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Useful information about working in Cardiothoracic Surgery

Who to call

  • On-call Registrar

  • Consultant responsible for the patient, and if they are not available/contactable:

  • On-call Consultant

  • The phone numbers for each Consultant as well as the Consultant on-call are displayed in the nursing stations on ward 42 or can be contacted via the hospital operator

Escalation of concerns

Many post-op cardiothoracic patients in the ward have had complex cardiac or thoracic procedures, where any delay in diagnosis or treatment can adversely affect outcome. Prompt review and discussion with senior staff and treatment are vital

  • Attend to calls immediately.

  • Bring the problem to the attention of the Registrar or Consultant.

  • If you are unable to contact the Registrar, contact the Consultant responsible for the patient or the on-call Consultant directly.

  • Follow the EWS (Early Warning Score) documentation on the ward as to what to do for each score and when to call a code.

  • If you have concerns regarding a cardiothoracic patient, do not rest until you have spoken to a Registrar or Consultant directly; leaving either a voice or text message is not sufficient.

Resources

"The House Officer Orientation Booklet" and "Ward 42 Management Guidelines – for House Officers and Registrars" available at the staff base in ward 42 ACH, provide a comprehensive outline of procedures and protocols.

Clerking of pre-operative patients

  • The Cardiothoracic Service at Auckland Hospital operates on patients who present both electively (from home) and those presenting with an acute cardiothoracic concern. Patients who present electively usually present to ward 42 the day prior to, or early on the morning of surgery. These patients are clerked in by the Cardiothoracic House Officers.

    • For patients coming in from home, take a complete history and examine thoroughly. Fill out the Thoracic or Cardiac Surgery Pathway booklet for each admission.

  • Chart all regular and any other pre-operative medications as advised by the Registrar, Consultant and case Anaesthetist.

  • Ensure all pre-operative investigations are completed as per the checklist

  • Ensure patients have been cross-matched appropriately (see guidelines available in ward 42 staff base)

  • The cardio-surgical summary and MDM notes provide a lot of useful information. In particular note anything that has happened to the patient since the cardio-surgical summary or thoracic MDM discussion and escalate any concerns to the relevant team Registrar in a timely fashion prior to the planned operation date.

  • Patients requiring acute cardiac surgery are usually admitted preoperatively to ward 31 or 34 under the care of the Cardiology team. These inpatients will already be fully admitted by the Cardiology Service and the job then is to check that the relevant parts of the surgery clinical pathway document are completed and are correct. Use the “Cardiac Surgery Pre-op checklist” stickers to do so. Escalate any concerns to the operating team in a timely manner.

  • Occasionally, patients will be acutely transferred to ward 42 under the care of the on-call cardiothoracic surgeon for acute thoracic surgery. These patients require full admission, medication charting and standard preoperative investigations including a valid Group and Hold. Clarify with the admitting Registrar regarding timing of surgery so medications can be withheld and any relevant urgent investigations can be obtained. Consent and surgical booking are usually completed by the responsible registrar.

  • Medications to be withheld will be indicated by the Anaesthetic team as part of their pre-operative assessment. Beta blockers should be continued on the morning of surgery but ACE inhibitors and ARBs should be withheld. SGLT2 inhibitors (e.g. empaglifozin) should be withheld five days prior to the scheduled operation. Check the Anaesthetic Assessment document found in the patient’s clinical notes for any other preoperative instructions when clerking patients in.

  • Anticoagulants and antiplatelets (excluding aspirin which can be continued) are usually withheld prior to elective theatre (see below “anticoagulation in CTSU patients”). A copy of this table can also be found in the house officer orientation booklet.

  • Clinical urgency may necessitate proceeding to operation despite these medications having been taken within the time periods noted above – the timing of the most recent dosing should be noted and the Registrar informed.

  • Make sure that the relevant investigation results are available: CXRs/ECHOs/coronary angiograms/CT scans, etc. Occasionally these investigations occur in private or happen outside Auckland (e.g. adult congenital patients). A summary of pertinent findings can usually be found within the patient’s notes or in either the cardiosurgical summary/thoracic MDM; otherwise notes may need to be obtained from the relevant hospital.

  • Consent for procedures will be completed by the Registrar or Consultant.

  • Bring any concerns to the attention of the Registrar or Consultant immediately. It is easier to sort issues out and obtain necessary investigations during regular working hours.

  • Decisions about stopping anticoagulation and who should have bridging should already have been made at the time of admission and patients coming in for bridging will be identified. Ask the Registrar if you are not sure.