General Surgery Department Induction Mr Roland Fernandes Consultant

General Surgery Department Induction Mr Roland Fernandes Consultant General and UGI Surgeon Roland. Fernandes@nhs. net 07904023613

Department structure • • Colorectal Surgery Upper GI surgery Breast Surgery Emergency surgery

Surgical Wards • • • KA 2 KB Channel Day ITU, HDU, Padua, outliers, Surgical patients in medical wards

SEAU • • • Accepted admissions from GP Could be from A&E 8 am to 8 PM Observe, investigate, admit, discharge, review, Review in the hot clinic Other surgical patients: Eg: Drains, complicated gall bladders, incisional hernias etc.

Emergency teams • Day team • Consultant, CEPOD reg, CEPOD SHO, SEAU reg, SEAU SHO, A&E registrar. • Night team: • Consultant, On call reg, SHO ( includes ENT cover) • Some weeks core trainee from ENT will cover General Surgery • Weekend team: Day time: • Consultant, day reg, A& E cover reg, SHO, foundation trainee • Night team: Consultant, reg on call, SHO

Emergency Surgery • • • Emergency surgery majority of activity Emergency consultant on call week ( hot week) Monday to Thursday Friday AM to Monday AM = Weekend 5 emergency surgeons: AS, RF, ANS, MI, BA Night cover from 6 pm to next day 8 AM ( by other consultants)

Elective admissions • SAU • For upper GI surgery, Colorectal surgery, some times breast surgery • Usually consultant and registrar led • Juniors are welcome to join • Check the drug charts • Some drugs could be missed • Check the VTE: Usually done by the reg or consultant • Start EDNs early on

Colorectal Surgery • • Mr Basnyat Lower GI lead Mr Harinath Mr Ramalingam Mr Aravind Miss Cooke ( Trauma lead) Mr Shrestha Mr Imtiaz • CNS: Larissa Williams, Fiona Cull, Ruth Burns • CNS Stoma nurses: Julie Bell, Complex colorectal surgery, lap, benign, malignancy, lap, open • Early rectal cancers: TAMIS,

Upper GI surgery • Mr Basu • Mr Fernandes • Mr Shah • • • CNS - Ola Non cancer surgery Complex gall bladders, CBD exploration Anti reflux surgery Hiatus hernia surgery Achalasia surgery

Breast Surgery • • Mr Nick Williams ( Breast surgery lead) Mr Chiana Mrs Sally Kum, breast nurse consultant No breast reconstuctions

VTE • VTE assessment mandatory • Performance is monitored and presented in the monthly meetings • Complete on Vital pac • Mostly, emergency patients is a problem • Please complete the assessments in 4 hrs/ 8 hrs • Very easy assess • No paper copies • Not required for paediatric cases • In day surgery; done by the reg or consultant

Surgical Handovers • Hand overs twice daily • Usually in the Surgical Resource room: except: Monday and Friday • Handover register: Please sign in. All must sign. • Evening hand overs: Needs to be signed. • Evening hand overs in the surgical resource room • Hand over not only emergency ; elective patients • Weekend handover is for every patient on Friday in the resource room at 1 pm • X rays, bloods etc. • CXR and AXR not reported routinely

Patient Safety • • • Datix Sepsis Hand wash Drug charts VTE Documentation

Drugs and prescriptions • • Do not prescribe if not sure Not to prescribe immune suppressants No to prescribe chemotherapy drugs Follow the micro guide: app

Audits • Regular Audits • Participation is important for appraisal and continuing education • Process • One audit per 12 months for core trainees and for ST trainees • Complete audit and present

Teaching • • Regular teaching Friday Surgical teaching; combined A&E teaching Monday X Ray meeting Colorectal MDT Breast MDT Radiology teaching Foundation teaching: Tuesdays and Thursday Grand rounds Wednesday Lunch time

Foundation trainee: Duties expectations • • • Write legibly Date and time State the senior person at the beginning of the note Relevant notes Always sign and stamp if you have one Organise all your jobs Prioritise your work Share your work with your senior colleagues Do not leave the FY 1 doctors with lots of jobs

FY ward duties/ expectations • Organise yourself, drug chart, IVF etc. • Keep a list of your patients, maintain hand over sheets • Keep up to date with the progress and results of the patients • Be ahead of the game; start EDN early on • Be vigilant on your patients; esp: patients moved to other wards, patients with poor early warning scores • Know who is covering your patients • Keep in touch with your consultant • Complete VTE online • Document results print or write

Speciality trainee/ Speciality doctor: Expectations • • • Make sure ward rounds are completed early on Decisions are made early on Jobs listed for juniors Chase the results through foundation doctors Supervise and teach juniors while on the ward rounds Prepare for the M&M meetings Maintain list of complications and mortality Be involved in audits and department academic activities. Guide juniors for audits

SEPSIS • • • SEPSIS seven: Give 3 Take 3 And Escalate Antibiotics with an hour

VITAL PAC • • • Access available for all Able to monitor the EWS on surgical patients Complete assessments esp VTE Take steps based on the EWS Remote monitoring of your patients Check the bloods results

EDN/ EPR • • • EDN is for discharging patients Start early on Do not leave this part to your colleagues Delayed EDNs is risk for complaints Discharges delayed if EDN is not completed esp weekend. Patients can not be discharged without EDN EPR is to check the previous consultations from clinic GP information can be accessed as well Do not ask GPs to chase up test results!

WEEKEND WARD ROUNDS • • • Organise Try to complete jobs as they come Share the jobs Smart: delegate some jobs to seniors Have lunch break If concerns, can not cope, talk to your seniors who will try to help • Understand the ENT emergencies and manage the situations • Keep some waiting list forms as well

CRITICALLY ILL PATIENT • • EWS more than 3 SEPSIS Do lactate Do bloods Resuscitate Escalate Out reach services Consultant

Patient transfer/ handovers • Always consultant needs to be involved and transfers or hand overs agreed between wards or hospitals • Do not accept any patient in or transfer out • Risk of mortality • Patient may not be fit • Always check before accepting

DNAR policy • • Check DNAR certification Registrar and above Do not resuscitate if DNAR completed Do not start DNAR certificate once the resuscitation has been started • Community DNAR • Do not leave this to the weekend teams, anticipate well ahead.

Death certification • • Death certification is team’s responsibility Needs to be completed on time NO DELAYS If not sure; check with your seniors ITU cases, cause not known, check with your boss Once issued, certification can not be changed Illegal to give wrong cerficate Coroner could be involved if persistent issues

Consent and site marking • Do not consent if you do not know, not been trained • Same rule for site marking • Foundation and core trainees are never asked for consenting patient who are undergoing surgery • Consent for other purposes • Usually by the consultant or speciality trainee or specialist doctor • Could potentially be a never event

Rotas and daily time table • Weekly time table is different from on call rotas • We aim to release 4 weeks ahead with some alterations to allow for changes • Concerns, you need to discuss with Mr Fernandes

Attending theatres • Make sure that ward rounds are completed and plans made for ward patients and sick patients • If you have too many patients or even very ill patient, then make sure that FY doctors are given advice before joining theatres • Leave your contact with nurses or other ward staff • Be prepared to remotely monitor through Vital pac and chase the results! • You are welcome to join and learn

DOPS/ WBA/CBD • Make sure this is completed and your supervisor has reviewed and signed off • Be proactive • May need reminding • Even if it means few times • Complete your mandatory training

Educational and clinical Supervisors • • You need to know the educational and clinical supervisors Need to complete initial meeting and documented Discuss your progress and concerns with your training Do not leave until last minute

Clinical Guidelines • Clinical guidelines are available on the trust website • These include on some protocols and guidelines

Mortality and Morbidity • • • Monthly Maintain a book or document All complications and mortality needs to maintained List of meetings available for the rest of the year Preparation of the details by foundation trainees and core trainees • Presentation by the specialist trainees/trust doctors • 11/9, 10/10, 8/11 and 11/12

TTM Course • Mandatory - ext 6185 • 17/10/2019 • 20/11/2019 • 12/12/2019 •

Pharmacy guidelines • • • TPN : monitoring Legibility Insulin Anti-epileptic drugs Review antibiotics Be aware of the dose CHECK BNF esp paeds If not sure take help Penicillin allergy………… All cancer patients go home with 28 days of clexane

How to book patients for surgery • Elective • Emergency

Incident reporting • • Need to know the procedure Check with your team or boss For all unexpected events Re-operations and significant issues where patient safety is compromised. Always check with your senior. • For all never events. • On line

Record keeping • • Legible Date and time Sign Relevant and precise Majority should be able to read Legal document Access under freedom of information act

Junior doctor representation • • • Foundation Core trainee Specialty trainee All other middle grades Monthly forum with Mr Fernandes to discuss training, education, patient safety and your concerns on the rotas and clinical issues.

Local teaching and attendance standards • • • Teaching on Friday: 80% attendance Attendance register maintained Please sign Similarly for x ray meeting Foundation teaching must

Speciality trainee/ Speciality doctor roles and responsibilities • Ward rounds ; daily • Cover for your patients when on leave, on call, nights, sick leave etc • Supervision of juniors • Escalation of sick patients • Communication • Audit leading • Mortality and morbidity presentation • Discuss your training needs and complete all the documentation • Patient safety • Teaching • ST trainee representation

Patient discharges • Please start EDN early on • Do not leave this to your colleagues • Do not ask GPs to chase up anything such as CT or endoscopy etc. • Delayed EDN could cause problems for patients and families • EDN is a must before patient discharge. • Be considerate to your friends and colleagues

Resources • Micro guide • Informational leaflets • Department policies

Annual leave • • Book early Don’t waste it Evenly space it out between rotations Don’t leave it to the last few weeks

Notes from nurses • Bloods and Cannulation the FI seem to presume that nurses are soley for blood taking and places cannulas at least this is a shared role • When patients self discharge or are transferred they need an EDN for audit purposes • Don’t take notes off the ward • Read the messages on the drug charts and complete the request, they are often ignored • Prescribe everything you possibly can ie fluids warfarin thinking of the night staff both doctors and nurses. •

Lesley • F 1 support • Will do allocations for first few weeks • Need a f 1 rep

Surgical Resource room • • Keep it tidy No food plates No pillows or blankets No confidential loose sheets Shredder Lock all the time Valuables This is being monitored

Concerns • • Mr Fernandes Your own consultant / ES / CS Surgical lead – Mr Ramalingam Divisional lead – Mr Hamade • Abbie / Dani

General Surgery Department Induction Mr Roland Fernandes Consultant General and UGI Surgeon Roland. Fernandes@nhs. net 07904023613