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HANDBOOK
UPPER GASTROINTESTINAL, HEPATOPANCREATOBILIARY AND ACUTE
GENERAL SURGERY UNIT
Monash Medical Centre Clayton
Handbook prepared by:Miss Kaye Bowers
HPB SurgeonUpdated October 2019 by:
Rhys JonesUGI fellow
Contents
Orientation..............................................................................................................5Unit Structure..........................................................................................................5Training Supervisor..................................................................................................7Other Useful Contacts..............................................................................................7Contact Numbers For The Team..............................................................................8Offices......................................................................................................................8Wards......................................................................................................................9Acute General Surgical Unit (Agsu)..........................................................................9Endocrine, Colorectal And Breast Surgery Patients...............................................11Interhospital Transfers...........................................................................................11After Hours Cover/Weekends................................................................................12Handovers..............................................................................................................13Ward Rounds.........................................................................................................13Anorectal And Urogenital Examinations................................................................14Surgical Bookings/Theatre Diary............................................................................14Theatre..................................................................................................................14Radiology...............................................................................................................15Pathology...............................................................................................................16Endoscopy/Ercp/Eus..............................................................................................16Outpatient Clinics..................................................................................................17Preadmission Clinic (AKA Surgical Review Clinic)...................................................18Review Of Hospital In The Home Patients.............................................................18Discharge Planning................................................................................................18Unit Meetings And Grand Rounds.........................................................................19Overtime................................................................................................................20Set Trainees - Meeting College Requirements.......................................................20Postgraduate Surgical Teaching.............................................................................21Undergraduate Medical Students..........................................................................21Computers And I.T.................................................................................................21Infection Control....................................................................................................23Venous Thrombo-Embolism Prophylaxis...............................................................24Registrars Role And Responsibilities:.....................................................................24Interns Role And Responsibilities:..........................................................................27Appendices............................................................................................................30
HANDBOOK FOR UPPER GI/HPB/GENERAL SURGERY UNIT
Welcome to the Upper GI, HPB and Acute General Surgical Unit Clayton.
This handbook is intended to provide you with a general guide to help your orientation on the unit. The unit provides an Oesophagogastric and Hepatopancreatobiliary service
as well as an Acute General Surgical service. The unit is staffed by a team of Upper GI and HPB surgeons dedicated to excellence in patient care and the teaching of trainees and
undergraduates. During your time on the unit you will see a diverse case-mix of upper GI, HPB and General Surgical conditions. It is a busy unit with complex surgical patients
providing excellent opportunities for learning on the wards, in outpatient clinics and in the operating theatre. We hope your time with us is a rewarding training experience.
ORIENTATIONAt the start of your term, please come to ward 33 to meet your registrars.
UNIT STRUCTUREHead of Unit
Mr Liang Low is the Head of Unit. His office is in the Department of UGI/HPB Surgery next to Ward 33.
Unit Streams
The unit is divided into the following:
• Hepatopancreatobiliary stream (liver, gallbladder and pancreas surgery)
• Luminal stream (oesophageal and gastric surgery)
• Acute General Surgical Unit (AGSU)
CONSULTANTS
Heptopancreatobiliary stream Luminal stream
Mr Roger Berry (Head of HPB Stream) A/Prof Paul Cashin (Service Director, General Surgery)
Ms Kaye Bowers (Special Projects) Mr Liang Low (Head of Unit)
Mr Dan Croagh (Clinical Research Lead) Mr John Gribbin
Mr Mark Cullinan (SET supervisor) Mr Niyaz Naqash
Mr Dean Spilias (Quality Assurance) Ms Jane Ghadiri
Mr Mithra Sritharan Mr Zdenek Dubrava (Head of AGSU)
Mr Hamish Shilton
Mr Daniel Foley
All consultants participate in the cover of the AGSU.
FELLOW 1 Upper GI/General Surgery Fellow 12 month rotation
REGISTRARS 1 Hepatobiliary registrar (SET trainee) 6 month rotation1 Luminal registrar (SET trainee) 6 month rotation2 AGSU registrars (SET trainees) 6 month rotation1 junior AGSU registrar (pre SET) 6 month rotation
RESIDENT/HMO1 resident works on the AGSU for 3 months.
INTERNSThere are usually six interns on to the unit for a 10 or 12 week rotation.2 Luminal2 HPB2 AGSU
TRAINING SUPERVISOR
Mr Mark Cullinan is the supervisor for undergraduate teaching and intern/resident and SET training Clayton Campus. Mr Cullinan will complete your term assessments in discussion with the other team members.
(Sarah Martin is the Hub Supervisor, General Surgery SET training).
OTHER USEFUL CONTACTSAdministration Assistant and PA to Mr Cashin and Mr LowRhonda Workman x46207Email : [email protected]
MDT CoordinatorMaree Borland: x43264Fax: 9594 6098Email: [email protected] or [email protected]
Clinical Research & Data Co-ordinator Carole MatthewsMob: 0466 571 617Email: [email protected] Carole is the contact for research, data and ethics queries.Carole works Monday, Wednesday, Thursday, Friday.
Surgical Bookings LiaisonAndrea Fisher (Monday, Tuesday)Skye Wallace (Wednesday, Thursday, Friday)Mob: 0407 939 073
Cancer Nurse Co-ordinatorTheresa DodsonMob: 0466 300 242Theresa should be made aware of any cancer patients attending the outpatient clinic or admitted to the ward. Theresa provides support for cancer patients and their families and assistance coordinating their outpatient and multidisciplinary care.Theresa works Monday, Wednesday and Friday.
Senior Clinical CoderJuliette Greskie x42304
Tissue Bank ManagerZdenka Prodanovic [email protected]
CONTACT NUMBERS FOR THE TEAMCONSULTANTSConsultants can be reached via the switchboard. Consultants are always happy to be contacted if you are concerned about a patient.
FELLOWThe fellow can be contacted via switch on his/her mobile. The fellow is generally always around and available for advice or support.
REGISTRARSLuminal Reg pager #164 HPB Reg pager #220 AGSU Reg pager #4519
HMOAGSU Resident pager #718
INTERNSLuminal intern 1 - pager #716 Luminal intern 2 - pager #654HPB intern 1 - pager #131 HPB intern 2 - pager #581AGSU intern 1 - pager #4518 AGSU intern 2 - pager #4578
OFFICESThere are two offices:
The JMO office is shared by the registrars, resident and interns. It is on level 3 in Ward 33.
Department of UGI/HPB Surgery Office The office is on Level 3 next to Ward 33.
Mr Liang Low, Mr Dan Croagh, Mr Mark Cullinan, the Fellow, Theresa Dodson, Andrea Fisher, Skye Wallace, Carole Matthews and Rhonda Workman are all located in this office.
A/Prof Paul Cashin is located on Level 5, Department of Surgery, E Block.
The master roster for the AGSU on call consultant is kept in this office, above Rhonda’s desk.
WARDSWard 33 is our home wardNUM: Karen JohnsonWard Clerk: Nicole PorterExtension: 43460/61
32W is the Gastroenterology ward and ward for many of our outliers.NUM: Nerine Wilson/Sara ColdicottWard Clerk: Fiona/SimoneExtension: 43768/67
ACUTE GENERAL SURGICAL UNIT (AGSU)Emergency admissions
All emergency admissions should be admitted under the AGSU (unless otherwise specified by a consultant) and are admitted and managed by the AGSU team.
Patients should only remain on the AGSU for a maximum period of 48-72 hours. Patients requiring longer inpatient stays should be transferred to either the Luminal or HPB stream under the most appropriate consultant (after discussion with that consultant). A direct registrar to registrar handover must occur on transfer.
ASU patients who have predictably longer stays will be immediately transferred to team A or B, at the discretion of the admitting consultant, either on admission or at the end of their surgery. The ASU consultant who received the patient will be responsible for arranging their appropriate ongoing care under Team A or B.
If a patient on ASU develops a complication prolonging their stay longer than the agreed 2-3 days, the patient will also be transferred to Team A or B.
Inpatient and external referrals
All external (eg. Casey, Dandenong, regional hospital) referrals and acute general surgical ward referrals are taken by the on call AGSU Registrar who should assess and then discuss with the on call consultant. Non acute specialty UGI/HPB referrals should be taken by the UGI/HPB registrar and discussed with either the on call AGSU consultant or a consultant of the appropriate stream.
All referrals must be seen in a timely matter on the day of referral by the registrar and should generally be seen by a consultant within 24 hours.
AGSU cover
The registrar on call for the AGSU will always hold pager 4519.
The consultant covering the AGSU changes each day at 1900 Monday to Friday. On weekends one consultant is rostered from 1900 Friday to 0800 Monday. The Fellow also participates in the on-call roster. Patients are to be admitted under the bedcard of A/Prof Paul Cashin when the fellow is on call. The on call consultant is responsible for all of the patients on the AGSU unit during their shift.
AGSU theatre lists
There is a dedicated AGSU theatre list each afternoon on weekdays and Saturdays. This is protected theatre time. You need to book emergency theatre cases and discuss the patient with the anaesthetist on call. Specify whether the case can wait until the scheduled AGSU afternoon list or if it is more urgent.
It is not appropriate to book or consent patients for theatre ‘just in case’ while key investigations are still pending. Only do so once a definitive decision has been made.
ENDOCRINE, COLORECTAL AND BREAST SURGERY PATIENTSEndocrine Surgery Patients
Mr Simon Grodski, Mr David Merenstein, Mr James Lee and Mr Suren Jayaweera (Endocrine Surgeons) have operating lists on Wednesdays & Fridays. One of the AGSU registrars is responsible for the endocrine patients and attending these lists. The AGSU interns are also responsible for the inpatient care of Endocrine Surgery patients.
Colorectal Surgery Patients
The Colorectal service and surgeons for Monash Health are located at Dandenong Hospital. The Luminal team are to look after any patients at Clayton that are under the care of the Colorectal team and to liaise with the responsible consultant. The Luminal registrar is primarily responsible to assist in theatre for any cases performed at Clayton by Colorectal surgeons (if unavailable other team registrars may be required to assist)
Breast Surgery Patients
The AGSU team are to care for any emergency Breast Surgery admissions and arrange transfer ASAP to the Breast unit at Moorabbin.
INTERHOSPITAL TRANSFERSWith the General Surgical subspecialties separated across different campuses at Monash Health, the need for inter-hospital transfers of patients often arises. The following protocol must be strictly adhered to.
1. Site A registrar contacts Site A ASU surgeon to discuss the case and deem suitability for transfer. In hours, the Site A surgeon see's the patient in keeping with a consultant lead ASU service.
2. Site A registrar contacts Site B ASU surgeon to discuss case. In difficult cases Site A ASU surgeon speaks to Site B surgeon directly.
3. Once accepted, Site A registrar speaks to Site B registrar to give a formal medical handover.
4. Nursing coordinator informed of plan to transfer and appropriate bed arrangements made.
5. Until transfer occurs the patient remains the responsibility of the Site A AGSU consultant and is managed by the site A AGSU team, with management advice obtained from the Site B Consultant as required.
AFTER HOURS COVER/WEEKENDSThe after hours on-call team are responsible for all AGSU, Luminal and HPB patients. The on call registrar always holds pager 4519.
WeekdaysOn weekday evenings 1 registrar covers until 21:30. Each of the Luminal, HPB and AGSU registrars participate in this roster.
NightsFrom 21:30 until 0800 there is an unaccredited night surgical registrar.There are ward based night residents from 21:30 to 0800.
WeekendsOn weekends there are 2 registrars rostered. 1 registrar is on call for the AGSU from 0800 to 2130. The second registrar does a round of the Luminal and HPB patients and is rostered until 12:30.
There are two interns on the weekend. One is rostered to do the A/B round, the other does the AGSU round. Between 12:30 and 21:30 there is a covering resident for UGI/HPB/AGSU/CTH/ENT/VASC. The UGI resident participates in this roster. The weekend morning intern must handover to the covering resident at the end of their shift.
On Saturdays there is a designated afternoon AGSU theatre list. There is no designated list on Sundays and cases are done in the emergency theatre as per priority and theatre availability.
It is extremely important that on Fridays every patient has a CLEAR weekend plan handed over AND documented. Interns must hand over all patients that have bloods/other investigations requested over the weekend and these results MUST be checked daily.
HANDOVERSA face to face comprehensive handover MUST occur at the change of each shift. All team members should meet in the Junior Surgery Office. Ideally registrar handovers of very sick patients should include a bedside visit wherever possible.
Every morning the team meet at 7.00am for a formal handover from the night cover (pager 430).
On occasion the registrar will be scrubbed in theatre at handover time. The in-coming registrar should change into scrubs and go into the theatre to receive a handover (at an appropriate moment during/after the operation).
WEB QI should be updated prior to each handover. It is extremely important that you keep WEB QI up to date.
The following patient groups must be formally handed over each and every shift
*Any new admissions
*Any patients that you are concerned about
*All pending investigations (bloods, radiology) to be followed up
*All patients scheduled for theatre on the AGSU list the following day
*All postoperative patients
If you are the night person handing over to the morning registrar you must handover all new patients admitted during the evening (5-9pm), not just during your shift!
WARD ROUNDSA registrar lead ward round for each of the AGSU, Luminal and HPB streams will follow the morning handover. Ideally the in charge or other senior nurse on each ward should accompany you on the round. If this is not possible you must inform the in charge nurse of the plans for your patients prior to leaving each ward.
The daily AGSU consultant ward round takes place each morning usually following the completion of the registrar round. A further AGSU consultant round may take place at the end of the day if required.
Consultant ward rounds occur on an ad hoc basis for the Luminal and HPB streams. A grand round for the entire unit takes place each Friday immediately following the unit’s morning
meetings, usually around 10:00. We usually divide into Luminal, HPB and AGSU teams for this round.
ANORECTAL AND UROGENITAL EXAMINATIONSIt is a mandatory requirement of the unit that the following protocol is followed for all examinations of a sensitive nature such as PR and PV examinations.
1. Explain the examination you plan to perform and the reasons why it is important to the patient.
2. Confirm verbal consent from the patient.
3. Document this consent in the patient’s file prior to performing the examination.
4. Have a chaperone present always (for male doctors performing examinations on female patients, a female chaperone is required).
5. Perform the examination in a manner that preserves the patient’s privacy, respect and dignity.
You should be aware of and be sensitive to the patient’s cultural background, particularly where the patient and doctor are not of the same sex.
SURGICAL BOOKINGS/THEATRE DIARYSkye Wallace and Andrea Fisher are the General Surgical/UGI Bookings Surgical Liaison Nurses (SLN) for Clayton.
For elective cases an REA form must be completed, including the consent page and either a letter from the rooms or clinic notes attached, and submitted to the Surgical Liaison office. REA forms are available on the wards or in the Junior Staff office. The Surgical Liaison office is in the Anaesthetic department on the 3rd floor.
The Theatre diary can be accessed via your Monash Health Outlook Calendar. It includes the planned theatre cases for all consultants. Please contact the SLN if you don’t have access or are having trouble viewing.
THEATRERefer to the theatre roster (Appendix 1) for each consultant’s lists. A registrar must attend (and prepare for) every theatre list. It is expected that the registrar will have reviewed the case notes, seen the patient preoperatively and ensured that everything required is arranged.
Jessie McPherson (private) lists take place in the Clayton theatres. Registrars must be available to assist at these lists and for emergency cases.
RADIOLOGYPlain XRs may be booked electronically. For all other radiology you need discuss your request with the radiology registrar in the relevant department. Ensure you know what test you need and what information you need from it. If it is urgent explain why. Make sure you know any required blood results eg renal function for CTs, INR for percutaneous drainage procedures/biopsies. If you have any difficulty arranging imaging, discuss this with your registrar or consultant.
Complex radiology requests and requests for interventional procedures are the responsibility of the registrar and should not be delegated to the intern.
It is imperative that radiology is requested early in the day in order to get it done in a timely manner. Being efficient will reduce patient stay and in the long run, by getting patients home earlier, will reduce your workload.
Intraoperative US (IOUS)
Intraoperative ultrasound is required for most liver resections. It is always used in liver resections for colorectal liver metastases.
To book an IOUS fill out the request form (in the JMS office) and take it down and discuss with the radiology registrar. You will need to do this at least a few days before surgery.
We now have our own laparoscopic ultrasound machine which we use for open and laparoscopic cases. Theatre should be notified of the need for the lap US at least the day prior to surgery to ensure the probe is sterilised. If IOUS is required in two theatres at the same time a machine from radiology will need to be booked for the second case.
Depending on the circumstances, the surgeon may perform the ultrasound him/herself and may not require the radiologist - always check prior and inform radiology when booking. An ultrasonographer is always required to work the US machine.
Intra-operative Cholangiograms (Image-intensifier)
An IOC using the image intensifier is routinely performed for all cholecystectomies. Occasionally cholangiograms will be performed during other HPB procedures.
The interns or registrars are responsible for booking the II for cases in advance. To book the image intensifier for an IOC either phone x42206 or go down to the book in radiology and write it in there (let radiology know you have written it in the book). The following information is required: date, am/pm list, consultant, patient name and operation.
For elective cases all IOC for the following week should be booked on the Friday afternoon. Keep your eye out for list changes during the week and adjust the bookings accordingly.
PATHOLOGYRegistrars should guide the interns as to what blood tests are required for each patient. An exhaustive panel of bloods is not required for all patients every day - this is unnecessary, unkind to patients and a waste of money.
All team members are responsible for checking all the bloods for their patients in a timely manner to enable problems to be identified and acted upon early (not at 5pm!)
Pancreatic resection cases should have a drain fluid lipase and amylase level performed on postoperative day 1 and day 3. A serum lipase and amylase is required on the same day.
For patients requiring TPN, the following bloods need to be requested before referring to the clinical nutrition registrar (pager 053). FBE/UEC/CMP/Lipids/Fe/Selenium/Cu/Zn/B12/Folate/VIT A, C, E, D.
Ensure pre-procedure coags/group and hold/cross match are performed if required (depending on the operation planned). All ERCP/EUS or percutaneous drainage procedures require coags pre procedure.
Remember to follow up the results of specimens sent for histopathology /microbiology/ biochemistry at surgery. Any patient who has had an organ/part of an organ removed will have the sample sent for histopathology (results may take up to 10 days). Registrars should keep a record of surgical cases that require follow up of histopathology as most patients are discharged prior to the availability of histopathology reports. Don’t rely on results being checked in outpatients as patients can fail to attend clinic.
ENDOSCOPY/ERCP/EUSMany of our unit’s patients will need endoscopy procedures (including ERCP and EUS) either as an inpatient or outpatient.
Referrals for endoscopy, ERCP or EUS can be made to either the Gastromed registrar (page 1043) or Mr Dan Croagh.
Complete a REA form and take it down to endoscopy - level 1 (DTC). REA forms are generally found on the wards, or in the offices. When booking an ERCP, find out who will be performing it and when. Consent should be obtained by the registrar (interns must not obtain consent). Fast the patient appropriately and don’t forget to check the pre procedure COAGS.
Mr Dan Croagh has both elective and emergency lists on which he performs gastroscopy, ERCP and EUS. As there are very limited opportunities to obtain the College required endoscopic numbers a registrar should always attend these list.
OUTPATIENT CLINICSOutpatient bookings on discharge are normally done by the ward clerk.
Call Huah (UGI Outpatients Manager) 9594 7789 or pager 350 if you have an urgent request.
Clayton: HPB, Luminal and General Surgical Clinic (run simultaneously)
Wednesday mornings 0900-12:30 Clinic M (ground floor near Zouki)
This is the unit’s main clinic. More complex HPB/UGI specialty referrals and follow ups are seen at the Clayton clinic.
Two consultants are allocated to each of the Luminal and HPB streams of the clinic.
One registrar must attend clinic every week and should see patients from both streams as required.
Moorabbin- General Surgical Clinic
Wednesday mornings 13:00 Outpatient C, weeks 1,3,4This clinic is for low complexity general surgical referrals and follow ups.2 consultants run the clinic.
Moorabbin- Upper GI Clinic
Wednesday afternoons 13:00 Outpatient A
This clinic is for low complexity UGI follow ups.1 consultant or Fellow runs the clinic.At least 1 registrar (ASU registrar) and the ASU resident must attend the clinic
The oncology service is located at Moorabbin. For oncology referrals, fax the referral to the oncology clinic and also inform both Theresa and the oncology registrar.
PREADMISSION CLINIC (aka Surgical Review Clinic [SRC])Surgical review
Wednesday mornings 0900-12:30 Day in Clinic M. This clinic runs concurrently with the UGI/HPB Outpatients session.
One resident and one intern are required to attend the SRC. Registrars should attend if assistance is requested in complex cases.
Anaesthetic review
The anaesthetic clinic is offsite. If an anaesthetic review is required the patient should be booked in. However walk-ins are accepted so you can send a patient directly from PAC to the anaesthetic clinic after phoning. You can also phone the anaesthetic clinic for advice at any time in hours.
REVIEW OF HOSPITAL IN THE HOME (HITH) PATIENTSThis is generally done by registrars at the request of HITH, however sometimes the resident/intern may be asked to review a patient if the registrar is in theatre. Please see these patients in a timely manner.
DISCHARGE PLANNINGRALS
A RALS referral is required for patients unable to go directly home who require interim care/rehabilitation. They require allied health assessment first (OT/physio/Social Work).
Referrals can be made by completing the orange form on the ward which the ward clerk will fax.
Please try to identify patients likely to need RALS and discharge plan ahead of time to avoid patients sitting in hospital awaiting assessment.
Post Acute Care (PAC)/Hospital in the Home (HITH)
Nurses will make referrals for patients requiring at home care of dressings drain tubes, INR, clexane etc at your request. Please try and plan ahead (at least the morning of the day prior) when these are required to avoid delays in discharge.
Adult HITH Program
The ward discharge summary must be now completed before a patient can be accepted for care by the Adult HITH program. After the discharge summary is finalized, the notes from the in-hospital stay should immediately be sent to SMR for scanning.
Extended VTE Prophylaxis
Patients at high risk of VTE should receive extended thromboprophylaxis post discharge as per the hospital guidelines.
UNIT MEETINGS AND GRAND ROUNDSAll team members are expected to complete their rounds and urgent tasks prior to, and attend all unit meetings on time (with the exception of the Combined Gastro/Liver mass meeting). The HPB registrar should try to attend the Liver mass meeting.
WEDNESDAY
0800 Combined Gastro/UGI meeting (weeks 2 and 4)
Level 3 Pathology conference room (near anaesthetic department)
Alternating with
Liver mass meeting (weeks 1 and 3)Level 3 Pathology conference room (near anaesthetic department)
FRIDAY
0700 Research meeting (Friday week 4)Level 3 meeting room (near UGI office)
0800 Multidisciplinary team meeting (MDT)Level 3 Pathology conference room (near anaesthetic department)
0900 UGI/HPB/AGSU Unit meetingLecture theatre 3 (ground floor)
Run concurrently with
HPB radiology meeting (weeks 1 and 3)Level 3 Pathology conference room (near anaesthetic department)
Followed by Grand round
MDT meeting
This is a meeting combined with radiology, pathology, oncology and radiation oncology in which cancer patients are discussed.
Each consultant will add his/her own patients to this meeting or may ask you to add the patient. Maree Borland (MDT coordinator) has a proforma that needs to be completed to list a patient for the MDT. In order to enable radiology and pathology sufficient time to source and review the relevant slides and images prior to the meeting, the deadline for submission of patients for discussion is 12pm Wednesday (or 10am the prior Friday morning when external pathology is required) and is strictly adhered to.
The consultants will present and discuss their patients. On occasion when a consultant cannot attend the meeting the registrar may be asked to present patients. This meeting offers an excellent learning opportunity.
UGI/HPB/AGSU Unit meeting
On weeks 2 and 4 we review a power point audit presentation of the preceding fortnight’s activity (Thursday to Wednesday inclusive). Admissions, operations and complications (including unplanned readmissions, complications, MET calls and deaths) should be presented. This is prepared and presented by the resident (under the guidance of the registrars).
Each week, the inpatients under the Luminal and HPB streams are presented (with the aid of WEB QI) by the respective registrars. This should be a concise presentation of each patient focusing on the current issues and plan. Sometimes consultants will ask to look at the imaging and or pathology while discussing a patient.
OVERTIMEAll overtime needs to be signed off by the head of unit. Overtime should be kept to a minimum through good teamwork and handover.
SET TRAINEES - MEETING COLLEGE REQUIREMENTSSET trainees must ensure they are up to date with the current college requirements for training. It is the responsibility of each trainee to ensure they meet the requirements and complete the necessary paperwork at the end of each rotation and prior to sitting their exams. The college strictly adheres to training requirements and will not allow registrars to sit exams or receive their FRACS if these requirements are not met (including operative numbers and endoscopy).
POSTGRADUATE SURGICAL TEACHINGClayton Teaching Program
There are 2 teaching sessions per week on a Wednesday and Friday morning.
Wednesday 0700-0800 - General, Upper GI and HPB Surgery
Friday 0700-0800 - Operative Surgery and Journal Club
Teaching sessions are compulsory for all registrars. Residents and interns are also encouraged to attend.
Two registrars are allocated to present a topic (with the aid of powerpoint) at each teaching session. Each presentation should last 20 minutes to allow 10 minutes for discussion. Registrars must ensure they are aware of the sessions allocated to them and, if there is a clash with another commitment or leave, must arrange a swap in advance. The registrars allocated to present should contact the consultant taking the teaching session the week before to confirm the topic and the focus of the presentation.
MASTER
The MASTER program of Surgical Trainee Tutorials is run at Dandenong and Clayton campuses. All SET trainees are expected to attend. Trainees will be allocated sessions to present at and must ensure they adhere to this commitment.
UNDERGRADUATE MEDICAL STUDENTSDuring university terms you will find final year students and several 3rd year students attached to our unit. Please help them to become an active part of the unit, provide informal teaching on the wards and rounds and encourage them to attend theatre (1-2 students at a time).
COMPUTERS AND I.T.AUDIT: WEB QI
WebQI is the audit program used by the General Surgical and Vascular Units at Monash Health.
Appendix 2 contains general instructions for compiling the weekly audit presentation.
Patient list management
Interns are responsible for keeping the patient list up to date. Web QI should be updated with the key clinical information and results of pathology and radiology at the beginning and end of your shift.
Hint: You’ll frequently find names coming up on your list you know nothing about as Mr Croagh’s endoscopy patients are entered into WebQI. On the following morning just use SMR to see what’s happened to the patient. Most are day cases and will have been discharged so just remove them from your list. If they aren’t discharged check what unit they are under – a lot are Gastromed. Leave admitted patients on the list, and ask the registrar if you need to see them as consults. Write (CONSULT) next to the ward on WebQI so it’s easy to know who’s under UPPER GI bedcard, and who’s not. This is the same with surgical day cases – just check the next morning on SMR to see if they went home vs admitted overnight. Jessie Mac patients may also be entered and will need timely discharge from WebQI.
Operation reports
The registrar is responsible for completing operation reports at the completion of each surgical case. It is mandatory to complete the post op orders section. Patients cannot be discharged from recovery to the ward without an operation report
Discharge Summaries
Discharge summaries should be a concise summary of key events and results. Do not cut and paste radiology or other reports in to a discharge summary. They are often misleading. Findings of key investigations should be summarised.
It is very important to specify the correct follow up - clarify if the follow up is Hepatobiliary Clinic/Luminal Clinic, Moorabbin Gen Surg clinic or a consultants private rooms. If a surgeon wishes to see a patient themselves please ensure the patient comes to the clinic on the week that the surgeon is there.Discharge summaries must be completed at the time of patient discharge to ensure the patient has a copy.
To make a follow up appointment after discharge, this is done through the e-referral system via SMR.
Enter the patient’s record and go to the cover page.1. Submit internal referral2. Fill in your details as the referrer3. Choose UGI or General Surgery as specialty unit4. Choose name of clinic - 222C Clayton UGI
248M Moorabbin AM 231M Moorabbin PM 222C: Cancer follow up or complex benign work 248M: New consults general surgery 231M: General follow up (most of the reviews will go here).
5. Choose site – Clayton or Moorabbin6. Choose urgency – Same specialty NO TRIAGE
Audit
The resident is responsible for preparing and presenting the fortnightly audit. Please refer to appendix 2 for instructions.
The audit presentation is to be forwarded to our Clinical & Data Co-ordinator, Carole Matthews each week. Her email is [email protected]
SMR (SCANNED MEDICAL RECORD)
SMR is the hospitals electronic patient record. You can use it to search patients past history (letters, discharge summaries, procedure reports etc.
SMR is also useful to check patients’ locations (In a patient’s record, click on “episodes” then hover over the top/current admission to see the patient’s status).
Infection ControlHospital acquired infections are commonly transmitted by hospital staff, ie doctors (all levels of seniority) and the nurses. We can do a lot to minimise infection by:
• Practicing good hand hygiene before and after contacting patients and their environment (5 Moments of Hand Hygiene)
• Not carrying anything (bags, books, documents or equipment) on ward rounds.
• Cleaning stethoscopes, if used, between patients.
• Being very careful when dealing with wounds and dressings.
• In ICU/HDU designating one person to have contact with the patient and another to manage the notes - all others to stand behind "the line".
• Not wearing neck ties or neck lanyards at the patient bedside- request a retractable belt lanyard from the Infection Control office.
VENOUS THROMBO-EMBOLISM PROPHYLAXISWe follow the network clinical guideline for VTE risk assessment and prevention. Pharmacological prophylaxis is to be administered at 16:00 unless otherwise specified. Management is summarized as follows and updates are available on the prompt system
REGISTRARS ROLE AND RESPONSIBILITIES:Inpatient service
• Conduct a daily morning ward round of and provide a clear plan of action for all inpatients.
• Review any unwell surgical inpatients, assess thoroughly, discuss with the consultant responsible for the patient and arrange appropriate investigations and management.
• At the end of the day re-review any unwell patients and patients who have had pathology and radiology results that warrant a change in their management plan or require information to be communicated.
• Keep patients and their families regularly updated on operative outcome, progress, results, management and discharge plans. Conduct family meetings as required.
• Liaise with the relevant consultants about the progress of their patients on a daily basis.
• Liaise with the nurse in charge about the plan for each patient including fasting/diet, drain tube plans, investigations, planned procedures, discharges, follow ups and relevant outpatient referrals (e.g. HITH).
• Provide clear instructions and support for interns/residents regarding documentation, and reasons for referrals and pathology and radiological investigations. More complex diagnostic imaging should be requested by the registrar and not delegated to the intern in order for clear and accurate communication of the information/procedure required.
• Receive referrals from the emergency department, other inpatient units and other hospitals when on call. Assess the patient, formulate a management plan and discuss with the relevant consultant.
• Make referrals to other units when required.
• Support the interns/resident to ensure adequate documentation of all inpatients’ investigations and management are correctly updated.
• Participate in a comprehensive face to face handover at the beginning/end of each shift.
Outpatient service
• See both new and follow up patients. Assess and formulate a management plan in discussion with the relevant consultant.
• Review HITH patients as required.
• Provide support for residents/interns in the preadmission clinic as required.
Operating theatre
• Ensure elective lists are booked appropriately a week prior to the actual list.
• Ensure required preoperative investigations have been performed and are available, review the results and alert the consultant of any concerns.
• Ensure that all patients are seen, consented, clerked and marked (when required) prior to start of each case.
• Ensure all relevant equipment is available for each procedure booked on the theatre list as per the consultant’s preference and/or request.
• Ensure any required intraoperative radiology (intraoperative ultrasound, image intensifier for cholangiogram) has been booked prior to the case.
• Perform and/or assist at elective and/or emergency cases.
• Ensure pathology specimens are correctly labelled and sent in an appropriate manner, and that the request slip contains the relevant clinical details.
• Ensure accurate documentation of operation details/findings, post op orders, observation limits and CMBS codes.
Training
• Take responsibility for your own surgical training. Ensure you understand the current college requirements for assessment and eligibility to sit exams (e.g. endoscopy, research). Don’t wait until your last term to complete these requirements - actively seek out training opportunities throughout your training. Be aware of all deadlines for submission of paperwork and don’t leave anything to the last minute - the College adheres to deadlines and requirements strictly.
Teaching
• Conduct informal teaching in the operating theatre and during ward rounds for students residents and interns.
• Participate in the education of interns and medical students by providing relevant tutorials during their General surgical term.
• Supervise the interns with minor procedures, skin closure etc.
Audit and clinical meetings:
• Support the resident in the preparation of the weekly unit audit.
• Present all inpatients and referrals under the unit during the weekly Friday Unit meetings for discussion.
• Prepare and present unit complications – mid month.
• Prepare and present unit complications full audit – end of month.
• Prepare and present the unit’s annual audit if this falls during your term.
INTERNS ROLE AND RESPONSIBILITIES:Inpatient service
• Attend the daily morning ward round with your registrar (and any consultant rounds), and document the plan for each patient concisely and accurately in the patient file. Each patient requires a file entry each day and sometimes more often.
• Liaise with your registrar about the progress of your patients and results throughout the day as required.
• At the end of the day re-review any unwell patients and patients who have had pathology and radiology results that warrant’s a change in their management plan or require information to be communicated.
• Liaise with the nurse in charge and allied health about the plan for each patient including fasting/diet, drain tube plans, investigations, planned procedures, discharges, follow ups and relevant outpatient referrals (e.g. RDNS, HITH)
• Order required pathology and radiology investigations as instructed by your registrar. If you do not understand why you are ordering a test or what information you want from it ask your registrar before going to radiology. (Complex radiology requests especially for complex interventional procedures should be ordered by your registrar)
• Follow up on all tests for each and every patient in a timely fashion and report to your registrar.
• Manage simple elements of patient care including fluid balance, electrolyte replacement, pain management and initial assessment of unwell patients.
• Discharge summaries. Prepare a concise summary of key events and results after reviewing the patients file (including the operation report). Record any complications accurately.
• Complete death certificates after discussion with your registrar.
• Ensure all inpatients’ investigations and management are correctly documented. Keep this regularly updated and print patient lists as required for rounds and handovers.
• Participate in a comprehensive face to face handover at the beginning/end of each shift.
Outpatient duties
• Tuesday pm, interns are required to attend the Upper GI post-op clinic. Please refer to the Medical Workforce rosters for allocations. If you are unsure of how to manage any particular patient, please contact either your Registrar, Fellow or Consultant onsite for assistance or advice. Avoid rebooking the patient into another clinic, treat the patient on the day.
If you are unable to attend the clinic, please ensure you delegate another intern to attend and notify Outpatients of any delays or changes to your attendance.
• Assist the resident in the preadmission clinic. Complete the patient admission clerking, take a history and examine the patient. Check required investigations have been done and the results are available (eg ultrasound report for lap cholecystectomy) and order any required preoperative investigations such as ECG, bloods, CXR (and follow up results). Discuss each patient with the resident at the clinic.
Operating theatre
• Make sure you know what patients and procedures are on each theatre list for your team.
• Review patients preoperatively wherever possible.
• As guided by your registrar ensure required intraoperative radiology (intraoperative ultrasound, image intensifier for cholangiogram) has been booked prior to the case.
• Attend theatre and assist at elective and/or emergency cases where possible.
Teaching
• Conduct informal teaching on the wards for students.
• Supervise students with minor procedures such as urinary catheter insertion, IV cannulation, arterial blood gas puncture.
A few survival pointers for interns
Ward rounds: Try and write your notes on rounds if possible. It avoids the need to come back and write at the end of the round. This will depend on the pace of your registrar/consultant. Carrying blank progress notes with you is often a good way to document quickly (add a patient label and insert in the file at the end of the round). Your documentation should be concise, accurate and informative. If you do not understand the issues/plan speak up and ask your registrar to clarify.
Always be prepared for rounds. Make sure you have the patient list updated and know the accurate locations of your patients before you start the round. Backtracking to wards to see missed patients is time consuming and very frustrating. Have the latest pathology and radiology results to hand.
Please do not leave the files lying around after the round. Put them away - the nurses are not there to clean up after you!
Support is always available: Your registrars and fellow are there to support and teach you. If you don’t know or need help ask.
Try to get to theatre: If you like surgery there are a lot of interesting cases/procedures every week. The consultants and registrars are more than happy for you to scrub and assist provided the ward is under control. Each intern should at least be able to close a wound at the end of their term.
Work together as a team: Although you will be allocated to either the Luminal stream, HPB stream or AGSU we are one unit. Help each other out if one team is very busy and cover each other to allow learning opportunities such as attending theatre.
Keep your registrar up to date even when in theatre: Registrars are often in theatre for extended periods during complex cases. If you need to discuss something with your registrar get changed into scrubs and go in. It’s a good idea to quietly check with the nurses if it is an appropriate time to speak to the registrar during a case. If there are decisions to be made, don’t wait until the end of the day to ask your registrar as this unnecessarily delays patient management.
If in doubt: Escalate to your registrar, fellow or consultant. Support is always available.
APPENDICESAPPENDIX 1 - THEATRE OPERATING SCHEDULE
APPENDIX 2 - EXAMPLE OF THE SURGICAL AUDIT PRESENTATION
APPENDIX 3 - CODING CHEAT SHEET
APPENDIX 4 - VTE PREVENTION
APPENDIX 1: CLAYTON THEATRE SCHEDULE
WEEK 1 Monday Tuesday Wednesday Thursday Friday SaturdayAM GHADIRI CROAGH BERRY
GRIBBIN(Renovasc)
LEE AGSU
PM AGSULOW
AGSUCASHIN
AGSUCROAGH
AGSUBOWERS
AGSUJAYAWERRA
WEEK 2 Monday Tuesday Wednesday Thursday Friday SaturdayAM AGSU CROAGH SPILIAS
GRODSKILEE AGSU
PM GRIBBIN AGSUCASHIN
AGSUGRODSKI
AGSUCULLINAN
AGSUDHIRDUBRAVA
WEEK 3 Monday Tuesday Wednesday Thursday Friday SaturdayAM CROAGH
GRIBBINCULLINAN BERRY
GRIBBIN(Renovasc)
AGSU
PM AGSULOW
AGSUCASHIN
AGSUSPILIAS
AGSUBOWERS
AGSUBOWERS
WEEK 4 Monday Tuesday Wednesday Thursday Friday SaturdayAM AGSU CROAGH FELLOW DUBRAVA MERENSTEIN AGSU
PM GRIBBIN AGSUCASHINJAYAWEERA
AGSUGRODSKI
AGSUBOWERS
AGSUMERESTEIN
APPENDIX 2:
EXAMPLE OF THE SURGICAL AUDIT PRESENTATION
Link: General Surgery and Upper GI Audit
APPENDIX 3:
‘Write Right’ – General Surgery/HPB
Documentation
Please note: Information contained in the Discharge Summary is supported by documentation in current inpatient notes.
APPENDIX 4: VTE prophylaxis
