Aboriginal Victorians experience poorer health and lower life expectancy than the general community. A number of complex barriers restrict Aboriginal and Torres Strait Islander peoples’ access to health services. For many Aboriginal people, hospitals are places to fear. They may have experienced racism and cultural insensitivity in the past, and some may not have the necessary knowledge and confidence about the healthcare they will receive.

While promoting better access and ensuring culturally-sensitive care for Aboriginal people is a whole-of-service responsibility, it is particularly important in the ED, which is the first point of access to health care for many Aboriginal people.

Bendigo Health employs an Aboriginal Hospital Liaison Officer (AHLO) who provides support to patients and their carers; information; assistance with admission and discharge planning; promotes health and well being to the Aboriginal community; promotes awareness within BH; and encourages links with the Bendigo Aboriginal community and specific services.

The AHLO service is accessed via referral with the patient’s consent, so please first ask if the person identifies as Aboriginal or Torres Strait Islander (a mandatory question) and if they are, ask if they would like an AHLO to visit them. Then complete an EPR referral and/or call them on ext 47131.

They can also be reached via Baret, and resources can be found on our intranet here.

The Aboriginal Support space is located on the ground level of Bendigo Hospital opposite Coffee Box. It offers a culturally safe space for patients, their families and staff, with seating, tea and coffee facilities, and a private garden.

AHLO also offers linkages to supports outside the hospital environment such as accommodation and Aboriginal Health Services for example ‘Bendigo and District Aboriginal Cooperative’ (BDAC).

A number of patients have ED management plans at Bendigo Health.  They are a mixture of frequent presenters with combined psychological/medical needs and other patients with very specific specialist care needs.

If a patient has a management plan, an Alert icon will appear on EPR. It is vital that you check this before seeing the patient.

These alerts are wide-ranging, including but not limited to:

• Clinical management plans - e.g.
  • if a patient is on a clinical trial for cancer treatment - there may be specific protocols that need to be followed
  • for recurrent presentations with chronic pain
• Behavioural plans - e.g.
  • patient has a history of a psychiatric disorder, violent behaviour or forensic history
• Child At Risk
• Family Violence

The main purposes of ED management plans are:

• To assist staff to meet the specific needs of the patient
• To direct actions when the meeting of these needs requires care that varies from usual practice
• To avoid over-investigating and over-treating
• To promote consistency of care between providers over time
• To facilitate early contact with relevant healthcare providers
• To prevent violence and harm

Unless the presenting problems are different from the plan or there are safety concerns, please always try to manage these patients consistently with their plan.  Consistency is the key - we have been treating many of these patients for years and it is possible for an entire care plan to be derailed by a single ED presentation managed “off-plan”.

If you notice that a patient is presenting often with a variety of problems or representing multiple times with the same problem, despite adequate referrals and investigations being done, please email the ED consultant in charge of the Management Plan portfolio. You can also make a direct referral to HARP if the patient meets their referral criteria.

To access a patient management plan:

• Open 'Notes'
• Select 'Plans and Pathways'
• If the patient has a management plan, there will be an 'ED Management Plan' tab at the top of the page

Of note, resuscitation plans are found in the same location.

In Victoria, by law, all persons over the age of 15 years involved in a motor vehicle collision must allow a registered medical practitioner to take a blood sample. A Doctor or RN may take the sample but in Bendigo it is a doctor duty.

Although the legislation provides for blood to be taken from ALL persons, the currently accepted Code of Practice (as approved by the Victoria Police, Traffic Alcohol Section) provides that samples need only be taken from drivers who present to hospital following a motor vehicle collision. In situations where there is uncertainty about who the driver is, then all those involved must be tested. Note that electric bicycles and electric skateboards are defined as Motor Vehicles under the Road Safety Act 1986.

If a person is unconscious or otherwise unable to communicate, a doctor or approved health professional is permitted to take a sample of person’s blood.

Specific equipment, including specimen tubes, and paperwork need to be used and then placed in the secure Police Blood Safe next to Resus.

If a patient refuses to have police bloods taken, this form must be completed and placed in the Police Blood Safe (copies of the form will also be kept near the safe).

See the Victoria Police Hospital Blood Guideline October 2024 for further information.

Instructions on how to book an Auslan interpreter can be found here.

In the case of an emergency, patients can use the Convo App (https://www.convoaustralia.com/app) on their phone until an interpreter arrives.

Please don’t discharge elderly/vulnerable patients or patients from out-of-town late at night alone or without close communication and understanding from family.

As a general rule, these patients should not be discharged overnight unless their case has been clearly discussed with a senior ED doctor or they have been flagged at handover as being safe for discharge home at night. They can be managed in SSOU overnight for discharge in daylight hours.

Falls in older people are very common presentations.

We need to take the approach that a fall from standing height = TRAUMA.

Injuries can be easily missed

• Clinical decision-making tools were created based on younger populations
• Often under-triaged as vital signs can be unreliable in the older population (e.g. medications masking the physiologic effects)

Injuries can be serious

• Serious injuries can result from minor mechanisms, incl high grade C-spine injuries
• More likely to have a fatal outcome from their injuries, down the track
• After admission for a fall <1m, the 1y mortality rate for age 65yo and older is 47%

We need to consider the:

• Cause
  • Most falls are not 'mechanical'. Only a trip/slip and fall is truly mechanical.
  • Syncope - cardiac arrhythmias. Vasovagal episodes are triggered. Beware of mis-labelling an unexplained syncopal episode as vasovagal in an older person.
  • Stroke - suspect if there is sudden weakness in the limbs or loss of balance.
  • Hypotension - orthostatic, volume depletion, occult sepsis
• Consequence
  • Perform a full trauma assessment - simply look at and palpate everything
  • Have a low threshold for imaging

Particular review areas

• Chest - CXRs should not be used to diagnose rib fractures. A CT is far more sensitive and importantly also assesses for underlying visceral injuries.
• Hips and pelvis - noting that patients with stable pelvic or impacted subtrochanteric NOF fractures may be able to WB initially

See the Trauma Victoria Older Person guideline.

Elderly patients with recurrent falls, especially in those who live at home alone, are at high risk of mortality and morbidity. These patients may require a range of assessments performed to determine risk, including but not limited to:

• Medication review
• Eye sight, mobility, strength/ balance, malnutrition
• Home environment concerns
• Foot problems, footwear education
• Social living concerns etc

The ED Care Co-ordinator and Geriatrics Registrar in the ED can assist with initial assessments and disposition decisions. Have a low threshold to admit to AMU or Geriatrics for allied health assessments.

Family Violence is unfortunately common, affecting a disproportionate number of patients who present to the ED. It may be evident either as part of the presenting issue (e.g. physical assault) or it may be identified on enquiry. Elder abuse can be particularly difficult to identify.

Enquiries and discussions about Family Violence need to be respectful and sensitive. The Bendigo Health PROMPT guidelines on Family Violence Assessment and Response and Non-Fatal Strangulation Guideline provide detailed guidance on assessments. The RCH guidelines on Family Violence and Child Abuse are also useful.

Particular care needs to be taken with documentation and discharge summaries. Sensitive documentation should be completed under the legal restrictive section of ePR.

This flow chart can assist in the initial steps in recognising and responding to Family Violence. It is vital to determine if there are any immediate risks to children and if any mandatory obligations apply. Note that a Family Violence and/or Child At Risk alert should be added onto ePR (further information below under 'Paediatrics' and instructions here).

The main family violence referral and support services are:

• The Orange Door (business hours only)
  • different numbers for regions - Loddon 1800 512 359, Mallee 1800 015 188, Echuca 1800 512 359
  • also provides support for families of children at risk
• Safe Steps (24/7)
  • for clients 1800 015 188
  • clinician only line 1300 739 282

This is a list of resources and contacts (hard copies are available in the yellow folder by the ED Care Co-ordinator's desk in the admin office) and there are further resources on the intranet, including videos.

Child Protection

During business hours (8.45am - 5pm Monday to Friday), contact the number covering the local government area where the child lives. The North Division (ph 1300 598 521) covers most of the area where our patient population resides.

Outside of business hours, the After Hours Child Protection Emergency Service receives new reports, as well as concerns for existing child protection clients who are considered to be at immediate risk and require urgent after hours assistance.

Contact the Priority Line on 13 12 78.

If there is no answer, please phone the direct line 9843 5422 (for health service use only).

Note that you should make a report about an unborn child, if you identify risks to their safety post birth. These risks may include substance misuse, family violence or poor mental health. Child Protection may use the information provided to mitigate risks to the unborn child.

See here for more information about making a report to child protection.

Child At Risk Alerts

See the section below on 'Paediatrics' for more detail about Child At Risk alerts on EPR.

Karen people are a culturally and linguistically diverse ethnic group from South-East Asia. Many are from Myanmar and due to conflict in that region, more than 150,000 Karen people have fled to refugee camps in Thailand.

We have a Karen community who have found their home in Bendigo. Bendigo Health has Karen interpreters on staff who are also on-call to assist after-hours where necessary.

Contact numbers:

• Business hours - 0448 592 431 and via Baret
• After 5pm and weekends – 0448 603 438

This website has more information on the Karen people in Bendigo.

Details of how to get an interpreter can be found here and here.

Notably, we are fortunate to have Karen in-house interpreters available after hours too. Contact numbers:

• Business hours - 0448 592 431
• After 5pm and weekends – 0448 603 438

Unless an absolute emergency, family members should not be used as interpreters.

If discharging a nursing home patient on a new medication, then write a hospital drug chart so the nurses at the nursing home can administer it. Then either supply the medication or write a normal discharge script so the nursing home can obtain it.  Imagine you are the nurse receiving the patient and then have to organise a GP to visit sometime in the next couple of days to get the script you have said the patient requires!

When discharging a patient to a care facility, contact that facility to let them know and provide a copy of the discharge summary to go with the patient – BH discharge summaries are only sent to the patient’s GP which can leave the care facilities out of the loop.

Also, make use of Residential-In-Reach services if appropriate. Bendigo Health have staff that can advise and help treat patients in nursing homes, including initiating palliative care measures with infusion pumps. They are available daily from 7am to 9pm on their mobile number 0428 173 482.  Outside of these hours, please still phone them and leave a message for all patients going back to a nursing home in Bendigo so they can touch base with them.

Bendigo ED has approximately 12,000 Paediatric presentations every year. Of these, less than a 100 are Category 1 patients. About 12% of patients need admission and the rest are discharged home after assessment for follow up in the community.

Paediatric Category 1 and 2 Patients

These patients are high risk and are to be seen by a consultant or registrar. They are not to be treated by interns or HMOs unless in the direct presence of a senior medical staff member.

Interns and Paediatric Patients

All children under the age of 2 seen by interns must also be seen by a supervising consultant or registrar.  The amount of time spent with the family by supervising staff will depend on how much of the presentation the supervising senior knows from other sources and the type of presentation.

As a general rule, no paediatric patient should be discharged by an intern without speaking to a senior doctor in ED.

ViCTOR Charts update

The ViCTOR (Victoria Children's Tool for Observation and Response), i.e. the observations chart, has been updated from September 2025 to include a new vital sign: the family/carer concern question - "Are you worried your child is getting worse?", which must be asked and documented during every paediatric observation. A "Yes" response will trigger a clinical review.

The change is mandated by Safer Care Victoria, as research has shown that parental concern is often a stronger predictor of deterioration than abnormal vital signs.

If nursing staff alert you to an affirmative response from family/carer, take this seriously and seek a review by a Consultant or senior registrar, as you would with any other abnormal vital sign.

Non-Accidental Injury

Child abuse is unfortunately common. As it is a possible cause for many different presentations, it can often be missed and/or misdiagnosed.

Children who end up with catastrophic injuries often have a string of presentations to the ED or GP prior to the event.

While Bruising and Fractures are the two sentinel injuries of non-accidental trauma, it has to be emphasised NAI should be considered as a differential with any injury in a child, even if trivial.

History inconsistent with injury or developmental age, changing history over time or between caregivers, unexplained delay in seeking health care are clues pointing towards NAI.

Similarly, there are injury based clues as well. TEN 4 FACES is a clinical decision rule widely used. It essentially states:

• Bruising in ‘TEN’ location (Torso, Ear, Neck) in child <4years-old
• Any bruising in child <4-6months-old
• Injury to FACES (Frenulum, Angle of jaw, Cheek, Eyelid, Sclera) in child of any age

If these criteria are met, then there is a clinical concern for abuse.

The old adage “If you don’t cruise, you rarely bruise” is true. Bruising in pre-mobile infants is NAI until proven otherwise. And children that are walking but not running get very few accidental bruises (picture the way an 18 month old toddler topples over onto their knees, hands and forehead- knees and forehead are the spots that bruises can be expected in this age group with the forehead taking the majority of them as the knees don't hit the ground with much force from standing height).

Bendigo has the following procedure to target the highest risk group (children under 4) so that MINOR injuries DO trigger consultant review and review of the old notes.

However NAI should still be considered in children of all ages.

Bendigo Procedure:
1) All injuries in children under 4 years MUST be discussed with a consultant (or registrar overnight).
2) The past history of presentations (the hospital record) must be reviewed and presented to the consultant when the discussion process occurs.

The following documentation is expected in ALL cases of child injury in under 4 year olds:

Source of history - i.e. mum, dad, ambulance, triage nurse notes
Consistency between history sources - did Mum, Dad and Auntie all give the same story? Was the same story given to ambulance, triage and you?
Correlation between history and clinical findings - do the injuries make sense with the history given?
Documented discussion with a senior ED doctor - write the full name of the senior doctor
Comment on general developmental stage - does the injury correlate with the developmental age? (rolling, toddling, running, climbing?)
Past medical history and review of previous notes - you must see the notes for all injured kids. Multiple minor injuries in small children or admissions for social problems should trigger further investigation.
Comment on whether the doctor is satisfied that it is an accident.

This need not be onerous. For example: "3yo boy, runs and climbs, Mum says he fell while running and hit head on pot plant, Step-Dad says same, O/E well kid, bruise and abrasion on forehead with no other sign of injury on body (correlates with history), good rapport between parents and child. D/w consultant/registrar (full name). Prev history - one URTI only. Dx Accidental minor head injury."

Red flags in the ePR medical history are previous minor injuries, any allied health input including social work, including when the child was born/neonatal period.  Most children’s histories are wafer thin and anything else should prompt further consideration.

The paediatric consultant should be contacted directly at any time if there is any concern or a second opinion is required.

Further information can be found on the  Royal Children's Hospital Clinical Practice Guideline.

Further information about mandatory reporting can be found here and on the Family Violence section on this page.

Child At Risk Alerts

The BH Prompt policy Recognising and Responding to Vulnerable Children Protocol instructs that the following patients must have a 'CAR' (Child At Risk) alert on their clinical file in EPR:

• Children with current DFFH involvement
• Children where a DFFH notification/report is being made, and the parent/guardian(s) and any other children the DFFH notification relates to
• Children in out of home care
• Children with non-accidental injury or alleged sexual abuse
• Children where there are significant concerns about a child's wellbeing requiring referral to support services

All staff have a responsibility to identify any patients or dependents of patients who are vulnerable children or in need of protection. Any staff member with clinical EPR access can enter or modify an alert. Please use the free text function to elaborate and be clear about the expiry date. This is important as once the child reaches adulthood, it can become unclear whether the alert is due to them previously being a child at risk, or to them having a child who is at risk.

Instructions on how to place an EPR alert can be found here.

Every time you see a pregnant patient consider the foetus and check its wellbeing. In the second trimester (and in some late first trimester, in experienced and trained hands), this can be done by bedside US performed by consultants or trained registrars. Midwives can attend on request for pregnancies >20 weeks gestation.

Women presenting with any pregnancy-related issues who are >20 weeks gestation should be sent directly to Birth Suite as per the referral process after consultation with the Birth Suite Associate Midwifery Manager (AMM). Triage nurses often make referrals directly.

Women who are >20 weeks gestation who present to the ED with non-pregnancy related issues such as chest pain, shortness of breath or trauma, should be triaged, assessed and treated in the ED and advice sought from Women’s & Children’s Services staff whilst in the ED. Any medical imaging requiring radiation must be authorised by a consultant.

There is a PROMPT protocol on this.

Most ED sources consider use of the pregnancy-adapted YEARS algorithm utilising a two-tiered D-dimer to risk-stratify for PE in pregnancy.

The Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) and the Royal College of Obstetricians and Gynaecologists (RCOG) guidelines do not recommend use of D-dimer to rule out PE.

The SOMANZ Guidelines provide comparisons of the performance of various imaging modalities and radiation doses.

Regarding foetal risk:

• If the procedure or cumulative procedures lead to a potential foetal dose greater than 10mGy, conservative estimates indicate an increased risk of childhood cancer from 20 per 10000 to 21 per 10000.
• Put another way, for every 1667 exposures of 10mGy there may be 1 additional case of childhood leukaemia increasing to 1 in 834 at foetal total dose exposure of 20mGy.

Regarding maternal risk:

• Previous assessments have estimated the lifetime risk of breast cancer from a dose of 20 mGy to the breast is approximately 1/1200 at age 20, 1/2000 at age 30, and 1/3500 at age 40.
• The lifetime additional risk from CTPA with a breast dose of 20 mSv dose in a 30-year-old woman is estimated as 1/2000 compared with a V/Q scan dose of 1.0 mSv that increases risk by 1/40,000.

A more simple comparison of V/Q and CTPA:

V/Q:

• whilst there may be slighter higher foetal radiation exposure, the increased risk of childhood cancer from a single V/Q scan (estimated dose 0.01-1.6 mGy) is negligible
• more sensitive for PE
• availability limited to only business hours

CTPA:

• negligible foetal exposure
• higher radiation exposure to breast tissue
• able to assess for certain alternative diagnoses
• available 24/7

These risks need to be discussed as part of counselling and consenting for imaging.

All psychiatric patients must have a medical assessment documented. This includes a set of observations and a varying assessment depending on circumstances.

All psychiatric conditions are clinical syndromes for which there is no diagnostic test and every acute psychiatric presentation can be mimicked by any number of underlying organic conditions. Therefore, a psychiatric diagnosis is always a diagnosis of exclusion, and so it is particularly important that non-psychiatric conditions have been considered and where practicable, excluded.

The role of an ED medical assessment is to:

1. Identify acute conditions that require acute treatment in a medical setting
2. Assess safety for transfer to the intended destination for specialised mental health care

An approach to ED medical assessments of mental health patients should consider:

• Tox/substances
  • Acute ingestions/overdoses - include asking specifically about paracetamol ingestion
  • Alcohol and drug ingestion - assessing risk of toxicity and withdrawal
• Trauma
  • acute injuries either from self-harm or misadventure
• Medical conditions
  • Organic causes and mimics - could there be a causative or contributory medical cause of the patient’s presentation?
  • Acute intercurrent medical illnesses
  • Long-term medication adherence - e.g. anti-hypertensives, hypoglycaemics
• Complications of treatment
  • e.g. hyperglycaemia, prolonged QT, lithium toxicity

Red flags include:

• Fever
• Older patient

A “medical clearance” does not indicate the absence of ongoing (chronic or longstanding) medical issues which may require further diagnostic assessment, monitoring and treatment, nor guarantee that there are no, as yet, undiagnosed medical conditions.

To go to a psychiatric ward, a patient needs to be physically well enough that they could be discharged from hospital. If there are issues that require follow-up, you should handover to the psychiatry registrar.

All Renal units (and Bendigo is no exception) take ownership of their patients and you should call them promptly when a dialysis or transplant patient arrives in ED. They expect the triage nurse to do this on the patient’s arrival, but all medical staff should make sure that this step has happened and continue to liaise with them closely.

Peritoneal dialysis

Peritoneal dialysis patients need a thin healthy peritoneum to keep them alive. Spontaneous peritonitis is a complication that must be treated rapidly to avoid a thickened, dysfunctioning peritoneum.

Suspected peritoneal dialysis (PD) related peritonitis is a medical emergency and patients should be discussed immediately with the renal team on arrival and not after work up. Symptoms can be as vague as nausea or feeling generally unwell. Obvious symptoms are abdominal pain and cloudy dialysate.

See the Prompt protocol and the antibiotic guideline for further details and contact the 4A renal ward nurses for assistance with collecting a sample of PD fluid (NB after a dwell time of at least 2 hours) and administering the intraperitoneal antibiotics.

If the 4A ward nurses are unavailable, try the ICU nurses or the renal team. If the situation is urgent and delays unacceptable, the steps to perform it are detailed in the Prompt guidelines.

Haemodialysis

Haemodialysis patients who present to the Emergency Department must have their presentation alerted to the Renal team.

In order to prevent or reduce the risk of AVG/AVF (Arteriovenous graft/fistula) damage, such as thrombosis, the limb in which there is an AVG/AVF in situ MUST NOT:

• Be used to take blood pressure readings
• Be used for routine intravenous (IV) therapy
• Be used for taking blood samples
• Have any name/alert bands attached

Patients who present disclosing sexual assault have specific management considerations (see the Prompt Policy for more detail). They may self-present or with the police (specialised detectives from SOCIT - Sexual Offences and Child Abuse Investigative Team).

All reasonable efforts must be made to ensure smooth and respectful care of alleged sexual assault victims.

Acute medical issues always take priority

Particular attention should be given to assessment for

• Head injury
• Neck injury
• Attempted strangulation (Prompt Guideline on Non-Fatal Strangulation)
• Bleeding - including anogenital bleeding
• Intoxication

Have a low threshold for imaging.

Consider the need for testing and/or treatment for sexually transmitted infections, including blood-borne viruses. Contact the Infectious Diseases team for advice about NPEP.

Forensic Examination

Only police can request a forensic examination. The police will contact the Forensic Nurse or Medical Examiner who may attend to the patient and collect forensic samples.

Alternatively, the patient may be facilitated to the Bendigo Multi-Disciplinary Centre for forensic examination, as deemed by the police and CASA, if no medical intervention in the ED is required.

Forensic Samples

To maintain the chain of evidence, forensic samples (including blood and urine testing for drugs) may only be taken by a Forensic Nurse or Medical Examiner, or the police.

Children

Any person aged under 16 and presenting with alleged sexual assault must be reported immediately to Child Protection Unit (CPU) Business hours: 1800 675 598, After hours: 131278 and the Police on 000 as per the Vulnerable Children - Child Abuse and Neglect protocol.

Post initial triage and medical assessment, ED staff should also contact the on call Paediatrician. Depending on the outcome of the assessment, a decision will be made whether to admit the child or arrange a time for further assessment by the Paediatrician. The Paediatrician may advise the patient to present to the Children’s Ward at a mutually agreeable time for a forensic examination.

Police and CPU who bring a child to the ED for the purpose of a forensic examination should be redirected to the on call Paediatrician 24 hrs a day to arrange an appropriate time and location for assessment.

Note that VIFM Forensic Nurse Examiners are not qualified to perform forensic examination on patients less than 18 years of age.

If there is no other resource available in Bendigo, the police should involve the Victorian Forensic Paediatric Medical Service through the Gatehouse at the Royal Children’s Hospital.

Documentation

As with any presentation potentially involving a crime, documentation should be detailed and accurate.

Careful documentation can assist should you be asked to write a police or coroner's report.

Tips

• Be objective
  • You should document what the patient told you and avoid using words such as 'claims' or even 'alleges', as this can be interpreted as an unreliable history.
• Document what you see
  • Your role is to write what you see, not to interpret injuries or make inferences about causation.
• Be specific
  • In documenting visible injuries, note exact locations and dimensions (e.g. '3 x 3cm bruise on the inner aspect of the proximal left forearm' - rather than 'a bruise on the arm')
• Give a clinical impression to determine your next step in management, not to give an opinion about the history or to interpret the injuries.
• Be sensitive about wording and confidentiality
  • Be selective in the contents of the discharge summary and make the assumption that the audience is broader than only the patient's GP.
  • Check with the patient for permission to include relevant details about the presentation in the discharge summary.

Safe discharge

As with all patients, you should enquire about the safety of discharge. See the Social Work section for further information about resources.

If relevant, see the Family Violence and Child Protection section.

Medical follow up

It is important to ensure that post-exposure care and any other concerns are followed up by either:

• GP
• Sexual Health Clinic

You should give the patient a discharge summary, specifying the exact reason for the referral. As above, be selective in the contents of the discharge summary.

CASACV (Centre Against Sexual Assault - Central Victoria)

CASACV provides a free counselling service to people aged 4 years and over who are affected by sexual assault. This is regardless of how long ago it happened and includes non-offending family and friends. 

This service is for people who are living in the Central Victoria Loddon Campaspe Region.

Patients can self-refer via their website or call 5441 0430 (Mon-Fri 9am-5pm).

Important contact numbers

Clinical Forensic Medicine staff at the Victorian Institute of Forensic Medicine (VIFM) - 24 hours - 9684 4480

Victorian Forensic Paediatric Medical Service (VFPMS) - 24 hours - 1300 66 11 42

Sexual Assault Crisis Line- 24 hours - 1800 806 292

Centres Against Sexual Assault (CASA) - Central Victoria - 5441 0430 (Mon-Fri 9am-5pm) - patient self-referral for crisis counselling support

Patients who represent to the ED with the same or related complaints are high-risk. There is a higher chance of complications, complaints and death. This includes patients who have come back, as instructed through safety netting on the first presentation.

Unscheduled representations are often associated with:

• Lack of information/follow up discharge care
• Medical errors
• Misdiagnosis
• Lack of appropriate ED treatment
• Patient or Family concern

Classic examples are the back pain patient who has an epidural abscess or the epistaxis patient who is never packed with a nasal tamponade device when bleeding stops in ED and is discharged home repeatedly. Or other challenging clinical scenarios like endocarditis when the patient represents with multiple vague symptoms.

Serious complications may arise from seemingly benign representations.

If a patient represents within 72 hours, it must noted in the triage description and on the electronic triage system that the patient is an unplanned representation.

Unplanned representing patients must be seen, where possible, by a different doctor on the second presentation and must be reviewed by a consultant or senior registrar overnight. This may involve consideration of keeping a patient for a face-to-face consultant review in the morning.

Careful consideration must also be given to patients representing with the same complaint over a longer timeframe.

It is important to note:

• The need to all be aware of the cognitive bias that comes with a patient who has represented – try to look at the case with a fresh mindset.
• Success of treatment does not equal diagnosis. For example: just because the patient’s pain was alleviated after Pink Mix on the first presentation does not prove gastritis as the cause. Colicky pain and ischaemic angina come and go by their nature.
• Try and appreciate the patient’s unmet needs. Be up front and ask what the patient/family are concerned about or what they specifically want from this presentation.
• Consider the urgency of patients requiring outpatient investigations – it can be difficult to get timely appointments for some imaging in the community, particularly out of town, and we may need to consider expediting this in some instances.