Administration Flashcards
A 15 year old female is brought to ED by her friends after she collapsed at work. She is found to have a positive B HCG and free fluid in the pelvis on ED ultrasound. The patient wants to self discharge as she is worried that her parents will be told about her presentation.
- State 6 important considerations in your approach to counseling this patient to stay in ED for further care
- List 3 important medico-legal considerations in this case and provide a short explanation for each
-Private room for counselling
-Chaperone - additional health care provider
-Sympathy/ empathy - patient centred language, empathetic approach
-Provide information - likely cause for collapse - ectopic pregnancy
-Explain concerning outcomes - life threat
-Confidentiality - explore why patient wants to discharge - reassure you do not need to inform her parents against her will
-Explain consequences if she still wants to self discharge
-Legal obligations - ultimately might need to escalate care and involve courts if patient wants to refuse treatment that may be lifesaving
-Consent - a mature minor may be able to give consent without parental involvement
-Gillick competence - a mature minor may have the competence to give consent
-Capacity - need to establish if she understands the outcomes of refusing care
-Refusal of consent - not allowed in life threatening cases if minor
-Emancipated Minor - a mature minor > 14 years living out of home and independent of parents may be treated as an adult in the eyes of the law
-Child protection/ rape and involving police in case of incest/ statutory rape
You are an ED consultant in a mixed urban ED. You have been approached by your senior clinical nurse informing you of a trainee she is concerned about. According to her she suspects the trainee has an alcohol misuse problem. On multiple occasions the trainee posts about his alcohol use on social media. She is concerned that there also may be recreational drug use. Furthermore several other nurses have reported he is abrupt, rude and does not communicate his plans. The registrar is an early phase advanced trainee who recently completed his primary examinations.
- List 4 examples of notifiable conduct that would require mandatory reporting to AHPRAH
- What further investigations would you need to complete before meeting with the registrar?
- What preparation or planning is required to arrange and set up the meeting?
You have organised to meet with this trainee to further discuss this issue
- State 6 important considerations you would need to explore in this meeting?
1.
-Practicing while intoxicated on alcohol or drugs
-Sexual misconduct in the practice of the profession
-Placing the public at harm because of an impairment/ health issue
-Placing the public at risk because of a significant departure from accepted professional standards
-Comprehensive data gathering before discussing such serious concerns in order to establish if a meeting with the reg is warranted
Objective data
-Patient care incidents - clinical errors/ complaints by patients about communication/ medication error
-Staff incidents - written complaints made against the trainee
-Professional behaviour - punctuality/ dress code/ attendance at mandatory training
-Review of performance indicators e.g. number of patients seen on shift
-Attendance at ward rounds/ teaching sessions
-Review of formal sick leave
-HR review of incidents at hospital
-WBA compliance
Subjective data
-Consultant team opinions of reg performance and professionalism
-The mental health of the reg should be a strong consideration before proceeding to a formal meeting
-If concerns are warranted
-ED director/ DEMT must be informed
-Reg needs to be informed that his performance will be discussed due to concerns raised
-A support person should be chosen by the reg to attend/ appointed by the director
-A suitable time and venue should be chosen - not when the reg is due for a shift on the floor
4.
-Investigate and ensure no need for mandatory reporting
-The behaviour or work incidents of concern need careful consideration
-Identify work stressors
-Identify personal stressors
-Identify lifestyle factors - drug or alcohol use
-Identify and offer ongoing support - family/ friends/ mentor/ DEMTs
-Offer alcohol/ drug liaison service referral
-Offer time off/ roster changes to accommodate for trainee burnout
Important to review regulations for mandatory reporting of conduct
Important to review ACEM documents for supporting the impaired physician
Aside from low threshold for sexual misconduct only notification only required if there is a substantial risk of harm to the public
A mandatory notification is not required if a practitioner is admitted with a mental health or inpatient treatment for drug issue
You receive a complaint from a patients mother, whose 10 year old son was treated in your ED yesterday for a fractured radius. The complaint alleges that they were made to wait 6 hours before the treating doctor, Dr Brown (an intern) was rude, manipulated their son’s fracture without any pain relief and told the patient to ‘stop whinging like a baby’ when applying a cast.
The complaint also states that the patient had to return to a different ED that night as the cast was painful. The doctors at the second hospital said the cast was ‘too tight and should have been split’ when it was put on.
- State 6 initial steps that need to be taken
- List 9 important departmental administrative concerns that may have lead to this scenario that need to be prioritised for review during your investigation of this case
-Thank the mother for bringing your attention to the problem
-Apologise for the pain the child felt and the unhappiness they felt during the care episode
-Ensure that the child is has adequate analgesia, has an appropriate cast in place and follow up in fracture clinic has been secured
-Undertake/ pledge to fully investigate the case
-Organise a time to provide feedback to the mother if she is keen on this option
Approach
-PPS EDS
-Patient factors vs Doctor factors vs Disease factors vs Environmental factors vs Parental factors
Personal
Place/ deparmental physical environment
Procedures
Equipment
Drugs
Systems
Personal
-Fitness to work - competency for role and responsibility
-Insight and awareness
-Personal issues/ stressors
-Mental health
-Substance abuse
-Inappropriate communication
Departmental
-Surge in ED? Too many patients for resources?
-Long waiting times
-Lack of senior supervision of junior staff
Procedures and protocols
-Orthopaedic guidelines
-Why is an intern manipulating a fracture
-Painful procedures without analgesia - analgesia protocol for children
-Lack of discharge advice re plaster care/ compartment syndrome
Systems
-Nursing system - where was nurse
-Fracture flagged by radiology
-Plaster technician support systems for ED
Improving Access Block
Reducing demand
- Increased number of medical staff-particular senior decision makers
- Increased nursing staff
- Increased allied health services
- Consideration of nurse navigator roles
- Increased bed numbers
- Increased community/GP funding for complex patients
- Availability of hospital outreach
- Increased rapid access outpatient clinics
Improving discharge
- Consideration of discharge targets
- Increased frequency of senior decision making ward rounds
- Consideration of nurse led discharges
- Increased allied health access
- Increased aged residential care access
- Increased community care supports
- Increased transit lounge capacity for patients only awaiting transport
-Patient remaining in department due to lack of ward beds for more than 8 hours
Reduce demand
In community
-Improve funding for GPs to care for complex care
-Hospital in the home, hospital in the nursing home
In ED
-Senior decision making 24/7
-Accelerated evidence based protocols - chest pain protocol
-Access to consultations and investigations
Increasing capacity
-Fast track
-Fast laboratory and XR turn around times
-Ensure adequate ED beds
-Bed coordinator
-Daily rounds
-Improved speed of investigations and consultations
-> 3 acute beds per 1000 population
Improving exit
-Morning and weekend discharges
-Transit lounge
-Post acute care services
A 20 year old man presents after a game of cricket where he sustained an impact to the eye with a cricket ball. He is complaining of pain and blurred vision. He has no injuries elsewhere and his vital signs are normal. Review a clinical photograph of his eye.
- Describe 2 significant findings and state the likely diagnosis
- List 6 aspects of his management
- During the consultation it becomes apparent your registrar does not know how to use the slit lamp for examination of the eye
Outline 7 important processes to follow in developing a teaching module for ‘ocular examination and slit lamp proficiency’ for the ED
Provide short explanatory notes for each step and ensure relevant aspects of educational theory is included regarding the teaching of a skill in the ED
-Grade IV, ‘8 ball hyphema’
-Place an eye shield
-Rest eyes, no reading / TV
-Bed rest with HOB elevated to 30 degrees
-Urgent ophthalmology consultation for consideration of surgical drainage
-Treatment: cycloplegics, acetazolamide, timolol 0.5% if raised IOP
-Analgesia/ antiemetics - paracetamol 1g, oral morphine, local anaesthetic - avoid NSAIDs
-Eye US to exclude retinal detachment/ vitreous detachment
-Check IOP
Collect data/ survey needs/ benchmarking
-What is currently being used in the ED for slit lamp education?
-Survey to regs and consultants - what package are they using to learn eye examination
-What are other ED’s using
-What is recommended by the local ophthalmology service
-Is there an existing teaching package for modification to my ED
Stakeholders
-Ophthalmology
-DEMT’s/ eye lead
-Directors of clinical teaching - residents
-Nursing staff
Clearly outline the expected competencies expected with completion of the module
Instruct teachers on ‘teaching on the run education principles’ for teaching the sill
Skill teaching includes:
-Knowledge (indications, contraindications, complications and their prevention)
-Skill (preparation, technique, dexterity)
-Communication (consent, comfort, dignity of patients)
Four step approach to teaching skills
-Demonstration: trainer demonstrates at normal speed, without commentary
-Deconstruction: trainer demonstrates while describing steps
-Comprehension: trainer demonstrates while learner describes steps
-Performance: learner demonstrates while learner describes steps
Teaching module format
Aim for combination of:
-Video online education, guidelines, checklists
-Regular didactic teaching on the subject - invite ophthalmology to attend
-Ask consultants to do regular on the run teaching sessions on slit lamp use
-Include as WBA requirment/ OSCE exam teaching station
Ensure compliance with completion of module
-Sign off by DEMT
-Include as part of reg assessment
Written feedback from participants on ways to improve
ACEM policy for managing and remediation of the poorly performing practitioner
Areas of performance managed
-Skills as clinician
-Decision making
-Supervision of junior staff
-Teamwork and leadership
Does not exist to manage impairments unrelated to clinical practice
Identification
-Self referral, referral by other college staff member or regulatory body
Management
-Management plan - learning needs analysis, peer review reports, courses, upskilling
-Supervisor selected -senior FACEM (at least 5 years)
-Time frames determined
-Performance management process
-Assessment and completion of remediation plan - report from individual and supervisor
ACEM policy on sustainable ED workforce for FACEMS
ACEM
Consultant lead ED as the staffing framework
Staffing based on number of annual presentations
Time allocation for clinical support activities - teaching, professional development
All patients have senior input, FACEM involvement optimal
Maximum long term weekend commitment of 10 weekends per year
One fellow to 3 trainees (advanced and provisional)
Shifts no longer than 10 hours
Minimum of 10 hours between shifts
Regular 48 hour periods off work
No more than 40 hours per 7 days
A 15 year old girl presents to ED with her parents who are very concerned about her weight. Her BMI is currently 15. She has been purging and refusing food at home over the last 2 weeks.
- List 8 clinical, bedside test or lab criteria that would require her to be admitted to the hospital?
- The child is refusing admission to the hospital and states you are abusing her rights. List 4 important medicolegal principles involved in this scenario. Explain how they apply or their implications
-BMI < 12
-HR < 40 or > 120
-BP < 80
-Postural drop > 20
-Temp < 35
-ECG: arrhythmia or QTc prolonged, ST deviation or repolarisation abnormality
-BSL < 2.5
-Na < 125
-K < 3
-Mg < 0.7
-PO4 < 0.8
-ALT > 500
-Albumin < 30
-Neutrophils < 1
Consent
-Can give or refuse consent if >18
-Age of maturity / limited decision making is > 16 (cannot refuse life saving treatment)
-If there is a dispute then escalate to chief medical officer and judge
-14-15 - Gillick competence
-< 14 unable to make any decisions for themselves
Must have competence (or capacity)
-For consent to be valid it must be given by a person who has the capacity to make that decision
-Need to be able to understand the nature of the condition, the options available, the treatment being recommended plus the risks and possible outcomes of any treatment
Physical conditions such as anorexia can impair capacity
Mental health conditions can impact capacity
