4 Clinical Workflow
4.0.1 Role of the Respiratory resident and ATR
As the Respiratory resident or ATR you will be the foremost members of our team on the wards. You are most likely the team members our patients and their families are going to have the most contact with. Ward staff will turn to you with any acute management issues – big and small. Most you will be able to manage on your own. Others you may want to discuss with the unit consultant. Over time, you will grow increasingly confident in making even complex clinical decisions.
Don’t feel pressured to make decisions you feel uncomfortable with. The Respiratory consultant on-call is always happy to discuss any clinical issues with you. In fact, the consultants do this amongst each other as well – it helps to bounce around ideas to shape the best way forward.
4.0.2 Weekly timetable
The routine
The Respiratory department offers a variety of clinical meetings and teaching sessions. Some meetings may occur in collaboration with our colleagues from Adult Respiratory Medicine. On these occasions, you may have the opportunity to follow the progress of patients who have been cared for at Monash Health since they were infants. Many are now all “grown-up”, some of them may have children of their own. These opportunities of longitudinal care are likely unique in the Australian Respiratory teaching landscape.
All locations listed are at Monash Children’s Hospital, unless indicated otherwise.
| Monday | Tuesday | Wednesday | Thursday | Friday |
9.00 am Ward round (commence in HDU, when operational) |
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| 8.00 am Bronchoscopy list Alternating Wednesdays MCH theatre |
9.00 am Meet Aviary Ward, L4 |
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| 1.15 pm Journal Club Office Aviary ward, L4 |
12.00 pm Dept Research Meeting Lecture Theatre 3 MMC |
11.00 am General Paediatric Radiology Meeting . Radiology Meeting Room |
12.00 pm (1st Friday of each month) |
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| 2.00 pm Respiratory Radiology Meeting, Radiology Meeting Room | 12.30 pm Paediatric Grand Rounds, Monash Uni Lecture Theatre, L5 | 1.00 pm Paed Tutorial, Paediatric Seminar Room, L4 | ||
| 2.30 pm Consultant Ward Round | 2.45 pm CF multi-disciplinary team meeting. | |||
3.30 pm Paed Sleep Meeting, MCSC, L4 Alternates with sleep teaching for JMS, MCSC, L4 |
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4.0.3 Ward rounds
As the unit’s ATR and Resident you will be conducting daily ward rounds. On occasion the ATR may be unavailable and the resident will be rounding on their own. Most questions coming up during the round can likely be discussed with the ATR after their return.
The on-call consultant is always available for urgent discussions and advice. Don’t hesitate to call them if you have any concerns about a patient or if you are unsure about how to manage a clinical issue. They are there to support you and ensure the best care for our patients.
Ward rounds start after the General Paediatric morning handover that runs from 8.30 am - 9.00 am. Morning handover is essential and mandatory for all JRMOs. All medical teams come together in this meeting, discussing developments and new admissionswith the night team. This is a unique opportunity to stay up to date on patients you might encounter during covering shifts or when being asked to see a child for a consult.
Our unit’s patients will frequently come up during these discussions. Management of airway and oxygenation issues are central to paediatric medicine and the most frequent reason for acute deterioration and admission of children to the PICU.
Make a note if there were concerns with patients under our care and bring them to the attention of the consultant when appropriate.
4.0.4 Consultant handover and ward rounds
The ward consultants change over on a weekly basis. However, some consultants elect to be on-call for two weeks at a time.
Consultant handover occurs on Thursdays, 9-10 am. The unit will provide you with the current video link or you can attend in person.
Both incoming and outgoing consultant take part in handover. Depending on the ward workload only one of the team’s JMS may be able to join. At times, other staff members may also join, such as an ANUM or physiotherapist.
The unit’s resident or ATR presents the patients under our care. This is an excellent opportunity for you to practice presenting patients in a clear and concise way. The aim of handover is to enable both to update the incoming consultant on the clinical course of the unit’s patients as well as enabling a constructive review of the management plan.
Usually, the structure of the handover will include:
- Inpatients
While there is no fixed order, presenting the most complex or sickest patients first enables the team to devote more time to discussing these patients. - Patients under shared bedcard / in NICU
- Active consults
Consults where our our team is currently involved should be presented and discussed. New consults who have not yet been seen can be discussed with the incoming consultant after the handover. - HITH patients
- Patient expects
4.0.5 Patients referred to us
Other teams will approach you for advice or a formal consult regarding one of their patients. We aim to see referred patients on the day of the referral or within 24 hours. Monash Health guidelines stipulate the following time-periods for review of referred patients:
- Urgent: within 4 hours
- Non-urgent: within 24 hours
- Elective: within 48 hours
The ATR should be made aware of referrals straight away so they can be triaged according to urgency. Ensure the referring team is clear in what they want us to do. The clearer the request, the better we can advise.
- Is the request for an ATR or a consultant review? Reviews by the ATR will always need to be discussed with the consultant on the same day.
- How urgently does the patient need to be reviewed? Some urgent reviews can’t even wait for 4 hours.
- Would the referring team like an answer to a clinical question, do they need us to perform a procedure or are they asking us to take over care?
- If the request relates to bronchoscopy see that you can get an overall picture of what else is happening with the patient:
- Are there other procedures planned for the patient during the same general anaesthetic?
- If so, where is the procedure taking place?
- Are there other teams involved and which other procedures are planned?
- Who is coordinating the procedure, who is doing the bookings?
- If the patient is already known to one of the Respiratory Physicians make sure the on-call consultant is aware of this. There may be long-term plans in place.
- We are usually very happy to agree to requests to take over a patient’s bedcard unless a different team would be better suited to care for this child. Requests for change of bed card under Respiratory always require approval by the Respiratory consultant on-call.
4.0.6 Asking another team for a patient consult
Our referrals to other teams should be concise and ask a clear clinical question. Avoid vague referrals such as “Fever. Renal cause?”. Think about which specific problem we want the referred team to address. Give a brief synopsis of the patient’s background, previous investigations relevant to the clinical question and our working diagnosis.
“Thank you for non-urgent review of this 6 year old boy with spastic quadriplegia, GMFCS level V. Multiple admissions for LRTI in setting of aspiration from above and below. Currently inpatient for confirmed pneumococcal LRTI, improving on BenPen. Unexpected fever spikes over past 48 hours, growth of Proteus mirabilis on CSU and rising creatinine (35⇢150). Need for further renal tract imaging and renal FU?”
Let the other team know how urgently out patient requires their review. If very urgent, make clear why and determine when our patient is likely to be seen by the other team. Apart from communicating your referral to the other team verbally, make sure you also refer through the EMR.