Impact of EWTD on patient:doctor ratios and working practices for junior doctors in England and Wales 2009

Temporal variation in survival following in-hospital cardiac arrest in Sweden

BACKGROUND

The aim of the study was to investigate what characterizes IHCAs that take place during the "day" (Monday-Friday 7 am-3 pm), "evening" (Monday-Friday 3 pm-9 pm) and "night" (Monday-Friday 9 pm-7 am and Saturday-Sunday 12 am- 11.59 pm).

METHODS

We used the Swedish Registry for CPR (SRCR) to study 26,595 patients from January 1, 2008 to December 31, 2019. Adult patients ≥18 years with a IHCA where resuscitation was initiated were included. Uni- and multivariable logistic regression was used to investigate associations between temporal factors and survival to 30 days.

RESULTS

30-day survival and Return of Spontaneous Circulation (ROSC) was 36.8% and 67.9% following CA during the day and decreased during the evening (32.0% and 66.3%) and night (26.2% and 60.2%) (p < 0.001 and p = 0.028). When comparing the survival rates between the day and the night, survival decreased more (change in relative survival rates) in small (<99 beds) compared to large (<400) hospitals (35.9% vs 25%), in non-academic vs academic hospitals (33.5% vs 22%) and on non-Electro Cardiogram (ECG)-monitored wards vs ECG-monitored wards (46.2% vs 20.9%) (p < 0.001 for all). IHCAs that took place during the day (adjusted Odds Ratio (aOR) 1.47 95% CI 1.35-1.60), in academic hospitals (aOR 1.14 95% CI 1.02-1.27) and in large (>400 beds) hospitals (aOR 1.31 95% CI 1.10-1.55) were independently associated with an increased chance of survival.

CONCLUSIONS

Patients suffering an IHCA have an increased chance of survival during the day vs the evening vs night, and the difference in survival is even more pronounced when cared for at smaller, non-academic hospitals, general wards and wards without ECG-monitoring capacity.

Weekend surgical handover enhances early management of acute clinical changes using a red flag system

INTRODUCTION

Recent implementation of the European Working Time Directive in Ireland has resulted in a change from thetraditional model of patient care to a system characterised by shift work among clinicians. Effective handover ofpatient information is essential for transfer of responsibility between clinicians and maintaining continuity of care. The weekend has been identified as a particularly vulnerable transition of patient care.

AIMS AND METHODS

Our study aims to determine if implementing a formal face-to-face handover accompanied by an electronictemplate in our surgical department can improve the number of adverse events reported back to the primary teamafter a weekend on call. Data was collected over 12 weekends between February and May 2016. A list of adverseevents was established, and during an initial observation period of 6 weeks, we documented the number of adverseevents that were informally handed over. A 6-week intervention was then performed, involving a formal face-to-facehandover on Monday morning supported by an electronic patient census using a red-flag system to highlightpatients who experienced an adverse event over the weekend.

RESULTS

Our results showed the mean number of adverse events recorded pre-intervention was 3.17 ± 0.6 over the 6-week period. Following the introduction of weekend face-to-face handover, there was 147% increase in the number of adverse events recorded with a mean of 7.83 ± 1.2.

CONCLUSION

The introduction of a formal face-to-face weekend handover with a red-flag system resulted in increased reporting of patient adverse events, allowing earlier recognition and management.

Physical and Mental Health of Patients Immediately After Discharge From Intensive Care Unit and 24 Hours Later

Background:

Monitoring the health status of patients discharged from intensive care units is a crucial method of service evaluation.

Objectives:

This study aimed to assess the physical and mental health status of patients immediately after discharge from the ICU and 24 hours later.

Patients and Methods:

This descriptive comparative study was conducted on 104 patients discharged from the ICUs of a referral trauma center in Shiraz, Southwest Iran. Physical parameters, including respiratory rate, need for supplemental oxygen, heart rate, blood pressure, and need for cardiac monitoring, were assessed. Hospital anxiety and depression scale (HADS) was used for mental health evaluation. The mental and physical status of patients were assessed before ICU discharge and 24 hours later; data were recorded in information forms and were analyzed using SPSS statistical software version 17.

Results:

At the time of discharge, the respiratory rate of 28% of the participants was more than 24 minutes, and 95.2% received supplemental oxygen. However, after 24 hours these values decreased to 10% and 21.6%, respectively. The mean heart rate and systolic blood pressure were within the normal range at both time points. Additionally, 63% of the patients had anxiety scores above 11 at both time points, reflecting high anxiety. The number of patients who reported depression increased from 58.7% at ICU discharge to 69.6% after 24 hours.

Conclusions:

Despite the considerable improvement in most of the patients’ physical condition in the first 24 hours after discharge from ICU, a significant number of them remain at risk for the development of adverse effects from this transition. The high prevalence of mental health disorders in these patients reveals the necessity to conduct follow-up consultations.

The use of abbreviations in surgical note keeping

Abbreviations are used to improve the speed of note keeping and to simplify patient notes. However studies have shown that they can reduce clarity, increase mistakes and cause confusion in management plans. Our review highlights the misuse of abbreviations in surgical note keeping.

Improving the quality and safety of care on the medical ward: A review and synthesis of the evidence base

Despite its place at the heart of inpatient medicine, the evidence base underpinning the effective delivery of medical ward care is highly fragmented. Clinicians familiar with the selection of evidence-supported treatments for specific diseases may be less aware of the evolving literature surrounding the organisation of care on the medical ward. This review is the first synthesis of that disparate literature. An iterative search identified relevant publications, using terms pertaining to medical ward environments, and objective and subjective patient outcomes. Articles (including reviews) were selected on the basis of their focus on medical wards, and their relevance to the quality and safety of ward-based care. Responses to medical ward failings are grouped into five common themes: staffing levels and team composition; interdisciplinary communication and collaboration; standardisation of care; early recognition and treatment of the deteriorating patient; and local safety climate. Interventions in these categories are likely to improve the quality and safety of care in medical wards, although the evidence supporting them is constrained by methodological limitations and inadequate investment in multicentre trials. Nonetheless, with infrequent opportunities to redefine their services, institutions are increasingly adopting multifaceted strategies that encompass groups of these themes. As the literature on the quality of inpatient care moves beyond its initial focus on the intensive care unit and operating theatre, physicians should be mindful of opportunities to incorporate evidence-based practice at a ward level.

Mortality following acute pancreatitis: social deprivation, hospital size and time of admission: record linkage study

Background

Very little is known about whether mortality following acute pancreatitis may be influenced by the following five factors: social deprivation, week day of admission, recruitment of junior doctors in August each year, European Working Time Directives (EWTDs) for junior doctors’ working hours and hospital size. The aim of this study was to establish how mortality following acute pancreatitis may be influenced by these five factors in a large cohort study.

Methods

Systematic record linkage of inpatient, mortality and primary care data for 10 589 cases of acute pancreatitis in Wales, UK (population 3.0 million), from 1999 to 2010. The main study outcome measure was mortality at 60 days following the date of admission.

Results

Mortality was 6.4% at 60 days. There was no significant variation in mortality according to social deprivation or the week day of admission. There was also no significant variation according to calendar month for acute pancreatitis overall or for gallstone aetiology, but for alcoholic acute pancreatitis, mortality was increased significantly by 93% for admissions during the months of August and September and 102% from August to October when compared with all other calendar months. Mortality was increased significantly for alcoholic aetiology in August 2004, the official month that the first EWTD was implemented, but there were no other increases following the first or second EWTDs. There were also indications of increased mortality in large hospitals when compared with small hospitals, for acute pancreatitis overall and for gallstone aetiology but not for alcoholic acute pancreatitis, although these increases in mortality were of quite marginal significance.

Conclusions

Although we found some evidence of increased mortality for patients admitted with alcoholic acute pancreatitis during August to October, in August 2004, and in large hospitals for acute pancreatitis overall and for gallstone aetiology, the study factors had limited impact on mortality following acute pancreatitis and no significant impact when adjusted for multiple comparisons.

Career choices of junior doctors: is the physician an endangered species?

There are increasing concerns regarding the recruitment and retention within general medicine. National surveys were conducted among foundation year 2 doctors (FY2), year 1 and year 2 core medical trainees (CT1 and CT2) and medical registrars (StR/ST3+) exploring their enjoyment of medicine, overall satisfaction, career aspirations, influencing factors and perceptions of the medical registrar. The results highlight that many doctors at the FY2, CT1 and CT2 levels are being deterred from general medicine by the perceived unmanageable workload and poor work-life balance of the medical registrar. Medical registrars themselves are less satisfied in general internal medicine than they are in their main specialties. Therefore, priority needs to be placed on clarifying the roles, and improving the morale, of medical registrars. If current trends persist, these will have a significant impact on patient safety, patient care and workforce planning.

Simulation to develop tomorrow's medical registrar

BACKGROUND

 Critical incident analysis reveals that poor performance in 'human-factor' or non-technical skills, such as decision making, leadership, teamwork and situational awareness, are frequently identified as key underlying features leading to adverse events. Simulation technology is a rapidly emerging modality used to develop technical and non-technical skills within specialist training as increasing shift-pattern work reduces work-based exposure and learning opportunities. To date, however, there is little literature regarding its use within core medical training to develop crisis resource management skills and medical registrar competency.

STUDY DESIGN

We present results from a pilot in situ high-fidelity, multidisciplinary, simulation training course in which core medical trainees practised the role of a medical registrar within challenging crisis scenarios.

RESULTS

Twenty-one trainees completed the simulation course. All trainees agreed that the course improved their clinical skills and knowledge, concentrated on key non-technical skills that are important in crisis management and, importantly, would change their clinical practice and improve patient safety. Trainee overall performance strongly correlated with assessment of non-technical skills during the simulation scenario. Trainees invited to return for a repeat session after previous concerns and specific feedback showed a visible improvement in performance, with an objective improvement in self-assessed performance.

CONCLUSION

This pilot programme shows the benefits of a high-fidelity, in situ, multidisciplinary simulation training course for core medical trainees in developing the key crisis resource management skills necessary at medical registrar level. As a historical apprenticeship model of training becomes increasingly variable and absent, we present a novel complimentary training strategy for tomorrow's medical registrars.

Patient need at the heart of workforce planning: the use of supply and demand analysis in a large teaching hospital's acute medical unit

Timely medical assessment is integral to the safety and quality of healthcare delivery in acute medicine. Medical staff are an expensive resource. This study aimed to develop a modelling system that facilitated efficient workforce planning according to patient need on the acute medical unit. A realistic 24-hour 'supply' of junior doctors was calculated by adjusting the theoretical numbers on the rota for leave allowances, natural breaks and other ward duties by a combination of direct observation of working practice and junior doctor interviews. 'Demand' was analysed using detailed admission data. Supply and demand were then integrated with data from a survey of the time spent on the process of clerking and assessment of medical admissions. A robust modelling system that predicted the number of unclerked patients was developed. The utility of the model was assessed by demonstrating the impact of a regulation-compliant redesign of the rota using existing staff and by predicting the most efficient use of an additional shift. This simple modelling system has the potential to enhance quality of care and efficiency by linking workforce planning to patient need.

Acute Medicine: triage, timing and teaching in the context of medical emergency admissions

Acute Medicine has been recognized as a sub-specialty of General Internal Medicine in the UK for 6 years. Acute Medicine aims to streamline diagnostic processes and treatment decisions for patients presenting with an acute illness in Internal Medicine in order to improve safety, patient experience and resource utilization. Acute Physicians are specialists in Acute Medicine. Co-location of patients in Acute Medical Units helps to rationalize logistical processes and supports training of junior doctors in supervised management of both life-threatening and complex medical emergencies. Research is needed to formally evaluate the impact of the format of service delivery on clinical outcomes and length of hospital stay for patients with comparable sickness profiles.