For DEMT Terence Yuen – Teaching 5/7/17

 

VFRAC – virtual fracture clinic

Update from Becky Pile ED physiotherapist

3 months running now

VFRAC reviews all referrals next day and then funnels cases:

• Direct to OT
• To ‘traditional’ fracture clinic + organizes repeat imaging
• conservative VFRAC management – simple fractures for phone management and LMO follow-up

Can manage other acute injuries eg. Achilles rupture

VFRAC needs to be booked for next day – please tell your clerk

No limit on booking numbers

Already a reduction of about 26% diverted from fracture clinic

Patient satisfaction information survey pending – being collected now

 

Adults only so far – no paeds

 

Clinical risk management and clinical governance

Dr Lucia Le Kim – deputy director with Dr Terence Yuen

 

Governance includes:

• policy
• Education
• Clinical guidelines / protocol
• Systems: escalation pathways / codes / mandatory competencies / credentialing
• Audit / review / quality / outcomes / KPIs / M+M / satisfaction / Riskman / in-depth case reviews / adverse events

All clinicians as they progress through their careers should develop an awareness of wider process of healthcare delivery in the hospital context, over and above individual patient cases

 

Risk

• Seen risk – eg. the patient you have seen who is unwell
• Assumed risk –
• Unseen risk – ie unseen waiting room patients and any patient who you have not personally reviewed

 

Traps

• Assumptions: interpretation of case / interpretation of investigations
• Interpretation of clinical stability
• Diagnosis momentum
• Geographical blindspots – eg. EOU / EDIS filters (clerical risk)

 

Failsafes

Eg. Chest pain: ECG to be seen by senior / EOU consultant review /

 

Mitigate risk by good communication

Avoid premature labelling / diagnosis

 

Take actions to re-stratify risk

• Re-utilize resources
• Reallocate resources
• Retrieve additional resources

 

Victorian forensic paediatric medical service (VFPMS)

Dr Bindu Bali

See presentation here

 

Paediatric arm of adult forensic service

Mandatory reporting – suspicion of physical or sexual abuse; not mandated to tell the family per se

Social work / IRS support to support clinician or family / access to phone

Issues regarding confidentiality if contacted by DHHS

Safety concerns can trump privacy legislation however it is a grey area

Admission often necessary to facilitate further survey but if no further medical needs exist then DHHS is responsible for safe accommodation

RED FLAGS: household violence / heavy use of drugs + alcohol / serious mental illness / child’s vulnerability (eg premobile / preverbal)

 

Bruising:

• Do not try to interpret
• Describe only
• Consider red flags : away from bony prominences / TEN – torso / ears / neck / if not fitting developmental stage

 

Journal club: EGDT and meta-analyses

Dr Ashley Loughman – see presentation here

 

Early goal directed therapy

How to assess meta-analyses

 

PRISM metaanalysis

• Prospective collection to ensure uniformity

 

Metaanalyses

• Theoretically pool information to get closer to the “common truth”
• Increases external validity
• Cons: inclusion biases / lack of negative studies / agenda driven bias / poor quality of original papers