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.

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.

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.

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.

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.

It is time critical and dialysate must be sent promptly. All PD patients require the Renal Consultant to be called on arrival immediately and before workup. Make sure a renal ward nurse is on the way to change the bag so it can be sent for microscopy.

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

Around 80-100 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.  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.

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.

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.

Complications of treatment, complications of illness, injuries/self-harm, ingestions/overdoses and concurrent medical illnesses all need to be considered.

At a minimum, you need to ensure:

1. There is no known, or apparent, contributory medical cause for the patient’s presenting mental health complaint/s that requires acute intervention in a medical setting.
2. There is no medical emergency.
3. The patient is medically stable enough for transfer to the intended destination for specialised mental health care.

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.

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 Switch, 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).

Karen people are a culturally and linguistically diverse ethnic group from South-East Asia. Most Karen people are subsistence farmers, living in small mountain villages, and growing rice and vegetables and raising animals. Many are from Myanmar and due to conflict in that region more than 150,000 Karen people have fled to refugee camps in Thailand.

Many Karen people have found their home Bendigo. It is common to see Karen patients in ED. Bendigo has a Karen interpreter on staff who can assist with interpreting services, and is on-call for these services after-hours where necessary.

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

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.

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

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

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.

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.

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.

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.

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 box next to Resus.