Working patterns of junior doctors in the Intensive Care Units of the North West

1
Working patterns of junior doctors in the
Intensive Care Units of the North West

• Dr S Laha, Dr R Challiner
• STC ICM Trainee Representatives
• ANWICU Trainee Representatives
• Dr J Goodall
• STC Chair Intensive Care Medicine
• ANWICU June 2006

2
Introduction

• Working patterns for junior doctors are changing
  due to
• New Deal
• EWTD
• SiMAP
• Hospital at Night
• Modernising Medical Careers
• Comprehensive Critical Care

3
New Deal

• 1991
• Agreement between representatives of junior
  doctors, consultants, the royal colleges, NHS
  managers and the government
• Both the New Deal and the EWTD apply
  simultaneously
• 56 hours of actual work per week (1994)

4
New Deal

• Since 1 December 2000 the New Deal has specified
  the maximum number of duty hours for all junior
  doctors posts as
• - 72 hours a week on on-call rotas on average-
  64 hours a week on partial shifts on average-
  56 hours a week on full shifts on average
• This is in conflict with the EWTD

5
European Working Time Directive

• Imposes minimum rest requirements
• minimum of 11 hours continuous rest in every 24
  hour period
• minimum rest break of 20 continuous minutes after
  every six hours worked
• minimum period of 24 hours continuous rest in
  each 7 day period (or 48 hours in a 14 day
  period)
• minimum of 4 weeks paid annual leave
• maximum of 8 hours work in each 24 hours for
  night workers
• 1998 Consultants and career grade hospital
  doctors
• 2004 Doctors in training

6
EWTD Timetable

• August 2000
• Timetable was set to incorporate juniors into the
  directive
• August 2004
• Interim limit of an average 58 hour maximum
  working week and EWTD rest requirements
• August 2007
• Interim limit of an average 56 hour maximum
  working week
• August 2009
• Deadline for the average 48-hour maximum working
  week this deadline may be extended by another
  three years with an interim limit of an average
  52 hours maximum working week

7
SiMAP Judgement

• Did time spent by doctors "on call", either at
  the medical centre or away from it, count as
  "Working Time?
• The Courts judgement was as follows
• "The characteristic features of working time are
  present in the case of time spent on call by
  doctors .where their presence at the health
  centre is required. It is not disputed that
  during periods of duty on call under those rules,
  the first two conditions are fulfilled. Moreover,
  even if the activity actually performed varies
  according to the circumstances, the fact that
  such doctors are obliged to be present and
  available at the workplace with a view to
  providing their professional services means that
  they are carrying out their duties in that
  instance".
• This means that
• "Time spent on call by doctors.must be regarded
  in its entirety as
  working time.if they are required to be present
  at the health centre. If
  they must merely be
  contactable at all times when on call, only time
  linked to the actual provision of services must
  be regarded as working time." (DoH)
• Resident on-call rotas become unworkable

8
Hospital at Night Tenets

• There is significant activity in the evening
  period but this falls off after midnight
• Activity varies by specialty - medicine in
  general continues to have activity throughout the
  night but surgery in general falls to a much
  lower level
• There are very low levels of activity in trauma,
  orthopaedics, medical and surgical subspecialties
• Few patients have life threatening conditions
• Around a quarter of junior doctors time is spent
  on tasks that do not require medical skills (eg
  requesting investigations, finding notes or
  information, some minor procedures)
• Nearly half of junior doctors' time is spent
  repeating tasks such as clerking or reviews

9
Hospital at Night Results

• Work should be drawn into the extended day by
• increasing support in the twilight hours
• ensuring test results are returned before the
  night shift
• ensuring the proactive risk assessment of
  patients
• improving handover arrangements.
• Emergency and elective capacity should be
  protected in order to support compliance with
  CEPOD and protect theatre time.
• Handovers must be improved to ensure continuity
  of information - this is vital, especially to
  full shift working. There should be senior input
  at handover and the handover should be
  hospital-wide.
• Some specialties require full-shift working (eg.
  paediatrics and maternity) but there is evidence
  to show that some specialties can function
  without this if senior assistance is 30 minutes
  away, provided that the night team is competent
  to maintain the patient.

10
UK MMC Career Framework Proposal
Continuing Professional Development
Senior Medical Appointments
Specialist and GP Registers
Article 14/11 route
CCT route
Postgraduate Medical Training
Continuing Professional Development
Specialty training inSpecialty/GP training
schools
Career posts
Specialist and GP training programmes (Run-through
training)
Fixed term specialist training
Foundation training in foundation schools
F2
F1
Undergraduate medical training in medical school
Arrows indicate competitive
entry
Medical school 4-6 years
11
Comprehensive Critical Care

• DoH 2000
• The number of critically ill patients a single
  medical team is able to manage will also affect
  the numbers of consultant staff required
  professional judgement indicates the number to be
  about 8 patients
• No specific guidance as to trainee numbers
  required
• ICS Workforce planning in progress (Manpower
  audit)

12
Why do this Audit?

• ICU requires 24 hour cover
• Increasing reduction of trainee hours
• Less availability
• Changing experience
• ICS are conducting Manpower review at present
• To give a baseline assessment of patterns in
  different ICUs within the region

13
Method

• Telephone questionnaire
• All general and specialist ICUs in
• Greater Manchester Critical Care Network
• Lancashire and South Cumbria Critical Care
  Network
• Total 22 ICUs ( General 19, Cardiac 3)
• Conducted over April May 2006
• Trainee chosen at random on each unit

14
Results
15
Total beds available in each ICU
16
Types of non-consultant cover in ICU
17
Types of non-consultant cover in ICU

• Large number of doctors exposed to ICU
• Majority of units (18/22) have single tier on
  call only

18
Types of non-consultant cover in ICU
19
Types of non-consultant cover in ICU

• 20 have no training grade cover generally the
  smaller units
• Non anaesthetist numbers small but present in
  most units

20
Numbers of Trainees directly covering the ICU
21
Rotamaster
22
Type of rota pattern
23
Frequency of nightshifts
24
Maximum number of consecutive nights
25
Handover

• 25 out of 26 rotas have a formal morning handover
• 14 out of 26 rotas have a handover allocated in
  the rota
• 13 ICUs had a consultant present at the
  trainees morning handover
• 10 ICUs had a consultant present at either
  evening handover or ward round

26
Out of hours commitments outside ICU
27
Number of first on-call with sole commitments
specific to ICU

No
Yes (including AE, ward referrals and transfers)
28
Hours of Formal teaching

• 10 ICUs have Consultant led or present at
  teaching
• 9 ICUs have protected teaching
• 4 ICUs offer out of unit training (eg follow up
  clinic, bronchoscopy lists)

29
Discussion
30
Workforce

• Overall the 22 ICUs at present
• 194 non-consultant doctors
• 36 (18.5) non-anaesthetists
• 59 (30.4) NCCG doctors
• EWTD / New Deal may mean even more doctors

31
Changing Experience

• Increasing number of non-anaesthetic trainees
• EWTD means less clinical exposure over a given
  period
• MMC
• Introduction of Foundation Years very junior
  doctors on ICU
• Redefined Specialist Training period

32
Rotas

• BMA recommend that full shift rotas with
  prospective cover should include least 8 people
• 44 of rotas are full shift
• 56 Consultant-written rota
• Majority of trainees do at least a 1 in 6 nights
• BMA recommend split nights
• Only 2 rotas have more than 4 consecutive nights
• Just over 50 have handover included in rota
• 55 have no non-ICU commitment

33
Teaching

• 45 have formal ICU Consultant led teaching (does
  not include ward round teaching)
• Most of these protected hours within rota
• Average 2.3 hours
• Likely to be increasing numbers of less
  experienced trainees rotating to ICU in the
  future may require more specific teaching

34
Summary

• Very difficult to assess trainee workforce
• No definitive guidelines for trainee numbers
  required
• Numbers already large and likely to increase
• Increasing numbers of non-anaesthetists
• Unclear what will happen to NCCG
• Experience definitely will change - possibly
  decrease
• EWTD compliant rotas in most hospitals

35
What should we do next?

• Encourage participation in ICS Manpower Census
• Repeat this audit regularly?
• Audit on national level?
• Review rotas with regards to handover inclusion
• More formal ICU protected teaching
• Perhaps combining smaller hospitals
• Already regional for Dual CCT trainees

36
Acknowledgements

• Dr Daniel Conway, Consultant Intensivist, MRI
• Ms. Dominique Grundy, IT Support, Hope
• All the trainees that put up with the
  questioning, even in the middle of the night!