Transcript Changing the role of critical care

What next as a consequence?
Dr JH Coakley MD FRCP
Medical Director and Intensive Care Consultant
Homerton University Hospital NHS FT
Homerton Row
London E9 6SR
[email protected]
Homerton University Hospital
• 550 beds (300 acute medical) in Hackney
• Emergency care predominates (106,000 A+E,
160,000 OPD, 35,000 IP, 5,000 births)
• Medical take 25 – 40 patients
• Surgical take 8 – 10 patients
• Orthopaedic and urology take – small numbers
Night staff August 2003
5pm
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
10pm
11pm 12mid
8am
Night staff October 2003
5pm
10pm
11pm 12mid
8am
Medical PRHO
Medical PRHO
Medical SHO
Medical SHO
Medical SpR
Surgical PRHO
Surgical SHO
Surgical SpR
Oncall from home
Orthopaedic SpR
ITU SpR
Oncall from home
Anaesthetic SHO
Clin Site Manager
Clin Site Manager
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
“My Night Support Network:” St
Elsewhere's
CSM
Cardiology SPR
CCU staff
Me:
Cardiology SHO
Other SHOs
ITU SPR
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 Unit
• 56 beds
• Planning based on 48 hour LOS
• Receives all acute admissions in surgery,
orthopaedics, urology and medicine
• Junior staffing proportionate to emergency
activity
• Busy!
Acute Care Team
• Consultant led 24/7 team with no commitments
other than acute care
• Extended normal working hours for acute care
(including consultants) and improved handovers
• Consider which clinicians are best able to deliver
the required competencies
• Integrate delivery of acute care across specialties
• Develop sustainable acute rotas
Acute Care Team
• Consultants (12P, 6S, 5T+O, 3U)
• 6 Medical ST 3+ or SpRs (AM or EM)
• 8 Medical ST 1 or 2, FY2 (ACCS or AM)
• 3 Surgical ST 2 to 6
• 1 Orthopaedic ST 2 to 6 (0800 - 2200 only)
• 1 ICM ST 1 to 6 (0800 – 1600 only)
• 6 Foundation Trainees – FY1
• CCO
• CSM
Handovers
• 0800 very brief
• 1030 to discuss PTWR issues – ACT
• 1600 brief, to hand over jobs etc from ‘cold’ to
‘hot’ team
• 2100 for night
Weekday and night ACT
Taking Care 24/7 – six person acute rota
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Hrs
1
N
22-10
N
22-10
N
22-10
N
22-10
O
O
O
48
2
2ndon
8 hrs
2ndon
8 hrs
2ndon
8 hrs
2ndon
8 hrs
2ndon
8 hrs
O
O
40
3
08-17
Early
08-17
Early
Admin
6hrs
O
N
22-10
N
N
60
4
O
O
15-23
Late
15-23
Late
Admin
6 hrs
O
O
26
5
15-23
Late
Admin
6 hrs
08-17
Early
08-17
15-23
Late
O
O
40
6
Admin
6 hrs
15-23
Late
O
Admin
6 hrs
08-17
Early
E
8-18
E
8-18
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 nonacute teams
What worked well?
• Doctors’ hours
• Relationships between physicians, surgeons,
critical care and outreach have improved
• Night handover is very good
• Patients seen by a consultant very quickly
• Emergency / elective split works well for “cold
team” juniors
• The change in surgical and orthopaedic rotas
works well for the ED.
…and what didn’t
• Stable Medical Leadership – daily change of
consultant (s)
• Junior Doctor Rotas
– too complex
– don’t facilitate continuity of care particularly for
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)