Safe staffing: this is how many doctors we really need
BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3136 (Published 18 July 2018) Cite this as: BMJ 2018;362:k3136
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This is a good baseline but I believe there is another model to consider when there is either no MAU/AAU or no capacity for urgent/emergency assessment and management.
These patients are generally processed in the Emergency Department by ED staff who perform triage/rapid assessment & treatment (RAT) and initiate emergency treatments (eg antibiotics in sepsis, chest drain insertion), order investigations early in patients' journeys (e.g. CT scans, bloods, Xrays) and redirect patients e.g. to ambulatory care. When specialty teams work alongside ED staff there are generally good relationships but multiple duplication.
We could work "smarter" at the start of the emergency pathway with one team one queue and single clerking to reduce duplication and reduce time to a senior decision maker. This would mitigate, to some extent, against the rota gaps that affect us all. A patient with severe pneumonia would be seen by one mega-team, whether GP referral or walk in.
Looking at the skills of all clinical staff available during an on call period (including ACPs, PAs etc and including ED staff) and the workload is key to managing emergency care. Silo working does not fit the demand and nature of emergency attendances in the current climate, in my humble opinion.
Competing interests: No competing interests
I was interested in the article in the BMJ of 28th of July by Andrew Goddard.
In the example of recommended safe staffing levels it was stated that it will take an average tier one clinician an hour and a quarter of their time to do all the tests required for a patient admitted with pneumonia.
It would seem likely that much of this work currently done by doctors could be done by other personnel and also much by computer automation.
I wonder what effort has been made to analyse in detail this type of activity to estimate the savings that can be made in clinicians’ time.
Kenneth Harden ( Retired GP ).
Competing interests: No competing interests
I share Dr Mann’s dismay.
But the failure of the Secretary of State, or of NHS England, to DO SOMETHING USEFUL can be laid at the door of the good doctors who murmur their protests but go on slaving away, to the detriment of the patients.
Somewhere in England, the authorities decided to open a new hospital. In the closing years of the century gone by.
They quite cheerfully agreed to appoint a few consultants. But forgot that they needed juniors too.
The existing consultants said that no new consultants would apply unless there were juniors.
Graciously the authorities agreed to pull out all the stops and search high and low for juniors. The search, across tbe English Channel, was successful. The hospiral opened with a full complement of medical staff of all grades.
Lessons? Just one. Don’t wait for the manna to fall from heaven: Act now.
Competing interests: No competing interests
Benchmarking safe medical staffing levels should have been a basic basic in SoS's hyped drive for #patientsafety. But this work has been carried out despite and besides Jeremy Hunt, not because of or by him.
Together with nursing levels it's probably the most significant factor affecting safe patient care in hospitals. All it has taken to achieve this is a good old-fashioned time and motion study to provide the basis for calculations for safe medical staffing, appropriately tailored to nature of workflow.
It's interesting that, while professionals raised the alarm over inadequate staffing/resourcing of the NHS some years ago, no attempt has since been made by DoH/NHSE to commission this work. We are missing some of the most basic information such as numbers of junior doctors on wards. While a similar workforce crisis is acknowledged to exist in general practice, it is dissonant that no figures for numbers of GP consultations are collected by NHSDigital here, either.
Thanks to RCP. Hopefully, hospitals will use these guidelines to calculate their medical staffing requirements and, when collated, RCP will inform us with a coherent view of the staff that the NHS needs and patients depend upon.
I don't want to seem pushy, but could the RCP/RCS /RCPsych now produce similar guidelines for the number of in-patient beds required? Given the disproportionate cuts to numbers of beds over the last 30yrs, it might explain why hospitals continue to be bursting , even though we're well into summer.
Competing interests: No competing interests
One queue and single clerking
I second Somers' suggestion of smarter emergency pathway with one queue and single clerking to reduce duplication.[1][2] During my elective in a Canadian hospital, I first experienced a hospital system which has no medical admission unit (MAU). The hospital has medicine or surgery consulting teams, which have physicians in charge of admission clerking. Once they decide to admit a patient, the patient is directly transferred to the ward floor, rather than waiting in MAU like the British system.
I endorse the Canadian system because it efficiently minimises number of handovers, which are prone to communication errors.[3] Another advantage is the emergency department has comparatively less pressure to immediately transfer patients out. That gives the emergency physicians more time to order investigations and establish a clear diagnosis before calling the admitting team. In comparison, during on-call shifts in British hospitals, I often observe arguments between the emergency and admitting teams about the diagnosis, blames on why the essential investigations were not performed prior to referrals, and confusion on the different management plans between teams in MAU and the wards. These are time-consuming political issues that hinder patients' therapeutic management.
Nevertheless, it can be difficult to assimilate emergency and acute medicine services in the UK. Emergency consultants may not feel comfortable managing acute medicine services, and vice versa for acute medicine consultants. It would require significant changes in their training schemes to help these physicians become more comfortable in managing both types of patients. I look forward to seeing innovative changes in both specialities to facilitate safe staffing.
References:
[1] Limb, M. Safe staffing: this is how many doctors we really need. BMJ 2018, 362, k3136, 10.1136/bmj.k3136. Available online: https://doi.org/10.1136/bmj.k3136.
[2] Somers, L. Re: Safe staffing: this is how many doctors we really need. https://www.bmj.com/content/362/bmj.k3136/rr-2 (accessed Aug 7, 2018).
[3] Eggins, S.; Slade, D. Communication in Clinical Handover: Improving the Safety and Quality of the Patient Experience. Journal of Public Health Research 2015, 4, 666, 10.4081/jphr.2015.666. Available online: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4693345/.
Competing interests: I have been paid for working as a physician, but not for writing this letter.