Delivering the standards for 7 day consultant

present care Dr Chris Roseveare

Co-Chair AoMRC 7 day Project sub-committee (and ‘jobbing’ consultant in acute medicine)

@croseveare

Admissions per day…

The weekend challenge…

Higher case-mix adjusted mortality

Weekend hospitalization and additional risk of death: NHS England inpatients 2009-10

Freemantle N et al. J R Soc Med. 2012 Feb;105(2):74-84

OR risk of death for admission on Sunday vs Wednesday = 1.16 (1.14-1.18) p < .0001

Not just the NHS... USA data

The weekend challenge…

Higher case-mix adjusted mortality

Greater illness severity amongst weekend admissions

Fewer consultants in hospital

…the benefits of consultant-delivered care should be available to all patients throughout the week

‘..I am relieved on Monday that nothing catastrophic has happened over the weekend’

7 day working: what do we mean?

• ‘Emergency’ Care:

• ‘Elective’ Care:

• ‘Urgent’ Care:

• Must Do’s

• Could Do’s

• Should Do’s

‘No point in me being here if I can’t get the tests done which enable me to make a difference’

‘No point me doing that test unless someone is going to act on the result’

‘Can’t send the patient home at the weekend because primary care isn’t working’

Standard 1 Hospital inpatients should be reviewed by an on-site consultant at least once every 24 hours, seven days a week, unless it has been determined that this would not affect the patient’s care pathway.

Standard 2 Consultant supervised interventions / investigations + reports should be provided seven days a week if the results will change the outcome or status of the patient’s care pathway before the next ‘normal’ working day.

Standard 3 Support services both in hospitals and in the primary care setting should be available seven days a week

‘optimum use of consultant time will be achieved if the consultant is…leading a team comprising doctors in training…and allied healthcare professionals..’

Sir Richard Thompson President , RCPL

‘While the RCP accepts this as an aspirational standard for all physicians, we believe that this will require service redesign and may have resource implications to make this a comprehensive reality’

‘The method by which a consultant-led review takes place need not be constrained to formal, physical bed-side ward rounds by a consultant’

Other appropriate methods of consultant-led review could include:

• Ward round undertaken by a doctor in training or SAS doctor, followed by a discussion of all, and review of selected patients by the consultant

• A multi-disciplinary team ‘board-based’ round.’

• Challenges for implementation

– contracts / job plans – specialism vs generalism – continuity of care – costs

‘A consultant presence should be maintained on the AMU for a minimum of 12 hours per day, 7 days per week’

How many consultants? Approximate number of beds on AMU

Number of admissions per 24hrs

Approx. Number of patient contacts 8am-8pm

No. consultant equivalents req’d on the AMU 8am-8pm

<30 ≤ 25 ≤55 1 - 1.5

30-50 25-44 55-89 1.5 – 2

51-70 45-60 90-135 2 – 3

>70 >60 >135 >3

Source: RCPL Acute Care Toolkit 4 October 2012

Current AMU staffing level

%

2012 NTN ‘Round 2’ fill rates: Acute Medicine 34% Geriatric Medicine 25% (33 vacancies in each speciality)

PART 2

More detailed summary of implications for each speciality / college

• Staffing requirements? • Which investigations / interventions? • Which support services?

Questionnaire to speciality organisations

– Responses from 36 medical specialities – Further information from 14 other organisations

Key messages…1 Most patients would benefit from a daily consultant review

Proportion of patients who would BENEFIT from a daily

consultant-led review

0%

1-10

%

11-2

0 %

21- 3

0 %

31- 4

0 %

41- 5

0 %

51-6

0 %

61-7

0 %

71-8

0 %

81-9

0 %

91-9

9 %

100%

General Internal medicine X

Psychiatry X

Geriatric medicine X

Surgery - general X

Surgery - trauma and orthopaedics

X

Obstetrics & Gynaecology X

Intensive care medicine X

Respiratory medicine X

Cardiology X

Paediatrics X

Key messages…2 Duration of consultant review varies by speciality, but continuity is key….

Key messages….3 ‘Approx. 6 hours of consultant time required for every 30 in-patients requiring review’

Key messages….4 More generalists needed for ‘cross cover’

– acute physicians – geriatricians – general physicians

Consultant supervised Investigation

Proportion of specialties indicating a regular need at the weekend ‘Top Ten’ specialties 36 survey respondents

Haematology 100% 97% Microbiology 100% 97% Clinical biochemistry / chemical pathology

100% 97%

Ultrasound 90% 83% Computed Tomography (CT) scan

90% 78%

Plain radiology 80% 89% Access to expert imaging opinion

70% 58%

Magnetic Resonance Imaging (MRI)

60% 56%

Diagnostic upper gastrointestinal endoscopy

60% 42%

Echocardiogram 60%* 19%*

Hospital based services

Proportion of specialties indicating a regular need at the weekend (%)

‘Top Ten’ specialties 36 survey respondents

Pharmacy 100 100 Physiotherapy 90 83 Specialist nurse review 70 61 Dietetics/Nutrition 70 44 Occupational therapy 40 47 Swallow assessment 40 17 Speech & Language therapy 30 31

Community based services

Proportion of specialties indicating a regular need at the weekend (%) ‘Top ten’ specialties 36 survey respondents

Social care team 90 67 Specialty community care team

80 58

Real time conversation with GP

70 47

Electronic communication with GP

60 50

Real time conversation with community practice team

60 50

Electronic communication with community practice team

50 44

Standard 7 Mental Health Standard 7 •People with mental health needs must be assessed within the appropriate timescales 24 hours a day, seven days a week: •Within 1 hour for emergency* care needs •Within the same day for urgent** care needs * An acute disturbance of mental state and/or behaviour which poses a significant, imminent risk to the patient or others. ** A disturbance of mental state and/or behaviour which poses a risk to the patient or others, but does not require immediate mental health involvement.

Seven Day Services 5 November 2013

Types of liaison service….

• Risk assessment following overdose / DSH • Acute psychosis management / advice • In-patient liason services – somatisation etc

Options? Hubs / Spokes Networks Skill mixes Outsourcing

Reconfiguration……..

Not every service will be available on every site….

Reconfiguration……..

‘You may need to travel further for your treatment’

‘Lets make 2013 the year we stop talking about 7 day services and start doing something about it’

@croseveare

Local Changes…..

• 10 consultant rota (1:8 with prosp. cover) • 12 hr/day split weekend = 16 PAs • 1 PA per consultant (previously 0.3PA) • 5% intensity supplement

Fewer weekday

consultant hours on AMU

Local Changes…..

• 10 consultant rota (1:8 with prosp. cover) • 12 hr/day split weekend = 16 PAs • 1 PA per consultant (previously 0.3PA) • 5% intensity supplement

Twice as many

weekends

A Phased Evaluation of the Impact of High-Intensity Specialist-Led Acute Care (HiSLAC) of Emergency Medical Admissions to NHS Hospitals (Commissioned call 12/128) 3 year study in 2 phases Prof Julian Bion, University of Birmingham J.F.BION@bham.ac.uk