Admin. ~ Short Answer

Question 1.

There have been a number of incidents in your emergency department short stay unit where patients have unexpectedly deteriorated during their stay.

 

A.) Outline the steps you would take to tackle this problem

Show Answer

  • QI cycle
    • Plan
    • Do
    • Check
    • Act
  • Investigate looking for
    • System factors
    • Process factors
    • Individual factors
    • Root cause analysis
  • Work out solutions
  • Implement
  • Audit changes

(4 marks)

 

 B.) How would you investigate this problem?

Show Answer

  • Root cause analysis
  • Looking for
    • System factors
    • Process factors
    • Individual factors
  • No-blame approach
  • Look at each case and find out the problem/s
  • Interview people involved to find out their opinion

(4 marks)

 

 C.) What are the types of issues that you think may have contributed to these incidents?

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  • System factors
    • Choice of patients
      • appropriate for SSU?
      • Senior supervision of patients going into SSU
      • Ed control of patients going into SSU
      • Access block causing pressure to put inappropriate patients in SSU?
    • Adequate nursing staff in SSU to look after patients
    • Appropriate monitoring equipment/layout
  • Process factors
    • Regular obs
    • Vital signs as trigger for patient review/escalation criteria/MET calls
    • Regular senior review of patients
  • Individual factors
    • Poor judgement re patient selection
    • Mis-diagnosis
    • No blame

(6 marks)

 D.) How would you implement the changes to be made?

Show Answer

  • Leadership from management and senior clinicians in ED
  • Engage all stakeholders
  • Educational material
  • Interactive educational sessions
  • Change obs forms with vital signs trigger points and escalation plan
  • Clearly marked admission forms with inclusion/exclusion criteria
  • Support in the SSU and ED as the changes are made

(6 marks)

 E.) What would you do then?

Show Answer

  • audit changes
    • adverse incidents
    • patient satisfaction
    • staff satisfaction
  • implement continual change/audit process

(4 marks)

Author: J Haire

Ref: Cameron p. 720-22; Dunn p. 7-8

 


 

Question 2.

You are the Director of an emergency department. You have received allegations from the Head of the Division of Medicine that an emergency physician in your department has been consistently rude and condescending to its medical registrars.

 

A.) Outline the steps you would make in response to this.

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  • Accept/acknowledge complaint
  • Apologise for their dissatisfaction
  • Record the details
  • Undertake to investigate
  • Arrange a follow-up time
  • Investigate
  • Discuss with staff involved
  • Inform administration if appropriate
  • Consider legal implications
  • Follow-up with complainant after investigation
  • Resolve complaint
  • Take action to prevent it happening again
  • Document process and outcomes

(8 marks)

 

 B.) How would you investigate this?

Show Answer

  • Interview Head of Division of Medicine to get details of complaint
  • Interview other witnesses/people involved
    • Discretion important
  • Interview the emergency physician to find out their view
    • Discretion
    • Private location
    • Non-judgemental
    • Find out if there are any physical or mental health issues
    • Explain that this is being investigated and why
  • Document

(6 marks)

 

C.) If these allegations prove to be founded, how would you then approach the problem?

Show Answer

  • Discussion with emergency physician
    • Explain behaviour cannot continue
    • Treat any underlying health issues
      • Refer GP
      • Employee assistance programs
      • Psychologist/psychiatrist
    • Report any significant issues to admin and APHRA
  • Provide support for anger management issues
    • Counselling
    • Can get human resources to help
  • Explain that after changes are implemented then will have to review and see if the changes have been effective
  • If no change then discuss with emergency physician again ? may require disciplinary action
  • Document

(6 marks)

 

Ref: Cameron p. 733-38; Dunn p. 9-12

 


 

Question 3.

The table shown describes the performance by Australasian Triage Scale (ATS) of your emergency department over a one month period.

Triage Category Percentage Number of Attendances Percentage seen within Performance Threshold Average Wait Time
                   % % Minutes
1 2 100 1
2 19 72 9
3 41 38 54
4 35 47 79
5 3 58 95
Did Not Wait            11
Total 100 49 53

 A.) What are the ACEM targets for time to be seen per triage category and what & is to be seen in that time?

Show Answer

ATS Category Time to be seen ACEM % seen in time target
1 Immediately 100
2 10 mins 80
3 30 mins 75
4 60 mins 70
5 2 hours 70

(5 marks)

 

B.) How does this department perform with regards to the ACEM targets?

Show Answer

  • Cat 1 meets target
  • Cat 2 slightly under target
  • Categories 3 and 4 significantly under target
  • Category 5 moderately below target
  • Overall needs improvement except for Cat 1s

(3 marks)

 

C.) What measures could be made within ED to improve these times?

Show Answer

  • System factors
    • Personnel resources
      • Staffing at all levels and disciplines
      • Rostering (numbers and skill mix) to meet demand periods
    • Pre-notification of sick patients by EMS so resources can be allocated
  • Process factors
    • Early and rapid senior review to expedite assessment times and disposition
    • Announcement of categories 1 and 2
    • Waiting room doctor
    • Early intervention by senior nursing staff
    • Nurse initiated radiology/labs
    • Effective tracking system
    • Communication systems
      • With orderlies
      • Radiology/lab
      • Other ED staff
    • Individual factors
      • Education re times and need for improvement
      • Need to make this a priority
      • Education re function of ED and what our role is i.e. when to handover care

(6 marks)

 

D.) What measures could be made in the rest of the hospital to improve these times?

Show Answer

  • System factors
    • Resources of ancillary departments
      • Timely radiology and lab results
      • Timely review of patients by in-patient teams
      • Timely movement of patient to wards
    • Bed numbers if access block a problem
    • Step-down units out of hospital
  • Process factors
    • Discharge planning
    • Timely pharmacy and allied health
  • Individual factors
    • Education that seeing patients in ED is a priority

(5 marks)

 

Ref: Dunn p.2-4


 

Question 4.

You have been called to assist a junior doctor dealing with an upset family. The family is unhappy with the proposal of a “Do Not Resuscitate” order for their elderly mother.

 

A.) What are you initial actions in response to this problem?

Show Answer

  • Make sure the rest of the ED is under enough control that you can take time out to deal with this problem
  • Gather information re:
    • Clinical situation
      • Diagnosis
      • Patient comorbidities
      • Patient pre-morbid function
      • May need to contact GP/other specialist for background information
    • What is known of patient wishes
    • What has been discussed so far
    • The likely issues that the family is upset about

(4 marks)

 

B.) How will you then approach the patient and the family?

Show Answer

  • Introduction of self and role
  • Acknowledge complaint
  • Apologise for their distress
  • Explain that you are her to investigate and try to resolve the problem
  • Investigate
    • Discussion with patient
      • What she understands of the situation and what the options are
      • What her wishes are
    • Discussion with family
      • What their understanding of the situation is an what the options are
      • What they think their mother’s wishes are
      • What their wishes are
    • Ascertain if family needs more support
      • More information
      • Social work support
      • Other family members
    • Resolve problem

(8 marks)

 

C.) What else needs to be investigated and resolved from this problem?

Show Answer

  • Investigate
    • Junior doctor approach
    • No blame
  • Educational opportunity for junior doctor in how to approach these matters.

(3 marks)

 

D.) When making these end of life decisions what are the important factors that need to be considered?

Show Answer

  • Patient autonomy
  • Realistic outcomes of further treatment i.e. futility, how it will improve quality of life
  • What is important to the patient
  • Family needs are considered and dealt with emphatically but do not override patient autonomy.

(3 marks)

 

Ref: Cameron p. 733-38; Dunn p. 9-12

 


 

Question 5.

You are the director of an urban emergency department.  Your staff have brought to your attention the case of a 24 year old woman who has presented to your emergency department on 15 occasions in the past two weeks.  On each occasion she complains of severe abdominal discomfort.  Investigations have failed to find a cause.  She has recently moved to your area from interstate, where she states “the doctors couldn’t help me”.  When given analgesia, she usually leaves the department without further assessment.
A.What are the possible causes for her presentations?

Show Answer

  •  Medical
    • Undiagnosed condition causing abdominal pain
    • Chronic pain disorder
  • Social
    • Social stressors causing distress manifest physically
  • Psychological
    • Poor coping mechanisms
    • Conversions disorder
  • Drug addiction/seeking

(4 marks)

B.How would investigate this problem?

Show Answer

  • Collateral information
    • Interstate hospitals and EDs
    • GP
    • Patient notes
    • Other specialists
  • Discuss her case with physicians in the ED and other specialties and other staff (nursing, allied health) that have seen her in the last 2 weeks
  • Review her presentations and investigations to look for causes
  • Review drug seeking data base

 

(4 marks)

C.What would you do after the investigation had been concluded?

Show Answer

  • Write a management plan for her next presentation
  • This may include
    • Further investigation
    • Referrals to other specialties e.g. drug assistance
    • Organising a GP to take her on
  • Write out an analgesia plan with limits if that is appropriate
  • Distribute this to all the stakeholders i.e. consultants, nursing staff etc. to get feedback
  • Engage patient and explain the plan including referrals etc. needed
  • Widely disseminate the plan
  • Ongoing evaluation to see if plan working

(6 marks; something similar, a logical plan)

 


 

 

 

 

 

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