ED General Information

It is important that patients are admitted to the appropriate specialty as quickly as possible. The Specialty Triage document was agreed following a meeting with Medical, Surgical and Orthopaedic lead clinicians. It is by no means exhaustive but it highlights some of the clinical conditions where there may be some uncertainty as to the appropriate specialty. We are working on presenting a more comprehensive version to hospital clinicians in the hope that we can ensure patients are admitted to the most appropriate team - without endless debate!

Please continue to discuss all patients where there is any dubiety regarding the primary reason for admission with the ED consultant in charge. All specialities have their own individual pressures and we need to try and make the right admission decisions at the front door.

Speciality Triage Poster

There is now a 2 blood sample policy for cross matching in NHS GGC. All patients require a current valid sample and a second one which is either: 

• A historic sample from a previous episode after May 2014
• A second sample taken during current episode when no historic sample is available

These samples must come from separate venepuncture events, ideally by two different people and at two different times with separate request forms.

In an emergency situation when the Major Haemorrhage  procedure is activated a second sample should be sent as soon as possible, however Group O Blood will be issued and blood products will not be delayed. There is a fridge in Resus containing Group O blood.

Please make yourself aware of the MAJOR HAEMORRHAGE PROTOCOL 

The doctor’s main responsibility is to the child, whose safety is paramount. All allegations of abuse or neglect, including anonymous referrals should be taken seriously. Always document on ED record and EDIS letter who is accompanying a child.

If you believe a child may be the victim of abuse, you should share this information with other responsible agencies where this is felt to be in the child’s best interest. This is in keeping with GMC guidance. You should ascertain from Social Work if the child is on an “at Risk register”. The GP’s Health Visitor may also be able to provide useful background information. The safest course of action in cases of suspected child abuse is often to admit the child to RHC under the most relevant specialty. This will allow more time for investigation and background information to be gathered.

Advice can be obtained from the Child Protection Service at RHC via the child protection advice line on 4516605 (9-5) or– ask to speak to the “Child Protection Paediatrician or Advisor”). A stand-by out of hours social worker can also be contacted on 305 6707. If a child is thought to be at immediate risk, contact the Police. Always discuss these cases with the consultant and/or registrar.

Where you are satisfied the child is safe for discharge but feel a shared referral needs to be made, please complete a shared referral on ECS/Portal. Then place a patient sticker in the Child protection diary so the secretaries know the form is complete on portal and awaiting distribution to the relevant parties. Remember to consider children at risk when an adult presents with eg overdose/intoxication. Always ask regarding whereabouts of children and their welfare.

There is a flowchart which details the process following a death in ED. This is located inside the folder within the grey box beside the nursing station outside cubicle 10. It is also available in the ‘how to’ section. 

When completing a death certificate please ensure that it is left inside the same folder under the appropriate section. It will be scanned and emailed to the Registry office by the ED secretaries. Please also fill out the stubs in the book of death certificates. 

It is necessary to inform Infection Control of any deaths which have C Diff noted as a Primary or Secondary Cause of Death. They can be notified on 13635 9am-5pm Mon-Fri and via a Datix outwith these times. This is essential information required by NHS GG&C and the Scottish Government.

Please fill out the death proforma and complete the logbook for each case. Document any discussions in the case notes and update the checklist. A referral to the Procurator Fiscal should be completed, if required, using the Notification of Death referral form on the Sharepoint folder. This should be printed and placed in the appropriate section of this folder. It will be emailed by the ED secretaries the following day.

Ensure the names of all deaths in ED are placed on the whiteboard beside the nurse control station in Majors. 

A Trackcare patient discharge letter should be completed for all deaths in ED to inform the GP of events.

Consider approaching any family whose relative has died if they are on the organ donation register. If you are not comfortable making this approach ask one of the nurses as many of them have been trained in this. Document the outcome of any discussions. You may need to take blood to facilitate tissue donation and the required bottles are in the marked cupboard in resus.

See also: How to > Death Certification

All patients discharged from the ED require a discharge letter to be sent to the GP. Discharges from the ED need to have a letter generated from the information entered in the Trackcare system (i.e. list of investigations and presenting complaint). This should be augmented by writing a very brief explanation in the ‘clinical Notes’ tab of the discharge so that the GP is aware of the attendance, diagnosis and any treatment and follow-up. It is helpful to start your clinical notes by indicating whether any Gp action is required.

Please don't tell/ask GPs to request further investigations or to refer to another specialty. Instead, please ask them to consider requesting said investigation or onward referral. You should aim to do these letters on the day of discharge.

The AHP Team can be contacted on 07929711566 (or page 11643))

Operational hours 8am-8pm Mon-Fri

AHP Team role
Identify potential patients who present at GRI ED/AAU where admission could be avoided through specialist AHP assessment/intervention and rapid onward referral to community supports/services. The team will provide expert advice regarding the future management of the patient and
influence decision to discharge or admit downstream for continued therapy where minimal goals cannot be achieved in the ED/AAU. The team will work within the 4 hour target in ED and complete essential only intervention within the ED/AAU environment.

The team will:
•  Provide functional and mobility assessment, supply aids and equipment, prescribe and organise packages of care, and refer on to community services to achieve discharge.
•  Involve and support carers in assessment and decision making.
•  Where assessment is not required assist in signposting staff or patients to the correct service.
•  Support service with non specific AHP assessments such as frailty/delirium screening.

As a guide the following list may indicate if assessment by OT/PT is required. Assessment need is based on the clinician’s clinical reasoning.
•  Not requiring medical related admission but there are concerns regarding:
- Frailty (HIS think Frailty tool)
- Any fall resulting in injury affecting mobility/function
- Patients with a history of falls within the past 12 months (as per NICE guideline – management of falls)
- History of cognitive impairment where there is concern regarding patients ability to function safely with their current supports.
- Situations where carers are under stress
- Joint pain or swelling or lower limb cellulitis affecting function (where medical admission is not indicated)
- Any new UL fractures where this may affect mobility and/or functional ability.
- Known dementia and unclear social circumstances
• Patients presenting with signs of BPPV where assessment/treatment is needed by a trained vestibular physiotherapist.

If it is thought that discharge is not achievable, interventions will be stopped at the most appropriate and earliest opportunity so that flow is not interrupted.

GRI Emergency Department Mission Statement

All of the GRI departmental and relevant guidelines can be found on the GRI ED app. This can be downloaded from App stores by searching NHSGGC Adult Acute care. The desktop version of the App is here. All resources | Right Decisions (scot.nhs.uk) The password should have been provided.

There is also a Sharepoint folder that contains all of the departmental proformas and advice leaflets. There are links on the app to certain documents on Sharepoint. Documents can be printed from this folder, if you are unable to locate them in the department (eg. irregular discharge forms, AP1nforms, discharge advice leaflets). Access to this will be provided on commencement of your post and we would recommend that you familiarise yourself with the content available.

There is a medical staff handover during the changeover periods at 08:00 and 16:00 , held within the ED Seminar Room. This includes all the doctors currently on shift and those just starting.

The handover includes familiarisation with staff allocations within ED, any current issues, daily reminders, teaching and a virtual walk through of the ED.

All of your patients within ED should be handed over using the brief format of:

• Age
• NEWS
• Diagnosis
• Outstanding issues
• Predisposition
• Handed over to…

Please familiarise yourself with the handover process document that is used to facilitate this process.

Patients who present to the ED are under no obligation to follow the advice of medical or nursing staff and may wish to take their own discharge. However in order to safely allow an “irregular discharge” the following criteria must be met and documented – there is an ED irregular discharge from which also lists these requirements and guidance notes.

1. Understands proposed treatment – purpose, benefits, risks
2. Understands consequences of refusal to follow advice – actual and potential
3. Able to retain information long enough to make a free and effective decision and explain their reasoning (even if you may disagree with their final decision).

Ensure that the patient is aware of what to look out for and when to return. Consider notifying an outside agency for follow-up (relative/GP). If the patient does not appear to be reaching a rational conclusion or you are unsure of their capacity then seek senior help.

There is a 'Discharge Against Medical Advice' form (located at the nursing station outside Cubicle 10, on Sharepoint and in the Triage+ room.), to be signed by the patient and clinician and then placed in their clinical notes.

All irregular discharges or DNA cards should be placed within the IRD box for consultant review the next day to facilitate patient recall.

Take bloods as early as possible. Ensure correct yellow label is attached. Label so that the print is orientated in the same way as written information would be entered on the bottle label. Use the right hand side express pod system next to cubicle 14 in majors. Please hand all urgent transfusion requests directly to the porter and ask them to bring them to the laboratory and hand them to the technician. This avoids the possibility of lost samples in the pod system. Do not wait on blood results coming back if patient admission is required in any case; the task of checking these results can form part of the inpatient management plan.

Ensure that you sign off all of your discharged patients blood results on Trackcare at the end of each shift. 

ED enjoys direct admission rights to AMU. Please write a short term plan eg 4-6 hours, for the nurses to follow, as well as a differential diagnosis for each admission. Aim to stabilise and resuscitate each patient as completely as possible before they leave the ED.

Between 9-21 hours a simple SBAR and Trakcare bed request suffice for most admissions. The only exception to this is the sicker patient who may require review by the  medical registrar #13220. After 2100 please let the medical SHO know of the admission #13001 in addition to the SBAR completion, which suffices as a nurse handover. 

Any cardiac sounding chest pain should as a rule be referred to cardiology, whose responsibility it is to find a bed.

In addition to the AMU, there is a 4 zoned assessment unit (AAU) adjacent to the ED, All GP referred patients are sent there, unless they are so unwell as to require treatment in resus. If this occurs medical staff normally attend resus but ED staff should be willing to help these patients should the need arise. Zone 4 acts as an ultra short assessment zone for low risk chest pains (HEART score <5) and outpatient PTE pathways.

You may already be aware of the Navigator project that was launched in GRI ED in 2015. Navigator is a project run by Violence Reduction Unit to support people to move away from violent lifestyles. Our Navigators use ED attendances as a reachable moment to offer support and an opportunity for change. Referral cards are in a small pink box by the Flow Coordinator desk. See https://www.mav.scot/navigator/ for more information.

Please use a Part A (4 page booklet) to record your history and examination findings. The Triage Plus consultant may have already written an initial plan and carried out some investigations on the Part A. Please check these results and discuss with the consultant if you require clarification or feel the plan should change. Generate a differential diagnosis and write a short term plan for the main issues that need to be treated and investigated prior to review on the receiving ward. Prescribe any medications on a Kardex. Use a fluid chart for any IV fluids required.

Only use the reverse side of the ED coversheet for documentation in minor injuries, where notes are appropriately curtailed to a brief history of the injury, an examination of the injured part, and documentation of the treatment and follow-up.

Remember you can access your patients Clinical Portal for other health boards via the Regional Portal link.

All drugs should be prescribed on the Kardex, with the only exception being patients who are needing single doses or take-home meds as these can be prescribed on the pre-printed section on the back of the ED coversheet. The quantity of drugs given should also be noted, eg. co-codamol x20. Prescribing guidelines for antibiotics in the ED are available in the GRI ED app and posters displayed within ED.

Please place a 'sticky note' on all x-rays that you review. This allows Radiology to assess if a patient may need to be recalled. Ed consultants review all radiology reports from the department and without sticky notes a laborious task becomes even more time consuming.

Police should, on request, be supplied with outline clinical information on certain patients:

• When a patient gives their consent
• At the specific request of the procurator fiscal
• The driver of a vehicle involved in a road accident
• Serious assault (e.g. requiring resus)
• Trauma death
• Rape / Terrorism / Gunshot wounds / threat to the safety of the public

Police frequently request information out with these categories, however you are bound by the GMC to protect patient confidentiality unless you can satisfy yourself that the patient would have no objection to the information being released.

Police statement requests will be emailed to you with an online proforma via Nadine Robertson, our ED secretary ext 66654

Get into the habit of asking the victims of assault for their consent to the release of information if asked and document clearly in the notes: “Consents to release of information to the police”.

GRI ED Referral Guide

For the most part, patients are admitted using the SBAR handover document on Trakcare. Some specialties still require a telephone handover (see document below).

Orthopaedic admissions should have ongoing analgesia prescribed on a Kardex.

There is no ENT cover at GRI out of hours. There is an ENT registrar on call via QEUH.

Ensure that a Kardex is completed for all Ward 46 admissions.

All children transferred to the RHC should have a transfer form completed and sent with the patient. The clinical notes should be scanned onto portal prior to the child leaving our ED.

We have 4 ultrasound machines which are kept in Resus.

Ultrasound 1

is the largest and is kept in the Trauma Bay. This is our primary US machine and is the only one able to save and print images so should be used by trainees with a logbook to complete.

Ultrasound 2

stays in the bay outside the decontamination room. This is our back-up to US 1 and has the 3 main probes that we need (curvilinear ECHO and linear).

Ultrasound 3

resides in the Resus store cupboard and can be used for fascia illaca blocks and for IV access. This is the only machine that should be lent out to other areas on the 'rare' occasions it needed to borrow a machine for IV access. 

Ultrasound 4

is tablet based and lives in the locked drawer below the computers outside Bays 3 & 4. and contains a linear probe.

All should be maintained on charge and fully cleaned with the appropriate wipes after each use. They are all checked as part of the daily Resus checks.

Unless there are clear and stated clinical reasons on the grounds of patient safety, all patients should be admitted to a ward, transferred or discharged or discharged within 4 hours of their arrival.

In view of this, we would ask you to have made a management plan for your patients by 2 hours and to discuss any issues with a Consultant at this point. Please request a bed as soon as possible (this can always be cancelled and admitting wards prefer advance in order to rearrange beds if necessary).

Vulnerable Adults are managed under the Adult Support and Protection Act 2007. An adult is deemed to be vulnerable if they satisfy the following 3 point test:

• unable to safeguard their well-being, property or affairs, and
• at risk of harm, and
• affected by disability, mental disorder, illness or physical or mental infirmity making them more vulnerable

If you have concerns please complete an AP1 form. These are located in the grey box beside the nursing station outside Cubicle 10 or can be printed from the Sharepoint folder. The contact numbers are on this form. You need to discuss the case with social work and Datix it, so that there is a record of the incident. If you suspect vulnerability and the occurrence of harm it is your responsibility to fill the form and refer to social work, even if you are admitting the patient.

A patient sticker should be placed into the logbook under vulnerable adults for all patients that you have completed an AP1 form for. This is within a folder in the grey box beside the nursing station outside Cubicle 10. The ED secretaries will ensure that the AP1 form is forwarded to the relevant social work department.