpatientsinexpeditiousfashion.

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Organisedischargemedicationspreferablydaybefore.Preparedischargeletterand aimtogiveacopytopatientorcarerbeforetheyleavetheward.Organise AmbulanceFormdaybeforedischarge(butnotonaFriday)andanycertificates(eg WorkersCompensationorSicknessBenefits).LiaisewithGPparticularlyifpatients conditionunstable.If,foranyreason,dischargehasbeendelayedensuredischarge medicationsandotherdetailinsummaryremainappropriate. Arrangeappropriatefollowupandfurthertests..Ifpathologytestingisrequiredon dayofdischarge,therequestformshouldclearlystatePATIENTforDISCHARGEso thatspecimenscanbecollectedaspriority.ArrangeOutpatientappointmentafter discussionwithregistrar.*NBEachpatientshouldhaveanEstimatedDischargeDate (EDD)thatisrevieweddailyandcommunicatedtobothstaffandthepatient. Therefore,dischargesandmedicationsshouldbeorganisedthedaybeforedischarge. 6.ORGANISATIONOFTRANSFERS EnsureyouarefamiliarwithHospitalproceduresBEFOREcommittingtoormaking arrangementsfortransferofpatientstoorfromotherfacilities,orforurgent consultationswithexternalSpecialists.Ensureallrelevantdetails,including medicationsprescribed,resultsofinvestigations,areprovidedanddetailed informationdocumentedinthemedicalrecord. 7.COMMUNICATINGWITHRELATIVES Ifyoudontknowtheanswer,saythatyoudontknowandadviseyouwillfindoutif possible.Doctorsaretomakethemselvesregularlyavailableforrelativeinterviews. Everyeffortshouldbemadetoassistbothpatientsandrelativesduringthepatients stayinhospital.Itisalwaysadvisabletobeconservativeindiscussingpatientstatus withfamily. Haveregardtothewishesofthepatientand/orlegalhealthattorneyinprovisionof detailsofdiagnosis,treatmentplansetc.Familiariseyourselfwithprovisionsin legislationineventofdiagnosisofnotifiabledisease. 8.DETERIORATIONOFPATIENTSCONDITION Whereapatientisdiagnosedasbeingdangerouslyill,theRMOorregistrarshould notifytherelativesofthisstatusassoonaspossibleandmeetwiththemtodiscuss prognosis.Includeseniornursingstaffinyourcommunications.Amajordeterioration inapatientsconditionshouldalwaysbecommunicatedtotheregistrarimmediately andtheconsultantnotified. 9.ORGANISATIONOFCONSULTATIONS ItisgenerallytheRMOsresponsibilitytoorganiseanyconsultationswhichhavebeen requested.Differentprotocolsarefollowedaccordingtowhomtheconsultationis directed.Unlessotherwiseadvised,requestsforconsultationsfromanyother specialistsshouldbehandedtotheregistrarallocatedtotheSpecialist.Ensure consultingregistrarisgivenaccuratehistoryofpatientspresentation,resultsof investigations,responsetotreatmenttodate,whatisbeingrequestedandwhy. 15 QMETRMOHandbook
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10.PRIVATE(INTERMEDIATE)PATIENTS ThecareofIntermediateorPrivatePatientsistheresponsibilityoftheConsultantin chargeofthecase.Theconsultantornursingstaffwilladviseyouiftheconsultant wishesyoutoseehis/herpatients.RMOsarerequiredtoprovidethesamecalibreof careasgiventopublicpatients.Inanemergency,theRMOshouldprovidethebest carepossibletothepatientandcontinuetomanagethecaseuntiltheconsultant concernedisabletoreachtheHospital,orthecareistakenoverbyanother Consultant(egIntensivist). RMOswillnotacceptnorshouldtheyaskforanypaymentofanykindfortreatment providedtoaprivatepatient.Failuretoadheretothisrequirementwillrenderthe officerpersonallyliableforanydamagesintheeventofanynegligenceorother claimsandmayresultindisciplinaryaction. 11.PATIENTSFROMVARIOUSCULTURALBACKGROUNDS Planaheadforpatientswhomayrequirelanguageassistance;interpretersfrom externalorinhousesourcesshouldbebookedinadvance.Avoidusingpatient's relativesandfriendsasinterpretersbecausetheymighthavelimitedEnglishskillsand medicalknowledge,andlittleunderstandingofconfidentialityrequirements.Be awareofresourcessuchasIndigenousLiaisonOfficersthatexistforAboriginaland TorresStraitIslanderstaffandpatients. 12.SUGGESTEDDAILYORGANISATION Organisegeneraldayinroughlythisorder: 1. Printoutalistofyourpatientsfortheday. 2. Ensurerequestforms,etc.aredoneearly(preferablythenightbefore). 3. Askthenamesofpatientswhoaresickseethesepeoplefirst(ifpossible,with theregistrar). 4. Seetheovernightadmissionsnextandensureinvestigations,etc.areorganised. 5. Ensureyouhavenotforgottenyouroutliers. 6. Seetherestofyourpatients. 7. Routineadmissions. 8. Checkresultsfrommorning(andprevious)investigationsordered. 9. Planandorganisedischarges(medications,letters,ambulancebookings,etc.)the daybeforepreferably.(KnowwhenPharmacycloses). 10. Ifyouhaveanearlywardround,seethesickpatientsandcheckresultsofrelevant investigationspriortotheround. 11. Beforeyouleaveforthedaymakesurethatmedicationchartsareupdatedto avoidwardcallresidentsfrombeingaskedtorewriteexpiredmedicationentries orenterdosesforwarfarinandinsulinorders(whichmakesthemverygrumpy). Thisalsoappliestoanyroutinepathologythatneedstobewrittenupforthenext day. 12. Beforeleavingthehospitalmakecontactwiththewardcallresidenttohandover detailsofpatientsyouconsiderwillneedreviewwithinthenextfewhours.

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13.PROFESSIONALDEVELOPMENT Lookfor,andbepreparedtoreflecton,constructivefeedbackonyour performancegiventoyoufromtheconsultantandregistrar. Demonstratethatyouareavalueaddingmemberoftheteambybeing enthusiasticanddiligentinyourwork,takinginitiativeandmakingthemostofall learningopportunities. Contributetoimprovingsafetyandqualityofcarebyofferingfeasiblesuggestions onhowworkpracticesandsystemsofcarecouldbeenhanced. Lowertheriskofharmbeingdonetopatientsbyregularlycheckingtheactionsof bothyourselfandthoseofyourcolleaguesandbeingpreparedtoopenlyadmit whenerrorhasoccurredsothatwemayalllearnfromit. Bepreparedtoassistyourinterncolleaguesintimesofneedieiftheirworkload significantlyexceedsyours,offertolendahand.

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Pathology
Formedin1997,PathologyQueenslandconsistsof33laboratoriesbasedatpublic hospitalsthroughoutthestate.PathologyQueenslandisadivisionofClinicaland StatewideServices(CaSS),andhasapproximately1500staffcomprisingconsultant pathologists,scientists,technicians,operationalandadministrativestaff.
Pathology Resource Page

ThePathologyQueenslandicon(maroonandwhitehelix)isavailableonmanyPCs acrosstheState. Alternatelyaccesshttp://qheps.health.qld.gov.au/pathology/home.htm Resourcesavailableviathislink: Pathologytestlist,whichincludes o Availabletestsandtestsearchfunction o Collectionrequirementsandtubetypes/colours o Transportrequirements o Turnaroundtimes o Laboratorycontacts Patientcollectionsheets RequestformsforpublicandMedicareeligible,andruralandremotepatients Publicpathologypriceschedule Informationaboutourlaboratories Researchandclinicaltrialsinformation ISTATonlinetestingmodule, LinktoClinicalandStatewideServices(CaSS)pages,and AdditionallinkstoAUSLAB,AUSCAREandGPConnectresourcepages BloodTubeRecognitionChart Seepage3. SpecimenCollectionRequirements Eachsampletobetestedmustcarryadequateidentificationofthepersonfromwhomit wascollected. Allspecimensandrequestformsmusthaveminimumtwopointsofidentification;ie either FullName(surnameandgivenname)andURNumber(twopoints) or FullName(surnameandgivenname)andDateofBirth(twopoints) Inaddition,transfusionsamplesmusthavethesignatureoridentifiableinitialsofthe collectingofficeronthesampleandthedate/timeofcollection.Ifthesampledoesnot havethedateandtimeofcollection,butissignedandallotherdetailsarecorrectand thereisadateandtimeontherequestform,thetransfusionsamplewillbeacceptedfor testing.Wherepriorapprovalhasbeennegotiated,HBCISorsimilarlabelsare acceptableforspecimenidentificationprovidedthatthelabelissignedbythecollecting officer. 18 QMETRMOHandbook
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Dependingonthetypeofspecimen,thefollowinginformationmayalsoberequiredfor correctidentificationofthespecimen: Ward/Hospital/Clinic SpecimenType(AnatomicalPathology&MicrobiologySpecimens) SpecimenSiteofOrigin(whereappropriate) SpecimensthatarenotlabelledwithfullnameandDOB,orfullnameandURNumberof thepatientareconsideredinadequatelylabelled.ThelaboratorywillissueaNOTEST notificationviatheAUSLABlaboratoryinformationsystem,advisingtheclinicianthat testingwasnotperformed. RequestFormRequirements Allspecimensaretobeaccompaniedbyarequestformsignedbythecollecting officerintheallcollectorsmustcompletesectionand/orthepersonwhosupervised thecollectioninthecaseofpatientcollectedspecimens.Forunsupervisedpatient collections(eg24hoururinecollections),thestaffmemberacceptingthespecimenis responsibleforcheckingthedetailswiththepatientandsigningthecollectors section. Therequestformisalegaldocumentthatmustbecompletedtoconfirmthatthe collectingofficerhasidentifiedthepatientandthatthespecimenisfromthepatientin question. Requestformsmustinclude: Fullpatientdetails(asperspecimenlabellingrequirements) Ward/patientlocation Detailsofrequestingclinician,includingsignatureandprovidernumber(ifyouhave one) Testsrequiredfulltestnamesarepreferable Collectordetails Collectiondetails,ietimeanddateofcollection Relevantclinicalnotes Incorrectlyorinadequatelycompletedrequestformsmayberejectedbythelaboratory. AccesstoPathologyResults ThelinktoAUSLABispresentonallPCs.Pathologyresultswillbe availableviaAUSLABonceanalysed.Cliniciansrequireaccesstoview Auslab.lnk results. LinktoAUSLABinformationandaccessforms: http://qheps.health.qld.gov.au/liss/auslab/auslab_forms.htm AUSCARE,thewebbrowserresultsreviewapplicationforAUSLAB,is availableatselectedsites.ContactLaboratoryInformationSystemsand Solutions(LISS)on0730009333,orvisit http://qheps.health.qld.gov.au/liss/auscare/home.htmformore informationaboutAUSCARE. 19 QMETRMOHandbook
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PrescriptionWriting
Doctors may only prescribe drugs available on the Queensland Hospitals List of Approved Medicines (LAM), an electronic copy of which is available on QHEPS http://www.health.qld.gov.au/qhcss/mapsu/sdl.asp. When an individual patient requires the use of a drug not on the standard List of Approved Medicines advice must be soughtfromthelocalDirectorofMedicalServicespriortoprescribing. All QH Hospitalseither haveintroduced,or are in the process of implementing,the Pharmaceutical Benefit Scheme (PBS). Patients can now receive up to one month's supplyofmedicinesfromthehospitalondischarge. AlllegalaspectsofdrugmanagementaregovernedbytheHealth(Drugs&Poisons) Regulations1996. InpatientMedicationorderingbasicrequirements: SeeQHmedicationchartguidelines http://qis.health.qld.gov.au/DocumentManagement/Default.aspx?DocumentID=26669 Theprescribermustensurethatallofthefollowingoccur: Doctorsownhandwriting.(Pharmacistsmayalsowriteoutthedrugorderand obtaindoctorsauthorisation) Thefirstprescribermustprintthepatient'snameunderthelabeltoverifythat boththeIDlabelandthemedicationordersrelatetothecorrectpatient Instructionsmustbelegible. Useofapprovedabbreviationsonly.See: http://qheps.health.qld.gov.au/medicines/documents/general_policies/abbreviati ons.pdf Dateofprescriptionclearlyindicated. Useofblack,nonwatersolubleinkispreferred;Eg,fountainpenisnottobe used. Usegenericdrugnameswithlocalexceptionsallowed. AdverseDrugReactionsectionMUSTbecompletedbythedoctorasnursingstaff willnotadministeranyoftheprescribedmedicationsuntilthisisdone. Administrationtimesmustbecompletedbytheprescribingdoctor. Toalteraprescription,cancelitandrewriteit. Allmedicationsthepatientisonpriortoadmissiontohospitalarerecordedon themedicationactionplan(MAP) or,ifthisisnotavailableonthefrontofthe medicationchart forreferencepurposes.(Redsectionatbottomofpage).This doesnotconstituteanorderforthesemedications. Dischargeandoutpatientprescriptionscontainingcontrolleddrugsmustprovide: Theprescribersname,professionalqualificationsandaddress. Thedateitiswritten. Thenameandaddressofthepatientforwhomitisprescribed. Thepatientsdateofbirth Adescriptionofthecontrolleddrugorthenameofthepreparationandthe quantityorvolume(inwordsandfigures)ofthedrugorpreparation. 20 QMETRMOHandbook
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RationalDrugPrescribingTengeneralprinciples: 1. Istheproposedmedicationnecessary?Whatisthefinancialcost?Whatarethe benefitsversustherisksinvolvedandwhatarethealternatives? 2. Knowthecharacteristicsofabsorption,distribution,metabolismandelimination ofthedrugtobeprescribed,giventheconditionsofthepatientsageandknowor possiblecomorbidities. 3. Determinethecorrectdrugdose,formanddosageinterval,takinginto considerationthepresenceofanyrelevantdiseasestateand/oradministration difficulties. 4. Consideranylikelydrugdruginteractions. 5. Beawareofthecommonadversedrugreactions(ADRs)forthedrugprescribed.If relevant,determinetheuncommonreactionsaswell.Ifthepatientisadmittedor hasasuspectedADRwhilstinhospital,theseshouldbereportedontheADRAC blueformandsenttopharmacy. 6. HasthepatienthadapreviousADRtothedrugconcerned,orhadanyother relatedsideeffects?Ifso,recordthedetailsoftheADRonthefrontofthedrug chart.Ifnot,ticktheboxmarkedNilKnown. 7. Informthepatientaboutthetreatmentproposed.Specifically,warnaboutany commonanddangerousadversedrugeffectsordruginteractions. 8. Medicationchartsmustbewrittenlegiblyinink.Ensureotherscanfully understandwhatyouhavewritten,andensurethatthedoseandtimingof administrationareenteredontheprescription.CheckthedosesinsuchasMIMS ifunsure. 9. Allmedicationsshouldbereviewedregularlytoidentifypotentialdrug interactionsanddrugswhichmaybediscontinuedifnolongerrequired.When ceasingdrugs,putaclearlinethroughtheactualorderandtheadministration section.WriteCeaseandsignanddatetheform.Ideally,thereasonforceasing shouldbeadded. 10. Ondischargefromhospital,fullyinformthepatientaboutthemedications prescribed.Inparticular,trytodiscusstheneedforadherenceandthe consequencesofnonadherence,warnaboutanylikelydrugeffectsondrivingor useofmachinery,andspecifydurationoftreatment.Ifthepatientisonlongterm medication,theymustbeinformedthattheyneedtoobtainfurthersuppliesonce thehospitalsupplyhasrunout.Inmostcases,theirGPcanwriterepeat prescriptions.Specifically,informthecliniciantakingoverthepatientscareabout thepatientsdischargemedications.

Nomorethanonedrugrequest(ietheprescriptionmayhavemultiplestrengths ofmorphineoroxycodone,butnotmorphineandoxycodoneonthesame prescription). Specificdirectionsabouttheuseofthedrug.Suchasasdirectedisnot acceptable. Thedosetobetakenoradministered.

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AntibioticUse Toensurethatantibioticsareprescribedappropriately,alwaysconsiderthefollowing 11principlesbeforeselectingaspecificantibiotic: 1. Ensureantibioticuseisindicatedonthebasisofclinicalfindings(treatthepatient, notthetest). 2. Appropriatemicrobiologicalspecimensshouldbeobtainedbeforecommencing theantibiotic.Egbloodcultures,sputumculture,microurine,etc 3. Ifavailable,checkpriormicrobiologyandsusceptibilityresultssothattheright drugischosen. 4. Wherethereisuncertaintyregardingthechoiceofdrug,checkTherapeutic Guidelines:Antibiotic,availableontheCliniciansKnowledgeNetwork. 5. Asmuchaspossible,antibioticsshouldbegivensingularlybutoccasionally, combinationsareindicated.Thesewouldinclude:broadspectrumcoverrequired inseveresepsisofunclearaetiology,especiallythefebrileneutropaenicpatient; polymicrobialinfection,egintraabdominalsepsisorpelvicabscess;andwhere thereisaneedtolimitorpreventtheemergenceofresistantorganisms,eg tuberculosis. 6. Ensurethatthepatientisnotallergictothechosendrug;takecareaboutclass specificallergyegPenicillinallergymeansthatdrugssuchasflucloxacillin, timentin,augmentinandamoxycillinarecontraindicated. 7. Considerspecialfactorsrelatedtothepatient,particularlypregnancyand lactation,renalinsufficiencyandhepaticinsufficiency. 8. Choosethebestrouteofadministration.Intravenousadministrationshould alwaysbeusedinitiallyinseriousinfections 9. Planthedurationofthecourseofantibioticswheninitiatingtreatmentand indicatethisonthedrugchart. 10. Ensurethatinitialtherapyismodifiedoncecultureresultsbecomeavailable. 11. Changefromintravenoustooralantibioticassoonaspracticable. SurgicalAntibioticProphylaxis ThechoiceofsurgicalantibioticprophylaxisshouldfollowtheAntibioticGuidelines unlessinstructedbyInfectionControl.ThisisimportantbecauseitisoneoftheHQCC Standardstoaudittheproportionofprincipalsurgicalproceduresthepatient receivedantibioticprophylaxisinlinewiththeprinciplesofTherapeuticGuidelines AntibioticExpertGroup,ProphylaxisSurgicalAntibioticGuidelines13thedition. Prophylaxisshouldbeconsideredwherethereissignificantriskofinfection(eg colonicresection)orwherepostoperativeinfectionwouldhavesevereconsequences (eginfectionassociatedwithaprostheticimplant).Antibioticprophylaxiscannotbe reliedupontoovercomeexcessivesoiling,damagedtissues,inadequatedebridement, orpoorsurgicaltechnique.Itisnotnecessarytoincludeantibioticsthatareactive againsteverypotentialpathogen,onlyantibioticsdirectedagainstthelikely pathogen.InfectionControlwilltakeintoaccountorganismscausinginfectionswithin theinstitutionandtheirpatternsofsusceptibility.

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InfectionControl
Effectiveinfectionpreventionandcontroliscentraltoprovidinghighquality healthcareforpatientsandasafeworkingenvironmentforthosethatworkin healthcaresettings. StandardPrecautions Useappropriatepersonalprotectiveequipmenttoprovideabarriertocontact withblood,bodyfluids,nonintactskinormucousmembranes Ensureyouarefullyimmunised Useaseptictechniquetoreducepatient/clientexposuretomicroorganisms Managesharps,bloodspills,linen,andwastetomaintainasafeenvironment Ensureregularroutineenvironmentalcleaning Handhygiene ImmunisationofHealthcareWorkers Itisrecommendedthatallhealthcareworkersknowtheirvaccinationstatusforthe followingcommunicablediseases: measles,mumps,rubella hepatitisB(mandatoryforQueenslandHealthshealthcareworkers) hepatitisA varicellazostervirus(chickenpox) influenza pertussis Formoreinformation: http://www.health.qld.gov.au/chrisp/policy_framework/framework.asp). HandHygiene Handhygienemustbeperformed: beforetouchingapatient beforeperformingaprocedure afteraprocedureorbodyfluidexposurerisk aftertouchingapatient,and aftertouchingapatient'ssurroundings. Foradditionalinformation,pleaserefertotheQueenslandHealthProtocol1:Hand Hygiene(availablehttp://www.health.qld.gov.au/qhpolicy/docs/ptl/qh-ptl-321-1-1.pdf). Themethodofhandhygieneisdisplayedbelow:

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SharpsManagement Occupationalexposurestobloodbornepathogensfromneedlestickandothersharps injuriesareasignificantbutpreventableproblem.Injuriesfromneedlesandother sharpdevicescarrythegreatestriskoftransmissionofabloodbornevirus(hepatitis BandCandHIV).Handlinganddisposalofsharpsmustbedonewithcareatalltimes. Sharpsshouldnotberesheathedormanipulatedbyhand,andmustbedisposedof immediatelyintoanappropriatereceptacleatthepointofgenerationbytheperson responsibleforitsgeneration. Formoreinformation: http://www.health.qld.gov.au/chrisp/policy_framework/framework.asp Transmissionbasedprecautions Transmissionbasedprecautionsareusedforpatientsknownorsuspectedtobe infectedorcolonisedwithepidemiologicallyimportantorhighlytransmissible pathogensthatcancauseinfection: byairbornetransmission(egTB,measlesvirus,chickenpoxvirus); bydroplettransmission(egmumps,rubella,pertussis,influenza); bydirectorindirectcontact(egcolonisationwithESBL,VREandMRSA),orwith contaminatedsurfaces,environmentorequipment;orbyanycombinationof theseroutes. Transmissionbasedprecautionsareappliedinadditiontostandardprecautions.In acutecaresettings,thiswillinvolveacombinationofthefollowing: appropriateuseofpersonalprotectiveequipment(PPE) patientdedicatedequipment allocationofsingleroomsorcohortingofpatients appropriateairhandlingrequirements enhancedcleaninganddisinfectingofthepatientenvironment FurtherInformation Forfurtherinformationhttp://www.health.qld.gov.au/chrisp/default.asporcontact yourlocalinfectioncontrolunit/practitionerorstaffhealthcoordinator.

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PreadmissionClinics
ThepurposeoftheClinicistodeterminethepatientsfitnessandarrangeappropriate referrals to optimise the health status of the patient in preparation for surgery or procedures. WHATISINVOLVEDWITHPREADMISSION? Patientsarefullypreassessedbyjuniordoctor,anaesthetist,nurseandalliedhealth staffasnecessary.Patientsarefullypreparedfortheirscheduledsurgeryatthisvisit. Medicaladmission,consent,anypreopscreeningtestsandanaestheticassessment areconductedattheseclinics. Consentisobtainedandupdatedasrequired.Thisshoulddoneinconsultationwitha registrarorconsultant,especiallyifyouareuncertainofwhatisactuallyinvolvedin theprocedure.ConsentformsandpatientinformationformscanbefoundonQHEPS: http://www.health.qld.gov.au/consent/Consentremainsvalidfor12months. Ensureappropriatepreandpostoperativeeducationisgiven.

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SECTIONDWARDCALL
SummaryofDos&DontsForWardCall Dos Callamoreexperienceddoctorwhenindoubt.Ifyouwouldseekadviceaboutthe problemduringdaylighthours,thenalwaysdothesameatnight. Listentoseniornursingstaff. PerformanArterialBloodGas(ABG)onChronicObstructivePulmonaryDisease (COPD)patientsonincreasedoxygen. Checkbloodtestsfromtheday. Manuallycheckthevitalsignsyourselfifitisabnormal. Thinkofdeliriumwhencalledtoseeanagitatedpatient. DONTS Neverdoanythingyoufeeluncertainaboutringsomeoneandask. DontgiveNonSteroidalAntiInflammatoryDrugs(NSAID)toanypatientunless younotifyaregistrar. DontgivehighflowoxygentoChronicObstructivePulmonaryDisease(COPD) patients. Dontdoarectalexaminationinneutropeniapatients. Dontanticoagulateuntilaregistrarisnotified. Dontprescribeantibioticsuntilaregistrarisnotified. Donthavemorethan3attemptsatIVplacement.Gethelp. Dontcommenceantihypertensivemedicationoranticoagulantsforstroke patientsafterhourswithoutapprovalofconsultantoncall. Inhypertensivepatients,dontstartanynewmedicationsorIVfluidswithout contactingtheconsultantorregistrarfirst. Dontinsertintravenouscannulaeanywhereotherthanthebackofthehandon renalpatients. Dontgivemaxolon/metoclopramidetopatientswithParkinsonsDisease WardCall 1. Yourpurposeistoalleviatepain,reactappropriatelytoimportantchangesin clinicalstatus,liaisewiththeoncallregistrarsandkeepthepatientsafe.Work withinyourcapabilities. 2. Prioritisecallsinorderofurgency.Thosepatientsrequiringresuscitation(orwho haveevidenceofhaemodynamiccompromise)takepriorityoverIVresites,etc. Ifyouhaveabacklogofcallsyoumayneedtostreampatientsinto: Priority1:Emergencies Priority2:Alleviationofpain Priority3:ClinicalmanagementcallsincludingIVresites,bloodchecksand medicationsheetauthorisations. 3. Don'tchangelongtermtreatmentunlessabsolutelynecessary.Ifyouconsiderit necessarytochangethetreatingteamsmanagement,calltheregistrarfirst. 4. Don'tgetoverinvolved(boggeddown!)tryingtosortoutchronicproblems. 27 QMETRMOHandbook
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5. Theregistrarsexpecttobecalledforadvice.Theyarededicatedtoproviding supporttowardcallandreviewingpatientswhohavebecomeacutelyunwell. Pleasedonothesitatetocontactthemwithyourqueries. 6. Aswithdaywork,discussthepatientwiththeregistrarcoveringthatunitpriorto consultinganotherdiscipline. 7. Don'tfeelobligedtorespondpharmacologicallytoeveryproblem.Itmaybe appropriatetodonothingapartfromreassurepatientsand/orwardstaff.Don't bepressuredintotakingactionwhennoactionisrequired. 8. Someproblemsrequireaninitialassessmentfollowedbyregularreview. Unnecessaryinterventionmaybeavoidedinthisway. 9. Usethetelephonetoyouradvantage.Politelyinsistthatyouaregivensufficient clinicaldatatoformulateadifferentialdiagnosisandassesstheurgencyofa problembeforeyouhangup.Alwaysaskforabriefbackgroundhistoryandalways askforthepatientsobservations.Requestinitialinvestigationsbyphonebefore youhangup,egUrgentCXR,ECG,haveIVtrolleynearby,etc. 10. Assesseachproblemfullyyourself.Requestssuchas"Thepatientjustneeds Maxolonorderedbecauseshe'svomiting."mayactuallybeduetoanunderlying acuteabdomen. 11. Remember,aboveall"Donoharm".Cantheproblemwaituntilthedaystaff arrive? 12. Legiblysignandprintnameandpagernumberinallchartentries.Thisfacilitates feedback(whichISgood).Chartentrymustinclude:date,time,ATSP(askedtosee patient)bynurse,briefhistory,examinationfindings,assessmentmanagement plan(includingfollowup) Progressnotesmustalsostate: whenthereisanychangeinconditionordiagnosis whenthereisanychangeintreatmentandwhy whenphonedtoseethepatient whenconsultantseesorisphonedregardingpatientscondition 13. AllIV'saredifficultat0300hrsconsideriftheIVcanwaituntilmorning.Ifitis essentialandyouareunsuccessfulafterafewattemptscalltheregistrar. 14. Bepreparedforcommoncallseg Prescribingvariabledosemedicatione.g.gentamicin,warfarin,heparinand insulincarryacopyofthedosenomogramswithyou,orknowwheretofind themonCKN Takingbloodknowwhichtubestouse(seepage3ofthishandbook) Nocturnalsedationknowcontraindicationstohypnotics Analgesiamorphine,fentanyl,endone,codeine,paracetamol,tramadol ChestPain PulmonaryOedema Lowurineoutput 15. Keeparecordofallyourcalls Logshouldinclude:timeofcall,extensionnumber,ward,nameofpatient, nameofnurse,reasonforcall. TakeapatientstickerorwritedowntheURnumbersoyoucancheckblood resultsorxrayslater. 28 QMETRMOHandbook
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RingingtheRegistrar Thiscanbedaunting,especiallyifyourenotsurewhatiswrongwithyourpatient, butbeingpreparedwillmakethiscallmucheasier.Thiswillhelpyoucommunicate yourconcerns,andalsomaximisethelearningopportunitiesofWardCall. 1. Formulateadiagnosis,investigationandmanagementplanpriortocalling. 2. Ifyoudonothaveagoodideaofwhatiswrongwithyourpatient,thatisokay, butensurethatyouhaveanadequatehistory,examinationandreviewofcurrent investigationsiebloodsandXRs. 3. Telltheregistrarwhatyourdiagnosisis,justification,andoutlineyour managementplan. 4. AskifyoumayinstituteRx(fluidsanalgesiamayalreadyhavebeengiven). 5. Remember,ifthepatientlooksveryillfromtheendofthebedandthenursing staffconfirmdeteriorationinclinicalstate,CALLAREGISTRAREARLY(orconsider aMETcall)andindicatetothemclearlyifyouneedtheirassistanceurgentlyieIm veryworriedaboutMrsXwhoistachycardicandhypotensiveduetoGITbleeding. Canyoucometothewardurgentlyandhelpme? 6. Aftertalkingtotheregistrar,ensurethatyouunderstandthereasonfortheacute managementplanandwhatthefollowupshouldbe.Askforclarificationifyou areuncertain,thendocumenttheplaninthechart ClinicalHandover Clinicalhandoverreferstotheprocesswherebyprofessionalresponsibilityand accountabilityforsomeorallaspectsofcareforapatient,orgroupofpatients,is transferredtoanotherpersonorprofessionalgrouponatemporaryorpermanent basis.Handoverspermeatethehealthcaresystemandcanoccuratshiftchange, whenclinicianstakebreaks,whenpatientsaretransferredinterandintrahospital, andduringadmission,referralordischarge. Handoverprocessesarehighlyvariableandmaybeunreliable,causingclinical handovertobeahighriskareaforpatientsafety.Breakdowninthetransferof informationorincommunicationathandoverhasbeenidentifiedasoneofthemost importantcontributingfactorsinseriousadverseeventsandisamajorpreventable causeofpatientharm. Recommendationsforeffectiveclinicalhandoverare: Ifpossiblerostershiftstooverlap Minimisepotentialinterruptions Makesureyouhavetherequireddocumentationavailabletoyoue.g.medical record,ward/unitchecklist Makesureyouhavetherequiredresourcese.g.computeraccess, radiology/PACS,pathologyresults,Viewer Patientrisksandallergiesshouldbeincluded Prioritisedeterioratingpatients Ensureyouareawareoftheoverallbedstatusofthehospital Askquestionsandseekclarificationifyouareunsureofanyinformationbeing handedovertoyou. 29 QMETRMOHandbook
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Handovershouldbeperformedfacetofacewheneverpossible,incombinationwitha writtenorcomputergeneratedhandoversheet/checklist.Highqualityeffective handoveroccurswhenoutgoingandoncomingstaffmembersshareacommon mentalmap Use of communication tools such as ISBAR may assist with handover and referrals. ISBAR is a recognised communication tool and is appropriate for clearly defined urgent situations such as phone calls to ward call but is not a substitute for quality effectiveclinicalhandover. HandlingSimultaneousCriticalCalls Notifytheregistrarondutyofanyseriouscallstothewardsthatthatcannotbe attendedwithin10minutes.EncouragenursingstafftoactivateMETcallswhere appropriate. Intheeventthattheregistrarisforsomereasonuncontactableandthematteris urgentthenaconsultantoncallshouldbeadvisedandthematterhandledas directed. PhoneOrders RequestsforMedication Alwaysfullyassesstheproblemyourselfbeforeprescribinganything. Thinkaboutwhatyouareprescribing: Isthismedicationnecessary? DoIhaveenoughinformationtoexclude? Takecarewhenreprescribing: What current and prn medications have been prescribed have these medicationsbeenadministered?Timelastadministered. Isthismedicationstillnecessary?Isitthemostappropriatemedication? Hastheproblemchanged? Ifnootheroptionisavailableandyoudecidetogiveaverbalorder: useaonceonlydose followtheproceduredetailedinthesectiononverbalorders(below) Remember,YOUareresponsible,sodontprescribeanythingthatyoufeeluncertain oruncomfortableabout,andsignoffanyphoneordersbytheendofyourshiftonly YOUcanverifythatwhatwasgivenwaswhatyouintended.

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VerbalOrders Medicationerrorsareamajorsourceofpotentialpatientharmandtheuseofverbal orphoneordersisaparticularlyerrorpronepractice.Verbalordersaremorelikelyto resultininappropriatemedicationordersthanwrittenordersandassuch,theiruse shouldbereservedforemergentsituations.Whilstverbalordersmayseemfaster andmoreconvenient,especiallyonabusywardcallshift,patientsafetyshouldtake priority.Youmayfeelpressured(eitherbytimeornursingstaff)togiveverbal medicationorders,howeveryoushouldnotprescribeanythingwithoutfullyassessing theproblemyourself(ideallyinperson)asthisplacesyouandyourpatientsatrisk. Avoidverbalmedicationorderswhereverpossible. Neveruseverbalorderswherethereishighpotentialforerror(egchemotherapy drugs)andavoidinhighriskdrugs:opioids,anticoagulants,potassium,ordrugs whichhavecomplicatedorsoundalikenames. Evensimpleorderssuchasfluidsortemazepammaycausepatientharm. Directclinicalassessmentandreviewofcontraindicationsremainsthebest methodforsafeprescribing. VerbalOrdersSafePrescribing Duetotheassociatedrisks,verbalmedicationordersshouldbecarefullyconsidered andideallyreservedforemergentsituations.Ifaverbalorderisunavoidable,you shouldusethefollowingprocesstoreducetheriskoferrorandensurepatientsafety: 1. Confirmpatientidentity 2. Spellthenameofthemedication 3. Considerusingthetradeaswellasthegenericnameifpotentialforconfusion 4. Avoidusingabbreviationsorshortformsofdrugnamestoavoidconfusion 5. Clarifydosewithspokennumbers(eg15milligrams:one,fivemilligrams) 6. Providecorrectdosageunitsandspecifyroute 7. Conveytheindicationforthemedication 8. Ensuretheorderisclearandunderstandabletotherecipient 9. Obtainareadbackfromasecondnurse 10. Reviewthepatientandsignoffphoneordersassoonaspossible(within24hours)

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ISBARCommunicationTool ISBARisacommunicationtoolusedforclearandconcisecommunicationwithother healthprofessionals.Examplesinclude: Nursetodoctorrepatientcondition/deterioration WardnursetopharmacyreD/Cmedications Medicaltoalliedhealthreferral Hospitaltocommunityreferral Doctortodoctorhandoversorreferrals,includinginemergencies IIntroduction Identifywhoyouare,andwhereyouarefrom SSituation Describethesituation BBackground Giverelevantbackgroundinformation AAssessment Provideanassessment RRecommendationSuggestsorrequestsactions Example: IntroductionIdentifywhoyouareandwhereyouarefrom MynameisJohnCitizensandIamthenightmedicalwardcallresident.Imcallingfrom I Ward1A SituationDescribethesituation Iamcallingtogetsomeadviceabout/IamcallingbecauseIneedhelpurgentlywith( patientnameandlocation.) Thepatient'sconditionis(stable/unstable) Theissue/problemIamcallingaboutis... BackgroundGiverelevantbackgroundinfo Ihavejustassessedthepatient: Vitalsignsare:Bloodpressure,Pulse,Respirationrate.SpO2%,temperature Iamconcernedaboutthe:(abnormalfindingsegthepatient's chest/abdomen/neurologicalexamination) Ihaverequestedthesetests(CXR,ABG,ECG,FBC,orE/LFTsorothers)andtheresults are Assessment Ithinktheproblemis(e.g.Ithinkthepatienthassevereacutepulmonaryoedema) Recommendation Suggestorrequest: Canyoupleasegivemeadviceabouthowtomanagethis? Canyoupleasecometoseethepatient?

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COMMONWARDCALLS Thissectionofthehandbookprovidesabriefoverviewofhowtoapproachwardcalls. Manyoftheproblemscanbeapproachedusinga3stepprocess: 1. Phonecallspertinentquestionstoassesstheurgencyofasituation,and treatmentorderstobegiventonursesandotherstaffonthewardpriortoyour arrival; 2. Thoughtsintransitthedifferentialdiagnosisandtheirimportantmanagement pointsthatyouneedtobethinkingaboutasyoumakeyourwaytothebedside fromwhereveryouarewhenyoufirstreceivethecall; 3. Bedsidemanagementwillincludeaquicklooktoplacethepatientintooneof threecategories:well,sickorcritical;vitalsigns;selectivehistoryandphysical examination;andsubsequentdetailedmanagement. Detailedinformationonhowtomanagespecificproblemsisoutofthescopeofthis handbook. Forthisinformation,recommendedresourcesinclude:

(CKNeBOOKSOnCall,Marshall&Ruedy,Cadogan1sted) https://wwwmdconsultcom.cknservices.dotsec.com/books/page.do?eid=4u1.0 B9780729538039..X50015&isbn=9780729538039&uniqId=2875984952#4 u1.0B9780729538039..X50015TOP UpToDatedatabaseofcommonclinicalconditions (CKNdirectlinkonlefthandside)http://www.uptodate.com/contents/search

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ANTICOAGULATION GuidelinesforAnticoagulationusingWarfarin RefertoWARFARINGUIDELINES(usuallylocatedatthefootofpatientbed)which havebeendevelopedbyQueenslandHealthSafeMedicationPracticeUnit. HeparinInfusionRates,MonitoringandOrdering RefertothebackoftheHEPARININTRAVENOUSINFUSIONORDER& ADMINISTRATIONFORMwhichhasguidelinesthathavebeendevelopedby QueenslandHealthSafeMedicationPracticeUnit. CARDIACARREST FollowstandardBLS/ALSguidelines CardiacArrestPagers EnsureyouareawareofyourlocalCardiacArrestalertsprocedures. ItisimportanttoknowthecompositionoftheCardiacArrestTeamandwhateach personsroleis. Youneedtobeabsolutelysureyouknowhowtoactivateanalertifyouthinka personishavingacardiacarrest. Priorities: 1. ActivatetheCardiacArrestTeam 2. Controlthesituation 3. AccesstoPatientegmovebed 4. ConnectO2 5. Maintainairway/checkairway. 6. Resuscitate 7. Earlydefibrillation 8. Callforchart 9. Managementfromnursingstaff"Whathappened?"

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CHESTPAIN ThereisaQueenslandHealthendorsedChestPainPathwaywhichcanbesubstituted forclinicalnotesinthepatientsrecord.Itallowsdoctorstoriskstratifypatientswith chestpainandhasbeenshowntominimisepotentialpooroutcomesinpatientswith onsetofchestpain. FormoreinformationgototheClinicalPracticeImprovementCentrewebpage: www.health.qld.gov/cpic DRIPS&PERIPHERALIVCANNULATION TheinsertionofI.VCannulaeisanessentialskillfordoctors.Ensuringyouare comfortabledoingthisprocedureinnonurgentsituationswillassistyouwhenyou arecannulatinginanemergency.Manyhospitalsprovideupskillingformedicalstaff whohavenotrecentlypractisedCannulationaskyourmedicaleducationstaffhow toaccessthese. DontForget:ALLperipheralIVsmustbechangedat72hoursunlessthereare extenuatingcircumstances.TheseMUSTbedocumentedinthechart. ENDOCRINOLOGY&METABOLISM HYPERGLYCAEMIA RefertoINSULININFUSIONORDERandBLOODGLUSOSERECORDADULTform. Theyaregenerallylocatedatthefootofpatientbed. DIABETICKETOACIDOSIS(DKA) DKAoccurspredominantlyinpatientswithtype1diabetesmellitusandisamedical emergencywitha35%mortalityriskusuallyfromelectrolytedisordersorcerebral oedema.Specialistmedicaladviceshouldbesoughtassoonaspossible. HYPOGLYCAEMIA Hypoglycaemiareferstoalowplasmaglucoselevelinconjunctionwith symptoms/signsofsympatheticnervoussystemactivationorCNSdysfunction. RefertobackofINSULINSUBCUTANEOUSORDERandBLOODGLUSOSERECORD ADULTform.Theyaregenerallylocatedatthefootofpatientbed.

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FALLSWARDcalls Resourcesavailableat:http://www.health.qld.gov.au/stayonyourfeet/resources.asp

PhoneCallQuestions/requests Patientdetailsandcircumstancesoffallbothhistoryandmechanics(SBAR). Establishifthereareurgentconcernsegheadinjuryorsuspectedfracture. Vitalsigns(includingGCSandBSL) ReviewurgentlyifchangeinLOC,fractureoracoagulationdisorder. If suspected head injury or unwitnessed fall, ask nursing staff to undertake quarterhourlyNeuroobs; HourlyHR,BP,Resp.rate,oxygensaturations,;hourly
for2hours;Hourlyfor5hours;4hourlyfor8hours.

ThoughtsinTransit Whatarethelikelyinjuries(excludefractureorheadinjury)? If known coagulopathy, age>65, suspected head injury, on anticoagulants/antiplateletsorfallfromheight>1mthenorderINR/APTTand CThead Whatisthemechanisme.g.tripvssyncope? Environmental factors e.g. most falls occur in hospital occur around the bedsideorbathroom?

Bedside UpdatefromnursingstaffincludingvitalsignsandGCS. ABCs,checkforinjuriesandcategoriseresponse. Ifseriousinjury,deterioratingvitalsignsornewonsetneurologicalsigns,call registrarforhelpandcommencestabilisation/investigation. Ifnotseriouslyinjuredthenconfirmhistoryandperformexamination.What precededthefall/dotheyrememberit/associatedsymptomsegincontinence, presyncope/collateral from witnesses. Review hydration status/ medication that may be contributing/ mobility status/ postural blood pressure/Bone health/currentfallsassessmentandcareplan Lookatthefallinthecontextofthewholepatienteghowhavecomorbidities contributed? eg delirium significantly increases falls risk and is under diagnosed.

Management Establishreasonforfallandworkoutwhatismodifiable Arrangeanyimmediateinvestigationsrequired Ifnoheadinjurydoaboveobshourlyfor4hours,2hourlyfor6hoursand4 hourlyfor8hours Painreliefifneeded/icetoaffectedarea Consider ongoing safety of patient eg increased observation for confused/ toiletingplans Ensuregooddocumentationinpatientrecordandcommunicateongoingfalls risk to treating multidisciplinary team so they can review and take action to decreasefuturefallsriskandinjuryprevention. Liaise with nursing staff to ensure that family will be notified and incident report(PRIME)willbecompleted.

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MENTALHEALTHBASICS MentalHealth Given the high prevalence of psychiatric disorders seen in the Emergency Department,medical,surgical,obstetricwardsandingeneralpractice,thisoverview maybeusefulirrespectiveofthenatureofyourcurrentterm. RiskScreen Whenconductinganinterview,equallyensurethesafetyofthepatient,yourselfand others.Ifconcernedneverleavethepatientunattended.Ensureyourownsafetyby havinganawarenessofroomentryandexitpoints,placementofduressalarmsand processforcallingadditionalstafftoattend. Always consider risks every time you assess a patient with a mental health or drug and alcohol presentation, including suicide and self harm, aggression, vulnerability, absconding and dependent children/others. From your screening, patients with identifiedriskfactorsrequirefurtherassessmentviaMentalHealthServices(MHS). Depending on the care setting you are working in, further assessment by Mental HealthServicesmaybearrangedthroughareferraltoConsultationLiaisonPsychiatry orseekingconsultationfromanAcuteCareTeam. MentalHealthAct2000(theAct) The purpose of theAct is to provide for the involuntary assessment and treatment, and the protection, of persons (whether adults or minors) who have mental illness whileatthesametime: safeguardingtheirrightsandfreedoms;and balancing their rights and freedoms with the rights and freedoms of other persons. Twokeyrequirementsapplytopersonswhohaveresponsibilityforexercisingpowers andperformingfunctionsundertheAct.Theseare: any power exercised under the Act that affects the liberty and rights of the person should be exercised only if there is no less restrictive way to protect thepersonshealthandsafetyortoprotectothers;and any adverse effect on the persons liberty and rights is to be kept to the minimumnecessaryinthecircumstances. Whatyoucando: TheActsetsoutprocessesforapersontobeassessedforthepurposeofdetermining whetherinvoluntarytreatmentisrequired.Theinvoluntaryassessmentprocessrelies on assessment documents (request for assessment and recommendation for assessment)beingcompletedfortheperson.Anyregisteredmedicalpractitioneris abletocompletearecommendationforassessment. The Act also provides examination processes (emergency examination order and justices examination order) that may need to precede involuntary assessment in certain circumstances. These processes enable the person to be examined for the purpose of determining whether assessment documents can be made. As a registeredmedicalpractitioneryoumayberequiredtoassessanindividualunderan emergencyexaminationorderorlesscommonlyunderajusticesexaminationorder. 37 QMETRMOHandbook
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Youmaybeaskedtoreviewpatientswhohavebeensecludedduetoimminentriskof violence when no less restrictive alternative is appropriate. Seclusion is defined as theconfinementofthepatientatanytimeofthedayornightaloneinaroomorarea fromwhichfreeexitisprevented.Orderscanonlybemadeforamaximumofthree hours.Youmustensurethecriterionofimminenceoflikelyphysicalharmissatisfied. Ifyouhaveanyconcerns,consultwiththePsychiatryRegistraroncall. Thingsyoucannotdo: AuthorisedDoctorsandAuthorisedPsychiatristshavespecialrolesundertheAct.As ResidentsarenotAuthorisedDoctors,therearecertainformsandfunctionsyouare not permitted to complete. These include the making of involuntary treatment orders, authorising limited community treatment and developing treatment plans; ceasing or extending the involuntary assessment period; revoking involuntary treatmentorders;completingtransferordersandissuingauthoritytoreturnforms. InvoluntarytreatmentofaphysicalillnessisnotauthorisedundertheAct.Itisnot appropriate to use the Act for some instances where patients refuse assessment or treatment, even if deprived of capacity which usually includes delirium and uncomplicateddementia.Forthesepurposes,theGuardianshipandAdministration Act2000provisionsmaybeappropriate,utilisingtheStatutoryHealthAttorneyofthe patienttomakedecisionsforthemwhencapacityisimpaired. MentalHealthMedicalEmergencies Medicalemergenciescanoccurinmentalhealthpatients.Listedbelowaresomethat aremorelikelytobeseeninMHS. Delerium Delirium is a medical emergency. It is one cause for agitated or disruptive patient behaviour,howeveritcanalsooccurinawithdrawnpatientasahypoactivedelirium. The manifestations of delirium include a reduced level of consciousness developing over a short period of time (hours to days), tending to fluctuate during the day, variouscognitivedeficits(disorientation,impairedmemoryorlanguagefunctioning), and perceptual disturbance (hallucinations or illusions). This combined with the patient misinterpreting stimuli due to the cognitive impairment frequently leads to misdiagnosis of a psychotic illness. Undertake a thorough physical assessment includingappropriateinvestigationstoidentifypathologicalaetiologyandtreatsame. NeurolepticMalignantSyndrome: This is a rare but lifethreatening adverse effect of antipsychotic medications. Patients are most at risk following commencement or dose increase of an antipsychotic medication, especially high potency typical agents. Features include rigidity, tremor, mutism, decreased consciousness level (from confusion to coma), hyperthermia, sweating, dysphagia, incontinence, tachycardia, high or unstable BP andelevatedCK&WBC. SerotoninSyndrome: Thisisanincreasinglycommonandseriouscomplicationofserotonergicmedications, oftenasaninteractionbetweenmultiplesuchagentswhencoprescribed.However it can occur from a single medication alone. These include psychiatric medications (SSRIs and some other antidepressants, lithium, sodium valproate), antiemetics (ondansetron, granisetron, metoclopramide), analgesics (tramadol, fentanyl, 38 QMETRMOHandbook
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pethidine, pentazocine), sumatriptan, sibutramine, antibiotics (linezolide, ritonavir), dextromethorphan, drugs of abuse (including LSD and ecstasy/MDMA), and herbal preparations (hypericum/St Johns Wort, tryptophan, ginseng). Features include clonus,hyperreflexia,tremor,rigidity,ataxia,hyperthermia,agitationandsweating. Clozapine: This is a powerful antipsychotic medication. It can cause various physical adverse effectsincludingtachycardiaandposturalhypotension.Itcancauseseriousadverse events which might necessitate its cessation in a patient, for example clozapine induced myocarditis, cardiomyopathy, and agranulocytosis. It is important to differentiateclozapineinducedtachycardiafromthemoreseriousmyocarditis. UsefulHyperlinks RANZCPClinicalPracticeGuidelines MentalHealthAct2000 GuardinshipandAdministrationAct2000

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SECTIONEMedicolegalandPatientSafetyIssues

WithholdingandWithdrawingLifeSustainingMeasures

Queensland Health Standard

The effect of this policy is to replace all local policies regarding the withholding and withdrawing of lifesustaining measures from adult patients. The accompanying Acute Resuscitation Plan (ARP) form replaces all Not For Resuscitation orders in Queensland Health facilities. This policy does not authorise euthanasia or physician-assisted suicide. This policy applies to both adult patients with capacity and adult patients without capacity to make decisions about health matters. The scope of the policy excludes children.

Withholding and Withdrawing Life-Sustaining Measures Implementation Standard

1. Purpose
This implementation standard identifies the minimum (and auditable) requirements that evidence the implementation of the Withholding and Withdrawing Life-Sustaining Measures policy. It also identifies the accountabilities and responsibilities of individual positions in relation to these requirements.

2. Scope
Adult patients of all Queensland Health public hospitals, state-wide services, outpatient services and community health services. The scope of this policy excludes children, and does not authorise euthanasia or physician-assisted suicide.

3. Definition of Terms
See Glossary of Terms in Withholding and Withdrawing Life-Sustaining Measures Policy.

4. Supporting Documents
(Procedures, Guidelines, Protocols etc) Withholding and Withdrawing Life-Sustaining Measures Implementation Guidelines National Health & Medical Research Council (RH&MRC) Guidelines Ethical Guidelines for the Care of People in Post-Coma Unresponsiveness (Vegetative State) or a Minimally Responsive State Organ and Tissue Donation After Death, for Transplantation Guidelines for Ethical Practice for Health Professionals (Forms and Templates) Acute Resuscitation Plan form Priority Care Plan (under development) Advance Health Directives

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5. Requirements
All clinicians and health professionals are required to act in accordance with the ethical and professional standards of their profession. That the Acute Resuscitation Plan form is filed at the front of a patients chart. Individual facilities may decide on the most prominent place to file the form.

6. Review 7. History

This standard is due for review on: February 2011.

Date of new / revised policy:

February 2010

Amended to
New Standard

8. Responsibilities
Position The patient Responsibility(ies) Is responsible for talking to those closest to them about their wishes for end of life care. If the patient has an Advance Health Directive and/or an Enduring Power of Attorney, the onus is on them to make its location known to their substitute decision-maker/s and, ideally, to the health care team. Must respect the patients wishes for end of life care. All substitute decision-makers have an ethical and legal responsibility to act in accordance with the Heath Care Principle (see policy glossary). Not only must they exercise their powers in accordance with the patients best interests, they also have a duty to seek out the wishes of the patient and advise the health care team of those wishes in the event the patient loses capacity. The substitute decision-maker will also be called upon when the patient enters the dying phase to provide consent for decisions about life-sustaining measures. Consent obtained from a substitute decisionmaker is not required to be in writing but should be documented. Must respect the patients wishes for end of life care. Medical officers are required to adhere to the standards of good medical practice in all decision-making about end of life planning and care. The most senior clinician involved in a patients care is responsible for initiating advance care planning, such as an Acute Resuscitation Plan, and ensuring any decisions about advanced care planning and care with the patient and/or their substitute decision-maker are kept current. The medical officer is also required to ensure that the communication channels between Accountabiliti es/ Audit Criteria N/A

The substitute decisionmaker

Can be subject to legal liability if they do not act in accordance with the Health Care Principle.

The medical officer responsib le for the patients care

Carries the medicolegal responsibility for that patient while under their care.

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themselves and patient, their substitute decision-maker and the health care team remain open. The medical officer is also responsible for ensuring that the choices of the patient are respected and that all decisionmaking reflects their best interests. Medical officers Are required to adhere to the standards of good medical practice for their profession. There is a responsibility to ensure any treatments are provided in ways that promote quality of life for the patient and are in their best interests. Medical professionals have a duty of care to discuss with the most senior medical officer involved when the active treatments become burdensome for the patient and those closest to them. Junior medical officers should not be excluded when end of life decisions are considered, although they should be supervised in any discussions about end of life decisions with patients and/or their families. Junior Registrars are not advised to authorise a patients Acute Resuscitation Plan form. Are responsible for adhering to standards of good clinical practice for the nursing profession. As well as having a key clinical role in observing and monitoring patient status and function, nursing professionals are often more accessible than medical officers in discussions with dying patients and their families. This means they have a responsibility to ensure any discussions about end of life care are recorded on the patients medical record, or if they have one, an Acute Resuscitation Plan. Nursing professionals should also be involved in case-conferencing with patients and those closest to them to ensure good communication between all clinical areas. Junior nurses should be supervised in all end of life discussions. Have a responsibility to act in accordance with the ethical and professional standards of their profession. Should be aware of the Health Care Principle if they are providing advice to substitute decision-makers.

Nursing professio nals

Allied Health professio nals Pastoral care and communit y workers General Practition ers

May have a patients original Advance Health Directive and/or Enduring Power of Attorney, and therefore when the time comes for

Carries the Medicolegal responsibility

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(GP)

decisions about withholding or withdrawing treatment to be made may be required to forward this document.

for that patient while under their care.

Dr Jeannette Young Chief Health Officer Approval Date: 15 February 2010 Implementation Date: 19 April 2010

Forfurtherinformationsee
http://qheps.health.qld.gov.au/policy/docs/pol/qh-pol-005.pdf

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InformedConsent
TheQueenslandHealthPolicystatementInformedConsentforInvasiveProcedures isavailableat:http://www.health.qld.gov.au/consent/documents/14025.pdf orseePatient Safety and Quality Improvement Service website: qheps.health.qld.gov.au/patientsafety PolicyStatement: Theresponsibilityforensuringapatienthasthenecessaryinformationandadvicelies withthemedicalpractitionerwhoperformsaprocedure,operationortreatment.In theeventthatthetreatingMedicalPractitionerasksanotherMedicalPractitioner (delegate)toobtainconsentontheirbehalf,thetreatingMedicalPractitionerremains legallyresponsibleforensuringthattheMedicalPractitionerobtainingconsentfully understandsanddisclosestheelementsofconsenttothepatient/parent/guardian (ifachild)/substitutedecisionmaker. TheMedicalPractitioner(ordelegate)obtainsconsentfromthepatient/parent/ guardian/substitutedecisionmakeraccordingtotheprotocolswhichguidean effectivecommunicationprocess,ie Theprocedureoutlinedinthispolicy,includingtheuseofprocedurespecific consentforms. Relevantlegislation,includingthePowersofAttorneyAct1998andthe GuardianshipandAdministrationAct2000. Procedure: (a)Presumealladultshavelegalcapacitytoconsent.Ifintheeventthatthepatient doesnothavecapacity,seetheGuardianshipandAdministrationAct2000,Powerof AttorneyAct1998.Forfurtherinformationonobtainingconsentforpatientswith impairedcapacity,pleaserefertotheconsentflowchartsontheOfficeoftheChief HealthOfficer'ssiteonQHEPS http://qheps.health.qld.gov.au/cho/resources/pdf/17229.pdf (b) The treating Medical Practitioner or delegate, seeking consent to Medical Treatment of the patient/ parent/ guardian (if a child)/ substitute decision makermustbeabletocomprehensivelydiscusstheissuesinrelationtomedical treatmentsetoutinparagraph(c)and(d)below. (c)Ensurethat,insofarasitispossible: Consentisvoluntarilygiven,inabsenceoftheinfluenceoftherapeuticorother drugsoralcohol,family,religious,culturalandmedicalstaffinfluences; Thepatient/parent/guardian(ifachild)/substitutedecisionmakerhas sufficienttimetoconsidertheinformationprovidedbythedoctor. (d)Thepatient/parent/guardian(ifachild)/substitutedecisionmakerisadvisedin laytermsof: Thediagnosis Recommendedtreatment; Materialrisksinpercentagetermsassociatedwith: Therecommendedtreatment. Alternativetreatmentoptions. Thenotreatmentoptions. insofarasareasonablepersonwouldexpecttobeadvisedofsignificantrisks; 44 QMETRMOHandbook
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 AND Significantrisksfortheparticularpatient, AND ThatnoassurancecanbeprovidedthatthetreatingMedicalPractitionerwill carryoutthetreatmentoption. (e)Acompetentadultmayrefuseanyandallmedicaltreatmentcontrarytomedical recommendations even in circumstances where such refusal may result in the deathofthepatient. (f)Generally,aparentmakesthedecisionfortheirchild.However,wherethechild hassufficientmaturityandunderstandingoftheproposedprocedure,thenthe childislegallyabletomaketheirowndecision.Intheeventofaconflict betweenaparentandachild,theFamilyCourtortheSupremeCourt (dependinguponthecircumstances)havethegeneralpowertointerveneinthe interestsofthechild InformedConsentProgram TheinformedConsentProgramhasdevelopedpatientinformationsheetsand consentformsforthoseinvasiveprocedurestobehighestrisk.Theseareloadedon: http://www.health.qld.gov.au/consent/html/for_clinicians.asp

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Certifying(orPronouncing)andReportingDeath

Manyhospitalsprovidetherequiredpaperworkandformsrequiredtobecompleted in"DeceasedPackages"usuallyavailableonthewards.Availablestatewide(see: http://qheps.health.qld.gov.au/patientsafety/htm/coro_mgt.htm) thesepackagesareusuallyelectronicandavailableasanicononeachdesktop. Uponthedeathofapatientinhospital,thedoctorwhoiscalledtopronouncedeath istoconfirmthatdeathhasindeedoccurred(usingtherecognisedclinicalcriteriafor death). Documentyourfindingsinthepatient'schart. Atypicalchartentrymayreadasfollows: CalledtopronounceMrSmithdeceased. Patientunresponsivetoverbalortactilestimuli. Noheartsoundsheard,nopulsefelt. Notbreathing,noairentryheard. Pupilsfixedanddilated. Patientpronounceddeceasedat1830hours,December10,2009 The doctor certifying the death should check the patient identification bracelet is correctandissecurelyattachedtothecorrectpatient. Certificates For deaths not reportable to the coroner, where the cause of death is known, complete the appropriate documentation Life Extinct Certificate or Cause of Death Certificate. Undersection30oftheBirths,DeathsandMarriagesAct2003,adoctormustissuea Cause of Death Certificate if they can form an opinion about the probable cause of death.Thedoctormusthaveeither: Attendedthedeceasedwhenthepersonwasalive; Examinedthedeceasedpersonsbody;or Consideredinformationaboutthedeceasedpersonsmedicalhistoryandthe circumstancesofthedeceasedpersonsdeath.TheCauseofDeathCertificate mustbecompletedassoonaspracticableduringtheofficedayonwhichthe treatingdoctorissoinformed. Ifyouareuncertainabouthowtocorrectlydocumentthecauseofdeath,approacha seniordoctorforassistanceandyourhospitalmedicolegalofficer. Ifanoncoronialautopsyistobedone,thetreatingdoctormustobtaintheconsentof thenextofkin,completeanautopsyrequestform(includingrelevantclinicaldetails) andcontactthepathologistpromptly.Thechart,CauseofDeathCertificate,autopsy request form and completed autopsy consent and authorisation form are to be deliveredtothepathologistassoonaspossible. If the death is reportable (see http://www.courts.qld.gov.au/courts/coronerscourt andhttp://www.legislation.qld.gov.au/LEGISLTN/CURRENT/C/CoronersA03.pdf)aska seniordoctorandyourhospitalmedicolegalofficerforadvice. 46 QMETRMOHandbook
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Generally,deathsarereportedtothecoronerbypolice.Insomecases,deathscan bereporteddirectlytothecoronerbythehospitalordoctorwhohasbeentreating thedeceasedperson.Example: Themedicalpractitionerseeksadvicefromthecoroneraboutwhetheradeath is/isnotreportable,or The death is reportable and the medical practitioner seeks the coroners authoritytoissueacauseofdeathcertificatebecausecauseofdeathisknown andnoautopsyorinvestigationappearsnecessary. Notes: StaffmustNOTrecommendaspecificfuneraldirectortobereavedrelatives.Rather, theyshouldgivethenamesofallthelocalfirmsandleaveituptotherelativesto decide. Perinataldeaths(stillbornorlessthan28daysold)requirebothaCauseofDeath Certificate(Form9)andaPerinatalSupplement(Form9A)tobecompleted. PleasetreatthecompletionofCauseofDeathCertificatesasamatterofpriority. Unnecessarydelaysaddanadditionalburdentobereavedrelatives. ItisusuallythedutyoftheRMOwhowasresponsibleforapatientimmediatelyprior to that patients death (the "treating doctor") to attend to cause of death certification.WhereanydifficultyisencounteredtheonusisontheRMOnominally responsibleatthetimeofapatientsdeathtotakeactivestepstominimisedelayin issuing the Cause of Death Certificate, and if necessary, to contact the Executive DirectorofMedicalServicesforguidance. Whatisareportabledeath? Refer to the CoronersAct2003 (http://www.legislation.qld.gov.au/LEGISLTN/CURRENT/C/CoronersA03.pdf) Reportable deaths are defined as deaths where

theidentityofthepersonisunknown thedeathwasviolentorunnatural thedeathhappenedinsuspiciouscircumstances acauseofdeathcertificatehasnotbeenissuedandisnotlikelytobeissued thedeathwasahealthcarerelateddeath thedeathoccurredincare thedeathoccurredincustody thedeathoccurredasaresultofpoliceoperations.

Forfurtherinformationseehttp://www.courts.qld.gov.au/1702.htm ThePatient Safety and Quality Improvement Service website: http://qheps.health.qld.gov.au/patientsafety/htm/coro_mgt.htm providesaCoronialManagementResourceswithinformationoncoronialguidelines, LifeExtinctFlowchart,Preservingevidencewhena"ReportableDeath"occursinahealth
caresetting. .

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PRIME(ClinicalIncidentManagementInformationSystem) A"clinicalincident"isanyeventorcircumstancewhichhasactually,orcould potentially,leadtounintendedand/orunnecessarymentalorphysicalharmtoa patientofQueenslandHealth.Clinicalincidentsincludeadverseevents(harmcaused) andnearmisses(noharmcaused). TheClinicalIncidentManagementImplementationStandard (http://qheps.health.qld.gov.au/policy/docs/imp/qhimp0121.pdf)providesstaff withacomprehensive"howtoguidethatnotonlyoutlinesresponsibilitiesforall levelsofstaffinrelationtoclinicalincidents,butalsothenecessarytoolsand processestoenablethistobeachieved.TheClinicalIncidentImplementation Standard: DefineswhatincidenttypesareconsideredwithinthescopeoftheStandardand howtheyshouldbemanaged; DescribeswhenandhowaRootCauseAnalysis(RCA)isconductedfora reportableevent; DefinesallegedBlameworthyActsandincludesguidanceonwhennottoconduct orceaseaRootCauseAnalysis; ProvidesclearrationaleanddefinedprocessesthatenableQueenslandHealthto learnfromadverseeventsandnearmissesandtakecorrectiveactionsto improvesafetyforallpatients. AlldoctorsshouldbeawareofPRIMEandunderstandhowandwhentouseit. Ensureyouattendtraining(askyourMedicalEducationUnitforlocalinformation). ForfurtherinformationseethePatient Safety and Quality Improvement Service
website.

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