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					CLINICAL TEACHING UNIT
 General Surgery




                   Orientation
                      Package
Welcome to:


   MCMASTER UNIVERSITY MEDICAL CENTER’S CLI NICAL
        TEACHING UNIT IN GENERAL SURGERY




This package will:
Give you an overview and introduction to the CTU:

        How the CTU works, who to call, where to go and generally how things are done
         on a day –to-day basis

        Details of the support services available, and how to access them

        Expectations of the resident and general learning objectives for the rotation
TABLE OF CONTENTS
What is the CTU: ................................................................................................................................................................................... 6

How the CTU works: ............................................................................................................................................................................. 6



ROUNDS AND OTHER EDUCATIONAL EVENTS:............................................... 7
1. Morning teaching rounds: ................................................................................................................................................................ 7

2. Morbidity & mortality rounds: ........................................................................................................................................................ 7

3. Breast Rounds: .................................................................................................................................................................................. 7

4. Hepatobiliary Rounds: ...................................................................................................................................................................... 7

5. Grand Surgical Rounds: ................................................................................................................................................................... 7



NOTIFICATION OF MOST RESPONSIBLE PHYSICIAN OF
CHANGES IN IN-PATIENT STATUS ..................................................................................... 8
Monday to Friday 0800hrs to 1700 hrs. ............................................................................................................................................... 8

Any day 1700hrs. to 0800hrs. or weekends .......................................................................................................................................... 8


Directory of Staff General Surgeons ....................................................................................................... 9

PRACTICE PROFILES.................................................................................................................................................... 10



SUPPORT SERVICES FOR WARD 4Z ............................................................................. 11
Unit Leader .......................................................................................................................................................................................... 11

Registered Nurse (RN) ........................................................................................................................................................................ 11

Registered Practical Nurse (RPN) ...................................................................................................................................................... 11

Education and Development Clinician ............................................................................................................................................... 11

Business Clerk (BC) ............................................................................................................................................................................ 11



SUPPORT SERVICES.......................................................................................................................... 12
Pharmacy ............................................................................................................................................................................................. 12

Nutrition Services ................................................................................................................................................................................ 13

Social Work Services ........................................................................................................................................................................... 14

Speech and Language Pathology (SLP) ............................................................................................................................................. 15

Physiotherapy Services........................................................................................................................................................................ 15



                                                                                                   3
Occupational Therapy Services .......................................................................................................................................................... 16

Skin,Wound and Stoma Clinician ...................................................................................................................................................... 18

Home Care (CCAC) ............................................................................................................................................................................ 18

Palliative Care ..................................................................................................................................................................................... 18

Geriatrics/Seniors Health.................................................................................................................................................................... 19

Rehabilitation ...................................................................................................................................................................................... 19

ETHICS CONSULTATION SERVICE ............................................................................................................................................ 19

Pediatric Trauma and the Pediatric Trauma Team ......................................................................................................................... 20

INDICATIONS TO CALL THE PEDIATRIC TRAUMA TEAM .................................................................................................. 21



RESIDENT EXPECTATIONS & DUTIES ......................................................................... 22
Ward Work .......................................................................................................................................................................................... 22

Charts ................................................................................................................................................................................................... 22

Patient Rounds..................................................................................................................................................................................... 22

Multidisciplinary Rounds ................................................................................................................................................................... 23

Operating Room .................................................................................................................................................................................. 23

Emergency Department coverage ...................................................................................................................................................... 23

Clinics ................................................................................................................................................................................................... 24

On Call Duties...................................................................................................................................................................................... 24


OTHER USEFUL INFORMATION ................................................................................................................................... 25

Photocopying: ...................................................................................................................................................................................... 25

Lockers:................................................................................................................................................................................................ 25

Food:..................................................................................................................................................................................................... 25

Books: ................................................................................................................................................................................................... 25



TIPS FOR SUCCESS ON THE WARDS........................................................................... 25
These tips come from a variety of sources, your staffpeople, nurses and previous residents. ........................................................ 25


APPENDIX A: STATEMENT OF PRINCIPLES AND GUIDELINES REGARDING SUPERVISION OF POSTGRADUATE
CLINICAL TRAINEES. ........................................................................................ ERROR! BOOKMARK NOT DEFINED.27


APPENDIX B: GUIDELINES FOR FEEDING TUBE CHANGES OR REPLACEMENTS ................................................. 27

Introduction: ........................................................................................................................................................................................ 27




                                                                                                     4
Feeding tube Replacements ................................................................................................................................................................ 27

Recommendations for Contrast Studies for Feeding tube Replacements ........................................................................................ 28

General Categories of Feeding Tubes ................................................................................................................................................ 28


COMMERCIALLY AVAILABLE GASTROSTOMY TUBES ............................................................................................. 28

Foley Catheters .................................................................................................................................................................................... 28

Mic-key gastrostomy tubes ................................................................................................................................................................. 29

‘Button’ gastrostomy tubes ................................................................................................................................................................. 29

Percutaneous endoscopic gastrostomy tubes ..................................................................................................................................... 29


OTHER TYPES OF FEEDING TUBES INCLUDE: .......................................................................................................... 29

G-J tubes or transgastric feeding jejunostomy tubes ........................................................................................................................ 29

Jejunostomy tubes ............................................................................................................................................................................... 29


APPENDIX C: REGIONAL AND INTERNAL POLICY CHANGES FOR DISCHARGE PLANNING IMPACTING
PHYSICIANS AT HHSC .................................................................................................................................................. 30


APPENDIX D: SAFE PRACTICE AND CENTRAL LINES.............................................................................................. 32




                                                                                                  5
WHAT IS THE CTU:

The CTU is a clinical teaching unit based on Ward 4Z. It is run by five general surgeons with an
interest in resident education. The director of this unit is Dr. Stephen Kelly. We are supported by
nursing personnel as well as other health care service providers. In addition, the ward houses the
inpatients of the GI medicine service. Teaching occurs in both formal settings such as rounds, as
well as patient based informal teaching at the bedside, in the Operating Room, and in the clinics.

4Z is located on the 4th floor, in the Yellow area. The ward is divided into north and south ends,
the charts for the patients are housed at both ends of the ward. There is a large board behind the
business clerks‟ desk, which lists all the patients and their room assignments. In addition, there is
a separate board at each end, which tells you which nurse is assigned to which room. If you
cannot find your nurse, ask, if she/he is on break the other nurses will cover and pass on any
messages.

HOW THE CTU WORKS:

Basically this is a surgeon-based rotation. You are assigned to work primarily with one or two
staff surgeons. Depending upon the number and level of training of other residents, you may
have other residents on your team as well. They might be senior or junior to you. Your
assignment is given to you by the Chief Resident or by Dr. Kelly. Although you may request a
particular team, no guarantees can be given, as assignments reflect the needs of all the residents on
the unit during your rotation. There will be a chief resident assigned to your team as well. There
may be times when you will be asked to participate in the care of patients that are not on your
team. Please remember the CTU works as a service of general surgery and when needed, it is
expected that you will help out, especially during emergency situations or particularly busy days.

Patients are admitted to the CTU ward 4Z under individual surgeons. These patients may come
through the Emergency Department, the Operating Room or elective admissions. If 4Z is full,
your patients may be admitted to another ward, but they are still under the care of your team.

There is a general surgeon on call each day. When your staff person is on call, you will be on call
as well during the day. Night calls will be as per the on-call schedule.

The Chief Resident will assign the call schedule; this should be available 2 weeks prior to the
beginning of the month. If you have any vacation requests, you must submit these as early as
possible. There is no guarantee that you will receive your request until it is deemed that clinical
service requirements are met.




                                                 6
Rounds and other educational events:
1. AFTERNOON TEACHING ROUNDS:

Friday 3:00pm., room 4E20. These teaching rounds are topic based and given by the residents
on rotation. The chief resident and Dr Kelly are responsible for assigning dates. These rounds
are attended by staff surgeons, residents, and clinical clerks.

Attendance at these rounds is mandatory. If an unstable patient prevents you from attending,
please send a message to your chief resident. Advanced scheduling of rounds means you should
be prepared the night before the night before. A busy night on call is therefore not a reason to
cancel rounds.

If there is an emergency necessitating rounds being canceled, it is the responsibility of the resident
involved and the chief resident to notify all parties either by phone or pager.

If you are scheduled to present rounds and you are in the OR with an urgent case, inform your
staff person that you must leave the OR to present rounds. Have the chief resident or Dr. Susan
Reid paged and a replacement for you will be sent to the OR.

2.      MORBIDITY & MORTALITY ROUNDS:

Monday 0700 Rm. 4E18

RESIDENTS ARE EXPECTED TO ATTEND AND BRING CASES WITH X-RAYS
OF ANY MORBIDITY FROM EITHER INPATIENTS OR OUTPATIENTS.

3. BREAST ROUNDS:

These are multidisciplinary rounds occurring once per week on Tuesdays at 2:00 p.m., in the
Pathology Department. You do not need to do any preparation for these rounds. Cases are
presented by the staff, with review of the radiology and pathology by members of those
departments.

4. HEPATOBILIARY ROU NDS:

These multidisciplinary rounds run on Friday mornings 0700 in Radiology by Dr. Marcaccio.
Please check with Dr. Marcaccio for the exact time if you are interested.

5. GRAND SURGICAL ROUNDS:

These city-wide rounds are presented each Wednesday morning at 0730, in the room 4E20.
Attendance for general surgery residents is mandatory, and strongly advised for off service
residents.




                                                  7
Notification of Most Responsible Physician of Changes in In-
patient Status
On occasion, in off hours, (after 5pm,or weekends) a patient may develop a serious change in
their condition. To alleviate concern as to who is the most appropriate staff person to notify, the
following guidelines are designed to help you ensure proper notification and keep the lines of
communication open amongst all physicians involved.



MONDAY TO FRIDAY 0800HRS TO 1700 HRS.

Notify the MRP either through paging or through the surgeon‟s office. If the surgeon is signed
out, then notify the surgeon on call. If the surgeon is on extended absence, i.e. vacation or
conference, his or her patients should have been transferred to a pre-arranged substitute. If so,
then notify that MRP.

ANY DAY 1700HRS. TO 0800HRS. OR WEEKENDS

Attempt to notify the MRP through paging. If their pager is signed out, then contact the surgeon
on call. If the MRP‟s pager is not signed out, yet they do not answer within 10 minutes, assume
you cannot reach them and contact the surgeon on call.

THE FOLLOWING ARE EXAMPLES OF CHANGES IN PATIENT STATUS
THAT REQUIRES A STAFF PERSON TO BE NOTIFIED:

                  Death of a patient.

                  Transfer to a higher level of care, i.e., ICU, or CCU

                  Any significant change in the patient‟s condition; whenever an unusual or
                   unexpected finding is observed; whenever the diagnosis or management is
                   in doubt; prior to the undertaking of a procedure or therapy which has the
                   potential for immediate or future serious morbidity

                  The consideration of referral to another specialty

                  Discharge of a patient not previously planned

                  These guidelines are specific to this Clinical Teaching Unit. For a full
                   review of the subject, please refer to the Ontario Colleges Publication
                   attached (see Appendix A)




                                                8
                D I RE C T O RY OF S TAF F G E NE RA L S U RGE O NS




    NAME          OFFICE      SECRETARY        PHONE      PAGER         EMAIL
                 LOCATION       NAME           NUMBER



 DR. SUSAN          2F45        BRENDA         527-0577    3001   REID@MCMASTER.CA
   REID                                        OR EXT.
                                                73188



DR. MICHAEL         2F41         SONIA         522-8344    3002       MARCACCI@
MARCACCIO                                      OR EXT.
                                                                    MCMASTER.CA
                                                73189




 DR. STEPHEN        2F43       SAMANTHA         EXT.       2214       KELLYST@
    KELLY
                                                76241               MCMASTER.CA
 CTU Director


DR. LEYO RUO        2F49         SUSAN          EXT.       2041   RUOL@MCMCMASTER.CA


                                                76626



  DR. WES           2F47         KRISTEN         EXT.      7413    STEPHENW@HHSC.CA
  STEPHEN
                                                73670




                                           9
                          P R A CT I CE P ROF I LE S


      AREA OF INTEREST                     SURGEON                    **SCHEDULE**

                                                            Monday – AM- administration
                                                                     -PM clinic 4V1
                                                            Tuesday – AM- clinic 4V1
          COLORECTAL                     DR. S KELLY                  PM endoscopy
                                                            Wednesday OR
                                                            Thursday – Administration
                                                            Friday – AM Clinic
                                                                    PM administration
                                                            Monday – administration
                                                                      PM clinic 4V1
                                                            Tuesday – Clinic (3V1)/Admin
                                            DR. W.
          COLORECTAL                                        Wednesday – AM - Endo
                                           STEPHEN
                                                                          PM Clinic (4V1)
                                                            Thursday – OR
                                                            Friday – AM – Endo
                                                                     PM Short Stay Unit/Administration
                                                            Monday – AM -ERCP
                                                            Tuesday – OR
     SURGICAL ONCOLOGY                    DR. L. RUO
                                                            Wednesday – AM-ERCP
                                                            Thursday – AM Clinic
                                                            Friday – OR/ERCP
                                                            Monday –AM Clinic (3V1)
                                                                     -PM OR
                                            DR. M.
HEPATOBILIARY/PANCRE ATIC                                   Tuesday – OR
                                          MARCACCIO
                                                            Wednesday – Administration
                                                            Thursday – PM Clinic
                                                            Friday - AM – ERCP
         CRITICAL CARE                                      Monday – OR
                                                            Tuesday – Clinic 3V1
                                                            Wednesday – Education
      GENERAL SURGERY                     DR. S. REID
                                                            Thursday – AM – Endo
                                                                       PM – Clinic
              BREAST
                                                            Friday – Administration/ICU
                                                            ICU 1 week every month


**All schedules are subject to change. Please check with the appropriate secretary for
final schedules**




                                         10
Support Services for Ward 4Z
UNIT LEADER

     The primary responsibilities of the unit leader are to coordinate the overall unit activity
     and to assist the interdisciplinary team in meeting the health needs of patients and their
     families, and to coordinate discharge planning.

     The Unit Leader assists new staff with learning needs, performs staff scheduling and daily
     assignments with staff in other areas when conflicts arise. She attends patient/family
     meeting, coordinates bed management (admission, discharge, and transfer of patients),
     and communication with other areas of the hospital on behalf of the ward.

REGISTERED NURSE (RN)

     The RN provides total care to the patients assigned to her. This includes assessment,
     planning, implementation, and evaluation. The RN is integral in the care of the patients
     on 4Z. She is the best source for information on the condition of your patients.
     Therefore, communication with the RN is imperative for optimum patient care.

REGISTERED PRACTICAL NURSE (RPN)

     The RPN assists the RN with patient care, within their scope of practice, e.g.; dressings,
     bathing, checking vitals. Feel free to discuss a patient‟s progress with the RPN. The
     RPN cannot take verbal or phone orders.

EDUCATION AND DEVELO PMENT CLINICIAN

     The Education and Development Clinician is a resource to all staff on 4Z to assist them
     in meeting their learning needs; to facilitate excellence in clinical practice and to provide
     continuous learning and professional development opportunities.

BUSINESS CLERK (BC)

     The business clerk provides clerical, administrative and business support to patients,
     families, and those providing service and /or care. She can assist you with patient-related
     long distance phone calls, faxes, or ordering special supplies. In collaboration with the
     Unit leader/charge nurse and RNs, the BC coordinates the admission, discharge, and
     transfer of patients. She transcribes orders, does staff scheduling, performs clerical
     functions, internal and external communication, and payroll. In order to make their job
     easier, please do not use their computer or phone. Also, please do not stand next to the
     desk when discussing patients with your colleagues, as it can disturb the business clerk as
     they are working.




                                             11
Support Services
PHARMACY

Pharmacy hours:

Monday to Friday 0800 –2000 hrs
Saturday, Sunday and Stat. Holidays 0900 – 2000 hrs
Pharmacist is on call during off hours, call through paging Ext. 76021

Pharmacist for ward 4Z:

The Pharmacist can be reached at ext. 76023 or pager #1264. The Pharmacist‟s role includes:

     Maintaining patient drug profiles and monitoring for drug interactions, side effects, and
      therapeutic goals.
     Providing drug information.
     Patient drug history and counseling.
     Discharge planning:
              1. Self – med program for appropriate patients
              2. Discharge prescription planning including “Limited drug use” and “Section 8”
                 Rx
              3. Discharge prescription review with patient and/or family

    Hospital Drug Formulary

     Only medications on the hospital formulary are routinely in stock in pharmacy. We can
      accommodate special request if a clinical situation demands it.

     Certain medications may need sub-specialty involvement, e.g. IV ciprofloxacin,
      amphotericin may need infectious disease involvement

     List of automatic substitutions approved by P & T committee

Drug Information Services

     Obtain investigational or special access drugs
     Study medications
     Set- up of clinical trial drugs




                                               12
Out –Patient Pharmacy
Located on main floor in gift shop
Rx for staff and family
Hours Monday – Friday 0830 – 1800 hrs
        Saturday 1000 – 1400 hrs
        Sunday and holidays, - closed


NUTRITION SERVICES

Two full-time registered dietitians provide in-patient and out- patient coverage (4V1 and Home
TPN Program) Monday to Friday. No service is provided on the weekends, but standardized
TPN order forms are available for use.

Role of the Registered Dietitian

Patient charts are routinely screened in order to identify those at nutritional risk. Documentation
by physicians of preceding nutritional problems (i.e. alteration in nutrient intake, weight loss) is
helpful when screening charts.

To ensure optimal patient care for certain high-risk populations, please request a nutritional
consult for the following:

       previously malnourished or suboptimal oral intake for > 5 days.
       dysphagia
       renal disease
       hepatic disease
       hyperemesis
       malabsorption due to -Crohn‟s disease, Ulcerative Colitis, and associated complications
        (i.e. fistula)
       significant weight loss, requiring implementation of oral supplements, enteral, or
        parenteral nutrition
       pancreatic cancer
       pancreatitis or pancreatic insufficiency
       oral or esophageal cancer/ stricture/surgery
       bowel obstruction
       intractable diarrhea


We perform nutritional assessments, implement, and develop nutritional care plans, monitor
outcomes, (i.e. anthropometric measurements, biochemical parameters,) and provide education to
patients and their families. 24 – 48 hours are required to set up home enteral or parenteral
support.

The Home TPN Program provides a service for those regional individuals unable to meet their
nutritional needs due to gut failure, with the goal of improving or maintaining their nutritional



                                                13
status in the home environment. Patients must be medically stable and have a home support
network.



SOCIAL WORK SERVICES



The 4Z Social Worker can be reached at. 75703, pager 1022

Social Work provides a broad range of psychosocial supports and services to the patient and
family and endeavors to assist the patient/ family in solving their problems. To do this in the
multidisciplinary team setting, we work with the patient/family, the team, and with community
agencies to achieve our combined goals.

Types of Referral for Social Work:

    Adjustment to Illness

    Adjustment to New Diagnosis

    Chronic Illness

    End Stage Diagnosis

    Emotional Problems

    Loss of employment

    Financial (EI, LTD, CPP, DISABILITY, WSIB, ODSP, etc.)

    Substance Abuse

    Person Abuse

    Homelessness

    Alternate level of care

    Placement from Hospital to a Long Term Care Facility

Discharge Planning * This is a process that begins when the patient is considered for admission
and will involve many team members. Please flag difficulties as they arise so they can be
addressed.

Hours are Monday – Friday 0900 – 1700 hrs. If you are not sure if a referral to Social Work is
appropriate, please call so the social worker can discuss it with you.



                                              14
SPEECH AND LANGUAGE PATHOLOGY (SLP)

The speech and language pathologist (SLP) for 4Z can be reached at ext. 73731 or pager 1144

Goals of the SLP:

     To provide assessment, consultation and treatment to those individuals who are at risk
      for or who have identified cognitive -–communication impairment.

     To provide assessment, consultation and treatment to those individuals who are at risk
      for or who have identified feeding / swallowing difficulties.

The following identified patient groups are at greater risk for oropharyngeal dysphagia and should
be considered for assessment to maximize outcome and minimize associated risks due to
dysphagia:

     Prolonged mechanical ventilation with or without tracheostomy

     Acute / chronic neurological event

     Acute /chronic cardiac / respiratory illness

     Dysphagia as primary complaint

     Dehydration /malnutrition

     Complex post surgical course

     Orthopedic fracture over age 60

     Head / neck trauma

Referral Process:

Verbal or written consultation for communication or swallowing assessment, Radiology
requisition for videofluoroscopy


PHYSIOTHERAPY SERVIC ES



The 4Z full-time physiotherapist can be reached at ext. 75398 pager 1563

The 4Z physio/occupational therapist‟s assistant ext. 73862

Standing or blanket orders exist for specific patient conditions:


                                               15
     Post surgical patients including all upper abdominal surgeries, excluding laparoscopic
      procedures

     All lower abdominal surgeries, including AP resections, low anterior resections, massive
      incisional hernia repairs, excluding femoral / inguinal hernia repairs, appendectomy,
      uncomplicated hernia repair

     Patients transferred from the ICU if they meet the above criteria

If a patient does not fall into one of the above categories, please write an order for physio
consultation, i.e., mastectomy patients for arm exercises, pre-op preparation of patients, or any
post surgical patient that develops chest or mobility issues.

Contraindications to treatment:

Pulmonary embolus, DVT (not heparinized) post-op hemorrhage, medically unstable patients.

Physiotherapy intervention includes assessment and treatment of the post surgical patient and
may involve:

     Chest care: deep breathing, coughing, manual techniques, positioning, suctioning,
      Incentive spirometers are limited but available for appropriate patients
     Functional Activities: Transfers, dressing
     Exercise Program for debilitated patients
     Mobility re-education: ambulation, use of aids, stairs
     Education re above and discharge planning with patient and family

Weekend Physiotherapy coverage exists but only covers priority patients:

     First day post-op
     Recent rib fractures
     ICU transfers with recent extubation, patients with extensive surgery or repeated surgery
     Patients with a change in their normal respiratory condition, i.e., increased secretions,
      worsening CXR, low O2 sats
     Debilitated patients and trach patients that have started to eat and are at risk for aspiration
      pneumonia
     Post-op ortho surgery patients with ambulation orders.


OCCUPATIONAL THERAPY SERVICES

We have organized the following information package to assist you during your time here. Please
read through this information and direct any questions or concerns to the Occupational Therapist
ext.75763 or pager 1257. We would be happy to assist you in your learning.
Appropriate Occupational Therapy (OT) Services offered on 4Z:

     Physical assessment



                                                 16
      Functional assessment: activities of daily living (ADL) and instrumental ADL

      Cognitive & perceptual assessment: as related to functional abilities

      Seating & cushioning, cushions

      ADL training; equipment prescription to increase independence and safety

      Hand & foot splint fabrication

      Functional mobility & transfers

      Wheelchair prescription & seating

      Input on patient‟s safety to return to home

      Liaise with team on discharge planning/ alternative living arrangements/referral to
       appropriate services

      Education on energy conservation and joint protection

      Education to family/caregiver

Please ask yourself the following questions when with your patients to help determine if
an OT referral would be appropriate:

1.       Is the patient over 60 years of age or frail?

2.       Does the patient live alone or lack social supports?

3.       Has the patient experienced a decrease in independence with self-care activities such as
         toileting, feeding, bathing, since hospitalization?

4.       Is there a concern with the patient‟s physical status with weakness or decreased balance
         during mobility, which may increase risk for falls?

5.       Have you identified any cognitive defects which may impact the patient‟s ability to
         prepare meals or look after themselves?

6.       Would the patient benefit from a more in-depth assessment of functional abilities to
         ensure they are safe to return home?




                                                 17
Remember:

The goal of Occupational Therapy is to improve or restore independence and, in turn, also to
prevent unnecessary readmissions. A written physician‟s order is necessary before OT can
become involved with a patient. Thanks for your referrals to Occupational Therapy!

                  OCCUPATIONAL THERAPY…Skills for the job of living!




SKIN, WOUND AND STOMA CLINICIAN



The Skin, Wound and Stoma Clinician is available 3 days per week on pager 1121 or Phone
Mail Ext. 76100

     Direct patient care, family education, consultation and assistance to staff members in
      ostomy, skin and wound management.

     Pre-op assessment, teaching, stoma site marking

     Collaboration with staff to establish plans to teach patient and/or family members

     Coordination of discharge with CCAC for community ET follow-up

     Reassessment of patients needs through outpatients (visits and/or telephone consults)



HOME CARE (CCAC)

The Homecare Coordinator can be reached at ext. 76111 or pager 1853. Home care can
provide nursing, physio or OT services. There is a separate referral sheet that must be filled out
for the home care consultation to be completed. Please be as specific as possible with respect to
dressings, & wound care. Please make the referral as early as possible to facilitate discharge
planning.



PALLIATIVE CARE

A palliative care consultation can be requested through pager 1561. The palliative care team can
provide nursing, physio or OT services. There is a separate referral sheet that must be filled out
for the home care consultation to be completed. Please be as specific as possible with respect to
dressings and wound care. Please make the referral as early as possible to facilitate discharge
planning.



                                               18
GERIATRICS/SENIORS HEALTH

The clinical Nurse Specialist for Geriatrics can be contacted on pager 1099 on Mondays,
Tuesdays, Wednesdays, pager 1814 on Thursdays and Fridays. She will perform the initial
consultation and confer with the geriatrician. This team can help with elderly patients who have
multiple medical and social issues. They may be able to help plan with respect to rehab, and
outpatient services available through the Geriatric Day Hospital. Seniors Health has a rehab unit
at the Hamilton General Hospital (7 Med West), where older adults meeting criteria for admission
can receive rehab.

                  For Geriatric Assessment referral call ext. 74549


REHABILITATION

Beds are currently located at Henderson and Chedoke.

Call intake at ext. 77001(Nurse clinician does the initial assessment)



ETHICS CONSULTATION SERVICE

The best decision about patient care is not always the easiest decision to make.

                  refusal of treatment

                  do not resuscitate orders

                  end-of-life decisions

                  beginning of life decisions

                  discharge planning

                  substitute decision-making

                  informed consent for treatment

Patients, families and staff must make difficult decisions everyday at our hospitals. Sometimes
there are no obvious answers or easy solutions. But differences in opinions, values and beliefs
need not be insurmountable.

Our Ethics Consultation Service helps patients, families and their caregivers reach common
ground. The consultation service is run by a team of health professionals with experience and
training in medical ethics. The team helps all those responsible make the best possible decisions
about patient care. Together they identify and clarify problems, explore implications and consider
options. While the ethics consultation service may make suggestions, the final decisions rests with
the patients, families and caregivers.


                                                 19
The Ethics Consultation Services is free, confidential and available to all. The team can begin
helping you within 48 hours of receiving your request.

There are three ways to contact the Ethics Consultation Service:

     you can ask any staff member on any ward to request an ethics consultation

     you can call the Clinical Ethics Committee secretary at (905) 521-2100 Ext. 73766 from
      Monday to Friday between 8:00 a.m. and 4:00 p.m.

     you can call hospital paging at (905) 521-2100 ext. 76443 and ask for the Ethics
      Consultation Service.

Your hospital is committed to helping build healthy communities, founded on the values of
respect, teamwork, caring, and innovation.

Our Ethics Consultation Service shares the same commitment for the well being of our patients,
families and caregivers.



PEDIATRIC TRAUMA AND THE PEDIATRIC TRAUMA TEAM


The pediatric trauma team at the Children‟s Hospital consists of the pediatric intensive care
unit resident (pager 1 000=Peds 1000), the pediatric surgery resident or the general surgery
resident on call, the pediatric intensivist, the pediatric general surgeon, emergency room
physician, ER nurse, a respiratory technologist, pediatric intensive care unit transport nurse,
and the emergency room social worker when available. The on-call radiology technician is
also paged in the pediatric trauma fan out.

The pediatric trauma team will be called either by the emergency department or by the
intensive care unit when a call is received about an injured child being en route. The
pediatric trauma team is activated by calling the paging system and asking for the pediatric
trauma team. The guidelines are to adopt an „overcall policy‟, in other words to call more
frequently than perhaps needed as consequences of injuries are hard to predict with children.
You should not accept trauma referrals from other hospitals and instead these calls should
be referred through the staff people. If you do get these calls by mistake from Critical or
paging please take the referring doctor‟s name and number and immediately contact the
pediatric surgeon on call in order to coordinate the care. If you do get warning from the
pediatric intensive care unit resident about an incoming trauma you should let the pediatric
surgeon know on call and also other possible surgical specialties that may need to be
involved.

If you are on call and receive a pediatric trauma team fan out page you will see a number of
possible codes. The location of where the child is going will also appear on your pager and
will either be the emergency department or the intensive care unit.



                                               20
Pediatric trauma team *2 = that the child is coming in (usually by ambulance) within 6 to
15 minutes

Pediatric trauma team *1 = that the child is coming in five minutes or less

Pediatric trauma team *0 = that the child is in the emergency department or ICU any
need to proceed immediately.

Usually the trauma team leader is the pediatric intensive care unit resident (Peds 1000).
When you arrive at the trauma identify yourself.

Your role in the trauma is to perform an assessment in the ATLS manner and coordinate
the surgical aspects of care. This means the timely involvement of neurosurgery, general
surgery, orthopedics surgery, plastic surgery, urology as well as maxillofacial surgery.
Remember that this is a team effort and cooperation will make the initial assessment and
resuscitation work of the best. Contact specialists early as it may lead to some
modification of the radiologic investigations (ie the CT scan technique). Whether you
have done the ATLS course or not you will have timely backup from the pediatric
general surgeon as well as the pediatric general surgery fellow.

Please assign a pediatric trauma score and a Glasgow coma score in your assessment
note.
PEDIATRIC TRAUMA SCORE (PTS)
                        +2                    +1                    -1

size                     >20kg                   10-20 kg             <10 kg

airway                   normal                  maintainable with    unmaintained
                                                 assistance 50-90

systolic BP              >90 mm                  50 – 90              <50

CNS                      awake                   obtunded             coma

open wound               none                    minor                major

skeletal                 none                    closed               open/multiple

  add up the scores from the six categories max+12; min -6


INDICATIONS TO CALL THE PEDIATRIC TRAUMA TEAM

Any injured child whom

    has serious one system injury (for instance moderate head injury – GCS13)



                                            21
     2 system injury (for instance head injury and fractured arm)

     is brought in by a Code 4 ambulance trip (lights and siren on) after a trauma

     is admitted to the pediatric Intensive Care Unit for trauma

     worrisome mechanism of injury in which high kinetic energy is involved or when another
      person has died in the collision.

___________________________________________________________________________


Resident Expectations & Duties
WARD WORK

You are responsible for the care of the ward patients on your team, in conjunction with your
senior and/ or chief resident and your staff person.


CHARTS

Daily notes are to be completed on each chart, the only exception is the ALC patient awaiting
placement, and they should have notes at least each week.

Discharge summaries must be dictated for each patient that is admitted for 7 days or longer or for
any patient who has multiple issues, or needs multiple follow – up investigations or appointments.

The face sheet of the chart needs to be completed for each patient regardless of length of stay.
This must be done in detail including all patient diagnoses.

All procedures on patients must be documented, central lines have a sheet that needs to be
completed.

If the clinical clerk is writing daily progress notes, you are responsible to monitor the quality of
those notes.


PATIENT ROUNDS

You are expected to round on your patients prior to the beginning of 0715 teaching rounds.
Although you may not be able to finish at that time, you should check on the ward to be sure
there are no urgent issues and to look in on your sickest patients. You may complete more
thorough rounds later in the am. It is essential to check your patients prior to going to the OR for
the day. Afternoon rounds should also be done, to check on investigations, labwork, and patient
progress. This round should not take you too long and must be done before you go home. If
there are any ongoing concerns, or additional issues that need to be followed through the evening,
please communicate with the resident on call for the evening.



                                                22
There are clipboards at each end of the ward that need to be checked each day and the issues dealt
with, this includes medication reorders, and other nursing identified issues for you to deal with.

Please look for the nurse assigned to your patients when you are seeing patients. Make sure you
communicate directly with the nurse regarding patient care, and any new orders or changes to
existing orders.



MULTIDISCIPLINARY ROUNDS

These are held once per week per team. These rounds allow all the involved health care providers
to review patients‟ progress and plans. It is especially valuable for discharge planning and for
communication amongst your colleagues. Please make every attempt to attend these rounds.



OPERATING ROOM

Surgical residents are expected in the Operating Room whenever their staff person has a case.
They are expected to arrive in sufficient time to assist with patient transfer, positioning and review
the chart if they are not already familiar with the case. Residents participating in the surgery are
expected to be familiar with the patient‟s history, physical findings, the rationale for the planned
operation, and the specific steps and surgical techniques.

Off service residents will also be expected in the Operating Room. This will provide them with
exposure to common cases, living anatomy, and principles of surgical decision making. They may
also be needed as surgical assistants.



EMERGENCY DEPARTMENT COVERAGE

When your staff person is on call, you will be on call for general surgery consultations during the
day 0800 – 1700. The emergency physician may call you directly with a referral. If you are a junior
resident, it is best to let your senior know about the referral. If you have a conflict with your
required attendance in the Operating Room or in the clinic, please discuss it with your chief
resident or your staff person. Patients in the ER are not to be left waiting. It is reasonable to
expect the patient to be seen within one half hour of referral, sooner if the patient is unstable, or
deemed urgent by the Emergency Physician. If you have any doubt, call for backup to your chief
resident or staff person. If you are coming off call and will not be available after noon when your
staff person is on call, you must speak to the chief resident and your staff person so appropriate
coverage can be arranged for new consultations.

No patient seen in consultation in the ER is allowed to be discharged, admitted, transferred,
referred to another service or have any type of invasive procedure performed upon them without
the knowledge of the attending surgeon.



                                                 23
All patients seen in the ER are to have a note dictated. Clinical clerks are allowed to dictate only
after you have personally reviewed the case with them. You are then responsible for the quality of
that dictated note. If it needs to be revised you will be invited to do so.

Please keep the green sheet from the ER record to give to your staff person.

CONSULTATIONS

All requests for consultations are to be accommodated in a timely fashion. If you cannot attend to
this duty you must inform your staff person and your chief resident. All consultations are to have
a note written in the patients chart and a note dictated as well. You must let your staff person
know about all consultations. If you are asked to “be aware” of a patient, this constitutes a
request for consultation and a formal consultation is to be undertaken.


CLINICS

Residents are expected to attend at least one outpatient clinic per week. Please check with your
staff person for times and locations. If you have more than one staff person, you may not be able
to attend both clinics, each week.


ON CALL DUTIES

        All Residents are expected to participate fully in the on call schedule, if you are junior you
        may be paired with a senior resident until you are deemed capable to take call on your
        own. The frequency of call will depend upon the number of residents participating,
        holidays, etc., and within PAIRO agreements. On call coverage includes covering
        General Surgery, Pediatric Surgery, including pediatric urology and pediatric neurosurgery.
        You do not cover adult Urology, orthopedics, adult neurosurgery, or plastic surgery.
        When there are two residents on call, first call will go to the senior resident. The senior
        resident will then decide whether to send the intern or junior resident or clinical clerk to
        see the patient. Clinical clerks should not be sent to the Emergency Room by themselves
        until the senior resident has had a chance to personally review the referral and be certain it
        is appropriate for the clerk to start with. If there are pediatric surgery referrals in the ER
        and you are detained in the OR, please let the pediatric surgeon know so they may attend
        to the patient. This principle holds true for all surgical referrals, patients referred from the
        ER should not be left waiting. If you are detained with other responsibilities, let the
        attending surgeon know.

        Please see the Appendix A for guidelines regarding the notification of the Most
        Responsible Physician.




                                                  24
Other Useful Information
PHOTOCOPYING:

        You will be provided with a PIN to access the photocopiers in the library and the hospital
        for the duration of your rotation. Please forward your email address to Dr. Reid and she
        will send you your pass number. This number is to be kept strictly confidential. Do not
        pass is on to anyone else. The accounts are monitored and there is a limit to how many
        copies you can make. You are to use the photocopier to support the research you do for
        your morning rounds only. The misuse of this pass number is a serious offense.

        Please see Dr. Carrie for overheads for rounds, batteries for pagers etc.

LOCKERS:

        Please see Carrie in the Department of Surgery and she will assign you a locker in the
        third floor residents‟ area.

FOOD:

        There is a snack bar on the main floor, and a cafeteria on the first floor that has restricted
        hours of operation. There are some restaurants directly across from the hospital.

BOOKS:

Dr. Reid has a large assortment of books in her office courtesy of Dr. EJ Thomas. Please feel free
to come down for a browse, if you want to borrow a book you can, but you must sign it out. Of
course, there is the Health Sciences Library on the second level.


Tips for success on the wards

THESE TIPS COME FROM A VARIETY OF SOURCES , YOUR
STAFFPEOPLE, NURSES AND PREVIOUS RESIDENTS.



     Call Computer Services for a password and access to the hospital EMR

     Fill in requisitions for tests.

     Inform the RN of any STAT orders

     Flag all other orders

     Discharges need to be planned in adequate time to meet patient/family and home care
      needs. Discuss discharge plans with R.N. and attending physician. Write orders the day
      before discharge.


                                                 25
 Organize your bloodwork, i.e., try to order everything you want the first time so the
  patient isn‟t poked multiple times

 If you tell a patient you are going to change an order or their diet, don‟t forget to write the
  order.

 It‟s OK to peek under dressings or take them off, just make sure you let the nurse know
  that you have done that so she can redo it.

 When you first come to the ward, let the staff know who you are and who you are
  working with and what your pager number is.

 Try to return pages promptly, check your pager in between cases in the OR

 Sign out your pager when you are off call or not in the hospital

 If you want a consult from another medical service, you must call them yourself.

 Learn how to work the ECG machine. (contact the ECG technician to arrange a teaching
  session if required.)

 Call your senior resident when you are unsure about something, or if a patient is sick, it is
  always better to call than to have to answer in the morning why you didn‟t call.

 Before retiring at night (if you get a chance!) go to the ward and check to see if they need
  anything, best time to check is around 11 o‟clock, this might save you some phone calls
  later.

 If you have any questions, concerns or suggestions, please let Dr. Reid know.




                                             26
Appendix B: Guidelines for Feeding Tube Changes or
Replacements

INTRODUCTION:

Feeding tube problems commonly lead to visits to the Emergency Room. Problems that
do not require a gastrostomy tube change are:
   1. Leaking connector on the end of the feeding tube – this can simply be taped or the
      connector changed with a ‘male’ white connector.
   2. Breakdown of the feeding tube near the end – trimming the gastrostomy tube and
      insertion of a suitable connector can temporize until a replacement tube can be
      placed in the pediatric surgery clinic
   3. Blocked Feeding tube – these can be flushed with saline, cranberry juice, or Coke
      to try and un-block them. As a last resort the G-tube can be replaced. The
      radiologist can often unplug blocked GJ tubes that cannot be unplugged with
      these techniques by using a guide wire (without removing the tube).
Feeding tubes may be either gastrostomy tubes, jejunostomy tubes or G-J tubes (see
below). Gastrostomy tubes are the most common feeding tube used. Gastrostomy tube
changes should ideally be done electively and on gastrostomy sites that are at least 8
weeks old (preferably 3 months). When a gastrostomy tube falls out it must be
replaced as soon as possible as otherwise the tract will close quickly. Thus a call from
a parent regarding a displaced gastrostomy tube should lead to an immediate replacement
of the G-tube either by the parent if they have been appropriately trained or a visit to an
ER department.

FEEDING TUBE REPLACE MENTS

In the emergency department all displaced Gastrostomy tubes should be replaced by a
Foley catheter that is well taped with the balloon inflated with 5cc of H20. The parents may
bring a specific tube type with them however do not re-insert a Pezzar (see below) type
tubes but rather a Foley type tube. With gastrostomy tubes the catheter should be taped or
marked next to the skin, since the balloon may migrate down into the duodenum and cause
obstruction.
All displaced Jejunostomy tubes should be replaced with a Foley catheter, which is well
taped, and with the balloon not inflated.
All completely displaced GJ tubes should have a Foley catheter placed in through skin
opening into the stomach and arrangements made for radiologic replacement of the GJ
tube that day or the following day. Depending on the indication for the GJ tube, feeds



                                             27
may not be able to be administered via the G-tube while arranging the GJ tube
replacement.
GJ tubes that have migrated (i.e. back into the stomach) can be assessed by an abdominal
X-ray.


RECOMMENDATIONS FOR CONTRAST STUDIES FOR
FEEDING TUBE REPLACE MENTS

1. LONG-STANDING G-TUBE OLDER THAN 8 weeks - Easy tube replacement with
balloon gastrostomy tube with good gastric returns from the gastrostomy tube -- no need
for contrast study.
2. Fresh gastrostomy tube (i.e.<8weeks from insertion) insertion easy or difficult -
gastrostomy tube study
3. Difficult gastrostomy tube replacement with or without gastric returns visible,
mandatory urgent contrast study by a gastrostomy tube.


If any doubt the child should not to be sent home and urgent
gastrostomy tube study to be done in radiology.

GENERAL CATEGORIES O F FEEDING TUBES

1. Inflatable balloon end catheter i.e. Foley catheter or Mic-key gastrostomy tubes.

2. Pezzar catheter (mushroom type end) – these should only be inserted by physicians
experienced in their insertion.

3. Pigtail catheters-these are the type of tubes used by the radiologist for feeding tubes

Commercially available gastrostomy tubes

FOLEY CATHETERS

Foley catheter-these are the same catheters that are used for bladder catheterization and vary in
size from 8 to 24 French (and larger). These are probably the best catheter to be inserted in the
emergency department, as they are not as soft as the Mic-key gastrostomy tube and are available.
These can often be placed into the stomach, and if it is a Mickey that has fallen out, then a Mickey
gastrostomy tube can be replaced at the following pediatric surgery clinic.




                                                28
MIC-KEY GASTROSTOMY TUBE S

These are Foley catheter type gastrostomy tubes which are 'skin level' and so are usually
placed in those children than have long-term gastrostomy tubes. These tubes are quite soft
and, if the gastrostomy site has constricted, will be difficult to insert. They vary in length but
most commonly are of the 14 French diameter. These are not available in the Emergency
department.

‘BUTTON’ GASTROSTOMY TUBES

These were more widely used previously and are made by Bard. The mushroom end keeps
the catheter in the stomach. These are more difficult to insert and require a straightener to
get them into the stomach. Physicians who are experienced in their insertion should only
insert these.

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY TUBES

These types of tubes are placed in the operating room with endoscopic guidance. They vary
in length but usually are approximately 15 cm and come in 12, 16, 20 French sizes. They
have a crossbar that sits close to the skin. The end of the gastrostomy tube that is within the
stomach age usually makes it quite difficult to pull out of the stomach. If they fall out they
can be replaced with a Foley catheter as a temporary measure.


Other types of feeding tubes include:

G-J TUBES OR TRANSGASTRIC FEEDING JEJUNOSTOMY
TUBES

Feeds via these tubes are usually continuous in nature. These are usually gastrostomy tubes that
have been radiologically converted to a jejunostomy tube by passing a tube through the stomach
and duodenum into the jejunum. They are used in children with gastroesophageal reflux or
motility disorders of the stomach. If these become blocked they will need to the either replaced
or assessed by a radiologist. Sometimes the installation of Cranberry juice or Coke can help clean
these tubes out. If they become displaced or fell not to be in the proper position a plain x-ray
should be obtained and compared to old films to assess where the end of the catheter is
positioned. On occasion contrast agent must be instilled through these catheters to confirm their
position.

JEJUNOSTOMY TUBES

These are feeding tubes that are surgically created and are used to provide enteral nutrition on a
more continuous basis. In the jejunum there is not the same amount of room as there is in the
stomach then care must be taken in replacing these tubes. For instance a Foley catheter can be
placed but the balloon cannot be inflated as it would occlude the jejunum creating a bowel
obstruction. However a Foley catheter can be inserted and well taped as a temporary measure to
keep the jejunostomy sites open.


                                               29
Appendix C: Regional and Internal Policy Changes for
Discharge Planning Impacting Physicians at HHSC




                          30
31
Appendix D: Safe Practice and Central Lines




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