Intended for healthcare professionals

Careers

Managing the take

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1654 (Published 07 April 2010) Cite this as: BMJ 2010;340:c1654
  1. Catriona J Shaw, specialist registrar in nephrology1,
  2. Victoria F Moxham, specialist registrar in nephrology1,
  3. Hugh Cairns, consultant nephrologist1
  1. 1Renal Unit, King’s College Hospital London, London
  1. hugh.cairns{at}kch.nhs.uk

Abstract

Hugh Cairns and colleagues describe an effective “take” strategy

Acute medical and surgical on-call, commonly referred to as “the take,” is a major part of most general junior doctor posts. The take is the mechanism through which most acute medical and surgical patients are admitted to hospital and provides junior doctors with their greatest exposure to acute medical and surgical problems.

Nearly five million patients are admitted non-electively to hospitals in the United Kingdom each year1; the large number of patients requiring assessment and often admission can be a major reason for a difficult take. The diversity of the clinical scenarios that present, the number of staff involved in the care of patients, the frequent shortage of beds, and the requirement to decide on, and sometimes prioritise, the need for admission all contribute to the difficulties. Even for routine admissions, errors in medical management result in harm to about one in 10 hospital patients, and about half of these errors are thought to be preventable.2

The aim of any period of take should be to provide efficient, accurate, well managed care to all patients.34 The take is also an opportunity for junior doctors to assume significant responsibility, deal with complex and often rapidly developing medical problems, and excel in medical care. As a consequence, many junior doctors find they learn a great deal during these intense periods of activity.

Often, however, the take is a source of extreme stress—not only for doctors (of all grades) but also for other healthcare professionals, the hospital as a whole, and, most importantly, the patients and their relatives. The recent changes in the working patterns of junior doctors in many countries have resulted in most medical teams working shift systems, which can reduce the sense of teamwork and affect continuity of care.5 A well planned strategy is therefore necessary to enable the take team to function efficiently and safely.

Before the take starts

It is important to be aware of the team members with whom you will be working and their different roles. The on-call consultant may be a single individual throughout your period on call or may change. Different consultants will run their take differently, with greater or lesser degrees of involvement. Nevertheless, the on-call consultant is ultimately responsible for the patients and should be kept informed of major decisions or changes.3 With the variety of shift rotas worked, there may be frequent changes of colleagues; this could disrupt your confidence and the team dynamic, particularly if you are junior and more anxious. Communication, empathy, and thoughtfulness will help minimise potential difficulties.

If you know where things are and how the system is supposed to run, you will feel more confident and will also use your time more efficiently. It is essential that you are familiar with the resuscitation equipment that is used in your hospital and the protocols for initiating and responding to a cardiac arrest. Awareness of clinical rooms and equipment, systems for organising emergency investigations and admissions, and the timing and the mechanisms of senior review and handover of patients will all make your life easier. In a new hospital it is worth determining the location of the different clinical areas because finding a specific area during a cardiac arrest can be difficult.

There are other individuals who will have a major effect on your work during the take—these include nursing staff in the accident and emergency department and on the wards, medical staff in the emergency department, on-call clinical staff in other services, and non-clinical staff such as bed managers, porters, receptionists, and ambulance crews. All these people affect how the take operates and the quality of service you provide to your patients. Introducing yourself to these staff will often help to develop relationships that enable the take to run more efficiently. Remember that all the staff in the hospital want to provide a good service, but the stresses and sometimes conflicting demands of the different roles can produce tensions that must be handled. For example, emergency department staff in the UK will often be particularly focused on preventing patients from breaching the four hour wait target—this is an important and valid target for the emergency department and the hospital.

Referrals from doctors in primary care are a common mechanism for patient referral to the emergency department. Junior doctors receiving calls from other doctors commonly create unnecessary barriers to seeing the patient. Remember that the general practitioner has probably seen many other patients that day for whom admission was not deemed necessary and he or she is often assessing the patient in an environment where tests and serial observations are difficult to organise. Most patients about whom a doctor contacts the on-call team need to be seen, and agreeing to this easily will save you, and others, time and effort.

Patient admission

Initial assessment

The admission process for any patient requires an initial assessment followed by actual admission to hospital (box 1).4 Prompt and efficient clinical assessment, supported by legible accurate documentation, appropriate investigations, and the institution of a clear management plan, are required for each patient with an acute healthcare problem.678 Early decision making and senior input ensure appropriate plans are made and referrals to subsequent specialties, if necessary, are facilitated. Planning patient discharge should start on admission (box 2).

Box 1: Main stages of admission process4

  • Assessment

  • Admission

Basic principles
  • Assess once to determine initial investigations and management

  • Find out what is wrong accurately and quickly

  • Ensure the patient goes to the right place for the right treatment, first time round

Box 2: Patient discharge

  • Take an objective look at the information you have written and ensure it is interpretable

  • Remember that beds for admissions depend on discharges

  • GPs—The information that you provide to continue the ongoing care of the patient after discharge is vital for good patient care. Remember that patients require ongoing care after they leave hospital

  • Coding—Hospitals are paid only if they bill correctly. Remember they are being paid for the work you have done

  • Patients—Patients will often read their notes and other documents. Think about what you say and never write anything you would not be happy for the patient (or a court) to read

  • Pharmacy—Pharmacy may well shut at midday on weekends. Hence early identification of patients, preparation of discharge documents, and planning of discharge medication need to be prioritised

In the UK, the Acute Medicine Task Force recommends that a doctor with appropriate skills in acute medicine or surgery should be present at all times in all units that receive acute medical emergencies.3 This doctor is usually a specialist registrar or year 3 specialty trainee, who will triage, aid clerking of patients, and review patients assessed by more junior doctors. Clear documentation of this process and the plans made is crucial. Ensuring that senior team members review patients provides optimal care and also provides a formal basis for teaching and assessment of junior doctors. It is now recommended that on-call consultants should be available to review patients during the on-take period—this should occur within 12 hours in most cases and always within 24 hours.3

The quality of the initial assessment affects the subsequent quality of care delivered (box 1)—either in rapidity of accurate diagnosis or instigation of investigations and treatment.4 Case studies 1 and 2 taken from the UK National Confidential Enquiry into emergency admissions in 2007 demonstrate the difference between a bad and a good initial assessment (box 3).9

Box 3: Case studies

Case study 1 is an example of how poor initial assessment can influence the final patient outcome. In contrast, case study 2 highlights a good initial assessment. Both cases are taken directly from the National Confidential Enquiry into Patient Outcome and Death report 2007.

Case study 1

A very elderly patient was admitted in the early hours of the morning to the emergency department with a fractured neck of femur following a fall at home. The patient had a medical history of ischaemic heart disease and chronic obstructive pulmonary disease and was taking medication to prevent cardiac failure.

An orthopaedic senior house officer did an initial assessment of the patient, with a cardiovascular and respiratory assessment being described as normal. Eight hours later the patient underwent a hemiarthroplasty performed by an orthopaedic specialist registrar. None of the patient’s cardiac medications had been given preoperatively because of a nil by mouth order.

There was no further entry in the patient’s notes from the initial assessment until a review in theatre recovery, which reported postoperative shortness of breath and an arterial oxygen saturation of 75%. Postoperative treatment was given for cardiac failure and, despite admission to intensive care and aggressive therapy, the patient died two days later. A postmortem examination showed that the patient had had an acute myocardial infarction that predated the admission.

The advisers judged the initial assessment to have been poor because of the brevity and lack of clarity of the clerking and the minimal assessment of the patient’s cardiac status. They commented that, if more time and attention had been paid to the patient’s clinical status in the preoperative period, the acute myocardial event may have been identified and the patient’s condition could have been optimised before surgery.

Case study 2

An elderly patient with epigastric pain was admitted to an emergency admissions unit on a Friday morning. The patient was seen by a surgical senior house officer, who did an initial clinical assessment and made a differential diagnosis of cholecystitis, peptic ulcer disease, or small bowel obstruction. A clear plan of management was documented. The patient was reviewed by a consultant surgeon within six hours and an ultrasound scan was arranged the same day, which showed a dilated common bile duct. Computed tomography was organised for the next day. The patient’s pain persisted with abdominal distension.

The computed tomography scan showed small bowel obstruction. The patient was reviewed again by a consultant surgeon that day. The patient’s general condition was judged to be deteriorating with increasing signs of sepsis.

An emergency laparotomy was performed by the consultant surgeon. At operation, a necrotic gallbladder was found with small bowel adhesions. A cholecystectomy and release of adhesions were undertaken. Postoperatively, the patient was admitted to an adult intensive care unit and required ventilatory and inotropic support because of persistent hypotension as a result of the sepsis. However, within two days the patient was extubated and the sepsis had resolved. The patient returned to the ward two days later.

It was the advisers’ view that this patient received good overall quality of care and that the initial assessment was good and well documented. There was an appropriately timed first consultant review with continued daily consultant reviews. The patient had a timely operation and had good postoperative care on an adult intensive care unit and, despite the predictable complications, made a good recovery.

  • Both cases are taken from the NCEPOD report9

Documentation

The principal purpose of medical notes and medical records is to record and communicate information about patients and their care. Failure to organise and complete notes properly can lead to frustration, debate, clinical misadventure, and litigation.7 Well structured documentation has beneficial outcomes on doctors’ performance and patient outcomes.6 Importantly in this era of shift work, which potentially fragments continuity of care, good documentation has the capacity to improve clinical management, handover, and patient safety.

Improving quality and safety for patients, and the rising expectations and costs of healthcare delivery, demand an accurate, clear documentation process.348 Clear guidelines and recommendations on documentation exist, which aim to maximise patient safety and quality of care, support best professional practice, and assist with compliance with information governance. In the UK, for example, guidelines have been published on the information that should be recorded for each patient contact. For each admission, a clear plan needs to be provided for investigations, next steps, and plans for discharge.8

Patients at risk of deterioration

All patients admitted to hospital are at risk of deterioration. Delayed recognition of acute illness or a deterioration in clinical signs may result in compromised care, delay in referral to critical care services, unnecessary admission to critical care, and avoidable morbidity or mortality.10 Track and trigger systems and early warning scores are now used in many hospitals to enhance early identification of patients who are deteriorating. Hospitals should have protocols for the escalation of care of a deteriorating patient, and you should be aware of your responsibilities in this process, including whom you should call at each level of score and what information they will require.

Teamwork/communication

Teams are the foundation of health care, and the multidisciplinary team provides the skills needed for a smooth transition from admission, through treatment, to discharge into primary care. As already stated, communication, both written and verbal, is crucial to the smooth running of the take. Communication must be concise and accurate to ensure the important and key features of the patient history are not lost in a mass of information.8 Open and transparent communication between all members of the team, patients, and relatives is essential (box 4). It must be remembered that the on-take consultant is ultimately responsible for the decisions made and must, therefore, be made aware of patients in a timely manner. The NHS Leadership Competency Framework, which incorporates the important factors that relate to the take, and elements of effective team working are shown in the figure and box 5.11

Box 4: Communication is key

  • Written information—“the clerking”

  • Clearly documented management plan

  • Verbal communication with the team

  • Verbal communication with patients and relatives

  • Documentation of verbal communication

  • Handover of relevant information

  • Politeness

  • Respect

Box 5: Teamwork—how to make it effective11

  • Understand your role in the team

  • Treat others with respect

  • Show willingness to help

  • Be flexible and adaptable

  • Communicate constructively and listen actively

  • Be reliable and take responsibility for your role

Guidelines

There are many clinical guidelines, national and local, that aim to make the process of acute admission safe and efficient. Some of these have already been referred to, particularly around documentation and communication. Most hospitals also have local processes, protocols, and formularies, all of which aim to improve patient care—common examples are guidelines for antibiotic prescribing in common infections and the treatment of venous thrombosis. Being familiar with these and documenting their use will help all members of the team be clear what is expected.

There are also internationally recognised scoring systems for a variety of common conditions, which help to identify patients at higher risk—for example, the Rockall score for gastrointestinal haemorrhage12 and the CURB-65 scoring system for the severity of pneumonia.13 Using these scores and referring to them in documentation improves patient care and safety.

Handover

Effective handover is an increasingly important element of safe patient care and also provides training opportunities for junior doctors. Clear structures for handover need to be embedded in hospital systems. Increasingly hospitals use electronic systems, although handover can also be effective using paper or white boards. Sufficient time must be allocated for handover, which should occur in an appropriate environment free from unnecessary interruptions. An effective handover provides relevant information to all members of the team, identifies the roles and responsibilities of the different clinicians, highlights important or pending investigations, and highlights the patients who are particularly at risk.1415 After each handover you must be aware of your various tasks and responsibilities. The consultant and team who are responsible for any patient must be clear at all times; this is particularly important when care is transferred from one team to another.15 Confidentiality must always be considered.

Crisis resource management and human factors

We are all human and fallible. Recognising this is crucial for organisations and individuals. The acute take can be a busy and stressful time with a great deal of information being obtained quickly, requiring speedy but valid interpretation and appropriate action. Human factors contribute to risk for patients—these include mental workload and distractions, leadership and personal qualities, workload management, and technical and clinical skills.16 Evidence from the crisis resource management literature, initially developed in the airline industry to improve flight safety, highlights social and cognitive factors that can improve performance, particularly in times of emergency (box 6).17 The ability and time to reflect, and awareness of when we need help, is important in reducing the risk to patients 17.

Box 6: Social and cognitive skills that can contribute to improved performance17

Social skills
  • Communication

  • Information sharing

  • Feedback

  • Leadership

  • Team building/climate (culture)

Cognitive skills
  • Preparation and planning

  • Workload management

  • Prioritisation and allocation

  • Monitoring and recognition

  • Situational awareness and decision making

  • Re-evaluation

Other
  • Teaching

  • Declaring emergency

  • Initial crisis management

  • Technical and clinical skills

  • Overall effectiveness

Conclusions

The ideal emergency admission is one where a patient is admitted because it is necessary, has appropriate investigations leading to a rapid diagnosis and correct treatment, and then has a timely discharge from hospital. All of this should be clearly and empathically communicated to the patient and relatives, with accurate systematic documentation in the notes as described above. Effective handover of all relevant information should occur throughout the admission between the teams caring for the patient, such that high quality, safe care is maintained. Remembering the stages of the admission process and the key role of good communication are central to the provision of safe and efficient patient care.

Key points

  • Thorough triage, patient assessment and investigation, and management plans need to be made and clearly documented. The involvement of a more senior doctor should be clearly documented, along with the role of the responsible consultant. Think about discharge planning on admission.

  • Patients admitted as an emergency should be seen by a consultant at the earliest opportunity, ideally within 12 hours and no more than 24 hours. Compliance will vary with case complexity.

  • Trainees need to have adequate training and experience to recognise critically ill patients and make clinical decisions. Mid level and senior support for decision making is vital.

  • A clear physiological monitoring plan should be made for each patient. This should include what is to be monitored: the desirable parameters, the frequency of observations, and the triggers for and level of medical review.

Footnotes

  • Competing interests: None declared.

References

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