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MANAGING ON-CALL SHIFTS JAKE GODDING AND CARI O’ROURKEObjectives ◦ To understand the structure of the on-call shift and the role of the on-call F1. ◦ To learn to give and receive effective handovers ◦ To consider ways to organise and prioritise your jobs ◦ To revise effective approaches to completing common on-call tasks, including recapping a structured approach to reviewing unwell patients using the ABCDE framework.STRUCTURE OF ON-CALL SHIFTSOVERVIEW OF SHIFT F1 shifts include: 1) Day, 2) On-call, 3) Night, 4) Take/Post-take 0800 Day Team 1700 On-call Team 2100 Night Team 0900 On-call shifts are for completing clinically urgent tasks that cannot wait until the next day Answer bleeps and complete Collect bleep tasks Return bleep Receive Handover to handover from Night Team Day TeamROLES AND RESPONSIBILITIES Tasks for On-call Team Tasks for Day Team • Reviewing and managing acutely unwell patients • Reviewing stable patients • Inserting cannulas or catheters • Discharging patients • Requesting or reviewing urgent investigations • Requesting or reviewing non-urgent • Prescribing or changing urgent* medications investigations • Clerking new patients • Prescribing or changing non-urgent medications • Updating acutely unwell patients and their • Clerking new patients relatives • Updating stable patients and their relatives • Miscellaneous • MiscellaneousROLES AND RESPONSIBILITIES Tasks for On-call Team Tasks for Day Team • Reviewing and managing acutely unwell patients • Reviewing stable patients • Inserting cannulas or catheters • Discharging patients • Requesting or reviewing urgent investigations • Requesting or reviewing non-urgent • Prescribing or changing urgent* medications investigations • Clerking new patients • Prescribing or changing non-urgent medications • Updating acutely unwell patients and their • Clerking new patients relatives • Updating stable patients and their relatives • Miscellaneous • MiscellaneousROLES AND RESPONSIBILITIES Tasks for On-call Team Tasks for Day Team • Reviewing and managing acutely unwell patients • Reviewing stable patients • Inserting cannulas or catheters • Discharging patients • Requesting or reviewing urgent investigations • Requesting or reviewing non-urgent • Prescribing or changing urgent* medications investigations • Clerking new patients • Prescribing or changing non-urgent medications • Updating acutely unwell patients and their • Clerking new patients relatives • Updating stable patients and their relatives • Miscellaneous • MiscellaneousHANDOVERSRECEIVING HANDOVERS For on-call shifts, this includes: ◦ Taking handover from the Day Team ◦ Answering bleeps How do you actually answer a bleep? What information do you need to gather? 36 745RECEIVING HANDOVERS For on-call shifts, this includes: ◦ Taking handover from the Day Team ◦ Answering bleeps How do you actually answer a bleep? What information do you need to gather? ◦ Clinical question 36 745 ◦ Patient details – name, hospital number, location ◦ Observations ◦ Target history - PC, PMH, DHx, TEP statusGIVING HANDOVERS For on-call shifts, this includes: ◦ Handing over to the Night Team ◦ Escalating to seniors How do you actually send a bleep? What information do you need to give and how? Who can you ask for help?GIVING HANDOVERS For on-call shifts, this includes: ISBAR ◦ Handing over to the Night Team ◦ Escalating to seniors I Introduction S Situation How do you actually send a bleep? What information do you need to give? B Background ◦ SBAR A Assessment Who can you ask for help? R RecommendationGIVING HANDOVERS For on-call shifts, this includes: ◦ Handing over to the Night Team ISBAR ◦ Escalating to seniors I Introduction How do you actually send a bleep? S Situation What information do you need to give? ◦ SBAR B Background A Assessment Who can you ask for help? ◦ Seniors – SHO, registrar, or consultant R Recommendation ◦ Nurses ◦ MET calls and arrest callsORGANISING YOUR JOBSMAKING YOUR LIST ◦ Make an organised jobs list in order of: ◦ Clinical priority ◦ Location ◦ Type of taskT ASK PRIORITISA TION What order should you complete the following tasks in? A. Chase several blood results from the day shift. B. Prescribe pain relief for a 72F who has uncontrolled pain a few hours post-cholecystectomy. C. Review an 83F who is scoring NEWS 6 for a “bit of a low BP” D. Review an 86M who is on warfarin for AF and has just fallen on the ward but is otherwise well. E. Prescribe maintenance fluids for a 66M who has been NBM for 6 hours. F. Prescribe a medication for a patient who is “normally on an antihistamine but doesn’t have it prescribed”COMPLETING COMMON ON-CALL TASKSINTERPRETING INVESTIGA TIONS ◦ ALWAYS stick to your system! ◦ Familiarise yourself with how to actually perform ECGs, bloods, and urine dips ◦ Make sure you get access to investigation requesting and viewing software ASAP ◦ Practise looking at as many ECGs and CXRs as possible ◦ Take a look at these resources: ◦ LITFL - https://litfl.com/ecg-library/ ◦ ECG Library - https://ecglibrary.com/ecghome.php ◦ Radiology Masterclass - https://www.radiologymasterclass.co.uk/tutorials/chest/chest_system/chest_system_start ◦ Geeky Medics - https://geekymedics.com/urinalysis-osce-guide/ ◦ If in doubt, just ask for help!PRESCRIBING ◦ Make sure you have familiarised yourself with common prescriptions, including: ◦ Analgesia ◦ Anti-emetics ◦ Laxatives ◦ Fluids ◦ Electrolyte replacement ◦ Warfarin dosing ◦ VTE prophylaxis ◦ Emergency drugsCLERKINGCOMMUNICA TION WITH RELA TIVES ◦ Practise your communication skills to help you with: ◦ Updating relatives (including breaking bad news) ◦ Gathering collateral histories ◦ Completing TEP discussions ◦ In general, while communicating with relatives, be sure to: ◦ Obtain consent from the patient (and document) ◦ Find out what they already know ◦ Fill in any gaps in a structured way ◦ Answer any further questions REVIEWING UNWELL P A TIENTS 1. Receive handover 2. Review observations (and look at patient) – if concerning, skip to Step 4 3. Review medical notes, drug chart, and available results 4. Assess patient – ABCDE framework 5. Formulate impression and management plan 6. Implement management plan 7. Escalate or handover 8. Document ABCDE APPROACH Examination Examination Examination Examination Examination • RR and • Patent SpO2 • HR and BP • GCS • Abdomen • Protected • Chest sounds • Pulse • Pupils • Calves Interventions • Heart sounds • Glucose • Signs of Interventions Interventions • Temperature bleeding • Airway • ABG adjuncts • COVID swab • ECG Interventions Interventions • Suction • Bloods • Medications • Medications • CXRSummaryKey Learning Points ◦ On-call shifts are for completing clinically urgent tasks that cannot wait until the next day ◦ Before you start work, find out all the key information that will help you in your on-call shifts, including: ◦ Structure of the shift – hours, wards to cover, handover location ◦ How to send and answer bleeps ◦ Seniors – names and bleeps ◦ Trust guidelines for common conditions (eg. DKA, hyperkalaemia, VRII) ◦ Download useful apps - BNF, Pocket/Smart Doctor, Rx Guidelines, Induction, MDCalc, MyShiftPlanner ◦ Use the SBAR framework to help you to give and receive effective handovers ◦ Make an organised jobs list to help you to prioritise your tasks in order of clinical urgency ◦ Familiarise yourself with common prescriptions ◦ Always use the ABCDE approach to review acutely unwell patients ◦ Most importantly, ALWAYS look after yourself!!Questions