Working in the emergency department is incredibly rewarding, don’t let concerns over the 4hr target distract you from the real privilege of working with a team of motivated clinicians helping 200-250 patients a day who have come to us because they have nowhere else to turn!
Welcome to the team!
Michelle Tinker
ED Consultant and Clinical Lead
The Department
The Emergency Department (previously known as the Accident and Emergency Unit) serves both urban and rural areas over a large geographic catchment area. This includes Cheshire, the Wirral and parts of North Wales.
We have approximately 85,000 annual attendances to the department. 15,000 of these are seen by our Urgent Treatment Centre (UTC) team which is GP and Advanced Clinical Practitioner (ACP) led, whilst the remainder are seen within the ED.
Medical Team
The Consultant team is made up of:
- Dr Tinker – Clinical Lead
- Mr Laundy – STAR lead, Rota lead
- Dr Wilson – Trust Major Trauma lead and CSO
- Dr Thevendra – Ultrasound and SHO teaching
- Mr Mittal – Specialty Tutor (Educational Lead)
- Dr Davison – Minor Injuries Lead, Recruitment Co-ordinator
- Dr Holder – Audit lead, Medical Link
- Dr Elliott – Medical Examiner, Clinical Educator
- Dr Lawrence-Ball – Paediatrics Lead, Clinical Educator
- Dr Michael Dromey – Locum Consultant, QIP lead,
Supported by 3 Associate Specialists
- Dr Zafiru – Associate Specialist, 5th Year Medical Student Lead
- Dr Hughes – Associate Specialist
- Dr Wlodarczyk – Locum Associate Specialist
There are 3-5 Specialist Trainees in the department and a number of substantive middle grades whom all have significant EM experience.
We are supported by the Advanced Clinical Practitioners (ACPs) who are nurses that have completed further training (including prescribing). They work independently; however they may not see certain cases (such as paediatrics) if they feel it is out with their training. The ACPs will often support the other nursing staff such as in resus and offer a valuable resource for the department.
Nursing Team
The Nursing team is headed up by Matron Maxwell (Head of ED Nursing) who is assisted by Matron Belton-Rose who is based in the ED. They are responsible for a team of approximately 120 nurses and healthcare support workers. There is always a senior (Band 7) nurse in the department and a Nursing team leader in majors. They are recognised by their navy uniforms. Please listen to them, as many of them have years of experience and have been in place longer than the Consultants!
We have a well-established Emergency Nurse Practitioner (ENP) service who see and manage the majority of minor injuries in conjunction with our department physiotherapists.
There is a Trust Trauma Co-Ordinator (Sister Milliken) who liaises closely with the department on trauma care and will attend trauma calls when available.
Physician Associates (PA)
We have a number of PAs who can take a history, examine, cannulate and devise management plans for their patients including admission / discharge decisions. However they currently cannot request ionising radiation investigations or prescribe medication. They may therefore approach you for assistance in these areas, however be cognisant that you are responsible for making a clinical judgement about the appropriateness of all prescriptions and investigations you make.
Education
Medical Students
For over 15 years the Countess of Chester Hospital NHS Foundation Trust Emergency Department (ED) has welcomed groups of final year students from the University of Liverpool as well as elective students from other organisations. The Liverpool students are assessed by portfolio in a similar manner to foundation doctors; electives are dependent upon the requirements of the specific university to which the student belongs. These medical students have now been joined by student physician associates.
We are proud of the quality of education we offer our students, be this acute teaching in majors, minors and resus or classroom sessions supported by the senior medical staff. The students will work alongside you on a full shift programme in order to experience the diversity of emergency presentations.
The feedback we receive from students in the ED is usually very good and a relatively large number of our students return to work in the hospital. The feedback from the most recent University review was excellent and some specific teaching practice was praised.
Students should be treated as a member of the team and afforded this level of respect. However, they are not qualified and any patient they see must be physically reviewed prior to any investigations, treatments or discharge. The students should be encouraged to document on the ED notes, including a diagnosis and management plan, and to date, time and sign these appropriately. At present, they do have access to view results on the computer system, but not to document and order investigations.
Trainee Advanced Care Practitioners (tACP)
The trust was one of the first to recognise the value of ACPs and we continue to have an active training program. The majority of our trainees are nurses by background however Paramedics and Physios can also undertake ACP training.
As would be expected, our tACPs span the spectrum of experience and level of training. As such, they may be unable request ionising radiation investigations or prescribe medication. Therefore, they may approach you for assistance in these areas, however be cognisant that you are responsible for making a clinical judgement about the appropriateness of all prescriptions and investigations you make.
If you review a patient on behalf of a tACP, you should review the patient yourself and ensure adequate documentation as per policy.
Who needs reviews?
Please ensure that you clearly document who you have discussed patients with and whether this was simply a discussion or if they physically reviewed them. All the senior team are aware that they should document themselves as well.
Teaching
All teaching is run through the OneMed system. For further details, please speak with Dr Elliott or Dr Lawrence-Ball. Please submit feedback for any sessions you attend; this allows the presenters to improve the sessions. All Doctors will be allocated a supervisor – please meet with them in a timely fashion. We also have 2 clinical educators who are available on pre-set days to help you complete assessments (e.g. mini-CEX).
F1/F2/Core Trainee teaching:
- Every Friday morning from 8-9am in the ED.
- The teaching programme is displayed on the junior doctors notice board.
- Doctors finishing nights and those starting at 8 & 9am are required to attend. Attendance for doctors on other shifts is voluntary
- There is compulsory FY teaching (Wednesday for FY2, Thursday for FY1). Foundation Doctors will be released from daytime duties in the ED to attend these. Unfortunately, we cannot release from nights to allow attendance.
- GP VTS will need to apply for study leave (as per the leave section) to attend their regional teaching.
- ACCS – should be released for all teaching sessions including from nights
Speciality Doctors/Trainee teaching:
- Trainees are currently scheduled to attend regional teaching on the first Tuesday of the month – the site of this rotates and is co-ordinated regionally.
- Thursday 1200-1300 – Middle Grade teaching via Teams, mix of journal club and teaching sessions providing by the MGs, seniors and external specialists.
There is a huge amount of material available for self-directed learning including:
- https://www.rcemlearning.co.uk
- http://www.stemlyns.org.uk and https://www.stemlynsblog.org
- https://www.theresusroom.co.uk
- https://dontforgetthebubbles.com
Rota
Mr Laundy is the ED Consultant in charge of rota and leave co-ordination.
Paul Bowen is the Medical Staffing officer in charge of ED rotas.
General Principles
- Every effort will be made to process all requests submitted in a timely fashion.
- Requests should be submitted a minimum of 6 weeks in advance
- Approval of ‘Short notice’ requests cannot be guaranteed but may be considered in exceptional circumstances only.
- Leave should be submitted via the medical staffing officer.
- Submit your leave applications early during your attachment and do not forget additional days accrued for working bank holidays. Last minute requests from multiple persons towards the end of an attachment are often met with disappointment.
- Please try to divide your leave evenly across your various clinical placements for the year.
- A maximum of 5 days may be carried over to the following leave year.
- Leave cannot be taken when on nights or weekends. These shifts must be mutually swapped on the correct form and signed by both parties.
Sickness
On the day of sickness, please telephone
- Medical staffing – a message may be left if no answer
- ED MTL – must be spoken with on 01244 366830, if no answer prior to 0800 please try again after
If you are suffering from diarrhoea, then you must be clear of it for 48 hours prior to returning to work.
Industrial Action
If you are undertaking industrial action, please ensure that you follow the trust pathways, and that Medical Staffing are correctly informed of your absence/attendance. The department will also try and ensure patient safety during these events. For the period of any industrial action, the trust will adopt a command-and-control structure utilising either a virtual or physical incident command centre (ICC).
General Expectations
Professional conduct is expected at all times. The ED is the public face of the hospital and due to the layout, patients and their relatives can often observe behaviours and hear what you are saying.
You are expected to be punctual, especially in the morning as your colleagues will want to get off home. If you are running late, please call the MTL on 3860 if it is safe to do so.
Please ensure that you take your breaks in a timely fashion following discussion with the MTL. If you feel that you can’t take a break, again, please let the MTL know who will facilitate this. If you are going to leave the department, please let a senior know so that in an emergency (e.g. fire) we can know where you are.
You are integral to the Emergency Medicine team and communication can be difficult due to the geography and workload, so please try your best.
We interface with many other teams within the trust – please be courteous at all times. Further information is available here - https://www.civilitysaveslives.com. If there are any issues, please speak with the MTL.
Your Shift
The daily allocations will normally be completed on the whiteboard in the back corridor by the offices. An initial decision will be made by the 0800 Consultant as to whether to zone or follow the tracker; this may well change over the day due to the dynamic nature of the department.
If the zones are operational, please be flexible as we may need you to swap between areas.
Please ensure that you get you breaks – we do try and coordinate these, but sometimes need to be reminded! You should take 30 minutes for every 4 hours worked. Please don’t wander off during them as we need to know where you are in case of a fire or major incident.
Following the pandemic, everyone is far more aware of the need for appropriate PPE – the full spectrum from gloves/aprons to FFP3/gowns/eyewear is available in the department. You should ensure that you are fit tested for a FFP3 or equivalent device. Please consider what is appropriate to minimise risk to yourself and the patients.
Things to consider:
- We have a number of specialist centres in the region (Walton, Clatterbridge and Liverpool Heart and Chest), please have a low threshold for discussion directly with them especially if the patient is under their care.
- Any patient who present after recent in-patient treatment at a specialist centre must be discussed with an EM senior clinician.
- Pathways on the intranet including STEMI/NOF/reversal of anti-cogulation
- Insulin – please ensure that trust policy is followed.
- DKA in < 18yrs of age – admit paeds, ³18yrs – admit medics
- Hand injuries
- Hand phalanx à Plastics
- All others à Ortho
- FI Blocks
- Please ensure that they are prescribed and documented and that the nursing staff are aware of the need for the post-procedure obs.
- ECG
- You will be asked to sign off on lots of ECGs during your time with us. Please ensure that you clearly record your name, signature, time/date and any diagnosis on it.
- If you have any concerns, please review the patient.
- Thoracic injuries
- Have a low threshold for CXR in frail/elderly patients with thoracic injuries (even after very innocuous-sounding injuries) especially if any abnormal physiology to ensure that we identify any pneumothorax early
- Discharging patients to primary care
- GP letter - don’t copy and paste your entire clerking. They only need a relevant summary and any specific follow-up you feel might be useful. They don’t have time to read all of it!
- Follow-up of investigations
- GPs don’t have access to our systems, so are unable to follow-up imaging, bloods, urines etc.
- Let the GP make the decision on what their patient needs – they often know them and their history better than us – consider ask, don’t tell. Please note that GPs cannot request MRI directly for back pain, they have to send them to their MSK service.
- Out-patient investigations
- Consider who is going to follow them up e.g. SDEC/fracture clinic, not primary care. All the results (whatever you write) will come back to the EM Consultants who then need to try understand it (e.g. 24hr tape)
- Be wary of requesting out-patient MRI scans – please discuss with a senior first.
Ultrasound
The department currently has 2 ultrasound machines in resus available for use. Currently we have:
- Mindray TE series
- Philips Lumify problem and tablet
These machines are not to leave the department unless approved by the MTL. For a password for it, please speak with Dr Thevendra. Please be aware of information governance if printing off any images and also ensure that any logbooks do not continue any patient identifiable information.
If you have an interest in Emergency Department ultrasound, contact Dr Thevendra. The majority of the senior staff are RCEM approved level 1 ultrasound assessors and can sign off competencies. There is a deanery-run introduction to ultrasound course run annually which is recognised by the Royal College of Emergency Medicine for level 1 training.
Safeguarding
All staff working in the ED have a responsibility to be aware of the potential for safeguarding issues to arise, be it in the context of injured children, young people being vulnerable owing to domestic violence in the home, poor parenting issues or with vulnerable adults attending with illness or injury. The Department supports this through induction training and supporting the release of staff to attend Trust sponsored training. This is available as face to face sessions or on-line training modules.
All ED clinical staff are required to undergo Level 2 and Level 3 training in safeguarding children – the latter also has a section on Domestic Violence as well as highlighting the international problem of Female Genital Mutilation. The Department also has other resources to support staff. All recent bulletins appertaining to SG are displayed on a specific noticeboard on the ED corridor near the coffee room. There you will also find the names of specific staff who specialise in SG matters – from both the ED and Child Health.
The key action you must take when faced with a safeguarding dilemma is to escalate the case through discussion with other colleagues. Level 3 training will help you understand the actions that may follow when such action is taken.
Audit and Research
The department has an active audit program and participates in the RCEM audit system in addition to the internal ones. The program has been very successful over the years leading to a number of changes within both the department and trust and people have had the opportunity to display their work at national conferences.
There are on-going departmental audits which you can partake in or if you have something specific that you would like to look at, please let us know.
The trust has a significant research interest which does include the ED. We have been participants in the CRASH series of trials and PARAMEDIC 2. If you have a specific interest, please speak with Dr Holder.
Targets
As you may be aware (especially from the national press) there is a 4-hour target for patients in the ED; this is NOT an ED-only target, but something that reflects upon the whole trust and requires the entire system to function in order to achieve.
Currently, the target is that 95% of patients should have left the department within 4 hours from their booking in time. Deposition of the patients may include discharge, admission to CDU or admission to a specialty ward. Whilst you need to be aware of this target, you should not let it compromise your clinical care.
Due to the target, the MTL will often be asking you about your patient – as before, please note that referral should be part of your plan not the end-point; do not wait for investigations that will not change your patient’s management (e.g. bloods in a patient with appendicitis). If there is any resistance to this from the specialties, please let a senior know. There have been instances where the specialties do not appreciate the pressure in the ED (from both targets and the elasticity in accommodating patients), equally we are not aware of the pressures elsewhere in the trust.
Various conditions have targets (CQINS) attached to them – these are mainly time-critical interventions such as thrombolysis for CVA and neutropenic sepsis. Again, clinical need may require precedent over these cases.
Sepsis
Sepsis is currently very topical in both the national and medical press, understandably so. There have been significant advances over the last 10 years in the management of sepsis. To this end, the trust has its sepsis6 campaign which is promoted around the buildings. Please consider sepsis and early antibiotics in your patients!
