Staff handbook ORTHOPAEDICS

GENERAL SURGERY

UROLOGY

Miss Helen Mackay

Consultant Orthopaedic Surgeon

August 2020

For review February 2021

An integrated care organisation

CONTENTS Pages: 4 Welcome to the Trust, Covid 19 Pandemic 5/6 Induction reverse timeline 7 Mandatory training at a glance 8 Speciality induction 9 Departmental induction 10 Escalation policy 10 Clinical supervision arrangements General Surgery + Ortho 11 Out of Hours supervision 11 Speaking Up Champions 12 Roles and responsibilities working in Surgery and Orthopaedics 12 Consultant of the Week (COW) Orthopaedics 13 Consultant rolling rota Orthopaedics, Gen Surg, Urology 14 Consultant cross cover Ortho, Gen Surg, Urology 15 Handover Ortho, Gen Surgery, Urology 16 Contacting the On Call teams 17 On call rota co-ordination 17 On call duties Orthopaedics 17 On call duties General Surgery 18 Hospital at Night 19 Structure of the Orthopaedic Department 20 Structure of the General Surgery Department 20 Structure of the Urology Department 21 Management structure of the Surgical Directorate 21 To bleep someone 21 Discharge information 22 Important telephone numbers 23 Guardian of Safe Working 23 Reporting incidents 24 Structured Judgement Reviews 24 Raising concerns about colleagues 24 Bullying and harassment 25 Annual, study and professional leave 25 Sickness reporting 26 Teaching and training 26 Educational opportunities Orthopaedics for all interested personnel 26 Educational opportunities Surgery for all interested personnel 27 Foundation programme teaching and other interested personnel 27 Staffing and contact in Department of Medical Education 28 Student doctors

29 Appraisal for trainees 29 Skills and competencies of medical staff in training 30/31 Consent 32 Hand hygiene

Generic guidance for those working in Surgery and Ortho 33 In hospital referrals 33 Plastic surgery 33 Oxygen and antibiotic prescribing 34 The patient with diabetes and foot problems 34 Post operative management 35 Compassionate care 35/36 Supporting palliative and end of life care 37 Clinical coding 37 Audit

Clinical guidance for those working in Orthopaedics 38 Paediatric Orthopaedic trauma 39 Spinal fracture management 40 Periprosthetic fracture management 41 Pathological fracture management 41 Patient representing after discharge 42 Golden patient-trauma 43 Prophylactic antibiotics 43 Thromboprophylaxis- trauma 44 BOAST guidance 44 Septic joints (native) 45 Fragility fractures and osteoporosis 45 Orthogeriatric support 46 Integrated fracture neck of femur pathway 46 Enhanced recovery for THR/TKR 47 Thromboprophylaxis-elective

Clinical guidance for those working in General Surgery 48/49 Bowel preparation and consultant pre-op preferences colorectal 50 Booking a laparotomy 50 Emergency laparotomy theatre check-in 51/52 Acute Emergency Laparotomy Pathway

Clinical guidance for those working in Urology 53 Ward rounds 54 Continuity of care - Urology 54 TCIs 54 M&M 54 MDT 55/56/57 Post-op care following TUR surgery 58 Acute Urology 58 Acute urinary retention 58 Chronic retention of urine 59 Scrotal pain 59 Ureteric colic 60 Beware of leaking AAA mimicking ureteric colic 61 Acute pyelonephritis 62 Haematuria 3

WELCOME TO OUR TRUST

Dear Doctor

Welcome to the Directorate of Surgery (Orthopaedics, General Surgery and Urology). We hope you find your stay with the team rewarding and worthwhile.

This handbook is intended to make your job easier by providing information about the departments, staffing, routine work and teaching activities.

Quality and dignity doesn’t just apply to patients it is also about working with colleagues. We are a friendly Trust and wish to make all those new to the Trust welcome. Teamwork is essential and central to the operational effectiveness of the organisation forming the backbone of quality patient care and safety. Please respect all of your colleagues. Be nice. Miss Helen Mackay, Consultant Orthopaedic Surgeon, July 2020

COVID-19 PANDEMIC

The Trust has developed SOPs regarding changes to clinical practice/operational processes in response to COVID-19. Please be guided by your departments and the Planned Care CBU. Patients should all be swabbed on admission. All patients if undergoing surgery must have a Coronavirus consent form completed. The following link is a useful contemporaneous guide. https://cpoc.org.uk/sites/cpoc/files/documents/2020-05/CPOC-FAQ.pdf The Trust is currently co-ordinating FIT mask testing for each of the clinical areas. Please communicate closely with your department as to when FIT testing will take place.

4

INDUCTION REVERSE TIME LINE

Within General Surgery, Orthopaedics and Urology

Karima Abdulla is our Rota co-ordinator. Karima is the

Rota co-ordinator for the whole of Planned Care CBU. Our

Operational Service Managers are Lyndsey Gilland for

General Surgery and Orthopaedics and Liz Taylor for

Urology and Vascular.

k.abdulla@nhs.net Ext 4318

lyndsey.gilland@nhs.net Ascom 3838/4522

liztaylor1@nhs.net Ascom 4522/3714

IT HELPDESK 6666

Orthopaedic desktop files that must be uploaded on your

log-in are

Web PACS, Medway (LIVE), VitalPAC Clinical, Evolve,

HealthRoster

- datamart1/shared files/orthopaedic handover

- datamart1/shared files/paediatric orthopaedic

handover

- datamart1/trauma database

General surgery desktop files that must be uploaded on

your log- in are

Web PACS, Medway (LIVE), VitalPAC Clinical, Evolve,

HealthRoster

- datamart1/shared files/surgical post take

- datamart1/shared files/surgical team list 5

INDUCTION REVERSE TIME LINE

Name of doctor Complete

Deanery HR confirm host Trust Southport and Ormskirk NHS Trust

Confirmation of College Tutor is expecting named trainee

College Tutor will allocate clinical and educational supervisor and departmental induction

Communication between trainee and Trust

Welcome message and clarification of any leave proposed by trainee. Rota co-ordinator to be informed

Allot Rota and provide HealthRoster access to trainees

Pre-induction security check photo for I.D badge and Car park

Confirm Access Car park for both sites ODGH and SDGH as required

Send induction programme to trainee including venue

Trainers to confirm availability

Induction packs delivered to Medical HR if not already in possession

Medical HR to ensure I.D badges are working in all areas

Medical HR to ensure IT/computer access arranged you may need to ring HR to ensure this is done completely for the specific files for your department

Trust induction date

Departmental induction date

Mandatory training

Review and debrief

Deficiencies in process and date escalated and sorted

6

TRUST MANDATORY TRAINING AT A GLANCE

When you commence in the Trust your department will be able to advise you on what mandatory training is required. This is a rough guide.

Name of doctor How often

Local fire safety 1 yr

Information governance (data security awareness) 1 yr

Infection prevention and control level 2 1 yr

Hand hygiene 1 yr

Resuscitation Level 2 Adult Basic Life Support (2 parts) 1 yr

Resuscitation Level 2 Paediatric Basic Life Support (2 parts) 1 yr

Moving and Handling level 2 1 yr

Blood Transfusion Theory 1 yr

Blood Transfusion e-learning 1 yr

Fire safety (general) 2 yr

Preventing radicalisation level 3-5 3 yr

Equality Diversity and Human Rights 3 yr

Safeguarding adults level 2 3 yr

Health, safety and welfare 3 yr

Safeguarding children level 2 3 yr

Safeguarding children level 3 3 yr

Conflict resolution 3 yr

Mental Capacity Act 3 yr

7

SPECIALITY INDUCTION – DOCTORS IN TRAINING

(INCLUDING DOCTORS STARTING ‘OUT OF PHASE’)

Name:

Speciality:

Position / Grade:

GMC No.:

Start date in the Trust:

Appointment confirmed by Lead Employer/ HR Department: Yes / No

Deanery E-Induction completed: Yes / No

Date attended Trust Doctors Induction:

If has not attended Trust Induction programme the following must be confirmed: (Do not complete if attended Trust Induction)

Topic Date Remarks

ID Badge obtained

Tunic collection arranged

IT Systems Request Form completed and returned to Voice & Data Services Dept.

PACS System Request Form completed and returned to Radiology Department

Clinical handover and bleep policy arrangements

Car Parking arrangements organised

Library Access arranged

Briefing on Waste disposal & sharps policy Clinical record keeping Information Governance Consent Infection Control Prescribing & antimicrobial guidelines Accident & incident reporting Death Certification & Cremation Forms Risk Management

8

DEPARTMENTAL INDUCTION The trainee should be briefed face-to-face and made aware of the following:

Topic Remarks

Educational Supervisor allocated Y / N

Educational Supervision arrangements, including portfolio access and review timetable

Y / N

Clinical Supervision arrangements, including patient safety considerations

Y / N

Department teaching/ audit Programme Y / N

Departmental Annual Leave arrangements Y / N

Study/Professional Leave arrangements Y / N

Sickness/ absence reporting arrangements, including return to work arrangements

Y / N

Briefing on Insight Service Y / N

Location of corporate and relevant clinical policies, including how to access on the intranet

Y / N

Major Disaster Policy Y / N

Quality of Discharge Summaries Y / N

The following are to be completed with all trainees, during the Specialty Induction:

Topic Remarks

Layout of site Y / N

Staff Restaurant Y / N

Rest Facilities/ Accommodation Y / N

Arrangements for collection of post Y / N

Orientation/ tour of Clinical Area Y / N

Introduction to Lead Nurse/ AHP in Clinical Area (s) where the trainee will be working

Y / N

Resuscitation Procedure and equipment, location of arrest trolley

Y / N

Briefing on: Medicines Management in clinical area, Identifying relevant key holders Obtaining Blood results

Y / N

Fire Safety Briefing: Location of firefighting equipment Fire Drills & Alarm systems Location of fire exits Use of fire extinguishers Fire Assembly Point

Y / N

Security arrangements Y / N

Educational/ Clinical Supervisor Signature: ………………………….. Trainee Signature: ..................................................................................

9

ESCALATION POLICY

At all times doctors working in the Department must be aware of who to escalate to when there are concerns about a patient.

It is advised that at the start of each shift each doctor is aware of the named senior to immediately escalate to ‘on the shop floor’ as well as who is non-residential on call and confirm that you can get hold of them. This is an opportunity to introduce yourself.

CLINICAL SUPERVISION ARRANGEMENTS

GENERAL SURGERY AND ORTHOPAEDICS

F1 and F2 doctors

Each Dr will be allocated an individual Consultant team (F1 doctors in Orthopaedics are ward based).

Each Dr will be allocated a CS and ES.

It is the responsibility of each Dr to arrange the necessary meetings as per the HORUS system.

CT and Speciality trainee doctor

Each Dr will be allocated an individual Consultant team.

Each Dr will be allocated a CS and ES.

It is the responsibility of each Dr to arrange the necessary meetings as per the ISCP system.

If you feel a particular situation would be suitable for ISCP, please highlight this to your CS early so the necessary focussed feedback can be given and documented in a timely manner.

10

OUT OF HOURS SUPERVISION

Clinical supervision out of hours will be provided by the On Call Consultant.

If there are any concerns regarding out of hours supervision/support this should be reported to the Clinical Directors and/or College Tutors depending on the situation.

SPEAKING UP CHAMPIONS

There is a close working relationship between the Executive Medical Director (Dr Terry Hankin), the Director of Medical Education (Dr Ann Holden) and the Medical Director for Patient Safety (Dr Chris Goddard). All are approachable and must be informed if there are any concerns regarding operational processes that could impact patient safety. They operate an ‘open door’ policy.

FREEDOM TO SPEAK UP GUARDIAN

Rev Martin Abrams

martin.abrams@nhs.net

11

ROLES AND RESPONSIBILITIES WORKING IN

GENERAL SURGERY AND ORTHOPAEDICS

F1 doctors

Daily ward round at 08.00 hrs.

To assist in the management of acute elective and inpatient surgical admissions.

To arrange all investigations and ensure results are acted upon and filed.

To monitor patients’ prescription charts with particular attention to antibiotic review and stop dates.

Timely communication/escalation if there are acute changes in the patient’s condition.

CONSULTANT OF THE WEEK (COW)

ORTHOPAEDICS

All patients admitted during the week from Monday 08.00hrs to the following Monday 08.00hrs fall under the responsibility of the COW.

The Consultant on Call for 24 hours will do the Trauma list the following day.

The Consultant on Call and the COW will be present at the Trauma meeting. The Trauma meeting starts at 08.00hrs each morning. This takes place in the Spinal Unit MDT room.

The CONSULTANT OF THE WEEK is available during the week 08.00hrs – 17.00hrs for advice. 12

CONSULTANT OF THE WEEK (COW) ROLLING

10 WEEK ROTA FOR ORTHOPAEDICS

THE COW WHO STARTS ON MONDAY WILL

DO THE ON CALL WEEKEND AT THE END OF

THAT WEEK

Consultant of the Week

1st cycle 2nd cycle 3rd cycle 4th cycle

COW 1 Mr. Suraliwala

10th August 2020

19th October 2020

28th

December 2020

COW 2 Miss Mackay

17th August 2020

26th October 2020

4th January 2021

COW 3 Mr. Adam

24th August 2020

2nd November 2020

11th January 2021

COW 4 Mr. Sangani

31st August 2020

9th November 2020

18th January 2021

COW 5 Mr. Selvan

7th September 2020

16th November 2020

25th January 2021

COW 6 Mr. Toh

14th September 2020

23rd November 2020

1st February 2021

COW 7 Miss Lever

13th July 2020 21st September 2020

30th November 2020

8th February 2021

COW 8 Mr. Hakim

20th July 2020 28th September 2020

7th December 2020

15th February 2021

COW 9 Mr. Ahuja

27th July 2020 5th October 2020

14th December 2020

22nd February 2021

COW 10 Mr. El-Nahas

3rd August 2020

12th October 2020

21st December 2020

1st March 2021

13

CONSULTANT ROLLING ROTA GENERAL

SURGERY

The General Surgical Consultants operate on a 24 hr on call period Weekend Friday 13.00hrs - Monday 13.00hrs Weekday 13.00hrs -13.00hrs There will be a handover between Consultants at 13.00hrs each day. The Consultant on Call on a Tuesday for example will be leading the PTWR on the Wednesday at 08.00 on 10b.

CONSULTANT COVER UROLOGY

The 3 Urology Consultants have a joint weekly rota with the Consultants in Whiston. They will cover both Southport and Ormskirk NHS Trust and Whiston (St Helens and Knowsley NHS Trust) when on call.

14

CONSULTANT CROSS-COVER

ORTHOPAEDICS

Regardless of the ‘Named Consultant’ above the bed, the COW team are the ‘go to’ team if there are acute concerns about in-patients. Out of hours the On Call team should be contacted.

CONSULTANT CROSS-COVER GENERAL

SURGERY

For cover for in-patients the ‘Named Consultant’s’ team will be able to state which other Consultant team will be covering for the absent ‘Named Consultant’. If the concern is urgent about a patient the On Call team must be contacted.

HANDOVER ORTHOPAEDICS

Morning handover starts at 08.00hrs. Spinal MDT room

Evening handover between tier 1 On Call doctors 20.00hrs,usually Doctors’ Mess.

HANDOVER GENERAL SURGERY

Morning handover starts at 08.0hrs 10b Evening handover 20.00hrs. 10b

HANDOVER UROLOGY

Morning handover 08.00hrs. Daily WR starts on 10b. Don’t forget to take the referrals from the ‘referral folder’. There is a high turnover of patients so please ensure that the on call team are aware of any patients you have concerns about.

15

CONTACTING THE ON CALL TEAM

ORTHOPAEDICS

Foundation 1 doctor bleep 3980 Tier 1 On Call (resident) bleep 5373 Tier 2 On Call (non-resident) switch board Consultant On Call (non-resident) switch board

CONTACTING THE ON CALL TEAM GENERAL

SURGERY

Foundation 1 doctor bleep 3980 Tier 1 On Call (resident) bleep 3981 Tier 2 On Call switch board

CONTACTING THE ON CALL TEAM UROLOGY

Urology emergencies are covered by the General Surgery Tier 1 On Call Tier 1 On Call (resident) bleep 3981 Tier 2 On Call (non-resident) switch board Urology Consultant On Call switch board When admitting patients as an emergency, please ensure that the nursing staff are informed that the patient is admitted under Urology and the list updated accordingly.

F1 ON CALL DOCTOR COVERS ALL 3

SPECIALITIES ON BLEEP 3980

16

ON CALL DUTIES ORTHOPAEDICS

All patients seen by the first tier doctor on call whether admitted or not should be discussed at the trauma meeting.

If you are referred a patient from AED, please review the patient, however avoid being a radiology service for AED, there is a radiology department.

Virgin Care Walk In Centre Is staffed by advanced nurse practitioners. This is independent of Southport and Ormskirk NHS trust. First on call doctors should not give advice over the phone. This is not safe.

The clinicians in Virgin Care do have access to the radiology department and have their own escalation policy within Virgin Care which includes direct access to the fracture clinic.

You are not expected to see patients directly if Virgin Care has sent the patient to AED at Southport.

ON CALL DUTIES SURGERY

All urgent surgical referrals need to be reviewed by the registrar or above before discharge. F2/CT doctors cannot discharge an emergency referral without review by Registrar grade or above.

Emergency admissions

F1 doctors will be responsible for the initial clerking of emergency admissions and the ordering of initial investigations. They will liaise with their F2 or middle grade about the management of such patients. It is important to be aware that rapid changes in condition can occur and particularly in the case of closed infections eg, renal obstructions, speed of treatment is vital. It is possible to miss the earlier signs of septicaemia because the patient remains apparently clinically well.

It is the responsibility of the F1 doctor to ensure that investigations ordered are followed up and results obtained and acted upon. If they are going off duty they MUST pass the information on to their successors.

ACCOMODATION 01704 70 4593

CAR PARKING (INC ID BADGES) 01695 65 6140

IT ISSUES CONTACT 6666

17

HOSPITAL AT NIGHT

RESIDENT ON CALL DOCTORS FROM

ORTHOPAEDICS AND SURGERY MUST

ATTEND THE HOSPITAL AT NIGHT

MEETING The workload of the Hospital at Night is delegated to The Hospital at Night Team which is overseen by the Nurse Co-ordinator with a handover meeting each evening at 21.00hrs.

Unless needed for urgent patient care, all resident doctors should attend the meeting to receive handover details of any patients who are, or may cause concern overnight.

At the same time the Night Co-ordinator will allocate routine on-going ward work. Junior members of the team may be required to cross cover specialties within surgery (Orthopaedics and General Surgery) if workloads require this.

The Medical Registrar is the medical lead for the whole team and should make every effort to attend.

All members of The Hospital at Night Team are required to sign in and must inform the Night Nurse Co-ordinator if unable to attend. The Hospital at Night meeting takes place at 21.00hrs in the Safety Hub (on the main corridor between Ward 9 and 10).

Orthopaedic first On Call doctors must attend – registration is taken.

The code for the door of the Safety Hub is 2407Y.

Attendance is monitored

If you cannot attend please phone your apologies to 4694.

18

STRUCTURE OF TRAUMA AND

ORTHOPAEDIC DEPT Clinical Director Mr. C. Sangani

Lower limb arthroplasty, tibial plateau and soft tissue knee

Consultants

Mr. D Selvan (DS)

Mr. R. Adam (RFA)

Secretaries

Janet Morton

Andrea Stevenson

4210

6168

Lower limb arthroplasty

Mr. K Suraliwala (KHS)

Mr. H George

Miss H Mackay (HEM)

Mr. R Adam (RFA)

Mr. C Sangani (CS)

Karen James

(Paediatric Ortho)

Emma Gow

A Stevenson

Tina Ray

6167

6167

4488

6168

4296

Foot and Ankle Mr. E Toh (ET) Elaine Davis 6881

Shoulder and Elbow

Mr. Z Hakim (ZAH)

Mr. N Ahuja (AHN)

Tina Ray

Andrea Stevenson

4296

6164

Hand and Wrist

Mr. W El-Nahas (WAN)

Mr. W Y Loh (WYL)

Elaine Davis

Elaine Davis

6881

6881

Speciality doctors and trainees

Mr. A Yasen - Associate Specialist

Mr. A Nemeth- Speciality doctor

Mr. A Zarugh- Speciality doctor

Mr. K Iyengar- Speciality doctor

Mr. I Ullah- Speciality doctor

Mr. F Odeh- Speciality doctor

Mr. D Sree – Speciality doctor

Trauma Nurse Coordinators

Laura Wright

Sarah Constantine

Caroline Forshaw

3823 and 4068

19

STRUCTURE OF GENERAL SURGERY DEPT Clinical Director Mr. P. Ainsworth

All consultants can be contacted via switchboard or by personal mobile phone

General and Vascular

Consultants

Mr. P F Mason

Secretaries

S Grahamslaw

4665

General and Colorectal surgery

Mr. P. Ainsworth

Mr. D Artioukh

Mr. H Babu

Mr. R Smith

Sam Hulse

Sam Hulse

Karen Ingham

4253

4253

4252

Upper GI Mr. R Satchidanand Karen Ingham 4252

General surgery

Mr. S Jmor

Terry Jones

Christine Peppin

6483

Speciality doctors and trainees

Mr. K Gokul- Associate Specialist

Mr. El Askalani- Speciality doctor

Mr. M Azam- Speciality doctor

Mr. Georgios Maroufidis

Mr. Mohammed El Shazly

Mr. Aloka Liyanage

Surgical Specialist Nurses

Kerry Hawkins- Vascular specialist nurse 5124

Joanne Sutton and Katie Roberts- Colorectal specialist nurses 4250

Louise Keenan- Upper GI specialist nurse 4696

STRUCTURE OF UROLOGY DEPARTMENT Clinical Director Mr. Athma

Consultants

Mr. Khadr

Mr. Mistry

Secretaries

Cathy Newton 4025

Adel Wright

Sheila Atkinson 4255

Mary McNab- Urology Specialist Nurse 4462

Sharon Jamieson- Urology Specialist Nurse 6277

Katie Hughes- Uro-Oncology Specialist Nurse

Diane Dobson- Urology Assistant Practitioner

Associate Specialists Mr. Athma Mr. Reddy

Speciality doctors Dr. D Samian Dr. K Velusamy

Speciality trainee Dr. M Abu Yousif (ST)

MANAGEMENT STRUCTURE OF SURGICAL

DIRECTORATE (INCLUDING ORTHOPAEDICS)

Mr. Chris Barben Medical Director for Planned Care CBU

Helen Baythorpe Assistant Director of Operations

Mandy Marsh Directorate Manager (3842)

Lyndsey Gilland OSM (3838) General Surgery and T+O

Liz Taylor OSM (3714) Urology, Vascular, Paeds Ortho

TO BLEEP SOMEBODY

ASCOM bleep. Use as cordless phone or bleep system (follow instructions PC desktop).

Bleep. 4477 then follow instructions (wait, bleep#, wait, extension#). Bleeps and keys must NOT be left on the ward. They should be returned to switchboard or passed to medical staff.

DISCHARGE INFORMATION

An Electronic Discharge information summarising the patient’s admission details should be completed by the team on the day of the patient’s discharge from the ward.

Please note- ‘Team’ includes all those clinical personnel who are trained to use the system, to ensure fair allocation of routine work.

Letters should be signed off on the MediSec system within 72 hours of the clinic.

21

IMPORTANT TELEPHONE NUMBERS

Southport Wards 14a 4889/4891

11A 5105/5106/E 3001

10B 4502

Therapy room 14a 4815

Ormskirk Wards F 6916

G 6903

H 6603

CWD 6912

Southport AED 4127 / 4128 / 4437 Ormskirk AED 6675 / 6683

Southport Theatres

Theatre Office 4264

Reception 4265

Co-Ordinator 4266

Recovery 4269

Trauma theatre 4881

Ormskirk Theatres Office 6020

6746

Reception 6751

Co-Ord 6173

Recovery 6748

Anaesthetic office Doctors common room

4103 / 4201

4254

X-ray Southport

X-ray Ormskirk

4105 / 4107

6672

Outpatients

Southport

Outpatients

Ormskirk

Ortho O/P reception 4117

Fracture clinic 4925

Plaster room 4571

Appliances 4119

General outpatients 4049

Endoscopy 4368

ECG 4045

General Outpatients 6680

Fracture clinic (office) 6594

Fracture clinic reception 6686

Mortuary Southport

Pathology Southport

Pathology Ormskirk

Biochemistry

Haematology

Transfusion

Microbiology

Pharmacy Southport

Pharmacy Ormskirk Medicines info

4014

4179

6849

4172

4175

4176

4179

4161

6422

6157

Library

CEC

ID badges

IT for desktop folders

PACS team

Car park

SDGH 4202 ODGH 6403

SDGH 4377 ODGH 6214

SDGH 4790 / 4799

ODGH 6666

Intranet-(Home→Clinical services→Radiology→Image Transfer Form

(David Lodwig 4565)

SDGH 5163 ODGH 6140

Cardiac Arrest 2222

Outreach 3914

Safety Hub 4694

GUARDIAN OF SAFE WORKING

Dr Sharryn Gardner (Paediatric AED Consultant)

e-Exception reports are generated through the ‘Allocate eRota system’.

You should all be provided with passwords when you start your rotation here at Southport and Ormskirk NHS Trust.

Please be clear to the Consultants when your shift is rostered to end

Handover- Morning 08.00-08.30hrs. Evening 20.00-20.30hrs.

e-Exception reports can be completed for

- When you were unable to avail yourself to teaching as you were unable to leave your clinical area

- When you have stayed beyond your rostered shift as it was not possible to leave your clinical area on time

- ‘Other’ can include when the intensity of the shift was felt to be unsafe in your opinion.

REPORTING INCIDENTS

DATIX forms can be generated to highlight incidents, near misses or good practice. DATIX incidents will be collated, lessons identified and feedback given to departments to improve clinical practice and ultimately improve patient safety.

All Clinicians have a professional duty to ‘speak up’ to promote a culture of patient safety. No one should be discouraged from completing DATIX forms through fear of being treated differently as a result of generating a concern.

SIRG (SERIOUS INCIDENT REVIEW GROUP)

This runs weekly and either the Executive Medical Director (Dr Terry Hankin) or Dr Chris Goddard (Associate Medical Director for Patient Safety) will be present.

23

STRUCTURED JUDGEMENT REVIEW

Structured Judgement Reviews are initiated following the death of a patient due to LRTI, UTI or Sepsis. If you are asked to complete a death certificate and you are not sure whether an SJR is required, the personnel in the Mortuary will be able to guide you.

Mortality screening tools must be completed for all patients.

Dr Chris Goddard is the Associate Medical Director for Patient Safety.

For Orthopaedic patients that have had an SJR, please contact Miss Helen Mackay if you wish to know the outcome.

For General Surgery patients that have had an SJR, please contact Mr P.F Mason or Mr K Gokul if you wish to know the outcome.

RAISING CONCERNS ABOUT COLLEAGUES

Occasionally one may have concern regarding the conduct or competence of a colleague. We have a professional duty to ‘speak up.’ Seek information/evidence, Patient safety concerns? Initiate/Intervention required, Escalate (clinical supervisor/educational supervisor/trusted senior colleague), Support for colleague and those that have raised the concern.

http://intranet/quality-risk-and-governance/freedom-to-speak-up-raising-a-concern/

BULLYING AND HARRASSMENT

Southport and Ormskirk Hospital NHS Trust is committed to improving the working lives of its staff. As such it operates a zero-tolerance policy to bullying and harassment.

PERS 37 Dignity at Work - Prevention of Bullying & Harassment Policy

24

ANNUAL LEAVE, STUDY LEAVE AND

PROFESSIONAL LEAVE

All leave should be requested through the ‘Allocate’ ‘MedicOnLine’ system. You should not make travel arrangements etc, until the period of leave is confirmed. You should not pay or book courses until the period of leave is confirmed.

Please inform your Consultant’s team and Secretary for the dates you are intending to be absent. 6 weeks notice must be given.

If Annual or Study leave falls on on-call duties then the doctor is responsible for arranging a swap, before leave will be granted.

SICKNESS REPORTING

Illness that necessitates your absence from work should be notified to the Operational Service Manager (OSM) and/or Karima Abdulla, as well as your team as soon as possible, particularly if this involves on-call work. The Consultant’s Secretary should also be informed separately.

Please inform them of your absence no later than 30 minutes before the start of the day shift. If you have a shift at night please call as soon as you can to enable appropriate cover to be found.

You will also need to contact the absence line on 0330 886 240. You will need to give them your employee number.

The self-certification scheme applies for episodes of less than one week; thereafter a medical note must be obtained and sent to medical staffing.

You will be required to undergo a return to work interview and for longer periods of leave occupational health assessment.

You should also let the School of Medicine/ General Practice know of any significant periods of sick leave that might affect your training.

25

TEACHING AND TRAINING

Formal postgraduate education is now a contractual obligation.

Our Trust is a friendly Trust and offers a broad experience to Trainees, our Clinical Business Units being Women’s and Children’s, Planned Care, and Urgent Care. Delivering quality training feeds into sustainable workforce planning, in terms of recruitment and retention for all members of staff.

Trainers may find it useful to ‘signpost’ when training is actively taking place in the work place, for example, ‘We are now conducting a teaching ward round/board round’. ‘I am now giving feedback to you on the scenario that we have just experienced’.

The Post-Graduate Centre is monitoring attendance at teaching and highlighting to CS/ES/Clinical Tutors if there has been non- attendance. This is so that support can be put in place if appropriate.

TIMETABLED EDUCATIONAL SESSIONS ORTHOPAEDICS

Trauma meeting: Weekdays 08.00hrs. Spinal MDT room

Orthopaedic tutorial: Friday 12.30-13.30hrs. Spinal MDT room

Consultant teaching rounds: COW and Board round 09.00hrs

Friday lunchtime meeting (Grand Round): Clinical Education Centre (lunch) 12.00 –13.00hrs – followed by lecture at 13.00hr.

TIMETABLED EDUCATIONAL GENERAL SURGERY

Surgery tutorial: Friday 1400-1600. Clinical Education Centre

Friday lunchtime meeting (Grand round): Clinical Education Centre (lunch) 12.00–13.00hrs – followed by lecture at 13.00hrs.

ATTENDING THE THEATRE IS ACTIVELY ENCOURAGED.

THIS IS AN EXCELLENT EDUCATIONAL EXPERIENCE. 26

FOUNDATION PROGRAMME TEACHING

Foundation Year 1: Alternate Thursday whole day

Foundation Year 2: Wed 1400-1600 (may move to whole day)

Director of Medical Education

Dr. Ann Holden

annholden@nhs.net

Associate Director of Medical Education

Mr. Krishnan Gokul

krishnangokul@nhs.net

Head of Medical Education

Mrs. Dawn Aspinall (ext 4517)

dawnaspinall@nhs.net

Foundation Programme Director

Dr. Katie Scott

katie.scott11@nhs.net

Foundation Programme Co-ordinator

Mr. Tony Brown (ext 5245)

tonybrown@nhs.net

Trust Clinical Tutor (Planned Care and Induction)

Miss Helen Mackay

helen.mackay4@nhs.net

Trust Clinical Tutor

(Simulation Lead)

Dr. Claire Thompson

clare.gerrard@nhs.net

Trust Clinical Tutor

(Acute Care)

Dr. Suchi Singh

suchinderyit.singh@nhs.net

Trust Speciality lead/College Tutor General Surgery

Mr. Dmitri Artioukh

dmitri.artioukh@nhs.net

Trust Speciality lead/College Tutor Orthopaedics

Mr. David Selvan

david.selvan@nhs.net

Trust Speciality Lead/College Tutor Urology

Mr. Rahul Mistry

rahulmistry@nhs.net

Associate Medical Director Patient Safety

Dr. Chris Goddard

christopher.goddard@nhs.net

Postgraduate/SAS Coord Rachel Cassidy soh-tr.PostGrad-News@nhs.net

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STUDENT DOCTORS

The Undergraduate Team will inform you where you need to present on the first day of your placement. Laura Lomas is your Undergraduate Administrator at soh-tr.undergraduateadministrators@nhs.net Dr Pete Gledhill is the Undergraduate Lead for student doctors. Andrew Burke is the Clinical Education Lead for undergraduate medical education. All students should be aware of their educational objectives and document this on PebblePad. Miss Helen Mackay is the Lead for student doctors for the Department of Orthopaedics. Surgery B Week 1 Week 2 Week 3 Week 4

Monday Induction CBL x 3 (Consultant led)

Ward/clinic/theatre Ward/clinic/theatre Vascular

Tuesday Ward/clinic/theatre Ward/clinic/theatre Ward/clinic/theatre Vascular

Wednesday Ward/clinic/theatre Ward/clinic/theatre Ward/clinic/theatre Vascular

Thursday Ward/clinic/theatre Ward/clinic/theatre Ward/clinic/theatre Vascular

Friday Ward/clinic/theatre Ward/clinic/theatre Individual Portfolio review (consultant led)

Vascular

Each student will be assigned to a paired Consultant team within Orthopaedics. The CBLs are usually on the first Monday of the placement. The date for the individual portfolio reviews will be given to you at the induction. Medical student rotations for surgery A + B start dates 14th September 2020 19th October 2020 23rd November 2020 18th January 2021 22nd February 2021 12th April 2021 17th May 2021 28

APPRAISAL FOR TRAINEES

All Foundation, Core Trainees and Speciality trainees should have three appraisal interviews during their appointment.

Foundation, Core Trainees and Speciality trainees will be allocated their Clinical Supervisor when they join the department and Educational Supervisor as appropriate. The Supervisor will guide you through your training in the department and help to address your educational and training needs.

It is the responsibility of the doctors in training to ensure that their competency / log book is completed and signed by their allocated Consultant Supervisor.

SKILLS AND COMPETENCIES OF

MEDICAL STAFF IN TRAINING

Trainees should know what competencies they need to achieve for their grade and stage of training. Your curriculum will guide you whether you are at Foundation, Core or Speciality training.

If you feel a particular event would be suitable for a WBA, please highlight this to your Clinical Supervisor who is allocated to you, or your Clinical Supervisor for a particular clinical session. Please generate the WBA in a timely manner, so this can be signed off by the tutor and key learning/development points can be extracted.

All trainees are encouraged to actively participate in the department teaching programme. Subject areas should be aligned to the speciality curriculum. ‘Observation of Teaching’ is part of your training portfolio.

Trainees will also have progress reports following the Annual Review of Competence Progression (ARCP)

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CONSENT

The Trust must show consent for procedures is obtained by a health professional competent and capable of performing the procedure, or the responsibility is delegated appropriately.

WHO IS RESPONSIBLE FOR SEEKING CONSENT?

1. The health professional carrying out the procedure is ultimately responsible for ensuring that the patient is genuinely consenting to what is being done: it is they who will be held responsible in law if this is challenged later

2. Where oral or non-verbal consent is being sought at the point the procedure will be carried out, this will naturally be done by the health professional responsible. However, teamwork is a crucial part of the way the NHS operates, and where written consent is being sought it may be appropriate for other members of the team to participate in the process of seeking consent

COMPLETING CONSENT FORMS

1. The standard consent form provides space for a health professional to provide information to patients and to sign confirming that they have done so. The health professional providing the information must be competent to do so: either because they themselves carry out the procedure, or because they have received specialist training in advising patients about this procedure, have been assessed, are aware of their own knowledge limitations and are subject to audit

2. If the patient signs the form in advance of the procedure (e.g. in out-patients or at a pre-assessment clinic), a health professional involved in their care on the day should sign the form to confirm that the patient still wishes to go ahead and has had any further questions answered (part 1B).

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3. The Consultant accountable for the patient’s care is responsible for ensuring health professionals who do not themselves carry out specific procedures, but could potentially provide the information patients need in coming to a decision, are trained, assessed and competent to do so.

4. The Consultant accountable for the patient’s care is responsible for ensuring that access to appropriate colleagues is available at all times to the health professionals ‘confirming’ the patient’s consent to answer any remaining questions to which they personally feel unable to respond.

ADULTS UNABLE TO CONSENT

If an adult is unable to give informed consent by nature of their acute illness or other capacity reasons, then no one else is able to give consent on their behalf.

In these cases a medical practitioner must act in what he/she perceives to be in the best interests of the patient. In emergency situations then proceed but for all other interventions seek senior help.

Consent form 4 must be completed and all efforts should be made to include the patient’s family and document this.

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HAND HYGIENE

The Five Moments for Hand Hygiene have been identified as the critical times when hand hygiene should be performed:

GENERIC CLINICAL GUIDANCE FOR THOSE

WORKING IN ORTHOPAEDICS AND GENERAL

SURGERY

IN HOSPITAL CONSULTANT TO CONSULTANT

REFERRALS

Pink and white Consultant to Consultant referral forms should be completed and taken to the relevant speciality.

PLASTIC SURGERY

We have a visiting Plastic Surgeon Mr Koshy, who visits the Trust on Tuesday afternoon. He works very closely with the Tissue Viability Nurse Lead (Dominic Williams). Pink and white Consultant to Consultant referral forms can be completed and given to Mr Koshy’s secretary who is based in the Hospital. He will endeavor to review the patients on Tuesday evenings. Plastics to have an urgent review clinic every morning at Whiston (they should be contacted if there are hand nerve injuries)

OXYGEN AND ANTIBIOTIC PRESCRIBING

Oxygen is a drug and the percentage of oxygen required should be clear. Serious patient safety incidents have occurred as a result of the wrong ‘dose’ of oxygen being prescribed. Does the patient needs to be on the NEWS 2 scale? Indication for antibiotics and the proposed stop date or review should be clearly documented once the decision to prescribe antibiotics is made. There is a combined consultant microbiology and COW (Orthopaedics) each Wednesday. The COW team and the Trauma Nurse Co-Ordinators should communicate to ensure all those Orthopaedic patients on antibiotics are discussed.

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THE PATIENT WITH DIABETES AND FOOT

PROBLEMS Patients that have diabetes and are admitted acutely with concerns about the ‘diabetic foot’ are not admitted under Orthopaedics in the first instance. They are admitted under Mr Mason (Vascular/General Surgery). There is a dedicated Multidisciplinary Foot Care Team (MDFT) who will aim to review the patient within 24 hours of admission. Kerry Hawkins (Vascular Specialist Nurse) and Dominic Williams (Tissue Viability Lead) are part of the MDFT. There are clear guidelines on the Trust Intranet regarding antibiotics to be given in the diabetic foot presenting acutely.

POST-OPERATIVE MANAGEMENT

READ THE OPERATION NOTE AND POST-OPERATIVE INSTRUCTIONS.

It is expected that all doctors working in Surgery and Orthopaedics (including Consultants), retain those core skills in identifying and acting when faced with the acutely unwell surgical patient. If you would value some revision in these skills courses that may be of interest are

- Care of the Critically Ill Surgical Patient (CCrISP) - Advanced Life Support

Simulation training is also available at the Post Graduate Centre to refresh your skills. 34

COMPASSIONATE CARE Southport and Ormskirk Hospital NHS Trust cares for many frail elderly people. If you think that a patient, despite all active management of their illness, may be entering the final stages of their life, please escalate this to senior personnel early. It is important that clear management plans are in place for each patient, including sensitively ascertaining a patient’s wishes for end of life care. The patient may have been admitted with a purple coloured form, DNAR form. The Palliative Care Team will always try to attend on the day of referral. It is essential that family are involved wherever possible.

SUPPORTIVE, PALLIATIVE AND END OF

LIFE CARE

At Southport & Ormskirk Hospital NHST Trust, the delivery of high-quality End of Life Care is everybody’s responsibility. The following processes are in place to support teams caring for patients who are in hospital and are likely to be in the last year of their life: The Gold Standard Framework is used to help recognise patients with life limiting conditions and to co-ordinate their care. It helps them plan ahead and live as well as possible right up to the end of their life. Advance Care Planning gives patients the opportunity to plan for a time in the future where they may lose capacity, and allows clinicians the opportunity to engage in Anticipatory Clinical Management Planning. 35

Where the possibility of recovery is uncertain, a ceiling of treatment should be agreed. If a cross-boundary DNACPR order has been made this will be printed on lilac paper. If a patient is recognised as likely to be dying, an Individual Plan for Care for those thought likely to be dying should be developed with the patient and their family. If their preferred place of care is home a Rapid End of Life Transfer should be offered. The documentation to support the above can be found in the ‘End of Life’ drawers on every ward. Advice and support is available to support teams from The Supportive (Transform) and Specialist Palliative Care Services who are based at Queenscourt Hospice. A Palliative Care Nurse Specialist can be accessed 9am-5pm, 7 days a week on (01704 517422). Palliative Medicine advice is available from the consultants (Drs Karen Groves and Clare Finnegan & team) 24/7 on 01704 517922.

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CLINICAL CODING

We need to ensure accurate coding as death certification, standardised mortality rates, audit and performance are all based on data collected from notes.

Please include all co-morbidities and the diagnosis pertaining to the current admission.

If you would like a chat about coding and the importance to the hospital contact Rob Kinney, who is our Senior Coding Manager and is enthusiastic to support clinicians.

CAN CODE CAN’T CODE

Diagnosis Differential diagnosis

Treat as Possible

Probably Likely

Presumed Maybe

Symptoms where no definitive diagnosis is made Suspected

?

Impression

AUDIT

Please discuss with your Clinical Supervisor or Educational Supervisor.

Each doctor should have been a key figure in a least one project per placement.

There are 6 audit meetings per year.

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CLINICAL GUIDANCE FOR THOSE

WORKING IN ORTHOPAEDICS

PAEDIATRIC ORTHOPAEDIC TRAUMA

There is a specific Paediatric Trauma folder. Paediatric patients will be entered into the folder by the Paediatric A&E (in Ormskirk). The cases should be discussed at the morning Trauma meeting before the adult trauma. Management plans should be inserted onto the file during the meeting.

If, as an On Call doctor you are phoned about a paediatric patient, do take the patient details and add them to the Paediatric folder, so this can be presented at the morning Trauma meeting. The Paediatric A&E should do this, however locum doctors rarely have access to this folder.

Emergency paediatric injuries:

There is an agreed protocol for certain paediatric injuries to be referred by Paediatric A&E to AHH Orthopaedics (AlderHey):

-Neurovascular compromised fractures -Displaced supracondylar fractures of the humerus (Grade 3) -Open fractures -Children under 4 who need urgent surgical treatment (septic arthritis for example)

Occasionally the Paediatric A&E will look for advice or assistance in dealing with injuries. Please be helpful.

Out of hours it may be necessary for the Orthopaedic Surgeon non residential on call to attend the Paediatric AED to examine the child.

HOW TO OBTAIN ORTHOPAEDIC ADVICE

9am to 5pm Monday to Friday COW or designated team member does a ward round in ODGH on weekday afternoons.

OUT OF HOURS On call team.

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SPINAL FRACTURE MANAGEMENT Most patients with stable osteoporotic wedge fractures associated with frailty are admitted under the Medics.

Patients should have the management plan documented in the notes. Some patients may have been discussed with the Walton Centre. The electronic system that must be used in communication with the WCNN is the ‘Orion system’. Each new referral generates an Orion code. This enables the WCNN to review the scans and input a management plan onto the Orion system.

Important information for the MDT is:

- Type of brace required, if any, for how long is the treatment period and can the patient remove it during sleep? When should the brace be worn in relation to sitting, standing, mobilizing? The bracing proforma is available in the Orthopaedic folder

- For frail elderly patients, please liaise with the Orthopaedic Therapist, Orthoptist (Eddie Gordon) or the Plaster Room, as a brace may not be appropriate for some patients and could impact on rehabilitation. Therapists on 14a will work with you regarding the appropriate to management, patient-centred care approach.

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PERIPROSTHETIC FRACTURE MANAGEMENT A periprosthetic fracture is fracture around metalwork, typically around a total hip replacement or a total knee replacement. If the stem of a THR is felt to be stable, we do have the facility to treat the fracture with open reduction internal fixation. Patients with complex fractures should be referred to Wrightington, Wigan and Leigh NHS Trust (WWL). They are a tertiary Orthopaedic hospital. We have a close working relationship with WWL. Referral forms are available from our Trauma Nurse Co-Ordinators (TNC). WWL ask that this referral be ‘Consultant Led’ and patients should have a thorough pre-operative work up, especially an ECHO to aid in the pre-operative planning as to whether the patient has their surgery at the Wigan site (HDU/ITU) or Wrightington. Please send referrals to email AcuteHip@wwl.nhs.uk (for all lower limb periprosthetic fractures). It is our responsibility that all images are transferred to their PACS system. We have a number of other partners in the region who can support us in managing complex fractures around metalwork/revision surgery such as St Helen’s and Knowsley NHS Trust. The decision on where to refer will be made at the Trauma meeting or by COW.

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PATHOLOGICAL FRACTURE MANAGEMENT

A pathological fracture is fracture in the bone as a result of a sinister process, most likely metastatic cancer. Please ensure an accurate work up, including CT chest, abdomen pelvis if the primary is not known. If a fracture neck of femur is thought to have occurred due to a process other than osteoporosis, it is important that full length femur views are requested before the patient is admitted to the ward. The Royal Liverpool Hospital has a Metastatic Bone Unit (MBU) for advice regarding management. There are specific referral forms available from the TNCs.

THE PATIENT WHO HAS HAD RECENT

SURGERY AND REPRESENTS TO AED AFTER

DISCHARGE

Patients will occasionally present to AED having been recently discharged from either Ormskirk (elective), Southport (trauma) or another hospital, with concerns about the operative site/joint. If there is concern about infection following surgery DO NOT commence antibiotics without speaking to a senior Orthopaedic doctor, preferably a Consultant (unless the patient is critically unwell and the ‘Sepsis 6 Pathway’ is actioned).

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GOLDEN PATIENT - TRAUMA

The night Orthopaedic on Call and second tier on call will select a suitable patient to be the first patient on the Trauma list (Golden Patient). Theatre and the ward should be informed who the golden patient is.

This patient should ideally be a neck of femur patient who has been medically optimised and on the Trauma Ward. A patient who has correctable abnormalities or requiring workup is not suitable. Please discuss with more senior doctors and the Anaesthetists on call. A patient awaiting admission is not suitable.

There are anaesthetic guidelines available regarding those patients that may need to be delayed in the pre-operative for optimisation of physiological status. The AAGBI working party consider the following acceptable:

- Haemaglobin concentration of < 80

- Sodium <120 or >150 mmol/L, Potassium <2.8 or >6.0 mmol/L

- Uncontrolled diabetes, Uncontrolled acute LVF

- Chest infection with sepsis (signs of systemic organ dysfunction due to sepsis)

- Correctable cardiac arrhythmia with a rate of >120/min

- Reversible coagulopathy

Ensure those patients are on Warfarin are optimised pre-operatively. Please see section on Warfarin in the fracture NOF pathway. DVT assessment forms should be completed on admission and at 24 hours for all patients.

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PROPHYLACTIC ANTIBIOTICS

For elective joint replacements/ major surgical procedures/ patient undergoing ORIF

JOINT REPLACEMENTS AND FRACTURE NECK OF FEMUR

Cefuroxime: Single dose – 1.5 grams at induction

If patient is allergic to Cefuroxime or have history of MRSA (or suspected), please refer to the antibiotic guidelines on the Trust intranet or the Mersey antibiotic guidelines.

THROMBOPROPHYLAXIS IN EMERGENCY HIP

SURGERY / MAJOR TRAUMA VTE PROPHYLAXIS FOR HIP FRACTURES NICE recommends mechanical and chemical prophylaxis.

Chemical prophylaxis to start on admission; however, it should be stopped for at least 12 hours prior to surgery and re-started 6-12 hours after surgery.

Mechanical prophylaxis such as TED stockings and pneumatic compression could be used when appropriate

VTE CHEMICAL PROPHYLAXIS FOR HIP FRACTURES (for those not on other anti-coagulants)

40mg Clexane sub-cutaneous at 1800

Patient admitted before 1800 should be given 40mg Clexane

Patient admitted after 1800 should not be given Clexane as they may require surgery next morning

40mg Clexane to be given the following evening whether or not the patient has had surgery on that day or if he is scheduled within the following day or two (this guideline will automatically give the Surgeon and Anaesthetist over 12 hours clearance prior to surgery)

Patients undertaking surgery late in the afternoon e.g. 16.00hrs should receive their post-operative Clexane dose on that day at about 20.00hrs and not at 18.00hrs. However, from Day 2 onwards, the guideline will continue at 18.00hrs. Duration: 28 - 35 days.

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BRITISH ORTHOPAEDIC ASSOCIATION

STANDARDS FOR TRAUMA GUIDANCE (BOAST)

The BOAST guidelines are available at www.boa.ac.uk. General trauma management guidelines are

- BOAST 1. Patients sustaining a fragility hip fracture

- BOAST 2. Spinal clearance in the trauma patient

- BOAST. Management of patients with pelvic fractures

- BOAST. Management of patients with open fractures

- BOAST 5. Peripheral nerve injury

- BOAST 6. Management of arterial injuries

- BOAST 8. The management of traumatic spinal cord injury

- BOAST 10. Diagnosis and management of compartment

syndrome of the limbs

- BOAST 11. Supracondylar fractures of the humerus in children

- BOAST 12. The management of ankle fractures

- BOAST 14. The management of urological trauma associated with pelvic fractures

- BOAST 15. The management of blunt chest wall trauma

- BOAST. The management of distal radius fractures

QUERY FOR THE SEPTIC NATIVE JOINT

If you are referred a query septic native joint, an aspirate of the joint if possible should be taken preferably before the commencement of antibiotics. DO NOT ASPIRATE IF METALWORK - SPEAK TO A SENIOR.

If possible please take a photograph of the aspirate and show this at the Trauma meeting (no patient details visible).

The aspirate should be sent for pus cells, gram stain and crystals in the first instance.

If there is any doubt regarding whether a native joint is a septic joint another Orthopaedic Consultant opinion should be sought +/- USS of the joint.

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FRAGILITY FRACTURES AND OSTEOPOROSIS

It has been agreed at the highest level between the EMD and the CDs of Medicine and Orthopaedics that the following conditions come under Medicine:

- Pubic ramus fracture - Distal radius fractures in the elderly - Osteoporotic wedge fractures

The following paragraph should be inserted at the end of clinic/ discharge letters:

“This patient has had a fragility fracture and may have osteoporosis. Please consider referring this patient for a DEXA scan in accordance with NICE TA161 as appropriate. However, if the patient is 75 years or over, there is no need for a DEXA scan, but please consider commencing anti-resorptive medication such as bisphosphonates.”

ORTHOGERIATRIC

CONSULTANT REFERRALS Please support them on their ward rounds as they are an excellent educational opportunity. All referrals to them should be made on the ‘pink and white’ referral forms. The Trauma Nurse Co-ordinators and nursing staff on the ward will advise you.

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INTEGRATED NECK OF FEMUR

CARE PATHWAY

Familiarise yourselves with the Best Practice Tariff and the Fracture Neck of Femur Database.

Mr D Selvan is the Lead for the New Integrated Fracture Neck of Femur Pathway.

All patients admitted to the Trust must have:

- A detailed clerking including accurate completion of the medication chart

- 2 group and save should be taken

Sustaining a fracture neck of femur is serious. 1 in 10 patients do not make it out of hospital and 1 in 3 patients are no longer with us at 12 months. Breaking a hip often signals overall ‘body frailty’. The aim of operative intervention is to reduce pain, improve function and to optimise independence.

ENHANCED RECOVERY FOR THR and TKR

There is a protocol for all patients to receive enhanced recovery.

Ours includes: Preoperative drugs (Tranexamic Acid 1g, Omeprazole 40 mg and Pregabalin 150mg all oral).

Reduce Pregabalin to 75mg in >75 years, poor GFR or frail patients.

Spinal anaesthetic.

Avoidance on opiates.

Intraoperative use of local anaesthetic deep in the wound.

Early mobilisation (ideally same day).

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THROMBOPROPHYLAXIS IN ELECTIVE JOINT

REPLACEMENT

Early mobilisation is the most effective therapy

DVT prophylaxis In light of recent NICE guidance (2018) this Trust will change to Enoxaparin (Clexane) 40mgs to be given 6 hours post operatively for both elective TKR and THR on day 0. - For Total Hip Replacement- From day 1 post op Clexane 40mg for 10 days post op followed by Aspirin (75mg-150mg) for a further 28 days (taking into account weight, renal function and contraindications, an alternative may be required).

- For Total Knee Replacement- From day 1 post op Aspirin 75mg-150mg for 14 days post op. Restarting Warfarin and other anticoagulants including Clopidogrel - Warfarin - Patient’s normal dose should be started as soon as is safe post op. This might be on the same day if the patient was first on the list and the dose of Warfarin is in the evening more than 6 hours post-surgery, or the following day. This will be led by the operating team. Clexane should be continued and stopped once INR within range for the patient.

- Aspirin (if part of patient’s medication pre-operatively) - Continue

as per pre-operative state.

- Clopidogrel - Decision to recommence led by Consultant team.

- Other anticoagulants- Decision to recommence led by Consultant team.

NB: If a patient has severe renal failure (defined as a creatinine clearance (eGFR) of less than 30 ml/min (timing of eGFR measurement closest to time of surgery start date) or have a prior diagnosis of CKD of 4 and 5, the VTE prophylaxis recommended for these patients is a low dose low molecular weight Heparin or unfractionated Heparin. If the patient declines VTE prophylaxis or if there is any contra indication to prescribing pharmacological venous thromboembolism (VTE) either post op or at discharge, this should be clearly documented in the patient’s records. Approved by: Dr D O’Brien, Consultant Haematologist

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CLINICAL GUIDANCE FOR THOSE

WORKING IN GENERAL SURGERY

Familiarise yourselves with the individual colorectal surgeon preference list for the pre-operative preparation of patients for major colorectal surgery. Patients are asked to attend the Surgical Assessment Unit on the afternoon prior to surgery. They need to be clerked in, VTE assessment and prophylaxis prescribed. 2 group and save samples are required. Check if suitable for electronic issue of blood. Prescribe pre-load. Prescribe bowel preparation as indicated. The majority of patients will then attend on the morning of surgery having had their bowel preparation at home. Please note that Mr Artioukh would like his patients admitted to hospital the day before surgery.

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CONSULTANT SURGEON PREFERENCES FOR PRE-OP

MANAGEMENT OF COLORECTAL PATIENTS Mr Smith

Mr Artioukh Mr Babu Mr Ainsworth

Bowel Preparation

2 Picolax day prior to surgery 1300 & 1800

2 picolax day prior to surgery 1300 & 1800 Full bowel prep for Right Hemicolectomy

Right sided- No prep Left sided- Phosphate enema 10pm & 6am Low anterior resection- Picolax – 13:00 & 18:00 day prior to surgery

Formation of stoma - No prep Left hemicolectomy,Hartmann’s right hemicolectomy, sigmoid colectomy, anterior resection, APR, reversal of Hartmann’s - 2 picolax 13:00 & 18:00 day prior to surgery

Fasting

No solid food for 6 hours pre op including milk Clear fluids up to 2 hours pre op

No solid food for 6 hours pre op including milk Clear fluids up to 2 hours pre op

No solid food for 6 hours pre op including milk Clear fluids up to 2 hours pre op

No solid food for 6 hours pre op including milk Clear fluids up to 2 hours pre op

VTE prevention

VTE risk assessment to be completed at admission and at 24 hours. Clexane to be prescribed evening before surgery and for 28 days post op. Dose according to VTE assessment chart. TEDS and Flowtrons unless contraindicated

VTE risk assessment to be completed at admission and at 24 hours. Clexane to be prescribed evening before surgery and for 28 days post op. Dose according to VTE assessment chart. TEDS and Flowtrons unless contraindicated

VTE risk assessment to be completed at admission and at 24 hours. Clexane to be prescribed evening before surgery and for 28 days post op. Dose according to VTE assessment chart. TEDS and Flowtrons unless contraindicated

VTE risk assessment to be completed at admission and at 24 hours. Clexane to be prescribed evening before surgery and for 28 days post op. Dose according to VTE assessment chart. TEDS and Flowtrons unless contraindicated

IV Fluids

Not unless stated Not unless stated Not unless stated Not unless stated

Carbohydrate drinks

Pre load sachets 50g 2 sachets on admission day prior & 1 sachet 2 hours prior to surgery Omit in medication controlled diabetics

Pre load Sachets 50g 2 sachets on admission day prior & 1 sachet 2 hours prior to surgery Omit in medication controlled diabetics

Pre load Sachets 50g 2 sachets on admission day prior & 1 sachet 2 hours prior to surgery Omit in medication controlled diabetics

Pre load Sachets 50g 2 sachets on admission day prior . No preload day of operation and 1 sachet 2 hours prior to surgery Omit in medication controlled diabetics

Protein drinks

Ensure plus drinks to be prescribed, BD for 3 days post op, only to continue if ordered through dietician

Ensure Plus drinks to be prescribed BD for 3 days post op, only to continue if ordered through dietician

Ensure Plus drinks to be prescribed BD for 3 days post op, only to continue if ordered through dietician

Ensure Plus drinks to be prescribed BD for 3 days post op, only to continue if ordered through dietician

Venflons No pre op venflon required

No pre op venflon required

No pre op venflon required

No pre-op venflon required

Prophylactic Antibiotics On induction

500mg Metronidazole 1.5g Cefuroxime Dose repeated if surgery 5 hours or longer. 120mg gentamicin if penicillin allergy

500mg Metronidazole 1.5g Cefuroxime Dose repeated if surgery 5 hours or longer. 120mg gentamicin if penicillin allergy

500mg Metronidazole 1.5g Cefuroxime Dose repeated if surgery 5 hours or longer. 120mg gentamicin if penicillin allergy

500mg Metronidazole 1.5g Cefuroxime Dose repeated if surgery 5 hours or longer. 120mg gentamicin if penicillin allergy

Post op requirements

All major resections & any anastomosis require post op oxygen 2L via nasal cannula for at least 24 hours. All bowel resections require post op clexane for 28 days Physio- chest and early mobilisation.

All major resections & any anastomosis require post op oxygen 2L via nasal cannula for at least 24 hours. All bowel resections require post op clexane for 28 days Physio- chest and early mobilisation.

All major resections & any anastomosis require post op oxygen 2L via nasal cannula for at least 24 hours. All bowel resections require post op clexane for 28 days Physio- chest and early mobilisation.

All major resections & any anastomosis require post op oxygen 2L via nasal cannula for at least 24 hours. All bowel resections require post op clexane for 28 days Physio- chest and early mobilisation.

BOOKING A LAPAROTOMY?

Emergency Laparotomy Theatre Check-in (available in theatres) and

The Acute Emergency Laparotomy Pathway should

be completed (available on clinical guidelines of clinical section on

intranet)

Emergency Laparotomy Theatre Check-in

Emergency lapartomy patient label Theatre Check-In

This proforma is to be completed fo all patients undergoing an emergency laparotomy

To be completed by the surgical team prior to the patient arrival in theatre

1.DOES THE PATIENT HAVE SEPSIS? YES/NO (if yes complete sepsis pathway) 2.SEPSIS PATHWAY COMPLETED YES/NO/Not Applicable 3.TAKE BLOOD GAS AND RECORD Lactate= (arterial or venous) 4.CALCULATE P-POSSUM M&M AND RECORD Mortality %= (www.riskpredication.org.uk) Morbidity %= 5.M&M STATED ON CONSENT FORM YES/NO 6.CONSULTANT SURGEON AWARE YES/NO 7.CONSULTANT ANAESTHETIST AWARE YES/NO

Name: Date: Signature: Time: FILE WITH THE ANAESTHETIC CHART IN THE MEDICAL NOTES

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Consultant surgeon and Consultant anaesthetist must review the patient pre-operatively and be present in theatre when the predicted mortality is > 5%

RISK CATEGORY (CIRCLE) LOWER (<5% Mortality) MEDIUM (5-10%) HIGH > 10%-Admit directly to Critical Care

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CLINICAL GUIDANCE FOR THOSE

WORKING IN UROLOGY

Urology is split across Southport and Ormskirk hospitals; acute

inpatients are at Southport and most of the planned procedures and

outpatient investigations are done at Ormskirk (cystoscopy, TRUS

Prostate biopsy, TWOC clinic); Requests for TWOC, SPC change or

flexible cystoscopy should be authorised by the registrar or above and

should be filled in through Medway. (The request form is in the orders

drop down. Please fill in the brief clinical details as this would help in

prioritising the patient).

WARD ROUNDS

Daily ward rounds are carried out 8:00am starting in Ward 10B. Please

ensure the list is up to date. Don’t forget to take the referrals from the

‘’referral folder’’.

The urology notes should be maintained as concisely as possible and

repetition avoided. Please record ward rounds in the notes whilst noting

the most senior person present. Time and date every entry and ensure

there are patient details on every page.

Essential information regarding the results of investigations such as CT,

MSU, bloods should be recorded in the notes to avoid prolonged

searching through case notes. Record decisions and plans for future

management. Always make sure you document what follow up is

required to save you time later. Check drug chart for VTE, review

medication and indication and duration of antibiotics.

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CONTINUITY OF CARE - UROLOGY

Continuity of care can be a problem in this unit as the turnover of

patients is very rapid, so before finishing for the day, please ensure that

the on call team is fully aware of any problem patients you have.

There is a high turnover of patients so do concise TTO’s; don’t forget to

add comorbidities.

TCI‘S

Consent should only be obtained by those familiar and capable of

performing the procedure. In general should be taken by a senior

person, i.e. Registrar or higher grade.

TCI’s - all need TED stockings unless contraindicated and VTE

assessment. The patients undergoing endoscopic procedures such as

TURP, TURBT, ureteroscopy or PCNL should not be given prophylactic

Clexane.

M&M

Add patients with complications in the M&M book. This is usually kept in

Mr Khadr’s office. These will be discussed at the Audit Meeting

MDT

Held every Thursday between 13:00 – 15:00hrs in Spinal MDT room.

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POST-OP CARE FOLLOWING TUR SURGERY

Do not underestimate a TUR.

The lack of an abdominal incision masks the fact that it is a fairly major

procedure that has dangerous complications. In order to focus your

mind on the likely complications you are advised to visit theatre early in

your attachment and watch some TUR procedures.

Resection of tissue particularly from the bladder leaves a potential or

actual defect in the wall. The cut edges of the defect, particularly if deep

will bleed and if pressure rise in the bladder, then extravasation of fluid

will occur through the defect.

The postoperative check

When the patient returns to the ward, and at regular intervals thereafter,

check:

NEWS score

Check the drainage bag to ensure it is running reasonably clear.

Some patients need FBC and U&E on day 1 post op

Stop Tamsulosin and Finasteride post TURP.

1. Early complications

a) Post op bleeding

Heavy bleeding will lead to clot retention which is painful and dangerous

as this may lead to extravasation. Perform a bladder washout if there is

clot retention or if there is any doubt about drainage (i.e. in the obese

patient where is very difficult to feel the bladder); any delay will only

make the evacuation more difficult as the clot hardens and cannot be

washed away from the eye of the catheter.

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Bladder washout

Always consider giving some analgesia as evacuation of the clot from

the bladder is very uncomfortable

With the bladder syringe aspirate the catheter; this may give free

drainage if there are only small amounts of clot;

If fails, inject vigorously 50ml saline as this disrupts the clot that can then

be aspirated; repeat all this until ALL clots have been evacuated;

If the catheter is obviously blocked or will not drain freely when entire

clot has been aspirated then remove the catheter, whilst maintaining

suction on the syringe. This will draw out the obstructing clot.

b) Bacteraemia

This is very dangerous especially in those elderly patients with multi

system disease; it can present as:

The full picture of SIRS, pyrexia, rigors, hypotension

or

Only one of these signs may be present

In the elderly, the only evidence may be confusion;

At first suspicion, do blood cultures and a septic screen, give antibiotics

and IV fluids if hypotensive.

c) Extravasation

This is most likely to occur after TURBT when the clot has been allowed

to develop. Leakage may be intra- or, more commonly, extra-peritoneal.

The patient will have abdominal pain, tenderness and it will be difficult to

maintain drainage. A bladder washout may fail to return the fluid that is

injected. If you suspect this, call for help.

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d) TUR syndrome

This rare, but potentially fatal, complication is often missed. During

surgery, considerable amounts of glycine may be absorbed through the

cut veins. May present as CNS phenomenon, confusion, fit, coma or

even with focal signs or sometimes dyspnoea. Its diagnosis is confirmed

by a low sodium i.e. less than 120 mmol/L. If you suspect this condition,

call for help urgently.

2. When to remove the catheter

Bladder tumours generally the catheter can be removed 24-48 hours or

when haematuria stops. If there has been a perforation, the catheter will

need to stay longer.

Prostate. These are normally removed on day 2 post op providing the

bleeding is light and the patient is afebrile. Prescribe Gentamicin prior to

TWOC if they had catheter before surgery or did ISC.

3. Late complications

a) Bleeding

Secondary haemorrhage may occur and cause clot retention, usually 7-

28 days post op. when the patient is admitted, pass a 3 way 22 FR and

wash out the bladder. Start on antibiotic, as it is often the result of an

infection.

b) UTI

Treat with the appropriate antibiotic.

c) Retention

Approx. 20% of patients are unable to void once the catheter has been

removed. These patients are usually the chronic retainers with detrusor

failure. ReTWOC in 1-2 weeks.

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ACUTE UROLOGY

All emergency admissions must have their urine tested using a dip stick

and if this is abnormal a sample must be sent to microbiology for formal

analysis.

1. Acute urinary retention (See Pathway)

Please ensure the following are documented in the history:

- Duration of symptoms

- Precipitating factors if any (recent surgery, UTI, anticholinergic,

constipation)

- Pain

- Volume of retention

2. Chronic retention of urine

Following catheterisation in patients with chronic retention (>1.5L) and

elevated creatinine (high pressure chronic retention)

- Monitor urine output for diuresis if UO>200 ml/h; may require iv

fluids (required in only ~10% as most of patients can be

encouraged to drink and are guided by thirst)

- Watch for decompression haematuria

- Check for postural hypotension (>20mmHg drop)

- Daily U&Es

- US KUB

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3. Scrotal pain

Testicular torsion (see pathway) – contact your senior immediately; if he

is not available, go higher; this is a rare problem in patients over 30. The

diagnosis can be difficult, if there is any doubt, surgical exploration must

be undertaken. There is yet no absolute test to exclude torsion which is

still a clinical diagnosis. Keep the patient starved until a decision

regarding surgery has been made.

Epididymitis – if you are confident this is not a torsion, admission is not

always required.

Treatment:

<35 Doxycycline 100 mg BD for 14 days, also consider referral to GUM.

>35 Ciprofloxacin 500 mg BD for 14 days

If unwell, they will need admission and Gentamicin or Cefuroxime 1.5g

TDS. Scrotal support and rest.

4. Ureteric colic (see pathway)

Features suggestive of ureteric colic:

Pain in the loin with radiation to groin; can radiate to testicle

Rolling about and cannot get comfortable in any position (vs

peritonism where prefer to be still)

N+V

Frequency (VUJ stone)

Unlikely, think of alternative diagnosis

Bilateral loin pain

History more than 48 hours

Hypotension

Beware of leaking AAA as it can mimic ureteric colic

Dipstix haematuria alone without colicky pain is not Ureteric Colic

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BEWARE OF LEAKING AAA AS IT CAN MIMIC

URETERIC COLIC

Investigation:

Urinalysis

CTKUB

Management

Analgesia – Diclofenac PR or IM, Paracetamol IV

If well, can go home and see in stone clinic in 4 weeks

WARNING: a patient who has a stone with high fever is at risk of losing

their kidney, as this often means that infection has occurred in an

obstructed urinary tract. Resuscitate, apply sepsis 6 bundle and inform

seniors as they might need nephrostomy or stent.

For proven renal tract calculi, remember to check serum calcium and

uric acid-prior to out patient clinic appointment.

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5. Acute pyelonephritis

Features suggestive of acute pyelonephritis:

-young female, usually sexually active with pain in the loin; no

radiation of pain

- fever

-previous or preceding cystitis

- N+V or poor appetite

In some cases can be difficult to distinguish from ureteric colic.

Investigations:

Urinalysis

MSU

Blood cultures

USS KUB

Management

Analgesia

Antibiotics: Gentamicin or Cefuroxime 1.5g TDS if Gent

contraindicated; change to oral Cefaclor 500mg TDS.

The pain associated with pyelonephritis takes a surprisingly long time to

settle even after the urine has been sterilised. Patients may feel quite

tired and washed out for a few weeks. Patients are discharged when

apyrexial with a course of 10 days of antibiotics.

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6. Haematuria

Patients need admission only if they are passing clots or are in urinary

retention. For the rest, refer to haematuria clinic.

For those with retention a wide bore catheter 20-22FR is placed and

irrigation is commenced. If the patient had a recent TURP there may be

difficulty in inserting the catheter; if not successful at the initial attempt,

senior help should be sought.

Southport and Ormskirk Hospital NHS Trust

Southport and Formby District General Hospital Town Lane Kew, Southport Merseyside PR8 6PN Tel 01704 547471

Twitter @SOHNHStrust

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