Bedoc Clinician Update Training 2008

BedocClinician UpdateTraining 2008 Refresher Training Module 1

Bedoc GP Update Training You will need to set aside 1 ½ hours to complete this training. If you wish this may be done in two sittings. PRINT OUT THE WORKSHEETS HERE Please have a pen ready to jot down answers. Policies and procedures relevant to the training is fully available on the Bedoc website. This presentation will contain links to these policies.

Bedoc Training Objectives • Good Clinical Care - to be aware of Bedoc policies and procedures that impact on Good Clinical Care: managing emergencies; safe and effective prescribing; managing challenging patients; learning from significant events. • Maintaining Good Medical Practice – to be aware of requirements to maintain core competencies in Out of Hours GP care • Relationships with patients – to be aware of call audit procedures and feedback mechanisms, patient complaints procedure and results of patient satisfaction survey • Relationships with Colleagues – to be aware of how teamwork affects Bedoc working environment, awareness of staff roles, staff appraisal and roles of executive team and council.

MODULE ONE: CONTENTS • MANAGING EMERGENCIES • PRESCRIBING • MEDICINES MANAGEMENT • CHALLENGING PATIENTS • ADVERSE INCIDENTS

Scenario 1. Managing Emergencies You are Centre doctor on a busy Saturday afternoon. The mobile doctor is visiting patients. You are working with a minor illness nurse, and there are 5 or 6 patients waiting to be seen. Whilst you are with a patient, the receptionist knocks on the door and rushes in, saying a patient has collapsed in the waiting room.

Scenario 1. Managing Emergencies You immediately go out to the waiting room and find that a young woman transferred from A&E with asthma has collapsed on the floor of the corridor, and is in extreme respiratory distress. As you move to assess the situation she stops breathing. What actions will you take? (please write down your actions)

Managing Emergencies – Possible Actions • Summon Help? • Carry out an initial Basic Life Support Assessment (click for guidelines) • Retrieve the Bedoc Resuscitation Box and begin advanced resuscitation? CLICK HERE TO CONTINUE WHEN REVIEWED ALL OPTIONS

Summon Help • WHO will you summon? • HOW will you do it? • DIAL 2222 AND ASK FOR THE CRASH TEAM TO BE SENT TO FRACTURE CLINIC • CLICK TO CONTINUE – REVIEW OTHER OPTIONS

Bedoc Resuscitation Box • Bedoc no longer has a resuscitation box in the centre. There is a box in the car for home visit use. • There is a pocket mask in the cupboard for Basic Life Support • BEDOC no longer has a defibrillator on site. • In extreme emergencies (respiratory or cardiac arrest) the correct procedure is to summon the Crash team. • CLICK HERE TO CONTINUE – TRY OUT OTHER OPTIONS

Bedoc Emergency Procedures • Within the Bedoc Centre, patients requiring emergency resuscitation are best helped by summoning the Crash team. Dial 2222 on any internal phone and clearly state that the Crash Team is needed in the Fracture Clinic. Stay with the patient until the Crash team arrive, if necessary providing basic CPR. • Patients with non-life threatening urgent care needs can be treated by GP and nurse using emergency injectable drugs,and nebulised drugs. Write down the answers to the following questions before clicking the links. • Where are the emergency injectable drugs stored? • How are the emergency injectable drugs accessed? • Where is the Bedoc Nebuliser and drugs stored? • What nebulised drugs are available? • CLICK HERE AFTER FOLLOWING THE LINKS ABOVE

Bedoc Centre Injections • The emergency injections are kept in a locked black case that is kept under the front reception desk. • The keys to the bag are kept in an envelope at the front of the top drawer of the filing cabinet in reception • Palliative care injections and controlled drugs are stored separately in the drug room in A&E • CLICK HERE TO SEE THE CONTENTS OF THE BAG • Click here to continue

Bedoc Nebuliser • The nebuliser and drugs are both stored in the cupboard in room 4, with disposable, single use, tubing and masks. • Salbutamol, combivent nebules are available for emergency treatment of Asthma or COPD; and pulmicort nebules for mild to moderate croup • Click here to continue

Scenario 2: Temporary patient • A 23 year old man is transferred from A&E who has an address outside the area. He is requesting treatment for his renal colic. He says he is normally prescribed pethidine tablets by his own doctor. He says he is allergic to diclofenac and is unable to take other anti-inflammatories.

Scenario 2: Temporary patient • What are the issues here? • What Bedoc policies apply in this case? • What clinical actions are appropriate? • What Bedoc procedures should be followed? • Jot down your answers before proceeding • Click here to continue

Issues • The story is suspicious for several reasons – the patient is presenting out of their normal area, they are requesting controlled drugs that have an abuse potential and a street value, there is no way of verifying the details with the GP as they have presented out of hours. Patients who manipulate doctors for drugs are often very plausible about why they cannot have alternatives, why they must have this particular treatment, and why they may have run out of their normal supply.

Bedoc Policies: Prescribing • The following issues are more likely to be of concern to an out of hours GP : Drug addiction, alcohol misuse and requests for tranquilisers and opiates,…. • Analgesics should be prescribed and dispensed with care. Opiate prescribing should only be for severe pain, and small quantities should be prescribed normally. • No controlled drug opiates should be prescribed to drug addicts • CLICK HERE FOR THE FULL POLICY • CLICK HERE TO CONTINUE

Bedoc Policies: Challenging Patients • Patients with or without a history of substance misuse, who are requesting potentially addictive medication • Particular concern should be raised if the patient has presented before, if the patient has lost a prescription or has been unable to collect their regular supply of medication/run out early for whatever reason. • Patients in any of the above categories may give false names or pseudonyms, differing addresses, differing spelling of names, different telephone numbers. In these cases a new patient chart is generated and the special patient notes may not be visible. • CLICK HERE TO SEE FULL POLICY • CLICK HERE TO CONTINUE

Clinical Options • Assess each case on its merits. • Ensure adequate clinical history and examination. Document in Adastra • Options could include: • Onward secondary care referral to establish diagnosis • Alternative supply of non-controlled analgesia e.g. small supply co-codamol or dihydrocodeine • A very small supply of Pethidine tablets (if confident not an addict and plausible story) • Document actions taken • Always prescribe using Adastra (only hand write on visits)

Bedoc Procedures • Fill out a Challenging Patient notification form (page 3 of the Challenging patient policy), and post to the Bedoc Office.

Telephone scenarios • Be wary of patients who ring requesting controlled drugs/ drugs of abuse. • Warning signs: • Aggressive, demanding tone • A complicated or implausible story • Not interested in giving a history – more focussed on getting what they want

Telephone scenario: addicts • HOW TO MANAGE CALLS FOR DRUGS: • Remain assertive • Aim for a full and comprehensive telephone assessment of the clinical problem • DO NOT tolerate verbal abuse (CLICK HERE) • Do not invite patients in to be seen if there is no clinical indication – it may be interpreted as a foot in the door to get drugs and potentially may cause an escalating problem • Be prepared to say NO on the phone.

Potentially violent or aggressive patients • Violence against NHS staff is rare. • Patients who are upset or under the influence of drugs or alcohol are more likely to become aggressive or violent. • Where possible try and prevent and predict potential problems: • On the telephone – verbal aggression, abuse, threats, demands. Try and contain and close call • Warnings from others – NHS Direct, A&E, receptionist, special patient notes

Potentially violent or aggressive patients • Look out for warning signs - • Patient becoming physically agitated, moving closer, staring or no eye contact, (non verbal clues) • Raised voices, demands, threats, verbal abuse • Protect yourself: • Move towards the door and exit • Press panic alarm (to be fitted in all consulting rooms) • Summon help from other staff (doctors, receptionist, drivers) • Receptionist can currently summon fast response from security with panic alarm

Potentially violent or aggressive patients • Support other staff: • If you recognise other clinical staff are at potential risk – take steps to protect them – invite them from the room, call emergency security response. • Don’t leave others vulnerable – if there is a potential problem consider dual consultation, consult with the door open, consider having hospital security on standby.

Scenario 3: Prescribing • At 5.30pm on a Sunday evening you see a 36 year old woman with a history of menorrhagia. This is an ongoing problem for several months. Her GP has treated her in the past with tranexamic acid. Over the previous 48 hours she has had significant bleeding, passing frequent clots. • What other information would you need? • What examination would you do? • Jot down your thoughts before proceeding

Scenario 3: Prescribing • Click here for Clinical Guidance on the assessment and treatment of menorrhagia (GP Notebook) • Your clinical assessment suggests she is not pregnant, haemodynamically stable, and does not require admission. Physical examination is normal. You request next day blood tests and GP follow up. Your preferred drug treatment is not available from the Bedoc formulary (CLICK HERE TO SEE THE FORMULARY). • What could you do? • Jot down your options before continuing

Scenario 3: Prescribing • Assess each case on individual merit • Consider the following: • Prescribe NSAID from formulary to be dispensed from A&E (e.g. ibuprofen or diclofenac); • Script for other treatment to be collected next day (e.g. mefenamic acid, tranexamic acid, COC pill) with referral back to GP for ongoing care/ other options (e.g. Mirena coil, referral) • Oral progestogens at large doses such as norethisterone 30 mg daily can be successfully used to control torrential bleeding (flooding): a regime of norethisterone at a dose of 30mg per day is initiated (which is generally effective within 24-48 h); the dose can then be reduced by 5mg per day and then stopped. This regime will be followed by a withdrawal bleed • Discussion with on – call gynaecology registrar if treatment/ investigation required before following morning CLICK HERE TO REVIEW BEDOC POLICY ON FORMULARY USE

Scenario 3: Prescribing • DO NOT issue a script for a non-formulary item and ask A&E to dispense. • ONLY items in the formulary should be dispensed from A&E. • DO NOT ask A&E to dispense if there are pharmacies open which the patient could access.

Scenario 4: Adverse event • A major IT problem causes complete loss of Adastra from 8am to 7pm on a busy Saturday. The contingency arrangements involve patient records being faxed from NHS Direct, and all patients being contacted by phone. At 9.30pm, 90 minutes after the IT link is restored, it is discovered that five patients from the morning were not contacted as the details had not come through on the fax, and no-one at Bedoc was aware of the problem.

Scenario 4: Adverse event • You are the duty doctor. • What is your first action? • CLICK HERE TO CONTINUE • Contact all five patients as soon as possible to assess their clinical condition

Scenario 4: Adverse event • You contact the five patients. Four have minor symptoms and appear not to have been harmed. The fifth patient is an elderly man with chest pain. You speak to his son. He waited 4 hours for a return call that did not come, his condition deteriorated and his son called an ambulance. He is now being ventilated in ITU. • What actions do you need to take? • Jot down your actions before proceeding

Scenario 4: Adverse event • Apologise. • Take contact details for the son. • Inform the son that this will be investigated and that someone will be in touch • Is this a significant event or a serious adverse incident?

Scenario 4: Adverse Incident • As there is potential serious patient harm that has resulted this is a Serious Adverse Incident (SAI). • SAIs need to be reported to the on call manager as soon as they occur. • How are SAIs defined? – see the policy • Click here to read the Bedoc Serious Adverse Incident Policy

Scenario 4: Adverse Incident • How do you contact the on-call manager? • CLICK HERE TO READ THE BEDOC SIGNIFICANT EVENT POLICY

CONCLUSION • PLEASE COMPLETE AND RETURN THE FEEDBACK FORM AT THE END OF THE WORKSHEET. • If you have email set up through Outlook or Outlook Express please click here to email confirmation of completion of the module. • If you access email through a web browser please email to tracey.lumbis@bedfordhospital.nhs.uk using ‘I have completed Bedoc Module 1 Training’ as the title of the email. • CLICK BELOW TO COMPLETE AND PRINT OFF YOUR CERTIFICATE (ENTER YOUR NAME AND DATE ON THE FORM) • CLICK FOR CERTIFICATE

CONGRATULATIONS! YOU HAVE NOW COMPLETED MODULE ONE

Bedoc Clinician Update Training 2008