Introduction

This case-study was submitted to us by two foundation doctors, Dr Kyle Stewart and Dr Pippa Woothipoom, who work for the South Devon Healthcare NHS Foundation Trust:

Torbay Hospital in South Devon uses a computer program called Infoflex to display jobs for the on-call teams.

During out of hours, nurses can phone main reception with details of the patient, job and ward which is then displayed on Infoflex for the on-call teams to complete.

It was recognised by the current cohort of FY1 doctors that many of the jobs added to the on-call Infoflex job list could have been dealt with by the patient’s team during the day. Leaving these tasks to the on-call team leaves less time for both acute and scheduled reviews out of hours. It is therefore not appropriate to leave a backlog of ward tasks for an on-call team to complete.

This audit is based on the job list for the FY1 doctors only. During a standard weekday there is one medical FY1 doctor who covers the ward from 5pm until 11.30pm and one surgical FY1 doctor who covers the ward between 5pm and 10.30pm. During a standard weekend day there are three medical doctors (9am-5pm, 10.30am-10.30pm and 11.30am-11.30pm). On the surgical side during a weekend day shift there are two doctors (9am-6pm and 3.30pm-10.30pm)

Audit description and setting the standard

This audit was designed to quantify the jobs FY1 doctors at Torbay Hospital are asked to complete out of hours, with particular focus on how many of these jobs were left over from the day team. As there will be occasions when patients deteriorate or there are unexpected events on the ward later in the day which run into out of hours, an allowance has been made. The standard set was:

Ward jobs left over from the day should take up no more than 10% of the F1s on-call job list. 

Method

All 2844 jobs put on the FY1 Infoflex job list for the month of January 2011 were taken from the Infoflex archive. Each job was designated a code based on its description from the nursing staff.  In total 20 different job description codes were needed. This coding system allowed all the jobs to be sorted and grouped for counting.

The data was separated into job totals for medical teams, surgical teams, weekdays and weekends. An example is shown below of how the coding system works. Hospital numbers have been anonymised throughout. The codes are as follows:  AR = acute review, rv bloods = review bloods, px fluids = prescribe fluids, rv scan = review scan.

Results

 A breakdown of the total number of each job type added to Infoflex for FY1s during the month of January 2011 is shown below.

Graph 1 - Average Job Breakdown For Weekend Day On-call:

Graph 2: Average Job Breakdown For Weekday On-call:

Discussion

It was found that a large proportion of the following jobs could have been completed during the day:

1.       Reviewing bloods

2.       Prescribing fluids

3.       Prescribing warfarin

4.       Amending / re-writing drug charts

5.       TTAs

6.       Bleeding patients

As for the other jobs for FY1 doctors, they are either less avoidable or account for a very small proportion of the total workload.

It was calculated that these “preventable” jobs accounted for 40% of weekday total and 53% of weekend total, over four times higher than the standard set of 10%. Leaving this many jobs for an on-call team allows less time for acute patient reviews. It also takes longer for the on-call team to complete ward tasks as they are not familiar with the history of many of the patients.

With improved organisation on the wards these figures could be improved. For example, patients should be bled early on a morning allowing warfarin to be prescribed in a timely fashion. For those patients who the phlebotomists are unable to bleed, there should be a system to alert the doctors or nurses allowing it to be dealt with earlier in the day. Improving a process as simple as bleeding patients would greatly reduce the number of warfarin prescriptions and blood reviews that are left for the on-call team.

The issue of reviewing bloods is particularly pertinent in the weekend shifts where the surgical team have to check an average of 15 bloods and the medical team check almost 30 in one shift. Many of these are routine bloods in stable patients who could have been bled on a Friday and then a Monday to take the stress off the on-call team.

Naturally, some patients will require weekend bloods, for example patients who are warfarin loading requiring INRs and warfarin prescriptions on a daily basis. More commonly, out of hours bloods are needed for patients who deteriorate in the afternoon or sick patients requiring daily bloods over a weekend. In these situations it is completely acceptable to arrange further blood tests or investigations and ask the night team to chase them. This is the type of work the on-call team should be involved with and is the reason a 10% cushion has been allowed.

Prescribing fluids is one of the most common jobs for the FY1 doctors in this audit and during weekdays is almost totally avoidable. During a weekday, fluid should be prescribed during the day to last through the night or there should be a clear plan in the notes for giving or stopping fluids which nursing staff can follow. As an on-call doctor, prescribing fluids for a patient you do not know means checking renal function and electrolyte balance, cardiac function, hydration status and other co-morbidities. It also often involves cannulation, turning what would be a simple job for the day team into an in-depth patient assessment, costing valuable time.

The most inexcusable of all jobs left for on-call teams is by far writing discharge summaries and re-writing drug charts. Even on wards with a high turnover of patients discharge summaries should be prepped throughout the admission, allowing them to be amended, signed and printed at the end of the admission. Asking an on-call doctor to write a discharge summary for a patient they have never met can be dangerous. In a pressured environment, trawling through a patient’s notes to write a summary of the admission is time-consuming and can lead to omissions from the discharge summary which could affect subsequent care.

As for drug charts, they should be looked at on every ward round as well as during drug rounds by the nursing staff. If a chart is due to expire over the weekend, it should be re-written by the day team in anticipation. Re-writing a drug chart is not an acceptable job for an on-call doctor. Amending drug charts often involves writing a start date or circling a time to give the medication on an incomplete prescription. Again, if the chart is being properly scrutinised on a ward round as well as numerous drug rounds this should be picked up almost immediately.

The issue of inserting venflons and bleeding patients is a contentious issue at Torbay Hospital. Often, there are dedicated HCAs to perform these procedures and take the pressure off the on-call team When these HCAs are not working, some ward nurses and HCAs will perform them, asking for a doctor’s help only if they fail after several attempts. Other nurses and HCAs on the ward are trained in phlebotomy and cannulation but do not routinely practice the skills, instead asking the doctors to do them as they feel “de-skilled”. There are also some who feel that phlebotomy and cannulation should be the job of a doctor only. The number of cannulas and requests to bleed patients shows huge variation between wards depending on the nurses present. Inevitably there will always be cannulas to be inserted out of hours, either as first time cannuals or as replacements for others that have tissued, fallen out, become infected or those that have been in for 72 hours. Similarly bloods will always need to be taken out of hours, either planned or during acute / routine reviews. The issue of whether venflons or bloods should be left to the doctors remains unresolved.

Conclusions

Good patient care involves completing all tasks during the day as well as forecasting potential issues overnight or through the weekend and acting on them if possible during the working day.

Half of the workload for FY1 doctors is taken up by jobs which could have been dealt with by the day team. These include reviewing bloods, prescribing fluids, prescribing warfarins, amending / re-writing drug charts, TTAs and bleeding patients. Although some of these may be left over in certain circumstances, the workload of an on-call doctor should be dominated by acute and planned patient reviews.

Re-audit

This first-cycle audit provided scope for identifying areas of change, creating interventions and re-auditing against the initial data to look for improvement.

At the start of April, the results of the first cycle were presented to the current cohort of Torbay Hospital FY1s, emphasising that almost half the on-call jobs were preventable as they could have been completed during the day. They were advised that improving organisation on the ward would reduce their on-call workload. A re-audit was undertaken during the last 2 weeks in April. A similar method of data collection and analysis were used.

Total numbers of jobs were not compared due to the different length of time over which the data was collected in each instance.

The graphs for the re-audit data are shown below next to the original data. The least common jobs have been grouped into an “other” column.

Graph 3 - Re-audit: Average job count per weekend day shift:

Graph 4 - Re-audit: Average job count per weekend day shift:

There was no significant difference in weekend job counts however the weekday job count was greatly improved (as shown below). This may be due to improvements in practice by the ward teams but as there is a global reduction instead of a reduction in one field, it is more likely that this simply represents a seasonal difference in workload.

Another annoyance for the on-call team which was found when the data was analysed in both audits was the haphazard nature in which nurses call jobs down from the wards to be added to the on-call list. Doctors are constantly being called back to the same wards as new jobs are added, instead of the team being able to deal with jobs left over in one visit.

More definitive interventions have since been put in place on two trial wards. Further re-audits are in the process of being taken. Hopefully with the new cohort of foundation doctors these new interventions will be incorporated into every day practice, improving ward efficiency and the quality of patient care.

Please note the content and opinions expressed in all case studies are those of the writer and do not necessarily reflect the views of NHS medical careers.