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(Surviving internship tips)
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*First learn the basic things about your job
 
*First learn the basic things about your job
 
*pharmacology only for dangerous delirious patient. Avoid it otherwise. Only when putting staff or self at risk . If you have a delirious patient there you shouldn't be doing it yourself. Med reg should be there too.
 
*pharmacology only for dangerous delirious patient. Avoid it otherwise. Only when putting staff or self at risk . If you have a delirious patient there you shouldn't be doing it yourself. Med reg should be there too.
 +
*take your lunch breaks
  
 
==Book recommendations and pdf sources==
 
==Book recommendations and pdf sources==

Revision as of 03:52, 27 January 2017

Here are a few pearls of wisdom from orientation for internship.

  • get slides from jhh

Detecting the deteriorating patient

  • Every hour delayed in diagnosing sepsis is associated with 8% increase mortality
  • Our "Track and Trigger" system is stipulated by the Between the Flags project [1]
    • SAGO = standard adult general obs chart
    • SPOC = standart paeds general obs chart - by age category
    • "Triage" ranking: 1. Clinical review 2. Rapid response 3. ALS pathway
    • Lecture notes on this topic, including what to do in each zone
    • Interns should err on the side of safety - if unsure whether to do a rapid response call, just do it (you won't get in trouble for being too careful early on)
  • NSW Health Protocol for deteriorating patients [2]
  • HETI online module for detecting the deteriorating patient using DETECT acronym [3]
  • SOCCER criteria (p13) [4]
    • Early
      • Base deficit -5 to -8mmol/L
      • Partial airway obstruction (excluding snoring)
      • Poor peripheral circulation
      • Greater than expected drain fluid loss
      • pH 7.2-7.3
      • PaCO2 51-60mmHg
      • Urine output < 200ml over 8 hrs
      • Noted decreased urine output
      • GCS < 9-11 or fall in GCS by > 2
      • Any seizure
      • Respiratory rate 5-9 or 31-40
      • New pain
      • SpO2 90-95%
      • Other
      • Systolic BP 80-100mmHg
      • Alteration in mentation
      • PaO2 50-60mmHg
      • Uncontrolled pain
      • Pulse rate 40-49 or 121-140/min
      • BSL 1-2.9mmol/L
      • Systolic BP 181-240mmHg
      • Complaining of chest pain
    • Late
      • Cardiac arrest
      • Urine output < 200mL / 24hrs
      • pH< 7.2
      • Unresponsive to verbal commands
      • Other
      • Anuric
      • Base deficit < -8.0mmol/L
      • GCS ≤ 8
      • PaO2 < 50mmHg
      • Pulse rate > 140 or < 40
      • Respiratory rate > 40 or < 5b/min
      • PaCO2 > 60 mmHg
      • Failure to reverse variable < 1 hr
      • SpO2 < 90%
      • Systolic BP < 80mmHg
      • Airway obstructed / stridor
  • LITFL Registrar's lecture on the topic

Calling criteria

  • From the policy[5]:

The colour coded zones on the Standard Observation Charts indicate when a patient is showing early and late warning signs of clinical deterioration and outline the appropriate escalation of care to a Clinical Review or Rapid Response. For example in the charts:

  • The Blue Zones (where applicable) represent criteria for which increasing the frequency of observations is required
  • The Yellow Zones represent early warning signs of deterioration and the criteria for which a Clinical Review (or other CERS) call may be required
  • The Red Zones represent late warning signs of deterioration and the criteria for which a Rapid Response Call is required.

NB: these may be altered for the individual patient, as may the obs frequency

Clinical reviews

  • Calling criteria
    • discretionary zone
    • Activation of the facility’s CERS based on Yellow
    • Zone observations or additional criteria is discretionary and based on your Clinical Judgement of the patient’s condition.
    • Decision to escalate or not to escalate MUST be done in consultation with the NURSE IN CHARGE.
    • With nurse, consider: what is usual for this patient, are there documented alterations to calling criteria, does the trend reflect deterioration, >1 yellow zone obs or additional criteria, or are you concerned?

Pathway:

  • First check if escalation is required or not. If not, continue:
  • Initiate appropriate clinical care
  • Repeat your patient’s observations
  • Increase the frequency of observations as indicated by the patient’s condition
  • Document an A-G assessment, reason for escalation, treatment and outcome in the Health Care Record
  • Inform the AMO as soon as practicable
  • Big DDx's for causes of deterioration (roughly similar to 4H's and 4T's)
    • Sepsis
    • Arrhythmia
    • Hypovolaemia/haemorrhage
    • Pulmonary embolus/dvt
    • Pneumonia/Atelectasis
    • AMI
    • Stroke
    • Overdose/sedation

Rapid response

  • Calling criteria
    • Any red zone observation
    • Deterioration in CR not reversed within 1 hour of review
    • Serious concern - you or nurse
  • Red zone obs
    • Call a rapid response
    • Initiate appropriate care
    • Inform the nurse in charge you have called for a rapid response
    • Repeat and increase frequency of observations
    • Stay with and own the patient as a priority
    • Get more people involved - if a ship is sinking, load it up
    • Document an A-G assessment, treatment, escalation process and outcome in health care record
    • Inform the AMO as soon as possible eg 7am if on nights

MEWS score

  • use it on MDCalc app
  • The Modified Early Warning System (MEWS) is a tool designed to identify patients with declining conditions.
  • It has been shown to be superior to clinical judgement for this purpose.
  • It was originally designed for nurses but can be used by any healthcare professional with adequate training.
  • MEWS is based on the principle that clinical deterioration can be seen through subtle changes in a number of parameters as well as large changes within a single variable.

ResidentGuide

End of life discussion

Discharge summaries

After hours

ECGs

Blood gases

Fluids

VTE risk

  • look up framework
    • identify patient risk
    • assess and documen vte risk and whether they need pharmacological vs mechanical prophylaxis
    • prescribe: heparin or lmw and why. Do we need mechanical prevention
    • engage the patient and need to mobilise early
    • its their responsibility as well
    • reassess every day
    • monitor practice
  • IMS to report pulmonary embolism
  • assess risk on discharge - will need vte prophylaxis at home-injections
  • risk factors: age obesity previous history pregnancy thrombophlebitis varicose veins
    • reduced mobility, cancer, use of HRT or oral contraception, surgical intervention, active infection, inflammatory bowel disease
  • HNE vte risk chart is in the office. This assists your risk stratification
  • UFH-preferred in patients with renal impairment. Ccr <30. 6hr halflife. Reversible
  • LMWH- need dosage adjustment in renal impairment
  • factor Xa inhibitors
  • direct thrombin inhibitors
  • heparinoid
  • contraindications: bleeding, thrombocytopenia, end stage liver disease, treatment with therapeutic anticoagulation, cns trauma
  • weigh risk vs benefit
  • Mechanical prophylaxis
    • graduated stockings
    • internittent compression device
    • foot compression device
  • contraindications:ulcers, trauma, fat, oedema, stroke patients
  • dedicated section of vte on the MED chart
  • use the heparin tool
  • report adverse incidents on IIMS
  • links
    • cec vte prevention on health nsw gov
    • vte prevention resource centre - safety and quality gov

Surviving internship tips

  • Common calls: Pain, hypotension, hypertension, low urine output, N+V, shortness of breath, chest pain, delirium/agitated patients, fever, hyperglycaemia, sleeping tablet requests
    • Look at app for common calls guide
    • Sleeping tablets: don't give if over 65. 1. leave job to end, probably will be asleep 2. sit there and read out the whole policy 3. state the hospital isn't a good sleeping place, give them ear plugs, talk about sleep hygiene
    • Confidently rule out serious causes eg hypertensive crisis
    • Talk to the nurse if they keep paging you - explain why you're not concerned. Call me if x, y, z happens
    • Will be some false positive alerts from nurses
    • Take 2 minutes to explain it and you'll save you later
    • Don't ignore nurses
  • Ask questions early, even simple ones
  • Be the patient advocate
  • If they yell, ask them their name and designation
  • Own your patient
  • Write the last name of registrar, what they exactly said etc - in progress notes
  • Work only at your own pace.
  • See sick patients before clearing the mon
  • Intern ED's are supernumery - not needed to increase ED patient flow
  • If someone questions whether to call at MET team, just do it - side of caution
  • Allied health prevents patients bouncing back to your ward
  • Don't forget pharmacist
  • Turn up an hour early to go through things if you're an intern
    • Read lists
    • Finding out what happened overnight
    • Know results
    • Imaging
    • Take COW with you so you don't need to memorise the bloods
  • Tell the consultant in the morning if anything bad happened overnight
    • Only unexpected death --> ring him
  • Start CV stuff early
  • Applying for jobs June in residency
    • Farrah: put together CV in 5th term of intern year-before that trying to not kill anyone
  • Courses are very expensive - not there just to get a point, but to expand knowledge - could just do an audit etc for free
  • Join hospital culture, meet people
  • First learn the basic things about your job
  • pharmacology only for dangerous delirious patient. Avoid it otherwise. Only when putting staff or self at risk . If you have a delirious patient there you shouldn't be doing it yourself. Med reg should be there too.
  • take your lunch breaks

Book recommendations and pdf sources

  • The Washington Manual Internship Survival Guide
  • On Call by Marshall + Ruedy
  • Titles available here, searchable pdfs and epubs

References

  1. http://www.cec.health.nsw.gov.au/patient-safety-programs/adult-patient-safety/between-the-flags/standard-calling-criteria
  2. http://www0.health.nsw.gov.au/policies/pd/2013/pdf/PD2013_049.pdf
  3. https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/deteriorating-patients
  4. https://www.safetyandquality.gov.au/wp-content/uploads/2012/02/UsingObservationCharts-20091.pdf
  5. http://www0.health.nsw.gov.au/policies/pd/2013/pdf/PD2013_049.pdf