1 Contents Acute Medicine Anaesthesia Antibiotic policy Anticoagulant control Blood transfusion ...

57 Pages·2016·0.93 MB·English

Contents

Acute Medicine
Anaesthesia
Antibiotic policy
Anticoagulant control
Blood transfusion requests
Cardiology
Career advice
Care of the Elderly
Chaplaincy
Chemical Pathology
Clinical Coding - a medical language you need to know
Clinical and Education meetings
Clinical Imaging
Complaints survival guide
Consenting patients for surgery
Diabetes & Endocrinology
Diabetic Foot Assessment Tool
Endoscopy
Evidence Based Healthcare
Foundation Programme
Gastroenterology
Haematology
Health and Safety
Histopathology
Hospital at Night
Human Resources
Imperial College Medical Students
Infection Prevention & Control
Governance: Quality and Patient Safety
Information Governance – Data Protection & Confidentiality
Laboratory Services
Library & e-Learning
Macmillan Cancer & Palliative Care Team
Microbiology
Oncology
PALS
Patient confidentiality
Pharmacy services
Research & Development
Resuscitation Services
Safeguarding and Child Protection Team
Sickle cell crisis
Stop Smoking Service
Stroke and TIA – see Care of the Elderly section
Study leave
Switchboard
TB Service
Urology Department (OPD6)
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Venous Thromboembolism (VTE)
Whistle Blowing Policy
Useful information
Useful phone numbers - Care of the Elderly
Useful phone numbers - Education Centre
Useful phone numbers - General
Useful phone numbers - GUM (Sexual Health Clinic)
Useful phone numbers - Library
Useful phone numbers - Medicine
Useful phone numbers -Obstetrics & Gynaecology
Useful phone numbers - Paediatrics
Useful phone numbers - Resuscitation Officer
Useful phone numbers - Surgery
Suggestions

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Education Centre

Lara Higginson Ext. 5406
Education Centre Manager

Vacant Post Ext 5405
Training Programme Coordinator (Consultants & SAS Doctors)

Lorna Edwards Ext 2525
Training Programme Coordinator (GP VTS & Training Grades)

Clodagh Finlay Ext. 5530
Foundation Programme Coordinator

The office is open from 8am to 5pm, Monday to Friday.

Access to the centre between the hours of 17:00 and 07:30 Monday to Friday and at
weekends is via ID access card.

Junior doctor post is also delivered here and is stored for collection in the
pigeonholes to the left of the front door. Parcels can be sent to the Education Centre
as long as they have the recipient’s name marked clearly within the address. We will
notify you if we have an item for you to collect and will keep it in the office until you
do so.

The Education Centre has a Monday – Friday Sandwich Man lunch service between
12:30 and 14:00.

College Tutors/ Leads
Directors of Medical Education Dr Michael Beckett / Miss Christina Cotzias
Medicine Dr Rashmi Kaushal / Dr Kevin Monahan
Surgery Mr Musa Barkeji
GPVTS Dr Julian Bradley, Dr Nan Sharma and
Dr Bhav Oberai
O&G Miss Susan Barnes
Anaesthetics Mr James Armstrong
Paediatrics Dr Anne Davies
Foundation Programme Directors Dr Jasmin Cheema and Dr Ravneeta Singh

Careers Advice
Dr Beckett, Miss Cotzias and the college tutors are always happy to talk to any
doctor wanting to discuss their career. Please contact Clodagh Finlay on ext. 5530 to
arrange this.

Doctors Mess Committee
President Dr Sunil Shetye
Chairperson Dr Iain Beveridge
Treasurer Dr Anna Babb
The doctors’ mess is on the second floor of the East Wing. You will need to get your
identity card programmed for access and note the keypad number.

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Imperial College London medical students

Glen Fernandes Ext 5448
Undergraduate Teaching Coordinator
Don McCrea Ex 5723
Senior Clinical Skills co-ordinator
Dr Elizabeth Owen Ext 5117
Director of Clinical Studies
Devina Alexander Ext 5920
Undergraduate Administrator

A&E and finding a bed

Consultants:
Dr Michael Beckett
Dr Zulfiquar Mirza
Miss Caroline Smith
Dr Jasmin Cheema
Dr Mohamed El-Askary
Dr Yunus Gokdogan

Doctor’s Office Ext. 5657 / 6160
Majors Nurse’s Station Ext. 5729 / 5730
Minors Ext. 5663
Observation Ward Ext. 5652
Paediatrics Ext. 5741
X-ray Ext. 5686

Patients are referred to your team by:
• A&E doctors (if admission is likely)
• GPs (to the duty medical and surgical team)
Patients presenting to the Emergency Department with a GP letter will be directly
referred to the appropriate specialist team irrespective of whether they have been
expected. This is as agreed by the Medical Director.

If your firm is expecting an emergency referral from a General Practitioner, the A&E
Sister should be informed on Ext 5730.
The Site Team Bed Manager (bleep 280) will advise the wards when elective
admissions have to be restricted due to bed shortages. They should be consulted
whenever there is a difficulty in finding a bed for an urgent or elective admission.
Space in the department is limited and it is often very congested, it is important that
patients are either discharged or admitted to the wards as quickly as possible. Only
investigations and procedures necessary for immediate management of the patient
should be performed in the department. GPs referring patients can fax referral letters
to the fax machine in A&E reception - 020 8321 2516.

Please note that the limited Observation Ward in A&E is for the use of A&E patients
only – that is patients under the on-going care of the A&E doctors. Patients referred
to specialties are not for admission into the Observation Ward.

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Acute Medicine Team

Dr Emma Rowlandson - Consultant in Acute Medicine (AIM Lead)
Dr Helen Burgess - Consultant in Acute and Respiratory Medicine
Dr Elora Mukherjee - Consultant in Acute Medicine
Dr Ashkan Sadighi - Locum Consultant in Acute Medicine
Dr Sanja Zrelec - Locum Consultant in Acute and Stroke Medicine
Dr Luke Smith - Locum Consultant in Acute Medicine and Clinical Toxicology
Dr Iftikhar Hussain – Locum Consultant in Gastroenterology & Acute Medicine
Moreblessing Zvorwadza (known as Moby): Matron
Shalee Lasam: Ward sister

The Acute Medical Unit (AMU) is situated on the first floor of the “new block”. It has
an overall capacity of 46 beds (divided into 4 clinical areas-AAU, MDU, AMU1 and
AMU 2). All newly admitted patients should come to AAU (Acute Assessment Unit),
where patients stay for a maximum stay of 12 hours. AMU 1 and 2 accommodate
acute medical patients with a maximum stay of 72 hours. The MDU is an escalation
ward that has 4 beds.

In addition, there is an ABG machine in MDU and a direct link to CCU and a link to
ITU via CCU.

If in doubt, please ask any of the AAU staff. Our ward clerks are very friendly and
knowledgeable (Katie in AAU and Tracey in AMU2).

Morning handover

A representative of every team (please nominate junior doctor in advance) should
attend hand over to ascertain the new patients who have moved to their respective
clinical areas, take referrals from on call team and get an update on any sick patients
managed overnight.

This occurs at 08:30 in Handover Room opposite MDU. It is attended by Night
Registrar, On-Call Consultant, AMU Team and ALL ward team junior doctor
representatives.

Ambulatory Emergency Care Unit

The Department of Acute Medicine runs the Ambulatory Emergency Care (AEC),
situated next to the Outpatient 1 Clinic, on the ground floor. It is open 8am – 8pm
Mon to Fri and the last patient is accepted at 5pm. During the weekend, it is open
from 11-2am (nurse-led).

The telephone [phone]) during the week is manned by a
Consultant/SpR and they can discuss your potential referral. If in doubt, just call and
discuss. Referrals are made via GP, UCC, A&E and the wards.

Referral process

1. If patients need IV antibiotics in AEC post discharge, they need to be referred
via the ICE system (OPAT).

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2. For everything else, please refer directly to AEC and discuss the case with
the team in AEC. Please print and complete all relevant sections on the form
and give as much information as possible. The notes often don’t arrive on
time to AEC therefore, please complete all sections of the form and preferably
speak to AEC team. OOH, leave the form in AEC or fax on 020 8321 2572
(but double check that they have received the referral the following day).

3. The form is kept here:
a. Common drive
b. Clinical (Newton)
c. Medical Take lists 2016
d. “AEC Referral” as a ward document

Acute Medicine Bleep Numbers

Registrars 603, 573
SHOs 582,568, 448
FY1s 482

Anaesthesia

Pre-operative Assessment Clinic - PAC

Preoperative Screening and assessment are carried out 4-6 weeks prior to proposed
surgery for elective cases. Patients for urgent procedures are screened and
assessed promptly, usually within 2 weeks of proposed surgery.

Aims

The objectives of the pre-operative assessments are to:

• Assess fitness for surgery
• Identify co-morbidities and optimise with multidisciplinary input
• Perform appropriate investigations
• Provide appropriate information to the patient. This information includes the
Risk/benefits of the surgery, anaesthesia and side effects, fasting and
medication guidance, enhanced recovery programme, postoperative pain
control and rehabilitation
• Obtain informed consent
• Anticipate potential complications and peri-operative management
• Minimise late and ‘on the day’ cancellation
• Improve patient satisfaction

Process

The Pre-operative Assessment Clinics (PACs) are run by trained nurses with
anaesthetic input. The patients for major procedures are assessed by junior doctors
who also provide information and obtain consent.

The completed patient self-assessment forms are screened by nurses in the PAC.
The patients for major surgery and patients with co-morbidities are requested to
complete a multidisciplinary assessment questionnaire. This questionnaire is
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designed to be used by junior doctors and nurses. The doctors are not expected to
do a separate clerking. The format of this questionnaire is systems based which
prompts further questions for positive answers to be assessed in detail.

Advice is provided for appropriate action to be taken in addition to investigations and
referrals. The doctors and nurses are expected to go through this multidisciplinary
assessment form, perform system examinations on the patient and request
appropriate investigations. The doctors also provide sufficient information to the
patient and obtain consent. The anaesthetist can be consulted if required.

Enhanced Recovery Programme (ERP)

Currently NHS Improvement is leading a major initiative in the UK to implement ERP
across a number of specialities including colorectal, musculoskeletal, urology,
gynaecology, and breast surgery. There are many perceived benefits from ERP for
patients, health professionals and hospital managers.

ERP allows patients to recover more quickly using a number of techniques which
include:

• Pre-operative carbohydrate loading
• Small incision surgery
• Reduced tubes and drains
• Minimal use of opioid analgesia
• Avoidance of fluid overload
• Early resumption of enteral feeding
• Early mobilisation

This has been encompassed into a protocol-driven care pathway ensuring great
consistency in patient treatment, from the pre-operative phase through to discharge.
The greater the adherence to ERP protocols, the greater the improvement in clinical
outcome. The protocols for each speciality are available in the PAC. The patients
should be informed about the value of ERP and encouraged to comply with the
requirements.

Investigations
Pre-operative investigations rarely uncover unsuspected medical conditions. The
National Institute for Clinical Excellence (NICE) has produced a guideline on
peri-operative investigations. The recommended investigations are graded as
follows:

RED Not needed

AMBER Test to be considered

GREEN Recommended

A simplified guideline is available in PAC and doctors are expected to follow this
guideline.

Guidelines and Policies
The following guidelines are available as hard copies in the PAC as well as on the
Intranet.

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 Pre-operative investigations
 Fasting guidelines
 Cardiac assessment
 Peri-operative antiplatelet policy
 Peri-operative management of surgical patients with diabetes mellitus
 Peri-operative management of medications
 Referrals to other specialities and to the GP
 Peri-operative management of anticoagulants
 ERP – colorectal, musculoskeletal, urology, gynaecology

Additional Information and Help
The nurses in the PAC will provide guidance and support.
If any doubt, the anaesthetist can be contacted either via the secretary on ext. 5824
or Switchboard.

Antibiotic Policy
International guidance on the treatment of sepsis (Surviving Sepsis Campaign)
recommends administration of effective intravenous antimicrobials within the first
hour of recognition of septic shock or severe sepsis.

There are antibiotic treatment guidelines on the Trust intranet, which include
individual guidance documents for ITU, Haematology/ Oncology, Paediatrics, Special
Care Baby Unit in addition to a Trust Antimicrobial Guide (for adult patients). Before
prescribing a restricted antibiotic, please discuss with the medical microbiology staff.

Important facts to remember when prescribing anti-infectives:
• Never start antibiotics on suspected viral infections
• Collect appropriate microbiological specimens before starting an antibiotic
• The indication for the antibiotic must be recorded on the drug chart and in
the medical notes. Failure to do so will result in unnecessary delay in the
dispensing of antibiotics from the pharmacy and may impact on the well-being of the
patient.
• Check for drug allergies and document description of allergy on the drug
chart. NB: 10% of patients who are genuinely allergic to penicillin are also allergic to
cephalosporin. When prescribing gentamicin for adults please refer to the Trust’s
Antimicrobial guideline on the intranet and the gentamicin calculator on the
homepage
• Consider altering the treatment only if there is no clinical response by 48
hours and/or once significant microbiological results are available.
• Review IV antibiotic prescriptions daily, and consider one of the following
actions at 48 hours:
1. Stop antibiotic
2. Switch from IV to oral therapy.
3. Change to a narrower spectrum or a broader spectrum
antibiotic
4. Continue with the same antibiotic and review every 24 hours
5. Consider Outpatient Parenteral Antibiotic Therapy (OPAT)

• The planned duration of treatment or review date should be specified; a 5-7
days course of antibiotics is sufficient for most infections unless stated otherwise.
• Topical antimicrobials must not be used except for the eyes or ears.
• If in doubt please discuss with the Duty Microbiologist on Bleep 316 ext. 5858
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or Consultant Microbiologists:
 Dr Farhana Butt ext. 6882
 Dr Nupur Goel ext. 6539
 Dr Stella Barnass ext. 5784

Uncomplicated UTI
First Choice
Nitrofurantoin po 50mg 6 hrly x 3 days for women and 7 days for men, provided
eGFR is greater than 45 ml/min.

(In pregnancy: Cephalexin po 500mg 12 hrly x 3 - 5 days)

Alternative
Trimethoprim po 200mg 12 hrly x 3 days for women and 7 days for men

Pyelonephritis
First Choice
Gentamicin IV 24 hrly (please refer to the Trust’s Antimicrobial Guideline on the
intranet.

(In pregnancy: Cefuroxime IV 750mg 8 hrly (change to oral after 48-72 hrs) for a
total of 10 to 14 days)

Catheter associated UTI
Consider removal of catheter under antibiotic cover.

Community acquired pneumonia
CURB-65 Score 0-1
Amoxicillin po 500mg 8 hrly x 7 days
If atypical infection suspected add Clarithromycin po 500mg 12 hrly for 7 days or
Azithromycin po 500mg 24 hrly for 7 days.

CURB-65 Score up to 2
Amoxicillin po 500mg -1g 8 hrly x 7 days + Clarithromycin po 500mg 12 hrly x 7 days
or Azithromycin po 500mg 24 hrly x 3 days.

CURB-65 Score 3 and upwards
Benzylpenicillin IV 1.2g 6hrly + Clarithromycin IV 500mg 12 hrly.
Review at 48-72hours to step down to Amoxicillin po 500mg 8 hrly +/-Clarithromycin
po 500mg 12 hrly, to complete a total course of 7 days treatment.
Azithromycin po 500mg 24 hrly x 3 days may be used as an alternative to
Clarithromycin.

In Penicillin allergic patients <CURB-2 use Azithromycin alone and CURB3-5 instead
of Benzylpenicillin, use Teicoplanin.

Aspiration pneumonia
First Choice
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Benzylpenicillin IV 1.2g 6hrly + Gentamicin IV 24hrly (please refer to the Trust’s
Antimicrobial guideline on the intranet for monitoring levels) + Metronidazole po
400mg 8hrly (if unable to give po, use Metronidazole IV 500mg 8hrly, but change to
po ASAP) for a total of 7 to 10 days.

In Penicillin allergic patients instead of Benzylpenicillin, use Teicoplanin.

Suspected bacterial meningitis (Notify CCDC)
First Choice
Ceftriaxone IV 2g 12hrly (discuss duration with Microbiologists). Durations will
depend on the causative organism.

If known to be allergic to cephalosporins use Chloramphenicol 1g 6hly IV (for
out-of-hours use, Chloramphenicol injections are available in the emergency drug
cupboard located on Osterley 2 ward and in A&E).

Cellulitis, Impetigo (requiring hospital admission)
First Choice
Benzylpenicillin IV 1.2g 6hrly + Flucloxacillin IV 1g 6hrly for 5 to 7 days

Alternative
Clarithromycin IV 500 mg 12hrly for 5 to 7 days or Azithromycin po 500mg 24hrly for
3 days.

Clostridium difficile diarrhoea (ensure patient is isolated within 2 hours of onset of
diarrhoea and inform Infection Prevention and Control Team)
First Choice
Stop offending antibiotic if possible. Metronidazole po 400mg 8hrly for 10 to 14 days.

Alternative
Vancomycin po 125mg 6hrly (only if failure on metronidazole). Anti-motility agents
must not be prescribed.

Typhoid fever (Enteric fever) (inform Infection Prevention and Control Team and
isolate in a side-room)
First Choice
Ceftriaxone IV 2g 24hrly for 14 days.

Alternative
Ciprofloxacin po 500mg 12hrly for 10 to 14 days (only to be used if confirmed as
sensitive by laboratory testing)

Abdominal sepsis/cholecystitis
First Choice
Amoxicillin po or IV 500mg-1gm 8hly + Gentamicin IV 24hrly (please refer to the
Trust’s Antimicrobial guideline on the intranet for monitoring levels) + Metronidazole
IV 500mg 8hrly

Alternative
In penicillin allergic patients use Teicoplanin instead of Amoxicillin
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