ED Muskoka Physicians - Living the Dream

Updates from Antibiotic committee meeting

Hi team

A few updates from the Antimicrobial stewardship committee meeting today. Exciting I know.
1. FYI – Peritoneal Dialysis patients presenting with ?SBP – there are NO nurses at MAHC authorized to access these PD catheters to obtain a sample (as per discussion with OSMH & RVH dialysis staff). Appropriate management includes a stat phone call to Nephrology to arrange for transfer for workup and management. Empiric antibiotic choices should be discussed with Nephro prior to transfer.
2. Several new ordersets have been drafted and are going to P&T, look out for these to be posted soon to Entrypoint. Hopefully they are helpful and less burdensome than that awful general sepsis orderset we used to have:
  1. 1) Endocarditis Order Set

    2) Meningitis Order Set
    3) Diabetic Foot Order Set
    4) Spontaneous Bacterial Peritonitis Order Set

    5) Acute Diverticulitis

    6) Necrotizing Soft Tissue Infection

    7) Febrile Neutropenia
    8) CDI Order Set and PR Administration of Vanco

There is also a document entitled:  “Intraabdominal Infections” that is NOT an orderset but provides useful evidence-based info on appropriate antibiotics to select. It will be posted to ENTRYPOINT to use as reference if you wish to access it when writing orders (or send your med students to find it to do some ‘self-study’ time!)
If there are other infection-related order sets you would like to see (or if you think a review of the literature is required on any current ones) please let me know and I can bring to committee!
Lastly, nothing to do with antibiotics, but if you weren’t at pharmacy rounds the other week an interesting tidbit of info that came up: Did you know that our hospital spent over $12 000 on the Zofran ODT wafers last year? If we had subbed every ODT dose for a PO dose we would have spent just over $600.  I forget the exact numbers but the PO dose is somewhere around $0.11 and ODT is over $2.00, IV dose is under $1.00. Interestingly, the ODT is NOT buccally absorbed, it just dissolves and then has to be swallowed and is absorbed in the GI tract just like the PO dose (still takes about 30min) – so my takeaway is that (except for in kids where swallowing a pill is an issue) if the patient can’t take PO, just give IV and skip the ODT!
Enough for today, enjoy your weekend everyone.
ps – yes, we are still waiting on baby to arrive!

HDMH ER stocking reminder

Hi all –

In follow-up to our discussions at Journal Club tonight, I wanted to remind everyone of the following:

1. PROBLEM SOLVING for STOCKING ISSUES: There is a clipboard with ORANGE paper that leans up against the glass behind the ‘captain’s chair’ MD computer that is labelled “Physician – Missing and/or needed items”. This is intended to be a place you can jot down items you found were not stocked or missing while on shift (i.e. no dermabond in suture carts, missing cast supplies, where the heck is our otoscope…) This is meant to assist in communication with our nurses that do the stocking at night, and Sara Tumber can also review this every once in a while to try to fix some of the common/systemic issues that come up.

2. NEW CENTRAL LINE AND ART LINE KITS: Sara has created boxes to house supplies for central lines and art lines. These live on top of the carts in Trauma 1 and are very clearly labelled. Not sure if anyone has used them yet – if you do, any feedback on whether anything is missing? Central line kits should contain all the necessities including lidocaine, sterile syringes, caps, dressings, glove/gown/masks, and sterile U/S probe covers…. should help facilitate a quick and safe set-up in the future. Same idea for art lines (both femoral and radial should be stocked in the same box)

Keep your eye out for an email from me with a doodle poll in the next couple of days. Before our next business meeting I am hoping to put together some patient information handouts that can be kept on hand in the ER, and want your feedback on what topics would be most useful. (This goes for SMMH and HDMH docs)


Pediatric urgent psych referrals (RVH)

Just a quick reminder (which was new information for me tonight) – for our adolescent mental health patients we can make a referral to the psych “Urgent Consult Clinic” at RVH. This is for adolescents ages 12-17 who are safe to be discharged but need psych follow up within 48h (ideally). They will be seen either in person or by OTN by a multidisp. team of an RN, social worker, and psychiatrist. This is supposed to be a one-time visit for consult & recommendations only.

Referral forms can be found in the MENTAL HEALTH BINDER in Huntsville (apparently there is a specific urgent consult clinic binder somewhere in Bracebridge too? We couldnt find it in Huntsville tonight)

Thought I’d pass this along as I’m pretty sure I had never heard of this service before and it sounds useful!

Stocking/Supply issues at HDMH

For HDMH staff – I am meeting with Kathy next week to chat about stocking in the ER. I have heard concerns about inconsistent stocking of certain items and have run across a few frustrations myself this summer so we are just going to do a walk-through the department to identify certain areas that need attention/feedback to our nursing staff who work through these re-stocking tasks at night.

Please let me know if you have areas of concern. My current list includes:

-Suture carts – ensuring they are stocked the same & with adequate supplies for busy days, including 25g 1 1/2 inch needles and adequate drape supplies if using the new utensil-only suture kits.

-ENT cart – plastic ear curettes, lido spray, cotton balls & cup, possibility of stocking otrivan or similar ?

-Trauma carts – ensuring radial & femoral art lines are clearly labelled and BOTH stocked along with supplies/tubing to set them up; creating a central line kit with all the materials needed (including sterile probe covers, chlorhex sponges, flushes, caps, tegaderm, mask & gown all in one bag);


Any other feedback? Thanks


Criticall documentation sheet

Hello again,

It was requested by our internal medicine colleagues at rounds a few months back that we clearly document our conversations with specialists (especially neurosurgeons) via Criticall on the chart of patients that are being admitted for monitoring at our hospitals.  Specifically, the inpatient doc needs to know who we spoke with and their recommendations for follow-up. This information too easily gets lost in the busy ER chart, so I have created a template sheet to use that will hopefully make this easier (and remind us what to ask on the phone!).  It can be used for other specialist consults as well (i.e. ortho) and should be stickered and included in the patient chart.

Copies of these template sheets can be found in the drawer to the right of the physicians desk in Huntsville under the (scribbled) label “Criticall”.  I will be bringing copies to Bracebridge today to include in the physician resource drawer there too. Please let me know if you have or hear feedback about these forms – is there any way to make them better/more useful?


HDMH Backup sign in Binder

Hi all –

As discussed at our HDMH ER group meeting, I have created a binder with ‘sign-in’ sheets in order to help us document our back-up calls.  It is a white binder, clearly labelled, located on the shelf behind the ‘captain’s chair’ .  When you are called in on back-up, please remember to grab this binder and sign in. It should be fairly self-explanatory (name, date, time, reason for call-in i.e. how many patients waiting). The more we remember to do this the better our data will be!

This should help us defend our back-up usage if god-forbid the ministry ever tries to claw back our funding, and it may be able to help us identify some trends about our high-needs times.

If the Bracebridge group is interested in doing something similar let me know.