Stratford

Population: 30,000
Affiliated Hospital: Stratford General Hospital

GENERAL INTRODUCTION TO THE DEPARTMENT AND SERVICES OFFERED

Stratford General Hospital is a 140 bed, Level “C” hospital providing Medicine, Intensive Care, Surgery, Paediatrics, Obstetrical Care, Palliative Care, Chronic and Rehab Care, Psychiatry, Orthopaedics, Urology, Otolaryngology and Plastic Surgery.
The Emergency Department of the Stratford General Hospital is a 14-bed Emergency Department with approximately 26,000 visits per year.  On average we see 70 patients per day however this can fluctuate anywhere between 50 and 150.
Our breakdown of patients by triage level is as follows:
Level 1        1 %
Level 2        9 %
Level 3        35%
Level 4        45%
Level 5        10%

The Medical Program Director and Chief of the Department is Dr. Miriam Mann.  Dr. Mann is a Royal College trained Emergency physician.  She currently works 2/3 clinical load in Emergency and does administrative work 1½ to 2 days per week.
The Emergency Department is staffed predominantly by full time Emergency physicians, 24 hours per day, 365 days per year.  Stratford General Hospital’s ED physicians also provide ED coverage at other rural hospitals in our area.  The majority are CCFP(EM) trained and are all highly skilled emergency physicians.  Several physicians also provide “back up” to the ED for ambulance transfers, high patient acuity or excessive volumes.

PHYSICAL SPACE
The Emergency Department is an old department, which consists of a long corridor with rooms off of each side.  This layout is not conducive to efficient patient care and patient observation.  A new Emergency Department will be built from 2007 – 2009.

SERVICES AVAILABLE
Laboratory staff are on duty 24 hours a day.  Most tests are available on a STAT basis.
Medical Imaging staff are in the hospital from 0800 hours to midnight.  X-ray is available on callback after midnight for emergencies, however single problems (such as non-displaced wrist and ankle fractures) are requested to come back at 8 o’clock in the morning for imaging.  The patient then returns to the Emergency to be seen by the day Emergency physician.
Ultrasound is available Monday – Friday 08:00 – 17:00 hrs.  &  Saturday 08:00 – 16:00
Nuclear Medicine is available Monday – Friday 0800 – 1700 hrs.   Lung scans can usually be done the next day.

SPECIALIST BACKUP
Stratford has excellent Specialist backup offering a variety of services at Stratford General Hospital:

6 Internists    The Internists cover the 5 bed Intensive Care Unit and routinely manage complicated Medical/Surgical patients.
6 General Surgeons    Including 2 with vascular training
5 Obstetrician/Gynecologists   
4 Paediatricians   
4 Anaesthetists    Including one GP Anaesthetist

These services, as well as the Department of Pathology and Laboratory Medicine, provide seamless coverage.

The hospital also has:
1 Plastic Surgeon            2 Otolaryngologists            2 Orthopaedic Surgeons
1 Ophthalmologist            2 Urologists                1 Full-Time Radiologist
3 Psychiatrists

These physicians provide as much on call coverage as they can.

In addition, SGH offers several out-patient programs such as:
Diabetic Teaching Hospital        Out-Patient Rehab            Out-patient Oncology
Out-Patient Physiotherapy

ORTHOPAEDIC CLINICS
Orthopaedic Clinics are available for follow-up of orthopedic problems.  There are 2 clinic days per week.  ED patients can be booked for follow-up by the ED clerk.

EMERGENCY DEPARTMENT PHYSICAL PLANT  (see attached floor plan)

ROOM    USUAL FUNCTION
174    Two-bed room, predominately fractures
176    Paediatrics and Medical problems
178    Trauma room.  Also Minor procedures and ENT
179    Minor procedures & Gynecology
180    Ophthalmology room with “slit lamp”.
Minor assessments and minor procedures.
181    Cardiac arrest room – centrally monitored.  Paediatric resuscitation equipment.
182 & 186    Paediatrics and less acute medical problems.  Patients must be ambulatory as these stretchers cannot be moved out of these rooms.
183    Cardiac monitoring – both beds are centrally monitored. 
185/187
(off the waiting room)    Paediatrics assessment, Migraines, Mental Health and other medical problems that do not require close observation or that require a quiet environment.

PAEDIATRIC RESUSCITATION EQUIPMENT is stored in room 181.  Boxes are available with the appropriate size equipment for children in a particular weigh group.  These boxes were developed using the Broslow tape.  Familiarize yourself with the location and contents of these boxes prior to working in the Emergency Department.

REFERRAL PATTERNS
London is our base hospital for pre-hospital services and is the usual referral centre.  When London cannot provide backup “Criticall” is used to locate the closest available bed.  Kitchener-Waterloo’s new program in invasive cardiology is now frequently used by Stratford to facilitate access to these services.

RESEARCH
Stratford General Hospital is participating in the “Transfer-AMI” trial and enrolling patients for immediate PCI post-thrombolysis.

LIBRARY
Several Emergency textbooks are available in the Emergency Department and are to be left in the Emergency Department.  In addition, the hospital library is adjacent to the doctor’s lounge.  Material must be signed out from this room.

EMERGENCY DEPARTMENT OPERATIONS:
1.    Chart Flow
Patients are first seen by the triage nurse and then registered.  Once the chart is generated it is placed in a slot for the nurses to pick up and place the patient into a room.  Once the patient is placed in a room the nurse will put the patients in appropriate order as per triage level.  The chart will be placed in the bottom row of the patient chart rack in order of priority for patients to be seen.  Once the physician has seen a patient and orders are written, the chart should be placed in the order slot on the wall opposite the chart rack.  While orders are being processed and patient care is under way the chart will be placed in the appropriate room slot that corresponds to the chart.  Charts are move to the X-ray slot when patients are in X-ray.  When patient care and orders are completed the chart will be paced in the reassessment slot.

2.    ER Charts
We have adopted the ePOD (emergency print on demand) Charting System.  This is a two-page chart.  Page 1 allows for standardized triage questions based on the presenting complaint.  In addition there is room for orders, nursing notes, diagnosis and signatures.  Page 2 is for physician charting.  There are some templates to assist with charting.  Many decision rules are included.  Discharge diagnosis and plan can be written on Page 2.  Health Records requires that a physician’s signature be on both pages of the chart.  The diagnosis does not need to be written on Page 1 if it is on Page 2 however, please write “see Page 2” in the diagnosis box to avoid confusion for the Health Records coders.

3.    ER Physicians Responsibilities  For Chart Completion
Charts are completed as above.  In addition, the physician must write billing codes in the bottom right-hand corner.  The ER physician does not need to write diagnostic codes as this is done by the Health Records coders.  It is vitally important that the ER physician charts the time a patient is seen as well as the discharge time if the physician discharges the patient. 
In addition it is a required element that we collect our “decision to admit” time.  This is written in a box on Page 1 of the clinical record.  Assessment, admission and discharge times are in small boxes on Page 1 as well.

IMAGING DOCUMENTATION
Emergency physicians are asked to complete a blue X-ray requisition including a brief history for patients where imaging is requested.  Physicians enter their interpretation of x-rays into the PACS system.  Follow-up of x-ray discrepancies is a quality assurance exercise in our department.