John Radcliffe Hospital
The main hospital in Oxford is the John Radcliffe (JR) Hospital, located in the Headington area three miles from the city centre. It has over 700 inpatient beds and houses many research departments of Oxford University, Oxford University Medical School and Oxford Brookes School of Health Care. It is one of the four hospital sites that make up Oxford University Hospitals NHS Trust:
- John Radcliffe Hospital: emergency medicine, acute general medicine, acute surgery, trauma, cardiothoracic surgery, neurosurgery, maxillofacial surgery, plastic surgery, ENT, ophthalmology, paediatrics, obstetrics and gynaecology, cardiology, gastroenterology, neurology, stroke services, intensive care (neuro-, cardiac, adult and paediatric).
- Churchill Hospital: cancer services, haematology, elective specialist surgery (colorectal, vascular, upper GI, transplant, urology), dermatology, infectious diseases, respiratory medicine, endocrinology, intensive care.
- Nuffield Orthopaedic Centre: Elective orthopaedics, rheumatology, rehabilitation medicine, bone infection unit.
- Horton General Hospital: a smaller district hospital in Banbury, with 230 beds
Trainees at HST level rotate through both John Radcliffe and Horton's Emergency Departments whilst placed in Oxford: experience of working in a busy major trauma centre with extensive access to medical and surgical specialists, whilst also spending some shifts in a smaller unit to retain fluency in hands on procedures and autonomy over patient care.
The Emergency Department
The Emergency Department at the John Radcliffe Hospital entered the new premises in January 2004. About 92,000 people attend the emergency department annually and around a quarter of those are children. Incorporated into the department is a dedicated Children's Emergency Department, staffed by a mixture of acute paediatricians and emergency physicians. The radiology department (with two CT scanners), Emergency Admission Unit, Emergency Theatres, Coronary Care and Intensive Care Units are all located immediately adjacent to the department.
The department currently (2014) has 15 Consultants who split their time between the JR and either Banbury, Prehospital care, Intensive Care or Academia. Consultants are present on the ‘shop floor’ from 8am to midnight. Registrars in the department have the opportunity to participate in research, teaching (medical students or SHOs), management or prehospital care during their SPA time (paid, one day a fortnight).
As the Major Trauma Centre for Oxfordshire, Buckinghamshire and Berkshire, the JR rotation provides a unique opportunity for Registrars to experience both major trauma and pre-hospital care.
Rapid Assessment and Triage
Three cubicles are dedicated to rapid triage of ambulance patients. This allows ambulance crews to rapidly handover patients and get back on the road, minimising ambulance queues. In these cubicles, patients are cannulated, bloods taken, vital signs recorded, analgesia provided, ECG performed and radiology requested, all under the direction of either an experienced nurse or the Consultant.
The resuscitation room has four trolley spaces including one for paediatric patients. All are equipped with state-of-the art monitoring, overhead theatre lighting and an overhead X-ray gantry. Ventilators are in the form of portable Oxylogs.
Majors - beds
There are 16 beds in majors for patients who cannot sit in the majors chairs and/or need monitoring.
Majors - chairs
There are a number of comfortable chairs for patients who are able to sit and do not require constant monitoring. From these chairs, patients can await results and receive infusions. Three cubicles are available for when the patient is being consulted. Use of the chairs has significantly increased the ‘majors’ capacity of the department.
The ambulatory side has 8 cubicles, a plaster room and an eye room (with a slit lamp). Emergency Nurse Practitioners also work in this area, providing a service for 15 hours each day.
Paediatric Emergency Department
There are 7 beds in this dedicated section of the department, with its own separate waiting area. The department is staffed by paediatric trained nurses. In day-time hours, medical patients are seen directly by paediatricians whilst all others are seen by the Emergency Department staff. At night, the Emergency Department sees all paediatric patients.
Emergency Admision Unit
This is a 27 bed ward based next to the Emergency Department and shared with the General Medical team. It accommodates acute medical patients (coming in from either the Emergency Department or directly from the community) and a selection of emergency patients (usually patients awaiting psychiatric input, awaiting transport or awaiting a few select scans).
Milton Keynes University Hospital
Milton Keynes is a thriving new city, which is being rapidly developed in a designated growth area of North Buckinghamshire, midway between Northampton and Aylesbury. It lies on the M1 and the London West Coast mainline railway. London is 35 minutes by train and London Luton Airport is 30 minutes' drive away. The city offers extensive shopping, sporting, leisure and cultural attractions, including an indoor snow dome and skydiving centre, and is surrounded by superb countryside. A wide variety of housing is available in the city and the surrounding villages. There is a wide range of schooling, both public and private in and around Milton Keynes.
Milton Keynes Hospital occupies a 60-hectare site to the south of the centre of the city, and is a medium sized district general hospital that serves Milton Keynes and surrounding areas. The hospital has approximately 400 inpatient beds and provides a broad range of general medical and surgical services, including A&E. The hospital provides services for all medical, surgical and child health emergency admissions. The hospital was officially opened in September 1984, Milton Keynes General NHS Trust formally came into being on 1st April 1992, and in October 2007 became a NHS Foundation Trust.
In addition to providing general acute services Milton Keynes Hospital increasingly provides more specialist services, including cancer, cardiology and oral surgery and has the responsibility for treating premature babies born locally and in the surrounding areas.
Since the advent of the Trust, significant changes to the range of services offered at the hospital have included the addition of a Renal Unit, the expansion of Postgraduate Education facilities, a new MRI scanning unit, and the expansion and re-location of the Cardiology Unit and Coronary Care Ward.
Specialist clinical support services are well provided for with Neurosurgery and Orthopaedic Oncology at Oxford, and Plastic Surgery at Stoke Mandeville.
The hospital is divided into 16 ward areas plus coronary care, critical care, SCBU, Ambulatory Care Unit and the recently opened 60 bedded Diagnostic and treatment Centre to fast track elective surgery. The purpose built out-patient building provides standard facilities, including X-ray with clinics run from designated rooms. There is a 9-bed facility offering Critical Care to all acute hospital patients' specifically invasive and non-invasive ventilation, intracranial pressure monitoring, haemofiltration and invasive cardiac monitoring.
There are twelve operating theatres.
The main imaging department is sited within the main hospital campus and also has a satellite radiographic room situated in A&E. There are 5 general radiographic rooms, 2 modern 'C' arms, one for the dedicated interventional service and 1 for gastrointestinal and vascular studies, MRI, Multi-slice CT and 2 general ultrasound rooms. Breast, obstetric, gynaecological and vascular laboratory services are also managed within the Imaging directorate and on-site. The department is supported with a full Radiology Information System and a PACS has been introduced in main x-ray and A&E x-ray with images distributed to the A&E department. Distribution of images to the wards and consulting rooms is currently under discussion.
Royal Berkshire Hospital
The RBH is a busy district general hospital serving a population of 600,000 and our ED sees approximately 105,000 patients per year with 25% of these being under 16 years old. We are a trauma unit operating within the Thames Valley Trauma Network. We have a 24hr cardiac catheterisation service and also run a 24hr stroke thrombolysis service. These are both consistently rated in the top couple in the country.
Emergency Medicine is at the heart of the hospital’s emergency care pathway and provides innovative and high quality care for patients from the moment they arrive at the hospital. It is a consultant led service with consultants providing leadership and patient care on the ‘shop floor’ 08:00-00:00 (at least) seven days a week. There is a strong commitment to ensure the ED is appropriately resourced to deliver high quality and timely emergency care. The Trust has been and continues to be very supportive of the developments that are taking place to address the pressures resulting from increased emergency admissions and a greater acuity of cases which present.
The department has excellent links with inpatient hospital teams: two EM consultant appointments being joint posts with the Intensive Care Unit and others are emergency physicians with dual training in paediatrics or interests in trauma and pre-hospital medicine. We work collaboratively with other inpatient teams as demonstrated by our HSJ patient safety award for work on neutropenic sepsis and falling door-to-balloon times for PCI and the provision of 24/7 stroke thrombolysis (led jointly by the neurology and emergency medicine consultant teams).
The Emergency Department is a purpose built unit that opened in 2002, with a dedicated paediatric area opened in Dec 2010. There are four resuscitation bays, (3 adult and 1 paediatric) which are equipped to provide state of the art care to critically ill and injured patients. We carry out conscious sedation for a wide variety of joint manipulations and cardioversions. There are 16 majors bays and a dedicated minor illnesses and minor injuries area - with treatment bays and a plaster room. In late 2016, a new initial assessment area was opened. This purpose-built unit with 8 cubicles rapidly assesses all adult ambulance arrivals and initiates early investigations as well as early treatment for our patients.
The paediatric emergency department has a dedicated waiting room, 5 majors assessment bays, a minor injury assessment cubicle and 2 treatment rooms. In addition, there is a decontamination unit within the ED, and two dedicated X-ray rooms. In 2014, we opened a new 8-bedded observation bay within the ED to enable us to carry out observational and ambulatory care medicine.
The main radiology department with CT, US and MRI scanning facilities is directly opposite the department, which has a computerised radiology PACS system. We have a purpose-designed Electronic Patient Record (Firstnet Cerner) system, which integrates many of these functions and provide seamless record keeping throughout the trust. We have a completely electronic pathology and radiology ordering system and are becoming a paperless hospital this year.
On the RBH site, there is also a dedicated ophthalmic casualty department, open daily. There is also a GP unit allowing selected arrivals to be diverted to more appropriate services. Within the region, there is a walk-in centre in Reading town centre and minor injuries units in Newbury and Henley.
These other services mean that we see a higher than average acuity of patient in the ED and the vast majority of patients have genuine emergency medicine problems. Our admission rate is approximately 25%. We have recently expanded our Emergency Nurse Practitioner service, who now provide cover until 1am 7 days a week.
Education and training
The department has a strong emphasis on education of junior doctors, and we the only ED within the region to be rated as ‘A’ or ‘Excellent’ from the School of Emergency Medicine Quality Grading every year since 2010. We are also the only trust in the region to be recognised as a centre for paediatric EM training, for which we recruited our first trainee in August 2016. We also offer Middle Grade Fellowship opportunities enabling the combination of Emergency Medicine training alongside a plethora of options such as PHEM, Education, Research or Sports Medicine.
We are proud to offer a comprehensive teaching programme to junior doctors, with protected weekly teaching which is consultant-led and based on the RCEM ACCS curriculum. Simulation sessions are incorporated in the programme and are run roughly every month in the simulation centre and when feasible in real-time in the department. These sessions are also consultant-led, and based on a library of scenarios covering major acute presentations, written using a new simulation proforma designed and tested by the ICM and simulation teams.
The trust regularly holds regular life support courses (including ATLS, ALS and APLS) and has developed a TILS (Trauma Immediate Life Support) course.
Quality improvement projects and pathways
We have a robust programme of audit; this includes the RCEM national audits as well as a local programme of key performance targets and the use of care bundles. These complement the highly active and effective Clinical Governance system which holds monthly meetings in the ED as well as joint meetings with other departments. Findings from audit and Clinical Governance are regularly fed into the educational meetings and communicated widely amongst the staff. There is close input from consultants to enable this work to be taken further in terms of a quality improvement project and management portfolio.
We have an incredibly strong research team across the Emergency Department and are currently recruiting to a number of portfolio studies. We have been the successful recipients of three Royal College of Emergency Medicine research grants to enable us to design and run a further three studies eligible for portfolio status. In 2016, we were recipients of awards for Innovation in Patient and Public Involvement from the Thames Valley and South Midlands Research Network, as well as The Royal College of Emergency Medicines’ "Principle Investigator of the Year", a phenomenal accolade.
Consultants in Emergency Medicine at the RBH
Dr Maria Dudek
Dr Liza Keating (ICU / EM) - TPD for ICM, Research
Dr David Mossop (EM / ICU) - Medical Associate Director
Dr David Clarke - Clinical lead
Dr Rosemary Hancock - Audit lead
Dr Omar Nafousi (EM / Paediatric EM) - PEM training lead
Dr Jane Brenchley - EM Head of School
Dr Rachael De Caux - NHSI Medical Director
Dr Robert Slater
Dr Lizle Blom - PHEM
Dr Dimitri Kontogeorgis - Mental Health lead
Dr Manish Thakker - Foundation programme TPD, Research
Dr Andrea Hinterholzer - Clinical Governance lead
Dr Simon Triscott - Specialty Tutor
Dr Sue Newton - PA programme
Stoke Mandeville Hospital
The Emergency Department for Buckinghamshire Hospitals NHS Trust is based at Stoker Mandeville Hospital and currently, sees approximately 80000 attendances annually. The department has benefited from recent substantial investment with the provision of a modern, spacious well equipped 5 bedded resuscitation area with dedicated trauma and paediatric bays, a 20 bedded Clinical Decisions Unit for the practice of observation medicine, a 5 bedded area to support Rapid Assessment and Treatment, and a dedicated departmental CT scanner.
There is an Acute Medical Unit and Surgical Assessment Unit for GP heralded patients, and a short stay ward for medical patients with a length of stay of less than 48 hours.
The ED is a trauma unit and can receive aeromedical transfers via a secondary land transfer. There are plans and funding to build an onsite helipad to deliver trolley push access into the resuscitation room.
The Trust provides courses in ALS, ATLS and APLS, for which the Consultants are instructors. There is an active teaching programme and the Consultants examine for both MCEM and FCEM.
There is an established ENP service that provides 3 ENPS 12 hours daily.
The ED at Stoke Mandeville also provides support to a Minor Injuries and Illness Unit at High Wycombe.
Medical Staffing is for 10 WTE Consultants, 12 middle grades (4 trainees) and 14 SHOs (8 FY2, 4 VTS, 1 CMT and 1 ACCS).
Since the hospital opened, there has been a computerised PAS in place. This has been expanded and developed. All link with the hospital Intranet as well as with the Internet and Electronic Patients Records (ERP). The Trust is involved in the national implementation of the Integrated Care Record Scheme [ICRS].
Wexham Park Hospital
Wexham Park Hospital is located on the outskirts of Slough and is part of the Frimley Health Foundation NHS Trust. The Emergency Department was rated “Outstanding” in the last CQC review. Wexham delivers high-quality, well-regarded clinical care and support to the population it serves.
We are currently in the process of building a brand new Emergency Access Centre which will include a new state of the art Emergency Department covering the whole ground floor which will have its own integrated radiology department and CT scanner, an 8 bed resus, 30 bed majors, a 10 bed initial assessment area and a large, dedicated paeds ED. This will allow us to provide truly excellent emergency care. We plan to move in in April 2019
The Department is currently preparing for the challenge of a move into a purpose built Emergency Centre (with an expected completion date of Sept 2018) which will increase capacity and both patient and staff experience.
Slough, featuring in “The Office” and of Betjeman fame is a large, and growing town and it faces a recognizable burden of clinical and other health challenges. It has excellent transport links, both by rail and road, with most areas of the Region and is easily accessed from London.
It serves a locale from South Buckinghamshire to East Berks including Windsor so the variety of population is broad.
Wexham ED has ~ 118,000 attendances per year, 30% of which are paediatrics. The Emergency Department at Wexham is busy and friendly, with support from twelve consultants and a cross-site Chief of Service. This provides cover from 8am to 11pm and sometimes up until 2am every day. As a consultant body, we are an extremely approachable and supportive team, and are readily available overnight when on-call. Several of the Consultants hold roles with RCEM, including an array of examiners who are always willing to help guide through the FRCEM exams. Currently the TPD is a senior consultant at Wexham and looks after some of the HSTs.
There is now a regular consultant paediatrician in the designated Paediatric ED providing support and training for those gaining ST3 competencies.
Nursing support is an integral and vital part of all ED practice, and is very closely interwoven at Wexham providing a friendly and open environment in which to work, learn and develop. This is highlighted by a range of nurse practitioner roles and training recognition for ACP. There also is a newly appointed nurse Consultant. When possible, trainees are encouraged to involve themselves in ‘Minors’ gaining experience in emergent treatment of many MSK problems.
Wexham has an excellent relationship with the ITU colleagues, and will often provide all of the immediate critical care required prior to ITU becoming involved. There are also secondment opportunities to anesthetics and ITU.
As a hospital it is also starting to provide a CESR route for any aspiring non training middle grades. You will be working with some extremely talented and committed regular SAS doctors who are able to also provide a wealth of knowledge.
Teaching and Research are well-supported. Specialist Registrars are fully supported in attending fortnightly Regional training days and there are also additional in house Registrar teaching days. There are extensive opportunities for Registrars to spread their wings beyond the clinical opportunities available and engage in active, real-time management projects further promoting the development needs for future consultant practice. Regular sim practice happens with some of the latest simulation models.
SHO teaching is also delivered on a regular pattern, both in-house and through the Regional ACCS teaching days. These can offer excellent opportunities for Registrars to expand teaching portfolios.
Wexham Park is very popular with trainees on the HETV rotation and we look forward to you joining us soon.
Hospitals and Locations
Wexham Park Hospital, Frimley Health NHS Foundation Trust
Wexham Park Hospital, Slough
Milton Keynes Hospital NHS Foundation Trust
Milton Keynes General Hospital
Buckinghamshire Healthcare NHS Trust
Oxford University Hospitals NHS Trust
John Radcliffe, Oxford
Royal Berkshire NHS Foundation Trust
Royal Berkshire Hospital, Reading
Stoke Mandeville, Aylesbury
Wycombe Hospital, High Wycombe