JCUH Department of Trauma & Orthopaedics Doctors Induction Information Booklet An overview of the trauma service, training opportunities and key performance issues August 2018

Welcome to the Department of Trauma and Orthopaedics at James Cook University

Hospital.

This induction information pack has been produced with the aim of providing an overview

of the Department - how it runs day to day. Also, it provides an understanding of what is

expected of the individuals within the team and the standard of practice required in

ensuring the safe and efficient care of our patients and their relatives.

The Department at JCUH consists of:-

• Ward 34 - Hip Fracture Unit

• Ward 36 - Trauma Ward

• Ward 25 - Elective Orthopaedic Ward

• Ward 22 - Children’s Ward

• Trauma & Orthopaedic Theatres

• Trauma Out-patient Department

We are dedicated to supporting education and personal development at all levels and we

offer a variety of quality teaching and learning opportunities of which we expect you will

take full advantage. Whilst the junior doctor training model has become fragmented, within

the trauma service we adopt a more inclusive philosophy. All patients in the service,

regardless of age or injury are the responsibility of us all. Similarly information transfer

regarding all patients is the responsibility of all clinicians in the junior tier. Please see

yourselves as a valued and active member of the trauma family and immerse yourself in

the running of the department.

The Department of Trauma and Orthopaedic Surgery has an international reputation for its

leadership in clinical research. We are active in supporting both commercial and non-

commercial research and are also acting as the UK lead for multi-national clinical trials.

There are opportunities to get involved in the research process with the potential to have

work published.

August 2018

Dear Colleagues,

In order to ensure optimal and safe care of orthopaedic trauma patients, it is important that

communication regarding cases and basic aspects of preparation for theatre are

understood fully by all team members. This is a two way process and whilst we expect the

below from you to enable us to maintain high quality patient care, we are duty bound to

reward high quality care with high quality training.

What we should expect from each other

In order to maintain good patient care and encourage a healthy training atmosphere there

are some generic points of professionalism which should be adhered to. These apply to all

doctors working in the team, across all grades.

1. Punctuality. There will always be the occasional ‘disaster’ morning but we will

not tolerate recurrent tardiness. This will be escalated via ISCP to the deanery if

it is felt to be a problem.

2. Respect. Every member of the team can expect to be treated with respect.

When personalities clash this can be challenging but we should remember that

we are adult colleagues working together for the best patient outcome. Where

issues arise these should be escalated appropriately at the earliest opportunity.

Trauma is often exacting and can be stressful and handling this is part of the

educational opportunities you will be given. There always is a hierarchy – please

respect the choices of the decision maker who is responsible for patient care –

you are not, and despite however senior you may feel, they are.

3. Civility. Behaving politely costs us very little. Simple courtesies should be

observed. Problems with colleagues should be discussed privately and not

gossiped about or aired in public.

Orthopaedic Trauma Junior Doctors

Daily working routine

What we expect from Trainees

So that we can help you train in a comfortable, educational environment, the following

have been laid out to ensure you are totally clear as to what is expected of you when

looking after trauma patients and delivering information at the trauma meeting:

1. The on call junior grades for any given day must be present at the following

morning’s trauma meeting. If this is not possible, a full handover to another

colleague of the same grade is expected. Regardless, a junior doctor of ‘SHO’ and

registrar grade is expected to be present and have all the relevant patient

information (starving status, relevant medical history, location, consent and marking

status) for all patients on the trauma list and those awaiting decision making.

2. All patients must have relevant investigations completed and checked before the

morning meeting. All results must have been reviewed by a doctor. The individual

requesting the investigation is responsible for ensuring the result is checked. Do not

ask nursing staff or perioperative practitioners to order bloods and leave it there.

Always ensure an individual with a medical degree has checked the blood results /

imaging requests and is present at the meeting to be responsible for their

discussion.

3. Handover is key to safe patient care. This needs to be a formal process between all

grades. Registrars must formally hand over all cases on the trauma board. All

patients on the trauma lists for the next day must be discussed and all

investigations and consent forms must be checked as well as marking of limbs. All

patients not in the hospital must be appropriately administrated so that an ongoing

plan exists. Effective handover is a GMC requirement and failure to adhere to this

will be escalated. All oncoming ‘night registrars’ must receive a sit down brief from

the outgoing ‘day registrar’. If no handover occurs due to poor punctuality, you will

let your colleagues and yourselves down, threaten patient safety and put

yourselves and your colleagues into a stressful position when the predictable poor

response the next day comes. Lack of knowledge of safe patient care is not

tolerated, will be highlighted and escalated to supervisors and the postgraduate

centre where required. This is not bullying, it is safety netting patient care through

establishing safe knowledge of investigations. Please do not put yourselves or your

colleagues into this position.

4. All clinics must be fully staffed. Any leave must be approved in advance and 6

weeks’ notice is required. We totally support any short notice swaps but these need

to be signed off appropriately.

5. Communicate with consultant colleagues. Any decision should be discussed with a

consultant and there is always more than one consultant available for such issues.

If, for any reason any of the normal channels aren’t open, you call Mr Eardley or

alert him through the Siilo group text.

6. Bluespier – all patients are administered through this system. All clerking is to be

done through this in terms of co-morbidities and diagnoses so that we can code for

our patients properly and can populate lists accurately. Training is provided.

Regular audit will be performed to ensure appropriate recording of correct details is

occurring. Every single data point regarding patient demographics MUST go on

Bluespier. Use the appropriate screens, not free text. The on call registrar at the

time of admission is responsible for data completeness.

7. Ward rounds and patient care responsibility – each week starting on Friday, one of

the four trauma trainees will be the named junior for the week. This will mean they

are providing oversight of the week and then they will be responsible for reviewing

the patients operated or admitted on that week until discharge. This will be sorted

by the juniors themselves internally. Please make yourself known to the on call

consultant and make it clear you are providing care that week.

8. Teaching – teaching opportunities are plentiful. It is expected that trainees attend

the Thursday evening teaching. Teaching is also available on Friday morning at

0715. This teaching is provided to increase your knowledge of Orthopaedic trauma,

basic science and anatomy. Attendance whilst not mandatory is encouraged and it

is expected as per the GMC guidelines to continue professional development.

Monday lunchtime teaching is available.

9. Mortality reporting – all patients that pass away must be discussed through the

mortality system. All trainees will engage with this in a timely manner when

requested, regardless of the time of passing of the patient.

10. Willingness to learn - we want to train you to be able to independently provide safe

and effective patient care. If you are not willing to learn we cannot do this. Areas for

improvement will be highlighted through constructive criticism and areas of

excellence will be praised. Please do not expect to not be questioned or challenged

– advancing your knowledge and ensuring patient safety through adequate

information handover should be expected and again is a key domain of good

clinical care. Thorough questioning and handover of information is expected and is

central to safe patient care.

What Trainees can expect from us:

Training is a two way process. We as trainers have responsibilities to trainees. We cannot

expect the above if not helping trainees meet their requirements.

A. Monday afternoon teaching is mandatory and there is no requirement to be in the

hospital during teaching term time. The trauma bleep will be covered by the Core trainee.

In their absence the Consultant will cover. Trainees are expected back at 1700 prompt to

take handover. Trainees attending late for on call will be escalated for poor performance.

B. Consultant supervision is mandatory and no case will be completed without appropriate

supervision, the level to be decided between trainee and trainer. Consultants will always

be available to assist, teach and supervise both in clinic and in theatre. All trainee only

clinics at consultant leave time will be reduced and that total can be influenced by the

trainee from the baseline depending on level of experience. All cases in these review

clinics can be discussed with the consultant both before and after should the need arise.

This is entirely dependent on prompt leave booking and interaction with the secretary.

C. All trainees will receive an ES and CS review in a timely manner.

D. All trainees will have WBA’s signed off in a timely manner. It is expected that any

WBA’s will be done contemporaneously and I do not expect any consultant colleague to

complete a WBA submitted more than 24h after the learning opportunity.

E. All trauma trainees will have the opportunity once in each 6-month attachment to

complete in a formal manner the complex and critical CBD’s. This will be provided by

myself and refreshments provided. All trainees to bring a case and the group will discuss

to enrich the learning opportunity.

F. All trainees will be exposed to the appropriate lists and clinics and indicative numbers

will be provided at the baseline as detailed in the subspecialty guidelines issued from the

rotation.

G. All trainees entering the department will be given the opportunity to take part in the

weekly mock exam as long as engagement is regular. Trainees not contributing for a

three-week period will be ejected from the scheme.

H. All trainees will be provided with time to complete a meaningful audit project. Contact

the audit lead for direction. It is expected that a closed loop audit will be undertaken by

each trainee and the obtaining of projects and timely completion is the trainees

responsibility.

I. All trainees will be provided with a research opportunity by the clinical research team

within the department. Completion is the trainee responsibility – we will provide roles that

will most likely if completed be published and presented nationally.

J. All trainees will be afforded opportunity where suitable to contribute to recruitment to

portfolio trials and they will be given certificates by the research nurses for their portfolios.

K. All trainees will have access to pastoral care where needed alongside established CS

and ES opportunities. All trainees have access to myself at any (reasonable) time to

discuss any issues. We have sorted out many difficult situations for trainees and protected

them from unacceptable pressures. What we don’t know about we cant help with so the

sooner we know the better.

L. Training is not a passive process and as consultants we should be expected to actively

find ways of improving out trainees performance. This should be done through well

delivered constructive criticism and praise where merited. Constructive criticism must

include an explanation of why the trainee needs to change their practice as well as an

agreed plan on how to do this.

TRAUMA ADMISSION PROCESS A guide for junior doctors

This process is to be followed in an efficient and timely manner to ensure safe and

effective patient management, prevent unnecessary delays and promote patient

satisfaction for all who come into contact with the service.

If not adhered to there is a risk that patient care, safety and satisfaction may be

compromised therefore to prevent this you should escalate any concern immediately to the

on call Orthopaedic Registrar who will take the necessary steps to provide additional

advice and/or support.

Sources of referral include the Emergency Department, out-patient clinics, GP’s, Wards

and other hospitals. Ward attenders may also present to Ward 36 for review if a

complication or concern arises following a recent discharge from one of our wards and that

requires urgent attention.

On call SHO responsibilities:-

Review all patients referred at the earliest opportunity, immediately where possible but

certainly within 1 hour of referral.

If this is not achievable and the patient is in the ED, please inform the on call Orthopaedic

Registrar. If the patient is on Ward 34/36 either as a new referral, admission or ward

attender and you are unable to see them within the hour then please, in the first instance,

request help from your Ward SHO or Nurse Practitioner colleagues. If they are unable to

provide assistance then please once again escalate to the Orthopaedic Registrar and / or

the Consultant on call.

For all patient admissions the following is to be initiated without delay:-

• Take patient details and ask Ward Clerk / Nurse in charge to admit patient onto

eCAMIS, request medical notes urgently and print patient labels. CHECK WITHIN

AN HOUR THAT THE NOTES HAVE ARRIVED – IF NOT, ESCALATE THE

PROBLEM. Lack of notes is one of the commonest reasons for delay.

• Inform Nurse in Charge that patient is for admission and request a bed to be

allocated.

• Liaise with Trauma Nurse Specialist Sarah Nellis who will provide advice / support

and assist in co-ordinating patient care during the acute phase of patient

management.

• Perform a full documented clerking and clinical examination as per Royal College of

Surgeons of England (1994) Guidelines for Clinicians on Medical Records and

Notes.SeeTable1.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4348450/pdf/main.pdf

• Complete drug chart to include usual medications, adequate analgesia & consider

laxatives. If antibiotics are to be prescribed please ensure that this is done in

accordance with the Trust Anti-microbial Prescribing Guidelines (Available on Trust

Intranet) and with advice from Microbiology or ID Team to ensure the appropriate

agent is used considering probable or identified organisms.

• If a septic arthritis is suspected discuss the case with the on call registrar and if

indicated ensure joint aspiration is performed prior to commencing antibiotics.

This should always be the case unless the patient is critically unstable and if a delay

in administering antibiotics may compromise patient safety.

• Complete individual patient VTE risk assessment on inside page of drug chart and

prescribe appropriate VTE prophylaxis. Pharmacological agents are generally used

as VTE prophylaxis – LMWH for at risk trauma patients and Apixaban for elective

patients, unless contraindicated or if an alternative plan is documented by the

patients Consultant. TEDS stockings are not routinely used for trauma and

orthopaedic patients. Patients anticoagiulated on admission, get discharged on the

same medication that they came in on.

• Perform relevant blood investigations pertinent to the admission clinical problem. If

results are required urgently please call lab and inform and call porter to transfer

immediately on an urgent basis. This will ensure that they are handed over to lab

staff rather than be placed into the routine drop box. If unsure about which bloods

to take, escalate. If you have requested blood tests YOU MUST REVIEW THEM or

hand them over.

• Request Nurse in Charge to perform admission MRSA PCR screen and if

transferred from a hospital abroad where treated as an inpatient to isolate and

perform CPE screening as per Trust IP&C Policy.

• If the patient has been transferred in from another UK hospital please request that

all relevant images are transferred electronically to the JCUH PACS system.

• Consider additional investigations which may assist with patient assessment. This

can be discussed and confirmed with the on call Orthopaedic Registrar if unsure.

Examples of relevant investigations include:-

All patients requiring surgery aged 50+ or who have a cardiac history should have an ECG please ask Nurse

in Charge to perform but you must personally review it.

All hip fracture patients with a history of cancer should have a full leg femur radiograph of the affected side.

Ensure INR checked for all patients who are taking Warfarin and consider reversal as per protocol if surgery

is proposed and bridging requirements. Please note there is a dedicated Warfarin reversal protocol for hip

fracture patients available within NOF pathway document and is displayed on Ward 34.

For those taking NOAC / DOAC anticoagulants please ensure renal function is checked as this will guide

minimum pre-operative washout period and again there is a protocol for this.

Patients with a pacemaker fitted should have a check if not already performed within the last year and

confirm type of device where possible.

ECHO if clinically indicated e.g. new murmur identified on auscultation / significant clinical signs of impaired

cardio-pulmonary function or where further investigation of cardiac function may assist in assessing fitness

for surgery / fluid management.

• Ensure patient and ward staff are aware of starvation status if surgery is planned.

Minimum 6 hours food and 2 hours clear fluids. Do not fast patients unnecessarily

and do not fast hip fracture patients admitted after midday but ensure fully worked

up and ready to go to theatre early the following morning.

• Consider IV fluids for all trauma patients to ensure optimum hydration and GKI for

insulin dependent diabetic patients.

• Add patient to Bluespier documenting full history & examination findings in notes

section along with any investigation findings, e.g. blood results, aspiration results,

etc.

Once fully clerked, for those patients returning home to await a date for surgery,

please take notes to Ward 36 and place into TCI drawer in filing cabinet. Please

ensure a contact telephone number is recorded for these patients both within the

medical notes and within the Bluespier notes section. Advise the patient to continue

taking diet and fluids as normal until called to inform otherwise.

Add a diagnosis by clicking ‘add diagnosis’ tab in left hand column and add all co-morbidities by clicking ‘add co-morbidities’ tab.

For all hip fractures a breach time for Best Practice Tariff must be documented

on Bluespier within notes section AND within procedure section to ensure visible on

theatre list.

To meet BPT patients should be operated within 36 hours of admission to A&E (or

from time of X-Ray if injury sustained on an inpatient ward)

Follow link for easy to use Bluespier guide: \\stas155\desktop$\snellis\An idiots

guide.pptx

Continuing Care & Patient Management – Ward Doctor and Nurse Practitioner Responsibilities

• All ward doctors and SpN Trauma to attend 8am Trauma Meeting in Seminar

Room.

• Liaise with Nurse in Charge following Trauma Meeting, obtain a patient handover,

prioritise duties and initiate any urgent tasks immediately.

• Accompany Consultant on ward round and present all patients to the consultant on

the round including Injury, mechanism of injury, relevant blood tests and

demonstrate observations for each patient.

• Attend Ward Huddles to review patient progress and share information with the

MDT. Once huddle done, meet with trauma nurse practitioner and go through plans

and tasks and check all key variables such as VTE status, antibiotics and XR’s

awaited.

• Daily documented review of all trauma patients based on the above.

• Review drug chart to ensure prescription safe and complete. Ensure analgesia

effective and appropriate VTE prophylaxis prescribed and administered. If

antibiotics are prescribed ensure a review / stop date is documented. Check that

the antibiotic is appropriate for the organism being treated and document in the

notes daily as a minimum – the type of agent prescribed, the reason for prescription

and days of treatment remaining.

• Check blood results and request any investigations necessary to further assess the

patient’s condition. For example :Post-operative blood check, CRP /WCC

monitoring for infected patients, LFTs & renal function for those on high dose

antibiotic therapy, INR for those taking Warfarin etc.

• Review fluid balance and ensure patients are adequately hydrated.

• Commence discharge planning early and ensure discharge letters and TTO’s are

completed in a timely manner to prevent unnecessary delays. Aim to complete at

least 24 hours in advance of discharge date wherever possible.

• Escalate any concern to the parent Consultant Team or On call Registrar. SpN

Sarah Nellis can assist with contacting an appropriate person if necessary.

• If unable to answer with accuracy any patient question regarding their ongoing care

or management then please, rather than risk giving incorrect information, refer to

the parent consultant team who will update the patient in due course. This will

prevent any confusion and ensure that only clear and accurate information is

passed to the patient.

• Prior to ending your shift please handover any outstanding issues to ensure

continuity of care and promote patient safety.

• It is expected that you make every effort to take advantage of available learning

opportunities. This may require negotiation with colleagues to ensure equal

opportunities and to cross cover where necessary. The Nurse Practitioners will

support you to do so whenever possible.

CARE OF HIP FRACTURE PATIENTS

A guide for junior doctors

ADMISSION NOTES FOR DOCTORS ♦ Full clerking to be done on Integrated Care Pathway including the “Fitness for theatre”

pro-forma and all blood results to be entered.

♦ Review X-ray, Chest X-ray and ECG

♦ Review all bloods and ensure Group & Save has been sent (usually sent by A&E)

♦ Mark, consent and place on Bluespier (please include NOF “breach time” on Bluespier i.e. 36hrs from A&E admission or time of X-Ray if an inpatient fall)

♦ Prescribe:

DVT prophylaxis (LMWH s/c for 4/52 unless contraindicated)

Analgesia (Regular IV/PO Paracetamol 1g, +/- codeine + Oramorph prn)

NB IV Paracetamol dose needs to be adjusted for patients less than 50kg – usual dose is 15mg/kg

Anti-emetics

IV fluids (Sufficient for 72 hours to allow for any delay to and return from heatre)

Laxatives – usually Macrogols (Laxido)

Patient’s normal medications.

♦ Document and inform staff of NBM instructions. Thank you.

OPTIMISED RECOVERY PATHWAY: ELDERLY HIP FRACTURES

DAY OF ADMISSION

Please refer to the document “A to Z of anaesthesia for elderly trauma patients” for comprehensive details of pre-operative testing and management.

• Admit to ward 34 and commence neck of femur pathway booklet • All patients will require a 12 lead ECG, CXR and a valid Group & Save • All patients will require full results in the notes for:

o FBC, U&E, LFT, Bone profile, Clotting • All patients will require pre-operative intravenous fluids to be running • Insert urinary catheter with hourly urometer for patients with clinical indication e.g. renal

impairment • Analgesia prescription:

o Regular IV Paracetamol 15mg/kg QDS § Note: 1g QDS is not suitable for all

o Regular Codeine 30-60mg QDS o Avoid NSAIDs unless patient is already established on them and renal function

is normal o PRN Oramorph 5-10mg 4 hourly for breakthrough pain

• Fasting as per trust guidelines. o Six hours for food/non clear fluids o Two hours for clear fluids

§ Fasting all patients from the previous evening is unnecessary. Positive attempts should be made to identify the probable time of operation and arrange fasting accordingly; identify the first patient on the list the night before (GOLDEN patient)

• Consent should be taken and the limb should be marked by the operating surgeon or nominated colleague, with reference to both the patient and the imaging

o All patients require a full assessment of capacity. Patients that lack capacity should have this formally documented. If capacity is unlikely to return, they should be consented in accordance with trust policy and the mental capacity act (speak to patient’s next of kin and family).

• Registrars/ Consultants should consider resuscitation status • Patient details should be added to Bluespier, including the 36 hour post-admission

(breach) time. • Acute medical problems should be managed in conjunction with the medical and

orthogeriatric teams • Drug KARDEX must be accurately filled • Potential concerns should be discussed with the trauma list anaesthetist at the earliest

opportunity • Calculate revised Nottingham Hip Fracture Score (Appendix 1) to help risk stratification

INTRAOPERATIVE SETTING

Anaesthesia should be tailored to allow an early return of postoperative function. In particular, techniques should permit a rapid cognitive recovery

• General Anaesthesia: o Minimise or avoid longer-acting IV opioids

• Spinal Anaesthesia: o 0.5% Bupivacaine 1.5-2.5mls or 2% Prilocaine 2.0-2.8mls o Avoid intrathecal opioids

• Consider avoiding peripheral nerve blocks in favour of high volume local anaesthetic infiltration (see below)

• IV Ondansetron 4mg • Tranexamic acid 1g IV at induction

o Consider dose reduction in frail patients (15mg/kg) • Consider single dose IV NSAID where appropriate • Low threshold for invasive arterial blood pressure monitoring if cardiovascular co-

morbidities • Consider need for higher level of care post-operatively • IV Antibiotic

o Single dose Ceftriaxone 2g +Teicoplanin 400mg • Transfusion threshold 8-9g/dL • Bair Hugger patient warming

o Consider starting in anaesthetic room

Surgical Technique

Cemented hemiarthroplasties:

• Thorough lavage of the femoral canal • Consider a suction catheter in the intramedullary canal whilst cementing

All patients:

• Subcuticular closure using monocryl and dermabond • Tegaderm dressing

PERI-ARTICULAR LOCAL ANAESTHESIA

• Ropivacaine (Naropin 0.2%)

o Maximum dose 4mg/kg, equal to 2ml/kg of Naropin 0.2% (usually 100ml) o Epidural needle allows easier insertion o Drug may be injected intra-articular, around anterior capsule and in the peri-

articular fat and fascia. Avoid intra-muscular injection. o Total drug dose recorded on anaesthetic form and operation note.

•

POSTOPERATIVE

It is worth noting that many patients are in less pain following fixation than they were pre-operatively. Intravenous doses of opioids are rarely required post-operatively.

• Continue the patients’ current medication e.g. Fentanyl patch, Gabapentin etc • Regular IV Paracetamol 15mg/kg QDS

o Note: 1g QDS is not suitable for all • Regular Codeine 30-60mg QDS • Avoid NSAID unless patient already established on them prior to admission and renal

function normal • PRN Oramorph 5-10mg 4 hourly for breakthrough pain • Regular Macrogols and/or Senna

Additional Medication:

• PRN IV Ondansetron 4mg • Continue IV fluids post-op but encourage oral fluid intake • S/C Dalteparin at 18:00 (consider Clexane 20mg in renal impairment)

DISCHARGE FROM RECOVERY

• Standard recovery protocols apply • Ensure prescription of:

o Regular and breakthrough analgesia o PRN antiemetic o DVT prophylaxis o Ongoing fluids

• Check block height for regional techniques • Regular observations, pain score, sedation, nausea • Check dressings

WARD CARE

• Patient assessment: o All patients require their EWS chart to be completed as per trust protocol. o The four hourly pain assessment charts must be completed. This is mandatory for

ALL patients. § Visual analogue score: at rest and with movement. § Vomiting score § Sedation score

o Hourly urine output for patients with renal impairment • Nursing and Physiotherapy assessment;

o ROM, power, proprioception. o Set criteria for mobilisation:

§ Stable observations EWS <1 § Pain score <4 § Vomiting score <1 § Sedation score <1 § No sensory or motor blockade.

o Aim to mobilise on the day after the operation • Ensure regular medications are appropriately prescribed. • Encourage eating and drinking

o Frail patients may require 24+ hours IV fluid in the postoperative period • Post-op x-ray reviewed and documented • Post-op blood tests

o Day 1 – FBC, U&Es and “elderly screen” as per ward protocol o Day 2 – FBC and U&Es o Day 4 – FBC and U&Es

APPENDIX 1 Revised Nottingham Hip Fracture Score

TOTAL NHFS Revised predicted 30 day

mortality (%)

0 0.7

1 1.1

2 1.7

3 2.7

4 4.4

5 6.9

6 11

7 16

8 24

9 34

10 45

Nottingham Hip Fracture Score: longitudinal and multi-centre assessment.

Moppett et al. BJA 2012;109(4):546-50

HIP FRACTURE PATIENTS ON WARFARIN

• As per existing fast track pathway, admission blood tests including clotting screen and INR to be taken in the Emergency Department (ED). Aim for INR <1.5 for surgery.

• Give 2mg IV vitamin K in the ED as part of fast track pathway for all hip fracture patients on warfarin, prior to the INR result being available and as soon as possible after the diagnosis is made.

• Once the patient is on the hip fracture unit, the admission INR result must be reviewed as a priority. If INR taken in ED is >3.5, give a further 3mg IV vitamin K as soon as possible.

• Recheck INR no sooner than 12 hours after the administration of the initial dose. • If the INR taken at 12 hour is >1.5 but <4.5, give a further 3mg IV Vitamin K for patients who

have previously received only 2mg. For patients who have already receive a total of 5mg Vitamin K check for any interacting drugs which may enhance the effect of warfarin. If so give further 2mg IV Vitamin K, otherwise repeat INR in further 12 hours.

• If the INR taken at 12 hour is >4.5, or unchanged from baseline, check a full coagulation screen and consider other causes (e.g. liver disease, DIC).

• If INR remains >1.5 pre-operatively despite vitamin K then give prothrombin complex concentrate (Beriplex 30 iu/kg), unless significantly increased risk of thrombosis, to avoid delays to surgery.

• If significant delay until surgery (i.e. >24hr) then consider bridging anticoagulation in high-risk patients – see above for details.

• Use graduated compression stockings on admission, if appropriate, or any other standard mechanical thromboprophylaxis.

Management of hip fracture patients taking NOAC’s, DOAC’s or antiplatelet drugs

Unlike for elective patients anti-platelet drugs such as Clopidogrel / Ticagrelor should not

be routinely stopped for any trauma patient and should not be a reason to delay surgery.

However it will likely preclude the ability to perform regional anaesthesia.

The Golden Patient: Improving efficiency and ensuring optimum care of hip fracture patients

Hip fracture patients are admitted almost every day to this hospital and as is well known,

the number of cases will continue to grow over time. This vulnerable group must be given

a high priority both in terms of placement on the trauma list but also globally with regard to

administration, clerking, follow up of pre-operative investigations and crucially at the junior

tier evening handover.

It is appreciated that on call commitments can be onerous and multiple pressures are

placed on the on call teams to administer to admitted trauma patients. In order to alleviate

this, the hip fracture unit has a specialist nurse who will instigate and coordinate the care

of these patients during working hours. Despite review by Sister Tate, the patients still

need to be seen however and comprehensively worked up by the ward doctors, including

the prescription of analgesia.

Ensuring that hip fracture patients are given operative priority is a national initiative that

this hospital must comply with and this is reconciled through the Best Practice Tariff (BPT).

In order to ensure that we are in the best possible position to optimise patient care and

ensure that hip fracture patients are in a position to be operated on, the following basic

elements of patient administration are worth reiterating:

• All hip fracture patients must be fully clerked in by the junior doctor on call within two hours of being admitted to the ward. If there are issues in achieving this,

escalation to the on call registrar must be made by the junior staff.

• All preoperative investigations must be reviewed by the on call junior doctor to

ensure that there is no missing information that may be required to allow operative

planning or anaesthetic assessment. Leaving investigations to be followed up by

another colleague, whilst sometimes unavoidable, is discouraged. Ownership of

information pertaining to the patient and its handover where unavoidable is the

responsibility of the admitting doctor.

• Any potential problem that may prevent prompt progression to theatre such as

anticoagulation reversal must be acted on as a matter of urgency as per the

relevant guideline.

• All hip fracture patients must be marked and consented by the admitting doctor

unless that individual is unable to do so. If a doctor is unable to mark or consent,

this must be passed on to the on call registrar so that they can ensure this is done

in a safe and timely manner. This is vital both for efficiency but most importantly for

patient safety.

• All pre-operative hip fracture patients must be handed over on a named patient basis in the evening. A hip fracture patient must be identified as the “Golden

Patient”: this is a patient that is suitable for placement first on the list the next day.

The golden patient must have their investigations personally reviewed in their

entirety, their consent and marking status reviewed and any outstanding issues

identified prior to the handover. If the junior doctor on call is unable to identify a

golden patient from the pre-operative hip fracture cases, the on call registrar is to be

informed. All patients are to be listed with their breach time and the list on which

they must be placed to prevent a breach. A breach occurs 36hrs following their

admission to the ED, not from diagnosis.

• Overnight, hip fracture admissions are to be seen as above. The on call registrar

must be made aware at 0700hrs of any new hip fracture admissions or any

changes in the golden patient status.

• As part of on-going quality improvement audit, the above practices will form part of

the monthly hip fracture audit, including time to review by a doctor and failure in the

golden patient status.

None of these issues are particularly onerous, it’s about efficient processing of information

and ensuring that the golden patient can feature as the first case on the list, reproducibly

unless in the rare occasion where clinical need decrees otherwise. The evening handover

is key. The aim is to have a simple binary statement at the morning trauma meeting; that

the golden patient is either safe to be sent for their operation or not.

Dear Doctors

I have had a request from GPs regarding Fractured Neck of Femur patients – they ask if

we can put on the discharge letters that it is a “Fragility Fracture” (if it is of course) as this

will greatly assist them with their new QOF.

(The definition of a fragility fracture is a low trauma fracture, e.g. sustained by a fall from a

standing height. Obviously if the fracture is due to an RTA or fall from the top of a

stepladder for example, then it is not a fragility fracture).

Whilst I have your attention regarding discharges, can I remind you that any changes or

actions ordered by the Orthogeriatrician should be included on the discharge letter also.

The Orthogeriatrician sees all the NOF patients and will often alter medications, stopping

some and starting new ones, altering doses etc and this is not always being relayed to the

GPs. Please consult the pathway when discharging patients to ensure what they have

noted is put onto the discharge letter.

Also, please ensure that any Osteoporosis medication that we start on their admission is

prescribed in the TTO’s and pointed out to the GP in the discharge letter that this has been

commenced as per NICE guidelines, with a polite request for them to add them to their

future repeat prescriptions.

One other request I have for you is to please remember to document in the pathway if

YOU start or stop a medication and why. We are constantly coming across prescriptions

that the Orthogeriatrician has started for example and somebody else has stopped or a

patient has been started on a medication by an ortho doctor but nothing has been

documented as to the reason why. Without this documentation we have no way of

knowing why you may have started something or stopped something or that you have

actually done it for the correct patient! (This has happened!)

Many thanks

Sister Anne Tate

Specialist Hip Fracture Nurse

Orthopaedics

Trauma Daycase

Admission Process A guide for junior doctors

Trauma Day Surgery (TDS)

Patient selection for Trauma Daycase admission :

Patients intended for discharge as a day case

Examples:

All common day case procedures - Distal radius #, olecranon #, clavicle #, fracture MUA

and cast application, soft tissue injuries, removal of metalwork, frame adjustment /

removal, simple ankle MUA / fixation etc.

Consultant lead decision:

Within working hours - discuss with the consultant on call and confirm appropriate for day

case surgery.

Out of hours - add patient details to Bluespier, send patient home and discuss in Trauma

meeting the following morning to confirm plan prior to calling patient to update.

Patient fitness:

SAU cannot accept patients who are immobile, bedbound or unable to sit in a chair.

Patients must be independently mobile and be able to self-toilet. Patients in wheelchairs

can only be accepted if they can transfer independently. SAU cannot facilitate hoisting.

Social:

Patients must have appropriate support upon discharge home:

• Continuous presence of a responsible adult for at least the first night after surgery

• Access to telephone

• Access to transport (may include taxi but will require escort)

• Accessible toilet

Special conditions:

• Diabetes: accepted if well controlled (both types I & II). Please put 1st on the list. If

patient requires a GKI they must be placed 1st on list and GKI will commence in

theatre. If the patient requires a GKI and cannot be placed 1st they must be

admitted to a ward.

• Obstructive sleep apnoea: Patients who use a CPAP machine can be accepted as

a daycase however they must bring their own machine and must be able to set up

and manage this independently.

• Raised BMI: raised BMI is not a contraindication for daycase surgery however to

be accepted they must be without associated co-morbidity and be expected to self-

care and mobilise independently post-operatively.

Work up to be competed in clinic / on initial presentation:

• Consent (if capable)

• Blood tests: FBC, U&Es,+/- coagulation

• ECG (if over 55yrs age, or any history of cardiac problems)

• Give Patient leaflet (+ add date and time of attendance at the top of the leaflet)

• Add to Bluespier ensuring patient contact number documented in notes section

• Take paperwork directly to SAU reception (male/female accordingly)

Time of attendance to SAU:

• AM List: 07:30

Bluespier:

List the patient on Bluespier in the allocated day case slot, Thursday AM, 2nd Trauma list. Ensure you add ‘SAU DAYCASE’ to procedure to allow this to show up on theatre list.

This way SAU staff can pick up planned day case admissions in advance via Bluespier

theatre list to allow allocation of a bed area for their date of admission.

DO NOT OVERFILL LIST – MAX 3 PATIENTS ON ALLOCATED AM LIST

Trauma Day Surgery (TDS)

Patient Information

DATE OF SURGERY:

TIME OF ATTENDANCE TO MALE / FEMALE SAU :

FASTING FROM:

Dear sir or madam;

You have been selected to have your planned surgery as a day case procedure. This

means that you can go home and come back on the day of surgery. After the surgical

procedure, you are expected to be able to go home on the same day, or the next morning

in few cases.

Please make sure that you will be able to have the following on the day of the surgery:

• Continuous presence of a responsible adult for at least the first night after surgery

• Access to telephone

• Access to transport (may include taxi)

• Accessible toilet

Your point of contact while awaiting surgery at home:

If you develop any problems, or have any queries, during office hours please telephone

Trauma Nurse Specialist Sarah Nellis Tel: 07741 616465 or out of hours Ward 36 Tel

01642 854536 for information or advice.

On the day of surgery:

• Please stop eating and drinking from midnight

• You should still take your usual medications at their regular time with a small

amount of water, even if within the Fasting time.

• Please attend to the Surgical Admission Unit (SAU) on the first floor, next to the

operating theatres, at 07:30am.

How to Manage Bluespier Inpatient List

The inpatient module in Bluespier tells you how many patients are still inpatients on the

system. The idea of this module is to remove your patients from the Trauma Board once

they have had their surgical procedure completed. They will then be managed from the

inpatient module until they are discharged.

You will use the inpatient module to discuss post-operative care of patients and those

under conservative treatment.

.

To access the Inpatient module, select Inpatient/TCI. You can filter by consultant/ward

or see all inpatients by selecting all consultants.

Use this list to discuss post-operative and conservative treatments. Once the patient has

been physically discharged from hospital you need to remove them from the Bluespier

system.

N.B “Discharging” the patient from Bluespier does not discharge the patients from your

PAS system.

To remove the patient from Bluespier’s inpatient list select the relevant patient and then

select Discharge from the left-hand side menu. You are required to enter a discharge date

and time.

Page 1 of 3 James Cook

CLINICAL PRACTICE GUIDELINE Haemodynamically Unstable Pelvic Fracture

Key Principles

• Early application of pelvic binder, Haemostatic resuscitation (Major transfusion

protocol) and prevention of hypothermia is the first line of management.

• Non responder bleeding pelvic fractures are rare when the above is applied early.

• Dual phase CT scan in suspected cases guides the choice of interventional

haemostasis in non-responders.

Resuscitation and Early Management This document assumes that the scope of patients discussed are managed in Trauma

Resuscitation environment, by multidisciplinary trauma team, in line with ATLS and local

protocols.

All patients with high index of suspicion of pelvic fracture should have pelvic binder

applied, ideally pre-hospital.

• First line of management:

Pelvic Binder (PB)+ Haemostatic resuscitation (Major Transfusion Protocol + prevent

hypothermia + Tranexamic acid) are always the first line of management of trauma

patients presenting with hypovolaemic shock.

• There is no indication for application of pelvic External Fixator (ExFix) in the

emergency department. Pelvic binder will provide similar, if not superior, control.

• In Trauma Units (non-MTC): Perform the above and contact the nearest MTC

Emergency Department for Emergency Transfer

Dual Phase Trauma CT Emergency Dual Phase Trauma CT (arterial and venous) for chest, abdomen and pelvis is

indicated in any patient with:

• Blunt injury + haemodynamic instability, at any stage of management.

OR

• High index of suspicion of bleeding pelvic fracture

Interventional Haemostasis If the CT demonstrates arterial bleeder (blush / extravasation), discuss with the

Interventional Radiologist and orthopaedic team/pelvic surgeon oncall for possible need

for embolisation.

If the CT demonstrates pelvic haematoma, with no arterial bleeder + patient is non- (or

transient) responder + no abdominal or thoracic source of bleeding.....proceed to ExFix +

Pelvic Packing (PP).

Other indications for ExFix + PP:

• Failure of embolization to control haemorrhage + no other source of bleeding

identifiable

• Patient needs to go to theatre for emergency laparatomy / thoracotomy, in the

presence of pelvic fracture + high index of suspicion of pelvic bleeding.

• Interventional radiologist unavailable or significant delay before angiography is

expected.

Management of Pelvic Binder during angiography:

If the binder is obstructing access for angiography, one of the following can be followed:

• An access can be cut in the binder without compromising the PB function. This is

the preferred protocol.

• A new PB can be applied at a higher, or lower, level before removing the

obstructing PB. This is to be supplemented with a sheet/bandage to bind both

ankles together, supporting hip internal rotation.

• Open the binder temporarily until the access is established, then re-apply the

binder.

ExFix/PB before laparatomy or pelvic packing:

In the presence of unstable pelvic fracture, laparatomy and/or pelvic packing should

always be performed with a pelvic stabilisation insitu (external fixator, or, in extreme cases,

binder)

• Failed packing: if the patient continues to bleed, consider angiography and other sources

of bleeding.

• Failed embolisation: consider packing, repeat angiography, and other sources of

bleeding.

• After interventional resuscitation:

Admission to ITU

Keep binder / ExFix on

No prophylactic anticoagulation within first 24 hours

Monitor for re-bleeding

DIABETIC FOOT REFERRAL PATHWAY

SICKNESS, LEAVE & ABSENCE A guide for junior doctors

Leave

The process must commence 8 weeks ahead of the intended period of leave as per trust

guidelines. The first port of contact is the junior doctor in charge of the relevant rota

(F2/Trust Fellow/CT or Specialist Registrar). The rota coordinator of each tier is

responsible for ensuring that there is adequate staffing at all times.

Friarage

* At any one time 1 junior and 2 middle grade’s will be granted absence from the Friarage

Hospital.

James Cook – Junior Tier

* At least one junior from each team must be available on any normal working day, and

two juniors from each team must be available when their team is on-call for trauma.

* Leave forms, both annual and study, must be signed by the employing Consultant (only

once signed off by the rota coordinator) in order that the period of absence is noted in all

diaries. The rota coordinator must sign first as the consultants are not aware of the level of

cover on the wards.

James Cook – Middle grade Tier

* All requests for planned leave must be signed by the employing Consultant (only once

signed off by the rota coordinator) in order that the period of absence is noted in all diaries.

The rota coordinator must sign first as the consultants are not aware of the number of

registrars away at any one time.

* Secretaries must be informed and changes to clinical duties implemented with a

minimum of 6 week notice. The completed form (with the rota coordinator, secretary and

consultant’s signature) should then be sent to Steven Cocks for recording purposes.

The following leave protocol applies at both the JCUH and FHN sites;

* A maximum number of 2 middle grades or 1 SHO will be permitted leave at any one time

at the Friarage

* A maximum number of 4 middle grades will be permitted leave at any one time at JCUH

* Only one junior from each team can be permitted leave when their Consultant is on call

for Trauma

* Leave must not be taken when scheduled for night work and leave must not be taken by

the registrar during their trauma week unless a full week swap has been organised and

signed for by both parties involved.

* All requests for planned leave must be authorised by the coordinator, Consultants,

Secretaries and Steven Cocks informed and changes to clinical duties implemented with a

minimum of six weeks notice.

* Completed annual leave and study leave forms should then be sent to Steven Cocks for

recording purposes. The Clinical Director will be notified of all Orthopaedic Registrar leave.

* Registrars’ must check the most up to date on call rota (http://stas16/intranet/services-a-

z/trauma/trauma-rotas/) and check that there are not already 4 registrars off during the

intended leave period. If it seems that your leave is appropriate according to the rules of

this protocol, annual leave forms should be placed into the leave in-tray in the Orthopaedic

office (off ward 36). The rota coordinator will then check and sign the form and leave in the

out tray for collection. NOTE: the rota co-ordinator must authorise the leave prior to

anyone else signing the form.

* Registrars’ must have another team registrar sign their leave form to either confirm on

call cover &/ or agree to look after the patients whilst the registrar is away (i.e. include the

patients on their own ward round). Of course juniors are free to contact any registrar within

a team if a particular registrar is away and their patient needs senior review.

Dear Colleagues

RE: ATTENDANCE AT WORK POLICY

Please find below the procedures to follow for all medical staff for any absences from

work.

• All medical staff (FY’s, CT’s & Registrars) immediately they are aware they are

unable to fulfil their duties should inform the Consultant On Call (via switchboard)

for absences affecting daytime and out of hours work including part-day absences

• A telephone message must also be left with Medical Personnel, for monitoring

purposes by 9:00 on the day.

• If you are On Call at this time you must highlight this to the relevant people and also

inform your colleague from whom you are to take over.

• If you are unable to attend on Bank Holidays or at a Weekend you must inform the

Consultant On-Call to enable them to make alternative arrangements.

• All staff should ring in daily to Medical Personnel to update them, on absence and

time scales of returning to work.

• The following certification requirements must be followed

Period of Absence Certification Requirement

1-7 days Self Certificate

8 days or more Fit note (Medical Certificate)

• Self certification forms are available from your GP surgery and pharmacy, these

should then be returned on the first day of your return to work

• Medical certificates are available from your GP and should be forwarded as soon as

possible to Medical Personnel

• All staff are advised to inform the Clinical Director and their Supervising Consultant

as soon as they are available to return to work

• A self certificate/return to work form must be collected on your first day back to

work, and your return to work interview must take place no later than 3 days after

your return with your Clinical Director/Supervising Consultant

• All absences of sickness are monitored and if the following indicators are met then a meeting will be arranged with yourself and the Chief of Service.

• Indicator One - An employee exceeds 2.9% sickness absence (pro rata for part time staff) in a 12-month rolling period or

• Indicator Two - 3 episodes of sickness absence in rolling 6 months or 5 episodes of sickness absence in rolling 12 months

A detailed copy of this Attendance at Work Policy is available on the Trust Intranet. We are

obliged to keep a record of all sickness absence. Increasingly formatted references

request the details of your sickness absence which we are obliged to provide, therefore we

require an accurate record.

Thank you for your co-operation

ORTHOPAEDIC REGISTRAR TIER

REQUEST FOR ANNUAL/STUDY LEAVE

Please complete all sections of this form, returning it to the Medical Personnel Officer, JCUH, at least 8 weeks prior to the commencement of leave. Leave must not be taken until approval has been received. NAME:……………………………… GRADE: Ass Spec/Staff Grade/SpR/StR/VTS/FY DEPARTMENT:……………………. HOSPITAL: JCUH / FHN 1. I wish to take my holidays/ study leave (delete as appropriate):

2. from ……………………… To …………………….. both dates inclusive.

from……………………… To …………………….. both dates inclusive from……………………… To …………………….. both dates inclusive

3. If any of the above dates are to be taken as lieu days, please specify which Bank Holidays have been worked ………………………………………………………

4. Please state a named registrar in your team that has agreed to take responsibility for your in patients

whilst you are away.

Name………………………. ……… Signature……………………….

5. Where prospective cover is required, please state on call duties and the names of colleagues providing cover on these dates. .

DATE OF ON CALL

TIME REQUIRED FROM TO

NAME OF COLLEAGUE COVERING

COLLEAGUE’S SIGNATURE

Doctors signature:…………………………………. Date:……………… Rota Coordinator…………………………… DATE: ……………. Authorising Consultant…………………………… DATE: ……………. Consultant Secretary………………………………. DATE:…………… Leave is/is not approved: …………………………………………………… SIGNED:……………………………..Medical Personnel Officer Extension 54312

ORTHOPAEDIC JUNIOR TIER

REQUEST FOR ANNUAL/STUDY LEAVE

Please complete all sections of this form, returning it to the Medical Personnel Officer, JCUH, at least 6 weeks prior to the commencement of annual leave. Leave must not be taken until approval has been received. NAME:……………………………… GRADE: Ass Spec/Staff Grade/SpR/StR/VTS/FY DEPARTMENT:……………………. HOSPITAL: JCUH / FHN 6. I wish to take my holidays 7. from ……………………… To …………………….. both dates inclusive.

from……………………… To …………………….. both dates inclusive from……………………… To …………………….. both dates inclusive

8. If any of the above dates are to be taken as lieu days, please specify which Bank Holidays have been worked ………………………………………………………

9. Where prospective cover is required, please state on call duties and the names of colleagues

providing cover on these dates DATE OF ON CALL

TIME REQUIRED FROM TO

NAME OF COLLEAGUE COVERING

COLLEAGUE’S SIGNATURE

Doctors signature:…………………………………. DATE:………….. Rota Coordinator…………………………… DATE: ………… Authorising Consultant…………………………… DATE: ………… Leave is/is not approved: …………………………………………………………… SIGNED:……………………………..Medical Personnel Officer Extension 54312