On-call Registrar Research Articles

EVALUATION OF THE ROLE OF THE ACUTE MEDICAL REGISTRAR IN ORTHOPAEDICS

This project hoped to evaluate a new role, encompassing an in-hours registrar physician being based on the orthopaedic wards for advice, patient reviews, and patient journey optimisation. This service aimed to provide input for all patients who required them outwith the already established ortho-geriatric service.The success of this role was assessed through feedback questionnaires, as well as through the auditing of functional indicators such as the burden on the on-call orthopaedic registrar and other departments for advice from junior doctors, plus the number of medical emergencies.The survey received a total of 42 responses from various staff roles. All respondents thought the role had improved patient care or the functioning of the department. Respondents thought the role primarily enhanced patient care and safety and led to increased support for junior doctors and nursing staff. Data showed a 44% reduction in medical emergency calls since the role began. Total calls outwith the department for medical support reduced by 100% in hours and 50% out of hours when analysed over 22 days. Over a 14 day period, calls to the on-call orthopaedic registrar also reduced by 100% in hours, with no significant difference out of hours.This role has improved patient care and safety and allowed faster medical support with reduced impact on orthopaedic and general medical services. Feedback has been very positive from all staff. The major limitation is lack of 24 hour support. Next steps will include expanding the role, as well as introduction of framework for professional development.

1068 Are There Delays to Emergency CEPOD Theatre Times? a Closed-Loop Audit Before and After Having a Dedicated CEPOD Registrar

Abstract Aim To evaluate delays to Emergency Theatre (CEPOD) start times, “knife-to-skin” times, turnover between cases, and whether having a separate Registrar for CEPOD has improved theatre flow. Method This was a closed-loop retrospective audit at Walsall Manor Hospital with data collected using the electronic system, in two 4-week blocks; from 13/06/2022 – 10/07/2022 and then again from 18/07/22 – 14/08/22. 4 days were excluded due to external factor delays which could not be attributed to the theatre team. The target for patients being sent for was 08:40 AM, and arrival was 09:00 AM as per hospital policy. Results 90.4% (47/52) of patients who were the first case of each day were sent for after 08:40 AM. 88.5% (46/52) arrived in the anaesthetic room after 09:00 AM. 94.2% (49/52) had “knife-to-skin” after 09:30 AM and 71.2% (37/52) after 10:00 AM. 36.5% (19/52) had a turnover time of more than 30 mins between cases. There were statistically significant differences between the mean times for the following categories when there was a single on-call Registrar vs when there was a dedicated CEPOD registrar: Time sent for (09:33 vs 09:08, p-value 0.015), Arrival Time (10:00 vs 09:32, p-value 0.010) and turnover time between cases (00:39 vs 00:11, p-value 0.018). Conclusions There are significant delays to CEPOD start times, anaesthetic times, “knife-to-skin times, and turnover times. Having a separate dedicated CEPOD registrar made a difference to the flow of emergency cases.

P27 Dermatology team huddle

Abstract When I started working in the BRI Dermatology department, I noticed that team morale appeared to have been impacted by the COVID-19 pandemic, and also that the department was not running as efficiently as it could be. To improve departmental efficiency, team-working and staff wellbeing following the COVID-19 pandemic, I surveyed staff to assess their thoughts on departmental efficiency, team-working and a daily team ‘Huddle’. I presented my findings in a departmental meeting, following which a daily team Huddle was initiated. All team members were invited. I created a Huddle proforma which included a checklist troubleshooting issues likely to arise in the day, a moment for a wellbeing ‘check-in’ and a celebration of staff achievement. The Huddle team leader rotated daily. After 6 months, I re-surveyed staff: 92% strongly agreed/agreed that patient care was delivered efficiently (60% pre-Huddle, P = 0.01); 96% of staff strongly agreed/agreed that the team worked well together (71% pre-Huddle, P = 0.03); 62% strongly agreed/agreed that the department was running smoothly/efficiently (33% pre-Huddle, P = 0.08). Staff strongly agreed that the Huddle had improved their wellbeing. Nonclinicians felt more confident to approach the on-call Registrar and Consultant. Respondents observed nonclinical staff were less likely to attend. The Huddle allowed staff to share information/concerns. Rotating the Huddle lead helped break down hierarchical barriers. Celebrating achievements boosted team morale and helped members feel valued. Recommendations include encouraging administrative/reception staff to attend and to set up virtual access for staff who work from home.

P15 Audit of outcome of ambulatory care emergency surgery patients

Abstract Introduction A proportion of emergency surgical patients are discharged with outstanding tasks (clinical review, imaging to be requested or results followed-up) pending. The turnaround time of these tasks typically placed at the bottom of the emergency surgical on-call list is dependent on the on-call registrar or house officer. The aim was to analyse the outcomes of pending tasks on ambulatory care emergency surgical patients and explore means to improve. Methods A retrospective audit of emergency surgical patients from October to December 2021 was performed using the daily on-call list database. Results Among the 149 patients with pending tasks on an ambulatory care basis, 80 were excluded (duplicate entries, unclear tasks, non-valid reasons). 38% of patients remained on the list for more than 24 hours with pending tasks. Only 75% of patients had pending tasks completed. Patients waited for 3.3 hours on average (59 to 350 minutes) for clinical review by the registrar or house-officer. The reasons for the delay in clinical review and task completion narrowed down to inappropriate timing (scheduled return in the mornings, when the on-call team are either busy with the ward round or in theatres) and time restraints. Conclusion Based on the above findings, it would be beneficial for our hospital to have a surgical hot clinic with staggered appointments rather than ad hoc return to the ambulatory unit. This would improve waiting times and would allow outstanding tasks to be completed by the surgical registrar or clinical fellow during clinic, increasing patient satisfaction. Take-home message A dedicated surgical hot clinic will reduce patient waiting times, increase overall patient satisfaction and ensure completion of outstanding clinical tasks.

P014 Giant Cell Arteritis Patient Pathway: A Multi-Disciplinary Approach to Service Improvement in the time of COVID-19

Abstract Background/Aims The RNHRD is a tertiary rheumatology centre offering a fast-track GCA assessment service. A 2018 departmental audit highlighted areas of good practice including timely assessment of cases but demonstrated irregularities in follow up processes. COVID-19 dramatically changed the way we could deliver our GCA service. Additionally, we saw increases in referrals, confirmed diagnoses and complex disease in our local population during the pandemic. This prompted us to undertake a service improvement project. Our main aims were to optimise follow up in line with national guidelines, enhance patient safety and improve the patient experience. Methods We undertook a service review, starting by mapping the patients’ journey. Guidelines were reviewed and stakeholders consulted. We identified several areas for improvement including; consultant-led risk stratification of patients, formalised follow up pathways and closer collaborative working with relevant departments. Additionally, we sought to streamline our processes to accommodate the increased COVID-19 workload. Results A risk stratified follow up pathway was created. Patients are stratified at initial review, by consultants, into low and high-risk pathways. Follow up intervals have been standardised in line with BSR guidance. Follow up patients are reviewed in a dedicated clinic; medical and nursing clinics run supervised by a vasculitis specialist. Patients transfer between different clinics, dependent on clinical stability. Patient information provided has been standardised, with increased emphasis on flare management and steroid side effects. In collaboration with patients this is being incorporated into a “GCA patient passport”, offering a consistent information resource for patients and clinicians. The nurse-led patient advice line is used frequently by GCA patients. All GCA queries are now directed to the on-call registrar, to ensure same day responses. Temporal artery ultrasound is well utilised and completed efficiently; 82% of scans between September 2019 and September 2021 occurred within 48 hours of referral. Via close working with vascular ultrasound, we have been able to create dedicated daily ultrasound capacity. Collaborative working with our Ophthalmology department has increased; communication channels between departments have been agreed, and education sessions have been provided. Processes for new GCA patients were streamlined, for example moving location of reviews. This ensured ongoing timely review of new GCA patients despite increased referral numbers. Conclusion COVID-19 had a significant impact on service delivery but provided a catalyst to develop our service. By engaging with stakeholders across disciplines, and reacting to patient feedback, we have been able to institute effective and meaningful change. This process is iterative and we plan further assessment of outcomes including co-morbidities and complications. Further formal patient surveys and development of a GCA expert patient group are underway and will inform further service development. Disclosure B. Mulhearn: None. J. Ellis: None. S. Smith: None. S.L. Tansley: None. S. Skeoch: None.

Senior triaging of ENT emergency clinic referrals alleviates pressures on the outpatient department.

The ear, nose and throat (ENT) emergency clinic is managed by foundation year (FY) doctors from taking referrals to discharging patients, under the supervision of a registrar. FYs learn essential skills and knowledge on how to manage common ENT problems. The clinic is often overloaded because of a high patient demand, and this limits the opportunities for teaching. We hypothesised that the clinic bookings would be better managed if referrals from general practitioners (GPs) were triaged by registrars. Telephone referrals from GPs for the ENT emergency clinic were directed to the on-call ENT registrar, between 8am and 1pm from Monday to Friday, and to the FY outside of this period. Consecutive referrals to the emergency clinic were analysed in a baseline audit and a post-intervention cycle. A total of 646 and 611 patients were given clinic appointments in the first and second cycles, respectively. Clinic session overbookings decreased from 85% to 46.3%. Appointments for referrals that were deemed inappropriate had reduced from 22% to 12.1%. Involvement of a registrar in taking referrals for the ENT emergency clinic was associated with a reduction in clinic overbookings. It is feasible and productive to involve a senior decision maker in the operational management of the emergency clinic, while preserving the delivery of this service by FYs for its training value.

Senior triaging of ENT emergency clinic referrals alleviates pressures on the outpatient department.

The ear, nose and throat (ENT) emergency clinic is managed by foundation year (FY) doctors from taking referrals to discharging patients, under the supervision of a registrar. FYs learn essential skills and knowledge on how to manage common ENT problems. The clinic is often overloaded because of a high patient demand, and this limits the opportunities for teaching. We hypothesised that the clinic bookings would be better managed if referrals from general practitioners (GPs) were triaged by registrars. Telephone referrals from GPs for the ENT emergency clinic were directed to the on-call ENT registrar, between 8am and 1pm from Monday to Friday, and to the FY outside of this period. Consecutive referrals to the emergency clinic were analysed in a baseline audit and a post-intervention cycle. A total of 646 and 611 patients were given clinic appointments in the first and second cycles, respectively. Clinic session overbookings decreased from 85% to 46.3%. Appointments for referrals that were deemed inappropriate had reduced from 22% to 12.1%. Involvement of a registrar in taking referrals for the ENT emergency clinic was associated with a reduction in clinic overbookings. It is feasible and productive to involve a senior decision maker in the operational management of the emergency clinic, while preserving the delivery of this service by FYs for its training value.

TP9.2.17Developing Novel Referral Pathways in Emergency Surgery

Abstract Introduction In line with the principles of GIRFT and recognising the demand on the Emergency Department (ED) the Acute Surgical Unit (ASU) developed a direct admission pathway entitled ‘ASU Direct’ (ASUD). Nurse led ED triage with adherence to a referral proforma allows direct admission of suitable surgical patients eliminating medical ED review or discussion with the on-call Registrar. Aim Investigate the usefulness of the ASUD pathway and adherence to admission criteria. Method Two retrospective audits of ASUD referrals were completed and compared with concurrent traditional registrar referrals. Inter-departmental discussions occurred between audit cycles. Results Audit 1: 13 days, 150 cases (8 excluded). 75 (53%) referred via ASUD, 67 (47%) via surgical registrar. Sixteen ASUD cases (22%) breached pathway protocols including 3 young women referred without pregnancy tests. Seventeen (25%) cases referred via the Registrar fulfilled ASUD criteria. Documentation complete in 56% of ASUD cases. Audit 2: (3 weeks after feedback) - 10 days, 120 patients (25 excluded). Fifty one ASUD cases (54%) and 44 (46%) registrar referrals. 24% cases breached ASUD criteria, 7 registrar referrals (15%) appropriate for ASUD. ASUD documentation completed in 60% with 100% pregnancy status recorded. Conclusions Proportion of ASUD / registrar referrals remained constant but there were fewer missed opportunities for ASUD. Inappropriate ASUD admissions remained similar. While ASUD worked well for visible pathology, less-so for protocol-driven abdominal pain. Senior ‘front-door’ triage in ED might improve protocol compliance, helping to develop such pathways, observing GIRFT and avoid unnecessary transfer of patients (especially during the COVID pandemic).

1580 Introduction of Dedicated Boarder’s Bleep and Registrar for Improved Clinical Communication, Management, And Care of Boarder Surgical Patients

Abstract Aim Surgical patients are often placed within non-surgical wards due to shortage of beds, however the care of these patients remains under the parent surgical team. Unfortunately, patients outwith surgical areas can frequently feel neglected, with staff often unsure who to contact for reviews. This project aims to improve communication between boarding wards and the surgical team, as well as improving patient care and management. Method This prospective study was based on the Model for Improvement Framework approach to quality improvement. Data was gathered using questionnaires from various staff members on non-surgical wards. Outcomes were measured on a qualitative basis. Results Qualitative data was collected from 45 nursing staff (NS). Prior to introduction of a designated boarder’s bleep, 25% of NS felt they knew who to contact for queries and reviews, whereas 46% contacted the parent ward and 29% contacted the on-call surgical registrar. Only 46% of boarded patients received daily reviews. Following introduction of a dedicated surgical registrar for boarders, 62% of NS felt they knew who to contact with 48% aware of surgical boarder’s bleep. Daily reviews of patients increased to 65% over the course of the cycles of this project. Conclusions Bed shortages can play a vast role in patient care and treatment. This study has effectively demonstrated an improvement in provision of patient care, demonstrating an increase in NS knowing who to contact, as well as a 19% increase in daily patient reviews. Introduction of a dedicated boarder’s bleep-holder has shown improvement in clinical communication and management.

Accuracy of after-hours trauma cervical spine CT reporting by radiology trainees: Experiences from two Australian teaching hospitals.

Like many teaching hospitals in Australia, after-hours computed tomography (CT) reporting at our institution is undertaken by the on-call radiology registrar. The accuracy of these reports is important as management is often initiated based on the interim findings, prior to review by the consultant radiologist. A common exception to this approach is cervical CT (CCT), as many hospital protocols recommend patients to remain in spinal precautions until the report is finalised by a consultant, although there are very few studies to support this practice. The interim registrar reports for all CCTs performed after-hours over a 12-month period were retrospectively reviewed. The final consultant report was used as the gold standard to establish accuracy of the registrar report. The primary outcome was discrepancy between the provisional and final reports. Any discrepancy was classified as either an 'overcall' or 'miss'. Discrepancies were graded by the RADPEER scoring system. A total of 1084 after-hours CCT studies were reviewed. The number of cases positive for injury was 37 (3.4%). The total number of discrepancies was 14 (discrepancy rate 1.3%), including 4 overcalls (0.3%) and 10 misses (0.9%). The discrepancy rates for junior and senior registrars were 1.7% and 0.7% respectively. Only 5 misses (0.5%) were considered clinically significant. Registrars reporting after-hours CCT have low rates of discrepancy with very few clinically significant misses. However, the reduced registrar sensitivity for detection of cervical injury highlights the ongoing importance of consultant review in the process of cervical spine clearance pathways.

Improving training and support by improving our out of hours handover, Central and North West London NHS Foundation Trust

AimsDuring out of hour handovers at St Charles Hospital – the two duty SHO (senior house officers) cover on site, whereas the on-call registrar and consultant are available to contact by phone. Some trainees may experience difficulties in contacting their seniors for support, or may not feel comfortable doing so. Trainees may also feel like they would benefit from being more informed of the hospital situation, or added learning and educational opportunities from the shift. The aim of this project was to improve the out of hours support for the on-call SHOs – which we hope to have positive short (such as improving confidence and performance) - and longer-term impacts (improving retention in the deanery and specialty).MethodThe project proposed instating a 15-minute Zoom call at the start of each night shift (9:30pm) which involved the on-call team (SHOs, registrar, consultants and ideally bed managers). Firstly – a survey monkey questionnaire was sent to trainees to gain a baseline on how supported/informed/ease and learning opportunities for that shift. The project then piloted three separate Plan Do Study Act cycles of change and collected feedback from trainees after each cycle. Both qualitative feedback and quantitative feedback from trainees were collected in the Likert scale format after each PDSA cycle.ResultResults showed that a key benefit of this call is that any pressing issues can be brought up and addressed. Furthermore, for the benefit of the trainees, generally trainees felt more supported whilst they are on call, and got to know the fellow on call team. In addition, trainees reported feeling more at ease when calling their senior colleagues.ConclusionIt is particularly important for doctors to feel supported and informed during their on call shift, especially in the current climate, where there are fast changes and adaptations taking place due to the pandemic. By adding a short meeting at the beginning of each night shift, doctors in the hospital demonstrated an increase in feeling supported, informed and having educational opportunities during their on call shifts. In the long term, by addressing on call issues and making trainees feel more confident and supported during their shift, is likely to benefit and improve recruitment and retention.

A quality improvement project (QIP) to address communication and safety concerns from the on-call team at the Bethlem Royal psychiatric hospital out-of-hours through the introduction of weekend safety huddles

AimsThere have been long-standing concerns about communication and safety on the Bethlem site out-of-hours due to its size, acuity and the number of specialist services; these issues were exacerbated by the COVID-19 pandemic. A Quality Improvement Project was designed to address communication and safety concerns from the on-call team at the Bethlem Royal psychiatric hospital out-of-hours through the introduction of weekend safety huddles.MethodDaily weekend safety huddles were introduced to improve communication regarding workload, acuity, new admissions, seclusion reviews, deteriorating patients; and to improve team cohesiveness and trainee support out-of-hours.The QIP team involved the deputy medical director, the associate director for speciality units, consultants, the college tutor, specialty registrars and core psychiatry trainees. Prior to initiating the huddles, the QIP team met to decide which specialties to involve, to agree on an agenda and liaise with other sites regarding existing huddles. Once the huddles began in April 2020, the team met periodically to agree next courses of action and to troubleshoot. The huddles initially involved acute services and eventually included CAMHS, Forensic, Older Adults, Specialist Units, all on-call consultants, the on-call registrar, two core trainees, the psychiatric liaison manager and the duty senior nurse.ResultData were gathered throughout the QIP using Likert scale surveys which were sent to all junior doctors on the out-of-hours rota. Paper surveys were used initially but were later replaced with Microsoft Forms to ensure anonymity.The percentage of respondents who answered “most of the time” or “all of the time” increased across all parameters when comparing data from before and after implementation of the safety huddles.These results included improvement in: understanding of workload and acuity (9% before vs 69% after), discussion of new admissions on site (4% before vs 90% after), discussion of patients with deteriorating mental health (35% before vs 90% after) and physical health (22% before vs 83% after), understanding of number of patients in seclusion (61% before vs 93% after) and feeling part of a cohesive “on-call” team (17% before vs 86% after). In addition, the results suggested a reduction in frequency of safety concerns on site (83% answered at least “sometimes” before vs 62% after).ConclusionThe results of the final survey demonstrated a measurable and positive impact on communications between the out-of-hours team, improved team cohesiveness and a reduction in safety concerns. The lessons learnt also influenced decisions made in formatting safety huddles at other trust sites.

The psychiatry virtual-on-call experience: Can it improve confidence of foundation and GP trainees with out-of-hours work in psychiatry?

AimsOut-of-hours (‘on-call’) work can be perceived by junior doctors to be a daunting experience, associated with feeling unprepared and less supported. Simulated on-call programmes have been used to great effect in medicine and surgery to improve junior doctors’ skills in task prioritisation, interpersonal communication and confidence on-call. However, few psychiatry-specific programmes exist.We aimed to: i) Develop a psychiatry specific virtual-on-call programme, ii) Investigate if the virtual-on-call programme improved confidence amongst junior trainees in key areas of psychiatry practice.MethodThe Psychiatry Virtual-On-Call programme commenced in December 2020. It involves attending an introductory on-call lecture, followed later in the rotation by a 2-hour simulated on-call shift. All trainees are expected to attend during their attachment and the simulated shifts are ongoing. During the shift, trainees are ‘bleeped’ with different psychiatry specific tasks. They work through the tasks, using local intranet policies and telephone advice from the on-call psychiatry registrar. Due to COVID-19 the sessions were delivered virtually. Participants completed a questionnaire evaluating confidence in ten domains, rated on a Likert scale from 0–10. Questionnaires were completed at four time-points during the programme; pre- and post-introductory lecture and pre- and post-simulated shift. Scores were compared using Mann-Whitney U tests. Significance was defined as P < 0.05 with Bonferroni correction applied for multiple testing.ResultTwenty-nine trainees attended the introductory lecture, 25 and 21 trainees completed the pre- and post-lecture questionnaire respectively. A non-significant improvement in confidence was reported in three domains: seclusions reviews, prescribing, detention under the mental health act.At the time of writing, ten trainees had attended the on-call shift. All participants completed a pre- and post-session questionnaire. The on-call shift was a useful learning experience (median score 9), and significantly increased perceived preparedness for on-call work from 3/10 to 7/10 (p < 0.001). Confidence was significantly improved in seven domains, most markedly in seclusion reviews, prescribing and mental health act tasks.ConclusionThe psychiatry virtual-on-call programme fills a niche in the training curriculum and is perceived by trainees to be a useful learning experience. The introductory lecture improved confidence in several domains, but not as effectively as the on-call shift. The on-call shift was well received by participants and significantly improved confidence in 7/10 domains. In summary, the virtual-on-call experience improves preparedness for out-of-hours psychiatry work. Follow-up of participants at the end of their psychiatry rotation will ascertain if they felt the programme to be useful during out-of-hours work.

A retrospective analysis of emergency referrals and admissions to a regional neurosurgical centre 2016–2018

Background and objectives Emergencies account for 60% of UK neurosurgical workload. We analysed the emergency referrals made to the on-call neurosurgical registrar in a regional centre over three years, aiming to identify temporal trends in volume of referrals, admission practices and major diagnostic categories contributing to referrals and admissions. Methods Individual referrals recorded in on-call databases were processed to extract basic demographics, call timing, diagnosis category and whether the patient was admitted under neurosurgery. Linear regression analysis was used to identify temporal trends across the three years. Results A total of 18128 calls were made to the on-call registrar between 2016 and 2018, with a significant increase in monthly calls. On average, one call was received every 88 minutes. An increasing proportion of these calls were taken out of office hours. Diagnostic categories accounting for the largest percentage of calls were traumatic brain injury (17.7%) and cauda equina syndrome (13%). Significant increases in referral volume were seen in cauda equina syndrome, traumatic brain injury, spinal trauma and spinal tumours, while no category had a significant decrease. The admission rate was 17.1% – no change was seen in this across the study period, resulting in increasing numbers of admissions, reflecting increasing referrals. Categories most likely to result in admission were hydrocephalus (41.1%), spontaneous subarachnoid haemorrhage (39.4%), intracranial infection (32.6%) and chronic subdural haematoma (CSDH, 32.2%). A change in admission rate was seen only for CSDH, with a significant increase in the percentage of referrals across the study period. Conclusion Emergency neurosurgical referrals continue to rise in the UK at a rate exceeding population growth. This implies a decreasing referral threshold. However, the constant admission rate suggests either an increasing amount of neurosurgical pathology, the threshold for admission/intervention has decreased, or a combination. Neurosurgical services need to adapt in order to meet increasing demands.

The Neurosurgical Registrar – are we still as busy as we were? A Quality Improvement Study

Introduction: Bleeps represent an important element of the on-call neurosurgical registrar’s workday. They provide instant contact between healthcare staff, while allowing doctors to perform tasks across the hospital. However the paging system causes interruptions and can interfere with patient care. We aim to develop and implement strategies to improve paging patterns and ultimately reduce unnecessary calls. Material and Methods: we conducted a retrospective analysis of electronic hospital bleep records over a 7-months period (March-September-2015) in which bleep logs were retrieved from the hospital paging system at University Hospital of Wales. The first cycle was followed by a set of interventions followed by a second data-collection cycle 12 months later.Results: The first cycle showed that on average the neurosurgical registrar received 57 bleeps per 24hrs. Almost a third of on-call bleeps were new referrals received from the local accident & emergency department or from other district hospitals. Other calls were received from our own hospital’s wards and Intensive Therapeutic Unit (10%), the paediatric ward (5%), neurosurgical theatres (5%) and emergency theatre (5%). The second cycle showed a 23% drop in the total number of bleeps compared to first cycle. The difference in bleep numbers was evident during the day shift, and no difference was noted during the night shift. No difference in the number of new referrals was noted. Conclusion: This project has shown that a simple change can result in a significant improvement. It also confirmed the value of team work and communication in improving quality of care.

Referrers’ point of view on the referral process to neurosurgery and opinions on neurosurgeons: a large-scale regional survey in the UK

ObjectivesThere is an increased reliance on online referral systems (ORS) within neurosurgical departments across the UK. Opinions of neurosurgeons on ORS are extensively reported but those of referrers have hardly...

Improving neurosurgical communication and reducing risk and registrar burden using a novel online database referral platform

Objectives: Documentation of urgent referrals to neurosurgical units and communication with referring hospitals is critical for effective handover and appropriate continuity of care within a tertiary service. Referrals to our neurosurgical unit were audited and we found that the majority of referrals were not documented and this led to more calls to the on-call neurosurgery registrar regarding old referrals. We implemented a new referral system in an attempt to improve documentation of referrals, communication with our referring hospitals and to professionalise the service we offer them. Methods: During a 14-day period, number of bleeps, missed bleeps, calls discussing new referrals and previously processed referrals were recorded. Whether new referrals were appropriately documented and referrers received a written response was also recorded. A commercially provided secure cloud-based data archiving telecommunications and database platform for referrals was subsequently introduced within the Trust and the questionnaire repeated during another 14-day period 1 year after implementation. Results: Missed bleeps per day reduced from 16% (SD ± 6.4%) to 9% (SD ± 4.8%; df = 13, paired t-tests p = 0.007) and mean calls per day clarifying previous referrals reduced from 10 (SD ± 4) to 5 (SD ± 3.5; df = 13, p = 0.003). Documentation of new referrals increased from 43% (74/174) to 85% (181/210), and responses to referrals increased from 74% to 98%. Conclusion: The use of a secure cloud-based data archiving telecommunications and database platform significantly increased the documentation of new referrals. This led to fewer missed bleeps and fewer calls about old referrals for the on call registrar. This system of documenting referrals results in improved continuity of care for neurosurgical patients, a significant reduction in risk for Trusts and a more efficient use of Registrar time.

You’ve been bleeped: found on the floor

The aim of this series is to present common on-call scenarios that you may face as a junior doctor and to provide a framework to help deal with your reactions when the bleep goes off. By reflecting the voices of a junior doctor and a medical registrar, this series will highlight the different perspectives of both the newly qualified doctor and the more experienced one. We aim to provide you with insights on how best to approach the initial problem and then how to manage the patient once you have reached the ward. #### Scenario It is Saturday morning. You are a foundation year 1 (FY1) doctor on call for the general medical wards at a busy district general hospital. You are on a ward round with the on-call medical registrar, reviewing the patients in the high dependency unit when your bleep goes off. #### Bleep “Is that the FY1 covering the wards? My name is Tom, staff nurse on ward 4. I’m calling about an 81 year old man called Ed Herts who we have found on the floor. No one saw him fall. He is in a lot of pain over his right side. He was originally admitted with cellulitis, but he has been in hospital for some time now. His observations are stable. Can you please review him?” ### How would you react to this bleep on the phone? A patient might fall for several reasons. Although this could be a simple slip or trip, patients may also fall due to an underlying medical problem. In the latter case, a fall could alert medical staff to an acute deterioration in the patient’s clinical condition. It is also important to consider that any fall could result in a major complication.[1]. On the phone you need to start to uncover the circumstances surrounding why the patient ended up on the floor. This might be …

Coordination of specialist care with clinical social networking

Introduction: Significant advances in Information Technology (IT), with increasing power of computing devices, ease of access to the Internet and the proliferation of smartphone technology allows more effective collaboration in real time to improve communication and ultimately patient safety. Professor Sir John Lilleyman, Medical Director of the National Patient Safety Agency, states, ‘Handover of care is 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.’ Professor Peter Rubin, Chairman of the Education Committee of the GMC, suggests, ‘Effective communication lies at the very heart of good patient care...... The changing face of medical practice – and particularly the introduction of shift working – makes that requirement more important than ever.’ Here we report the use of clinical social networking via smartphone and tablet technology to manage specialist referrals across multiple provider sites. A collaboration between clinicians at EKHUFT and the healthcare specialist IT company DocCom. Aims and Objectives: Shift working, cover across multiple sites and providers created difficulty in ensuring every member of the multi-disciplinary team (MDT) had access to up-to-date patient information, including advice already given by other members of the specialist team. There was no consistent way of ensuring clear communication and documentation of referrals. The aim here was to develop a robust, accessible real-time clinical social networking platform to manage tertiary renal referrals across multiple providers via mobile technology. Methods: DocCom have developed a secure clinical social networking platform, ‘Careflow’. All medical staff, along with specialist nurses in the renal MDT at EKHUFT, are supplied with Apple devices to which Careflow was deployed. The app connects to the DocCom service in the cloud. Risks of holding patient identifiable data in the cloud (allowing access both within and outside of International Journal of Integrated Care – Volume 14, 01 November – URN:NBN:NL:UI:10-1-116474– http://www.ijic.org/ International Digital Health and Care Congress, The King’s Fund, London, September 10-12 2014. N3) are mitigated by appropriate use of encryption. DocCom is ISO 27001 certified and holds an NHS Information Governance Statement of Compliance (IGSoC). A referral group was created to allow the MDT to communicate and collaborate around referrals. Results: All renal tertiary referrals at EKHUFT are now documented in the “renal referrals” group in Careflow. As an example of a typical patient pathway; a referral is received to the on-call renal registrar who then documents the referral on Careflow allowing other members of the MDT to instantly view. For referral from another site the nephrology consultants covering that site are then alerted to the referral, may then perform a clinical review of the patient and document findings and management plan on Careflow. This allows clear and transparent clinical conversation around the patient’s care. This referral may result in transfer to the renal ward, arranged by the ward manager who is already involved in the conversation. Conclusions: This system provides efficient communication and collaboration for a tertiary referral centre via mobile technology for a mobile workforce, demonstrating potential gains in both improving quality of care and patient safety by clinical innovation and use of IT in healthcare achieved by an active collaboration between clinicians and IT specialists.

Radiology registrar on-call reporting accuracy

Radiology registrar on-call reporting accuracy