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WORKING ON THE WARDS Matt Moxon and Tara TiwaryObjectives ◦ To understand the structure of day shifts ◦ To learn effective ways to: ◦ complete ward rounds ◦ organise your jobs ◦ complete common ward tasks ◦ To practise applying this learning to tackling common scenarios.STRUCTURE OF DAY SHIFTSOVERVIEW OF SHIFT F1 shifts include: 1) Day, 2) On-call, 3) Night, 4) Take/Post-take 0800 Day Team 1700 On-call Team 0000 Night Team 0800 Day shifts are for completing ward rounds and any ward tasks Prepare for ward Complete ward round tasks Complete ward Handover to round On-call Team ROLES AND RESPONSIBILITIES • Printing off the list at the start of the day and updating it at the end • Joining daily ward round, document plans, formulate jobs list • Do the jobs from the ward round • Review unwell patients on the ward • Update relatives • Handover to the on-call team - patients who are clinically unwell to be aware urgent bloods • Bloods, cannulas, catheters, enemas, ABGs etc • DREs! • Verification and Certification of Death • Interpreting ECGs and CXRs • Communication/liaising with MDT especially nurses • DOCUMENT EVERYTHING • Go to teaching and have lunch!!!!!!!COMPLETIN G WARD ROUNDS OVERVIEW OF WARD ROUNDS Daily – consultant/reg led or independent- MDT en mass See every patient under that consultant / speciality • Print off list • Prep notes – try and have an idea of what is going on with the patients to summarise to Dr leading WR if they need it. • (Curtain duty) • Listen to Consultant/Reg leading WR • Documentation of conversation, observations, obs charts, stool charts, input/output, examination, and the plan. Try add to your list as you go. • Looking up/requesting medications, results/investigations as you go - use the COW Divide and ConquerDOCUMENTATION Some ward round documentation tips: • Ensure you have written the time and date in the margin and the name of the Doctor completing the ward round as well as the location • Follow on in the margin the most up to date observations including temperatures and input/output charts as needed • Start the documentation with the patient age/gender and presenting complaint, then current problems/diagnosis list • Note any current medications/treatment regimes they are on and any relevant past medical history • Write any recent investigations that have been reviewed • Follow on with the conversation led by the consultant – how are they progressing today • Document any examination done and the findings • Write out the impression given • Document any management plansCOMPLETING YOUR OWN WARD ROUNDS ◦ Start off the same as normal - prepping notes, going through investigations beforehand. ◦ Go at your own pace ◦ Ensure the plan has been actioned from the last senior WR and the effect/outcome of the interventions ◦ Difficult to make plans/make any drastic decisions- should always have a senior to ask and talk through your planORGANISIN G YOUR JOBSMAKING YOUR LIST ◦ Everyone has their own way- sorting into categories, organising by bay/patient. Working off your ward list or making a new one on a fresh sheet of paper ◦ Generally split into prescribing, bloods, imaging/investigations, TTAs and a MISC (family updates, referrals etc)MAKING A MASTER LIST ◦ Meeting as a team to go through each patient you’ve seen on WR ◦ Prioritisation- tempting to go for the quicker, easier jobs first but ensure that urgent/treatment dependant/discharge dependant things get sorted first so that results don't come back later in the day – your on-call colleagues will love youCOMPLETIN G COMMON WARD TASKSBLOOD AND IMAGING REQUESTS ◦ Depending upon the specialities (surgery for example) daily bloods are common – depending on how bloods are taken (DAs, phlebs) ensure these are requested the day before. This can really help as sometimes results are back by WR. ◦ Any other requests decided on the day during WR should be requested and put on whoever's going to take them radar ASAP ◦ Requests for imaging will depend upon their urgency- this should be made clear during the WR ◦ Whether something needs to be vetted with the DFR- most CT scans are urgent. ◦ Make sure you have the notes to hand, what question wants to be answered ◦ Ensure if they're having contrast (CTTAP, CTPA) that they have a cannula!!!!!MAKING REFERRALS ◦ This can be intimidating when referring to more senior colleagues for requests/reviews - make sure you do your preparation before bleeping and have the notes with you ◦ Different trusts will have different ways of referring to specialities – some are phone/bleep based and lots on online systems which you need to keep checking ◦ General structure is SBAR: ◦ Situation – who you are, why you're referring, punchy first line! ◦ Background – events leading to referral, this admission and any relevant PMHx ◦ Assessment – how the patient is clinically = can help to prioritise reviews/scans ◦ Recommendation – what you would like to happen – review/advice/scan etc. ◦ Make sure you document that you have referred to a speciality for review and if they have accepted and who you spoke to!WRITING DISCHARGE SUMMARIES AND TTAS ◦ If a patient is ready to be discharged as per senior WR (F1s still can't discharge), getting TTAs going ASAP is important. ◦ If you ever have a spare minute and you're stuck for something to do, starting TTAs in preparation for their discharge will help in the long run. ◦ A TTA purpose is to help transition patient plans to Primary Care and make sure nothing is missed, but a good TTA can also help you out in the future with clerking etc. ◦ Trusts will have a self explanatory proforma to complete which generally consists of: ◦ Presenting complaint/story ◦ PMHx and allergies ◦ Investigations and results ◦ Diagnosis ◦ GP letter ◦ MedicationsWRITING DISCHARGE SUMMARIES AND TTAS ◦ The GP letter should outline key points and any ongoing interventions needed by Primary Care I.e. medication dose changes and any repeat investigations – if these are urgent make sure the patient knows they need to book an appointment with their GP or call them yourselves to make an appointment ◦ As well as ongoing regular medications you need to document: ◦ New medications started – indication and expected course length ◦ Medication stopped/altered doses – indication ◦ Medications held – indication and when to restart ◦ Be aware that certain medications need regular monitoring by the GP e.g. ramipril 2 week U+Es, Warfarin – regular INR checks when initiating ◦ When prescribing controlled drugs on TTA your trust may have additional paperwork that needs to be completed for dispensing.COMMUNICATION WITH RELATIVES ◦ F2F / phone. Ensure patient is happy with you speaking with them. ◦ See what they know already - Patient and relatives view/ideas on what is going on can be very different. ◦ Explain what has been done, what the plan is moving forward ◦ Can be really difficult when we don't have all the answers sometimes. ◦ Manage expectations ◦ Document conversationPREPARING FOR THE WEEKEND ◦ Usually making a handover list for the cover doctor to do. ◦ Ensure you write a good backstory and why each job needs to be done as makes weekend life easier(ish) ◦ Anyone unwell who will need a review over weekend either consultant or F1 ◦ Request any bloods that need to be done and chased. ◦ Ensure fluids are prescribed and all other medications including VTE + analgesia ◦ Ensure if patients are on warfarin INRs are appropriately requested ◦ Anyone expected to be discharged over w/e try and make the discharge summary is complete TTAs shouldn't be the on call Drs job ◦ Ensure TEP forms are completed for unwell patients/expected deathsSummaryKey Learning Points ◦ Get to know your patients on your ward ◦ Make the effort to get to know and help out nurses, PTs, dieticians, DAs you will be thankful! ◦ Be organised, find a system that works for you and prioritise jobs ◦ Document everything ◦ There will always be extra work- try to finish on time if it can wait until the following day. ◦ Make things as easy as possible for the on-call team ◦ Look after yourself- take breaks off the ward ◦ Apps to help you – pocket doctor, MDCALC, BNF, Microguide, induction.Questionshttps://forms.gle/AR8kJ8Sf2tXotbi46