Night Time Emergency Department Secondment:
An Alternative to Extended Junior Doctor Surgical Cross-Cover in ENT and Beyond?
Williams
1Institute
With declining working hours, ever-tighter
budgeting and reduced trainee numbers,
innovative solutions were required to
maintain a specialist knowledge base for
ENT care at night. The literature warns of
the dangers of increasing surgical crosscover, resulting in junior doctors covering
specialties with inadequate training,
working outside their sphere of interest.
Hope
2
A
of Naval Medicine, Gosport, UK. 2MDHU Derriford, Plymouth, UK.
Richard.williams8@nhs.net
Cycle 1
Management Solutions
The Problem
Background
1
R,
An audit of ENT/Plastic Surgery
junior doctor activity at night
- Increase inter-departmental cross-cover
thus diluting the knowledge base of the
covering junior doctor
- Derriford Hospital is a 900-bed
tertiary referral center serving a
population of 450,000.
- Plastic and ENT Surgery junior
doctors cross-cover at night
- Aug 2011 saw an enforced
reduction in junior doctors from 12
to 10
- 6/52 prospective data
- Audit of Hospital at night ward
tasks completed
- Audit of Emergency Department
(ED) consultations and compliance
with current Clinical Quality
Indicators (CQIs)
- Increase compensatory leave allowing
increased frequency of night shifts, which
would reduce junior doctor training
experience
EMERGENCY DEPARTMENT CLINICAL QUALITY
INDICATORS AUDIT
Median door to doctor wait (mins)
Patients total stay over 4 hrs (%)
GOLD
STANDARD
CYCLE 1
CYCLE 2
CYCLE 3
< 60
102
77
52
< 5.00
9.96
4.03
4.89
182.4
147.6
144.4
Mean patient length of stay (mins)
Total number of patients treated by
ENT/Plastics
123
271
307
Patients treated by ENT/Plastics as 1st clinical
decision maker (%)
35
63
65
Further Development
- Extension of service framework to other
specialties
(e.g.
orthopedics
and
psychiatry) and other hospitals.
- The establishment of a hospital wide
service to deal with generic ward tasks
without recalling seconded juniors from
ED.
- Hospital systems to reduce the amount
of routine ward tasks performed at night
Cycle 1 Conclusions
- ENT/Plastics Surgery junior doctor were
underemployed at night
- Poor CGIs for ENT/Plastics patients
- Large duplication of work with ED and
ENT/plastics dual clerking patients
- 64% ward tasked were generic
- 68% ward tasks were routine
INTERVENTION
THE SECONDMENT OF THE NIGHT
ENT/PLASTICS SURGERY JUNIOR
DOCTOR TO THE ED AS THEIR PRIMARY
PLACE OF WORK
Job Description
Cycle 3
Further re audit of ENT/Plastic
Surgery junior doctor activity at
night
- 6/52 prospective data
- Audit of Emergency Department
patients seen and compliance with
current Clinical Quality Indicators
- To assess lasting effect of service
Conclusions
• PTs received more expedient care
• PTs seen by more complaint specific clinician
• ENT maintained a specialist junior doctor service
without increased cross-cover
• ENT reduced junior doctor salary expense with ED
funding banding change
• ED secured improved CQIs
• ED staff freed of the burden of dual clerking
• JUNIORs increased training exposure by 26%
• JUNIORS received increased salary banding
Cycle 2
A re-audit of ENT/Plastic Surgery
junior doctor activity at night
- 6/52 prospective data
- Audit of Emergency Department
patients seen and compliance with
current Clinical Quality Indicators
- Analysis of impact on exposure to
training.
- Based in ED minors 2100-0700
- See and treat all potential ENT and
plastic surgical cases upon presentation
- To be re-called for ward tasks according
to priority category
- To work within a structured system of ED
clinical supervision for patients not
formally followed up by ENT/plastic
surgery services.