What next as a consequence?

Dr JH Coakley MD FRCPDr JH Coakley MD FRCPMedical Director and Intensive Care Medical Director and Intensive Care ConsultantConsultantHomerton University Hospital NHS FTHomerton University Hospital NHS FTHomerton RowHomerton RowLondon E9 6SRLondon E9 6SR

john.coakley@homerton.nhs.uk

Homerton University HospitalHomerton University Hospital

• 550 beds (300 acute medical) in Hackney550 beds (300 acute medical) in Hackney• Emergency care predominates (106,000 Emergency care predominates (106,000

A+E, 160,000 OPD, 35,000 IP, 5,000 A+E, 160,000 OPD, 35,000 IP, 5,000 births)births)

• Medical take 25 – 40 patientsMedical take 25 – 40 patients• Surgical take 8 – 10 patientsSurgical take 8 – 10 patients• Orthopaedic and urology take – small Orthopaedic and urology take – small

numbersnumbers

Night staff August 20035pm 10pm 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

11pm

Night staff October 20035pm 10pm 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

11pm

Oncall from home

Oncall from home

handover

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

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

CCU staff

Me: Cardiology SHO

Cardiology SPR

ITU SPR

CSM

Other SHOs

“My Night Support Network:” St Elsewhere's

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.

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

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

Is there a simple solution?

• Ignore it and hope it will go away?

• Expand consultant grade?

• Expand training grades?

• Expand some other (doctor) grade?

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

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.

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

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….’

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

Acute Care UnitAcute Care Unit

• 56 beds56 beds

• Planning based on 48 hour LOSPlanning based on 48 hour LOS

• Receives all acute admissions in surgery, Receives all acute admissions in surgery, orthopaedics, urology and medicineorthopaedics, urology and medicine

• Junior staffing proportionate to emergency Junior staffing proportionate to emergency activityactivity

• Busy!Busy!

Acute Care TeamAcute Care Team

• Consultant led 24/7 team with no Consultant led 24/7 team with no commitments other than acute care commitments other than acute care

• Extended normal working hours for acute Extended normal working hours for acute care (including consultants) and improved care (including consultants) and improved handovershandovers

• Consider which clinicians are best able to Consider which clinicians are best able to deliver the required competenciesdeliver the required competencies

• Integrate delivery of acute care across Integrate delivery of acute care across specialtiesspecialties

• Develop sustainable acute rotasDevelop sustainable acute rotas

Acute Care TeamAcute Care Team

• Consultants (12P, 6S, 5T+O, 3U)Consultants (12P, 6S, 5T+O, 3U)

• 6 Medical ST 3+ or SpRs (AM or EM)6 Medical ST 3+ or SpRs (AM or EM)

• 8 Medical ST 1 or 2, FY2 (ACCS or AM)8 Medical ST 1 or 2, FY2 (ACCS or AM)

• 3 Surgical ST 2 to 63 Surgical ST 2 to 6

• 1 Orthopaedic ST 2 to 6 (0800 - 2200 only)1 Orthopaedic ST 2 to 6 (0800 - 2200 only)

• 1 ICM ST 1 to 6 (0800 – 1600 only)1 ICM ST 1 to 6 (0800 – 1600 only)

• 6 Foundation Trainees – FY16 Foundation Trainees – FY1

• CCOCCO

• CSMCSM

HandoversHandovers

• 0800 very brief0800 very brief

• 1030 to discuss PTWR issues – ACT1030 to discuss PTWR issues – ACT

• 1600 brief, to hand over jobs etc from 1600 brief, to hand over jobs etc from ‘cold’ to ‘hot’ team‘cold’ to ‘hot’ team

• 2100 for night2100 for night

Weekday and night ACTWeekday and night ACT

Taking Care 24/7 – six person acute rota

Mon Tue Wed Thu Fri Sat Sun Hrs

1 N22-10

N22-10

N22-10

N22-10

O O O 48

2 2ndon8 hrs

2ndon8 hrs

2ndon8 hrs

2ndon8 hrs

2ndon8 hrs

O O 40

3 08-17Early

08-17Early

Admin6hrs

O N22-10

N N 60

4 O O 15-23Late

15-23Late

Admin6 hrs

O O 26

5 15-23Late

Admin6 hrs

08-17Early

08-17 15-23Late

O O 40

6 Admin6 hrs

15-23Late

O Admin6 hrs

08-17Early

E8-18

E8-18

49

Nos 4+1 4+1 4+1 4+1 4+1 2* 2* 44

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

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

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.

Implementation Group

• New working party– Consultants– Juniors– Managers– Nurses– Weekly meeting to identify problems (and

more importantly solutions)

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

What worked well?What worked well?

• Doctors’ hoursDoctors’ hours

• Relationships between physicians, surgeons, Relationships between physicians, surgeons, critical care and outreach have improvedcritical care and outreach have improved

• Night handover is very goodNight handover is very good

• Patients seen by a consultant very quicklyPatients seen by a consultant very quickly

• Emergency / elective split works well for Emergency / elective split works well for “cold team” juniors“cold team” juniors

• The change in surgical and orthopaedic rotas The change in surgical and orthopaedic rotas works well for the ED. works well for the ED.

……and what didn’tand what didn’t

• Stable Medical Leadership – daily Stable Medical Leadership – daily change of consultant (s)change of consultant (s)

• Junior Doctor RotasJunior Doctor Rotas– too complextoo complex– don’t facilitate continuity of care particularly don’t facilitate continuity of care particularly

for longer stay patientsfor longer stay patients

…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

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.

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’

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)