7 Day Consultant Ward rounds for medical emergency admissions Seven day services in action

16th November, Hilton Metropole

Mark TempleConsultant Physician & Nephrologist

Heart of England Foundation TrustAcute care fellow, RCP

Concern quality & safety patient care (OOH): RCP Position statement November 2010

Hospitals undertaking the admission of acutely ill medical patients should have a consultant physician on site for at least 12 hours per day, seven days a week, at times relating to peak admission periods. The consultant should have no other duties scheduled during this period.

Delivering high quality care beyond AMU 7 day consultant review Medical & surgical wards

Particular risk: Transfer out of AMU within 24-48 hrs – evolving acute illness

Move to a different landscape!From AMU : enhanced staffing (cons) organisation of careTo wards:

– Unfamiliar with pt/acute care– Uncertainties about diagnosis & management – Quality monitoring /response pt deterioration?

Patient transfer Friday pm (next cons round 72 hours +?)

Pts transferred out of AMU – receive a consultant review within 24 hrs – 7/7

Patients transferred out AMU: Early review - Consultant of team responsible for continuing care – “Golden Hour” priority duty in first working hour– Template cons physician working 7/7 all wards

• “Buddy” arrangements : link medical teams to Surgical wards

• Weekday: re-schedule conflicting duties 8.30-10• Weekend: consultant rota for shared bed patch• Review all new transfers in + acutely ill

Aim: Consistent consultant review, critical time acute illness

• Confirm diagnosis, Rx, discharge, ceilings of care

• Involve/ communicate management plan to new ward team

• Senior assessment vs anticipated clin. trajectory

• Support ward team & covering med staff – concerns unfamiliar patient

• Benefits of consultant delivered care

Acad Royal Med Coll 2012

• NCEPOD consistent evidence delayed/ absent consultant care = unsafe poor quality care

• AKI: Adding insult to injury 2009

• Time to intervene 2012

Birmingham Heartlands Hospital – Consultant Physician duties 7 / 7

Review of unselected (GIM) patients WeekdaysMedical & Surgical wards

0845 – 6 consultants with ongoing care duties:

Initial: “smart start” board round

Clinical review • all new transfers in• sick pts / potential discharge

Week-ends & BHsMedical & Surgical wards

0900 – 4 consultants (ongoing care) Initial: Handover

Clinical review • All new transfers in • Sick pts / discharge

Achieving consultant “Golden hour” rounds - all wards with unselected (G)IM in-pts

• Widespread recognition – good for patient care– Consultant agreed and

implemented• More acute physicians –

allowed redeployment • Reassured : reliable JD support

– Assist with admin, discharge, request tests, prescribing

– Optimal use consultant time OOH

– Optimal use consultant expertise – senior decision making

• Reassured : staff & support 7/7 to implement consultant plan – Therapy , diagnostic and social

services. Pathways out of hospital

• Recognise extra work- job plan (4 extra physicians on site)

• Use existing synergies. Greatest resistance to additional w/e rota - consultants not providing 24/7 service

How to change consultant working The Physicians story - Paul Woodmansey (2011)

• AMU consultant cover 12hrs w/d, 6-8hrs w/e

• W/E Troubleshooting Consultant visits all med wards : sick & quick d/c

• Increase early discharge• Coincided reduction

mortality (all and w/e)

• Major change working life : introduced with relative ease

• Consultant proposed tried & accepted

• Good for pt care• “Greatest challenge is cons

delivered (not led) service required”

• “Pace .. in hospital .. pts need daily senior input” Clin Med 2011 (11) 1: 17-19

Impact of “Golden hour” ward rounds

• Nursing staff: welcomed cons on their ward 7/7. Decisions on existing in- patients.

• Jun Doctors: – reduced workload – Improve training, feedback

• Consultants / ALL :Monday working more manageable

• Where d/c pathways not @ w/e discharge set up for Mon/Tues

• Associated : improved LOS