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This letter raises important issues surrounding the provision of appropriate patient care out of hours. They highlight issues arising from work systems design including: shift pattern; availability of senior staff; awareness of policies and procedures and staff exhaustion.
The tension between long shifts and tiered staff versus shorter shifts and more handovers is not straightforward. It seems, from reviewing the medical literature, that handovers were initially thought to be innocuous, however it has since been shown that they can be ‘one of the most perilous procedures in medicine, and when carried out improperly can be a major contributory factor to subsequent error and harm to patients.’ Safe handover: safe patients 2006. The advent of working hour restriction has dramatically increased the frequency of care transitions. One organisation estimated a 40% increase in junior doctor handovers, with an average 5-day admission necessitating 15 transitions.
The mitigation of handover error has been widely studied. Most solutions have generally relied upon the human in the system working harder, be that complying with mnemonics or completing of paperwork. More robust solutions support the human by making it ‘easier to do the right thing’. These solutions include: altering shift pattern to provide time for handover; automatic generation of handover information from electronic care records and the provision of facilities to handover without distractions.
The solutions proposed by the authors are likely to support the frontline staff, with the care huddle providing an opportunity for: increasing team situational awareness, colleague support in problem solving and decision making and escalation of problems to senior staff. Staggering the night shifts could improve safety by reducing the cliff-edge change of staff, with all healthcare professionals traditionally changing shift at the same times. However, increasing the total number of shifts would require more staff members.
The turbulence from handover can be reduced using multiple methods; however any improvement attempt could unintentionally introduce error. It is therefore important to understand where the error is being generated prior to selecting an appropriate intervention and then assessing the impact upon the system. The TIDiER checklist could be of assistance in this: https://doi.org/10.1136/bmj.g1687
And there is also the wider "safety net" that is now gone:
- a hospital canteen that stays open through the late evening and night;
- a Doctors Mess where one can meet up, chat, even moan about things with one's peers who are in the same boat;
- able to readily take holidays, arrange a wedding or christening, when you want;
- and of course a Firm not just for the teaching and learning but also for support and guidance when things get tough.
From an occupational health perspective these are important, but not very difficult, organisational things to look at.
Dil
Competing interests:
No competing interests
26 January 2018
Dil Sen
Clin Senior & Hon.Onsultant in Ocupational Medicine
Univ Manchester
Centre for Occupational & Environmental Health, Univ Manchester, Oxford Rd, manchester
Re: We must support junior doctors working after hours
This letter raises important issues surrounding the provision of appropriate patient care out of hours. They highlight issues arising from work systems design including: shift pattern; availability of senior staff; awareness of policies and procedures and staff exhaustion.
The tension between long shifts and tiered staff versus shorter shifts and more handovers is not straightforward. It seems, from reviewing the medical literature, that handovers were initially thought to be innocuous, however it has since been shown that they can be ‘one of the most perilous procedures in medicine, and when carried out improperly can be a major contributory factor to subsequent error and harm to patients.’ Safe handover: safe patients 2006. The advent of working hour restriction has dramatically increased the frequency of care transitions. One organisation estimated a 40% increase in junior doctor handovers, with an average 5-day admission necessitating 15 transitions.
The mitigation of handover error has been widely studied. Most solutions have generally relied upon the human in the system working harder, be that complying with mnemonics or completing of paperwork. More robust solutions support the human by making it ‘easier to do the right thing’. These solutions include: altering shift pattern to provide time for handover; automatic generation of handover information from electronic care records and the provision of facilities to handover without distractions.
The solutions proposed by the authors are likely to support the frontline staff, with the care huddle providing an opportunity for: increasing team situational awareness, colleague support in problem solving and decision making and escalation of problems to senior staff. Staggering the night shifts could improve safety by reducing the cliff-edge change of staff, with all healthcare professionals traditionally changing shift at the same times. However, increasing the total number of shifts would require more staff members.
The turbulence from handover can be reduced using multiple methods; however any improvement attempt could unintentionally introduce error. It is therefore important to understand where the error is being generated prior to selecting an appropriate intervention and then assessing the impact upon the system. The TIDiER checklist could be of assistance in this: https://doi.org/10.1136/bmj.g1687
Competing interests: No competing interests