7 day working: implications for emergency services

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Information about 7 day working: implications for emergency services
Health & Medicine

Published on April 26, 2014

Author: croseveare

Source: slideshare.net

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Practical issues around the implementation of the Academy of Medical Royal Colleges' standards for 7 day consultant-present care, along with the potential impact on training

7 day working: implications for emergency services Dr Chris Roseveare Co-Chair AoMRC 7 day Project sub-committee

The weekend challenge… Higher case-mix adjusted mortality Greater illness severity amongst weekend admissions Fewer consultants in hospital

…the benefits of consultant-delivered care should be available to all patients throughout the week

7 day working: what do we mean? • ‘Emergency’ Care: • ‘Elective’ Care: • ‘Urgent’ Care: • Must Do’s • Could Do’s • Should Do’s

Standard 1 Hospital inpatients should be reviewed by an on-site consultant at least once every 24 hours, seven days a week, unless it has been determined that this would not affect the patient’s care pathway.

Standard 2 Consultant supervised interventions / investigations + reports should be provided seven days a week if the results will change the outcome or status of the patient’s care pathway before the next ‘normal’ working day.

Standard 3 Support services both in hospitals and in the primary care setting should be available seven days a week

Sir Richard Thompson President , RCPL ‘While the RCP accepts this as an aspirational standard for all physicians, we believe that this will require service redesign and may have resource implications to make this a comprehensive reality’

• Challenges for implementation – contracts / job plans – specialism vs generalism – continuity of care – costs

PART 2 More detailed summary of implications for each speciality / college • Staffing requirements? • Which investigations / interventions? • Which support services? Questionnaire to speciality organisations – Responses from 36 medical specialities – Further information from 14 other organisations

Key messages…1 Most patients will benefit from a daily consultant review

Key messages…2 Duration of consultant review varies by speciality, but continuity is key….

Key messages….3 ‘Approx. 6 hours of consultant time required for every 30 in-patients’

Key messages….4 More generalists needed for ‘cross cover’ – acute physicians – geriatricians – general physicians

Consultant supervised Investigation Proportion of specialties indicating a regular need at the weekend ‘Top Ten’ specialties 36 survey respondents Haematology 100% 97% Microbiology 100% 97% Clinical biochemistry / chemical pathology 100% 97% Ultrasound 90% 83% Computed Tomography (CT) scan 90% 78% Plain radiology 80% 89% Access to expert imaging opinion 70% 58% Magnetic Resonance Imaging (MRI) 60% 56% Diagnostic upper gastrointestinal endoscopy 60% 42% Echocardiogram 60%* 19%*

Consultant-supervised Intervention Proportion of specialties indicating a regular need at the weekend (%) ‘Top Ten’ specialties 36 survey respondents Emergency surgery 70 58 Interventional radiology 50 47 Therapeutic upper gastrointestinal endoscopy 50 39 Percutaneous coronary angiography 50 25 Radiological feeding tube placement 40 31 Haemodialysis 40 31 Bronchoscopy 20 33

Hospital based services Proportion of specialties indicating a regular need at the weekend (%) ‘Top Ten’ specialties 36 survey respondents Pharmacy 100 100 Physiotherapy 90 83 Specialist nurse review 70 61 Dietetics/Nutrition 70 44 Occupational therapy 40 47 Swallow assessment 40 17 Speech & Language therapy 30 31

Community based services Proportion of specialties indicating a regular need at the weekend (%) ‘Top ten’ specialties 36 survey respondents Social care team 90 67 Specialty community care team 80 58 Real time conversation with GP 70 47 Electronic communication with GP 60 50 Real time conversation with community practice team 60 50 Electronic communication with community practice team 50 44

Training implications – Supervision vs autonomy – Generalism vs specialism – Consultant numbers / patterns of working

•Rapid and appropriate decision making •Improved safety, fewer errors •Improved outcomes •More efficient use of resources •GP's access to the opinion of a fully trained doctor •Patient expectation of access to appropriate and skilled clinicians and information •Benefits for the supervised training of junior doctors. Benefits of consultant delivered care…

Any thoughts from trainees about the positive / negative impact of greater consultant 7 day working?

Autonomy vs supervision Medical ST7 ‘I learn most when I am left on my own to get on with it – wouldn’t want the consultant looking over my shoulder all the time’

‘The method by which a consultant-led review takes place need not be constrained to formal, physical bed-side ward rounds by a consultant’

Other appropriate methods of consultant-led review could include: • Ward round undertaken by a doctor in training or SAS doctor, followed by a discussion of all, and review of selected patients by the consultant • A multi-disciplinary team ‘board-based’ round.’

Teaching vs service at weekends Medical CT2 Trainee ‘Consultants don’t tend to teach on weekend ward rounds so they are much quicker’

Structured education.. AMU Consultant ‘Consider impact on attendance at grand rounds, xray meetings journal clubs, etc’

Continuity of training.... Medical Consultant ‘Consultant rota needs to be in synch with trainee to ensure maximal contact time’

Current consultant contract: 3hrs weekend time = 4hrs weekday time More weekend hours = fewer total training hrs

A Phased Evaluation of the Impact of High-Intensity Specialist-Led Acute Care (HiSLAC) of Emergency Medical Admissions to NHS Hospitals (Commissioned call 12/128) 3 year study in 2 phases Prof Julian Bion, University of Birmingham J.F.BION@bham.ac.uk

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