Swab Policy

WHO Checklist

We appreciate that different hospitals have different WHO pre-operative checklist paperwork and practices. In our on-going attempts to standardise theatre practice I would be grateful if you would consider the following:

• The Department’s pre-list WHO meeting takes place at 0830 outside the back of Th 1, every day of the week. Following introductions the Theatre teams will agree on:

  • List order

  • Pre + post op considerations

  • Operating tables + equipment

• The first patient of each list should be sent for by 0840

• The patient will not be anaesthetised until the pre-operative component of the WHO form, attached, is signed.

• The verbal WHO TIMEOUT checklist (middle column) is surgeon led at the point when the prep and setup is complete so that everyone can listen and take part. Please remember to prompt the anaesthetist to record ASA on their sheets so that our NHFD auditors can find them.

• Introductions are performed for every case, unless all the staff are unchanged.

• Once the checklist is complete the circulating nurse will sign the box and the surgeon will be allowed the scalpel.

• At the end of the procedure there is a WHO SIGN OUT to be performed at the end of the procedure which is again, surgeon led. The surgeon will confirm the name of the procedure that has taken place and ensure all parties are aware of any immediate concerns for recovery. The surgeon will then ask the scrub nurse and anaesthetist if they have any post-operative concerns and deal with any intra-operative specimens.

• The surgeon will then smile sweetly and thank all concerned.

HI guide

Lucy Morgan is now the Head Injury Nurse Specialist Bleep 6670 or email lucy.morgan@ouh.nhs.uk

Note the LETTER proper contains the current protocol, while the appendix is the superseded protocol.

• Head injuries requiring <24 hours observation will continue to be managed in the Emergency Assessment Unit (EAU) and discharged the following day.

• Patients referred to neurosurgery because of a HI will be assessed by the neurosurgical registrar as per existing policy.

• Patients requiring admission >24 hours due to their injuries (which include a HI) will be admitted to the trauma ward under the care of trauma but with a named, designated neurosurgeon responsible for assessment and management of the HI.

• Patients for whom the reason for their continued hospital admission is exclusively HI will be admitted to NIPS ward or trauma ward under the named care of a consultant neurosurgeon. Trauma service will continue to advise on any other injuries that do not clinically require admission.

• All HI patients will be supported by the HI team as it becomes established.

• Patients requiring out-patient follow up for their HI will be seen in neurosurgery out-patients or by the HI team.

Screens logins

Daily Screens handover meeting 0800-0845

Night F2 to present cases. Please follow running order:

1. Spines admissions and inpatient imaging

2. OARS Referrals

3. Theatre lists

4. Admissions (including previous days TDA and Day case admissions)

5. Post-Op Imaging

6. Ward Imaging

7. Sick inpatients for discussion

8. Deaths and Complications

9. Bluespier list discussion

10. AOB

Night Registrar to present imaging:

Please be aware of the additional morning meetings that you are expected to attend, so please make every effort to return from the theatres’ WHO meeting ASAP.

On Fridays you are NOT to attend the WHO, so that teaching can start promptly. Your consultants are aware that you are supernumerary until 0930 on those days.

1^st Wed – Trauma Service Clinical Governance Meeting (Kadoorie Lecture Theatre)

2^nd Wed – Major Trauma Centre Clinical Governance Meeting (Kadoorie Lecture Theatre)

3^rd Wed – Ortho Geriatric Meeting (Screens)

Alternate Thursdays – MINT Meeting (Screens)

Fri – Donut Round with the Consultant of the Week (Screens) – An e-mail from ‘Trauma Education’ will be circulated with review and reference material on a particular subject in advance of the meeting. We provide a 26 week syllabus that will cover everything you need. There is no expectation that you will read or remember everything provided but would strongly recommend that you keep the e-mails somewhere accessible. This will greatly facilitate your ability to prep for an unfamiliar case. The aim is that this is a discussion facilitated by the consultant and not another tutorial.

Automatic acceptant indications

Minimum and necessary guidance for trauma transfers

Notes to support minimum and necessary guidance

Part of the success of the Thames Valley Trauma Network is our Automatic Acceptance policy (attached). The reason it works is that the decision to transfer does NOT involve discussion with the specialties or concern about the availability of a bed or operating list. The patient is then transferred ED to ED as a blue light transfer (this should include open fractures to avoid unnecessary delay). However, you will still be occasionally be called by an ED doctor about a case that fulfils the criteria. Please advise them to follow the policy, which is available in their department.

When contacted about cases that do not fulfil the Automatic Acceptance Policy, please remember the answer is always ‘yes, we will review and aim to transfer within the next 24-48hrs’. The referrer should complete an OARS referral. The case should be discussed with the COTW / On Call consultant ASAP to allow a decision to be returned via OARS. All referrals over the previous 24hrs should be presented during the tertiary referral section in the morning meeting (after Spines) to allow the OARS response to be filled in there and then.

Damage Control Theatre set up

Unless you are old with a significant chest injury or have an unsurvivable brain injury, arriving at this hospital with a pulse means you are very likely to survive. Fortunately the majority of patients arrive with enough physiologic reserve that urgent life, limb and eyesight saving interventions are not necessary. However some patients do not have the luxury of time and much of what they did have to offer was spent pre-hospital. If you waste what precious remaining minutes they have, then they will die. Early identification allows everyone to up the tempo and avoids unnecessary time wasting through assessment and investigation. We certainly cannot waste time thinking through problems, for the first time, with an exsanguinating patient in front of us. Please let me introduce you to the Damage Control Protocol / Checklist.

The default equipment setups are self-explanatory.

If you are in ED and need to consider a surgical intervention please call the Theatre coordinator (bleep 1048) and ask for the ‘Damage Control Trolley’. This is pre-prepared and sits outside Th 1. It will be brought toTheatre by a member of the scrub team. Once in theatre, specialty trays will be ready on standby. Please note a thoracotomy tray is on the shelf in ED.

Prior to commencing Damage Control Surgery a WHO timeout is still required. This should be augmented by the Damage Control Checklist + Timeout. 15 minute timeouts will then be completed to ensure team awareness of physiologic trends and facilitate decision making. These Checklists will be on the walls of Theatre 1, available in hard copy and on the OxTrauma Intranet site (http://orh.oxnet.nhs.uk/OxTrauma/Pages/Default.aspx).

JMcM Advice

Stop that bleeding

Your vascular toolkit

Peripheral vascular trauma made simple

Some useful advice on major haemorrhage control. Also, some reading for quick reference.

Major Haemorrhage Activation Process

The Major Haemorrhage Protocol (MHP) is designed to facilitate the provision of appropriate quantities of blood and blood components in a timely, structured and organised manner for patients with major haemorrhage.

Successful transfusion for these patients requires prompt action and good communication between all members of the multi-disciplinary teams and with the blood transfusion laboratory, particularly regarding on-going transfusion requirements.

A recent investigation of a massive haemorrhage event highlighted a number of learning points for the management of patients with major bleeding.

Action points

• Communication with laboratory is vital

When handing over patients to another team, you should identify one person in the team to liaise directly with the Transfusion Laboratory and co-ordinate blood ordering.

• Return of MHP Boxes when standing down MHP

It is the responsibility of the identified liaison individual in the clinical team to inform the Transfusion Laboratory when MHP packs are no longer required and they wish to “stand down”. The timely manner of this “stand down” is essential to avoid blood wastage. The porter allocated to attend the MHP can be requested to return unused components to the Transfusion Laboratory.

• A multi-disciplinary approach

A multi-disciplinary approach is fundamental to the continuity of care and effective communication when managing patients during major haemorrhage.

Haematology SpRs are available to provide advice about the management of MHPs. They are contacted automatically when the MHP is activated during working hours, and can also be contacted via bleep 6888. They are available via switchboard outside normal working hours and may contact the clinical team to offer assistance should haemorrhage be prolonged.

For further information please see:

http://ouh.oxnet.nhs.uk/BloodTransfusion/Pages/MajorHaemorrhageProtocol.aspx

https://www.youtube.com/watch?v=mQwuZEIFP8A&feature=youtu.be

JR VTE Advice

https://www.nice.org.uk/guidance/ng89

http://ouh.oxnet.nhs.uk/Pharmacy/Mils/MILV10N8.pdf

Summary of important points

• Always perform and assessment and document decision in you letters

• When considering mobility, if using the gastro-soleus complex then they are generally sufficiently mobile

• Split dosing of LMWH is permitted to prevent prolonged periods without cover due to timing of admission and peri-op events

• Dalteparin is derived from porcine intestinal mucosa. Please discuss this where patients may have religious or dietary objections.

FFATGB JR Guideline

In order to tighten up on our pre-op management of patients we have introduced the FFATGB mnemonic. Part of the problems has been uncertainty by the juniors with regard to expected operating time. As a result people are excessively starved, dehydrated and under anti-coagulated. Please prime the F2s to ensure that they have ideally dealt with all of these issues in advance of the ward round.

F – Fluids

F – Feeding – Please be aware of our pre-op fasting guidelines. The Nursing staff will make sure the fasting times are maintained but they need the Ensure drinks prescribed on EPR as a matter of routine on admission. [Ensure 220ml 10pm night before surgery, and >100ml no later than 6:30 on morning of surgery]

A – Analgesia

T – Thromboprophylaxis

G - Glycaemic control

B – Bloods (both ordering and reviewing)

Acknowledgement of the FFATGB checklist should be recorded in every Consultant Hot Round Letter.

P&A II Setup

Cell salvage should be warned they may be needed for all cases

General enquiries and non urgent bookings: cell.salvage@ouh.nhs.uk

Cell salvage coordinator bleep: 9759

Emergencies: Call 4444 and ask for cell salvage

Adequate imaging in the right format is also required.

Our Radiology colleagues are aware of the protocol below, but sometimes need reminding.

If images are sent from another hospital it is important that a call is logged with the help desk (imandtservicedesk@ouh.nhs.uk ) ASAP so that they can be transferred from the MDT server to the main server. You will need to provide the patient’s MRN number and details of the images you wish transferred. This will then allow us to manipulate the imaging on our main server.

The following 3D reformats of the pelvis should be produced when there has been a pelvic or acetabular fracture.

‘Horizontal Spin’ – Whole pelvis, 360 degree spin in the horizontal plane (aka ‘pirouette’)

‘Vertical Spin’ – Whole pelvis, 360 degree spin in the vertical plane (aka ‘backflip’)

And in those cases were there has been an acetabular fracture.

‘Hemi Horizontal Spin’ – Injured half of pelvis (split through middle of sacrum and pubic symphysis), 360 degree spin in the horizontal plane (aka ‘hemi pirouette’)

If there are bilateral acetabular fractures we would be grateful for a Hemi Horizontal Spin of both sides.

If these re-formats cannot be generated from the data set provided by an external hospital there are only 2 options.

• Repeat CT

• Radiology arranges for referring hospital to perform reformats on their computer and send.

FIB guide

FI blocks make a big difference to our NOF patients. You should consider having this within your skillset.

Please see link for BJA Education article on FICB

https://www.sciencedirect.com/science/article/pii/S2058534919300435?dgcid=author

OUH trauma protocols

Clinical Guidelines for Mass casualties - https://www.england.nhs.uk/publication/clinical-guidelines-for-major-incidents-and-mass-casualty-events/

It is very unlikely you will be able to remember all of this. So at the very least, know where to find it. It is aimed specifically at civilian doctors who do not routinely deal with blast or ballistic injuries.

Please be aware of other information available.

CitizenAid (https://www.citizenaid.org/home )– This is government generated advice with an App which covers a whole range of badness.

If you want to communicate to the emergency services where you are anywhere in the world, I would recommend you download the What3Words App https://what3words.com . Three words are used to describe everywhere within 3m on the planet.

RUN, HIDE, TELL - (UK government advice)

https://youtu.be/4jxOXbpTmnk

RUN, HIDE, FIGHT – (US government advice)

https://www.youtube.com/watch?v=5VcSwejU2D0

GO Guide for trauma team

MTC Geris input

John Radcliffe Orthogeriatrics

(1) Please use the NOF power plan on EPR when clerking hip fracture patients in ED ( it is designed to improve the quality of the prescribing for these patients and ensures the basics are right from the start – it is also a lot quicker for you !)

(2) The geris registrar on call ( bleep 6669) should be informed of all new hip fracture patients admitted after 16:00 on a weekday and at weekends so they can review them

(3) The GO patients are your responsibility out of hours - if you need medical advice for a hip fracture patient on the ward that is under the GO team please contact the medical reg on-call (bleep 1475) – the on call geris reg does not cover these patients out of hours

(4) A perioperative fellow or geratology registrar will be have bleep 4384 on the JR site and you can contact them between 09:00 and 17:00

(5) If you need urgent medical review for a MTC Geriatrics patient or hip fracture patient that is currently on the ward please contact the medical reg on-call (bleep 1475)

MTC Geriatrics

This service forms part of the major trauma MDT and provides a liaison service to all MTC patients with an ISS of 15 or more, above the age of 65. Although these criteria are at present based on resources, please recognise that there are other frail patients with fragility fractures that would benefit from their input.

Policy for management of potential older Trauma patients moving to the Horton

To confirm the medical suitability of patients who are identified for transfer to the Horton (not for urgent medical reviews), the GO/MTC team and Geratology SpR will help with the following:

- All hip fracture irrelevant of age

- All trauma patients over 60 years

Monday to Friday

0800-1600 – GO/MTC team b4384/6671

1600 – 2130 – On call Geratology SpR b6668

Nights - this decision should be deferred to the morning

Weekends/BH

9-2130 – On call Geratology SpR b6668

Nights – this decision should be deferred to the morning

For all new admissions to trauma: If the patient is acutely unwell and needs urgent medical attention the first port of call should be the on call medical SpR. The periop teams/geris SpR will endeavour to assist if possible.

We cannot guarantee to review patients for suitability for transfer within the 4 hour breach time at the current time.

Cancellation policy flow chart

EPR Micro referral

The OUH Clinical Infection advice service is moving to EPR requesting for referrals from 1st May 2019. Please note this e-mail refers to Adult Infection advice service only. There is no change to the Paediatric ID service. The way to do this is in the attached document. Please note that the services are site based so choose the correct ‘consult message’

• Infection advice JR 1&2 and Cardiac

• Infection advice West Wing and Trauma

• Infection advice Churchill

• Infection advice NOC

• Infection advice Horton

Use EPR to request a review of an in-patient or if you need an opinion without a clinical review.

Please ask your junior to include sufficient clinical details to allow the referral to be triaged and located, their own name and bleep number, and your name. Referrals received after 3pm will be triaged (up to 5pm) but a clinical visit, if required, may be delayed until the following day

For emergencies, the Infection registrar bleeps will operate as usual.

• JR sites 1 and 2 plus cardiac (excluding trauma): 4076

• West wing and trauma: 4075

• Churchill 5039

• Horton 9799

• Nuffield Orthopaedic Centre 7186

• JR Adult ITU at JR and Microbiology lab 4077

• ID ward registrar 5885

Please note: the following trust-wide advice services will continue unchanged in parallel with EPR-requested clinical consultations.

• Unsolicited consults generated by positive Blood Cultures or other significant labs results

• Antimicrobial stewardship ward rounds.

• Infection Prevention and Control rounds.

• Intensive care ward rounds

• Specialist MDT meetings

OUT OF HOURS

Please DO NOT use EPR referrals for urgent cases. Contact details are unchanged and are below.

Weekends and bank hols 9am – 5pm:

Microbiology registrar: 4077,

Infectious Diseases registrar : 5885

Consultants available via switchboard.

All evenings 5pm – 9am

Microbiology or Infectious Diseases registrar via switchboard.

Consultants available via switchboard

Please can we ask that ALL overnight ED / outpatient decisions are discussed with the On Call Consultant in the morning before the screens meeting.

This should have been part of our morning routine for some time, but I accept that it has not become an ingrained habit.

I would also like to remind you that you should be generating a letter equivalent to a new patient clinic consultation (or an EPR entry) for each of these interactions.

Process mapping for Orthoplastics cases

When operating in another teams theatres, make sure:

1) all kit you need is available

2) your scrub staff and radiographer are informed and available

3) whether your 'home' theatre can continue to run otherwise 'stand down' until case complete

Kit required by plastics team to be taken to main JR theatres

Sterile TQ

Plastics major set x 2

Dermatome and mesher

Self-retainers Large and small multiple

Ligaclips – all sizes

Micro set and sutures

Ring forceps

Micro backround

Implantable Doppler and machine

Drains (suction) x 2

Paediatric NG tube for suction

Jelonet (large), dressing gauze, sterile mefix,

Note we want warm saline, lignocaine, papavarine

(ST non latex gloves, SA gloves box sent down for theatre)

OUH Traction guide

• Skin traction is ONLY to be used in conjunction with a Thomas splint for the temporary immobilisation of a femoral shaft fracture prior to surgery. Its application should be for no more than 24 to 48 hours. If the Thomas splint cannot be tolerated it should be removed as a matter of urgency after discussion with the consultant. At this point skin traction should be discontinued.

• Skin traction (with the 2.5kg maximum weight) via a balanced traction system affords neither pain relief nor reduction of the femoral fracture and should NOT be used.

• Acetabular and pelvic fractures requiring traction should be managed with a skeletal pin and a minimum of 5kg weight. A tibial skeletal pin can be inserted in the Emergency Department / Ward under local anaesthetic or taking advantage of the sedation used for reduction.

I have attached a practical guide on the application of a Thomas splint.

Please find below a link to further information from the RCN (you need to be logged into hospital server)

http://ouh.oxnet.nhs.uk/TraumaUnit/Document%20Library/Nursing%20-%20Clinical%20Education/Protocols%20and%20useful%20informations/Traction/Traction%20-%20principles%20and%20application%20-%20RCN%20guidelines.pdf

http://ouh.oxnet.nhs.uk/TraumaUnit/Document%20Library/Nursing%20-%20Clinical%20Education/Protocols%20and%20useful%20informations/Traction/Skin%20Traction%20-%20Clinical%20Guidelines.docx

Radiological justification guidelines

C spine in children

IR guideline

CT Trauma imaging guide

Please be aware of the guidance when ordering Paediatric c-spine imaging (attached), Interventional radiology (attached) + Whole Body CT (WBCT)(aka Trauma CTs / Pan Scans).

• On EPR you must give a clinical indication that is sufficient to justify a WBCT. This is to allow us to be compliant with the mandatory IRMER requirements and provide the reporting radiologist with information that will help them focus on the areas of interest. The attached document outlines the acceptable justification requirements. The expectation is that the majority will be covered by:

  • High energy blunt trauma + (clinically suspected injuries) + (name + bleep of TTL)

  • Injury to more than one body part + (clinically suspected injuries) + (name + bleep of TTL)

  • Fall > 3 metres or down flight of stairs + (clinically suspected injuries) + (name + bleep of TTL)

  • Penetrating truncal injury + (clinically suspected injuries) + (name + bleep of TTL)

• If you suspect fractures of the extremities, a head to toe scout view should be performed. This needs to be requested verbally, in addition to the EPR request, before the patient is placed on the CT table

• If you suspect open peri-articular injuries you should obtain single shot AP x-ray using the digital x-ray in resus BEFORE the patient goes for a Trauma CT. If organised this is quick and should not delay life or limb saving interventions. If there is a periarticular fracture please place a separate CT request on EPR. This is particularly useful for cases likely to go to theatre for emergency procedures eg open fractures. Return trips to CT is a waste of time and resource.

• If you suspect a lower limb vascular injury, please specifically request lower limb angiography. This involves a different contrast strategy and will allow the vessels down to the trifurcation to be adequately visualised.

• It has taken some time to resolve but we now have a CRIS code on EPR for patients who require rotational profile lower limb CT scans performed- this involves small field of view scans limited to the lower limb joint areas only for patients suspected of joint rotation & limb shortening. Code is CRPLL.

Trauma Matrix

Our inpatient documentation is now being recorded in EPR instead of Bluespier. For the time being Bluespier is still used for Operation Notes and Outpatient letters. Rehabilitation prescriptions are now being completed by AHPs using information from EPR Trauma Matrix. Although originally designed for polytrauma, very few monotrauma cases do not have something else that needs to be managed.

To avoid duplication of activity, for the whole team, we are insisting that a Trauma Matrix is completed on admission (see attached EPR admission proforma) and copied, pasted and updated daily into the ward round entry.

• Date and mechanism of injury

• List of injuries and active co-morbidities +/- complications

• Completed management of injuries and active co-morbidities (with dates)

• On-going management. The outstanding issues that need to be addressed eg planned operations + x-rays. Once they have been completed they can be dragged into the completed management column and annotated with a date.

The only additional entries will involve a small amount of subjective and objective observation.

Head Injuries with normal CT - Please bear in mind that people can have significant head injuries without abnormal CT findings. In Polytrauma Clinic, it is surprising how many significant on-going problems are only elicited with direct questioning. If patients have a history of loss of consciousness please keep ‘Head Injury’ on the Rehabilitation Prescription.

Screens – If you are presenting a polytrauma case, update and use the matrix. This will be more useful and save you typing up another script, only for it to go in the bin.

Consultant letters – The consultants will often start their letters with a trauma matrix at the top of their inpatient letters.

Discharge Letter – If the Trauma Matrix is kept up to date this is the ONLY INFORMATION that should be pasted into the EPR discharge letter. The GPs (or rather their admin staff who transcribe into the GP electronic notes!) do not need or want anything else!