Drug protocols

• Lothian Antimicrobial Policy: is available on the Intranet and on posters throughout most of our areas. Please document the antibiotic’s indication and duration.

• Gentamicin and Vancomycin calculators are available in the Intranet. The calculator should be printed and filed.

• Oxygen: do not forget to prescribe if your patient requires it.

• Anticoagulation: The protocols for starting and maintaining all anticoagulation has been recently updated and is available on the intranet. This includes warfarin, non-fractionated heparin and LMWH. We will soon start using the apixaban for DVT/PE but there is no protocol available at the moment.

• When using apixaban for stroke prevention in non-valvular atrial fibrillation, please follow the guideline on the intranet.

Protocols

• NEWS ≥ 4: Should trigger a medical review within 20 minutes. If the nurses are worried, treat that with respect and respond appropriately. Do not be afraid to ask for help quickly and escalate. There are avoidable deaths each year here because of a failure to recognise and respond to a deteriorating patient. The Adult Medical Emergencies Handbook is on this link and in the wards.

• Sepsis 6: Always consider Sepsis in acutely unwell. Patients who are NEWS ≥4 or SIRS ≥2 with suspected infection should have: Blood cultures, lactate sent and fluid balance monitoring. They should also receive broad-spectrum antibiotics, oxygen and IV fluids as appropriate. Call for senior support early. Please use the \sepsis6[spacebar] as a prompt for documentation and a checklist.

• Blood transfusions: Please stick to our transfusion protocols that can be found in the intranet. You will need to phone the bloods bank to request the red cells concentrates. To prescribe other blood products need to be discussed with haematology SpR on-call.

• Major haemorrhage: A major haemorrhage call can be put out using 2222 specifying ‘major haemorrhage'. Information is available on the intranet.

• Cognitive impairment: we get a lot of frail elderly patients admitted, many of who have cognitive impairment. Every patient over 65 should have an AMT or 4AT documented on admission.

• Deaths: If a patient dies, it is mandatory to discuss the cause(s) of death with the consultant responsible for the patient, and document them in the patient’s record. Refer the case to the procurator fiscal as appropriate and document the discussion in the notes.

  Post-mortem forms are available on the ward or in the MAU doctor’s room. Please use the \deathcert[spacebar] short code to document on trak and send to GP.

• DVTs: Suspected DVTs need a Well’s score calculated and a D-dimer sent. We have protected slots in the morning and radiology is also pretty good in the afternoon. Remember to put the patient’s Well’s score or D-dimer in the doppler request.

  DVTs are all mainly looked after by our excellent ambulatory care team but occasionally spill over – speak to a member of the ambulatory care team if they are around.

• DNACPR: We use the Lothian wide DNACPR form and policy. Guidance is available on the intranet Scottish Government website. If you have a potentially sick patient it is good practice to actively seek to establish what level of escalation is appropriate. Ask your consultant. Remember that a senior needs to countersign the form – remind them if they have not done so.

• Thromboprophylaxis: Medical patients are generally medium to high risk for DVTs so should receive anticoagulation unless very mobile. Please follow the guidelines.

Useful Trak short codes

• \idl (space) for generic immediate discharge letter template

• \ptwr (space) post take ward round checklist

• \depat (space) structured response to deteriorating patient

• \sepsis6 (space) sepsis 6 checklist

• \deathcert (space) when someone’s died checklist

• \frail (space) brief frailty checklist

‘Special’ immediate discharge letter codes

If you type \idl in to the start of the blank letter text box, then press F6, you get a list of these.

• \IDLACS (space) acute coronary syndrome

• \idland (space) angina

• \idlast (space) asthma

• \idlcopd (space) copd

• \idldka (space) DKA

• \IDLHF (space) heart failure

• \idlnst (space) nstemi

• \idlpe (space) PE

• \idlpneu (space) pneumonia

• \idlst (space) STEMI

• \idltia (space) TIA

Investigations

• ECGs: almost every patient should have an ECG on admission to hospital. The nurses in MAU emergency will generally do these. If the nurses are busy, you have to do it yourself.

• ABGs: processed in the lab. They can go in the pods. Please phone Biochemistry on bleed 8452 and let them know you are sending a sample.

• Bloods: should be sent using the pod system. You will need to contact the lab on bleep 8452 if requesting bloods overnights.

• Blood cultures: Do not pod. Our BC contamination rate is high. Please help us reduce it by using the correct technique for collecting BCs.

• Cross matching: Take 2 samples and hand write the full details. If the patient does not have a CHI, use the hospital number.

• X-ray: Order on Trak and let the nurse in charge know. For portable X-rays, order on TRAK and bleep the radiographer on-call on 8204. Urgent investigations are best discussed with the radiologist on duty for that service – generally by going up to the department in person or phoning along e.g. DCN. Certain procedures e.g. CT guided biopsies/drainage need discussed in person. Out of hours or at the weekend, all radiology (except for plain films) need discussed with the radiologist on call as well as being booked on Trak.

• Echo and 24h tape: Fill a form in for these and take to the MAU doctor’s room where there is a place to leave them. If you want the investigation done that day, take the request across by hand and ask explaining the clinical reasoning behind the urgency. You may need to go via the Cardio Reg.

• Endoscopy: We have a GI Reg available 9am to 9pm on 8279. Patient who need a scope should be discussed with the GI Reg early on and have an endoscopy requested on TRAK. Have someone show you how to do this, as it is not intuitive. There are usually inpatient scope slots at 8:30am daily for ‘emergencies’.

• LPs: Try to take 4 samples if possible with about 7 to 8 drops of CSF in each. Use the order set ‘meningo-encephalitis’ or 'SAH' on TRAK. Xanthochromia is only done ‘in hours’. Do not send the specimens in the pod. Call the haematology technician on call to let them know you are sending a sample (8477).

In department

• Medical registrar on-call 8399

Other areas

• Cardiology SpR: 8689 in the mornings and 4028 in the RIE after 1pm

• Stroke SpR: 8699 or ask switch board for the TIA/Stroke hotline

• Respiratory SpR: #6433

• Surgery SpR: 8272

• Urology SpR: 8181

• Gastroenterology SpR: 8279

• ID SpR: 8161

• Haematology SpR: 8422

• Gynaecology SpR (RIE): 1625

• Orthopaedic SpR (RIE): 2181

• General Surgery SpR (RIE): 2254

• Prof John McKnight - JohnMcknight@nhslothian.scot.nhs.uk

• Prof Mark Strachan - mark.strachan@nhs.net

• Dr Tim Morse - tim.morse@nhslothian.scot.nhs.uk

• Dr Matthew King - matthew.king@nhslothian.scot.nhs.uk

• Dr Donald MacLeod - Donald.macleod@nhslothian.scot.nhs.uk

• Dr Claire Gordon - claire.gordon@nhslothian.scot.nhs.uk

• Dr Stuart Ritchie - stuart.ritchie@nhslothian.scot.nhs.uk

• Dr Ailsa Howie - aisles.howie@nhslothian.scot.nhs.uk

• Dr Emily McMurray - emily.mcmurray@nhslothian.scot.nhs.uk

• Dr Ganesh Arunagirinathan - g.arunagirinath@nhslothian.scot.nhs.uk

• Dr Gareth Stewart - gareth.x.stewart@nhslothian.scot.nhs.uk

• Dr Friederike Boellert - friederike.boellert@nhslothian.scot.nhs.uk

• Dr Andrew Leitch - andrew.leitch@nhslothian.scot.nhs.uk

• Dr Phil Reid - phil.reid@nhslothian.scot.nhs.uk

• Dr Vicky Tallentire - vicky.tallentire@nhslothian.scot.nhs.uk

• Dr Jenni Crane - jenni.crane@nhslothian.scot.nhs.uk

• Dr Ruth Young - ruth.j.young@nhslothian.scot.nhs.uk

Clinical meetings

• Grand Round: Wednesday at 1pm on Teams.

• M&M: We have weekly unit meetings on Friday at 8:30am in the MAU doctors’ room. You are meant to attend if you are scheduled to be at work. If you are not scheduled to work, you are welcome to attend. Most people find them quite informative. Speak to Dr Claire Gordon about good cases or topics.

Teaching

• FY teaching: FY1 teaching is on Thursday from 12:30pm to 1:30pm and FY2 teaching is on Tuesday from 12:30pm to 1:30pm in Seminar Room 3, Medical Education Centre, 3rd floor OPD. Laura McVay organises it, so if there are any problems let her or Dr Claire Gordon know. You are expected to attend teaching in all but very exceptional circumstances (e.g. unexpected patient deterioration).