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What next as a consequence?

What next as a consequence?. Dr JH Coakley MD FRCP Medical Director and Intensive Care Consultant Homerton University Hospital NHS FT Homerton Row London E9 6SR john.coakley@homerton.nhs.uk. Homerton University Hospital. 550 beds (300 acute medical) in Hackney

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What next as a consequence?

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  1. What next as a consequence? Dr JH Coakley MD FRCPMedical Director and Intensive Care ConsultantHomerton University Hospital NHS FTHomerton RowLondon E9 6SRjohn.coakley@homerton.nhs.uk

  2. Homerton University Hospital 550 beds (300 acute medical) in Hackney Emergency care predominates (106,000 A+E, 160,000 OPD, 35,000 IP, 5,000 births) Medical take 25 – 40 patients Surgical take 8 – 10 patients Orthopaedic and urology take – small numbers

  3. Night staff August 2003 5pm 10pm 11pm 12mid 8am Medical PRHO Medical PRHO Medical SHO Medical SHO Medical SpR Surgical PRHO Surgical PRHO Surgical SHO Surgical SpR Orthopaedic SpR ITU SpR Anaesthetic SHO Clinical Site Manager

  4. Night staff October 2003 5pm 10pm 11pm 12mid 8am Medical PRHO Medical PRHO Medical SHO Medical SHO Medical SpR Surgical PRHO Surgical SHO Surgical SpR Orthopaedic SpR ITU SpR Anaesthetic SHO Clin Site Manager Clin Site Manager Oncall from home Oncall from home handover

  5. Case Study 1 - HUH • Busy clerking in A&E. • Call from CSM: patient SOB on ward. Warrants urgent medical opinion. • Attend ward immediately. Patient VT. • Preliminary investigations, management in progress. O2, ECG, GTN, cardioversion kit ready, anaesthetist in attendance. • Prompt, appropriate patient management

  6. Why this worked: • Experienced, highly skilled CSM prompt diagnosis and management • Excellent communication from CSM; I was able to ascertain urgency and prioritise • All preliminary investigations / management underway • All necessary members of multidisciplinary H@N team called to scene SUPPORTED

  7. “My Night Support Network:” St Elsewhere's CSM Cardiology SPR CCU staff Me: Cardiology SHO Other SHOs ITU SPR

  8. Case Study 2 - St Elsewhere’s • Intermittent Loss of Capture Pacing wires • Initial management, A B C • Called for help; SpR 1 hour away • Unfamiliar instructions over phone • ITU SpR called to assist with airway/sedation (and moral support!) • CSM called by ward nurses. • Ancillary Staff called in by me.

  9. Why this didn’t work: • Night duty- SHO dedicated to cardiology • SpRs on call from home • Only resident SpRs : Anaes and ITU • Sprawling site • No enforced handover • No perceived value to H@N • OK when under control • No co-ordinated effort when things go wrong ISOLATED

  10. Reality check - EWTD 2009 • Continuity of care by individual juniors is dead • We therefore have to introduce continuity by system and/or team • We have to get as many people away at night as possible • We cannot afford to lose continuity of training either

  11. Is there a simple solution? • Ignore it and hope it will go away? • Expand consultant grade? • Expand training grades? • Expand some other (doctor) grade?

  12. Is there a complicated solution? • Elective emergency split (service and training) • Recognition that most emergencies are “medical”, even in non-medical patients • Avoiding increases in doctor numbers for all tiers of all rotas • Minimise night and weekend working • Expand ‘normal’ working day

  13. Total football…..the ACT Put simply, it means all 10 outfield players in a team are comfortable in any position. So if a defender wants to go on a mazy run towards goal, a midfielder will fill in for him at the back - and stay there. It may sound crazy, but it was a style of play that made Holland the greatest side of the 1970s.

  14. Taking Care 24/7 – how we ran it • Project Board – meetings every 2 weeks • Medical Director • Operations Director • Clinical Director of Medicine • Director of PGME • Associate director of HR • Medical staffing • Junior doctor representative • Senior nursing representative • Project manager

  15. Taking Care 24/7 - obstacles • Dislike of change • Risk aversion • MMC • EWTD • Custom and practice • ‘the college says….’ • ‘the dean says….’ • ‘my boss says….’ • ‘I’m not covered to….’

  16. Taking Care 24/7 • Communication: • Medical Council, Directorate Boards, Clinical Board, Postgraduate meetings…. • Reference Groups for medical and nursing staff • Discussion documents e-mailed • E-mail discussion encouraged • Homerton Life; CEO’s Brief etc • Lots of corridor and canteen conversations • People can still hear the wrong message

  17. Acute Care Unit 56 beds Planning based on 48 hour LOS Receives all acute admissions in surgery, orthopaedics, urology and medicine Junior staffing proportionate to emergency activity Busy!

  18. Acute Care Team Consultant led 24/7 team with no commitments other than acute care Extended normal working hours for acute care (including consultants) and improved handovers Consider which clinicians are best able to deliver the required competencies Integrate delivery of acute care across specialties Develop sustainable acute rotas

  19. Acute Care Team Consultants (12P, 6S, 5T+O, 3U) 6 Medical ST 3+ or SpRs (AM or EM) 8 Medical ST 1 or 2, FY2 (ACCS or AM) 3 Surgical ST 2 to 6 1 Orthopaedic ST 2 to 6 (0800 - 2200 only) 1 ICM ST 1 to 6 (0800 – 1600 only) 6 Foundation Trainees – FY1 CCO CSM

  20. Handovers 0800 very brief 1030 to discuss PTWR issues – ACT 1600 brief, to hand over jobs etc from ‘cold’ to ‘hot’ team 2100 for night

  21. Weekday and night ACT

  22. Taking Care 24/7 – six person acute rota

  23. Example – most FY2 - ST2 • 16 weeks per year acute work • Full shift for acute work • Protected training time in “cold” specialty for rest of year – no nights; no weekends

  24. Example – most ST3+ • 12 weeks per year acute work • Full shift for acute work • Protected training time in “cold” specialty for rest of year – no nights; no weekends

  25. What is the impact on training? • On 1:12 SpR rota they got 130 weekdays every 6 months of which 15 were ‘on-call’ which meant two days (total 30) off ie 100 days of cold training. • Now 4.5 months or 95 weekdays of cold training • Not much different from before even given the reduction of hours from 56 to 48. • Better supervised during their hot spell. • Either way, the overall effect for a medical SpR is pretty negligible.

  26. Implementation Group • New working party • Consultants • Juniors • Managers • Nurses • Weekly meeting to identify problems (and more importantly solutions)

  27. IG - Terms of Reference • To identify successful aspects of the new model of delivery of care • To identify problems in the delivery of care to all patients admitted as emergencies via the ACU • To suggest possible solutions to these without breaching EWTD or significantly increasing costs • To advise on the impact of the ACT on the non-acute teams

  28. What worked well? Doctors’ hours Relationships between physicians, surgeons, critical care and outreach have improved Night handover is very good Patients seen by a consultant very quickly Emergency / elective split works well for “cold team” juniors The change in surgical and orthopaedic rotas works well for the ED.

  29. …and what didn’t Stable Medical Leadership – daily change of consultant (s) Junior Doctor Rotas too complex don’t facilitate continuity of care particularly for longer stay patients

  30. …and what didn’t • Acute Medicine Rotas • Surgery overburdened out-of-hours • Information about patients • Communication between the ACT and the ‘cold’ team when a patient is sent to the ward. • Ward Jobs between 1700 and 2200 • Afternoon handovers

  31. Disappointments • Surgical and orthopaedic attendance at handover in the morning. • Engagement of the latter in general. • Handover – is it clinical, operational, strategic or just a problem raising forum. • Ward teams handing over multiple jobs which should have been done during office hours. • Not handing over genuinely sick patients.

  32. Disappointments • Not ‘my patient’ or ‘my specialty’ – are we trying to produce doctors or technicians? • Which ACU patients should be seen by physicians? • ‘Not my job to clerk patients’

  33. Hard to change, easy to stay the same, but…… Don't be so gloomy. After all it's not that awful. Like the fella says, in Italy for 30 years under the Borgias they had warfare, terror, murder, and bloodshed, but they produced Michelangelo, Leonardo da Vinci, and the Renaissance. In Switzerland they had brotherly love - they had 500 years of democracy and peace, and what did that produce? The cuckoo clock. So long Holly. Orson Wells (Third Man)

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