Hot and cold rotas

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Hot and cold rotas

• Dr JH Coakley MD FRCPMedical Director and
  Intensive Care ConsultantHomerton University
  Hospital NHS FTHomerton RowLondon E9
  6SRjohn.coakley_at_homerton.nhs.uk

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Homerton University Hospital

• 550 beds (300 acute medical) in Hackney
• Emergency care predominates (106,000 AE, 160,000
  OPD, 35,000 IP, 5,000 births)
• Medical take 25 40 patients
• Surgical take 8 10 patients
• Orthopaedic and urology take small numbers

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Night staff August 2003
5pm
10pm
12mid
8am
11pm
Medical PRHO Medical PRHO Medical SHO Medical
SHO Medical SpR Surgical PRHO Surgical
PRHO Surgical SHO Surgical SpR Orthopaedic
SpR ITU SpR Anaesthetic SHO Clinical Site Manager
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Night staff October 2003
5pm
10pm
12mid
8am
11pm
Medical PRHO Medical PRHO Medical SHO Medical
SHO Medical SpR Surgical PRHO Surgical
SHO Surgical SpR Orthopaedic SpR ITU
SpR Anaesthetic SHO Clin Site Manager Clin Site
Manager
Oncall from home
Oncall from home
handover
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Reality check - EWTD 2009

• Continuity of care by individual juniors is dead
• We therefore have to introduce continuity by
  system and/or team
• We have to get as many people away at night as
  possible
• We cannot afford to lose continuity of training
  either

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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.
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Whats 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 -

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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 NWP

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Taking Care 24/7 - obstacles

• Dislike of change
• Risk aversion
• MMC
• EWTD
• Custom and practice
• the college says.
• the dean says.
• my boss says.
• Im not covered to.

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Taking Care 24/7 - enablers

• Dislike of change
• Risk aversion
• MMC
• EWTD
• Custom and practice
• the college says.
• the dean says.
• my boss says.
• Im not covered to.

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Taking Care 24/7 - enablers

• Communication
• Medical Council, Directorate Boards, Clinical
  Board, Postgraduate meetings.
• Reference Groups for medical and nursing staff
• Discussion documents e-mailed
• E-mail discussion encouraged
• Homerton Life CEOs Brief etc
• Lots of corridor and canteen conversations
• People can still hear the wrong message

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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!

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Acute Care Team (ACT)

• Consultant led 24/7 team with no commitments
  other than acute care
• 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

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Acute Care Team

• Consultants (12P, 6S, 5TO, 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

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Handovers

• 0800 very brief
• 1030 to discuss PTWR issues ACT
• 1600 brief, to hand over jobs etc from cold to
  hot team
• 2100 for night

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Weekday and night ACT
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Weekend ACT
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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

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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

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What is the impact on training?

• For a typical junior doctor the time available
  for the delivery of daytime service rose from 52
  of the year to 60 of the year, and the shifts
  devoted to acute care fell from 78 to 60 per
  year. This allows more time to be spent in
  daytime training learning the skills required to
  deliver elective work.
• The costs saved on junior doctors rotas amounted
  to about 0.25m recurrent .

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What worked well?

• Doctors hours
• Relationships between physicians, surgeons,
  critical care and outreach have improved
• Night handover is very good
• Patients seen by a consultant very quickly
• Emergency / elective split works well for cold
  team juniors
• The change in surgical and orthopaedic rotas
  works well for the ED.

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and what didnt

• Stable Medical Leadership daily change of
  consultant (s)
• Junior Doctor Rotas
• too complex
• dont facilitate continuity of care particularly
  for longer stay patients

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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)