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’.
Thank you very much for this summary. Your insights make sense!
Vishal Gulati (@vgul) said:
Very thoughtful and insightful post. I agree with most of what is said. it is true that the benefits of overnight senior staffing will be seen by a very small number of patients in the scenario you have highlighted where the major decision is whether or not to discharge but if you project a more comprehensive (and costed) extended hours staffing which includes imaging, scoping, labs etc could rapidly increase the ‘area under the curve’ of rapid decision and improved care and who knows, even lives saved.
Dr Emyr Wyn Jones said:
Did you have immediate electronic access to information from the GP record (either via a local shared care record or via the national Summary Care Record) in the ED/AMU? If so – did it provide useful information to support clinical decision making? If not – would you/your patients have benefited from such access?
Hi Emyr – thanks for your comment: we have the Hampshire Healthcare Record which is often useful, particularly for drug lists, although not available for all patients.
“the skills of an intensivist are more likely to be required than those of a physician.”
We’re already in!!!
Do job plans of consultant intensivists generally reflect a requirement for overnight residence in hospital or ‘on-call from home’ but with high expectation of being called in overnight?
Very useful post. It seems that there are many patients arriving in the afternoons and evenings whose care is being delayed until the night. I agree with you that our efforts need to be focused on that time.