General Surgery Induction

ADMISSIONS

• We have elective patients – who usually get admitted after their operations (Ward B1)
• Patients for elective day case surgeries get admitted in Day Surgery Unit (DSU)
• Emergency Referrals come through to On- call Registrars/ SHO bleeps
• Referrals are usually from A&E, GP, Urgent Care Centre (UCC), Clinics, or sometimes self-present
• Ward referrals from other specialties should be directed to the Registrars bleep

Patient pathways after admission:

• Discharged directly from Surgical Assessment Unit (ESH) – located on Ward B5 Station 1
• Discharged home with outpatient clinic follow up
• Home leave and return to Hot clinic for review or US on ESH
• Admitted to ESH
• Put on the abscess pathway or Hot gallbladder pathway (SDEC Pathway)

WARD ROUNDS

There are two ward rounds that usually happen every day.

On-call Ward Round/ Post Take Ward Round (PTWR)

• There are two on-call consultants for each week. They are on-call every alternate day. They work from Monday 8am to Monday 8am the following week. Any patients admitted during this time are admitted under the named on-call consultant for the day.
• Following the morning handover, the on-call consultant (from previous day), on-call registrar, SHO and FY1 will see the on-call patients (who are admitted over the last 24 hours) on the list.
• These patients are considered ‘on-call patients’ for the next 24 hours. They are transferred to the respective firms under the named consultants, by the on call FY1 at 5 pm on the post take day.
  
  

Non-On-call Ward Round

• Everyday there is a registrar assigned to do the non-on-call ward round for each firm.
• Every consultant does the ward round once a week. They have a day allocated for ward round.
• The team comprises of the Consultant, Registrars, SHO, PAs and FY1s (depends upon availability)
• They will see all inpatient non-on-call patients.
  
  

Elective lists

• We usually have several operating lists per day, for different firms.

SURGICAL REGISTRAR ON CALL
Bleep 7954

Responsible for

• Overseeing and reviewing all referrals to the general surgery team including both those from A&E and GPs during the day and night
• Attending Trauma, EmLap calls from A&E/ Resus or MET calls when requested
• Receiving in-patient referrals from other departments
• Consenting, Booking and operating on cases in CEPOD during the night
• Inform the emergency theatre on Bleep 7224 and the on-call anaesthetist on Bleep 7018 every time a patient is booked for CEPOD
• You must collect the NerveCentre device from the site coordinator’s office before starting a night shift and during weekends.
• WEEKEND ONLY: additionally, also cover CEPOD during the day

CEPOD Registrar on Call
Bleep - 5090

Responsible for

• Consenting, Booking and operating on cases in CEPOD during the day.
• Attend the morning Theatre handover to discuss all cases booked (so be prepared), to help decide order of operating.
• Inform the emergency theatre on Bleep 7224 and the on-call anaesthetist on Bleep 7018 every time a patient is booked for CEPOD.
• Helping surgical registrar on call in between cases to review cases/ book and consent new cases.
• WEEKEND ONLY: ward round of non-on-call patients during the day.

SURGICAL SHO ON CALL
Bleep 7947

Responsible for

• Receiving A&E, UCC, GP referrals during the day and night.
• Consenting and booking/assisting with cases during the day and night
• Maintaining a list of patients on the acute surgical take.
• Overseeing care of all general surgery patients during the day and night, often supporting the FY1s with acutely unwell patients.
• Overseeing care of urology, vascular patients.
  
  

You must collect the NerveCentre device from the site coordinator’s office before starting a night shift and during weekends

SURGICAL FY1 ON CALL
Bleep 7956

Responsible for

• Receiving & clerking patients during the day and night.
• Maintaining a list of patients on the acute surgical take.
• Moving patients from the on-call lists to the inpatient lists of the firm to which the admitting consultant belongs following the Post Take Ward Round Day.
• Primarily responsible for the ward jobs and care of all general surgery patients during the day and night
• Additionally, responsible for the ward jobs and care of urology and vascular patients from 5pm-8am
• You must collect the NerveCentre device from the site coordinator’s office before starting a night shift, during weekends and at 5 pm Monday to Friday.

WEEKEND WARD FY1

Responsible for

• Attending the general surgery non-on-call ward round and contributing to seeing these patients and documenting the ward round during the day on
• Primarily responsible for the ward jobs and care of all general surgery patients during the day.
• The on-call team are likely to be busy seeing new patient referrals, so it is primarily your responsibility to help the on-call ensure that the ward jobs are done, and important scans chased, followed-up and on-call team is informed of these and help the on-call FY1.
• Updating the individual firm lists for the patients.
• You are expected to carry a bleep, which are available on SAU doctors’ office.

WARD FY1 -
Bleep Colo A 7601, Colo B 7653, Upper GI 7505

Responsible for

• Attending the general surgery inpatient non-on-call ward rounds for each firm and contributing to seeing these patients and documenting the ward round on
• Ensure you print sufficient copies of the list for the ward round for the day.
• Each firm has their own bleep
• You are expected to collect the bleep every morning before the shift from ESH Doctors’ Office and carry it throughout the day. Kindly deposit the bleep at the end of your shift after switching it off.
• Any outstanding tasks should be handed over to the on-call team on NerveCentre after 5pm.
• Ensure the Firm list is up to date with patient details, Consultant in charge and plan.

• When you start in the Trust, ensure you get access to the Microsoft Teams.
• The on-call list can be found on by logging into any of the trust computers: log into Microsoft Teams➝ general surgery ➝
  TRIANGLE-HEADED RIGHTWARDS ARROW
  Unicode: U+279D, UTF-8: E2 9E 9D files ➝ On call take list ➝ choose date)
• For the firm lists - log into Microsoft Teams➝ general surgery ➝ files ➝Colo A/ ColoB/ Upper GI/ Vascular/ Urology) ➝ choose date)
• Note the handover list document name is saved as ‘Date; Consultant On-calls Name; shift : Day/Night
  • E.g. 21.08.2021 Mr. Sellahewa Day

• In order to maintain continuity of care, patient safety and avoid errors/omissions in care an effective and up to date patient list is imperative.
• Updating of the list should occur throughout & be finalized at the end of each shift.
• For data protection reasons this list is to be stored electronically only
• Any printed copies of the list should be disposed of in confidential waste bins at the end of the day.

• Responsible Consultant surgeon
• Location (ward and bed) – ensure patients are moved to the correct sections on the list.
• Patient Details = name, date of birth, hospital number and age
• Brief History of presenting complaint, examination and past medical history – using SBAR (see documentation section)
• Results of significant or pending investigations
• Current diagnosis
• Details and dates of any procedures
• Any outstanding tasks

MINIMUM TO BE INCLUDED IN WARD ROUND ENTRIES:

Subjective
History, or state of any experienced symptoms in the patient’s own words.

Objective

• Observations,
• fluid balance,
• details of any drain/stoma output if relevant
• Examination findings
• Results of any investigations
  
  

Assessment

• Diagnosis/ Differential diagnosis
• In post-operative reviews, include a summary of patient’s progress, and any new issues.
• Documentation that patient is fit for discharge, if appropriate
  
  

Plan

• Any pending investigations
• procedures,
• Referrals or
• Medication changes and the rationale.
• Follow up details if pending discharge.
  
  

Note:

• Entries must be written contemporaneously where possible
• You must document if an entry is written in retrospect
• In acutely ill patients remember the importance of documenting an accurate timeline of events.
• Entries must be legible and accurate

Any outstanding jobs after 5pm should be handed over to the on-call team on NerveCentre.

It is the duty of the Ward team to ensure all jobs are completed, all referrals are made in a timely fashion, all discharge summaries an TTOs are completed in a timely fashion to ensure no delay in treatment or discharges.

Other sections which must be completed

• Diagnosis must be accurate for correct coding - “possible” cannot be coded, use “probable/likely”
• Procedures - Accurate title of the operative procedure, with the correct date must be completed.
• Allergies
• Co-morbidities – please ensure all co-morbidities are entered in the discharge summary.
• All medications must be documented, even those which have not had any alteration during this admission.
• Sick notes are available on every ward. Sick notes are given for 2 weeks. The patient needs to contact the GP if he/ she wants more than 2 weeks.

Things to remember

• EDS must be filled in PRIOR to patient’s discharge
• It will save time if you update details regularly, especially for patients with long or complicated admissions
• Avoid abbreviations
• This is a legal document, your comments should be accurate, and professional.
• Spell check
• It is mandatory to complete and EDS for all patients, including those who are deceased or those who have self- discharged.
• All patients should be given a discharge summary before they leave the hospital – the discharge advice should be explained again – by either Nursing staff/ Junior doctors

Need to get Study leave form signed from Clinical lead/ Medical Staffing  

• Any study leave needs to be agreed with the Clinical Director of Surgery and have him sign this form 
• Email and hand in physical copy of form to medical staffing 
• You need to provide evidence of the course booked as well. 

If you are unwell and unable to work, then as early as possible you must ensure you do the following; 

• Contact the consultant on call via phone and inform them 
• Contact medical staffing via phone/email and inform them  
• Contact Junior Doctor Rota Coordinator (Marium Parvez ) on email.
• Contact your colleagues via WhatsApp as courtesy to inform them also 
• Log your absence on Medirota.
• Inform medical staffing upon the end of your absence so that they can ‘close your absence’ and acknowledge your return to work

If you are unwell due to Covid-19 symptoms, then follow the trust covid-19 absence protocol –contact med staffing & occupational health for more details. 

Emergency leave (including Carers leave, bereavement leave etc.) 
This should be requested on Medirota and discussed on the phone with medical staffing.

Submitting Locum / WLI forms:
All the RCL and WLI claims forms needs to be handed over to Karen Rock

• We admit patients with mild head injuries for 24-48 hours observation. These patients are only accepted after CT head and on advice of Neurosurgical team at QE through the NORSE portal (this is done by A&E). – NORSE review template is available on Sunrise – the QE advice needs to be added to this template and saved.
  
  
• We admit and treat patients with chest injury (Rib fractures/ Chest drains for monitoring) – if they are straight forward these need not be discussed with cardiothoracic team, but if in doubt A&E will discuss with cardiothoracic team at New Cross Hospital.

• Patients with abscesses can be managed either by incision and drainage under local anaesthesia on ESH or under general anaesthesia in theatre.
• Where drainage under general anaesthetic is required, patients should be seen and consented by SHO/ registrar then booked in theatre for later the same day or for the next day in the Surgical SDEC theatre/CEPOD of the next day (SDEC pathway/abscess pathway)
• Some patients (e.g. immunosuppressed, insulin-dependent diabetics, clinically unwell, suspected necrotizing fasciitis) will need admission and drainage as an emergency.

• We accept all post-operative general surgery/ urology (by Urology registrar or on call SHO)/ vascular complications (by Vascular registrar/consultant) for assessment on ESH/ A&E. Some complications (e.g. Wound infection) can be managed on ESH and discharged. Others such as post-operative intra-abdominal collections will need admission.
• The agreement with A+E is if complications occur within 28 days of discharge, referrals are made directly to the on-call team from A+E. However, not all post-op complications are surgical (post-operative pneumonia, PE, DVT) and clinical judgment should be used.

• Urological patients should be admitted under the Consultant Urologist on call following review by the urology team during the day.
• During the night the surgical SHO on-call receives Urology referral and discuss with the offsite Urology Registrar on-call, if required.
• Cases which should be urgently discussed with the inpatient urology team/ consultant urologist on call include suspected testicular torsion, urinary retention where a catheter cannot be passed and an obstructed infected renal tract. Please see the urology handbook for more information.

• Children under 5 should be sent to Birmingham Children’s Hospital for assessment directly by A&E and should NOT be accepted by the general surgery team.
• Children over 5 with general surgical issues should be accepted for assessment on PAU/A&E. Paediatric torsions are covered by Urology.

• Vascular team accepts vascular referrals during the day.
• During the night the Vascular registrar on-call receives referral and informs the on call SHO/ ESH nursing team about the patient.
• Suspected aneurysm ruptures are dealt with by A&E who informs the Vascular Consultant & Registrar on-call before the patient actually arrives in A&E.

• Plastic surgery emergencies will be covered by General Surgery SHO/FY1 after 5 pm with direct liaison with Plastic Surgery on call consultant.
• These patients will be admitted under plastic surgery consultant.

• The on call registrar/ consultant should be immediately made aware of any patient actively bleeding/ profoundly septic/ clinically unwell whilst resuscitation is under way.
• The on-call registrar/ consultant should be made aware of patients within an hour with acute abdominal pain/ peritonitis/ appendicitis/ bowel obstruction.
• When you are worried about a patient never be afraid to call the on-call registrar. If you are unable to contact the registrar, call the consultant. If both consultant and registrar are in theatre and no other seniors are on site, visit theatre to discuss cases.

When receiving referrals from A&E or GP/Urgent Care it is important to ask about :

• Patients observations
  • Any patient with unstable observations should be stabilised in A&E prior to transfer to the ward.
  • Any referrals from GP/UCC with unstable observations should be directed to A&E for us to assess them there ensuring they are stable and safe to transfer to the ward.
• COVID-19 symptoms - Any patient from A&E should be swabbed before transfer to the ward. If they have COVID-19 symptoms/clinical suspicion they are transferred to the appropriate isolation wards. The bed managers will organise this, it is your responsibility to ask/identify if they do or do not have symptoms & inform the nurse in charge
• Diarrhoea - Any patient with ongoing diarrhea will need a side room so you must inform the nurse in charge of this prior to transfer to the ward.
• Liaise with the ESH nurse in charge so that you know whether there is space on ESH to accept patients from A&E/GP/UCC. You should also inform the nurse in charge if you have accepted a patient under the general surgery team, so they are aware
• The nurses/ ANPs on ESH often help the on-call team during busy hours by receiving referrals from GP/UCC.
• If you are unsure whether a referral is not appropriate for the general surgical team then please ask your registrar and if they are not with you feel free to direct the GP/UCC to speak with them on their bleeps
• Inform PAU nurses when accepting children for surgical reviews from GPs or from A&E.