Standard Operating Procedure for AMU

Introduction

The day team will meet at the nursing station on AMU at 0800hr every morning.  At this brief huddle, the team will:

1. Write names of on-call team on the white board (including ANP and Pharmacy)
2. Identify new CCU admissions and priority patients
3. Quantify number of patients to be seen and if any remain unclerked.  If so, ensure these patients are stable enough to wait
4. Identify any patients suitable for Cardiology (complex Cardiac cases or chest pain)
5. Identify if the Frailty team are available, and who they are going to see
6. On weekdays, allocate one of the 3 FY1s to go on ward rounds with Dr Buabeng or Cardiology, rather than on the post-take round.  If there is a delay in these rounds starting, this FY1 should use the time to do any outstanding IDLs.

Mornings

The morning consultants will complete the post-take ward and ‘advance the take’ on Cortix.

At 0900hr, the middle graders will meet at the nursing station and put their names and phone numbers on the white board.  They will then identify which ‘back bay’ patients need to be seen (patients already seen by a consultant on previous days).  This will include patients in AMU, still in ED, and occasionally in overspill areas (Orthopaedic Outpatients).  Patients should be divided amongst the middle graders, who should aim and expect to get all patients seen by the 1130hr huddle (usually no more than 6 patients each in 2.5 hours).  The person holding the ‘first-on’ phone should help with this, but if patients are waiting to be seen, he/she should prioritise this instead. 

The morning duty consultants will see their own patients.  Dr Buabeng will usually see his own patients.  If in doubt, middle graders should check with a consultant to see which patients they need to see. 

After seeing their own patients, the duty consultants will review any patients under Acute Medicine in CCU (this may need to be done earlier if these patients are unstable). 

After this, the duty consultants will help the middle graders to see any remaining patients still unseen.

Morning Huddle

The whole team will gather in the big handover room at 1130hr.  At this meeting, middle graders will summarise the progress for the patients they have seen, and ask for consultant advice or review for the following groups:

1. Unwell or deteriorating patients (unless known end of life care)
2. Patients without a clear diagnosis
3. Patients who are not improving despite treatment
4. Patients not seen by a consultant for ≥3 days
5. Patients who may be suitable for discharge, but senior input needed to confirm
6. Patients where the next step in management is not clear to them
7. Patients where there is a specific question which needs senior advice
8. Patients where there is patient or family discontent or tension

The duty consultants will see patients or give advice as above.  If a middle grader requests a senior review, this should happen.

Afternoons

The late shift consultant starts on AMU at 1300hr, and takes the ‘first-on’ phone.  He/she will see patients in a rolling review until 2000hr.  If there is a bottle-neck of patients awaiting clerking by the AMU team, the consultant should see patients who have been seen by ED only, so time is not wasted. 

At 1530hr, the middle graders, FY1s, nurse in charge, and morning consultants (if available) will attend the afternoon huddle in the handover room.  The late shift consultant may prefer to continue with the acute take.  At this handover, the focus will be:

1. Identifying outstanding investigations and who will chase the results
2. Planning downstream ward moves or potential discharges for the next day
3. Identifying any patients who still need a senior review (should occur that day)
4. Planning who needs bloods the next day
5. Ensuring that anyone who can go home, does go home

At 1700hr (on weekdays only), the evening team will meet at the nursing station on AMU and agree roles eg who is holding the ‘second-on’ phone.  They will put their details on the whiteboard.  The on-call consultant and late shift consultant will be part of this huddle, and the team will use it to prioritise workload and take stock of the situation that day.  The evening team should come to this huddle prior to going for breaks. 

General Principles re Communication

1. Phones should be answered (unless in exceptional circumstances). 
2. All reasonable efforts should be made to help families asking for information. 
3. Consultants or the Nurse in Charge should be made aware of any dissatisfied relatives or patients, so the concerns can be addressed immediately. 
4. Patients should be told the same day of any scan results (unless there are specific reasons why this is not appropriate).

Who to Ask for Advice

Issues arising with any patient should go first to their own consultant, if they are available.  If not, queries should go to the consultant who saw them that morning.  If neither of those people is available, the duty consultant for that session should be approached. 

If morning consultants are not going to be available in the afternoon, they should let the FY1s know at the huddle.

Locum Consultant Role

As the locum consultants do not have the same need for SPA time, their role differs a little from that of the substantive team.

1. Early shift – as standard, but also should be present on AMU in the afternoon to help with problems in the back bays or see new admissions till 1700hr.
2. Late shift – as standard.
3. On-call – work clinically on AMU seeing new admissions from 1300hr, alongside the late shift consultant.

Content by Dr Sian Finlay