Emergency On-call Duties: Audit of support, education and training provision in one NHSE region

Physiotherapy February 2003/vol 89/no 2

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IntroductionOnce qualified, physiotherapists areexpected to help to deliver an emergencyservice for acute respiratory patients.During such duties they are expectedaccurately to assess and identify patients'problems, use this information to de-termine and evaluate the nature andextent of their problems, implementspecific treatment programmes anddemonstrate a sound rationale for choiceof interventions.

Provision of this service is most often by means of a departmental emergencyon-call rota, usually involving physio-therapists working in isolation. While no study has isolated the impact ofundertaking on-call duties on the stresslevels of physiotherapists, Mottram andFlin (1988) demonstrated the treatmentof critically ill patients to be a key stressfactor for newly qualified physiotherapists.They considered the impact of this stress might result in altered job perform-ance and difficulty in adjustment to the

professional role. Strategies for guidance,support and training may help alleviatethis and the use of guidelines, protocolsand standards should help departments inthe development of these strategies.

Guidelines, protocols and standardsprovide explicit statements of expectedpractice performance and aim to achievewidespread adoption of best clinicalpractice (Buttery, 1998). They should bebased on the best available evidence andin the absence of this evidence should be based on expert opinion, patient orprofessional experience, or consensus(Mead, 1998). The Association of Chart-ered Physiotherapists in Respiratory Careis a national Clinical Interest Grouprecognised by the Chartered Society ofPhysiotherapy as an expert body in card-iopulmonary physiotherapy. With itscommitment to the development,maintenance and promotion of highstandards of respiratory care, theAssociation of Chartered Physiotherapistsin Respiratory Care published Standardsfor Respiratory Care (1996). Fifteen state-ments were produced in response to aneed to define good physiotherapy pract-ice and document national standards in respiratory care. Each statement hascriteria against which practice can beaudited.

Standard 9 addresses the provision ofemergency duty respiratory physio-therapy. It comprises eight criteria against which good practice can be monit-ored (see box 1). The emergency dutystandard has been documented to helpboth new graduates and those physio-therapists not routinely working in thefield of acute respiratory care. It providescriteria defining standards of support,education and training of staff before theytake part in such duties.

Audit aims to improve the quality andoutcome of patient care through struct-

Emergency On-call Duties Audit of support, education and trainingprovision in one NHSE region

Summary The purpose of this audit was to investigate thepost-registration support, education and training available forphysiotherapists in one Regional Health Authority before theyundertook emergency on-call duties. Practice was auditedagainst agreed standards of practice established by theAssociation of Chartered Physiotherapists in Respiratory Care.

A postal questionnaire was sent to 20 large generalhospitals in the NHS Executive Trent Region. A response rateof 90% (n = 18) was achieved. Awareness and adherence to the standards was evident in all the physiotherapydepartments investigated. The standard least adhered to was that which suggests there should be an agreed level of staff training before starting on-call duties. This studydemonstrates that support, education and training providedto physiotherapists within the Trent Region are in widespreadagreement with the standards of practice of the Associationof Chartered Physiotherapists in Respiratory Care, butprovision varies between units.

Key WordsAudit, on-call, standards ofpractice, Association ofChartered Physiotherapists inRespiratory Care.

by Tracy DixonJulie C Reeve

Dixon, T and Reeve, JC (2002). ‘Emergencyon-call duties: Auditof support, educationand training provisionin one NHSE region’,Physiotherapy, 89, 2,104-113.


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ured peer review whereby cliniciansexamine their practice against standardsand modify practice where indicated(NHSE, 1996). Criterion-based audit isfounded on the principle that it ispossible to devise measurable criteriaagainst which a valid reliable andquantitative assessment of individual andgroup per formance can be made inrelation to a specific guideline, protocolor standard (HQQ, 1997).

To date there has been only onepublished attempt to audit the use andimplementation of the Association ofChartered Physiotherapists in RespiratoryCare standards (Brown et al, 1997). Thiswas in response to a motion at the AnnualRepresentative Conference of the Chart-ered Society of Physiotherapy in 1992which called for a national audit ofemergency/on-call physiotherapy servicesthroughout the United Kingdom.

The Association of Chartered Physio-therapists in Respiratory Care agreed toundertake this, the aim being to auditwhether physiotherapy provider units hadthe essential components of an emerg-ency respiratory service against the Assoc-iation of Chartered Physiotherapists inRespiratory Care standards. A question-naire to all members of the CharteredSociety of Physiotherapy was published inPhysiotherapy Journal (ACPRC, 1994) andstaff involved in both the organisationand provision of emergency services were asked to respond. The response tothe audit was poor, with a total of 52responses from all members. Lack ofinformation identifying respondentsmeant that repetition of information fromindividual units could not be excluded.This poor ill-defined sample did not allowfor any meaningful statistical analysis.

Recommendations from this initialsurvey were to redesign the audit tool andre-audit a sample of senior respiratorystaff. This audit undertook to fulfil theserecommendations, focusing on the sup-port, education and training recom-mendations of the standards; thusstandard 9 and its associated criteriaformed the basis of this audit.

Other than the previous Association ofChartered Physiotherapists in RespiratoryCare audit (Brown et al, 1997), to theauthors’ knowledge only three publishedstudies have investigated on-call practice,provision and efficacy. Ntoumenopoulosand Greenwood (1991) documented the

hours of provision of cardiothoracicphysiotherapy services across Australiaand how these services were organised.An incidental sample of hospitals withintensive care units was used to investigatethe variance of 24-hour physiotherapyprovision. Findings indicated a widevariability in service with 43% (n = 18)providing only normal working hourscover. This study looked solely at serviceprovision and did not investigate explan-atory, causal or practice issues.

Jones et al (1992) further investigatedchest physiotherapy practice in inten-sive care units in hospitals throughoutAustralia, the United Kingdom and HongKong. Provision of 24-hour on-callphysiotherapy services varied between

ACPRC Standard 9: All patients requiringemergency physiotherapy out of normalworking hours receive safe and effective

treatmentCriteria1. There is evidence of an agreed written emergency protocol.

The protocol may include:Method of referralExpected response timeOrganisational details – recording system, security, bleep system,travel arrangements, accommodation and reimbursement system.

2. There is an induction programme for all staff participating in theemergency duty rota.

3. All participating staff are trained to an appropriate agreed level inaccordance with local requirements.

Aspects requiring specific training may include:Assessment of the acutely ill patientPhysiotherapy skills relating to respiratory careUse of respiratory equipment availablePain managementEndotracheal suctionPhysiotherapy management of the ventilated patient

4. There is evidence of ongoing training for all staff participating inthe provision of an emergency service.

5. There is experienced specialist support available for staff.

6. There is documentation of service use.

Documentation may include:AppropriatenessResponse timeReferral source – profession and specialty

7. The service is monitored in accordance with local requirements.

8. There is evidence of the follow-up of inappropriate use of services.

Box 1


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countries with 97% (UK), 49% (Australia)and 0% (Hong Kong) responders prov-iding these services. A regular after-hoursservice was provided in 16% (UK), 41%(Australian) and 6% (Hong Kong) units.This study did not focus exclusively on on-call provision; it looked at numerousaspects of chest physiotherapy in inten-sive care units. It used small sample num-bers in each country, with respondersreturning questionnaires per intensivecare unit rather than per hospital. Thequestionnaire structure varied betweencountries making comparability of dataincomplete in some cases. It made noattempt to investigate on-call provision indetail and did not consider on-callpractice or procedures.

More recently Ntoumenopoulos andGreenwood (1996) investigated the pro-

vision of additional evening physio-therapy for post-operative pulmonarycomplications and intrapulmonary shunt(ventilation-perfusion mismatch) afterabdominal surgery. Thirty-one elderlypatients received either daytime only ordaytime plus evening physiotherapy forup to 48 hours. Physiotherapy includedcombinations of positioning, gravity-assisted drainage, breathing exercises,manual techniques, coughing and air-way suctioning. Measurements (over 48hours) included intrapulmonary shuntand incidence of post-operative pulmon-ary complications. The authors suggestedadditional evening physiotherapy mightreduce post-operative deterioration in gas exchange after major abdominal surg-ery but that the effects of the individualphysiotherapy techniques utilised wereunclear. While this study went some wayto analysing the effect of additionalevening physiotherapy on short-termvariables it did not address longer-termoutcomes such as effect on length of stayin intensive care units or hospitals.

The paucity of evidence in the pro-vision, practice and effectiveness ofemergency on-call physiotherapy dutiesrequires attention and this audit wasdeveloped in an attempt to determine abaseline description of service provision,practice and adherence to national stand-ards from which research investigatingcausation may be developed.

The aims of this audit were therefore:

1. To audit current practice in thedelivery of an emergency on-callservice in one National Health Service Executive region against the Association of CharteredPhysiotherapists in Respiratory Carestandard 9 and its associated criteria.

2. To ascertain what support, educationand training are currently provided for qualified physiotherapists in oneRegional Health Authority before theytake part in an on-call rota.

Method Design and ImplementationAn audit of 20 hospital physiotherapydepartments in the NHS Executive TrentRegion was undertaken using a postalquestionnaire to elicit information onemergency duty service provision, supportand education for qualified physio-

Section 1: Emergency duty protocolQ1 Does your department provide an emergency duty protocol for

staff participating in the on-call rota?

Yes – Please go to Q2No – Please go to section 3

Q2 Which of the following statements best describes the emergencyduty protocol within your department?

There is an emergency duty protocol that is explained verbally tostaff, but it is not documented in the written formThere is a written emergency duty protocol clearly documentedwithin your department

Please state type of protocol if none of above are applicable

Q3 Which of the following areas are covered within your emergencyduty protocol?

Guidelines regarding expected response time following referralDocumentation of patient assessment and treatmentSecurity arrangements for the on-call physiotherapistThe contact system, eg bleep or phone

Necessary travel arrangements, eg hospital taxi serviceAccommodation arrangements whilst on-callAny remuneration / reimbursement system

Information regarding available equipmentA plan of the hospital

Please state any other areas covered within the emergency dutyprotocol

Box 2: Examples of questions from the audit tool


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therapists. Geographical location, ease ofimplementation, resource limitations andpotentially faster response times wereimportant considerations in decidingupon the audit tool. Standard 9 of theAssociation of Chartered Physiotherapistsin Respiratory Care Standards forRespiratory Care was used as the basis forthe audit. There is currently no nationallydeveloped and validated tool available toaudit these standards and thus theauthors developed their own in the formof a postal questionnaire. This contained21 questions with sub-sections relatingdirectly to the criteria documented instandard 9. Examples of questions askedcan be seen in box 2. For ease of com-pletion and analysis, where possible amajority of closed questions were used toachieve a direct measure against the crit-eria (see question 1). Filtering was used to ascertain further details where neces-sary but exclude responses to inap-propriate questions for others (seequestion 1). Additional information wascollected via supplementary open-endedquestions (see questions 2 and 3).

The audit was distributed by post with astamped addressed envelope to maximiseresponse rate and on yellow paper tomake it easier to read (Chesson, 1993). Acovering letter was included to explainthe purpose of the audit, identify theresearcher and assure confidentiality. Anumber on the last sheet assisted withfollowing up late responses and codedeach questionnaire. Confidentiality wasassured. Twenty-eight days were allowedfor questionnaire completion and 15 werereturned by the requested date, with afurther three being returned followingpostal written reminders. Responses wereavailable only to the authors and kept in alocked cabinet.

At the time the project was undertaken,it was not obligatory to obtain permissionfrom an NHS research ethics committeeto question NHS staff. The proposal wasapproved through the approval processthen in force in the university for under-graduate physiotherapy projects whichtook account of ethical issues such as thesensitivity of questions and the security ofdata as well as an assessment of risk.

Sample There is little guidance on an appropriatesample size for audit purposes as theresults will not be generalisable to other

subjects. It seems that large numbers arenot essential, between 20 and 100 usuallybeing adequate (Buttery, 1998). Thesample should be large enough to beconfident that the observed level ofcompliance and any associated prob-lems provide a reasonable reflection ofreality.

Twenty large acute trust hospitals fromwithin the NHSE Trent Region wereselected. All were between 500 and 1,000beds, had physiotherapy departments,were teaching hospitals and had intensivecare units.

Senior I physiotherapists specialising in the field of acute respiratory care were invited to participate in the audit.Subjects were not selected randomly butformed a convenience sample from thetarget population.

A pilot study was undertaken on tworepresentatives of the target subject groupat NHS hospital trusts outside the targetregion. The purpose of the pilot study wasto identify any anticipated problems withambiguity of instructions or questions.Comments on questionnaire design,content and problems with completionwere sought. Minor changes to the layoutand grammar were made.

Data AnalysisAll raw data collected were of thenominal/ordinal level. Results wereanalysed and presented using a variety ofdescriptive statistical methods. Dataanalysis was done by hand owing to thesmall sample size.

ResultsThe results are presented in sections,each section representing a sub-sectionwithin the questionnaire.

Response RateTwenty questionnaires were distributed,and 18 were returned. This high responserate indicates excellent compliance andsome reduction in bias of the sample(Oppenheim, 1992). Three were comp-leted by superintendent physiotherapistsand the remaining 15 by senior physio-therapists. Seventeen of the respondentswere personally involved in preparingstaff for participation in the on-call rota.Sixteen respondents were aware of theAssociation of Chartered Physiotherapistsin Respiratory Care Standards for Respir-atory Care.

Authors

Tracy Dixon MScMCSP is a seniorphysiotherapist inWestcotes HealthCentre, Leicester.

This article waswritten as part of herBSc honours degree,undertaken atSheffield HallamUniversity.

Julie Reeve MScGradDipPhys iscurrently a seniorlecturer inphysiotherapy atAuckland Universityof Technology. She kindly providedsupervisory andeditorial support inher position of seniorlecturer at SheffieldHallam Universityfrom which she iscurrently on leave of absence.

This article wasreceived on April 19, 2001, andaccepted on May 27,2002.

Address forCorrespondence

Tracy Dixon BScMCSP, SeniorPhysiotherapist,Charnwood andNorthwest LeicesterHealthcare Trust,Westcotes HealthCentre, Fosse RoadSouth, Leicester LE3 0LP.


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General InformationAll respondents provided a physiotherapyservice out of normal working hours(assumed to be from 8.30 am to 4.30 pm).This service took the form of an emerg-ency call-out rota (referral by phone orbleep) in all departments, with sixrespondents offering no further means ofservice.

Other types of emergency service pro-vision can be seen in figure 1.

Staff grades were required to participatein on-call duties in 17 hospitals. In threehospitals the only staff to undertake on-call duties were those who had completeda rotation or specialised in respira-tory care. Four respondents did not usesenior I physiotherapists as part of the on-call rota. One respondent used allstaff and senior II physiotherapists butused senior I physiotherapists only if theyspecialised in respiratory care.

Figure 2 illustrates at what stage phys-iotherapists were expected to undertakeon-call duties. One respondent expectedall new staff, regardless of grade andexperience, to participate in on-callimmediately following employment, but provided a training programme tosupport this.

Section 1: Emergency duty protocolsAll respondents said they had an emerg-ency duty protocol for physiotherapistsparticipating in the on-call rota.

Sixteen respondents had a documentedprotocol and one had an emergency dutyprotocol that was orally explained but not documented in writing. Figure 3represents the grade of physiotherapistresponsible for the establishment of theemergency duty protocol.

Figure 4 highlights areas suggested bythe Association of Chartered Physiother-apists in Respiratory Care to be coveredwithin the emergency duty protocol andthe percentage of hospitals adhering to these. Six respondents had all tensuggested areas covered within theirprotocol.

Section 2: Induction programme beforeon-call dutiesAll respondents reported a form ofinduction training programme availableto physiotherapists. A formally organisedinduction programme, which all mustattend before participating in emergencyduties, was available in 14 hospitals with

0 5 10 15 20

Number of respondents

Emergency call-out rota

Planned call-out rota

Fig 1: Type of emergency service available

Shift work

Nu

mb

er o

f re

spo

nd

ents

2

4

6

8

10

12

0

Fig 2: Stage of staff physiotherapist participation in on rota call

Specialist training Immediately After one rotation

0 2 4 6 108 12


Superintendent

Senior I

Fig 3: Responsibility for establishment of emergency duty protocol

Focus group

100 20


Fig 4: Areas covered within the emergency duty protocol

Plan of hospital

Available equipment

Accommodation

Security arrangements

Response time following referral

Reimbursement system

Travel arrangements

Contact system

Documentation of assessmentand treatment

Method of patient referral


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four hospitals providing training on aninformal basis.

Ten respondents covered all aspectsrecommended by the Association ofChartered Physiotherapists in RespiratoryCare for inclusion in induction program-mes. Reasons for non-adherence to sugg-ested areas were not stated. Aspects otherthan those suggested by the Association ofChartered Physiotherapists in RespiratoryCare included paediatric respiratory care(n = 3), specific medical conditions orpathologies (n = 2), cardiothoracicsurgery and tracheostomy management(n = 1).

Induction programmes involved thedirect input of senior I respiratoryclinicians in all hospitals. Nine resp-ondents indicated senior I physiother-apists had sole responsibility for inductiontraining. Seventeen hospitals offeredsome form of induction programmebefore expecting physiotherapists toparticipate in the on-call rota.

Figure 5 illustrates those for whomrespondents considered it necessary toundertake an induction programme.Additional responses included bank staff(n = 1), those returning to work followingcareer breaks (n = 1) and senior cliniciansworking in other clinical areas (n = 4) torequire induction training also.

Length of time given to the inductionprogrammes varied between respondents.Seven respondents provided inductiontraining lasting from one to five workingdays. The option of completing one fullrotation in respiratory care was availablein some departments if this duration wassubsequently found to be insufficient.Three respondents stated the inductionduration for new staff before on-callduties depended purely on their pastexperience, knowledge and confidence.Six respondents indicated a period ofmore than five days induction training –the structure of this varied from twoweeks based on an intensive care unit toeight weeks of lectures on an impromptubasis but including five days gainingpractical experience.

Section 3: Level of trainingAgreed standards of practice for phys-iotherapists before participation inemergency duties were present in 11hospitals. One respondent was in theprocess of reviewing practice and dev-eloping such standards. The remaining

six hospitals had no agreed standards in place.

Of those with agreed standards, formalassessment of achievement of thesestandards was poor. The majority ofrespondents used informal, subjectivemethods to measure competence in-cluding senior physiotherapist satisfact-ion, peer assessment by others in the in-duction group, and self-assessment. Onerespondent used a knowledge quiz.

Competence was mainly assessed bysenior I physiotherapists (n = 15).

Section 4: On-going trainingAll respondents stated some form ofongoing training in emergency duties wasavailable for physiotherapists within theirdepartments. The majority of depart-ments (n = 11) implemented an optionalongoing training programme withresources available for continuingprofessional development opportunities.Training for physiotherapists in the form of a compulsory in-service trainingprogramme took place in seven hospitals.One respondent failed to answer thequestion.

Ongoing training in emergency resp-iratory care occurred annually (n = 2),biannually (n = 4), monthly (n = 6) orweekly (n = 2). Four respondents provid-ed training on request only and five unitsprovided training on request in additionto their more formal ongoing trainingprogrammes.

In 16 units, senior I respiratorytherapists were responsible for ongoingtraining of staff participating in emerg-ency on-call duties.

Nu

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er o

f re

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Fig 5: Staff receiving on-call induction

All new staff Limited respiratoryexperience

Staff grades only

2

4

6

8

10

12

0


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Section 5: Support available while on-call All respondents stated that some form ofsupport was provided to physiotherapistsduring emergency duties. Figure 6indicates the type of support available.Two respondents stated a senior phys-iotherapist would always work at weekendsas back-up if an inexperienced member ofstaff was nominated as first-line cover.

Sections 6 and 7: Documentation andmonitoring of serviceFifteen respondents monitored theemergency on-call service provided bytheir department in some way.

Areas documented by respondentsincluded patient assessment and treat-ment (n = 13), inappropriate call-outs (n = 3) and on-call response times (n = 3).Recipients’ evaluation of on-call training(n = 7), adherence to the emergency dutyprotocol (n = 10) and practice whileactually on call (n = 10) were monitored.No hospital monitored the referrersatisfaction with the on-call serviceprovided. Other areas monitoredincluded on-call usage trends, use of on-call rooms, workload on-call and cost (n = 1).

Overall Compliance Key questions in each section of thequestionnaire were used to ascertainoverall compliance to Association ofChartered Physiotherapists in RespiratoryCare criteria, summarised in figure 7.

Discussion Where standards exist, compliance withthem should be monitored and this forms an intrinsic part of the audit cycle.Monitoring should provide objectivemeasures of how successfully the standardhas been implemented in everydayclinical practice, identify reasons for any non-compliance or variance, andinform decisions about how to increasecompliance (Buttery, 1998). Guidelines(standards and protocols – terms oftenbeing used interchangeably) provideevidence about expected practice andmay be used in litigation proceedings, butcompliance with guidelines does notdefend against liability where these areinappropriately applied (Mead, 1998).Any non-compliance warrants furtherinvestigation but should be examinedwhile considering applicability to local situations or individual patients.Practitioners have a responsibility to be aware of the existence of guide-lines/standards/protocols and to makevalue judgements as to the applicability of these locally.

This audit examined the local im-plementation of national standards butdid not attempt to address the quality ofthe service provision. Association ofChartered Physiotherapists in RespiratoryCare standard 9 states that all patientsrequiring emergency physiotherapy out ofnormal working hours should receive safeand effective treatment. The associatedcriteria essentially reflect broad state-ments of service provision rather thanconsidering the safety and effectiveness ofinterventions. While respondents mayadhere to these broad standards, actualpractice may vary and this should beaudited in the future. Other forms ofaudit such as observation of practice, peerreview, self-assessment and review ofinduction and training programmesshould be undertaken. Physiotherapists’rules of professional conduct (CSP, 1996)state that chartered physiotherapists shallpractise only to the extent that they haveestablished and maintained their ability towork safely and competently. The

Nu

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2

4

6

8

10

12

0

Fig 6: Types of support available while on call

All senior staffby phone

All senior respiratory staff

by phone

Senior respiratory staff

by phone orin person

0 5 10 15 20Number of respondents

Fig 7: General compliance with ACPRC standards

Experienced support available

Agreed level of training

Service monitored

Documented protocol

On-going training

Induction


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responsibility for this within the on-callenvironment lies initially with physio-therapists but it requires provider units tomonitor competency to practise andensure service needs are met. Clearlyidentification of the quality of the serviceprovision needs closer attention in futureresearch.

Despite a small sample size, a quest-ionnaire response rate of 90% (n = 18) isconsidered good (Babbie, 1973) andsuggests that the sample is representativeof the target population studied. It maybe suggested that the high response rate reflects the importance of this topicto the subject group, making it possible to identify general trends, educationalopportunities, and variance in serviceprovision within the target population.

These results should not be extra-polated to the wider population and it isrecommended that this audit should bereplicated at a national level. The majorityof our respondents were responsible forthe training and support offered inpreparing staff grades for participation inthe on-call rota. This is a potential sourceof bias. As our study’s main aims sought adescription of service provision andadherence to standards, it was felt thatsenior cardio-respiratory clinicians werein the most appropriate position toprovide the information. Future studiesfocusing on the quality of the serviceprovided should seek wider views,including those from physio-therapistsreceiving training, those requesting on-call services, and patients.

The results of our audit identify similarfindings to those of the previous Assoc-iation of Chartered Physiotherapists inRespiratory Care audit in 1996. Itextended this by addressing not onlywhich standards were being adhered tobut also the underpinning practice usedin implementation of the standards. Italso examined the type and amount ofsupport and training provided. Thisinformation has not been previouslysought.

Emergency Duty ProtocolsIt is believed hospitals using therapist-driven protocols enhance practitioners’per formance (Meredith et al, 1994).Written protocols should help provide a safe framework for basic practice,enabling clinicians to make clinicaldecisions within the scope of their own

knowledge and experience. Our auditindicated that the emergency dutyprotocols in the sample studied offerguidance on service provision rather thanguidance on patient care which wouldhelp clinicians in making decisions aboutappropriate treatments for specificconditions. Clinical guidelines providerecommendations for specific clinicalinterventions which have beensystematically developed (Mann, 1996).Having clinical guidelines in place shouldhelp inexperienced physiotherapists inclinical decision-making. Professionalgroups should be working towards thedevelopment of these.

Induction ProgrammesReasons for the variance in the frequency,length, and content of training prog-rammes between provider units, in-cluding the impact of these variations,require further investigation. Mead(1999) believes it is difficult to ensure thelocal use of specific national guidelinesand it is therefore accepted that nation-al standards may need adaptation to thelocal context where scope of practice,resources required and mode of practicewill vary according to local conditions anddemands. Our results demonstrated localvariations and may show that inapprop-riate areas of practice are suggestedwithin the Association of CharteredPhysiotherapists in Respiratory Carestandards or indicate that resourcesavailable (eg staff and time) for formaltraining in all suggested areas areimpractical.

Agreed Standards of Practice While determining whether respondentshad agreed standards of practice beforeparticipation in emergency duties, ouraudit did not ascertain the variability orcontent of these standards betweenresponders. However, the number ofdepartments using formal methods toassess standards was disappointing.Achieving agreed standards before on-callduties should ensure safe, effective levelsof practice. Competency-based testingmay be one means of assessing standardsin order to meet local requirements butthis must include clinical decision-makingand problem-solving strategies. Ourresults may highlight some of the conflictsand difficulties of assessing competency topractise in staff who may be recently


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designated fit to practise or professionallyregistered or have previous experience.

The Chartered Society of Physiother-apy’s first rule of professional conduct(CSP, 1996) describes physiotherapists’responsibility to maintain their comp-etence to practise. With the clinical gov-ernance initiatives implemented fromApril 1999, physiotherapists, educatorsand managers must take increasinglyseriously the need to demonstrate thiscompetence. One of the key componentsof clinical governance is to ensure thatthose providing care are appropriatelytrained and have the skills and com-petencies required to deliver the careneeded. These initiatives may enablecompulsory regional or national pro-grammes to be developed to ensuremaintenance of a contemporary know-ledge base, and address the difficultiesinherent in assessment of competency.Clinical Interest Groups may need to consider their role in the develop-ment and implementation of nationally agreed standards in the future.

Departments need to ensure that key advances, changes in practice andmaintenance of professional skills are addressed by ongoing training anddevelopment programmes.

Strategies for dealing with staff notreaching agreed standards were notsought in this audit but would providevaluable information for development offuture guidelines.

Specialist SupportThe fact that many respondents offeredsupport for physiotherapists carrying outemergency duties demonstrates clearrecognition of the stressful and specialistnature of the work and the necessity toprovide on-the-spot support for lessexperienced staff. The level of take-up ofthis support was not investigated but may prove useful in further work.

Documentation and Monitoring ofService ProvisionAreas monitored proved widespread but variable. Given current quality of careinitiatives it is surprising that no resp-ondent monitored referrer satisfact-ion. Procedural difficulties in referral,

appropriateness of referral and satis-faction with the outcome of referral mustbe considered in the delivery of anemergency service from both consumers’and providers’ perspectives. Monitoringof inappropriate use of on-call servicesand strategies for dealing with theserequire further investigation. Theseaspects of service provision should be keyareas for audit given the current pressureson healthcare resources. Documentationof physiotherapy call-outs should beconsidered fundamental for audit,research and legal purposes.

ConclusionThis audit has demonstrated differinglevels of support, education and trainingfor physiotherapists before participationin emergency duties. This consists of an induction programme in all units,guidance in the form of written protocols,regular in-service training and, in themajority of departments, senior supportwhile on-call. It has also shown that alljunior physiotherapists working within the Trent Region are expected to part-icipate in the delivery of an emergencyrespiratory care service. It has showncurrent practice in the delivery of anemergency physiotherapy service in theTrent region to be broadly in agreementwith standards for emergency duty caresuggested by the Association of CharteredPhysiotherapists in Respiratory Care, butthat compliance with individual criteria isinconsistent throughout the chosensample. This variability indicates thenecessity for review and development ofmore specific guidelines. Clinical InterestGroups should be involved in the furtherdevelopment of these.

Key future work needs to widen thesample audited in this study. It shouldaddress the quality of practice as well asservice provision and examine whetherAssociation of Chartered Physiotherapistsin Respiratory Care standards of practiceare adequate for the needs of patients,physiotherapists and other health careproviders. Audit of other Association ofChartered Physiotherapists in RespiratoryCare standards should also be under-taken.


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Key Messages

� Junior physiotherapists are expectedto participate in the delivery of anemergency physiotherapy service.

� Support, education and training forphysiotherapists before participationin emergency duties is variable.

� Variability in support, education andtraining provided indicates thenecessity for review and developmentof more specific guidelines.

� Quality of practice as well as serviceprovision needs to be reviewed.

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Emergency On-call Duties: Audit of support, education and training provision in one NHSE region