A nurse checks on a patient in the cancer ward

Departments

A typical day in the Emergency Department

Shift times

Shifts fall into three groups: day (8am to 6pm), evening (1pm to 11pm) and night (10.30pm to 8.30am).

The day and night shifts begin with hand-over. The evening shift also starts with a meeting of the evening team (consultant, registrars and residents). Meal times and other breaks are not fixed and it is generally left for individuals to take breaks when mutually suitable - i.e. not all staff off at once.

The Emergency Department has a "streaming" model of care, with patients streamed at triage to paediatrics, Team 1, Team 2 or Fast Track. Medical staff in these teams are self-contained and registrars are rostered to work shifts in one of these care areas. Each care area is generally supervised by an Emergency Physician or a senior registrar toward the time of their Fellowship Exams.

Hand-over

Formal hand-over occurs at three fixed times every day: 8am, 3pm and 10.30pm. There is also usually a brief “catch-up” round at midday.

The functions of hand-over are:

  1. To hand-over responsibility of patient care at the end of your shift
  2. Discussion of clinical management with senior staff (although this should be done at all times; you should not wait for hand-over to seek advice)
  3. Education: Hearing various patient presentations and the appropriate management is one of the ways we learn about patient care.

After hand-over, you should review the patients you have been handed over in order to ensure they are stable, and that the stated management plans are in place.

If you are handed over a patient that has already been admitted, the admitting unit should undertake the ongoing care, however, you should still check that the patient is stable, have a brief on the issues pertaining to their admission and be prepared to assist with minor or time-critical matters.

Picking up patients

Rarely will you be asked to pick up a new patient; generally we assume that you will see another patient when you are able. You need not wait for your previous patient to leave - most of us take our next patient whilst waiting for investigation results etc.

There is no protocol about which doctors can see which patients, except for interns who must discuss all their patients.  If you have not had a paediatric or critical care rotation we expect you to seek us out for discussion of these patients, even if it’s within the first 30 seconds of seeing your patient.

When to seek help

Between 180 and 220 patients are seen every day in the ED, so it is important to maintain the flow of patients into and out of the department.

In most cases the need for admission is not reliant on investigation results, but sometimes the decision will hinge on results or consultations within the ED or with inpatient units.

Discharging patients

In general, patients are discharged home or admitted to hospital (inpatient ward or EMU).  A number of items must be attended to when this occurs.

Discharge home

     Medications

     Discharge instructions – when to see an LMO, when to return to the ED

     LMO letter

     Method of transport- usually self or family, but some may need an ambulance

 

Admission to ward

     Bed must be arranged

     Inpatient unit must accept the admission

     Electronic interim orders/admission notes

 

Transfers

     Contact receiving hospital and receiving specialist

     Letter, including all investigations

     Ensure relatives are aware

 

Admissions to EMU

     Electronic ED Departmental form / interim orders

     Medication chart and intravenous orders

     Discharge letter (compulsory)

ED consultants

There is consultant cover on the floor from 8am to 11pm. Outside these hours the ED consultant is on-call, and will stay back or be on recall if the need arises. This may occur with excessive clinical acuity or in the event of an inter-hospital transfer.

The MDT / Fast Track consultant – spends most of shift at ‘front door’ which involves front-loading care, initiating investigations, providing definitive care where able, and controlling flow of patients from the waiting room to the main cubicles. They also supervise the fast-track resident.

Cubicle supervising consultant – responsible for patient flow in main ED, coordinates hand-over, supervises all junior staff, works closely with the Nurse in Charge to coordinate flow in and out of the ED.

Nurses

The Nurse in Charge has no direct patient care and works with the emergency physician.

Cubicle nurses provide direct patient care to patients in cubicles and Fast Track areas.  The allocation chart next to the Nurse in Charge will tell you which nurse is looking after your patient – duties include general observations, nursing care, medications, and assistance in procedures when necessary.

Some nurses have skills to insert an IV, and if they have time may do so if asked. Often they will initiate investigations as part of initial cubicle assessment, including pathology and radiology.