Administration Flashcards
What are the aspects of professionalism that are often assessed?
- If professionalism appears in the domains assessed, these are the typical things that will be looked at
- ie a cardiac history station becomes a capacity assessment for a patient wanting to leave
What are the important points to address in planning for mass casualties/Disaster in an OSCE?
Initial
- METHANE sitrep
- Try to determine number and type of casualties
- Activate hospital disaster plan
- Activate disaster triage system, give people triage cards (Black, red, yellow and green)
Space
- Create capacity
- Decontamination zones
- Utilize outpatients, radiology and ambulances bays for extra space
- PACU and theatre for extra ICU level spaces
Staff
- notify important stakeholders (Chiefs of ICU/Surgery/Anaesthetics and medicine, CEO, Security, bed manager, Ambulance, Police)
- Call in off duty medical and nursing staff
Stuff
- Ventilators (may need to repurpose from rest of hospital)
- Pelvic binders, Donway splints, tourniquets if trauma
- Analgesia, antibiotics and tetanus immunisation
- Early contact with blood bank, rationalise product use
- Wound dressings
Patients
- Decant as many patients from the wards, short stay, main ED and ICU
- Cancel all non-urgent surgery
- Cancel any clinics and decant patients
How should development of a new policy be adressed?
Audit Cycle Simplified = IDCCID
Identify
- The problem
- Ie unclear policy around CTB in trauma
Define
- The standards
- Ie canadian CTB score for HI
Collect
- the date such auditing the identified problem
- Audit of CTBs ordered, missed diagnoses, LOS awaiting results
Compare
- the performance to state or national standards
- Compare miss rates and CTB’s ordered with other departments
Implement
- The new policy or change
- New policy on CTB ordering, or new CLD for paediatric asthma etc
Data
- re-audit to compare with previous data and determine if new strategies succesful
- Ie less misses or less CTB’s ordered, shorter LOS for asthma CLD
The impaired physician (alcohol, drugs, mental illness etc) OSCE
Assessment
- organise a meeting outside of working hours
- Consider a support person for the physician (advocate for them)
- Any whistleblower needs to be protected and kept confidential
- Whole process is confidential
- Determine if threshold reached for mandatory disclosure/reporting
- Identify work stressors
- Identify personal stressors
- Screen lifestyle factors (drugs/etoh)
- Consider audit of cases looked after by this doctor (determine if practicing in a safe manner)
- Screen for risk of suicide/SH
Management
- Offer ongoing support (family, friends, DEMT, GP, psychologist, work place support)
- Drug/alcohol liason service referral if indicated
- Offer time-off or roster changes to help with burnout
- Advise them to contact their indemnity insurance
- If no serious issues found then general advice on workplace behaviour to improve standing
Mandatory reporting thresholds
- Sexual misconduct
- Practicing while intoxicated on alcohol or drugs
- Impairment putting patients at risk (phyiscal health, mental health etc)
- Substantial departure from accepted professional standards placing patients/public at risk
Sexual Misconduct
- Very serious, mandatory investigation
- Paid suspension during Ix
- Police, AHPRA and work related HR will be involved
Improving flow for overcrowding and access block in the ED
Equations
- 1 SSU bed for every 4’000 presentations per year, minimum size should be 8 beds
- 1 resus bay for every 15’000 presentations per year (minimum 1)
- 3 hospital beds per 1000 people in the population (ie city, town, suburb)
- ED size = 50m^2 per 1000 yearly attendances
- Total number of treatment spaces should be 1/1100 yearly presentations
- Approximately 1 consultant and 4 juniors (mix reg, res and intern) per 20,000 yearly presentations
- >90% of admissions should go to the ward within 4hrs of arriving
- Approx 1 admitting registrar per 10 inpatient team admissions per day
Access block vs Overcrowding
- Overcrowding is when treatment/ED is dysfunctional due to the arrival rate outpacing the treatment rate and discharge/transfer rate, leading to an increase in morbidity/mortality
- Also defined as when ED function is impeded because the number of patients waiting be seen, undergoing assessment/treatment or awaiting departure exceeds either the physical or staffing capacity of the ED
- ED overcrowding is a marker of whole hospital dysfunction and requires WHOLE HOSPITAL Approach
Access block
- The proportion of patients in the ED awaiting admission to inpatient bed who have been in ED >8hrs
- The number 1 cause of overcrowding in the ED
National Emergency Access Target
- 90% of patients presenting to ED should be admitted, transferred or discharged within 4hrs
Ways to reduce overcrowding
- Senior staff review early
- Ordering of investigations at triage or soon after (before formally assigned to a clinician, ie RAT teams or nurse initiated meds/Ix)
- Streaming of patients to Fast track/rapid assessment areas
- Increasing the number and seniority of ED staff
- Physical rebuilding to increase number of patient care spaces
- Transfer to inpatient wards once a verbal plan from inpatient team has been documented
- Flow management hospital team for early inpatient discharge planning
- Hospital avoidance strategies such as GP liason with nursing homes, HITH programs etc
- Care pathways for patients (NOF fracture, COPD, pneumonia, frequent flyers etc)
- Reducing demand, increasing capacity, improving egress
NOT shown to reduce overcrowding
- Ambulance bypass
- Nurse on call
- Ambulatory care clinics
Dangerous Departments
- Make recommendations to the state ministerial on healthcare
- Key stakeholders are all the hospital directors, ED consultants, patient advocates, nursing bosses
What are the general points to be addressed in most management questions?
Overall Governance
- department, hospital director, state ministerial etc
Stakeholders
- ED, hospital wide, state wide etc
People
- staff number, staff type, addition of nurse practitioners etc
Place
- SSU (make new or repurpose a ward), rebuilding of hospital etc
Equipment/Services
- Full time pathology/radiology etc
Systems
- Streaming of patients ie fast track, paeds etc
Guidelines
- Chest pain rapid rule out pathway, NOF pathway etc
- Admission protocols (can go to ward before inpatient reg review)
- Admitting rights
Approach to frequent flyers?
Underlying issue
- Unmet needs (housing, social, medical, pain, drugs etc)
- Inconsistent care approach
- Poorer outcomes
- Increased investigations, radiation exposure and drug prescriptions (opiates, antibiotics etc)
- Make up a large part of the healthcare costs across multiple systems (ie ED, GP, ambulance etc)
- Usually defined as 10+ presentations per year
Demographics
- Homeless
- ATSI/specific ethnic groups
- Drugs/alcohol
- Elderly
- Complex social, medical or psych
Individualised Care Plans
- Identify patients regular issues
- Tests to do and not do
- Consensus plan from key stakeholders (ED, SW, GP, specialists, exec +/- patient themeselves)
- EMR alert that is easy to see and access for any staff
- Idea is to ensure consistency and connect patient to better solutions in and outside the ED
- Define the history and problem, define the needed actions
Study/Plan/Act/Do
- The admin mantra
- The QI cycle (Plan, Do, Check, Act)
- Clinical governance (risk to patient and hospital, needs a champion or clinical lead to own the issue)
Study
- The number of frequent flyers
- Their presenting issues
- Complications in the past
- key services to be involved
Approach to prisoners?
Special points
- Treat with the same equity and care as any other patient
- High risk patient group
Consent
- Clarify based on state and institutional guidelines if patient can make own medical decisions
- Some states/situations the patient has a guardian who makes medical decisions
I CURE for capacity
I- Impairment or disturbance of the mind (drugs, alcohol, head injury, mental diasbility etc) temporary or permanent preventing them having capacity
C- Communicate their decision
U- Understand the information in order to make a decision
R- Retain the information
E- Employ the information to make the decision ie weigh up risks and benefits, different options
Approach to domestic violence?
Mental Health screen
- SIGECAPs
- Suicidal
Offer supports
- SW
- Safe steps
Domestive violence screen
- HITS mnemonic
- High risk behaviours (Strangling, weapons at home
Abuse types screen
- Sexual
- Monetary
- Verbal
- Emotional/psychological
- Physical
- Isolation
- Stalking
Kids involved?
- If kids at home and potential for them being abused then meets mandatory reporting, refer to DHS and child protection
Mandatory reporting
- Normally reporting is up to the victim
- Serious or extremely dangerous injuries meet mandatory reporting guidelines
Serious Injuries include Gun shot wounds, stab wounds, strangulation, serious head and neck injuries, serious fractures
- If perpetrator has access to a gun, is carrying and threatening to use another weapon (ie knife)
- Potential or actual child abuse or elder abuse are both mandatory
- Screen if children at home or could be at risk
-Consider competency assessment in victim re reporting
Discharge
- If cleared for discharge and deemed competent
- Written and verbal advice
- very clear return advice, give number for social work
- 1800RESPECT domestic violence hotline
Approach to root cause analysis or critical incident analysis?
Try to make differential diagnosis
- Systems issue? Skill issue ? hardware issue etc
- Ensure open disclosure and apologize to family
Take a History
- Data collection
- written notes, triage, meds given, timeline etc
- Self (individual training etc)
- team (who was on, level of seniority, did those needed or called come to help?)
- environment (good ergonomics, the right place to do the procedure etc)
- system (efficiency, policies, demands, previous similar issues)
- patient and illness (Paeds patient in adult department, severe illness always going to deteriorate etc)
- task and technology (VL vs DL etc)
Perform an Examination
- Interview those involved
- Debrief and support staff involved
- Support, SW, counselling and psychological care +/- chaplaincy for patient/family
- Equipment, drugs, environment etc
- NEAT targets, overcrowding and access block when incident occurred
Do investigations
- Notes, procedures, guidelines
- Who are you reporting to ie Governance ? (CEO, health minister etc)
- Ensure legal team involved
- Media team liason
Interim report
- Prinicpal diagnosis
- SAC 1 (severity assessment code)
- Important stakeholders involved
- Recommendations
- Management plan to address the root causes of the issue
- Auditing , MM and QI cycle (plan, do, study and act)
Factors contributing to CI?
- Bad Disease/Patient (inevitable, uncommon, PHx etc)
- Bad doctor (incompetent, lack of training etc)
- Bad night (insufficient staffing, access block, overcrowding)
- Bad consultant (poor decisions, didnt come in/answer phone etc)
- Bad specialists (poor advice, not coming in to help etc)
Approach to end of life care?
Screening tools
- Crystal
- Script
- “surprise question” would i be surprised if this patient died in the next 12 months?
- Clinical Frailty scale
- Pre-existing AHCD
Substitute decision makers
- MPOA/EPA
- Guardianship
- Capacity
- Cultural practices (ie ATSI)
Discussions
- Current state of illness
- Trajectory of illness
- Quality of life
- Non-beneficial treatment
- Doing as little harm as possible (ie limit invasive procedures)
- No longer DNR/NFR but use term “allow for natural death”
- Goals of Care form
Comfort
- EOL meds
- Hygiene (secretions, changing diapers, catheter)
- Quiet and private room
- Chaplaincy
- Loved ones around it possible
- Palliative care/pain team involvement
- Return home if possible
General approach to critical incident management
Acknowledge
- Open disclosure
- Inform director
Apologise
- To patient and family
Assure
- Assure patient/family and assume care of the situation
- I will personally run the analysis on this and communicate with the family
- Support the doctor involved, take over patients, send home
- Get doctor to look into EAP and contact medical indemnity
Assess
- Investigate, RCA, define corrective measures
Arrange F/U
- Communicate with the patient and family
- Get appropriate medical, legal, SW etc follow up for them
Clinical Governance
- Incident report, SAC1/2/3
- Audit cycle
- Present in M&M
- Consider teaching session
- Develop or review guideline
