After Hours

Important considerations

• As in Preparing for a Term but particular emphasis on
  • Very portable water bottle
  • Food to have while walking
• Sit everywhere
• Phone orders: You can start treatments before physically getting there by ordering on the phone as a STAT order
• Eating
  • For evening shifts eat at the beginning of your shift as you’ll unlikely have time during the rest of the time
  • For night shifts have a routine that works (e.g. snack/hydrate around 1am, meal at 4am, snack/hydrate at 7am)
• Timing
  • During nights the main job rush hour comes at about 10pm to 1am then again at about 6:30am to 8am because that is when the nurses have changed shift and the new nurses identify new tasks for the JMOs
  • Therefore to save repetitive walking you can wait until 11:30pm to do all the jobs in a clean sweep by ward
• Know which wards you cover

Preparation

• EMR setup
  • Have the following lists
    • Ward lists
    • Whole of hospital list, this is helpful to scan through if called or paged about a patient and at least you’ll know if they’re in the hospital
    • Multi-patient task list
    • Task manager
    • After hours custom list
      • An after hours custom list is used for all the patients you need to chase anything for; use instead of the folded/scrunched A4 sheet. Consider including
        • Reviews
        • Med/Surg reg reviews
        • Handover
  • Have all your auto-texts ready
• Things
  • Always carry a notebook or some paper at least
    • Whenever a call comes, you can easily note down everything the other party can tell you, know the patient’s condition, start to address the issues, remember what investigations and treatment you’ve commenced and importantly follow up and eventually hand over

Prioritising after hours jobs

1. MET Calls/Rapid Resonses
2. Clinical reviews
3. Organisation
   • First go through the multi-patient task list then the task manager and assess the urgency of the jobs
4. Verbal handover from any doctors about urgent things
5. Multi-patient task list: Handover tasks
6. Task manager/JMO job books: the rest of the jobs

• Specific prioritisation for particular jobs
  • Cannulas (see IV Cannulation) IVABx/other active treatments/severe electrolyte derangement replacement > IV fluids/mild electrolyte replacement > protocol-driven change
    • Always set up pre-emptively for five or six cannulas
    • Carry common spares for tape/gauze/tourniquets/dressings
    • Can consider doing the easier cannulas first to build up confidence
  • Venepuncture
    • Generally MET calls/clinical reviews > handover bloods > timed bloods (e.g. APTT)
• Have an autotext for common procedures

Junior Medical Officer Dr [name]

Asked to insert IDC

Indication: [indication]

Patient consented to procedure
Sterile technique applied
Hand hygiene performed
Draped
Cleaned urethral meatus with sterile normal saline
Lubricant inserted into urethra
Has had [Y/N] and to where] recent travel
Inserted [#] French IDC first pass
Inflated with 10mL sterile water
Drained clear straw-coloured urine
Procedure well tolerated by patient
Nil complaints boiced

Urine sent for MCS and urine creatinine, sodium and osmolality

Plan:
- Monitor urine output/colour
- Team to chase urinary investigation results
- Notify medical officer if any concerns

Reviews

WARNING

Always call a senior if you are concerned about a patient

1. Cardiac arrests/Code blues (attend immediately)
2. Rapid response/MET calls (attend <10 minmutes)
3. Clinical reviews/yellow zones (attend <30 minutes)
4. Patient reviews
5. Handover reviews
6. Other/protocol-based reviews

Clinical Reviews

• See Common Ward Calls for specific presenting complaints
• Consider adopting the following procedure:
  1. Call back so you can triage and know what’s going on
  2. Question fruitfully, getting as much info as you can before seeing the patient (see the phone call questions sections of the various presenting complaints notes)
  3. Look through documentation and notes
  4. Look through the patient’s eMeds; consider telling the nurse to consider witholding/reducing some of the meds and giving others (e.g. PRNs)
  5. Optional: Initiate basic investigations/management as appropriate
  6. Optional: Prepare notes
  7. Add the patient to your custom list for follow up/handover
  8. See the patient and document
  9. Generate differentials
  10. Consider senior advice
  11. Commence management
  12. Chase and hand over
• Note the following investigations you can order
  • Blood, cultures, ABGs, VBGs
  • Any nursing assisted investigations (e.g. swabs, urinalysis, urine MCS)
  • ECG
  • CXR ± other x-rays
  • Obs/neuro obs/limb obs/other obs of all types/postural BPs
  • BSLs
• Note the following management you can start
  • IV fluids
  • Oxygen
  • Symptomatic relief you’re comfortable prescribing (e.g analgesia, anti-emetics, aperients)
  • Electrolyte replacement you’re comfortable with
  • Bronchodilators
  • PPIs
• Common plans
  • Continue as per team (unless not doing so)
  • Continue monitoring
  • ± senior review or discuss with senior
  • Notify MO if any concerns
• Common clinical reviews:
  • Falls
  • Aggression
  • Delirium/confusion/reduced level of consciousness
  • Chest pain
  • Abdominal pain
  • Limb pain
  • Low/high urine output
  • Headache
  • GI bleeding
  • Vague pain of any other body part
  • Symptomatic relief

Protocol Based Reviews

1. See the patient
2. Set up auto-text the first time you do them
3. Document/cross off job list

[Insert type of review] Medical Officer Dr [name]
Asked to review day 3 IVC
Patient consented to review

[size] _G IVC in _[position]
- Nil pain
- Nil erythema
- Nil oedema
- Nil induration or palpable cord along path of cannula
- Patient afebrile
- Nil other complaints
- Visual infusion phlebitis score = _

Impression:
- IV site appears _health/unhealthy
- Sign of cannula infection/phlebitis: _yes/no

Plan:
- Keep and observe cannula for further 24 hours/please remove IVC and re-site
- Team to review need for cannula mane
- Notify Medical Officer if any concerns

Handover

• Use a piece of paper to write down all the reviews and code blues you have done to prepare for the handover
• A brief summary of the shift: “this shift was quiet” or “this shift was a bit challenging”
• Any code blues (MET calls)? Any rapids?
• Any clinical reviews?
• Any patients you’ve concerned about/anyone to keep an eye out for?
• Anything to chase?
• Any other information you have about a patient that can help a collage?