Night shift presents its own challenges for ED registrars.  You have to deal with the mental and physical stresses of working a night shift while working with less resources than are usually immediately available.  The consultants have all been there before and understand the difficulties, and there is always a Consultant on-call overnight to assist you if needed.  If there are difficulties or issues overnight, please pull aside the day consultant and have a chat to them, they are there to support you.

At present, there are 3 Registrars rostered to each night shift, along with HMO and intern support. We will discuss with you individually when it is deemed safe to step-up into the “in-charge” role overnight. If rostering has it that there is more than one senior registrar on overnight, you are welcome to work out between yourselves your designated roles for the night.

When to call the on-call ED consultant

In general you should contact the ED consultant on-call when you feel out of your depth and there is a critical management or decision required.  Having insight into your own level of experience is an essential ability for you to be a safe doctor regardless of seniority.

The guidelines are placed on the wall in the fishbowl and can be found here:

One of the keys to safety is a team approach. We encourage ANUMs to call the ED consultant directly if they are not comfortable with a situation. If this happens on your shift you should not take offence as it is a sign of an ED being safe, and something you will want to happen when you are a consultant.

Tips for being in-charge overnight.

• Allocate roles for your team early.
• Consider allocation of patients who are handed over – in general resus and complex patients are better allocated to a Registrar who is not in-charge, so that you do not get too bogged down with these patients and can maintain an overview of the department.
• If you can, do a quick personal walk-around of the department as soon as handover is finished. This can help you identify patients who appear sicker than they sounded, and that you know the patients who have a potential to deteriorate.
• Communicate regularly with the nursing team leader.
• Keep the ED Floor notes comments up to date.
• Keep an eye out for Category 2 patients, and ensure you see all chest pain ECGs early.
• Try to take breaks, allocate breaks to your team, and go home on time.
• Interns: all patients reviewed by interns should be discussed with you and ideally physically reviewed by yourself. It can take a while to get to know which interns need to be monitored more closely, so aim to monitor interns that you don’t know closely at first until you get a feel for their skill set.
• HMOs and Junior Registrars: HMOs should discuss all their patients with you. Registrars do not have to but should be encouraged to do so if required. Again, if you don’t know them well, monitor closely at first until you get a feel for their skill set and need for extra help.

 

Night Shift Radiology

We have radiographers on-site 24/7, who can do X-rays and CT scans. CT scans are reported externally in a timely manner. All Registrars are encouraged to look at all patient images and correlate them with the clinical findings.

Calling in US or MRI after-hours:

It is important to remember that when an MRI or US is arranged overnight, that this may affect staffing for these scans the following day.  Of course, if it is indicated urgently overnight, then it should be performed.  The in-charge ED registrar must be involved in the decision to call in.

At present there is no overnight call-in US service (call-back finishes at 10pm). There is however a call-back MRI service, however this needs approval by the on-call radiologist.

Night Shift Referrals

Please see our referrals tab for more information about inpatient referrals.

There is an Emergency Department Admissions to Inpatient Units Protocol on PROMPT (hospital intranet)

Firstly, there is a team of people with you in the hospital overnight:

• Medical Registrar - Medical, rehab, GEM, Hospice referrals; and admit other medical specialty patients once accepted.
• Surgical Registrar – Surgical (including Paeds), Plastics, Urology referrals.
• Paediatric Registrar
• O+G Registrar
• ICU Registrar
• Anaesthetics Registrar
• ECAT team
• Radiographers

At home/oncall

• Orthopaedics
• Cardiology
• Oncology
• Renal
• Private Specialists

A common cause of anxiety amongst ED registrars is disturbing on call doctors sleep and the sometimes-difficult interaction that can follow.  Often the doctors you are calling have been on shift the day prior, and will be the day after, and so considering this is important. Equally, they are on-call, and if a discussion is needed then it is important that you call.

To minimise interruptions, aim to group your referrals. Scan the board and check in with your team before calling, so that you can minimise the number of calls made. If there are beds available on the wards for the patient, and calling the on-call doctor will facilitate their admission or transfer under interim orders, then it is reasonable to call no matter what the time. Improving patient flow improves patients’ outcomes for the whole department, this is important. Remember to document agreement to send up on interim orders. If there are no beds, and the patients are stable and straightforward, it is reasonable to batch these referrals for the morning (eg. 6-7am).  Remember that when you refer to a Registrar that they may need to notify their consultant, so the time for this should also be taken in to consideration.

Activation of Cath-Lab for STEMI's is at the discretion of the cardiology registrar, please call them ASAP, either when you get notification from AV or for walk-in patients as soon as ECG is seen, to ensure no delays.

If you get a response from an inpatient (IP) registrar that you believe will not deliver quality care and you have been unable to convince the referring team to attend to your request then the admitting consultant would want to know.  This is best clarified with the on-call ED Consultant prior to involving the consultant and it is courteous to inform the IP registrar that you will be following this course of action.

A note about ENT

As we have no ENT service on call for Bendigo Hospital, the way we manage these patients may be a little different. In general, the ED Consultant can drain quinsies – these can be admitted overnight to SSOU and the procedure done in the morning. Life threatening ENT emergencies require the ED Consultant on-call to be contacted.  Please see the referrals tab for more information.

Night Shift SSOU

You are allowed to admit patients to SSOU under the emergency consultant bed card if pathways are strictly adhered to.  This admission must be accompanied by an appropriate discussion and handover during the morning board round.

Please be mindful that the ultimate call of whether a patient is suitable for SSOU lies with the in-charge ED Registrar. This is not a decision that can be made by an inpatient speciality team. Under no circumstances should elderly patients with abdominal pain be admitted to SSOU - they usually have surgical pathology even though not immediately apparent.

It is acceptable to admit elderly patients, and those from out of town where transport is not possible, to the SSOU overnight to facilitate safe discharge in the morning. Please flag those that may be discharged early.

Other Critical Care Support for sick patients or MAC Calls

If you are faced with a sick patient and need assistance, the oncall consultant is the best person to contact.

However do not forget that there is an anaesthetic and intensive care registrar in house 24 hours a day to assist you if you require.  You can contact them by direct phone from the daily oncall list, or they will respond if a code blue is called. Utilising the inpatient registrar, anaesthetics or ICU to assist you will help cognitively offload some decision, enhance patient care, and alert appropriate units who will be involved in the patients care.

Overnight you are still required to respond to the Emergency Department internal MET system, which is called a MAC Call (Make A Call).

Code Blues on the Ward

ED doctors do not attend code blues. Designated nursing staff from ED attend codes.