ED-Surgery Escalation Plan

Introduction

The Surgical and ED teams have worked closely to provide an agreed process, to aid patient flow through the ED and help to maintain our acute beds for those patient who need them.

Between 07:00-18:00 SDEC should be utilised as much as possible for those  patient who may not require admission. If you have any doubts contact the SDEC sister

SDEC exclusion criteria
  • Any patients with symptoms of or recent contacts with Covid-19 infection
  • Diarrhoea and/or vomiting
  • NEWS 4+
  • Any patient requiring oxygen treatment
  • Non-ambulant patient
  • Outlying non-surgical patients (Medicine, Orthopaedic referrals from HRI)
  • Acute vascular pathology (suspected AAA, Acute Limb Ischaemia, Diabetic Foot Sepsis)
  • Haemodynamically unstable PR bleed / Large volume witnessed PR bleed
  • Trauma patients with GCS < 15 
  • Patients with head injury or who require neurological observations
  • Suspected cauda equina-refer to CES pathway
Streaming to SDEC
Between 7AM and 6PM, the following groups of patients can be referred directly to the SDEC Nurse-In-Charge (NIC) from the ED Triage Nurse without ED doctor review (if conditions 1-3 fulfilled)
  1. ANY of the following conditions
  2. Do not meet any of the SDEC exclusion criteria
  3. Had relevant bloods and preferably a cannula (see SDEC bloods)

Conditions

  • Upper abdominal pain in Patients with known gallstones
  • Lower abdominal pain in patients aged between 16 and 50
    • With a negative pregnancy test and no PV bleeding (in female patients)
    • No prior history of inflammatory bowel disease or liver disease (in all patients)
  • Small volume red rectal bleeding in a haemodynamically stable patient
    • ‘Small volume’ rectal bleed includes bleeding predominantly on the toilet paper, <200mls, maximum of two bleeds prior to ED attendance, haemodynamically stable, no evidence of collapse/dizziness. If in doubt, speak to the NIC

    • Absence of melaena – a PR examination by ED clinical is required

  • Post-operative wound problem who have had general surgery, breast, urology or plastic surgery operations over the past 4 weeks
    • (triage nurse to have details of name of operation at time of referral to SDEC nurse)
  • Abscesses; Peri-anal, Pilonidal, Back or Chest
    • Limb abscesses should be referred to Orthopaedics
    • Groin abscesses in IVDU patients should be assessed by an ED doctor to ensure correct referral to general or vascular surgery.
    • Patients who are not septic with ‘general surgery’ abscesses who present outside SDEC opening hours can be discussed by the triage nurse with the SAU NIC. If the patient is stable, they can be sent home and asked to return to SDEC at 7AM once all the details have been given to the SAU NIC. The patients should be asked to fast from 2AM but can drink clear water up to 6AM.
  • Patients with known umbilical or groin hernia – presenting with worsening symptoms from their hernia
SDEC Streaming Bloods

Blood test requirements:

  • Abdominal pain: FBC, U+E, LFT, CRP, Amylase, Clotting Screen
  • Rectal bleeding: FBC, U+E, CRP, Clotting Screen
  • Wound problem: FBC, U+E, CRP
  • Abscess: FBC, U+E, CRP
  • Hernia: FBC, U+E, CRP, Clotting Screen
Surgical Referrals – (Non-Streaming Patients)

All other surgical referrals should be referred as normal to the surgical team. For patients who require an in-patient bed:

  • If the surgical team need a CT / Ultrasound to aid decision-making, this may be facilitated or requested in ED. If the surgical registrar feels that the patient may not be suitable for surgical admission, they should contact the on-call surgical consultant before the CT result is obtained to obtain a rapid in-reach surgical consultant review and aid appropriate transfer out of ED
  • If the surgical team feel the referral is inappropriate or unclear (or more likely to need a different specialty), senior surgical review will be delivered within 30 minutes of referral in ED with three possible outcomes (accept onto Surgery, discharge home, Surgical team to make onwards referral as necessary)
  • Criteria for contacting the on-call surgeon include:
    • Delays or difficulties in contacting the surgical team (often due to theatre or other acute pressures)
    • Delay in treatment or surgical review or indecision/disagreement on destination of the patient
    • Consultant surgical opinion should be sought early if needed by the senior ED doctor or sister in charge to avoid delays
    • The first port of call should be the first on consultant (day or night, depending on the time) and if unavailable, the second on-call consultant should be called
    • At CRH the surgical consultant can arrange for review by the “Sub-Acute surgeon”

If patients require urgent surgical assessment and/or treatment at CRH and no bed is available at HRI, the patient must be transferred immediately to HRI ED for surgical assessment

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