SAQ 001



SAQ 001

A 45 year old man has a pre-hospital cardiac arrest and is dead on arrival in your ED. He was sent home from your department six hours previously, after being referred by his GP with central chest pain. His family are waiting for you in your office. Explain how you would handle this difficult situation?

This is a complex situation with social/medicolegal qualities

Pre consultation

Patient chart ordered

Speak to Dr/nurse/LMO

SW notified

Timely balance of info vs keeping the relatives waiting

Doctor issues

Is this an isolated incident?

Documentation

MDU

Mentorship

Support

Policy and procedure (are they fully orientated and appropriate discharge ?did they ask)

Departmental process

Scenario

Appropriate

Quiet

No bleep

Private

Senior nurse

Safety aspects

Approach

ID yourself as most senior in dept and you who will be dealing with this

Blame

?accept blame

you are “pts advocate”

need to outline a plan

not role to admit liability

establish discharge facts ?self discharge

coroner/PM

nature of events

arrange FU post PM/ further Ix

Difficulty with IHD

Check CK, TnI and ECG

Departmental process and policy

who discharged

minimum documentation

reassess policy

SAQ 002

Your charge nurse approaches you to say that several of the nursing staff in your ED have voiced concerns that one of your RMOs is stealing and using opiates from the ED. How do you handle this situation? (or sexually harassing staff, abusing patients, doing incompetent stuff; you pick the atrocity)

Introductory statement

This is a serious charge that may have significant implications in terms of the systems in place for handling of opiates, the RMO involved, the team and the law. Management will need to encompass all these aspects.

Investigate the allegations

Talk to the nurses making the allegations requesting specifics:

4where

4when

4how - narcotics taken from dangerous drugs cupboard Vs. taken from the pt for whom they were intended

4action taken by nursing staff

4relationship to the RMO;

If @ drug cupboard:

4investigate the drug cupboard contents and the daily tally

4talk to those staff involved with drug counts on the affected days

If from patients intended to be given the drugs:

4Talk to the nurses caring for the patients re. amounts given, where stored between aliquots & where remains disposed of

4Review patients charts

Suspicious behaviours

Undue drowsiness

Over-prescribing of opiates esp pethidine (eg; excessive doses)

Giving opiates to patients themselves rather than by nursing staff

Unexplained absences from ED

Review RMOs performance

4Request feedback from registrars & consultants re. RMO’s performance clinically & as member of the team

4Look for “at risk” behaviour patterns

4Ask re performance in previous terms

4Chart review of patients treated by RMO

Advise from hospital legal team

4Legal obligations re:

4Reporting of opioid theft/ abuse to police services for investigation

4Reporting of potential opiate abuse to the medical board

Discuss with RMO

4Appointment time

4private room

4minimize disturbances

4ask re. Coping & whether any issues that RMO wishes to raise

4discuss allegations with RMO and ask for response to allegations

4non-judgemental approach

4Safety of RMO once allegations made (suicide risk greatest in first days after exposed)

If allegations correct:

4offer drug counselling information / confidential medical services for doctors

4suggest sick leave until counselling/ drug rehabilitation in place

4ensure confidentiality

4address any underlying stressors that may be contributing to drug use

If denies allegations that appear true:

4Gather evidence

4Will need external review eg; medical board

4Formal investigation instigated

Review the procedures in the ED re. handling of opiates

4QA review of the policies and procedures involved in handling of all S8 drugs

4compare handling policies and procedures with those in other similar emergency departments

4quality improvement

 

SAQ 003

Your medical superintendent sends you a memo saying that your junior medical staff numbers are about to be reduced from 8 to 6. How do you respond? Detail your further responses if you do not achieve the desired outcome. (The impending closure of your observation ward would be an alternative problem to consider).

Immediate response:

Ask for an appointment in a few days time to discuss the issues involved

Gather information:

Potential Impact on Emergency Department Patient?

Current Clinical Indicators & Waiting times

Number and type of complaints

Critical Incidents/near misses and root cause analysis if done

Junior Doctor Issues…

Are junior doctors leaving? (And Why? Better training/opportunities elsewhere, poorly treated, stress, fatigue, poorly supported)

Roster issues with less staff? More nights/increased stress

Gather data on number of patients seen vs years since graduation (SHOs tend to see more patients so their loss has a much greater impact)

Policy and Procedure

Emergency is a mandatory term for interns (ie probably would lose staff at a JHO/SHO level, increased supervision needed for interns)

College guidelines: Access Block, Waiting times vs Triage category

Safe working hours project AMA

Any reasons for decreased staff

Decreased junior doctors numbers across hospital

Apparent budget constraints

Other departments have a greater need

Investigate potential solutions for reduction in staff

1. Find an alternative workforce:

Locum junior staff or increase senior staff numbers

General Practitioners

Close non-essential or less-essential services to free up doctors

Paediatric registrar to see children directly

Nurses: Nurse practitioners to run minor injury clinic, early pregnancy assessment clinic, community wound reviews, nurse initiated protocols (analgesia, bloods, x-ray)

2. Decrease number of patients

Improved discharge planning - TRACC nurse etc to decrease unplanned representations to ED

Only do core ED business

3. Measures to prevent blow-out in waiting times

Rapid Assessment Team

4. Improve junior doctor training and support

During Meeting…

Set out information in writing, clearly and concisely.

Approach to interview should be of honesty and collaboration. Demonstrate a clear willingness to be part of the solution.

Further Action Needed?

If no resolution apparent, escalate the concerns to the next person up the management ladder (district manager, state health minister)

If still no resolution apparent and reduction of junior doctors does eventuate…

Audit clinical indicators/waiting times/complaints/complications/overtime costs/critical incidents /sick leave every 4 weeks

Formally document critical incidents and near misses

Increase support to junior staff - extend senior/reg cover, informal and formal debriefing, promote healthy lifestyle, ensure appropriate meal breaks, pay overtime as needed if staff willing and able to do it.

Notify other departments and junior doctors and ask for their support and understanding during this time. Can they back up our claims and notify management of issues they encounter as they arise

If patient outcomes become affected?

Report to Executive Director of Medical Services, District Manager, State Health minister, AMA, Unions.

Whistle blowing and media to be used as a very last, extreme resort.

SAQ 004

Set up a protocol in your ED for the management of (insert one of the following here):

• DKA

• Thrombolysis

• Chest pain

• MI

• Suspected epiglottitis

• Suspected AAA

Thrombolysis Protocol

Be careful of the wording of the question re: “how to write” versus “write the protocol”

Template for “How to develop a policy or protocol”

1. Gather key stakeholders

a. ED staff

b. Other relevant departments

2. Gather information

a. Current evidence

b. Protocol from other hospitals (don’t reinvent the wheel)

c. Consider hospital infrastructure (eg access to cath lab)

3. Develop a Policy with the frame work..

a. Purpose and Scope (Who the policy is to be used by)

b. Content

c. Indications

d. Contraindications

e. Dose

f. Issues

g. Side Effects

h. Complications and their treatment

i. Date for review

4. Educate and Certify

5. Quality Assurance and Policy Review as evidence changes

THROMBOLYSIS POLICY

Purpose of this Policy:

To provide appropriate reperfusion therapy aiming for a door-to-needle time in thrombolysis of less than 30 minutes

Use of this Policy:

This policy is for use in the Emergency Department as part of the Chest Pain Policy.

Background of Chest Pain Management:

Immediate management of chest pain or ischaemic symptoms should consist of:

1. Application of oxygen and administration of aspirin/GTN

2. Full set of vital signs

3. Treat any life threats (arrhythmia)

History is brief and should focus on 2 points:

1. Is this ischaemic chest pain?

2. Are their contraindications to lysis?

A ECG should be performed within 5 minutes of presentation shown to a senior doctor (training registrar or consultant) for identification of ST elevation AMI which fulfil criteria for thrombolysis

A CXR is not vital prior to thrombolysis

Indications for Thrombolysis

1. ECG criteria for AMI fulfilled

a. New bundle branch block

b. 1mm ST elevation 2 or more of inferior leads

c. 2mm ST elevation in precordial leads

d. true posterior AMI (ST elevation V9, ST depression V1)

2. AMI with 12

Using an alias

Asking for specific narcotic by name and dose

Requests specific doctor

Concurrent alcohol or drug abuse

Premature requests for refills

Reports lost/damaged/stolen medication

Third party requests

Therapeutic dependence with true chronic problems

Known to Medicare Prescription Shopping Information Service

Known to local drug management program

Management

1. Manage the Patient

* At the initial instance take claims at face value and offer complete assessment with physical examination and investigations.

* Provide non-narcotic analgesia - NSAIDS, paracetamol, buscopan, hot packs, TCA, (ensure alternatives are non-addictive)

* See further information - other hospital presentations, prescription shopping hotline, hospital medical chart, GP, pharmacy

* Consider underlying social issues

* Consider undiagnosed organic cause

* If narcotic seeking cannot be confirmed give narcotics to alleviate distress with clear end-points and limits on doses. A script for a limited supply (48 hours) until patient can return to normal GP. If ongoing opiate need inpatient assessment should be offered.

* For multiple drug allergies consider drugs that don't release histamine: fentanyl, oxycodone

* For chronic pain ensure patient has had appropriate investigations have been done to exclude organic causes of pain.

* If you are confident the patient is opiate seeking expect a loud outburst and threats when opiate is denied. Avoid confrontation in public places (eg corridor, waiting room) and do this in a private area. Have security staff near.

* Listen to concerns/threats and then give a calm explanation as to

- why you are concerned and refusing opiates

- department policy that supports the refusal

- offer alternative management

- offer admission/referral for further investigation

- offer support/referral for drug rehab, pain clinic

- offer withdrawal support

- Do not provide a script for opiates. Any scripts that are given should be tamper proof

- Notify GP of presentation.

* Document carefully in patients chart.

2. Management for Emergency Department doctors

* stay up to date in acute and chronic pain management techniques

* be aware of where to refer for chronic pain management clinics and drug rehab (inpt vs outpatient)

3. Management of Emergency Department

* consider written guidelines re the use of opiates in migraines/chronic LBP,

* audit the 'frequent flyers' and develop individual pain management plans

* education sessions for staff

* clear protocols to contact security if patient becomes aggressive

4. Management of your community

* know where drug rehab is available and provide support/referral as needed

* notify to medical board if an individual community doctor seems to be over-prescribing opiates

SAQ 105

A woman presents to your Emergency Department with multiple injuries sustained in a "fall" at home a week earlier. What features of the history and examination would lead you to suspect domestic violence as the cause of her injuries ? She admits that she sustained her injuries during a beating by her husband. What is your management ? Outline your management of the social issues pertaining to this case.

Medical Mx

Life threats – strangulation, blunt injury, HI

Associated injuries – bruises, wound

Tetanus prophylaxis

Pregnant ?check fetus

Social

Accommodation - safe house

- offer hospital admission

Children ?safe, previous DOF involvement

Safety of patient and family

Mobilise support network – friends, family, religious

DV support groups

Support with notifying police

Support if returns to partner

Drug and alcohol abuse

Financial issues

Educate/provide information in writing

Follow-up phone call

Psychiatric illness - depression

- suicide risk

Pregnancy increased risk

Environment in ED

Same sex nurse

Try to interview alone

Support ++

Establish trust and show empathy

Social Work involvement

Ensure privacy

SAQ 226

Outline the ACEM clinical indicators used in measuring Emergency Department performance. Also briefly outline strategies to maintain performance according to these indicators (100%).

Clinical indicators are a measure of the clinical management and outcome of care within the Emergency Department.

ED clinical indicators should be measurable, achievable, relevant to the clinical practice of emergency medicine and acceptable to emergency physicians as a reasonable measure of performance.

ED clinical indicators are a part of overall quality management in Emergency Medicine. Others features of quality systems include risk management; consumer participation; complaint analysis and resolution; clinical audit and review; occupational health and safety; and human resource development.

Current ACEM recommended clinical indicators for Emergency Departments:

• Access:

o Indicators – waiting time; access block.

• Safety:

o Indicators – lost time to work related injury; body fluid exposures; patient falls.

• Acceptability:

o Indicators – patient satisfaction survey ratings; written complaint rate.

• Effectiveness:

o Indicator - admission rate by triage category; time to thrombolysis; unplanned representation within 48hrs.

• Efficiency:

o Indicator – waiting time by Australasian Triage Scale.

• Continuity:

o Indicator – provision of written health information for sentinel conditions (eg: asthma, wound care; provision of discharge summary.

Strategies to maintain performance:

Generally:

• Utilise clinical indicators as part of overall quality management within the ED.

• Strive for accurate data collection / performance measures.

• Education of staff as to what specific clinical indicators are.

Specifically:

• Waiting time: ensure adequate staffing levels; ensure accurate data collection; review of work practices / time-management / triage practices.

• Access block: multi-faceted problem involving whole hospital systems; requires review of systems within ED and whole of hospital regarding usage of in-patient beds.

• Safety indicators – staff education, ensure protocols regarding safe use and disposal of sharps and adequate receptacles present, protocols for patient lifts, and protocols regarding use of rails on beds and escorting mobilizing patients.

• Acceptability indicators – publicise to ED staff patient satisfaction survey results to highlight good and bad aspects.

• Admission rate by triage category – ensure accurate data collection; protocols in place regarding senior review prior to any discharge from ED; ED right of admission with in-patient units.

• Time to thrombolysis – staff education regarding indications / contraindications for lysis; review of work practices – ECG and ECG review by senior staff within 10min of arrival; ensure availability of thrombolytics within the ED.

• Unplanned representations - protocols in place regarding senior review prior to any discharge from ED; medical staff education programs esp.: commonly missed injuries.

• Waiting time – as previous.

• Provision of written information / discharge summaries – letter templates on computer terminals; pre-formatted patient information sheets.

SAQ 313

You receive a letter from your hospital administration informing you that the Director of Cardiology has made a complaint regarding times to thrombolysis for acute myocardial infarction in your emergency department. They request a response.

(a) How would you approach this situation? (50%)

(b) What strategies could you implement to improve your times to thrombolysis? (50%)

Complaint from Cardiology to administration regarding ED ‘times to thrombolysis’

Response required back to the hospital administration.

(a) Approach:

• Express initial concern regarding lines of communication between ED and Cardiology. Given that Director of Cardiology didn’t raise this matter directly with ED.

• Verify and validate the data being used to show that there are delays in time to thrombolysis – esp: ensure that problems are not due to incorrect data entry.

• If data correct and delays are occurring –

• Analyse the three issues with this ED system – process, information and decision-making.

• Analyse the cases where delays have occurred looking for common issues that have lead to delays eg:

• Process problems: appropriate triage of patients with chest pain, adequate nursing and medical staff to manage case-mix / case-load (benchmark to ACEM standards), systems for early ECG, adequate clinical areas (monitored) to manage the case-load of chest pain patients (benchmark to ACEM standards), adequate equipment – enough ECG machines, thrombolytics within ED etc.

• Information problems – notification of chest pain patients into ED, is the information (ie: ECG) getting to the appropriate medical staff.

• Decision making problems – information reaching the appropriate people who can make a decision regarding lysis, educational issues regarding lysis – inability to make decisions, other systems interfering / delaying lysis ie: PTCA access system, patient decision making regarding consent to lysis

• Where problems identified – redesign system, with assistance of other stakeholders ie: cardiology, hospital administration where appropriate

• Plan for audit of any new system / changes and report back – to close quality improvement loop

(b) Strategies to improve time to thrombolysis:

• Process:

• Ensure rapid, accurate and efficient triage process for chest pain patients eg: Category 2 NTC

• Chest pain patients triaged to dedicated monitored area for rapid processing

• ECG performed and sighted by senior medical staff member within 10 minutes of arrival

• Dedicated nursing and medical staff (with ability to make decisions on lysis) to manage all chest pain patients

• Information:

• Relevant staff notified of arrival of chest pain patient

• ECG sighted by medical staff who can make decisions on lysis

• Thrombolysis indications / contraindications readily accessible in treating area for reference

• Decision-making:

• Education of nursing and medical staff of system (care-tracks) for managing chest pain patients

• Education of medical staff making decisions regarding lysis – regarding indications, contraindications etc

• Simple to follow consent forms / procedure for patients

• Ensure care-track streamlines with any care-track for primary PTCA access

• Continual quality improvement – audit what you do

SAQ 312

You are a newly appointed consultant at a major referral hospital. The director asks you work on a solution to the "access block" problem that exists in your department.

Outline your approach to this problem.

Definition: Access block has been defined by the ACHS and ACEM as the percentage of all patients admitted, transferred or dying in the ED where their total ED time exceeds 8 hours.

Approach to working on a solution:

1. Gather information:

• From director - regarding what they see as the problem / any historical background local and elsewhere / solutions already tried.

• Information from other hospitals / literature as to initiatives which have worked on this problem.

2. Determine immediate stakeholders:

• Inpatient medical teams, bed managers, nurses on wards, directors of nursing, medical administrators

3. Determine potential fixers:

• divisional directors, medical administrators, district manager, health minister

4. Define the problem:

• Waiting times in all categories, number of admitted patients waiting for beds, time from patient ready to bed ready, times of ward patient discharges, numbers of patients in ED corridors

• Document and graph - actual times, trends from previous years, seasonal variation

5. Make “fixers” aware there is a problem:

• Invite them to meet with you.

• Present your data including graphs, photos of trolleys in corridors etc

• Indicate that such a workplace is “unsafe” for patients, for staff liability, even as a fire hazard.

• Indicate that working under conditions of access block is undermining staff morale (sick leave stats / resignations may support this) and impairing patient care (adverse events / critical incidents occurring to patients with prolonged stays in ED)

• Make them aware that this is a hospital problem, not just an ED one, as evidenced by its presence in many larger Australian hospitals, and all large US hospitals.

6. Suggest solutions:

• A commitment required from management that long term (eg: work practices) and short term strategies (eg: beds reopened and staffed) will be needed, and met.

• That “root causes” in your hospital need to be addressed with the immediate stakeholders (from admission process to discharge process).

• Other healthcare delivery systems (eg: medihotels, day of surgery admission, short stay wards, chest pain units) will also need consideration to change ED work load.

• Develop a policy re: ambulance diversion and a system for going on “alert” prior to access block.

7. Agree to a timetable of implementing changes.

8. Plan to measure the impact of any changes to processes.

• Follow up with statistics to show whether real changes have occurred and feedback to administrators.

9. Consider raising profile of this issue

• Eg: via occupational health & safety, specialty colleges, AMA, media with director’s guidance / consent.

SAQ 154

A 25 year old woman is brought to your Emergency Department after being raped

• What is your management ?

• Outline your history, examination and investigations

• Outline your forensic examination

ALTERNATIVE QUESTION

A 22yo woman presents following an alleged assault. She is withdrawn and will not discuss the details of the incident.

On examination, she has multiple bruises of varying appearance over her body and face. The nursing staff report blood on her underpants while undressing.

Describe your assessment of this woman.

Exam Q

Also see SAQ 155, 175, 369, 442, 482

ISSUES

Extreme Sensitivity

Open support approach

Quiet and private room with no interruptions

Same sex nurse/SW (chaperone)

Support person to stay with patient throughout - never leave alone

Meticulous documentation

Don’t shower, change clothes or wash teeth

Mx

1. Life Threats

2. Assess physical injury

3. Assess genital injury

4. Psychological support

5. STD prophylaxis

6. Pregnancy prophylaxis

7. Tetanus prophylaxis

8. Gathering of forensic evidence

9. Support contacting Police

10. Ensure safety of patient and children on discharge

ASSESSMENT

Hx Event,

when/where/how/by whom,

nature of rape (vaginal/oral/anal),

other injuries (head/face/trunk extremeties),

alcohol or drug intoxication

Forensic hx – showering since ? Changed clothes since ? time of rape

O&G Hx – pregnancies, LNMP, last intercourse, contraception

PMHx, Meds, Allergies, ADT status ? hx – depression

Social hx – DV, dependents safe

Except for serious injury, be careful the Ex and Ix do not compromise forensic assessment.

Ex Life threats – strangulation, HI, haemoperitoneum, haemothorax

General exam – ass inj – defence wounds, bruises

O&G exam – injuries – vaginal/anal/oral (abrasions, lacerations, bruises, discharge)

Ix For trauma as indicated

Bedside

BSL, urinalysis (UTI, hematuria)

Lab

Bloods

FBE (Hb) if blood loss

Beta-HCG

LFT baseline

U&E, Cr

Coags, G&H if bleeding

Check blood type (?anti-D)

Serology Hep B&C, HIV, VDRL

Baseline, need to rpt inn 3 and 6/12

Swabs high vaginal, cervical (?STD)

Imaging as indicated

FORENSIC EXAMINATION

Should be done by government medical officer (GMO) or experienced forensic doctor

Objectives:

Proof of sexual contact

Consent vs use of foce

Identity of assailant

External

Collect all clothing as evidence

Skin any marks including evidence of restraints

Loose hair, nail trimmings, skin scrapings, dried blood

Comb pubic hair

Internal

Swabs (vaginal, cervical, +/- rectal, buccal)

For sperm: vaginal aspirate – wet mount within 72h Wood light for semen

PSA, acid phosphatase within 48h

Serology

Scrupulous documentation

MANAGEMENT

1. Resus/Stabilisation

ABC

Check obs

IV access if needed

Injuries: external, genital

2. Specific Treatment

Treat external injuries starting with life-threatening (external or internal hemorrhage)

IV antibiotics if indicated

ADT

a. Prevent pregnancy (risk 1%)

check beta-HCG (?already pregnant)

post-coital contraception

within 72h

levonogestrel 75mg q12h x 2tabs

SE – nausea, vomiting, dizziness, fatigue

Prophylactic metoclopramide

Advise: will get withdrawal bleed, next period will be late, check beta-HCG in 2/52

b. Prevent local STDs (risk 5%)

N. gonorrhea ceftriaxone im 250mg stat

Chlamydia doxycycline po 100mg bd 7d

Erythromycin if ?pregnant

c. Prevent blood-borne STDs

HIV discuss starter pack

2 x antiretroviral agents

SE – GI, hepatic, cutaneous, heatologic

2/52 course, then FU at ID clinic

weigh risk of infection vs risk of treatment

HBV if never immunised/sAb levels low:

Hep B Ig + commence course of Hep B s Ag x 3

HCV ?interferon (seek advice from ID)

3. Supportive care

Analgesia, antiemetic

Psychosocial input: social worker, rape counsellor, psyc service, legal services/police

Forensic assessment: GMO

Family support

4. Disposal

Depends on injuries – gynae, medical, surgical, ortho

If sent home, ensure tight follow up:

LMO – check test results, follow up tests

O&G – STDs, pregnancy

SW, counsellor

SAQ 285

Discuss the advantages and disadvantages of having a chest pain unit

Start with general concept

For risk stratification using Hx/ECG/pathology TNI and stress testing

Advantages

Decreased length of stay

Decrease in bed days

Discharge planning

Stress test

Managed care plan

PR aspect

Initiative

Disadvantages

Set up costs

Ownership

Poor pt selection

Undifferentiated pts being put through a differentiated system will result in stuff-ups (Eg PEs or aneurysms)

Variation on question would be setting up a chest pain unit

OVERVIEW

Used for risk stratification

Danger of undifferentiated patient in differentiated system

NEEDS

Demographics

Numbers presenting, admissions, etc

LIAISON

With Cardiology, Physicians

PROTOCOLS

Use of TnI & ECG

EDUCATION

Medical staff

Nursing staff

STAFFING

After hours coverage

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