It’s time to shift the focus

John had tried to hold on as long as he could. The cough had started on Christmas Day; he had hoped to be able to see his own GP on Monday but by the Sunday of the 4 day holiday his breathing was becoming a real struggle. He’d had chest infections before – ever since his stroke 3 years ago he had been prone to this, but his GP usually managed to keep him out of hospital. The stroke had left John with a significant left sided weakness, but with the assistance of twice daily carers he got by. John didn’t want to go into hospital, but the doctor from the out of hours service convinced him that it was the best option; the combination of a significantly reduced oxygen saturation, low blood pressure and a tachycardia left him with little alternative. ‘The hospital will patch you up and have you out in no time’, he promised.

Intravenous antibiotics and fluids were started swiftly on his arrival in the emergency department’s resuscitation room – a chest x-ray confirmed lobar pneumonia and within 48 hours he was starting to feel better; by New Year’s day he was back on oral antibiotics and starting to mobilise with assistance from the physio. By the following Sunday – a week after admission – he was deemed to be ‘back to baseline’ – able to be discharged, as soon as his ‘package of care’ could be restarted. 30 minutes in the morning and 15 minutes at lunchtime was all he would require – hopefully this would just take a phone-call…

But of course nothing is ever that simple. John’s carers had been reallocated to other clients following his hospital admission; re-establishing his care package would take some time and there was already a backlog of other patients which had built up over the Christmas period. A week, at least, would be required in order to get things re-started. In the meantime he would have to wait. In his hospital bed.

This week I have stepped outside my usual ‘comfort zone’ of the Acute Medical Unit, to lead a general medical team on the wards in our hospital. My patients have been those who don’t fit into a clear-cut speciality category and who are not old enough to require the skills of a geriatrician. Patients like John.

Meanwhile, acute and emergency medicine have been in the spotlight – most hospitals have been on ‘black alert’ and many have declared major incidents. A large influx of patients with acute respiratory illness has left Emergency Departments struggling to cope; figures released by the Department of Health have confirmed that the proportion of patients waiting over 4 hours prior to discharge or transfer from the ED has risen dramatically. Queues of patients on trolleys and ambulances lined up on the hospital forecourt have become a common sight; the ‘A&E crisis’ has barely been out of the news.

But there is another story, which is not being told. The story of patients like John, and many thousands of others like him, waiting in hospital beds across the UK; no longer unwell, but unable to leave hospital until social care can be arranged. For some, the needs are complex: patients can wait for a number of weeks for funding to be arranged or a new care placement to be found. However, even those whose care needs are already well established are experiencing delays.

This is not a new problem – we have been talking about ‘delayed discharges’ for at least 20 years, and January is always a particular challenge after the Christmas break. However this year undoubtedly feels worse than ever. Much worse. Health care funding has been ring fenced by the government, while social care funding has been subject to significant cuts. It is not hard to understand why the problem has arisen. Furthermore, there is no slack in the social care system – when a patient goes into hospital the carers cannot sit back and wait for them to be discharged; there is always someone else who needs help. Everyone needs to be prioritised, and a patient whose care needs are being met in a hospital bed inevitably slips down the priority list. In the meantime, ‘health’ is picking up the bill and our hospital beds are all full.

The solution to the current ‘A&E crisis’ will not be found in the A&E department itself. It will not be found by telling patients to ‘stay away’. The majority of those waiting for long periods in our A&E corridors are unwell and require an in-patient bed: to solve this problem we must look further downstream. It is time to re-focus our attention on the cause of the crisis, not the symptom. If we want to unblock A&E we must unblock the hospital.

Thankfully John’s hospital stay was shorter than was initially anticipated – on this occasion our discharge facilitation team worked some magic and by the middle of the week he was on his way home. There will many others in hospital beds across the UK tonight, and for many nights to come, who will not be so lucky…..

 

 

John gave his consent for has case to be shared; his name and some clinical details have been changed to protect his anonymity

Breaking down the communication barriers: reflections on a day in primary care

It was all a bit confusing. Lisa had apparently missed her hospital follow-up clinic the previous week, although she was not aware of this appointment; a letter from her consultant indicated that this had, in any case, been booked in error as her ‘surgical episode’ was completed during her hospital stay. If she had any ongoing symptoms she needed to make an appointment with her GP – so here she was. The discharge summary had been uploaded onto the GP’s computer, but seemed to bear little resemblance to Lisa’s description of events during her hospital stay. Things did not quite add up. The explanation for her ongoing symptoms might have been straightforward, but her GP was ‘flying blind’. What’s more he had only 8 minutes to solve this: barely enough time to get past the hospital switchboard. The clinic was already running late – he would have to make some calls at lunchtime and get back to her later….

 

I had intended to do this every year, although it never quite worked out as planned: the last time I spent a day in general practice was in 2009. Back then it had been an eye-opener for me – a realisation that the majority of primary care work was very different to the tiny portion that involved an interaction with a hospital team. Much has happened in healthcare over the past 5 years – a change of Government, a new Health and Social Care Act, a transition from PCTs to CCGs and a seemingly inexorable rise in workload. I was under no illusions that a Tuesday with the duty GP at a local surgery would be any less demanding than my usual ‘day job’ on the Acute Medical Unit.

And so it transpired: GPs are clearly busy. I lost count of the number of patients who came and went during the course of the day; some were straightforward, some more complex. The variety of decisions ranged from rheumatology to dermatology, gynaecology and psychiatry; the skills of the ‘expert generalist’ were on show from start to finish. Problems were solved; solutions were provided. The system worked smoothly……until Lisa arrived, to illustrate the frustrations which occur when patients make the transition to and from secondary care.

There was a time when almost every patient would have had a ‘routine’ hospital follow-up clinic appointment a few weeks after discharge. It was an opportunity to tie up loose ends; to ensure that blood tests, histology results and scan reports had been reviewed; a chance to answer any questions that the patient may have had about their hospital stay and subsequent symptoms. A dictated letter to the GP would follow, supplementing the information provided at the time of hospital discharge. Of course, in many cases this was all superfluous – the patient took a day off work, paid for parking and waited several hours to tell a very junior doctor that all was well; meanwhile Primary Care picked up the bill. It is not hard to understand why shifting ‘follow-up’ back to the GP seemed a logical solution.

We have shifted the work, but not the information. Old-style dictated discharge summaries were informative, but rarely reached the GP in time to be of any real use. The electronic discharge summary now arrives more quickly, but the quality is highly variable. Furthermore, shorter hospital stays often mean that test results are not available at the time the patient goes home. Finding the right balance between speed and quality of information when a patient leaves hospital often feels like a search for the Holy Grail. If we are going to expect GPs to provide early follow-up for patients discharged from hospital we need to find a better way to ensure accurate and timely information is available for this first visit.

Telephone communication used to be much easier – ten years ago if I phoned a surgery and asked to speak to a GP I would be immediately connected; receptionists now are more reluctant to interrupt GPs during a consultation and usually offer a ‘call back’ time. I can understand why this change has happened – workload, confidentiality and risk of ‘cognitive overload’- but it has added another nail to the communication coffin.

The solution may lie in information technology. Primary care IT clearly works well for the patient in primary care; hospital IT works – albeit slightly less well – for the patient in hospital. Locally, our hospital systems have certainly moved forward since 2009: we now have electronic prescribing, an easily searchable electronic document system and a user-friendly interface which allows results, patient records and letters to be accessed via a single log-in. The system on the GP’s desk was still slicker – a few clicks and the printer had churned out a prescription, blood forms, patient information sheet and a sick note; a similar process in hospital would probably have involved a search for a spare terminal, a temperamental printer and at least one re-boot – but we are moving in the right direction.

The current lack of an electronic interface between hospital and community is as frustrating as the difficulty in getting past the hospital switchboard or GP receptionist when we try talking to each other. In Lisa’s case, access to the hospital computer system would have been revealing – scan results, histology, blood tests and an operation note could have been reviewed with a few clicks of a mouse. At my hospital desk I could have achieved this; sitting quietly in the corner of the GP’s consultation room, I could only offer sympathy. The information is readily available; we need to find a way to make this information more accessible.

They say that you should not judge a man until you’ve walked a mile in his shoes; a single day in primary care may not have been the full mile, but provided me with a snapshot of the pressures which are faced by those clinicians working outside the hospital walls. Breaking down the communication barriers is crucial – we should definitely do this more often.

A Seven Day Service

It was a fairly typical Sunday afternoon in 2011. The emergency department was experiencing its usual surge of ambulance arrivals: every cubicle in ‘majors’ was occupied and a queue of patients on trolleys was slowing growing in the corridor. The nurse in charge seemed as calm as ever: I asked what I could best do to help. ‘Have a look at the queue – see if there are any you can get home’, she suggested – more in hope than expectation.

‘My husband is dying…’

John was second in the queue and didn’t look like he was going home, but judging by his reduced conscious level, he appeared to need urgent attention. I asked a passing nurse if there was any space in resus – ‘all full’, she replied as she sped to the assistance of another patient. John’s wife was reading to him – she put down the prayer book when I introduced myself and asked her the problem. She had been crying, but spoke clearly ‘My husband is dying and needs to go to the hospice – please can you help us?’

John was 52. He had pancreatic cancer with cerebral metastases and had exhausted all therapeutic options. He had seen the palliative care team the previous week and a bed had been arranged at the hospice for his admission on Monday; his wish to avoid hospital and not to be resuscitated in the event of a cardiopulmonary arrest had been documented. While eating his lunch he had experienced a brief grand-mal seizure; this had happened before, but this time he had not regained consciousness and his breathing now appeared laboured and noisy. His wife thought he had probably aspirated, and had phoned the hospice to see if they could take him one day early.

‘He will have to go to A&E…’

The hospice nurse had confirmed that his bed was available, but weekend admission would require referral from a doctor, and he would have to arrive before 5pm. She advised his wife to phone the GP, but the Out-of-Hours operator explained that a doctor could not attend for several hours – ‘I am afraid he will have to go to A&E’, she said: it appeared to be the only realistic option. An ambulance had arrived, and here he was – on a trolley in a corridor, seemingly within his last few hours of life, while his wife tried to offer whatever comfort she could. ‘I know John wouldn’t want this; it’s all my fault that he is here – I wish I had never phoned’. Five o’clock had come and gone.

Guidelines, toolkits and standards…

Much has happened since 2011: 7 day guidelines, toolkits and standards have been produced by various Royal Colleges, the Academy of Medical Royal Colleges and NHS England. I have attended and spoken at many meetings, conferences, summits and working groups. Sir Bruce Keogh has indicated that developing 7 day services is a key priority for the NHS in England, and has set a timescale for delivery by 2018. There is international evidence from the UK, USA, Spain and Australia that patients admitted to hospital at weekends have a higher chance of dying during their hospital stay than those admitted during weekdays; a large NIHR-funded research project (the HiSLAC study) is underway to investigate whether increased levels of consultant staffing could influence this.

The need for the current situation to change has been clearly, and repeatedly stated, and yet at ‘ground level’ the signs of real change seem to be relatively small.

Must do’s, should do’s and could do’s

Unfortunately the messages get confused. Government ministers talk of providing a service that is more convenient for patients: a GP appointment on a Saturday or Sunday to avoid taking a day off work; a scan at a weekend when the equipment is lying idle. Shops are open at weekends, so why shouldn’t the same be true of GP surgeries and hospital outpatient clinics? It is important to inject a modicum of reality into such discussions. At present we are many miles from being able to deliver an elective service which looks the same on a Sunday as it does on a Tuesday. This is a ‘could do’ for the future, but not the key priority for 2014.

At the other end of the spectrum, clinicians regularly remind us that they are already providing a 7 day emergency service: general practitioners are always available via the ‘out of hours service’ and hospitals provide 24/7 care, often consultant delivered, for those who are severely unwell and deteriorating. The fact that the ‘must do’s’ are being delivered does not change the fact that there is a group of patients who fall between these groups. The ‘Should do’s’: Patients in hospital who are not unwell enough to go to intensive care, and are unlikely to die before Monday, but who are not well enough to go home; community patients who don’t need to be in A&E, but whose urgent care needs can’t be met by the out-of-hours service. Large numbers of patients fall through huge cracks in the system at weekends, and the knock on effect on Mondays is felt both in primary and secondary care.

Solutions cannot be cost-neutral…

The responses from senior clinicians are predictable: ‘not enough money’, ‘not enough staff’, ‘can’t sacrifice my weekday service’, ‘a recipe for burnout’. We have to be clear that attempting to deliver radical change on a ‘cost neutral’ basis is a recipe for disaster; you cannot provide more care at weekends with the same number of people without impacting on weekday services. There will be some efficiency savings if we can smooth out the variability of emergency care across seven days, but this will probably not offset the increased cost of staffing an improved weekend service.

 It’s time to change…

There will need to be investment, but significant change will not occur unless the clinicians want to make this happen. It is easy to put up barriers, to find reasons why it cannot be done, or to blame others for not sharing the burden; but we cannot allow the status quo to continue, year-on-year. As we head into 2015, all clinicians need to ask themselves the following question:

If a member of my family became unwell at a weekend, would I be confident that my service would be able to deliver the care that they needed?’

If the answer is ‘no’, then the time has come to change this.

It would have been easy to have allowed John to join the weekend hospital mortality statistics: to move him to a ward and wait for his final moment to come, or hope that he survived long enough to arrange a Monday morning transfer. His wife would have accepted this, but her grief would have been compounded by guilt. On a busy Sunday evening there were many things I could have done with the 45 minutes which it took to undertake 3 phone calls and negotiate transfer with an ambulance crew on the ED forecourt; but this was undoubtedly the most worthwhile thing I did that day. The hospice nurse even agreed to waive the ‘not after 5pm’ rule following my telephone conversation with the on-call Palliative Care consultant. John died, peacefully, later that night, with his wife at his hospice bedside.

 

Footnote: Although ‘John’s’ wife agreed that I could share details of his case, his name, age and some clinical details have been changed to protect his anonymity.

A ‘typical’ chest pain

‘I am very pleased to tell you that your coronary arteries are normal’ – these were the only words that Joan remembered the cardiologist telling her after her angiogram. Perhaps the amnesic effect of midazolam had an influence of this; or perhaps not. As reassuring as this sounded, it did not feel like the conclusion to the problem that she was hoping to achieve. Today was the culmination of a journey which had started with an ambulance trip to A&E, 6 weeks earlier, following a ‘111’ call; after two normal ECGs a 12 hour stay on the clinical decision unit and a negative troponin she was back with her GP describing her episodic central chest pain – sometimes exertional, sometimes not. She was 65 and had a few ischaemic risk factors – certainly enough to justify a referral to the chest pain clinic. A proforma was completed, an exercise test was equivocal, and an angiogram was performed with surprising speed and efficiency. ‘What should I do if I get it again?’ – she asked the nurse who handed her the discharge paperwork. ‘You will have to discuss that with your GP…..’.

Her son, a family acquaintance of mine, read the cardiology discharge summary out to me over the phone: ‘It says she has atypical chest pain’ – incidentally the same diagnosis she had been given in A&E 6 weeks earlier – ‘so what does that actually mean?’. An interesting question indeed.

‘Rule-out medicine’

It’s easy to have a pop at specialists with a case like this, but that is not the intention of this blog. If we are honest, most hospital clinicians have been guilty of making a ‘non-diagnosis’ once or twice. The phenomenon of ‘rule-out medicine’ was even the subject of a symposium at an acute medicine conference that I attended in London a few years ago; erudite speakers described the increasing sensitivity of testing strategies in conditions such as pulmonary embolism (PE), acute coronary syndrome (ACS) and sub-arachnoid haemorrhage (SAH). Never again would patients be sent away from the acute medical unit with even a remote possibility of one of these life-threatening conditions. Our indemnity insurers could breathe easily in their beds at night once more.

Of course, our patients’ breathing may not be quite so relaxed. A symptom severe enough to justify a visit to the hospital, deserves an explanation; but how often does the medical clerking – and even the consultant ward round – conclude with the words ‘Plan: exclude PE’ (or ACS / SAH)? Exclusion of a serious diagnosis may provide the reassurance we need to discharge a patient from hospital; however it is equally important to consider what is causing the symptoms. Chest pain should never be described as ‘non-cardiac’ or (worse still) ‘atypical’.

When we wrote up our first year’s experience of outpatient management for patients with suspected PE, almost 10 years ago, we concluded that a group of patients could be managed without hospital admission. All of the (albeit carefully selected) patients in whom pulmonary embolism was identified over this period had been managed safely in the community, with no readmissions or unexpected deaths; however there was a small group of patients in whom the outcome was less positive. All of these were patients in whom PE was excluded, but where no explanation for the symptoms had been identified. Many returned to hospital soon after discharge, and although only a small number were subsequently found to have a significant condition, the message was clear: a positive diagnosis is important. ‘Not a PE is Not a Diagnosis’ became my mantra.

Of course medicine is not always that simple; it is often much easier to tell a patient what is isn’t, than to tell them what it is. Sometimes there remains a list of possibilities: a differential diagnosis with pointers towards several different causes – to pick one would be disingenuous; furthermore there is no test which will prove that a pain is of musculoskeletal or oesophageal origin with the degree of certainty with which we can exclude a cardiac cause. Communicating uncertainty to a patient without raising anxiety is a skill which all acute physicians, and other hospital specialists need to develop. But, equally important is that we make the effort to think about the cause of a patient’s symptoms; ruling out serious pathology should not be the conclusion of our role.

Providing advice on what to do if a symptom recurs following discharge is another crucial component of hospital care. Chest pain resulting from of oesophageal spasm can be severe, tends to be recurrent and invariably happens at rest. If a patient phones 111, it is very likely that the call will result in an ambulance trip to A&E, particularly if they have cardiac risk factors. A clear explanation of the likely cause of the patient’s symptoms, combined with a management strategy in the event of recurrence may prevent repeated visits to hospital, which tend to raise anxiety and uncertainty yet further. General Practitioners are highly skilled in communicating and managing uncertainty, but the practicality of the advice to ‘discuss that with your GP’ and the likelihood of recurrence while awaiting an appointment needs to be questioned.

Joan was fortunate to have a fantastic General Practitioner – one of the best in the area. He listened to her symptoms, which sometimes related to exertion, but were also exacerbated by certain movements and posture. He also noted that they often occurred when she was tired or stressed and that their onset coincided with the anniversary of her husband’s death. She fought back tears as she described how lonely she felt at times since then. Reassured by her normal coronary arteries, a diagnosis of musculoskeletal chest pain, exacerbated by anxiety and depression, was made; a management plan was instigated, which saved further visits to A&E, or calls to 111. Joan had reached a satisfactory – but sadly atypical – conclusion, to her fairly typical chest pain.

A Good Case…

The case report had been written, submitted, rejected and re-written three times; this was getting frustrating for Sarah. When her consultant had suggested she write up this case, it seemed that her prayers had been answered – that gaping hole in the ‘publications’ section of her CV would soon be filled, improving her chances of being short listed for a specialist registrar post in her chosen speciality. However, as she now contemplated yet another re-drafting of the manuscript which stared back at her from the computer screen, she wondered whether revising for her forthcoming PACES examination would be a better use of her time…

Many of us have been in this situation – getting a case report published can certainly be a frustrating business; if there was an ‘I’ve been rejected by the BMJ / NEJM / Lancet’ T-shirt, I would have a small collection by now. But as the editor of a journal I now see this from the other side. The pressure to publish means that the volume of case reports received on a weekly basis far exceed the number we can include, so most will be rejected. Selecting those which are likely to be of greatest value to the readers of the journal is not a particularly scientific process – and I will not claim that we always get this right. But there are things which you can do to make the job of the editor easier, and improve your chances of success.

In this blog, I have summarised a few tips, which I hope may help those who are struggling to get that first elusive publication.

  • Focus on the ‘learning points’:

In my view, cases should be more about ‘learning’ than ‘reporting’. Clinicians are busy people – if we are going to invest 15-20 minutes of our time to read a case report we need the outcome to be more than just a ‘raise of the eyebrows’. I like to think that, after reading the report, my practice will change and I will do something different as a result; something that makes me say ‘Wow – I am so glad I read that’, or ‘the next time I see a patient with that problem I will have to look out for that’. So ask yourself what you, and your team learned from the case and summarise this into some learning points around which the case history and discussion can be structured.

  • Rarity does not always equate to publishability:

Common things occur commonly, but there are a lot of rare conditions; so it’s actually not unusual to see a patient with something unusual presenting on the acute medical take. A patient with a really rare condition can cause a diagnostic challenge, but the chances of anyone ever seeing it again are slim: there may be learning points around the diagnostic process, but the rarity does not make it publishable in itself. Of course, if your literature search suggests that this is the ‘first ever’ case of something really important then you have an opportunity to pitch this to one of the top international journals – but you should still prepare yourself for an uphill struggle.

  • Select your journal / audience carefully

A common reason for rejection of a case report is that the focus is not right for the target audience of the journal. Although the patient may have presented to the acute medical take, if the learning points relate to the subsequent specialist or outpatient care, there may be limited relevance to a journal whose readers are mainly acute physicians. Discuss this carefully with your colleagues and co-authors – getting it right first time will pay dividends.

  • Read some back issues before you submit

It’s a good idea to look at the style of previously published case reports in the journal you have chosen; make sure the format of your article is similar. Most journals also have an ‘instructions for authors’ page on their website. Read this carefully and follow to the letter.

  • Keep the ‘case history’ focussed

The case history needs to include information relevant to your learning points, but does not need to be a full reproduction of the patient’s clerking or progress notes. In general ‘less is more’ in this situation. Relevant blood tests can be tabulated and remember to include images of x-rays, scans and ECGs where relevant.

  • Make the discussion a true ‘discussion’

The ‘discussion’ section should not simply be a literature review, but provides the opportunity to highlight aspects of the patient’s presentation which illustrate the learning points which you summarised at the start. This will usually involve some reference to the relevant literature, highlighting similarities or differences to previously published cases; however exhaustive repetition of material which can easily be found in a recent NICE guideline or Cochrane review is not the best use of this space. Ask yourself how this patient changed your practice and what made it important to share this; what was it that enabled you to reach the diagnosis, or where did you go wrong? What were the key aspects of the patient’s history, examination or investigation which made the difference? If more than one treatment option exists, which did you choose and why?

  • Don’t forget to talk to the patient and ask for their consent

Case reports are essentially patient stories – the information belongs to the patient and therefore should not be published without their consent. Some journals do not insist on written consent, except for the publication of images; however it is still good practice to obtain this before submission. You can usually download a consent form from the journal’s website. Although the case history should always be anonymised, the authors’ details will usually indicate the hospital at which the patient was treated, and it will often be possible for patients to be identified from the clinical information, particularly if the problem is unique or unusual. The increasing accessibility of journals via the internet, along with the ability for readers to ‘screen grab’ and share via social media raises the likelihood of a patient or acquaintance recognising their story. In some cases consent can be difficult to obtain – for example if the patient has died, or cannot be contacted; some editors may still be prepared to publish, but it is worth sending a covering email detailing the efforts you have made to obtain this, and the reasons why you believe the case should still be published.

  • And finally: proof read carefully – and don’t rely on your spell checker

As an Editor, nothing is more frustrating than a badly written paper, filled with spelling or grammatical errors which obscure an otherwise interesting case. Spell checkers work – up to a point – but won’t correct most medical terminology and plenty of words have alternative spellings which won’t be identifed as incorrect. All ‘track changes’ should be removed, and make sure all the authors are happy with the final version. It is also worth getting a senior colleague with publication experience to read and critique the paper before submission.

Rejection can be frustrating, and redrafting can be time consuming; hopefully, following these tips will improve the chances of turning your ‘good case’ into a great case report.

‘Pulling the all nighter’ – reflections following a consultant night shift in the AMU

The Sunday evening call from my consultant colleague was perfectly timed. Our cricket team’s penultimate game of the season had come to a premature end with a heavy defeat and I had not yet sipped the consolatory beer which awaited in the clubhouse. It had been a challenging weekend for those working on AMU. Bank Holiday weekends are never easy, particularly in August when many of the new junior doctors are still finding their feet. This weekend the problem was compounded by overnight gaps in the middle grade rota which had not been filled by our usual locum agencies. Senior House Officers plugging registrar vacancies had provided a solution of sorts, but lack of flow into medical beds over the previous night had led to some lengthy delays in the emergency department. The duty executive had requested a ‘consultant-delivered solution’ to prevent any repeat. Our consultant weekend rota ensures a daytime consultant presence on AMU with overnight availability from home. But the idea of ‘pulling an all nighter’ after two long and challenging days was not a safe prospect for my colleague. So I volunteered. How hard could it be? I had done blocks of 7 consecutive night shifts as an A&E SHO and 60 hour weekends as a House Officer. In our day….etc,…but of course things have changed a lot since then. The numbers of patients being admitted as emergencies has risen substantially, as has their complexity and acuity. So here are a few immediate reflections based on my observations of a single night managing the Acute Medical take:

  • Consultant physician presence after midnight has limited impact on overnight patient flow

 Late night discharges are uncommon and most patients deemed unwell enough to be referred to the medical team at that time are likely to benefit from observation until morning. Though I was able to discharge one patient after midnight, following careful discussion and agreement, such cases are likely to be unusual.

  • Getting the treatment plan right from the outset may shorten length of stay

A clearly documented consultant review may help to ensure early morning discharge, freeing up beds for the next cohort of arrivals. The morning consultant post take ward round can take up to 4 hours but was considerably shorter for my colleague working the Bank Holiday Monday morning, enabling him to focus on discharges and new admissions.

  • Most ‘overnight problems’ do not start overnight

The patients I saw in the emergency department between midnight and 5am had mostly been in the hospital since the early evening, and most of the ‘crises’ had arisen during the daytime. The fact I was seeing them at that time reflected delays in the system by which people arrive in hospital and staffing levels during the afternoon evening.

  • Carers and families often stay with the patient until they have ‘settled into the ward’

 It is unusual for a member of the patient’s family to be present during a morning ‘post take’ ward round; but many of the patients who I saw on Sunday night were still accompanied by their families or carers. This provided the opportunity to glean some collateral history or to discuss an escalation plan which otherwise would have been delayed until ‘visiting time’ next day.

  • Establishing escalation plans and ceilings of care was a key benefit of consultant presence

 Identifying those patients who will benefit from critical care review is crucial; however it is  often much harder for junior doctors to define ceilings of care when patients are first admitted to hospital.  Presence of a consultant to initiate these difficult discussions with a patient and their carer may help to avoid inappropriate escalations of treatment – the importance of this was evident throughout that night.

 

The idea of consultant physicians working night shifts would have been hard to contemplate a decade ago. As emergency pressures rise and gaps in our middle grade rotas become ever more prevalent, the concept of a resident AMU consultant between midnight and 8am may not be so far-fetched. But this will come at a cost. Under the current consultant contract a ‘programmed activity’(PA) of consultant time after 7pm is 3 hours, as compared to 4 hours during daytimes. Most consultants will have around 8 clinical PAs in their contract, so a 12 hour night shift from 8pm-8am will comprise half of their weekly work schedule. To provide this service on a seven day basis, in addition to a weekday and weekend daytime presence will require a lot more consultants than we have at present.

Would this be a cost effective use of resources? The number of individuals whose outcome will be changed by the presence of a consultant physician after midnight is likely to be small. Discharge decisions at this time, particularly for older patients, are fraught with danger and usually better deferred until the morning. For those patients presenting after midnight who are acutely unwell and deteriorating, the skills of an intensivist are more likely to be required than those of a physician. There will be some quality benefits, but these may be hard to measure and justification of a business case to provide this kind of expansion will require hard data.

Based on my observations on that Sunday night, the immediate approach should be to boost staffing during the afternoon and early evening, when most of the patients arrive in hospital. Ensuring the presence of enough senior decision makers so that all patients have undergone initial assessment, investigation and seen a consultant before 10pm is more likely to bring benefits: earlier discharges, appropriate escalation decisions, the opportunity to talk to a patient’s family before they leave the hospital premises, and hopefully better outcomes. Such schemes need to be piloted so that any benefits can be quantified.

Overnight consultant physician presence may be inching closer, but we currently have neither the resources nor the personnel to deliver this on a large scale. Recruitment to acute and general medicine training posts has not been easy over recent years and the necessary expansion is likely to take a decade or more to realise. We need to use what we have now as effectively as we can; allowing consultants to sleep and arrive fresh for the start of the day may be a better option than asking them to ‘pull the all nighter’.

 

A Long and Fortunate Life

Shortly before my grandmother died, at the age of 90, she told me that she felt fortunate: fortunate to have maintained her health for so many years – and fortunate that the NHS had been there for her when she needed it. Not that she had ever been a great user of the Health Service – a thyroidectomy and essential thrombocythaemia required a few tablets, periodic blood tests and infrequent visits to the haematology clinic – but overall Peggy was right to feel lucky.

She was, of course from a generation which had lived through challenging times – she brought up two children, while her husband fought Rommel in North Africa, and endured the subsequent rationing that is hard to imagine in today’s society; she was a tireless fundraiser for the Royal British Legion and Women’s Royal Voluntary Service, for which she was awarded a well-deserved MBE; until her mid-80s she delivered Meals on Wheels, in her Morris Minor, to those Sussex residents for whom time had been less kind. After her own mother had died young, she had to endure the death of her own daughter from ovarian cancer; when her husband suffered a dense left middle cerebral artery stroke she drove daily to his nursing home for 2 years, to sit with him, help with his meals and provide personal care. She would never admit how these events must have affected her: a true exponent of the British ‘stiff upper lip’.

But Peggy felt fortunate for another reason: she was from the generation who still remembered the time before the NHS existed; the time when healthcare was based on ability to pay rather than the needs of the patient. She spoke at times about the sacrifices which people had to make in order to get the treatment which was deemed to be required; things which we now take for granted, such as maternity care or visits to the GP, would have to be funded out of an already stretched household budget. Undoubtedly this had a major influence on her own use of the healthcare services; she knew that the NHS would be there if she needed it, but would not have visited her GP unless it was ‘really necessary’. Peggy understood the limitations of the service – the fact that resources were not unlimited and needed to be shared equitably; she just could never quite believe that she might be the one who deserved her share. She would never have complained – on the occasions when appointments were cancelled or delayed, or mistakes were made, she was sure that ‘everyone had done their best’. If ever she did call out her GP, her immaculate house would be cleaned in time for his arrival. She would have been mortified if she had been too unwell to offer him a cup of tea before he left – to see his other ‘more deserving’ patients.

As the NHS reaches its 66th birthday we must remember that the numbers of patients who remember the time before it existed is falling; the current octa- and nonagenarians will soon be replaced by generations of patients who were too young to appreciate the sacrifices that were required in the days before 1948. It is much easier to take for granted something which we have never had to manage without. In celebrating this landmark in the history of our fantastic National Health Service we must also celebrate the lives of those who have, undoubtedly, contributed to its longevity.

Peggy’s final days were mercifully swift; as someone who had given so much to so many for so long, she would never have wished to be dependent on others, nor for her life to be extended. A fortunate end, indeed, to her long and fortunate life.

Dr Chris Roseveare BM FRCP

Consultant Physician, University Hospitals Southampton Foundation Trust

Chris.roseveare@uhs.nhs.uk

Twitter: @croseveare

This post was previously published on the British Geriatric Society website on 4th July 2014 http://britishgeriatricssociety.wordpress.com/page/3/

‘Your Safety is our Top Priority’

‘This is your captain speaking: I am afraid there is going to be a sixty minute delay to the start of our journey’.

The fuselage shudders under the collective groan of the 240 disappointed passengers hearing these words over our plane’s PA system. Until a moment ago the Boeing 757 appeared ready for departure to Gatwick, via the island of Skiathos. However the airport at Skiathos only has capacity for two planes, and there are already two planes in situ. We cannot depart for this 15 minute ‘hop’ until space has been created…..’for safety reasons’.  For some this now means a delay to the start of their holiday; for others like me, our arrival home from Greece will be later than expected. The Captain reiterates his apology, followed by a reassurance that ‘your safety is our top priority’.

My mind turns to thoughts of what is probably going on in hospitals across the UK right now: it is Friday afternoon, so the deluge of pre-weekend emergency referrals will have started. Clinicians and bed managers will be working hard to create the necessary capacity to receive those patients for whom admission will be required. But the wards are already full, and inevitably some will arrive before that capacity has been created; a backlog will soon start to build up in the waiting rooms and corridors of acute medical units and emergency departments. Triage processes will ensure that the sickest patients will be allocated to areas in which they can be seen and treated most quickly, but some will face delays. As the patient:staff ratio rises, the amount of time which can be afforded to each patient will fall; there is a danger that someone, somewhere, will miss something important….

The airline industry is heralded as the paragon of safety to which healthcare systems should aspire, but as the temperature rises on this hot Greek afternoon, the stark contrast in our approaches when capacity is ‘full’ cannot be clearer. There is a reason for the difference: airline delays are inconvenient for passengers, but can always be ‘trumped’ by safety concerns. A short delay is an acceptable price to pay to ensure that you eventually reach your destination unscathed. In urgent healthcare, delays can also compromise safety; waiting is generally bad for your health. If paramedics announced to their passengers that they’d been asked to wait on the patient’s Tarmac until hospital capacity had been cleared, the resulting groans might represent more than just disappointment.

Clearly there are times when a delay to admission may be an acceptable option – safety in healthcare often requires different levels of risk to be balanced; managing this balance is a key skill for senior clinicians working at the interface between primary and secondary care. However until there is a recognition of the need to maintain empty capacity in acute receiving areas of all hospitals there will often be a feeling that we are selecting the ‘least bad’ option at times when the number of admissions exceeds the number of discharges.

My flight proceeds uneventfully and we touch down the predicted hour later than scheduled. As we taxi to Gatwick’s South terminal, a quick scan through my 200 unread emails reveals a staffing challenge for the weekend ahead: two vacant medical SpR shifts remain unfilled and the usual  locum agencies have been unable to help. There is a plea for colleagues to help the on-call medical consultant, who will need to ‘act down’ to provide cover. I am left wondering what announcement our Captain would have made if his First Officer had been absent and no replacement could be found. I suspect I would still be sitting on a very different piece of Tarmac.

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