Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
HOSPITAL MEDICINEMay 2012, version 1.1HOSPITAL SKILLS PROGRAMHOSPITAL SKILLS PROGRAM
Health Education and Training Institute NSW Hospital Skills Program Hospital Medicine Module Version 1.1 Sydney: HETI 2012
This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated requires written permission from HETI.
© HETI 2012
ISBN 978-0-1936-3-6
For further copies of this document, please contact HETI, or download a digital copy from the HETI website: www.heti.nsw.gov.au
This document is the latest version of the Hospital Medicine Module prepared by the HSP Hospital Medicine Module Development Working Group, led by Dr Mary G T Webber.
Members of the Hospital Medicine Module Development Working Group:
Dr Mary G T Webber Hospitalist, Ryde Hospital
Dr Michael Boyd Hospitalist, Ryde Hospital
Dr Ross White Hospitalist, Ryde Hospital
Dr Simon Leslie Director of Emergency Department, Shellharbour Hospital
Dr Cathie Hull Workforce Development and Innovation, NSW Health
Dr Briege Hamill HSP Director of Training, HNE Local Health Network
Dr Ross Kerridge Director of Perioperative Service, John Hunter Hospital
Mr Peter Davy Curriculum Developer, HETI
www.heti.nsw.gov.au/hsp
MAY 2012 VERSION 1.1 PAGE 1
Hospital Skills Program Hospital medicine
P2 Section 1: Background and overviewP3 RationaleP4 Formative assessment and
entrustable professional activityP8 Summary of the module
P10 Section 2: Concurrent inpatient assessment, stabilisation and management
P12 Section 3: Common problems and conditions
P15 Section 4: Procedural entrustable professional activities
P17 Section 5: Responses to emergencies
P20 Section 6: System design and the characteristics of hospital practice
P24 References
P25 Appendix 1 Patient safety frameworkP26 Appendix 2 CANMEDs domainsP27 Appendix 3 Case study
Preamble The Hospital Skills Program vision
The Hospital Skills Program (HSP) provides a life-long pathway for self-directed medical education across three levels of agreed expertise, using a variety of traditional and non-traditional resources and methods appropriate to the working environment of the participant, resulting in the acquisition of a skills portfolio useful to an employer, and appropriate to the local patient community.
The HSP recognises the heterogeneous nature of the skills and circumstances of Career-Medical-Officer-equivalent medical practitioners, their continuing value in the delivery of health services to the population of NSW, and their right to meaningful educational opportunities in a mode appropriate to their working lives and geographic locations.
HSP recognises that self-directed education is the realm and property of the adult learner, and that accountability for learning remains with the individual. Therefore HSP exists firstly to identify, coordinate and facilitate the delivery of learning opportunities, and to assist the individual to evaluate their progress across the three levels of HSP and to plan for their own future needs.
Furthermore, the HSP provides a mechanism to align clinical learning activities with the goals of the health system and to deliver priority education to hospital generalist doctors when this need is identified by expert groups such as NSW Health and the NSW Clinical Excellence Commission.
Dr Mary G T Webber Hospitalist
Ryde Hospital, NSW
PAGE 2 HSP: HOSPITAL MEDICINE MODULE
Section 1: Background
The HSP Hospital Medicine module identifies the anticipated capabilities of doctors working in a hospital generalist role in NSW hospitals. Doctors participating in the HSP will have at least two years of clinical postgraduate experience and not be currently participating in a specialist vocational training program.
This module has been developed by HETI on behalf of NSW Health as part of the Hospital Skills Program for generalist doctors. It aims to guide doctors, their employers and educators with regard to learning and professional development needs, workplace responsibilities and clinical tasks.
This module is one of several that have been developed by HETI for the HSP. The other modules describe capabilities required for clinical work within a variety of medical contexts (including Mental Health, Aged Care, Paediatrics, Women’s Health, Drug and Alcohol Medicine, Rural Health and Aboriginal Health).
The HSP modules were developed with particular reference to the Australian Curriculum Framework for Junior Doctors (ACFJD), prepared by the Confederation of Postgraduate Medical
Education Councils. The HSP modules have a similar structure to the ACFJD, comprising the categories of clinical management, communication and professionalism. The modules also identify common illness problems and conditions for which HSP participants are likely to respond, and describe the procedures and clinical skills that are expected of HSP participants.
The presentation of the Hospital Medicine module is intended to recognise and reinforce a mode of practice within hospital medicine that focuses on the continuity and quality of clinical care, patient safety and patient flow.
Further curriculum work is underway to review module learning outcomes in terms of “entrustable professional activities” (Ten Cate 2006). These are broader capabilities that can be used to provide direction for professional development and to assess doctors as having the capacity to carry out particular clinical responsibilities, either under supervision, or independently (eg, leading a Clinical Emergency Response System team in hospital wards or managing a normal delivery in the Emergency Department).
Overview of the Hospital Medicine module
The HSP Hospital Medicine module identifies the capabilities of doctors working in the developing field of Hospital Medicine, with a particular focus on learning how to respond to clinical and system demands. These occur across many specialist teams without necessarily being the core business of that team or specialty.
Hospital medicine has recently emerged as a parallel rather than competitive stream of care, which supports inpatient specialist teams to focus safely on delivering their core skills, while reducing the transaction costs and variations of
care delivery across the hospital, and working to increase its safety and efficiency for patients.
It is anticipated that while the themes and concerns of this stream of medical practice will be widely applicable, their particular application will be site-specific and responsive to local conditions.
MAY 2012 VERSION 1.1 PAGE 3
Rationale for a module in Hospital Medicine
The forces of population growth and ageing, social dislocation, ethnic diversification and altered systems of care that emphasise very short admissions and community-based models of service have combined over the last 30 years to alter the demographics of the inpatient population in irrevocable ways.
Patient characteristics have changed. It is widely recognised that today’s patients are older, sicker, have more interrelated co-morbidities, are more likely to suffer a complicating cognitive decline or mental illness and less likely to have a secure network of informal carers. Such patients require expert multi-disciplinary care delivered in systems responsive to the patient in context.
Less widely recognised are the effects of the way medicine is practised on this changing inpatient scenario. Doctors in hospitals are traditionally trained into specialities based upon discipline groupings (eg, cardiology, orthopaedic surgery) or defined hospital contexts (eg, the emergency department or the intensive care unit). Expertise and skills are developed to an extraordinary depth and detail within those fields as determined by specialist colleges, and as those fields advance. Specialisation inevitably narrows focus, and focus is assumed to be a good thing.
Innovation and training tend to increase specialisation, and specialisation is recognised, valued and rewarded, often by release from the confines of public hospital practice. Expert focus on system characteristics is the business of medical administrators who are often, though not always, separated from the realities of 24/7/365 clinical practice by their own process of specialisation.
Several characteristics of our current medical system, coupled with rising demand, predispose to patient risk. There is widespread dependence on specialist Visiting Medical Officers and specialist and super-specialist training and services are condensed into district-based networks. These networks are often dominated
by a few tertiary facilities offering advanced care in an environment of significant bed pressures and complex access issues. The rapid turnover of trainee junior medical staff creates challenges in providing adequate and consistent education, orientation and support.
It is difficult to manage clinical risk in an environment in which not even the most dedicated professional can have knowledge of everything that happens to a patient during their stay. Information loss is a pervasive hazard. Time-based performance targets for emergency departments place downward pressure on the ‘setting up and sorting out’ phase of the early admission process and bed pressures mean that patients must be discharged as soon as practicable – and sometimes before.
Outliers (eg, a medical patient in a surgical ward) are common and patients often suffer from several moves between specialised areas, such as from emergency department to emergency medical unit, and then to clinical decision units, between wards and beds, to off-site treatment units, between specialist teams, through transit lounges and surge beds, and to and from high acuity areas and rehabilitation units. Prevailing conditions and rising demand predispose to conditions of risk for the inpatient population.
The following data provide a context for the development of an HSP module in Hospital Medicine.
There were 1326 hospitals in Australia in the financial year 2009/10. The 753 public hospitals accounted for 67% of hospital beds (56,900) and the 573 private hospitals accounted for 33% (28,000), proportions remaining unchanged from 2008/09. There were 8.5 million separations for admitted patients in 2009/10, with 5.1 million occurring in public hospitals and almost 3.5 million in private hospitals.
PAGE 4 HSP: HOSPITAL MEDICINE MODULE
This was an increase of 3.2% on average each year between 2005/06 and 2009/10 for public hospitals, and 5% for private hospitals. The proportion of admissions that were ‘same-day’ continued to increase, by 5% on average each year between 2005/06 and 2009/10, accounting for 58% of the total in 2009/10 (51% in public hospitals and 68% in private hospitals). For overnight separations, the average length of stay was 5.9 days in 2009/10, down from 6.2 days in 2005/06 (Australian Institute of Health and Welfare 2011).
The World Health Organization’s High 5’s program for patient safety articulates the top five challenges for patient safety that are generated by hospital admission (WHO, 2010):
1 concentrated injectable medicines
2 medication accuracy at transitions in care
3 correct procedure at the correct body site
4 communication failures during patient handovers
5 addressing health care associated infections.
These are complex problems and the need for a whole-of-hospital medical, multidisciplinary, and system engagement in patient safety is apparent.
Other risks of hospitalisation have been studied, especially through the deteriorating patient literature (eg, CEC, 2008), and a group of diagnoses can therefore be identified that are appropriate for the generalist hospital medicine practitioner to master. Innovative system design presents opportunities to influence the conditions that predispose to medical error and patient deterioration, avoiding situations like that described in Appendix 3.
Hospital generalists need to develop expertise in recognising, tolerating and managing risk. They also need to be familiar with the supporting legal framework of hospital practice, to act as reservoirs of information, support junior staff, and practise empirical decision making and
reflective practice. This requires self and system knowledge skills, such as recognising the point of need for speciality consultation. Properly managing this specialist interface requires a profound knowledge of local conditions and is a poorly recognised yet vital skill set for the coordination of patient access to care.
Hospital medicine responds to the characteristics of the inpatient population and provides a bridging function across discipline silos, seniorities, specialities and disciplines. The proper concerns of hospital medicine are the challenges, both clinical and systemic, that occur across many different teams, and which are not the core business of the team. Practitioners show maturity in understanding and promoting the management of the patient within their social and clinical context regardless of the location in the hospital in which they are employed. Such knowledge is built and held in a permanent continuous workforce.
Formative assessment and entrustable professional activities
The HSP provides a framework for workplace-based, competency-based formative assessment and the recognition of current competencies. The HSP framework for formative assessment is underpinned by core principles of authentic workplace based assessment. Assessment in the HSP is valid, reliable, feasible and fair.
A valid assessment task is one that accurately assesses the capability or competency as outlined in the HSP module. For example, a valid assessment of an emergency department tracheal intubation procedure would be the direct observation of a doctor performing this skill, but not a multiple choice test of how much a doctor knows about the anatomy and physiology of respiratory structure and function.
An assessment is reliable if it yields consistent and precise results and is free from bias or error.
MAY 2012 VERSION 1.1 PAGE 5
A feasible assessment is one that is cost effective, allows sufficient time for the assessment tasks to be carried out by the doctor and can be administered using available relevant workplace equipment and other resources.
A fair assessment is one that allows for the recognition of current capabilities and achievement no matter how, where or when learning has occurred. A fair assessment also is one that does not disadvantage any particular individual on the basis of age, gender and other personal attributes.
Entrustable professional activities (EPAs) are sets of professional tasks that doctors perform in their clinical roles. These medical tasks are entrusted to doctors by health system employers and supervisors. Professor Olle ten Cate (2006) who first described EPAs, notes that this concept emphasises the notion of trust, formalising what medical managers and supervisors practise when they identify doctors who they trust to complete particular professional tasks on the ward or in other hospital contexts.
The EPAs described in this module have been identified by the Hospital Medicine Module Development Group through an analysis of clinical activities that are of central importance to the practice of hospital medicine.
Because the sum of what doctors do in hospital medicine practice is greater than the parts described by individual competencies, EPAs provide an approach that minimises the atomisation of professional competencies, which is an undesirable side-effect of some competency-based assessments (Van der Vleuten and Schuwirth, 2005).
Ten Cate (2006: 750) identifies the following criteria for EPAs:
• part of essential professional work
• require specific knowledge, skill and attitude
• generally acquired through training
• lead to recognised output of professional labour
• usually confined to qualified staff
• independently executable within a time frame
• observable and measurable in their process and their outcome
• lead to a conclusion (done well or not done well)
• reflect the competencies to be acquired.
Using the concept of EPAs and building formal entrustment decisions into the HSP has many advantages for the field of hospital medicine, including:
• providing guidance for professional development and progression
• supporting supervision and guiding workplace based assessment
• integrating professional competencies into broader capabilities reflecting real-world practice in hospital medicine
• fostering a developmental continuum of workplace-based learning, formative assessment and workplace progression.
Through involvement in the module’s educational experiences, including access to relevant resources, HSP participants will be able to engage in the entrustable professional activities relevant to their practice at the HSP level designated. This will support a career-long process of increasing depth of expertise and synthesis of clinical skills for doctors working in hospital medicine.
PAGE 6 HSP: HOSPITAL MEDICINE MODULE
Levels of competence
Ten Cate and Scheele (2007: 543) argue that these EPAs “are the constituting elements of professional work” and applying this concept to postgraduate medical education involves considering multiple levels of professional activity.
An HSP level has been allocated for each EPA in the Hospital Medicine module. The three levels of the HSP reflect the developing knowledge and skills required of increasingly complex clinical management scenarios and increasing work role responsibility, entrustment and accountability. Each of the three levels broadly distinguishes doctors in terms of proficiency, experience and responsibility. The following is a summary of the criteria on which the HSP levels have been determined.
It is assumed that doctors will practise medicine with the degree of autonomy that is consistent with their level of experience (E), clinical proficiency (CP) and responsibility (R) to ensure patients receive care which is appropriate, effective and safe. The levels are cross referenced with levels described for the patient competencies in the National Patient Safety Education Framework (see Appendix 1).
MAY 2012 VERSION 1.1 PAGE 7
Table 1: Defining levels of entrustable professional activity in the Hospital Skills Program
Key HSP 1 HSP 2 HSP 3
Level of experience (E)
Has limited workplace experience in this discipline.
Has moderate to large workplace experience in this discipline.
Has substantial workplace experience in this discipline.
Clinical proficiency (CP)
Reliably recognises familiar situations and key issues. Has a good working knowledge of the management of these. Decision-making is largely rule bound. Demonstrates effective clinical decision making and clinical proficiency in defined situations.
Recognises atypical presentations, recognises case specific nuances and their relational significance, thus reliably identifies key issues and risks. Decision making is increasingly intuitive. Fluent in most procedures and clinical management tasks.
Has an intuitive grasp of a situation as a means of linking his or her understanding of a situation to appropriate action. Able to provide an extensive repertoire of management options. Has a comprehensive understanding of thje hospital service, referral networks and links to community services.
Responsibility (R) Uses/applies integrated management approach for all cases; consults prior to disposition or definitive management; and arranges senior review of the patient in numerous instances, especially serious, complex, unclear or uncommon cases.. Observes family conference discussions about care and discharge planning if requested by senior clinician (and permitted by the family or carer/s)
Autonomously manages simple and common presentations and consults prior to disposition or definitive management for more complex cases. Conducts family conference discussions about care and discharge planning under supervision of senior clinician.
Works autonomously, consults as required for expert advice and refers to admitting team about patient who require admission. and other medical specialists as required. Independently conducts family conference discussions about care and discharge planning under supervision of senior clinician.
Patient safety (PS)
Level 2 Level 2 - 3 Level 3
PAGE 8 HSP: HOSPITAL MEDICINE MODULE
Summary of the Hospital Medicine module
The rationale of hospital medicine is to understand the patient in context, and to use excellent clinical skills, a broad system view and expert local knowledge in making decisions.
The Hospital Medicine module aims to support the development of a doctor with a top-to-bottom, side-to-side perspective. It emphasises the following themes: continuity, quality, safety, flow and advocacy for hospital services and persons.
Continuity of hospital medicine care extends across hospital organisation and health discipline boundaries. Continuity of care also implies a relationship between clinician and patient that exists from admission to discharge and extends to supporting the patient through building relationships with general practitioners and other health professionals following discharge.
Haggerty et al (2003) in their review article on continuity of care argue that three types of continuity exist:
Informational continuity: The use of information on past events and personal circumstances to make current care appropriate for each individual.
Management continuity: A consistent and coherent approach to the management of a health condition that is responsive to a patient’s changing needs.
Relational continuity: An ongoing therapeutic relationship between a patient and one or more providers.
This module supports enhanced quality of care by hospital practitioners. Good hospital medicine practice leads to improved quality of care as measured by indicators such as length of stay and treatment costs.
Patient safety is focused on minimising risk of patient harm due to the experiences during their hospital stay. Approximately 10% of patients in hospitals experience actual harm as an
unintended consequence of care, such as a hospital acquired infection or medication error (Australian Patient Safety Foundation, 2010).
This module recognises the goal to expedite patient flow in a manner that ensures patients receive safe and timely care. This goal is not only to be achieved within the hospital, but it is expected that the hospital medicine practitioner will engage with the local health professional community to ensure appropriate patient care.
Hospital medicine practitioners routinely act as advocates for the effectiveness and efficiency of hospital services and the people providing hospital services.
Hospital generalists who participate in the Hospital Medicine module are expected to demonstrate the following personal characteristics: seniority in the health system, commitment to the health service, excellent situational awareness and confidence in their own skills, with the broad clinical experience to get things done for the patient.
The following topics covered in the Hospital Medicine module align closely with the Clinical Excellence Commission’s priority areas for clinical improvement (www.cec.health.nsw.gov.au):
Handover processes:
• Development and embedding at local level
• Using current resources
• Rolling audit and feedback
• Leadership and promulgation
• Team to team, term to term, day to night, week to weekend and return, across holidays, between clinical units, hand-back, building and supporting the hospital team.
Leading in system-wide responses to the deteriorating patient at ward level
• Participating in resuscitation teams
• Follow through and carriage of recurring issues
MAY 2012 VERSION 1.1 PAGE 9
• Training in technical and non-technical topics
• Feedback loops to achieve prevention
• Mentorship and participation in multi-disciplinary teams
• Advocacy and trialling for equipment and training
• Performing audit
• Providing feedback and development
• Troubleshooting.
Transitions of care
• Admission negotiation skills
• Medical participation and leadership in multi-disciplinary teams
• Care and discharge planning meetings
• Standards in medical record keeping
• Promoting general practitioner liaison
• Discharge processes and their review
• Transfers between and inside institutions and levels of care
• Knowledge of local networks
• Retrieval services
• Escalation of failing systems and patient and community advocacy.
Medical education and support to junior staff
• Junior doctor and collegial support
• Cross-disciplinary professional development
• Medicolegal frameworks for practice
• Accessing and interpreting policies
• Recognition and assistance to the clinician in difficulty
• Conditions and requirements for supporting international medical graduates.
Organisational liaison and support
Medical error and clinical governance
• Open disclosure
• Ethical aspects of hospital practice
• Incident management and reporting
• Complaints management
• Clinical incident review
• Morbidity and mortality meetings
• Local quality systems
• The Coroner’s Court – purpose of
notification.
End of life processes
• Mentorship and participation in
multidisciplinary teams
• Development of local networks within the
hospitals and into the community
• Practical assistance and support to junior
staff
• Ethical issues and medicolegal requirements
• Processes of death certification and organ
donation.
Occupational health and safety
Public health
• Epidemiology of local environment
• Notification requirement of infections
• Multiresistant organism isolations and drug
reactions
• Health literacy - for example, health literacy
is defined in Health People 2010 as: “The
degree to which individuals have the capacity
to obtain, process and understand basic
health information and services needed
to make appropriate health decisions …
includes the ability to understand instructions
on prescription drug bottles, appointment
slips, medical education brochures, doctors
directions and consent forms, and the ability
to negotiate complex health care systems.”
Conditions that occur across the hospital and
across multiple specialist teams (but which
may not be the core business of that team)
and managing conditions of clinical risk are
considered to be the proper concerns of the
Hospital Medicine module.
PAGE 10 HSP: HOSPITAL MEDICINE MODULE
Section 2: Concurrent inpatient assessment, stabilisation and management
Rationale
It is characteristic of providing hospital wide care to be called to assess a patient not on one’s ‘home’ team, or who has undergone a change of clinical status, or altered symptoms. This intervention has traditionally been provided by the most junior medical staff, working in overstretched roles, and confronted by patients whose complexity can be overwhelming (CEC, 2008). The hospital medicine role requires considerable experience and maturity, a tolerance of uncertainty and the capacity to act safely with incomplete information, and to understand and to balance risks.
Knowledge of local systems and capabilities across the 24/7/365 environment is required to provide efficient care and makes this a proper field of activity for Hospital Medicine. Furthermore, this skill involves understanding the patient in context — to make sense of disparate sources and levels of information — skills that are enhanced in the practitioner with seniority, with judgement, with corporate knowledge, and who functions in continuity roles across a single site.
Consideration of the inpatient environment reveals different skill and knowledge sets relevant to different groups of patients. While a deal of attention has been paid to the problems of acute patients, it is timely to separately consider and articulate the needs of chronic patients and periprocedural patients. Doing so results in a more satisfying and richer knowledge set, more reflective of the working realities of hospital medical staff and a better basis for planning education and training. Overlap between groups is inevitable. The specific requirements of the other main groups — pregnant women, children and adolescents, are beyond the scope of this module.
This section has been written to support hospital doctors by identifying some of the patient and environmental factors and skills involved in accurate patient assessment, initiation of correct investigations, and diligent follow-up of results. Articulating the differing requirements of patients in different care streams helps the practitioner to broaden their thinking, speed-up decision-making and response, reduce preventable errors, and improve system and patient outcomes.
MAY 2012 VERSION 1.1 PAGE 11
Tabl
e 2.
1: E
ntru
stab
le p
rofe
ssio
nal a
ctiv
ities
for
con
curr
ent
inpa
tient
ass
essm
ent,
stab
ilisa
tion
and
man
agem
ent A
cute
pat
ient
sC
hron
ic p
atie
nts
Per
ipro
cedu
ral p
atie
nts
EPA
HM
2.1:
R
ecog
nise
and
co
rrec
tly a
ct o
n ob
serv
atio
ns(H
SP
2)
Mon
itor r
espi
rato
ry ra
te, m
etho
ds
and
effe
cts
of o
xyge
n de
liver
y, ra
pid
chan
ges
in lo
ss o
f con
scio
usne
ss
and
conf
usio
nal s
tate
s, b
lood
glu
cose
le
vel,
delir
ium
sco
re, p
ulse
rate
s an
d ca
rdio
vasc
ular
sys
tem
cap
acita
nce,
ur
ine
outp
ut, A
lcoh
ol W
ithdr
awal
Sca
le.
Mon
itor s
wal
low
ing,
den
titio
n, n
utrit
ion,
im
plic
atio
ns o
f wei
ght l
oss
and
gain
, flu
id b
alan
ce, b
owel
func
tion,
cog
nitiv
e de
clin
e, c
hang
es in
mob
ility
and
ac
tiviti
es o
f dai
ly li
ving
. Con
duct
men
tal
stat
e ex
am.
Ass
ess
norm
al a
nd a
bnor
mal
phy
siol
ogy
in s
urgi
cal
reco
very
, the
effe
cts
of a
naes
thet
ic a
gent
s on
leve
l of
con
scio
usne
ss, f
unct
iona
l abi
lity,
resp
irato
ry ra
te
and
effo
rt, p
osto
pera
tive
tem
pera
ture
, flu
id b
alan
ce,
post
oper
ativ
e ag
itatio
n an
d so
mno
lenc
e, A
lcoh
ol
With
draw
al S
cale
, pai
n sc
ores
.
EPA
HM
2.2:
O
rder
and
in
terp
ret
inve
stig
atio
ns(H
SP
2)
Ele
ctro
card
iogr
am, c
hest
X ra
ys,
Blo
ods,
Tro
poni
n T,
Wel
ls c
riter
ia/
pulm
onar
y em
bolis
m ru
le-o
ut c
riter
ia
(PE
RC
), ac
ute
myo
card
ial i
nfar
ctio
n,
ches
t pai
n, p
ulm
onar
y oe
dem
a, s
epsi
s.
Inte
rpre
ting
arte
rial b
lood
gas
, CT
brai
n,
CT
pulm
onar
y an
giog
ram
, bla
dder
sca
n.
Ass
ess
for f
alls
, del
irium
, dep
ress
ion,
de
men
tia, c
onge
stiv
e he
art f
ailu
re,
chro
nic
obst
ruct
ive
pulm
onar
y di
seas
e –
re
spira
tory
func
tion
test
s, re
nal f
unct
ion,
co
gniti
ve te
stin
g.
Inte
rpre
t ele
ctro
card
iogr
am, s
odiu
m a
nd
pota
ssiu
m, h
aem
oglo
bin,
whi
te c
ell c
ount
and
ar
teria
l blo
od g
as. I
nter
pret
the
ches
t X ra
y an
d ab
dom
inal
X ra
y, fl
uid
bala
nce
and
repl
acem
ent,
asse
ssin
g bl
ood
loss
, bla
dder
sca
n.
EPA
HM
2.3:
In
stitu
te
stab
ilisa
tion
and
prev
ent
prog
ress
ion
(HS
P2)
Obt
ain
vasc
ular
acc
ess
– c
entra
l and
pe
riphe
ral,
treat
with
em
erge
ncy
drug
s,
man
age
gluc
ose,
inse
rt an
indw
ellin
g ca
thet
er a
nd n
asog
astri
c tu
be. A
sses
s ho
urly
out
put a
nd p
repa
re fo
r ope
ratin
g th
eatre
. Man
age
a se
izur
e. Im
plem
ent
adva
nced
car
diac
life
sup
port
and
adva
nced
pae
diat
ric li
fe s
uppo
rt.
Con
trol h
aem
orrh
age
and
seve
re p
ain.
Eva
luat
e flu
id re
quire
men
ts, m
anag
e de
rang
ed e
lect
roly
tes,
resp
ond
to
prog
ress
ive
rena
l fai
lure
, med
icat
ions
to
sta
bilis
e rh
ythm
, wou
nd/u
lcer
car
e/fu
ngal
infe
ctio
n. P
rovi
de d
eep
vein
th
rom
bosi
s pr
ophy
laxis
and
app
ropr
iate
us
e of
ant
ibio
tics.
Mon
itor b
lood
glu
cose
le
vel.
Scr
een
for h
ospi
tal-a
cqui
red
infe
ctio
n. P
repa
re fo
r ope
ratin
g th
eatre
an
d pr
ovid
e an
alge
sia
for c
hron
ic p
ain.
Pro
vide
opt
ions
in p
ain
cont
rol a
nd n
arco
tic u
se
and
cess
atio
n. C
ontro
l hae
mor
rhag
e, p
rovi
de
arrh
ythm
ia a
nd a
ntic
oagu
latio
n m
anag
emen
t in
the
perio
pera
tive
perio
d. P
rovi
de p
erio
pera
tive
wou
nd
man
agem
ent,
intra
veno
us fl
uids
, pat
ient
con
trolle
d an
alge
sia
as re
quire
d, to
tal p
aren
tera
l nut
ritio
n an
d pe
ri-op
erat
ive
nutri
tiona
l opt
ions
.
EPA
HM
2.4:
M
anag
e di
spos
ition
(HS
P2)
Iden
tify
need
for i
nter
depa
rtmen
t or
inte
rhos
pita
l tra
nsfe
r. A
cces
s re
triev
al
syst
ems.
App
ropr
iate
not
ifica
tions
and
be
d m
anag
emen
t sys
tem
s. P
repa
re fo
r re
triev
al.
Par
ticip
ate
in c
are
and
disc
harg
e pl
anni
ng p
roce
sses
. Ass
ess
pote
ntia
l fo
r reh
abili
tatio
n an
d id
entif
y ne
ed fo
r pa
lliat
ive
care
. Rec
ogni
se th
e ef
fect
s an
d tim
ing
of a
ltere
d w
eigh
t-be
arin
g.
Ant
icip
ate
the
effe
cts
of s
urge
ry (e
g, C
a++
af
ter t
hyro
id s
urge
ry).
Man
age
early
dis
char
ge
proc
esse
s, in
clud
ing
appr
opria
te a
nalg
esia
and
an
tibio
tics
for d
isch
arge
. Man
age
wou
nd fa
ilure
, id
entif
y su
rgic
al d
eter
iora
tion,
iden
tify
patie
nts
who
nee
d to
retu
rn to
occ
upat
iona
l the
rapy
, and
lia
ise
with
nur
sing
and
hos
pita
l man
agem
ent a
s ap
prop
riate
.
PAGE 12 HSP: HOSPITAL MEDICINE MODULE
Rationale
The population at highest risk for acute hospital admissions and with the highest complex and chronic care needs are those aged 85 years and above. This age group has increased in numbers and as a proportion of the population over the period 2001–2011 and will continue to increase (GMCT, 2002), as Table 3.1 indicates.
In clinical practice, hospitalised patient populations show ‘herd characteristics’ determined by local demographics, patterns of referral, and the role delineation of the hospital. Patients admitted with disabling co-morbidities that are not ‘on the list’ of services provided under clinical services planning can face a difficult time obtaining access to care. Hospital doctors responsible for inpatients need to be cognisant of and adept in managing complex
overlapping health needs. Articulating these conditions and requirements for the differing but related groups (include acute patients, chronic patients and periprocedural patients) assists the doctor to work in a complex decision-making environment. These are problems or conditions that occur across many different teams without necessarily being the core business of the team, making this an appropriate field for hospital medicine activity.
Table 3.1: Population at highest risk for acute hospital admissions (from GMCT, 2002)
Hospital Medicine Module. NSW Hospital Skills Program. Version 1.2.
15
Section 3: Common Problems and Conditions Rationale The population at highest risk for acute hospital admissions and with the highest complex and chronic care needs, are those 85 years and above. This age group has increased progressively over the period 2001 - 2011 and will continue to increase (GMCT, 2002) as Table 1 indicates.
Table 1 Population at highest risk for acute hospital admissions (from GMCT, 2002)
In clinical practice hospitalised patient populations show ‘herd characteristics’ determined by local demographics, patterns of referral, and the role delineation of the hospital. Patients admitted with disabling co-morbidities that are not ‘on the list’ of services provided under clinical services planning, can face a difficult time obtaining access to care. Hospital doctors responsible for inpatients need to be cognisant of and adept in managing complex overlapping health needs. Articulating these conditions and requirements for the differing but related groups, which include acute patients, chronic patients and peri-procedural patients assists the doctor to work in a richer decision making environment. These are problems or conditions that occur across many different teams without necessarily being the core business of the team, making this an appropriate field for Hospital Medicine activity.
Section 3: Common problems and conditions
MAY 2012 VERSION 1.1 PAGE 13
Tabl
e 3.
2: E
ntru
stab
le p
rofe
ssio
nal a
ctiv
ities
for
com
mon
pro
blem
s an
d co
nditi
ons
Acu
te p
atie
nts
Chr
onic
pat
ient
sPe
ripro
cedu
ral p
atie
nts
EPA
HM
3.1
Pro
vide
med
icat
ion
for b
lood
pre
ssur
e(H
SP
2)
Pro
vide
BP
sup
port
in th
e si
ck p
atie
nt.
Inte
rpre
t the
pla
ce o
f and
cho
ices
in
inot
rope
s.
Pro
vide
app
ropr
iate
ther
apeu
tic c
hoic
es in
re
nal f
ailu
re, a
nd a
djus
t ant
i-hyp
erte
nsio
n m
edic
atio
n w
ith a
ge.
Pre
scrib
e, in
itiat
e an
d w
ithho
ld a
nti-h
yper
tens
ive
med
icat
ions
. Im
plem
ent c
hoic
es in
nil
by m
outh
pa
tient
s.
EPA
HM
3.2
Man
age
card
iac
prob
lem
s(H
SP
2)
Man
age
new
ons
et s
hortn
ess
of b
reat
h an
d ch
est p
ain.
Inte
rpre
t the
alte
red
elec
troca
rdio
gram
. Ass
ess
pre-
sync
ope
and
sync
ope.
Pro
vide
app
ropr
iate
ther
apeu
tic c
hoic
es
in c
ardi
ac a
nd re
nal f
ailu
re, p
ostu
ral
hypo
tens
ion.
Man
age
new
atri
al a
rrhyt
hmia
s an
d sh
ortn
ess
of
brea
th in
the
perip
roce
dura
l per
iod.
EPA
HM
3.3
Pro
vide
end
of l
ife
care
(HS
P 2
)
Con
duct
end
of l
ife d
iscu
ssio
ns a
nd
impl
emen
t no
CP
R/ i
nter
vent
ion
orde
rs.
App
ly c
oron
er’s
requ
irem
ents
, cul
tura
l an
d lin
guis
tic d
iver
sity
requ
irem
ents
.
App
ly p
allia
tive
proc
esse
s an
d th
erap
eutic
s, re
ferra
l pat
tern
s an
d so
urce
s of
loca
l cap
acity
.
App
ly c
oron
er’s
lega
l req
uire
men
ts, c
onse
nt a
nd
guar
dian
ship
, dec
isio
ns to
ope
rate
, ope
n di
sclo
sure
an
d cu
ltura
l con
text
.
EPA
HM
3.4
Man
age
infe
ctio
us
cond
ition
s(H
SP
2)
Iden
tify
and
notif
y he
alth
aut
horit
ies
of a
n ou
tbre
ak o
f H1N
1, s
ever
e ac
ute
resp
irato
ry s
yndr
ome,
influ
enza
, no
rovi
rus,
her
pes
zost
er a
nd o
ther
no
tifia
ble
dise
ases
.
Iden
tify
and
notif
y he
alth
aut
horit
ies
of h
epat
itis,
tube
rcul
osis
, hum
an
imm
unod
efic
ienc
y vi
rus.
Pla
n fo
r MR
Os
- M
RS
A, E
SB
L, V
RE.
EPA
HM
3.5
Pro
vide
pai
n m
anag
emen
t(H
SP
2)
Inte
rpre
t the
phy
siol
ogy
and
phar
mac
olog
y of
acu
te p
ain
cons
ider
ing
alte
rnat
ives
in m
edic
atio
n an
d de
liver
y sy
stem
s, a
nd s
plin
ting.
Inte
rpre
t the
phy
siol
ogy
and
phar
mac
olog
y of
chr
onic
pai
n an
d al
tern
ativ
es, a
nd a
pply
ca
re s
yste
ms
for c
hron
ic p
ain.
Rec
ogni
se o
ptio
ns in
pha
rmac
olog
y of
pe
ripro
cedu
ral p
ain.
Man
age
deliv
ery
syst
em in
nil
by m
outh
pat
ient
s, p
lan
for s
urge
ry, a
nd p
resc
ribe
anal
gesi
a to
pro
mot
e m
obilis
atio
n.
EPA
HM
3.6
Man
age
thro
mbo
sis
and
DVT
pr
ophy
laxis
(HS
P 2
)
Rec
ogni
se th
e ap
prop
riate
ness
of
hep
arin
ver
sus
clex
ane.
App
ly
thro
mbo
sis
embo
lism
det
erre
nt. A
sses
s an
d m
anag
e he
art v
alve
pat
holo
gy,
thro
mbo
sis,
vas
cula
r occ
lusi
on a
nd
acut
e m
yoca
rdia
l inf
arct
ion.
Pro
vide
app
ropr
iate
ther
apeu
tic c
hoic
es in
re
nal f
ailu
re, I
nter
natio
nal N
orm
alis
ed R
atio
an
d m
edic
atio
n in
tera
ctio
ns.
App
ly c
urre
nt p
ract
ice
in w
ithho
ldin
g w
afar
in/
plav
ix/as
pirin
and
pro
vide
alte
rnat
ives
. App
ly a
nti-
coag
ulat
ion
reve
rsal
pro
cess
es a
nd in
terp
ret
deci
sion
tree
s. M
anag
e pe
ripro
cedu
ral,
acut
e m
yoca
rdia
l inf
arct
ion
and
com
plic
atio
ns.
EPA
HM
3.7
Pro
vide
dru
g an
d al
coho
l car
e(H
SP
2)
Pre
scrib
e m
etha
done
on
entry
to
hosp
ital,
asse
ss a
gita
tion.
Use
a d
rug
and
alco
hol s
ervi
ce, u
se a
m
enta
l hea
lth s
ervi
ce (e
g, fo
r rev
iew
of
trans
ferre
d in
patie
nts)
. Ass
ist p
atie
nts
to
rem
ain
sobe
r.
Writ
e up
and
inte
rpre
t an
alco
hol w
ithdr
awal
sca
le,
iden
tify
and
man
age
benz
odia
zapi
ne w
ithdr
awal
, m
anag
e po
st p
roce
dure
ana
lges
ic re
quire
men
ts a
nd
beha
viou
rs.
EPA
HM
3.8
Pro
vide
m
enta
l hea
lth /
psyc
hoso
cial
car
e(H
SP
2)
Res
pond
app
ropr
iate
ly to
dis
char
ge
agai
nst m
edic
al a
dvic
e, id
entif
y ps
ycho
sis,
lega
l fra
mew
orks
of r
estra
int,
acut
e m
ood
diso
rder
, and
man
age
treat
men
t pho
bia.
Sup
port
patie
nts
expe
rienc
ing
lone
lines
s,
soci
al is
olat
ion
and
loss
of i
ndep
ende
nce.
S
uppo
rt pa
tient
s ex
perie
ncin
g fu
nctio
nal
chan
ges
and
men
tal h
ealth
issu
es w
ith
prol
onge
d or
repe
ated
hos
pita
lisat
ion
Impl
emen
t gua
rdia
nshi
p re
quire
men
ts a
s ap
prop
riate
.
Man
age
patie
nt fe
ar a
nd p
ost-
diag
nosi
s di
stre
ss.
PAGE 14 HSP: HOSPITAL MEDICINE MODULE
Tabl
e 3.
2 co
ntin
ued:
Ent
rust
able
pro
fess
iona
l act
iviti
es fo
r co
mm
on p
robl
ems
and
cond
ition
s
Acu
te p
atie
nts
Chr
onic
pat
ient
sPe
ripro
cedu
ral p
atie
nts
EPA
HM
3.9
Rec
ogni
se a
nd
man
age
delir
ium
, de
men
tia a
nd
depr
essi
on(H
SP
2)
Ass
ess
and
man
age
the
new
ly a
gita
ted,
co
nfus
ed o
r with
draw
n pa
tient
. Int
erpr
et
and
resp
ond
appr
opria
tely
to fl
uctu
atin
g at
tent
ion.
Ass
ess
and
man
age
the
post
-eve
nt
depr
esse
d pa
tient
, pos
t-st
roke
de
pres
sion
, the
effe
cts
of s
enso
ry lo
ss.
App
ly th
e S
AD
sco
re.
Ass
ess
and
man
age
perip
roce
dura
l del
irium
, DR
AT
scre
enin
g.
EPA
HM
3.10
Pro
vide
ear
ly
reco
gniti
on a
nd
prom
pt tr
eatm
ent
for s
epsi
s(H
SP
2)
Ass
ess
and
man
age
com
mon
in
fect
ions
— u
rinar
y tra
ct in
fect
ion,
co
mm
unity
acq
uire
d pn
eum
onia
, un
diffe
rent
iate
d se
psis
in th
e el
derly
, in
imm
unos
uppr
esse
d gr
oups
, fe
brile
neu
tropa
enia
, her
pes
sim
plex
en
ceph
aliti
s, a
spira
tion
pneu
mon
ia,
cellu
litis
, Pne
umon
ia S
ever
ity In
dex
and
seps
is e
scal
atio
n. R
ecog
nise
impe
ndin
g an
d se
vere
sep
sis
and
redu
ce ti
me
to
antib
iotic
s an
d co
rrect
ion
of s
hock
.
Ass
ess
and
man
age
mul
ti re
sist
ant
orga
nism
s, d
enta
l inf
ectio
n, re
curre
nt
infe
ctio
n, s
kin
ulce
rs.
Ass
ess
and
man
age
intra
-abd
omin
al in
fect
ion,
di
verti
culit
is, p
rost
hesi
s in
fect
ion,
wou
nd in
fect
ion.
EPA
HM
3.11
Man
age
nutri
tion
need
s(H
SP
2)
Man
age
subs
trate
repl
acem
ent a
nd
med
icat
ion
man
agem
ent i
n ni
l by
mou
th.
Man
age
mal
nutri
tion
and
tota
l par
ente
ral
nutri
tion
and
diffi
culti
es w
ith s
wal
low
ing.
Man
age
re-f
eedi
ng s
yndr
ome,
nas
ogas
tric
feed
ing,
det
erm
ine
the
indi
catio
ns fo
r an
d m
anag
e a
perc
utan
eous
end
osco
pic
gast
rost
omy,
man
age
med
icat
ion
choi
ces
via
tube
feed
ing.
Man
age
com
men
cem
ent a
nd c
essa
tion
of fo
od a
s ap
prop
riate
to th
e pa
tient
’s co
nditi
on, m
anag
e to
tal
pare
nter
al n
utrit
ion,
per
ipro
cedu
ral g
lyca
emic
con
trol,
ente
ral a
nd p
aren
tera
l nut
ritio
n.
EPA
HM
3.12
Mai
ntai
n gl
ycae
mic
co
ntro
l(H
SP
2)
Mon
itor f
or d
iabe
tic k
etoa
cido
sis,
hy
pero
smol
ar s
tate
s, h
ypog
lyca
emia
, st
abilis
ing
bloo
d gl
ucos
e an
d m
anag
e as
app
ropr
iate
.
Mod
ify o
ral h
ypog
lyca
emia
age
nts,
co
mm
enci
ng in
sulin
, con
verti
ng a
way
from
in
sulin
slid
ing
scal
es.
Impl
emen
t ope
ratin
g th
eatre
sch
edul
ing
requ
irem
ents
in d
iabe
tes
mel
litus
, adm
inis
ter
intra
veno
us fl
uids
and
pre
scrib
e in
sulin
in n
il by
m
outh
sta
tes,
sto
p/st
art a
n or
al h
ypog
lyca
emia
ag
ent.
EPA
HM
3.13
Man
age
derm
atol
ogic
al
prob
lem
s(H
SP
2)
Mon
itor a
llerg
ic re
actio
ns, i
nfec
tious
ag
ents
, sca
bies
, dru
g er
uptio
ns a
nd
man
age
as a
ppro
pria
te.
Man
age
pres
sure
are
as a
nd v
enou
s st
asis
.M
anag
e w
ound
man
agem
ent a
nd a
cute
deh
isce
nce.
EPA
HM
3.14
Res
pond
ap
prop
riate
ly to
ob
esity
(HS
P 2
)
Pro
vide
intra
veno
us a
cces
s,
med
icat
ion
dose
cal
cula
tions
, opt
ions
fo
r obs
truct
ive
slee
p ap
noea
, airw
ay
optio
ns, t
rans
port
and
man
ual h
andl
ing
optio
ns.
Mon
itor c
hron
ic c
ellu
litis
, con
tinen
ce,
men
tal h
ealth
, and
pro
vide
opt
ions
for
reha
bilit
atio
n (in
clud
ing
surg
ical
opt
ions
).
Impl
emen
t inv
estig
ativ
e an
d op
erat
ive
optio
ns fo
r po
st-o
pera
tive
resp
irato
ry d
epre
ssio
n, D
VT a
nd P
E
prop
hyla
xis.
MAY 2012 VERSION 1.1 PAGE 15
Rationale
Unintended consequences have arisen from shortening admission length, less invasive approaches to surgery and subspecialisation. Interventions once commonly performed by the intern, such as inserting and maintaining a suprapubic catheter or changing a PEG tube, and even performing a lumbar puncture occur less frequently in general wards. Much initial patient stabilisation is being performed in the emergency department. In larger institutions the use of support staff such as surgical dressers is not uncommon. An increased number of interns rotating through and a newly recognised need for accreditation of procedural skills and consent requirements have resulted in challenges to acquiring and maintaining procedural skills and a gradual procedural deskilling of hospital medical staff outside specialist units.
The recognition of the realities of practice in a resource-poor environment can provide an impetus to develop and decentralise teaching materials to satisfy the minimum skill set required for a given location. Advances in communication technology offers significant opportunities in this area.
It is anticipated that consistent, skilled hospital medicine practitioners may function as the locus, not only of skill delivery, but of the provision of accreditation and teaching opportunities for junior staff. Knowledge of the indications for a procedure within a specific patient and resource context, and the ability to reach a reasoned decision and plan for intervention, distinguishes the advanced practitioner.
The increasingly aged and complex nature of the inpatient population, and the emerging need to integrate the efforts of many specialist and subspecialist, nursing and allied health systems, and then to function within a restricted resource base, dictates that a particularly broad set of
knowledge skills is required for the hospital medicine practitioner. This is a poorly articulated skill set worthy of additional study when implementing the Hospital Medicine module.
EPA HM4.1 Airway skills (HSP 3)Open the airway. Insert Guedel’s and nasopharyngeal airway. Perform bag valve mask ventilation. Insert laryngeal mask. Set up and monitor continuous positive airway pressure and bi-level positive airway pressure. Carry out decision making in support of, setting up for, and performing simple endotracheal tube airway management. Implement techniques to escalate care for difficult endotracheal tube patient (eg, can’t ventilate, can’t oxygenate). Perform surgical airway. Detect and respond appropriately to changing conditions.
EPA HM4.2 Vascular access (HSP 2)Provide normal and difficult venous access. Obtain arterial blood gases. Place central venous lines — ‘blind’ and under ultrasound. Attach monitoring and perform and confirm correct placement protocol for central vascular catheterisation. Implement best practice recommendations to avoid central catheter infection. Evaluate the need for and place an intra-osseous needle. Perform emergency venous cut down and place arterial lines — by touch and under ultrasound — and attach monitoring. Evaluate the need for and place peripherally inserted central catheter lines.
EPA HM4.3 Cardiovascular (HSP 3)Manage intravenous fluids. Evaluate the need for cardioversion, and if required, prepare for the conduct and performing of cardioversion. Initiate and monitor external pacemaking. Identify electrical and mechanical capture. Place temporary pacemaker in emergencies and interpret basic cardiac echo.
Section 4: Procedural entrustable professional activities
PAGE 16 HSP: HOSPITAL MEDICINE MODULE
EPA HM4.4 Respiratory (HSP 2)Conduct emergency identification and drainage of tension pneumothorax. Insert intercostal catheter placement and maintain, monitor and remove underwater seal drainage. Conduct pleural drainage.
EPA HM4.5 Central Nervous System (HSP 2)Perform lumbar puncture under asepsis. Obtain and interpret cerebral spinal fluid pressures. Perform sip test to evaluate basic swallowing.
EPA HM4.6 Gastrointestinal (HSP 2)Initiate focused assessment with sonography for trauma scan. Provide peritoneal tap and drainage. Place nasogastic tube and provide confirmation of correct placement protocol. Provide for the care and removal of drains. Provide indications for the organisation and replacement of percutaneous endoscopic gastrostomy tubes.
EPA HM4.7 Urinary (HSP 2)Perform a bladder scan. Insert a simple male and female indwelling catheter, maintain aseptic technique, implement difficult catheter techniques, insert and replace suprapubic catheters as required.
EPA HM4.8 Management of Pain (HSP 2)Provide regional anaesthetic for pain control. Manage patient-controlled analgesia including writing up, setting up, and ceasing as appropriate. Adjust traction as required. Provide simple postoperative pain skills (eg, using Pain Buster). Provide opiate substitution as required.
MAY 2012 VERSION 1.1 PAGE 17
Rationale
Knowledge and expertise in the common causes and presentations of deterioration is an appropriate skill and knowledge set for the hospital medicine practitioner to learn, maintain, and develop.
Knowledge of uncommon but serious conditions should also be developed and maintained. In this section a number of condition-specific knowledge and procedural skills are synthesised, building into an ‘emergency responses set’ appropriate to managing the undifferentiated patient whose condition deteriorates in hospital.
The most common presentations are respiratory distress, hypotension and neurological derangement.
The most common diagnoses for Medical Emergency Team/CERS scenarios are sepsis, pneumonia, atrial fibrillation and seizures (Calzavacca, Licari, Tee et al 2008).
Delay to activation of the MET/CERS team is known to be associated with worse outcomes (Quach, Downey, Haase et al 2008).
The hospital practitioner is cognisant of the many local determinants of willingness to activate the MET/CERS team, and actively supports the whole team to make the call.
Section 5: Responses to emergencies
PAGE 18 HSP: HOSPITAL MEDICINE MODULE
Tabl
e 5.
1: E
ntru
stab
le p
rofe
ssio
nal a
ctiv
ities
for
res
pons
es t
o em
erge
ncie
s
Com
pone
nt c
ompe
tenc
ies
EPA
for
rel
ated
but
unc
omm
on
cond
ition
s (c
onte
xtua
l)E
PA H
M5.
1 Im
plem
ent B
LS/
ALS
/ DE
TEC
T/
AP
LS o
r eq
uiva
lent
(H
SP
2)
Hol
d cu
rren
t cer
tific
atio
n or
teac
hing
exp
erie
nce
with
in la
st 2
yea
rs, a
ppro
pria
te
to c
linic
al c
onte
xt –
eg,
with
pae
diat
rics
or w
ithou
t, fa
mili
ar w
ith m
ajor
topi
cs in
re
susc
itatio
n, a
ble
to le
ad a
med
ical
resp
onse
and
pro
vide
a m
inim
um o
f bas
ic
airw
ays
supp
ort.
Inst
itute
car
diov
ascu
lar s
uppo
rt in
ana
phyl
axis
.
EPA
HM
5.2
Man
age
airw
ays
obst
ruct
ion
(HS
P 3
)
Iden
tify
muc
ous
plug
ging
, ide
ntify
pre
sent
atio
ns o
f for
eign
bod
y, id
entif
y ne
ed fo
r and
pe
rform
suc
tion,
pos
ition
ing,
for d
iffic
ult i
ntub
atio
n to
mid
-leve
l ski
lls a
ccor
ding
to
anae
sthe
tic g
uide
lines
.
Man
age
trach
eost
omy
tube
car
e, id
entif
y an
d m
anag
e th
e ai
rway
in e
pigl
ottit
is, a
nd p
erfo
rm
emer
genc
y su
rgic
al a
irway
.
EPA
HM
5.3
Man
age
resp
irato
ry
failu
re
(HS
P 2
)
Iden
tify
type
1 a
nd ty
pe 2
resp
irato
ry fa
ilure
and
resp
ond
appr
opria
tely
to e
xace
rbat
ion
of c
hron
ic o
bstru
ctiv
e pu
lmon
ary
dise
ase.
Iden
tify
sign
s of
det
erio
ratio
n in
pat
ient
with
se
vere
ast
hma,
esc
alat
e br
onch
odila
tors
and
set
up
salb
utam
ol in
fusi
on a
ppro
pria
tely,
id
entif
y cl
inic
al c
riter
ia fo
r tra
nsfe
r to
Hig
h D
epen
denc
y U
nit.
Use
pne
umon
ia s
ever
ity
scor
e. Id
entif
y cr
iteria
for u
se o
f, se
t up
and
adju
st C
PAP
and
BIP
AP.
Iden
tify
pneu
mot
hora
x, d
ecom
pres
s an
d pl
ace
inte
rcos
tal d
rain
. Util
ise
appr
opria
te c
linic
al
and
labo
rato
ry in
vest
igat
ions
in ru
ling
in/o
ut a
pul
mon
ary
embo
lism
.
Est
ablis
h an
d ad
just
ven
tilat
or s
ettin
gs. I
dent
ify
Gui
llan-
Bar
re a
nd m
yast
heni
a gr
avis
and
inst
itute
th
erap
y. R
ecog
nise
whe
ther
to e
scal
ate
care
and
to
alte
r ven
tilat
or s
ettin
gs.
EPA
HM
5.4
Man
age
card
iova
scul
ar
cond
ition
s (H
SP
3)
Rec
ogni
se a
trial
fibr
illatio
n w
ith ra
pid
vent
ricul
ar re
spon
se, a
sses
s pr
ecip
itatin
g ca
uses
, us
e ap
prop
riate
dru
g th
erap
ies
and
follo
w-u
p. R
ecog
nise
and
app
ropr
iate
ly re
spon
d to
the
emer
genc
e of
acu
te p
ulm
onar
y oe
dem
a, u
sing
vas
cula
r dila
tors
, flu
id o
ff lo
ad if
re
quire
d, C
PAP
if n
eces
sary
. Rec
ogni
se a
nd c
an tr
eat b
rady
card
ia in
clin
ical
con
text
. R
ecog
nise
indi
catio
ns a
nd lo
cal p
roce
sses
for p
lace
men
t of t
empo
rary
pac
ing,
can
re
cogn
ise
clin
ical
ly s
igni
fican
t hyp
oten
sion
in a
var
iety
of c
linic
al c
onte
xts,
incl
udin
g oc
cult
gast
roin
test
inal
ble
edin
g an
d dr
ug re
actio
n, c
an p
lace
arte
rial l
ines
and
PIC
C a
nd
cent
ral l
ines
and
initi
ate
inot
ropi
c su
ppor
t, re
cogn
ises
the
EC
G, l
abor
ator
y an
d cl
inic
al
man
ifest
atio
ns o
f acu
te m
yoca
rdia
l inf
arct
ion,
fam
iliar w
ith a
nd a
ble
to in
itiat
e lo
cal
esca
latio
n pr
oces
ses
for i
nter
vent
iona
l car
diol
ogy.
Pla
ce a
tem
pora
ry p
acin
g w
ire. D
emon
stra
te
basi
c co
mpe
tenc
y in
ultr
asou
nd d
etec
tion
of
peric
ardi
al ta
mpo
nade
. Per
form
em
erge
ncy
peric
ardi
al d
rain
age.
Eva
luat
e an
d re
spon
d to
tra
nsfu
sion
reac
tion.
Loc
ate
and
follo
w m
assi
ve
trans
fusi
on g
uide
lines
.
MAY 2012 VERSION 1.1 PAGE 19
Tabl
e 5.
1 co
ntin
ued:
Ent
rust
able
pro
fess
iona
l act
iviti
es f
or r
espo
nses
to
emer
genc
ies
Com
pone
nt c
ompe
tenc
ies
EPA
for
rel
ated
but
unc
omm
on
cond
ition
s (c
onte
xtua
l)E
PA H
M5.
5 M
anag
e ne
urol
ogic
al
cond
ition
s
(HS
P 2
)
Eva
luat
e th
e si
gnifi
canc
e of
a c
hang
e in
Gla
sgow
Com
a S
cale
in a
wid
e va
riety
of
clin
ical
sce
nario
s. R
ecog
nise
sei
zure
and
initi
ate
airw
ay s
uppo
rt an
d dr
ug tr
eatm
ent
and
inve
stig
atio
n. In
terp
ret t
he c
ereb
ral C
T in
age
-nor
mal
and
age
-abn
orm
al s
cans
. P
erfo
rm lu
mba
r pun
ctur
e. Id
entif
y de
liriu
m a
nd in
stitu
te a
ppro
pria
te p
harm
acol
ogic
an
d no
n-ph
arm
acol
ogic
man
agem
ent.
Rec
ogni
se p
hysi
olog
ical
sig
ns o
f inc
reas
ing
intra
cere
bral
pre
ssur
e an
d ac
tivat
e lo
cal r
esou
rces
to m
anag
e pr
essu
re.
Iden
tify
the
need
for a
nd p
erfo
rm e
mer
genc
y as
pira
tion
of a
blo
cked
ven
tricu
lo -
per
itone
al
shun
t.
EPA
HM
5.6
Man
age
seps
is
(HS
P 2
)
Rec
ogni
se p
hysi
olog
ical
cha
nges
of s
yste
mic
infla
mm
ator
y re
spon
se s
yndr
ome
and
seve
re s
epsi
s an
d im
plem
ent e
ffect
ive
and
appr
opria
te m
anag
emen
t. D
emon
stra
te
appr
opria
te u
se o
f ant
ibio
tics
in fe
brile
neu
tropa
enia
. Rec
ogni
se th
e ne
ed fo
r ino
tropi
c su
ppor
t and
man
age
trans
fer t
o hi
gher
leve
l car
e.
Rec
ogni
se s
epsi
s fro
m re
nal c
alcu
li, o
bstru
cted
ur
eter
and
resp
ond
appr
opria
tely.
Iden
tify
epid
ural
ab
sces
s an
d re
spon
d ap
prop
riate
ly.
EPA
HM
5.7
Man
age
rena
l di
sord
ers
(H
SP
2)
Per
form
bla
dder
sca
n, p
lace
urin
ary
cath
eter
s, m
odify
dru
g do
sage
s in
con
ditio
ns o
f re
nal f
ailu
re, r
ecog
nise
the
phys
iolo
gica
l and
ele
ctro
card
iogr
am m
anife
stat
ions
of l
ife
thre
aten
ing
elec
troly
te d
istu
rban
ces
of s
odiu
m, p
otas
sium
and
inst
itute
em
erge
ncy
treat
men
t.
EPA
HM
5.8
Oth
er –
ha
zard
ous
but
less
com
mon
(H
SP
2)
Rec
ogni
se d
iabe
tic k
etoa
cido
sis
and
hype
rosm
olar
sta
tes
in th
e in
patie
nt a
nd in
stitu
te
stab
ilisa
tion.
Iden
tify
acut
e m
arro
w fa
ilure
, Add
ison
ian
cris
is,
thyr
oid
cris
is, W
erni
ckes
enc
epha
lopa
thy,
B
erib
eri /
vita
min
def
icie
ncy,
incl
udin
g vi
tam
in D
.
PAGE 20 HSP: HOSPITAL MEDICINE MODULE
Section 6: System design and the characteristics of hospital practice
Rationale
Experienced practitioners in hospital medicine bring additional dimensions to the culture and functioning of their hospitals. Translation of theory into practice, managing a difficult colleague, culture building, promoting cooperation, identifying an opportunity or a threat, responding to changing conditions over time are advanced cognitive and system skills that are under-recognised. Understanding these issues and achieving the hospital skills and knowledge sets listed below will demonstrate the advantages of a whole-of-hospital perspective.
System skills for hospital medicine practitioners:
• Understanding the health system, especially governance and accountability frameworks at local, network, state and federal levels.
• Identifying where knowledge about the local hospital system is stored. Who are the key personnel?
• Recognising the resource characteristics of overlapping clinical frameworks — retrieval, ambulance, disaster, public health, mental health, drug and alcohol, children’s health, trauma and burns networks, tissue donation and transplant, community services.
• Implementing successful systems to reduce avoidable readmission or failed discharge.
• Identifying and containing system failure — single events, multiple events, identifying emerging trends, and having a system-wide view.
• Improvising solutions and understanding the characteristics of high reliability organisations, with the purpose of building organisational resilience.
• Responding swiftly to the deteriorating patient (eg, through situational awareness, identifying and intervening when something goes wrong, knowing the importance of acute prevention, and implementing hazard reduction and reporting systems such as incident information management system [IIMS] and hazard registers).
• Adopting successful approaches to knowledge translation and the implementation of clinical guidelines, applying these to local conditions and understanding the possible constraints in health literacy in the local environment.
• Demonstrating good handovers and record keeping processes, including accessing and modifying electronic health records as required.
• Demonstrating good educational and presentation skills, planning and delivering good educational experiences for colleagues with differing levels of expertise. Understanding meta-cognition (ie, thinking about thinking) — for example, the use and shortcomings of mental heuristics, cognitive biases, clinical reasoning and knowing how doctors think.
• Demonstrating strong communication skills with staff, patients and carers.
• Implementing the overlapping roles of medical expert, health advocate, scholar, professional, communicator, collaborator and manager — for example, through consideration of the CANMED’s domains (see Appendix 2).
• Acting as an effective manager in assisting in shaping the attitude of hospital teams. (eg, understanding what the local clinical environment can offer), holding corporate
MAY 2012 VERSION 1.1 PAGE 21
hospital knowledge, promoting alternative solutions, building and using trust relationships and social capital.
• Practising niche skills and understanding the local niche requirements (eg, the role of the dietician in total parenteral nutrition and re-feeding).
• Understanding the role of the doctor in the community, the epidemiology of the local area and the cultural mix and requirements of its communities.
• Predicting the nature of hospital work in 10 years (eg, the effect of increasing obesity, responding appropriately to the needs of culturally and linguistically diverse patients, the impact of rising rates of poor mobility, psychosocial stress, mental illness, social fragmentation and increasing numbers of very old patients).
• Recognising the ecology of the local area, being a health advocate for disadvantaged social groups and assisting the health literacy of patients (eg, preventing complications of age-related conditions).
• Developing planning and marketing skills — project management and continuity roles, change management, clinical redesign, research projects.
• Managing multiple roles in accreditation by HETI, the medical colleges, Quality Society of Australasia, Work Health and Safety, ACHS Evaluation and Quality Improvement Program (EQuIP) or equivalent, and providing a focus for medical quality improvement cycles.
The entrustable professional activities listed in Table 6.1 emerge from considering the holistic character of hospital practice, across the three broad categories of inpatients: acute, chronic and periprocedural. These topics and skills also contribute to identifying the requirements of system design.
PAGE 22 HSP: HOSPITAL MEDICINE MODULE
Tabl
e 6.
1: S
yste
m d
esig
n an
d th
e ch
arac
teri
stic
s of
hos
pita
l pra
ctic
e
Acu
te p
atie
nts
Chr
onic
pat
ient
sP
erip
roce
dura
l pat
ient
sE
PA H
M6.
1 M
inim
ise
med
ical
err
ors/
so
urce
s an
d re
spon
ses
(H
SP
3)
Mon
itor e
arly
det
ectio
n sy
stem
s –
fla
ggin
g, p
reve
ntio
n, o
pen
disc
losu
re,
futil
e cl
inic
al c
ycle
s.
Impl
emen
t sys
tem
des
ign.
Cha
nge
care
pa
ths
as a
ppro
pria
te. M
anag
e or
phan
pa
tient
s, d
etec
t and
inte
rven
e in
faili
ng
care
.
Pla
n ca
re a
nd s
afe
syst
ems.
Man
age
diffi
cult
team
s an
d pl
an fo
r cha
ngin
g ca
re re
quire
men
ts.
EPA
HM
6.2
Res
pond
to
med
ical
em
erge
ncie
s (H
SP
3)
Coo
rdin
ate
CE
RS
team
s –
impl
emen
t tra
inin
g in
acu
te re
spon
seC
oord
inat
e C
ER
S te
ams
– im
plem
ent
train
ing
in E
OL
deci
sion
mak
ing.
Coo
rdin
ate
CE
RS
team
s –
impl
emen
t tra
inin
g in
co
mpl
ex te
am e
nviro
nmen
ts.
EPA
HM
6.3
Lead
han
dove
r pr
oces
ses
(H
SP
2)
Con
duct
han
dove
r pro
cess
es in
to a
nd
out o
f ED
, int
o an
d ou
t of I
CU
/ HD
U, o
ut
of h
ospi
tal.
Man
age
the
Wat
ch L
ist.
Impl
emen
t car
e an
d di
scha
rge
plan
ning
sy
stem
s.C
ondu
ct u
rgen
t tra
nsfe
rs a
nd h
and
offs
.
EPA
HM
6.4
Eng
age
in
adva
nced
cl
inic
al
reas
onin
g
(HS
P 3
)
Take
his
tory
for d
iffer
ent g
roup
s of
pa
tient
s.R
ecor
d m
anag
emen
t pla
ns a
nd a
pply
e-
reco
rds
and
prob
lem
list
s.C
ondu
ct re
ason
for a
dmis
sion
(RFA
) sur
veys
, car
e pa
thw
ays,
pre
-adm
issi
on c
linic
s an
d im
plem
ent
delir
ium
avo
idan
ce s
yste
ms.
EPA
HM
6.5
Faci
litat
e le
arni
ng a
nd
teac
hing
(H
SP
3)
Del
iver
Lea
rnin
g O
n Th
e R
un, T
each
ing
On
The
Run
and
dev
elop
car
e pa
thw
ays
for l
ess
expe
rienc
ed c
olle
ague
s.
Con
duct
pat
ient
car
er a
nd fa
mily
ed
ucat
ion
and
care
pla
nnin
g.Im
plem
ent p
roce
dura
l gui
delin
es a
nd d
isch
arge
ad
vice
as
appr
opria
te.
EPA
HM
6.6
Dem
onst
rate
an
d pr
omot
e le
ader
ship
(H
SP
3)
Pro
vide
app
ropr
iate
man
agem
ent f
or
clin
icia
n le
ader
s.W
ork
appr
opria
tely
with
mul
tidis
cipl
inar
y te
ams.
Lead
acr
oss
tradi
tiona
l bou
ndar
ies.
MAY 2012 VERSION 1.1 PAGE 23
Tabl
e 6.
1 co
ntin
ued:
Sys
tem
des
ign
and
the
char
acte
rist
ics
of h
ospi
tal p
ract
ice
Acu
te p
atie
nts
Chr
onic
pat
ient
sP
erip
roce
dura
l pat
ient
sE
PA H
M6.
7 S
olve
pro
blem
s in
the
loca
l en
viro
nmen
t (H
SP
3)
Dep
loy
effe
ctiv
e cl
inic
al g
over
nanc
e st
ruct
ures
. Esc
alat
e ac
ute
care
issu
es a
s ap
prop
riate
. Con
duct
ope
n di
sclo
sure
an
d m
anag
e ris
k of
med
ical
err
or.
Adv
ocat
e w
hen
nece
ssar
y fo
r loc
al
serv
ices
and
pat
ient
pop
ulat
ions
.
Man
age
end
of li
fe p
athw
ays,
sys
tem
in
terfa
ce is
sues
aro
und
chan
ging
di
rect
ions
of c
are,
acc
omm
odat
ion
and
cont
ext.
Ass
ess
patie
nt c
ompe
tenc
y.
Esc
alat
e pr
oces
ses
for p
atie
nts
requ
iring
off-
site
se
rvic
es. N
egot
iate
with
the
Bed
Man
ager
as
requ
ired.
EPA
HM
6.8
Par
ticip
ate
in c
linic
al
gove
rnan
ce
(HS
P 3
)
Par
ticip
ate
in lo
cal s
afet
y co
mm
ittee
s,
drug
com
mitt
ees,
reco
gnis
e th
e A
PIN
CH
list
of h
igh
risk
med
icat
ions
(a
ntih
yper
tens
ives
, pot
assi
um, i
nsul
in,
narc
otic
s,ch
emot
hera
peut
ic a
gent
s,
hepa
rin).
Impl
emen
t ref
erra
l sys
tem
s fo
r tim
ely
allie
d he
alth
inte
rven
tion.
Dis
char
ge a
nd
adm
issi
on d
ocum
enta
tion
revi
ews.
Man
age
surg
ical
load
dur
ing
low
act
ivity
tim
es,
cond
uct r
evie
ws
of ti
mel
ines
s an
d ou
tcom
es o
f tra
nsfe
rs fo
r offs
ite c
are.
EPA
HM
6.9
Man
age
conf
lict
(HS
P 2
)
Effe
ctiv
ely
man
age
a di
scha
rge
agai
nst
med
ical
adv
ice.
Impl
emen
t gua
rdia
nshi
p re
quire
men
ts a
s ap
prop
riate
.M
anag
e di
ffere
nces
of p
rofe
ssio
nal o
pini
on.
EPA
HM
6.10
A
ssis
t the
pr
actit
ione
r in
diffi
culty
(H
SP
3)
Ass
ess
clin
ical
com
pete
nce
and
resp
ond
appr
opria
tely
to w
orki
ng w
ith
impa
ired
doct
ors.
Man
age
wor
kloa
ds a
cros
s te
ams,
re
spon
d ap
prop
riate
ly w
ith p
erfo
rman
ce
outli
ers
and
enga
ge e
ffect
ivel
y w
ith lo
ng
term
sta
ff.
Man
age
afte
r hou
r’s w
orkl
oads
and
cal
l bac
k sy
stem
s.
PAGE 24 HSP: HOSPITAL MEDICINE MODULE
References
Australian Institute of Health and Welfare (2011) Australian hospital statistics 2009–10: Health services series no. 40. Canberra: AIHW.
The Australian Patient Safety Foundation Annual Report 2009 -2010.
Calzavacca, Licari, Tee et al (2008) “A prospective study of factors influencing the outcome of patients after a Medical Emergency Team review” Intensive Care Medicine 34: 2112–2116.
Clinical Excellence Commission (2008) Recognition and management of the deteriorating patient.
Confederation of Postgraduate Medical Education Councils (Version 2.1) Australian Curriculum Framework for Junior Doctors.
Greater Metropolitan Transition Taskforce (2002) “Care of the acutely ill older person in greater metropolitan hospitals”.
Haggerty J, et al (2003) “Continuity of care: a multidisciplinary review” British Medical Journal 327: 1219–1221.
Miller G (1990) “The assessment of clinical skills, competence, and performance” Academic Medicine 65 (supplement): S63–S67.
Quach, Downey, Haase et al (2008) “Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension” Journal of Critical Care 23: 325–331.
RCA Team at RNSH (2011) RCA Summary.
Ten Cate O (2006) “Trust, competence, and the supervisor’s role in postgraduate training” British Medical Journal 333: 748-751.
Ten Cate O, Scheele F (2007) “Competency-based postgraduate training: can we bridge the gap between theory and clinical practice?” Academic Medicine 82 (6): 542–547.
US Department of Health and Human Services (2010) Healthy People 2010 <http://www.healthypeople.gov/Document/pdf/uih/2010uih.pdf>.
Van der Vleuten C, Schuwirth L (2005) “Assessing professional competence: from methods to programs” Medical Education 39: 309-317.
World Health Organization (2010) <http://www.who.int/patientsafety/implementation/solutions/high5s/ps_high5s_project_overview_fs_2010_en.pdf>.
MAY 2012 VERSION 1.1 PAGE 25
Four levels of knowledge and performance elements have been defined in the patient safety framework. The level of knowledge and performance required by an individual is determined by their level of patient safety responsibility:
Level 1 Foundation knowledge and performance elements are required by all categories of health care workers (as defined below).
Level 2 Knowledge and performance elements are required by health care workers in categories 2 and 3.
Level 3 Knowledge and performance elements are required by health care workers in category 3.
Level 4 Organisational knowledge and performance elements are required by health care workers in category 4.
Some knowledge and performance elements in levels 2 and 3 may not be relevant for all non-clinical managers.
Four categories of health care workers have been defined in the patient safety framework.
Category 1 Health care workers who provide support services (eg, personal care workers, volunteers, transport, catering, cleaning and reception staff).
Category 2 Health care workers who provide direct clinical care to patients and work under supervision (eg, ambulance officers, nurses, interns, resident medical officers and allied health workers).
Category 3 Health care workers with managerial, team leader and/or advanced clinical responsibilities (eg, nurse unit managers, catering managers, department heads, registrars, allied health managers and senior clinicians).
Category 4 Clinical and administrative leaders with organisational responsibilities (eg, Chief Executive Officers, board members, directors of services and senior health department staff).
Health care workers can move to higher categories of the patient safety framework as they develop personally and professionally.
Source: Australian Council for Safety and Quality in Health Care (2005) National patient safety education framework. <www.health.gov.au/internet/safety/publishing.nsf/Content/ C06811AD746228E9CA2571C600835DBB/ $File/framework0705.pdf>.
Appendix 1: Patient safety framework
PAGE 26 HSP: HOSPITAL MEDICINE MODULE
In 2001 the Royal College of Physicians and Surgeons of Canada developed a diagram that shows the seven CanMEDS roles and the relation between each.
Medical Expert:“As Medical Experts, physicians integrate all of the CanMEDS roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centered care. Medical Expert is the central physician role in the CanMEDS framework.”
Communicator:“As Communicators, physicians effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.”
Collaborator:“As Collaborators, physicians effectively work within a healthcare team to achieve optimal patient care.”
Manager:“As Managers, physicians are integral participants in healthcare organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the healthcare system.”
Health Advocate:“As Health Advocates, physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations.”
Scholar:“As Scholars, physicians demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge.”
Professional:“As Professionals, physicians are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour.”
Reference: Royal College of Physicians and Surgeons of Canada. CanMEDS 2005 Framework.
The Royal College of Physicians and Surgeons of Canada in 2001 developed a diagram that shows the seven CanMEDS roles and the relation between each.
Medical Expert:
“As Medical Experts, physicians integrate all of the CanMEDS roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient‐centered care. Medical Expert is the central physician role in the CanMEDS framework.”
Communicator:
“As Communicators, physicians effectively facilitate the doctor‐patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.”
Collaborator:
“As Collaborators, physicians effectively work within a healthcare team to achieve optimal patient care.”
Appendix 2: CANMEDs domains
MAY 2012 VERSION 1.1 PAGE 27
This case study from a root cause analysis team at a large teaching hospital illustrates the importance of the hospital-wide perspective advocated by the Hospital Medicine module to avoid problems such as suboptimal communication within and between clinical teams about the deteriorating clinical picture of a patient.
A 52-year-old man with a history of gastric banding for obesity (2009), gastric ulcer (2009), low haemoglobin requiring iron infusions and unstable Type II diabetes mellitus presented to a large emergency department (ED) following referral from his general practitioner (GP). The patient had presented to his GP for review of swelling in his left calf. He also reported a two month history of increased shortness of breath on exertion, postural dizziness, increased heartburn, malaena, and occasional band-like chest pain. The previous day the patient had seen his gastroenterologist (who had performed the original gastric banding surgery) and at that appointment the gastric band was loosened to relieve symptoms of reflux. The GP documented that she suspected ‘severe reflux esophagitis from the gastric band, which is bleeding and causing symptomatic anaemia’.
On presentation to the ED the patient was appropriately triaged. His observations were within normal limits, although a postural drop in his blood pressure was noted. An ECG was preformed showing sinus tachycardia. A chest x-ray was unremarkable. The patient was admitted under the appropriate team with a provisional diagnosis of ‘shortness of breath secondary to anaemia’. Due to ward closures for the Christmas period he was not admitted to the treating team’s ward.
During the second night following admission, the patient had seven episodes of clinical deterioration falling within the Yellow zone and one episode falling within the Red zone of the standard adult general observations (SAGO) chart. These episodes were related to desaturation and tachycardia. These episodes were not escalated as per the ‘Between The
Flags’ guidelines. He also had two falls during his admission (no injury). ECG changes during his admission showed ST elevation and tachycardia, while his troponin levels were elevated and consistent with pulmonary emboli (PE). The patient also had an echocardiogram which suggested PE. He was reviewed daily by his treating team, but the staff specialist was not involved in ward rounds (this is standard for this procedural-based outpatient specialty). Medical review also included extensive review overnight which revealed a suspicion of PE, but evidence of clinical handover was limited.
Findings of a gastroscopy/endoscopy were consistent with the provisional diagnosis. During this procedure, the patient again desaturated and required anaesthetic reversal. While in the unit for these procedures, the staff specialist and patient discussed his discharge and, although the staff specialist would have preferred the patient to remain as an inpatient overnight, due to the patient’s insistence that he be discharged, it was agreed that he be discharged home later that afternoon. The staff specialist was unaware of any episodes of clinical deterioration of the patient, falls or echocardiogram results during the admission.
Before discharge, the patient was reviewed by the junior member of the medical team and in light of the patient’s clinical condition was again reviewed by the registrar. The patient’s saturation levels at this time fell within the Red zone of the SAGO chart. Despite this, he was discharged home.
Later that evening, the patient developed shortness of breath, chest tightness and epigastric pain and an ambulance was called. When it arrived, the patient complained of a sudden onset of chest pain and dyspnoea, and lost consciousness. He remained in asystole and was transported to the same ED where continued resuscitation attempts were unsuccessful. His death was referred to the Coroner.
Appendix 3: Case study for reflection
PAGE 28 HSP: HOSPITAL MEDICINE MODULE
Notes page
Health Education and Training Institute
Building 12 Shea Close Gladesville Hospital tel.+61 2 9844 6551 fax.+61 2 9844 6551 [email protected] Post: Locked Bag 5022, GLADESVILLE NSW 1675
www.heti.nsw.gov.au/hsp
HOSPITAL MEDICINEMay 2012, version 1.1HOSPITAL SKILLS PROGRAMHOSPITAL SKILLS PROGRAM