Title: Administration

Q: What is quality assurance?
A: System to:
 - Establish standards
 - Monitor meeting of standards
 - Correct deviations from this

Q: What is continuous quality improvement?
A: Management approach that provides service to meet patient needs with process itself leading to continuous improvement e.g. automatic data collection and interrogation

Q: What is total quality management?
A: Whole organisation commitment to CQI

Q: What is the continuous quality improvement cycle?
A: Plan, Do, Study, Act, repeat
PDSA

Q: Conflict management techniques
A: Compromise
Accommodation
Avoidance
Competition
Collaboration

Q: What proportion of complaints around inadequate care are substantiated?
A: 50%

Q: Response to complaint
A: Early genuine supportive of right to raise issue
Involve seniors early
Apologise without admitting error
Document conversations
Determine the key issue/s
Systems-based approach
Offer support
Advise on time to respone

Q: What proportion of patients suffer an adverse event in hospital?
A: 1/10

Q: What proportion of hospital admissions have avoidable death?
A: 1/250

Q: What proportion of patient adverse events result in harm?
A: 1/3

Q: Management of patient safety incident
A: Senior staff early
Immediate clinical management
Open disclosure explanation
Document
Safety system notification
Explain investigative procedure

Q: What is the difference between a root cause and a causal factor?
A: Causal factor contributory but removal does not prevent recurrence with certainty vs. root cause

Q: Graded assertiveness
A: Probe, Concern, Challenge, Emergency

Q: What proportion of admissions have missed or delayed diagnosis?
A: 5-10%

Q: What is the most common cause of error in ED?
A: Diagnostic error

Q: What is anchoring bias?
A: Premature diagnostic closure

Q: What is confirmation bias?
A: Wanting something to be true and interpreting evidence to confirm this

Q: What is attention coning?
A: Tendency to focus on area of comfort or experience

Q: What is representative bias?
A: Distortion of importance of information based on source e.g. QAS notes

Q: What is availability bias?
A: Alteration of estimation of probability based on recency

Q: What is ascertainment bias?
A: Missing second fracture

Q: Techniques to reduce cognitive error
A: Forcing functions
Automation
Simplification of tasks
Fatigue mangement
Checklists
Policy/guidelines
Cognitive forcing strategies

Q: How common is unplanned representation?
A: 3%

Q: Risk factors for violence in ED
A: Violent in last 72 hours
Male
Substance abuse
Psychosis
Personality disorder
Childhood abuse

Q: Risk factors for organic cause of violent behaviour?
A: Age >40 with new presentation
Visual hallucinations
Disorientation
Altered conscious state
Altered vital signs
Unconcerned regarding personal privacy

Q: Patient management plan production
A: Key stakeholders including patient
Standard medical care
Specific situation for use
Wide dissemination
Audit

Q: Consequences of ramping
A: Delayed access to care
Poor outcomes
Reduced response times of ambulance
Increased ambulance costs from overtime
Impacts funding of hospitals and ambulance as per KPI's
Poor publicity
Low morale
Interpersonal conflict between patients, QAS and ED staff

Q: ACEM statement on stroke lysis
A: May improve functional outcome with increased risk of bleeding and no mortality benefit
NNT for excellent outcome is 10 and for functional independence is 13
NNTH is 42 (sICH) and 122 (death from ICH)

Q: Access block improvement
A: Increased hospital capacity
 - Whole of hospital approach
 - Increased inpatient beds
 - Hospital efficiency clinical redesign
 - Overcapacity protocols
 - Bed management processes
 - Time-based targets for inpatient teams
 - Out-of-hours staffing
Reduced hospital demand
 - HITH
 - Chronic disease outreach
 - Frequent attenders program
 - ARP documentation
 - Residental care integration

Q: What is cultural competency?
A: Attitude, skills, knowledge that allows safe and biopsychosocial cross-cultural interaction

Q: Benefits of NEAT
A: Can serve to drive quality, efficiency, improve overcrowding, hospital function and patient outcomes

Q: What is overcrowding?
A: ED function impeded by number of patients exceeding capacity
Primarily due to access block

Q: When is ambulance diversion warranted?
A: Exhausted all other internal mechanisms to avert crisis
Internal disaster protocol triggered

Q: Proportion of Australians that drink at harmful levels?
A: 1/5

Q: Proportion of ED presentations secondary to alcohol?
A: 1/12

Q: Management of sexual assault
A: Clinical care
 - Forensic examination with consent
Pregnancy prophylaxis
STI screening and prophylaxis
HepB vaccination + HBIG if un-immunised
Consider HIV prophylaxis
Social work
Arrange f/u - STI monitoring, PEP evaluation and ongoing support

Q: Risk of STI post-sexual assault
A: 4-5%

Q: Antibiotic STI empirical therapy following sexual assault
A: Ceftriaxone IM 250mg + Azithromycin 1g PO + Metronidazole 2g PO stat

Q: Risk of HIV transmission for consensual vaginal sex
A: 0.1-0.2%

Q: Risk of HIV transmission for consensual anal receptive intercourse
A: 0.5-3%

Q: Pregnancy prophylaxis dosing
A: Levonorgestrel 1.5mg PO up to 5 days from time

Q: Efficacy of levonorgestrel pregnancy prophylaxis
A: 85% if within 72 hours

Q: What proportion of women presenting to ED have suffered family violence in last 24 hours?
A: 2%

Q: What proportion of those that present to ED following family violence are asked about it?
A: 10%

Q: What is the best question for domestic violence identification?
A: Do you feel safe at home?

Q: What are primary, seconary and tertiary homelessness?
A: Primary - Sleeping on street
Secondary - Living with friends/relatives
Tertiary - Caravan park/boarding house with no fixed lease

Q: How much more frequently do homeless people present to ED?
A: 10x

Q: Management principles for prisoners
A: See quickly
Maintain confidentiality as best able
Use guard advice around safety precautions
Investigate more thoroughly in ED as coming back is difficult/costly
Low threshold for admission
Clear written discharge advice and prescription/instruction
Liaison with prison medical staff to ensure capable of providing level of care required

Q: Incidence rate of aggressive behaviour?
A: 0.5-2%

Q: What proportion of disturbed patients have acute mental illness?
A: 50%

Q: What proportion of behaviourly disturbed are intoxicated?
A: 50%

Q: Strategic approach to ED violence
A: Environment - Visibility, security staff, duress alarms
Staff - Education, training, team approach
Systems - Reporting, OHS follow-up

Q: What is an ED frequent attender?
A: >3 times per year

Q: Management of frequent attenders
A: Usual medical care (higher mortality and risk of serious illness than general population)
Acute treatment plan development
Multidisciplinary care coordination in ED

Q: Management of the drug seeker
A: Ensure new organic pathology not evident
Treat genuine pain if present
Set clear limits once relatively certain
No discharge scripts
Offer referral to support services

Q: Proportion of Australians overweight or obese?
A: 63%

Q: Proportion of children in Aus that are overweight or obese?
A: 25%

Q: Overweight BMI
A: 25-30

Q: Obese BMI
A: >30

Q: Bariatric BMI
A: >40 or >150kg

Q: Did not wait average across Australia
A: 5.4%

Q: Factors associated with did not wait
A: Prolonged waiting time
Low SES
Young adults
Triage 4 or 5
Parents with young children
ED overcrowding
ED attendance out of hours

Q: What is battery?
A: Intervention without consent

Q: Essential elements of competence
A: Maintain and communicate a choice
Understand situation
Understand consequences
Justify their choice

Q: Emergency treatment of children without consent
A: Document attempt made to find consenting adult
Document opinion of second clinician
Notify medical superintendant

Q: Can paediatric medical information be provided to parents?
A: Yes unless over 14, living independently and considered competent

Q: Documentation of discharge against medical advice
A: Document assessment of competence, discussions had and have witnessed
Get patient to sign form if willing (but need notes also)

Q: Reportable deaths
A: Unknown identity
Violent or unnatural death
Suspicious
Cause of death certificate unable to be completed
Death related to healthcare
Death in care, custody or as a result of police operations

Q: What defines death related to healthcare
A: Need both of:
 - Health care, of failure to provide healthcare, caused or contributed to death
 - Before healthcare provided, wouldn't have expected patient to die from or be contributed to by healthcare or for death to occur at that time

Q: Define death in care
A: Disability under Disability Services Act and lived in care facility
Involuntary assessment or treatment under MHA or forensic disability act
Child awaiting adoption
Child who lived away from parents due to Child Protection Act

Q: Strategies for managing overcrowding
A: Hospital wide approach
 - Bed management protocols
 - Early discharges and planning from whole hospital
 - More senior staff across hospital
 - Protocol driven approach to internal emergencies
ED approach
 - More senior staff
 - Physical space
 - Audit of flow and system design
 - Early senior review
 - Increased SSU utilisation
 - Fast track streaming
 - Mandated time targets

Q: Are medical practitioners obliged to provide treatments not in patients interests?
A: No with the exception of Qld where consent from patient or substitute decision maker is required to withhold life-sustaining measures

Q: Medications for palliative care
A: Morph 10-20mg/24 hours
Midaz 10-20mg/24 hours
Hyoscine hydrobromide 1.2-2.4mg/24 hours

Q: Liverpool care of the dying pathway
A: Diagnose dying and communicate to family
Assess what is important to patient and family
Medications
Withhold useless tests
ARP written
ICD deactivated
Consider artificial nutrition and hydration (rarely needed)
Assess skin integrity

Q: What proportion of Australians die in hospital?
A: 65%

Q: Evidence for pre-hospital intubation
A: One study of head injury showed improved neurological outcome at 6 months but higher incidence of cardiac arrest

Q: When is pre-hospital thrombolysis recommended?
A: If >1 hour from definitive PCI centre with STEMI

Q: Factors in deciding on retrieval transport modes?
A: Pressurisation
Space for crew/patient/equipment
Urgency
Distance
Helipad availability

Q: Indications for pre-hospital intubation
A: Respiratory failure
Behavioural control
Obtunded
Predicted clinical course
Threatened airway obstruction

Q: When can confidential detail be disclosed?
A: Other law mandates
Person has expressed consent for disclosure
Public interest

Q: Mandatory reporting
A: Reportable deaths to coroner
Communicable infectious diseases
Child abuse
Elder abuse (not in Qld)
Domestic violence (only if children at risk in Qld)

Q: What can be released to police?
A: Patient name, DOB, address, nature of incident, description of injuries and conscious state
NO statements on causation

Q: Examples of primary, secondary and tertiary prevention in ED
A: Primary - Post-exposure prophylaxis
Secondary - Screening for chlamydia in at-risk population
Tertiary - Treatment of established disease to prevent complications

Q: In what groups may screening be of utility?
A: STI
Family violence
Alcohol dependence
Smoking cessation

Q: Evidence for rapid response teams?
A: Improves outcomes for trauma, MI, sepsis

Q: Proportion of ED patients that suffer deterioration warranting a local ED rapid response?
A: 1.5%

Q: Ideal SSU parameters
A: 5-10% of total ED volume
Average LOS 10 hours
<24 hours stay
80% discharge rate

Q: Benefits of SSW
A: Access to investigations to ensure accurate diagnosis before admission/discharge
Admission to correct inpatient team once diagnosis made
Reduced inpatient costs
Improved patient flow in ED
Temporary accommodation for patients in crisis
Safeguard for overnight junior staff
Shorter LOS and cost vs. inpatient

Q: Admission requirements for SSW
A: Senior clinician controlled admissions
Treatment plan
Defined objectives for admission

Q: Exclusion criteria for SSW
A: >24 hours expected admission
>1 issue or complex
No clear treatment plan
Intensive nursing requirements
Violent/psychotic

Q: Acceptable failed SSW with inpatient referral
A: 10-20%

Q: Protocol development steps
A: ´Key stakeholders
´Reason for protocol
´Inclusion
´Exclusion
´Process
´Complications and management
´Monitoring
´Planned audit

Q: When is mandatory reporting required for impaired doctors?
A: ´Practicing while intoxicated with drugs or alcohol
´Sexual misconduct in the practice of the profession
´Placing the pubic at risk of substantial harm due to impairment
´Placing the public at risk because of a significant departure from accepted professional standards

Q: High risk DNW
A: Chest pain
Headache
Immunosuppressed
Pregnant
Child
Abnormal vital signs
Psychosis
Suicidal ideation
Geriatric
GP concern (referral)
Intoxication
Impaired judgement

Q: Ideal retrieval distance for rotary air retrieval
A: 75-175km

Q: ATS 2 treatment acuity and performance indicator
A: 10 min; 80%

Q: ATS 3 treatment acuity and performance indicator
A: 30min and 75%

Q: ATS 4 treatment acuity and performance indicator
A: 1 hour and 70%

Q: ATS 5 treatment acuity and performance indicator
A: 2 hours and 70%

Q: Definition of handover
A: Transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis

Q: Should handover involve patients?
A: Should be informed of nature of ongoing care, who is providing it and if they have any concerns

Q: Should handover be documented?
A: Manner in which all staff can readily access continued care arrangements and provides a record of key elements of handover