What on earth were we thinking of? - Homerton University Hospital

<strong>What</strong> on earth were we
thinking of
Dr JH Coakley MD FRCP
Medical Director and Intensive Care Consultant
Homerton University Hospital NHS Foundation
Trust
Homerton Row
London E9 6SR
john.coakley@homerton.nhs.uk

Why
• The philosophers have only interpreted the
world, in various ways; the point is to change it
Karl Marx
• He who rejects change is the architect of
decay. The only human institution which rejects
progress is the cemetery.
Harold Wilson

Homerton University Hospital
• Approximately 550 beds (270 medical) in
Hackney
• Emergency care predominates (110,000 A+E,
160,000 OPD, 35,000 IP, 5,000 births)
• Medical take 25 – 40 patients
• Surgical take 8 – 10 patients
• Orthopaedic take – small numbers

Total football…..
Put simply, it means all
10 outfield players in a
team are comfortable in
any position.
So if a defender wants to
go on a mazy run
towards goal, a
midfielder will fill in for
him at the back - and stay
there.
It may sound crazy, but it
was a style of play that
made Holland the
greatest side of the 1970s.

Is there a simple solution
• Ignore it and hope it will go away
• Expand consultant grade
• Expand training grades
• Expand some other (doctor) grade

This is not something we can avoid,
despite…..
• Pounder R Junior doctors’ working hours: can 56
go into 48 Clin Med 2008: 2; 126-7
• Continuity of care will suffer
• Patient safety will be compromised
• Third way – being on-call in hospital
• Horrocks M, Cripps J EWTD 2009 – meeting the
challenge in surgery Ann R Coll Surg Engl
(suppl) 2008; 90: 80-81
81
• ST3+ not required to do full shifts at night

Is there a complicated solution
• Elective emergency split (service and training)
• Recognition that most emergencies are
“medical”,, even in non-medical patients
• Avoiding increases in doctor numbers for all
tiers of all rotas
• Minimise night and weekend working
• Expand ‘normal’ working day

Reality check - EWTD 2009
• Continuity of care by individual juniors is dead
• We therefore have to introduce continuity by
system and/or team

Demand for emergency care is rising
A&E Attendances (million)
A&E Attendances in England
2001-02 to 2005-06 (million)
20.0
18.0
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
-
14.0
+7.5%
18.8
2001-02 2005-06
Emergency admissions (millions)
5.0
4.0
3.0
2.0
1.0
0.0
Emergency admissions in England
2001-02 to 2005-06 (millions)
3.9
+4.6%
4.7
2001-02 2005-06
Emergency admissions (millions)
35.0
30.0
25.0
20.0
15.0
10.0
Emergency bed days in England
2001-02 to 2005-06 (millions)
5.0
0.0
31.8
-0.9%
30.7
2001-02 2005-06

Emergency Admissions: A journey in the
right direction - The Trolley Tsar’s s view
• Sickest patients seen by most junior doctors
• Admissions scattered through hospital – safari
ward rounds
• Dying throws of acute medicine and acute
surgery – emphasis on specialties
• Process and care have improved in last 5-105
years - but more action still required

The Emergency Department:
Medicine & Surgery Interface Problems &
Solutions, RCS (Eng) 2004
Key Recommendations
• Early senior-led decisions
• Assessment units
• On-take team with no other commitments
• Committed acute physicians based on AU

NCEPOD 2005 - Findings
Time between gross physiological instability and subsequent referral to ICU
n=162, 66% had clearly identifiable gross physiological abnormalities > 12 hours
prior to referral to ICU.

NCEPOD - patients who died
• Training must be provided for junior doctors
in the recognition of critical illness and the
immediate management of fluid and oxygen
therapy in these patients.
• Consultants must supervise junior doctors
more closely and should actively support
juniors in the management of patients rather
than only reacting to requests for help.
• Junior doctors must seek advice more readily.
This may be from specialised teams e.g. outreach
services or from the supervising consultant.

NICE – July 2007
Education and training should be provided
and staff should be assessed to ensure that they
can demonstrate competence.

NCEPOD 2007
• Delays in seeing a doctor of adequate seniority may
have a detrimental effect on patient care
• more important for patients to be seen by a consultant within a reasonable
time frame determined by clinical condition rather than by a consultant of
appropriate specialty
• can result in delayed definitive care and poor outcome
• Lack of, or poor, decision making by training grade
doctors
• Ability of trainees to recognise critically ill patients
is poor – simple physiology though

NCEPOD 2007
• Robust handover systems need to be put into
place between clinical teams
• These should be readily identifiable and
protocol based
• Clinicians should be made aware of protocols
and mechanisms

Acute medicine - making it work for
patients (RCP 2007)
• 5 We recommend that a contribution to the
practice of acute medicine from appropriately
trained consultants in emergency (A&E)
medicine and critical care should be facilitated.
• 6 We recommend that appointments in acute
medicine should be developed that include
commitments to accident & emergency (A&E)
departments, high-dependency units and
intensive care units, as well as AMUs.

<strong>What</strong>’s s it all about
• We have got it wrong
• We must do better
• It’s s a system problem
• Therefore the system must change
• How

<strong>What</strong>’s s it all about
• We have created Procrustean silos
• Patients don’t t come to hospital because they are
orthopaedic, or surgical or medical (or anything
else)
• They come because they are sick and they think
we can help
• Emergency admissions are more predictable
than elective

<strong>What</strong>’s s the vision for emergency care
• 98% in 4 hours – basic minimum acceptable standard
• Emergency care delivered across boundaries by
specialists who are interested and committed
• Set up ‘cold team’ and ‘hot team’ for training and service
delivery
• Over time (say five years) integration of acute,
emergency and critical care medicine to provide a
seamless service
• Improve training while complying with EWTD 2009
• Extend consultants’ “normal” working day -

Taking Care 24/7 – how we ran it
• First formal meeting on 1st November 06
• Regular, fortnightly Project Board meetings
since January 07

Taking Care 24/7 – how we ran it
• Project Board – meetings every 2 weeks
• Medical Director
• Operations Director
• Clinical Director of Medicine
• Director of PGME
• Associate director of HR
• Junior doctor representative
• Senior nursing representative
• Project manager
• Representative of the National Workforce
Projects

Acute Care Unit
• 56 beds
• Planning based on 48 hour LOS
• Receives all acute admissions in surgery,
orthopaedics, urology and medicine
• Junior staffing proportionate to emergency
activity
• Busy!

Acute Care Team
• Consultants (12P, 6S, 5T+O, 5 ICM, 3U)
• 6 Medical ST 3+ or SpRs (AM or EM)
• 8 Medical ST 1 or 2, FY2 (ACCS or AM)
• 3 Surgical ST 2 to 6
• 1 Orthopaedic ST 2 to 6 (0800 - 2200 only)
• 1 ICM ST 1 to 6 (0800 – 1600 only)
• 6 Foundation Trainees – FY1
• CCO
• CSM

Acute Care Team (ACT)
• Consultant led 24/7 team with no commitments
other than acute care between 0800 and 2000
• Extended normal working hours for acute care
(including consultants) and improved handovers
• Consider which clinicians are best able to deliver
the required competencies
• Integrate delivery of acute care across specialties
• Develop sustainable acute rotas

Weekday and night ACT

Weekend ACT

Taking Care 24/7 - blockers
• Dislike of change
• Risk aversion
• MMC
• EWTD
• Custom and practice
• ‘the college says….’
• ‘the dean says….’
• ‘my boss says….’
• ‘I’m m not covered to….’

Taking Care 24/7 - enablers
• Dislike of change
• Risk aversion
• MMC
• EWTD
• Custom and practice
• ‘the college says….’
• ‘the dean says….’
• ‘my boss says….’
• ‘I’m m not covered to….’

Taking Care 24/7 - enablers
• Medical Council, GEM Board, Clinical
Board, Postgraduate meetings….
• Reference Groups for both medical and
nursing staff
• Discussion documents e-mailed e
to
interested parties
• E-mail discussion encouraged
• Homerton Life; CE’s s Brief etc
• Lots of corridor and canteen conversations

Taking Care 24/7 - enablers
• Draft papers on operating policy covering:
• Rotas
• Formal plans
• New structures and processes/procedures
• Open fora
• Differences of opinion
• Robust discussion about the philosophy of
provision of care for emergency/acutely unwell
inpatients

<strong>What</strong> works well
• Doctors’ hours
• Relationships between medics, surgeons, critical
care and outreach have improved
• Night handover is very good (but H@N)
• Patients seen by a consultant very quickly
• Emergency / elective split works well for ‘cold
team’ juniors
• The change in surgical and orthopaedic rotas (for
the ED).

Example – most FY2 - ST2
• 16 weeks per year acute work
• Full shift for acute work
• Protected training time in “cold” specialty for
rest of year – no nights; no weekends

Example – most ST3+
• 12 weeks per year acute work
• Full shift for acute work
• Protected training time in “cold” specialty for
rest of year – no nights; no weekends

<strong>What</strong> is the impact on training
• On 1:12 SpR rota they got 130 weekdays every 6
months of which 15 were ‘on-call’ which meant
two days (total 30) off ie 100 days of cold
training.
• Now 4.5 months or 95 weekdays of cold training
• Not much different from before even given the
reduction of hours from 56 to 48.
• Better supervised during their hot spell.
• Either way, the overall effect for a medical SpR
is pretty negligible.

ACT – mortality for non-elective
admissions

Mortality rate
Like for like comparison
Mean
Standard
Deviation
31 st July 06 to 6 th November 06
3.4%
1.1%
30 th July 07 to 5 th November 07
2.8%
1.1%

Admissions per week
Like for like comparison
Mean
Standard
Deviation
31 st July 06 to 30 th October 06
229
15.1
30 th July 07 to 29 th October 07
249
28.0

Rate of 28 day readmissions
Like for like comparison
Mean
Standard
Deviation
31 st July 06 to 30 th October 06
9.0%
2.4%
30 th July 07 to 29 th October 07
10.6%
2.9%

Surprises
• Pressure in system largely related to elective
activity well over plan
• Emergency admissions numbers largely as
predicted
• Increase in night and weekend emergency
admissions
• Major problem is “outflow” from “cold” areas
• Majority of consultants enthusiastic about
principles and helpful in their criticism

Hard to change, easy to stay the same,
but……
• Don't be so gloomy. After all it's not that awful.
Like the fella says, in Italy for 30 years under the
Borgias they had warfare, terror, murder, and
bloodshed, but they produced Michelangelo,
Leonardo da Vinci, and the Renaissance. In
Switzerland they had brotherly love - they had
500 years of democracy and peace, and what did
that produce The cuckoo clock. So long Holly.
Orson Wells (Third Man)