|Thursday, 29 August 2013|
Around-the-clock consultant presence will have limited benefit unless out-of-hours availability for the rest of the healthcare team is also improved, so writes Lindsey Chisholm
This arises out of a background of increasing public and press interest and concern pertaining to outcomes, in particular mortality rates, for patients admitted both electively and as emergencies to our hospitals.
As the previous article explained, last autumn’s Seven Day Consultant Present Care report from the AoMRC suggested there would be significant benefits to patients if care was delivered by consultants every day of the week, including at weekends.
I doubt any reader of this edition of Surgeons’ News would aspire to anything less than high quality consultant-led care of their patients, regardless of the time of day or night.
Some may feel that changes and improvements could be made to our current provision of care outwith the normal working day and that this should take priority over opening clinics and elective operating theatres at the weekend. In many hospitals, operating theatres are used at the weekend for waiting list initiatives, often with little or no additional staffing in place in wards, or elsewhere in the hospital infrastructure, to accommodate this.
The first and second standards of the AoMRC report are already being met and have been met for several years in various surgical departments in many hospitals. The concept of consultant review of surgical inpatients at least once every 24 hours is not new. Many consultants who currently undertake lengthy Saturday and Sunday morning ward rounds during which all surgical patients are reviewed, on both days, will have participated in such rounds as trainees. Many trainees will consider this to be the norm.
In several specialties, there is now a consultant present in the hospital 24 hours-a-day. In paediatrics and obstetrics, shift working at consultant grade is becoming commonplace. Many Accident and Emergency departments now have consultants available in the department around the clock. In some surgical departments, shift working by consultants is already standard, with a consultant available on site at all times. Some departments have even doubled up their surgical consultants on call, allowing one to start the emergency theatre list while the other does a ward round of the acute admissions and, at weekends, all the current inpatients. There are many ways to manage the current surgical workload.
While a greater consultant presence may improve patient care, such change is unlikely to influence patient outcome without sufficient provision of other members of staff to support this. Perhaps the numbers of junior medical staff on duty at the weekend should increase? Many years ago, each surgical team had its own houseman on duty for its patients. The number of patients covered by each houseman was fewer than at present and the junior doctors and ward nursing staff had the benefit of working with colleagues with whom they were familiar. The constraints of the EWTD have resulted in minimal numbers of junior medical staff working at night and on weekends with cross cover across specialties. Many junior medical staff find weekend working much more onerous than their weekday jobs. Junior doctors are reported to feel less supported at the weekend. Does this simply reflect their workload? Is this in part because there are fewer consultants or senior colleagues around?
What about nursing staff? While surgical receiving wards are staffed to cope with expected peaks and troughs in emergency admissions, the elective surgical wards may not be as well staffed at weekends as they are in the week. Where are the specialist nurses in the evenings and at the weekend? Who is going to mark the stoma site for the patient requiring a Hartmann’s? Where is the ERAS nurse who will ensure that patients on an enhanced recovery programme meet all their daily goals? Can we as a profession expect the ward nurses to take on this extra work in addition to their usual duties simply because it is the weekend?
Is there a hospital where the phlebotomy service at the weekend is as reliable as during the week? Hard pressed junior doctors may find themselves providing a phlebotomy service at the weekend, and doing so relatively late in the day, with a resulting delay in blood results being made available which in turn delays progression of investigations and interventions. In the meantime these junior doctors are trying to complete discharge prescriptions before the pharmacy closes at lunchtime. Where are the pharmacists, dieticians, occupational therapists and physiotherapists? What about portering services? Is there an ECG service at the weekend? What about the case notes which cannot be retrieved from the medical records department? The list goes on.
A major concern at the weekend is the provision of diagnostic services. Many radiology departments are now staffed by senior medical staff who expect to do a list of CTs, ultrasound scans and other imaging for patients who have been admitted as an emergency or whose clinical condition has changed. Limited portering and nursing provision, however, means some investigations may be postponed until the next elective list with a resulting delay in diagnosis and prolonged length of stay.
Outwith ‘normal working hours’ the availability of allied healthcare professionals, administrative staff, and porters is drastically reduced. Surely the NHS should be improving the facilities for dealing with current inpatients and emergency admissions before undertaking elective work at the weekend and in evenings? Increasing the number of consultants on duty at weekends and having those consultants present in the hospital 24 hours-a-day will be a very expensive way of making little improvement in the standards of patient care and throughput. Provision of a full quota of all the allied health professionals, nursing, clerical and ancillary services at the weekend is an absolute necessity to support any increase in consultant-provided care 24 hours-a-day and needs to be addressed before there is an expansion of elective work into the weekend.
Consultant Surgeon, Royal Alexandra Hospital