Clinical Work Instructions

[Melbourne MICA]

Hi all

I'm not sure of your local terminology but I'm refurbishing our "Clinical Work Instructions". These are the instructions which describe how to carry out all the procedures. They are not the prototcols/guidelines such as give drug A at 0.5mcg/kg/min in the patient with inadequate perfusion etc.

They cover every thing from how to tie a reef not (I kid you not!!) to inserting a pneumocath.

I was wondering if anyone can provide a link to their own service to check out how you guys go about such things.Our department is looking to revamp our CWI's into a modern 21st C look and feel - not to alter the intent of them - that's a separate process.

Basically we want to add pretty picks, diagrams etc rather than just have plain old boring text.

I appreciate there may be confidentiality or other issues so please don't get yourself (or me) into hot water.

Any assistance appreciated.

MM

 

[Shishkabob]

Here's just one example from the AMR Dallas protocols, if you want more give me a holler, but the only other one with pictures if the burn seciont with a picture of a body in the anatomical position with burn %s


Example of how they write it

C. INTRAOSSEOUS THERAPY

INDICATION
To administer life-saving drugs or fluids to children less than six years of age who are in severe shock or
cardiac arrest and who do not have peripheral veins available for IV access.

TECHNIQUE
1. Select site 2 fingerbreaths below proximal tibial tubercle.
2. Place towel roll under knee and externally rotate leg to expose broadest side of bone.
3. Prep area with Betadine and use sterile technique.
4. Fill 5 mL syringe with IV fluid and have partner immobilize leg.
5. Using a 16-18 gauge intraosseous needle, insert needle through soft tissue, into bone, with a rotating
technique.
6. Remove stylette, attempt to aspirate bone marrow into fluid-filled syringe, then flush fluid through
needle.
7. Connect to IV tubing and begin fluid administration as ordered by medical control or standing orders.

POTENTIAL COMPLICATIONS
1. If IV will not flow, needle may have gone through marrow and into bone on the other side. Back out
slightly and try infusion again.
2. Fluid may leak around needle, causing swelling. With infiltration, another site must be used.
3. Infection
4. Fat embolism

CONTRAINDICATIONS
1. Fracture on same extremity
2. Recent fracture near site or other infection near site.

(And the pic thats included)

 

[Melclin]

Seems like a lot of effort to go too just to add some pretty colours.

Do the CWIs see much use in AV? We certainly don't use them at uni.

 

[MrBrown]

We have a "manual of best practice standards" back in the day and it was a tabular format e.g. one column would have "do xxx" and the next to the right would be a picture showing what it was or doing it.

 

[Melbourne MICA]

More than meets the eye

Seems like a lot of effort to go too just to add some pretty colours.

Do the CWIs see much use in AV? We certainly don't use them at uni.

There's a bit more to it than that!!!!!

Wait till you get on the road my man. You will definately come across them during your training at some point and once qualified will also see them at CPE days (education update days). The CWI's are the black and white of every procedure in the AV manual. They spell out precisely how you carry out each and every skill (and include the test for each as well). And we usually here about them from this end when something in them is either unclear or worse, wrong!!!

But they look and feel at bit dated, a bit stolid so that's why I'm asking our illustrious (and ever helpful) cross continental colleagues for a bit of help or a few ideas. The pics really help when you are trying to get a gist of a new procedure/skill but can't quite get to grips with the text description.

And while I'm at it thanks Linuss for the example and Mr Brown for the info.

MM

 

[Melclin]

Yeah I have a copy. Its just, I thought they might be a bit like other canonical documents (the catholic CWIs come to mind ) in that few people actually model their practice on them.

I personally find the approach of texts like Roberts and Hedges "Clinical Procedures in Emergency Medicine" more helpful. I don't take well to wrote learning - few people do - and that's the kind of approach that the current CWIs seem to require. Roberts takes a more conceptual approach but also provides clear narratives of how to perform procedures. I realise that might be problematic in that the CWIs are almost like pieces of legislation in the clarity that they require, but maybe just something to consider (perhaps an expansion of the "rationale" column providing more discussion/narrative - I don't presume to tell you how to do your job, just a thought from the student perspective ).

 

[Melbourne MICA]

Cwi"s

I take your point but elaboration on principles isn't really the role of the CWI's. If a component of a procedure requires a rationale it's included in the CWI. eg "place the apex elctrode pad in the mid axilla line da da da, place the sternum electode pad..... (rationale) "pad placement reduces transthoracic impedance improving defibrillation efficiency". Simple but concise explanation of procedure and simple rationale but the point is made. You could easily spend pages examining transthoracic impedance issues but you do that elsewhere.

The CWI's are required (legally) so as ensure everyone who uses a skill knows exactly how it is to be done.

The CWI's are also based on best evidence. At the moment I am looking at one dealing pad placment for paeds pts over 10kg for example. The manufacturer says (on the packet) that adult pads must be used on all infants greater than 10kg. But how do you fit adult pads on a approx 1yo child and where exactly so they still work and comply with accepted standards? I'v had to spend a fair bit of time figuring out this problem and complying with AHA, ARC and ILCOR standards as well as satisfying our CPG committee.

As you can imagine its a trciky problem.

MM