aagbi linkman conference 20 th sept 2011 dr phil das, peterborough

Out of Hours Cover

The Peterborough Experience

Out of Hours Cover

The Peterborough Experience

AAGBI Linkman Conference

20th Sept 2011

Dr Phil Das, Peterborough

Introduction

Background 2007 - 2010♦ Reduction in non consultant grades♦ Ongoing discussion around rotas

2011♦ Change to OOH Cover inevitable♦ Internal Opposition and Treachery♦ External Obstruction♦ Proposed Trial change

O&G resistance

The way forward

Anaesthetic Emergency Cover 2011 2

Pre 2008

Suspension of HSMP (Highly Skilled Migrant Programme) November 2006

Implementation of MMC August 2007 Implementation of EWTD - 48 hour max.

Overall reduction in non consultant grades to run emergency rotas

Increased Staff Grades – but 6 of 13 resigned/poached


2008 - 2010

Ongoing discussions♦ no trainee after midnight♦ resident consultant♦ Cost in lost sessions = 4-5 new consultants♦ Locums used each year August - October

Nov/Dec 2010 moved to single site hospital


Peterborough Hospitals pre 2010


Peterborough Maternity Unit

Peterborough District Hospital

Edith Cavell Hospital

Peterborough City Hospital 2010


Peterborough City Hospital


2011- Peterborough City Hospital

Peterborough City Hospital fully open♦ Single site (at last)♦ Problems with equipment, operation & processes♦ Massive £38 million budget deficit♦ CEO long term sick leave♦ Job cuts – ‘severance scheme’

♦ August trainee shortage problem loomed♦ Warned ‘no money for locums’


2011- Train of events... April 13th Department Business Meeting.

♦ Clinical Tutor announcement

From Monday 18th July there will no theatre trainee after midnight

May 12th Special Department Meeting♦ Discussion of ‘no trainee after midnight’ plan

• Other hospitals cited in support (Exeter, Taunton)

♦ Opposition from within• Disliked change of hours/workload/responsibilities• Wanted more written details and increased remuneration

June 7th Trust CGC Meeting♦ Presentation by RG – OOH incl. morbidity/mortality in other

hospitals vs Peterborough♦ Agreed to set up ‘Steering Group’ to reduce OOH Surgery


2011- Discussions

June 16th Department Business meeting♦ Out of hours cover discussed:

• Why change was needed• What changes were proposed


Why Change?

Reduction in trainee numbers and hours worked Eight novice trainees starting in August - 3 months to train Unable to cover 3 rota tiers full time with staff available Financial Constraints – high cost of locum cover Consultant delivered service for sickest patients OOH

deemed to be best practice.

.....Anaesthetic Emergency Cover 2011 11

What Change?

No resident theatre trainee midnight to 7:30am No change to ITU or Maternity trainee shifts (24hr cover) Theatre cases after 10:30pm consultant decision only More urgent emergencies (while consultant in transit) to

be dealt with by ITU anaesthetist. Assistance from Maternity trainee if not occupied on

Labour Ward. ITU consultant to come in and assist if appropriate.


2011- Proposed change and treachery

June 16th Department Business meeting (cont)♦Proposed plans for no trainee after midnight♦Consultant resident until midnight – on call after

June 21st

email from obs. consultant anaesthetist (‘Agent X’) to key O&G personnelYou may have heard through the grapevine that there are plans afoot to change the way the anaesthetic cover for nights is to be provided……......obstetric trainee will be holding the arrest bleep and will also be expected to attend to the sick patients before the anaesthetic consultant arrives.....

June 22nd

multiple emails (responses escalated up)…….•It is clear that there are significant potential risks.............. (Risk & Lit)•.........we would be severely criticised for having just one anaesthetist on site if anything went wrong (Medico-legal)•.......the plan described by ‘X’ in her email below must be revised as it will not meet these standards and will therefore be unacceptable on safety grounds. (O&G Governance Lead)


2011- Trial to go ahead but ...

June 30th

20 out of 21 generalists voted to implement Trial change to evening & night cover for 3 months from August

July 19thGuidelines and Scenario docs circulated before department meetingGuidelines and Scenario docs forwarded to O&G by ‘Agent X’

July 20th

email + 2 page letter from O&G.I understand that you have taken an anaesthetic trainee off the night rota and clearly there is now a gap in the service provision.There are clear safety standards documented around Anaesthetic provision on Labour Ward.........


2011- Trial postponed

July 22nd Department Business MeetingDocuments for trial of OOH cover approved

July 26thTrial supporting documents circulated widely

July 27th & 28th

Multiple email replies (escalated up to management)…..

…concerned about the provision for cover for the Trauma Team. (Trauma Lead)

…. formally express my concerns as the Matron

…..who will take responsibility when the first patient dies?

....I fear there is an increased likelihood of no one turning up to manage the airway

Trial start postponed♦ To obtain more supporting evidence♦ Locums to fill gaps


2011- O&G obstruction

August 3rdCGC Meeting.

O&G presented Risk Assessment Document ...

Significant Hazards Non adherence to NHSLA maternity standards in relation to ‘safer childbirth’ RCOG 2007 ……………………

Adverse Effects• Unnecessary stress for staff.• Maternal death• Severe disability to baby• Death of baby• Adverse reputation to Trust• Risk of litigation to Trust

Reinforced decision to postpone trial


2011- crucial CGC meeting

Evidence gathering ..........

September 6th CGC meeting O&G + ‘Agent X’ in opposition Presentation addressing issues raised by O&G

Out of Hours Emergency Cover 2011 17


Addressing The O&G Concerns

Safety Issues and feasibility At least 15 other hospitals run a system of cover with no theatre

anaesthetic trainee 24:00 to 08:00 No increase in adverse incidents related to change

Published Documents ‘Breached guidelines’

Clinical Negligence Scheme For Trusts - Maternity


Safer Childbirth – Minimum Standards...RCOG 2007


High Quality Women’s Healthcare. RCOG 2011


Guidelines For Obstetric Anaesthetic Services. OAA/AAGBI 2005


Common ThemesStaffingThe duty anaesthetist should be immediately available for the obstetric unit 24 hours per day.No change

DutiesIf the anaesthetist has other responsibilities, these should be of a nature that would allow the activity to be delayed or interrupted should obstetric analgesia or anaesthesia demands arise. The new scheme documents specify this.

ResponsibilitiesThe duty anaesthetist for obstetrics should not, in addition, be responsible for the intensive care unit or other anaesthetic duties.

No sole responsibility for other duties.


Guidelines for provision of anaesthesia & critical care services between 18:00 and 08:00

Changes to appease O&G.

A. General Principles♦ The maternity trainee may occasionally take on some more general

responsibility between midnight and 08:00 but must be immediately available at all times to attend the labour ward.

B. Scenario Guidelines1.Cardiac arrest calls♦ c. If the ICU trainee is not immediately available ...........should also arrange to

fast bleep the maternity trainee (who may be able to respond if not occupied on the delivery unit).

2.Assistance in theatre for complex case such as polytrauma or ruptured AAA♦ ICU trainee -> Maternity trainee -> ICU consultant


Consequences of No Change

Risk Management Considerations Difficulty obtaining locums at a time of increased demand Variable quality of locums sent – unlikely to be as good as our

own trainees Locums unfamiliar with layout and procedures in hospital Locums may turn up late or not at all Consultant having to ‘act down’ if no locum – loss of routine

sessions


Consequences of No Change 2

Financial Considerations

Locum Costs 2009 - approx £180,000 (£14,000 pw) Locum Costs 2010 – approx £123,000 (£9,519 pw) Locum Cost 2011 (interim) - approx £6,300 pw Locum Cost during Trial £0


2011- CGC meeting decision

September 6th CGC meeting. Approval given to commence the Anaesthetics Emergency Cover

Out of Hours Trial on Thursday 8th September 2011 Email announcement and supporting documents sent out

Emails in response……….

• (whatif)…a 2nd urgent Obstetric case requires a theatre immediately (O&G Cons.)

• …. concerns … we do not have staff trained to anaesthetic standard covering every night (Trauma Lead)

• I hope this will not have an impact upon the Medical Registrar at night (Respiratory Physician)

• Unfortunately, taking out this one inexperienced trainee seems to have had a catastrophic effect on anesthetic cover......(Colorectal surgeon)

Out of Hours Emergency Cover 2011 27

September 2011- Trial up and running

However………………………..

Despite all the grumbling………….

September 8th

Trial change in OOH cover started.

So far so good.


The Way Forward The trial continues Ongoing work to reduce emergency OOH operating Planned weekend Trauma lists Careful detailed audit Revert back to the original scheme from Mon 31st October Review trial data Discussion/decisions

♦ Full implementation♦ Partial implementation♦ Yearly 3 month implementation♦ Non implementation – employ locums 3 months each year


Thank youThank you

Questions

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