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Self-Discharge

Still in the ED

  • Explain why we would like them to stay and the management options as clearly as possible
  • Assess mental capacity (over 16 years)
  • Complete
  • Remember under 18’s, legally don’t have the right to refuse treatment (however, the principles of the mental capacity act should be applied)

Left ED

  • Assess the risk, do we need to:
  • Inform Nurse-in-Charge
  • Add to handover board if actions are required by the in-hours team
Searchs: abscond, absconded, did not wait, didnt wait, didn’t wait

VFC/Orthopedic – Trust Treatment & Follow-Up

Select the appropriate body area for guidance table

No Spinal injuries, back pain, Cauda Equina, foot drop etc to be referred to VFC
 

Patients that will not be suitable & need a “face-to-face” as below

  • Homeless patients
  • Prisoners
  • Non English Speaking Patients
  • Inpatients
  • Patients with Hearing Difficulties
  • Phoneless Patients
  • Injuries Associated with Domestic or Child Abuse
  • Children under 2 Years of Age
Hand Injury Referral
Our local hand surgeons have requested the following reduce the number of transfers to BRI
 
Hand Trauma – Refer to BRI:
  • All soft tissue pathology (tendon, nerve, nailbed, complex wounds, infections, compartment syndrome, necrotising fasciitis)
  • Open hand fractures, regardless of location
  • Phalangeal fractures
  • Any case requiring an on-call opinion
T&O (VFC or F2F Clinic) – HRI:
  • Closed fractures proximal to the MCPJ (metacarpal and proximal onwards)
  • UCL injuries and similar (e.g. boxer’s knuckle)
  • Simple dislocations without fracture or with small bony avulsion
  • Mallet finger (with clear documentation of whether bony or non-bony)
No Follow-Up Required:
  • Simple wounds
  • Closed extra-articular tuft fractures
Upper Limb

Lower Limb

5th MT zones

Acute Coronary Syndrome (ACS) – 2025

First take a good history, not ALL chest pain needs to be investigated as ACS. However, its worth noting older patients and women are more likely to have atypical presentations. Be wary that some patients with negative troponin give a history of Unstable Angina and therefore require admission.

Read more: Acute Coronary Syndrome (ACS) – 2025

ACS Treatment (Not STEMI going for PPCI)

  • Aspirin 300mg stat
  • Ticagrelor 180mg stat
  • Fondaparinux 2.5mg sc stat. 

Anticoagulated with a DOAC, or with Warfarin (with a therapeutic INR),

  • Aspirin 300mg stat
  • Clopidogrel 300mg stat

Treatment STEMI going for PPCI

  • Aspirin 300mg stat
  • Plus Either:
    • Ticagrelor 180mg stat (Hx of CVA)
    • Prasugrel 60mg stat (NO Hx of CVA)

Direct admissions to CCU

Patients with ST Elevation (if not accepted for primary PCI) or those with CP + new ST Depression should be discussed with a local Cardiologist and come directly to CCU.

As it is difficult to be prescriptive for every other circumstance, a discussion with a senior/cardiologist may be worthwhile in order to best manage and place your patient within the hospital.

Patients where MI is excluded

If patients do exit the pathway (no new symptoms, no new ECG ischemia and troponins that meet the exit criteria to exclude an MI), two other important possibilities still require consideration:

  1. Is the history in keeping with unstable angina? (This is still an ACS). If so the patient will require an acute inpatient admission with telemetry and IP cardiology review.
  2. Is the chest pain due to a significant alternative diagnosis? If so this still needs to be actively considered/ investigated/ treated.

Time Critical Medications

Time Critical Medication (TCM) is scheduled medication that the patient is already on when they present to the Emergency Department (ED).

The medications are “time critical” because a
delayed or missed dose can result in harm with exacerbation of symptoms and the development of complications leading to an increased mortality.

Movement disorders – Parkinson’s / Myasthenia medication
Immunomodulators including HIV medication
Sugar (Insulin)
Steroids – Addison’s and adrenal insufficiency
Epilepsy – anticonvulsants
DOACs and warfarin

Its really important for our patients that these medications are prescribed and given while in ED/uSDEC/fSDEC.

If you are withholding these medication (which may be necessary) -please the reason for this clearly in the notes.

PDMedCalc has superseded Optimal

Paediatric Flow at HRI

There is rapidly growing evidence, outcomes for children are improved by early attendance at specialist sites. As there is NO onsite paediatric speciality provision at HRI. It has been agreed that children likely to benefit from early Paediatric/Neonatal care move to CRH as swiftly as possible. This will be done using the agreed pathway, to reduce treatment and speciality input delay.

Read more