Marathon

Orientation for Locum Physicians at Wilson Memorial General Hospital
Purpose:
As a facility we want to provide a welcoming environment for locums and one in which they understand the expectations of their function within the hospital. In addition, we want locums to understand what they can expect from their physician colleagues, and other health care team staff while here. This document is to help ensure that key components of orientation take place for every locum within the facility working with the health care team.
Background Information:
Wilson Memorial Hospital serves the community of Marathon and the adjacent First Nations communities of Pic River and Pic Mobert. Additionally, we occasionally receive patients from White River. There are nine acute care beds including a cardiac room and an obstetrics LDRP (labour-delivery-recovery-postpartum) room. There is also a critical care observation room, and a total of 12 chronic care beds. The staff is made up of 2 RN’s and 1-2 RPN’s on each shift. The nursing shifts are twelve hours long and run from 7:00am to 7:00pm daily. Typically the RPN’s provide service on the chronic care patient ward. The RN’s work in acute care with one RN per shift assigned to the ward, and one to the ER. The RN’s do cross cover and move between the two acute care areas of the hospital to assist one another with their respective workloads. Physiotherapy services are available between 7:30am and 3:30pm Monday to Friday. Lab hours are 7:30 am to 4:00 pm Monday to Friday with lab staff available on call outside of those hours. Outpatient hours are from 8am to 12:30pm. Diagnostic Imaging services are available 8:00 am to 4 pm with staff available for on call work outside of those hours. Only one of the technicians has been trained to do ultrasound so that service is not consistently available on-call. One of the physicians (Dr. Barb Zelek) can do some limited obstetrical ultrasound assessments if the ultrasound technician is not available.
On call Services:

• On call: On weekdays, physicians are on call from 08:00am-08:00am the following day or the shift may be split into two 12 hour blocks (8:00-20:00 and 20:00-08:00). Elective booked procedures (ie. Toenail resections, breast cyst aspirations, cast removals etc.) are typically done in the morning. The physician remains on call for the hospital during the entire call shift. Procedures arising from the clinic day, such as incision and drainage of abscess may be referred to the physician on call. We try to avoid doing elective procedures during the hours of 17:30 -19:30 as this allows for the RN’s to have dinner, and complete their shift handover. The on call physician is not expected to remain on site at the hospital during their evening and weekend call blocks, however they are expected to remain within a 10 minute response time from the facility. Pagers will be supplied by the hospital as will cellular phones. As a locum, it is important to be within easy reach of a telephone while on call. The nurses who page have been instructed to page the physician for all urgent or stat calls. Very infrequently after hours, the physician may also receive calls from THAS (telephone health advisory system) to discuss patients enrolled with the Marathon Family Health Team.
• Triage: At our facility, we encourage the community to use the emergency department for urgent and emergent care problems. When the RN relays a history therefore, it is reasonable for the physician to provide the RN with instructions to give the patient regarding care and follow-up. For example, an 8 year old presenting with ear pain and no fever may be instructed to try Tylenol and/or Advil for 24-48 hours and follow up with the clinic at 48 hours if symptoms persist. The community has been well trained in this regard, and so it is not necessary that the physician on call see all of the patients presenting to the ER. We do try to provide as supportive an environment for our staff as is reasonable, so if the staff asks specifically that the physician comes to see the patient, the physician is strongly encouraged to do so.
• Handover: Patients deferred out of one’s own call day (i.e. Someone presenting at 2am with ankle pain asked to return at 10 am the next day) may be seen by the deferring physician or handed over to the next call day physician with clear verbal handover. We have an understanding as a physician group that a handover will happen, if necessary, at the end of each call shift to relay information on acute inpatients and outpatients and anyone in the process of being worked up who the on call physician would like to sign over. Patients admitted on call are transferred to their usual family doctor the next morning. If they do not have a doctor or their doctor is away, the locum will be expected to follow these patients to time of discharge.
• Backup: We do not have an official second on call program. However, there are two back-up systems that can be used if the on call physician requires assistance. Firstly, we have a sign out board at the nurses station and all physicians are expected to sign out on the board if they are unavailable. In critical situations if the on call physician requires assistance, this board should provide an easy way to determine who might be available to come and assist. Secondly, there is always one physician on call for obstetrics – this physician will always be carrying a pager and is on call for a week at a time. It is understood by our group that the “Obs doc” will be available for any Emergency backup requirements, unless that doctor makes specific arrangements to have his/her responsibilities covered by another physician. Please note that our policy is to offer one another assistance when requested. The same is expected of the locum: that they would come urgently if called to assist in the ER. Occasionally a physician is required to travel with land or air ambulance to transfer a patient to Thunder Bay. Usually this is the role of the on call physician, and that physician has an obligation to arrange for on call coverage of the hospital prior to going on the transfer. As well, the locum physician may be contacted to cover the ER so that another physician can provide en route care for a transferred patient, and our expectation is that that support would be offered if at all possible.
• Disaster: In the unlikely event that there is a large or overwhelming number of casualties in the Emergency department, the physician on call may call a “Code Green”, or disaster. If the locum physician is on call, he/she should immediately call one of the local colleagues and then follow the instructions as per “Code Green” policy in the Policy Binder (see below).
• Obstetrics: While it may not be expected that a locum would provide obstetrical services, we have a policy that the on call physician will function as the “baby doc” at a delivery. Each locum is expected to familiarize themselves with the obstetrics room and neonatal resuscitation cart at the start of their time here. The locum is expected to assess pregnant patients presenting on call who are less than 37 weeks gestational age. If the locum feels a delivery is imminent, they are expected to call in the obstetrical physician for that week for the delivery. Any patient presenting to the hospital who is 37 weeks gestational age or greater is usually considered the responsibility of the obstetrics physician on call that week. The RNs will usually call in that physician themselves.

Inpatients:

• Admitted patients: It is our expectation that the MD on call will be responsible for all inpatients after 17:00. In order to ensure good care however, the on call physician should expect to receive a handover about any inpatients that may develop problems through the night. If this has not happened for a particular patient and the on call physician is called, they have the right to have the hospital contact the attending physician to either provide care or contact the on call physician with an appropriate handover. On weekends, the on-call physician is expected to round on all active inpatients. They should be provided with a weekend transfer note on the chart to facilitate provision of care. The note should be explicit regarding a care plan including anticipated problems or issues. On weekdays, the locum is expected to round on their inpatients prior to the start of the clinic day with the goal of discharging patients eligible for discharge by 11am.
• Short Stay Admissions: An on-call physician may decide to admit a patient but anticipates that the admission will be brief. These “short-stay admissions” have been defined by our hospital as (i) any patient held in hospital more than 4 hours, (ii) but less than 36 hours, and (iii) with no transfer of care to another physician. In these cases, it is often seen as burdensome to have to complete the usual admission paperwork (History and physical form). Our hospital policy for Short-stay admission paperwork states that a completed ER form is sufficient documentation for an admission history and physical. A discharge summary is still required that includes the discharge diagnosis and discharge plans.
• ER hold: An on-call physician may choose keep a patient in ER for observation for a period of time after initial assessment. As a general rule, this will be considered an ER hold if the duration of stay is less than 4 hours. If more than 4 hours, it then generally becomes a Short Stay Admission and documentation must conform to the standards outlined in the hospital policy. Exceptions would be situations where a patient is waiting for test results but is not being actively managed (e.g. atypical chest pain awaiting the 6-hour triple screen result to rule out ACS).

Transfers:
Thunder Bay is our regional referral center. If the locum needs to discuss a transfer patient with a specialist, then TBRHSC should be called 1-807-684-6000 ext 1 and that service will connect with the specialist requested. For critically ill patients, or in the case when there are no available beds in Thunder Bay, “Criticall” can be contacted and they will seek the nearest available bed and specialist appropriate to the case. The number for “Criticall” is posted on each of the telephones in ER and at the nurse’s station.
Call ins:
At our facility the lab and diagnostic imaging staff are on call after their regular hours are complete (lab and DI after 16:00). Each call-in costs the hospital 6 hours of regular time service. Where it is determined that waiting to obtain lab or x-ray services until the regular hours of operation is unlikely to impact care, our tendency as physicians is to wait. For example, one might choose to splint an ankle for a number of hours rather than seek an immediate x-ray in a case where it is possible to do so.
Medical Records:
It is expected that all physicians will sign off all of their lab work, x-ray reports and charts prior to the completion of their locum. It is the responsibility of the discharging physician to complete the discharge summary on any patients they have cared for. The exception to this would be a patient cared for by their family doctor during the week and then discharged on a Saturday by the on call physician. The attending physician would then complete the discharge. A key will be provided to the medical records department for the duration of the locum stay. Prior to departure, the locum is requested to stop in at health records and ensure that any outstanding charting is completed. All medical record entries must note the date and time. You will be requested to provide an example of your signature and initials in medical records at the start of your locum stay.
Policy Binders:
All of the hospital policies pertaining to nursing care should be found at the nursing station. Policies pertaining to medical care will be found in each of the ER rooms and in the physicians’ office. At our facility we have a series of medical directives which pertain to emergent or urgent situations which the nursing staff can enact on behalf of the physicians. These directives should be signed in advance by physicians under whose care they may be enacted. They have each been signed by all of the physicians who make up the Medical Advisory Committee, however, it is important that you review them and if reasonable to you, sign them prior to your first shift in ER. A package for your signature can be found in the Health Records department.
Formulary:
There is a hospital formulary which outlines all of the medications that are kept in stock in the hospital. There are a number of non-formulary medications that may also be available, and you can check with the RN if you have questions about a particular medication.
Mask Fitting:
If you have never been fit in another facility for a mask for the prevention of FRI (Febrile Respiratory Illness) then please speak with the Director of Client Services regarding having a mask fitting scheduled. Your mask should stay in the facility for your use in the Emergency Department or on the ward.
Feedback:
If you have any feedback regarding your work at Wilson Memorial General Hospital, please feel free to contact the Chief of Staff, Dr. Scott Wilson. If you have feedback regarding the conduct of staff at our facility, it would be appreciated if you could put that feedback in writing to Mrs. Jill Pascoe, Director of Client Services, and CC it to the Chief of Staff to follow up. Thank you for being willing to provide service to our facility.
Useful Phone Numbers:

• Hospital: 229-1740
  • Switchboard Ext: 221
  • RN station Ext: 229 or 230
  • Emerg RN desk Ext: 317
• Clinic: 229-3243
• Health Unit: 229-1820