7 day working: implications for emergency services

7 day working: implications for

emergency servicesDr 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 1Hospital 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 2Consultant 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 3Support services both in hospitals and in the primary care setting should be available seven days a week

Sir Richard ThompsonPresident , RCPL

‘While the RCP accepts this as an aspirational standard for all physicians, we believe that this will require serviceredesign 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 2More 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 100Physiotherapy 90 83Specialist nurse review 70 61Dietetics/Nutrition 70 44Occupational therapy 40 47Swallow assessment 40 17Speech & 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 67Specialty 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 phasesProf Julian Bion, University of [email protected]

Thank You