Paediatric Patients

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.

Diagnosis requires a high-index of suspicion together with careful investigation and interpretation of injuries. All suspected victims of abuse must be assessed top-to-toe and all concerns about possible abuse must be discussed with a senior clinician.

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? Did the same story get 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 - we have last names and this is a good place to use them.
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. Old history- one URTI only. Dx Accidental minor head injury."

Clues pointing to NAI in the Bendigo 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.

Pregnant Patients

Every time you see a pregnant patient consider the foetus and check its wellbeing with a foetal doppler (hand held doppler or US by consultants/registrars). If you can't do this yourself then ask maternity services to come and do it for you.

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)

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.

Renal & Peritoneal Dialysis Patient

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, useless 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 AVF or AVG 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

Management Plans and Alerts

Around 80-100 patients have ED management plans at Bendigo health.  They are a mixture of frequent-flyers 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.

Elderly and those from out-of-town

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 hand-over as being safe for discharge home at night. They can be managed in SSOU overnight for discharge in day light hours.

Fall in Elderly

Elderly patients with recurrent falls, especially in those who live at home, 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

Escalate your concerns to a senior doctor who may recommend a Medical/GEM admission for allied health assessment.

Nursing Home Residents

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 the drug. Then either supply the drugs or write a normal script so the nursing home can obtain the medication.  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 patient in nursing homes, including initiating palliate care measures with infusion pumps. They have a mobile that can be contacted via switch and have recently expanded their hours.  Please leave a message on their mobile for all patients going back to the nursing home so they can touch base with them.

Blood Alcohol testing in motor vehicle collision

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.

Representations

Patients represent to hospital for a number of reasons

• We got the diagnosis wrong the first time
• We failed to communicate the diagnosis, treatment and anticipated clinical course appropriately
• The condition has got worse and they have come back, as instructed through safety netting on the first presentation

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.

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:

1) You MUST discuss with and get senior staff to lay eyes on the patient

2) Escalate investigations, opinions or management to a standard expected by the community and your colleagues.

3) Think very hard before discharging them again.

Psychiatric Patients - Medical Clearance

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 and coincidental 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 patients

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 the referral on Patient Flow Manager (look for 'AHLO').

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 in Bendigo

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.