Western Health ED tips for common presentations

see also:

• Western Health ED main page
• Sunshine ED Fast Track

• ensure you have read the various orientation documents - see Western Health ED medical orientation
• discuss with senior Dr in ED within 20-30minutes
• early bed requests and inpatient referrals - if inpatient team do not respond in a timely manner (eg. 30min), d/w senior ED doctor to escalate to inpatient consultant
• for resus patients likely to need a critical care bed, contact ICU reg EARLY!
• ensure all patients discharged home have discharge letters and certificates/patient info sheets as indicated
• if a patient is likely to require > 4hr LOS in ED, consider admitting to EOU if appropriate (eg. a reasonable probability they can be discharged home from there)
• if there are delays for inpatient unit to review the patient and “admit” whilst in ED, if the patient is stable and safe for transfer to an available ward bed for admission there, complete an “Interim Admission Order” and inform the inpatient unit the patient will be transferred to ward bed (there is generally no need for the patient to remain in ED awaiting CT scan results unless this is likely to result in transfer to another hospital - if there is high probability of discharge home, then an EOU bed should be considered).

• palliative care - how to provide palliative meds on discharge back to NH - complex and not possible once external pharmacies close around 8pm!
  • syringe drivers with Morphine/Midazolam can be started in ED to be continued in the NH
  • Patients who require prn morphine/midazolam need a script with the S8 drugs written up and ampoules dispensed from their local community pharmacy - DO NOT discharge patient from ED with ampoules of S8 drugs!
  • patients may need to be admitted overnight to arrange medications in the morning
  • if there are no palliative care beds available, admit under gen med or aged care

• both Footscray and Sunshine have CCU and cath lab facilities
• there is also a cardiogeriatrics unit at each site for patients with congestive cardiac failure, etc.
• contact cardiology registrar via mobile and fax ECGs as indicated
• see:
  • cardiology
  • Western Health STEMI angioplasty/thrombolysis process
  • the adult patient with chest pain in the ED

• see also:
  • addiction medicine (alcohol and other substance use)
  • cannabinoid hyperemesis

• see:
  • diabetic ketoacidosis (DKA)
  • endocrinology

• patients with tonsillitis, peritonsillar abscess (quinsy), or uncomplicated epistaxis can generally be admitted to EOU for ENT reg review
• see:
  • ears, nose and throat surgery (ENT)

• based at Footscray
• there is no OPG machine at Sunshine - only at Footscray
• refer patients with dental abscesses, fractured mandibles, etc.
• see:
  • faciomaxillary, facial trauma

• patients needing scopes as an outpatient should generally be referred to their LMO to arrange privately as there is a long wait list in the hospital system - exceptions are for those who are too high risk to have a scope in a day procedure centre (eg. morbid obesity, serious co-morbidities)
• see:
  • gastroenterology
  • upper GIT bleeding

• see:
  • general surgery
  • the patient with acute abdominal pain in the ED

• see:
  • general medicine

• after hours (eg weekends and after 5pm weekdays), aged care patients are admitted by the gen med registrar
• see:

• don't forget to have a low index of suspicion for ectopic pregnancy in all females of childbearing age with abdo pain, PV bleeding or syncope, even if they have just had a menses
• don't forget to check pregnancy status BEFORE ordering x-rays or medications which may not be appropriate in pregnancy
• hyperemesis gravidarum - usually admitted to EOU
• vaginal bleeding in early pregnancy
  • Western Health early pregnancy assessment service (EPAS) referral process
• pelvic inflammatory disease (PID)
• ovarian cysts and other cysts in the adnexae

• there is a HITH registrar who supervises admissions to HITH team
• once accepted, a HITH nurse will generally assess the patient in ED to ensure suitability, etc.

• based at Footscray, but may review patients at Sunshine
• see:
  • The febrile adult presenting to the ED
  • infectious diseases
  • infectious_diseases
  • the immunocompromised patient in the ED
  • sepsis / septicaemia

• Sunshine Hospital is within the Mid-West Mental Health catchment
• Footscray Hospital is within the South-West Mental Health catchment which is based at Werribee Hospital
• discuss all patients of concern with suicidality risk, psychosis, or those placed on MH Assessment Orders with EMH (even if being admitted to a medical ward - EMH need to inform Consultant Liaison MH team)
• see:
  • psychiatry and mental health
  • mental health services issues at Western Health
  • rapid sedation of the agitated or aggressive patient in the ED
  • managing violence or the aggressive patient in the ED
  • medical clearance of the acutely disturbed patient prior to transfer to a mental health facility

• see:
  • neurology
  • Mx of acute migraine
  • ED Mx of vertigo and BPV - don't forget posterior circulation stroke - especially in older patients with risk factors such as diabetes

• WH has a neurosurgery registrar, however, if not available, may need to contact RMH neurosurg registrar
• remember to complete the “Hub and Spoke” radiology form (in radiology dept) early so that scans will be sent to destination hospital for review by the receiving unit (eg. RMH)
• if there is a neurosurgical emergency and RMH is not able to accept, contact ARV to arrange and expedite transfer
• see neurosurgery

• oncology unit is based at Sunshine
• see also:
  • oncology

• Eye injuries
• ophthalmology
• there is a slit lamp in the procedure room near EOU at Sunshine
• consider referral to Western Eye Clinic for follow up review of corneal FBs, etc

• orthopaedics in the ED
• Western Health Orthopaedics and Fractures
• Western Health Virtual Fracture Clinic and also the Falls and Fracture Prevention Clinic
• adult orthopaedics is only at Footscray
• patients with an obvious dislocated ankle MUST have this relocated ASAP - within minutes of arrival - and before x-ray to reduce risk of serious morbidity due to skin necrosis

• see:
  • paediatric emergency medicine

• plastics is only at Sunshine
• see plastic surgery

• all patients on dialysis or with renal transplant who require admission must be admitted under renal unit whatever their presentation is - contact renal reg early!
• see renal medicine (nephrology)

• Sunshine and Footscray have IRCU beds for higher dependency respiratory patients requiring non-invasive ventilation or adrenaline or salbutamol infusions, if these beds are unavailable, contact ICU consultant to request a HDU bed so that the patient can be moved from ED resus (the ICU reg may be first contact point, but they may not be empowered to accept a patient not fulfilling critical care criteria)
• see:
  • respiratory medicine

• stroke service is only available at Sunshine
• patients with acute stroke within 4hrs of onset must be escalated to the stroke team for urgent CT brain and consideration for time critical thrombolysis, or transfer to RMH for clot retrieval
• see also: stroke (CVA), transient ischaemic attack (TIA)

• see:
  • pneumothorax - currently patients with intercostal catheters cannot be managed on ward at Sunshine, need transfer to Footscray either under thoracics or under resp. medicine

• be alert for patients fulfilling “trauma call” criteria - see ED major trauma call
• road trauma cases require:
  • blood alcohol kit testing or as a minimum, an alcohol breath test and if under limit, a “Negative Breath Test form” signed and placed in the police safe
  • TAC certificate
• major trauma cases are generally NOT admitted within WH but transferred to a major trauma centre - this may require liason with ARV (see emergency medical retrieval services for transfer of the critically ill)
• see also:
  • trauma
  • massive blood transfusions

• urology is based at Footscray, if at Sunshine, consider EOU and then transfer to Footscray if indicated
• renal colic
  • patients with ureteric stones and suspected infection require urgent referral to urology and potential intervention within hours!
• acute urinary retention - the complexities of arranging trial of voids!
• see also urology

• see vascular surgery at Western Health
• based at Footscray
• at Sunshine, contact the vasc reg at WH
• see:
  • abdominal aortic aneurysm (AAA)
  • peripheral vascular disease (PVD or PAD)