Read the introduction to DME by Dr Mason (below) He usually emails it to the new starters on your first day It is a good idea to save the appendix containing 'useful numbers' to your phone as this can really save you time.

DME has five core wards: G3, F4, G4, G6, C6 and C4 (Frailty and Acute Medicine for the Elderly - FAME)

• Dr R W S Biram
• Dr T Burton
• Dr D R Forsyth
• Dr J L Hampton
• Dr C G Nicholl
• Dr M Vindlacheruvu
• Dr S J Wallis
• Dr K J Wilson
• Dr J Diver
• Dr R Ortuno
• Dr S D'Souza

In DME there is a strong focus on the MDT due to our patients commonly having complex social/care backgrounds. The MDT meeting will consist of:

• Doctors
• Nursing Staff
• Occupational Therapists
• Physiotherapists
• Social Workers

They normally take place twice weekly. It is an opportunity to discuss the discharge needs for ALL of the patients on the ward.

Acute Block

This is 2 months, consists of ED clerking shifts as part of the general medical take and 4 weeks of service needs. The shifts timing can vary from 8:00 am to 6 pm shift and juniors also do a week of shorter 2-10pm shifts. You do one set of four nights in ED and a few weekends. There are plenty of zero days and the annual leave for this rotation is ideally taken during the service needs part. For more about leave make sure you attend the general medicine meeting towards the start of the rotation.

Ward Block

2 months on a home ward. This is usually normal ward days (08.30-18.00) with some long shifts (08.30-21.15) and weekend (08.15-21.15) shifts. Evenings (18.00-21.15) you will be on call for all DME wards + stroke, and on weekends for all DME wards except C4.

Ward F4

On ward F4 the consultants rotate every 5 weeks, currently this is between Dr. D'Souza and Dr. Wilson. Typically 1 registrar, 1 SHO and 1 FY1. It is a friendly and productive ward. You will enjoy it and learn a lot!

• There is a Consultant ward round on Monday and Wednesday mornings
• Discharge planning MDTs are held on Monday and Thursday afternoons at 14.30
• Departmental meeting on Friday at 11.15 in the J3/N3 seminar room
• Radiology meeting friday at 12.30 in Level 4 seminar room in radiology block
• DME lunch/lunchtime meeting 13.00 (usually free lunches!) in J3/N3 seminar room
• Although there a 4 fewer beds on F4 (21 rather than 25), the consultants and registrars attend clinics together most weeks. This is great opportunity to do your own ward round and can be a really good experience.
• This is an all female ward and there is sometimes a board round in the morning where we go through all the patients and update their clinically fit for discharge date, run through their discharge date etc.
• Dr Wilson has a clinic in Ely on Tuesday mornings and Wednesday afternoons

Ward G6

Ward G6 is the trusts specialist delirium and dementia ward. The staff are all amazing and managing the often difficult behaviour so the FY's can learn a lot from them.

There are 2 consultants in charge who rotate - Dr Colin Mason and Dr Duncan Forsyth - They tend to switch every 3 or 4 months.

• Every morning kicks off with a board round at 8.35 which all the doctors and nurse in charge are expected to attend and discuss potential discharges and discharge planning issues
• There is a consultant ward round every Monday and Thursday. On other days the consultant usually sees only the new patients,
• The Registrar does a WR every Wednesday. On Tuesday and Friday the FY1 and SHO do the ward round
• Discharge planning MDTs are held on Monday (12:00) and Thursday (1:30).
• Departmental meeting on Friday at 11.15 in the J3/N3 seminar room
• Radiology meeting friday at 12.30 in Level 4 seminar room in radiology block
• DME on G6 is quite chilled. A lot of the patients are usually just awaiting discharge planning.
• Its advisable to keep on top of TTO's and discharge summaries so you can have lots of spare time to complete your eportfolio
• DME lunch/lunchtime meeting 13.00 (usually free lunches!) in J3/N3 seminar room

Ward C4

Ward C4 [FAME] is the acute frailty unit. There is now 1 consultant, 2 registrars and 1 SHO/FY. C4 is meant to be a short-stay unit where patients are generally more unwell, but have less social discharge issues so once they are medically fit they get discharged. If they do need to wait for care then they tend to get transferred to a 'Core' DME ward [G4, F4, G3, G6, C6]. This ward only works if there is good patient flow so one of the important things as a junior is to ensure the consultants make it clear which patients are for core wards ASAP. It can be busy but is quite a nice ward to be on with afternoons after MDT quite free - if jobs are done on the ward round! Lots of learning how to communicate with families can be done.

• Daily board meeting at the nurses station at 8.45am
• Daily MDT 2pm-3pm, junior needs to scribe [DME MDT templates available as .dmemdt]
• Departmental meeting on Friday at 1pm in the J3/N3 seminar room [free lunch]
• Radiology meeting friday at 12.30 in Level 4 seminar room in radiology block

Ward C6

New DME ward, very friendly. This is a model DME ward with regard to layout, lighting etc.

• Consultants: Dr Wallis and Dr van der Poel (5 weeks each)
• Ward manager: Charlotte Foster
• The ward office is shared between the whole MDT, and you will get to know the physios, OT, dietitian and pharmacist well
• Ward round usually starts around 9-9.15 am.
• Board review every day around 2 PM and formal MDT (involving social workers etc) twice a week: Monday and Thursday, usually at 1.30pm. FY1s and SHO's usually take notes, so remember to get the .mdtdme smart-text from another doctor before starting. The discussion can go very quickly and before you know it the team will be discussing the third patient on the list while you're still clicking through the first one! Usually there will be 2 juniors writing the notes so it's helpful to prep the MDT notes beforehand, then arrange it so you're taking notes for every other patient. The pharmacist can also give you a list of medication requirements for discharge planning (i.e. MDS or MAR chart)
• There is a Consultant ward round on Monday and Thursday mornings, and the consultant will usually post-take on all new patients every morning.
• Department meeting on Friday at 13.15 in the J3/N3 seminar room
• Radiology meeting friday at 12.30 in Level 4 seminar room in radiology
• DME lunch/lunchtime meeting 13.00 (usually free lunches!) in J3/N3 seminar room

Ward G3

DME ward, often referred to as the “dicharge ward”. Most of the patients here are medically fit for discharge and awaiting some kind of social care. MDTs are crucial to knowing where the patient's are going and happen every Tuesday and Thursday at 13:30pm. If you are on G3 it is a good time to do any audits or projects.

Ward F4 Between 8:30-9 print the list, pick up the team bleep and check with the nurse in charge if there are any issues needing prompt attention. You can start prepping a post-take ward round note for any new patients. The consultant usually arrives around 9am and there is a quick board round with the ward clerk (Sandra) and the charge nurse to clarify discharge plans and urgent jobs. Ward round usually takes till lunch time. MDT is at 13:30. The afternoon is generally spent speaking to families, doing the ward round jobs, chasing bloods and doing teaching for the medical students. If there is any free time, try to make a start on discharge summaries for stable patients to avoid a rush later on. Between 17-18:00 any outstanding jobs are collated and handed over to the on-call doctor (152172). The consultant usually pops in towards the end of the shift to briefly go through the list and address any issues.

Ward G4 On G4 ward the day starts with a board round at 9:15 where brief discussions about each patient's discharge planning takes place. Other wards have this meeting at lunchtime. Before this it's important to print out a list of patients and review any outstanding bloods results/ investigations. Following this there is a consultant ward round on a Monday and Thursday, a junior doctor led round on Tuesday and Thursday and a registrar ward round on Wednesday. There is an MDT meeting at 2pm on Monday's and Thursday's where the OT, Physio, social workers, nurses and doctors meet to discuss the discharge planning for every patient. Any new patients arriving before 16:30 are also reviewed by the consultant every day otherwise the afternoon is free to complete ward jobs and update families. At the end of the day blood results are chased and ordered for the following day and outstanding jobs handed over to the on-call team. The number for the oncall team can be found on connect– typing in 'junior doctor rota' and searching for the Junior doctor on call for the evening. On Friday, you make sure to write a weekend job list for the junior doctor on call.

Ward C6 -Day starts at 8.30am on the ward by printing out patient lists, reviewing patients / results from prior day, and chasing any outstanding jobs from previous day. Have a look on the small board in the doctors room as this has discharges for the day, and try and get at least the medications done before the ward round. If you have time have a look through the notes for any new patients - the consultants have post-take ward round templates which they can share with you on Epic, and when Dr Wallis is on you can start filling in a summary for any new patients. Dr van der Poel prefers to write her own post-take note. There is a quick informal board round at around 9.00 where brief discussions are held about each patient's progress / likely place of discharge. New / sick / going home patients are seen first with the consultant. Rest of the patients are seen by either the consultant (consultant ward round day) or by registrar/SHO/FY1 (on other days). Ward round is usually finished by lunch time. One of the juniors (usually FY1) often peels off during the ward round to get urgent jobs (TTOs, arranging Ix, referrals) done to speed up the process. MDT meeting involving doctors, OT, PT, social worker and senior sister is held every Monday and Thursday afternoons at 1.30pm for about an hour to discuss discharge planning for each patient. New patients that arrive on the ward before 4.30pm are reviewed by the consultant. Apart from this, afternoons are taken up by finishing off jobs (including making referrals, chasing various investigations and blood results, completing TTOs/discharge letters for patients going home the next day etc), reviewing any unwell patients and updating family/relatives. At 5-6pm, blood results should be checked and acted upon (remember that many patients do not need frequent bloods, especially medically fit patients waiting for care). The consultant catches up with the rest of the team about how the patients are doing, so any concerns / problems can be raised. Any urgent outstanding tasks should be handed over to on call team. On Friday afternoon the consultant will run through the list with the team to highlight who needs reviewing or bloods over the weekend, and this will be handed over by email to the weekend team.

Ward G3

Ward G3 is a split ward between DME and other teams outliers, DME usually has between 17 and 20 patients on the G3 list, they can be new admissions or DME transfers.

It's a friendly ward and a pleasure to work in, normal days start at 8:30 am -I start by checking the G3 list under 'teams' in Epic 'DME TEAM 5' (ignore that it says D5) -Wait usually till just before 9am to print just in case new patient pops up -Then I check board at nurses station to see if our EPIC list matches who is on ward and thought to be under our team, beware that not all new patients belong automatically to DME! -Board round is at 9am with Nurse in charge, medical team and OT/PT if they can make it, we discuss discharge issues and any new nursing/pt/ot concerns, great time to orientate yourself when joining the ward for the first time -Following this is ward round, varying in technique by Consultant, some like to split the ward depending on staffing -Communication with patients and families very important on this ward as with many DME wards, I'd make an effort to speak to everyones family when spotted just to discuss, it saves them becoming worried/agitated later on and keeps everyone up to date with the plan, on G3 there tends to be enough time for plenty of communication unless it is unusually busy/ sick patients -Tuesday and Thursday at 13:30 is MDT in the MDT room, a tiny windowless room which is under plans for refurbishment! An excellent opportunity to learn all the discharge paperwork acronyms! -Prep for MDT on Tues and Thurs after ward round by pending notes for all patients as there will not be time to do this in MDT, make a new note, type in DFM to the search bar so it comes up as a discharge planning note, then ask a colleague to share the epic .phrase '.mdtdme' which makes a proforma for the MDT to fill out, its quite simple really -Prep these notes for MDT with whatever details you can glean from WR/previous MDTs and this will make life so much easier! -You tend to be able to leave on time around 6pm as long as nobody is very unwell/other safety reasons -over all a very satisfying place to work and DME has been my favourite rotation thus far

-Again, my main advice apart from practicalities of above is to SPEAK with patients and family as much as possible, many of the patients will be Medically fit for discharge while waiting for care/placement etc and good communication and rapport with pt and family helps so so much. A good time to get better with difficult communication such as frustrations/complaints or end of life discussions. Most important job for my training I've had so far. Good luck!

The most common presentations tend to be

1. Falls [the term Mechanical Fall is a big no no]
2. Confusion/Delirium
3. Sepsis
4. Reduced Mobility [NEVER use the term 'Off legs' or 'social admission']

In general, regardless of the presentation, we aim to do a comprehensive geriatric assessment which involves full PT and OT assessment and discussion with their family about how they are coping at home.

Nearly everyone gets a confusion screen [FBC, U&E, CRP, Bone profile, B12/Folate, TFTs, Urine dip, CXR +/- CT Head], and if someone has a fall it is always worth getting a pelvis XR from the off as there have been a couple of incidences of missed hip fractures.

The Trust antimicrobial guidelines are available on CONNECT and are very comprehensive. C-Diff is an issue in this group of patients so try and stop PPI's and keep a close eye on the stool charts [smart link .ipstool]. The gastro team will consider faecal transplant in some refractory cases of C-Diff so this is something to bear in mind.

Discharge planning is a big part of the DME job. It can be a bit daunting at first but once you have grasped how the system works you can make a bit difference and it can be very satisfying. Ideally, you want to be able to discharge patients as soon as they are medically fit to avoid them de-conditioning and spending unnecessary time in hospital. Often this is not possible, but good preparation and planning can help.

See the 'How to survive an MDT document below for an overview of how discharge planning works. (Thinks change frequently so it will soon become out of date, but hopefully it wont be far off)

When patients are considered for placement, either residential or nursing care, the nursing staff will complete the CHC (continuing healthcare checklist). If the patient is positive then the various members of the MDT (Nurses, Doctors, OT and physiotherapy) will have to provide evidence of their care needs. In order to perform this on EPIC you need to start a new note and change the note type to CHC Medical Summary. This will then create a list of headings which you need to fill in regarding this patient. It is important to do these quickly as their absence will slow the discharge process.

Patients with terminal illness and likely to deteriorate rapidly may have a “Fast track” discharge, meaning that funding for care should be available more quickly than through the usual pathways. This can still take a while, especially for a large care package, so make sure patients and their families are aware of this. You will need to complete the medical summary for the fast track paperwork, which can be done on Epic. This should be a priority job once the decision for fast track discharge is made as the process cannot start until it's done. Inform the nurse in charge who will bleep the specialist discharge planning team.

FALLS ASSESSMENT

When a patient has a fall on the ward a doctor needs to review them. Depending on the circumstances this can be a brief review or a more in depth one. If a fall is witnessed, check with the witness (often Nursing Staff) what exactly happened. If the fall is unwitnessed take a history from the patient, important points to note include if they had any of the following: -chest pain -shortness of breath -palpitations -dizziness -loss of consciousness (if this occured check with Nursing staff for how long and any signs of seizures). Ask the patient what they were doing when they fell, were they going from sitting/lying to standing ?postural.

Once you have got a history examine the patient. You will want to assess the patient for signs that may have caused a fall and for any injuries post fall. Typically you would do a cardiovascular and respiratory exam, (if history indicates do abdominal exam too) gross neurological exam (if any abnormalities do full exam), cranial nerve exam (especially pupils). You will also want to check the patient's head if there was a head injury for any signs of bruising or cuts and examine the patient's arms and legs for any potential fractures.

From examination order appropriate investigations. If a patient has hit their head and is on anticoagulants it may be necessary to request a CT head. Otherwise request X-rays if there is any possible fractures and blood tests if history indicates a medical cause of fall (e.g. sepsis).

Discuss with the Nurses on the ward if the patient requires ongoing Neuro Obs and if so how frequently. If there are no concerns then let staff know to stop Neuro Obs and document in the notes.

If you have any concerns at all about the patient always speak to your SHO or SpR for advise.

CAPACITY ASSESSMENT AND DOLS FORMS

As soon as a patient needs to be discharged it is important to establish whether they have capacity for discharge decisions. Most commonly to SpR/Consultant will make this decision but sometimes it will be you. You then need to record it on epic [Mental capacity is an available order]. If the patient doesn't have capacity and is being kept in hospital 'against their will' such as being Red Specialed [meaning they have someone supervising them at all times] then Deprivation of Liberties 'DOLS' paperwork needs to be completed and sent to the DOLS leader [Heather Ayles]. It is best to do this early on as it can always be removed at anytime.

SAFEGUARDING

The nurses generally deal with safeguarding issues.Often patients come in from the community with SOVA's against their carers/family and these are all investigated by the social workers and Heather Ayles. As the junior it is important to keep a check on SOVAs and whether they have been resolved as if they haven't this can act as a barrier to discharge. If you have concerns then information on how to raise an issue is available on CONNECT - there is an online form which you can document on EPIC but also remember to refer to the safe guarding team on EPIC and give them a call aswell just to be sure it is on their radar.

REFERRAL TO COMMUNITY PALLIATIVE CARE

Patients who are sent home with end of life care usually need referred to the community palliative care team. Go to: Connect > Departments and Services > Palliative Care Department > Hospice Services, Links and Referral Forms The “Common Referral Form For Cambridgeshire” is used for most patients. Arthur Rank Hospice is the main point of referral. There is a fax and telephone number on the referral form, and its usually worth ringing the patient's GP to keep them up to date.

This isn't the same process as a Fast Track Discharge for end-of-life patients with a poorer prognosis, but Consultants and Ward Managers will usually get involved with the paperwork for these patients.

CQUINS AND ADMISSION ASSESSMENTS

Particularly emphasized in DME, each patient should have at least three assessments performed on admission - VTE Assessment, Frailty CQUIN and Dementia CQUIN.

These are all found under the “Admissions” tab in EPIC. A frailty assessment is very subjective, and needs some information around the patient's social history - make sure to click “Row Info” at the top of the assessment section for a full breakdown of the Rockwood Frailty score we use at Addenbrooke's.

Dementia CQUIN requires an AMTS 4 if the patient has no previous dementia, filed under the “Dementia Score” section. If there is a known diagnosis, you'll have to move on the the “Dementia Assessment” section below and complete Step 3.

It's very useful to set up your patient list to show whether or not these assessments have been done - under Properties for your list, show “VTE Assessment Done?”, “Frailty CQUIN done?” and “Dementia CQUIN done?” for a useful tick-or-cross view of assessment.

• Not all DME patients are seen over the weekend
• Each ward will hand over the 1-2 sick patients that need review over the weekend to the Consultant/SpR on Friday via email (usually the seniors do this, or they will tell you who/what to email)
• At the weekend there is a ward round for the new patients and all those handed over by the individual wards
• From about 1pm you are left to get on with the jobs, answer bleeps, and do jobs handed over by the juniors
• The junior handover is usually on the EPIC “summary” or “to do” section
• It's a good idea to print a list of all the DME patients with the above sections so that you can work through jobs/have a quick summary in front of you when you are called.
• Evenings on DME 6-9pm can be very busy, particularly at nurses handover time. If someone is very ill then the RRT are happy to come and help. Sometimes you may find the med reg is less keen to come but its worth a try. You tend to get handed over around 10-20 bloods to 'chase' as the labs can get a little slow. If they still haven't come back by abut 8.30 it is worth checking through the patient notes and deciding which ones are 'urgent' as the night SHO will not be pleased if you hand them over 15 sets of bloods to chase as they are usually rushed off their feet with sickies.
• Be aware that although you may be based on a DME ward during the weekdays, if you are doing a long day, you will also be covering DME/AME/Stroke and their GMED from 18:00 to 21:00 which is when handover is (in the David Dunn Suite near the main entrance). Note that you may be scheduled to be covering a different speciality instead from 1800 to 21:15, and you should check this on the latest “Junior Medical Rota” timetable that can be found on Connect2. This could be the Hepatology/Renal/Rheum/Derm + their GMED, Cardio/Resp + their GMED, and Gastro/Diab&Endo/MSEU/ID. Bleeps are usually found in the F/G5 seminar room except for the diabetes bleep which is found in the F6 Doctor's Office.

You will often find yourself being asked by one of the ward staff to visit a patient's family member, often by the patient's bedside, in order to answer question or discuss certain aspects of care - though in some other departments, conversations about care may be led by more senior members of the team, in DME it often falls upon you to answer such questions and alleviate fears. As a general set of rules:

- Have a look through the notes - familiarise yourself with the patient's complaints, treatments, and discharge plans. Take care to note if any information has been held from the patient or visitors, and/or if the patient has expressed a wish for certain details not to be discussed. - Introduce yourself - Ask who you're speaking to - Identify all people within the bedspace/area - Obtain patient's consent to discuss with this particular person - Arrange privacy (day room, meeting room may also be an appropriate location for more sensitive topics) - Arrange seating if necessary - Ascertain the person's current knowledge level - Allow time for visitors and loved ones to absorb information and understand what is being said, giving time also for questions to be asked - Do not hurry! Such conversations are instrumental to provision of care on DME wards, and often provide helpful in gaining information on the patient and their home setup - REMEMBER TO DOCUMENT.

Tips for documentation - Remember to write who you're speaking to - address them by the names they introduced themselves with - Remember to write why you're speaking to them, and where (by patient's bedside, with patient's consent/in patient's best interests) - Document every topic that you have discussed, and try to document by paraphrasing and using terms you had used in the conversation itself. Jargon and complex terminology is often lost on patient's and their visitors, and so you should write as you have spoken - Do not be afraid to document feelings and moods, and ensure to also make note of the questions asked by the visitor, as well as your responses. - Keep the sentences short and concise.

Download the INDUCTION app for lots of useful numbers for wards/departments/advice

• F4 Doctor's office - 2946
• G4 Doctor's office - 4590
• G6 Doctor's Office - 3429
• G3 Doctor's Office - 56535

Good work life balance with the day finishing on time or an hour late occasionally. On-calls include weekend shifts 8.15-21.15 and week day long shifts 8.30-21.15.

Please see the 'Geriatrics Profanisaurus,' for example 'Bed blocker' is a horrible phrase which nobody working in DME should utter and 'Mechanical Fall' does not exist, very eye opening document.

A very useful introduction to DME by Dr. Mason:

The Guide

• dme_junior_doctor_induction.docx

The Appendices

• appendix_1_ward_timetables.docx
• appendix_2_discharge_planning_terminology.docx
• appendix_3._the_geriatrics_profanisaurus.docx
• appendix_4._talking_to_relatives.docx
• appendix_5_talking_to_patients_with_dementia_and_delirium.docx
• appendix_6_delirium_information_sheet_for_carers.pdf
• appendix_7_pathology_guidance.doc
• appendix_8_stopp_start_criteria.pdf
• appendix_9_useful_contacts.docx
• appendix_10_-_twenty_one_tips_for_junior_doctors_working_with_older_people.docx

This rotation may not offer too many opportunities for skills (e.g. not many LPs… although plenty of PRs!) but it is good chance to get some things ticked off, like your TAB (you will get to know all the staff really well, and have frequent MDTs so there are plenty of people to ask to complete a TAB for you). Also there will often be students assigned to your ward who will probably be keen for any sort of teaching you may be able to offer, and it is not difficult to find time to do this on a quiet afternoon.